Bringing down the rate of new HIV infections over the next decade will require a much closer focus on what is driving the HIV epidemic at country level, and a better understanding of how national epidemics are made up of micro-epidemics in key populations.
In Kenya, for example, three simultaneous epidemics are going on, geographically dispersed and requiring different interventions, said Mark Dybul, Executive Director of the Global Fund to Fight AIDS, TB and Malaria. One in the Homa Bay region is driven by gender inequality, another is concentrated among men who have sex with men in Mombasa but also involves injecting drug use, and a third epidemic with mixed routes of transmission is centred on the capital Nairobi.
“We need to go country by country, micro-epidemic by micro-epidemic,” he said. “We don’t know exactly how to intervene but we know enough to make some pretty big bets. If we shift our mindset from 'we will scale up X, Y or Z', to 'we will end the epidemic', we will pick the right X, Y or Z.”
In order to reduce new infections, HIV prevention will have to be embedded within wider programmes tackling the social issues that increase vulnerability to HIV infection, such as gender-based violence. “A lot of the issues are social issues, not just medical issues,” said Dybul
Ambassador Deborah Birx, United States Global AIDS Coordinator, warned that a renewed emphasis on HIV prevention for young people will be needed to meet the challenge of the 'youth bulge' – the doubling in size of Africa’s 15-24 age group since 1990 as a consequence of improvements in infant survival. Although the HIV incidence rate is declining in most countries, and is down 15% overall in sub-Saharan Africa, the doubling of the 15-24 age cohort by 2020 means that the total number of new infections will go up.
The size of this youth cohort in sub-Saharan Africa will equal the size of the combined youth cohort of India and China, said Ambassador Birx. HIV prevention activities will need to be targeted at different age bands in the youth cohort to achieve greatest impact. This means emphasising:
- The DREAMS package of interventions for 15-20 year old women
- Voluntary male medical circumcision and condoms for men aged 20-30
- ARVs for 25-35 year olds.
Young women and girls account for 71% of new infections among adolescents in sub-Saharan Africa, according to PEPFAR, more than 1,000 infections each day, and these infections are largely concentrated in ten countries in eastern and southern Africa that are being targeted through the DREAMS partnership between PEPFAR, three pharmaceutical companies and the Bill and Melinda Gates Foundation. The DREAMS package of interventions consists of:
- Empower young women and reduce the risk of sexual violence, through violence prevention and post-violence care, condom provision, pre-exposure prophylaxis (PrEP) provision, HIV testing and counselling.
- Develop a better understanding of which partners are transmitting HIV to younger women, in order to better target interventions to men.
- Reduce the risk of sexual partners by targeting prevention, HIV testing and counselling and treatment to men, and by developing services that will encourage testing and treatment among men.
- Strengthen the family economically and support positive parenting, for example through cash transfers and educational subsidies.
- Mobilise communities to change social norms concerning sexual activity and gender-based violence.
Improved targeting will also depend on gathering more data, making it available in real time and acting quickly to change course. Ambassador Birx said that PEPFAR will be making much more of its programme and partner data available online in order to improve performance.