Controlling the HIV epidemic: ambitious funding, expanded workforce, innovations and micro-focus needed

Advocates who seek to end AIDS by 2030 should be ready to call on Hillary Clinton to massively increase United States support for the Global Fund to Fight AIDS and the US President’s Emergency Plan for AIDS Relief (PEPFAR) if she wins next month’s US presidential election, Professor Jeffery Sachs of Columbia University told the International Association of Providers in AIDS Care’s 'Controlling the HIV Epidemic with Antiretrovirals' summit last week in Geneva.

“We have arrived at a breakpoint where we can do something new. Politicians listen to this community if it is clear, if it is timely. President Clinton will listen on January 20. She has waited a long time to be President.”

Professor Sachs called for the US to give an additional $10 billion a year for the Global Fund and PEPFAR in addition to $4.3 billion already pledged to the Fund between 2017 and 2019 and $4.3 billion allocated in 2016.

“Wars in Iraq and Afghanistan cost $5 trillion. For what? Don’t ever let the US government tell you it hasn’t got the money to do this. The top 12 hedge fund managers earned $10.2 billion in 2015. They make enough money themselves to fund this.”

In addition to funding, two major challenges face the global AIDS response between now and 2030, the meeting heard. Expanding the capacity of the health system to treat all who need antiretroviral therapy will require millions of community health workers to be recruited and trained, while limiting new infections in sub-Saharan Africa will be impossible without a greater focus on young women and their partners, and on understanding the ways in which many micro-epidemics in key populations and localities can be controlled with the right mix of interventions.

Sachs spoke of the need for investment in community health workers in order to expand health system capacity, for example through transfer of antiretroviral provision for patients on stable therapy to community settings. “Volunteers can’t do what systematised community health workers can do,” said Sachs.

UNAIDS is working in partnership with the One Million Community Health Workers Campaign to reinforce the importance of national programmes to fund, recruit and train community health workers in sub-Saharan Africa, as an essential towards achieving the 90-90-90 target. Community health workers can also support the delivery of other forms of chronic disease care currently lacking in most countries in sub-Saharan Africa, such as management of hypertension and diabetes.

But, “the need for community health workers is probably six or seven times the 1 million CHW [community health worker] target” said Dr Jim Campbell of the Global Health Workforce Alliance.

Mark Heywood, Executive Director of the South African public interest law firm Section 27, warned that the aspiration to expand the health workforce needs to confront the political roadblocks that sit in the way, not least the escalating crisis of governance in South Africa.

“Politics continually sits in the way of translating evidence into practice. Without paying attention to the centrality of politics we live in a cloud cuckoo land of wishful thinking,” he said. But, “At AIDS 2016 Michel Sidibe called for 200,000 properly-trained community health workers for South Africa – the call was heard by the South African government at the highest level. Now we need plans and funding, not lip service.”

“The next phase is going to be perhaps the most challenging – the challenge is improving the quality and deepening the response. How are we going to go from three-and-a-half million to seven million people on treatment in South Africa without paying attention to the health system and social justice? We cannot achieve 90-90-90 without social justice.”

Community health workers need to be treated with respect and recognised as an important part of the health system, he said.

“We should think of community health workers as a key population, not only because they often overlap – many of them are young women – but because they are capable of bringing about a revolution.”

“Community health workers are routinely put in harm’s way every day. In South Africa many of community health workers use supermarket plastic bags because they are not provided with plastic gloves, and [record keeping fails] because they don’t have pencils to record basic information.”

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.

“Let’s not claim that we have tools and just need to implement – we need new tests and new injectables,” said Dr Eric Goemaere of MSF, which has led many of the innovations in treatment delivery that have enabled treatment to be scaled up in low- and middle-income countries.

Innovations identified as urgently needed in the field by experts at the meeting include PrEP for pregnant and breastfeeding HIV-negative women, faster implementation of viral load testing and injectable long-acting antiretrovirals for treatment and prevention.

PrEP for HIV-negative pregnant and breastfeeding women: Meta-analysis shows an incidence of HIV infection of 3.8% in pregnant and breastfeeding women in sub-Saharan Africa, with subsequent mother-to-child transmission rates of around 18% during the peripartum period and almost 30% during the breastfeeding period. Hyper-endemic countries need to be supported to develop national policies on when and how to offer PrEP to pregnant and breastfeeding women, said Jennifer Cohn of the Elizabeth Glaser Pediatric AIDS Foundation.

Faster implementation of viral load testing: Only four countries in sub-Saharan Africa have well-established programmes for viral load monitoring of people on treatment and only two countries of 13 high-burden countries – South Africa and Kenya – were able to meet the majority of the need for viral load tests in 2015, according to Gottfried Hirnschall of the World Health Organization. The volume of testing taking place in most other countries is still low, although six countries have now secured funding to support viral load monitoring and are moving to establish national programmes. But, some of the countries with the highest burden of HIV – Nigeria, Mozambique, Zambia and Zimbabwe – are still in the early stages of working out how they will provide viral load monitoring.

Injectables: Injectable antiretroviral products for treatment or prevention have the potential to improve adherence and viral suppression and reduce the need for pharmacy visits. Professor Francois Venter of Wits University, South Africa, said “ART is starting to look increasingly like contraception, which has moved away from oral pills to injectables, implantables and rings. There has been a slow and steady move towards longer-lasting agents. Injectables [for ART] are exciting but it’s early days yet and we have to be careful what problem we are fixing. We still need adherence research, especially to show how to get people to come back for the next dose – we have a problem with this in contraception.”

Injectable products are also being explored as PrEP, although studies already planned won’t produce results that allow marketing approval of injectable PrEP until after 2020. If pharmacokinetics and drug delivery mechanisms prove successful, a biodegradable implant might eventually deliver up to a year’s protection without the need for removal. However, Jim Rooney of Gilead Sciences warned that getting from Truvada PrEP to a world of implantable products will require new thinking about the design of studies to achieve regulatory approval. “It’s not going to be possible to do placebo-controlled trials in the future and non-inferiority studies [comparing the innovator product to Truvada] have significant statistical challenges. We need to develop new models of clinical trials so that companies will be willing to do the studies,” he told the meeting.

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