PHM-Exch> A strategic revolution in HIV and global health Lancet

[Claudio Schuftan]

The Lancet, Volume 377, Issue
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A strategic revolution in HIV and global health****

Original Text****

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Last week saw the conclusion of a landmark event in the recent history of
AIDS. The two turning points took place in New York. The visible one was a
high-level meeting on AIDS, which brought 3000 participants to the UN to
review progress in defeating an epidemic 30 years into its devastating
course. Ambitious new targets were agreed. Countries committed themselves
to, by 2015: halving sexual transmission of HIV; halving HIV transmission
among people who inject drugs; ensuring that no child will be born with HIV;
getting 15 million people onto treatment; and halving deaths from
tuberculosis among people living with AIDS.****

But the invisible turning point was the realisation that simply
strengthening the vertical programme that is AIDS has to end. The new
opportunity is integration. As one senior UNAIDS scientist put it—AIDS is
not an exceptional disease; it is an exceptional opportunity. Part of the
reason for a change in strategy is a matter of brutal reality. Investment in
AIDS is in decline relative to other spheres of global health. But the
incredible success of the AIDS movement also means that it is in a strong
position to embrace—warmly and generously—other sectors of global health.
AIDS can be the engine that broadens a front to defeat the diseases of
poverty.****

A good example of the new integration opportunity is AIDS in children. There
are around 400 000 new childhood HIV infections each year. But in the 68
countries where most child deaths occur, coverage with antiretroviral
treatment for prevention of mother-to-child transmission (PMTCT) of HIV is
painfully low. The independent Countdown to 2015 group estimated that PMTCT
coverage was only 22% in these countries in 2010.****

Led by a coalition of UN agencies, global health initiatives, and civil
society organisations, a new commitment was sealed last week—to eliminate
paediatric HIV infections. The Global Task Team put together to deliver this
goal is not isolating AIDS, as perhaps it might have done a few years ago.
Their objective is to eliminate new paediatric HIV infections and, at the
same time, to improve maternal, newborn, and child health in the context of
HIV. The monitoring arrangements for tracking progress in HIV in children
will embed this broader perspective. For example, one cannot address
paediatric HIV without tackling HIV in women. The 2009 baseline of 1·4
million HIV-positive women delivering a child must be cut to 700 000 by
2015. New HIV infections in women aged 15—49 years will be reduced from 1·04
million in 2009 to 520 000 in 2015. Unmet need for family planning must fall
from 11% in 2009 to zero in 2015. And HIV-associated maternal deaths will be
cut from 21 000 to 2100 by 2015. If these successes were to be achieved,
there will be fewer than 40 000 new paediatric infections in 2015, a 90%
reduction.****

This new approach will require new money. Bernhard Schwartländer and
colleagues recently set out their vision for the resources needed to finance
the next phase of the AIDS response. Solving AIDS will only happen if health
systems are strengthened too. The total investment required to fund a set of
basic programme activities, together with what Schwartländer and colleagues
call “critical enablers” and “synergies with development sectors”, is
US$16·6 billion this year, rising to $22 billion in 2015. PMTCT is only a
very small proportion of that total: $0·9 billion this year, rising to $1·5
billion in 2015. Eliminating paediatric AIDS over the next 4—5 years is
entirely possible—but only if AIDS is attacked as part of a comprehensive
programme of interventions, from strengthening maternal health to scaling up
family planning services.****

This strategic revolution in global health poses important questions for
AIDS governance. The Global Fund to fight AIDS, Tuberculosis, and Malaria is
already reinventing itself slowly, but successfully, as a financing
mechanism with a broader remit. But it is UNAIDS, led by the politically
astute and charismatic Michel Sidibé, that is perhaps in the best position
to be a catalyst for integration. Unlike WHO, UNAIDS is not a member-state
governed organisation. Indeed, UNAIDS was created precisely to fill gaps in
the AIDS response left by countries, donors, and other UN and non-UN bodies.
Its mandate is to be bold, to say and do what others cannot say and do. The
forthcoming UN General Assembly meeting in New York in September will be an
opportunity for UNAIDS to unveil a potentially new leadership role in global
health—one complementing but distinctive from that of WHO, one that puts
AIDS at the leading edge of a new movement for integrating health responses
to disease.
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