The International AIDS Conference 2016, returned to Durban, South Africa, sixteen years after the 2000 conference, where Nkosi Johnson, an 11-year-old boy, gave a memorable address in which he called for the social acceptance of people living with HIV(PLHIV). While stigma still persists against PLHIV, there is much progress to be proud of in the acceptance of PLHIV around the world. The 2016 IADS Conference was not short of high profile speakers and attendees, from Bill Gates, Elton John, Charlize Theron, government officials, NGOs, to community and individual activists who fight for PLHIV and ‘special populations’ at grassroots level. I attended the conference, one of the largest gatherings of the global community, on basically a single issue. The treatment campaign has seen the dissemination of ARTs across the world, which has transformed the HIV pandemic from an emergency, during Nkosi Johnson’s time in 2000, to a chronic disease in 2016. Almost a Non-Communicable Disease (NCDs) in terms of ‘treatment is prevention’ parlance. But one with crucial differences.
A key message from the 2016 Conference, is that this is not the time for complacency and a victory celebration. The battle is far from over. In fact there are three (3) yawning gaps that the fight against the pandemic needs to tackle.
First, there is a gap in achieving declining rates of HIV infections around the world, which is threatening the quest to end new infections by 2030. The world is experiencing rising infection rates among special populations such as adolescents, especially adolescent girls; LBGT communities; middle-aged men; and sex workers. More effective targeting of prevention measures is critical, as is careful identification of high risk sub-populations and bespoke intervention design. Crucially, both the donor community and affected countries should invest in prevention as well as in treatment. While the political and moral imperatives of treatment make it a no-brainer intervention, no effort should be spared by countries to design and roll out a comprehensive prevention strategy in order to alleviate both the medical and the fiscal burden for future generations. In allocating future resources, donors and affected governments need to devise commitment mechanisms that avoid free-riding by either party in either prevention or treatment, as the work from RethinkHIV by Collier et al (2015) and Hausken and Ncube (2015) shows. Fast-track and scaling-up are an imperative if we are to see a decline in future incidence, as is rolling out the test-and-treat approach, but for this to be more than a slogan, it requires longer term funding commitments from donors and affected countries alike: these are not yet on the horizon.
Second, there is a gap in understanding and preparation for the fiscal cliff represented by the future quasi-liabilities generated by growing treatment costs over next 35 years. Work by Atun et al (2016) at RethinkHIV, shows that these ‘hidden HIV debts’ are rather high and some countries in Africa, such as Malawi for example, will be unable to meet these liabilities from domestic resources. Clearly, recognising these liabilities as future commitments to pay, just like debt, means fiscal-sustainability frameworks ought to be rethought, particularly for Low and Lower-Middle-Income countries. More involvement by multilateral institutions to monitor and manage these liabilities for the welfare of these countries is required.
Third, there exists a gap in appreciating and understanding the high costs of second-line treatment and the hidden costs of service delivery to those affected by HIV. With failure rates of over 35%(and even higher among children) in the first twelve months of 1st line ART therapy, and discrepancies between first and second line drugs of the order of $400, these costs, though still somewhat hidden, are substantial and could significantly shift the magnitude of the future liabilities related to keeping people alive. With only 20% of the overall response currently earmarked by UNAIDS for prevention, studies on the scale of this issue could help illustrate further the medical and fiscal benefits of a more ambitious prevention campaign.
Clearly, there is much to be proud of in the last 16 years, but with more than million people dying every year, complacency would be dangerous at this stage. If we are to have any hope of defeating the pandemic, we must continue to ask the questions which policy makers find difficult to answer.
Written by Prof Mthuli Ncube, Professor of Public Policy, Blavatnik School of Government, University of Oxford; and former Leader of the RethinkHIV.
7 September 2016.
RethinkHIV is a consortium of senior researchers from London School of Hygiene & Tropical Medicine, Imperial College London, Harvard School of Public Health, Centre for the Study of African Economies and Blavatnik School of Government at Oxford University.
The consortium will evaluate new evidence related to the costs, benefits, effects, fiscal implications, and developmental impacts of HIV interventions in sub-Saharan Africa, in order to maximise contributions to the fight against HIV there.
The aim of RethinkHIV is to find ways of creating, optimising, and sustaining fiscal space for domestic HIV investment, as well as exploring long-term, sustainable national and international financing mechanisms. RethinkHIV is funded by RUSH Foundation.