This interview with Kelly Curran, Director of HIV/AIDS and Infectious Diseases at Jhpiego, is the first in a four-part series in which experts reflect on the progress made since the groundbreaking AIDS 2000 Conference in Durban and the challenges that remain. The 21st International AIDS Conference is being held in Durban, South Africa, July 18-22.
What has been the biggest accomplishment in addressing the HIV/AIDS epidemic to-date? How can we build off this success to accelerate progress and ensure equitable access?
The scale up of prevention, care and treatment services over the past 15 years has been nothing short of remarkable. I often think back to the pre-Global Fund, pre-PEPFAR era—hospitals were filled with the sick and the dying, inpatient wards had two or three emaciated people in each bed, with others lying on the floor and even under beds. Nurses and doctors were demoralized because they had little to offer their patients. I know doctors who left clinical practice during this period because they simply couldn’t take one more patient’s death.
My husband is originally from a high prevalence region in Tanzania, so we have experienced the epidemic as it affected family members as well as professionals. During the pre-treatment era, so many young adults died, so many children were orphaned. When PEPFAR and the Global Fund came it was like a miracle. One of our relatives, who had been diagnosed with HIV in 1996, was able to start ART in 2004 at one of the first PEPFAR-supported sites in Dar es Salaam, and because of that he is still with us 20 years after his diagnosis. The scale up of prevention services has also been impressive. In the nine years since WHO and UNAIDS encouraged countries with high HIV prevalence rates to add voluntary medical male circumcision (VMMC) to their prevention programs more than 11 million men have received substantial, lifelong protection through VMMC, two million of them in Jhpiego-supported sites.
Prevention of mother to child transmission is another huge success story. Thanks to routine HIV testing during pregnancy and provision of antiretroviral treatment to pregnant and breastfeeding women through Option B+, mother to child transmission rates have fallen dramatically. Some of the hospitals we work with in Kenya have gone more than a year without seeing a single new pediatric HIV infection, for example, and some lower prevalence countries, most recently Thailand, have eliminated mother to child transmission. But as long as young women remain at risk of HIV infection, we will need robust prevention of mother-to-child transmission (PMTCT) programs.
What are your biggest concerns regarding the current state of HIV/AIDS prevention and treatment efforts?
My biggest concern is ensuring that the HIV response is adequately resourced to achieve epidemic control by 2030. We are living in a golden age of science. Compared to where we were even a decade ago we have great tools with which to control the epidemic: rapid HIV tests, fixed dose combination pills for first line ART, viral load testing so that patients and providers know whether their regimen is working and whether they are at risk to transmit the virus.
On the prevention side, we have VMMC for young men and adolescent boys in generalized epidemics and oral PrEP for populations at very high risk. We know that early initiation of lifelong ART enables people living with HIV to live long and healthy lives with a low risk of transmitting to a partner or a child. We have all these tools, we know how to use them, but unfortunately at present there simply aren’t enough domestic or global resources to provide all 37 million people living with HIV with treatment, and to provide effective primary prevention services to those at risk. Ambassador Deborah Birx often reminds PEPFAR’s implementing partners that because of the “youth bulge,” the large cohort of young people now reaching sexual maturity in the highest prevalence countries, the population at risk of HIV is now much larger than it was at the beginning of the epidemic, so even as new infection rates have declined, a larger population is at risk. We also need to preserve enough resources for research and development—particularly in vaccines and finding a cure–so that we can really end AIDS once and for all.
Make no mistake, we have made substantial progress, but the epidemic is not yet controlled, and we run the risk of losing ground if the commitment to battling HIV and AIDS wanes even slightly. We need to be mindful of the history of malaria control, where major progress has often been followed by periods of complacency in which the disease comes roaring back. Ending the AIDS pandemic is possible but in the absence of a vaccine or a cure it is going to be a long term effort requiring the ongoing commitment of the most affected countries, the donor community, civil society, scientists and implementers.
Given that 60 percent of vulnerable individuals lack access to treatment, what needs to be done in the next 10 years to ensure increased access to HIV/AIDS prevention and treatment programs for marginalized and under-prioritized populations (including women and children, transgender people, sex workers, etc.)?
Ensuring that those who are most likely to contract and transmit HIV have access to effective primary prevention and early initiation of treatment is our most critical priority. Adolescent girls and young women in sub-Saharan Africa continue to face high rates of new infection, and we are pleased to be working to address this as a partner on the DREAMS Initiative, a public-private partnership which aims to sharply reduce new HIV infections among this vulnerable population.
In many countries key populations (sex workers, men who have sex with men, transgender people and people who inject drugs) are underrepresented in treatment programs; they may test, especially if outreach or community-based testing is available, but because of stigma and even outright discrimination, they may not successfully link to or remain engaged in care and treatment services.
We were thrilled to learn of PEPFAR’s USD100 million commitment to expanding key populations programming, because in order to ensure that key populations get the services they need to stay healthy and avoid onward transmission, programs need key population-specific service delivery models, such as drop in centers, staffed by compassionate providers and counselors at locations with hours that are appropriate for those being served. These centers can provide both treatment and primary prevention services, ideally including oral pre-exposure prophylaxis (PrEP), a highly effective prevention intervention—one pill once per day for high risk individuals who are still HIV-negative– that so far has not been adequately scaled up.
When taken as directed, oral PrEP is as effective at preventing HIV as oral contraceptives are at preventing pregnancy and we are pleased that it is starting to gain traction. Jhpiego and our partners, including the National AIDS and STI Control Programme of Kenya, look forward to the opportunity to provide oral PrEP to those at highest risk of HIV infection thanks to new funding from the Bill &Melinda Gates Foundation for a four-year effort called Bridge to Scale designed to reach men who have sex with men, sex workers and adolescent girls and young women in high prevalence counties in Kenya.
Reaching key populations is essential, however we also need to think strategically about heterosexual men in sub-Saharan Africa as a priority population. Because of traditional gender norms that frame health-seeking as a feminine behavior, heterosexual men are less likely than women to test for HIV; when they do it is often because they are already symptomatic. Of course by this time their immune function has already been affected, and they may have transmitted HIV to their sexual partners. We need to develop service delivery models that heterosexual men will actually use, and we need to work on developing a social norm where it is seen as “manly” to test for HIV, or to be virally suppressed if positive.
Jhpiego has had the privilege of serving more than two million men and youth in our VMMC programs. Medical male circumcision has been shown to reduce female to male HIV transmission by up to 70%, making it one of the most effective—and cost effective–HIV prevention tools available. VMMC is also an important platform for reaching men with other services—HIV testing and linkage to care and STI screening and treatment are key components of the service package.
In Lesotho, Jhpiego has invested in providing antiretroviral therapy to men who test positive in the VMMC clinic, where men are telling us that they appreciate having a “male friendly” option for receiving HIV services. Adolescents of both sexes are another population that needs special attention. HIV-negative adolescents are just entering the period of highest HIV acquisition risk, and HIV-positive adolescents often struggle to stay engaged in care and adherent to their medications.
Finally, I think we also need to look at regional differences in coverage of treatment and prevention services. While the countries of Southern and Eastern Africa continue to face very high HIV prevalence rates, most of them have made impressive progress in terms of coverage of services. Less progress has been made in West and Central Africa, where only 24% of people living with HIV have access to treatment; nearly one third of all the world’s annual pediatric HIV infections occur in Nigeria.
In Nigeria we are working with Local Government Authorities and a local NGO to scale up prevention of mother to child transmission services. Stigma remains a barrier to care in much of West Africa; in Cote d’Ivoire we are working with the Ministry of Health on a chronic care model that provides care to people with diabetes and hypertension as well as HIV and TB; our hope is to normalize treatment for HIV and TB so that providers, patients and communities view them like any other chronic health condition.
What do you see as the top priorities to ensure progress on HIV/AIDS is made in the next 10 years? What partnerships do we need to realize the success of these priorities?
The next decade is a critical time in the HIV response. Tremendous progress has been made in terms of resource mobilization, scientific discovery and on the ground implementation of services. The epidemic has peaked and both AIDS deaths and new HIV infections are declining. However, we run the risk of leaving the HIV response half finished. Despite all our hard work and all the progress to date, 1.2 million people died and 2 million were newly infected with HIV ….
The world has invested so much—financially, technically and from a human perspective–in the global HIV response; we need to finish the job. Approximately half of the people living with HIV worldwide have access to treatment; we need to find those still undiagnosed and bring them into care. But we also need to ensure that highly effective primary prevention services such as male circumcision and oral PrEP are adequately resourced and reach those at highest risk of infection; in the absence of a cure, two million new infections a year is simply not sustainable.
Partnerships are critical going forward – and honestly, the global AIDS response has always been about partnerships: activists and advocates, scientists and donors, policymakers, and NGOs, frontline healthcare workers and people living with the virus all working together to control the epidemic. We never would have gotten this far without working together.
I am heartened that domestic spending on HIV has increased in many of the most affected countries. To finish the job, we need to expand our partnership by encouraging even more engagement from the private sector; not just internationally but in the most highly affected countries. Jhpiego is proud to partner with a wide variety of collaborators – US government agencies, foundations, private companies, UN agencies, Ministries of Health and Defense, and national and community organizations in the countries where we work. Jhpiego treats partnership as an investment – it’s an organizational priority for us. We seek to serve as a technical resource for our partners, and to learn from them as well. Partnerships are the only way we will make continued progress, and we’re always looking to explore new ways of making a difference through partnership.
International AIDS Conference: Reflecting on the past decade and a half since the International AIDS Conference in Durban served as a catalyst for global advocacy and access, what is the significance of the return of the conference this year to Durban? What do you hope to bring away from AIDS 2016?
AIDS 2000 in Durban was a turning point in the global AIDS response. Combination antiretroviral therapy had been available in high income countries for several years, but required a major commitment to a complicated regimen of pill taking, often with significant side effects. Only thousands of the tens of millions living with the virus in the developing world had access to treatment. Our prevention tools were limited—abstain, be faithful, use condoms—in both number and effectiveness. PMTCT programs were focused on scaling up single dose nevirapine. We didn’t yet have rapid HIV tests, and turnaround time for results could be weeks. In many countries pregnant women present very late for their first antenatal visit, and time after time I saw women learn that they were HIV+ only after having given birth.
AIDS 2000 was when the world said “enough is enough” to the inequity of having treatment in high income but not low or middle income countries. Thanks to the activists and the advocates, resources were finally mobilized to begin to meaningfully address the pandemic, first the Global Fund, then PEPFAR; the Bill & Melinda Gates Foundation has also played a catalytic role.
In some ways Durban 2016 feels like a different universe. We know that early treatment not only saves lives but prevents onward transmission; nearly half of the world’s people living with HIV now have access to ART. We not only have point of care rapid HIV tests, but point of care CD4 machines and increasingly, access to viral load testing even in the poorest countries. The single-dose nevirapine era has been relegated to the history books, and a small number of countries, including Thailand and Cuba, have eliminated mother to child transmission. In primary prevention, powerful new interventions such as male circumcision and oral PrEP are paying off in infections averted and lives saved. And today, the prevention research pipeline is full of promising new technologies: long acting (injectable) PrEP, broadly neutralizing antibodies–there is even a vaccine candidate in a Phase 3 clinical trial.
AIDS 2000 in Durban is remembered for its commitment to bringing treatment to the developing world. My hope is that AIDS 2016 in Durban is remembered for its commitment to bringing effective primary prevention services to all those in need. Investment in preventing further infections have enormous impact for the health and welfare of families, countries and our greater global community.
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This article first appeared on GBCHealth.org and is reproduced with permission.