Michel Sidibé

A call to action for comprehensive HIV services for men who have sex with men

Where surveillance has been done, it has shown that men (MSM) who have sex with men bear a disproportionate burden of HIV. Yet they continue to be excluded, sometimes systematically, from HIV services because of stigma, discrimination, and criminalisation. This situation must change if global control of the HIV epidemic is to be achieved. On both public health and human rights grounds, expansion of HIV prevention, treatment, and care to MSM is an urgent imperative. Effective combination prevention and treatment approaches are feasible, and culturally competent care can be developed, even in rights-challenged environments. Condom and lubricant access for MSM globally is highly cost effective. Antiretroviral-based prevention, and antiretroviral access for MSM globally, would also be cost effective, but would probably require substantial reductions in drug costs in high-income countries to be feasible. To address HIV in MSM will take continued research, political will, structural reform, community engagement, and strategic planning and programming, but it can and must be done.

Meeting the demand for results and accountability: a call for action on health data from eight global health agencies

Margaret Chan, Director-General of the WHO, and the heads of seven other global health agencies, call for a concerted global effort to collect better health data.

Time to act: a call for comprehensive responses to HIV in people who use drugs.

The published work on HIV in people who use drugs shows that the global burden of HIV infection in this group can be reduced. Concerted action by governments, multilateral organisations, health systems, and individuals could lead to enormous benefits for families, communities, and societies. We review the evidence and identify synergies between biomedical science, public health, and human rights. Cost-effective interventions, including needle and syringe exchange programmes, opioid substitution therapy, and expanded access to HIV treatment and care, are supported on public health and human rights grounds; however, only around 10% of people who use drugs worldwide are being reached, and far too many are imprisoned for minor offences or detained without trial. To change this situation will take commitment, advocacy, and political courage to advance the action agenda. Failure to do so will exacerbate the spread of HIV infection, undermine treatment programmes, and continue to expand prison populations with patients in need of care.

Defeating AIDS—advancing global health

After more than a decade of major achievements the AIDS response is at a crucial juncture both in terms of its immediate trajectory and its sustainability as well as its place in the new global health and development agendas. In May 2013 the UNAIDS-Lancet Commission -- a diverse group of experts in HIV health and development young people people living with HIV and affected communities activists and political leaders -- was established to investigate how the AIDS response could evolve in a new era of sustainable development. The UNAIDS-Lancet Commission has come together at a moment when the lessons of the AIDS response including its whole-of-society perspective can be informative and even transformational for other spheres of global health. The path to ending AIDS as a public health threat by 2030 as set out in this report should be a major part of the post-2015 development agenda. On the basis of our analysis and discussion we make the following seven key recommendations: Urgently escalate AIDS efforts get serious about HIV prevention and continue expanding access to treatment; Mobilise more resources spend efficiently and emphasise sustainability; Demand robust accountability transparency and better data; Forge new paths to uphold human rights and address criminalisation stigma and discrimination; Reinforce and renew leadership and engagement of people living with HIV; Invest in research and innovation in all facets of the AIDS response; and Promote more inclusive coherent and accountable governance for AIDS and health. In conclusion the question is no longer whether the fight against AIDS can be won; the only questions are: will it be won -- and when? The answers to these questions will eventually depend on the decisions made by leaders and institutions at all different levels in all sectors and parts of society and on the personal choices people make in their private lives. (Excerpts)

HIV: know your epidemic, act on its politics

The ‘know your epidemic, know your response’ is an increasingly well-known rallying cry to put evidence at the heart of national AIDS programmes. While this is welcome, it is unlikely to be sufficient to deliver evidence-informed responses. In our view, it is equally important that national programmes routinely seek to understand and address the political determinants of whether and how evidence is used to guide policies and national programmes. We make this case because politics, ideology and ignorance have, in many countries, proved far more influential on HIV policy than evidence and best practice guidance. Partly as a result of this, we can expect another 7000 persons to be infected with the virus today, just as they were on World AIDS Day, earlier this month. Prevention policies and their messages are still not targeting people most at risk and laws and regulations continue to stand in the way of effective policies in too many countries.1 Policy emerges through interactions among institutions (the structures and rules which shape how decisions are made), ideas (which include not only evidence but also the way that problems and solutions are framed – often based on underlying values and training) and interests (groups and individuals who stand to win or lose from change).2 Understanding these interactions can provide insights into the process of policy change and can identify and address political barriers and opportunities that undermine evidence-informed policy. Lack of routine screening for congenial syphilis3 and the limited use of magnesium sulphate to prevent eclamptic seizures4 illustrate the limits of technical evidence and analysis in the health policy arena in low-income countries. Despite the role played by politics in the response to HIV, a search of the peer-reviewed literature dealing with HIV policy change in low- and middle-income countries identified only 28 papers reporting empirical case studies concerning HIV/AIDS.5 Scrutiny of those papers reveal that high-profile success stories and highly contested issues in a very small number of countries receive the bulk of attention while the de facto policy-making addressing the HIV pandemic in the rest of the world remains largely ignored.6 Other under-explored areas in this set of literature include the extent to which political dynamics at the global level interact with national politics, and the role and influence of domestic parliamentary processes in challenging and demanding greater accountability from institutions responsible for determining the national AIDS response. The apparent neglect of a political analysis of HIV policy is surprising not just because politics is central to policy-making in health generally, but because HIV has acted as a lightning rod in the health sector – generating considerable public attention, resources, research and controversy. The HIV policy literature acknowledges that institutional context plays a defining role in explaining policy outcomes but there is little predictive power in the limited findings. Some areas that have received attention include the impact of regime type, degree of centralization of power, and location of the government agency tasked with leading and coordinating HIV policy dialogue with, for example, the inclusion of the scientific community and civil society in policy formulation.7 Political, professional, religious, organizational as well as social institutions (e.g. governing gender norms, sexuality) are powerful determinants of HIV policy and represent longer-term targets in terms of policy change. If we are to bring about changed norms, there is a need to conduct more transparent public policy dialogue with these institutions, to understand how their values and mores affect HIV risks and HIV responses and how to address them. The literature reveals the tremendous impact of ideas on HIV policy. The social construction of who is thought to be at risk plays into the perceived political acceptability of action on HIV.8 Similarly, moral values concerning sexuality and drug (mis)use shape decisions on whether or not to act and the nature of action. Policy entrepreneurs have used ideas to frame issues. For example, that ARV provision can break the cycle of denial, stigma and silence of HIV.9 Some have framed routine HIV testing as a proven public health intervention while others have portrayed it as a threat to human rights which has led to quite different policy outcomes. Similarly, framing the need for an ‘African’ as opposed to ‘Western’ response to AIDS has led to fundamentally different policy prescriptions.10 While it is intuitive that interests and political incentives facing stakeholders help explain why specific HIV policies emerge, the literature typically fails to reveal what these interests constitute. Analysis of the incentives facing political leaders suggests that electoral calculations, international standing and risks to the workforce, economy or the uniformed services have triggered action and inaction. Similarly, there has been some analysis of the financial interests of the research and development pharmaceutical industry in relation to intellectual property protection as interests driving policy ends. Although limited, the literature confirms a commonsense understanding that politics are important determinants of HIV policy and offers a number of lessons for those wishing to influence such policy. The most important among these is that a failure to appreciate the political dimensions of HIV can frustrate efforts to promote and implement evidence informed policy. We suggest that prospective policy analysis11 that examines the interactions among institutions, ideas and interests in specific priority, evidence-informed interventions and approaches ought to become a routine component of national HIV programmes. In our view, the know-your-epidemic analysis coupled with a programmatic gap analysis should inform the development of evidence-based policies whose prospects for implementation are buttressed by forward-looking policy analysis.

Tuberculosis and HIV: time for an intensified response

This article describes several urgent actions that are needed to promote rapid scale-up of effective and integrated services for tuberculosis and HIV and to tackle the factors that increase vulnerability and put people at risk of HIV-related tuberculosis. These include: bold national leadership health system restructuring to foster greater integration of tuberculosis and HIV services that provide routine tuberculosis screening treatment and prevention to people living with HIV; and to offer HIV counseling and testing to all patients with signs and symptoms of tuberculosis decentralized care to ensure improved access investment in new tools and better use of existing tools and global leadership from donors countries of the global south and key health agencies.

The Vancouver Consensus: antiretroviral medicines, medical evidence, and political will

In 1996, the global HIV community gathered in Vancouver, Canada, for the XI International AIDS Conference and shared the clear evidence that triplecombination antiretroviral treatment held the power to stem the tide of deaths from AIDS. The HIV treatment era had begun. As we gathered again in Vancouver in July, 2015, it was clear that a new transformative moment is upon us. The Vancouver Consensus statement, which emerged at the recently concluded 8th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2015), signals the scientifi c affi rmation that, rather than limiting access to those who are immune compromised, immediate access to antiretroviral medicines holds the power to rapidly advance the fi ght to end AIDS. The consensus—signed by more than 500 researchers, clinicians, and civil society experts—is clear: “All people living with HIV must have access to antiretroviral treatment upon diagnosis. Barriers to access in law, policy, stigma and bias must be confronted and dismantled. And as part of a combination prevention eff ort, PrEP (Pre-Exposure Prophylaxis) must be made available to protect those at high risk of acquiring HIV. The strategic use of ARVs—through treatment and other preventive uses—can save countless millions of lives, reduce new infections, and move us vastly closer to our goal of ending the epidemic. A new era of opportunity against this epidemic has dawned, and we must seize it.” The Vancouver Consensus statement comes as a series of major international studies reported results in recent months. Building on knowledge accumulated during the past decade, the Strategic Timing of AntiRetroviral Treatment (START) trial released results showing signifi cant health benefi ts of immediate antiretroviral treatment rather than waiting for immune deterioration. With participants from 35 countries worldwide, including just over half from low-income and middle-income countries, START showed a 57% lower risk of the combined endpoint of serious AIDSrelated events, serious non-AIDS-related events, or death among those randomly assigned to immediate antiretroviral treatment. The TEMPRANO trial showed similar impressive benefi ts of immediate antiretroviral therapy among African patients, with a 50% lower rate of tuberculosis and a 60% lower rate of bacterial infection, as well as clear benefi ts of isoniazid preventive therapy. Off ering immediate access to antiretroviral medicines is further supported by studies, including the fi nal outcomes of HPTN052, also reported at IAS 2015, which showed that antiretrovirals can prevent transmission from people living with HIV to their uninfected partners. Final results of the HPTN052 study confi rmed that the eff ects are powerful and durable, with a 93% reduction in risk over time through early treatment and no evidence of HIV transmission from people with fully suppressed viral load to their partner. Meanwhile, the evidence base is growing that antiretroviral medicines can eff ectively protect people at risk of infection though prophylactic use and that implementation among key aff ected populations is feasible. Around the world today, however, health policy restricts access to antiretroviral medicines to varying degrees. Only ten countries have formally adopted the option for people diagnosed with HIV to start antiretroviral treatment immediately. Many countries have not fully implemented WHO recommendations to start antiretroviral treatment for people living with HIV at or below CD4 cell counts of 500 cells per μL, several years after their introduction. Some countries

Leveraging HIV Treatment to End AIDS, Stop New HIV Infections, and Avoid the Cost of Inaction

We have the tools at our disposal to significantly bend AIDS-related morbidity and mortality curves and reduce human immunodeficiency virus (HIV) incidence. It is thus essential to redouble our efforts to reach the goal of placing 15 million people on life-saving and -enhancing antiretroviral therapy (ART) by 2015. In reaching this milestone, we can write a new chapter in the history of global health, demonstrating that a robust, multidimensional response can succeed against a complex pandemic that presents as many social and political challenges as it does medical ones. This milestone is also critical to advance our ultimate goal of ending AIDS by maximizing the therapeutic and preventive effects of ART, which translates into a world in which AIDS-related deaths and new HIV infections are exceedingly rare.

AIDS governance: best practices for a post-2015 world

As we closer to the 2015 deadline of the Millennium Development Goals it is imperative to address an agenda for global health and development post-2015. In a similar process of self-reflection the global AIDS community is identifying features of the AIDS response that are most important to protect enhance and extend. In drafting a more ambitious global health agenda that will best serve people in 2020 and 2030 a few principles fundamental to the success of the AIDS response must remain prioritized. First is the centrality of justice human rights and gender equality seeing as discrimination and criminalization of people living with HIV remain the main barriers to services in many societies. Second the participation of people living with HIV directly improved the acceptability and effectiveness of programs; therefore these people and communities should have a central place in governance arrangements. The third principle is integration and the exploitation of further collaborations (in addition to UNAIDS and several national AIDS councils) across health and development. Finally the recognition of data as an input and output and the importance of its transparency and accountability is key. Michel Sidibe the Executive Director of UNAIDS calls for the critical self-reflection and transformation of the global governance for health and the requirement of outstanding investments by all citizens.

Strength in unity

Recent increases in resources for achiev-ing the goal of universal access to HIV prevention, treatment, care and support have given renewed impetus to the longer-standing political commitment for achieving targets in sexual and repro-ductive health and rights. As a result, we see increasing optimism that progress on these interdependent goals can be achieved – particularly if they are tackled together.The AIDS response has been remarkably successful in transform-ing a deafening demand for inclusive policy processes and evidence-informed, rights-based programmes into tangible achievements measured in lives saved and dignity restored. The most visible manifestations of these achievements are the more than 4 million people presently on antiretroviral treatment and the tremendous advances in overcoming the stigma and discrimination faced by people who inject drugs, men who have sex with men, and sex workers and their clients.It is encouraging to see evidence that well designed AIDS responses can and do strengthen health systems.