Ending AIDS: What Got Us Here, Won’t Get Us There
Today is World AIDS Day, a day to celebrate the enormous progress made in the three decades since the HIV epidemic emerged. It is also a time for reflection as we pause and pay homage to all of those who have fought and continue to fight for a world without AIDS, and remember those who lost their lives along the way.
A decade ago, today’s progress towards confronting the global HIV epidemic would have been unimaginable. The commitment of affected countries and communities combined with a remarkable global response has enabled nearly 21 million people—half of those living with HIV—to access life-saving HIV treatment. Treatment has transformed HIV into a chronic, but manageable, illness. In addition, results from large-scale population surveys conducted in Africa by the Population-Based HIV Impact Assessment (PHIA) project confirm this good news. More people than ever are testing for HIV as they seek and stay on treatment. These surveys are also helping us focus our resources in order to reach the millions that still need help.
We even dare to speak of a future free of AIDS.
What got us here? While the availability of affordable and highly effective drugs to treat HIV was a game-changer, global progress against this epidemic has relied on a comprehensive strategy called “the public health approach to find people living with HIV, engage them in care, and provide treatment and important supportive services.”
This remarkable treatment scale-up was enabled by the streamlined and standardized characteristics of the public health approach. Standardized strategies for patient management, drug purchasing and distribution, laboratory testing, and documentation facilitated the rapid expansion of HIV programs, even in settings with limited numbers of physicians, nurses, pharmacists, and laboratory experts. Critically, this systematic approach enabled simple and clear messages for both patients and health workers, and allowed HIV treatment to be provided by the breadth of healthcare providers, including physicians, nurses, medical officers, and community health workers.
Yet, the way forward requires fundamental change. In order to reach global goals, another 10 million people living with HIV need to start treatment in the next three years. This won’t be easy, especially as resources have plateaued due to the misperception that the AIDS crisis is over. In many of the places most severely affected by HIV, fragile health systems translate to overwhelmed health workers and crowded clinics. Patients have to travel long distances to reach health facilities, taking them away from their families and jobs and creating financial burdens. All of these reasons compel us to innovate and iterate. We must think of new ways to extend prevention and treatment services to those not yet reached.
What got us here—i.e. the public health approach—won’t get us there—HIV epidemic control.
An important new strategy is called differentiated service delivery, or DSD. DSD retains key elements of the public health approach but enables the tailoring of services for different groups of patients based on their needs. While most of the attention to date has focused on the “what” of HIV treatment—what counseling to provide, which tests to order, and which drugs to use—DSD addresses the “how.” This may mean adjusting the intensity, location, and frequency of care, as well as the type of health worker to fit the needs of specific groups of patients.
One DSD model involves community-based treatment groups. First developed in the southern African country of Mozambique, the approach enables people living with HIV to provide support for each other in the community, while one member of the group returns to the clinic each month to get checked, report on the other members, and pick up medications for all. It’s a patient-centered approach that leverages the ability of individuals with HIV to self-manage their health, support and collaborate with each other, and avoid long waits at congested clinics.
DSD models are also needed for groups of persons living with HIV with unique needs like pregnant women, adolescents, men who have sex with men, sex workers, and people who inject drugs. The latter groups bear a disproportionate burden of HIV and face major societal barriers such as stigma and discrimination that stand in the way of access to vital services. Engaging members of these communities in designing, testing, and implementing DSD models is fundamental to their success.
Patients and communities have always been central to the AIDS response. As the public health approach evolves into DSD strategies, let us seize the opportunity to learn from their commitment and innovations.
Miriam Rabkin, MD, MPH, is associate professor of Epidemiology and Medicine at the Columbia University Mailman School of Public Health, and director of Health Systems Strategies at ICAP at Columbia University.
Wafaa El-Sadr, MD, MPH, MPA, is a University Professor of Epidemiology and Medicine at Columbia University, the director of ICAP at Columbia University, and director of the Global Health Initiative at the Mailman School of Public Health.