5 lessons for achieving equity to end HIV
Today, we pause and join the rest of the world to mark 34 years since the first World AIDS Day. This year, we rally around UNAIDS’ theme, slogan and call to action of Equalize and PEPFAR’s challenge to put ourselves to the test and achieve equity to end HIV.
During the last four decades we’ve seen stunning achievements in the global and local responses to HIV. We’ve made the impossible possible through breakthrough research, interventions and innovations as the world galvanized its effort to fight HIV. As a result, we’ve made great strides in prevention and treatment options, saving millions of lives along the way. The number of people newly infected has been cut by more than half since the peak in 1996. While the Covid-19 pandemic has slowed progress, we have successfully adapted programs to the reality of tackling concurrent epidemics so that people living with or affected by HIV can continue to receive prevention interventions coupled with lifesaving treatment and support. Despite the challenges of Covid-19, the recent monkey pox outbreak and shrinking resources, we remain hopeful that we will be able to end this epidemic by 2030 through ongoing concerted efforts, advocacy, and utilizing the tools, knowledge and skills we have.
Yet we still have unfinished business. Approximately 1.5 million new HIV infections occur per year and inequalities persist. According to the latest figures from UNAIDS, every week, more than 10,000 children and young women aged 15–24 years become infected with HIV. Key populations—sex workers, men who have sex with men, people who inject drugs, transgender people—and their sexual partners accounted for 70% of all HIV infections globally last year. The makeup of today’s HIV epidemic shows a clear picture of disproportionate impact on children, adolescent girls and young women, and key populations.
Understanding why these gaps persist is important. Barriers to health equity include gender, cultural and social norms, stigma and discrimination, and policies, among others. These all contribute to lagging progress among these vulnerable groups, limiting access to both prevention and treatment options.
To overcome these challenges, we must double down on evidence-based, data-driven and locally led programming.
Gathered through decades of experience advancing community response to HIV, with results contributing to the UNAIDS 95-95-95 targets, we believe the following five lessons are important to incorporate into future HIV programs if we are to end this epidemic by 2030.
Empower clients to improve their own health services. Community engagement and feedback are key to improving community-level services, and community-led monitoring is a powerful tool for doing this. In a pilot in Nigeria, community-led monitoring was shown to be an effective way to support real-time adaptation and to allow clients to reflect on services, set goals and determine the long-term impacts of interventions.
Engage children and adolescents in designing their own prevention program. We can achieve equity by moving away from westernised approaches and including those most affected in the design of programs and interventions. We've seen progress in South Africa where Pact not only designed the ChommY program for children 10–14 years, but with them. This approach has ensured that we not only developed a program that requires limited resources for implementation as it draws on traditional games, songs, stories and more, but it acknowledges that our program needs to match the life experiences and culture of those who are most affected by HIV in the country, both of which have been lauded by local officials.
Account for context and client needs through patient-led and differentiated services. Overcoming barriers to health equity requires approaches that are targeted for people’s specific needs, including orphans and vulnerable children, adolescent girls and young women, and their caregivers. For example, in the Dominican Republic, migrants are less likely to visit health care facilities to access treatment because they are viewed as “illegal.” By adapting our programming to include home delivery of ARVs, we have made progress in reaching a group that is vulnerable due to a perceived status in the country.
Sustained viral suppression takes a village, particularly for young people. Knowing your status, getting treatment, if needed, and adhering to treatment are critical to fighting HIV. But supporting overall mental health and resilience among young people living with HIV can ensure sustained viral suppression. In countries across Africa, such as Tanzania, Rwanda, and South Sudan, promoting positive relationships with caregivers is a key aspect of our work. It has helped to develop support networks for youth with strong, positive relationships that they can rely on when times are hard.
We must address a more comprehensive range of needs to improve health, resilience and wellbeing, particularly for children and youth. While addressing immediate health needs are paramount, supporting educational and financial needs of young people lays a strong foundation for sustained health gains. In countries such as the Dominican Republic, South Sudan, Tanzania and Namibia, household and youth economic strengthening, including vocational training, financial literacy, entrepreneurship training and internships and apprenticeships, is a key component of our work to support the overall resilience of people living with or affected by HIV.
These recommendations are based on our programming experience, and we believe they would effectively and efficiently extend the reach of evidence-based HIV prevention and treatment programming to achieve durable viral suppression as we get close to epidemic control in some settings as well as maintaining and sustaining progress in places that have already reached epidemic control. All organizations working to fight HIV and AIDS should continue to monitor the impact of work even after it stops, in order to learn whether the benefits have endured beyond the project lifespan. Most importantly, we must share those learnings with the wider community so that we can all better plan and design for more sustainable outcomes.
We are committed to the global mandate to end the AIDS epidemic by 2030, and hope the lessons shared above will help us all as we put ourselves to the test and seek to achieve equity to end HIV.