Names 13 countries for “particular focus” with aim for epidemic control by 2020 . . .
Botswana, Côte d’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe to be focus of efforts . . .
Providing some clarification to proposals to shift the focus of the President’s Emergency Plan for AIDS Relief to a limited number of countries, the State Department today released a “Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020)” in advance of the United Nations General Assembly meeting today.
Released in concert with an announcement of country survey results indicating that five African countries are poised to “approach epidemic control,” a press statement bills the “strategy,” as one “which reaffirms U.S. support for HIV/AIDS efforts in more than 50 countries, ensuring access to services by all populations, including the most vulnerable and at-risk groups [while it] outlines plans to accelerate implementation in a subset of 13 high-burden countries that have the potential to achieve HIV/AIDS epidemic control by 2020 . . .”
Big on photos and short on details, however, its 10 colorful inside pages give broad, brief and differing descriptions of the means through which the goals it describes will be reached.
It begins with Sec. Tillerson’s introduction explaining that the strategy “includes investing in more than 50 countries . . . to maintain life-saving treatment for those we currently support,” while also “making essential services like testing linked to treatment more accessible,” promising to “provide even more services for orphans and vulnerable children” and “to accelerate progress toward controlling the pandemic in a subset of 13 countries, which represent the most vulnerable communities to HIV/AIDS and have the potential to achieve control by 2020.”
The document also promises that the strategy “sets a bold course for achieving control of the HIV/AIDS epidemic” in 10 of the 13 countries, “in partnership with and through attainment of the UNAIDS 90-90-90” testing and treatment goals.
The greatest detail is provided in a list of “action steps” that include “Acceleration of optimized HIV testing and treatment strategies particularly to reach men under 35,” “Expansion of HIV prevention, particularly for young women under age 25 and men under age 30,” (including through expanded medical circumcision programs), “Continuous use of granular epidemiologic and cost data,” “Renewed engagement with faith-based organizations and the private sector,” and “Strengthened policy and financial contributions by partner governments in the HIV/AIDS response.”
The document does include a “case study” of Swaziland’s progress against HIV, noting that PEPFAR’s Country Operational Plan for the coming year includes expanding antiretroviral treatment access with efforts to start treatment at the time of diagnosis, viral load testing, self-testing for HIV, targeted interventions to young women and girls, orphans and other children at risk, medical circumcision and condom access, traditional-leadership, optimizing mobile services, and “ensuring priority populations and key populations” have access to the services they need.
Lacking are details on the resources that will be provided — either to the 13 countries, or to the remaining countries where PEPFAR programs currently work to provide access to essential HIV services that include expanding access to antiretroviral treatment that prevents illness and transmission. And while it does include the names of the 13 countries, it remains unclear what will happen in those countries, and at what cost to other efforts.
The apparent intent to narrow focus to a limited number of countries, and what that would mean to those countries, as well as to those not included has been a subject of concern since Sec. Tillerson, defending proposed deep cuts to foreign aid funding, told appropriators in May that available program money would “sustain the HIV AIDS treatments in 11 countries to continue to take those to conclusion. As patients roll off those rolls, new treatments can be available” (as treatment for HIV is a lifelong requirement for survival, “roll off those rolls” in this case is an apparent euphemism for “die”).
This document, too, emphasizes the role that deaths will play in achieving its aims, referring to the epidemiological measure of “R0”, in this case “when the total number of new HIV infections fall below the total number of deaths from all causes among HIV-infected individuals” and accompanying this explanation with two graphs including deaths as “Progress needed to achieve epidemic control in 13 high-burden countries.” Another chart shows that while the number of deaths among people with HIV in Swaziland is dropping slightly and can continue to drop, it must drop less steeply than the number of new infections to “control” the country’s epidemic by 2020.
While neither of those charts includes a goal for the numbers of people with HIV receiving the treatment that prevents both death and transmissions, the role of treatment is highlighted in a graph illustrating the signs of success in Swaziland, Lesotho, Zimbabwe, Malawi, Zambia, and Uganda released today as well, and highlighted in the “strategy” document.
That figure shows those countries’ progress toward the UNAIDS 90-90-90 testing and treatment goals of 90 percent of all people living with HIV knowing they are infected, 90 percent of them accessing treatment, and, in 90 percent of them treatment being consistent and effective enough to suppress their virus, preventing transmissions and illnesses. All of the countries, data collected through the PEPFAR/Centers for Disease Control and Prevention/ICAP at Columbia survey of Population-based HIV Impact Assessments show are close to, and in some cases exceeding the goal of viral suppression among those who know their HIV status and are receiving treatment. All, however, fall short on the percent of people living with the virus who know it — the foundation on which the success of the other 90s is based. This logjam, noted at the July International AIDS Society Conference in Paris, has highlighted the need for both expanded and innovative strategies to reach people who are not currently being reached with health and HIV services that include routine screening, testing and unobstructed treatment access — particularly those with some of the highest exposures to risks, and lowest exposures to health services, including people engaged in sex work, men who have sex with men, transgender women, and people who inject drugs. How that can happen is not included in the iteration of the Strategy for Accelerating HIV/AIDS Control (2017-2020) released today. Stay tuned . . . It seems likely that more details will follow.