2015: 7 hot topics from the global HIV response

2015 has been a momentous year for the HIV response and global development. Bold commitments have been made to accelerate efforts towards the common goal of ending AIDS as a global public health threat by 2030.

The hardest chapter is yet to come, achieving objectives will mean tackling related challenges, such as poverty, gender disparities and damaging legal and political contexts. But first, let’s reflect on progress with a roundup of the biggest news in 2015.

1. HIV treatment for all

2015 saw the launch of new World Health Organisation (WHO) guidelines declaring that all people living with HIV should receive antiretroviral treatment, regardless of their CD4 count, and as soon as possible after their diagnosis. The move to introduce universal treatment recommendations was certainly a positive one, and was warmly welcomed by HIV and AIDS organisations around the world.

But the challenges of implementing these guidelines and ensuring that barriers to treatment adherence and access are overcome, remains a significant one. The number of people now eligible for treatment has jumped from 28 to 37 million – the total number of people living with HIV globally. Of this, 19 million people are living with HIV, yet unaware of their status. Increasing uptake and access to HIV testing, as well as access to treatment is critical to the successful implementation of guidelines in the future.

2. The rallying call for pre-exposure prophylaxis (PrEP)

"The argument is over about PrEP," declared Anthony Fauci, Director of the US National Institute of Allergy and Infectious Diseases (NIAID), during his opening speech at the 2015 National HIV Prevention Conference (USA). "If you take the drug, it works, not only in a clinical trial but in the field.

Since the release of the iPrex trial results in 2010, which showed that PrEP reduced new HIV infections in gay men by 92%, interest surrounding PrEP and its efficacy have been hotly debated. In 2015, the UK PROUD study, the French/Canadian IPERGAY study, and the South African PARTNERS project announced resoundingly positive results on the effect of PrEP among different populations. Its use as a viable HIV prevention tool was further cemented with the release of UNAIDS technical guidelines on the delivery of PrEP. The new WHO guidelines also endorsed PrEP for key affected populations, including men who have sex with men (MSM), as one of its two key recommendations.

There remain clear barriers around affordability and access that need to be overcome, yet PrEP still remains a welcome addition to the HIV prevention toolkit.

3. #EndAdolescentAIDS

The global HIV response has seen progress in many areas, yet there is still a problem around inequality, with adolescents and young girls a key group who are being left behind. Among adolescents, AIDS-related deaths rose by 50% between 2005 and 2012, compared to a 30% fall among all people living with HIV. AIDS also remains the leading cause of death among adolescents in Africa and the second leading cause of death globally.

Reaching adolescents effectively is a significant challenge, not least because of the complexities of this age group, which sits uncomfortably between children and adults. Kate Iorpenda, Senior Advisor on Children and HIV at the International HIV/AIDS Alliance told us: “Uncomfortable paradoxes abound in the field of adolescent health and can be a minefield for practitioners to even discuss let alone agree a way forward when it comes to programming.”

However in 2015 we saw many key influencing organisations pulling their weight to prioritise the targeting of adolescents. The All In initiative was launched to provide a platform to unite voices and reduce unnecessary deaths of adolescents living with HIV. PEPFAR also earmarked nearly half a billion US$ for the DREAMS partnership, an initiative to help end AIDS among young and adolescent girls in East and Southern Africa.

4. From the Millennium Development Goals to the Sustainable Development Goals

2015 saw the first ever United Nations target achieved when it was announced that Millennium Development Goal (MDG) 6 was reached nine months early. The target relates specifically to halting and reversing the spread of HIV and AIDS by 2015, and achieving universal access to treatment for all those who need it. The treatment target dubbed ’15 by 15’, whereby 15 million people are put on antiretroviral treatment by 2015 – was met.

The end of the MDGs in September 2015 ushered in a new era of global development and a review of progress to date helped shape policy for the next five years – the Sustainable Development Goals (SDGs). Comprising 169 targets, HIV features specifically under target 3.3, which calls to end AIDS by 2030, and 3.8, to achieve universal coverage and access to healthcare and essential medicines. Other targets relating to the HIV response are goals on gender, inequality, sexual reproductive health and rights and discriminatory laws.

5. The right people, the right location

The idea that everyone is at risk is important, after all, HIV does not discriminate. But when it comes to allocating money and attention, greater efficiencies can be made by concentrating efforts in areas that will feel the greatest impact. This means that the right interventions are delivered where the most new infections occur and among the right groups.

Inequality in the response has meant that key affected populations have been left behind. In addition to adolescents and young people, other groups such as gay men, sex workers and people who use drugs have also fallen through the cracks. Fulfilling the UNAIDS Fast Track targets, the major aim of which is to end AIDS by 2030, will require focusing resources on evidence-informed programmes, targeted at populations most at risk and in the communities they reside. This was reaffirmed by UNAIDS in its 2015 World AIDS Day Report, Focus on location and population: on the Fast-Track to end AIDS by 2030.

6. Less complacency, more action

The release of the new UNAIDS 2016-2021 strategy in October saw one of the first UN agency strategies to be aligned with the SDGs. The strategy calls on stakeholders not to lose momentum of progress made during the MDG era, and to overcome a new challenge in the HIV response, ‘the oppressive weight of complacency'.

What has become clear is that the ‘business as usual’ approach will no longer work going forward – in order to achieve the Fast Track Targets of 90-90-90 by 2020 and ending AIDS by 2030, efforts need to be redoubled and investments front-loaded. UNAIDS Executive Director, Michel Sidibé warned: “If we do not accelerate investment and action in the next five years, we risk having HIV infections and AIDS-related deaths rebound by 2020. Without immediate Fast-Tracking of our response, the costs of the epidemic — to national finances and to human lives — will grow into a debt we can never repay."

It is clear that now is the time to act and that there is only a small window of opportunity to make progress sustainable.

7. Laying the groundwork for the UNGASS on drugs

2015 laid the groundwork for what will no doubt be an important year for drug policy in 2016. The United Nations General Assembly Special Session (UNGASS) on the World Drug Problem will convene in April – the first UNGASS on drugs since 1998, which committed to achieving a ‘drug-free world’.

Throughout the year, major stakeholders have stated that a drug-free world is unachievable, and that there is a need to move towards a drug policy that is people-centred and based on health and human rights. Injecting drug use accounts for 30% of all new HIV infections outside of Africa – accounting for an ever growing proportion of people living with HIV.

The United Nations Office on Drugs and Crime (UNODC) released its World Drug Report, which highlights the need for drug use to be seen in the context of a social and health condition. Whilst there were strong calls from delegates at the 4th International Harm Reduction Conference (IHRC 2015) in Malaysia to recognise that criminalisation of drug users and punitive laws are hampering access to vital health and harm reduction services.  At a high-level meeting before the Commission on Narcotic Drugs meeting in in December, UNAIDS Executive Director, Michel Sidibé stated: “Investment in harm reduction is a crucial foundation of an efficient drugs policy that not only saves lives but is also cost-effective. Everyone has the right to health.”

Drug policy remains a political minefield, but keeping health and human rights at the centre has to be the way forward for 2016, to ensure nobody is left behind in the response to HIV.