Holding our hands up for prevention
As we mark the 29th World AIDS Day, Sarah Hand says that with enough commitment, political will and funding we have the tools to achieve UNAIDS’ ambitious fast track targets – but only if we recognise the need for a new approach to HIV prevention.
UNAIDS’ latest estimates show that over 18 million people worldwide are now on HIV treatment – an increase of one million people in just six months. This is a big confidence boost in our collective ability to meet the UNAIDS fast track targets and get 30 million people on treatment by 2020. However, if we are serious about ending the HIV epidemic, we must also turn the tap of new infections off, right at its root. We must stop the need for treatment in the first place.
Unfortunately we are not seeing the same gains in HIV prevention that we have seen in treatment access. There were over 2 million new infections last year – a figure that has hardly changed over the past five years, even with a clear understanding of the locations and populations most vulnerable and at risk.
Recognising what needs to be done differently is key to addressing prevention. Recognising who is actually at risk, and when in their lifecycle, needs a step change in approach for many organisations in the HIV response. There has to be an absolute commitment to work on primary prevention with those who need it and not using precious and limited resources on those who don’t.
Put simply, educating adolescents on sex and providing them with condoms will not, on its own, prevent HIV.
Getting everyone tested, and those living with HIV on treatment, is certainly one way of reducing new primary infections – we know treatment as prevention works. However, this strategy alone will not bring about the long term gender, cultural and equality changes that are necessary to really break the cycle of new infections from one generation to the next. Nor will it necessarily mean properly resourcing and applying the right interventions with the right population groups.
For example, the evidence is clear on the benefits pre-exposure prophylaxis (PrEP) can bring to certain groups such as well-informed gay men and other men who have sex with men in certain locations. Commitment is needed to ensure these groups can access and benefit from this progress.
However, responding effectively to the growing number of infections among adolescent girls - who still carry the largest burden of new infections globally – needs us to look well beyond the transmission of HIV alone and much deeper into the economic, cultural and social drivers of vulnerability. Put simply, educating adolescents on sex and providing them with condoms will not, on its own, prevent HIV.
Holistic HIV prevention is key to ending the epidemic. Good HIV prevention programming also has the opportunity to change so much more than the transmission of HIV alone – improving overall gender equality and rights. With commitment, drive and political leadership it really is possible to not only achieve the UNAIDS’ 90-90-90 targets, but help deliver the wider aims of ‘good health and wellbeing’ and ‘gender equality’ within the Sustainable Development Goals framework (SDGs 3 and 5).
This means taking seriously a ‘combination prevention' approach which includes evidence-based biomedical, behavioural and structural interventions that are delivered with equal measure, equal commitment and equal funding. We must be careful not to allow one approach to run ahead because we see results or quick wins, with the hope that it will somehow lessen the need for the other more complex approaches.
Addressing the root causes of risk for so many young adolescent women across East and Southern Africa as they start to explore their sexuality is not easy. And the causes of risk are certainly not the same across these diverse regions of the African continent. But without sufficient investment and a real willingness to tackle issues such as gender inequality, gender-based violence, and length of time in education (and the quality of education), alongside the economic opportunities for young women within gender and traditional roles, HIV prevention interventions will not bring about the sustained change through the lifecyle that is needed.
We must also recognise that the most vulnerable in our societies still risk being left behind as the HIV response makes wider progress. Those who remain most vulnerable such as transgender women and people who inject drugs must have their health and human rights upheld. We could easily go full circle on the epidemic and in 15 years’ time find that those most marginalised in societies – those who are discriminated on the grounds of sexual orientation, criminalised for sex work, or subject to regressive drug laws – are denied evidence-based services and continue to be the most affected by HIV.
As we mark this year’s World AIDS Day there is reason to be cautiously optimistic. The HIV response has come a long way and we now know how to diagnose, prevent and treat HIV. We must now ensure everyone benefits from this and no-one is left behind.
Sarah Hand is Chief Executive Officer of AVERT.