Ending the HIV epidemic by 2030 is undoubtedly a noble endeavour, and is the aim put forward by the UN in SDG 3.3. In full, the target states: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”. To quantify the current progress of this goal the UN has chosen the “number of new HIV infections per 1000 people” as a statistical indicator. However, the SDG HIV target and use of this specific indicator is reflective of a perspective that sees only reducing incidence rates as successfully addressing the pandemic. Through the lens of statistics such as these the SDG3.3, and its predecessor Millennium Development Goal 6, have been successes, with the global incidence and mortality rates of HIV/AIDS declining since the early 2000s. These gains reflect improvements in the management of HIV/AIDS since the 1990s, spurred on by a global response supporting programs surrounding medical research, education campaigns, and contraception use. However, as the population of people living with HIV/AIDS increases, this focus on incidence rates becomes misguided. In 1990 the population of people living with HIV was around 8 million. In 2016 it was 36 million. Even if tomorrow we put a stop to any new HIV transmissions, people with HIV will live far beyond 2030 – the burden of the disease is still around for an entire generation to come. In focusing on ending transmission, the SDG target shows how poorly we understand the problem, and there are 3 areas in which this is most evident.
Firstly, the SDGs promote a conversation focussed on reducing HIV infections and fail to bring adequate recognition to AIDS as a chronic disease. On top of this, international funding for HIV/AIDS has peaked and the SDGs marginalize the need for funding post-2030. Finally, in a world where funding is finite, the SDGs are implicated in draining funding for management of chronic HIV. While we understand the pressure to limit the overall number of SDG targets & indicators, SDG target 3.3 carelessly paints the HIV/AIDS problem as black and white – a disease epidemic that rapidly became a global tragedy but one that can be quickly eradicated sometime in the not-too-distant future.
Commanding the conversation
In 2018, numerous global bodies founded on the pursuit of good public health, and even those specifically established to combat the AIDS epidemic, still demonstrate ignorance towards the chronic nature of AIDS. The UNAIDS document outlining their recent ‘Fast-Track’ strategy begins with a claim that mirrors the SDG target. In the document, the reader is introduced to the program by the words “we can end the AIDS epidemic by 2030”, which are followed by an announcement that their target is to reduce the HIV incidence to 200,000 by 2030. UNAIDS proudly boasts that this achievement would constitute “ending AIDS as a public health threat”. This shows a dangerous level of naivety regarding the unremitting nature of HIV/AIDS – to millions of people living with chronic HIV not constitute a threat to public health? In July of this year, Peter Sands, (Executive Director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria), wrote in the Lancet of how we are currently not on track to reach the SDG3.3 target of ending the HIV epidemic. His article claims an ‘insufficient emphasis on HIV prevention” and states “more assertive action [is] needed to turn off the tap of HIV infections” if we are to achieve the SDG3.3 agenda. That is not to say that these organizations disregard the need to manage HIV as a chronic disease. For example, both Peter Sands and WHO DG Tedros Ghebreyesus are vocal supporters of integrating HIV management into the mainstream public health system (and link with UHC). To position HIV treatment alongside non-communicable diseases, such as cancer and heart disease, helps to satisfy the need to manage HIV as a chronic disease, as well as provide conventional health care systems with the ability to learn from the motivated and engaging HIV response of the last three decades. That said, other international aid agencies and foundations (Bill and Melinda Gates Foundation, US President’s Emergency Plan for AIDS Relief PEPFAR) and more importantly domestic governments and charities look to organisations such as UNAIDS and the Global Fund for strategy and funding, meaning these figurehead organizations run the global conversation and heavily influence policy for HIV/AIDS. When this conversation is founded on the SDGs, it posits no new HIV infections by 2030 as the final hurdle and neglects the need for the re-orientation of health systems towards managing HIV, and the comorbidities that those with HIV are a risk of, as a chronic disease.
The golden years are over
According to IHME data, the fight against HIV/AIDS internationally received approximately 28% of all development assistance for health funding in 2015, a value vastly out of step with its global burden of disease, even if that implies that many other health burdens are not properly funded rather than HIV “over”-funded. The golden years for HIV/AIDS funding are probably over – in fact, at the recent 2018 AIDS Conference, a common thread regarding funding was the phrase ‘flatlining is the new increase, reducing is the new flatlining’. This impending decrease in funding is in part due to increasingly insular world governments and a shifting focus from HIV/AIDS to other areas of Global Health desperately (also) in need of funding. HIV/AIDS is not going to continue to see the funding increases it has in the past. So we must then ask ourselves – if this is the case before SDG 3.3 is achieved, what happens when the target is eventually achieved, yet we still have many people who will need lifelong therapy?
Wording the target in such a way that implies HIV/AIDS is an issue that is ‘fixable’ within the near future is completely irresponsible. It implies that by 2030 we will no longer need funding for this issue when in fact, even if the goal is achieved, we will need funding for the lifetime of a whole generation beyond the point when there is no new transmission of HIV. Even if one assumes that this funding is the responsibility of domestic governments, the SDG should be amended in order to focus political power towards the true long-term goal.
With funding forecasted to at best flatline in the near future, we must ensure that the funding we do have is spent in the most efficient way possible. Within the fight against HIV/AIDS there is an internal struggle – one between prevention, and treatment. With new innovations in prevention, including pre-exposure prophylaxis, or PrEP, there is increased demand for funding for prevention. But where does this money come from? In order to fund PrEP, a highly effective prevention intervention, the money must be diverted from other aspects of the HIV/AIDS fight. By choosing to focus on prevention, rather than treatment, in their SDG target indicator, the UN has implicitly given preference to methods such as PrEP in combating HIV/AIDS. So how will the various agencies who allocate their funding see this? If they prescribe dominance to SDG3.3, they will prioritize the funding of prevention; draining more and more of the funding previously allocated to treatment in order to meet their much-lauded target.
Re-orienting SDG 3.3
The wording of this SDG target is flawed and dangerous. Through examining the foci of the agencies dedicated to the fight against HIV/AIDS, the sources of funding, and how that funding is spent, we have outlined why the goal should be changed to better encompass those marginalized people who live with the scourge of HIV, and will continue to live with it long after this ‘target’ is achieved and everyone walks away, patting themselves on the back for a job well done. A focus on incidence rates sidelines the peril of people currently living with HIV. Implicitly, recent talk from Tedros and Sands regarding integrating HIV care into health systems aligns with this, however, an explicit and immediate rewording of SDG3.3 to recognize the importance of treatment is crucial to empowering HIV positive people and ensuring them that their challenges are being addressed. In reality, we must re-orient the health system to manage HIV as a chronic disease. There-in lies the greater challenge – both financially and in term of health systems reform. In the current international & funding environment, “ending the epidemic of new HIV cases” is in direct tension with efforts to sustainably manage those on treatment, even if most in the HIV community clearly emphasize both are vital.
We must meet this challenge going forward, or risk leaving behind vulnerable people who we should be bringing with us into a bright new ‘post-AIDS’ future.