It Is Time to Streamline the Global HIV/AIDS Architecture
HIV activists protesting against patent laws that pushed up costs of essential medicines in Cape Town in  2014.

I endured a dreary weekend in a Paris hotel while others rushed home. As the junior English speaker of a task force of United Nations (UN) member states, it fell to me to finalise our report. It was the early 1990s and we had travelled across Asia, Africa and Latin America collating confusing evidence and conflicting opinions that now required urgent synthesis and circulation to the world.   The question before us concerned the relatively new HIV/AIDS.

Incontinent patients overflowing Malawian hospitals, mountains of roadside coffins in Uganda, lost orphans in Johannesburg, emaciated drug users under Beijing flyovers, terrified migrants in Mumbai slums, panic-stricken sex workers in Nairobi, stigmatised gay men in Rio de Janeiro, contaminated blood recipients in New York, and later, raped women from the Rwanda genocide. These were some observations from the first-ever task force world tour of the HIV scourge.

Alongside unpicked harvests, collapsed businesses, and infected armies destabilising nations. It convinced us that the business-as-usual mode of UN agencies would not do. 

But what might a transformed global AIDS effort look like?  There was unanimity that a whole-of-society approach was urgent. Our findings led to the 1993 World Health Assembly and 1994 UN Economic and Social Council resolutions. The Joint United Nations Programme on HIV/AIDS (UNAIDS) duly opened its doors in 1996. 

HIV probably originated early in the 20th century by jumping from apes to humans in Africa and spread slowly through travel. The virus was identified in 1983  as the epidemic got going. Since then, 86 million people have been infected and 40 million have died. 

Remarkable struggle against HIV

Community Health Workers attend a training session on HIV in Kirehe, Rwanda.

The forty-year struggle against HIV/AIDS has been remarkable. It sparked unprecedented global unity that we can only envy nowadays – with numerous UN resolutions including unanimous support at the Security Council in 2000, the first time a health matter reached so high.   

HIV stimulated unprecedented institutional innovation.  UNAIDS pioneered UN reform with 11 quarrelsome UN agencies joining hands. It made consultation fashionable and welcomed civil society, including patient groups, onto its governance. Unprecedented generosity was unleashed with the 2002 formation of the Global Fund’s dedicated financing channel for HIV/AIDS, tuberculosis and malaria.  The bilateral US President’s Emergency Plan for AIDS Relief (PEPFAR) was formed in 2003. 

HIV turbo-charged research with the first antiretroviral treatment becoming available in 1987, averting 21 million deaths till now.  Subsequent therapeutic advances including post-exposure prophylaxis turned HIV from an assuredly fatal condition to one that causes less than one death per 10,000 population. 

Prevention – a controversial matter of sexual abstinence, condoms, and clean needles –  got a boost in 2012 with pre-exposure prophylaxis alongside a revolution in diagnostics including tracking the immune status of patients.

Nowadays, treated HIV is akin to a chronic disease with almost normal life expectancy.  Although the holy grail of an HIV vaccine remains elusive, promising innovations underway include six candidate vaccines in Phase 1 clinical trials. The benefits of scientific investments in HIV have been profound. They accelerated  COVID-19 and malaria vaccines development and even personalised cancer therapy. 

Human rights values underpinned HIV struggle

Delegates at the 2022 International AIDS Conference calling for the end to criminalisation of key populations most vulnerable to HIV/AIDS.

But even more, the values underpinning the HIV struggle transformed society. People with HIV refused to be victimised and taught marginalised communities such as LGTBQ+ to stand up for their rights and win basic legal entitlements in many places. Religious orthodoxies performed theological gymnastics to sanction condom use thereby benefitting the reduction of other sexually-transmitted infections and contributing towards cervical cancer prevention.  

HIV education strategies countering stigma enabled people with TB  and the mentally ill to come out of the shadows.  The skills to manage AIDS  brought compassion and courage to overcome the fear of contagious conditions such as Ebola.   

 The human rights gains triggered by HIV/AIDS established the primacy of inclusion in public policy such as for refugees and migrants. Of course, such rights are not universally realised and often threatened. But HIV showed the worth of struggling and how to do it.

HIV  widened public health ambitions, and birthed health diplomacy to create the modern global health movement. The bold demand for antiretrovirals for all with HIV disease was a precursor of the COVID-19 slogan, “no one is safe until all are safe”.  The universalist vision of HIV treatment negotiated far-reaching flexibilities in the Trade-Related Intellectual Property Rights (TRIPS) regimen allowing treatment costs to drop by a staggering 99 per cent.  This got the generic medicines genie out of its over-priced bottle.

The HIV emergency is an inspiring battle against today’s emergency around non-communicable diseases (NCDs) – diabetes, cancers,  cardiovascular and respiratory conditions – that cause  74% of global deaths. And so NCD treatment costs have tumbled including insulin.

New paradigm of accessibility

Thus, HIV gave rise to a new paradigm of availability, accessibility, and affordability  for all essential drugs and diagnostics. That makes feasible, Universal Health Coverage (UHC), the core of  Sustainable Development Goal 3.  HIV has shown what is doable against the odds, given the vision, will, partnerships, and resources. 

It is the last aspect – resources – that raises new questions, considering HIV’s trajectory.  There were 39 million people living with HIV in 2022 giving a global median prevalence of 0.7 per cent among adults  aged 15-49 years. In the same year, 1.3 million were newly infected (reduced by 59% since the 1995 peak) and 630,000 died (reduced by 69% from its 2004 peak).

A 2021 UN General Assembly  Political Declaration called for ending AIDS  by 2030 through sufficient HIV reduction to remove it as a population threat. The associated strategy centres on prevention through testing and treatment, a creative approach that could also work with some other conditions. 

The key targets are that 95% of people living with HIV should know their HIV status, 95% of the latter should be on antiretroviral treatment, and 95%  of treated people should be virally suppressed, and therefore unable to transmit infection to others.  

By 2022, 89% of people who were aware that they had HIV were on antiretroviral treatment.

There is impressive progress. By last year, 86%  of people living with HIV knew their status, 89%  of HIV-aware people were accessing treatment of which 93% were virally suppressed. 

The 2030 targets should be achievable with several countries already reaching or exceeding the 95/95/95  benchmarks.  From being a global pandemic,  HIV has been geographically contained. Africa still accounts for most (38 per cent)  of new infections with HIV’s gender dimension most evident in sub-Saharan African women who bear the brunt.

The global decline is bucked by parts of Eastern Europe and Central Asia, Middle East and North Africa, and Latin America showing rising incidence. Nevertheless, HIV is increasingly concentrated in key populations such as gay and transgender persons, and in vulnerable settings such as sex work, injecting drug use, and prisons.  Certainly, there is more to do especially with authorities whose retrogressive and prejudiced policies fuel virus spread.  That reinforces the case for targetted, not generalised, approaches. 

It necessitates decentralised, focused spending by re-orienting global flows towards low- and middle-income countries. They currently spend $20-22 billion annually on HIV, of which around 60%  comes from their own budgets. External aid from PEPFAR, Global Fund, and others provide the rest.

UNAIDS projects a $29.3 billion global investment requirement in poorer countries in 2025. Meanwhile, as a sign of success, more and more people live long healthy lives on permanent HIV treatment. The sustainable financing of an increasingly endemic condition needs figuring. 

The last mile is always the most expensive to traverse. Especially at a time when the going is harder due to many conflicts and climate change disasters that increase population displacement and vulnerability.  But more HIV funding will not defuse underlying causes while making a marginal difference to mitigating the symptoms.

Should UNAIDS close by 2030?

UNAIDS Executive Director Winnie Byanyima addressing the UN.

With HIV already out of the list of top 10 killers by 2019, how cost-effective is our array of HIV-focused bodies?  It implies getting HIV out of the current vertical campaign mode and integrating it into UHC systems.  Why wait till 2030 to make the transition?

There is a reluctance to move faster because such change poses an existential threat to HIV-centered institutions. Do we still need UNAIDS and its $210 million annual budget? Can we justify the individual HIV units and separate programme spends of the 11 co-sponsoring agencies of UNAIDS? Can we continue to spend $15.7 billion bi-annually on just three diseases – HIV, TB, and malaria, as the Global Fund does? Not to forget the billions on HIV via the World Bank and bilateral donors, including PEPFAR’s $6.9 billion in 2023. 

A fundamental re-ordering is needed. Perhaps downsized UNAIDS staff could return to their original home at WHO which should continue its normative guidance and country support technical roles.  Thanks to the aid localisation movement and the maturing of civil society over the past decades, there are plenty of groups on the ground to keep running with the psychosocial and human rights aspects of the HIV struggle.

And the Global Fund, while continuing to finance HIV, TB, and malaria, should extend value-for-money by taking on additional challenges worthy of its clout (say dementia and cancer).

There are many examples of organisations adjusting their work in the face of altered requirements. But never has a UN agency closed shop voluntarily. UNAIDS, at its start, pioneered  UN reform. It could trail blaze again by closing its doors, say in 2030. 

A  commemorative monument could be erected at its spacious Geneva headquarters. The new occupants – putting their great minds to tougher tasks – will be inspired by walking past the exhibition in the foyer on one of our greatest public health triumphs. 

Perhaps they will pause for reflection at the display containing the medal of  the Nobel Prize for Medicine – a fitting way to bid farewell to UNAIDS, the only world agency with the foresight to do itself out of business.  

Mukesh Kapila, Health Policy Watch editor-at-large, is a physician and public health specialist who has held senior positions at the World Health Organization, United Nations, and as Under-Secretary-General at the International Federation of Red Cross and Red Crescent Societies. He began his public health career as the Head of Conflict  & Humanitarian Affairs for the UK’s Foreign Office.  

This is the first of a series of periodic “stocktake” papers reflecting on progress made and constraints faced on the journey to achieving the Sustainable Development Health Goal, SDG 3.


Image Credits: Louis George 2011 , Cecille Joan Avila / Partners In Health, Marcus Rose/ IAS, Flickr.

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