By Bekker et al.
Inspired by unprecedented improvements in human health and development in recent decades, our world has embarked on a quest that only a generation ago would have been considered unreachable—achieving sustainable health and development for all. Improving the health and wellbeing of the world’s people is at the core of the Sustainable Development Goals (SDGs), reflected in targets that call for ending the epidemics of AIDS, tuberculosis, and malaria; achieving enormous improvements in maternal and child health; and tackling the growing burden of non-communicable diseases (NCDs). Attaining universal health coverage is the means by which these ambitious health targets are to be achieved.
Although on their face, the SDGs reflect an unprecedented level of global solidarity and resolve, the trends that increasingly define our world in 2018 are inconsistent with both the sentiments that underlie the SDGs and the ethos that generated such striking health and development gains in recent years. Democracy is in retreat, and in many countries the space for civil society is declining and the human rights environment deteriorating. Official development assistance for health has stalled, as an inward-looking nationalism has in many places supplanted recognition of the need for global collaboration to address shared challenges. The loss of momentum on global health ignores the urgent need to strengthen health systems to address the steady growth of NCDs, which now account for seven of ten deaths worldwide.
Recent trends in the HIV response are especially concerning. Although the number of new HIV infections and AIDS-related deaths have markedly decreased since the epidemic peaked, little progress has been made in reducing new infections in the past decade. Without further reductions in HIV incidence, a resurgence of the epidemic is inevitable, as the largest ever generation of young people age into adolescence and adulthood. Yet where vigilance and renewed efforts are needed, there are disturbing indications that the world’s commitment is waning. Allowing the HIV epidemic to rebound would be catastrophic for the communities most affected by HIV and for the broader field of global health. If the world cannot follow through on HIV, which prompted such an extraordinary global mobilisation, hopes for achieving the ambitious health aims outlined in the SDGs will inevitably dim.
At this moment of uncertainty for the future of the HIV response and for global health generally, the International AIDS Society and The Lancet convened an international Commission of global experts and stakeholders to assess the future of the HIV response in the context of a more integrated approach to health. A central finding of the Commission is that the HIV epidemic is not on track to end and that existing tools are insufficient. Although antiretroviral therapy (ART) has transformed the HIV response by averting deaths, improving quality of life, and preventing new HIV infections, HIV treatment alone will not end the epidemic. The UNAIDS 90-90-90 approach must be accompanied by a similarly robust commitment to scaled-up primary HIV prevention and to the development of a preventive vaccine and a functional cure for HIV. Ironically, the diminishing energy on HIV is occurring at the moment when lessons learned during the HIV response could serve as pathfinders in the quest for sustainable health for all.
From its inception, the HIV response was a unique undertaking, apart from the broader health system. Although elements of a disease-specific approach will and should be retained, the future of the HIV response will also depend on finding opportunities for integrating HIV services more closely within health systems. Wholesale abandonment of vertical HIV funding would involve considerable risks, as the laser-like focus on a single disease accounts in large measure for the HIV response’s successes. Unique attributes that have defined the HIV response (including its multisectoral and inclusive approach, engagement of civil society, emphasis on equity and human rights, galvanisation of scientific innovation, and foundation of global collaboration and problem solving) must be preserved and mainstreamed across global health practice.
Whether to integrate HIV within broader health systems is not an either–or choice, and optimal paths will differ between settings, populations, and services. To be effective, more integrated approaches must yield improvements both to HIV-related and non-HIVrelated health outcomes. In most cases, approaches to integration will and should be incremental, allowing learning by doing. To assess the health and financial benefits of such win-win scenarios, the Commission engaged modellers to examine different scenarios for incremental integration of HIV-related and non-HIVrelated services. These include: models in South Africa and Kenya for screening of HIV alongside screening for diabetes, hypertension, and other NCDs; integration of HIV in reproductive health services in Nigeria; integrated management of HIV and sexually transmitted infections in India; and integration of harm reduction and overdose services and ART for people who use drugs in Russia. In each of these scenarios, integrated approaches generated concrete improvements in HIV and broader health outcomes. With one exception (antiretroviral pre-exposure prophylaxis [PrEP] in India), integrated models were consistently found to be cost-effective.
The HIV community must make common cause with the global health field— to make universal health coverage a reality, to substantially increase the share of resources devoted to health, and to build worldwide recognition of health as key to progress across the breadth of the SDGs. The global health field must take a leading role in resisting the turn towards authoritarianism, xenophobia, and austerity with respect to essential public health investments. In a time of fragmentation and uncertainty, the global health field can aid in reminding all of us of our common humanity. Health systems must be designed to meet the needs of the people they serve, including having the capacity to address multiple health problems simultaneously. No one can be left behind in our efforts to achieve sustainable health. Recognising health as an investment, major new resources (from national governments, the international community, and the private sector, involving innovative financing mechanisms) must be mobilised to support stronger, sustainable, and peoplecentred health systems.