No Sustainability Without Equity: The Future of HIV Programming

As the global HIV and AIDS crisis continues to evolve and we move toward epidemic control, people with HIV are living longer, which means the types of support they need from their health care systems look different. At the same time, troubling gaps in equity persist and must be addressed if we are to end AIDS as a public health threat. What can we learn from PEPFAR and other programs to inform our continued efforts to sustain the HIV response in an equitable, locally led way?

This is the question we sought to address during our satellite session at the recent AIDS 2024 conference in Munich, Germany. Below is a brief summary of the presentations, which were followed by a lively panel discussion and Q&A session.

We were joined by Jen Kates, senior vice president and director of the Global Health & HIV Policy Program at KFF. She summarized research that she and her colleagues at KFF have done on the effects of PEPFAR, the US global HIV program and the largest commitment by any nation to address a single disease. Right now, it stands at an important juncture: having been in existence for two decades, it faces a changing global health landscape, political challenges at home, and questions about its next phase and future HIV investments.

While PEPFAR was designed as a vertical, singularly focused, global HIV initiative and has been credited with helping to change HIV’s trajectory, KFF wanted to examine whether it has had spillover effects (negative or positive). So, with partners from Brandeis University, they compared non-HIV outcomes in PEPFAR countries with other similar low- and middle-income countries. The researchers asked: Has PEPFAR ‘crowded out’ other health investments, potentially resulting in worse health outcomes in other areas? Has it improved other health outcomes given its significant investments in the health workforce, laboratory services, and other elements of health systems strengthening?

They found that PEPFAR is largely associated with positive health and non-health spillover effects, and there is no evidence of negative spillover or crowding out of other health investments. Specifically:

• Overall mortality rates were 20% lower than they would have been without PEPFAR, which is beyond the reductions from HIV alone.
• In PEPFAR countries, childhood immunization rates went up for several childhood diseases.
• PEPFAR is associated with keeping boys and girls in school, as out-of-school rates went down in PEPFAR countries.

While Jen said further analysis in specific areas is warranted, overall, the findings point to the overwhelming impact of the program and indicate that a reduction in PEPFAR support could reduce some of these gains. If PEPFAR has had these impacts, this should create fertile ground for a more sustainable response. As the global health community looks to the future of HIV programming, it is important to remember what effects these programs are having beyond the immediate obvious and intended results.

A.K. Nandakumar

My portion of our session discussed the Global AIDS Strategy 2021–2026’s call for the application of an equity lens across all aspects of the response, using timely data to identify and address the inequities and disparities that prevent HIV programs from reaching all communities. This responsibility is shared among countries, donors, and civil society. Yet despite this focus, disparities still exist in both access and outcomes, and we need more research in this area.

While we have made significant gains, they are threatened by changes in the broader global environment such as flat funding; climate change; public debt; and eroding commitments to human rights, gender equality, and gender diversity. In short, we are not on track to meet global HIV targets for 2030. Country and donor health priorities have begun to diverge, and there are concerns that the rushed transition of certain programs to countries could place equity gains at risk, especially for the most vulnerable and marginalized populations.

I am part of a technical working group tasked with exploring some research questions around progress in this area—questions about how HIV programs compare to the broader health systems; what the evidence tells us is the best way to address HIV-related inequities; the best ways to go about integrating HIV services into broader health and social services; the implications for equity when we do; and options for prioritizing equity at each stage of the response, from resource mobilization to planning and utilization, addressing social and gender norms, ensuring an enabling policy environment, and monitoring and evaluation.

Our resulting equity report found some clear takeaways. Most notably, there can be no sustainability in the HIV response without equity. Equity is a prerequisite for ending AIDS as a public health threat. At the same time, we found that the equity of the HIV response tends to be better than the equity of the general health care system. We studied this across 15 countries.

The evidence shows that addressing the disproportionate impact of HIV on key populations will be crucial to ensuring and sustaining equity. How do we ensure that these key populations are not left behind? By making sure that the approaches we implement provide essential services while also addressing key social and behavioral determinants.

Another important recommendation is that equity cannot be an initiative. It must be a way of doing business. That is, you program to equity first, and you worry about everything else second. It has to do with how you mobilize resources; how you pool resources; how you allocate resources; and, most importantly, how you bring civil society and the community into the planning process.

With donor funding decreasing, we need to be innovative in our solution making, including finding ways to incentivize countries to put equity at the core of their work and coming up with different co-financing and co-investment approaches.

Lastly, we need to have a monitoring and evaluation framework that keeps us laser focused on these issues of ensuring equity in financing, policies, and outcomes by involving people in the decision making process.

Marian W. Wentworth, MSH

With these important research findings in mind, my remarks focused on what happens when it’s time for these programs to transition from donor to country leadership.

For more than five decades, MSH’s approach has been to work closely with our country partners to build solutions. We take a whole-of-government, locally led approach to drive strong health outcomes across the board.

Two examples illustrate situations where this has been effective in transitioning HIV programming. In Uganda, where MSH leads USAID’s Strengthening Supply Chain Systems (SSCS) Activity, we worked with the Ministry of Health as it built a 10-year road map for technology improvements to the country’s supply chain. This involved stakeholder engagement and participation from well beyond the Ministry, as multiple government agencies worked together on long-range planning. As a result, after one year, the availability of antiretrovirals (ARVs) in Uganda’s national medical stores went from 76% to 93%, and the percentage of ARVs that were available in 90-day packs instead of 30-day packs went from 59% to 87%. The availability of these long-term doses is extremely important for patients trying to maintain viral suppression.

Another example comes from our work through the Reaching Impact, Saturation and Epidemic Control (RISE) program in Cameroon, funded by PEPFAR and USAID. There, working with multiple government agencies was essential as the country worked to integrate HIV care into its essential package of services for universal health coverage. In their first year of incorporating that program, Cameroon was able to take care of almost 450,000 people living with HIV. The enrollment of persons living with HIV into their standard health care system is on target to be 100% of persons living with HIV, which would be a tremendous accomplishment.

What is the ‘secret sauce’ that makes this kind of transformation possible? This is the question some of my MSH colleagues addressed in their recent research, which was presented more fully in a separate session. They conducted a literature review and deep dive into two countries that have taken increasing ownership of their HIV response. While the research showed consensus on several factors that impact these processes—leadership and management capacity; the political, economic, and policy environment; and the level of private-sector and civil society engagement—there was a notable lack of metrics on whether transitions were locally led.

At MSH, our decades of experience have taught us that stronger health systems lead to better health outcomes—for all people, including those living with HIV. Strong health systems will sustain effective, resilient, responsive HIV programs. Governments must be able to lead, finance, and manage their own systems, and to do so they need to drive the conversations about where investments are made and how to plan for the long term. If we don’t listen to what they have to say, we risk losing the spillover benefits that Jen talked about from programs like PEPFAR, and we won’t be closing the equity gaps that Nanda described.

I’m confident that if countries lead the way, they will take us toward a future where we can eliminate HIV as a public health threat once and for all.