Three Questions for MSH’s Top HIV Expert, Sarah Konopka, on the State of the Fight

The UNAIDS Global AIDS Update 2022 report paints a disturbing picture of global progress against HIV and AIDS thrown off track by the COVID-19 pandemic. More than 1.5 million new infections were reported in 2021, 1 million more than global targets. The numbers of individuals with HIV on lifesaving treatment grew at the slowest rate in a decade, even as effective and safe treatments have been available for years.  

Not all are at equal risk. Select groups make up less than 5% of the global population, but they and their sexual partners comprised 70% of new HIV infections in 2021.  

Girls and young women aged 15 to 24 years are one of these populations: they face a three times greater risk of acquiring HIV than their male counterparts in sub-Saharan Africa. 

At the same time, the US President’s Emergency Plan for AIDS Relief (PEPFAR) is embarking on a strategic reset, focusing on equity, sustainability, and security, among other pillars. 

Against this backdrop, MSH Infectious Diseases Team Lead and HIV Practice Lead Sarah Konopka reflects on the state of the battle against HIV and AIDS. 

Where are we now in the fight against HIV, particularly in light of the pandemic? 

We’ve made incredible progress in controlling the HIV epidemic, and over the last two decades in particular, but the fight is far from over. The COVID-19 pandemic has disrupted both prevention and treatment services.  

But, if we’re honest, we were not on track long before that.  

Inequalities—in access, in resources, in rights—continue to fuel new infections. It is unacceptable that 38 countries reported increases in HIV infections since 2015. More than that, it’s heartbreaking, because we made a commitment, as a global community, to leave no one behind and because we have the tools to prevent it. 

What is the single biggest challenge right now facing HIV and AIDS prevention and control? 

Global expansion of HIV treatment is a public health success story. Data tell the story best: at the end of December 2021, 28.7 million people were accessing antiretroviral therapy (ART), and an estimated 16.2 million AIDS-related deaths have been averted since 2001.  

But progress is not equal: Some populations and communities continue to be excluded from these success stories. Adolescent girls, young women, and other key populations continue to bear the brunt of new infections. Access to treatment varies depending on where you live and who you are; we see this variation even within towns and districts.  

Our challenge is this: there is no one-size-fits-all solution. We’ve known this for a long time, and we’ve made incredible progress in developing differentiated service delivery models; engaging communities as service providers; and making drugs accessible through multiple channels, from private pharmacies to community drop locations. 

But we need to keep innovating, and we need to do more to reach people where they are. We need to challenge structural and policy barriers that perpetuate inequalities. We need to engage communities in the response, supporting them to drive the agenda and implement solutions. The other great challenge, of course, is that as we face this reality, funding is dwindling.  

As an organization implementing HIV programs on behalf of the US government, what are some of the challenges, successes, and lessons MSH has learned over the years? 

Since the early stages of the HIV and AIDS epidemic, MSH has used a whole systems approach to deliver tailored, gender-sensitive, and high-quality services to vulnerable populations in countries across the globe and achieve UNAIDS’ ambitious 95-95-95 goals. With local partners, we create and lead approaches to strengthen health systems and deploy sustainable solutions for essential health system functions, including pharmaceutical services; supply chain; commodity management; health financing; laboratory and surveillance systems; health workforce; and local governance, stewardship, and management. Our evidence-based practice is grounded in science and always locally led in partnership with the public and private sectors, civil society, and faith-based organizations, from health ministries to the community. 

In supporting local actors to develop and institutionalize resilient health systems, we’ve learned a few things: 

(1) There’s no service without a product. Ensuring that patients can access what they need when they need it, whether that’s a diagnostic service, a medicine, or a screening for a referral, is critical. And you can’t plan for, provide, and monitor high-quality services without strong health system functions in place.  

• Ukraine, prior to the the Russian military invasion, was on track to purchase nearly all of the HIV medicines the country needed. Over the last few years, the country has struggled with a number of supply chain challenges, such as ineffective quantification of needed medicines and drugs not being registered in the country. This was often exacerbated by poor coordination across government actors. MSH supported the government and partners with strategic analyses to inform decision making to address these barriers. For example, the MSH-led Safe, Affordable, and Effective Medicines (SAFEMed) for Ukrainians Activity undertook an analysis of the universe of HIV manufacturers, their existing WHO prequalification (or FDA approval), and whether they were registered in Ukraine. This analysis highlighted gaps and led the government of Ukraine to engage with manufacturers to facilitate registration and encourage participation in public procurement processes. It was also used to encourage the Global Fund and other donors to be comfortable with Ukraine’s National Procurement body to procure antiretrovirals directly rather than through international organizations. 

(2) Service and system integration. We have seen, again and again, that better integration leads to better services, efficiencies, increased savings, and better outcomes.  

• In Ethiopia, integrated HIV and TB services helped ensure that 94% of TB patients in the region where we worked were tested for HIV and, of those who tested positive, 90% were started on ART. 
• In Angola, MSH and local partners developed a community health information system that enabled civil society organizations to track clients across the continuum of services, often outside of health facilities. The system was adopted nationally and led to the inclusion of community HIV indicators disaggregated for key populations and risk factors in the national health information system. This allowed for their needs to be considered as policy makers and program managers use data to inform decision making for their HIV programs. 

(3) Local ownership is essential. Ultimately, health systems need to be adaptable and resilient if they are to sustain services, supplies, and coverage in the face of new emergencies, whether political, climate, or public health related. Strong systems rely on strong functional management systems, clear yet flexible processes that prevent corruption, and reliable financing—all with strong local institutions and champions that will steer through the storm. 

• For the Global Fund, MSH comprehensively reviewed Namibia’s Central Medical Store (CMS) organization, structure, and operations; proposed a sustainable governance model; and developed turnaround strategies. The six-month project included oversight of short- to medium-term operational improvements to lay the foundation for long-term strategic restructuring and governance of the CMS. 

Even amid these challenges, I’m optimistic we can build on the solid progress we’ve made and incorporate these lessons to effect meaningful change to stem the backsliding we’ve seen in recent years. Now is the time to reflect on what truly works and to make the most of the resources available to build toward sustainability.