The global HIV response has brought out the best in many people, communities and governments around the world. They have led with public health principles focused on outcomes and accountability, and a commitment to those left behind.
Yet, the fundamentals that have been the bedrock of HIV response success are necessary, but insufficient to meet serious challenges facing the response — from rising risk environments for vulnerable girls and women to stalled HIV prevention progress, threats to the human rights and healthcare access of key populations, and COVID’s role in undermining the effectiveness of the HIV, tuberculosis and malaria responses in many countries.
Overcoming these multi-sectoral challenges will require HIV response initiatives to build stronger and more effective bridges within global health and broader development, while continuing to excel in expanding lifesaving services.
The political declaration that emerged from the June United Nations High-Level Meeting on AIDS provided several footholds to help build these bridges and propel the changes needed to end the HIV pandemic by 2030, and will be central to discussions at this week’s United Nations General Assembly meetings in New York. In particular, the declaration is notable for its focus on disease prevention, people-centered health services, enhanced coordination and the inclusion of targets for reductions in death and new infections. Importantly, the Biden administration has also strongly reiterated the need for the HIV response to reinforce sexual and reproductive health rights and the fundamental human rights of marginalized people.
By making “bridge-building” an explicit target of policymaking, we have the opportunity not only to accelerate an end to HIV, but also to advance broader health security and development. Given the maturity of the HIV response and the emerging funding support for COVID and health security, failing to reach across and build partnerships at scale risks serious inefficiency and missed opportunities for impact.
At their core, responses to longstanding pandemics such as HIV, tuberculosis and malaria have built and relied upon many of the same health systems components that we think of as health security: From data systems to health workforce development, disease surveillance and effective laboratory testing. For instance, the HIV response has developed and scaled up widespread HIV self-testing — an intervention that is among the holy grails of health security and is a major priority for the COVID response and future pandemic preparedness.
More explicit bridges between the HIV response and health security (in addition to malaria and tuberculosis response) at the country-level can ensure that years of experience implementing interventions such as self-testing seamlessly informs COVID and other responses. Conversely, health security investments into features such as early warning programs identifying populations or geographies at risk for COVID or malaria can benefit HIV prevention efforts through strengthened national data systems. The White House’s new pandemic preparedness request provides funding and strategies to pursue these priority actions and support stronger health systems and pandemic outcomes.
In recent years, HIV response has extended to programs in the U.S. President’s Emergency Plan for AIDS Relief such as DREAMS, which rightfully focuses on preventing infections among adolescent girls and young women — a rapidly growing population in many countries hardest hit by HIV. The COVID pandemic has undercut some of this progress by disrupting HIV prevention programs, worsening risk environments that drive teenage pregnancy, sexual violence and trafficking and HIV infection, and diminishing educational and economic opportunities for women and girls.
We must advance our HIV prevention efforts for women and girls. That includes supporting emerging medicines that are easier for women and girls to use, urgently building new partnerships with bilateral and multilateral networks and investments to address targeted issues. This applies, in particular, to investments designed to address the sexual and reproductive health needs of vulnerable young women, advance girls' secondary education, prevent and respond to sexual violence and “triple wins” such as investments in community health worker programs that enhance health outcomes, reduce HIV risks and create opportunities for career advancement within healthcare, particularly for young women.
The challenges of today also call for the HIV response to urgently focus on building stronger connections with partners that can more robustly and holistically support stigmatized and marginalized groups — in particular, members of the LGBTQ community. By taking partnerships such as these to scale and carefully tracking progress, investments made for HIV response can provide greater support to the health and wellbeing of highly vulnerable, marginalized populations. But this work is impossible without standing firm and protecting human rights, including using the full force of our government when negotiating with governments around legal and regulatory frameworks that often work against public health objectives — including decriminalization of same-sex sexual relations, a top priority of the Biden-Harris administration.
Lastly, critical to the next phase of the HIV response (and the achievement of broader sustainable development goals) is making progress against structural factors that impede the ability of communities to reduce risks of HIV. This can only be done by redoubling partnerships to leverage the massive investments of development actors — from development banks to multi-sectoral development programs in education and economic development. This renewed focus will enable targeted co-investments that contribute to reduced risk environments, not only for HIV, but for other diseases affected by poverty and inequity.
An example of this is the Biden-Harris administration’s use of the newly created Development Finance Corporation (DFC). Secretary Blinken noted at his first DFC board meeting that “our development finance tools can mobilize private sector resources to help counter the devastating health and economic consequences of the [COVID] pandemic.” Encouragingly, the administration has invested in multiple new partnerships designed to advance global health objectives.
The promise of the HIV response draws from the effectiveness of its public health interventions and from its demonstrated ability to evolve. Yet the response is facing historic levels of challenge from COVID and multi-sectoral threats. By remaining focused on its progress while strategically building stronger bridges, the HIV response will be in the best position to achieve its goals and contribute to broader health in our highly interconnected world.
Charles B. Holmes, MD, MPH is a distinguished scholar at the O’Neill Institute for National and Global Health Law and Director of Georgetown University’s Center for Innovation in Global Health. He previously served as chief medical officer and deputy coordinator for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).