Advancing Global Health And Strengthening The Hiv Response In The Era Of The Sustainable Development Goals: The International Aids Society-Lancet Commission

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. Key messages•The HIV pandemic is not on track to end, and the prevailing discourse on ending AIDS has bred a dangerous complacency and may have hastened the weakening of global resolve to combat HIV•Existing HIV tools and strategies are insufficient, and although dramatic gains can be made through maximizing existing prevention and treatment strategies, the HIV pandemic is likely to remain a major global challenge for the foreseeable future•Tens of millions of people will require sustained access to antiretroviral therapy for decades to come, vigilance will be needed to prevent a resurgence of the epidemic as the largest-ever generation of young people age into adolescence and young adulthood, and intensified efforts are required to address HIV among populations and settings that are being left behind•Allowing the pandemic to rebound after achieving such remarkable progress would not only increase the human and financial costs of HIV, but it would potentially demoralise the global health field and diminish support for similarly ambitious global health undertakings•A rejuvenated global effort on HIV is essential; to renew and strengthen the global HIV response, the world's impressive commitment to the scaling up of HIV treatment services must be matched by a similarly robust commitment to expanded access to HIV prevention•The HIV response must make common cause with the broader global health field to herald a new era of global solidarity for health, and specific action is urgently needed to respond to the rapidly rising health toll associated with non-communicable diseases, including taking health into account in the development of public policies of all kinds. HIV services should, where feasible, be integrated with broader health services, in co-located sites where possible, with the aim of improving both HIV-related and non-HIV-specific health outcomes; greater integration of HIV and global health must preserve and build on key attributes of the HIV response, including participatory community and civil society engagement and an ironclad commitment to human rights, gender equality, and equitable access to health and social justice•The new era of global health solidarity should focus on the development of robust, flexible, people-centred health systems to end communicable diseases, develop effective measures to address the steady rise of non-communicable diseases, achieve universal health coverage, provide coordinated services tailored to the needs of health service users, and effectively address the social and structural determinants of health •The HIV pandemic is not on track to end, and the prevailing discourse on ending AIDS has bred a dangerous complacency and may have hastened the weakening of global resolve to combat HIV•Existing HIV tools and strategies are insufficient, and although dramatic gains can be made through maximizing existing prevention and treatment strategies, the HIV pandemic is likely to remain a major global challenge for the foreseeable future•Tens of millions of people will require sustained access to antiretroviral therapy for decades to come, vigilance will be needed to prevent a resurgence of the epidemic as the largest-ever generation of young people age into adolescence and young adulthood, and intensified efforts are required to address HIV among populations and settings that are being left behind•Allowing the pandemic to rebound after achieving such remarkable progress would not only increase the human and financial costs of HIV, but it would potentially demoralise the global health field and diminish support for similarly ambitious global health undertakings•A rejuvenated global effort on HIV is essential; to renew and strengthen the global HIV response, the world's impressive commitment to the scaling up of HIV treatment services must be matched by a similarly robust commitment to expanded access to HIV prevention•The HIV response must make common cause with the broader global health field to herald a new era of global solidarity for health, and specific action is urgently needed to respond to the rapidly rising health toll associated with non-communicable diseases, including taking health into account in the development of public policies of all kinds. HIV services should, where feasible, be integrated with broader health services, in co-located sites where possible, with the aim of improving both HIV-related and non-HIV-specific health outcomes; greater integration of HIV and global health must preserve and build on key attributes of the HIV response, including participatory community and civil society engagement and an ironclad commitment to human rights, gender equality, and equitable access to health and social justice•The new era of global health solidarity should focus on the development of robust, flexible, people-centred health systems to end communicable diseases, develop effective measures to address the steady rise of non-communicable diseases, achieve universal health coverage, provide coordinated services tailored to the needs of health service users, and effectively address the social and structural determinants of health 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-HIV-related 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-HIV-related 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 people-centred health systems. The SDGs sharply elevate global health and development aspirations, contemplating a world that is far more prosperous, secure, healthy, and equitable, where human rights and dignity are universally respected, and where human development unfolds in a manner that preserves the natural environment. Yet, the 3 years that have passed since the SDGs were agreed have dimmed prospects for achieving many of these visionary aims. By contrast with the international solidarity, shared commitment, and increased investments that characterised the era of the Millennium Development Goals (MDGs), much of the world has, since 2015, turned inward and toward authoritarianism, repression, a diminished role for civil society, a policy of austerity for public investments, and suspicion of international cooperation. As a result of civil conflicts that have yet to elicit an appropriate international response, more people than ever have been forced from their homes and countries. At a time when the fruits of scientific advances are so evident, denial in many quarters of the role of humankind in the degradation of our environment threatens the very health and wellbeing of our planet and our civilisations. Among the reasons why the world opted for such an ambitious agenda for the SDGs was the success of the HIV response. As a result of a worldwide mobilisation, the incidence of HIV infections peaked and began to decrease in all parts of the world, and AIDS-related mortality decreased from 1·9 million in 2005 to 1·0 million in 2016.1AIDSInfoJoint United Nations Programme on HIV/AIDS.http://aidsinfo.unaids.orgDate accessed: June 14, 2018Google Scholar The HIV response has not been an unalloyed story of achievement, as the world's capacity to respond effectively to the epidemic has been undermined by 15 years of relative inaction in the epidemic's early stages, an approach to epidemic management that has undervalued primary prevention, and the enduring stigma associated with HIV. The broader global health community, facing both historic opportunities and profound challenges, could potentially benefit from lessons learned from the successes and failures of the global HIV response. With its multisectoral and inclusive approach, mobilisation of political commitment, engagement of civil society at every level, emphasis on equity and human rights, galvanisation of scientific innovation, and foundation of global collaboration and problem solving, the HIV response has properly been cited as a model for the future of global health.2Piot P Quinn TC Response to the AIDS pandemic—a global health model.N Engl J Med. 2013; 368: 2210-2218Crossref PubMed Scopus (85) Google Scholar The global health challenge remains immense, with millions of people in low-income and middle-income countries (LMICs) dying each year from causes that have either been largely eradicated or are decreasing in prevalence in high-income countries (figure 1).3GBD 2016 Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (662) Google Scholar Whether the world is prepared to meet these challenges is unclear. Although the incidence of communicable, maternal, neonatal, and nutritional diseases have decreased worldwide since 1980,3GBD 2016 Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (662) Google Scholar the most recent projections indicate that financial resources available for health programmes in LMICs are likely to fall far short of amounts needed to reach the health targets set forth in the SDGs.4Global Burden of Disease Health Financing Collaborator NetworkFuture and potential spending on health 2015–40: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries.Lancet. 2017; 389: 2005-2030Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Persistent weaknesses of health systems undermine prospects for progress in addressing the full panoply of health challenges. At the very moment when HIV could serve as a pathfinder for global health, there are signs that global commitment to build on the gains achieved against HIV thus far is waning. From 2013 to 2016, international HIV assistance was reduced by roughly 20%, from almost US$10 billion to US$8·1 billion.5UNEnding AIDS. Progress towards the 90–90–90 targets. Joint United Nations Programme on HIV/AIDS, Geneva2017Google Scholar Relinquishing the fight against HIV before it is over would have disastrous consequences, both for people affected by HIV and for the broader global health community. Unless further investments are made to accelerate expansion of HIV prevention and treatment programmes, the HIV epidemic is likely to rebound and grow far more serious in the coming years, especially as the world's largest-ever cohort of young people age into adolescence and young adulthood.6Piot P Abdool Karim SS Hecht R et al.the UNAIDS–Lancet CommissionDefeating AIDS—advancing global health.Lancet. 2015; 386: 171-218Summary Full Text Full Text PDF PubMed Google Scholar Notwithstanding the enormous progress that has been made in the HIV response, HIV remains “the epidemic of our time”.7Corey L Gray GE Preventing acquisition of HIV is the only path to an AIDS-free generation.Proc Natl Acad Sci USA. 2017; 114: 3798-3800Crossref PubMed Scopus (4) Google Scholar In 2015–16, an estimated 36·7–38·8 million people were living with HIV worldwide, including 1·9–2·5 million newly infected in 2015.1AIDSInfoJoint United Nations Programme on HIV/AIDS.http://aidsinfo.unaids.orgDate accessed: June 14, 2018Google Scholar, 8GBD 2015 HIV CollaboratorsEstimates of global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2015: the Global Burden of Disease Study 2015.Lancet HIV. 2016; 3: e361-e387Summary Full Text Full Text PDF PubMed Scopus (218) Google Scholar More than 35 million people have died of AIDS-related causes; 1·0 million of these deaths were in 2016.9WHOGlobal Health Observatory (GHO) data.http://www.who.int/gho/hiv/en/Date accessed: June 14, 2018Google Scholar A refusal to follow through to achieve long-term control of the epidemic would merely repeat a longstanding pattern in global health, when failure to sustain a surge in global interest in combating particular health threats allows these epidemics to return in force. The history of malaria elimination efforts is a case in point, as the failure to sustain malaria-related control programmes, funding, and research investments led to an abandonment of the global malaria elimination campaign in 1969 and subsequent increases in the global malaria burden.10Nájera JA González-Silva M Alonso PL Some lessons for the future from the Global Malaria Eradication Programme (1955-1969).PLoS Med. 2011; 8: e1000412Crossref PubMed Scopus (0) Google Scholar At a moment when the means to improve human health are greater than ever, allowing a resurgence of HIV through neglect and apathy could deal a blow from which the broader cause of global health could need decades to recover. The relationship between the HIV response and the broader global health field is multilayered and bidirectional. Even as the HIV response offers important lessons from which global health can learn, it is also clear that controlling the HIV epidemic will depend in large measure on the broader global health and development fields. However, the exceptionalist approach to the HIV epidemic, in which the HIV response has often unfolded as a vertical undertaking, distinct from other health programmes, has achieved historic results and should not be jettisoned lightly. Both the HIV response and the broader global health field share a commitment to the development of health systems that are capable of addressing several health challenges at the same time. In many settings, robust, if still flawed, service systems have been developed for certain populations (eg, pregnant women, children) or for priority health conditions (eg, maternal and child health, HIV, and other communicable diseases). However, health systems as a whole are largely unprepared for providing care that is holistic, universal, and well coordinated. In the still-early years of the SDG era, the gap between reality and the vision of sustainable health remains gaping. In the midst of uncertainty about the long-term feasibility of an exceptionalist HIV approach and the prospects for achieving the lofty health targets in the SDGs, the International AIDS Society (IAS)-Lancet Commission on the Future of Global Health and the HIV Response was established in 2016 to critically examine future prospects for global health and the HIV response. The Commission was tasked with assessing the future of the HIV response in a more integrated global health and development agenda, with the aim of advising how best to achieve global control of the HIV pandemic in an era in which health and development priorities are proliferating. The Commission studied the history of the HIV response to discern how experience in responding to HIV might inform and strengthen global health more broadly. Modelling exercises were undertaken to assess the effect of various approaches to improve integration of HIV and non-HIV-related services. The most salient threats to global health and to the goal of universal health coverage were identified. With this report, we summarise the findings of the Commission, and we seek to articulate a vision for the future of the HIV response and global health that builds common cause across health and development movements and sectors. Rather than despair over the trends and patterns of the past several years, we must instead look to the extraordinary achievements of the past two decades to embolden us and reinforce our resolve to rejuvenate the HIV response and strengthen the broader cause of global health. By taking on board the lessons of the HIV response, the global health field can be made fit for the purpose of realising the vision of sustainable health for all. Global health can serve as a driving force to repudiate and discredit the continuing retreat from international solidarity, human rights, reason, scientific evidence, and open societies. Global health can serve as a pioneer in a re-engineering of the development project, from one based on charity from the high-income countries to one that tackles the central determinants of global health inequities. Just as the HIV response has demonstrated that global problems demand global solutions, the future health and wellbeing of our planet relies on us to recognise, celebrate, and build on our common humanity. With respect to the flagging response to HIV, the Commission hopes that this report serves as a wake-up call. Without a thorough rejuvenation of the HIV response and a change of course, we are likely to see a resurgence of the epidemic. After such history-making successes from unprecedented global solidarity and collaboration, the world can and must do better. To realise the vision of sustainable health for all, we must ensure that health systems are equipped to bring communicable diseases under control and to respond effectively to the growing burden of NCDs. A focused response and categorical HIV funding will remain crucial to avoid a resurgence of HIV and to bring the global pandemic under control. However, immediate and incremental steps are needed to strategically integrate HIV services into co-located primary care platforms and toward the longer-term goal of creating fully integrated, co-located, and patient-centred health-service systems. The Agenda for Sustainable Development envisages “a world free from poverty, hunger, disease and want, where all life can thrive.”11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar SDG 3 calls for concerted action to ensure healthy lives and promote wellbeing for all at all ages.11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar SDG 3 also calls for ending the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases; eliminating preventable deaths in children younger than 5 years; and reducing by a third the number of deaths from NCDs.11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar Under the Agenda for Sustainable Development, universal health coverage serves as the primary vehicle for continuing and fully leveraging the momentum on health.11UNResolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development (A/Res/70/1). United Nations General Assembly, New York2015Google Scholar The health targets of SDG 3 build on historic gains made under the MDGs (panel 1).12UNThe Millennium Development Goals Report 2015. United Nations, New York2015Google Scholar The health gains during the MDG era coincided with, and were enabled by, advances across the broader development agenda. Whereas nearly half of the population in LMICs lived on less than $1·25 per day in 1990, this proportion had fallen to 14% by 2015.12UNThe Millennium Development Goals Report 2015. United Nations, New York2015Google Scholar Primary school attendance worldwide increased between 2000 and 2015, and differences in secondary school attendance between boys and girls diminished or disappeared altogether in some regions.12UNThe Millennium Development Goals Report 2015. United Nations, New York2015Google ScholarPanel 1Health targets for Sustainable Development Goal 3•By 2030, reduce the global maternal mortality ratio to less than 70 deaths per 100 000 livebirths•By 2030, end preventable deaths of newborn babies and children younger than 5 years, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 livebirths and under-5 mortality to at least as low as 25 deaths per 1000 livebirths•By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases•By 2030, reduce by a third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and wellbeing•Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol•By 2020, halve the number of deaths and injuries from road traffic accidents globally•By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information, and education and ensure the integration of reproductive health into national strategies and programmes•Achieve universal health coverage, including financial risk protection, access to quality and essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all•By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination•Strengthen the implementation of the WHO Framework Convention on Tobacco Control in all countries, as appropriate•Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily affect developing countries, provide access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affirms the right of developing countries to use to the full the provisions in the Agreement on Trade-Related Aspects of Intellectual Property Rights regarding flexibilities to protect public health, and, in particular, provide access to medicines for all•Substantially increase health financing and the recruitment, development, training, and retention of the health workforce in developing countries, especially in least developed countries and small-island developing states•Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction, and management of national and global health risks •By 2030, reduce the global maternal mortality ratio to less than 70 deaths per 100 000 livebirths•By 2030, end preventable deaths of newborn babies and children younger than 5 years, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1000 livebirths and under-5 mortality to at least as low as 25 deaths per 1000 livebirths•By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases•By 2030, reduce by a third premature mortality from non-communicable diseases through prevention and treatment, and promote mental health and wellbeing•Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol•By 2020, halve the number of deaths and injuries from road traffic accidents globally•By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information, and education and ensure the integration of reproductive health into national strategies and programmes•Achieve universal health coverage, including financial risk protection, access to quality and essential health-care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all•By 2030, substantially reduc