Finishing the job on HIV/AIDS

What it will take to end the HIV/AIDS pandemic as a global health threat by 2030

In the wake of the COVID-19 pandemic, there is a renewed need for domestic and donor support to end the HIV/AIDS pandemic as a global health threat. This requires a strong emphasis on galvanizing political and programmatic leadership to sustain the response, centering programs around health equity, sustainably strengthening public health systems, and health security.

In 2001, the Heads of State of Africa met in a special summit in Abuja devoted specifically to addressing the exceptional challenges of HIV/AIDS. The HIV/AIDS pandemic had been raging worldwide with an acute impact on most countries in Africa. The spread of the disease was impacting every dimension of society–in African countries most affected, AIDS had lowered life expectancy of adults on average by 20 years. This session, which came soon after the unprecedented U.N. Security Council Resolution in 2000 declaring HIV/AIDS a security threat, acknowledged the tremendous impact that the spread of HIV was having on the continent as not only a health crisis, but also an economic and security crisis, which would lead to massive instability in the continent if left unchecked.

The Abuja summit concluded with heads of state committing to take personal responsibility and provide political leadership at the highest level to commit all necessary resources and measures to attack the epidemic–from pledging 15 percent of budgets to the health sector, providing access to affordable treatment, scaling-up educational efforts, to reforming national policies. These commitments helped spark a regional movement to attack the HIV/AIDS pandemic on the continent by governments, donors, advocates, non-profits, private companies, and more.

Twenty years later, the annual number of new infections has dropped by 75 percent (from 3.4M to 870,000), and deaths have dropped 80 percent (from 2.3 million to 460,000) in Africa.¹ Several high-burden African countries have reached the UNAIDS 90- 90-90 targets.² It is no coincidence that this period has resulted in the fastest economic growth in Africa’s history and has seen tremendous gains in other development indicators such as poverty alleviation, educational attainment, gender equity, and maternal and child health. Analysis comparing U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) recipient countries with similar non-PEPFAR supported low-and middle- income countries found that PEPFAR countries experienced 35 percent greater reductions in child mortality, 25 percent reductions in maternal mortality, and significant improvements in childhood immunizations. GDP per capita growth rates were 2.1 percentage points higher for PEPFAR countries compared to non-PEPFAR supported countries, and the share of girls and boys out of school declined by 9 and 8 percent respectively. The effects were strongest where PEPFAR engaged in more intensive planning and funding.³

Despite this progress, we are at a new inflection point in the HIV/AIDS pandemic in part because of the COVID-19 pandemic. The pandemic particularly impacted access to HIV prevention services, and the rate of decline of new infections has slowed. If the current pace continues, we will be off-track to reach the UNAIDS global target of 370,000 infections by 2025.

What is worse is that the most vulnerable populations continue to be at the highest risk. Approximately 52 percent of children living with HIV receive the lifesaving treatment they need, compared to 76 percent of adults.⁴ Adolescent girls and young women continue to be more than twice as likely to be infected relative to their male counterparts. And Key Populations (KP)–men who have sex with men, transgender persons, people who inject drugs, sex workers, incarcerated people)–make up an increasingly large share of new infections.

PEPFAR’s five-year strategy

To meet the moment in the trajectory of the HIV/AIDS response, we launched PEPFAR’s new 5-year strategy on December 1, 2022. The strategy outlines several areas that PEPFAR will be pursuing to help achieve the global goal of ending HIV/AIDS as a global health threat. There are three key areas where African policymakers have a unique role to play in the response.

1. Elevating HIV/AIDS to the highest levels of political leadership to sustain the response

The 2001 Abuja summit was a powerful example of African political leadership. African heads of state outlined concrete goals and commitments and helped to galvanize the global community to aid in the response. In the decade that followed, thanks in large part to continued African leadership and partnerships, 27 countries increased the proportion of their expenditures on health. However, the situation has deteriorated; in 2016, 19 African countries were spending less on health as a percentage of their public spending than the early 2000s, and only three countries exceeded the 15 percent threshold.⁵

New political leadership is needed to sustain progress. Over the next decade, HIV/AIDS programs should primarily become the responsibility of African countries as support from outside donors inevitably declines, even as PEPFAR continues its commitment to our partner countries. This should start with clear political commitments from Heads of States to lead and manage their own HIV response–by articulating and acting on their own vision and holding their ministries accountable for results. This will help to unlock greater programmatic leadership for the oversight and management of HIV prevention and care efforts, and the broader strengthening of health systems (workforce, labs, data and surveillance, supply chains, etc.) that underpin HIV/ AIDS programs.

In many countries, donors are currently performing many of the core functions around performance management and service delivery. Until countries take over programmatic accountability, the HIV/AIDS response will continue to be viewed as a donor-led activity. Over time, more robust political and programmatic leadership should help to unlock financial leadership as well by encouraging ministries of finance, and development to recognize that investing in HIV/AIDS and health systems programs domestically will yield high returns.

PEPFAR will help to enable these three components of sustaining the response by working with countries in partnership with the African Union (AU) and other regional and global entities to jointly develop a sustainability roadmap, articulating a shared pathway for countries to take increasing responsibility for their own epidemics and hold all parties accountable for results.

2. Improving health equity for priority populations

The HIV/AIDS pandemic does not affect people uniformly. We know that persistent inequities for the most marginalized populations persist—countries should address these inequities head-on to close these gaps. This starts with adolescent girls and young women, who remain disproportionately impacted by the HIV/AIDS pandemic in Africa. Governments need to recommit to providing holistic, multi-layered support and enabling policy environments that for meet the needs of girls and women given the intersecting challenges they face that increases their risk for contracting HIV. This includes ensuring they can stay in school, access economic opportunities to earn livable incomes, receive comprehensive destigmatized sexual and reproductive health services like PrEP, and thrive in their daily lives free from violence.

Children remain less likely than their adult counterparts to receive treatment, despite the existence of highly effective pediatric treatments in the form of dolutegravir. This gap is unacceptable, and the seven countries that make up the roughly 80 percent of these missing children (Democratic Republic of Congo, Mozambique, Nigeria, South Africa, Tanzania, Uganda, and Zambia) should especially double down on the funding and management of preventing mother to child transmission (PMTCT) and care linkage programming.

Lastly, Key Populations (KPs)—continue to bear the highest per capita risk of contracting an HIV infection. Governments and donors need to bring KPs and community organizations in the lead to inform the design and expansion of equitable and nondiscriminatory prevention, testing, and treatment services. Governments also need to look critically at the restrictive laws and policies that criminalize or stigmatize these populations and prevent them from accessing the services they need–and learn from peer countries in the region who have successfully pursued reforms.

3. Leveraging the PEPFAR platform to strengthen public health systems and health security

During the COVID-19 pandemic, the recent Ebola outbreak in Uganda, and other disease outbreaks, the public health infrastructure, relationships, and practices that PEPFAR has helped to establish and strengthen for HIV proved essential to responding to new and unexpected health threats. While maintaining focus on HIV as our core mission, moving forward, PEPFAR will continue to apply lessons learned from HIV and intentionally strengthen overall public health systems to respond to health security threats. Such investments will aim to protect HIV/AIDS gains and ensure increased sustainability for countries’ HIV/AIDS response.

Regionalized and modernized supply chains for health commodities

The COVID-19 pandemic has clearly demonstrated the need for a robust regionally diversified, sustainable pharmaceutical manufacturing and supply chain ecosystems to protect against health security threats, including in Africa. A strong, diversified, and sustainable manufacturing base would also decrease procurement costs, prevent stockouts, introduce new products faster, and create substantial economic benefits. However, between 70-90 percent of drugs consumed on the African continent are imported; (China and India have comparable populations and import 5 percent and 20 percent, respectively). For vaccines, only 1 percent of vaccines consumed are manufactured in Africa.⁶ For Africa to address this challenge, it needs a holistic approach and an enabling environment for sustainable regional manufacturing that allow manufacturers to supply multi-country geographies, promote healthy competition, and enables sizeable, sustainable manufacturers to emerge. PEPFAR will lead by setting explicit, ambitious targets for African procurement of HIV commodities for the next decade and will adjust our procurement policies to help jumpstart demand–and drive other donors to follow.

To create this enabling environment, we will need to work with African policymakers and multilateral organizations to develop tariff and trade policies, environmental policies, and regulatory policies to support sustainable local manufacturing capacities. It will also be critical for African policymakers to certify and fund the African Medicines Agency (AMA) to lead in certification of products and implement the African Free Trade agreement to enable cross-border trade. Leaders of global and African development finance institutions should take this opportunity to provide financing and other support to pharmaceutical manufacturers standing up or expanding operations and enhancements to health supply chains across the region.

But manufacturing is not enough to get the products to the people who need them quickly and efficiently. We continue to see high rates of stockouts across PEPFAR-supported countries, and our supply chains are simply not people-centered.

African policymakers need to promote a long-term vision for a modern and sustainable supply chain, which includes movement away from the emergency nature of Central Medical Stores and integration of private sector providers across the value chain; strengthening government capacity in supply chain leadership, oversight, comprehensive planning and risk management; and diversifying channels of last-mile delivery of products beyond the public clinics. Policymakers need to also recognize that supply chains go beyond ministries of health and engage the ministries of finance, development, and trade to remove bottlenecks that create artificial supply shortages at the port or the border. PEPFAR will coordinate with African partners and other donors to help to strengthen country capacity to lead in the development and implementation of this long-term approach to supply chain modernization.

Despite the lessons from Ebola, COVID-19 and other outbreaks, the health workforce remains one of the most under-invested areas of the public health system. Africa needs 6,000 field and 25,000 frontline epidemiologists but has only trained 2,000 and 5,000 respectively. In 2017, the AU launched a two million community healthcare worker initiative, but to date only a few hundred thousand professionalized workers have been deployed, and many remain un-salaried, and poorly trained, equipped, and supervised. Nurses continue to be under-equipped and poorly prepared for new outbreaks, leading to high rates of mortality among their cohort.

Country leaders need to bring together ministries of health, education, and finance to develop an integrated plan to train, finance, and support the next cohort of nurses, community health workers, epidemiologists, and health data scientists. PEPFAR and other disease-specific donors need to align their future health workforce investments to better support those integrated country plans and, workforce leadership programs going forward.

Empowered national public health institutes

National Public Health Institutes (NPHIs) serve as the backbone of an effective public health response; during COVID-19, countries with strong NPHIs were more effective in coordinating the outbreak response. More than 30 African countries have already created NPHIs, and for those countries it is incumbent on political leaders to financially support their core capabilities (surveillance, lab networks, emergency operations centers, research). PEPFAR will work to strengthen NPHIs by partnering with the Africa CDC to enlist NPHIs to lead on core HIV-control functions such as conducting household surveys to measure the epidemiological change in the disease and leveraging their EOCs to tackle pockets of new infections.

PEPFAR has a critical role to play in the future of the HIV/AIDS response. But without leadership from policymakers, all our collective efforts will be unsustainable. African leaders need to recognize that strong public health systems are a fundamental element of strong national security and economic growth, and prioritize it accordingly in domestic budgets, laws, and policies. Country leaders also should endorse, fund, and strengthen regional institutions such as the Africa CDC and AMA who are taking a lead in coordinating the health response. Disease-specific donors including PEPFAR need to come together to harmonize and prioritize public health systems and security investments, and support country leadership in developing and implementing integrated national plans. We have come so far, and together we can end HIV/AIDS as a public health threat on the continent and globally.

Leveraging lessons from COVID-19 to build stronger health systems

Sir Winston Churchill averred, in the aftermath of World War II, that one should never let a “good” crisis go to waste. The COVID-19 pandemic offered several lessons for Africa’s health systems that should form the basis for a stronger, more inclusive recovery. One such lesson is that African governments ought to prioritize investments in the health sector as a means, not only to improve population health, but also to safeguard the economy. African health systems are chronically underfunded; it is estimated that on average African countries’ government expenditure on health, as a share of gross domestic product (GDP), is 2 percent—far less than the 5 percent recommended threshold for low- and middle-income countries to register meaningful improvements in population health outcomes.⁷ Under-investment in the health sector meant that African health systems were ill-prepared for the pandemic, and thus, suffered great economic loss.

One way to unlock additional financing and resources for the health sector is to exploit efficiency gains by reducing wastage. Two strategies are worth considering. African countries could achieve better outcomes from existing resources by introducing and institutionalizing the use of economic evidence to guide and inform healthcare resource allocation decisions in ways that promote value-for-money. One such approach is health technology assessment (HTA). HTA is a multidisciplinary process that uses explicit methods to determine the value of health interventions and services in ways that promote efficiency and other health system goals. Good examples of countries that have implemented HTA to improve the efficiency of their health system include Thailand’s universal coverage scheme, and the UK’s National Health Service (NHS). Likewise, there is also a need for African governments to tackle corruption head-on by implementing effective anti-corruption strategies. Some estimates put the loss of healthcare resources owing to weak governance and accountability environments that in turn facilitate health sector corruption to as much as 10 percent annually.⁸

The second lesson is that African countries ought to foster self-reliance by investing in the manufacture of essential health commodities. The vaccine nationalism and apartheid witnessed during the COVID-19 pandemic, coupled with international supply chain disruptions, exposed the vulnerability of African health systems to over-reliance on imports. Some estimates indicate that Africa imports more than 80 percent of its pharmaceutical and medical consumables, and 99 percent of its human vaccines.⁹ It is encouraging that several African countries have since initiated plans to establish local vaccine manufacturing. African governments must also understand that the sustainable development of vaccines and pharmaceutical manufacturing is underpinned by a vibrant research and development (R&D) ecosystem. While African countries have committed to spending 1 percent of their GDP on R&D, the continent’s funding of R&D stood at only 0.42 percent, compared to the global average of 1.7 percent.¹⁰

The third lesson is that African governments must re-prioritize universal health coverage (UHC). COVID-19 revealed that countries with advanced UHC systems are far better at responding to a pandemic or health shock.¹¹ A system where individuals face financial barriers to access healthcare, compromises vital public health strategies during a disease outbreak (i.e., detect, isolate, and treat) such that infected individuals go undetected and cannot access isolation or treatment services, and thus continue to spread disease. While many African countries have made political commitments to UHC, this commitment has hardly translated to investment and implementation. Out-of-pocket spending, as a share of total health spending, in Africa is also among the highest in the world at 38 percent—with countries like Nigeria having levels as high as 77 percent.¹² During the pandemic, this manifested in the form of individuals not accessing testing, isolation, and treatment because they could not afford to pay for these services, and in some cases, individuals are being forcefully detained in health facilities for not being able to pay the costs of isolation or care.

In addition to increasing health sector funding, several shifts will be required to course correct the continent’s UHC aspiration. The first shift is the need for African countries to re-orient their UHC plans and ground them on tax-funded approaches as opposed to contributory health insurance. Many African countries are planning or already implementing public health insurance systems that rely on individual/household premium contributions as a means to achieve UHC. There is overwhelming evidence that it is problematic to achieve scale and equity in coverage, with health insurance systems that rely on individual/household premium contributions—especially in Africa where large shares (up to 80 percent) of the population are in the informal sector with unpredictable and irregular incomes. A recent analysis found that only four out of 36 African countries (Rwanda, Ghana, Gabon, and Burundi) have achieved health insurance coverage levels greater than 20 percent, and that coverage for all four countries, was characterised by substantial funding from tax revenues.¹³

Contributory health insurance systems were also found to be highly inequitable on the continent. A third shift is the prioritization and financing of common goods for health (CGH). CGH are core, population-based functions that are essential to the health and wellbeing of entire societies, as opposed to individual-based services. Examples of CGH include disease surveillance systems, research and development, regulatory systems, and public health policies. CGH not only support the health and wellbeing of populations generally, but also bolster health security.

Lastly, several regional opportunities abound for African governments to leverage and strengthen their health systems. I will highlight two here. First, African leaders should take advantage of regional integration to strengthen healthcare markets and systems. The Africa Continental Free Trade Area (AfCFTA), is the world’s largest free trade area in terms of population (1.3 billion) and number of countries (54), and has the potential to spur the growth of Africa’s health markets by opening up markets for labour (health workers) and health commodities, and by attracting investments into the continent’s health sector. In addition, it has the potential to support the continent’s initiative to develop vaccines and pharmaceutical manufacturing.

Another regional opportunity that African health systems should take advantage of is, the continent’s strong regional organizations that include the African Union (AU), the Africa Centres for Disease Control and Prevention (Africa CDC), and the African Development Bank (AFDB). These organizations not only have immense convening power, technical capacity, and capacity for advocacy, but they have also put in place initiatives whose implementation will leapfrog Africa’s health system. For instance, the AU and Africa CDC have outlined a blueprint to strengthen health security in Africa labelled the “New Public Health Order.” The AU has articulated a plan to spur pharmaceutical manufacturing—Pharmaceutical Manufacturing Plan for Africa (PMPA), while the Africa CDC has also laid out a framework for the development of local vaccine manufacturing (the partnership for Africa Vaccine manufacturing). Further, the AFDB has established the African Pharmaceutical Technology Foundation, that plans to spend $3 billion over the next decade to support the continent’s pharmaceutical and vaccine manufacturing plans. However, these efforts will only be successful if African governments support and facilitate the leadership role of these regional agencies.

As we look forward to 2023 and beyond, here is hoping that African governments learn from the COVID-19 pandemic and invest in nurturing the resilience of the continent’s health system to safeguard