The HIV response is in danger – the promise of ending AIDS is under threat

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In Cambodia, although many achievements have been made towards reaching its national HIV targets, the rate of decline in new infection has stalled and a slower rate of decline is observed among young people. Heng Chivoan

Last year, world leaders came together at the UN in New York and agreed a groundbreaking Political Declaration on HIV and AIDS. That plan takes on the inequalities that drive the pandemic by setting ambitious strategies and targets to dramatically reduce new HIV infections, reduce AIDS-related deaths by 2025, and end the AIDS pandemic as a global health threat by 2030 – if world leaders fulfil it.

Data just released in the new UNAIDS report, In Danger, reveals that the world is not on course to end AIDS by 2030. The 3.6 per cent reduction in global HIV infections in 2021 is the smallest annual fall since 2016. On the current trajectory, there will be a projected 1.2 million new HIV infections worldwide in 2025, more than three times higher than the target of 370,000. Eastern Europe and central Asia, Middle East and North Africa and Latin America have all seen increases in annual HIV infections over several years. In Asia and the Pacific – the world’s most populous region – UNAIDS data now shows new HIV infections are rising where they had been falling. Climbing infections in these regions are alarming.

The human cost of a stalled HIV response is chilling. Globally, more than 1.5 million people became infected with HIV last year. That’s 4,000 people every day, more than a quarter of them were young people aged 15-24. Worldwide, an adolescent girl or young woman acquires HIV every two minutes. Although affordable treatments are available to prevent most AIDS-related deaths, the AIDS pandemic took a life in every minute with 650 000 people died of AIDS-related illnesses in 2021.

In Cambodia, although many achievements have been made towards reaching its national HIV targets, the rate of decline in new infection has stalled and a slower rate of decline is observed among young people. These must be brought down dramatically in order to reach the national ultimate goal of ending AIDS as a public health threat by 2025. More innovative and efficient interventions are needed to encourage people most at risk of HIV transmission to seek HIV testing and HIV prevention methods.

Cambodia is a global pioneer in several aspects of the HIV response, including its approach to the implementation of Pre-Exposure Prophylaxis (PrEP) as showcased in the global report. However, the gains made are fragile and at risk of being lost if concerted, holistic, and sustainable approaches are not used by all HIV stakeholders, including leveraging on the valuable and unique support from PLHIV and key populations communities and networks.

The Covid-19 pandemic, the war in Ukraine and the global economic crisis have created extraordinary headwinds that threaten the national HIV response. Global solidarity is fraying, richer countries are cutting or redeploying humanitarian budgets, low- and middle-income countries are saddled with debt repayment and being forced to cut back spending on essential services like health and education and, in many countries, there is a lack of political will to challenge inequalities, gender-based violence and the criminalisation and marginalisation of groups of people that are vulnerable to HIV transmission.

In Cambodia, lessons learned during the Covid-19 response are being used to bolster the quality of support to the HIV response. This includes increased use of virtual interventions for HIV prevention, care, and support; scale up of multi-month dispensing and same-day-initiation of ART treatment in majority of HIV health facilities; and increased access of people living with HIV to social protection programs. Such innovations have been critical not only to better reach the communities in need, but also to cushion the growing financial constraints that the national HIV response encounters.

The human and financial cost of not ending AIDS by 2030 would far outweigh the cost of the immediate and necessary action to turn the ship around.

The good news is that success is possible, and Cambodia has provided a great example through its achievement of the 90-90-90 targets in 2017 and scale up of PrEP. Other examples of success from the Asia and Pacific region include the use of digital technologies and community-led services to reach more key populations, especially young people, in the Philippines and Thailand, and scale up of HIV testing and reduction of new infections in Vietnam.

Here are five ways that countries can defend and expand their HIV response.

• Address the inequalities that stop people receiving HIV prevention, testing and treatment services. In diverse settings, countries and communities are taking action to end inequalities and close gaps. Building on this momentum, policy makers need to strengthen their understanding of localised epidemics to focus on eliminating the inequalities that are slowing progress against the pandemic.

• Realise human rights and gender equality. Punitive, discriminatory, counterproductive laws and policies must be removed. The human rights of women and girls, including their sexual and reproductive rights, must be upheld. Countries must prioritise and integrate focused, well-resourced efforts to end gender-based violence into national HIV responses.

• Make a new push for HIV prevention. Countries urgently need to elevate the political and financial prioritisation of HIV prevention and move to large-scale implementation of prevention projects so that innovations such as PrEP and long acting injectables become much more widely accessible, especially to vulnerable groups of people like young women and adolescent girls, gay men and other men who have sex with men, sex workers, people who use drugs and transgender people.

• Support and effectively resource community-led responses. Countries must recognise the essential role of community-led responses and integrate them into national HIV planning, implementation and monitoring. Communities should be effectively resourced and laws that impede community-led responses should be removed.

• Ensure sufficient and sustainable funding. Major new investment and innovative financial mechanisms are needed to ensure a fully funded global AIDS response, both from international donors and governments in low- and middle-income countries. Coordinated international action is also required to alleviate the debt crisis facing too many countries and to counteract the need for short-sighted and counterproductive national austerity measures.

In Cambodia, two key priorities for urgent action are (1) ensuring that all people at risk of HIV infection have access to HIV prevention options (including PrEP, HIV self-testing, condoms, and prevention information), and (2) exploring programmatic and financial models that ensure a quality and sustainable HIV response for the continued health and wellbeing of all people in Cambodia for years to come.

Ending AIDS is a promise that can and must be kept.