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UNAIDS report overlooks significant aspects of the global HIV response

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UNAIDS' World AIDS Day 2018 report is selectively silent on persistently high AIDS mortality and looming treatment rationing in light of donor disengagement.

This year’s UNAIDS report highlights the importance of viral load testing, a critical indicator of the effectiveness of HIV treatment in people living with HIV.

Yet the focus on HIV testing and regular viral load monitoring overlooks fundamental aspects of today’s HIV epidemic and continued high numbers of AIDS-related deaths.

The report also fails to profile the significant shortfalls in international support to effectively fight the HIV/AIDS epidemic.

The situation today

AIDS-related deaths have remained strikingly high in recent years, despite increased access to antiretroviral treatment.

Globally, 30 per cent to 40 per cent of people starting HIV treatment today have advanced HIV disease, otherwise known as AIDS.

Across sub-Saharan Africa, people living with HIV arrive at MSF-supported hospitals with such advanced stages of HIV disease that 25 to 30 per cent die within 48 hours of arrival.

Their slow progression towards death was missed at each step until it was too late.

The key difference between 30 years ago and today is that many people living with HIV seeking treatment within MSF-supported facilities already know their status and are on antiretroviral treatment (ART). Yet they interrupted their treatment because of the countless obstacles they encountered, or they developed treatment failure that was either not diagnosed or never treated with second or third-line antiretrovirals.

Worse still, they succumb to preventable and treatable diseases such as tuberculosis, bacterial infections, cryptococcal meningitis, toxoplasmosis and pneumocystis pneumonia.

Critical gaps in the HIV response

While increased HIV testing and viral load monitoring are important parts of the HIV response, other critical parts remain neglected: retention in HIV care, management of treatment failure, and prevention, detection and management of AIDS-related illness.

While viral load monitors treatment success, access to CD4 testing remains essential to determine the presence of AIDS, and trigger lifesaving treatment for opportunistic infections.

This means continued resources and attention to support people living with HIV through the challenges of lifelong treatment is key, as is the systematic detection and treatment of AIDS at all levels.

Funding at odds with ambitious global targets

The UNAIDS report also fails to highlight serious funding gaps and difficulties that are pulling the HIV response off track.

This selective silence may suggest that ‘all is well’ while the effects of reducing funding across the international donor landscape are now being felt in several countries where MSF works. This sits at odds with ambitious global targets to control the HIV epidemic.

Countries in West and Central Africa, where almost 30 per cent of AIDS-related deaths occur, face a major overall funding gap, with resources needed to implement the fast track approach being 81 per cent greater than the amounts available in 2017.

This stands in direct contrast with recently adopted acceleration plans that call for swift scale-up.  

Central African Republic and Guinea face funding shortfalls for ART in their Global Fund allocations of 2018-2020. Without additional resources, these countries will be forced to reduce initiation rates instead of accelerating urgently needed scale-up.

In Mozambique, the implementation of the Mexico City Policy by the US administration has indirectly affected and disrupted HIV services for the most vulnerable.

Zimbabwe has a projected gap of $85 million for the 2020 time period for their projected ART needs.  

Urgent action needed to curb the epidemic and reduce the senseless loss of life

UNAIDS must shed light on these gaps and lead the mobilisation of international donors where additional resources are needed.

Countries cannot be left behind with the impossible choice of rationing or slowing down lifesaving prevention, treatment and care services.

Instead of rhetorical promises for better global health while flat-lining their contributions, donors need to step up with additional commitments, including to the replenishment of the Global Fund.

The consequent withholding of timely treatment initiation, uninterrupted treatment, early detection and adequate care for AIDS-related illness among people living with HIV will lead to more deaths, not less.

Médecins Sans Frontières (MSF) has been involved in HIV care since 2000.

In 2017, MSF supported 215,900 people living with HIV on treatment in 27 countries in Africa, Asia and Eastern Europe, with a focus with a focus on implementing treatment strategies to reach more people earlier in their disease progression, and placing people living with HIV at the centre of their care.

MSF is increasingly developing approaches to treat AIDS and address treatment failure, improve paediatric and adolescent HIV care, and improve the delivery of treatment in neglected contexts such as West and Central Africa and countries affected by conflict.

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Press Release 29 November 2018