Forward: Measuring Progress Toward Epidemic Control.

Abstract

Eighteen years ago, in the January 2003 State of the Union Address, PEPFAR was born as a clear expression of the compassion of the American people to end the human suffering of the AIDS epidemic and bring hope and life to communities around the globe. Over the next decade, with ambitious goals, programmatic evolution, and a keen focus on measuring outcomes and impact, PEPFAR demonstrated that anything is possible. Outcomes, such as viral load suppression, need to be measured specifically and directly at both the individual and community level and linked to the demographics of the population to ensure everyone in need of prevention or treatment receives services. Impact needs to be measured to demonstrate the value of policies, programs, and investments. Since 2014, PEPFAR has measured outcomes and impact in many ways, including through the pioneering national, population-based, HIV-focused PHIA surveys to estimate HIV prevalence, incidence, and, critically, individual-level and community-level viral load suppression. Beginning in 2016, results from the first 3 of these HIV surveys showed that once people started HIV treatment, regardless of age, sex, or location, most stayed on treatment and were virally suppressed. These survey results demonstrated that countries were moving toward epidemic control and were closer than expected to a time when the financial resources needed to address the epidemic would be sustainable. The surveys also provided a way to validate and improve HIV estimates derived from the excellent work of UNAIDS, in partnership with countries, on the Spectrum model. Although the survey results showed clear progress toward the sustainable development goals for HIV, they also identified critical programmatic gaps, such as the unacceptably high HIV incidence among young women and high HIV prevalence among 20- to 30-year-old persons. Both these findings underscored the urgency of reaching young people with prevention and treatment programming. In addition, few young men and women younger than 25 years were aware that they were infected with HIV; they were unknowingly able to infect others, and critically, they were not on life-saving treatment to protect their own health. PEPFAR responded quickly to these critical gaps by substantially increasing the investments in prevention and treatment for all young people and key populations. The surveys also called attention to the need to work with communities and governments to address structural barriers by changing policies to improve access to HIV treatment and highlighting the need for client-centered services. Survey results from Nigeria, Cameroon, and Cote d'Ivoire were instructive to partners and governments who came together to address the barriers posed to accessing health services by both formal and informal client fees. PEPFAR and the Global Fund supported governments in making policy changes, significantly increasing access and increasing equity of access to both prevention and treatment services. These surveys were complex in design and execution, returning test results in the household to individuals who consented to participate in the surveys; collecting, storing, and testing specimens from the remotest places; and collecting and analyzing data to rapidly inform the programming of PEPFAR resources. These surveys were historic for the improved outcomes and impact on HIV and TB/HIV programming, and they provide important lessons to benefit future global health programming. When PEPFAR began, HIV was a death sentence in many parts of the world, and the global community did not think that a public health approach to infectious disease at scale was plausible. Since 2016, 13 additional surveys have been completed across the PEPFAR-supported countries. Taken together, these surveys are demonstrating that when programmatic gaps are accurately measured, the global health community can respond with novel and scalable solutions to address population and geographic gaps and bring us closer to reaching epidemic control.