Initiatives to fill the gaps in Africa's AIDS response

Abstract

In early July, the 29th African Union Summit saw political leaders from across the continent convene in Addis Ababa, Ethiopia. The agenda for the summit included climate change, conflict, internet presence and infrastructure, and a focus on empowering women and young people—and, of course, HIV/AIDS. On July 3, African Union heads of state and government adopted AIDS Watch Africa's Strategic Framework, committing to two major new initiatives to help make up lost ground in efforts to end AIDS by 2030: an emergency plan to address the epidemic in west and central Africa and the recruitment of 2 million community health workers. The west and central Africa emergency plan aims to address the large shortfall in diagnosis, treatment, and viral suppression among people living with HIV in the region. The UNAIDS 2020 goal of 90% of people knowing their status, 90% (81% of all people with HIV) of those on treatment, and 90% (73%) of those with viral suppression is the central pillar of efforts to end AIDS by 2030, but worldwide few countries are near this goal. Based on 2015 figures (the most recent available at the time of going to press): 57% of all people living with HIV know their status, 46% of all people with HIV have access to treatment, and 38% are virally suppressed; however, for west and central Africa these proportions are 36%, 28%, and 12%—4·7 million people were not receiving antiretroviral treatment and 330 000 people died of HIV. The catch-up aims for the region are to boost the number of people on treatment to 2·9 million, recruiting 1·2 million extra people. The concentrated epidemics in south and east Africa, have historically distracted attention from west and central Africa, which has not benefited from the infrastructure of research and health-systems developed in countries with higher prevalence. Nonetheless, the area has a substantial burden—for example, Nigeria has the second largest number of people living with HIV after South Africa. Ten countries in the region have developed national HIV plans (Benin, Cameroon, Central African Republic, Côte d'Ivoire, Democratic Republic of the Congo, Guinea, Liberia, Nigeria, Senegal, and Sierra Leone), but the reliance on donors in much of the region means that many of these plans are vulnerable. Of around 3 million people living with HIV in Nigeria, a third are on treatment, but over 900 000 of these are treated with the support of international donors. It is essential for national plans to build in sustainability and durability. The second initiative of the African Union Summit would fit well with efforts to build sustainability into national HIV/AIDS programmes. Community health workers are a cost-effective way to deliver tried and tested interventions to people with limited access to health facilities—testing, counselling, and treatment initiation could be vastly expanded with a cadre of 2 million additional workers helping to reach the first two 90s of the UNAIDS target. However, much of the research on and experience with deployment of community health workers has been in east and south Africa; therefore if these workers are to have an impact in west and central Africa, cultural adaptation to these new settings will be needed to optimise their effects. Ensuring recruitment and deployment of health care workers and success of the initiative to address the epidemic in west and central Africa will require considered and well thought out national plans. Governments should take lessons from countries with long-histories of national strategic HIV planning, and particularly the shortcomings of those plans. The Treatment Action Campaign has recently criticised the new National Strategic Plan of South Africa for failing on numerous fronts: roll-out of pre-exposure prophylaxis (PrEP), gender equality, engagement of lesbian, gay, bisexual, and transgender groups, and saliently, use of community health workers. The African Union's adoption of new initiatives to help achieve the goal of ending AIDS by 2030 is encouraging. And a raft of new interventions—PrEP, self-testing, and new generic medicines—mean that the possibility of achieving an end to AIDS has never seemed more realistic. But government commitments at an international level will mean little without effective national plans to tailor the deployment of new interventions and community health workers to local settings that recognise the diversity and patchiness of the HIV epidemic in sub-Saharan Africa at subnational levels. And the progress, effectiveness, fairness, and success of these programmes, and the progress in recruiting and deploying community health workers, should be revisited at future African Union Summits—initiatives are one thing, accountability and delivery are quite another. Divergent paths to the end of AIDSWriting in the middle of the northern hemisphere's summer holidays, the lull in journal submissions and acceptance that peer-review probably won't happen for a few weeks gives time to pause and reflect on the broader picture in HIV/AIDS in 2017. Just a few weeks after the International AIDS Society Conference on HIV Science and the launch of UNAIDS updated statistics on the global HIV epidemic, now is a good time to take stock. Full-Text PDF