Geoff Garnett, Deputy Director, Global Development and Global Health, at the Bill & Melinda Gates Foundation
The sessions, publications and conversations in and around International AIDS Conferences reflect the zeitgeist of our response to the AIDS pandemic, where prevailing sentiments swing between optimism and defeatism. By the time the 22nd International AIDS Conference (AIDS 2018) took place, more than 20 million people living with HIV were using effective treatment, but millions more need to be treated. HIV incidence has declined, but ongoing transmission adds to the numbers in need of treatment. HIV programmes are well funded compared with other healthcare programmes, but resources are constrained and in jeopardy. In many populations, the target of 73% virally suppressed has nearly been reached. However, reductions in transmission are not as high as hoped because young adults, key populations and the newly infected are underrepresented in those on treatment. In summary, AIDS 2018 made it clear that we need to keep going, building on successful HIV treatment programmes, and that keeping going will require ever more efficiency.
A system under mounting pressure can either break or adapt. I believe that in differentiated service delivery, we have a framework to facilitate the adaptation of the HIV response so that we can sustain efficient HIV treatment without sacrificing quality. Reserving intense patient management for the few allows a simpler, easier “public health” approach to be followed for the many, reducing the burden for both the patient and provider. Asking for the minimum effective package should drive our programming, and we are seeing, in early results from Zambia, Ethiopia and South Africa presented at AIDS 2018, that less frequent appointments and easy drug collection are improving clinical outcomes. Such simplification is a necessity, but the innovation, experimentation and shared lessons supported by the World Health Organization, the International AIDS Society and inter-governmental learning networks like the Coverage, Quality and Impact Network (CQUIN), highlighted at AIDS 2018, should make the spread of DSD models more successful.
Despite the barriers to bringing DSD approaches to scale, it is becoming fashionable and being applied to testing and primary prevention; these are areas where services should have been differentiated all along. Hopefully, this disruptive thinking, considering the circumstances and perspectives of those at risk and their communities, will allow testing and prevention to be better focused and more effective. Studies of differentiated treatment delivery among key populations presented at AIDS 2018 showed that it was acceptable and improved outcomes. As key populations should also be a focus for testing and primary prevention, we should think about how these additional services can be included.
Paradoxically, while DSD offers a more efficient approach, the implementation dip requires that resources be used to develop and promote differentiated approaches. If these resources generate complex, intensive testing, treatment and prevention models requiring ongoing external leadership, then they will be in vain. Welcome results at AIDS 2018 on the effectiveness of teen clubs and peer navigators illustrate effective approaches, but we should consider how best such innovations can be efficiently and sustainably taken to scale.
The treatment of millions has been made possible by the development and distribution of drug that are both lower cost and more effective. To sustain HIV control, we need service delivery that is both lower cost and more effective over the long run. DSD should be a path to get there.
