Twenty years ago, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was established to lead the global response to the HIV epidemic. Today, PEPFAR is a public health engine: a critical platform for strengthening health systems, preparing for and responding to pandemics, and enabling global health security. Here, we share how PEPFAR made it possible for FHI 360’s teams to effectively respond to COVID-19 in countries with established HIV infrastructure.
A little more than a month after World AIDS Day 2019, COVID-19 started to impact our HIV programs in Asia as countries like Cambodia, Thailand and Vietnam began quarantine. Community testing ground to a halt. People living with HIV worried about access to their medications. HIV pre-exposure prophylaxis (PrEP) enrollment slowed. COVID-19 testing diverted laboratories from HIV services. By March 2020, the rest of the world was equally impacted. FHI 360’s HIV programs were determined to continue serving people, but there were deep concerns. We were not alone, of course; the global HIV community was facing COVID-19 together. But with so much uncertainty, we wondered: Would COVID-19 substantially set back hard-won gains toward epidemic control? Did we have the tools in hand, or could we develop the tools, to weather this crisis?
We have come a long way from the haunting, early days of the HIV pandemic when hopelessness characterized the situation for children living with HIV. Without treatment available, approximately half of those children were destined to die before their second birthday. The global public health community did not know if it could halt transmission of HIV from mother to child. There were no effective, child-friendly formulations of antiretroviral therapy (ART).
For those of us who work in the field of HIV, words like “eradication” or “elimination” are not commonly used. Yet, new evidence and tools suggest that getting to zero might just be possible if we look at HIV through a fresh lens and focus our limited resources in strategic ways. As World AIDS Day nears, an example in Vietnam shows one promising approach.
Vietnam is at a tipping point. The country is working hard to scale up methadone maintenance treatment for injecting drug users and to provide antiretroviral (ARV) treatment for those living with HIV. External resources, however, are declining and every dollar (or Vietnamese dong (VND)) makes a difference. The cascade of HIV care — an approach that links prevention outreach, testing and treatment services across a continuum of care — helps identify the key opportunities to improve services to stop the spread of HIV. This tool has come to Vietnam at a critical time. Vietnam’s HIV epidemic is still in a concentrated phase, with the highest seroprevalence among populations at higher risk. These include injecting drug users, female sex workers and men who have sex with men.
Using the cascade — in every facility, commune, district and province — helps Vietnam monitor HIV service system performance and focus its remaining human, financial and programmatic resources on the ultimate aim of the HIV response: viral suppression. The cascade approach identifies “leaks” in the system to target resources on interventions that diagnose people with HIV, initiate ARV treatment quickly and sustain those individuals with continued care. Knowing where the drop-offs are most pronounced can assist decision makers and service providers in implementing system improvements and service enhancements that make the greatest impact on individuals, communities and Vietnamese society.
Having multiple sexual partners, particularly when relationships overlap in time, is a major driver of the HIV epidemic. Overlapping, or concurrent, relationships increase the number of people who are connected in a “sexual network,” and HIV spreads more quickly the larger the sexual network. Although young people report having multiple sexual partners, few HIV prevention programs for youth tackle this topic.
FHI 360, on behalf of USAID’s Interagency Youth Working Group, recently helped address this gap with a new publication, Promoting Partner Reduction: Helping Young People Understand and Avoid HIV Risks from Multiple Partnerships. The late Dr. Doug Kirby of ETR Associates was a major contributor.