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Prioritizing Development Published online by Cambridge University Press: 30 May 2018
Introduction
Thirty years after the human immunodeficiency virus (HIV) was first identified, the HIV epidemic continues to cause large-scale human suffering and economic losses. Since featuring prominently in the MDGs, HIV has received unprecedented global political and financial commitment, being allocated 25 percent of all international assistance for health in 2011. But, despite significant successes, the goal will not be achieved, and the HIV epidemic in sub- Saharan Africa is still one of the most important causes of loss of life and health. The global HIV response will thus have to be a major continued focus of national and international development strategies after 2015.
Two Goals to Address the HIV Epidemic in the Most Affected Countries
Sub-Saharan Africa is home to 70 percent of those living with HIV globally (UNAIDS, 2013b). Within Africa, the Southern region has been hit hardest by the epidemic, with Botswana, Lesotho, South Africa, Swaziland, and Zimbabwe being termed hyperendemic (having an HIV prevalence greater than 15 percent among the adult population). We recommend two goals to address this:
Goal 1: Achieve ART (antiretroviral therapy) coverage of at least 90 percent among HIV-infected adults with a CD4 count <350 cells/μL before expanding the HIV treatment scale-up to people with higher CD4 counts.
Goal 2: Attain circumcision coverage of at least 90 percent among HIV-uninfected adult men.
Why Focus ART First on Those Most in Need?
Since the advent of ART, the WHO has gradually increased its recommended threshold for starting patients on ART to include increasingly healthy patients. WHO treatment thresholds are based on the CD4 count, a cell count that decreases in concentration with deteriorating immune system function. In 2011, a clinical trial, hailed as a game changer in the HIV field, provided evidence for even earlier initiation of ART. It showed that providing ART early in the course of the disease reduces the chance of an infected person passing HIV to an uninfected partner by 96 percent (Cohen et al., 2011). Currently, several large ongoing trials aim to establish the causal effect of providing ART to all HIV patients regardless of CD4 count, i.e., Treatment as Prevention (TasP), when implemented at the population level in sub-Saharan Africa (Essex, DeGruttola, Lebelonyane, and Habibi, 2013; Havlir and Kamya, 2013; Hayes et al., 2014; Iwuji et al., 2013; Stop AIDS Now! 2014).
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