Global solidarity and resilient HIV services

The global HIV epidemic is not over and may be accelerating during the  COVID-19 pandemic, with a devastating impact on communities and countries. In 2019, there were still 38 million people living with HIV infection. One in five people living with HIV were not aware of their infection and one in 3 people receiving HIV treatment experienced disruption to the supply of HIV treatments, testing and prevention services, especially children and adolescents. In 2019, 690 000 people died from HIV-related causes and 1.7 million people were newly infected, with nearly 2 in three (62%) of these new infections occurring among key populations and their partners.

Despite significant efforts, progress in scaling up HIV services was already stalling before the COVID-19 pandemic. Slowing progress means the world will be missing the “90-90-90” targets for 2020, which were to ensure that: 90% of people living with HIV are aware of their status; 90% of people diagnosed with HIV are receiving treatment; and 90% of all people receiving treatment have achieved viral suppression. Missing these intermediate targets will make it even more difficult o achieve the end of AIDS by 2030.

The breakdown in essential HIV services due to COVID-19 threatens lives. COVID makes it difficult and dangerous for frontline health workers to deliver continuous, high quality HIV services to everyone who needs them. Sickness and restricted movement make it difficult for people living with HIV to access services. Economic disruption caused by COVID can make HIV services unaffordable or unobtainable. And the pandemic may interfere with supply chains and service delivery. For example, as of July 2020, one third of people on HIV treatment had experienced drug stockouts or interruptions in supplies. Supply disruptions such as these are devastating; a WHO and UNAIDS modeling study showed that six-month disruption in access to HIV medicines could lead to a doubling in AIDS-related deaths in sub-Saharan Africa in 2020 alone.

Now is the time for us to once again make a leap in our response to work together to end COVID-19 and get back on track to end HIV by 2030. On World AIDS Day 2020, WHO is calling on global leaders and citizens to rally for “global solidarity” to overcome the challenges posed by COVID-19 on the HIV response.  WHO has chosen to focus on “Global solidarity, resilient HIV services” as the WHO theme for World AIDS Day this year.

The key actions are:

1. Renew our fight to end HIV

   The global AIDS response has slowed down: it’s time now to invest, to innovate HIV services with broader health care and the pandemic response to get back on track to end HIV by 2030. Missing the global targets for HIV for 2020 should not be a setback but a renewed call to do better.

2. Use innovative HIV services to ensure continued HIV care.

   There are many new approaches countries are adopting to ensure HIV care during the pandemic. WHO has recommended multi-month prescriptions of HIV medicines to protect the health of people on HIV treatment and to reduce the burden on overburdened health services.

3. Engage and protect our nurses, midwives and community health workers

   We urge policymakers to ensure that frontline health workers, nurses, midwives and community health workers are engaged and protected when delivering services for HIV and COVID-19. 

4. Prioritize the vulnerable – youth and key populations
   We need to ensure that children, adolescents and members of key and vulnerable populations affected by HIV do not fall through the cracks of health care disruptions during COVID-19.  Key populations include people who use drugs, men who have sex with men, sex workers, transgender people and people in prisons that are disproportionately affected by HIV. 
   

Please join us for a webinar to celebrate World AIDS Day on 1 December 2020 from 13:00 to 14:30 Geneva time (Central European Time). The event will cover global efforts to ensure global solidarity and resilient HIV services, including during the COVID-19 pandemic.

The speakers will include:

Dr Tedros Adhanom Ghebreyesus, Director General, World Health Organization (WHO)

Honourable Lizzy Nkosi, Minister of Health, The Kingdom of Eswatini

Mr Peter Sands, Executive Director, The Global Fund to Fight AIDS, Tuberculosis and Malaria

Ms Winnie Byanyima, Executive Director, Joint United Nations Programme on HIV (UNAIDS)

Dr J.V.R. Prasada Rao, Former Secretary of Health, India and Former SG’s Envoy for AIDS in in Asia and the Pacific

Dr Ren Minghui, Assistant Director-General, Universal Health Coverage/Communicable and Noncommunicable Diseases, WHO

Dr Meg Doherty, Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO

Ms Cindy Amaiza, National Coordinator, Y+ Kenya

Ms Sasha Volgina, Programme Manager, Global Network of People Living with HIV (GNP+)

Dr Adeeba Kamarulzaman, President, International AIDS Society (IAS)

Ms Erica Burton, Senior Advisor, International Council of Nurses (ICN)

Dr Alex Schneider, Founder, Life4me+

Mr Asghar Satti, National Coordinator, Association of People Living with HIV (APLHIV), Pakistan

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This year’s annual U.S. Conference on HIV/AIDS (USCHA) concluded on October 21 with a plenary session featuring several federal HIV leaders and I was honored to be included. I am grateful to NMAC for convening this conference virtually during the COVID-19 pandemic, enabling the community along with federal and state partners to continue to share important information, strategies, and experiences about HIV, sexually transmitted infections, viral hepatitis, leadership, and race. Following are some highlights of what I shared with the participants.

Status and Next Steps for the Ending the HIV Epidemic Initiative

Naturally, participants wanted to know about the status of Ending the HIV Epidemic: A Plan for America (EHE) given all that has happened this year and what lies ahead for this national initiative. I reiterated that EHE remains a priority at the U.S. Department of Health and Human Services and that its agencies and offices are moving forward with implementation activities. Some important EHE developments include:

• The 57 jurisdictions prioritized in the initiative’s first phase are working to revise their EHE Plans based on feedback CDC, HHS, and HRSA shared on the draft plans back in March. Acknowledging the impact of the response to COVID-19 on state and local health departments and their key community partners, the deadline for submitting the revised plans was extended to December 31, 2020.
• The Ready, Set, PrEP program, which provides PrEP medications at no cost to individuals who qualify, made some COVID-related adaptations earlier this year to help ensure patient retention in ongoing PrEP care and adherence to medications, and also reduce the burden on the nation’s health care providers and health care systems. The program authorized 90-day prescription fills and implemented automatic enrollment eligibility extensions between June 1 and September 29. We’ll be making enhancements to GetYourPrEP.com , the enrollment portal for Ready, Set, PrEP in the coming weeks. Soon you’ll see additional Ready, Set, PrEP marketing assets featuring real people who take PrEP telling their stories of how PrEP has affected their lives.
• In August, we launched America’s HIV Epidemic Analysis Dashboard, known as AHEAD. It’s an online data visualization tool designed to help jurisdictions, researchers, public health professionals, HIV service organizations, and others across the country track progress towards meeting EHE goals. AHEAD displays graphical representations of data on the six EHE HIV indicators for the 57 jurisdictions prioritized in the initiative, as well as state data for the 21 states in which EHE counties are located. In collaboration with our partners at CDC, additional data was recently added to the site. The new indicator data includes preliminary 2019 data and data on the first quarter of 2020 on HIV diagnoses and linkage to HIV medical care.
• To continue making progress on EHE’s Diagnose strategy, HHS, CDC, HRSA, IHS, and SAMHSA are encouraging and facilitating HIV self-testing options in communities where there has been a reduction in availability of in-person HIV testing due to COVID-19.  Self-testing can be an effective on-going strategy to help identify and link individuals to needed HIV prevention and care services in a post-COVID-19 world.  Jurisdictions are encouraged to explore ways HIV self-testing can help us meet our EHE targets for HIV diagnoses.
• The Prevention through Active Community Engagement (PACE) officers, a team of U.S. Public Health Service Commissioned Corps officers supporting EHE activities in HHS Regions 4, 6, and 9, continue their work to facilitate broad community involvement in the development and implementation of jurisdictional EHE plans. They are also facilitating discussions about the intersection of HIV disparities and social determinants of health and racial inequality.

Damián Cabrera-Candelaria, Treatment Program Manager at NMAC , the USCHA conference convenor, also asked me about efforts to combat racism in health services, whether employment opportunities for people with or affected by HIV will result from EHE, and responding to HIV in Puerto Rico, which was to have hosted this year’s USCHA.

The closing session also featured remarks from my federal colleagues and partners in the EHE initiative: CDC’s Dr. Jonathan Mermin, HRSA’s Dr. Laura Cheever, SAMHSA’s Dr. Neeraj Gandotra, NIH’S Dr. Maureen Goodenow, and NIH’s Dr. Anthony Fauci.  You can view the closing plenary on YouTube. 

Joining many colleagues from across the HIV community, I commend NMAC for innovating this year to make USCHA possible once again and salute their staff along with the many presenters and participants who shared ideas and learned from one another throughout the conference.

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New disease outbreaks, like the novel coronavirus that recently emerged in China’s Hubei province, generate headlines and attention. Meanwhile, however, Americans face a slower but much more pervasive health crisis: obesity.

Nearly 40% of Americans are considered obese. Rates of obesity for children have increased in recent decades, putting more people at increased risk of heart disease, diabetes and some cancers. One in 5 deaths of those aged 40 to 85 are now attributed to obesity, and one recent study projects that by 2030, nearly half of all U.S. adults will be obese.

This problem is too often treated only as an issue of personal responsibility, with calls for people to eat healthier diets and exercise more. It is true that Americans need to cut their caloric intake, especially of foods high in sugar and saturated fats, and get more exercise. Nearly 80% of U.S. adults are not meeting federal guidelines for physical activity, which recommend 2.5 to 5 hours of moderate physical activity weekly.

But our built environment, which includes not only buildings but roads, sidewalks and public spaces, also plays an important role in physical health. Researchers call cities that promote sedentary lifestyles and poor diet obesogenic. As a researcher focusing on urban issues, I am encouraged to see city planners paying increasing attention to helping residents lead healthy lifestyles. 

Fat cities

Modern U.S. cities were designed to make exercise unnecessary. Cars and elevators symbolized urban areas as machines for more efficient living. Now it is clear that these improvements provide great benefits but also impose health costs.

Recent studies show that urban sprawl encourages more driving and is associated with higher weight. This correlation suggests that the layout and design of cities can hinder or promote healthier lifestyle choices.

As a thought experiment, what would a city that makes residents more overweight look like? It would probably have few fresh food facilities and discourage physical activity, thus encouraging people to eat fast food and sit in cars rather than walking or bicycling. In other words, it would resemble the standard car-centric U.S. cities that have emerged in the past 50 years.

Cities did not create the obesity epidemic, but they can make it worse by neither promoting nor prompting healthier lifestyles. And it’s not just happening in the U.S. Around the world, health experts contend, cities are making people fat.

Fat cities

Modern U.S. cities were designed to make exercise unnecessary. Cars and elevators symbolized urban areas as machines for more efficient living. Now it is clear that these improvements provide great benefits but also impose health costs.

Recent studies show that urban sprawl encourages more driving and is associated with higher weight. This correlation suggests that the layout and design of cities can hinder or promote healthier lifestyle choices.

As a thought experiment, what would a city that makes residents more overweight look like? It would probably have few fresh food facilities and discourage physical activity, thus encouraging people to eat fast food and sit in cars rather than walking or bicycling. In other words, it would resemble the standard car-centric U.S. cities that have emerged in the past 50 years.

Cities did not create the obesity epidemic, but they can make it worse by neither promoting nor prompting healthier lifestyles. And it’s not just happening in the U.S. Around the world, health experts contend, cities are making people fat.

Getting out and about

Planners are also paying increasing attention to encouraging physical activity by making it easier and safer for people to recreate, walk, bike and take public transportation. Longevity studies show that people live the longest in environments where physical activity is part of everyday life.

Providing more walkable spaces, better protected bike lanes and more recreational spaces are important steps. But even smaller changes can be effective.

Cities can close off streets on weekends to encourage communities to get out and walk. They also can provide more seating in public places, so that less-fit residents can rest during their journeys. Using public spaces in cities as places where people can exercise promotes equity, rather than allowing physical activity to become restricted to private gyms with often-expensive monthly fees.

Studies show that when cities are designed to provide walkability, bikeability, public transportation and more attractive green recreational spaces, then physical activity across the entire community increases. Minneapolis-St. Paul was rated the nation’s fittest city after it made a commitment a decade ago to expand bike lanes, tree planting and safer sidewalks. The changes encouraged residents to walk more and get more exercise. 

Cities as machines

It will be expensive to create healthier cities. But a recent survey of mayors revealed that a majority believes their cities were too car-centric. Many wanted to invest more in bike infrastructure, parks and public sports complexes. Cities with high levels of obesity typically don’t make these features a priority.

The U.S. health care system, with its emphasis on tests and interventions to treat individual illness rather than on prevention, is the most expensive in the world with only modest levels of health outcomes and life expectancy compared to similarly wealthy countries. Integrating better diets and more physical activity into everyday urban life can help Americans become healthier more effectively, and at less cost.

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New York Governor Andrew Cuomo says the state is ‘on track’ to end its AIDS epidemic by the end of 2020.

In 2018, New York had an all-time low of 2,481 new HIV diagnoses, an 11 percent decrease from 2017 and a nearly 30 percent drop from 2014.

Additionally, 32,000 New Yorkers are now taking a daily pre-exposure prophylaxis (PrEP) pill, which drastically cuts the chances that someone who is still healthy becomes infected from risky sex or injection drug use.

More than 100,000 New Yorkers have died from AIDS-related causes since the 1980s, according to the social service organization Gay Men’s Health Crisis.

‘Five years ago we launched an aggressive, nation-leading campaign to end the AIDS epidemic in New York and to ensure every person living with HIV or AIDS gets the support they need to lead a full and healthy life,’ Cuomo said in a statement.

‘This new data shows we are on track to meet that goal and continue our historic progress to finally bend the curve on an epidemic that has taken too many lives for too long.’ 

In 2014, Cuomo and the state launched the Ending the Epidemic initiative, which receives about $20 million in funding annually.

The plan has a three step approach: identifying people with HIV who are undiagnosed; making sure people diagnosed with HIV keep up with their healthcare; and stopping HIV transmissions completely for people at high risk with PrEP.

PrEP users take a pill every day. The pill contains two medications, which help prevent HIV from establishing permanent infection, according to the Centers for Disease Control and Prevention (CDC).

Almost 32,000 New Yorkers filled at least one prescription for PrEP in 2018, a 32 percent increase from 2017. 

Starting on January 1, New York will require health insurance plans to cover PrEP without co-pays. 

In the early days of the HIV/AIDS epidemic, New York City was one of the hardest hit cities in the US due to its large gay community and population of intravenous drug users.

At the height of the epidemic, there were 12,719 AIDS diagnoses in one year in 1993, according to data from the Department of Health and Mental Hygiene.

Today, that number is close to 1,000.

In the US, more than 1.1 million people are infected with HIV. Nearly 40,000 new infections were diagnosed last year.

Once a person contracts HIV, the virus sets about attacking and destroying immune cells that normally protect the body from infection.

In the last decade, doctors have gained a much improved understanding of how to control HIV.

The rate of deaths from the disease has plummeted since the peak of the AIDS epidemic in the early 1980s.

The CDC recommend everyone between the ages of 13 and 64 be tested for HIV at least once.

Those who are at higher risk, including men who have sex with men or those who have a sexual partner who is HIV positive, should be tested as often as once a year or more.

Although HIV is treatable, the infection has no cure.

Cuomo is not the only politician to vow to end the HIV/AIDS epidemic. Earlier this year, President Donald Trump announced his campaign to end HIV transmissions in the US by 2030 – about 10 years later than Cuomo’s goal.

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A new study suggests that high levels of sugar consumption in the 1970s and 80s may be responsible for the obesity epidemic among American adults today.

In other words, if high-sugar diets in childhood have long-lasting effects, the changes we see now in adult obesity rates may have started with diets decades ago, when those adults were children.

The findings are published in the journal Economics and Human Biology.

“While most public health studies focus on current behaviors and diets, we took a novel approach and looked at how the diets we consumed in our childhood affect obesity levels now that we are adults,” said Dr. Alex Bentley, head of the University of Tennessee’s Department of Anthropology and lead researcher of the study.

Consumption of excess sugar, particularly in sugar-sweetened beverages, is a known contributor to both childhood and adult obesity. Many population health studies have identified sugar as a major factor in the obesity epidemic.

One problem with this theory, however, has been that sugar consumption in the U.S. began to decline in the late 1990s while obesity rates continued to rise well into the 2010s.

For example, by 2016, nearly 40 percent of all adults in the US, a little over 93 million people, were obese. In Tennessee alone, the adult obesity rate more than tripled, from about 11 percent in 1990 to almost 35 percent in 2016. By 2017, however, obesity in Tennessee had fallen 2 percent from the previous year.

“Since the 1970s, many available infant foods have been extremely high in sugar,” said Dr. Hillary Fouts, coauthor of the study and cultural anthropologist and professor in the UT Department of Child and Family Studies.

“Other independent studies in medicine and nutrition have suggested that sugar consumption during pregnancy can cause an increase in fat cells in children,” she added.

Dr. Damian Ruck, postdoctoral research fellow in the Department of Anthropology and coauthor of the study says “Up to this point, no studies had explicitly explored the temporal delay between increased sugar consumption and rising obesity rates.”

For the study, the researchers modeled the increase in U.S. adult obesity since the 1990s as a legacy of the increased excess sugar consumption measured among children in the 1970s and 1980s.

They tested their model using national obesity data collected between 2004 and 1990 by the Centers for Disease Control and Prevention. They compared those obesity rates with annual sugar consumption since 1970 using the median per capita rates issued by the U.S. Department of Agriculture.

The model also roughly captures how obesity rates vary by age group among children and teenagers.

“Our results suggest that the dietary habits learned by children 30 or 40 years ago could explain the adult obesity crisis that emerged years later,” said Ruck.

A large portion of the sugar increase before 2000 was from high fructose corn syrup (HFCS), which after 1970 quickly become the main sweetener in soft drinks and a common ingredient in processed foods. At peak sugar consumption, in 1999, each person in the US consumed on average around 60 pounds of HFCS per year and more than 400 calories per day in total excess sugars.

U.S. sugar consumption has declined since 2000. “If 2016 turns out to be the peak in the obesity rate,” Bentley said, “that is coincidentally one generation after the peak in excess sugar consumption.”

The team is planning to continue their research by exploring the effects of sugar-sweetened beverages. “This is important because obesity disproportionately affects the poor,” said Bentley.

In a paper published in Palgrave Communications in 2018, Bentley and his colleagues found that the relationship between low income and high rates of obesity became noticeable on a national scale in the early 1990s. The 2018 study shows that the correlation between household income and obesity rate has grown steadily, from virtually no correlation in 1990 to a very strong correlation by 2016.

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Cape Town – A new UN report shows that while important progress has been made in addressing the Aids epidemic for children and adolescents, countries failed to meet the goals set for 2018.

South Africa represents 9% of children acquiring HIV through vertical transmission across the world, only topped by Nigeria and Mozambique.

While this seems like a bad indication of how HIV/Aids is being handled, Scott McQuade from the South African branch of UNAids said otherwise.

“South Africa has the largest population of people living with HIV, about 20% of the global burden. Having only 9% of the global burden of vertical transmission indicates the relative success of South Africa in moving towards elimination of mother-to-child transmission.”

The Western Cape further beats the odds. In its 2018 report, the Health Department reported a 0.2% mother-to-child HIV transmission rate at 10 weeks. The most recent data indicate that 12.6% of adults in the Western Cape have HIV, the lowest rate of all provinces. The city and NGOs continue to urge people to get tested and educated about HIV prevention.

The Joint UN Programme on HIV/Aids (UNAids) in partnership with the US President’s Emergency Plan for Aids Relief introduced the Start Free Stay Free Aids Free framework and goals in 2016. The programme sought to end Aids as a public health threat for children and adolescents by focusing on 23 countries (mainly in Africa and Asia) with high numbers of children, adolescents and young women with HIV.

The programme had three main goals. To ensure 95% of pregnant women living with HIV knew their status and were on antiretroviral therapy (ART), to reduce the number of women aged 10-24 acquiring HIV to fewer than 100000 annually by 2020, and to make sure that 95% of all adolescents 10-19 years of age with HIV are receiving ART by 2020. They missed the mark in 2018 and indicators for 2020 are not looking too optimistic.

The 23 countries in the focus group for the programme represent 86% of pregnant women with HIV, 80% of children ages 0-14 acquiring HIV, 85% of girls and women ages 10-25 acquiring HIV, and 85% of young people ages 0-19 living with HIV.

South Africa was one of the countries included in the programme.

The new UNAids report shows that many of the countries studied made significant strides in reducing HIV among young people, but overall their efforts fell short. Children are a difficult group to target with these efforts. Vertical transmission of HIV is still a major problem and according to the study, only 63% of infants exposed to HIV during birth were tested before two months of age. South Africa tested more than 85% of babies exposed to HIV in the first two months.

But the fight to eradicate HIV and Aids in South Africa needs to be increased. According to the UNAids study, less than 30% of men and women ages 15-24 have a comprehensive understanding of HIV prevention.

This problem is exacerbated by an intense lack of funding to combat Aids – global numbers indicate that funding decreased by $1billion (R14bn) last year.

According to the report, the geographic concentration of where children are most acquiring HIV is so substantial that changes in only a few countries could improve global trends.

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