- Email: [email protected]
AIDS and global health: the path to sustainable development
Comment
As national economies grow and countries make the transition from low-income to lower-middle-income or even upper-middle-income status, the GFF will work with them to mobilise additional domestic resources to ensure sustainable financing for health services. And through its link to the ministries of finance, the GFF will also leverage investments beyond the health sector, such as in education, water and sanitation, and civil registration and vital statistics systems. The GFF is projected to avert nearly 4 million maternal deaths and 100 million child deaths by 2030.10 The Every Woman Every Child movement’s many partners, along with the leadership of UN agencies, have a key role in implementation of the GFF to ensure that international support is well coordinated and based on the most effective policies and practices. In the past 15 years, financing for global health has increased from millions to billions of dollars. Ending preventable maternal, newborn, child, and adolescent deaths by 2030, however, is a trillion-dollar financing challenge. Together with other financing partnerships, including the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance, the GFF will help us take this next quantum leap from billions to trillions with a smart, scaled, and sustainable approach to financing. We call on all development partners to join with us in Addis Ababa in moving towards a better, more prosperous future for every woman and every child.
Hailemariam Desalegn, Erna Solberg, *Jim Yong Kim Office of the Prime Minister, Government of Ethiopia, Addis Ababa, Ethiopia (HD); Office of the Prime Minister, Government of Norway, Oslo, Norway (ES); and The World Bank Group, Washington, DC 20433, USA (JYK) [email protected] HD is the Prime Minister of Ethiopia. ES is the Prime Minister of Norway. JYK is President of The World Bank Group. We declare no competing interests. 1 2
3
4 5
6
7
8
9 10
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. United Nations Foundation. Every Woman Every Child, Global Strategy 2.0. 2015. http://www.everywomaneverychild.org/global-strategy-2 (accessed June 29, 2015). United Nations Department of Economic and Social Affairs. Sustainable Development Goals knowledge platform. https://sustainabledevelopment. un.org/topics/sustainabledevelopmentgoals (accessed June 29, 2015). UN. Millennium Development Goals. http://www.un.org/millenniumgoals/ (accessed June 29, 2015). UNICEF, WHO, The World Bank, UN. Levels and trends in child mortality report 2014 estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund, 2014. WHO, UNICEF, UNFPA, The World Bank, United Nations Population Division. Trends in maternal mortality: 1990 to 2013 estimates by WHO, UNICEF, UNFA, The World Bank, and the United Nations Population Division. Geneva: World Health Organization, 2014. PMNCH, WHO, The World Bank, Alliance for Health Policy and Systems Research. Success factors for women’s and children’s health, Ethiopia. Geneva: PMNCH, 2014. http://www.who.int/pmnch/knowledge/ publications/ethiopia_country_report.pdf (accessed June 29, 2015). The World Bank. A smarter approach to delivering more and better reproductive, maternal, newborn, and child health services. Health Results Innovation Trust Fund annual report. Washington, DC: The World Bank, 2014. The World Bank. Global monitoring report 2013. Washington, DC: The World Bank, 2013. The World Bank. Global Financing Facility: business plan. June, 2015. http:// www.worldbank.org/en/topic/health/brief/global-financing-facilitybusiness-plan (accessed June 29, 2015).
AIDS and global health: the path to sustainable development Published Online June 25, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)61040-6 See Comment page 108 See The Lancet Commissions page 171
106
“If we are to go forwards we must go back and rediscover those precious values…” Martin Luther King
The publication of the report of the UNAIDS–Lancet Commission, Defeating AIDS—advancing global health,1 is the result of some 2 years of dedicated work by commissioners with diverse expertise in HIV, health, and development, including young people, people living with HIV and affected communities, activists, and political leaders. The commissioners were asked how to transform the AIDS response to make the vision of ending the AIDS epidemic as a public health threat a reality, and to look at how lessons from the AIDS response could inform a new era of sustainable development beyond 2015.
Why a Commission on AIDS and global health, and why now? To go forwards in the era of sustainable development, lessons from the AIDS response are important for understanding the many global health and environmental health challenges before us. While the world has (and will always face) new health challenges, the HIV/AIDS epidemic is unique in the international response it galvanised—it was, according to the Commission, “an unprecedented response to an unprecedented health threat”. Since the first reported cases of AIDS in the early 1980s, about 78 million people have become infected with HIV and 39 million have died of AIDS-related causes.2 Before the era of antiretroviral treatment (ART), HIV/AIDS brought devastation to www.thelancet.com Vol 386 July 11, 2015
communities and unprecedented personal and national challenges. Many key developments in global health were partly or wholly created or defined in response to the HIV/AIDS epidemic, including ART, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States President’s Emergency Plan for AIDS Relief, community involvement and activism, the legal recognition of the right to health in the constitutions of many countries, such as Brazil,3 and the role of international and national pharmaceutical companies in global health. The Commission is published in the year we transition to a world defined by Sustainable Development Goals,4 in the aftermath of our inadequate response to the recent Ebola outbreak, and in an era with unprecedented inequity in health but with hopeful signs that most low-income and middleincome countries are predicted to have some economic growth.5 Donors and governments are confronted with complex decisions as to which competing health and development issues to prioritise. HIV/AIDS is still a major public health threat, especially to specific populations. In 2013, 1·5 million people died of AIDS-related causes, 22 million had yet to access ART, and about 19 million of the 35 million people living with HIV did not know they were infected.1 HIV incidence and AIDSrelated mortality are higher in adolescent girls and young women in southern and eastern Africa, sex workers, men who have sex with men (MSM), transgender people, injecting drug users, prisoners, and migrants than in other populations. These are also the groups least likely to live in enabling environments that can address stigma and discrimination, human rights violations, gender inequality, and violence against women, or to have the necessary legislation in force. Therefore, our Commission calls for all aspects of a comprehensive AIDS response to be funded and targeted where they will make the most difference, either in geographical hotspots or among populations most at risk of HIV. The Commission undertook an extensive consultation process with many stakeholders in 22 regional, country, academic, youth, civil society, and virtual dialogues. The Commission report summarises the evidence on biomedical, behavioural, and structural interventions from the AIDS response, poses four scenarios for scaling up evidence-based interventions, and makes calls for better data, investment, and synergies with www.thelancet.com Vol 386 July 11, 2015
Pascal Deloche/Godong/Corbis
Comment
other sectors to drive progress on defeating AIDS and to translate the lessons learnt to advance global health and development. The guiding principles identified by the Commission within the AIDS response—namely, community activism and leadership, human rights,6 and valuing human life in funding research and programmes where they will make the most difference—are crucial lessons for global health. We wish to highlight the key messages from the Commission. First, value for human life and human rights must guide global health efforts, including the actions and decisions of scientists. A crucial lesson learnt from the HIV/AIDS epidemic is that public health outcomes improve when the human rights of people with HIV infection or most at risk are defended (among them, access to treatment, freedom from persecution and discrimination, access to education, and employment). Second, community activism is a global public good that deserves investment and acceptance by all states and stakeholders as an essential factor to improve and refine health outcomes and future public health responses. Community activism and voice are needed to communicate the urgency for committed investment in health and to assist the research community to provide new solutions and approaches. Third, the political and social determinants of health are part of committed investment in HIV/ AIDS and health within sustainable development. The 107
Comment
Commission has identified that only a massive and rapid expansion of a comprehensive AIDS response in the next 5 years can achieve the ambitious UN goal of ending AIDS as a public health threat by 2030. Yet modelling suggests that scaling up to the goals of the most ambitious scenario would generate a staggering US$1157 billion by 2030, which could benefit other global health and development challenges. A governance structure is required that builds on the lessons from HIV/AIDS and is adapted to create a more inclusive, coherent, and accountable governance for AIDS and health. The UNAIDS–Lancet Commission supports the call by the Lancet–University of Oslo Commission on Global Governance for Health7 for the establishment of a global multistakeholder, multisector platform to address the determinants of health, and an Independent Scientific Monitoring Panel on Global Health to report on progress in addressing the barriers to health equity. Fourth, respect for, and investment in, research and innovation must remain a core part of the AIDS response and that of global health. Research priorities in HIV/AIDS identified by the Commission will translate to global health—for example, identifying high-risk populations and geographical hotspots, sociobehavioural research to understand the drivers of HIV/AIDS transmission, implementation research, and country or regional specific research partnerships with international centres of excellence. Finally, we must not repeat the same dynamics that led to reduced access to health care for people living with HIV. Access to second-line and third-line ART regimens is still limited by high prices and in most cases there is no option for generic production due to restrictions placed by patents and the enforcement of intellectual property. People living with hepatitis C and children with
HIV/AIDS or rare paediatric diseases are only some of the communities who do not have access in many parts of the world to adapted, affordable treatment and diagnosis. Partners in global health are ever emerging, in communities, the private sector, or new bilateral donors such as China, Brazil, and India. Global health challenges are for all to partake in, guided by common notions of equity and human rights, preferably entrenched and enforceable in accountability and legal frameworks. Beyond the publication of the UNAIDS–Lancet Commission report, and beyond the important lessons collated by the Commission’s leadership, is the hope that we can ignite on a grand scale the commitment to a whole-of-society approach not only to defeat AIDS but also to address global health challenges post 2015. Selina Lo, Richard Horton The Lancet, Beijing 100738, China (SL); and The Lancet, London, UK (RH) We thank Peter Piot and Michel Sidibé for leading the drafting of the report and the UNAIDS–Lancet Commission. We thank the United Nations Programme on HIV/AIDS (UNAIDS) for providing the financial support for this Commission. We thank the commissioners and peer reviewers for their time and thoughtful contributions to the process and all contributors in person or online to the Commission report. In particular we thank Helena Legido-Quigley, Joanne McManus, Kent Buse, Tim Martineau, and the UNAIDS team for their coordination efforts in producing the Commission report. 1
2 3 4
5 6 7
Piot P, Abdool Karim SS, Hecht R, et al, on behalf of the UNAIDS–Lancet Commission. Defeating AIDS—advancing global health. Lancet 2015; published online June 25. http://dx.doi.org/10.1016/S01406736(15)60658-4. UNAIDS. The gap report. Geneva: Joint United Nations Programme on HIV/AIDS, 2014. Biehl J, Petryna A, Gertner A, Amon JJ, Picon PD. Judicialisation of the right to health. Lancet 2009; 373: 2182–84. Sidibé M. The sustainable development agenda and the end of AIDS. Lancet 2015; published online June 25. http://dx.doi.org/10.1016/S01406736(15)61041-8. Jamieson DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Global Commission on HIV and the Law. HIV and the law: risks, rights and health. New York: Secretariat, Global Commission on HIV and the Law, 2012. Otterson OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67.
The sustainable development agenda and the end of AIDS Published Online June 25, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)61041-8 See Comment page 106 See Perspectives page 127 See The Lancet Commissions page 171
108
2015 marks a pivotal turn in development debate and practice. In September, UN member states are expected to endorse a bold agenda that will guide social, economic, and environmental action over the next 15 years. The agenda, built around 17 Sustainable Development Goals (SDGs), signals a transformational shift towards societywide, people-centred approaches. The universality and
breadth of the sustainable development agenda will demand an overhaul in how countries, sectors, and issuespecific groups work together. This year too marks a watershed moment in the long struggle against the AIDS epidemic. The trajectory of the AIDS epidemic has been broken in most regions, and sustainable solutions are being rapidly taken to www.thelancet.com Vol 386 July 11, 2015
As national economies grow and countries make the transition from low-income to lower-middle-income or even upper-middle-income status, the GFF will work with them to mobilise additional domestic resources to ensure sustainable financing for health services. And through its link to the ministries of finance, the GFF will also leverage investments beyond the health sector, such as in education, water and sanitation, and civil registration and vital statistics systems. The GFF is projected to avert nearly 4 million maternal deaths and 100 million child deaths by 2030.10 The Every Woman Every Child movement’s many partners, along with the leadership of UN agencies, have a key role in implementation of the GFF to ensure that international support is well coordinated and based on the most effective policies and practices. In the past 15 years, financing for global health has increased from millions to billions of dollars. Ending preventable maternal, newborn, child, and adolescent deaths by 2030, however, is a trillion-dollar financing challenge. Together with other financing partnerships, including the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance, the GFF will help us take this next quantum leap from billions to trillions with a smart, scaled, and sustainable approach to financing. We call on all development partners to join with us in Addis Ababa in moving towards a better, more prosperous future for every woman and every child.
Hailemariam Desalegn, Erna Solberg, *Jim Yong Kim Office of the Prime Minister, Government of Ethiopia, Addis Ababa, Ethiopia (HD); Office of the Prime Minister, Government of Norway, Oslo, Norway (ES); and The World Bank Group, Washington, DC 20433, USA (JYK) [email protected] HD is the Prime Minister of Ethiopia. ES is the Prime Minister of Norway. JYK is President of The World Bank Group. We declare no competing interests. 1 2
3
4 5
6
7
8
9 10
Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. United Nations Foundation. Every Woman Every Child, Global Strategy 2.0. 2015. http://www.everywomaneverychild.org/global-strategy-2 (accessed June 29, 2015). United Nations Department of Economic and Social Affairs. Sustainable Development Goals knowledge platform. https://sustainabledevelopment. un.org/topics/sustainabledevelopmentgoals (accessed June 29, 2015). UN. Millennium Development Goals. http://www.un.org/millenniumgoals/ (accessed June 29, 2015). UNICEF, WHO, The World Bank, UN. Levels and trends in child mortality report 2014 estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: United Nations Children’s Fund, 2014. WHO, UNICEF, UNFPA, The World Bank, United Nations Population Division. Trends in maternal mortality: 1990 to 2013 estimates by WHO, UNICEF, UNFA, The World Bank, and the United Nations Population Division. Geneva: World Health Organization, 2014. PMNCH, WHO, The World Bank, Alliance for Health Policy and Systems Research. Success factors for women’s and children’s health, Ethiopia. Geneva: PMNCH, 2014. http://www.who.int/pmnch/knowledge/ publications/ethiopia_country_report.pdf (accessed June 29, 2015). The World Bank. A smarter approach to delivering more and better reproductive, maternal, newborn, and child health services. Health Results Innovation Trust Fund annual report. Washington, DC: The World Bank, 2014. The World Bank. Global monitoring report 2013. Washington, DC: The World Bank, 2013. The World Bank. Global Financing Facility: business plan. June, 2015. http:// www.worldbank.org/en/topic/health/brief/global-financing-facilitybusiness-plan (accessed June 29, 2015).
AIDS and global health: the path to sustainable development Published Online June 25, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)61040-6 See Comment page 108 See The Lancet Commissions page 171
106
“If we are to go forwards we must go back and rediscover those precious values…” Martin Luther King
The publication of the report of the UNAIDS–Lancet Commission, Defeating AIDS—advancing global health,1 is the result of some 2 years of dedicated work by commissioners with diverse expertise in HIV, health, and development, including young people, people living with HIV and affected communities, activists, and political leaders. The commissioners were asked how to transform the AIDS response to make the vision of ending the AIDS epidemic as a public health threat a reality, and to look at how lessons from the AIDS response could inform a new era of sustainable development beyond 2015.
Why a Commission on AIDS and global health, and why now? To go forwards in the era of sustainable development, lessons from the AIDS response are important for understanding the many global health and environmental health challenges before us. While the world has (and will always face) new health challenges, the HIV/AIDS epidemic is unique in the international response it galvanised—it was, according to the Commission, “an unprecedented response to an unprecedented health threat”. Since the first reported cases of AIDS in the early 1980s, about 78 million people have become infected with HIV and 39 million have died of AIDS-related causes.2 Before the era of antiretroviral treatment (ART), HIV/AIDS brought devastation to www.thelancet.com Vol 386 July 11, 2015
communities and unprecedented personal and national challenges. Many key developments in global health were partly or wholly created or defined in response to the HIV/AIDS epidemic, including ART, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States President’s Emergency Plan for AIDS Relief, community involvement and activism, the legal recognition of the right to health in the constitutions of many countries, such as Brazil,3 and the role of international and national pharmaceutical companies in global health. The Commission is published in the year we transition to a world defined by Sustainable Development Goals,4 in the aftermath of our inadequate response to the recent Ebola outbreak, and in an era with unprecedented inequity in health but with hopeful signs that most low-income and middleincome countries are predicted to have some economic growth.5 Donors and governments are confronted with complex decisions as to which competing health and development issues to prioritise. HIV/AIDS is still a major public health threat, especially to specific populations. In 2013, 1·5 million people died of AIDS-related causes, 22 million had yet to access ART, and about 19 million of the 35 million people living with HIV did not know they were infected.1 HIV incidence and AIDSrelated mortality are higher in adolescent girls and young women in southern and eastern Africa, sex workers, men who have sex with men (MSM), transgender people, injecting drug users, prisoners, and migrants than in other populations. These are also the groups least likely to live in enabling environments that can address stigma and discrimination, human rights violations, gender inequality, and violence against women, or to have the necessary legislation in force. Therefore, our Commission calls for all aspects of a comprehensive AIDS response to be funded and targeted where they will make the most difference, either in geographical hotspots or among populations most at risk of HIV. The Commission undertook an extensive consultation process with many stakeholders in 22 regional, country, academic, youth, civil society, and virtual dialogues. The Commission report summarises the evidence on biomedical, behavioural, and structural interventions from the AIDS response, poses four scenarios for scaling up evidence-based interventions, and makes calls for better data, investment, and synergies with www.thelancet.com Vol 386 July 11, 2015
Pascal Deloche/Godong/Corbis
Comment
other sectors to drive progress on defeating AIDS and to translate the lessons learnt to advance global health and development. The guiding principles identified by the Commission within the AIDS response—namely, community activism and leadership, human rights,6 and valuing human life in funding research and programmes where they will make the most difference—are crucial lessons for global health. We wish to highlight the key messages from the Commission. First, value for human life and human rights must guide global health efforts, including the actions and decisions of scientists. A crucial lesson learnt from the HIV/AIDS epidemic is that public health outcomes improve when the human rights of people with HIV infection or most at risk are defended (among them, access to treatment, freedom from persecution and discrimination, access to education, and employment). Second, community activism is a global public good that deserves investment and acceptance by all states and stakeholders as an essential factor to improve and refine health outcomes and future public health responses. Community activism and voice are needed to communicate the urgency for committed investment in health and to assist the research community to provide new solutions and approaches. Third, the political and social determinants of health are part of committed investment in HIV/ AIDS and health within sustainable development. The 107
Comment
Commission has identified that only a massive and rapid expansion of a comprehensive AIDS response in the next 5 years can achieve the ambitious UN goal of ending AIDS as a public health threat by 2030. Yet modelling suggests that scaling up to the goals of the most ambitious scenario would generate a staggering US$1157 billion by 2030, which could benefit other global health and development challenges. A governance structure is required that builds on the lessons from HIV/AIDS and is adapted to create a more inclusive, coherent, and accountable governance for AIDS and health. The UNAIDS–Lancet Commission supports the call by the Lancet–University of Oslo Commission on Global Governance for Health7 for the establishment of a global multistakeholder, multisector platform to address the determinants of health, and an Independent Scientific Monitoring Panel on Global Health to report on progress in addressing the barriers to health equity. Fourth, respect for, and investment in, research and innovation must remain a core part of the AIDS response and that of global health. Research priorities in HIV/AIDS identified by the Commission will translate to global health—for example, identifying high-risk populations and geographical hotspots, sociobehavioural research to understand the drivers of HIV/AIDS transmission, implementation research, and country or regional specific research partnerships with international centres of excellence. Finally, we must not repeat the same dynamics that led to reduced access to health care for people living with HIV. Access to second-line and third-line ART regimens is still limited by high prices and in most cases there is no option for generic production due to restrictions placed by patents and the enforcement of intellectual property. People living with hepatitis C and children with
HIV/AIDS or rare paediatric diseases are only some of the communities who do not have access in many parts of the world to adapted, affordable treatment and diagnosis. Partners in global health are ever emerging, in communities, the private sector, or new bilateral donors such as China, Brazil, and India. Global health challenges are for all to partake in, guided by common notions of equity and human rights, preferably entrenched and enforceable in accountability and legal frameworks. Beyond the publication of the UNAIDS–Lancet Commission report, and beyond the important lessons collated by the Commission’s leadership, is the hope that we can ignite on a grand scale the commitment to a whole-of-society approach not only to defeat AIDS but also to address global health challenges post 2015. Selina Lo, Richard Horton The Lancet, Beijing 100738, China (SL); and The Lancet, London, UK (RH) We thank Peter Piot and Michel Sidibé for leading the drafting of the report and the UNAIDS–Lancet Commission. We thank the United Nations Programme on HIV/AIDS (UNAIDS) for providing the financial support for this Commission. We thank the commissioners and peer reviewers for their time and thoughtful contributions to the process and all contributors in person or online to the Commission report. In particular we thank Helena Legido-Quigley, Joanne McManus, Kent Buse, Tim Martineau, and the UNAIDS team for their coordination efforts in producing the Commission report. 1
2 3 4
5 6 7
Piot P, Abdool Karim SS, Hecht R, et al, on behalf of the UNAIDS–Lancet Commission. Defeating AIDS—advancing global health. Lancet 2015; published online June 25. http://dx.doi.org/10.1016/S01406736(15)60658-4. UNAIDS. The gap report. Geneva: Joint United Nations Programme on HIV/AIDS, 2014. Biehl J, Petryna A, Gertner A, Amon JJ, Picon PD. Judicialisation of the right to health. Lancet 2009; 373: 2182–84. Sidibé M. The sustainable development agenda and the end of AIDS. Lancet 2015; published online June 25. http://dx.doi.org/10.1016/S01406736(15)61041-8. Jamieson DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet 2013; 382: 1898–955. Global Commission on HIV and the Law. HIV and the law: risks, rights and health. New York: Secretariat, Global Commission on HIV and the Law, 2012. Otterson OP, Dasgupta J, Blouin C, et al. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67.
The sustainable development agenda and the end of AIDS Published Online June 25, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)61041-8 See Comment page 106 See Perspectives page 127 See The Lancet Commissions page 171
108
2015 marks a pivotal turn in development debate and practice. In September, UN member states are expected to endorse a bold agenda that will guide social, economic, and environmental action over the next 15 years. The agenda, built around 17 Sustainable Development Goals (SDGs), signals a transformational shift towards societywide, people-centred approaches. The universality and
breadth of the sustainable development agenda will demand an overhaul in how countries, sectors, and issuespecific groups work together. This year too marks a watershed moment in the long struggle against the AIDS epidemic. The trajectory of the AIDS epidemic has been broken in most regions, and sustainable solutions are being rapidly taken to www.thelancet.com Vol 386 July 11, 2015