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Doubts hang over PEPFAR finances
Editorial
The role of testing in HIV prevention Despite worldwide roll-out of antiretroviral therapy, HIV incidence has been stable for the past 10 years. Prevention strategies, such as treatment as prevention, safer sex, and more recently pre-exposure prophylaxis have been viewed as the mainstays of efforts to reduce incidence. But one essential part of the prevention armamentarium has, at times, been overlooked: accessible testing. The UK could be about to address this oversight as a draft quality standard document from the National Institute for Health and Care Excellence (NICE) recommends the introduction of routine HIV testing. NICE outlines six quality statements that encourage testing for HIV in different settings and populations, including patients in high-prevalence areas and in atrisk demographic groups who are admitted to hospitals, attending emergency departments, or visiting general practitioners. The NICE statement also recommends that people who are at risk take tests at least annually. The speed and ease of modern HIV testing might make people more inclined to accept routine testing.
When a test for HIV was first introduced in 1985, no effective treatment was available, and a positive result was seen more as a death sentence than as a chance to prevent further disease. However, prognosis today is very different and, in the UK, a positive result from an HIV test can lead to far better health outcomes than living with undiagnosed infection. Routine testing is likely not only to increase the numbers of diagnosed infected patients and thereby decrease transmission, but also to reduce stigma around HIV testing and infection more generally. Crucially, to implement routine testing effectively, systems need to be put in place in parallel to ensure linkage to care, treatment, and adherence interventions for people identified as HIV positive and comprehensive prevention advice must be provided for those with negative results. Perhaps the next step for routine testing is availability for an even wider audience than that proposed by NICE. Normalisation of HIV testing might encourage more thought about risks in all people, helping to eliminate stigma as awareness spreads. ■ The Lancet HIV
For more on global HIV incidence see Articles Lancet HIV 2015; 3: e361–87 For the NICE draft quality standard see https://www.nice. org.uk/guidance/GIDQS10040/documents/draftquality-standard For more on HIV testing in London see Correspondence Lancet HIV 2017; 4: e153
Doubts hang over PEPFAR finances In January, we considered the future of HIV/AIDS funding in the USA in light of the election of President Donald Trump, particularly overseas funding and the US President’s Emergency Plan for AIDS Relief (PEPFAR). When asked about his views on the fight against HIV/AIDS, the President’s response was positive. However, in the latest list of options for funding cuts from the White House, PEPFAR is in the extensive list of federal agencies and departments in the crosshairs. PEPFAR has been vital in the fight against HIV. Yet, the Trump administration budget documents suggest cuts of US$242 million to PEPFAR. The document proposes savings by reducing support to low-priority countries and programmes that are ineffective—although it could easily be argued that countries with struggling HIV programmes are those in greatest need of international support. A further $50 million of cuts have been suggested for domestic HIV/AIDS programmes in the USA, undermining the idea of “America first”—more like “some of America first”. www.thelancet.com/hiv Vol 4 May 2017
Former US president and founder of PEPFAR, George W Bush, has spoken out in response to the proposed cuts, less than a month away from the April 28 deadline for spending legislation, sharing the importance of PEPFAR for the USA and the rest of the world. He calls for full funding for the initiative because “saving nearly 12 million lives is proof that PEPFAR works”. He says that cuts to PEPFAR now could halt the crucial progress made in the past 15 years, and that the work should continue “until the job is done”. The USA has led by example in the global AIDS response, and even inspired commitment from other governments. Although we hope that this will continue and urge the new administration to maintain their commitment, the doubt surrounding ongoing support should act as an impetus for countries that are substantial beneficiaries of PEPFAR support to strengthen their national plans to ensure the continuity of HIV care programmes and for other bodies to make plans to step into the breach. ■ The Lancet HIV
For the previous Editorial on PEPFAR funding see Editorial Lancet HIV 2017; 4: e1 For the reduction options document see http://www. politico.com/f/?id=0000015b14ec-d040-a17b-bfeea7410001 For more on Politico proposed cuts see http://www.politico. com/story/2017/03/donaldtrump-cuts-to-domesticprograms-congress-236579 For George W Bush’s opinion piece see https://www. washingtonpost.com/opinions/ george-w-bush-pepfar-savesmillions-of-lives-in-africa-keepit-fully-funded/2017/04/07/ 2089fa46-1ba7-11e7-98871a5314b56a08_story. html?utm_term=.1e5d1a0699cb
e189
The role of testing in HIV prevention Despite worldwide roll-out of antiretroviral therapy, HIV incidence has been stable for the past 10 years. Prevention strategies, such as treatment as prevention, safer sex, and more recently pre-exposure prophylaxis have been viewed as the mainstays of efforts to reduce incidence. But one essential part of the prevention armamentarium has, at times, been overlooked: accessible testing. The UK could be about to address this oversight as a draft quality standard document from the National Institute for Health and Care Excellence (NICE) recommends the introduction of routine HIV testing. NICE outlines six quality statements that encourage testing for HIV in different settings and populations, including patients in high-prevalence areas and in atrisk demographic groups who are admitted to hospitals, attending emergency departments, or visiting general practitioners. The NICE statement also recommends that people who are at risk take tests at least annually. The speed and ease of modern HIV testing might make people more inclined to accept routine testing.
When a test for HIV was first introduced in 1985, no effective treatment was available, and a positive result was seen more as a death sentence than as a chance to prevent further disease. However, prognosis today is very different and, in the UK, a positive result from an HIV test can lead to far better health outcomes than living with undiagnosed infection. Routine testing is likely not only to increase the numbers of diagnosed infected patients and thereby decrease transmission, but also to reduce stigma around HIV testing and infection more generally. Crucially, to implement routine testing effectively, systems need to be put in place in parallel to ensure linkage to care, treatment, and adherence interventions for people identified as HIV positive and comprehensive prevention advice must be provided for those with negative results. Perhaps the next step for routine testing is availability for an even wider audience than that proposed by NICE. Normalisation of HIV testing might encourage more thought about risks in all people, helping to eliminate stigma as awareness spreads. ■ The Lancet HIV
For more on global HIV incidence see Articles Lancet HIV 2015; 3: e361–87 For the NICE draft quality standard see https://www.nice. org.uk/guidance/GIDQS10040/documents/draftquality-standard For more on HIV testing in London see Correspondence Lancet HIV 2017; 4: e153
Doubts hang over PEPFAR finances In January, we considered the future of HIV/AIDS funding in the USA in light of the election of President Donald Trump, particularly overseas funding and the US President’s Emergency Plan for AIDS Relief (PEPFAR). When asked about his views on the fight against HIV/AIDS, the President’s response was positive. However, in the latest list of options for funding cuts from the White House, PEPFAR is in the extensive list of federal agencies and departments in the crosshairs. PEPFAR has been vital in the fight against HIV. Yet, the Trump administration budget documents suggest cuts of US$242 million to PEPFAR. The document proposes savings by reducing support to low-priority countries and programmes that are ineffective—although it could easily be argued that countries with struggling HIV programmes are those in greatest need of international support. A further $50 million of cuts have been suggested for domestic HIV/AIDS programmes in the USA, undermining the idea of “America first”—more like “some of America first”. www.thelancet.com/hiv Vol 4 May 2017
Former US president and founder of PEPFAR, George W Bush, has spoken out in response to the proposed cuts, less than a month away from the April 28 deadline for spending legislation, sharing the importance of PEPFAR for the USA and the rest of the world. He calls for full funding for the initiative because “saving nearly 12 million lives is proof that PEPFAR works”. He says that cuts to PEPFAR now could halt the crucial progress made in the past 15 years, and that the work should continue “until the job is done”. The USA has led by example in the global AIDS response, and even inspired commitment from other governments. Although we hope that this will continue and urge the new administration to maintain their commitment, the doubt surrounding ongoing support should act as an impetus for countries that are substantial beneficiaries of PEPFAR support to strengthen their national plans to ensure the continuity of HIV care programmes and for other bodies to make plans to step into the breach. ■ The Lancet HIV
For the previous Editorial on PEPFAR funding see Editorial Lancet HIV 2017; 4: e1 For the reduction options document see http://www. politico.com/f/?id=0000015b14ec-d040-a17b-bfeea7410001 For more on Politico proposed cuts see http://www.politico. com/story/2017/03/donaldtrump-cuts-to-domesticprograms-congress-236579 For George W Bush’s opinion piece see https://www. washingtonpost.com/opinions/ george-w-bush-pepfar-savesmillions-of-lives-in-africa-keepit-fully-funded/2017/04/07/ 2089fa46-1ba7-11e7-98871a5314b56a08_story. html?utm_term=.1e5d1a0699cb
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