Accelerating progress

When President George W. Bush ratified PEPFAR in 2003, it was against the backdrop of an African continent staggering under the immense weight of the HIV crisis. Eight thousand people were dying daily, and healthcare systems across the continent were overwhelmed by people suffering from advanced HIV disease. While the initiation of PEPFAR was rooted in a moral imperative, it also addressed a global security concern; without urgent action, HIV would undermine political and economic stability worldwide. Twenty years later, the response has evolved from an emergency response. Nonetheless, for many countries with a significant burden of HIV disease, closing the gaps to achieve 95-95-95 targets by 2030 remains a formidable challenge. Across sub-Saharan Africa, millions of people living with HIV must still be reached, connected to care and successfully started on treatment.

Success in securing the 2030 targets hinges on addressing programme gaps for specific cohorts, like children, adolescent girls, young women and men, and key populations. In the coming years, PEPFAR is committed to accelerating efforts to reach these groups, supporting gender-equitable programming, empowering youth in programme design and optimising child outcomes. PEPFAR also remains focused on addressing health inequities for key populations, ensuring that care and treatment programmes are tailored to their unique needs. Scaling access to holistic, people-centred prevention services is also critical. While long-acting PrEP, like cabotegravir,4 holds much promise, it will be critical to accelerate access to these tools with an equity lens, ensuring that such prevention services are accessible broadly. Across PEPFAR-supported countries in Africa and Asia, men who have sex with men and professional sex workers have a much higher risk of acquiring HIV than the general population. Moreover, laws criminalising key populations in many countries undermine efforts to reach and engage them in national HIV programmes. As such, efforts to accelerate the HIV response must go hand with strategies that advance a human-rights approach to healthcare, supporting collaborative efforts to reach the 10-10-10 goals of the Global UNAIDS Strategy, including working to address punitive laws, gender-based violence and promoting enabling policies for equitable HIV impact.5

Sustaining the gains

For nations on track to reach the 2030 goals, the next big challenge will be to sustain the progress once the 95-95-95 targets are met. Preserving the hard-fought gains necessitates new models for how services are managed, delivered and financed, with countries leading in partnership with civil society and PEPFAR supporting. In settings with generalised epidemics, this will likely mean addressing concurrent threats like non-communicable diseases (NCDs). Managing hypertension in People Living with HIV (PLHIV) is emerging as a crucial priority in sub-Saharan Africa, where it is estimated that nearly a quarter of PLHIV have elevated blood pressure.6 Reassuringly, recent evidence from Uganda and Tanzania suggests that integrating HIV programmes with routine hypertension services can be effective and affordable.7 As HIV programmes evolve to address NCDs like hypertension, it will also be essential to determine ‘all of domestic and all of market’ approaches that increasingly leverage domestic resources to fund the HIV response. The importance of country ownership, implementation and financing in sustaining the response is undeniable and inevitable.

Shared responsibility and transformative partnerships

The twin imperatives of acceleration and sustainability pivot on shared responsibility, accountability and transformative partnerships. Achieving the 95-95-95 targets by 2030 will be determined by each country’s willingness to lead and fund its HIV response. It is also predicated on the ongoing commitment of all global actors (eg, development banks, UNAIDS, Global Fund, etc), regional bodies and civil societies to align overlapping and complementary programmatic priorities to transform the global HIV response.

The path to realising the 2030 target demands accelerating PEPFAR’s commitment to health equity and a vision for sustaining the gains. PEPFAR, conceived in a crisis, now stands at another crucial juncture, ready to transform in alignment with the next phase of the global HIV response to country-led, country-run efforts. We believe this transformation will be both expansive and exponential.