AVAC’s HIV Testing Blog Series #1: Can HIV Self-Testing Help Slow the Epidemic?

On July 17^th, the World Health Organization Released new consolidated guidelines on HIV testing services that bring together new and existing recommendations on the intervention that WHO calls “the gateway to prevention services and life-saving treatment and care.” HIV testing is also the first “90” in the UNAIDS Fast Track targets that seek to have 90 percent of people living with HIV tested, 90 percent of those individuals tested on ART, and 90 percent of those on ART virologically suppressed by 2020. Given that WHO estimates just 51 percent of people living with HIV know their status, there’s much work to be done on the testing front. The new consolidated guidance provides recommendations for lay provider testing (e.g., not by a medical professional) and advises countries on how best to target.

AVAC will be delving into various aspects of the advocacy, policy and implementation landscape around testing in P-Values posts in the coming months. In this blog, by veteran HIV journalist Mark Mascolini, we take a look at self-testing—an intervention that doesn’t yet have full WHO guidance, but is on the horizon.

How would you rate a personal diagnostic system that’s accurate, easy-to-use, private, and completely confidential? Five stars, perhaps, until you learn that it costs more than many who need it most say they can pay, misses all diagnoses in a key disease period, and may inspire false—and risky—confidence. That quick take on the pros and cons of HIV self-testing distills a slowly swelling data cache, a World Health Organization (WHO) Technical Update, and two well-reasoned analyses of new technologies that could change the way many high-risk people learn they carry HIV and may even limit HIV transmissions. But research has yet to nail down whether the clear benefits of self-testing outweigh potential drawbacks. In its new guidelines on HIV testing services WHO says that there “promising evidence” for the acceptability of self-testing and recommends implementation through country demonstration projects and pilot programmes, but stops short of a general recommendation. For this, WHO says it will wait for data from several trials whose results are expected in 2015/2016.

In the meantime, though, there’s a wealth of information for advocates and activists to consider.

Possible pluses and minuses of HIV self-testing

Pluses	Minuses
Privacy	Cannot detect early infection
Anonymity	Requires self-motivation for follow-up
Ease of use	Misunderstanding of procedure, interpretation
Accuracy	Mental distress over positive result
Testing option for high-risk people	Cost impact on access
Mutual testing of sex partners	Partner coercion
Easier repeat testing, for example, for PrEP	Condom-free sex after negative result
Wider HIV testing lowers late-diagnosis rate	Missed opportunity for STI screening

Where does testing fit in to “ending AIDS??

Testing is the cornerstone of the UNAIDS launched the 90-90-90 initiative, which aims to ensure that 90 percent of everyone living with HIV know their HIV status by 2020, and that 90 percent of those individuals are on ART and 90 percent of individuals on ART are virologically suppressed.

Just achieving the first 90—the testing goal—is a major undertaking. UNAIDS estimates that that 54 percent of people living with HIV across the globe don’t know they’re infected, To reach that goal, many countries are launching plans to massively expand HIV testing—and the draft versions of PEPFAR country operation plans that circulated earlier in 2015 bore this out with funding and detailed national planning. Much of this expansion is focused on linking people who test positive to ART; there is far less discussion of how testing could be used as an entry point for additional prevention services, including PrEP, for people who are HIV negative. But for PrEP-watchers, this is a key concern. Leveraging testing expansion as an entry point for effective prevention could revolutionize HIV prevention; in addition, safe and effective PrEP use requires HIV testing on a regular basis to ensure that the mono- or dual-therapy is not being used by someone who has acquired HIV.

Is self-testing a partial solution?
With all of this context, the question remains: How can public health authorities expand HIV testing when many high-risk people avoid it because they fear stigma and discrimination—especially if they test positive? HIV self-testing—usually done at home—could be a big part of the answer because it’s completely private. All HIV self-tests are easy to use, though users must be able to read and understand instructions. Studies of the oral HIV self-test found that more than 80 percent of users understood how to use the kit and interpret the results. Research involving untrained self-testers found low operator error rates ranging from 0.37 to 5.4 percent.

No one doubts the demand for confidential self-testing systems. Two recent systematic reviews of self-test studies in the US, Europe, Asia, and Africa figured that 70 percent of potential users in one analysis and up to 84 percent in another found current HIV self-test kits acceptable, and high proportions thought them easy to use. And it seems clear that home-use kits can reach high-risk people. An FDA modeling study of an oral fluid diagnostic test predicted that 2.8 million people would use the test in 1 year and that it would prevent 4,000 new HIV transmissions. Half of the participants in another analysis said the self-test was their first HIV test. In countries that license HIV self-tests, kits can be bought off the shelves of many pharmacies or purchased online. Vending machines may one day dispense HIV self-tests.

Ready access to these tests, and their confidentiality, could encourage repeat use by high-risk people and facilitate the regular HIV testing necessary for effective PrEP. (UNITAID issued a call for proposals on PrEP that could include an HIV self-test.) A trusted self-test could promote mutual testing by sex partners. One systematic review determined that 80 to 97 percent of test users reported partner testing. Some research suggests rapid self-test kits will enable joint testing by new partners and could alter subsequent sexual behavior. Research confirms the intuitive assumption that wider HIV testing cuts the late-diagnosis rate and thus improves individual HIV care.

Current self-test devices use either a spot of blood from a finger pin-prick or oral fluid swabbed from the mouth. A systematic review found that potential users consistently preferred the oral test over the finger-prick. The oral test may yield an incorrect result a bit more often than the blood tests (see table below), but all tests licensed by regulatory agencies are highly reliable. WHO cautions though, that user errors and local HIV prevalence can affect self-test accuracy. People who want to buy an HIV test online should make sure regulators have licensed the test they seek because unlicensed tests may be less accurate.

Cost and inability to detect HIV in the early months of infection are two prime drawbacks of current HIV self-tests. For example, two licensed tests in the United States cost about US$40 per kit, while a test licensed in the United Kingdom in 2015 costs £30 (USD$46) Most survey respondents in self-test studies said they would not pay more than US$20 for such a test. In many regions, the poorest people are those with the highest HIV burden, so high cost could undercut the HIV-preventing potential of self-testing.

All current self-tests detect HIV antibodies, which take time to develop in a newly infected person. Almost everyone will have detectable antibodies within three months of infection, but before that someone can be HIV-positive and still test negative on an HIV self-test kit or other HIV antibody tests. Health experts fear that a negative self-test in the first weeks of HIV infection—when viral load and the potential for HIV transmission are highest—could lead some people to feel safe having sex without a condom. Because self-tests detect antibodies, they cannot be used in infants, who carry maternal HIV antibodies even if they are HIV-negative themselves.

The newest HIV self-tests give results in 15 to 20 minutes at home. Some health authorities fear that people who test positive at home may be less likely to seek counseling (which self-test makers facilitate) and less likely to enter care than people who test positive in a center where health workers read rapid-test results and counsel people immediately. If people self-test because they fear stigma, the same fear may keep them from seeking counseling or care. People with limited phone or internet access, some worry, would have a harder time seeking counseling and starting care. And if sexually active people can test themselves for HIV at home, they may be less likely to get tested regularly for other sexually transmitted diseases.

Another conceivable drawback of self-testing is that partners will coerce their mates into testing themselves and even abuse them if they don’t or if they test positive. Data supporting or disproving these hypotheses remain limited, and WHO reports no accounts of human rights violations or violence associated with self-testing.

Comparing three representative HIV self-tests

	Home Access HIV-1 Test System	OraQuick In-Home HIV Test	BioSure HIV Self Test
Licensed	1996 in USA	2012 in USA	2015 in UK
Where can I get it?	Online or by phone	Drug stores	Online
How it works	Blood sample from finger-prick sent to lab.	Oral fluid from mouth swab put in testing device.	Blood sample from finger-prick put in testing device.
How long does it take to get results?	Three to seven business days after you mail test sample.*	20 to 40 minutes	15 minutes
What happens next?	If you test positive, the lab runs a second confirming test.	If you test positive, you must go to testing center or medical clinic for a confirming test.	If you test positive, you must go to testing center or medical clinic for a confirming test.
What else does the testing company provide?	If you test positive on a first test and follow-up test, company provides confidential counseling and referral to an HIV provider in your area.	If you test positive on a first test, company provides confidential counseling and referral for a confirming test.	If you test positive, company offers online assistance to find testing center for a confirming test.
How soon after HIV infection will the test show a positive result?	Test detects HIV antibodies, not HIV itself. Antibodies take 3 to 6 months to develop after infection.	Test detects HIV antibodies, not HIV itself. Antibodies take 3 to 6 months to develop after infection.	Test detects HIV antibodies, not HIV itself. Antibodies take 3 to 6 months to develop after infection.
How accurate is the test?	More than 99.9% of people who are HIV positive will get a positive result. More than 99.9% of people who are negative will get a negative result.	About 92% of people who are HIV positive will get a positive result. That means up to 1 in 12 positive people may get a negative result. Up to 99.98% of people who are negative will get a negative result. About 1 in 5000 results will be false-positive.	99.7% of people who are HIV positive will get a positive result, while 99.9% of people who are negative will get a negative result.
What HIV strains can it detect?	HIV-1	HIV-1 and HIV-2	HIV-1 and HIV-2
How much does it cost?	About $40	About $40	About £30

*Or on day sample arrives in lab with more expensive express service.

A WHO Technical Update concludes that “HIV self-testing has the potential to increase access to HIV testing including among people living with HIV without their knowledge, and those who are in need of HIV care, treatment and support.” The WHO document offers a clear summary of policy and regulatory considerations for policy makers and implementers.

New Report on HIV Prevention R&D Investment Highlights 2014 Global Funding Trends

The recent UN Report on the Millennium Development Goals (MDGs) calls out the 40 percent reduction in new HIV infections since the MDGs were established in 2000 as a singular MDG achievement¹. That progress reflects 15 years of HIV research in many forms—from female condoms and voluntary medical male circumcision, to new strategies for preventing vertical transmission to the scale-up of ART. Over the years, this progress has been supported by investments from many government, philanthropic and private sector funders of HIV prevention research.

The 11th annual report on the state of HIV prevention research investment, HIV Prevention Research & Development Funding Trends 2000–2014: Investment Priorities To Fund Innovation In An Evolving Global Health and Development Landscape, suggests that this work is still on the agenda for funders, albeit with a small cohort supplying the bulk of the resources.

The new report, released in Vancouver at the IAS 2015 conference, was prepared by the HIV Vaccines & Microbicides Resource Tracking Working Group (RTWG), led by AVAC, in partnership with the International AIDS Vaccine Initiative and UNAIDS. HIV Prevention Research & Development Funding Trends 2000–2014: Investment Priorities To Fund Innovation In An Evolving Global Health and Development Landscape documents that absolute funding levels have been stable over the past few years. This reflects an overall decline in real spending given biomedical research inflation.

In 2014 funders invested a total of US$1.25 billion in research and development (R&D) for HIV prevention—representing a decrease from the 2013 funding level which totaled US$1.26 billion.

In 2014, the US public-sector and the Bill & Melinda Gates Foundation account for 83 percent of all HIV prevention R&D funding and the number of philanthropic funders engaged in HIV prevention research has continued a steadily decline since 2010. Thus, the report points to the need for a broader funding base.

Despite the slight decline in funding, HIV prevention R&D is still delivering important advances. The 8th IAS Conference on HIV Pathogenesis, Treatment and Prevention in Vancouver July 20-22, will showcase results for a range of groundbreaking research that has been supported over the past several years, including the Strategic Timing of Antiretroviral Treatment (START) trial, the HPTN 052 treatment as prevention trial and several groundbreaking oral PrEP trials.

Results from studies of a vaginal ring containing the antiretroviral dapivirine are expected in the next 12 months. Several different HIV vaccine candidates, neutralizing antibodies and long-acting injectable ARVs are currently in trials that could lead to multiple efficacy trials starting over the next two years.

While the report focuses on financial resources, in also highlights the essential role of individual trial participants. In 2014, there were over a million participants in HIV prevention research trials globally. With continued human and financial investment, the 40 percent reduction in new HIV infections attributed to the MDGs is hopefully only the beginning.

For more information on the HIV Vaccines & Microbicides Resource Tracking Working Group, the full report, executive summary, graphics and slides visit www.hivresourcetracking.org.

¹ The MDGs consist of eight global goals, with goal six to combat HIV/AIDS, malaria and other diseases. For more information on the MDGs see: www.un.org/millenniumgoals/aids.shtml.

Targets that Require Work: PrEP and Combination Prevention

Targets are urgently needed for daily oral PrEP and combination prevention. This graphic, from AVAC Report 2014/15: HIV Prevention on the Line, proposes goals and shows what’s in place and what is missing today.

AVAC Report: HIV Prevention on the Line

AVAC’s annual report of the field, the upcoming CROI meeting and why the coming year is the best and worst of times for HIV prevention

Next week, scientists, advocates and clinicians will gather in Seattle for the Conference on Retroviruses and Opportunistic Infections (CROI), a venerable HIV meeting that often triggers media coverage of the AIDS epidemic and the potential for curbing it and preserving health in people living with HIV.

A range of data is expected from CROI including “late-breaker” abstracts that will showcase data from IPERGAY and PROUD, two trials of oral PrEP using TDF/FTC in gay men and other men who have sex with men in Europe and Canada, and another trial of the microbicide 1% vaginal tenofovir gel in South African women. There will also be data from a PrEP “demonstration project” that provided the strategy in a real-life context for Kenyan and Ugandan couples with one HIV-positive and one HIV-negative partner.
We don’t know what the specific headlines will be, but we can say with confidence that one take-away must be this: The future of HIV prevention is on the line.

In our latest report, AVAC Report 2014/15: Prevention on the Line, we provide a clear agenda for what needs to happen, what’s missing, and why it matters now more than ever before.

Specifically, we argue that:

Ambitious prevention goals matter. They can galvanize new action, in part by expanding our sense of what’s possible.

But these goals will only work if they’re feasible, well-defined, measurable, and backed by adequate resources and political support. The prevention goals issued so far are inspiring but they don’t yet meet those requirements.

As the UNAIDS “Fast Track” for 2020 set aspirational goals, clear short-term targets are also urgently needed. We can’t wait for five years to see if the world is on track to end the AIDS epidemic.

The global AIDS response is running at a major financial deficit. New targets will not be met—and may even be irrelevant—if we fail to close a growing global funding gap.

Recent breakthroughs in HIV research have transformed the ability to curb new infections, making it possible to contemplate the end of the global AIDS epidemic. But prevention could be left behind if global leadership fails to make it a priority.

Recently, UNAIDS issued broad goals for HIV testing, ART provision and virologic suppression over the next five years. According to the agency, achieving these “90-90-90” goals would put the world on track to effectively end the AIDS epidemic by 2030.

On the prevention front, UNAIDS seeks to reduce new infections worldwide from 2.1 million in 2013 to 500,000 in 2020, and to eliminate stigma and discrimination. These are ambitious goals and worth aspiring to. But something important is missing from the picture—intervention-specific targets with the specificity, strategy and resources to match. The goal is great. What’s missing is how to get there.

In twenty years, we will have ample hindsight as to whether today’s targets mattered in the quest to end AIDS.

But right now, foresight and focus are urgently required. We’re concerned about whether the targets that have been set are the right ones, how much targets matter—particularly in the context of a global response running at a disastrous funding deficit—and where prevention targets other than those focused on the antiretrovirals in HIV-positive individuals—fit in. We’re also cognizant that targets can turn from audacious to absurd in the blink of an eye if financing, political will and community buy-in are missing.

AVAC works in coalitions in many of the countries hardest hit by the epidemic. Targets that are developed Geneva, Washington DC and other corridors of power can bear little resemblance to the realities of AIDS endemic countries and communities. Where there’s no reality, there’s no relevance. It’s essential that countries have the technical and financial resources to make global targets relevant to national context. Otherwise, the loftiest goals will be ignored.

As we argue in this Report, targets have played a critical role in changing the course of the epidemic. Likewise, a poorly-thought out target can have no impact at all. Right now, it’s critical that targets and tactics are matched to the lofty but achievable goal of bringing an end to AIDS. This is why we’ve devoted the first section of the Report to a look at why targets matter, what targets are missing, and how advocates for a comprehensive response need to work together to ensure smart, strategic targets across the spectrum of prevention options.

We also focus on issues that underpin (and, sometimes, undermine) the ability to meet these targets. We identify three specific areas for action:

Align high impact strategies with human rights and realities. Biomedical advances of the past eight years have made it scientifically plausible to talk about ending the epidemic. But plausible doesn’t mean possible. Today some scientists and public health professionals are focused on what can be achieved biomedically—without enough attention to the structural and social contexts in which treatment prevention are delivered. At the same time, some rights-focused partners speak of HIV as being exclusively pill-oriented, suggesting that there isn’t any dynamism or action on the rights-based fronts. It need not be a permanent rift—indeed it cannot be. If science does not get synched up with human rights then then there is little hope of bringing the epidemic to a conclusive end.

Invest in an oral PrEP-driven paradigm shift. The world is failing to deliver the most effective interventions with smart strategy and at scale. Daily oral PrEP for HIV prevention is just one example. Global targets for PrEP may be released in the coming months, but there aren’t any plans in place to meet them. Demonstration projects are small and disconnected, funding is limited and policy makers aren’t heeding the growing demand from men and women, including young women in Africa. Now is the time to spend and act to fill these gaps.

Demand short-term results on the path to long-term goals. It will be years before the world has an AIDS vaccine, cure strategies, long-acting injectable ARVs or multipurpose prevention technologies that reduce the risk of HIV acquisition and provide contraception. But there’s plenty of activity in clinical trials and basic science for these long-term goals. This activity needs to be aligned with short-term goals that can be used to measure progress and manage expectations.

As AVAC Report goes to press this week and as we prepare for CROI next week, the United States is grappling with profound questions about the ways that the lives of Black men and women are valued under the law. The world is trying to understand how the West African Ebola epidemics got out of control—and how to bring them to an end. And there is continued concern and vigilance over anti-homosexuality laws in Nigeria and the Gambia, and in hate-mongering environments and legislation that endanger LGBT individuals and many other marginalized groups around the world.

These events are not separate from the work that we do to fight AIDS. They embody the issues of racism, inequity, poverty and security that drive the epidemic that must be addressed to end it. In addition to the HIV-specific work laid out in these pages, it is essential to work towards fundamental, lasting and positive change in each of these areas. That will be history-making, indeed.

Press Release

With future of HIV prevention “on the line,” AVAC calls for sharper, bolder strategy to end the epidemic

Contacts

Mitchell Warren, mitchell@avac.org, +1-914-661-1536

Kay Marshall, kay@avac.org, +1-347-249-6375

New York — In a report issued today, AVAC warned that global HIV prevention efforts are in jeopardy due to an absence of strategic targets, resources and specific implementation plans to translate science, slogans and goals into action. The report calls for a robust set of global HIV prevention targets tailored to specific interventions and demands action in several key areas of the global AIDS response, including expanded rollout of daily oral pre-exposure prophylaxis, or PrEP, and alignment of science and human rights-based agendas.

“We’re at a make-or-break moment and the future of HIV prevention is on the line,” said Mitchell Warren, AVAC’s executive director. “Advances in HIV treatment and prevention research have made it possible to contemplate ending the AIDS epidemic in our lifetimes, but that will only happen with smarter planning, increased resources and greater accountability.”

The report was released ahead of the Conference on Retroviruses and Opportunistic Infections (CROI) in Seattle (Feb. 23-26), where researchers are expected to present data from several major HIV prevention trials, including studies that could help drive global implementation of PrEP, as well as a key study of a tenofovir-based vaginal gel for women.

Report calls for smart, realistic goals and targets for HIV prevention

Today’s report, entitled Prevention on the Line, takes a close look at global goals for HIV prevention and what it will take to make them a reality. UNAIDS recently adopted the broad goals of reducing new HIV infections worldwide from 2.1 million in 2013 to 500,000 and eliminating stigma and discrimination, both by the year 2020.

Drawing upon lessons from WHO’s “3 x 5” HIV treatment initiative and other case studies, the AVAC Report concludes that ambitious prevention goals are critical – but that they will only work if they’re feasible, well-defined, measurable and supported with adequate resources and political commitment. In the case of the new UNAIDS prevention goals, the report points to a critical need for more specific, interim targets that can be tracked between now and 2020; for better data and monitoring approaches; and for resource allocations that are directly tied to achieving those targets.

“The UNAIDS prevention goals for 2020 are ambitious and inspiring,” said Warren. “But something important is missing from this picture: how to get there. We need a clear path forward, including short-term targets, so we don’t wait five years to see if the world is on track. And new targets won’t be met – and may even be irrelevant – if we fail to close the growing global funding gap for HIV prevention.”

Bold action needed to advance AVAC’s agenda to end AIDS

The report also recommends key actions to advance AVAC’s three-part agenda to end AIDS. First issued in 2011, the agenda calls for sustained efforts to deliver proven prevention tools, demonstrate and roll out new options such as PrEP and develop long-term solutions such as long-acting ARV-based prevention, vaccines and cure strategies.

Key recommendations for 2015 include:

1. Align high-impact HIV prevention with human rights and realities. Research has demonstrated the potential of high-impact prevention strategies, including biomedical approaches like HIV treatment for people living with HIV and voluntary medical male circumcision (VMMC). But these strategies won’t succeed in the real world if we give short shrift to human rights concerns, or if we fail to involve affected communities in designing and implementing prevention programs. Recent experience with treatment and VMMC, in particular, has shown that community buy-in is an essential ingredient of successful rollout and scale-up.

2. Invest now to scale up access to PrEP. Landmark trials have shown that daily oral PrEP is a powerful HIV prevention tool, and studies at next week’s CROI meeting could provide additional support. But the pace of rollout remains far too slow. Demonstration projects are small and disconnected, funding is limited and policy makers are not yet heeding growing demands for access. Funders should invest now in large-scale targeted implementation of PrEP, linked to national programs. National regulatory authorities and health ministries should prioritize licensure and rollout.

3. Accelerate research into long-term solutions. We must sustain and accelerate research on solutions such as an effective AIDS vaccine, long-acting antiretroviral prevention and treatment and a cure. Just like the rest of the AIDS response, this research needs its own short-term targets, aligned to long-term goals.

The new report and related resources, including downloadable graphics, are available now at www.avac.org/report2014-15.

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About AVAC: Founded in 1995, AVAC is a non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic.

Ugandan Advocates Emphasize Prevention Based in Evidence, Not Opinion

At this year’s World AIDS Day commemoration in Uganda, President Yoweri Museveni’s remarks were reported to question some of the scientifically proven HIV prevention interventions including voluntary medical male circumcision and condoms.

Political leadership is critical for an effective HIV/AIDS response. Over the past twelve months, Ugandan civil society has worked tirelessly to address national challenges including the anti-homosexuality law and enforcement of a law criminalizing HIV transmission. They have also responded to these recent developments.

Here is an op-ed written by Regional Policy and Advocacy Manager at the East/West Africa Bureau of the AIDS Healthcare Foundation and former AVAC Fellow Alice Kayongo-Mutebi.

HIV Prevention on the Line

World AIDS Day brought commemorations of those lost, recognition of those still fighting and celebration of those who are living and thriving with HIV.

In advance of World AIDS Day, AVAC developed a briefing paper, HIV Prevention on the Line, and associated advocacy tools that frame key issues for HIV prevention advocates. The resources provide messages and recommendations that address the fact that today HIV prevention is at a crucial moment. It is indispensable and advancing in leaps and bounds. Yet it is also in jeopardy.

Click here to view and download the resources about what needs to happen next.
Click here to read an accompanying editorial, published today in the Huffington Post.

HIV Prevention on the Line puts the current discussion about global targets for ending AIDS in context. What makes a good target? What targets have worked in the past—and why? What is the state of HIV prevention targets and plans today? We summarize key points now and will bring out a complete analysis in the full AVAC Report 2014/15, early in the new year.

We have also developed a slide set for advocates who may be preparing for World AIDS Day events or talks. Also check out a video of AVAC Executive Director Mitchell Warren’s take on the state of HIV prevention this World AIDS Day.

What are you doing or thinking for World AIDS Day? We would love to post blogs, pictures and statements from our partners. Please share them with us at avac@avac.org or post them to our Facebook or Twitter pages. And as usual, we’re eager to hear your input on advocacy messages, strategies and priorities.

UNAIDS Report has Bold Vision, Key Messages—But Needs More Precision on HIV Prevention

UNAIDS recently released Fast Track: Ending the AIDS Epidemic by 2030, its report for World AIDS Day (December 1, 2014). Coming nearly two weeks early, the launch was, itself, fast-tracked—and there’s plenty of “we can’t wait” urgency within the pages of the report, starting with the first page (that does more, typographically, with red ribbons than you might believe is possible). It reads:

“We have bent the trajectory of the AIDS epidemic. Now we have five years to break the epidemic or we risk the epidemic springing back even stronger.”

This is on target and a message to convey urgently and with clarity. UNAIDS has its work cut out as an agency that can provide leadership, mobilize resources and push for the shift to community-based service delivery that emerges as one of the core recommendations in the report.

In broad strokes, it’s the right message, with the right vision, at the right time.

But an effective response depends on strategy, details, milestones, resources and specifics—and these are still lacking. This is to be expected, as the UNAIDS Prevention and Non-Discrimination Targets are still in draft form.

The Fast Track World AIDS Day report is clear on what needs to happen to achieve the “90-90-90” goal that calls for 90 percent of people living with HIV to know their status, 90 percent of those to be on antiretroviral therapy (ART) and 90 percent of those to be virologically suppressed by 2020.

It also suggests the components of prevention programming that should also come on line—listing, in various places, male and female condoms, voluntary medical male circumcision, oral pre-exposure prophylaxis (PrEP) for sex workers, men who have sex with men, serodiscordant couples and adolescents, as well as cash transfers for young girls, harm reduction, structural interventions, mass media and behavior change. These prevention elements appear in different subsets throughout the document, leaving some confusion about what, exactly, is essential.

Everything that the UNAIDS report lists is important. But the details of what goes where—which packages, in which places—and what specific terms mean are missing. Cash transfers, for example, can be delivered in a range of ways, with different objectives and different outcomes.

There are also some elements that receive considerably less emphasis. Research and development of more potent ARVs for treatment and prevention, new prevention options for women and other key populations, vaccine and cure strategies, are fundamental to long-term success in “breaking the epidemic”. Within the five-year timeframe set by UNAIDS, there are short-term milestones to set and achieve in each of these areas, even though the ultimate goals may not be reached for many years.

The good news is that this is a solvable problem. We as advocates and activists must use our impatience and collective wisdom to fast-track a process to ensure that clear targets, resources and messages are developed with the same strategy, rigor and urgency as 90-90-90.

AVAC is working with many of our partners to inform this process. This new report adds urgency to this task and clarity to the questions we need to address. As the report stresses, we must all “hold one another accountable for results and make sure no one is left behind.”

In the coming days, AVAC will release “Prevention on the Line”—a briefing paper with core recommendations for effective target-setting across the research-to-rollout continuum. This will summarize core messages and analysis that will be expanded in AVAC Report 2014/15. To receive the Report and other updates in your inbox, please join our Advocates’ Network. Stay tuned—and stay in touch.

Click here to download the new UNAIDS report.

Calling the Prevention Community: The UNAIDS targeting process needs all hands on deck

Today UNAIDS hosted a webinar to describe and discuss its proposed prevention targets. These have been developed to complement the 90-90-90 target which seeks to have 90 percent of people with HIV know their status, access antiretroviral therapy (ART) and achieve virologic suppression by 2020. 90-90-90 is, of course, a combination treatment and prevention target since virologic suppression reduces the risk of HIV transmission. But AIDS advocates have been asking for targets with similar specificity and ambition for non-ART prevention—including attention to stigma, discrimination and criminalization, since rights-based delivery of services is absolutely essential.

UNAIDS has released both a prevention target draft and a draft of non-discrimination targets. Together, these two documents are the beginning of what a comprehensive response, complementing 90-90-90 could look like. But, as we describe below, there is still a pressing need to review and clearly articulate the rationale for the specific targets being laid out—particularly in the HIV prevention target draft. This is because the prevention target draft has a narrower set of possible objective than the non-discrimination target draft, which lays out two broad approaches to setting these targets—and invites input on the overall strategy.

AVAC and partners have reviewed both draft documents; you can read the composite feedback from Stop AIDS Now and the International HIV/AIDS Alliance on the draft non-discrimination target here. In this post, we focus on the prevention target draft.

The overall prevention goal is to reduce the number of new HIV infections to below 500,000 per year by 2020. There are two population specific sub-goals:

By 2020, new infections in key populations will be reduced by 75%
By 2020, new infections in young women and girls will be reduced by 75%

As UNAIDS’ Karl Dehne presented on today’s webinar, the over-arching target was selected for the following reasons.

These overarching goals are ambitious, and it is both necessary and exciting to envision how they could be achieved. The prevention targets document begins to map out what Dehne calls the “programmatic targets” that could contribute to these overarching objectives. The proposed “results” framework for these programmatic targets as presented today looks like this:

AVAC and partners who have reviewed the document and the results framework feel that urgent attention and discussion is warranted to ensure that the eventual finished product has the impact that’s needed. We have submitted a letter and a mark-up of the targets document itself that articulate a range of concerns. UNAIDS has also posted shared Google documents of both the prevention and non-discrimination target drafts, and they can be viewed here:

The comment period for both documents closed yesterday (November 12, 2014). However, on today’s webinar, UNAIDS’ Chris Collins said that there was still a narrow window for weighing in—but that feedback did need to come in “as soon as possible.” The above Google Docs remain available. You may also reach out to advocacy@unaids.org.

We will be working with partners to amplify questions and priorities in the coming days—and welcome feedback and input on the documents, our analysis and the overall process for developing these goals. Please be in touch and watch this blog for more updates!

FY2015 US Global AIDS Budget Plan: The Human Impact

The US government’s efforts to fight the global AIDS pandemic through both the US President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria have been transformative in the global AIDS response. To maintain the current total level of US global HIV/AIDS funding in Fiscal Year 2015, the US House of Representatives has proposed restoring US$300 million in PEPFAR funding. As illustrated in this infographic, amfAR has estimated the potential human impact of US$300 million to expand lifesaving HIV prevention, Treatment U=U and care services.

AVAC’s annual report of the field, the upcoming CROI meeting and why the coming year is the best and worst of times for HIV prevention

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