CROI 2023: PEPFAR at 20: Remarkable progress but work remains

Rabita Aziz, MPH

2/28/2023 Facebook Twitter LinkedIn Email

In the 20 years since the U.S. President’s Emergency Plan for AIDS Relief was launched, more than 20 million people have been placed on lifesaving antiretroviral treatment, more than 7 million HIV infections have been prevented, and more than 5.5 million children have been born free of HIV, U.S. Global AIDS Coordinator and Ambassador Dr. John Nkengasong said at the recent Conference on Retroviruses and Opportunistic Infections. More than 70,000 health workers have been trained to deliver HIV and other health services in resource-limited countries, he added.

Several PEPFAR-supported countries are on track to reach global goals by 2025, including having 95% of people with HIV know their status, having 95% of those individuals on HIV treatment, and having 95% of those individuals be virally suppressed. But the epidemic is far from over, with 1.5 million new infections every year and more than 650,000 deaths, of which more than 425,000 are in Africa. More than 10 million people with HIV still lack access to treatment, which not only prevents illness but prevents transmission to others.

Sixty percent of new HIV infections remain in Africa, Ambassador Nkengasong said, with young people aged 15 to 24 at disproportionate risk even in countries on track to meet 95-95-95 targets. In Malawi, 76% of adolescents and young adults know their status, compared to more than 95% of adults with HIV.

The numbers are more stark for adolescent girls and young women specifically — in Eswatini, only 64% of young women know their status. That number isn’t much higher than it was in 2016, when 53% of young women knew their status. These women are becoming infected at a higher rate than their male counterparts, he said. “We’re seeing three times more new infections in girls than in boys.”

“We really need to look at this young population and how do we identify them and bring them into treatment,” Ambassador Nkengasong said. “Once we link them to treatment, their viral suppression is as high as it is in adults.”

With the growing “youth bulge” in Africa, where “young people today haven’t seen the ugly face of HIV that we all saw 20 years ago,” more effective strategies to reach young people must be developed, he said, suggesting that PEPFAR should develop behavior studies to better understand how to identify and bring young people into treatment.

Substantial inequities persist in HIV care in certain populations, including in HIV treatment outcomes between adults and children, Ambassador Nkengasong said, with 41% of children receiving HIV treatment being virally suppressed, compared to 70% of adults with viral suppression. “Between 2018 and 2021, we have not made significant progress in achieving viral load suppression in children,” he said. Even identifying children with HIV remains a fundamental challenge that must be addressed, he said.

Knowledge of HIV status among gay men, men who have sex with men and transgender populations remains “remarkably low,” he said, pointing to policies and structural barriers reinforcing stigma and discrimination against these marginalized communities and preventing them from seeking testing and care.

“Unless we look at punitive policies and repeal them, we’ll continue to face challenges in providing care to this subset,” Ambassador Nkengasong said. Once reached with testing and treatment, the rate of viral load suppression is the same as for other adults, he noted.

Looking ahead to the next five years of PEPFAR, the goal is to accelerate the response while sustainably strengthening public health systems, he said.

“We must continue to scale up current interventions to reach 95-95-95 but also use new tools, including long-acting PrEP, to turn down the tap,” he said, while expanding access to treatment to accelerate progress towards epidemic control.

HIV gains must be protected as governments move to strengthen global health security and pandemic preparedness and response, Ambassador Nkengasong said, noting that HIV and global health security platforms share many parallels in terms of service delivery and systems. Many African countries leveraged HIV platforms for COVID-19 responses, including deploying health workers for vaccine administration, delivering COVID-19 tests and other commodities, and leveraging laboratories for COVID-19 responses, he said.

In the future, he hopes to see better integration of platforms to be more cross-cutting no matter the disease area, whether it’s for HIV, COVID-19, antimicrobial resistance or other health emergencies. “We should have platforms that are multipurpose in nature so we can be ready to respond while protecting HIV gains,” he said.

“PEPFAR at 20 represents the greatest act of humanity, in solidarity, in fighting an infectious disease,” Ambassador Nkengasong said. “It offers a model on how we design future interventions in global health using data driven and matrix approaches,” he added.