5. The way forward: recommendations for long-term success

Sharply reducing the number of new infections and AIDS deaths by 2031 requires new ways of thinking about AIDS and responding to the challenges that the pandemic poses. It requires new prevention and treatment tools, sound policies to optimize the effectiveness of programs, innovative approaches to AIDS financing, the creation of strong and durable capacity in countries, transition from a focus on individuals to one that views communities as critical fulcrums for success, and management practices to maximize efficiency and effectiveness. The pandemic is not going away, but its magnitude and severity can be dramatically curtailed—if the global community brings the seriousness of purpose to this problem it deserves.

Given all that has been achieved in controlling the AIDS pandemic so far, we are not starting from square one. Rather, in some cases, we simply need to do more of what we have been doing, only better and more effectively. In other respects, though, achieving the aids2031 vision demands that we jettison old ways of doing business and venture out in new directions. Above all, we need to adopt a long-term perspective and recognize the pandemic for the generations-long challenge that it is.

As discussed in Chapter 2, “Generating knowledge for the future,” certain breakthroughs—such as the development of a highly effective vaccine or the unexpected emergence of an affordable cure for AIDS—could dramatically alter the epidemic’s course for the better. Many of the recommendations in this chapter focus on strengthening and accelerating efforts to achieve such breakthroughs. However, most of the recommendations do not assume that major breakthroughs are certain to occur. Indeed, a number of possible occurrences could set progress back: widespread drug resistance, social or political changes that increase vulnerability, or the refusal by decision-makers to allow evidence to guide programs and policies. For these reasons, planning for the future needs to have built-in flexibility and responsiveness to new knowledge as it emerges.

1 Build the knowledge base for long-term action

Increasing the durability of treatment programs and reducing the level of new infections to the point that the epidemic can eventually be eliminated requires developing new and better AIDS-fighting tools and strategies. Better knowledge also is required to focus prevention and treatment programs most effectively. Programs and policies should adapt based on new and emerging knowledge to stay relevant. Decision-makers at the national and subnational level require substantially better and more timely knowledge to respond effectively.

1. Sustain financing for AIDS research and development—Robust funding will continue to be needed to generate the tools and technologies required over the next generation. Key focus areas for research include development of a preventive vaccine, a cure, microbicides, pre-exposure prophylaxis, simpler diagnostic devices, and less costly treatment options.
2. Adopt a new paradigm for vaccine research—The existing paradigm for vaccine research, in which competing teams of research scientists work independently on vaccine candidates, often duplicating each other’s work and failing to pursue other promising options, must be replaced. A new, collaborative, “open source” approach is needed, akin to the strategy successfully pursued with the Human Genome Project.
3. Build the evidence base for longer-term programmatic and policy action to address key drivers of national and subnational epidemics—Researchers should prioritize the development of user-friendly tools to assess, characterize, and understand key drivers of national and subnational epidemics. Increased investments in ethnographic and other social science research are needed to guide and evaluate the development of AIDS programs. All countries should undertake periodic assessments of incident HIV infections by modes of transmission and geographic distribution.
4. Invest in both efficacy and effectiveness studies—Prevention research must move from a single-minded focus on efficacy studies to include an emphasis on effectiveness in the real world. Greater investments are also needed to evaluate particular combinations of strategies.
5. Implement prospective impact evaluations—Evaluation should become a mandatory component of program design and implementation. Where possible, prospective impact evaluations should be built into programs, and results should be used to adapt programmatic and resource allocations. Impact evaluation efforts of programs funded by PEPFAR, the Global Fund, the World Bank, and other key funders should be aligned and coordinated. UNAIDS could help facilitate coordinated efforts in this area.
6. Intensify development of incidence assays—With the goal of strengthening impact evaluations, focused research is needed to develop affordable, reliable, user-friendly assays to measure HIV incidence.
7. Invest in operational and translational research—Focused research is needed to identify the factors that increase or decrease programmatic impact. Operational research is also needed to inform programmatic management of efficiency—for example, by generating optimal unit costs for well-run programs. Funders should invest in such studies.
8. Establish research centers of excellence in developing countries—Centers of excellence for research on AIDS and other priority health concerns should be established and locally led in low- and middle-income countries.

2 Give prevention the priority it deserves

Decision-makers must move from lip service to meaningful action on HIV prevention, prioritizing it as the mainstay of a sustainable response. The agreed goal for prevention policies and programs should be to maximize the number of infections prevented.

1. Ensure strong leadership on HIV prevention—If the number of new HIV infections in 2031 is to be sharply lower than it is today, political leaders must build strong support for prevention programs and policies, even if they may show results only years down the road. Policies and practices that stigmatize and marginalize groups or individuals at high risk of infection must be avoided. Through visible leadership and adoption of sound programs and policies, political leaders should work to achieve concrete progress toward gender equality and the empowerment of women and girls.
2. Alter the AIDS funding balance—Financial support for HIV prevention must be increased to permit rough parity between prevention and treatment spending at the global level, taking into account country-level variations based on specific national needs. In implementing this recommendation, it is critical that donors and national decision-makers do not compromise treatment programs, as both treatment and prevention are essential and complementary components of an effective response.
3. Implement combination prevention programs—Every sound HIV-prevention plan reflects a strategic combination of behavioral strategies to promote risk reduction, biomedical interventions to reduce the likelihood that any episode of risk behavior will result in transmission, and social and structural approaches that minimize vulnerability and promote environments that are more conducive to HIV prevention. National plans need to describe how these different components fit together, justify the selection of interventions, explain how synergies will be captured and maximized, articulate concrete targets for results, and indicate projected causal pathways to achieve these results.
4. Focus prevention efforts on the populations and settings where they are most needed—Based on periodic assessments of the modes of transmission for new infections, decision-makers should select interventions and allocate resources to focus on the right mix of services in the right populations and geographic settings. Decision-makers should avoid the temptation to withdraw or not renew funding for services that are effectively helping to reduce rates of new transmission. Effective focusing of prevention services will simultaneously address emerging populations and sustain support for programs that are working.
5. Implement an all-out prevention effort in Southern Africa—In each hyperendemic country, the head of state should visibly lead a high-level prevention effort that maximizes the coverage and quality of HIV-prevention interventions. Major efforts should focus on the implementation and scaling-up of social change and community-level interventions. In hyperendemic countries, every adult citizen should know his or her HIV status and be appropriately supported in case of HIV infection.
6. Ground prevention programs in the strengths of people living with HIV—Prevention programs should undertake massive training and hiring of people living with HIV. Especially in high-prevalence settings, prevention efforts should invest in sustained campaigns to combine increased access to antiretroviral therapy, strong anti-stigma efforts, and a collective investment among all of society—including people living with HIV. To ensure local relevance, planning and priority-setting processes should involve civil society organizations and affected communities.

3 Ensure universal access to accessible, affordable, and sustainable treatment for people living with HIV

Historic achievements in expanding treatment access must not blind us to the reality that the current treatment model is not sustainable. Notwithstanding marked declines in drug prices, standard antiretroviral regimens remain too expensive and complex to make life-long therapy for tens of millions of individuals feasible in the most resource-limited settings. Additional strides are needed to improve treatment regimens and ensure their availability to all people living with HIV. In moving forward, the global community should adopt as its first priority extending life for the greatest number of people. To the greatest extent possible, consistent with maximization of treatment gains for people living with HIV, treatment strategies should maximize their contribution to reducing HIV transmission.

1. More efficient regimens and treatment delivery strategies—Urgent attention should focus on the development of regimens that are longer-lasting, simpler to take, less prone to resistance, and less costly than those currently being used. For example, single-pill regimens or drugs that need to be taken only once a month rather than each day could significantly improve treatment adherence and delay the emergence of drug resistance. Efforts should be pursued to further lower the prices of antiretroviral regimens while maintaining economic incentives for continued biomedical research. All countries—and the global community as a whole—should pledge to achieve universal access to optimally effective first-line regimens for all people living with HIV. In addition, program managers and implementers, with the support of national governments, international donors, and technical agencies, should maximize efficiency in the delivery of treatment services.
2. Diagnostics for resource-limited settings—In addition to continuing efforts to expand access to existing diagnostic tools, intensive efforts should focus on the development of simple, affordable diagnostic tools. These include less expensive rapid tests for the diagnosis of HIV, as well as point-of-care tools that permit readings on key immunological and virologic indicators for the management of patients on antiretroviral therapy.
3. Intensified focus on treatment adherence—As an essential component of every treatment program, donors should amply fund intensive support for patient adherence, including but not limited to treatment buddies to help patients overcome impediments to adherence. Adherence interventions should build on robust evaluation research.

4 Implement a new code of conduct for the AIDS response

All AIDS stakeholders need to adopt new ways of working and new mechanisms of accountability to move from a short-term mindset to a longer-term perspective that requires local ownership, local capacity, and an evidence-informed and rights-based approach.

1. Incentivize evidence-informed and rights-based programs and policies—Strategies should specifically incentivize AIDS programs and policies to prioritize populations most at risk.
2. Adopt a minimum legal framework—All countries should adopt a minimum legal framework for the AIDS response (as discussed in Chapter 3, “Using knowledge for a better future”), consisting of legislation, such ass
   

   • Decriminalize HIV status, transmission, and exposure

   • Decriminalize same-sex relationships/sexual practices

   • Guarantee equal rights of people living with HIV

   • Guarantee equal rights for men and women

   • Eliminate laws that limit access to health services for marginalized populations, including sex workers, people in same-sex relationships, and drug users

   • Decriminalize harm-reduction approaches for prevention of AIDS among those injecting drugs

3. Support community-driven responses—New mechanisms should be established for civil society review and approval of proposals to build community capacity and implement community-generated and driven AIDS programs. Particular attention should be given to community-based programs developed by and for key vulnerable populations, including but not limited to injecting drug users, men who have sex with men, sex workers, and young people. International donors should provide financial support for such programs.
4. Build social capital to create AIDS-resilient communities—Programmatic and policy responses should work to encourage a sense of agency, ownership, and responsibility about both individual and community responses to AIDS. Prevention and treatment models should be explicitly premised on the conceptualization of health as a public good and a human right, with a particular emphasis on addressing the needs of marginalized populations. Through focused funding, advocacy, and policy support, dynamic partnerships across organizations both within and outside the community should be facilitated, with the aim of building social capital. Mechanisms for local accountability that involve broad citizen participation should be supported, developed, and implemented.
5. Build national capacity—Funders should prioritize investments in educating new cadres of health professionals to manage AIDS and other health priorities. Rigorous monitoring indicators should be developed and implemented to assess achievements in building national capacity and guiding adaptation of strategies.
6. Transition programs to local ownership—As part of the new code of conduct, international nongovernmental organizations (NGOs) or other subcontractors that deliver AIDS programs should be mandated to include meaningful measures to build local capacity in their budgets and work plans, with the goal of eventually transferring primary responsibilities for all aspects of program implementation to local entities. Performance indicators to assess success in achieving these aims should be developed and implemented, and donors should make funding contingent on local stakeholders owning the programs.
7. Develop local leadership—The new code of conduct should require all programs to include specific strategies and budget lines to build and sustain local leadership to support the AIDS response.

5 Ensure robust, sustainable financing for a long-term response to AIDS

The world should transition from a funding paradigm that aims to cover AIDS-related costs to an investment paradigm that incentivizes quality, efficiency, and long-term planning and results.

1. Renew and sustain global financial commitment—Bilateral donors, national governments, philanthropic foundations, multilateral institutions, and other stakeholders should collectively commit to fund efficient, well-focused responses that have long-term horizons that aim for sharp declines in new infections and AIDS deaths over the next generation.
2. Establish long-term budget horizons for long-term change—Budget lines should be sufficiently robust to support substantial, long-term efforts and project cycles of 10–20 years.
3. Prioritize low-income and high-prevalence countries—The Global Fund, PEPFAR, and other leading donors should prioritize funding for the poorest countries, especially those with high HIV prevalence. Middle-income countries should assume the costs of their national AIDS programs.
4. Improve program management to optimize effectiveness and efficiency—Concerted efforts should focus on improving the management of AIDS programs. Incentives should be developed to encourage efficiency, including strategic integration of AIDS interventions with other services.

6 Exert leadership to achieve the aids2031 vision

The global attention span may sometimes be rather short, but the pandemic will remain a serious health threat for generations to come. Although its severity will vary tremendously from one country to another, it will continue to pose a historic test. Over the coming decades, AIDS will demand our attention, vigilance, and commitment.

1. Institutionalize AIDS as a political issue—In all high-prevalence countries, an annual parliamentary debate on AIDS should be mandatory, allowing national leaders to assess progress achieved, identify shortcomings, and plan for the future. In Southern Africa, AIDS should be a core cabinet matter, with active and well-monitored engagement of all relevant sector ministries. Planning horizons for national responses should be extended from 3–5 years to 10–20 years. At the global level, AIDS should remain a standing agenda item and a topic of ongoing debate and discussion at the United Nations and in the G20 forum. Leading regional political bodies should have permanent AIDS monitoring systems in place and convene at regular intervals to assess progress and address challenges.
2. Structure reviews of national and subnational plans with a long-term view—Yearly progress toward adopting long-term strategies, plans, and budgets should be reviewed.
3. Keep the focus on AIDS—The overall AIDS response must be much more closely linked with broader development efforts, yet it must be recognized that the progress achieved thus far would never have occurred without the AIDS movement’s singular focus on fighting the pandemic. AIDS shares some characteristics with other diseases and development priorities, but it is quite different in other ways. A new balance is needed that embeds the AIDS response in broader health and development efforts yet keeps a distinctive focus on addressing the unique and often politically and socially sensitive challenges of AIDS.
4. Hold leaders accountable—AIDS leaders have long decried punitive laws and policies that impede a sound response to AIDS epidemics and urged that funding be targeted to those who need services the most. Less often have the political leaders who adopt punitive policies or ignore most-at-risk populations been called to account. That must change. International bodies, civil society groups, the news media, and other stakeholders need to be more willing to criticize those who undermine effective action on AIDS. Leaders who fail to prioritize action for communities most at risk or who adopt punitive policies such as sodomy statutes or bans on harm-reduction services need to know that their actions have consequences.
5. Broaden the AIDS coalition—At global, regional, and national levels, AIDS stakeholders should work to broaden the coalition of AIDS supporters and champions to bring in a new generation of actors and to engage and work with advocates for other diseases, populations, and international development priorities.
6. Strengthen watchdog functions—Funders should significantly increase investment in independent civil society watchdog groups to monitor governments and other key stakeholders. As a general rule, watchdog groups should not include organizations that receive donor support for the provision of AIDS services.

Surprises and challenges will undoubtedly confront the world over the next generation. Yet despite these uncertainties, there are some clear actions that are needed today to change the face of aids by 2031. The choices in the coming years will determine the fate of millions of people.