Is Global Progress Against HIV Lost in Translation?

As the world cheers rapid progress toward ambitious goals in sub-Saharan Africa, experts look at why the United States lags behind

December 6, 2016

When the United Nations Programme on HIV /AIDS (UNAIDS) published its 90-90-90 treatment targets in 2014, many politely called the goals “aspirational.” The objectives set a high worldwide standard for HIV diagnoses, treatment, and viral load suppression: by 2020, 90 percent of those infected with HIV worldwide will be aware of their status, 90 percent of HIV-positive people will be taking antiretroviral medication, and 90 percent of those on treatment will have achieved viral load suppression.

Despite the great progress in improving access to testing, care, and treatment, many thought the new goals were too ambitious, especially in countries with large epidemics and medical systems without the investment and infrastructure of more developed regions.

But data released on December 1, 2016, World AIDS Day, show striking progress. In sub-Saharan Africa, home to more than 70 percent of the world’s HIV burden, ICAP’s Population-based HIV Impact Assessment (PHIA) project revealed that three countries already have the 90-90-90 goals in view. According to PHIA’s preliminary findings, Malawi, Zambia, and Zimbabwe now have rates of viral suppression in adults hovering just above or just below the 90 percent target. On the other hand, Centers for Disease Control and Prevention (CDC) data suggest a much smaller portion of the 1.2 million HIV-positive people in the United States are virally suppressed.

What could explain this dichotomy? At Columbia University’s Mailman School of Public Health, a history of engagement in all levels of HIV/AIDS research and service may provide clues.

ICAP, one of the School’s largest programs, devised the PHIA project to establish a baseline for progress against the epidemic in places hardest hit by HIV. ICAP’s World AIDS Day announcement marked PHIA’s first report; eventually the five-year, $125 million dollar PEPFAR-funded project will disseminate nationwide figures in 13 countries.

Some at the Mailman School work on the domestic angle of the epidemic, providing clinical services to vulnerable populations in Northern Manhattan and the Bronx. Others work to improve access to prevention and treatment for the most marginalized members of our society. For them, the unexpected gap separating HIV progress in the three sub-Saharan African countries from this wealthy nation merits careful analysis as to whether successes there could be adopted to boost progress in this country.

It is possible that more generalized epidemics—as compared to the United States, where HIV is concentrated largely among marginalized and stigmatized groups such as gay men, the poor, and substance users—allow for a more systemic, sustained, and widespread response to HIV. Just as a campaign to reduce cigarette smoking or discourage littering can be broadcast nationwide, a strategy to combat an infection spread in greater numbers throughout the population may be easier to devise than one aimed at predominately stigmatized groups, where institutionalized structural, cultural, and economics issues can obstruct progress.

In both rural and urban areas in the U.S., racial and ethnic minorities shoulder a large part of the HIV disease burden. The challenges of reaching these groups are often compounded by stigma and prejudice, and these communities’ distrust of health care. (Read about HIV in rural South Carolina as told through the documentary film, Wilhemina's War.)

Lisa Metsch, Chair and Stephen Smith Professor of Sociomedical Sciences, recently published a study in JAMA that vividly illustrates these challenges. Working with a national population of HIV-infected substance users, Metsch and her colleagues found that neither financial incentives nor regular coaching about HIV care were effective in encouraging this population to remain on HIV treatment, as their low rate of viral suppression made clear.

Metsch can account for the paradox by suggesting that more attention must be focused on marginalized populations in the U.S. “We need to look at structural inequalities and social factors such as poverty, racism, mass incarceration, and unstable housing if we are to achieve the aspirational UNAIDS goals and the goals of our U.S. National HIV strategy,” she said. “Persistent health disparities in the United States make it much harder to reach communities in need.”

Investigators will now analyze the PHIA data for evidence of what strategies can be translated to the United States. A reversal of the familiar local-to-global paradigm means successes abroad can help us better serve those in need here at home. Of course, it remains to be seen how this translation of expertise will be affected by the unfamiliar post-election landscape, which may lead to new limits on access to resources, prevention messages, and other possible obstacles. Even so, given that reduction in population-level viral load is critical to finally turning the corner on HIV, there can be no question that ICAP’s PHIA data shows the world that a sustained, supported response can make a measurable change in a country’s HIV trajectory.