Youth Wave Threatens HIV Fight in Africa

At Mailman’s Grand Rounds, Ambassador Deborah Birx outlined PEPFAR’s strategy to do more with less

March 29, 2016

The fight against HIV/AIDS in sub-Saharan Africa faces an unprecedented challenge in the form of a demographic tsunami of young people, Ambassador Deborah Birx, the U.S. Global AIDS Coordinator, told the audience at the Dean’s Grand Rounds on the Future of Public Health on Wednesday.

Birx oversees implementation of the President's Emergency Plan for AIDS Relief, the largest commitment ever by any nation for an international health initiative dedicated to a single disease. As of September 2015, the program and its partners, including Columbia’s ICAP, support life-saving treatment for 9.5 million people worldwide, mostly in Africa, which bears more than 70 percent of the global HIV burden.


But according to Birx, PEPFAR’s continued success is threatened by demographic changes brought about through dramatic reductions in infant mortality. Starting in 2000, efforts expended to achieve the Millennium Development Goals raised the number of children age 5 and younger by 65 percent, with most of the progress in sub-Saharan Africa. Even though HIV risk is lower than it was a decade ago, this oncoming wave of young people, now reaching reproductive age, could raise the number of infections from 2 million to a record 2.5 million, according to a WHO estimate.

“The great news is that the MDGs, were terrifically successful in terms of improving under 5 survival,” said Birx. “But we didn’t adequately plan for who was going to educate those adolescents, who was going to provide healthcare for those adolescents, and who was going to provide jobs for those adolescents.”

Rewriting the Rules for Treatment

To prepare for the coming population wave and make further progress against HIV, Birx said PEPFAR must double the number of people on treatment in the next five years—all while maintaining current funding levels, which have been flat since 2010. Doing this, she said, takes changing the way patients get treatment.

At the start of the AIDS crisis, patients were very sick and frequent medical visits were a necessity. That model persists today. Even those on treatment and whose infections are under control, continue to be seen every month or two. “That is not a sustainable system,” Birx said. It strains health systems and individuals who must lose a day of work and pay for transportation to a clinic.

Going forward, PEPFAR is working with countries to allow healthy patients to be seen every three to six months. A controlled diabetic or routine asthmatic wouldn’t need medical attention every month. The same should apply for HIV. “It’s the right thing to do for clients to come less frequently, if they’re healthy,” said Birx. “We have to create that sense of chronic care based on wellness and feeling good.”

A New Way to Identify People Living with HIV

PEPFAR’s efforts to curb mother-to-child transmission have been very successful, cutting the rate of new infections by 60 percent. For adults, however, the results have been much more spotty. The traditional explanation for this shortcoming was that HIV-positive men were noncompliant, either not taking their medications or missing appointments. The data told a different story: In fact, men remain in care at the same rate as women. The difference? “They’re just diagnosed a whole lot less than women,” said Birx.

One way to better identify HIV-positive men and women is suggested by data from a just-released PEPFAR study of an intervention that employed HIV-positive patients incentivized to bring their peers in for testing. Results show that these individuals identified through these social networks were more than twice as likely to be HIV-positive compared to those reached by the traditional method of paid community workers. “The network understands who is at risk,” said Birx.

Circumcision and Education

Two of PEPFAR’s signature prevention strategies in sub-Saharan Africa are gender-specific. For men, PEPFAR-supported voluntary circumcision campaigns have decreased the risk of infection in Sub-Saharan Africa by more than 60 percent—a level of effectiveness Birx likened to a vaccine. For adolescent girls and young women—who account for 71 percent of new HIV infections in the region—PEPFAR is banking on better access to education, through the DREAM project, a collaboration with private and philanthropic partners like the Gates Foundation and Johnson & Johnson. A study in Botswana, found one additional year of schooling for adolescents cut in half the risk that a woman is HIV-positive by her 32nd birthday.

Opportunity for Overall Health

To meet the challenge of the coming youth wave, Birx said even more research is needed. PEPFAR seeks ways to improve service delivery through implementation research such as ICAP’s PEPFAR-funded START study in Lesotho, as well as research to understand why young women are so susceptible to infection, whether through behaviors or their biology. ICAP is also in the early phases of launching a home-based population survey to gain a better understanding of the nature of HIV exposure in 15-20 countries.

These efforts will not just save the lives of millions at risk for HIV, but will pay dividends for other diseases, creating health systems for the future. “If we get it right [for HIV], we have it right for diabetes, we have it right for hypertension,” said Birx. With the exception of programs to reduce maternal and infant morality, the public health infrastructure in Sub-Saharan Africa is being built from the ground up. “That’s what we have to create together,” she said. “We should look at it as an incredible opportunity.”

Watch video of Ambassador Birx’s lecture: