A Time to Make Country ‘Pivots,’ Always with an Eye toward Epidemic Control


Taking stock of the new strategies, initiatives and ‘pivots’ that global stakeholders have released since World AIDS Day 2014, it is incredible to reflect on how far and how fast we have traveled in a little less than 365 days.

At the same time, it is overwhelming to plan, implement, and monitor HIV programs in accordance with these emerging strategies. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Office of the Global AIDS Coordinator (OGAC), and the World Health Organization (WHO) have issued guidance and ambitious targets for achieving epidemic control. For example, the PEPFAR 3.0 Strategy proposes a data-driven approach that targets populations with the highest HIV prevalence and geographic areas where services are likely to provide the most efficient and effective impact. By 2017, PEPFAR hopes to achieve the following targets:

  • 40 percent reduction in new HIV infection in young women in ten countries
  • 13 million voluntary medical male circumcisions to prevent infections in young men
  • 9 million women, men, and children on ART [i]

Meanwhile, the new DREAMS (Determined, Resilient, Empowered, AIDS-free, Safe Women) and ACT (AIDS Relief and Children’s Investment Fund) initiatives launched in more than ten countries. OGAC instituted quarterly program reviews, tracking expenditure analysis, monitoring evaluation reporting, site information monitoring systems, and above site support. In July, WHO issued new guidance expanding the scope of HIV testing services, and in September released new anti-retroviral (ART) and PrEP guidelines to treat all, regardless of CD4 count. Needless to say, a major shift in the HIV epidemic has started, and the clock is ticking.

This rapid shift brings me back to 1989, when I was working in Boston at the AIDS Action Committee (AAC). At the time, several large organizations focused on caring for people living with HIV, primarily young, gay Caucasian men. As the epidemiological landscape shifted towards new populations—young black men, Latino men who have sex with men (MSM), people who inject drugs (PWID), and low-income women—these organizations needed to quickly re-adapt their methodologies and skills to meet more diverse needs.

For some groups, this shift was painful. Staff were divided, priorities adapted, and several organizations folded in the process. But for others, epidemiological modeling and community outreach became the centerpiece of their mandates, ultimately strengthening their foundations. Diverse people came together, resulting in a truly transformational response. MSM who had never before talked with people who inject drugs began to volunteer at needle exchange programs. Black preachers were approached to discuss HIV in their churches. Just a few years prior, everyone thought HIV education had no relevance for the black community; now, the CDC reports that black Americans carry some of the heaviest burden of HIV[ii].

As I think back on these years, I am reminded that we must implement at a pace that countries can absorb. We must be pragmatic and cannot be too ambitious in our approaches. National AIDS programs, missions, and implementers are still trying to make the shift in resources to new regions. Just as in the early 1990’s, this may involve closing down sites, opening new ones, hiring and training staff, and funding new priorities. We must give the National AIDS Programs and governments time to create clear and accountable implementation strategies and to set up accountability systems to meet these new requirements.

But we also must not let a government’s hesitation to “do the right things, in the right places, right now” keep that country from achieving epidemic control. Country ownership cannot become a shield to hide behind if a government’s policies ignore epidemiological data, or if leaders fail to commit funding or implement programs in regions with the greatest unmet need for services, while continuing to direct resources to the lowest volume sites.

I am committed to making the shift and targeting resources that have the highest HIV prevalence, for I have seen the difference that it can make in the U.S. response to HIV. We do not want to be the preacher who is left standing in front of his community saying, “They came to tell me, but I was too afraid at the time to do anything.”


[i][i][i] Pepfar.gov

[ii] According to the CDC, in 2010 young black MSM accounted for 55 percent of new HIV infections among young MSM overall.


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