Repeating the same inputs in the same way, in the same environment, will always produce the same outcomes. These words of wisdom were told to me long ago. They are important words to remember if change is your goal. Said slightly differently, this has been one of the major themes of the International AIDS Conference this year. In session after session, we have been hearing speakers tell us that we cannot just keep doing the same things over and over again.
At the same time, we have been hearing about how we are making great progress in many countries towards getting more people living with HIV (PLHIV) on antiretroviral therapy (ART), the medicines that, when taken consistently, enable PLHIV to live normal, healthy lives. Likewise, in some countries HIV transmission rates are decreasing. Indeed, in India, where I am currently living and working, more than 600,000 PLHIV are currently on ART, and the HIV incidence among most key populations is widely believed to have reduced by as much as 50%.
If we are doing so well, why do we need to change what we are doing? Won’t continuing with or current efforts yield continuously positive results? Unfortunately, it is not this simple. We are no longer operating in the same environment where we were five or ten years ago. In a sense, we have have been successful at reaching the “easy” clients with services. If you will, we have picked the low hanging fruit. We now have to help the harder to reach clients get the HIV prevention and treatment services they need. In addition, while funding for HIV services had been increasing annually during most of the previous 10 years, funding is now leveling off or decreasing in most countries.
So, how do we do this? What needs to change? We need to be more strategic with our targeting of clients and more efficient with our with our delivery of services. Although, theoretically, anyone can become infected with HIV, in reality, when we look at the HIV prevalence data in countries, we see that HIV does not exist equally in all geographic locations and among all population subgroups equally. In addition, not all HIV services and methods of delivering those services are necessary in all geographic areas and with all population subgroups. It will not be effective to blanket a whole country with a fixed set of services.
Instead, we need to focus our funding and our efforts on key affected populations; those groups of people, such as men who have sex with men, sex workers, people who inject drugs, transgenders, migrants, prisoners, and others with disproportionate levels of HIV prevalence, where they are located, and only with the specific services they need. We will have to conduct HIV surveillance studies as accurately as possible so that we can locate our services where they are most needed. We will have to engage our clients meaningfully so that with their participation, we can tailor our efforts and services appropriately to the clients’ needs. And, we have to do this with tolerance and without stigma and discrimination.
If we do this–if we change our inputs–we will continue to see progress toward reducing HIV morbidity, mortality, and transmission. We will move closer toward the end of AIDS.