The 10th IAS Conference on HIV Science (IAS 2019) was notable to me for two reasons. Firstly, it was a shift away from the 90-90-90 national targets to a more nuanced awareness of which populations are not being reached with existing HIV services. Secondly, differentiated service delivery (DSD) models were applied not only to stable patients on antiretroviral therapy (ART), but to all aspects of the HIV care cascade, including testing, linkage, care for those with advanced disease, and prevention.
In a special session on designing data-based responses, United States Global AIDS Coordinator Ambassador Deborah Birx expressed concern over the lack of global progress for comprehensive treatment and early viral suppression for men and boys and young women. She cited significant challenges in HIV testing and linkage to care in the population-based HIV impact assessment (PHIA) survey countries and the country of Namibia, which, despite having reached 94-96-95 levels, fails to reach men with HIV testing services. The consequences of universal test and treat efforts not reaching men was highlighted by phylogenetic data from the PopART trial. This data shows high HIV transmission rates among young people in sub-Saharan Africa, particularly male-to-female transmission in the age group of 25-29 year old men.
A dedicated satellite session on differentiated, innovative service delivery for men, organized by Unitaid, the World Health Organization and Population Services International, highlighted the need to design services that encompass other health concerns for men in addition to HIV, such as non-communicable diseases. An engaging session on HIV self-testing showed that offering men HIV self-test kits in community venues with choices on whether to test on site or at home led to high uptake and reporting of self-test results in South Africa. Uptake of HIV self-testing was also found to be high among men and adolescents not reached by home-based testing in a cluster-randomized trial in Lesotho. The benefits and potential shortfalls of HIV self-testing distribution to female sex workers and other key populations through peer distribution were also highlighted.
Several sessions and abstracts emphasized that linkage to care and re-engagement in care remains a challenging area. Strategies for promoting “durable linkage” to care following HIV diagnosis was the topic of a satellite session organized by the International AIDS Society. Same-day ART initiation showed promise both among adolescents in Thailand and men who have sex with men with acute HIV infection in Amsterdam. A satellite session on differentiated service delivery for people at high risk of disease progression organized by ICAP at Columbia University promoted a call to action for innovative programmes and implementation research to improve the coverage, quality and impact of the evidence-based package of recommendations for adults at high risk of HIV disease progression. While enhanced case management was not found to improve viral suppression rates among men who have sex with men in four cities in the United States, HPTN 078 demonstrated that they were willing to re-engage in care, when reached.
This year’s conference also drew special attention to HIV prevention and sexual and reproductive health and rights. Using peer influencers to recruit black and Latinx men who have sex with men in New York City increased knowledge of pre-exposure prophylaxis (PrEP), decreased PrEP-related stigma and increased communication about PrEP. With high rates of PrEP uptake among young women in South Africa who wish to conceive, promoting sexual and reproductive health and rights as part of HIV services, including screening and management of sexually transmitted infections, is critical for reaching young men and women.
Looking ahead to the 23rd International AIDS Conference (AIDS 2020), its theme of resilience is appropriate to describe the next phase of the HIV response – one in which we need to draw upon communities, clients and advocates to ensure that we develop and implement HIV services that truly respond to people’s needs and preferences.