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To Achieve an AIDS-Free Generation, We Need More Problem Solvers

My professional interests and work priorities are centered on HIV prevention and treatment programs, particularly working with key populations, prevention of mother-to-child transmission (PMTCT), male involvement, and service integration.

I wish I could say I discovered some fantastic, innovative new programming interventions when I attended the 21st annual International AIDS Conference in Durban last month. But despite the hundreds of presentations, thousands of posters, and a steady stream of celebrity appearances—including Charlize Theron, Prince Harry, Elton John, and Edward Cameron—I didn’t.

I went from session to session, poster to poster, looking for that kernel of innovation to inspire me. However, it seems that programmatically, we continue to do a variation of the same demand creation and service delivery models we’ve been doing to address the HIV epidemic for years.

Mobile technology and social media have made some activities more efficient, but these are still somewhat limited to urban populations and countries where there is high mobile phone use. 

Medical innovation alone doesn’t always lead to success.

Yes, medical innovation continues. Pre-exposure prophylaxis (or PrEP) in particular was highlighted during the conference. But medical innovation alone doesn’t always lead to success.

“The truth is we have every tool we need to prevent the spread of HIV,” Charlize Theron said in her remarks. “Every tool we need. Condoms. PrEP. PEP. ART. Awareness. Education. And yet 2.1 million people, 150,000 of them children, were infected with HIV last year.”

It’s the “and yet” piece I was expecting to get some insight into.

In the end, it was South Africa’s presentation on the success of its PMTCT program that stood out to me. Their journey has been long and challenging, but the presenters cited impressive results, including:

  • More than 95% antiretroviral (ART) coverage among pregnant HIV-positive women (up from ~80% in 2009)
  • 95% early infant diagnosis coverage
  • 1.5% mother-to-child transmission rate at 6 weeks (down from 8.2% in 2008)
  • Approximate 84% reduction in new pediatric infections since 2009
  • 450,000 new pediatric HIV infections averted since 2009
  • 74% coverage of ART in children aged 0-14 years (up from only 53% in 2012).

His question to any challenge is: what do you need to make this happen?

What contributed to this success wasn’t anything new, but a case of doing what we know works and getting it right. The presenters credited the following combination of factors:

  1. Unwavering commitment by the minister of health, the PMTCT Technical Working Group, and leaders at provincial and facility levels.
  2. Rapid policy changes to implement new World Health Organizations guidelines—such as Option B+ and testing exposed infants at ten weeks instead of six—as soon as they were published.
  3. Strong, continuous activism. South Africa’s Treatment Action Campaign (TAC), founded in 1998, is widely acknowledged as one of the most important civil society organizations active on AIDS in the world. One of its most significant victories was the 2002 Constitutional Court ruling in which the South African government was ordered to provide antiretroviral drugs to prevent transmission of HIV from mothers to their babies during birth.
  4. Standardized data collection tools and triangulation of data from various sources. Data are regularly analyzed by the national PMTCT Technical Working Group to inform policies and programs and to identify weak system links and barriers to the uptake of services.
  5. Task shifting, integration of services (maternal, newborn, and child health/PMTCT), and continuous mentorship and supervision at health facility and community levels.
  6. Community structures and innovations for referrals and linkages. South Africa created the successful mothers 2 mothers support group model and more recently , a National Department of Health initiative for registering pregnancies. Pregnant women can use a cell phone app to register themselves, or be registered by a community health worker or a health care professional at a facility. The women receive regular free messages with updates on the stages of their pregnancies and reminders about routine medical follow-ups. The program also enables women to voice their opinions about the services they receive at local health care facilities.

These factors are nothing new. But what struck me is that South Africa has managed to get all these pieces working together toward the same goal, which in and of itself is incredible.

At the end of the presentation I asked one of the presenters what she thought contributed to such a strong and coordinated PMTCT program. Her answer was that the minister of health is a problem solver. His question to any challenge is: what do you need to make this happen?

These results are a wonderful reminder. We know what we need to do to achieve an AIDS-free generation, but it’s going to take steadfast leadership and commitment to get there.