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To Eradicate HIV by 2030, We Must Invest in Health Workers

In September, UNAIDS announced its plan to end the AIDS epidemic by 2030, using its new fast-track strategy.

The strategy relies upon countries to step up their investments and the pace at which they deliver HIV services, especially antiretroviral therapies.

And it emphasizes a “90-90-90” target—that is, enabling 90% of people living with HIV to know their HIV status, 90% of people who know their status to have access to HIV treatment, and 90% of people on HIV treatment to achieve viral suppressions.

These are worthy goals, but ambitious.

They will require greater investments not only in antiretroviral therapies, rapid viral load testing kits, and condoms, but in strengthening fragile health systems. That means financing better health infrastructures, building laboratories, and—perhaps most importantly—investments in health workers, on whose shoulders will fall the burden of reaching the most at-risk populations in underserved communities.

In an emergency, nothing can compensate for an inadequate supply of skilled health workers. 

When the HIV epidemic first began, it was described as an emergency pandemic. We knew little, and little could be done for those infected and their families. Health workers were frightened to deal with clients or suffered burnout from caring for those for whom they knew there was no hope.

As we learned more about the virus and, eventually, how to control and treat infections, health workers became more confident and able to handle prevention, treatment, and care.

The disease transitioned from an emergency to a developmental effort.

Now we are facing an Ebola epidemic, and it carries many of the same underlying challenges we saw during the emergency phases of HIV.

But we know now, after decades of dealing with HIV, that the backbone of any response to a global health emergency is made up of health workers—especially those who can provide primary care and are trained, recruited, and retained in health posts near vulnerable communities.

In an emergency, nothing can compensate for an inadequate supply of skilled health workers.

My point is this: Donor and country intervention plans that focus on HIV treatment and preventing new infections must be complemented with a balanced focus on strengthening the health system, specifically the health workforce.

The money and human resources devoted to HIV have been huge. But new resources for health systems strengthening have been modest by comparison. Within public health communities, there has been fierce debate about whether the scaled-up investment in HIV programs has strengthened or weakened fragile health systems.

Existing health workers are often attracted to better-paying jobs in HIV, to the detriment of primary care.

One benefit, according to debaters, is a greater awareness of the severe health worker shortage, brought to light by the fact that there are not enough health workers available to deliver antiretroviral therapies and HIV services, particularly in urban centers.

One cost, though, is that existing health workers are often attracted to better-paying jobs in HIV care and laboratories, to the detriment of primary care provision.

But the debate should not be about the comparative advantages of vertical and horizontal approaches. Instead, let’s focus on how investments around HIV might also strengthen primary health care systems.

As Secretary of State John Kerry said at the UNAIDS event in September: “We need to continue to make strategic and creative investments that are based on the latest science and best practices.” One such investment is in a trained health workforce, one that communicates about prevention, provides HIV care and treatment, and can use the same skillsets to deal with Ebola.

We need a health workforce that will not only help end the AIDS epidemic by 2030, but also be in place and prepared for other health emergencies as they arise.