Letter to UNAids: End Aids deaths by 2030

Dear Winnie Byanyima (UNAids Executive Director) 

We, the undersigned, while acknowledging the tremendous work of UNAids to date in addressing the Aids epidemic, ask that UNAids give greater attention to the main diseases that kill people living with HIV. We are calling on UNAids to reassert its commitment to ending Aids deaths by:

1) Committing to measuring deaths attributable to the main diseases that kill people living with HIV; 

2) Developing ambitious targets for the reduction of deaths from these causes, as well as targets for measures that will bring about those reductions; and

3) Working with countries and other relevant organisations on strategies for mortality reduction that will help to ensure those targets are achieved.

The UNAids 90-90-90 targets have helped to focus attention on HIV diagnosis, antiretroviral (ART) scale-up, retention in care, and the achievement of virological suppression on ART. Mortality reduction targets, however, have received less attention. This is regrettable given that access to essential diagnostics and medicines to prevent and treat the major opportunistic infections and cancers affecting people with HIV remains very poor in resource-limited settings. 

The World Health Organisation (WHO) has published a guideline for managing individuals with advanced HIV disease (AHD) to reduce HIV-related deaths. The guidelines address interventions to prevent, diagnose and treat common opportunistic infections, including tuberculosis, cryptococcosis, and severe bacterial infections, along with rapid initiation of antiretroviral treatment and enhanced ART adherence support. Currently, no clear targets exist for these key interventions, either globally, or to our knowledge, in a systematic fashion at the national level.

Setting new 90-90-90 targets for CD4 testing, cryptococcal antigen, and TB testing, and treatment, aligned to the WHO AHD package of care would be a positive step towards ending Aids deaths by 2030.

This phase of the Aids response necessitates strategies and global targets to address the main causes of Aids-related deaths. Specifically, we call on UNAids to:

1) Measure deaths from the major killers of people living with HIV.

Although mortality from TB is estimated annually in the Global Tuberculosis Report, mortality estimates for the other major killers in HIV are notably absent. We request that UNAids work with the WHO, the US ​​President’s Emergency Plan for AIDS Relief (Pepfar), and others to obtain national and global quantification and monitoring of the main killers of people living with HIV. 

2) Develop ambitious targets for the reduction of deaths from tuberculosis, cryptococcal meningitis and severe bacterial infections among people with HIV.

We ask that UNAids adopt ambitious targets for reducing mortality from the main killers of people with HIV, as well as targets for the interventions needed to make that happen. We and others are happy to engage with you in terms of what those targets should be.

3) Producing relevant strategies to ensure that those targets can be achieved.

One of the roles of UNAids (mandated, by Economic and Social Council Resolution 1994/24, ) is to: “Strengthen the capacity of national governments to develop comprehensive national strategies and implement effective HIV/Aids activities at the country level.” In this capacity, we call on UNAids to work to address the gaps in terms of a strategic response to HIV-associated mortality.

We also ask that you support national governments to adopt these targets and indicators in relevant national plans and guidance, which should also align with WHO recommendations.  

UNAids has been instrumental in advancing the global response to the Aids epidemic and we hope that it can help lead the world towards ending Aids deaths by 2030.

We look forward to your response in the coming weeks and request an opportunity to discuss these issues with you at your earliest convenience.

Signatories

Rita Oladele, University of Lagos, Nigeria; Medical Mycology Society of Nigeria; Thomas Harrison, St George’s University of London, UK; Nelesh Govender, University of the Witwatersrand, South Africa; Joe Jarvis, London School of Hygiene and Tropical Medicine, UK; Botswana Harvard Aids Institute Partnership; Angela Loyse, St George’s University of London, UK; David Boulware, Professor of Medicine, Infectious Disease & International Medicine, Department of Medicine, University of Minnesota; David Meya, senior lecturer in the School of Medicine at the College of Health Sciences; Bilkisu Ibrahim Jibrin, Federal Ministry of Health, Abuja, Nigeria; Sayoki G Mfinanga, National Institute for Medical research, Muhimbili Centre; Lillian Tugume, Infectious Diseases Institute, Uganda; Radha Rajasingham, University of Minnesota, US; Amir Shroufi, CDC Foundation, South Africa; Tom Chiller, infectious disease clinician, Atlanta, US