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To mark World AIDS Day—December 1-- I asked David Wilson, the World Bank’s Global AIDS Program Director, for a few thoughts on the state of the epidemic, new approaches to reaching populations at risk of HIV infection, and lessons from the AIDS response that might apply to the current Ebola outbreak in West Africa.
Q: On World AIDS Day 2014, how would you characterize the state of the epidemic?
A: First, there is much to celebrate. We’ve seen significant scientific progress against AIDS even in the last year, including new evidence of effective HIV prevention approaches. Since 2001, new HIV infections have declined by one-third and HIV treatment has expanded 40-fold. It’s important to take a moment and recognize these achievements.
However, new HIV infections remain alarmingly high in many communities, including key populations and girls and young women in sub-Saharan Africa. HIV prevalence is 28 times higher among people who inject drugs, 12 times higher among sex workers, 19 times higher among men who have sex with men and up to 49 times higher among transgender women than in the wider community. We still have a lot of work to do to reach these groups with effective prevention approaches.
Girls and young women under 25 are at particular risk. They account for one-quarter of new HIV infections in sub-Saharan Africa. Each week, 2,500 girls and young women become newly affected in South Africa alone.
Q: Which new approaches to HIV prevention are you most excited about?
A: In the last month, two studies of PrEP (pre-exposure prophylaxis), or use of AIDS drugs like Truvada, to prevent people acquiring HIV, were stopped early because their protective effect was too great to permit the studies to continue. So, that’s a very hopeful development.
Q: What studies has the Bank done to contribute to new HIV prevention knowledge?
A: Adding to previous studies in Tanzania and Malawi, the World Bank recently completed a study that shows cash transfers reduce transmission of sexually transmitted infections and HIV among young men and women in Lesotho. We also launched a study to better understand the role of cash transfers in HIV prevention in Swaziland, the country with the world’s highest HIV prevalence.
I would like to link PrEP and cash transfers. Where PrEP has failed, it is because adherence (taking the pills as needed) has been low. It may be possible to combine PrEP and cash transfers among key populations and young women in the highest burden contexts, with cash transfers reinforcing PrEP adherence and also having an additional direct protective effect.
The use of both PrEP and cash transfers hold promise to substantially reduce new HIV infections among key populations, such as girls and young women in Africa.
Q: In recent months, the global health community has turned its attention to containing the Ebola outbreak in West Africa. What lessons from the AIDS response apply to the current crisis?
A: There are some similarities and also great differences between the two diseases. Some lessons have been learned, others have not. A lesson learned from AIDS is the need to respond urgently. The global response to AIDS was far, far too slow. The global response to Ebola, including the Bank response (with funds disbursed in 9 days, the fastest in our history) has been much quicker.
A lesson we have not sufficiently learned is the need for robust health systems to support disease responses, including responses to newly emerging diseases. Just as health systems a decade ago were inadequate to support AIDS treatment, so health systems today have been inadequate to respond to Ebola in the most affected countries. The need to build functioning health systems is especially acute in post-conflict countries. It is striking that post-conflict countries in West Africa have struggled to contain Ebola, while their neighbors who have enjoyed many years of peace have been able to limit its spread.
Follow the World Bank Health team on Twitter at @worldbankhealth
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