AIDS and universal health coverage—stronger together
Authors: Kent Buse, Jonathan Jay, Morolake Odetoyinbo
Journal: The Lancet Global Health (2015)

On World AIDS Day, Dec 1, we commemorate those who have died, reflect on the state of the epidemic, and reunite for the struggle ahead. The AIDS movement has much to celebrate—new infections are down from 3·1 million to 2·0 million since 2000 and AIDS-related deaths have fallen by more than 40% since 2005.1UNAIDSFact sheet.http://www.unaids.org/en/resources/campaigns/HowAIDSchangedeverything/factsheetDate: 2015Google Scholar Over 15 million people now access treatment.1UNAIDSFact sheet.http://www.unaids.org/en/resources/campaigns/HowAIDSchangedeverything/factsheetDate: 2015Google Scholar Yet AIDS remains the leading cause of death among women of reproductive age and the leading cause of death in Africa—including among young people.2UNAIDSOn the fast-track to end AIDS by 2030: focus on location and population.http://www.unaids.org/sites/default/files/media_asset/WAD2015_report_en_part01.pdfGoogle Scholar 17 million people lack access to treatment, and 19 million do not know that they live with the virus.3UNAIDSAIDS by the numbers.http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdfGoogle Scholar The Sustainable Development Goal (SDG) for health reflects a fundamental shift in political priorities, offering a major opportunity for the maturing global AIDS response. The SDGs emphasise more integrated and holistic approaches, recognise the burdens of an increasing number of health concerns—including progressive chronic diseases affecting people living with HIV—and demand more fair and sustainable ways of paying for health through universal health coverage (UHC). If approached strategically, the SDG agenda, including UHC, can significantly benefit people living with and affected by HIV. Both UHC and the AIDS response share common goals around equity, non-discrimination, dignity, and social justice. Therefore, we propose that both movements unite around a five-point agenda designed to deliver health, dignity, and wellbeing for all. First, both movements must promote inclusive governance and broad partnerships. The Greater Involvement of People Living with AIDS (GIPA) principle has proven crucial to delivering more responsive programmes—and therefore results. The principle is reflected in community-based services run by people living with and affected by HIV, multisector national AIDS programme committees, and seats for civil society on the Boards of the Global Fund and UNAIDS. UHC programmes should promote similar involvement from enrollees and broader civil society, including people living with or affected by AIDS or their representative organisations, to improve design and implementation while enhancing legitimacy. Second, we must mobilise resources and align investments. The SDG goals carry a major price tag, but at a cost of 3–4% of global gross domestic product, they are a bargain.4Institute of Global Environmental StrategiesBig “ethical failing” if inaction on sustainable development continues: Jeffrey Sachs.http://www.iges.or.jp/files/press/PDF/20150730_e.pdfGoogle Scholar The AIDS response has a tradition of setting, and reaching, bold targets. UNAIDS's Strategy calls for an increasingly diversified bundle of front-loaded investments of US$30 billion annually by 2020, setting a course to end the epidemic as a public health threat by 2030.5UNAIDSOn the fast-track to end AIDS: 2016–2021 Strategy. UNAIDS, Geneva2015http://www.unaids.org/sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdfGoogle Scholar UHC programmes, which mobilise new health funding from domestic sources, can help close the AIDS financing gap. National UHC pools sometimes fund AIDS services directly, as in South Africa and Thailand;6World Bank GroupGoing universal: how 24 developing countries are implementing universal health coverage reforms from the bottom up. World Bank, Washington, DC2015http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/09/10/090224b0830cc779/1_0/Rendered/PDF/Going0universa0s0from0the0bottom0up.pdfGoogle Scholar where they do not, they can relieve financial pressure on AIDS programmes by supporting cross-cutting needs such as infrastructure and health workforce development. UHC and HIV financing plans must be well aligned for efficiency and sustainability. Third, we must emphasise a holistic approach to people-centred development, as the SDGs have done, integrating the full spectrum of people's health needs. UNAIDS's Strategy commits to the implementation of HIV-sensitive UHC schemes and stresses access to integrated services, including for HIV, tuberculosis, sexual and reproductive health services, maternal and child health, hepatitis, drug dependence, food and nutrition support, and non-communicable diseases, especially at the community level. Yet current health delivery models remain too facility-based, doctor-dependent, and disease-focused. For these and other reasons, 400 million people lack access to basic health services.7World Health OrganizationWorld Bank GroupTracking universal health coverage: first global monitoring report.http://www.who.int/healthinfo/universal_health_coverage/report/2015/en/Google Scholar HIV can be an entry point: Ethiopia's Health Extension Programme, with funding from HIV investments, has recruited, trained, and supported over 35 000 rural community health workers providing sustainable, comprehensive primary care. As services are integrated, both the AIDS and UHC movements must serve as watchdogs to ensure UHC programmes emphasise quality, prioritise the most marginalised, and eliminate discrimination in health-care settings. Fourth, we must tackle the fundamental social determinants of health,8Buse K Hawkes S Health in the Sustainable Development Goals: ready for a paradigm shift?.Globalization Health. 2015; 11: 13Crossref PubMed Scopus (203) Google Scholar even in the presence of biomedical interventions, resilient health systems, and fair health financing. Advancing human rights and gender equality are essential to ensure access to services, but a much broader spectrum of determinants must be addressed to prevent illness in the first place—from junk food marketing to income inequality. The UHC and AIDS movements share a powerful interest in keeping people healthy, and should act politically to address these determinants.9Altman D Buse K Thinking politically about HIV: political analysis and action in response to AIDS.Contemporary Politics. 2012; 18: 127-140Crossref Scopus (16) Google Scholar Finally, enhanced accountability is essential. The AIDS response uses a rigorous reporting and accountability mechanism that yields a spectacularly high response rate.10Taylor A Alfven T Hougendobler D Tanaka S Buse K Leveraging nonbinding instruments for global health governance: reflections from the Global AIDS Reporting Mechanism for WHO Reform.Public Health. 2014; 128: 151-160Summary Full Text Full Text PDF PubMed Scopus (16) Google Scholar The multistakeholder platform allows collective monitoring, course correction, and direct accountability. Similar participatory mechanisms would help to create the political space for open and inclusive dialogue on progress towards UHC. Through a shared agenda, the AIDS and UHC movements have a transformative opportunity to realise health as a global human right and ensure that no one is left behind. We declare no competing interests.