Jhabindra Bhandari

Globally, the COVID-19 pandemic is severely affecting livelihoods of majority of the people who are poor and socially disadvantaged with limited access to basic primary health care services. In this context, the pandemic is having a catastrophic impact on the most vulnerable communities in many developing countries and threatens progress against many epidemics such as HIV, TB and malaria.
The global response is still inadequate. Therefore, the fast-tracking strategy to achieve a focused set of ambitious and people-centred HIV services to address the existing gaps in prevention, treatment, care and support. The target aims to ensure that 90 per cent of people at risk of HIV infection have access to comprehensive HIV prevention services, including sex workers and their clients, men who have sex with men, transgender people, people who inject drugs and prisoners.

Treatment access
Achieving the 90–90–90 treatment targets where 90 per cent of people living with HIV know their status, 90 per cent of people who know their HIV status are accessing treatment, and 90 per cent of people on treatment have suppressed viral loads provides an entry point to progress towards ending the AIDS epidemic 2030. Ensuring healthy life and promoting well-being for all is essential to sustainable development. More importantly, the recent UNAIDS report on the global AIDS epidemic shows that the treatment targets will not be met because of deeply unequal success and the increasing threats of the pandemic. This will have creeping impacts on the progress we have made over the decades. It is crystal clear that more investments are needed to mitigate the impacts of the epidemics on individuals, families and communities.
The first HIV case in Nepal was diagnosed in 1988. Over the years, the HIV epidemic has evolved from a low prevalence to concentrated epidemic among key and vulnerable populations. These include people who inject drugs, men who have sex with men, transgender people, sex workers, migrants and their families. According to National Centre for AIDS and STD Control (NCASC), the estimated number of people living with HIV was 29,503 in 2019. The prevalence among the adult population was 0.13 per cent.
Despite impressive progress, concerted efforts are needed to close the gaps in the treatment cascade. Because late diagnosis of HIV remains the most substantial barrier to scaling up HIV treatment and hence contributes to HIV transmission. In addition, there is limited access to HIV testing and treatment services in most of the developing countries. Scaling up treatment requires scaling up of facility-based services with an array of community-based HIV service delivery. There are emerging needs of promoting innovation in HIV service delivery technology, including mobile health, e-Health and tele-health. With the innovative HIV prevention technologies, more and more key and vulnerable populations can be reached out for testing and treatment services. Digital technologies and social media connect people in innovative ways to share experiences, access information, deliver services and catalyse social movements.
Community-led response is critical to empower adolescents, young people, key and vulnerable populations to access testing and treatment services. Recent consultations with governments, civil society organisations, and networks of key populations, development partners, experts, academia and private sectors reveal that the new HIV strategic plan must account for changed political context of governance, new realities of emergencies such as COVID-19, growing inequality, rising migration, rapidly expanding innovations in information, communication and technology.
On the other side, human rights barriers, stigma and discrimination undermine an effective response at all levels. Promoting and protecting human rights is essential to ensure that the infected people have easy access to comprehensive HIV services in the community. Addressing gender inequality is crucial as it contributes to differential access to health services for men, women and transgender people. There is now increasing focus on resilient health and community systems in the national response. This approach is crucial to ensure that people have access to effective, efficient, and accessible services through well-functioning and responsive health and community systems. During health emergencies, people face disruption of services, including HIV-related services, destruction of livelihoods, and poverty. Therefore, national response needs to be more ambitious and result-oriented to ensure tangible progress in key prevention and treatment indicators.
Without strong civil society engagement, it is almost impossible to effectively reach out to the vulnerable people with the prevention, testing, treatment and care services. They play critical role in the AIDS response with mounting evidence of its positive impact. It is important to ensure that the capacity of civil society organisations is further strengthened to effectively deliver community-led services by mobilising key populations and communities.

Public–private partnership
Effectiveness and relevance of HIV services broadly rely on the leadership of civil society organisations, networks of people living with HIV, and vulnerable populations. Apart from this, people with disabilities and displaced people are equally at higher risk of HIV infection because they are vulnerable to violence, sexual abuse, stigma and discrimination.
Therefore, new strategy needs to broaden options for targeted rights-based, evidence-informed and gender-specific HIV testing and innovative public–private partnerships. Moreover, national procurement and supply management systems should be robust and efficient. In the changing context, we also need to focus on preparedness and capacity building of governments in order to minimise disruption in HIV services in times of emergency and integrate HIV services into national emergency preparedness and response plans.

(Bhandari is a senior doctoral research fellow in global health and health systems)