Mitzy Gafos

The session was a panel discussion on epidemic control and epidemic transition. It addresses issues of the definition of ‘control’, the programmatic needs to achieve ‘control, and the types of data matrix needed to allow monitoring of movement to epidemic control and transition to sustainable control.

Measures of progress to ‘control’ available for ‘zero infections, zero deaths’. Need better measures of zero stigma e.g. key population access to services, criminalisation, marriage equality, qualitative assessments of social norms. Addressing social factors, i.e. stigma, key to achieving 90-90-90 and delivery of prevention services i.e. PrEP. U=U potentially powerful stigma reduction tool. Clear need to include service users in planning i.e. young people, MSM, injecting drug users, and in some cases provide platform and ‘get out of their way’ so they can implement. Need granular data among key populations to avoid overemphasising progress to control. Ongoing need to address social factors in implementation of programmes and measure progress in order to support sustainability of ‘control’. Need to plan for backwards movement from target and ensure programmes are adaptable to change. SDGs provide framework to advance ‘control’ in multisectoral manner and in political sphere.

Clear recognition across all panellists of the need to build civil society involvement into the design, implementation and monitoring of programmes, to address structural and social drivers of the epidemic that also impact on related factors such as other SHRH services and the NCD agenda, and the need to measure our progress at the granular level to understand inequalities of services and achieve ‘leaving no one behind’. The session wasn’t able to provide examples of how best to achieve many of these recommendations and that will be a useful next step.

Nanina Anderegg

This session looked at epidemic transition and control as well as the indicators and metrics used to measure transition points in order to study progress and identify gaps. It also tackled the question if the metrics are measuring what they should and if other indicators are needed.

In this session the importance of data, indicators, and metrics to identify and fill gaps in the epidemic transition and control was discussed. It was stressed that most of the gaps are found in key populations, where there often is no epidemic control and that community engagement and involvement is a necessary condition to sustain epidemic transition and control. The problem of stigma and discrimination and the lack of indicators and metrics to measure these were highlighted as major obstacles to achieve epidemic control. It was further recognized that countries have a good understanding what data and metrics are needed; that it is not necessary to agree on a single indicator for measuring epidemic transition and control among the multiple existing indicators; and that the indicators might need a very different degree of complexity and accuracy dependent on whom they have to be reported to.

Metrics and indicators are important to measure gaps and progress in epidemic transition and control. However, as introducing a new metric always involves investment, thoughts about cost-effectiveness have to be incorporated and the community should be involved in deciding on which metrics are lacking and needed. A clear take home message from this session was that stigma and discrimination - especially among key populations - need to be addressed urgently in order to sustain epidemic transition and control and new indicators might be needed in order to measure progress in this direction.

Raminta Stuikyte

The panel discussed metrics how we know that we are reaching the end of HIV epidemics that would translate into sustained action. The panelists brought different perspectives: is stigma and discrimination addressed, do metrics work for key populations and are fit for purpose.

The “epidemic transition” was discussed from perspectives of donor, manager, human rights, and epidemiology. PEPFAR use granulating data for understanding the dynamics of epidemics in localities and populations, and directing resources to make impact. UNAIDS started using the “epidemic transition” metric (incidence:mortality ratio) to measure progress towards the global 2030 goal. Joe Amon cautioned against “seductive” idea of having a “tipping point” : the epidemic can rebound, complexities of stigma and discrimination might not be captured. Hence communities should be involved in designing metrics as well as programs to ensure equity and quality. U=U campaign is therefore so powerful since PLHIV are part of solution. National managers need non-technical indications of the progress – like life-expectancy - that speak to politicians and treasuries. Metrics should be fit for purpose, lead to sustained action and work for highly-stigmatized groups like key populations who attribute to 40% of new infections globally.

The discussions of metrics outside the epidemiological circles helps to create ownership of the metrics inside the broader HIV movement, more relevant and practical. It revealed the tensions between wanting to simplify our progress to the world and complexities of HIV like legal and policy factors and wish to assess both “control” and sustainability of that control. The indicators should lead to actions and ensure that populations - not large in size or criminalized - are not overlooked in defining when we achieved the goal of ending the HIV epidemic and how we sustain that achievement.

Sandra Hsu Hnin Mon

Panelists discussed HIV epidemic control, current successes and challenges in the effort towards epidemic control, and the steps required to reach, sustain, and support epidemic transition. Panelists denounced complacency – advising adapting the HIV response as the epidemic fluctuates within communities, while ensuring that individuals are treated with dignity.

Human rights, inclusion, and equality remain critical to supporting and sustaining epidemic control. In striving for HIV epidemic transition, Joe Amon cautioned against focusing solely on the “tipping point” and overlooking the risk of rebound. Sustainability may only be achieved when issues such as NCDs, chronic AIDS complications, and human rights barriers are addressed along the way. Thinking about programmatic indicators and metrics, we need a translatable and achievable metric for stigma and discrimination, particularly as experienced by key populations. Basic indicators of intolerance exist, but further granularity is required for community, and subsequently national, engagement. Nduku Kilonzo repeatedly stressed the need for technical and financial justification of country investment in programs and services. In other words, cost-effectiveness is key for countries with fewer resources to allocate and reallocate as international and programmatic policies evolve and adapt – as they should – to the epidemic as it changes with communities.

HIV epidemic control and transition is achieved when new infections become rare, everyone who seeks treatment and care are treated with dignity, and the world sees a significant decline in stigma and discrimination against minority and underserved populations. The path toward epidemic transition must acknowledge, accept, and adopt the mindset that people at risk of HIV and those who live with the virus are part and parcel of the solution. At the same time, equal access for all must be accompanied by a willingness to transform, to ensure that the AIDS response is as dynamic as the populations it serves.