We can build on 15 years of US leadership in the global AIDS response

World AIDS Day is always a good time to celebrate the enormous progress the world has made in combating the HIV epidemic and to recognize the U.S.’s exemplary leadership that has spanned multiple administrations and eight Congresses. This is especially the case after last night’s Senate passage of the PEPFAR Extension Act of 2018, passed earlier this month by the House and which is now on its way to the White House.

We’ve reached over 21 million people living with HIV with life-saving treatment globally and saved a generation of people who have enjoyed healthy, productive lives and gone on to better their communities, societies and our world. Investments in the U.S. President’s Plan for AIDS Relief (PEPFAR) have also been associated with socioeconomic development, diplomatic and security gains, and improved global public perception of the U.S.

{mosads}However, as UNAIDS reported earlier this year, we have miles to go before we actually end AIDS. And, there are new threats on the horizon, from the largest youth population in history (growing and vulnerable), to non-communicable diseases and declines in donor funding for HIV programs. So how do we reach the rest in need? We must tighten up the gaps in our programs; doing so will magnify their impact. In addition to our relentless focus on our progress, we need to more closely examine our shortcomings through the lens of health-care quality.

For example, each new HIV infection represents a quality signal that needs to be measured, understood and addressed. A new HIV infection represents an opportunity that was missed to reach someone with treatment in time to suppress their virus in order to prevent onward transmission. Or to provide a vulnerable girl or young woman with the tools needed to protect herself in time to prevent a risky sexual encounter.

Similarly, HIV drug resistance develops when there are gaps in quality of service delivery and health systems, and leads to treatment failure and resurgent HIV disease. It’s a problem that is accelerated by gaps in supply chains and by programs not moving quickly enough to identify and support people with unsuppressed viral loads.

Finally, each of the nearly one million deaths that occurred globally last year represents a gap or failure in some element of our response. A recent study reported that 5 million deaths per year were due to subpar quality care. I have seen lethal consequences of people living with HIV who weren’t started on TB preventive therapy. And the patient who tested positive for HIV, was not started on treatment and who presented years later with a fatal brain infection. Deaths are often the consequences of minute gaps in our systems, and therefore readily preventable.

Given these and other gaps, this is a critical time for every country to invigorate their approach to delivering quality health care, as noted recently by WHO head Dr. Tedros and the Lancet Commission on Quality. This includes developing national policy and strategy frameworks for quality and infusing better data and quality standards into health programs, whether for maternal, newborn and child health or HIV and TB.

PEPFAR and the global community have recently taken substantial strides towards improving the quality of HIV programs. PEPFAR’s groundbreaking use of new incidence test technologies that allow detection of recent infections should result in better allocation and targeting of prevention investments. Similarly, in 2017 WHO launched the Global Action Plan on HIV Drug Resistance — its focus is on measuring and tracking key indicators of program and systems quality in order to decrease HIV drug resistance. And PEPFAR is for the first time measuring mortality at the clinic level, which will drive more effective programming.

Congress has played an immensely important leadership role in supporting this strong and dynamic global HIV response, including through the 2013 PEPFAR reauthorization that spurred improved data for decision-making and program quality. And 15 years of historic U.S. investment in PEPFAR and the Global Fund have created the foundations we need to be able to save millions more lives, while protecting entire societies against the destabilizing force of this epidemic.

It is my hope this World AIDS Day that our leaders in Congress and in the administration remember this history, and can envision the bright future ahead for millions of people if we remain committed to this fight.

Charles Holmes was former PEPFAR chief medical officer and deputy U.S. Global AIDS coordinator and now co-Directs Georgetown University’s Center for global health and quality. He is also co-Chair of the World Health Organization global HIV services quality working group.