Over the past twenty years, we have made great progress in the global fight against HIV/AIDS. Today, 28.2 million people are accessing life-saving treatment that did not exist 30 years ago and new HIV infections have declined 31% since 2010.

The movement for universal health coverage (UHC) has the opportunity to build on the gains that have been made in the HIV response. We have effective treatment methods and proven prevention interventions at our disposal. Now, we must address the gaps in coverage that exist throughout the world to ensure that improved health outcomes and HIV services are available to everyone. The fight to end HIV depends on our ability to reach all those in need.

HIV NEEDS UHC

Reaching the underserved requires a strong primary health system. The foundation of UHC is a strong primary health system, staffed with professional health workers of all cadres that are equitably distributed in all regions. Globally, one out of four people living with HIV (PLHIV) do not have access to treatment. Many of those without access to HIV services lack access to other health services, as well. Without a strong primary health system, people can routinely fall through the cracks created by poor health workforce and clinic distribution and are left underserved. It is imperative in the fight against HIV to reach those who are often left out of the health system and to close the gaps that still remain in access to health services.

The current barriers are social; they are addressed by overall health-seeking behavior and trust in the health system. Key populations and their sexual partners account for an estimated 62% of new infections globally. They also account for the vast majority (between 77% and 99%) of new infections regionally. Young people (aged 15–24 years) represent about 17% of the global population, but accounted for an estimated 28% of new HIV infections in 2019. Compared to women living, there are 1 million more men living with HIV who are unaware of their status, 1.8 million more men who know their status but are not on treatment, and 1.6 million more men who are not virally suppressed. The limiting factor in preventing these infections is not simply epidemiological knowledge or developing preventative medication, as it was at the beginning of the HIV pandemic. Now, it is social barriers and overall trust in the health system that prevent us from reaching key populations. Continued stigma, discrimination by health workers and communities, and criminalization of people living with HIV dissuade people—particularly those from key populations—from seeking health services. A more comprehensive and universal approach that demonstrates care for all would go a long way toward building trust and encouraging health-seeking behavior among those who feel the health system does not currently serve them.

HIV programming works best with integrated services. Reaching the underserved is most likely when HIV services are integrated with other health care. HIV, tuberculosis, and other chronic non-communicable diseases are common comorbidities and should, wherever possible, be delivered together with HIV services to reduce the number of visits required and catch early diagnoses, contributing to improved health outcomes among PLHIV. Many young people would benefit from integrated HIV and sexual and reproductive health services, as the need for prevention tools for HIV and other sexually-transmitted diseases overlap. More children living with HIV could be captured with a better link between HIV services and maternal and child care. A strong UHC system would help to offer all of these services together, improving health outcomes across the board.

UHC NEEDS HIV

HIV researchers and clinicians are practiced in sharing lessons learned and assuming shared responsibility with communities. The HIV response has centered the role of community members as service providers, peer advocates, and decision-makers in public health policy. The UHC movement can build on this and ensure that civil society plays a role at every level and that services are delivered equitably. We can expand the links that HIV researchers and clinicians have built with the faith-based community, women’s groups, and youth organizations to institutionalize community-buy in from the inception of a country’s UHC platform. Trust in the overall health system can be built by utilizing the HIV sector’s model of peer communicators and health workers recruited from the communities they serve.

The global response to HIV can offer a model for pandemic response as new pathogens arise. The HIV response infrastructure has already been leveraged for the COVID-19 response, leaning on HIV-financed health workers, laboratory systems, surveillance sites, health clinics, procurement and supply chain systems, and community-based organizations. Key population groups and PLHIV networks helped to broaden the reach of testing services and education. We can also continue to learn from the early days of HIV as we combat vaccine hesitancy and seek to educate the public on the importance of prevention tools in new pandemics. The lessons of the fight against HIV— particularly the recognition that no one country is safe from a pandemic until all are—can be applied to any new global health crises that arise. The HIV community knows how to respond to pandemic threats and has infrastructure ready to scale up as we prepare for future threats.

We recognize that global health access will not come with disease-specific services alone. However, given the unequal response to health issues across the world, these specific services are still greatly needed to address key groups that remain underserved for particular diseases like HIV. We need UHC to complete the fight to end HIV as a public health threat, and the UHC movement needs the lessons and infrastructure built by the HIV response to serve as a foundation and ensure equitable access.