In higher income countries, AIDS progress is at risk of stalling due to challenges with stigma, aging populations and the needs of key population groups. The future of HIV care will depend not only on scientific breakthroughs, but on whether health systems are equipped to deliver these innovations equitably. So much of the science is there, it’s now about organisation, tools and access. Cross sector partnerships are not new but, is there more to be done to arm health systems with the right the tools and funding so that breakthrough innovations get to the people who need them?
In the past decade, we’ve seen remarkable strides: the scale-up of antiretroviral therapy (ART), global momentum toward the UNAIDS 95-95-95 targets, and wider access to pre-exposure prophylaxis (PrEP). But these gains risk plateauing unless policymakers, the HIV community, and industry work together to close persistent gaps in service delivery.
When thinking about innovation in healthcare, it is often cutting-edge ‘hard’ technologies – such as next-generation treatment options – that are assumed to be the differentiators for patients. But potentially life-changing innovations only matter if they reach the people who need them, and too often now, HIV innovations don’t reach those with the greatest need.
Why patient-centred HIV policies matter
Over the past decade, access to HIV innovations in Europe have been constrained for several reasons. Spending has been flat – declining an average of 0.1% annually – which is significantly lower than overall pharmaceutical growth in the region. Further country-level restrictive market access conditions, such as NHS England’s procurement decision to introduce contracts for HIV drugs based on price criteria, may limit treatment choices for patients by prioritising drug price over clinical features. This will potentially favour older, generic drugs over new therapies, delaying access to innovative treatments that could enhance adherence and quality of life. Similarly, in Switzerland, mechanisms to increase co-payments for patients for high-cost patented drugs could also limit access to effective treatments.
In terms of healthcare delivery, in high-income countries, up to half of adults with HIV are aged over 50 – and many are managing comorbidities. Redesigning the system so HIV care is not siloed but integrated into primary care or chronic services matters – it means people can access care for multiple conditions at once, and the system becomes more sustainable.
To improve access to HIV care, it’s crucial to understand why health systems aren’t delivering the best healthcare to all patients – and how to reach those from vulnerable groups – including sex workers, people who inject drugs, people in prison and other closed settings, men who have sex with men (MSM) and transgender people. Those facing the greatest burden stand to benefit most from advanced technologies and inclusive policies that help them stay connected to care, reduce stigma, and maintain adherence to treatment.
Driving policies and partnerships for HIV innovations to transform care
In 2021, France launched a direct access programme to enable certain breakthrough therapies to be available with free pricing and 100% reimbursement before final HTA negotiations through their national health system. But France has also made further steps to prioritise patient centric care. Prescription rights policies were also changed in 2021 so that GPs could initiate PrEP for patients – normalising HIV prevention into everyday primary care and making starting or renewing a course of treatment easier.
GP prescribing of PrEP policy came in during the COVID-19 pandemic and MSM was the population in which it truly made a difference. There is untapped potential in this policy which could have greater impact if it is rolled out across Europe, widened to target other populations and supported by public campaigning.
For initiatives like the one in France to be implemented and then ultimately succeed, several things need to happen.
1. Collate real-world evidence and data to clearly set out benefits and practicalities to decision-makers
2. Allocate funding – for technologies, governance, and importantly, workforce training. HCPs will be the ones driving the change, and it’s essential that they are engaged and receive the right support
3. Work with patient organisations and community centres to raise awareness of the campaign. Campaigns should use lay language, models that represent the diversity of the population, and use out of home adverts in appropriate locations to reach the intended audience
There is also a role for the private sector to play in helping to establish policies which can improve patient access to care and technologies. The pharmaceutical industry can bring a wealth of knowledge not just in research and development but in policy and system support from across disease areas. Industry, with connections across country borders, in collaboration with patient advocacy groups which have deep patient understanding, should be seen as invaluable partners to governments seeking to streamline and improve HIV care.
Policymakers and health system decision-makers should partner with industry and patient organisations to invest in system redesign and fair regulatory processes – so that the exciting scientific innovations coming through have the disruptive impact intended, and reach those with the greatest need.