Global HIV prevention is not on track: how a health systems approach can promote sustainable progress in African countries

The expansion of the global HIV response has led to substantial reductions in mortality and new infections over the past two decades. Yet, despite these gains, rates of new HIV infections remain much higher than projected, resulting in long-term consequences for controlling the epidemic. Challenges include siloed delivery approaches shaped by the demands and priorities of external funding, lack of integrated data systems for prevention, unaddressed structural risks, and limited community and multisectoral engagement. There is substantial concern that the inability of health systems to consistently reach vulnerable groups, especially with extraordinarily effective new biomedical tools, threatens the long-term control of the HIV epidemic. In this framing paper (the first paper in a six-part Series), we argue that countries that have adopted (or are planning to adopt and invest in) a more integrated health systems approach to the HIV response will be better able to achieve sustainable prevention outcomes and withstand external funding shocks. Focusing on sub-Saharan Africa, we examine current systemic barriers, the risks of continued fragmentation of programmes and accountability, and opportunities to realign HIV programmes—that will be explored thoroughly in the other papers in this Series—through a focus on strengthened governance, a decentralised health systems approach, community engagement, and strengthened pathways for new product introduction and scale-up.