In the 1980s, AIDS looked like an unsolvable global killer. Since then, the disease has taken the lives of more than 35 million people.
But the emergence of anti-retroviral therapies after the mid-1990s, proven HIV testing and prevention methods, and money and willingness in many countries to offer treatments and services to their people has helped stymie a global pandemic.
As recently as four years ago, global health leaders were bold enough to launch a strategy to largely prevent and treat HIV by 2020 worldwide and end the epidemic by 2030.
Researchers warn, however, that even with notable advances in the fight against HIV, the pandemic remains all too real.
Complacency, persistent infection among key populations around the world, stigmas, injustices and uncertain funding are issues that could hamper the battle to end HIV/AIDS.
Worldwide in 2017, nearly 37 million people were living with HIV, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). The vast majority live in low- and middle-income countries, with an estimated two-thirds of them in sub-Saharan Africa.
In 2014, UNAIDS and some partners initiated the “90-90-90 targets,” part of an ambitious plan to end the AIDS pandemic. The aim is to diagnose 90 percent of all HIV-positive people, provide antiretroviral therapy (ART) to 90 percent of those diagnosed, and achieve viral suppression for 90 percent of those treated by 2020.
As of 2017, 75 percent of people living with HIV knew their status, 79 percent who knew their status were accessing treatment, and 81 percent were virally suppressed. While those figures show progress, some global health and HIV/AIDS experts say it’s not on the mark to end the epidemic by 2030.
As we near another World AIDS Day on December 1, three UC researchers offer their perspectives on the state of the HIV/AIDS epidemic.
Key advances, global response
“The most important accomplishment is the recognition that antiretroviral therapy (ART) can both treat HIV infection and decrease infectiousness,” said George Rutherford, MD, director of Global Strategic Information at the UCSF Institute for Global Health Sciences. “Following the landmark HPTN 052 study (of ART clinical trials in nine countries), public health agencies, international and national, have acted swiftly on this information and established aggressive targets, such as the 90-90-90 targets with endpoints of decreasing both incidence and mortality.”
“While I think we acted quickly on new knowledge, the essential capping of budgets to support ART and all the things that need to go along with it suggest that we may have slower progress in the future than we have had in the past five years,” said Rutherford.
“The number of people who are now receiving life-saving ART has significantly increased globally, including in regions that have had very high incidence rates like Southern and Eastern Africa, which is a major accomplishment,” said Steffanie A. Strathdee, PhD, an infectious disease epidemiologist and associate dean of Global Health at UC San Diego. “We now know that if we can reduce the amount of HIV in one’s body below the level of detection (HIV viral load), they won’t transmit HIV to their sexual partners. In other words, undetectable means un-transmissible. Getting this message across to people, for example, in the “U=U” campaign, is encouraging people to start ART and keep taking their meds.”
But, unfortunately, Stathdee said, the global response has not been adequate. “The donor base is shrinking and is shaky. Without a vigorous, renewed commitment to the Global Fund to End HIV, TB and Malaria, the outstanding gains we’ve made could be lost. And quickly.”
“We have more tools in our HIV prevention toolkit, such as Pre-Exposure Prophylaxis (PrEP), but we must also make sure that these tools are accessible,” said Brandon Brown, MPH, PhD, associate professor in the Center for Healthy Communities and Department of Social Medicine, Population and Public Health at UC Riverside.
“PrEP (daily medicine for people at very high risk for HIV) uptake is low in the US, and PrEP is not highly available in many parts of the developing world,” said Brown. “We have to work harder to get it right in the US and also identify the ways to roll out and ensure uptake of PrEP in other places.”
“And, of course, we need to continue to expand universal HIV testing and treatment for all people living with—or at risk for—HIV. Stigma is the major barrier to accomplishing this, but, sadly, efforts to address this have been lagging.”
Marginalized populations
“The key populations at risk depend on the region of the world,” said Strathdee. “In sub-Saharan Africa, young women and girls have shockingly high HIV incidence rates. In Central Asia and Eastern Europe, injection drug use is the main driver of HIV infection. In the US, young men having sex with men of color have very high HIV incidence rates that equal that of some African countries, and we have seen outbreaks of HIV infection among people who inject drugs.”
“Certain key populations (KP) have been left behind in many countries, but there is a growing realization by countries that KPs cannot be left out of the solution,” said Rutherford. “In Ukraine, for instance, there has been a recognition that much of the heterosexual transmission stems from untreated drug users. Diagnosing and treating drug users, as daunting as that may sound, will dramatically decrease not only heterosexual transmission but also perinatal transmission.”
“In many places people living with HIV are invisible, and it is nearly impossible for those who have HIV to get an HIV test or treatment due to high stigma, and, in some cases, legislation which criminalizes HIV transmission and even sexual identity,” said Brown.
Policy and research challenges
“The challenge for policymakers is clear: figure out how to increase funding for 90 percent ART coverage and everything that goes with it,” said Rutherford. “For researchers, the questions are: how to better prevent mortality from HIV and how to efficiently provide the evidence that policymakers need to continue the investment in HIV epidemic control.”
“A political will to allocate appropriate resources to HIV prevention and treatment is needed,” said Strathdee. “We can’t just treat our way out of this epidemic. There are still about two million people getting infected with HIV every year, and that’s simply unacceptable. Increasingly, human rights abuses and violations are key drivers of HIV infection. This includes racism and laws that criminalize homosexuality, sex work or drug use.”
To guard against complacency, “we have to convince other scientists and the rest of the world that our job in HIV is not done,” said Brown. “There is a sense that we have done all we can with HIV and that funding must be shifted to other health issues.
“Under this (US) administration, there is also the huge issue of the erasure of LGBT rights and, just recently, transgender rights. Since the LGBT population holds a high burden of HIV in the United States, we have to fight to ensure that HIV prevention and treatment is seen as a human right for all people. Like many areas of healthcare, HIV is a political issue — one that disproportionately affects the most marginalized and disenfranchised people in our society. That has to change if we’re going to continue to make progress.”
Also, with ART, the number of long-term HIV survivors around the world continues to increase, said Brown. “But there may not be adequate services for these people, specifically to address their depression, isolation and cognitive decline,” he said. “To do the research and really get the word out, we need to engage communities of people living with HIV.”
Current research and lessons
“We work on developing the best epidemiological evidence to show the relationship between public health and clinical programs, including funding and impact,” said Rutherford, whose research all over the world is funded primarily by the Centers for Disease Control and Prevention through the Presidential Emergency Plan for AIDS Relief (PEPFAR).
“We also are heavily involved in WHO (World Health Organization) guidelines and thinking through to the next generation of public health questions -- for example, how to decrease mortality above and beyond ART,” he said. “We are active in health information systems to support both our surveillance and monitoring and evaluation work. Finally, we are deeply committed to improving quality of systems – data quality, quality of public health, such as prevention, programming and clinical quality.”
Strathdee has led a research and training program on the Mexico-US border for over a decade. “I’ve learned that when you include local community stakeholders and policymakers in the planning, execution and dissemination of your research project, you have a much better chance of developing a prevention program that’s sustainable.”
“And by including students and fellows from both the US and the international site, like we have with the UCGHI GloCal Health Fellowship program, you end up mentoring the next generation of researchers in global health. And that’s amazing to watch,” she said.
One GloCal fellow’s study found that “simply decriminalizing possession of syringes doesn’t mean that police officers won’t continue to bust people who use drugs for carrying them.
“In Mexico, it’s actually legal for people to carry syringes without a prescription, but people who inject drugs don’t know that, and hence, police officers trying to meet their ‘quotas’ still arrest them, going as far as to hang out at the needle exchange waiting to apprehend someone who was trying to get sterile syringes to protect themselves from HIV and viral hepatitis. It drove me crazy!
“To address this, my colleague Leo Beletsky (law professor at Northeastern University) and I developed a police education and training program in Tijuana that shows police officers that when they confiscate syringes from people, they’re actually putting themselves at risk through needlesticks.
“Our program worked -- Tijuana police are much less likely to confiscate syringes now.”
In Brown’s research on HIV and aging, he collaborates with community groups in Palm Springs, California, which has a high prevalence of HIV-positive gay men over age 50. “We are taking the lead from our stakeholders, including primarily people living with HIV, their caregivers, providers, researchers and community-based organizations that serve people living with HIV.
“Resiliency is a major focus,” said Brown. “There is lots of research into the causes of ill health for people living with HIV, but little work on what helps people living with HIV thrive.
“We hope that the methods and lessons we learn can be applied globally—the numbers of people aging with HIV in epicenters like sub-Saharan Africa and other places are huge, and we can’t ignore the aging issue or health and social services systems will be overwhelmed.”