Keep money flowing to HIV battle so achievements will not be lost
UNAIDS-led goal of ending the epidemic by 2030 is beyond reach, writes Adèle Sulcas
August 1, 2018 - AIDS is far from over. This is the bracing and deeply scary conclusion of the world’s largest global conference on HIV and AIDS (in fact on any global health issue), the 22nd International AIDS conference, held last week in Amsterdam. Here 16 000 HIV scientists, policy makers, community leaders, donors and activists of all stripes joined hands – sometimes uneasily – to share new research, lessons learned, promises, hopes, and sometimes the cold reality of disappointing clinical research findings. After more than 30 years, thousands of clinical trials and billions of dollars invested, there is still no ‘cure’ for HIV, nor a vaccine. The idea that every failure is a step closer to success is of no immediate consolation.
The dizzying array of plenaries, special sessions, pre-conferences, workshops, “global village” presentations and ‘poster sessions’, youth programmes, report launches, awards, marches, and plenty of ‘corridor’ discussion was spiced with celebrity appearances: Charlize Theron, Elton John, Prince Harry, Conchita, Omar Sharif’s grandson and Elizabeth Taylor’s three grandchildren. But the glitz factor paled as the spotlight turned on the deadly serious work of reviewing what it will take, in both science and money, to vanquish HIV and AIDS.
I refuse to be cynical about a ‘talk shop’ forum – or at least about this one. A staggering amount of energy, commitment, and stubborn persistence has been invested in the global collective effort, by HIV scientists, policy makers, civil society, and people living with HIV, towards an eventual cure, vaccines, better drugs, and effective prevention. But for the first time in recent global health history, there is a reluctant but inevitable consensus that the world is not close to the UNAIDS-led goal of ending the epidemic by 2030. We are in this for the long haul.
“The discourse on ‘ending AIDS’ has bred a dangerous complacency,” said Peter Piot, founding director of UNAIDS and head of the International AIDS Society-Lancet Commission on advancing global health and strengthening the HIV response in the era of the Sustainable Development Goals. It was a mistake to adopt “the end of AIDS” rhetoric, the commission concluded.
A quick recap so the gravity of this can sink in: In 2017, an estimated 37 million people worldwide were living with HIV, 20.9 million of them were accessing antiretroviral therapy (so more than 15 million are not, yet), 1.8 million people became newly infected with HIV, and 940 000 people died from AIDS-related illnesses (more or less the population of Amsterdam). Since the beginning of recorded AIDS history, a total of 35 million people have died.
UNAIDS’s ‘fast-track’ target of all countries reaching 90-90-90 by 2020 (90% of people living with HIV know their HIV status, 90% of the people who know are on antiretroviral treatment, or ART, and 90% of those on treatment have suppressed viral loads) has slipped from our grasp.
Still, the fight against HIV has made astonishing gains in the past 15 years, since the fine-tuning of antiretroviral medications, the creation of the world’s largest financing mechanisms to get these treatments to countries that could never afford them on their own, and – for South Africa in particular - since we rapidly accelerated past the tragic denialism of Thabo Mbeki and created the world’s largest ART program, enrolling 4.2 million people. And some countries – Namibia and Botswana among them – are close to their 90-90-90 targets, ahead of schedule, proving that with political will, it is possible.
But we are not maintaining – to varying degrees in different parts of the world – this pace of progress, and global financing for the epidemic is in worrying decline, with countries’ domestic resources not yet able to fill the gaps. The global amount needed to reach the ‘fast-track’ targets by 2020 is $26 billion, but ‘only’ $20 billion has been committed by donors (through the two major funders, the multilateral Global Fund to Fight AIDS, TB and Malaria, and the US’s PEPFAR), leaving a huge shortfall. Decreases in international support are not being made up for by affected countries’ own increases in domestic funding (South Africa is one exception) – and for middle-income countries, the problem is often policy, not money.
In southern and eastern Africa, adolescents and young women remain the most vulnerable to HIV infection. It is unconscionable that in the ART era, AIDS-related deaths in some parts of the world are going up, as is the rate of new infections – in 49 countries. ‘Key populations’ everywhere, meaning sex workers, men who have sex with men, injecting drug users, transgender people, prisoners, and migrant populations still face enormous barriers in accessing the right care and treatment.
There is, however, quite a lot of very good news. Science has verified that “undetectable means untransmissible” (‘U=U’) meaning that once ART lowers an HIV-positive person’s viral load to the point that it is clinically undetectable, the virus cannot be transmitted, sexually or via breastfeeding. Treatment as prevention works, so the “universal test and treat” approach, where anyone diagnosed HIV-positive is put on ART immediately irrespective of CD4 count, works. Results announced here from a trial in eSwatini showed a 44% reduction of new HIV infections using this approach, proof of concept not just in a research setting but in real life. A ‘dual combination’ therapy (2 drugs instead of three) is showing promise in clinical trials. A new ‘mosaic’ vaccine candidate (among others) targeting different HIV strains has made it through hurdles others haven’t, and started a large-scale efficacy trial in 5 sub-Saharan African cities in November 2017 (results are expected in 2021).
But, the oft-vaunted claim that “the end of AIDS is in sight” is now officially off the table.
More money is needed to fund the global response, new approaches to prevention – particularly among adolescent girls and young women – must be prioritized, and the fight against HIV must be taken out of its silo and integrated into the broader global health agenda. This message permeated the atmosphere of the conference.
Setting aside South Africa’s double-edged distinction of being the world leader in the numbers of both people living with HIV and people on antiretroviral treatment, it was exhilarating to witness South African leadership and scientific pioneering here.
The conference’s international co-chair and President of the International AIDS Society is Professor Linda-Gail Bekker, deputy director of the Desmond Tutu HIV Centre at UCT. Nono Simelela (now an Assistant Director-General of the World Health Organization), Qurraisha Abdool Karim and Salim Abdool Karim, Glenda Gray, Lynn Morris and many others were among the leaders of the research and policy vanguard. The presence of Nelson Mandela was evoked by many (non-South Africans) quoting his inspirational words (“It is always impossible – until it is done”), not least Bill Clinton in his closing-ceremony address, and cries of ‘Amandla’ introduced a protest at the conference’s opening ceremony on Monday night, in protest against the lack of action by UNAIDS head Michel Sidibé against a staff member accused of (but not fired for) sexual harassment. Health Minister Aaron Motsoaledi pulled off an admirable price-cut negotiation for a new TB drug, bedaquiline (TB is the leading cause of death for people living with HIV), though in a session on "eliminating HIV on the road to Universal Health Care" he did not so much as mention the recent promise of national health insurance.
Among other commendable health-related promises from our President and health minister are improvements to South Africa’s distressed public health system: a ramp-up in cancer care and the addition of 2 million people getting onto antiretroviral treatment by 2020, in pursuit of our own 90-90-90 target (we are currently at 85-71-86). We need to remember the fatal error made during the dawning of our democracy – when the then-imminent HIV catastrophe was foreseen but took a back seat to the urgent business of creating our new Constitution – and hold them to it.
Adèle Sulcas has worked in global health for 20 years, including at the Global Fund to Fight AIDS, TB and Malaria and the World Health Organization, and at the time of writing was Acting Editor of the Global Fund Observer. This OpEd was first published in Business Day online on 1 August 2018.