AIDS and The Trap of Complacency

Photo: Francesco Marzoli

[This article has been published in Spanish in El País - Planeta Futuro]

Let us not fall into the trap of complacency. Yes, it is true that thanks to the enormous progress achieved during recent decades, HIV infection has evolved from being a death sentence to becoming a manageable chronic condition. This is the vision that many in our environment have of this disease. But it is also true that despite billions of Euros invested and the collective effort of thousands of health workers, social workers, community-based organizations, policy makers and researchers from around the world, the global response to the AIDS epidemic is at a precarious moment.

Despite billions of Euros invested and the collective effort of thousands of professionals (...) from around the world, the global response to the AIDS epidemic is at a precarious moment

The member states of the United Nations boldly included the goal of ending AIDS among the Sustainable Development Goals to be achieved by 2030. Unfortunately, the pace of progress does not match this ambitious goal. Notwithstanding a remarkable 34% reduction in AIDS-mortality since 2010, in 2017 about one million people died from this disease. One million, more than 2,500 people a day.

One often overlooked explanation for this high mortality is that, despite a global trend to offer antiretroviral therapy (ART) earlier, HIV diagnosis occurs late in a significant proportion of cases. A study including data from 55 countries showed that almost 40% of patients who started ART in 2015 did so in very advanced phases of the disease, with levels of immunosuppression associated with increased comorbidity, hospital admission, mortality and health expenditure. Some may think that this is a phenomenon limited to low-income countries and, again, complacency and prejudices, will mislead them.

World AIDS Day 2018 - WHO campaign  

In Catalonia, for example, despite a reduction in the number of late diagnoses in recent years, in 2016, 43% of new HIV diagnoses occurred late and 23% in phases of advanced disease. Being a heterosexual man is consistently associated with a higher prevalence of advanced disease at the time of HIV diagnosis. Other factors include older age and lower educational level and, in studies carried out in Europe, having been born in a foreign country. Understanding the social determinants associated with these risk factors is fundamental for decreasing AIDS-mortality.

In Catalonia, for example, despite a reduction in the number of late diagnoses in recent years, in 2016, 43% of new HIV diagnoses occurred late and 23% in phases of advanced disease

Indeed, the reduction in mortality observed in recent years is greater in women than in men, likely reflecting differences in health-seeking behaviour and a gender disparity in antiretroviral coverage. In 2016, 60% of women and 47% of men living with HIV globally received ART, far from the target for 2020 (81%, 90% of the 90% diagnosed). To achieve this goal by 2020, nearly three million additional people should receive treatment each year. This will be extremely challenging in the context of stagnating funding, shortage of health workers, and the persistence of the scourge of stigma and discrimination, too often politically fuelled.

On the other hand, despite a remarkable increase in the efficacy of HIV prevention measures, the global access to these interventions is clearly insufficient, not reaching those who need them most. This dramatic reality translates into a reduction in the number of new annual infections well below the target. The nearly two million new infections occurred in 2017 show how unrealistic these objectives are, given the complex reality in which we live.

And again, this is not a phenomenon limited to low income countries. In fact, the greatest reduction of new infections between 2010 and 2017 was observed in sub-Saharan Africa, being up to 30% in southern and eastern Africa, compared to 8% in Western Europe and North America. In turn, in Eastern Europe, the Middle East, North Africa and Central Asia, the number of new infections doubled during the last 20 years. Access to condoms, pre-exposure prophylaxis, male circumcision, syringe exchange and substitution treatment for opiate dependence should be radically increased globally, and especially among the most vulnerable populations.

Sadly, the greater vulnerability of women and girls in certain regions of the world results in a disproportionately concentrated number of new infections among them. In sub-Saharan Africa, women accounted for about 60% of new infections in 2017. An effective AIDS response should go hand in hand with a firm global and national commitment to fight harassment, abuse and violence against women at home, in the workplace, and in the community. 

In sub-Saharan Africa, women accounted for about 60% of new infections in 2017

Men who have sex with men, sex workers, transgender people, people who inject drugs and prisoners are considered by the joint United Nations programme on HIV/AIDS (UNAIDS) to be the five groups especially vulnerable to HIV. Globally, almost half of new infections in 2017 occurred in these population groups and their sexual partners, including 25% of new infections in sub-Saharan Africa and 90% in Western Europe. The UNAIDS strategy promotes a human rights-based approach to development so as not to leave anyone behind. Unfortunately, punitive policies and practices that hinder an effective response to AIDS are still common in some countries. This includes travel restrictions, mandatory HIV testing, and criminalization of same-sex sexual relations, sex work, and drug use. Once again, the too often claimed political will to put an immediate end to these practices and discriminatory laws emerges as a fundamental element for the global control of the AIDS epidemic. It is the responsibility of the state to ban these policies and protect everyone.

And let us not forget children. They are being left behind. We dreamt about eliminating new HIV infections by 2018, but in 2017, about 180,000 children became newly infected, and close to two million children were living with HIV globally, most of them in sub-Saharan Africa. Even more outrageously, only half of those diagnosed received antiretroviral treatment. And this time, yes, this is a reality of the poorest countries in the world that should shake our consciences. Paediatric AIDS is still a neglected disease.

And let us not forget children. They are being left behind. We dreamt about eliminating new HIV infections by 2018, but in 2017, about 180,000 children became newly infected, and close to two million children were living with HIV globally

So, no, AIDS is not even close to being over. The history of the AIDS response is certainly remarkable, and should be enthusiastically acknowledged. But let us not fall into the trap of complacency, or we will never see its end.