The Worldwide Response to the HIV/AIDS Pandemic Since 1981. Lessons Learned.

[This article has been published in Spanish in Esglobal]

How did we go from 270 reported cases of AIDS in the United States in 1981 to 37 million people living with HIV worldwide in 2017? What did we do right and what could we have done better?

Infection by HIV went from being a death sentence to a treatable chronic disease

Infection by HIV went from being a death sentence to a treatable chronic disease with a life expectancy nearly that of an uninfected person. Lifesaving drugs were developed in the 1990s and are continuously being improved. In 2017, approximately 50% of the global population living with HIV were receiving antiretroviral treatment (ART).

The introduction of triple drug treatment in developed countries in 1996 saved millions of lives and as people started ART, they no longer died of AIDS.

Millions of people in African countries died from AIDS-related complications between 1995 and 2005

However, poorer countries with a high burden of HIV still faced the AIDS death sentence. A decade went by before treatment was slowly introduced in resource-limited countries starting in 2003. Millions of people in African countries died from AIDS-related complications between 1995 and 2005 while HIV was becoming a treatable chronic disease in developed countries. What can we learn from this deadly ten-year gap? 

Prevention vs Treatment

An overall reluctance to support ART for developing countries pervaded the UN agencies, academics and major donors in the late 1990s. Triple therapy costs ranged from 8000-15000 USD/yr/person. Funds were limited and the clinical management and treatment of HIV required trained personnel and complex infrastructure.

An overall reluctance to support ART for developing countries pervaded the UN agencies, academics and major donors in the late 1990s

A debate raged on for several years as to whether donor funds would be better spent on HIV prevention or on treatment. Arguments were made that prevention including STD control, condoms, voluntary counselling and testing and safe blood supply was more cost effective for saving lives than was treatment. Additionally, it was argued that fragile African health systems would not be able to ensure quality clinical management and adherence due to lack of trained clinicians, and poor infrastructure.

Activism and Innovation

In 2000, civil society groups, activists and people living with HIV (PLHIV) protested high HIV drug prices. The worldwide activism led to the availability of generic quality ART at about 350 USD/yr/person. At the same time the Global Fund for AIDS, malaria and tuberculosis was created to combat these three deadly diseases. Finally, the WHO initiated the 3x5 initiative which sought to treat 3 million PLHIV by 2005 and the demand for treatment in Sub-Saharan Africa (SSA) grew.

Since 2005 operational and implementation innovations have resulted in simplified approaches for HIV clinical management and treatment. The public health approach to scaling up ART has found innovative ways to bypass many of the complications arising from fragile health systems and the scarcity of qualified health personnel. Task shifting to lay personnel, differentiated care adapted to local and individual needs and out-of-clinic community programs are now common in HIV/AIDS care worldwide.

Equity in the HIV response

Could we have tested and implemented simplified approaches earlier? What would the HIV epidemic look like today if ART had been available in SSA in 1996 and a decentralized public health approach gradually implemented?

We need to learn from the history of the HIV pandemic response so we can ensure that equity be a key component

We need to learn from the history of the HIV pandemic response so we can ensure that equity be a key component in our future responses to pandemic health threats. We can recognize that the example of a smallpox vaccine for which a one-size fits all approach effectively eradicated the disease is rare in global health. We must not be afraid to tailor solutions to different realities.

Over twenty years of evidence has shown that PLHIV with undetectable viral load do not transmit HIV

In 2018 we still face challenges in equity of HIV care. Over twenty years of evidence has shown that PLHIV with undetectable viral load do not transmit HIV. This has led to the Undetectable=Untransmittable (U=U) campaign which empowers PLHIV and de-stigmatizes HIV. The U=U advocacy is growing in wealthy countries but is only valid if a test is available to ascertain the undetectable viral load. The problem is that the viral load test can cost from 30-50 USD/test and requires trained personnel and complex infrastructure. In 2017, surveys from several African countries showed that less than 25% of PLHIV had a viral load result.

Alongside the U=U approach to living with HIV, the development of new highly potent antiretroviral drugs with fewer side effects and less prone to generating drug resistance has heralded in a new era for ART

Alongside the U=U approach to living with HIV, the development of new highly potent antiretroviral drugs with fewer side effects and less prone to generating drug resistance has heralded in a new era for ART. SSA first line and second line treatments have always lagged behind those prescribed in the developed world ART treatment in SSA is often based on drugs that have been phased out in the developed world due to toxicity or other undesirable effects. Additionally, the low interest and painfully slow development of pediatric formulations of ART has led to many deaths in HIV-infected children over the past two decades. We need to ask ourselves what is necessary for research advances in the HIV care field to benefit PLHIV living in developed and LMIC without a 5- to 10-year time lag.

The fight against AIDS in the new sustainable development agenda

We cannot rely solely on activism and corporate philanthropy to solve problems of equity in health. In recent years, International health organizations such as WHO, UNAIDS and UNICEF have played an increasingly important advocacy role. The UNAIDS  90-90-90 targets to have 90% of PLHIV tested; 90% tested initiating ART; and 90% on ART with sustained viral load suppression by 2020 has been a tremendous motor for innovation in the fight against AIDS and has given visibility to the 25 million people living with HIV in SSA.

The Sustainable Development Goal 3 (SDG 3) to “ensure healthy lives and promote well-being for all at all ages” has also set the target to end the HIV epidemic by 2030 and has made equity a key issue. Health targets have proven to be more than just neat numbers, and have brought together civil society, research and health institutions to make huge advances in HIV treatment and care for all.

We need more integrity, accountability and transparency in the HIV response

In the face of currently decreasing donor funds for research and implementation, rampant mistrust in governments and industry, corruption at all levels, exorbitant profit margins for shareholders in the private health care industry, we need more integrity, accountability and transparency in the HIV response. 

The SDG 16 advocates to “provide access to justice for all and build effective, accountable and inclusive institutions at all levels”. This provides a framework for reestablishing trust in both the public and private sectors. Metrics for the number of people treated for AIDS should be accompanied by private and public sector transparency indicators with regard to the HIV pandemic response. These pillars of good practice will be necessary to end the HIV epidemic not just for some, but for all.