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
AIDS is far from over. This is the bracing and 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 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 in science that every failure is a step closer to success is of no immediate consolation. It was a dizzying array of plenaries, special sessions, preconferences, workshops, "global village" presentations and "poster sessions", youth programmes, report launches, awards, marches and plenty of "corridor" discussion spiced with celebrity appearances: Charlize Theron, Elton John, Prince Harry and Conchita. But the glitz factor paled as the spotlight turned on the 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 have 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, about 37-million people worldwide were living with HIV, 20.9-million of them were accessing antiretroviral therapy (ART) — 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.
Since the beginning of recorded AIDS history, 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 status, 90% who know are on 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, and — for SA in particular — since we rapidly accelerated past the tragic denialism of Thabo Mbeki and created the world’s largest antiretroviral programme, enrolling 4.2-million people. And some countries — Namibia is one — are close to their 90-90-90 targets, proving it is possible with political will.
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 $26bn, but "only" $20bn has been committed by donors — through 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 (SA is one exception). For middle-income countries, the problem is often policy, not money.
THE DISCOURSE ON ENDING AIDS HAS BRED A DANGEROUS COMPLACENCY. IT WAS A MISTAKE TO ADOPT THE RHETORIC.
In Southern and East Africa, adolescents and young women remain the most vulnerable to HIV infection. It is unconscionable that in the ART era, AIDS-related deaths 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 migrants, 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", 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. A dual-combination therapy (two 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 have not, and a large-scale efficacy trial in five African cities started in November 2017. Results are expected in 2021.
But the oft-vaunted claim that "the end of AIDS is in sight" is now off the table. More money is needed to fund the global response, new approaches to prevention — particularly among adolescent females and young girls — must be prioritised and the fight against HIV must be taken out of its silo and integrated into the broader global health agenda. This message permeated the conference.
Setting aside SA’s double-edged distinction of being the world leader in the numbers of both people living with HIV and people on ART, it was exhilarating to witness South African leadership and scientific pioneering here. Among them were the conference’s international co-chairwoman and president of the International AIDS Society Linda-Gail Bekker (who is also the deputy director of the Desmond Tutu HIV Centre at UCT); Nono Simelela, an assistant director-general for family, women, children and adolescents at the World Health Organisation; Quarraisha Abdool Karim, the scientific director at the Centre for the AIDS Programme of Research in SA; Salim Abdool Karim, director of the Centre for the AIDS Programme of Research in SA; Glenda Gray, director at the Perinatal HIV Research Unit in Soweto; and Lynn Morris, head of the HIV virology section at the National Institute for Communicable Diseases.
The presence of Nelson Mandela was evoked by many quoting his inspirational words: "It is always impossible — until it is done." Cries of "Amandla" introduced a demonstration at the conference’s opening ceremony, in protest against the lack of action by UNAids head Michel Sidibé against a staff member accused of sexual harassment.
Health Minister Aaron Motsoaledi pulled off an admirable price-cut negotiation for a new TB drug, though in a session on Eliminating HIV on the Road to Universal Health Care he did not mention the recent promise of National Health Insurance.
Among other commendable health-related promises from our president and health minister are improvements to SA’s distressed public health system, a ramp-up in cancer care and the addition of 2-million people onto ART by 2020 in pursuit of our own 90-90-90 target (currently at 85-71-86). We need to remember the fatal error made during the dawning of our democracy in 1994, when the then-imminent HIV catastrophe was foreseen but took a back seat to the urgent business of creating our new Constitution.
• Sulcas has worked in global health for 20 years, including at the Global Fund to Fight AIDS, TB and Malaria and the World Health Organisation. She now edits the Global Fund Observer.