December 1st is World AIDS Day and while in the early 1980s there wasn’t anything to celebrate, in recent years HIV/AIDs has become a much more manageable disease, at least in the developed world.
Once again, as with so many diseases, treatment options, access, and disease burden fall along societal lines. In developing countries AIDS is still considered a major health epidemic, but access to antiretrovirals are not at the levels they need to be, so while rates of infection have come down, the disease still persists.
World AIDS Day takes place on the 1st December each year. It’s an opportunity to highlight the success of worldwide efforts to combat HIV/AIDS, as well as the importance of continued support for these efforts. Founded in 1988, World AIDS Day was the first ever global health day. The 2019 theme for UNAIDS and the WHO is Communities Make The Difference.
While much progress had been made since the beginning of the AIDS epidemic, the numbers are still staggering. According to UNAIDS:
- In 2018, there were 37.9 million [32.7 million–44.0 million] people living with HIV.
- 36.2 million [31.3 million–42.0 million] adults.
- 1.7 million [1.3 million–2.2 million] children (<15 years).
- 79% [67–92%] of all people living with HIV knew their HIV status.
- About 8.1 million people did not know that they were living with HIV.
- 24.5 million [21.6 million–25.5 million] people were accessing antiretroviral therapy (end of June 2019).
- 1.7 million [1.4 million–2.3 million] people became newly infected with HIV (end 2018).
- 770 000 [570 000–1.1 million] people died from AIDS-related illnesses (end 2018).
- Every week, around 6000 young women aged 15–24 years become infected with HIV.
- In sub-Saharan Africa, four in five new infections among adolescents aged 15–19 years are in girls. Young women aged 15–24 years are twice as likely to be living with HIV than men.
- New HIV infections have been reduced by 40% since the peak in 1997.
- In 2018, around 1.7 million [1.4 million–2.3 million] were newly infected with HIV, compared to 2.9 million [2.3 million–3.8 million] in 1997.
- Every week, around 6000 young women aged 15–24 years become infected with HIV.
The data from WHO and UNAIDS shows that the majority of people living with HIV are in low and middle-income countries. Over two thirds of all people living with HIV live in the WHO African Region (25.7 million).
Eastern Europe and Central Asia continues to see a relatively high number of deaths per year at 38,000. This has been attributed to the limited access to ART in that region. Just 38% of all people living with HIV in that region access ART. Only the Middle East and North Africa, at 32% is worse.
While HIV is prevalent among the general population in these regions, an increasing number of new infections occur among key population groups. These key populations include: men who have sex with men; people who inject drugs; people in prisons and other closed settings; sex workers and their clients; and transgender people.
When performing a root cause analysis, it becomes clear that the primary drivers for these trends are often associated with legal and social factors, which increases exposure to risk situations and creates barriers to accessing effective, quality and affordable HIV prevention, testing and treatment services.
That said, as a result of concerted international efforts to respond to HIV, coverage of services has been steadily increasing. In 2018, 62% of adults and 54% of children living with HIV in low- and middle-income countries were receiving lifelong ART.
However, not everyone is able to access HIV testing, treatment and care. Notably, the 2018 Super-Fast-Track targets for reducing new pediatric HIV infections to 40 000 was not achieved. Global targets for 2020 are at risk of being missed unless rapid action is taken.
But, between 2000 and 2018, new HIV infections fell by 37% and HIV-related deaths fell by 45%, with 13.6 million lives saved due to ART. This achievement was the result of great efforts by national HIV programs supported by civil society and international development partners.
So what are the treatment options?
The answer, unfortunately, is not complete. The WHO has said the following with regard to the availability and effectiveness of the treatment options available to people with HIV.
HIV can be suppressed by combination ART consisting of 3 or more ARV drugs. ART does not cure HIV infection but suppresses viral replication within a person's body and allows an individual's immune system to strengthen and regain the capacity to fight off infections.
In 2016, WHO recommended that all people living with HIV be provided with lifelong ART, including children, adolescents and adults, and pregnant and breastfeeding women, regardless of clinical status or CD4 cell count. By mid-2019, 182 countries had already adopted this recommendation, covering 99% of all people living with HIV globally.WHO updated its HIV treatment guidelines in 2018 and 2019 to reflect the latest scientific advances.
The HIV treatment guidelines include new alternative ARV options with better tolerability, higher efficacy, and lower rates of treatment discontinuation when compared with previous recommended medicines. WHO recommends the use of dolutegravir-based or low-dose efavirenz for first-line therapy, and raltegravir and darunavir/ritonavir for second-line therapy.
Transition to dolutegravir has already started in 82 low- and middle-income countries and is expected to improve the durability of the treatment and the quality of care for people living with HIV. Despite improvements, limited options remain for infants and young children. For this reason, WHO and partners are coordinating efforts to enable a faster and more effective development and introduction of age-appropriate paediatric formulations of ARV drugs.
Globally, 23.3 million people living with HIV were receiving ART in 2018. This equates to a global ART coverage rate of 62%. However, more efforts are needed to scale up treatment, particularly for children and adolescents. Only 54% of children and adolescents were receiving ART at the end of 2018.
Expanding access to treatment is at the heart of a set of targets for 2020, which aim to bring the world back on track to end the AIDS epidemic by 2030.
So what about a vaccine?
Researchers have been working on an HIV vaccine since the 1980s, but progress towards an effective vaccine has been much slower than anticipated. The WHO recommends pre-exposure prophylaxis (PrEP) as a prevention choice for people at substantial risk of HIV infection as part of a combination of prevention approaches.
According to Avert, a model developed by the International AIDS Vaccine Initiative has estimated that a 70% effective vaccine would have a greater impact on new infections than PrEP alone. The biggest reduction in new infections would be achieved by a combination of PrEP, universal antiretroviral treatment for people already living with HIV, and a vaccine.
An HIV vaccine is a more realistic prospect today than a decade ago and an optimistic forecast of HIV vaccine availability is that one might be available by 2030.
So, until we have an effective vaccine, we will continue to monitor the progress of this important treatment program and maintain hope for the day we see an end to this horrible epidemic.
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