Opinion: Lessons learnt from the evolutions of HIV treatment

The case number of new HIV infections in Taiwan has been on the decline for the last three years. According to the Taiwan Ministry of Health and Welfare, the number of people who were newly diagnosed with HIV infection had dropped to 1,392 as of the end of December 2020, a decline of 21% from the same period last year.

When UNAIDS announced a visionary goal to end AIDS epidemic by 2030, it first set the 90-90-90 targets for 2020: 90% of all people infected with HIV will know their HIV status; 90% of all people who know they are HIV-positive will receive treatment; and 90% of all people receiving treatment will have a plasma HIV RNA load of below 200 copies/mL. According to the statistics of the Taiwan Centres for Disease Control, Taiwan has already achieved 90-93-95 for the three targets.

Despite this achievement, HIV-related stigma and discrimination continue to be a barrier for people living with HIV, or PLHIV, individuals at-risk, as well as the elderly living with HIV to receive long-term care of good quality.

If Taiwan is to meet UNAIDS’ “fourth 90” — 90% of all HIV-positive people whose viral load is under suppression enjoying good health-related quality of life — stigma must be reduced, health care facilities must be non-discriminating, and adequate social support will be essential. In making this happen, there are lessons that can be learned from the past.

The history of antiretroviral treatment

The major milestones in the history of HIV/AIDS treatment have lent many lessons both scientifically and socially. When the “AIDS cocktail” — a combination drug treatment — was first introduced in 1996, Taiwan followed the rest of the world by adopting it as the go-to treatment in 1997. Even though it led to dramatic improvements in the care of PLHIV, the initial cocktail regimen proved to be a complex medication regimen.

Some patients would have to take more than 20 pills divided in three to five times a day and often experienced side effects such as nausea, vomiting, fatigue, and diarrhoea. Even then, only 70-80% of patients were able to keep the viral loads stably suppressed; 20-30% of patients were not able to control their viral load, and some even developed drug resistance.

People had high expectations of the AIDS cocktail when it was first introduced, hoping that it would cure AIDS, but it failed. Although the virus could be undetectable with highly sensitive tools after treatment, it could still exist in the organs or lymphoid tissues. Once the treatment was stopped, the virus would start replicating.

Because of the suffering from short-term and long-term side effects of the older regimen and not being able to eradicate the virus, more conservative treatment approaches were adopted. For example, doctors treated the patients based on the levels of viral load and their immunity instead of starting treatment immediately upon diagnosis.

Structured treatment interruptions — for example treatments that alternated with interruptions every three months — were assessed to reduce the cumulative exposure duration to treatment and its associated side effects.

However, it became clear that, without continuous treatment, patients’ health would be negatively affected, the virus would spread, and there’d be an increase in the risk of developing AIDS and dying. Those treating HIV infection realized that, in order for treatment to be effective, treatments needed to be efficacious and easy to administer with minimal side effects.

Since 2016, several treatments consisting of single-tablet daily regimens have been introduced and approved by the Taiwanese authority. These recently introduced antiretroviral treatments are not only more effective but milder in terms of short- and long-term side effects than previous regimens consisting of more than 20 pills a day.

These advances have meant international organizations are able to promote early treatment as well as integrated lifetime treatment and support as opposed to the unintegrated HIV care and social services common in the past.

The adoption of antiretroviral therapy, or ART, has changed many aspects of HIV treatment and prevention and brought hope for increased longevity to PLHIV. HIV infection is no longer seen as a death sentence. As a matter of fact, HIV infection today is regarded as a chronic disease and it is no longer difficult to enjoy,  with continuous treatment, a nearly normal lifespan.

However, the stigma and discrimination attached to HIV infection mean some of the greatest challenges in administering effective treatments are social rather than medical. When HIV/AIDS first appeared in the early 1980s, stigma and fear of the disease were common throughout politics, health services, and the general public. Many, if not most, general practitioners refused to see patients with HIV, gay men were often barred from donating blood, and sometimes travel was restricted for PLHIV.

When addressing the social issues that negatively affect the treatment and quality of life of PLHIV, partnerships across the public, private, and nonprofit sectors have historically proven very effective.

One of the first successful HIV activism organizations was the Terrence Higgins Trust, a United Kingdom-based NGO that raised awareness about the facts of HIV, raised funds for treatment, and integrated with existing health services to help improve treatment for those living with HIV.

THT served as an early example of what is possible in advancing HIV/AIDS treatment when an advocacy organization proactively engages government, health services, and the general public, and has provided many lessons to the advocacy organizations that followed.

Today, most of the egregious mistreatments of PLHIV seen when the disease first appeared are uncommon, but that’s not to say that no more work needs to be done. While PLHIV are not often overtly stigmatized as they were 40 years ago, they still often lack the family and social support that they might have if they were not HIV-positive.

Long-term care and social acceptance are keys

The majority of people newly diagnosed with HIV infection in Taiwan are young men who have sex with men. Although, with the continuation of treatment, their lifespan can approach that of the general population, a person’s mental well-being may deteriorate over time.

This could be because of a variety of reasons such as lack of family support or difficulty maintaining stable relationships. In cases of frailty due to ageing and the need for care, the absence of social resources also poses a major threat to maintaining good health-related quality of life.

It is imperative that the government look into the issues of long-term care for PLHIV as soon as possible to help them achieve good health-related quality of life in old age. Setting up designated elderly care institutions for PLHIV and training young PLHIV as care providers might be temporary solutions. Whether these facilities or others alike could be set up, however, is still dependent on societal acceptance of those PLHIV.

While tremendous improvements have been made in HIV treatment, there is still a long way to go toward eliminating the disease in Taiwan as well as addressing the stigma and discrimination towards PLHIV. It is important to look at the lessons learnt from the past to understand how to better streamline and integrate HIV care in the future.

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