The 'end of AIDS' is not even nearly in sight, experts warn

LONDON — The global effort to fight HIV and AIDS is in danger of backsliding due to “dangerous complacency” and an overemphasis on treatment at the expense of prevention, experts have warned.

New figures released Thursday by the United Nations’ AIDS agency reveal that current progress toward preventing new HIV infections and AIDS-related deaths is too slow to control the disease and meet ambitious global targets. Approximately 1.8 million people became infected with HIV and 940,000 people died from AIDS-related illnesses in 2017, according to UNAIDS — only marginally less than in 2016.

However, the number of people living with HIV accessing antiretroviral therapy increased by 2.3 million people, up to 21.7 million.

The Sustainable Development Goals call on countries to end the epidemic by 2030, and a  fast-track target agreed by the United Nations General Assembly in 2016 aims to reduce the number of new infections per year to 500,000 by 2020. UNAIDS has also set the “90-90-90” target, which calls for 90 percent of people living with HIV to be diagnosed and 90 percent of those identified patients to start on treatment, which should suppress the disease to the point it is undetectable in 90 percent of them.

The new data comes as the community gears up for the 22nd International AIDS Conference in Amsterdam, The Netherlands, next week, leading to calls from advocates for renewed activism and commitment to fight the infection.

Speaking at the Institute for Development Studies in the United Kingdom last week, Peter Piot, the founding director of UNAIDS and now director of the London School of Hygiene and Tropical Medicine, said the global community has slipped into a state of “dangerous complacency” about the epidemic.

“We are not on track, we need to reboot our efforts and move away from the ‘end of AIDS is in sight’ rhetoric,” which has been “counterproductive and is not supported by the facts,” he said, pointing to messaging from donors, notably former United States President Barack Obama, that the end of AIDS was in sight.

He called on the AIDS community to embrace the fact that HIV and AIDS is a protracted development challenge which will take ongoing work and funding to ensure patients can stay on antiretroviral drugs for their lifetimes, and to help address escalating new infections.

“What we need is a long-term view … since AIDS is no longer an epidemic, it is now endemic,” he said.

Piot’s warnings were echoed in a new report published Thursday by the International AIDS Society-Lancet Commission, which worked with more than 40 experts to make recommendations on how HIV and global health efforts can be better integrated to improve outcomes in both. The report warns of a possible resurgence of the epidemic and highlights the risks for adolescents and young people, especially girls, in sub-Saharan Africa for whom AIDS is the fourth leading cause of death. The continent’s looming demographic bulge will exacerbate the issue unless action is taken, it adds.

“HIV rates persist in high risk, marginalized populations and ... a resurgence of the epidemic is likely as the largest generation of young people age into adolescence and adulthood,” according to a press release launching the report.

Christine Stegling, executive director of the International HIV/Aids Alliance, agreed that the response needs to be reinvigorated, having been deprioritized by international funders in recent years.

“We made this mistake as a global community to talk as if it [eradicating AIDS] was already done … but we are really only half way there [and so] it is still an emergency … we are nowhere near being done,” she told Devex.

Stegling said she hoped the upcoming conference would be an opportunity to bring a sense of urgency back to the AIDS agenda and make it a high-priority political topic again, as opposed to being overly technical and medicalized.

“We need to make AIDS political again [to] create momentum … that AIDS is still an emergency and needs lots of people working on it and it will not be solved by integrating it into universal health care … because it’s not a health problem, it’s a political and social problem,” she said.

The HIV/AIDS Alliance wants more resources for addressing the structural drivers of HIV, which it says include gender inequality, stigma, discrimination, criminalization, and poverty, alongside technical interventions such as new vaccines, drugs, and treatments. Such a “combination prevention” approach, which combines biomedical and behavior change interventions with work to address structural barriers, is the way forward, both Stegling and Piot said.  

This will require working more closely with communities, Stegling said, since “people make up communities and it is communities that have been the key to successful AIDS responses” in the past, she wrote in a recent blog.

“We know what community and civil society structures are effective in responding to HIV. Our choice is to strengthen these structures to promote innovation and remove the barriers to effective HIV prevention, treatment, care, and support,” Stegling said.

Asia Russell, executive director of the Health Global Access Project, an HIV and AIDS advocacy organization, blamed international donors, whose funding has flatlined over the past seven years, for stalling progress.

"The global AIDS response is profoundly off track. This harsh reality is the consequence of major funders, in particular the U.S. government, refusing to invest in life-saving funding increases, exacerbating scandalous inequities in treatment and prevention access that are leaving millions of people waiting for life-saving services,” Russell said in a statement.

In contrast to the trend of recent years, the UNAIDS report found that last year saw an increase in donor funding for HIV and AIDS. Spending in low- and middle-income countries increased by 8 percent to $20.6 billion for 2017, mostly from the U.S. President’s Emergency Plan for AIDS Relief and the multilateral Global Fund to Fight AIDS, Tuberculosis and Malaria. At the same time, the report warned that a 20 percent funding gap persists, and that the increase in funding is unlikely to continue.

“This welcome news comes with a caveat: There were no new significant commitments from donors in 2017. As a result, this one-year rise in donor funding is not expected to continue, and it could even decrease,” it states.

In particular, campaigners say that preventing people who inject drugs from contracting or spreading HIV is chronically underfunded. People who inject drugs are 23 times more likely to get HIV, and people who inject drugs and their sexual partners account for about a quarter of all new HIV cases outside of sub-Saharan Africa, according to UNAIDS. The situation is most acute in eastern Europe, central Asia, and the Middle East and North Africa. In Myanmar, the prevalence rate among drug users stands at 34 percent, the report showed.

Piot described the rising number of new infections in eastern Europe as “getting out of control” and blamed politicians who fail to acknowledge drug use and take steps such as needle exchanges to prevent transmission.

Devex will be on the ground at the AIDS2018 conference in Amsterdam, July 23-27. Follow reporter @Sophie_Ed1984 for updates from the conference, or keep an eye out for more Devex stories.