The world has made remarkable progress in the fight against HIV/AIDS, the deadly virus that has killed about 40 million people since the 1980s. However, the goal of ending AIDS as a major public health threat by 2030 is still far from being achieved. What are the main obstacles and opportunities in this global effort?
The success story of antiretroviral therapy
One of the most significant achievements in the history of medicine is the development and widespread use of antiretroviral therapy (ART), a combination of drugs that suppresses the replication of HIV and prevents it from destroying the immune system. ART has transformed HIV from a death sentence to a chronic condition that can be managed with daily pills.
According to UNAIDS, a UN body that coordinates the global response to HIV/AIDS, ART has saved about 21 million lives since 2001 and averted millions of new infections. In 2020, about 27.4 million people living with HIV were receiving ART, up from only 7.8 million in 2010. As a result, the annual number of AIDS-related deaths has declined by more than half since its peak in 2004.
ART has also contributed to improving the quality of life and economic productivity of people living with HIV, as well as reducing the stigma and discrimination they face. Moreover, ART has been shown to reduce the risk of sexual transmission of HIV by up to 96%, making it a powerful tool for prevention as well as treatment.
The persistent gaps and inequalities in access to ART
Despite the remarkable progress made in expanding ART coverage, there are still millions of people who do not have access to this life-saving treatment. UNAIDS estimates that about 19.4 million people living with HIV were not receiving ART in 2020, mainly due to lack of testing, diagnosis, linkage to care, retention in care, and adherence to treatment.
The gaps and inequalities in access to ART are especially pronounced in low- and middle-income countries, where most people living with HIV reside. In sub-Saharan Africa, which accounts for about two-thirds of the global HIV burden, only 68% of people living with HIV were receiving ART in 2020, compared to 88% in Western and Central Europe and North America.
Furthermore, some key populations that are disproportionately affected by HIV, such as sex workers, men who have sex with men, transgender people, people who inject drugs, and prisoners, face multiple barriers to accessing ART, such as criminalization, stigma, discrimination, violence, and lack of tailored services. UNAIDS reports that these key populations and their sexual partners accounted for 62% of new HIV infections in 2020.
The emerging innovations and opportunities for ending AIDS
To overcome the challenges and accelerate the progress towards ending AIDS by 2030, UNAIDS has outlined a new strategy that calls for increased political commitment, financial investment, community engagement, human rights protection, and scientific innovation. Some of the emerging innovations and opportunities that could help achieve this ambitious goal include:
- New formulations and delivery methods of ART that are more convenient, affordable, and effective. For example, cabotegravir is a long-acting injectable drug that can prevent HIV infection for up to two months with a single shot. It has been shown to be superior to oral PrEP (pre-exposure prophylaxis), a daily pill that reduces the risk of acquiring HIV by up to 99%. Cabotegravir could be especially beneficial for women in high-prevalence settings who face difficulties in using oral PrEP due to social and gender norms.
- New tools and technologies for HIV testing and diagnosis that are more accessible, accurate, and rapid. For example, self-testing kits allow people to test themselves for HIV at home or in other private settings without needing a health worker or a laboratory. Self-testing can increase the uptake of testing among hard-to-reach populations who may not access conventional testing services due to fear, stigma, or inconvenience.
- New approaches and interventions for HIV prevention that are more comprehensive, inclusive, and tailored. For example, combination prevention packages that integrate biomedical (such as ART and PrEP), behavioral (such as condom use and risk reduction counseling), and structural (such as legal reform and social support) components can address the multiple factors that influence HIV transmission and acquisition. Combination prevention can also cater to the specific needs and preferences of different populations and contexts.
- New research and development for HIV cure and vaccine that are more promising, collaborative, and ethical. For example, gene therapy is a novel technique that aims to modify the genetic material of cells to make them resistant to HIV infection or replication. Gene therapy has been successfully used to cure two individuals known as the Berlin patient and the London patient who were also receiving bone marrow transplants for cancer. Gene therapy could potentially offer a functional cure for HIV that does not require lifelong treatment. However, it is still in its early stages and faces many scientific and ethical challenges.
The bottom line
The end of AIDS is not in sight, but it is not impossible either. The world has the tools, the knowledge, and the experience to end the HIV/AIDS epidemic by 2030. What it needs is the will, the resources, and the solidarity to make it happen.
