Experts warn that gains against HIV remarkable, but not irreversible

DURBAN, South Africa – The 21st International AIDS Conference officially kicked off Monday. But over the weekend, two days of pre-conferences have already addressed a multitude of aspects of the epidemic.

Even more than most diseases, the HIV pandemic is driven by, and fought on, multiple fronts. Clinical issues are shaped by scientific, economic and social aspects of the disease – and progress on those areas has been uneven. At a pre-conference plenary on "Achieving global AIDS targets: what will it really take?" a panel attempted a high-level overview of both the road already travelled, and the current crossroads.

In some ways, progress since the last International AIDS Conference to take place in Durban, in 2000, has been stunning.

In 2000, the number of HIV-infected persons on antiretroviral treatment (ART) was fewer than 1 million. South Africa had a president, Thabo Mbeki, who questioned the link between HIV and AIDS – a skepticism that would ultimately lead to hundreds of thousands of preventable deaths from HIV.

And at the 2000 AIDS meeting itself, Peter Piot, executive director of the London School of Hygiene & Tropical Medicine reminisced, it was "remarkable to see how much time was being spent, not on how can we do this, but on why all this was impossible" – that broadening the access to treatment and decreasing the number of new infections was too difficult and too expensive to be a realistic option.

Today, both Thabo Mbeki and his theories are retired from South Africa's government. The number of people on ART is 17 million. Mother-to-child transmission of HIV has been sharply curtailed. And there is a sense that the end of HIV is a possibility.

There is sharp disagreement, however, on how much work it will take to make the end of AIDS a reality.

The session on achieving global targets was organized in part, moderator Ben Plumley said, in response to an "extremely disappointing high-level UN forum" – the 2016 high-level meeting on ending AIDS organized by the Joint United Nations Program on HIV/AIDS (UNAIDS) in June.

Plumley, who is the CEO of nonprofit organization Pangaea, stressed that the session was "not a UNAIDS-bashing session."

But, he said, at the June meeting, "UN basically said to us 'we've done it' . . . and we disagree."

The generally recognized goals with respect to AIDS are the so-called 90-90-90 goals. They state that by 2020, 90 percent of all people living with HIV should know their HIV status, 90 percent of all people with diagnosed HIV infection should receive ART, and ART should lead to viral suppression in 90 percent of those treated.

Those goals are intermediates on the way to a goal of ending AIDS as a global public health threat. In practical terms, that goal is defined as fewer than 200,000 new infections and AIDS-related deaths by 2030.

The scientific path to those goals is clear, if not simple. Paul Stoffels, chief scientific officer at Johnson & Johnson, said that "The end of HIV in our lifetime, we're only going to see if we can get a vaccine. There is no other way."

As the long-term work on getting a vaccine is underway, in the short term, it is important to further expand access to ART, use rational combinations of ART, and monitor viral loads during treatment to keep ahead of drug resistance. And a mundane but critical factor is to avoid drug shortages that can lead to involuntary treatment interruptions.

If those conditions are met, Stoffels said, "Life expectancy can be normal life minus two years, and maybe even normal life. People can see their kids and their grandkids grow up, if therapy is done well."

BUMPS IN THE ROAD

What is less clear is whether those necessities will be achieved.

Piot, who was the founding executive director of UNAIDS before joining the London School of Tropical Hygiene, identified several obstacles to achieving the goals.

Some of those obstacles are purely practical. For example, the sheer number of people who will receive ART if the 2020 goals are achieved means that "we are up for a crisis in antiretroviral supply" due to the sheer amount of raw materials needed to make the necessary drugs.

Others are mathematical – "the world is now entering the largest cohort of sexually active young adults," meaning there are that many more opportunities for sexual transmission.

But there is also a lack of sustained focus. In part, the global public health response to AIDS has become a victim of its successes.

"We are very concerned about complacency," Piot said. "Civil society support has really collapsed, [and] if there is activism, it's what I call hashtag activism – people think we've done it when we send some tweets."

As a result, funding has dwindled even as needs have increased.

2016 is the year that the Global Fund to end AIDS, tuberculosis and malaria is re-funded for another three years. There is concern whether major donors like the U.K., in the grasp of its own Brexit woes, will live up to their commitments to the fund, which spends around $4 billion a year "to support programs run by local experts in countries and communities most in need."

"Imagine a world where the Global Fund and PEPFAR" – The President's Emergency Plan for AIDS Relief – "and others are not . . . able to provide money for what is needed," Piot said. "That's also where I don't hear enough activism."

When funding is available, there is still the question of what to fund first.

Much of the funding against HIV goes to direct programs, including antiretroviral drugs.

But in the poor countries where the bulk of infected individuals live, HIV is only one part of a larger jigsaw of poverty and stigmatization.

Yasmeen Raphael, chair of the Women Now Pan-African Women's HIV group, said that the response of the young women she talks to can too often be summarized as "how do you keep me in school when after school I have to go back to my reality? After your program I am hungry. . . . My issues are those of hunger and poverty."

Alan Whiteside, professor at the Balsillie School of International Affairs and a scholar on the impacts of AIDS, argued that this reality is true – but its presentation can also be turned around, focusing on the success stories.

In Swaziland, for example, 93 percent of children are enrolled in school, including orphans. "Those kids are in school because they are receiving food, and that's a success of the AIDS program," he said.

In the same vein, Botswana saw new HIV infections drop when it increased the duration of compulsory schooling by one year.

"It takes some good news," Whiteside said. The message to donors, he said, needs to be not one of gloom, doom and looming reversal of fortune, but that "we have done so much. And we only need a little bit more to get to the end."

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