Too soon to speak of the end of Aids
There has been remarkable progress in the Aids response. We have come a long way since the 13th International Aids Conference was hosted in Durban in 2000.
Back then, the country’s political commitment to tackling HIV was questionable, upholding myths rather than scientific evidence. It is hard to believe that was just 16 years ago when today South Africa has the largest and one of the most vibrant HIV treatment programmes in the world, with more than 3.1 million people on antiretroviral therapy, funded mostly by domestic sources.
Beyond South Africa, between 2000 and 2014, new HIV infections decreased globally from 3.1 million to 2 million, a reduction of 35%. From 2005 to 2014, a 41% in Aids-related deaths was observed worldwide. The power of partnerships, through the strength of activism and science, is progress that should indeed be celebrated.
But these numbers also hide a disturbing reality. In 2014 alone 1.2 million people died of Aids; since 2000, HIV-related deaths among adolescents have tripled and in many countries, mostly in the developing world and among key populations – men who have sex with men, transgender people, sex workers and people who inject drugs – HIV infections are on the rise.
It is clear that the global rhetoric around the current “end of Aids” needs to be matched with an equally robust reality check and strengthened commitment – politically and financially – to complete the business at hand. In particular, adequate funding needs to be purposefully redirected to support intensified civil society responses, which have always been an integral part of the backbone of the Aids response, or else – while new HIV infections are falling globally – the end of Aids will remain an illusion for those who are most at risk, most marginalised and most stigmatised.
Primary action should be taken in four key areas before celebratory cries about the “end of Aids” can ring true:
• Address the risks and vulnerabilities of young women and girls comprehensively: Of the two million new HIV infections in 2014, almost half were in Eastern and Southern Africa among adolescent girls and young women, who are disproportionately at risk. In sub-Saharan Africa, 71% of adolescents living with HIV are girls. Socially-embedded inequalities render young women and girls extremely vulnerable, who acquire HIV five to seven years earlier than young men. In some countries, HIV prevalence among young women and adolescent girls is as much as seven times that of their male counterparts.
Promising programmes such as the DREAMS initiative challenge the direct and indirect structural determinants that increase girls’ risk of acquiring HIV. These kinds of programmes go far beyond the health system and address factors including poverty, gender inequality, gender-based violence and restricted access to education. More innovative partnerships like this are needed to overcome the cultural and gender-based dimensions and other structural barriers of the epidemic. Unless these hurdles are successfully surmounted, it is far too early to talk of ending the epidemic among women and girls, a priority population in "getting to zero".
• Focus on key population epidemics within and across all HIV scenarios: Among key populations there has been a recent resurgence in the HIV epidemic. New HIV infections are rising among men who have sex with men, notably in Western Europe and North America. Critically, these are areas where significant decreases had previously been recorded, which does not auger well if we are even to contemplate the notion of ending the epidemic. There has also been an increase in the number of new HIV infections in Eastern Europe and Central Asia, mainly among people who inject drugs. In South Africa, 25% of new HIV infections occurred among key populations and globally, transgender women are nearly 49 times more likely to be living with HIV compared to other adults of reproductive age. Collectively this paints a bleak picture. It also signposts where increased energy, attention and resources must be placed to ensure that the gains made are consolidated in prevention, care and treatment outcomes across the cascade for key populations – importantly including in generalised HIV epidemic scenarios.
• Engage men and boys as recipients of health services: In an era of "test and offer", ensuring sustained access to HIV treatment – with its knock-on benefits of "treatment as prevention" – it is becoming clearer that enhanced efforts to reach men and boys need to be made. In Eastern and Southern Africa, for instance, only 10% of young men are aware of their HIV status. In these regions, the number of men accessing testing and treatment is far lower than expected. Additionally, men are less likely to remain on treatment and have an increased risk of dying from AIDS compared to women.
Pioneering models of ensuring that men and boys have increased access to, and are retained in health services, need to be promoted and scaled up. Addressing this divide will be a key driver if HIV is to be assigned to the history books.
Remove core structural and policy barriers that impede access to and uptake of comprehensive HIV services: While there are many examples of change – in the workplace and across other sectors – in many contexts, laws, policies and practices continue to discriminate against and stigmatise people living with HIV. The "end of Aids" will not materialise when adult consensual same-sex relations are still a crime in at least 76 countries, including in almost all of the countries where HIV is most prevalent. The criminalisation of HIV transmission, exposure and non-disclosure and policies that are not supportive of the realities facing key populations, including those living with HIV, establishes an environment that fuels, rather than ends, the HIV epidemic. Similarly, cross-sectoral legislation that does not proactively support the empowerment of young women and girls, and policies that are not young person-centric, will ensure that our global response remains a reactive one. The "science" of rights-affirming policy action as a catalyst for managing the epidemic must be more strongly promoted. Aids will not end until the battle for human rights is won.
While science has indeed made previously unimaginable inroads into triumphing over Aids since the global HIV community last convened in South Africa, it is imperative that the foundation of a sustained HIV response – both in the medium and longer term – is more adequately secured. Now, more than ever, is the time to systematically build on the hard-won gains and investments of the past to ensure that there is no resurgence in HIV.
We need, along with renewed political will to remedy the current Aids malaise, to: ensure that sustained and predictable financing is in place to support the expanding number of people living with HIV on antiretroviral therapy from 15 million to 37 million support committed scientists and research to find a cure – or at least a remission off therapy – and a vaccine uphold constituency agency and civil society-led responses, especially in new and influential programme areas expand catalytic and innovative public-private partnerships that will enhance scale-up continue support for novel approaches and discoveries in the move towards precision HIV medicine strengthen community systems, as well as integrated and multi-disciplinary strategies ensure that a practical implementation science agenda – one that promotes cross-sector learning – acts as our guide.
Collectively – as people living with HIV and from key populations, activists, scientists, funders, policy-makers and programme implementers – it is clear we still have a long way to go.
Until this is done, Aids will not end.
* Prof Chris Beyrer is International Aids Society President, Desmond M Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health.
** Prof Linda-Gail Bekker is Director of The Desmond Tutu HIV Centre and Professor at the University of Cape Town.
*** Prof Françoise Barré-Sinoussi is Professor at the Institut Pasteur, Director of the Regulation of Retroviral Infections Division at the Institut Pasteur, Recipient of the Nobel Prize in Physiology or Medicine.
This article first appeared on www.spotlightnsp.co.za