Can We Treat Our Way Out of the AIDS Epidemic?

Harsh Realities Yet To Be Faced Before An End Is Possible

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Photo credit: Omar Havana/Getty Images News

Since as far back at 2011, global health experts have asserted that, with increased testing and treatment, the end of the global AIDS epidemic could effectively be over by as early as 2030. In the face of such ambition—which reflect, in part, the genuine successes seen in reducing AIDS-related deaths worldwide—some have begun to question whether they lay the groundwork for a sustainable global policy or oversimplify the very real challenges we have yet to face.

On December 1, 2014, the United Nations Joint Programme on HIV/AIDS (UNAIDS) placed the question front and center in their annual World AIDS Day Report, warning that "(without) scale-up, the AIDS epidemic will continue to outrun the response, increasing the long-term need for HIV treatment and increasing future costs." 

The report was designed to fast track the agency's 90-90-90 strategy, the initiative of which aims to

By achieving these goals, it is believed that the epidemic will burn itself out by reducing the so-called "community viral load" to levels where the transmission of HIV is far less likely.

This would require that roughly three out of every four person living with HIV be placed on ART—and adhere to ART—in order for the strategy to succeed.

It's an ambitious goal, one that has never been achieved in the history of infectious diseases, which has led some to argue that a true "end" can only be achieved, not with treatment but with the development of a fully sterilizing HIV vaccine.

Moreover, the strategy would require that those on therapy remain on therapy for a lifetime, the cost of which would demand a sustained investment from both donor countries and domestic governments.

Despite these challenges, UNAIDS officials believe that the campaign presents a "winnable fight," citing advances made in their "15 by 15" campaign (which placed 15 million people on ART by 2015), as well as a dramatic reductions in new infections in sub-Saharan Africa and other hyper-prevalent populations.

If realized, the 90-90-90 campaign would cut the annual infection rate by 75% (or 500,000) by 2020, after which the goals would become even stricter, requiring that 86% of the HIV population be placed on fully suppressive ART at a cost of roughly $27 billion per year.

In doing so, say UNAIDS authorities, the annual infection rate could be slashed from the current 2.1 million to as little as 200,000 infections by the year 2030.

Challenges to Achieving the 90-90-90 Goals

Today, only around 40 percent of adults and 24 percent of children with HIV receive ART, with rates of viral suppression varying significantly from country to country (ranging from as high as 83% in Rwanda to less than 60% in most of Western Europe).

Much of the data suggests that suppression rates in Eastern Europe and parts of Latin America fall well below these standards.

Worse yet, nearly 40% living with HiV are entirely unaware of their status, according to November 2016 report from the World Health Organization (WHO). 

Even in the U.S., only around 60 percent of those on therapy are able to achieve viral control, while nearly half of the HIV-positive Americans have yet to be placed on ART.

In order to improve upon these figures, increased effort has been made to expand HIV testing to all Americans aged 15 to 65; to improve patient surveillance and retention efforts; to increase preventive interventions, including pre-exposure prophylaxis (PrEP); and to overcome the numerous socioeconomic barriers that prevent as many as one in four Americans with HIV from getting tested.  

Meanwhile, in developing countries with some of the highest HIV infection rates, serious doubts remain as to whether the 90-90-90 goals can be achieved, despite calls from the WHO to expand treatment to all persons living with HIV irrespective of CD4 count, geographic region, income, or disease stage.

At a debate at the Southern African HIV Clinicians Society Conference in September 2014, clinicians argued that the 90-90-90 strategy had almost insurmountable challenges to overcome, citing the flattening of funding in the current donor climate, as well as insufficient healthcare infrastructures to support the scale-up in many low-income countries.

With few systems in place to monitor adherence, find lost patients, or prevent drug pipeline interruptions, the attendees overwhelmingly agreed that 90-90-90 goals were not only unattainable but could negatively impact the individual patient's care and needs.

For its part, even the UNAIDS concedes that the challenges for implementation are vast, and that, in order to achieve the saturation envisioned in the 90-90-90 manifesto, the global community would have to "defy expectations." A 2016 study from researchers at the Yale School of Public Health concluded that the 90-90-90 initiative would end up costing $54 billion, an increase of 42 percent over current funding reserves.

Still, the same researchers insist that it would be money well spent and that, without it, the consequences of inaction could very well reverse many of the gains made in global fight, allowing the epidemic to spring back with the kinds of increases seen in Eastern Europe and Central Asia, where infection rates have literally doubled since 2004.

Sources

United Nations Joint Programme on HIV/AIDS (UNAIDS). "Fast-Track: Ending the AIDS Epidemic by 2030." Geneva, Switzerland; issued December 1, 2014.

Raymond, A.; Hill, A.; and Pozniak, A. "Large disparities in HIV treatment cascades between eight European and high-income countries – analysis of break points." International Congress on Drug Therapy in HIV Infection; Glasgow, Scotland; November 2-6, 2014; abstract O237.

AFP. "Almost half of HIV infections worldwide undetected: WHO." Published November 29, 2016.

Southern African HIV Clinicians Society (SAHIVCS). "Debate: Can we treat our way out of the epidemic?" ;SAHIVCS Conference 2014; September 24-27, 2014; Cape Town, South Africa.

Science Daily. "New UN treatment targets for HIV/AIDS would be 'expensive but worth every penny.'" Published online May 30, 2015.

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