Linda-Gail Bekker, President of the International AIDS Society, fears there may be a resurgence of the HIV epidemic.
In October 1987, as fears of a global epidemic worsened, AIDS became the first illness to be debated in the chamber of the general assembly at the UN. While just over 71,000 cases had been reported that year, the disease was not well understood, nobody knew its true extent, nor how widespread it might get. A sense of dread underscored the debate.
Today, the AIDS epidemic is real and has been for many years. In 2017, almost one million people around the world died from AIDS-related illnesses, taking the overall number of deaths from the start of the epidemic to just over 35 million. Close to a further two million people contracted HIV last year, putting the number estimated to have the virus at almost 37 million.
If the figures look shocking today, they would have felt catastrophic 30 years ago. And yet the new regime of drugs, coupled with the wide access to treatment services around the world, mean that many people with HIV are now able to lead normal, healthy lives. Of the 37 million with the virus, some 22 million receive antiretroviral therapy, which is saving their lives and preventing new infections.
The targets
The global response to HIV/AIDS since 1987 has been well-funded and clear in purpose. Its success even gave the UN the confidence in 2016 to green-light an ambitious set of targets. With investment brought forward, HIV services would expand to such an extent that by 2020 they would be able to cut infections and AIDS-related deaths by 75%. The momentum of this would, in turn, end the AIDS epidemic as a public health threat by 2030 – defined as reducing the number of new infections and AIDS-related deaths by 90% against a 2010 benchmark.
Underpinning this is the 90-90-90 target. This says that by 2020, 90% of all people living with HIV will know they have the virus, 90% of those with a diagnosis will receive antiretroviral therapy, and 90% of those on antivirals will achieve viral suppression.
While it looked feasible in 2016, the plan has since hit a snag. A new report, published in The Lancet, argues that the global response to HIV/AIDS is at risk from “dangerous complacency” and faces a “moment of uncertainty,” which could undo the progress made and trigger a resurgence of the epidemic.
Threat remains
One of the authors is Dr Linda-Gail Bekker, President of the International Aids Society and Professor at the University of Cape Town in South Africa. She believes the complacency, in part, comes from premature triumphalism. “We as a community declared victory. If you go to Europe or cities where AIDS was prominent, such as San Francisco, we have seen a downturn in the incidence. So it’s not unreasonable that policy-makers might see that and say, well, now we can move onto something else.”
The problem with this is that the AIDS epidemic is not homogeneous. “It may be under control in a few cities,” says Bekker, “but in certain countries we are seeing rises in the incidence. In one whole region, central Asia and eastern Europe, we have seen an enormous upsurge. And in large parts of Africa, they don’t have anything near epidemic control. In these high-burdened areas, this is not the time to disengage.”
While the threat remains, the funding is not keeping pace. In recent years, the worldwide investment in HIV response has stuck at about $19·1bn, says the report, which is around $7bn short of the sum needed to hit the 90-90-90 targets.
Shifting political landscapes are also having an effect: “In many countries the space for civil society is declining and the human rights environment deteriorating,” says the report. “Official development assistance for health has stalled, as an inward-looking nationalism has in many places supplanted recognition of the need for global collaboration to address shared challenges.”
Modelling scenarios
All this puts the UN targets in doubt, says Bekker: “We have tried shining a spotlight on policy and political leadership, but unless we see nothing short of a miracle and a great deal of funding, I think we are going to have to recalibrate on some of those goals.”
The report also argues that the HIV response needs to stop standing apart from other heath campaigns. “From the earliest recognition of the epidemic… the HIV response adopted an exceptionalist approach,” it says. And rather than work with health systems to manage HIV as one of many health problems, it usually had specific funding and services. To address this, the report contains detailed modelling for a number of scenarios where the HIV response works hand-in-hand with related public health drives.
“These models show it is feasible; you are likely to get better health outcomes and it is cost-effective, which we hope will impress some policy-makers,” says Bekker. “We don’t believe any of the funding should go away from HIV, but if we programme for the wider good, those health dollars could help more than just HIV, they could improve health more broadly. We hope that would be attractive to funders, that they feel they would be getting a double bang for the buck.”
First step
This could have other benefits, too, such as overcoming HIV stigma. “For many people, it’s easier to get into a mobile testing vehicle ostensibly to test your blood pressure than it is to test for HIV,” says Bekker. “Putting it in the context of a broader health agenda can have a big impact in normalising HIV. It becomes like other health screening opportunities.”
By advocating such measures, the report is itself a vital first-step in ensuring the global HIV response stays broadly on track. “We need a more sustainable plan,” says Bekker. “If we don’t do something like this we are at great risk of derailing completely.”
Linda-Gail Bekker
- Studied medicine at the University of Cape Town in South Africa
- Worked at Rockefeller University in the US on host immunology
- Won the 2009 Royal Society Pfizer Award for her research into tuberculosis epidemiology
- Elected President of the International AIDS Society.
Image Credit | Science Photo Library
