The beginning of the end of AIDS?

By David Deakin

Many of us can remember the situation with HIV and AIDS over a decade ago. New infections were still rising, especially among young people. Deaths from AIDS-related diseases were increasing rapidly, eventually peaking in 2005. Stigma was a huge problem for most people living with HIV. There were more than 15 million children orphaned by AIDS. As well as having a devastating impact on families, these issues were also damaging many countries’ economies.

What was the church’s reaction to this crisis? Unfortunately, at that time the church was often perceived to be part of the problem. Many congregations were still in denial that their members were dying from AIDS, and some believed that AIDS was a judgement from God.

Yet the last decade has seen amazing progress in the response to HIV and AIDS. The rate of HIV infections and deaths is slowing down, and world leaders are now trying to end the AIDS epidemic by 2030. What has caused this transformation?

The world wakes up

Antiretroviral therapy (ART) has been available since the 1990s, but at first it was incredibly expensive, costing more than 10,000 USD each year for one person. Campaigns such as the Treatment Action Campaign (TAC) of South Africa were very successful in making ART much more affordable (see page 22 for more details).

The next important breakthrough was in July 2005 when the leaders of eight high-income countries (known as the G8) met at Gleneagles, Scotland. Influenced by a powerful advocacy campaign, the leaders agreed to work towards universal access to HIV prevention, treatment, care and support. They also made commitments to provide funding to achieve this goal.

After this meeting, the number of people receiving ART steadily increased. In 2005, fewer than 2 million people were receiving effective treatment. By March 2015, this number had grown to 15 million.

As a result of effective treatment, HIV-positive people are now living longer. The disease is no longer considered to be a ‘death sentence’, but instead has become a manageable long-term illness. With good treatment, HIV-positive people can now have a similar lifespan to people who do not have HIV.

Steps forward in prevention

When people first started trying to prevent the spread of HIV, the ABC approach was popular (abstain from sexual activity, be faithful, use a condom). However, this way of thinking was too narrow. The organisation INERELA+ developed the SAVE approach (Safer practices, Access to treatment, Voluntary counselling and testing, and Empowerment) to be more holistic, while still including the ABC principles (see page 19 for more details).

In 2007 a new prevention method was recommended by UNAIDS and the World Health Organization (WHO) – voluntary male circumcision. This reduces the risk to men of contracting HIV through heterosexual intercourse (although it only partially lowers the risk, so other methods of protection must also be used). Between 2007 and 2013, around 6 million men were newly circumcised in 14 countries in East and Southern Africa with a high prevalence of HIV.

Further progress in treatment

It was well known that ART could save lives. But in 2011, an important piece of research showed that effective ART could also help to prevent the transmission of HIV from one person to another. This is because ART can reduce the amount of HIV present in a person’s body (known as their ‘viral load’), to the point where it cannot be detected in a blood test. When a person’s viral load is this low, their risk of transmitting HIV to another person is greatly reduced (though they should still take other precautions).

Another development in HIV prevention was pre-exposure prophylaxis (PrEP). This is a special type of daily medication that can help to prevent people from becoming infected with HIV. It is intended for those who are at high risk of exposure to HIV (such as sex workers or people who inject drugs). Other protection methods must also be used, as it is not 100 per cent effective in preventing HIV from being passed on.

Preventing mother-to-child transmission

There has been great progress in preventing mother-to-child transmission of HIV. In 2011 the ‘Global Plan’ was launched, which aimed to stop children becoming infected with HIV and to protect the health of mothers. Without any health care interventions, a pregnant woman who is living with HIV has up to a 45 per cent chance of passing HIV on to her baby. However, with proper treatment, this risk can be reduced to below 5 per cent. In 2013 WHO recommended that all pregnant and breastfeeding women with HIV should be provided with ART.

The Global Plan focused on the 22 countries with the highest number of pregnant women living with HIV. Between 2009 and 2013 there was a remarkable 43 per cent decrease in the number of new HIV cases in children in 21 of these countries. 

Future challenges

World leaders have set an ambitious goal of ending AIDS by 2030. At present there are still more than a million AIDS-related deaths a year, so dramatically reducing this figure in the next 15 years will be a huge challenge. There are currently more than 36 million people living with HIV, and all of these will need access to treatment. UNAIDS has set the target that, by 2020, 90 per cent of people will know their HIV status, 90 per cent of those living with HIV will be treated, and 90 per cent of those treated should have a viral load so low that it cannot be detected in a blood test.

There are many challenges to achieving this. One priority is making it easier to carry out viral load testing (measuring the amount of HIV in someone’s blood to check, for example, how well their ART is working). Currently these tests are usually processed in a laboratory, requiring time and special equipment. It is much quicker and simpler if viral load testing can be carried out at the same time and place as a person’s health care appointment. This is called point-of-care testing. Organisations such as UNITAID are working to make these tests more affordable and widely available to health care services.

Another challenge is helping people to access second- and third-line ART. When someone begins ART, the combination of medicines they are given is called ‘first-line’ therapy. However, if their strain of HIV becomes resistant to the medication, or if they experience bad side effects, they will need to change to a different combination of medicines. This is called ‘second-line’ or ‘third-line’ therapy. In many countries, first-line ART is now available at an affordable price, but second- and third-line medicines cost much more. This is because some pharmaceutical companies have patents for these medicines, meaning that other manufacturers are not allowed to produce them. Advocacy initiatives that overturn pharmaceutical patents will become even more important in the coming years.

Perhaps the ultimate challenge is the development of a vaccine against HIV. Scientists have not yet been able to achieve this, but research is ongoing.

No one left behind

As progress is made in prevention and treatment, another challenge is ensuring that vulnerable groups of people are not left behind. People who often find it harder to access treatment include children, sex workers, men who have sex with men, injecting drug users and people with disabilities. Sometimes people living with HIV are also suffering from other illnesses (for example, TB and Hepatitis C), and these diseases need to be dealt with better. Although stigma around HIV has reduced, there is still a huge amount of stigma against many of these groups of people. This is an area where the church could play a much greater role in the future, if it is courageous enough.

A unique opportunity

There has been dramatic progress over the last ten years in addressing the huge challenges posed by HIV. The outlook now is so much more positive. But with more than a million people still dying every year because of AIDS, the task is as urgent as ever.

More than 30 years since HIV was identified, the global AIDS response is at a crossroads. We can invest now to end AIDS by 2030, or we can simply maintain the current efforts and potentially miss this unique opportunity. Let’s pray and act to ensure that AIDS is beaten for good.

David Deakin is Tearfund’s HIV Team Leader.