The reality is a mix of YES and NO. While the facts and figures shared in the latest report by UNAIDS reveal that as a world we are NOT already on the path, they do show that we CAN be there if world leaders take bold actions ensuring that the HIV response has the resources it needs and that the human rights of everyone are protected.
Progress made in the past decade notwithstanding, there still is a huge gap between the targets set up to end the AIDS epidemic by 2030 and what has actually been achieved. The UNAIDS report- The Urgency of Now: AIDS at a Crossroads- shows that while the end of AIDS is within our grasp, currently the world is off track. Globally, of the 39.9 million people living with HIV, nearly 25% (9.3 million), are not receiving life-saving treatment, including 660,000 children living with HIV.
Then again with 630,000 people succumbing to AIDS-related illness in 2022, we are off-track to meet the target of reducing AIDS-related deaths to below 250,000 by 2025. Women and girls are still disproportionately affected, particularly in sub-Saharan Africa. Globally, 4,000 young women and girls became infected with HIV every week in 2022.
World leaders had pledged to reduce annual new infections to below 370,000 by 2025, but new HIV infections are still more than three times higher than that, at 1.3 million in 2023. New HIV infections are rising in three regions- the Middle East and North Africa, Eastern Europe and central Asia and Latin America. Nearly 25% of the new HIV infections were in Asia and the Pacific. These worrisome trends are mainly due to a lack of HIV prevention services for marginalised and key populations and the barriers posed by punitive laws and social discrimination.
HIV prevention and treatment services will only reach people if human rights are upheld, if unfair laws against women and against marginalised communities are scrapped, and if discrimination and violence are tackled head on.
We have to put people living with HIV and communities at risk at the centre of our responses to end AIDS. Keeping this in mind, the UNAIDS 2025 targets include that less than 10% of people living with HIV and key populations experience stigma and discrimination; less than 10% of people living with HIV, women and girls and key populations experience gender based inequalities and gender based violence; and less than 10% countries have punitive laws and policies.
Scientific research has thankfully increased the number of prevention options we have today to stop the spread of HIV infection. But there is a deadly gap and unacceptable delay in converting scientific breakthroughs into public health gains by making these options available for people most at risk of HIV infection.
"We have to fill the product introduction gap - accelerate time to regulatory approvals of product introduction to impact; demand creation and programme platforms for prevention; and differentiated and integrated service delivery for people. We must also fill the product development gap - long acting and event driven; user-friendly and developed with users; dual purpose and multi-purpose methods must be our top priority," says Mitchell Warren, Executive Director of AVAC.
"We still have a long way to go before we come even close to the 95-95-95 targets. But the good news is that these targets recognise a much greater centrality around policies and behaviour change and put the individual at the centre of the epidemic. They recognize that the people we are leaving behind are our biggest worry", says Warren.
He rightly believes that our task is not only to develop additional HIV prevention options but also to deliver them at scale with speed and with equity, to actually have an impact on the epidemic. We now have a range of methods available- oral Pre-Exposure Prophylaxis (PrEP), the vaginal ring, injectable cabotegravir, and next generation products.
PrEP is one of the new HIV prevention options for HIV-negative people who can reduce the risk of HIV acquisition by taking an antiretroviral medication. And the latest addition is the long acting (once every 6 months) injectable lenacapavir that has been found to be highly effective in preventing HIV in cisgender women as well as in gay, bisexual and transgender people.
Biomedical options are critically important as they are the fruits of science developed through research and development processes. "But translating them into choices for people is what our job is, as public health practitioners - not just to develop but to deliver and to make sure that those products reach people as viable choices. This requires policy makers, donors, governments, implementers to make the mix available, accessible and affordable," said Warren.
Studies have proved that expanding testing and treating and then introducing PrEP has lowered the incidence of HIV in communities that had access to it.
In Warren's opinion, "We should not forget that biomedical products- whether for prevention or for treatment- exist in behavioural and structural contexts. Biomedical products will just sit on the shelf and have no impact unless we address behavioural and structural issues. None of these methods can help if we do not address access and equity. While we develop biomedical products around the pathogen-around the HIV virus- we need to design the programmes around the people. That is what matters and that is how you get to impact.
"We have typically moved far too slowly in moving science into impact - moving a product to the real world. For PrEP we got the evidence in 2010, but it was more than 10 years later that we really began to see the scale of the programme. Same with the dapivirine ring. We knew in 2016 that it was safe and effective. But it has taken years post-efficacy to move into recommendations and to product introduction. The world has moved faster with cabotegravir for which approvals have come much faster. There are three companies in India that now have licenses to produce generic cabotegravir. But these would get in the market only around 2027. So, things are happening faster now, but not fast enough to keep pace with an epidemic that continues despite global targets, despite our desire to be done with AIDS," said Warren.
The deadly delays between developing pathbreaking health technologies, and benefitting those for whom these were developed (the most at risk and marginalised and least likely to access care) must end. We have to ensure vaccines convert into vaccinations of the 'last person in queue' first - without any delay. Same holds true for the full range of disease prevention, diagnostics, treatments we have today.
"The fraying of solidarity between and within countries is putting progress in danger, but the path that ends AIDS is a path that has been proven, and is a path that leaders have promised to take. World leaders pledged to end the AIDS pandemic as a public health threat by 2030, and they can uphold their promise, only if they ensure that the HIV response has the resources it needs and that the human rights of everyone are protected," said UNAIDS Executive Director, Winnie Byanyima.
The 5th HIVR4P Conference to be convened in Lima, Peru will bring together around 1500 participants from across a broad range of scientific disciplines, including representatives of key and affected populations in the HIV response to advance scientific knowledge, and enhance global scientific and community collaborations to address the challenges and opportunities in HIV prevention. Hopefully it will advocate for accessibility and availability to meet the needs and preferences of the most vulnerable people with a view to end AIDS by 2030.
