In the Sustainable Development Goals (SDGs), the UN has called for the world to end AIDS by 2030. But the global AIDS response may be a victim of its own success, or of its snappy slogans — donor countries are starting to de-prioritize funding for HIV, in part because they think that the end is near.
So how near are we, really, to the end of AIDS?
End what, exactly? — First, let’s try to agree on what “ending AIDS” means.
According to Natella Rakhmanina from Elizabeth Glaser Pediatric AIDS Foundation, epidemiologists usually talk about disease control (reducing transmission), elimination (stopping transmission within a specific geographic area, such as a country), or eradication (permanent reduction of a disease to zero cases).
Let’s check out UNAIDS’ report, Fast-Track: Ending the AIDS Epidemic by 2030 to see which of these they want the world to do by 2030. The famous 90-90-90 targets UNAIDS has put forward are focused on reducing transmission: “HIV infections may not disappear in the foreseeable future, but the AIDS epidemic can be ended as a global health threat.” (p. 6, emphasis added)
In other words – the Fast-Track goal is not to eradicate, or permanently reduce HIV to zero cases, but to control HIV. “Control AIDS by 2030” is definitely less sexy as a slogan than “end AIDS”, though it would have been more accurate.
If we were talking about really ending, or eradicating HIV, a lot of things would have happened first. Here are some milestones that occur to me, but please share yours:
- We’d have more, better data. Currently, only 100 countries have key population size estimates for just one of the key populations vulnerable to HIV (sex workers, men who have sex with men, transgender people, and people who inject drugs), and only 38 of those are adequate, meaning that they use scientifically sound methods. Trans people bear the brunt of the data vacuum: only 20 countries have ever reported any HIV data at all on transgender people to UNAIDS, even though they face the greatest risk: UNAIDS estimates that 19% of trans people are living with HIV. Most countries also lack any data about HIV among women and girls, though we know that they are at greater risk in many countries. No data means no programs, and no funding targeted to reach those populations with HIV prevention services, treatment and care. I published an article with three co-authors earlier this year which found that criminalization of homosexuality is associated with implausibly low size estimates for men who have sex with men. To get better data on key populations, countries have to first tackle the laws that keep those populations in hiding — and that won’t happen overnight.
- There would be a vaccine – Dan Sharp of STOPAIDS, which has a youth campaign called “It Ain’t Over” to mobilize action to combat HIV, points out that no epidemic has been ended without a vaccine. The rate of new infections around the world remains high, and with challenges to prevention and treatment access, a vaccine is critically needed. In 2016, a US-led clinical trial was launched to test a possible HIV vaccine among South African adults. Historically, vaccines have been essential to eradicating infectious diseases, but we are not close to having a vaccine yet — and if donors don’t invest in research, we won’t get one by 2030.
- A majority of people living with HIV would be on treatment – In order to end AIDS, we’d need to end viral transmission of HIV. As UNAIDS argues, that means all those living with the virus to have such low viral loads that the virus is undetectable in their blood, so all those people need to be on antiretroviral treatment for prolonged periods, which means they also need to be willing to come out of hiding and take a test. But we’re just halfway to that target: UNAIDS currently estimates there are 37.5 million people living with HIV in the world, of whom only 19 million are on treatment. That means 18.5 million people are not aware that they have HIV, and may be actively transmitting HIV to others.
- Middle-income countries would fully finance their own HIV programs – PEPFAR and the Global Fund have begun withdrawing funding for HIV programs from middle-income countries – believing those countries should be wealthy enough to fully finance own programs. But in far too many cases, it’s just not happening, and HIV spikes after the donors leave. The problem? In some cases, countries are not as rich as their income statistics make it look; others are, but don’t value health; and others would frankly rather not fund the politically touchy interventions we know will work: harm reduction (needle exchanges, opioid substitution therapy), prevention services (condoms, lubricant) and more for criminalized, stigmatized populations. Venezuela is one catastrophic example — the oil-rich country has not invested in health systems, which are collapsing — and AIDS-related deaths are sky-rocketing. When states fulfill the right to health for all citizens, including sex workers, men who have sex with men, transgender people and people who inject drugs, then we may be able to think about eliminating HIV within the borders of a few countries.
- One or more countries will have successfully eliminated HIV –– Currently, no country is even close to eliminating HIV transmission within their borders (Sorry, North Korea – denial is not elimination). WHO does have a process to validate elimination of mother-to-child transmission of HIV, which some countries have successfully done. WHO does not have a process yet for certification of countries as having eliminated the HIV epidemic. Getting that certificate of elimination will bring fantastic global prestige to governments. When we really get near the end of AIDS, expect to see countries knocking each other over to be the first to claim elimination (and godspeed to them).
In the meantime, we won’t get close to eradication, elimination or even control of HIV if we don’t keep up the momentum — and continue to tell it like it is.
What signs would you look for to mark the end of AIDS?