Despite Focus on Coronavirus, AIDS Still Looms

HIV epidemic outpacing the AIDS response in Asia Pacific?

By: Bobby Ramakant

With the world’s attention on the damage being wrought on the global health system by the Covid-19 coronavirus, which at this writing now has affected 250,000 people and killed more than 10,000, there are troubling signs that a far worse scourge – HIV – is outpacing the AIDS response, at least in the Asia Pacific. 

Since the beginning of the epidemic, 75 million people have been infected with HIV and about 32 million people have died. There is no cure although anti-retroviral drugs are keeping millions alive at an enormous cost. If the flow of drugs were to stop, they would mostly die. 

With nine months left to meet the 2020 targets set by UNAIDS, the Joint United Nations program on HIV/AIDS for HIV-related illnesses, we are not on track to end the disease by 2030. In the Asia Pacific region, despite unprecedented progress initially in scaling up HIV programs for prevention, treatment, care and support (in different countries and key populations), we are still lagging way behind. "Asia and the Pacific boast some of the earliest successes in responding to the HIV epidemic,” according to the latest UNAIDS report. “The region's response, however, is highly uneven, and several national HIV programs are not keeping pace with their growing HIV epidemics. Creeping complacency in other countries risks squandering gains made thus far."

Annual new HIV infections are rising rapidly in Bangladesh, Pakistan and the Philippines. Improved access to HIV treatment has reduced the annual number of AIDS-related deaths by 24 percent since 2010, but the epidemic is claiming a growing number of lives in Afghanistan, Bangladesh, Indonesia, Pakistan and the Philippines," according to the report. 

According to UNAIDS, at least three quarters of new HIV infections in the region are among key populations and their sexual partners. This highlights the need for legal reforms and other initiatives to reduce the discrimination and marginalization faced by these populations, and for increased support for community-led activities. 

Gay men and other men who have sex with men are experiencing rapidly growing HIV epidemics in several countries, with young men especially at risk. Amid an increase in the availability of heroin - and little improvement in the availability of harm reduction services - a resurgent epidemic is underway in some locations among people who inject drugs. 

Despite legislative reforms and other progress, shrinking civic space and stigma and discrimination against people living with HIV and key populations stand in the way of more rapid progress against the epidemic.

The 2020 targets are to ensure 90 percent of people living with HIV know their status, 90 percent of these are receiving lifesaving antiretroviral therapy (ART) and 90 percent of these have undetectable levels of the virus.

Globally, 37.9 million people are living with HIV, 79 percent know they are HIV positive, 60 percent of these are on lifesaving antiretroviral therapy and only 53 percent of the people living with HIV have undetectable levels of the virus.

In Asia and the Pacific region, 5.9 million people are estimated to be living with HIV. Of these, 69 percent know their status, 78 percent of these are on lifesaving anti-retroviral drugs and 49 percent living with HIV are virally suppressed. 

It is no surprise that these targets are far less met for key populations (such as, sex workers, gay men and other men who have sex with men, people who use drugs, transgender people and prisoners). Currently, there are 310,000 new HIV infections in Asia and the Pacific region. The new infection rate has declined but is quite far off from the 2020 target. The region is also not on track to meet the 2020 target to reduce AIDS-related deaths. 

Not ensuring that every person living with HIV is virally suppressed, is a missed opportunity to prevent onward transmission of HIV and to reduce AIDS-related deaths, said Ishwar Gilada, a governing council member of the International AIDS Society (IAS) from Asia and the Pacific and President of the AIDS Society of India. Scientific evidence has shown that if every person living with HIV who is on antiretroviral therapy (ART) and has undetectable viral load, then his/her risk of transmitting HIV becomes negligible, and the person can lead a normal healthy life commensurate to the principle ‘Undetectable = Untransmittable’ (U equals U). 

"Some partial success must not set in any complacency,’ Gilada said. “The World Health Organization guidelines 2016 recommend routine viral load monitoring should be carried out at six months, at 12 months and then every 12 months thereafter if the patient is stable on antiretrovirals. It is very important to scale up viral load testing in India and every other nation, to monitor the viral load suppression." 

Every new case of HIV transmission is an opportunity to do a reality check on how it could have been averted, Gilada said. “Every case of late or missed HIV diagnosis; delay in putting people living with HIV on treatment; stigma and discrimination blocking access to care; or people living with HIV not being virally suppressed; are among reality checks we cannot fail to miss, if we are to end AIDS. 

These reality checks will inform us of corrective actions that are needed to be on track to end AIDS. Most importantly, game changing insights into finding solutions that will work in local contexts of communities and regions, come from people who are most affected. 

Gilada said health professionals “must ensure that all people living with HIV know their status, all of them receive antiretroviral therapy (ART) and remain virally suppressed, and no further transmission of HIV takes place, thereby making Undetectable = Untransmissible (U=U) a reality.”

UNAIDS targets of achieving 90-90-90 are not only critical but central to meet these goals. But no less emphasis should be given to ensure that while we progress towards (and beyond) 90-90-90, we must also optimally utilize every scientific, evidence-based prevention option, so that new HIV infection rates decline steeply to hit zero as soon as possible. The whole concept of epidemic control lies not only in reaching the treatment targets of diagnosis, treatment and viral suppression, but also it has to include essential needs of primary prevention, stigma reduction (ideally elimination) and human rights-based approaches.

With only 129 months left to end AIDS by 2030, we need to reflect urgency in improving the HIV response, in every country, as well as for every key population - we need to walk-the-talk on 'no one is left behind' principle. "We need to deliver with what we have today, which means comprehensive prevention (such as condoms, oral pre-exposure prophylaxis (PrEP), Post-Exposure Prophylaxis (PEP), and other evidence-based tools to prevent HIV transmission), human-rights based approaches, along with scaling up treatment, support and care."

Bobby Ramakant writes for Citizen News Service. Twitter @bobbyramakant, @CNS_health