The Sustainable Development Goals (SDG), adopted by member countries of the United Nations in 2015, set a target of ending the epidemics of AIDS, Tuberculosis and Malaria by 2030 (SDG 3.3). The key indicator chosen to track progress in achieving the target for HIV-AIDS is “the number of new HIV infections per 1,000 uninfected population, by sex, age and key populations”. In the terminology of HIV prevention and control, the phrase “key populations” refers to: men who have sex with men; people who use injected drugs; people in prisons and other closed settings; sex workers and their clients, and transgender persons.
In order to infuse energy and urgency into global efforts to combat HIV-AIDS and complement the prevention target set by the SDGs, an ambitious treatment target was also adopted through UNAIDS, the lead UN agency that coordinates the battle against HIV. The “90-90-90” target stated that by 2020, 90% of those living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained anti-retroviral therapy and 90% of all people on such therapy will have viral suppression. The gaps in detection, initiation of drug therapy and effective viral control were to be bridged to reduce infectivity, severe morbidity and deaths from undetected and inadequately treated persons already infected with HIV, even as prevention of new infections was targeted by SDG 3.3.
Where are we, at the end of 2019, on the road to the 2020 and 2030 targets? While much success has been achieved in the past 20 years in the global battle against AIDS, there has been a slowdown in progress which seems to place the targets out of reach. There has to be a fresh surge of high-level political commitment, financial support, health system thrust, public education, civil society engagement and advocacy by affected groups — all of which were part of the recipe for rapid progress in the early part of this century.
High and low points
It is the confluence of those ingredients that made it possible for the world to achieve a reduction in new HIV infections by 37% between 2000 and 2018. HIV-related deaths fell by 45%, with 13.6 million lives saved due to Anti-Retroviral Therapy (ART). Not only were effective drugs developed to combat a disease earlier viewed as an inescapable agent of death but they also became widely available due to generic versions generously made available by Indian generic manufacturers, led by the intrepid Yusuf Hamied. A rush of public and private financing flowed forth in a world panicked by the pandemic. Ignorance and stigma were vigorously combated by coalitions of HIV-affected persons who were energetically supported by enlightened sections of civil society and the media. Never before had the world of global health resonated so readily to the rallying cry for adopting a rights-based approach and assuring access to life-saving treatments. According to a recent report by UNAIDS, of the 38 million persons now living with HIV, 24 million are receiving ART, as compared to only 7 million nine years ago.
Why then the concern now? At the end of 2018, while 79% of all persons identified as being infected by HIV were aware of the fact, 62% were on treatment and only 53% had achieved viral suppression — falling short of the 90-90-90 target set for 2020. Due to gaps in service provision, 770,000 HIV-affected persons died in 2018 and 1.7 million persons were newly affected. There are worryingly high rates of new infection in several parts of the world, especially among young persons. Only 19 countries are on track to reach the 2030 target. While improvements have been noted in eastern and southern Africa, central Asia and eastern Europe have had a setback, with more than 95% of the new infections in those regions occurring among the ‘key populations’. Risk of acquiring HIV infection is 22 times higher in homosexual men and intravenous drug users, 21 times higher in in sex workers and 12 times more in transgender persons.
Complacency, new factors
There are several reasons for the slowdown in progress. The success achieved in the early part of this century, through a determined global thrust against the global threat, led to a complacent assumption of a conclusive victory. The expanded health agenda in the SDGs stretched the resources of national health systems, even as global funding streams started identifying other priorities. Improved survival rates reduced the fear of what was seen earlier as dreaded death and pushed the disease out of the headlines. The information dissemination blitz that successfully elevated public awareness on HIV prevention did not continue to pass on the risk-related knowledge and strong messaging on prevention-oriented behaviours to a new generation of young persons. Vulnerability of adolescent girls to sexual exploitation by older men and domineering male behaviours inflicting HIV infection on unprotected women have been seen as factors contributing to new infections in Africa.
Even the improved survival rates in persons with HIV bring forth other health problems that demand attention. Risk factors for cardiovascular disease are high among survivors as they age, with anti-retroviral drugs increasing the risk of atherosclerosis. Other infectious diseases, such as tuberculosis can co-exist and cannot be addressed by a siloed programme. Mental health disorders are a challenge in persons who are on lifelong therapy for a serious disease that requires constant monitoring and often carries stigma.
Need for vigil in India
The Indian experience has been more positive but still calls for continued vigilance and committed action. HIV-related deaths declined by 71% between 2005 and 2017. HIV infection now affects 22 out of 10,000 Indians, compared to 38 out of 10,000 in 2001-03. India has an estimated 2.14 million persons living with HIV and records 87,000 estimated new infections and 69,000 AIDS-related deaths annually. Nine States have rates higher than the national prevalence figure. Mizoram leads with 204 out of 10,000 persons affected. The total number of persons affected in India is estimated to be 21.40 lakh, with females accounting for 8.79 lakh. Assam, Mizoram, Meghalaya and Uttarakhand showed an increase in numbers of annual new infections. The strength of India’s well established National AIDS Control Programme, with a cogent combination of prevention and case management strategies, must be preserved.
Drug treatment of HIV is now well founded with an array of established and new anti-viral drugs. The success of drug treatment to prevent mother-to-child transmission, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), and male circumcision, especially among MSM population, is well-documented. Given the wide diversity of the HIV virus strains, development of a vaccine has been highly challenging but a couple of candidates are in early stage trials. However, mere technical innovations will not win the battle against HIV-AIDS. Success in our efforts to reach the 2030 target calls for resurrecting the combination of political will, professional skill and wide ranging pan-society partnerships that characterised the high tide of the global response in the early part of this century. The theme of the World AIDS day this year (“Ending the HIV/AIDS Epidemic: Community by Community), which is communities make the difference, is a timely reminder that community wide coalitions are needed even as highly vulnerable sections of the community are targeted for protection in the next phase of the global response.
K. Srinath Reddy is President, Public Health Foundation of India, and author of ‘Make in India: Reaching a Billion Plus’. The views expressed are personal