The end of AIDS

Financial Mirror (Cyprus) - - FRONT PAGE -

The AIDS pan­demic claimed around 36 mil­lion lives be­tween 1981 and 2016, and a sim­i­lar num­ber around the world cur­rently live with the HIV virus. Some 1.2 mil­lion peo­ple died of AIDS last year, and another 1.8 mil­lion were in­fected. Those sta­tis­tics are daunt­ing, but the star­tling news is that the goal of an “AIDS-Free Gen­er­a­tion” is re­al­is­ti­cally within reach. The re­quired pol­icy steps should be agreed in the early days of US Pres­i­dent-elect Don­ald Trump’s ad­min­is­tra­tion.

The key rea­son that the epi­demic can be ended is a sci­en­tific find­ing back in 2011 that showed that HIV-positive in­di­vid­u­als re­ceiv­ing an­tiretro­vi­ral (ARV) treat­ment sup­press the HIV virus in their blood­streams so dra­mat­i­cally that they are very un­likely to trans­mit the virus to oth­ers through sex or shared nee­dles. This find­ing con­firmed the con­cept of “treat­ment as pre­ven­tion.” If a high enough pro­por­tion of HIV-positive in­di­vid­u­als re­ceive ARV treat­ment, it is pos­si­ble not only to save their lives, but also to break the trans­mis­sion of the virus it­self, thereby end­ing the epi­demic.

Build­ing on this idea, AIDS spe­cial­ists de­vel­oped two cru­cial ideas: “90-90-90” and the “cas­cade of AIDS care.” The 90-90-90 pro­gramme aims to en­sure that by the year 2020, 90% of all HIV-in­fected in­di­vid­u­als know that they are in­fected (the first 90); 90% of all those who know they are in­fected are re­ceiv­ing ARV treat­ment (the sec­ond 90); and 90% of all those re­ceiv­ing ARV treat­ment suc­cess­fully sup­press the HIV virus in the blood. The idea of the cas­cade is that if each of the three “90s” is achieved, the pro­por­tion of all HIV-in­fected in­di­vid­u­als with vi­ral sup­pres­sion would be 90% x 90% x 90%, which is equal to 72%.

If 72% of those in­fected to­day can no longer in­fect oth­ers, the HIV/AIDS epi­demic will be cur­tailed. In­deed, if 90-90-90 in 2020 be­comes 95-95-95 by the year 2030, the pro­por­tion of HIV-positive in­di­vid­u­als that can­not in­fect oth­ers would rise to 86%. The on­go­ing epi­demic would grind to a halt, just as a measles epi­demic among chil­dren in a met­ro­pol­i­tan area ends when 80% per­cent of the chil­dren are vac­ci­nated, even if the other 20% of chil­dren re­main un­vac­ci­nated. Some cases would re­main, but the AIDS catas­tro­phe would be over.

The goal of reaching 90-90-90 by the year 2020 and 95-9595 by 2030 is re­al­is­tic, if coun­tries strive for suc­cess. Swe­den re­cently an­nounced that it has reached the 90-90-90 tar­gets. Many other high-in­come coun­tries are close. With in­ter­na­tional help and na­tional ef­forts, 90-90-90 could be achieved not only in high-in­come coun­tries but in de­vel­op­ing coun­tries as well.

For most of the world, the big­gest chal­lenge is en­sur­ing that by 2020 at least 90% of HIV-positive in­di­vid­u­als are tested and learn that they are in­fected – the first of the three 90s. To reach this goal, peo­ple who are symp­to­matic or at high risk need to be con­nected to the health sys­tem for test­ing.

Once an HIV-in­fected in­di­vid­ual tests positive, achiev­ing the sec­ond 90% (AVR treat­ment) de­pends mainly on fund­ing and staffing; with a suf­fi­cient health bud­get, medicines can be made avail­able for all in­fected in­di­vid­u­als.

Achiev­ing the third 90% (sup­pres­sion of the vi­ral load) de­pends mainly on whether AVR-treated in­di­vid­u­als take the med­i­ca­tions on sched­ule. That may re­quire so­cial sup­port to en­cour­age the pa­tients to con­tinue the med­i­ca­tions even when they feel healthy, and to help en­sure the timely and af­ford­able sup­ply of med­i­ca­tions.

The 90-90-90 tar­gets can be reached even among im­pov­er­ished and hard-to-reach pop­u­la­tions, thanks to a new and pow­er­ful pub­lic-health so­lu­tion: com­mu­nity health work­ers (CHWs) sup­ported by smart­phones. CHWs are lo­cal com­mu­nity res­i­dents with at least a high-school ed­u­ca­tion, who are trained for a few months in the man­age­ment of spe­cific health chal­lenges, such as iden­ti­fy­ing po­ten­tially HIV-in­fected in­di­vid­u­als, bring­ing them to the clinic for test­ing, and help­ing them to ad­here to their med­i­cal pro­to­cols. New smart­phone apps help them to do their job.

In ru­ral Africa, where doc­tors are typ­i­cally very scarce and AIDS preva­lence is of­ten high, the high life-sav­ing po­ten­tial of CHWs has been very well demon­strated and doc­u­mented. More­over, be­ing a CHW of­fers a good way for young peo­ple to start their ca­reers. Though ini­tial com­pen­sa­tion is very mod­est (per­haps $100 per month), the ex­pe­ri­ence and train­ing can put th­ese young work­ers on a path to­ward fur­ther ed­u­ca­tion (such as nurs­ing), ris­ing skills, and higher in­comes.

Yet, de­spite the po­ten­tial to bring the AIDS epi­demic to an end, the world is cur­rently stuck in limbo. Sadly, our gov­ern­ments op­er­ate not on the ba­sis of bold goals and the means to achieve them, but on “busi­ness as usual.” Six­teen years ago, busi­ness as usual meant al­most no treat­ment of poor peo­ple with AIDS, be­cause fi­nanc­ing was not avail­able. At that time, I rec­om­mended a new “Global Fund” to fi­nance AIDS treat­ment, an idea that was adopted and then helped to start an era of AIDS con­trol in Africa.

Pres­i­dent Ge­orge W. Bush’s ad­min­is­tra­tion made a ma­jor US fi­nan­cial com­mit­ment to AIDS, and the Global Fund and US pro­grammes to­gether helped mil­lions of peo­ple gain ac­cess to treat­ment. Yet, af­ter the 2008 fi­nan­cial cri­sis erupted, Pres­i­dent Barack Obama lev­eled off the US fi­nanc­ing, and the global AIDS con­trol ef­fort got caught in a “half-way” mode. As of 2016, roughly half of all HIV-positive in­di­vid­u­als are on ARV treat­ment, far short of the 90% tar­get.

The in­com­ing Trump ad­min­is­tra­tion should grasp the his­toric op­por­tu­nity to help bring AIDS to an end through a mod­est fi­nan­cial com­mit­ment by gov­ern­ments and other fun­ders. An ex­tra $10 bil­lion per year from all sources would likely be suf­fi­cient to get the job done, with just $3-4 bil­lion an­nu­ally from the US.

Skep­tics will scoff that Trump is an un­likely cham­pion of such an ef­fort; but, frankly, who would have guessed 15 years ago that Bush would be the key mover of the fi­nan­cial scaleup of the fight against AIDS? His­tory is full of positive as well as neg­a­tive sur­prises; the end of AIDS can be a his­toric achieve­ment of our gen­er­a­tion, if we reach for it.

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