“HOW much does the world want to eliminate AIDS?” That was the question hanging over the 22nd meeting of the International AIDS Society (IAS), which opened in Amsterdam this week. “How much” is a phrase with two possible interpretations: emotional desire and financial willingness.
The IAS meetings, which began in 1985 as workshops for scientists and clinicians, quickly attracted activists and celebrities. Bureaucracies followed. In 1996 UNAIDS, an agency dedicated to dealing with the illness, was set up. In 2002 the Global Fund, a public-private partnership, was created to raise and spend money on AIDS, and on tuberculosis and malaria. In 2003 America’s PEPFAR, the President’s Emergency Plan For AIDS Relief, got going. Combined with the efforts of health services, these organisations have helped turn things around. The annual death rate from an illness that has, so far, killed 35m people, has fallen from a peak of 1.9m to 900,000. New-infection rates have dropped from 3.4m to 1.8m. And 22m people are now on antiretroviral drugs (ARVs).
This is all cause for celebration. But there is also a sense that things are fraying at the edges. Targets are not being met. Money is not arriving as expected. A scandal at UNAIDS, involving allegations of sexual harassment by a former deputy director (who denies wrongdoing), is casting shadows. And scientific progress is patchy.
The peak of AIDS hubris seemed to come at the IAS meeting in Melbourne in July 2014. Michel Sidibé, UNAIDS’s director, announced the 90-90-90 aspiration—that by 2020, 90% of those infected will know they have the disease, 90% of those will be on ARVs, and 90% of them will have their virus levels suppressed to the point of clinical negligibility. This was ambitious enough. But in December of that year, the UN itself topped it by proposing an “end to AIDS” by 2030.
Neither of these things is going to happen. There was good news in Amsterdam, that Namibia has just reached its 90-90-90 targets. But in Africa this puts it alongside only Botswana and eSwatini (as Swaziland now wants to be known). In the world as a whole the numbers are 75-79-81, up from 67-73-78 in 2015, so there is a long way to go. As to ending AIDS, it is not even clear what that means—short of eradicating HIV from someone’s body. The UN aspired to “ensure that HIV investments increase to $26bn by 2020, including a quarter for HIV prevention”. That, too, looks unlikely. Since 2014, only in 2016-17 did expenditure on AIDS rise, by 8% to $21bn.
To cry “more money” is the easiest thing in the world. But the AIDS campaign really does need more if it is to succeed. Each life saved by putting someone on ARVs is a charge on the future until that person dies, which will probably be in several decades’ time. The fact that an untreated individual may go on to infect others means that a dollar spent now really is worth more than one spent in the future.
This is not necessarily a call for more foreign aid. As Mark Dybul, a former head of both PEPFAR and the Global Fund, told the meeting, though truly poor countries do depend on such aid for their AIDS programmes, somewhat richer ones could afford to fill the gap from the pockets of their own taxpayers, but choose not to do so.
As to what the money should be spent on, finding those infected and treating them remains top of the list. But increasing effort needs to be devoted to prevention. Here, PEPFAR is leading the way. As Deborah Birx, its head, observes, her organisation has supervised and paid for the circumcision of 15m African men. Circumcision is a cheap and effective way of reducing a man’s risk of HIV infection (the foreskin of the penis is rich in the type of cells the virus breeds in). PEPFAR has also had measurable success with projects aimed at girls and young women, particularly by paying for them to stay in school longer than they otherwise would have. This improves both their confidence and their earning power. And that makes them less susceptible to the blandishments of “sugar daddies” who offer enhanced lifestyles in exchange for sex.
The wild card, however, is pre-exposure prophylaxis (PrEP). This employs a combination of two well-established ARVs, tenofovir and emtricitabine. Ingested before intercourse, it stops HIV taking hold in the first place. Trials in rich countries have shown that it works extremely well. The question is how to deploy it in those parts of the world, particularly Africa, where the epidemic is rife.
Deciding who should get ARVs is easy. Anyone who is infected with, or has been exposed to, HIV is a candidate. Deciding who should be offered PrEP is trickier. Obvious target groups include prostitutes, injecting drug users and the promiscuous.
Gratifyingly, as Peter Godfrey-Faussett, a scientific adviser to UNAIDS, observes, in trials in rich countries people identified as being in need of PrEP tend to come forward willingly. Whether that will be true in Africa remains to be seen, though studies in South Africa suggest that, with a little bit of encouragement, many prostitutes quickly see the advantages. Although Truvada, the original, proprietary version of the combination, is expensive, generic equivalents are now available for about the same cost, a dollar or less a pill, as the ARVs used for treatment. According to Dr Godfrey-Faussett, mathematical modelling suggests that aiming PrEP at the 3m people most in need of it should therefore be a cost-effective way of slowing the virus’s spread.
That is just as well, for other hopes of yesteryear are proving slow to materialise. Cervical rings doped with dapivirine, which early trials suggested may be almost as effective for women as circumcision is for men, have yet to obtain regulatory approval. The idea of effecting a true cure by using a drug to activate HIV in those bodily tissues where it hides, and then priming the immune system to recognise and kill it, was knocked back by a study presented to the meeting by researchers from Imperial College London, which showed no effect. And, though large-scale trials of a vaccine developed by Johnson & Johnson, a drug company, are planned, the road to an effective vaccine is littered with the corpses of trials that have got so far and no further.
Back, then, to the tried and trusted: ARVs. Though 90-90-90 will not be achieved by 2020, this will not be the first time a target has slipped. But achieved eventually, and then o’erleaped, it must be. If the world really does want to eliminate AIDS, governments, both rich and middle-income, need to be cajoled into paying now. Paying later will be dearer.