Blog: Health Matters

World AIDS Day (WAD), observed each year on December 1, is a moment to stand still and reflect on the impact of HIV/AIDS over the last number of decades. WAD was first celebrated in 1988 with the theme “Join the Worldwide Effort,” therefore making 2019 the 31st year of creating awareness and showcasing awareness. The theme for WAD 2019 is “Communities make the difference.” You will recognize the red ribbon as a symbol to show solidarity with people living with HIV/AIDS.

I started thinking about the theme for the December blog some months ago and decided to write it as a set of Frequently Asked Questions on the topic of HIV/AIDS, in partnership with experts and individuals working in the field of HIV/AIDS.  

I first became aware of the disease as a physician working in South Africa, where I had the opportunity to care for patients with HIV/AIDS. I was impressed by the words of Nelson Mandela, “Let us give publicity to HIV/AIDS and not hide it, because the only way to make it appear like a normal illness like TB, like cancer, is always to come out and say somebody has died because of HIV/AIDS, and people will stop regarding it as something extraordinary.” This became an inspiration for me to become an advocate for creating awareness on the topic throughout my working career.    

What are HIV and AIDS?

• HIV is the acronym for Human Immunodeficiency Virus, a virus that attacks the human immune system, making an individual more susceptible to comorbidities and eventually resulting in AIDS (Acquired Immune Deficiency Syndrome). 

HIV, as an illness, was first mentioned in the mid 1980s.  How much has changed since then?

• The thinking is that HIV originated in West Africa as a disease that crossed species from chimpanzees to humans. It is unclear as to how many people were infected by HIV or had AIDS prior to the early 1980s. We now have more exact figures, and the estimate is that approximately 37.9 million people are currently living with HIV/AIDS, and 1.7 million new infections were recorded in 2018.   
• AIDS has become a treatable disease, with an estimated 24.5 million people receiving antiretroviral treatment as of mid-2019, an increase of more than 3 million people in comparison with 2017, which is a remarkable effort, but more still must be done.    

Is the HIV/AIDS burden still more skewed towards women?

• Yes; women account for half of the worldwide HIV/AIDS burden. Women and girls aged 10–24 years are twice as likely to become infected as men in the same age group,  mostly due to cultural, social and economic factors, with gender inequality and sexual violence the biggest risk factors in this group. 
• Globally, every week, around 6,000 young women aged 15–24 years become infected with HIV. In sub-Saharan Africa, four out of five new infections among adolescents aged 15–19 years are in girls. These statistics serve as a sobering reminder that women and girls are particularly vulnerable to HIV infection and need new HIV prevention tools.
• This is one of the reasons why an ongoing clinical study called “Imbokodo” was developed to test an investigational mosaic-based vaccine regimen in 2,600 young women in five southern African countries.

What can be done to enhance the awareness about HIV/AIDS in society in general? Is HIV/AIDS still receiving the attention that it did some years ago?

• Reducing the stigma around HIV is key in helping people get tested and accessing treatment, as are continued calls on public and private sector leaders and other key partners to stay focussed on the actions and funding needed to further advance research and undertake health initiatives and data collection. 
• In many parts of the world, significant progress has been made in reducing new HIV infections, reducing AIDS-related deaths and reducing discrimination, especially in eastern and southern Africa, but gender inequality and denial of human rights are also leaving many people behind.
• This year's awareness of the need of those impacted by HIV was especially high. In October, important steps were taken to ensure support for one of the major driving forces behind the treatment and elimination of AIDS – the Global Fund to Fight AIDS, Tuberculosis and Malaria. 
• In an unprecedented show of global solidarity, donors at the Global Fund's Sixth Replenishment Conference pledged US $14.02 billion for the next three years – the largest amount ever raised for a multilateral health organization, and the largest amount by the Global Fund.

What advice can be given to women and girls living with, or at risk of, HIV/AIDS?

• Young women and girls have to be at the center of the response to HIV in Africa. It is unacceptable that young women and girls are still twice as vulnerable to HIV in sub-Saharan Africa, and six times more vulnerable in the worst hit countries. Change is possible, and now is the moment to act!  
• The best advice to young girls impacted by, or at risk of, HIV is to engage with community services such as DREAMS Thina Abantu Abasha, a peer-to-peer program that supports this group through empowerment and education. When young women have the right information, feel empowered and can see a path for their future they are more inclined to make the right choices to protect themselves.

What needs to be done to reduce the stigma associated with HIV/AIDS?

• Helping people and communities understand that living with HIV is no different than living with any other chronic disease and that a diagnosis does not change you. It is important to reinforce this point by focussing on the science that proves that when a person in treatment has an undetectable virus in their body, they are unable to transmit it. 
• What we call undetectable equals untransmittable. 
• If we can get communities to view the disease in this way, that will go a long way toward shattering the stigma that prevents people from accessing testing and treatment

What is the role of pre-exposure prophylaxis (PrEP)? Is this effective on its own as a prevention method, or should it always be used in combination with other methods?

• In countries where it has become available, PrEP is an important new HIV prevention tool, and one that is highly effective when used by individuals as prescribed. PrEP’s efficacy was established in clinical studies where other HIV prevention strategies such as condoms were encouraged.
•  As a relatively new intervention, PrEP is not yet available in many developing countries with high HIV prevalence. It also requires the individual to remember to take the pill daily, as directed. That’s why it is important to ensure we have a prevention toolbox for HIV that also includes a broadly available vaccine that offers durable protection against HIV.

How far are we from the successful development of a vaccine?

• Finding a preventive vaccine is often called the “Holy Grail” of HIV. The search for a vaccine began the moment HIV was discovered over 35 years ago. There have been several disappointments in this area over the years, but also signs of hope. Today, science is building on lessons learned from past research and there is a new optimism in the field. A number of pharmaceutical companies, working with global partners, are very involved in a renewed global push to find a vaccine.
• On November 21, 2019, the first Phase 3 (late-stage) study for an investigational, mosaic-based vaccine regimen called “Mosaico,” in development at the Janssen Pharmaceutical Companies of Johnson & Johnson, started in the United States. Mosaico is scheduled to be conducted at sites in seven additional countries across the Americas and Europe in the coming months and will test the safety and efficacy of the vaccine in 3,800 men who have sex with men (MSM) and transgender individuals. Mosaico joins a companion efficacy trial, the Phase 2b “Imbokodo” study, which is also testing a mosaic vaccine regimen in five southern African countries. Both Mosaico and Imbokodo are focused on testing the vaccine in populations who are at increased risk of HIV infection.
• Another vaccine candidate being researched by the NIH is also being explored for efficacy in South Africa. We are hopeful that the current progress in HIV vaccine research means that the world will achieve an effective preventive vaccine for HIV in our lifetimes.

Is the target of 90:90:90 achievable? Are there countries that have already achieved this?

• Tackling the HIV/AIDS epidemic requires complete focus, and having the UNAIDS’ 90-90-90 targets plays a large role in doing so. The targets look to ensure that 90% of people who are HIV-positive know their status, 90% of those diagnosed are receiving antiretroviral treatment and that 90% of people on treatment have a level low enough that they don't risk transmitting the virus. 
• The most recent data from UNAIDS indicate that the world is making real progress in meeting the 90-90-90 targets by 2020. In 2018 (the latest year for which data are available), an estimated 79% of people living with HIV knew their status; among people who knew their status, 78% were accessing treatment; and among people accessing treatment, 86% were virally suppressed. The world still has significant progress to make, and investing in HIV community education and diagnostic programs remains critical.

How has treatment for HIV changed since the epidemic began in the 1980s? What are the main comorbidities for people living with HIV today?

• Thankfully, over the past quarter-century, advances in treatment have changed an HIV diagnosis from a “death sentence” to a chronic, manageable condition for many patients. In fact, with prompt diagnosis and access to quality treatment, people living with HIV can expect to enjoy a normal lifespan. As many people with HIV grow older, researchers are taking a closer look at the impact of aging on disease progression, and the long-term effects of inflammation in the body caused by the virus itself. There is also an increased focus on ensuring that antiretroviral medicines are safe over the long term, including for patients who develop conditions that are more common with aging, including non-communicable diseases (NCD) such as cardiovascular disease and diabetes. It is increasingly important to integrate NCD care and treatment for people living with HIV. 
• Worldwide, tuberculosis (TB) remains one of the leading causes of death among people with HIV, which is why it remains critical to take a coordinated approach to tackle the twin epidemics of HIV and TB. Great strides have been made against both diseases, but they remain among the world’s worst infectious diseases, killing an estimated two million people annually.

Resistance towards antibiotics is a significant concern in the medical world. How much of an issue is this with antiretroviral treatment? And how can this be overcome?

• Drug resistance is a challenge in HIV therapy, although somewhat less so currently compared to bacterial diseases such as tuberculosis (multidrug-resistant TB is one of the leading global drivers of mortality due to antimicrobial resistance). With HIV, we have largely worked out – at least for the time being – how to suppress the virus using the right number of drugs deployed from different classes of antiretroviral. Of course, we can’t afford to be complacent – we must continue to work as a global health community to ensure that today’s HIV medications reach everyone who needs them, particularly in developing countries.

Finally, that all important question “Do you believe that HIV can be cured?” 

• Yes, we will get there eventually. We know it can be done, as the medical community has discovered with two patients who achieved complete remission for HIV after receiving bone marrow transplants to treat blood cancer. But we need to find a more practical and less invasive way to cure HIV. 
• Hopefully, the discoveries the scientific community makes today – across the fields of prevention, treatment, or cure – will lay the groundwork for ending the pandemic in the future.

The final inspirational words came from three leaders working in the DREAMS Thina Abantu Abasha program: Ensure that young women have a voice and that they are empowered to speak up; help girls remain positive about their future, as they can and will make a difference; remain vigilant and continue to address the issue of stigma; and include men and boys in awareness campaigns, as sexual equality and respect for women and girls are the important success factors for the future! 

Sources:

• Interviews with Dr Hanneke Schuitemaker (Global Head of Viral Vaccine Discovery and Translational Medicine in the Infectious Disease and Vaccines Therapeutic Area and  Professor of Virology at the Academic Medical Center of the University of Amsterdam), Stacy Meyer (Vice President, Global Operations & Partnerships, Johnson & Johnson Global Public Health) and team leaders from the DREAMS Thina Abantu Abasha program.
• http://hivinsite.ucsf.edu/hiv?page=basics-00-01
• https://www.unaids.org/en/resources/fact-sheet
• https://en.wikipedia.org/wiki/History_of_HIV/AIDS
• https://www.worldaidsday.org/
• https://www.unaids.org/en/resources/campaigns/WAD_2019
• https://www.avert.org/professionals/hiv-social-issues/key-affected-populations/women
• https://www.theglobalfund.org/en/
• https://www.unaids.org/en