The AIDS world is dealing with something unprecedented: good news.
Bear in mind that "good" is a relative term, especially when dealing with the worst pandemic in human history. But the data are still noteworthy:
- There were 1.5 million AIDS deaths last year, down from 2.4 million a decade ago;
- There were 2.1 million new infections, down from a peak of 3.4 million;
- The number of people living with HIV has held steady at 35 million.
With the numbers heading in the right direction, scientists and activists alike are hoping to accelerate the trend and write the final chapter of the AIDS pandemic.
The plan, unveiled by UNAIDS, aims to end the spread of HIV by 2020, and eliminate the disease altogether by 2030. It goes by the moniker 90-90-90.
What that means, practically, is:
- Ensuring 90 per cent of the infected are tested and diagnosed; currently that number is about 55 per cent;
- Getting 90 per cent of those who are diagnosed on treatment with antiretroviral drugs; that number is currently 37 per cent;
- Aiming to have at least 90 per cent of those infected attain an undetectable level of virus in their bodies (essentially a functional cure); currently those rates range from 40 to 80 per cent in various countries.
Michel Sidibé, the director of UNAIDS, said the goal is obviously ambitious but history shows that clear targets are the best way to progress.
"90-90-90 is not just a numeric target, it's a moral and economic imperative," he said. "It will drive the HIV-AIDS epidemic into history."
Much of the progress to date is due to widespread use of antiretrovirals for both treatment and prevention, and the 90-90-90 plan depends largely on dramatically expanding their use. (ARVs are drugs that prevent the virus from replicating, staving off illness and making people less infectious and less likely to spread the disease.)
Dr. Julio Montaner, head of the B.C. Centre for Excellence in HIV/AIDS, said the plan is a good one.
"This is a natural evolution of the philosophy of treatment as prevention," he said. "But the big question is: 'Who's going to pay for it?'"
Currently about $19-billion a year is being spent on tackling the HIV-AIDS pandemic, with much of the money coming from Western donor countries. To implement the 90-90-90 plan, that would have to jump to $24-billion next year, and then upwards as millions more get on treatment and have their viral loads monitored. But supporters argue that spending more money upfront will actually lead to lower costs in the long run.
There is a recognition too that drugs alone – for prevention and treatment – will not be enough.
"Without a vaccine we will not be able to end the epidemic," said Dr. Wayne Koff, chief scientific officer of the International AIDS Vaccine Initiative. "Despite all our efforts, we still have a couple of million new infections a year, so we need an effective vaccine." Developing a vaccine is proving more difficult than scientists ever imagined, but there is steady progress.
Dr. Salim Abdool Karim, director of the Centre for the AIDS Programme of Research in Durban, South Africa, said he is encouraged by the new initiative but cautioned that the extent of the challenge cannot be overstated.
"Thirty-four years into the epidemic, AIDS is far from over," he said. "We can't talk about elimination or eradication, not with 35 million people living with HIV and no vaccine." Dr. Karim said while drug treatment is effective, there are practical challenges to getting help to those who need it, including the stigma that discourages people from being tested and treated, and dysfunctional health systems in some of the countries hardest hit by HIV-AIDS. That's why only 14 million of those infected are now on treatment.
"The impediments that exist are not medical; they're social and political," he said.
Where everyone agrees is that the key to reining in the epidemic is to focus on marginalized populations where infections and deaths continue to rise, such as intravenous drug users (where HIV is 28 times more prevalent than in the general population) and sex workers (12 times higher).
Special attention also needs to be paid to the few countries that are still driving the epidemic. Fifteen countries, chief among them South Africa, Nigeria, Uganda and India, account for 75 per cent of new cases.
The road to 90-90-90 in 2020, and to eventual elimination of AIDS, in either 2030 or beyond, starts with getting to a point where there are fewer new cases than deaths, meaning the overall threat is dropping.
That milestone is very close and, as Dr. Karim said: "The world cannot afford to miss this historic tipping point."
André Picard