Are we on track to end AIDS, end viral hepatitis and end STIs by 2030 ?

Shobha Shukla *

Well, it seems to be a mixed bag of gains and losses. While there are reasons to celebrate, significant gaps remain to be plugged. The latest Global Health Sector Strategies Report of the World Health Organization (WHO) shows that while there has been a substantial increase in expanding service access for HIV, viral hepatitis and sexually transmitted infections (STIs), 2.5 million people are still dying every year due to these three infections. Thus, these illnesses continue to pose a major global health challenge.

In lead up to the world's largest AIDS conference this year - 25th International AIDS Conference or AIDS 2024, there is a growing call to #PutPeopleFirst. People-centred responses grounded in human rights can help accelerate progress towards ending AIDS, viral hepatitis and STIs.

Are we keeping the promise?

If a person living with HIV is virally suppressed, then undetectable equals untransmittable (#UequalsU) becomes a reality - as there is zero risk of transmission while the person remains healthy and productive (comparable to others without the infection).

On the positive side, globally, 86% of people living with HIV know their status, 76% of them are on lifesaving antiretroviral treatment, and 71% of them are virally suppressed.

- 5 countries have already met the 2025 targets of 95-95-95 (95% of people with HIV should know their status, 95% of them be on antiretroviral therapy, and 95% of them be virally suppressed by 2025).

- 16 other countries are likely to reach these targets by 2025.

- 19 countries have eliminated vertical (mother to child) transmission of HIV and/or syphilis. Also, dual HIV/syphilis rapid diagnostic tests are being rolled out for pregnant women in antenatal care and for key populations.

Infection rates are declining but are they declining fast enough?

Yet many indicators remain off-track to achieve the 2025 and 2030 global targets. While HIV incidence and HIV-related deaths are declining, the rates of decline are not fast enough. There were 1.3 million new HIV infections and 630,000 HIV-related deaths in 2022 -many of them due to late engagement in care and structural barriers to service access.

By the end of 2022, only 13% of people living with chronic hepatitis-B infection had been diagnosed and 3% had received antiviral therapy, while only 36% of people living with hepatitis-C infection had been diagnosed and 20% had received curative treatment. Despite having a vaccine for preventing hepatitis-B, it resulted in an estimated 1.1 million deaths in 2022.

More than 1 million new cases of STIs occur every day

In an exclusive interview given to CNS (Citizen News Service), Dr Meg Doherty, WHO Director of the Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, said: "We have the tools to be on the pathway to reach our 2025 targets and our 2030 goals. For HIV, we have done very well in terms of increasing service coverage, access to testing, treatment and viral load testing.

But we are off the mark on our impact targets- the number of people dying from these infections, the number of people getting new infections. Even in countries reaching the 95-95-95 service targets, new cases are occurring among young girls or women in subsaharan Africa. We have to do much more work with key populations- men who have sex with men, transgender persons, people who inject drugs, people in prisons, people who sell sex - because they often get left behind in the response.

There needs to be extra political commitment and community involvement to ensure that they have the same approach to having equitable access to testing, access to treatment, access to viral load testing and being virally suppressed."

Why are sexually transmitted infections on the blindspot?

Globally every year 374 million people (183.4 million of them being women) get infected with a range of sexually transmitted infections (STIs) such as trichomoniasis, chlamydia, gonorrhoea or syphilis, even though these infections are treatable, curable and preventable.

There were 8 million syphilis cases in 2022. Moreover, an estimated 220,000 deaths every year are attributed to syphilis alone. The report also shows that more women suffer from chlamydia than men and almost the same number from syphilis.

Dr Doherty agrees that, "We have been ignoring STIs for a long time. Our public health programmes for STIs have somehow not got the attention that they need. Also, as compared to HIV, there is even greater stigma and discrimination when it comes to STIs. People like to keep their sexually transmitted infections quiet; they like to maybe go to the private sector, to take their antibiotics on their own and not have to share that - because often many STIs are self-limiting or can be treated in a few days to a week.

But there are some STI with major consequences affecting many people around the world- like the human papilloma virus (HPV) and the associated cervical cancer, anal cancer; and we also have the herpes viruses.

We are seeing a rise in congenital syphilis that can be fatal for the newborn infant. This is really a breakdown of public health programmes. Perhaps testing may not be happening for syphilis for pregnant women. There are also problems with accessing penicillin for treatment of syphilis in some places."

Person centeredness in healthcare

Dr Meg Doherty stressed on having more people-centred, rights-based and gender transformative responses for controlling STIs, just as there are for HIV control programmes.

"It is important for people to feel that they are in control of their health. In our technical guidelines we have self-testing, self-care, and self-collection of samples for STI testing. We want to instill ownership in people- not only over their choice but also to become aware of STIs and their treatment. It is the person centeredness we have to have in healthcare facilities. Primary health centres should be able to offer multiple testing in one area- test for HIV, syphilis, other STIs, viral hepatitis- for people at risk."

Need to do more on addressing viral hepatitis

Currently, 50 million people are infected with hepatitis-C virus (HCV) and 254 million with chronic hepatitis-B virus (HBV) around the world, with 1.2 million new hepatitis-B infections each year. As per latest data, only 13% of people with hepatitis-B infection had been diagnosed and only 3% (7 million) were on treatment. Only 36% of people with HCV had been diagnosed and 20% had received curative treatment, even though antiviral medicines can cure more than 95% of persons with HCV infection.

"We have had a vaccine for hepatitis B for so many years," reminds Dr Doherty.

Hepatitis-B vaccine is a 3 dose vaccine given at 0, 1 and 6 months. But for the kids, the 1st dose must be given within 24 hours of birth.

If the mother is an active carrier of chronic hepatitis-B the birth dose has the strongest influence on reducing the acquisition of hepatitis-B for the infant. But many countries are not fully implementing the birth dose vaccine. The problem is again of linkage to care. People are not accessing treatment. Also, countries are not purchasing the lowest cost or the best access price for the treatment or for the diagnostic tests.

Just like we did for HIV, we have to get access price for hepatitis diagnostics and treatments to scale them up. Otherwise we are only serving a small proportion of the infected population. The message has to be spread and people have to start demanding, and unless they know how they would demand," says Dr Doherty.

Protecting the medicines that protect us

A cause of concern is that multi-antibiotic resistant gonorrhea cases are being reported in parts of the world, and we also have cases of resistance to dolutegravir - the wonder drug used in HIV treatment.

“Knowing about antimicrobial resistance (AMR) allows us to have a good public health response to it. We have good surveillance systems for multi-resistant gonorrhea with 87 different sites around the world reporting on it.

But apart from setting up surveillance systems for STIs, we are also changing the guidelines- advocating for good communication and knowledge sharing, ensuring good stewardship of antibiotics, and also working for better regimens to come forward. There are at least two new medicines that are coming up to address drug-resistant gonorrhea," said Dr Doherty.

She added: "In hepatitis we have not seen a lot of resistance yet but we are doing surveillance to keep an eye on it. For HIV we have been doing surveillance for many years and right now we are reassured that dolutegravir-based regimens are still the working horse of HIV treatment. WHO recommended combination of Dolutegravir, Tenofovir and Lamivudine-based regimen is working well for most people living with HIV.

But we have seen in certain settings that if not used properly or if used in people who have had a lot of different regimens in the past, there could be resistance developing [in the virus] against dolutegravir. So we have to be very careful as we want to protect that regimen. That also means we need to have a second-line regimen ready that might be able to be an alternative in the future. But right now dolutegravir is working very well for the majority of the people."

Connect, reconnect and recommit to end AIDS at #AIDS2024

Dr Doherty shares her message for the upcoming 25th International AIDS Conference (AIDS 2024): "My message is to connect, reconnect, and recommit to ending AIDS by 2030 - and - do it by bringing along other disease areas as well. We will only get there in this new world of multiple problems - whether it is climate change, or new infections, or NCDs or emergencies - if we work collaboratively with others. Also, do not lose energy. We need to work harder now because it is the last mile for HIV.

HIV is not going to go away, people will be living their lives with HIV for years to come. But getting to a place where countries are in control of the number of new infections and they own their programmes.

That is an awful lot of hard work that we need to do in the next six years. I hope that we can get ourselves to a point by 2030 where we have a significant number of countries that are able to manage their HIV epidemic and other diseases in their country and that people are living happy and long lives- not just with HIV but also with their NCDs, and with other infections."