HIV science has advanced but policies-programmes have been slow to #endAIDS

Shobha Shukla *

HIV science has advanced but policies and programmes have been slow to respond towards ending AIDS, said Mitchell Warren, co-chair of the global conference on HIV Research for Prevention (HIVR4P) and Executive Director of AVAC (Global Advocacy for HIV Prevention).

Scientific advances have seen huge gains on HIV prevention and treatment fronts. Sadly, what has not changed is the lack of equity in the response. Those who are the most marginalized, most stigmatised and most criminalized continue to remain so. No wonder, the number of new HIV infections has almost plateaued at 1.7 million per year, he said.

With only 118 months left to keep the promise of ending AIDS, it is vital to accelerate stronger action towards keeping these goals and targets. Mitchell Warren was in conversation with CNS (Citizen News Service) around the HIVR4P.

2021 marks the 40th year since the first case of AIDS was reported. While a lot has been achieved in this period, the fight against HIV is far from over. Despite having more tools than ever before to control the HIV epidemic, we still saw 690,000 persons dying of AIDS related causes in 2019. Speaking in a plenary at the virtual 4th HIVR4P conference, Winnie Byanyima, Executive Director of UNAIDS said that this is not progress enough as each one of those AIDS related deaths was preventable.

"Today, science has provided us with more potent prevention technologies. But prevention technology means little if people cannot access it. The gaps in HIV prevention continue to be driven by profound inequalities that leave the most vulnerable behind. While new HIV infections fell globally by 23% between 2010 and 2019, they barely changed among people who inject drugs, female sex workers and transgender women. This alarming epidemic is fuelled by gender inequalities, and social norms and structures that magnify risk to HIV", she said.

Although there is yet no cure or vaccine for HIV, science is making great strides in the field of HIV treatment and prevention- more user-friendly antiretroviral therapy, pre-exposure prophylaxis (oral PrEP), dapivirine vaginal ring, long acting injectables- and many others (like multipurpose prevention technologies (MPTs) to prevent HIV, STIs and unintended pregnancies) are in the offing. But translating scientific research into public health impact has been an Achilles heel.

Mitchell Warren rightly points out that, "Safe and and efficacious products, developed through years of research and clinical studies, are neither safe nor efficacious if they simply sit on the shelves and are not in the hands of people who need them. Sadly, very often in research and development, there is a disproportionate focus on the product and we tend to forget about the people."

the long journey of product development and delivery

The first step is, of course, development of new safe and effective products through years of clinical research. Then comes the delivery phase - getting WHO pre-qualification, regulatory approvals, marketing and demand creation for potential users of these products and training of healthcare workers to provide these options as viable choices without stigma and prejudice. If we only do research and development and forget about the second 'd' of delivery, these products will be of no good. Also, the people who are going to use the HIV prevention products, must be part of this journey from the very beginning and not just be the recipients of someone else's journey, says Mitchell.

He firmly believes that it is not just about developing the product, but also about the programmes and policies that need to put them in the hands of those who want them.

“Oral PrEP does not magically appear in people’s mouths nor does the vaginal ring magically appear in women’s vagina just because they were found to be safe and effective in clinical studies. It is the programmes that need to deliver them and create demand and awareness about them. There are still communities who do not know that oral PrEP even exists- in the same way that decades later after its inception, women still did not know about the existence of the female condom. It really speaks of the need to focus more on the recipients, and not just on the product.”

UNAIDS and WHO have recently updated their clinical studies' ethics guidelines that were first launched in 2007. The updated guidelines re-assert the importance of good participatory practice in the clinical studies' design and conduct. They also re-assert good participatory practice in the sharing of not only data from the study but also the products (if found to be safe and effective), with the study participants.

only a treatment and prevention combo will work

While an increasing number of people living with HIV are now accessing antiretroviral treatment and getting virologic suppression, we seem to be failing on the front of primary prevention. Mitchell rightly emphasises that it is only through a combination of treatment and prevention that the HIV/AIDS pandemic can be controlled. HIV requires an integrated and comprehensive response- treatment for those who are infected, and prevention options for people who are uninfected. We need to help people access an array of options at their disposal. Until we move from options to choices, we are not likely to reduce the number of new infections, he said.

Agreed Winnie that we must respond with science and with rights to secure for the rest what has been possible for the few, because we cannot succeed unless the most vulnerable communities are at the centre of the HIV/AIDS response.

She informed that to make HIV prevention an urgent priority, the new more ambitious overarching UNAIDS target - defined with detailed thresholds for each vulnerable population group to identify and close the inequalities- is that 95% of the people at risk of HIV infection use combination prevention by 2025. Also, for the first time, UNAIDS has proposed targets for establishing supportive legal and policy environments with access to justice, gender equality and freedom from stigma and discrimination. If targets promoting favourable societal environments are met 440,000 AIDS related deaths would be averted and 2.6 million additional new infections would be prevented, said Winnie who leads UNAIDS.

In the words of Mitchell Warren: "We stand at one of the most precarious moments in public health. We have not succeeded but we have made progress. Science moves quickly and we have the responsibility as advocates and as a global community, to take the fruits of science to the people. The task is huge, the opportunity though, to do the right thing and to meet people where they are and to improve global public health, has never been more opportune. We have more tools to end AIDS and we have to learn to use them faster, better and more equitably."