We cannot #endAIDS if we blindly depend on the Global North

Bobby Ramakant *

If we look back over the past four decades since the first case of HIV was diagnosed, we cannot miss the stark writing on the wall: had the whole world depended only on the rich nations of the Global North, then we would have miserably failed to deliver lifesaving antiretroviral therapy to over 28.7 million people living with HIV by end of 2021.

It will also become amply clear how vital remains the central driving force of key affected communities as well as the Global South in making medicines affordable and accessible. Rich nations have spurred health innovations indeed. But it is the people most at risk of HIV and the countries in the Global South that have made the dream partially come true of making these scientific breakthroughs reach those who are most in need.

With 101 months left to end AIDS by 2030, countries globally have to ensure 100% people living with HIV know their status, 100% of them are receiving lifesaving antiretroviral therapy along with full spectrum of HIV care cascade, and are virally suppressed. In addition, 100% of people should have full access to HIV combination prevention options so that we can deliver on zero new case targets.

"We do not have to wait till 2030, we already have the tools and approaches which science has proven that they work. We have to implement what we know works," said Dr Ishwar Gilada, Governing Council member of International AIDS Society (IAS) and President of AIDS Society of India (ASI) – a national network of HIV medical experts and researchers. Dr Gilada was chairing a press conference hosted by ASI and Organized Medicine Academic Guild of India at the 24th International AIDS Conference (AIDS 2022) in Montreal, Canada.

92% HIV medicines globally come from India

"Currently 92% of lifesaving antiretroviral therapy for people living with HIV worldwide comes from Indian generic manufacturers. Compared to the price of these medicines in the Global North, credit goes to most affected communities and Indian generic medicine manufacturers who have made medicines affordable. Most of the generic antiretroviral medicines cost 1% or less when compared to the cost of the same in rich nations.

For example, best available three-in-one medicine was costing USD 10,452 per patient per year, but lowest quoted cost from Indian generic manufacturers is USD 69, which is merely 0.7% of international cost. Likewise, cost of treatment of those infected with hepatitis C virus was USD 84,000 for three months therapy, but Indian manufacturers have brought down the cost to as low as USD 215 – which is less than 0.3% of international cost," added Dr Gilada.

If we are to scale up lifesaving medicines along with full spectrum of HIV care services, particularly in low and middle-income countries, role of countries in the Global South, such as India, is pivotal.

Agrees Dr Beatriz Grinsztejn, President-Elect of International AIDS Society (IAS): "India as one of the biggest producers of generic medicine, has been able to develop, produce, and export generic antiretroviral treatments which are key for scaling up access to these medicines." She strongly advocated for boosting South-South cooperation on health.

Inequalities determining trajectory of HIV epidemic in the Global South

"Scale up of antiretroviral therapy has improved over the years as well as access to HIV services, however it is also fundamental to ensure the quality and sustainability of the programmes which are being implemented," added Dr Grinsztejn. "Countries in the Global South have many issues in common as inequalities are still determining the trajectory of HIV epidemic in low and middle-income countries."

Dr Beatriz said "There are compelling factors that demand reassessments of policy frameworks for emerging South-South cooperation. A framework which is holistic and aims for generating health-driven research and development, will strike a balance between promoting and protecting the right to access of medicines."

Bridge the gap between "what we know," and "what we do"

Dr Ann Duerr, Scientific Affairs Director, HIV Vaccine Trials Network (HVTN), and Professor, Vaccine and Infectious Disease Division, Fred Hutch, Seattle, USA expressed concern on latest UNAIDS global AIDS update shared at AIDS 2022. In 2021, every 2-3 minutes an adolescent girl or young woman was infected with HIV and every minute we lost a life to AIDS.

Dr Ann Duerr said: "It is high time that we redouble our efforts globally. We need to increase implementation of what we know works. This includes increasing HIV treatments, and also increasing the preventive measures such as pre-exposure prophylaxis (PrEP) along with full range of combination prevention options, especially among populations at risk."

She strongly called upon India to help boost implementation science, which addresses the gap between "what we know" and "what we do." "By closing these gaps, we can redouble our efforts to fight the global epidemic of HIV infection," she added.

Commendable progress but challenges remain

Dr Glory Alexander, who is the founder of ASHA Foundation in India and elected as Vice President of AIDS Society of India (ASI), is also a part of the AIDS 2022 organizing committee. She said that "over the years, we have been able to reduce the number of new HIV infections by about 37% since 2010, and decreased AIDS-related deaths by 66% since 2010 in India. That is huge achievement and was possible largely due to scale up of antiretroviral therapy."

However, "among the key populations, HIV seroprevalence continues to remain very high - between 1.5% to 6.25% (compared to general population where HIV incidence is around 0.21%). This needs to be reduced before we can even think of achieving #endAIDS targets. Along with scaling up HIV care services we also have to reduce inequities, failing which it will be very difficult to reach out to the targets of 100-100-100 by 2030" said Dr Glory Alexander to CNS (Citizen News Service).

Dr Glory's concern regarding high HIV rate among key populations is also echoed by the United Nations joint programme on HIV/AIDS (UNAIDS). According to the UNAIDS, the risk of acquiring HIV is 35 times higher among people who inject drugs than adults who do not inject drugs; 30 times higher for female sex workers than adult women; 28 times higher among gay men and other men who have sex with men than adult men; and 14 times higher for transgender women than adult women.

Dr Ishwar Gilada rightly pointed out that it is not 'Global North vs Global South', but a call for reimagining the fight to end AIDS based on principles of solidarity, equity, and social justice. While Global North currently leads on health innovations, it is no less vital to ensure that these scientific breakthroughs reach the most-in-need people globally without any delay (or without any barriers like cost).