We are at an extraordinarily promising moment in the global response to HIV — still the greatest infectious disease pandemic of our time. The insight that successful HIV treatment has potent effects on the onward transmission of the virus has shifted global programming toward treatment as prevention and has already brought about remarkable reductions in new infections.
The need to realise quality treatment for all is more urgent now than ever before. The successes of prevention of mother-to-child transmission, again largely due to the strategic use of antiretroviral drugs, has been another remarkable success, preventing enormous numbers of paediatric infections in the most affected countries and improving outcomes not only for these infants but for their mothers, families and communities.
Male circumcision campaigns have shown not only that this effective, preventive intervention can reduce risks for men and that young men are willing to undergo the procedure, but are now starting to demonstrate real benefits for women too. Taken together, these advances have led to optimism that the HIV pandemic can be controlled, that we can achieve treatment success for the many millions living with the virus and that, we might be able to finally end the Aids pandemic.
Few would have predicted a decade ago, when antiretroviral treatment was just rolling out in Sub-Saharan Africa, that the regions most affected by HIV would lead the world in these advances.
But this is precisely what has happened. The greatest successes in HIV prevention, treatment, and epidemic control appear to be happening in the very large, generalised, and predominately heterosexual epidemics of Southern and Eastern Africa. HIV is coming under control in countries as diverse as Malawi, Botswana, Kenya, and Rwanda; rates of new infection are falling in more than 25 African nations. This is truly extraordinary and one of the great public health, scientific, and humanitarian achievements of our time.
But there is a great deal of work undone — and much of it has to do with those populations, in Africa, but also in South and Southeast Asia, Eastern and Western Europe, and North, South, and Central America, who have long been disproportionately affected by HIV — and excluded from care and support.
HIV rates among men who have sex with men are not falling in most of the world — but are rising in 2014, and this is true in settings and contexts as diverse as Kenya, China, Thailand, the UK, France, and Peru. These men continue to have high burdens of new infection, but also face stigma, discrimination, and barriers to HIV services which limits our ability to address their critical, unmet needs.
A second population of profound concern is people who inject drugs. HIV infection is actually relatively easily controlled among this group: if they have access to sterile injecting equipment, they use it. If there is quality drug treatment available on demand, including opioid substitution therapy with drugs like methadone and buprenorphine, substantial numbers of people who inject opiates will seek treatment.
Using these simple tools in combination with HIV treatment for drug users living with HIV, epidemics among this group have been virtually eliminated in multiple countries. The problem here is that in so many regions, these basics of the HIV response are denied to the communities that need them.
In 2014, just two regions worldwide are still seeing expanding HIV epidemics. These regions are Eastern Europe and Central Asia, and the Middle East and North Africa. Failed policies toward this group are at heart of the HIV epidemics in these regions, and the failed public health policies there are virtually ensuring HIV infection will continue to expand. Russia has aggressively promoted her failed HIV responses in the regions under her influence, stopping the methadone programme for drug users in Crimea, as one harsh example, on the first day of the Russian occupation.
Sex workers are the third key population for whom too little access to care and services are available, and for whom HIV burdens are still unacceptably high. This is a particular challenge for that region of the world where HIV rates are highest among women — Southern Africa. All of the countries where more than 50% of female sex workers are living with HIV are in Southern Africa. And these women are too often excluded from HIV treatment, from prevention programmes and from preventing mother-to-child transmission programmes.
This must change if we are truly to see an end to the Aids pandemic. Sex workers, of course, include women, but also men and transgender persons who sell sex. All three groups share vulnerabilities to HIV, but the latter two may be even more frequently excluded from services.
Finally, there is a population at extraordinary risk for HIV but who don’t fit into our usual thinking about key populations. In Southern Africa, and in particular in some of the hardest hit communities in South Africa, Swaziland, Zambia and other heavily burdened states, it is young women and adolescent girls who have the highest rates of new infection, and for whom HIV prevention is an urgent priority.
In some communities, HIV rates are beginning to rise among these young women as early as age 12, and can reach over 15% of women by age 21, when rates in men of the same age are dramatically lower. We don’t fully understand these dynamics, but it is clear that the challenges these women face in avoiding HIV infection as they grow toward adulthood are a key HIV prevention research priority. If we cannot do better for and with them, we will not achieve success in global HIV control.
Chris Beyrer is a professor at the Johns Hopkins Bloomberg School of Public Health and the president of the International Aids Society, and Linda-Gail Bekker is on the UCT Faculty of Health Sciences, chief operating officer of the Desmond Tutu HIV Foundation and president-elect of the International Aids Society.