Not long ago, the very notion of an AIDS-free world was onemany of us working in the field did not dare dream of. Now there is a new senseof optimism, driven in large part by some extraordinary scientific advancesthat have elevated the potential of anti-retroviral treatment as prevention toofficial health policy. They have been complemented by the development of aninternational scientific strategy and alliance working towards an HIV cure “ anidea that until recently many believed was redundant.
“Getting to Zero” has been the slogan for World AIDS Day(Dec 1) since 2011 and will remain so through until 2015, coinciding with theMillennium Development Goal target of halting and beginning to reverse thespread of HIV/AIDS. This offers a starting point for some more sanguinereflection on how, amid generalized talk of zeros, targets and goals, we can soeasily lose sight of the extraordinary barriers that prevent them being reachedin the first place.
Asia is a case in point. There is no single “Asian epidemic”“ each country in the region faces a different situation. In Cambodia, forinstance, one of only eight countries globally to have achieved universalaccess to anti-retroviral treatment, national HIV prevalence has dropped from 3percent a decade ago to around 0.5 percent through concerted government and NGOcampaigns. Yet a breakdown of that figure reveals an HIV prevalence among drugusers in the country of around 20 percent.
Injecting drugs is a major driver of HIV transmission inmany countries in Asia. According to UNAIDS, about 16 percent of people whoinject drugs in Asia are living with HIV In some countries, this estimate isconsiderably higher: 30 to 50 percent in Thailand, 32 to 58 percent in Vietnamand 22 to 28 percent in Malaysia. Assertive campaigns around clean needles andopioid substitution therapy, or OST, by the Malaysian government over the pastfive years have proven hugely successful in driving down new infections amongdrug users, and are evidence that harm-reduction programs are key to reducingnew infections. Globally only around 3 percent of injecting drug users haveaccess to anti-retroviral treatment “ a figure that illustrates the challengesof getting to zero in this key population.
If we are serious about reaching zero, we have to get evenmore serious about tackling stigma that not only impacts injecting drug usersbut also gay men and sex workers. A host of new evidence is pointing to new andworrying HIV infection spikes among gay men in countries like Pakistan, Nepal,Thailand, Cambodia, China, Vietnam, India, Indonesia, Myanmar and thePhilippines. In some cases these account for the bulk of new infections, yetfunding for programs to reach out to these communities does not reflect thefast-changing nature of the epidemic
It is also untenable that at a time when we have achievedsignificant global coverage of the prevention of mother-to-child transmissionservices, only around 30 percent of pregnant women are offered an HIV test inEast, South and Southeast Asia. It is deeply worrying that across these regionsonly around 16 percent of HIV-infected pregnant women receive antiretroviralsto prevent mother-to-child transmission of HIV. We need to closely analyze whycurrent services are not reaching mothers.
Yes, we do have the science to eventually get to zero andend AIDS but the road is full of barriers, bolstered by the stigma ofmarginalized groups. In many cases that stigma is driven by government policiesthat continue to maintain and enforce repressive policies toward those groups.Stigma and discrimination have always been the main drivers of HIV/AIDS. It hasbeen a combination of community activism, evidence-based policy programming,political courage and scientific developments based on the three pillars ofprevention, treatment and care that has successfully tackled those barriers.
Research has led to dramatic progress over the past years,in particular in developing strategies to use anti-retroviral molecules asprevention tools. Vaccine research is also greatly advancing. More than ever,we need a fourth pillar: an HIV cure. We still have some way to go tocompleting the cure puzzle, but some of the pieces are ever so slowly beginningto fall into place.
The case of the “Berlin Patient” “ the first person to befunctionally cured of HIV “ has been well documented. Promising too are theresults of two recent studies presented at the International AIDS Conference inWashington earlier this year. One indicated that there exists a unique cohortof patients in France who were treated for a limited period very early afterinfection and for which no sign of viral resurgence is observed several yearsafter treatment has been stopped. The study confirms the benefits of treatingHIV at the very early stages of infection. The other study revealed that twoHIV-positive men had achieved undetectable viral loads after bone marrowtransplants received as a treatment for cancer.
We now have more knowledge, technology and scientific toolsat our disposal to seriously attempt to put the pieces together. Some 15 trialson HIV cure related research are currently taking place, the results of whichover the coming years will help to inform us if we are on the right tracktowards getting to zero and ending AIDS.
(Francoise Barre-Sinoussi is director of the Regulation ofRetroviral Infections Unit at the Institut Pasteur in Paris and president ofthe International AIDS Society. She was awarded the 2008 Nobel Prize inMedicine for the co-discovery of HIV. Adeeba Kamarulzaman is the director ofthe Center of Excellence for Research in AIDS at University of Malaya in KualaLumpur.)
