December 1, 2020 – December 1 is World AIDS Day. Roger Shapiro, associate professor of immunology and infectious diseases, has worked for over two decades to improve health outcomes for HIV-infected pregnant women and their children. Here, he assesses progress in the decades-long fight against HIV/AIDS.
Q: In 2020, how is the world doing in terms of battling HIV/AIDS?
A: The Joint United Nations Programme on HIV/AIDS (UNAIDS) targeted 2020 as the year when we would achieve the 90-90-90 goal everywhere—which means that 90% of people with HIV know their status, 90% of those known to be infected are on treatment, and 90% of those who are treated are virally suppressed. While we have made progress, the overall numbers for these targets in 2019 were 81%, 67%, and 59%. So we have room to improve.
But there are a few bright spots too, including the fact that over 25 million people living with HIV now receive ART, which is threefold higher than in 2009. At least 14 countries have now met the 90-90-90 targets, including high-prevalence countries such as Botswana and Eswatini. This increase in treatment is almost certainly having an impact on prevention, and new infections have decreased 40% since the peak in 1998. Half as many new infections now occur in children compared with a decade ago.
We still need to do better, and closing the treatment gap is critical both to keep people with HIV healthy and to bend the prevention curve even further.
Q: What challenges does the coronavirus pandemic pose to HIV/AIDS prevention and treatment efforts?
A: 2020 has been a challenging year in so many ways, and there has been a lot of concern that COVID may derail efforts to fight HIV. I think much of this concern is valid, especially when considering the logistics involved in getting antiretrovirals to people during lockdowns. There has also been a diversion of resources toward COVID testing and care. Many of the labs that test for HIV viral loads are now doing COVID testing on the same machines, so we may be seeing an impact on HIV monitoring capacity because of COVID.
The first statistics for ART use during the COVID epidemic were encouraging, with no apparent decrease in overall uptake in the first half of 2020. This is good news for now, but we need to keep an eye on these numbers, as there is a long way to go and more lockdowns and shipping disruptions may lie ahead. COVID also adds cost to everything, including HIV programs. Patient care delivery is harder, and it is estimated that drug costs may increase 10%–25% because of COVID.
On the other hand, COVID may present some real opportunities for HIV prevention efforts. When people stay home because of COVID lockdowns or the closure of bars, less HIV transmission will occur. COVID has shown the world, or at least most of the world, that preventive measures such as mask use and distancing can be used to fight a deadly virus. The challenges for HIV prevention are very different, but we may be able to harness some of the messaging about the use of personal protection measures from the COVID epidemic and apply it to the HIV epidemic. We are also gaining a massive amount of experience regarding COVID vaccine development, some of which has been built on the HIV research infrastructure, and soon we will learn lessons in worldwide distribution. These lessons can be applied to HIV down the road, whether for treatment, a future vaccine, or the rollout of PrEP (pre-exposure prophylaxis)—medication for preventing HIV—in hard-to-reach places.
Q: What are some highlights of the progress that’s been made this year?
A: We are always moving forward on treatment and prevention, and 2020 was no exception. I think the best news this year has been the successful trial of a long-acting injectable antiretroviral, called cabotegravir, for HIV prevention in women in Africa. In the past, poor adherence to PrEP has been a limitation, and this recent study found that a long-acting injection every eight weeks was highly effective at blocking HIV transmission, and over eight times as protective as standard oral PrEP. There has also been progress this year in treatment options available for pregnant women, with encouraging outcomes with newer regimens. A more cautionary tale this year has been further evidence for substantial weight gain with newer treatment combinations, and this remains an active area of research.
In terms of drug development, there has been progress toward new medicines that might last for up to six months, which will open up new possibilities for long-term treatment and prevention. And finally, we are learning more all the time about how to use broadly neutralizing monoclonal antibodies to treat HIV and to drive the amount of virus in the body to lower and lower levels. These new products are getting better all the time, and might lead to future treatment options that can be dosed every few months, perhaps in combination with the long-acting antivirals that are being developed.