The state of AIDS

Big 3 poster Max Essex

December 1, 2014 — The first World AIDS Day was December 1, 1988. That same year, the Harvard School of Public Health AIDS Initiative (HAI) was established to help end the epidemic. Max Essex, the Mary Woodard Lasker Professor of Health Sciences at HSPH and Chair of HAI, has been involved in HIV/AIDS research since the beginning of the epidemic.

The disease that became known as AIDS was first reported in 1981. What’s the state of the epidemic today?

Overall, I think the epidemic is at a plateau. Today, about 35 million people worldwide are living with HIV. That number isn’t rising nearly as rapidly as it used to, but neither is it decreasing as rapidly as people would like. There are several reasons for that. About 50,000 people in the U.S. are newly infected with HIV each year and several million people are newly infected each year in the world. The number of people with HIV isn’t going down faster, in part, because many people are being kept alive longer. There’s been tremendous success with the utilization of drugs to save people’s lives. As more and more lives are saved, the total number of people living with HIV increases. We have to prevent more new infections to compensate for the fact that people who are HIV-infected might now live for 20 to 40 years, as opposed to dying in six or eight years.

Should we be optimistic about seeing an end to the epidemic?

It depends on how you define end. I don’t think there’s any chance whatsoever that in the next 25 to 50 years we’ll see an end to the epidemic in the sense that we don’t have new cases. I do think we could dramatically reduce the number of new infections so that the burden HIV/AIDS places on healthcare systems could be dramatically reduced, especially in those regions of the world which have the highest rates, such as sub-Saharan Africa.

What are the big research questions today?

The big research question that seems most obvious to me is prevention. How do you dramatically reduce rates of new infection? “Treatment as Prevention” is part of the answer and we’re studying that in a large clinical trial in Botswana. In addition, there are combination prevention approaches that combine proven prevention interventions like male circumcision, PrEP, and a whole range of things, with cost-effectiveness analysis to see how you can get the most out of healthcare dollars spent.

Beyond prevention, I would say a big question in treatment is how do you move to drugs that will cause the least amount of resistance with the fewest side effects so you get the highest adherence among patients? The most recent drugs are better than the earlier generations of drugs, but we always run into the dilemma that the newest drugs are also the most expensive. If they have the great advantages of not causing much drug resistance or many side effects, then inevitably there’s a lag time that big pharmaceutical companies like to have before they become available in the developing world because Western countries will pay much higher prices. For at least the next five to ten years, in my opinion, there will be a lot of emphasis on choosing the best drugs for therapy in the developing world that generate the least amount of drug resistance.

—Martha Henry