Special Edition: BIO DIGITAL 2021

‘HIV remains a pandemic of inequalities’: The fight against HIV/AIDS, 40 years on

By Rachel Arthur contact

- Last updated on GMT

2020 goals 'were missed by a long way'. But 2030 goals are still within reach, says the UN. Pic:getty/dariaren
2020 goals 'were missed by a long way'. But 2030 goals are still within reach, says the UN. Pic:getty/dariaren

Related tags: Aids, Hiv, Nih, Fda, BIO

June 2021 marks the 40th anniversary of the publication of the first reported cases of AIDS in the US. A session at BIO Digital – featuring Dr. Anthony Fauci, Director of NIAID at the NIH – will focus on four decades of innovation as well as the critical importance of collaboration and investment moving forward.

On June 5, 1981, the Centers for Disease Control’s Morbidity and Mortality Weekly Report described 5 cases of Pneumocystis​ pneumonia in gay men. Since then, the HIV/AIDS pandemic has resulted in over 75 million HIV infections and 32 million deaths.

The UN wants to end the AIDS epidemic by 2030. But a key set of global 2020 targets to tackle HIV/AIDS were ‘missed by a long way’:​ and the COVID-19 pandemic has added a new set of complex challenges to efforts.

And yet– if the 40th​ anniversary can provide the right momentum to refresh efforts and put the focus on the biggest challenges – the UN says its 2030 goal is still within reach.  

June 2021: A chance to refocus

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) announced a Fast-Track approach aiming to end the AIDS epidemic by 2030. This included a set of interim targets for 2020.

Deaths due to AIDS-related causes declined by 39% from 2010 to 2019, and at least 26 countries are on track to achieve a 90% reduction in AIDS-related mortality by 2030, including nine countries in eastern and southern Africa.

But despite this, the 690,000 AIDS-related deaths in 2019 far exceeded the 2020 target of reducing mortality to less than 500,000.

A UN report published in March does not mince its words: placing the fault of the failed targets firmly at inequalities – and social and structural factors that perpetuate such inequalities.

“There has been intensive action and progress against HIV in some places and population groups, while inaction in other places has allowed HIV epidemics to expand and deaths to mount," ​reads the report, titled 'Addressing inequalities and getting back on track to end AIDS by 2030'.

“The stark contrast of successes in some areas and failures in others confirms that HIV remains a pandemic of inequalities.

“For example, gender inequality, anchored by harmful gender norms, restricts women’s use of HIV services, and sexual and reproductive health services. This can impact decision-making, including the ability to refuse unwanted sex or to negotiate safer sex. 

“Vulnerable, marginalized and criminalized communities also remain at higher risk of HIV infection because they are not receiving essential information and HIV services, whether for prevention or care."

Key stats

  • In 2016, the UN General Assembly set the target of having fewer than 500,000 new HIV infections by 2020.  Last year, the figure was 1.7 million (three times the target)
  • Similarly, the 690,000 AIDS-related deaths in 2019 far exceed the goal of less than 500,000 deaths a year. 
  • Deaths due to AIDS-related causes declined by 39% from 2010 to 2019, and at least 26 countries are on track to achieve a 90% reduction in AIDS-related mortality by 2030, including nine countries in eastern and southern Africa.
  • New HIV infections have been reduced by 23% since 2010. 23 countries are on track to achieve a 90% reduction by 2030.
  • The 280,000 young women newly infected in 2019 was nearly three times greater than the 2020 target of fewer than 100,000.
  • An estimated 150,000 new HIV infections among children (aged 0–14) occurred in 2019, compared to a 2020 target of less than 20,000.  
  • Key populations continue to be left behind. For example, annual HIV infections among sex workers, people who inject drugs and transgender people have barely changed.

Source: 'Addressing inequalities and getting back on track to end AIDS by 2030', UN Report of the Secretary-General, March 31, 2021.

AIDS in the era of COVID-19

Modelling indicates that the impact of the COVID-19 pandemic on the HIV response could result in 123,000 to 293,000 additional HIV infections and 69,000 to 148,000 additional AIDS-related deaths globally.

The COVID-19 pandemic has ‘placed enormous additional pressures on HIV responses, health systems and the people in need of services', ​says the UN.

It has also exacerbated the problems with inequalities: having ‘exposed the inadequacy of investments in public health, the persistence of profound economic and social inequalities and the fragility of many key global systems and approaches.’

Health systems are at risk of being overwhelmed from COVID-19 infections, while COVID-19-related restrictions have a disproportionate impact on low-income households, women and girls, people living with HIV and key populations, the report noted.

Meanwhile, HIV services and commodity supply chains have been disrupted by the COVID-19 pandemic, with many countries reporting dips in new HIV diagnoses and treatment initiations in 2020 and early 2021.

'Some may argue that the world cannot afford to end AIDS during these difficult times. Such short-sighted approach was exactly what left the world so vulnerable to COVID-19'

And yet, at the same time, community-led initiatives pioneered by the HIV response and developed over the last 40 years have helped countries galvanize their COVID-19 response.

“The use of HIV resources to train health-care workers and strengthen clinical, laboratory and disease surveillance infrastructure has enhanced overall pandemic preparedness and resilience. HIV experts, systems and resources were quickly mobilized in response to the COVID-19 pandemic.

“The COVID-19 pandemic has highlighted the agility of the HIV response and the many spill-over benefits of HIV investments in health and development.”

However, the report warns against using COVID-19 as an excuse for letting efforts to tackle AIDS and HIV fall by the wayside.

“Some may argue that the world cannot afford to end AIDS during these difficult times. Such short-sighted approach was exactly what left the world so vulnerable to COVID-19. Countries can no longer afford to under-invest in pandemic preparedness and responses. The evidence and lessons learned from the HIV response show that investing too little, too late merely leads to millions of additional people requiring services, greater risk and uncertainty, and higher future costs.”

2030 targets can still be met

But not all is lost. While the UN notes that momentum has struggled and targets have been missed, it is using the 40th​ anniversary milestone to refocus efforts and look at where work needs to be focused. The good news is that it believes the 2030 targets can still be achieved.

Its new goal is to keep new annual HIV infections to under 370,000 - and annual AIDS-related deaths to under 250,000 - by 2025. 

Its March report - accesible here​- highlights the biggest challenges and how the strategy can be put back on track.

These will be expanded on with a United Nations General Assembly High-Level Meeting on HIV and AIDS on June 8-10.

“The global AIDS community and UNAIDS have used an inequalities lens to develop a bold new strategy, with new targets that are ambitious, granular and tailored to reach the furthest behind first,  ​says the UN.

BIO Digital will reflect on the outcomes from the UN High-Level meeting in a session on Monday 14 June, titled ‘How to end the HIV/AIDS Epidemic: Collaboration and Investment to address global unmet needs and prioritize research’.

Dr. Anthony Fauci, Director of NIAID at the NIH, and Dr. Julie Gerberding, Executive Vice President and Chief Patient Officer for Merck, will focus on 4 decades of innovation in HIV treatment and prevention as well as the critical importance of continued collaboration and investment to address global unmet needs and prioritize HIV in a post-COVID world. 

“Ending the HIV/AIDS epidemic is possible through continued innovation – but unwavering global commitment across multiple stakeholders is necessary to make this a reality,” ​notes BIO Digital.

First of all, there's the need for ‘urgent, transformative action’ to reduce and end inequalities; as well as increased domestic and international investment in HIV, health, social protection, humanitarian responses, pandemic preparedness and control systems.

‘Bold political leadership’ will also be required to address social injustices and inequalities that make certain groups of people highly vulnerable to HIV infection.

And there is a clear funding gap that needs to be addressed, with the UN identifying ‘chronic under-investment'. In 2019, $19.8bn was available for the HIV response in low-income and middle-income countries – nearly 30% short of the $26bn per annum that Member States had agreed to mobilize by 2020. One of the goals, moving forward, is to see $29bn per annum reached by 2025.

The biggest takeaway is that - without tackling persistent inequalities - the world risks being stuck in a continuous loop where progress is made and lost.

“It is imperative to break out of an increasingly costly and unsustainable cycle of achieving some progress against HIV but ultimately not enough to bring about an end to the pandemic”,​ notes the UN.

“Inequalities are the key reason why the 2020 global targets were missed. By ending inequalities, transformative outcomes can be achieved for people living with HIV, communities and countries.

“Getting back on track will require urgent, transformative action to reduce and end inequalities, as well as increased domestic and international investment in HIV, health, social protection, humanitarian responses and pandemic preparedness and control systems.”

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