First published on www.thelancet.com
By Stefano Vella, IAS Governing Council Member and David Wilson, Global HIV/AIDS Program Director, The World Bank, Washington, DC, USA
The International AIDS Conference in July celebrated the success of antiretroviral treatment (ART) in reducing illness and death. The pall of despair that hung over the the previous Durban conference in 2000 has truly lifted, and in one of the great success stories of global health 17 million people have begun ART. Despite this achievement the mood was sombre as the goal of an end to AIDS receded; but it was also purposeful, and we can do much to bring the goal closer.
We commend the UNAIDS 90-90-90 strategy for fostering testing and linkage to treatment and WHO for guidelines to support it. However, substantial implementation obstacles exist, the greatest of which is that a large proportion of people living with HIV do not know they are infected. In particular, key populations are less likely to access HIV services because of the stigma and discrimination reinforced by laws that criminalise people who inject drugs, men who have sex with men, and sex workers. Even if expanded testing enables us to achieve the first 90 (assuming we know the correct country denominators) and even if patients are retained and adherent for life (regrettably improbable), the 90-90-90 cascade omits 27% of those with HIV. Transmission dynamics are complex, and the 27% left behind most probably include hard-to-reach, stigmatised populations and people with difficult to detect acute primary infection, who together are responsible for most transmissions. The UNAIDS prevention gap report shows new HIV infections stagnating at 2·1 million annually, with many countries experiencing unexpected increases. IHME’s independent estimates are even higher—74 countries with increased HIV incidence and 2·5 million new infections every year. In many countries, including Botswana, South Africa, and Swaziland, HIV incidence remains distressingly high, even as we approach or attain the ambitious 90-90-90 treatment goals. Moreover, in a cluster randomised test and treat trial in KwaZulu-Natal, TasP did not reduce new HIV infections. True that the HPTN 052 results provide incontestable proof of treatment as prevention efficacy among carefully selected stable partners in a meticulously monitored research setting. But we are not yet seeing, nor should we expect to see, comparable population level effectiveness in the real world. Without underestimating the transformative effects of treatment in reducing AIDS morbidity and mortality and slowing HIV transmission, we will not end this epidemic with tablets alone.
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