On June 5th, the world will observe the 30th anniversary of the officially recognized beginning of the HIV/AIDS pandemic. Interestingly, scientists now believe that the first instances of HIV infection may have occurred in the beginning of the 20th Century. Nonetheless, only on June 5th, 1981, when a cluster of 5 homosexual men in Los Angeles became infected with a rare type of pneumonia, was modern medicine officially aware of the new disease via a short blurb in the CDC’s Morbidity and Mortality Weekly Review. This short report would later be recognized as the first description of what would be named AIDS in the medical literature.
The 30th anniversary of this report will shine a spotlight on the pandemic at a time when policymakers are grappling with austerity measures threatening to shrink global health budgets.
To be sure, there will be a lot of back-slapping and celebration over the scientific advances already made in the fight against HIV/AIDS. What was once a death sentence, is now a better understood infectious disease which can be treated with antiretroviral therapy (ART). However, ART is by no means a perfect therapy, and is much worse than the treatment of other infectious diseases. ART is lifelong, and a certain percentage of patients develop resistance to ART, and/or suffer significant side effects, though these are decreasing with newer medications.
In fact, HIV positive patients started on ART today can expect to live an almost normal lifespan, all else being equal. This assumes that the HIV positive person is tested, adheres to their treatment regime, and that they are able to access health care resources. You can see where stumbling blocks prevent many patients from obtaining the care they need even in the United States. Waiting lists for ART have begun to grow in certain states under financial pressures.
Globally, approximately 33 million people are HIV positive, and only about one third of all HIV positive people are receiving the ART that they need. Dismal this percentage may be, the number of HIV positive people receiving ART in developing countries had increased markedly over the past decade. It is an important success, but one which rich countries are increasingly describing as “unsustainable”, which is sort of code for, “this is going to be too expensive for us.”
A recent article in the Annals of Internal Medicine, written by two well known national HIV/AIDS experts, continues the refrain that with 2.5 million new HIV infections each year, providing ART to everybody is unsustainable. Or rather, that providing ART and the lifelong health care needed to treat HIV positive patients is not economically possible in resource poor countries.
This is unfortunate because the scope of the pandemic will only increase. With no change in the status quo, it is estimated that by 2031 there will be 3.6 million HIV infections a year (up from 2.5 million a year), and that by 2050 there could be 70 million people living with HIV just counting those in Africa.
To cut the number of annual new infections in 2031 to 1.3 million, it would cost $722 billion over the next 20 years. A more targeted program, which would spend $397 billion, would cut new infections to 1.7 million a year by 2031.
However, new research has shown that ART, given early enough in the infection, appears to drastically decrease the ability of an HIV positive person to infect another person. This prevention-as-treatment approach is still controversial, as it is unclear when is the best time for an HIV positive person to start ART. Many HIV/AIDS specialists feel that they can not ethically start an HIV positive patient on medications which serve only to protect society at large, while not improving the health of the HIV positive patient. However, it is currently unknown if starting a patient as soon as possible on ART will ultimately improve their health, . . . meaning that treatment-as-prevention may turn out to be a win-win solution.
Current trials underway will provide more evidence based guidance concerning the optimal time to start an HIV patient on ART. Should prevention-as-treatment prove to be beneficial for the individual patient, and helpful for society at large in terms of preventing new infections, then scaling up treatment programs could tackle the pivotal prevention issue as well.
Since the HIV/AIDS pandemic is still relatively young, preventing new HIV infections is of paramount importance. The most efficacious way to break the back of the pandemic would be an effective vaccine, or a cheap one-time curative treatment. Should a highly effective vaccine become available tomorrow, then it would be obvious where the dollars for prevention would go.
But what if it takes 100 years for an effective vaccine to be developed?
Most likely, an HIV vaccine or feasible cure will be seen sometime within the next century. However, many HIV/AIDS experts are openly predicting, or calling for, revolutionary advances in HIV/AIDS care and prevention, while describing the current situation as fiscally unsustainable. But what if ART is the best tool we have to effectively treat and prevent HIV/AIDS for the foreseeable future?
If we hope for the best (a vaccine/cure), but plan for the worst (unabated pandemic growth), then we should redouble our preventive efforts and try to make treatment available to as many as possible in the developing world.
Why speculate about the lives that could be saved tomorrow when we have the tools to save them today?
Besides the growing role of prevention-as-treatment, there are other evidence based preventative tools such as using ART to prevent mother to child transmission, education programs, and male circumcision, condoms, clean needles, etc, which could be intensified in use.
Far from bemoaning the lack of a ground-shaking breakthrough, there already are a lot of tools in the toolbox. While a vaccine may be decades away, new technologies such as cell phones and iPads could allow millions of people to participate in educational and treatment programs, which wouldn’t have been feasible in the past.
Nonetheless, while I would expect a good chunk of politicians to “kick the can down the road” in terms of addressing the HIV/AIDS pandemic, it is disappointing that many prominent HIV/AIDS specialists, are also concluding that treatment programs are unsustainable, especially considering the tremendous progress already made.
While economic times may currently be challenging, given that well over 70 million people may be living with HIV by mid-century, we may one day regret not going all out in terms of addressing the pandemic today.
Thirty Years of HIV and AIDS: Future Challenges and Opportunities
Carl W. Dieffenbach, PhD, and Anthony S. Fauci, MD
Ann Intern Med. 2011;154.