EDITORIAL

HIV—No time for complacency

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Science  15 Jun 2018:
Vol. 360, Issue 6394, pp. 1153
DOI: 10.1126/science.aau2663
PHOTO: LORÈAL FOUNDATION
PHOTO: DEAN DEMOS

Today, the global HIV epidemic is widely viewed as triumph over tragedy. This stands in stark contrast to the first two decades of the epidemic, when AIDS was synonymous with suffering and death. But have we turned the tide on HIV sufficiently to warrant directing our attention and investments elsewhere?

Highly effective treatment, through an array of about 30 new antiretroviral drugs, has given people living with HIV an almost normal life span and instilled hope in high-burden communities. Activism played a key role in ensuring global access to treatment. Simplified, low-cost, one-pill-a-day, three-drug combination regimens with minimal side effects are now widely available. The Global Fund to Fight AIDS, Tuberculosis, and Malaria and the U.S. President's Emergency Plan for AIDS Relief support global access to life-saving treatment in poor countries and helped increase treatment coverage from about 2 million people in 2005 to about 21 million in 2017. HIV transmission from mothers to their babies has been reduced to such low levels that plans for its global elimination are well under way.

PHOTO: MISHA FRIEDMAN

The AIDS response has now become a victim of these successes: As it eases the pain and suffering from AIDS, it creates the impression that the epidemic is no longer important or urgent. Commitment to HIV is slowly dissipating as the world's attention shifts elsewhere. Complacency is setting in.

However, nearly 5000 new cases of HIV infection occur each day, defying any claim of a conquered epidemic. The estimated 36.7 million people living with HIV, 1 million AIDS-related deaths, and 1.8 million new infections in 2016 remind us that HIV remains a serious global health challenge. Millions need support for life-long treatment, and millions more still need to start antiretroviral treatment, many of whom do not even know their HIV status. People living with HIV have more than a virus to contend with; they must cope with the stigma and discrimination that adversely affect their quality of life and undermine their human rights.

A further crucial challenge looms large: how to slow the spread of HIV. The steady decline in the number of new infections each year since the mid-1990s has almost stalled, with little change in the past 5 years. HIV continues to spread at unacceptable levels in several countries, especially in marginalized groups, such as men who have sex with men, sex workers, people who inject drugs, and transgender individuals. Of particular concern is the state of the HIV epidemic in sub-Saharan Africa, where young women aged 15 to 24 years have the highest rates of new infections globally. Their sociobehavioral and biological risks—including age-disparate sexual coupling patterns between teenage girls and men in their 30s, limited ability to negotiate safer sex, genital inflammation, and vaginal dysbiosis—are proving difficult to mitigate. Current HIV prevention technologies, such as condoms and pre-exposure prophylaxis, have had limited impact in young women in Africa, mainly due to their limited access, low uptake, and poor adherence.

There is no room for complacency when so much more remains to be done for HIV prevention and treatment. The task of breaking down barriers and building bridges needs greater commitment and impetus. Now is not the time to take the foot off the pedal of the global AIDS response if the United Nations Sustainable Development Goal target of a 90% reduction in HIV incidence by 2030 is to be met. The social mobilization and activism that characterized the early HIV response are even more critical now. More effort and investment are needed to support ongoing treatment, increase testing and treatment, deliver effective prevention programs to those most at risk, and expand the available prevention strategies, ultimately with a vaccine and a cure.

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