Follow the science

The message is clear: UN Member States must follow the science. To advance the HIV response, Member States must agree on an evidence-based political declaration, as well as implement evidence-informed national responses.

The United Nations High-level Meeting (HLM) on HIV and AIDS in mid-2021 marks 40 years since AIDS was first reported. Attention falls squarely on the progress made so far and what must still be done to strengthen the response to HIV. The UN HLM decides on the targets that will shape the next decade of the HIV response. Unavoidably, the impact of COVID-19 on the HIV response so far and to come is central to its discussions.

Four decades of responding to HIV demonstrate the importance of science. The COVID-19 pandemic is a stark reminder that following the science is an inherently political decision. The HIV response must seize the opportunity and capitalize on the political commitment towards public health generated by COVID-19. Here, we outline the science that should be followed, highlight the gaps that science has yet to fully address, and call attention to the policy and practice that should be adapted according to the science.

UN Member States affirm commitment to end AIDS

Member States adopted the 2021 Political Declaration on HIV and AIDS at the UN HLM. The 22-page declaration, titled “Ending inequalities and getting on track to end AIDS by 2030”, expresses “deep concern and regret that the international community did not meet the 2020 targets … despite the fact that we have the knowledge and tools to prevent every new HIV infection and each AIDS-related death”. It carries the message: “The end of AIDS is in reach, but urgent action is needed.”

The IAS welcomes the declaration as a step in the right direction and notes that it makes progress in the three areas of the IAS 2021-2025 Organizational Strategy: promote science, support action and empower people. However, the IAS is concerned that some Member States voted against the declaration, weakening it. To move ahead in the response to HIV – and other pandemics – there must be global solidarity.

Waiving patents and increasing flexibility on intellectual propriety rights will make life-saving HIV treatment and COVID-19 vaccines available to millions more people. This demands bold action and strong political leadership that goes further than what Member States agreed on in the declaration.

The power of science

Remarkable scientific progress has provided many of the tools we need to tackle the HIV pandemic. Landmark studies have shown that treatment saves lives and reduces onward transmission. People on effective treatment who have undetectable levels of the virus cannot transmit HIV to sexual partners; and the effectiveness of treatment on preventing perinatal transmission has been established for more than 20 years [1]. HIV treatment in the form of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP) and other modalities has also proven to be effective in preventing HIV acquisition.

Timeline 1981 to 2021: The key scientific advances that changed the response

  • 1981

    First cases of AIDS reported

    Five healthy gay men contract a rare pneumonia associated with severe immunosuppression; later identified as AIDS

    References

  • 1983

    HIV-1 discovered

    Retroviruses isolated from white blood cells of people living with AIDS/pre-AIDS and eventually named HIV

    References

  • 1984

    AIDS identified as a global epidemic

    AIDS not restricted to gay and bisexual men; transmission through heterosexual sex, mother-to-child transmission, blood contact all contribute to pandemic

    References

  • 1985

    First diagnostic tests available

    Blood test detecting antibodies against HIV allows people to know their HIV status

    References

  • 1987

    First antiretroviral (ARV) drug approved

    Zidovudine (AZT) becomes available as first antiretroviral treatment (ART)

    References

  • 1994

    Evidence published that ARV drugs reduce mother-to-child transmission of HIV-1

    Using AZT during pregnancy for infants post-delivery reduces HIV transmission from mother to child

    References

  • 1995

    First protease inhibitor approved as ARV drug

    This is crucial in the development of effective combination ART

    References

  • 1997

    Foundation of the health and human rights movement

    Jonathan Mann is Director of WHO’s Global Programme on AIDS and provides critical leadership on understanding the importance of human rights in the HIV response and to protect public health

    References

  • 2007

    First person living with HIV is cured

    Timothy Ray Brown, the “Berlin patient”, previously diagnosed with HIV, has a stem cell transplant for leukaemia and remains off ART – and free of HIV

    References

  • 2008

    Swiss statement that people with viral suppression are unlikely to pass on HIV

    First pronouncement that people with suppressed viral load are unlikely to pass on infection

    References

  • 2008

    First action to measure and address HIV stigma by and for people living with HIV

    International collaboration between activists to develop a tool to assess stigma. Progress towards addressing stigma can be measured

    References

  • 2009

    First vaccine to show reduction in risk of acquiring virus

    After a series of disappointments, a vaccine regimen shows some protective efficacy

    References

  • 2010

    Discovery that ART can be effective for prevention as PrEP

    ARVs taken daily by people who do not have HIV are effective to prevent infection

    References

  • 2011

    Evidence that early ART limits transmission of HIV-1 in serodiscordant couples

    HPTN 052 shows that early initiation of ART reduces sexual transmission of HIV-1. HPTN 071, with over 48,000 participants in Zambia and South Africa, shows that immediate referral to HIV treatment substantially reduces infections

    References

  • 2015

    Evidence of the benefit of early ART established

    People living with HIV who start ART soon after diagnosis, instead of waiting until becoming immunocompromised, have improved clinical outcomes

    References

  • 2016

    Evidence that HIV treatment can prevent onward transmission between sexual partners

    ART can prevent sexual transmission of HIV in serodiscordant couples as a result of effective ART reducing virus presence to undetectable levels – now known as U=U (undetectable equals untransmittable)

    References

  • 2018-19

    Evidence that no HIV transmission between men who have sex with men when HIV-positive partner is virally suppressed

    PARTNER study finds zero transmission among gay couples when the HIV-positive partner is virally suppressed; supports U=U. Second PARTNER study reiterates these results

    References

  • 2019

    ECHO study finds no increased risk of HIV acquisition among people using different long-acting reversible contraceptives

    This evidence empowered women to make sexual and reproductive choices using effective contraceptives

    References

  • 2019-21

    Evidence of the efficacy of long-acting injectable ART

    Long-acting injectable HIV treatment is effective at supporting sustained viral suppression and may improve adherence as it no longer requires people to take pills daily

    References

  • 2020

    Long-acting injectable ARV is highly effective for the prevention of HIV infection

    A long-acting injectable for PrEP is found to be effective at preventing HIV, adding an option to the HIV prevention toolbox that does not require adherence to an oral daily pill

    References

Reality check

37.6 million

people are living with HIV

690,000

died from AIDS-related causes in 2020

1.5 million

newly infected in 2020

Despite the advances and worldwide efforts over the past 40 years, around 37.6 million people are living with HIV and 1.5 million were newly infected and 690,000 died from AIDS-related causes in 2020 alone [2]. Only 10 countries met the UNAIDS 90-90-90 targets (that at least 73% of all people living with HIV are virally suppressed) by 2020 [3]. Tremendous progress has been made in developing effective treatments and prevention options, but we are still to develop a safe and effective HIV vaccine or cure.

In late 2019, a new pandemic, COVID-19, emerged. Disruption of essential health services during this pandemic is a global reality: 94% of countries reported disruptions in the first quarter of 2021 [4].

The response to COVID-19 has captured full attention and diverted political interest, funding [5], expertise and healthcare services [6] from people living with and affected by HIV.

Access to HIV prevention reduced and there were decreases in testing [7] and treatment initiation [8,9,10]. Among PEPFAR-supported programmes, voluntary medical male circumcisions reduced by 74% in April-June 2020 from the same quarter in 2019 [11]. In South Africa, lockdown was associated with decreases of 48% in HIV testing and 46% in ART initiations in April 2020 [12].

Tipping point

The impact of COVID-19 could be a tipping point for global health: an opportunity for improvement, innovation and investment in health systems or a risk of a colossal global scale if lessons are not learned for the future.

Following the science has never been more important. Many principles that have long been advocated for in the HIV response have also been important in following the science for the COVID-19 pandemic.

These include ensuring targeted, localized, context-specific responses that respect human rights and meaningfully engage communities.

An onslaught of misinformation has meant, in some cases, that the “defence of science” has been needed to strengthen the connection between science and policy to ensure an evidence-informed response for both COVID-19 and HIV. Varying national responses to COVID-19 are a reminder of the intersection and, often, tension between politics and following the science.

Seize the political commitment

The COVID-19 pandemic has also driven an unprecedented level of personal and political will – and urgency – to protect public health. The immediate public health emergency and long-term disruptions to economies triggered a high level of public and private commitment and, crucially, funding. This has helped drive logistical support and coordination and vaccine research and development unheard of in modern history.

COVID-19 has brought to the fore issues of health inequity and the importance of resilient health systems. It is essential to assess how some of the lessons learned from the COVID-19 response might strengthen pandemic preparedness and responses to infectious diseases in the future.

There is opportunity to adapt and enhance the approaches from the COVID-19 response to HIV and sustain political attention on public health.

This includes harnessing digital technology and community partnerships in research and health service delivery.

Learning from COVID-19

Financial barriers and the influence of vested interests in intellectual property must be removed if we are to protect global public health. As of March 2021, 78% of all COVID-19 vaccine doses had been administered in just 10 countries [13]. Through the Agreement on Trade-Related Aspects of Intellectual Property Rights, selected World Trade Organization (WTO) members have been called upon to waive intellectual property rights that prevent lower-income countries from manufacturing the vaccine [14].

We must heed critical lessons from the HIV response to address inequities in access to COVID-19 vaccines across the world.

Although the first effective HIV treatment was discovered in 1996, it took years before low- and middle-income countries could access combination therapy. In that time, many lives were lost as ARVs were not available and prohibitively expensive to the majority of people living with HIV [15].

It took unprecedented community mobilization, activism, global commitment, financing and political will, including the “3 by 5” initiative and subsequent 90-90-90 targets, to facilitate the rapid expansion of access to ART in resource-limited settings. We must not let history repeat itself and lose countless lives again due to inequitable access to scientifically proven and effective health interventions.

The coinciding of the WTO conversations with the HLM means that Member States’ interests relating to trade, intellectual property, access to COVID-19 vaccines and political priorities in the HIV response are inextricably linked. The denial of the basic human right to health in some countries poses the risk of failure in the responses to both HIV and COVID-19 [16]

The challenge

The HIV response must build on 40 years of robust science and also incorporate important lessons from the COVID-19 pandemic. The challenge is ensuring that the results of scientific research inform policies implemented at scale and enhance the delivery of programmes and healthcare practices. This can be achieved in three main ways: promote science, support action and empower people.

Promote Science

Support Action

Empower People

Promote
Science

Know your epidemic, know your response

The “know your epidemic, know your response” approach remains crucial. Unless programmes are implemented within an implementation science framework and the impact of interventions are measured, we don’t know where to do more, scale up, develop further innovation or stop if an intervention does not work.

Science tells us that accessible HIV testing, with rapid linkage to care and treatment, is vital in controlling the HIV pandemic and reducing AIDS-related deaths. Globally, fewer than 60 countries were able to monitor all aspects of the 90-90-90 targets in 2019, with even fewer doing so among key populations – men who have sex with men, people who inject drugs, sex workers and transgender people. UNAIDS reports that only 47 countries can measure ART coverage among gay and bisexual men, 29 among people who inject drugs and 33 among prisoners [17]. This means that we don’t know how many people in key populations are unaware of their HIV status and if they need life-saving treatment or further support to attain viral suppression.

Invest in research and development

For decades, a safe and globally effective HIV vaccine has remained elusive, hampered by complex challenges, including viral diversity and the virus’s ability to evade immune responses. However, new approaches, including passive immunization and candidates designed to trigger a better immune response, are in early stages of development, with some showing promising results [18].

HIV vaccine research enabled the rapid development of the COVID-19 vaccines through existing vaccine technologies, clinical trial infrastructures and collaborative networks. In turn, the success of technologies developed for a COVID-19 vaccine, such as the messenger RNA (mRNA) vaccines, has triggered a heightened interest in exploring the potential of these technologies for future HIV vaccine candidates. Increased global investment in HIV vaccine research is pivotal as only a vaccine is likely to provide durable control of the HIV pandemic [19].

Key points from the UN Political Declaration

Member States:

  • Underscored the “critical role of science and technology, including biomedical and clinical science, social and behavioural science, and political and economic science, and evidence-based approaches in shaping the direction of and accelerating the HIV response”.
  • Committed to collecting, using and sharing reliable, detailed data disaggregated at a national level to best understand health needs of priority populations.
  • Committed to ensuring that science and evidence-based differentiated HIV services are part of the package of universal health coverage, including for key and vulnerable populations.

Follow the science: Invest in knowledge gaps

Global research investments must address key knowledge gaps to advance the most critical scientific issues in HIV, including biomedical prevention, such as vaccines and long-acting technologies and progress towards a cure, as well as social science and evaluations of innovative and stigma-free models of healthcare.

Support
Action

Address structural barriers

UNAIDS points out that the translation of science into policy and then policy into action are key gaps in our HIV response [20]. These gaps are hard to close.

Removing legal and structural barriers to accessing HIV and other services, which include laws and policies that criminalize or discriminate against key populations, has been shown to improve health outcomes for specific populations [21]. A total of 67 UN Member States nonetheless have provisions that criminalize same-sex contact [22].

Migrants, particularly those who are undocumented, rarely have access to healthcare. People who inject drugs and sex workers are criminalized in many settings, which means that they can’t access services. Higher rates of incidence of ill-health, such as mental illness or drug and alcohol dependence, have been documented in specific groups, such as people who are homeless [23] and in prisons or other closed settings [24], than in the general population.

Gender-based violence and gender inequalities also drive the HIV pandemic. In sub-Saharan Africa, young women and adolescent girls make up about 10% of the total population and accounted for one in four new infections in 2019. Keeping girls and teenagers in school in high HIV-prevalence countries prevents new HIV infections by increasing knowledge and providing more life opportunities [25].

Political leaders must recognize and address structural barriers to health, repeal punitive laws and policies, end discrimination and reduce the effects of stigma. India recently passed comprehensive laws setting out a human rights-based approach to managing its HIV response. This followed extensive stakeholder consultation about how to address needs of stigmatized and marginalized groups [26]. An IAS-Lancet Commission [27] is reviewing and revitalizing critical issues in health and human rights, including in the HIV response. Science can help fill knowledge gaps and inform better policies; yet it is governments’ responsibility to create environments that enable the realization of the right to health for all.

Change policies

COVID-19 has accelerated policy support for and implementation of differentiated service delivery (DSD) for HIV. Delivery of PrEP was adapted in Ethiopia with extended refills and online education, in Thailand with extended refills and increased telehealth, and in South Africa through mobile clinics and home delivery [28]. DSD for HIV treatment was expanded in response to COVID-19, including eligibility, ART refill duration and prescription length, community-based ART options and expansion of HIV services with non-communicable diseases [29].

In over 50 countries, harm reduction services were adapted quickly to mitigate disruptions and service delivery challenges during COVID-19 movement and other restrictions. Models of service delivery were innovated by simplifying prescribing requirements, offering take-home opioid agonist therapy and increasing access to naloxone and harm reduction services through mobile services [30].

We must bolster the evidence base for the adaptations to service delivery that were implemented as emergency measures in response to COVID-19. The innovations to HIV and other health services that are proven to increase acceptability, uptake and adherence should remain in place.

Key points from the UN Political Declaration

Member States:

  • Committed to ending inequalities, discriminatory laws and practices, stigma and discrimination and human rights violations, which perpetuate HIV.
  • Recognized the contribution of HIV infrastructure to COVID-19 and the commitment to “build back better” from the COVID-19 pandemic.
  • Committed to a fully funded HIV response and increasing annual HIV investments in low- and middle-income countries to US$29 billion by 2025.

Follow the science: Accelerate the uptake of evidence

The uptake of evidence must be accelerated to achieve specific evidence-based policy changes at the global, national and sub-national levels through tailored engagement, dialogues and advocacy on priority areas in the HIV response.

Empower
People

Bridge the digital divide

Use of digital devices and platforms can support people to look after their health. In some places, HIV self-testing kits and PrEP can be ordered online and digital platforms are used to facilitate the creation of peer support groups for adherence. During the COVID-19 pandemic, an initiative in Jamaica disseminated information through social media, using animated cartoon characters to reach adolescents [31].

Central to the success of digital interventions is internet access, with innovations that are designed and implemented to protect client confidentiality and privacy. However, countries where the HIV burden is highest, like in sub-Saharan Africa, experience irregular internet service and exorbitant pricing for mobile data [32]. Despite progress towards e-delivery of health, people in internet-poor settings are being left behind. Governments must recognize that internet access is rapidly becoming essential to healthcare and opens a range of public health opportunities.

Enable community leadership

During the COVID-19 pandemic, community-based models for ART delivery were used more extensively in HIV services in Cote d’Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Mozambique, South Africa, South Sudan, Tanzania, Uganda and Zimbabwe [33]. In South Africa, as of October 2020, more than 1.3 million people living with HIV were receiving ART refills at community pick-up points, including private pharmacies, community venues and lockers. Community-led research has been key in improving access to HIV tests [34] and informing the tailoring of harm reduction services [35].

The HIV response has shown the impact of communities demanding access to information, leading research, monitoring impact to ensure accountability, and advocating until policies and interventions reflect evidence and people’s choices and preferences.

Community leadership is critical for understanding the social context and how to deliver interventions. Vaginal rings have been shown to be effective in reducing the risk of HIV acquisition. However, recent work in four southern African countries found that women frequently had to negotiate their use [36]. If the rings are not as empowering as intended, it will reduce uptake and their potential in decreasing risk of HIV acquisition.

In challenging situations, communities can often be the first to organize. In Mexico, despite governmental funding cuts to HIV services, civil society is working to obtain alternative funding, including setting up online donations and partnerships with industry [37].

Key points from the UN Political Declaration

Member States:

  • Acknowledged inequities that drive HIV transmission and disproportionately affect key and vulnerable populations.
  • Committed to supporting community leadership and ensuring that more HIV services are community led.
  • Committed to putting gender equality and human rights of all women and girls at the forefront of efforts to mitigate the risk and impact of HIV.

Follow the science: Engage communities in HIV research

Support must be provided to people and communities living with and affected by HIV to effectively engage in the HIV response. This includes empowering communities to lead and critically engage with cutting-edge science and strengthening the capacity of researchers in resource-limited settings to lead HIV science across all disciplines.

Conclusion

Following the science is key to achieving health equity and universal health coverage for HIV and other disease areas. Innovation must be accessible and equitable, science must inform policy, and community leadership must be taken seriously at every step. The greatest victories over the past 40 years have not been from HIV scientific breakthroughs alone, but from forming a common front that united scientists, activists and policy makers. The IAS, and its members, must call for the world to follow the science as we gather for the UN HLM and also lead the global HIV community in continuing to innovate and follow the science of tomorrow.

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