THE FORGOTTEN PANDEMIC: 40 YEARS OF HIV-AIDS PANDEMIC. And what has the HIV-AIDS pandemic brought to help the COVID-19 pandemic?

The COVID-19 pandemic has taken up so much space that few of us are aware of 40 years of the HIV-AIDS pandemic.

“From October 1980 to May 1981, five young men, all active homosexuals, were treated for Pneumocystis carinii pneumonia confirmed by biopsy at 3 different hospitals in Los Angeles, California. Two of the patients died. All 5 patients had previous or current laboratory-confirmed cytomegalovirus (CMV) infection and candida mucositis. The five patients described in this US Centers for Disease Control and Prevention (CDC) historical report on June 5, 1981, were previously healthy gay men aged 20–36 years. Their illness and deaths marked the dismal dawn of AIDS recognition. The HIV-AIDS pandemic has been with us for four decades and at least 32 million lives have been lost”.

So far, there have been many lessons learned from the HIV-AIDS pandemic. Investment in science played an essential role in mitigating the effects of this pandemic. But much remains to be learned, including equity, justice, discrimination, and stigma.

And now, the most serious thing is that lessons learned from the HIV-AIDS pandemic have not yet been “fully transferred” to the current COVID-19 pandemic.

However, the HIV-AIDS pandemic is still expanding in Eastern Europe, Central Asia, the Middle East, and North Africa and this already occurred even before the start of the COVID-19 pandemic.

It took 15 years, from the emergence of AIDS, for the development of effective antiretroviral therapy (ART) in 1996. It was demonstrated early on that the disease was not restricted to gay and bisexual men; a group of people with hemophilia in the US who received pooled plasma products became infected. At that time, HIV had not yet been identified and therefore a test for screening these blood products had not yet been developed. Only with the identification of the retrovirus as the causative agent in 1983 was possible to develop the first HIV test and, the recognition, in 1985, that HIV infection could be asymptomatic.

Since then, the absence of any effective therapy and the slow pace of research has sparked many movements targeting entities such as the US FDA (Food and Drug Administration), the pharmaceutical industry, and indifferent and hostile governments. And the answers emerged especially with clinical research, and after hundreds of clinical studies, the first three-drug combination (ART) proved effective in 1996 and the first patients were showing recovery despite their extremely serious clinical conditions. At the same time, there was a serious epidemic in Thailand, with the virus initially spreading among injecting drug users, but quickly becoming an infection of sexually active young men and women with devastating consequences for Thailand, and other nearby countries in the region. However, for these people in the region and most of humanity, this therapeutic advance was not yet available and it would not be available for years to come.

And what was seen?

The majority of HIV patients on ART were in high-income countries; however, most people living with HIV were in low- and middle-income (LMIC) countries. This period from 1996 to 2003 showed a high loss of lives from AIDS and Sub-Saharan Africa was by far the most affected region.

We are watching the “same movie” with the new pandemic (COVID-19): the low- and middle-income countries with fewer resources for diagnostic tests and fewer vaccines.

But as for AIDS care, what has changed afterward?

AIDS care was then expensive, complex, and challenging. However, the idea that some would live but most would die, based largely on geography, was ethically unacceptable.

The echoes of the International AIDS Society Conference in Durban, South Africa, in 2000, were echoed with the clamor that the world must act to prevent unnecessary deaths. There was, at this time, disbelief that rich nations would invest the necessary sums of money to make HIV treatment available around the world.

However, in 2005, with the creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria and with PEPFAR (The U.S. President’s Emergency Plan for AIDS Relief), there was global advocacy and political struggle to drastically reduce the cost of ART, a lifelong commitment to care for millions of people. Mortality rates have been reduced. New and better drugs were developed through massive public sector investment in HIV research.

And now, when the US National Institutes of Health sought trial sites for COVID-19 vaccine trials, in 2020, they turned to research networks and HIV trial sites. Until the advent of COVID-19, the HIV research effort was the largest in history devoted to a single disease.

The world’s attention had already shifted away from HIV/AIDS as the disease morphed from almost certain death to a manageable chronic condition.

While universal health coverage has become a focus in global health; regrettably, HIV has increasingly become an infection in more marginalized communities: sex workers, men who have sex with men (MSM), transgender people, and people who use themselves injecting drugs, teenagers, and prisoners. And, indeed, by 2019, the majority of new HIV infections worldwide were in these populations, for whom limited access to HIV services remains a staunch obstacle to saving lives and controlling the pandemic.

After 40 years, we are still unable to provide basic public health interventions such as harm reduction, needle and syringe changes, and drug treatment for millions of opioid-dependent people.

Was there an impact of the COVID-19 pandemic on HIV?

In 2020, we saw global declines in HIV testing, STD services, and increases in unplanned pregnancies and numerous other activities related to HIV prevention.

However, in contrast, four decades of experience with HIV benefited the response to COVID-19.

First, many leading HIV scientists started the COVID-19 work and helped lead their countries’ efforts. Second, HIV clinical trial infrastructures were quickly involved in the COVID-19 vaccine and therapeutic research. And efforts to make ART available globally, should set an example and are even vital to ensuring equal access to COVID-19 vaccines.

Despite the victories achieved so far, the truth is that the HIV/AIDS pandemic is far from over, although many are working towards the end of the HIV/AIDS pandemic by 2030.

Below we can see the latest global data on the HIV/AIDS pandemic:

. 37.6 million [30.2 million-45.0 million] people were living with HIV worldwide in 2020.

· 1.5 million [1.1 million-2.1 million] people were newly infected with HIV in 2020.

· 690,000 [480,000–1 million] people died of AIDS-related illnesses in 2020.

· 27.4 million [26.5 million-27.7 million] people had access to antiretroviral therapy in 2020.

· 77.5 million [54.6 million-110 million] people have been infected with HIV since the beginning of the epidemic (until the end of 2020).

· 34.7 million [26 million-45.8 million] people have died from AIDS-related illnesses.

How many people are living with HIV?

· In 2020, 37.6 million [30.2 million-45 million] people were living with HIV.

o 35.9 million [28.9 million-43 million] adults.

o 1.7 million [1.2 million-2.2 million] children (up to 14 years).

· 84% [68->98%] of all people living with HIV knew their HIV status in 2020.

· About 6 million [4.8 million-7.1 million] people were unaware they were living with HIV in 2020.

How many people living with HIV have access to antiretroviral therapy?

· At the end of December 2020, 27.4 million [26.5 million-27.7 million] people had access to antiretroviral therapy, compared to 7.8 million [6.9 million-7.9 million] in 2010.

· In 2020, 73% [57–88%] of all people living with HIV had access to treatment.

· 74% [57–90%] of adults aged 15 and over living with HIV had access to treatment, as did 53% [37–68%] of children aged 14 and under.

· 79% [61->98%] of adult women aged 15 and over had access to treatment; however, only 68% [52–83%] of adult men aged 15 years and older had access to treatment; however, only 68% [52–83%] of adult men aged 15 years and older had access to treatment.

· In 2020, 84% [63->98%] of pregnant women living with HIV had access to antiretroviral drugs to prevent transmission of HIV to their sons and daughters.

How many new HIV infections are there?

• Since peaking in 1998, new HIV infections have declined by 47%.
• In 2020, there were 1.5 million [1.1 million-2.1 million] new HIV infections, compared to 2.8 million [2 million-3.9 million] in 1998.
• Since 2010, new HIV infections have fallen by about 30%, from 2.1 million [1.5 million-2.9 million] to 1.5 million [1.1 million-2.1 million] by 2020.
• Since 2010, new HIV infections in children have fallen by 52%, from 320,000 [210,000–500,000] in 2010 to 160,000 [100,000–240,000] in 2020.

How many are AIDS-related deaths?

• Since peaking in 2004, AIDS-related deaths have been reduced by more than 61%.
• In 2020, approximately 690,000 [480,000–1 million] people died of AIDS-related illnesses worldwide, compared to 1.8 million [1.2 million-2.6 million] in 2004 and 1.2 million [840,000–1.8 million] in 2010.
• AIDS mortality has decreased by 42% since 2010.

How does HIV present itself in women?

• Every week, about 5,000 young women between the ages of 15 and 24 are infected with HIV.
• In sub-Saharan Africa, six out of seven new infections among teenagers aged 15 to 19 are among girls. Young women between the ages of 15 and 24 are twice as likely to be living with HIV as young men.
• More than a third (35%) of women worldwide have experienced intimate partner sexual or physical violence or non-partner sexual violence at some point in their lives.
• In some regions, women who have experienced physical or sexual violence from an intimate partner are 1.5 times more likely to be infected with HIV than those who have not.
• Women and girls accounted for approximately 50% of all new HIV infections in 2020. In sub-Saharan Africa, women and girls accounted for 63% of all new HIV infections.

In summary, current data on the HIV/AIDS pandemic are:

• In 2020, 84% [68->98%] of people living with HIV knew their HIV status.
• Among people who knew their status, 87% [67->98%] had access to treatment.
• And, among those who had access to treatment, 90% [70->98%] had achieved viral suppression.
• Of all people living with HIV, 84% [68->98%] knew their status, 73% [57–88%] had access to treatment, and 66% [53–79%] had an undetectable viral load in 2020.

And now we are facing a new pandemic, also far from being controlled. At least two lessons from the HIV/AIDS pandemic can be shared to better “fight” the COVID-19 pandemic:

• investment in science, a lot of investment, for the development of effective therapies and prevention tools was needed for the HIV/AIDS pandemic. Continued investment in science will be needed to beat this new pandemic.
• global human solidarity — without human solidarity, we would never have made HIV treatment accessible to the majority of people living with the virus.

This precisely urgently be applied to the COVID-19 pandemic. Vaccines for this infection must be available to everyone; only with global access to vaccines can we defeat this pandemic.

Drawing parallels between the HIV and COVID-19 pandemics, there are disparities in access to vaccination by populations in developing countries, just as there was with access to antiretroviral agents at the beginning of the HIV/AIDS pandemic.

We have to focus on what has been achieved in the fight against HIV/AIDS; that was truly remarkable. We will need this wisdom and a lot of dedication and also GLOBAL SOLIDARITY BETWEEN PEOPLE AND COUNTRIES in this another pandemic year.

References:

• BREYER C — Lancet 2021; 397: 2142–2143
• UNIAIDS.org.br/access on 15 June 2021
• Fifth United Nations General Assembly High-Level Meeting on AIDS, from 8 to 10 June 2021.

Note: This article was written in October 2021.