As with any viral outbreak, the two main goals from Day One of the known HIV epidemic/pandemic have been controlling the spread of the virus (prevention) and treating those who have been infected. Over the past thirty-plus years, major strides have been made in all areas of both the prevention and treatment of HIV.
To date, there are forty HIV antiretroviral medications approved by the FDA for use in HIV-positive individuals. This includes seven classes of drugs and multi-drug combinations. Numerous other new classes of drugs are in development, including therapeutic vaccines, gene therapies, and monoclonal antibodies. Research into basic cure science, particularly HIV reservoirs and immunity, and evaluating strategies for both HIV remission and HIV eradication is being conducted at numerous academic institutions, governmental agencies, and biotech and pharmaceutical companies around the world.
Prevention encompasses many aspects including syringe exchange, counselling and testing, behavior modification as well as biomedical interventions such as treatment as prevention, post-exposure prophylaxis (PrEP), condom use, medical male circumcision, microbicides, and vaccines. With a refinement and wider utilization of many of these prevention strategies, in combination with a greater global access to ARVs (of the 36.7 million HIV-positive people, 19.5 million are on treatment), an average reduction in new HIV cases worldwide of 2.3 percent per year since 2010 has been achieved. However, the question remains to be asked, with billions of dollars invested into battling the HIV pandemic, at our present course, without a widely applicable remission strategy of eradication cure, are we likely to see an end to HIV? Can we treat and prevent our way out of the HIV pandemic?
More directly, during a presentation at this year’s 9th IAS Conference on HIV Science (IAS 2017), Dr. Anthony Fauci, Head of the National Institute of Allergy and Infectious Diseases, NIH, asked the question, “Can we end the HIV pandemic without an HIV vaccine?” Dr. Fauci has been a leading voice and decision maker in HIV since he was named Director of the NIH in 1984, one year after HIV was officially discovered. To answer his own question, Dr. Fauci responded, “Theoretically, yes. Practically—possibly, but not likely.”
Dr. Fauci explored the possibility of ending the pandemic without a vaccine, analyzing several important strategies essential to ending HIV without a vaccine. He pinpointed numerous gaps that prevent the likeliness of this occurring.
Dr. Fauci cited UNAIDS’ 90-90-90 global initiative. In 2013, UNAIDS set forth a final target to, in part, “drive progress towards the concluding chapter of the AIDS epidemic.” This ambitious target has become the hallmark of HIV- related efforts across the globe. This initiative established the objective of achieving by the year 2020:
1. 90% of all people living with HIV will be aware of their HIV status
2. 90% of all people with diagnosed HIV infection will be on sustained antiretroviral therapy
3. 90% of all people receiving antiretroviral therapy will be virally suppressed.
According to UNAIDS in 2016, seventy percent of people living with HIV globally were aware of their status, fifty-three percent were on antiretroviral treatment, and forty-three percent were virally suppressed. Unfortunately, this is a long way away from achieving the 90-90-90 goal, particularly with only three years remaining of the outlined time frame of 2020. According to Dr. Fauci, using the statistics from 2016, by the year 2010, we may be able to achieve one of the 90-90-90 goals with ninety percent of HIV-positive individuals aware of their HIV status, but only eighty-one percent of HIV-positive people on therapy and seventy-three percent virally suppressed.
PrEP has been highly touted as a means of reducing new infections; however, Dr. Fauci pointed out that currently only ten percent of the 1.2 million people in the U.S. at substantial risk of contracting HIV are utilizing PrEP. This despite the many studies which show PrEP to be a viable means of protection from HIV.
Dr. Fauci discussed the economic feasibility of ending the HIV pandemic without an HIV preventative vaccine. In order to maintain the 19.5 million people currently on ARVs, as well as treat the 17.2 million who are in need of treatment, in addition to the 1.8 million individuals newly infected each year and provide PrEP to those at substantial risk, a total of $350 billion dollars will be needed between 2016 and 2030 for low- and middle-income countries. However, Dr. Fauci stated that donor contributions have been on the decrease and, according to Kaiser/UNAIDS study, decreased seven percent in 2016 to its lowest level since 2010. These economic factors create yet another substantial barrier to reaching an end to the HIV pandemic.
Dr. Fauci concluded that despite the substantial impact that enormous advance in HIV treatment and prevention, “implication gaps persist logistically, politically and economically [that] hinder achieving the goal of a durable end to the HIV pandemic.” He concludes that “an HIV vaccine, evenly a modestly effective vaccine, is essential to achieving this goal.” Thus Dr. Fauci believes that “we will need an HIV vaccine to achieve a durable end to the HIV pandemic.”
Jeannie Wraight is the former editor-in-chief and co-founder of HIV and HCV Haven (www.hivhaven.com) and a blogger and writer for TheBody.com. She is a member of the Board of Directors of Health People, a community-based organization in the South Bronx and an advisor to TRW (Teach me to Read and Write), a community-based organization in Kampala, Uganda. She lives with her husband in New York City.