Is the World Any Closer to Ending AIDS?

November 30, 2012

DIBYANGSHU SARKAR/AFP/GettyImagesAn Indian child walks past a mural painted on the side of a train Kolkata in West Bengal, India. India has the world’s third largest population living with HIV/AIDS. Photo by Dibyangshu Sarkar/ AFP/ Getty Images.

An AIDS-free generation? Sounds hopeful enough, but if the latest HIV catchphrase has you gazing optimistically at today’s youth, you might want to look a bit further down the line.

Only 13 percent of high schoolers and 35 percent of 18- to 24-year-olds have been tested for HIV, even though the group accounts for more than a quarter of new infections (26 percent) in the United States. That means that more than 1,000 young Americans contract HIV every month and the vast majority — roughly 60 percent — don’t know it, won’t seek treatment and can easily and unknowingly pass the virus on to others, according to the Centers for Disease Control and Prevention’s most recent Vital Signs report.

Those are just some of the new figures circulating in the lead-up to World AIDS Day, which is Saturday. Not all the data are bad. Far from it.

Take, for instance, some of the stats from a new UNAIDS report, which shows progress being made on a number of fronts:

AIDS-related deaths are down globally: They fell to 1.7 million in 2011, down from 2.3 million in 2005.

New infections are down globally: They fell to 2.5 million new cases in 2011 — a full 20 percent lower than in 2001.

Treatment is up globally: The number of people receiving life-saving drugs is up 20-fold since 2003. By the end of 2011, around 8 million people were being treated with AIDS drugs around the world.

Yet in the same breath as the optimism, UNAIDS officials are quick to add that the world has a long way to go before reaching the AIDS goals it set for itself back in 2011, which include universal access to antiretroviral therapy and cutting in half the sexual transmission of HIV.

So what’s it all mean? With treatment up, deaths down, a “startling” number of U.S. teenagers infected and a mixed report on the 2015 goals, what’s the take-home message this year on World AIDS Day?

Here to help us contextualize this year’s AIDS figures is Jon Cohen, a Science magazine correspondent who has long covered the domestic and global fight against HIV.

Let’s start with this recent UNAIDS report. What did you find to be most significant?

Cohen: There’s a lot of progress being made in getting antiretroviral treatment to more people. The number receiving treatment is up to eight million people right now in low- and middle-income countries. But there are 15 million people in need, so there are seven million who still aren’t receiving drugs, who need treatment now. And the goal is by 2015, to get drugs to all of those people. It doesn’t look like it’s going to happen.

There’s also a goal to reduce sexual transmission between 2011 and 2015 by 50 percent. And there’s been a reduction in transmission, but about half of it is within mother-to-child transmission. It’s not sexual transmission, which remains the main driver of the epidemic.

Another goal is to reduce transmission by injecting drug use by 50 percent. It turns out that the places that have the highest transmission by injecting drug use are in many cases doing the least to seriously address the problem.

So there’s good news in the sense that the epidemic has stabilized, that new infections are dropping compared to a decade ago. And the more sobering news is there’s a lot of progress that the world collectively agreed should happen by 2015…and it just doesn’t look like much of it is going to happen.

The CDC released U.S.-specific figures earlier this week. What did you find was most interesting about those figures?

Cohen: At a big-picture level, the fact that they’re focusing on youth is in itself the real message. And the message that they’re putting out is that young people — which they define very broadly, from 13 to 24 — account for one-fourth of the new infections. And about 60 percent of the people in that age bracket who are infected don’t know their status….You can’t help people who are infected unless they know that they’re infected.

… The other major theme in this CDC report — there’s a lot of talk of the spread of HIV among men who have sex with men. That’s where the epidemic is in the United States. It’s among young, black, gay men. That’s the real root of the problem. One of the trickier questions to answer is why. Why is this population so vulnerable? It turns out their behavior isn’t that different from other groups in terms of number of sexual partners, condom use or risk factors like drug and alcohol use. But one thing that is markedly different is these men tend to have sex with black men. The population that they’re in has a high prevalence that makes it much more likely that they’ll contract the virus. And in many cases, HIV is being transmitted from older men to younger men, which is a great risk factor in and of itself. If you’re older, you’re more likely to become infected. It seems obvious, but a lot of young people don’t think that through.

Does the CDC have a new plan for addressing this?

Cohen: Yes, they have a plan, but it’s the same plan that they’ve been pursuing. I think that the real limiting factor here is that…states determine how they educate kids — that’s where the kids are getting their messages. The health care systems in individual states differ dramatically. And a lot of kids at highest risk have the least access to health care. So it’s a really complicated problem.

Coming out of the International AIDS Conference in July, we were hearing a lot about treatment as prevention. Treat infected individuals as early as possible, suppress the virus in their systems and they’ll be far less likely to spread the disease, even if they engage in risky behavior. Is there still so much buzz around that idea?

Cohen: Sure. You’re going to hear more and more about it over the next years as we see actual progress in communities that roll out massive treatment. It works. The problem is that a lot of people that start treatment don’t do it properly and they don’t fully suppress their virus. If you don’t fully suppress your virus, you’re not going to get the bang for the buck in terms of treatment as prevention.

There’s something called the treatment cascade. What the CDC and other groups have shown is about 20 percent of the people in the United States don’t know their HIV status, about 20 percent of the people who learn their status will never hook up with a health care provider, 20 percent who do hook up with a health care provider never start drugs and 20 percent who start drugs don’t take them properly. So there’s a cascade of problems all along the way and it’s a cascade that’s even more pronounced in youth. Until that is addressed more aggressively, the real treatment as prevention benefit isn’t going to be realized….The solution is finding a way to help people who have many problems to take drugs every day for the rest of their lives.

Are there places in the world where this seems to be working particularly well?

Cohen: The hardest-hit places in the world, like South Africa, have more HIV infected people, a higher burden than anywhere: 5.7 million HIV-infected people within the total of 34 million in the world. And I think treatment as prevention in South Africa is more promising than anywhere. The problem — and this came out of the CDC report — the problem isn’t simply that people are taking more risks. In a place like South Africa, the odds of you partnering with someone who is infected are much higher than the odds of you partnering with someone who is infected in the United States, especially if you’re a heterosexual. If it’s a Russian roulette, there are more bullets in the gun. So treatment as prevention can probably have the most dramatic impact in the places that are hardest hit.

We’ve also heard a lot recently about universal testing. What’s behind this recent push?

Cohen: The fact remains that many people in the world who are infected don’t know their status, so there’s a lot of effort to make testing routine and not have it be something that’s an exceptional thing. There are a lot of emergency rooms now in the United States that offer treatment to everyone who comes in, regardless of what they’re coming in for. You can come in for a broken arm and you’ll still get the test. It’s being done in some places as an opt-out policy, which means that everyone’s going to receive an HIV test unless they say they don’t want it. That’s completely different than in the old days when it was a big deal to get an HIV test.

If the universal testing approach achieves its goal — everyone is tested and a lot more people who are HIV-positive are diagnosed — where would the extra money come from to to treat everyone?

Cohen: One of the things that the UNAIDS report highlights is that there’s been a plateauing of funding coming from wealthy countries, but a lot of hard-hit countries are increasing their domestic spending. That’s where the bulk of new funding is coming from. So I think South Africa, again, is an excellent example. It’s a country that a few years ago set out to test 15 million people in its population of 50 million. And it just poured a ton of new money into its own HIV/AIDS prevention and care budget. The money’s going to have to come more and more from these countries.

There’s an Abuja Declaration that was signed many years ago by developing countries, that they would spend at least 15 percent of their GDP on health care, and many countries haven’t lived up to that commitment, and so the wealthy world, and indeed the middle-income and low-income countries that are living up to that commitment, are now looking more critically at the countries that haven’t.

Is there any talk of the United States increasing funding for this?

Cohen: In terms of the United States, there’s a push to do what is called a “Robin Hood Tax,” which is to put a tax on all electronic financial transactions, and it’s been lobbied for a few years now. I don’t know that it’s had much traction. But that could introduce new money. I can’t imagine that the U.S. Congress, given the country’s budget woes, is going to launch a massive new program to do anything internationally in terms of HIV and AIDS. It might, but it doesn’t seem like that’s going to happen. The U.S. is the biggest donor to the Global Fund and is also independently doing the PEPFAR program (President’s Emergency Plan for AIDS Relief) to bring drugs and prevention to countries around the world.

So I think the real question is to look at other wealthy countries. The U.S. is leading the way. And I don’t mean to sound like a booster, because I’m just looking at it critically. I think the U.S. is doing its fair share and there are other wealthy countries in Europe that are not….One of things that stood out to me a couple years ago at the International AIDS Conference was that is was held in Vienna, Austria, and Austria doesn’t contribute much of anything to the Global Fund to Fight AIDS, Tuberculosis and Malaria. I think you have to look critically at Russia, as well, and what is it contributing? I think there are several Middle Eastern countries that are very well off that aren’t contributing much. I think Saudi Arabia is an exception….

This is one of the actual Kumbaya things that the world has accomplished. The creation of the Global Fund is a revolutionary idea that basically came out of nowhere in 2002 and has provided treatment to half the people in the world who are getting treatment today who are in resource-limited places. It’s a magnificent accomplishment and it’s been done by the world saying collectively, ‘We can do something with our money to solve a problem.” But the fund has to be replenished constantly.

And we also have to look more critically at what it means to be a middle-income country. There are more and more low-income countries that are moving into middle-income status and there’s a World Bank report that came out last year that says that more countries are moving up the ladder and I think the wealthier world wants those countries to pull their weight.

Let’s talk a bit about prevention. Where does research for a vaccine stand?

Cohen: That’s still the dream. I mean, if you could go get three shots and never have much of a risk of HIV, that would be the ideal way to bring the epidemic to a screeching halt. And certainly, it’s worked with lots of other infectious diseases, where in a very short time, we’ve derailed epidemics. The polio epidemic, for example. That came out in 1955 and by 1961, that epidemic had been ground to a halt in the United States. The vaccine was only used by 70 percent of the people and the vaccine was only 70 percent efficacious. So you can you can get a lot of mileage out of a vaccine.

Where we stand with an HIV vaccine is that this is a very hard vaccine to make and we know that because so many smart people have tried, so many companies have tried, so much money has gone into this and there is no candidate vaccine on the horizon that looks all that promising. The basic research is progressing and there’s been a lot of advances made in trying to find the proper antibody response. Antibody is just one immune response that can stop a virus but it’s an important one and that’s been a very hard thing to find with HIV vaccines — a vaccine that actually triggers the immune system to produce an antibody that works against many, many strains of the virus….We have the target, we just don’t know how to get there.

Are there any other interesting studies out there that you you’re keeping an eye on at the moment?

Cohen: This stuff moves in fits and starts. Right now, the low-hanging fruit have all been picked. All the easy answers are there. So now the questions that remain are incredibly complicated questions. How do you cure someone who is infected? That remains another dream, just like the vaccine. One person has been cured. But the way he was cured isn’t applicable at large. He had leukemia and had his immune system basically eradicated and a new immune system put in. That’s not practical at all. So the basic research that’s going into a cure and into vaccines is really the most exciting stuff and it’s defined by serendipity. It’s defined by people stumbling upon things that they weren’t necessarily even looking for. So there’s no way to predict what’s going to come out of that.

In terms of large clinical trials of drugs, we’re way passed that era. There are loads of good drugs on the market. And in terms of proving that drugs prevent infection, we know that. There’s still a dream for a microbicide that women can use — a vaginal gel that stops HIV. And I think that we’ll see progress there.

I also think that we’ll see progress with people starting to use antiretrovirals in uninfected people. We know that pre-exposure prophylaxis works. Studies have shown that that works. It’s not used in many places, but it certainly can protect people.

Finally, people use World AIDS Day to take stock of where we are with all of this. What would be your summary for this year?

Cohen: I think that all these disease days are a marketing campaign by the World Health Organization and other public health institutions. They don’t have a lot of meaning unless something has really changed dramatically in that time period. In this past year, the big shift and the big insight didn’t happen in the past few weeks. It happened six months ago, 12 months ago, where there became a mantra where we really now have the tools to end AIDS epidemics in specific locales with all the prevention modalities that have proven themselves….

Frankly, I think that there is a bit of reluctance to speak honestly about the challenges that remain because they’re so daunting. A lot of what these disease health days are trying to do is to convince donors to keep funding and solve the problem. So they, of course, want to highlight progress because they want donors to know that they’re getting their bang for their buck. And it’s true, they are. Progress is being made. It’s not a fiction. But when you balance it against the things that haven’t happened and the reluctance of many countries to do the right thing, to do the scientific thing, it’s a very difficult thing for organizations like the United Nations, which is made up of member states, to come out and critically point fingers and say, “These countries are failing and here’s why.’ They try to, and if you read between the lines to find the information, it’s there. But it’s not as blunt as journalists would like it to be and I think that’s part of our job, to highlight that Russia has a huge injection drug use problem and outlaws methodone, which has been shown to work in country after country to get people off injecting opioids. So why isn’t that front and center highlighted and hammered in again and again? It’s just politically dicey.

I think that the one thing that the world can dance in the streets about right now is how much progress is made with slowing mother to child transmission. It’s pretty easy to stop HIV from moving between an infected mother and her baby and there’s a whole health care infrastructure that’s set up for pregnant women. Places that take advantage of the medication that exists basically don’t have transmission from mother to children. That’s just something that has had a major impact in the world and that’s one goal that’s attainable if there could just be more of a concerted effort to take advantage of what we know and to highlight the places that aren’t doing it and to shame them. It does require a certain amount of shame, but it’s possible.

Jon Cohen discussed the CDC’s latest Vital Signs report about HIV/AIDS among youth with Hari Sreenivasan on Tuesday’s PBS NewsHour. Watch the full interview here.

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