Is the UN’s goal to end AIDS by 2030 realistic?

With the success of antiretroviral therapy and advances in research, is it realistic to believe that a cure for HIV/AIDS could be on the horizon?

It’s difficult to say, according to a new commentary that points to gaps in accurate accounting of what interventions are working where and how funding is being used.

“Developing a vaccine is proving to be very difficult and I would put my money on finding a cure before we develop a vaccine,” Brian Williams, PhD, of Stellenbosch Universityand co-author of the commentary published in The Lancet, told Medical Economics regarding the likelihood of ending AIDS.

Brian Williams, PhD

“In a sense, antiretroviral therapy (ART) is already a kind of vaccine except that it stops infected people from infecting uninfected people rather than preventing uninfected people from becoming infected. ART is also a ‘functional’ cure in the sense that the viral load is reduced to almost undetectable levels,” he said. “But even if we had a vaccine, we would have to vaccinate many hundreds of millions of people at risk, while if we had a cure we would only need to cure the 35 million people who are currently infected and hopefully already on ART.”

Whether by vaccine or cure, the goal to end HIV/AIDS is a global effort. In 2014 and again in 2016, the Joint UN Programme on HIV/AIDS announced a goal to end AIDS by 2030 using a 90-90-90 target. The idea is that if at least 90% of people infected with HIV know their status, and at least 90% of them are taking antiretroviral therapy and at least 90% of them are virally suppressed, the goal to end AIDS would be within reach. This is not to say that HIV would be completely eradicated, however. According to Williams’ commentary, the working definition of an end to AIDS is fewer than one new HIV infection and one new AIDS-related death per 1,000 people. Even if that happens by 2030, Williams noted that 35 million people would still live with HIV infection.

Currently, about 60% of HIV-infected individuals know their status, 50% are on ART and 90% of individuals on ART are virally suppressed, he said. There have been large gains in the last several years, with an average of 2 million individuals starting ART annually from 2010 to 2015, to an estimated 18 million receiving treatment by 2016, according to the report. The goal, Williams said, is to reach 27 million people on treatment by 2020. Just one person in treatment could prevent seven new infections, he added.

Next: Financial barriers

Financial barriers

Williams cautioned against optimism, though, noting that a 2016 report indicates that despite $100 billion spent globally to fight AIDS from 2010 to 2015, new infections in five targeted regions of the UN program were unchanged during that same period except for in Eastern Europe where the number of new cases is actually rising.

“If this massive spending and roll-out of antiretroviral therapy has not significantly reduced the rate of new HIV infections, the prospect of ending AIDS in the foreseeable future is bleak,” the commentary notes. “By contrast, other estimates suggest that the continued expansion of antiretroviral therapy will substantially reduce the rate of new infections and AIDS-related deaths in sub-Saharan Africa and elsewhere, the money has been well spent, and further expansion of treatment will reduce costs.”

The commentary urges an accurate review of new HIV infections and AIDS-related mortality so that if current programs aren’t working, the global strategy to fight HIV can be changed.

The immediate action that can be taken now by primary care physicians in the effort to  move toward a cure is to encourage all patients who have any risk of HIV infection to be tested and, if necessary, begin treatment on the same day-a process that is now routine in San Francisco. Monitoring should continue every six months to ensure viral suppression. In places like London and San Francisco, aggressive plans like this are helping healthcare providers win the battle against HIV. But in other places, there is still much work to be done.

“In many countries in Africa the health services are quite dysfunctional,” Williams said. “However Malawi, which is the third poorest country in the world with one of the worst epidemics of HIV in the world has what is, in my view, the best patient monitoring system certainly in Africa and competes with the best in the world.”