World Winning War against HIV/AIDS with Evidence to Prove
By Henry Neondo
A new report by the Joint United Nations Programme on HIV/AIDS (UNAIDS), released Tuesday, shows that the AIDS epidemic is beginning to change course as the number of people newly infected with HIV is declining and AIDS-related deaths are decreasing. Together, this is contributing to the stabilization of the total number of people living with HIV in the world.
To prove the point, new UNAIDS report shows new HIV infections have fallen by nearly 20% in the last 10 years, AIDS-related deaths are down by nearly 20% in the last five years, and the total number of people living with HIV is stabilizing. What is more, the report was released on a day when research field gave clear evidence that daily antiretroviral pill reduces HIV risk in gay men.
Data from the 2010 UNAIDS Report on the global AIDS epidemic shows that an estimated 2.6 million people became newly infected with HIV, nearly 20% fewer than the 3.1 million people infected in 1999.
In 2009, 1.8 million people died from AIDS-related illnesses, nearly one-fifth lower than the 2.1 million people who died in 2004.
At the end of 2009, 33.3 million people were estimated to be living with HIV, up slightly from 32.8 million in 2008. This is in large part due to more people living longer as access to antiretroviral therapy increases.
“We are breaking the trajectory of the AIDS epidemic with bold actions and smart choices,” said Mr Michel Sidibé, Executive Director of UNAIDS. “Investments in the AIDS response are paying off, but gains are fragile—the challenge now is how we can all work to accelerate progress.”
The 2010 report contains basic HIV data from 182 countries and includes country-by-country scorecards. The report gives new evidence that investments in HIV prevention programming are producing significant results in many of the highest burden countries.
From 2001 to 2009, the rate of new HIV infections stabilized or decreased by more than 25% in at least 56 countries2 around the world, including 34 countries in sub-Saharan Africa.
Of the five countries with the largest epidemics in the region, four countries—Ethiopia, South Africa, Zambia and Zimbabwe—have reduced rates of new HIV infections by more than 25%, while Nigeria’s epidemic has stabilized.
Sub-Saharan Africa however continues to be the region most affected by the epidemic with 69% of all new HIV infections. In seven countries, mostly in Eastern Europe and Central Asia, new HIV infection rates have increased by 25%.
Among young people in 15 of the most severely affected countries, the rate of new HIV infections has fallen by more than 25%, led by young people adopting safer sexual practices. In South Africa, the rate of new HIV infections among 18-year-olds declined sharply from 1.8% in 2005 to 0.8% in 2008 and among women 15–24 years-old it dropped from 5.5% to 2.2% between 2003 and 2008.
In 59 countries including 18 of the 25 countries with the highest HIV prevalence, less than 25% of men reported having sex with more than one partner in the last 12 months. Eighty-four countries reported the same behaviour trends for women.
Condom use and availability have increased significantly. Eleven countries—from Burkina Faso, to India, and Peru—report more than 75% condom use at last higher-risk sex.
Data from 78 countries show that condom use among men who have sex with men was more than 50% in 54 countries.
Reports of condom use by sex workers are also encouraging. In 69 countries, more than 60% of sex workers used a condom with their last client.
Access to HIV prevention services including harm reduction programmes for people who inject drugs has reached 32%—far short of what is needed to protect drug users from HIV worldwide.
Even though many countries have included male circumcision in their prevention programmes, uptake at a population level remains low, and has not made a significant impact on the rate of new HIV infections.
From the research filed, the iPrEx pre-exposure prophylaxis, or PrEP, trial evaluated the safety and effectiveness of a once-daily dose of the antiretroviral drug TDF/FTC (brand name Truvada) for HIV prevention among 2,499 HIV-negative gay men and transgender women who have sex with men. At the end of the three-year trial, there were 36 infections in participants who received TDF/FTC and 64 in placebo recipients. This translates into an average 43.8% reduction in HIV risk overall in participants who received TDF/FTC compared to those who received the placebo.
The iPrEx findings add to a growing body of evidence confirming the powerful potential of antiretroviral drugs for HIV prevention. This includes findings from CAPRISA 004, a trial of 1% tenofovir gel as an HIV prevention tool for heterosexual women, which found that women who received the gel had an estimated 39 percent lower risk of infection compared to those who received an inactive placebo gel.
After many years of disappointing results from biomedical prevention trials, iPrEx and CAPRISA 004—along with the RV144 AIDS vaccine trial—mark the beginning of a new era of HIV prevention.
“The positive results of the iPrEx oral PrEP study are a major milestone in HIV prevention research and provide important information about how antiretroviral drugs might be used for prevention by HIV-negative people at high risk for HIV infection,” said AVAC Executive Director Mitchell Warren.
“It’s a result that requires immediate action. Because the pill evaluated in iPrEx is licensed and available as treatment for HIV-positive people, gay men and others at risk of HIV need immediate information about what these data tell us and what questions remain. Moreover, gay men and others at risk of HIV need to give crucial input and have influence on what the next steps for this new intervention might be,” Warren said.
“There is a global imperative to act on the results with ambitious, carefully prioritized research and implementation agendas, including strategic demonstration projects,” Warren continued.
The trial underscores the importance of providing a comprehensive prevention package. All of the iPrEx participants received a full prevention package, including condoms, safer sex counseling and treatment of sexually transmitted infections. At each monthly clinic visit, participants were tested for HIV and counseled about daily use of the trial drug, a level of counseling and testing not easily achieved outside of a clinical trial.
The trial also demonstrates that PrEP is only safe in people with confirmed HIV-negative diagnoses. Two cases of drug resistance documented in iPrEx occurred among two men who started PrEP while in the earliest phases of HIV infection, and therefore did not test positive for HIV using the trial’s diagnostics.
iPrEx shows that adherence to the drug regimen is essential. Participants who received TDF/FTC and had detectable levels of drug in their blood were at much lower risk of HIV compared to participants who received TDF/FTC and had no drug in their blood. The trial also analyzed risk of infection as it related to reported rates of pill taking. Participants who reported taking their pills correctly and consistently the majority of the time had significantly lower risk of HIV infection compared to those who reported taking the pills less frequently.
These data can’t be extrapolated to people at risk of HIV via heterosexual sex or injection drug use. Differences in biology of the vagina and rectum, and between HIV risk in sexual versus injection exposure make it essential that ongoing trials looking at PrEP in these contexts must continue.
Even though the number of new HIV infections is decreasing, there are two new HIV infections for every one person starting HIV treatment.
Investments in HIV prevention programmes as whole have not been adequate or efficiently allocated. HIV prevention investments comprise about 22% of all AIDS-related spending in low- and middle-income countries.
More people are living longer and AIDS-related deaths are declining as access to treatment has expanded. The total number of people on treatment increased by seven and half times over the last five years with 5.2 million people accessing life-saving drugs in 2009, compared to 700 000 in 2004.
Over the course of the last year alone, an additional 1.2 million people received treatment—a 30% increase compared to 2008. In addition, there has been a secondary dividend of stopping new HIV infections with increased access to HIV treatment.
However, nearly twice the number of people—10 million—are waiting for treatment. New evidence shows that scaling up treatment has led to reductions in population mortality in high-prevalence settings.
The results could be better—most people receiving antiretroviral therapy in sub-Saharan Africa start treatment late, which limits the overall impact of HIV treatment programmes. Countries have made slow but good progress in integrating tuberculosis and HIV programmes.
As more countries are using effective treatment regimens to prevent HIV transmission to babies, the total number of children born with HIV has decreased. An estimated 370 000 [230 000–510 000] children were newly infected with HIV in 2009, representing a drop of 24% from five years earlier.
Significant gains were observed in sub-Saharan Africa where new HIV infections among children have fallen 32%.
Just 14 countries now account for more than 80% of the gap in providing services to prevent mother-to-child transmission. Nigeria alone contributes to 32% of the worldwide gap.
The report also contains new data which shows that human rights efforts are increasingly being integrated into national AIDS strategies, with 89% of countries explicitly acknowledging or addressing human rights in their AIDS strategies and 91% having programmes in place to reduce stigma and discrimination.
However, punitive laws continue to hamper access to AIDS-related services—79 countries worldwide criminalize same sex relations and six apply the death penalty. In the Asia-Pacific region, 90% of countries have laws which obstruct the rights of people living with HIV.
UNAIDS estimates that a total of US$ 15.9 billion was available for the AIDS response in 2009, US$ 10 billion short of what is needed in 2010 and funding from international sources appears to be reducing.
Donor governments’ disbursements for the AIDS response in 2009 stood at US$ 7.6 billion, lower than the US$ 7.7 billion available in 2008. Declines in international investments will affect low-income countries the most—nearly 90% rely on international funding for their AIDS programmes.
The report highlights the urgent need to sustain and scale up good investments and for countries to share the financial burden of the epidemic. Many countries are under-investing and need to increase their domestic financial commitments to sustain and scale up the AIDS response.
A new Domestic Investment Priority Index developed by UNAIDS shows that almost half of the 30 countries in sub-Saharan Africa are spending less than their capacity— commensurate to their disease burden and availability of government resources. The index also shows that some developing countries with strong economies can meet a substantial portion of their resource needs from domestic sources alone.