What would my 23-year-old self have made of my 63-year-old self moderating a session on the end of AIDS as a public health threat by 2030? I’m sure he could not have imagined a World AIDS Day.
In October of 1983, I was in my fourth month as the first communications director of the Gay Men’s Health Crisis (GMHC) in New York. If we weren’t then, we would soon be the largest AIDS service organization in the United States. I had been in New York for less than a year, working on morning drive at a news and talk radio station. Fresh from years in Alabama and Georgia, my naÏvety knew no bounds.
For us, then, AIDS was an emergency. We thought we were fundraising and counselling and managing politicians to get past a crisis. It soon became clear that the numbers were vast and the crisis would become a fact of life and death for affected communities across the world. More chilling still, AIDS had been present in humans since the early part of the twentieth century but, because only Africans were dying, no-one had even noticed.
By October of 2023, the twin miracles of pharmaceutical discovery and global political will had turned HIV into a manageable chronic condition, but I had become much more world weary about the crisis ever concluding. I moderated a panel that month at the World Health Summit in Berlin and left it thinking that the world really could achieve the UNAIDS goal of ending AIDS as a public health threat by 2030.
The triumph of hope
“Sixteen years ago, I landed in Lilongwe and, on the way from the airport, there were roads full of coffin makers… I’ve been back and I’ve seen what happens when there is a commitment of resources and the will to fight AIDS,” Dr Mamadi Yilla, the Deputy Global AIDS Coordinator for Multisector Relations at the U.S. Department of State, told the panel. My moment of hopelessness came standing on the Thai – Burmese border sometime around the turn of the century and wondering how people caught up in fighting, without reliable access to primary care could ever be treated with the new highly active antiretroviral therapies.
Despite the coffins and the insurrections, we are within grasp of the current 90-90-90 global targets: ninety percent of those infected knowing their status, 90 percent of them on treatment and 90 percent of them with undetectable viral load. “Being hopeful is what has carried us through the last 30 years,” said another panel member, Christine Stegling, the Deputy Executive Director for Policy at UNAIDS. It was naïve and almost foolish hope but it changed the world
To understand how vast the accomplishment is, appreciate that minimal success in HIV is defined as 90 percent being on treatment effective enough to remove any trace of the virus; in Europeans being treated for hypertension, at least 40% do not control their high blood pressure. Those Europeans have no stigma, no supply chain interruptions, no systemic lack of primary care and very few side effects, yet they are four times as likely as a typical African with HIV to be incapable of controlling their life-threatening illness
We will need more resources and more political will to reach the remaining ten percent. The technological innovations coming will be especially important in the areas where the challenges are toughest. “The places that we’re getting to late are the ones with the most need,” said panellist Janet Dorling, Senior Vice President, Intercontinental Region and Global Patient Solutions at Gilead. “They’re often the ones with the most people at the most risk…But with partnerships we can do things differently,” she added.
About 4,900 women a week are still contracting HIV and 4,000 of those are in Africa, Dorling said. Reaching them is complicated by the baked-in inequity around women’s access to healthcare in Africa, panellist Florence Riako Anam said. She is the co-Executive Director of the Global Network of People Living with HIV – GNP+.
Five countries are on track to remove AIDS as a public health threat by 2030, while 16 more are almost there, Stegling reported. The disproportionate share of national and donor resources required to achieve 100-100-100 goals should, I think, be seen as justified. “Everything about the HIV response is a model. This HIV response has taught us about how we serve vulnerable people whatever the threat impacting them” Yilla said
The incredible world waiting for us
The key role in reaching the end of AIDS as a threat will come from people living with it. “The ultimate goal for us is to be undetectable [have an undetectable amount of the virus in the bloodstream] because we will live long healthy lives… but also because the science tells us that if we’re undetectable, there’s zero risk of transmission… We must now use the confidence of the science to shift how we talk about HIV,” Riako Anam said.
Science and innovation will be vital too. One innovation, Stegling said, tends to become transiently fashionable – the focus of all attention – while others are neglected, often those for women. Then the pack moves on. “They take one thing and bold it, while forgetting everything else,” Riako Anam agreed.
Innovation can not only prevent infections and improve quality of life; “innovation can help combat barriers and inequity,” Dorling said, but cautioned that it had to be innovation centred on those living with or vulnerable to HIV. Without transformative, multi-sector partnerships, the panellists concluded, new technologies and approaches would still come to Africa a decade late.
Scientific progress means that there is “an incredible world waiting for us”, Yilla said. Digital practitioners in Lusaka are already using telemedicine to deliver expert care through remote clinics. Digital technologies and AI could transform many aspects of care, she thought. But, she added, that progress in discovery had to be accompanied by progress in policy. Several panellists discussed a wave of bad policies on issues such as criminalising same-sex partnerships and any sexual relationships at all for people living with HIV and AIDS. “Bad policy will undermine the gains we have made in HIV,” Stegling warned.
There is “a growing global numbness to pain,” Riako Anam said. It is made worse by those too young or too forgetful to remember how things were twenty years ago in the boom time for coffin makers. “There is a whole generation who don’t know what 2003 was like and some of these people are making decisions,” she added. “They don’t remember what people with HIV looked like then.”
I remember clearly the skeletal, lesion-covered bodies of the early years of the epidemic. I also remember the hopelessness that set in as the scale of the epidemic became clear. This panel reminded me that I have, throughout the forty years since, underestimated the power of hopeful people to change the world. The threat is now almost over.