Not long ago, the very notion of an AIDS-free world was one many of us working in the field did not dare dream of.
Now there is a new sense of optimism, driven in large part by scientific advances that have elevated the potential of anti-retroviral treatment as prevention to official health policy. They have been complemented by the development of an international scientific strategy and alliance working towards an H.I.V. cure — an idea that until recently many believed was redundant.
“Getting to Zero” has been the slogan for World AIDS Day (Dec. 1) since 2011 and will remain so through until 2015, coinciding with the Millennium Development Goal target of halting and beginning to reverse the spread of H.I.V./AIDS. This offers a starting point for some more sanguine reflection on how, amid generalized talk of zeros, targets and goals, we can so easily lose sight of the extraordinary barriers that prevent them being reached in the first place.
Asia is a case in point. There is no single “Asian epidemic” — each country in the region has a different epidemiology. In Cambodia, one of only eight countries to have achieved universal access to anti-retroviral treatment, national H.I.V. prevalence has dropped from about 3 percent a decade ago to around 0.5 percent through concerted government and N.G.O. campaigns. Yet a breakdown of that figure reveals an H.I.V. prevalence among drug users in the country of around 20 percent.
Injecting drugs is a major driver of H.I.V. transmission in many countries in Asia. According to UNAIDS, about 16 percent of people who inject drugs in Asia are living with H.I.V. In some countries, this estimate is considerably higher: in the range of 30 to 50 percent in Thailand, 32 to 58 percent in Vietnam and 22 to 28 percent in Malaysia.
Strong campaigns around clean needles and opioid substitution therapy (O.S.T.) by the Malaysian government over the past five years have proven hugely successful in driving down new infections among drug users, and are evidence that harm-reduction programs are key to reducing new infections.
It is simply unacceptable that less than one in 10 injected drug users in the region have access to prevention services and fewer still are able to access anti-retroviral treatment. The issue is further complicated by the overlapping of sex work and injecting drug use in many parts of Asia. Globally only around three percent of injecting drug users living with H.I.V. have access to anti-retroviral treatment — a figure that illustrates the challenges of getting to zero in this key population.
If we are serious about reaching zero, we have to get even more serious about tackling stigma that not only impacts injecting drug users but also gay men and sex workers. A host of new evidence is pointing to new and worrying H.I.V. infection spikes among gay men in countries like Pakistan, Nepal, Thailand, Cambodia, China Vietnam, India, Indonesia, Myanmar and the Philippines. In some cases these account for the bulk of new infections, yet funding for programs to reach out to these communities does not reflect the fast-changing nature of the epidemic
It is also untenable that at a time when we have achieved significant global coverage of the prevention of mother-to-child transmission services, only around 30 percent of pregnant women are offered an H.I.V. test in East, South and South-East Asia.
It is deeply worrying that across these regions only around 16 percent of H.I.V.-infected pregnant women receive antiretrovirals to prevent mother-to-child transmission of H.I.V. We need to closely analyze why current services are not reaching mothers.
Yes, we do have the science to eventually get to zero and end AIDS but the road is full of barriers, bolstered by the stigma of marginalized groups. In many cases that stigma is driven by government policies that continue to maintain and enforce repressive policies toward those groups. Stigma and discrimination have always been the main drivers of H.I.V./AIDS. It has been a combination of community activism, evidence-based policy programming, political courage and scientific developments based on the three pillars of prevention, treatment and care that has successfully tackled those barriers.
Research has led to dramatic progress over the past years, in particular in developing strategies to use anti-retroviral molecules as prevention tools. Vaccine research is also greatly advancing.
More than ever, we need a fourth pillar: an H.I.V. cure. We still have some way to go to completing the cure puzzle, but some of the pieces are ever so slowly beginning to fall into place.
The case of the “Berlin Patient” — the first person to be functionally cured of H.I.V. — has been well documented. Promising too are the results of two recent studies presented at the International AIDS Conference in Washington earlier this year. One indicated that there exists a unique cohort of patients in France who were treated for a limited period very early after infection and for which no sign of viral resurgence is observed several years after treatment has been stopped. The study confirms the benefits of treating H.I.V. at the very early stages of infection. The other study revealed that two H.I.V.-positive men had achieved undetectable viral loads after bone marrow transplants received as a treatment for cancer.
We now have more knowledge, technology and scientific tools at our disposal to seriously attempt to put the pieces together. Some 15 trials on H.I.V. cure related research are currently taking place, the results of which over the coming years will help to inform us if we are on the right track towards getting to zero and ending AIDS.
Françoise Barré-Sinoussi is director of the Regulation of Retroviral Infections Unit at the Institut Pasteur in Paris and president of the International AIDS Society. She was awarded the 2008 Nobel Prize in Medicine for the co-discovery of H.I.V. Adeeba Kamarulzaman is the director of the Center of Excellence for Research in AIDS and Dean of the Faculty of Medicine at University of Malaya in Kuala Lumpur.