What Will It Take to Reach HIV Epidemic Control?

Tremendous achievements have been made in the global HIV/AIDS response, yet obstacles remain before the world reaches the point of eliminating AIDS.

Globally, deaths due to AIDS peaked  at 2 million in 2004. Mortality has dropped to 650,000 in 2021, reflecting impressive improvements in HIV treatment. New infections have been declining each year as well, but 1.5 million people were infected in 2020, far greater than the goal of 500,000 set by UNAIDS.

“Though these numbers are encouraging, they are not what we had hoped to see by now. But we have reasons to be optimistic about the future,” says Jessica Justman, MD, senior technical director at ICAP, a Columbia-based organization addressing a wide range of global health threats, including HIV.

“Exciting new prevention technologies are increasingly available and, even more important, we have new approaches to reach populations that have not yet had access to HIV services.”

The goal of UNAIDS is to eliminate AIDS as a public health threat by 2030, but it’s important to realize the epidemic will not be over then, says Justman, who is also associate professor of medicine in epidemiology at Columbia University’s Mailman School of Public Health and the Vagelos College of Physicians and Surgeons.

“The HIV epidemic will most likely evolve, and HIV will become increasingly endemic, a term we all became more familiar with when talking about COVID.”

We recently spoke with Justman about some of the tactics needed to control the HIV epidemic.

Focus on the gaps

Further reductions in infections and deaths will not be possible with a one-size-fits-all strategy. Each country is different, and even in countries where infections are declining, some groups are being left behind.

More granular data are critical for identifying populations in need and designing tailored programs to reach them, Justman says.

In Africa, young people (between 15 and 24 years of age) are one such group, as identified by population-based HIV surveys that a number of countries have conducted with funding by PEPFAR through the CDC, with technical assistance from ICAP.

“Whether you look at the countries making the best progress or countries making the least, younger adults living with HIV are getting left behind: Fewer people under 25 are tested, treated, and virally suppressed compared to people over 25,” Justman says.

Adolescent girls, who account for six of every seven HIV infections among adolescents in sub-Saharan Africa, are also a priority. Services need to meet these groups where they are to be effective, and ICAP has created a learning network, CQUIN, to bring together health system leaders to identify and disseminate the most effective models of care that are tailored to these groups.

“Some groups may be best served by a peer-to-peer system in the community, others by health care workers at facilities. We need to adapt and be flexible,” Justman says.

Optimize rapid tests for recent infection for greater impact

Rapid tests for recent infection identify people with new HIV infections, and the aggregated data can identify hot spots of current HIV transmission.

People who have been infected with HIV within the past year make less mature antibodies compared to those with longer-term infections, and the rapid tests for recent infection leverage this difference.

“Because recently infected individuals have higher HIV viral loads, they are more likely to transmit the virus to others,” Justman says, “and identifying them as soon as possible can potentially prevent subsequent transmissions.”

ICAP is working to deploy these recency tests at thousands of sites in countries around the world and at the most impactful sites.

“Here is another area where data are critical,” Justman says. “The data tell us that conducting HIV testing in outpatient health care clinics and voluntary testing sites is worth doing. These are the settings where we can more often find people who have a recent HIV infection that they were not aware of.”

Deploy new advances in HIV prevention and treatment

Last year, the FDA approved a long-acting injectable agent (cabotegravir) that prevents HIV infection. “This prevention strategy is an important step forward, not just for the United States, but in the quest for global HIV epidemic control,” Justman says.

In the past decade, the use of pre-exposure prophylaxis (PrEP) pills has helped to prevent infections and reduce HIV transmission around the world (the pills are highly effective at reducing the risk of becoming infected by HIV through sex when taken daily as directed).

But adhering to a strict daily regimen is difficult for most people.

Recent studies that involved ICAP-supported research sites show that injectable PrEP, with injections every eight weeks, was more effective at preventing new HIV infections than oral daily PrEP.

“Some individuals find periodic injections are more convenient and offer more privacy than taking daily oral pills,” Justman says. “We think injectable PrEP offers an important new way to prevent new infections in groups at increased risk of HIV, such as adolescent girls and young women, as well as female sex workers, men who have sex with other men, and transgender  women.”

The “last mile”

None of this will be easy, Justman says, but controlling the epidemic will be helped by the many improvements in health care systems around the world in the past decades.

“It’s important to recall the context. Twenty years ago health care systems in many countries had buildings in need of urgent repairs, labs without equipment and without consistent water or electricity. Hospitals and clinics were crowded and shoeboxes filled with index cards served as medical records,” she says. “It is completely different now and many health systems are expanding capacity and increasingly using the latest digital technologies to manage the care of people living with HIV.

“But we need to remember that it gets harder when you are trying to run the last mile.”