No turning back: time to end AIDS as a public health threat

The HIV epidemic has been—and continues to be—marked by deep inequities in access to prevention and treatment, writes Mandeep Dhaliwal

On 5 June, 1981, the US Centers for Disease Control and Prevention (CDC) published an article about a pneumonia-like lung infection in five young gay men—an alarming illness the world now knows as AIDS. While HIV prevention and treatment have come a long way since then, the past four decades have been marked by staggering losses of life and livelihoods around the world due to the disease, underpinned by inequities that have hindered access to life saving tools and services for hundreds of millions of people.

Developments in HIV science have been transformative for people living with HIV, key populations, and other people at risk of HIV. A growing number of options to prevent and manage infection—including pre-exposure prophylaxis (PrEP)bimonthly injections, an intravaginal silicone ring, and advancements in antiretroviral therapy (ART)—have turned a once deadly disease into a chronic, but manageable condition for people who are able to access care. Now, recent reports of a promising new HIV vaccine candidate signal just how far science and innovation have come.

However, despite this significant progress and the hundreds of billions spent on HIV/AIDS, the global epidemic has been—and continues to be—marked by deep inequities in access to these lifesaving prevention and treatment options, echoing the current “moral failure” of global covid-19 vaccine inequity.

Even after decades of progress, marginalized communities still face stigma, discrimination, and criminalization that continue to put them at risk of HIV. Chronically underfunded health systems in low and middle income countries (LMICs) exacerbate these risks, especially during times of crisis. A recent report by the Global Fund found that HIV testing fell 41% as a consequence of the covid-19 pandemic across Africa and Asia, while others have documented decreases of as much as 50% in the scale-up of HIV treatment and reductions in HIV testing by 25-50%.

Worse yet, those at risk of and living with HIV in LMICs may still be grappling with these knock-on effects for years to come: low income countries account for just 0.2% of all covid-19 vaccine doses distributed globally, and the entire African continent accounts for just 1%.

The colliding epidemics of HIV and covid-19 demand that we urgently learn and apply lessons from both to create more equitable systems for health that can help end AIDS as a public health threat by 2030, put an end to current crises, and protect against future health challenges. Yet we must act decisively, and we must prioritize human dignity and equity.

The most recent United Nations Secretary General report on HIV/AIDS makes a clear first recommendation: reduce and end intersecting inequalities that obstruct progress to end AIDS. To start, we must work to change the fact that at least 92 countries still criminalize HIV transmission, exposure, or nondisclosure, and at least 69 countries and territories still criminalize consensual same sex sexual relations. More broadly, countries must have legal and policy frameworks grounded in science and human rights and strengthen systems that reach populations currently being left behind—especially those left furthest behind.

Dismantling legal and policy obstacles and investing in strong systems for health free from stigma and discrimination are crucial for an effective HIV response, and will make countries more resilient in the face of future outbreaks. All this would be aided by policy shifts, like the recent US endorsement of a waiver on covid-19 vaccine patents, that help address “the misalignment” between public health priorities and intellectual property protections, and promote more equitable access to diagnostics, medicines, and vaccines.

In 2001, the first ever United Nations General Assembly High Level Meeting on AIDS made history by setting in motion a significant scale up of the global AIDS response. Twenty years on, the United Nations General Assembly High Level Meeting on AIDS could be equally historic in catalyzing a significant step change in action to end the inequalities that continue to fuel the HIV epidemic—inequalities that assault human dignity and deny people access to life saving technologies and basic services. As in 2001, this will take courage, humanity, and political will.

Powered by global solidarity and backed by the full power of communities and the strength of our multilateral system, this courage, humanity, and political will can help drive the transformative action needed to end entrenched inequalities and improve the lives of people everywhere. There is no turning back if we are going to end AIDS as a public health threat by 2030 and leave no one behind.

Mandeep Dhaliwal is the director of HIV, health, and development at the United Nations Development Programme. Twitter @Mandeep_Dh

Competing interests: none declared.