The 25th International AIDS Conference kicked off Monday, July 22, in Munich, Germany with calls to redouble efforts to end the global epidemic as funding cuts and threats to the rights of LGBTQ people and other vulnerable populations jeopardize progress.
Sponsored by the International AIDS Society, the confab, which takes place every other summer, brought together more than 10,000 researchers, care providers, policymakers, advocates, and people living with HIV. But some would-be delegates were unable to obtain visas to attend, and the IAS recently announced that future meetings would rotate among five world regions to ensure equity and inclusion.
With the advent of highly effective antiretroviral treatment and long-acting PrEP — including a new twice-yearly injection that showed 100% effectiveness in a study of young women in Africa — experts said there are now tools to end the epidemic, but many people still lack access.
"We're seeing impressive innovation across the entire spectrum of HIV research," but "science doesn't happen in a vacuum," IAS president Dr. Sharon Lewin told reporters ahead of the opening session.
"All around the world, we're seeing an increase in regressive policies, attacks on human rights, the spread of misinformation, cuts to global health funding, and waning trust in international institutions, which are roadblocks to progress on ending HIV," she continued. "To end HIV as a threat to public health and individual well-being, we need an evidence-based, human rights-based HIV response and a political climate that respects science."
Snapshot of the epidemic
In advance of the conference, UNAIDS released its latest annual report, "The Urgency of Now: AIDS at a Crossroads." The report shows that ending AIDS as a public health threat by 2030 is still an achievable goal, but "success or failure will be determined by the actions taken this year," UNAIDS Executive Director Winnie Byanyima said at a news briefing.
According to UNAIDS, 39.9 million people were living with HIV and there were 1.3 million new infections and 630,000 AIDS-related deaths worldwide in 2023, falling far short of global targets. While AIDS-related deaths have dropped by more than half over the past decade, one person still dies of HIV every minute.
Nearly 30.7 million people are on antiretroviral therapy, but this too falls short of the goal of 34 million by 2025. Currently, around 9 million people living with HIV are not accessing treatment. UNAIDS estimates that 86% of people with HIV knew their status, 89% of people diagnosed were on treatment, and 93% of those had viral suppression in 2023. The global "95-95-95" targets call for all three metrics to reach 95% by 2030.
A study presented at the conference by UNAIDS economist Erik Lamontagne and colleagues showed that rapidly scaling up the global response could avert nearly 35 million new infections, nearly 18 million deaths, and "huge economic cost" between now and 2050.
But inadequate funding for the HIV response is a growing concern as the world's resources are poured into wars, Byanyima said. At the end of 2023, $19.8 billion was available for the response, about $9.5 million less than needed. In the United States, funding for the President's Emergency Plan for AIDS Relief, or PEPFAR, which provides HIV prevention and treatment in more than 50 countries, has been flat for a decade and is currently at risk of being cut. At the same time, poor countries are unable to fund their own domestic response due to crushing debt.
Despite progress on biomedical prevention and treatment interventions, social issues are proving more difficult to tackle, according to Lewin. A growing authoritarian backlash threatens vulnerable populations in many countries, from the Anti-Homosexuality Act 2023 in Uganda to laws restricting reproductive rights and health care for transgender people in the U.S. Studies have shown that laws against same-sex relations and crackdowns on gender-nonconforming people limit access to HIV testing, PrEP, and treatment.
"We have to tackle the discrimination and stigma that are pushing the most marginalized people away from life-saving services," Byanyima said. "We need to get political leaders to stand on the right side of justice, to decriminalize same-sex relations, decriminalize sex work, let people come forward to fight stigma and discrimination, and speak up against hate."
Key research
Scientific highlights at the conference included a case report on the seventh person cured of HIV after a stem cell transplant for cancer treatment and two studies on the use of the antibiotic doxycycline every day — rather than only after sex — to prevent sexually transmitted infections, an approach dubbed doxyPrEP.
But a groundbreaking HIV prevention study garnered the most excitement. As the Bay Area Reporter previously reported when Gilead Sciences released interim data last month, the PURPOSE 1 trial enrolled more than 5,300 adolescent girls and young women in Uganda and South Africa.
The study showed that the antiretroviral drug lenacapavir, given by injection once every six months, dramatically lowered HIV incidence compared with the background rate in the local population and was superior to daily PrEP pills. There were zero new infections among women randomly assigned to receive lenacapavir.
"These stellar results show that twice-yearly lenacapavir for PrEP, if approved, could offer a highly effective, tolerable and discreet choice that could potentially improve PrEP uptake and persistence, helping us to reduce HIV in cisgender women globally," said presenter Dr. Linda-Gail Bekker of the University of Cape Town in South Africa.
Lenacapavir is currently only approved as treatment for people with multidrug-resistant HIV. Before it can receive Food and Drug Administration approval for PrEP, it must demonstrate effectiveness in other populations. Results from PURPOSE 2, a parallel study of gay and bisexual men, transgender women and men, and nonbinary individuals, are expected in late 2024 or early 2025.
Bekker's presentation received a standing ovation — and lenacapavir PrEP was hailed as a "game-changer" — but many fear that the new prevention tool will not be accessible to the people who need it most.
Lenacapavir for HIV treatment now costs about $40,000 per year, but the price could be brought down to around $40 with voluntary licensing and competition between generic suppliers, according to a study presented at the conference. Although lenacapavir PrEP is not yet approved in any country, activists are already demanding that Gilead license less expensive generic versions for low- and middle-income countries.
"In view of the company's ongoing commitment to communities affected by HIV, we have been developing a strategy to enable broad, sustainable access globally," Gilead said in a statement.
According to Byanyima, twice-yearly PrEP would be a crucial advance for people who must live in hiding and have difficulty accessing services due to repressive laws and for young women who fear domestic violence.
"This is not a Gucci handbag for rich people," she said. "We are only six years away from 2030 and we still have 1.3 million new HIV infections per year. We want this miracle prevention to reach all those who need it now, not in six years' time."
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