AIDS 2014: The beginning of the end of HIV?

  • by Stephen J. LeBlanc
  • Wednesday August 27, 2014
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Last month, 12,000 HIV activists, scientists, doctors, and policy makers attended AIDS 2014, the XX International AIDS Conference in Melbourne, Australia. Headlines from the conference were dominated by the tragic downing of Malaysia Airlines Flight 17, which killed six conference attendees including AIDS researcher Joep Lange and his life partner Jacqueline van Tongeren. The most important story of the conference got less attention. International AIDS policy leaders are, for the first time, making serious specific plans to end the epidemic phase of global HIV and wielding antiretroviral treatment of HIV infected people as the most important tool for doing so.

The biennial International AIDS Conference is the largest regularly held conference on any health issue in the world. The conference is part scientific conference, part business convention, part international development meeting, part social scientific meeting, and part global HIV caregiver/patient/activist networking session, with a fair dose of boosterism and show business. Former President Bill Clinton spoke. International activist Bob Geldof spoke. Sir Elton John sent a video. A fashion designer displayed beautiful dresses manufactured from condoms. Public buildings throughout Melbourne were lit deep crimson red and festooned with red banners in recognition of AIDS 2014. There were art events, receptions, dances, dinners, preconference meetings, satellite meetings, and post conference events. Each attendee received an "exclusive invitation" to a champagne event with 10 percent discount shopping at an upscale department store, the invitation illustrated with an elegant model in a fashionable crimson dress.

The world's-fair like atmosphere of the conference has tended to cause AIDS researchers to announce scientific and treatment advancements at other gatherings. Instead, the conference is perhaps most important in providing international AIDS leaders an opportunity to speak to the world with a collective voice in an attempt to direct global efforts to combat AIDS. 

The most important message was eloquently expressed by UNAIDS Executive Director Michel Sidibe in his address to AIDS 2014 attendees: "My vision for ending AIDS [by 2030] looks like this: voluntary testing and treatment reaching everyone, everywhere; each person living with HIV reaching viral suppression; no one dies from an AIDS-related illness or is born with HIV; and people living with HIV live with dignity, protected by laws and free to move and live anywhere in the world."

While the hope for ending AIDS is timeless, this statement includes something startlingly new. Identifying and treating those with HIV has become recognized as the most important tool for reducing new HIV infections worldwide. Efforts for an HIV vaccine, for new prevention technologies, and for a cure continue, but the new priority for preventing new infections and eventually ending global AIDS is providing virally suppressive anti-HIV drugs to every HIV infected person throughout the world.

The new emphasis for global HIV testing, treating, and suppressing has been summarized as the 90-90-90 goals, which were outlined by UNAIDS in a position paper published this year. (see The goals, simply stated, are by 2020 to achieve 90 percent of all people with HIV knowing their HIV positive status, 90 percent of all people who know they are HIV-positive receiving antiviral treatment, and 90 percent of all those treated having sustained suppressed HIV viral load. According to UNAIDS, with these targets, 73 percent of people living with HIV worldwide will have undetectable viral load. This is three times higher than the percentage of those who are HIV-positive with suppressed viral load today.

The statement that global access to highly effective anti-HIV treatment is not only possible, but is the key to ending the spread of HIV globally, is a radical shift in thinking about the importance of treating HIV infected individuals in the poorest countries. In 1996, at the XI International AIDS Conference in Vancouver, headlines reported that protease inhibitors and other highly active anti-HIV therapy were miracle lifesaving drugs for those who could afford them. At that time, it was a nearly universally held view among global AIDS leaders that the drugs would have minimal impact on the course of HIV outside of the developed world "because most people with HIV will never have access to them."

That mindset began to change in 2003 with the commencement of the President's Emergency Plan for AIDS Relief under President George W. Bush. PEPFAR sought to dramatically expand anti-HIV treatment in lower income nations. Even under PEPFAR, however, treatment for the HIV-infected was seen as a separate effort from prevention of new infections. The rationale for providing treatment to infected individuals in PEPFAR was to reduce AIDS deaths and the resulting social and political instability, rather than to prevent the spread of HIV infections. 

Major scientific support for using treatment of HIV infected individuals as a central tool in preventing new HIV infections was first published in 2011. (The HPTN 052 trial.) According to UNAIDS, as of 2014, among all prevention interventions evaluated to date in randomized, controlled trials, HIV treatment has demonstrated by far the most substantial effect on HIV incidence. UNAIDS cited interim findings from the PARTNER study that indicate that among 767 serodiscordant couples, no case of HIV transmission occurred when the person living with HIV had suppressed virus �" after an estimated 40,000 instances of sexual intercourse.

This is the background for the 90-90-90 goals announcement. While the goals are largely viewed as doable, enormous challenges remain. First, one of the presuppositions of the goal is redefining those eligible to receive treatment in low- and middle-income countries (LMICs) under national and international programs. At the present time, the most widely used criteria for treatment of people with HIV in LMICs is to treat those with under 350 CD4 cells. This guideline is believed to triage available anti-HIV treatment to the most ill and about 18 million people are believed eligible for treatment under this guideline. (According to UNAIDS, the world is now on track to provide HIV treatment to at least 15 million people by 2015.) At the end of 2013, the WHO recommended raising the international treatment guideline to anyone with less than 500 CD4 cells. This raises the number of people needing treatment in low and middle-income countries to almost 30 million. Increasing eligibility to all HIV-positive people raises the number of people requiring treatment to 34 million.

Adding 19 million additional people to the pool of those recommended receiving HIV treatment has met with some resistance from governments, funders, and planners. Encouraging people who have never felt sick as a result of HIV infection to take daily antiviral treatment is also a challenge. In one presentation on preventing mother to child transmissions, an HIV activist from Africa stressed that HIV-positive mothers who were not experiencing HIV symptoms should not be pressured into taking medication after giving birth to their babies. This drew an emotional response from one doctor who practiced in lower income communities and said he wished he had the power to force people to take their medications.

Despite these challenges, the 90-90-90 goals are a significant advance in the fight against global AIDS. These goals are the first statement of an international plan to end global AIDS that uses only currently available technologies and an expansion of proven workable programs.


Voluntary male circumcision

The other prevention method that received substantial attention at AIDS 2014 was voluntary medical male circumcision (VMMC), discussed in more than 80 presentations and abstracts. Male circumcision has been shown in a number of studies to reduce the risk for men in Africa of becoming infected with HIV through sex with a woman by as much as 60 percent. Implementation of large-scale voluntary male circumcision in Africa began in 2008. According to the World Health Organization, about 5.8 million men were circumcised in 14 priority countries of East and Southern Africa since 2008, with more than half of those circumcisions performed since 2013. The WHO estimates that attaining and maintaining 80 percent coverage of male circumcision in the 14 sub-Saharan countries could prevent an estimated 3 million HIV infections and save more than $16 billion in future health care costs.


Cure research

AIDS cure research was widely discussed at the International AIDS Conference, but little new science was presented. Former San Francisco resident Timothy Brown (the Berlin patient), remains to date the only person functionally cured of HIV infection. While the therapy used to cure him (bone marrow transplantation with HIV resistant cells) remains an area of study, particularly under sponsorship of the California Institute for Regenerative Medicine, no results in that regard were reported at the conference.

The AIDS cure research story that received the most attention at AIDS 2014 was the announcement that the "Mississippi baby" (now a 4-year-old child) had developed a detectable HIV viral load after two years of being functionally cured. This was widely reported as a huge blow to AIDS cure research efforts. However, the child was never the subject of any clinical trail or experimental therapy, but was instead a baby born HIV-positive, who was put on daily antivirals at 30 hours of age. The child mostly continued this therapy for a year and a half. Thereafter, the child and mother missed doctor's appointments for about five months and the child did not receive antiviral therapy. For virtually all people with HIV, it would be expected they would have a high viral load after five months with no drugs. When the child returned to the doctor, at about age 23 months, the doctor was very surprised to find the baby had no detectable virus. The child was not put back on drugs and a number of ultra sensitive tests showed there was no detectable virus anywhere in the baby's body. The child stayed undetectable, healthy, and showed no signs of an immune response to HIV until the positive viral load test in June 2014.

For AIDS cure researchers, the Mississippi child is one example that complete HIV viral suppression without use of antiviral drugs is achievable for a sustained period of time (two years in this case), but that HIV can also apparently rebound from a hidden compartment in the body even when the most sensitive tests available can detect no complete HIV virus.


Social issue

The social issue that drew new levels of attention at AIDS 2014 is decriminalization and destigmatization. UNAIDS has strongly called for destigmatization and decriminalization of those with HIV and of sex workers, injection drug users, and men who have sex with men who are at highest risk of becoming infected. The prestigious medical journal the Lancet released a special issue devoted to HIV and sex workers. Presentations were made regarding how police can work cooperatively with high HIV risk communities to reduce HIV transmission. Decriminalization activists reported back from the first HIV is not a Crime conference that took place in June.

In 2016, the International AIDS Conference will return to Durban, South Africa, which hosted the conference in 2000. This will be only the second time the conference has been in Africa and only the fourth time the conference has been hosted outside of the world's highest income nations. Africa will be the primary proving grounds for whether the visionary leadership embodied in the 90-90-90 goals can translate into actually reducing new HIV infections and eventually ending AIDS across the globe. South Africa has the highest total number of HIV infected individuals of any nation on earth, with an estimated six million people having the virus. When the International AIDS Conference next invites the world to review and reflect on the response of global leaders to HIV, the toughest and most affected crowd will be sitting front and center.


Stephen J. LeBlanc is a member of the AIDS Policy Project.