Ending the HIV pandemic: preparing for the future

Last month, ahead of the International AIDS Conference in Brisbane, Australia, a landmark study published in The Lancet by Laura N Broyles and colleagues reported that people living with HIV who maintain low—but still detectable—levels of the virus (less than 1000 copies per mL) have almost zero risk of transmitting it to their sexual partners. It was a stunning result, adding compelling evidence to further bolster the undetectable equals untransmittable (U=U) HIV campaign. U=U means that individuals living with HIV who successfully sustain an undetectable viral load by consistently taking antiretroviral therapy are unable to transmit the virus through sexual activities. Establishing the link between low viral load and the absence of transmission has far-reaching implications for the prevention and control of HIV, encouraging the wider adoption of affordable viral load testing and helping to destigmatise HIV. There is understandable excitement regarding this finding, and other recent scientific progress in HIV—from the rise of post-exposure prophylaxis, to the development of long-acting injectable treatments. The Sustainable Development Goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030, generally considered by the UN as a 90% reduction in new HIV infections and AIDS-related deaths by 2030, compared to 2010 levels. Any new tools to help meet this ambitious goal are welcome. However, as has been shown many times before, health technologies alone are not sufficient to end the HIV pandemic. Writing in The Lancet HIV, Vincent Guilamo-Ramos and colleagues argue that the Ending the HIV Epidemic initiative in the USA is unlikely to meet its goals. Launched in 2019, the initiative aims to reduce annual new HIV infections to fewer than 3000 by 2030. However, with an estimated 32 100 new infections in 2021, substantial efforts are still required to achieve the target. Guilamo-Ramos and colleagues identify four priorities to address the inequities that are hampering progress: reducing stigma, expanding the HIV workforce, mitigating harmful social determinants of health, and recommitting to and reinvesting in health in the USA. These priorities are relevant not only for the USA, but for HIV globally. The United States President's Emergency Plan for AIDS Relief (PEPFAR) is the key funder of aid for HIV/AIDS globally. In 2023, it had a budget of US$6·9 billion, with $4·8 billion designated for bilateral HIV efforts and the remainder going to UNAIDS and The Global Fund to Fight AIDS, Tuberculosis and Malaria. In its 20 years, it has transformed the global HIV response. However, it now faces the unprecedented risk of not having its funding renewed. Congressional Republicans are threatening not to reauthorise PEPFAR unless prohibitive restrictions are brought in to limit what they claim are links to abortion services. PEPFAR has long been a bipartisan political success amid fractious US politics. To lose it would be sorry condemnation of the USA's ability to be a global health leader, as well as a disaster for health. As Lucie Cluver and colleagues warn in The Lancet, the loss of PEPFAR would undoubtedly result in death, orphanhood, and suffering for millions of children. The funding gap for HIV in low-income and middle-income countries is widening, and further cuts will exacerbate the situation. UNAIDS has estimated a staggering 90% funding gap for prevention programmes for key populations in 2022. These populations include men who have sex with men, sex workers, transgender individuals, people who inject drugs, and those incarcerated and in other closed settings. Ensuring that they can access prevention and treatment is essential. But a shortfall in funding, combined with continued punitive legal and social conditions, perpetuate the barriers to accessing crucial health-care services, posing a grave threat to progress. The HIV and wider global health community is focused on the 2030 deadline for global HIV/AIDS targets and what can be done to meet them. For now, HIV/AIDS should certainly have a place on the agendas of the three upcoming 2023 UN high-level meetings on pandemic prevention, preparedness and response; universal health coverage; and tuberculosis in September. But as highlighted by the International AIDS Society–Lancet Commission, the HIV pandemic is not on track to end, and is likely to remain a major global health issue for the foreseeable future. Its impact will extend well beyond the end of the SDG era. Planning for this eventuality, and making the case for the inclusion of HIV as a priority in the post-SDG world, needs to begin now. For The Lancet study see Articles Lancet 2023; 402: 464–71For The Lancet HIV article see Viewpoint Lancet HIV 2023; 10: e5526–56For the Correspondence from Cluver and colleagues see Correspondence Lancet 2023; published online Aug 17. https://doi.org/10.1016/S0140-6736(23)01723-3For the UNAIDS report see https://thepath.unaids.org/wp-content/themes/unaids2023/assets/files/2023_report.pdfFor The International AIDS Society—Lancet Commission see https://www.thelancet.com/commissions/global-health-HIVFor more on PEPFAR see World Report page 598 For The Lancet study see Articles Lancet 2023; 402: 464–71 For The Lancet HIV article see Viewpoint Lancet HIV 2023; 10: e5526–56 For the Correspondence from Cluver and colleagues see Correspondence Lancet 2023; published online Aug 17. https://doi.org/10.1016/S0140-6736(23)01723-3 For the UNAIDS report see https://thepath.unaids.org/wp-content/themes/unaids2023/assets/files/2023_report.pdf For The International AIDS Society—Lancet Commission see https://www.thelancet.com/commissions/global-health-HIV For more on PEPFAR see World Report page 598 Reauthorise PEPFAR to prevent death, orphanhood, and suffering for millions of childrenAs researchers on HIV, AIDS, and paediatric health, nothing is more central to our work than preserving children's lives. Considering the current challenge to the 5-year reauthorisation of the US President's Emergency Plan for AIDS Relief (PEPFAR),1 we used 2023 UNAIDS estimates on the prevalence of children orphaned by AIDS, infant and young child HIV-infections, and incidence of adult and child AIDS deaths to estimate PEPFAR's effect on child survival and health. We focused on sub-Saharan Africa: the region receiving more than 90% of PEPFAR funds and containing two-thirds of all people with HIV. Full-Text PDF Abortion foes threaten PEPFARRepublicans question funding for the President's Emergency Plan for AIDS Relief, one of the USA's most effective global health programmes. Susan Jaffe reports from Washington DC. Full-Text PDF Is the USA on track to end the HIV epidemic?Despite progress in reducing new HIV infections in the USA, publicly available data suggest that new HIV infections continue to occur at an alarming rate. In this Viewpoint, we highlight the regularity with which the existing systems for HIV prevention and treatment delivery in the USA fail and the clearly inequitable effect of the systems’ failure among several priority populations of the Ending the HIV Epidemic (EHE) initiative. Existing data cast doubt on whether the current EHE efforts will suffice to achieve its 2030 goal of reducing annual new HIV infections to fewer than 3000. Full-Text PDF PEPFAR reauthorisation hangs in the balanceSince its creation by US President George W Bush in 2003, the US President's Emergency Plan for AIDS Relief ( PEPFAR ) has been a crucial component of the global HIV response—supporting HIV programmes in low-income countries hit hardest by HIV/AIDS. Over US$110 billion of investment through PEPFAR has radically reshaped health systems: increasing surveillance capacity, creating large networks of clinical service facilities, and managing drug supply chains. An estimated 20 million people are currently on HIV treatment and 1·5 million have access to pre-exposure prophylaxis thanks to PEPFAR. Full-Text PDF