The end of AIDS?

Abstract

In recent years, the phrases “AIDS-free generation” and “end of AIDS” have become rallying cries for the global HIV community. The fact that people dare even imagine these goals becoming realities is testimony to the advances made in the understanding of HIV and AIDS and treatment of the diseases, so that a person infected with HIV need never develop the debilitating and terminal immune dysfunction. Indeed, when naming this journal, we made the decision not to include the word AIDS partly in recognition of the huge steps forward in the past few decades and the hope that AIDS would be soon, relatively speaking, consigned to the past. In this issue of The Lancet HIV, a study by Viviane Lima and colleagues provides irrefutable evidence of just how comprehensive coverage with antiretroviral drugs can drive down the incidence of AIDS. Using data on people living with HIV in British Columbia, Canada, from 1990 to 2013, the researchers from the British Columbia Centre for Excellence in HIV/AIDS in Vancouver show how the introduction of combination antiretroviral drugs in 1996 precipitously reduced AIDS morbidity and mortality. In 1994, at the peak, 696 AIDS-defining illnesses were recorded in the province; in 2013 this number was just 84. The number of AIDS-related deaths declined from 241 in 1996 to 44 in 2013. These figures show how access to effective HIV drugs can achieve substantial and sustainable reductions in AIDS and that an end to AIDS is a real possibility under the right circumstances. In a linked Comment, Stefano Vella points out that the end of AIDS is not the end of HIV and that although the current treatments and strategies might be sufficient to prevent AIDS, innovations will be needed in health care to eliminate HIV, and even under the most favourable circumstances, eradication of the virus and new infections is a long way off. Of course, the success in British Columbia reported by Lima and colleagues has been achieved under circumstances unlike those in much of the world where most people with HIV live. And AIDS remains a substantial, albeit declining, problem. Whereas AIDS-related deaths in the province declined by 82% from their peak in 1994, worldwide AIDS mortality fell by 35% from its peak in 2004 (a signal in the global lag in access to medicine)—when an estimated 1·5 million people died of AIDS-related causes. Against this backdrop, a commitment to the UNAIDS 90-90-90 targets (90% of people with HIV diagnoses, 90% of people with diagnosed HIV on treatment, and 90% of people on treatment with suppressed virus) will consolidate efforts made so far in the fight against AIDS. As highlighted by Wilson and colleagues in Correspondence to this journal in January, the initial scaling up of identification and treatment might not rapidly diminish the numbers of new HIV infections. However, ensuring that people with HIV are able to start treatment before they are severely immunosuppressed and can effectively manage their infection will help to contribute to a worldwide reduction in AIDS-related morbidity and mortality. With this in mind, recent reports of a breakdown in parts of the HIV programme in India are a major concern. Although India's prevalence of HIV is not among the highest in the world, the sheer size of the country means that India is home to about 2·1 million people with HIV. But according to a Wall Street Journal blog, the Delhi Network of Positive People say that in New Delhi access to drugs for people on treatment is becoming a problem. More worryingly, the most basic measures of prevention are apparently not accessible in some centres—sexual health clinics have run out of supplies of free condoms. In the short term, the damage might not be too great, but if the situation in India persists, an increase in AIDS morbidity and mortality could result. The Indian government must act fast to restore consistency to the programmes coordinated by the National AIDS Control Organisation—for a country that positions itself as a leading producer of generic affordable medicines for the global market not to be able to provide essential medicines to its own population is a major failing. Data from some settings suggest that an end to AIDS is tantalisingly within reach. However, complacency could jeopardise the progress so far. Countries with weaker health systems must do their utmost to ensure care for people living with HIV is protected from disruption. Until there is a cure, HIV infection must be prevented from progressing to AIDS by providing patients with accessible, consistent, and reliable care.