Is AIDS getting out of control again?

This week, Alvaro Bermejo steps down after 12 years in the role of Executive Director of the International HIV/AIDS Alliance.  Before going he has issued a stark warning on the back of data released by UNAIDS in its 2015 World AIDS Day report.

Every year UNAIDS releases an annual World AIDS Day report full of epidemiological data and analysis on the global HIV epidemic. We’ve come to expect a triumphalist tone from these reports over the last few years. The 2015 report is no exception.

We fully agree there is much to be proud of. Particularly the progress in extending treatment to the 36.9 million people living with HIV; right now, nearly 16 million people have access to lifesaving drugs. 

However, Alvaro Bermejo’s has raised concerns, in the context of the current UNAIDS-led push to ‘Fast Track’ the AIDS response by 2030, about the apparent flat-lining in the number of people who are becoming newly infected with HIV.

What does the data say?

In the latest UNAIDS strategy (2016-2021), the agreed target for ‘eliminating’ new infections is to reduce them to 200,000 a year by 2030. Dr Bermejo would argue that a reduction of 200,000 infections is an insufficient target, but leaving that aside, he further questions whether the international community is on track to end the AIDS epidemic by 2030. This commitment was made by the world as part of the new Sustainable Development Goals which kick in next year.

In his final report to the Alliance Board of Trustees this week, Dr Bermejo suggests the data presented in the 2015 UNAIDS report is misleading. He notes that the reductions in HIV infection are based on a comparison with figures from 2000. This hides the reality that much less progress has been made in reducing new HIV infections than the report seems to indicate.

According to Dr Bermejo, “Something is not going as planned. We were aiming for a 50% reduction between 2010 and 2015 (see previous UNAIDS  strategy 2011-2015). Previous figures had suggested that we had only achieved a 13% reduction by the end of 2013. This year these figures have been revised down to show that we have achieved an 8% reduction since 2008, or approximately 1% a year.”

He continues “This has happened while we were busy congratulating ourselves for the initial declines in deaths and new infections since their peaks ten years ago (there were 4.9 million new HIV infections in 2004) and more recently, when we have been talking about - but have not yet witnessed - the massive prevention benefit of using HIV treatment to decrease the risk of HIV infection.”  Of course, one reason for this is that most people (over 50%) do not know they have the virus. 

Why new HIV infections are not falling quickly enough?

The focus of the UNAIDS report this year is on populations and locations and this approach is not disputed.  The report itself recognises many of the causes of the failure to reduce the number of new infections:

  • Poor targeting of HIV prevention services – the wrong people in the wrong places – or even if on target, simply failing to reach them.
  • Failure to invest in systems that reach the populations who are most vulnerable and most stigmatised – sex workers, people who use drugs, gay men and other men who have sex with men and transgender people.
  • And under-investment in HIV prevention.  According to UNAIDS global investments for the AIDS response need to increase from US$20 billion in 2014 to more than US$31 billion by 2020, with a quarter of this being invested in prevention.  However, we know we are struggling to attain these funding levels. Research by the Kaiser Family Foundation and UNAIDS published in July this year, acknowledged that the $20 billion raised in 2014 was already below the UNAIDS estimate of $22-24 billion needed to address the impacts of HIV last year.

A call to action

We need political will and financial investment in HIV prevention if we are really to see a reduction in the number of new infections.  For Dr Bermejo, it is this and only this that will end the AIDS epidemic.

“I’m ashamed of myself for not having dared (enough) to be a party pooper. We were bowing when we should have been howling. Even as I prepare to leave the Alliance, I’m struggling. Maybe I’m reading it wrong but if we wait longer to see how trends settle before drawing conclusions, we may be too late. 

“In my view, we have enough data to know that we are not reducing new HIV infections fast enough. This is not the picture of an epidemic heading towards the end of AIDS but one that is threatening to get out of control again.”

Christine Stegling is set to take up the role of Executive Director of the Alliance in January 2016.