In the runup to next week’s international Aids conference in Melbourne, Australia, the UN has claimed that Aids-related deaths and new HIV infections have fallen by more than a third in a decade, raising hopes that the disease could be wiped out by 2030.
“If we are smart and scale up fast by 2020, we’ll be on track to end the epidemic by 2030, so that Aids is no longer a public health threat,” Michel Sidibe, head of UNAids, said on Wednesday. “We have a fragile window of opportunity, because what we do over the next five years will determine the next 15.”
The optimism, however, is tempered by two facts: not only are more than half of the 35 million people living with HIV unaware they are infected, but the number of people with drug-resistant HIV, though relatively low, is increasing.
Deenan Pillay, director of the Africa Centre for Health and Population Studies in South Africa, says about 30-40% of his patients have experienced the virus replicating in their bodies after a year of treatment.
Growing numbers of these patients have the potential for a resurgence of the virus, according to Françoise Barré-Sinoussi, who was awarded the Nobel prize in 2008 for helping to discover HIV. “You will have patients with resistant form, they will transmit the virus to others, and long term if this is happening in several countries in the world, we may have a re-emergence of HIV appearing with a form of virus that is resistant to the current panel of antiretroviral drugs that we have.”
While Barré-Sinoussi’s laboratory is working towards a cure or vaccine for HIV, antiretrovirals remain the best defence. Current treatment programmes, which use a combination of three antiretrovirals, tend to suppress the virus and stop its progression. This has meant that most parts of the world are no longer dealing with Aids, but with what Barré-Sinoussi calls chronic HIV infections. Such treatment often allows the patient to enjoy a better quality of life.
Problems of antiretroviral resistance arise when the medication and follow-up care is scarce. Resistance can occur if a virus undergoes a mutation that means it is no longer affected by the drugs. One way to avoid this is to test patients regularly to monitor their virus levels. If resistance is detected, the patient should be given a new set of antiretrovirals, which should eliminate the resistant viruses.
If the medication is not taken properly, for example if a patient stops taking it, or if they take a reduced dose, the virus will begin to multiply in the patient’s body. This has consequences for health, but also increases the chance of antiretroviral resistant mutations gaining a hold.
In Malawi, UNAids estimated that just over 10% of adults were living with HIV in 2012, with 46,000 deaths attributable to Aids that year. The country has planned to roll out both the regular testing and salvage treatment – the last line of defence against HIV – along with early treatment, but there is not enough money to do it. The problem is exacerbated by the high price of less common antiretrovirals – salvage treatment costs more than 14 times as much as the most common antiretroviral treatment.
Where countries do have the funds for medication, inadequate health systems and social issues can cause different problems. In South Africa, more than 6 million people are estimated to be living with HIV. But although the country has put aside funds for common antiretroviral treatments, it is often difficult to get them to patients, either because there is a large amount of internal migration or because health systems are oversubscribed.
This is of particular concern in areas with a high level of transmission. In South Africa’s rural Hbalisa subdistrict of KwaZulu-Natal, where Pillay’s work is focused, a young woman coming into adolescence now has an 80% chance of being infected with HIV in her lifetime, he says. “It is inevitable that we will see transmitted drug resistance,” Pillay said. “The debate is the degree to which that transmitted drug resistance will compromise our ability to control the epidemic.”
One of the solutions suggested by Barré-Sinoussi is to use new funding models to provide treatment. Last year Cameroon said it could not supply antiretrovirals to half of the patients who needed them because of a shortage of drugs. In 2005, the French president, Jacques Chirac, instated an airline tax that has been used to fund treatment in the developing world for HIV/Aids, TB and Malaria. Barré-Sinoussi has requested a meeting with the current president, François Hollande, to argue for a percentage of the Robin Hood Tax to be devoted to global health to plug the gap.
It is a sentiment echoed by Sharonann Lynch from Médecins sans Frontières’ Access Campaign. She says a reliable, steady funding stream is needed, which could be supplied by a tax on financial transactions. This would allow clinics to buy more drugs, helping to cover contingencies such as disrupted supply lines and allowing patients to take away up to three months’ supply.
“If we can address better procurement and supply, we can reach more people and make it easier. The health system has got to adapt,” Lynch said. “It is about getting treatment into people’s lives, not the other way around.”