Progress in addressing HIV is “In Danger”
Published on 27 June with its launch timed to coincide with the International AIDS Society’s AIDS 2022 conference in Montreal from 28 July to 2 August, this Global AIDS Update 2022 is the most sobering for many years. The Joint United Nations Programme on HIV/AIDS (UNAIDS) says that millions of lives are at risk as progress falters.
This article is based on the aforementioned Update and the UNAIDS press release launching the Update.
New data paint a disturbing picture
New data from UNAIDS on the global HIV response reveals that during the last two years of COVID-19 and other global crises, progress against the HIV pandemic has tailed off and resources have shrunk, and millions of lives are at risk as a result.
“These data show the global AIDS response in severe danger. If we are not making rapid progress then we are losing ground, as the pandemic thrives amidst COVID-19, mass displacement, and other crises. Let us remember the millions of preventable deaths we are trying to stop,”
The organization says that globally the number of new infections dropped only 3.6% between 2020 and 2021, the smallest annual decline in new HIV infections since 2016. Eastern Europe and Central Asia, Middle East and North Africa, and Latin America have all seen increases in annual HIV infections over several years. In Asia and the Pacific – the world’s most populous region – UNAIDS data now show new HIV infections are rising where they had been falling. Climbing infections in these regions are alarming. In Eastern and Southern Africa the rapid progress from previous years significantly slowed in 2021. It is not all bad news, though, with notable declines in new HIV infections in Western and Central Africa and in the Caribbean, but even in these regions, the HIV response is compromised by threats to the availability of financial resources.
The Update says that waning progress meant approximately 1.5 million new infections occurred last year – over one million more than the global targets. Marked inequalities within and between countries, are stalling progress in the HIV response, and HIV is further widening those inequalities.
There are marked sex and gender differences in HIV infection
Unsurprisingly, young women and adolescent girls are disproportionately affected with a new infection every two minutes in 2021. The gender HIV impact, particularly for young African women and girls, occurred amid disruption of key HIV treatment and prevention services, millions of girls out of school, and spikes in teenage pregnancies and gender-based violence exacerbated by the COVID-19 pandemic. In sub-Saharan Africa , adolescent girls and young women are three times as likely to acquire HIV as adolescent boys and young men.
The Update notes that during the disruptions of the past few years, key populations (KPs) have been particularly affected in many communities – with rising prevalence in many locations. UNAIDS data have shown increasing risk of new infections faced by gay men and other men who have sex with men (MSM) globally. As of 2021, UNAIDS KP data show MSM have 28 times the risk of acquiring HIV compared to people of the same age and gender identity while people who inject drugs have 35 times the risk, sex workers 30 times the risk, and transgender women 14 times the risk.
Race is also a factor
Racial inequalities are also exacerbating HIV risks. In the United Kingdom and United States of America, declines in new HIV diagnoses have been greater among white populations than among black people. In countries such as Australia, Canada and the United States, HIV acquisition rates are higher in indigenous communities than in non-indigenous communities.
Access to treatment has faltered
The report also shows that efforts to ensure that all people living with HIV (PLHIV) are accessing life-saving antiretroviral treatment are failing. The number of people on HIV treatment grew more slowly in 2021 than it has in over a decade. And while three-quarters of all PLHIV have access to antiretroviral treatment, approximately 10 million people do not, and only half (52%) of children living with HIV have access to lifesaving medicine; the gap in HIV treatment coverage between children and adults is increasing rather than narrowing.
The AIDS pandemic took a life every minute, on average, in 2021, with 650,000 AIDS deaths despite effective HIV treatment and tools to prevent, detect, and treat opportunistic infections.
Is politics one of the reasons for these differences?
“These figures are about political will. Do we care about empowering and protecting our girls? Do we want to stop AIDS deaths among children? Do we put saving lives ahead of criminalization?” asked Ms Byanyima. “If we do, then we must get the AIDS response back on track.”
There were significant differences between countries. Some of the countries with the biggest increases in the number of new HIV infections since 2015 included the Congo, Madagascar, Philippines, and South Sudan. On the other hand, India, Nigeria, South Africa and Tanzania had some of the most significant reductions in the numbers of HIV infections even with COVID-19 and other crises. Examples of progress point toward what effective pandemic response requires – with some of the strongest progress where community-led services, enabling legal and policy environments and equitable services, are most noticeable.
The report sets out the devastating consequences if urgent action is not taken to tackle the inequalities which drive the pandemic. It shows that on the current path the number of new infections per year would be over 1.2 million in 2025 – the year in which United Nations member states have set a goal of fewer than 370,000 new HIV infections. That would mean not just missing the pledge on new infections but overshooting that pledge by more than three times. Millions of avoidable HIV infections every year are making it ever harder and more expensive to ensure people living with HIV have access to lifesaving treatment and the targets to end the AIDS pandemic by 2030 are reached.
"Global shocks including the COVID-19 pandemic and the Ukraine war have further exacerbated risks for the HIV response. Debt repayments for the world’s poorest countries reached 171% of all spending on healthcare, education and social protection combined, choking countries’ capacities to respond to AIDS. Domestic funding for the HIV response in low- and middle-income countries has fallen for two consecutive years. The Ukraine war has dramatically increased global food prices, worsening food insecurity for people living with HIV across the world, making them much more likely to experience interruptions in HIV treatment.
At a moment when international solidarity and a surge of funding is most needed, too many high-income countries are cutting back aid, and resources for global health are under serious threat.”
Funding is increasingly a major stumbling block
As Alan Whiteside points out in his article The 2022 International AIDS Society Conference in Montreal: a personal overview[ACW1] , funds for HIV are shrinking. In 2021, the international resources available for HIV were 6% lower than in 2010. Overseas development assistance (ODA) for HIV from bilateral donors other than the US has nose-dived by 57% over the past decade. The HIV response in low- and middle-income countries (LMICs) is $8 billion short of the amount needed by 2025. Global trade rules are obstructing LMICs’ production of the medicines needed to end the pandemics, including new and emerging long-acting HIV medicines. Prices are still unaffordably high for these countries to procure at scale.
“When international support has been most needed, global solidarity has stalled. Leaders must not mistake the huge red warning light for a stop sign. This must become a moment for a surge of international support,” said Ms Byanyima.
“We can end AIDS by 2030 as promised,” said Ms Byanyima. “But what it takes is courage.”
If both the national and international goodwill is present, it is still possible for leaders to get the response back on track. This requires both “national action and international solidarity”. Last year leaders agreed a roadmap, set out in the Political Declaration on HIV and AIDS, which can end AIDS by 2030 – if leaders want to meet its obligations. It is both achievable and affordable – indeed, ending AIDS will cost much less money than not ending AIDS. Importantly, the report says, actions needed to end AIDS will also better prepare the world to protect itself against the threats of future pandemics.
The package for success is based on tried and proven interventions. These include: community-led, people-centred services; upholding of everyone’s human rights, the removal of punitive and discriminatory laws, and the tackling of stigma; the empowerment of girls and women; equal access to treatment including new health technologies; and health services, education, and social protection for all.
Over the past two years, global multiple and overlapping crises have had a devastating impact on people living with and affected by HIV, and they have adversely affected the global response to the AIDS pandemic. The new data revealed in this report are frightening: progress has been faltering, resources have been shrinking and inequalities have been widening. Insufficient investment and action are putting all of us in danger: we face millions of AIDS-related deaths and millions of new HIV infections if we continue on our current trajectory.
Together, world leaders can end AIDS by 2030 as promised, but we need to be frank: that promise and the AIDS response are in danger. Faltering progress meant that approximately 1.5 million new HIV infections occurred last year—more than a million more than the global targets. In too many countries and for too many communities, new HIV infections are rising when what we needed was rapid declines. This situation is salvageable but, given the scale of the emergency, the only safe response is to be bold.
Marked inequalities, within and between countries, are stalling progress in the HIV response, and HIV is further widening those inequalities.
Every two minutes in 2021, an adolescent girl or young woman was newly infected with HIV. The COVID-19 pandemic led to disruptions to key HIV treatment and prevention services, millions of girls out of school, and spikes in teenage pregnancies and gender-based violence.
The AIDS pandemic took a life every minute in 2021, with 650,000 AIDS-related deaths despite effective HIV treatment and tools to prevent, detect and treat opportunistic infections. The number of people on HIV treatment grew more slowly in 2021 than it has in over a decade: while three quarters of all people living with HIV have access to antiretroviral treatment, approximately 10 million people do not. Only half (52%) of children living with HIV have access to life-saving medicine, and the inequality in HIV treatment coverage between children and adults is increasing rather than narrowing (see our separate article on the creation of a new global alliance to tackle children and AIDS).
In crisis, however, UNAIDS says that it also sees strong resilience in a diverse range of countries—and in pockets within many more countries. This is especially true where the required level of funding from national governments, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) or the Global Fund comes together with robust community-led responses and cutting-edge science. These exemplars of effective pandemic response have achieved remarkable progress in reducing new HIV infections and increasing access to treatment. They prove that it can be done and guide us in what we need to take to scale worldwide.
But this report also shows far too many instances where we are not moving fast enough to end the inequalities that drive pandemics—or where we are moving in the wrong direction: tech monopolies instead of tech sharing, austerity instead of investment, clamping down on marginalized communities instead of repealing outdated laws, and inhibiting control instead of promoting and enabling inclusive, community-centred delivery.
When international support has been most needed, global solidarity has stalled. Overseas development assistance for HIV from bilateral donors other than the United States of America has plummeted by 57% over the last decade. Leaders must not mistake the huge red warning light for a stop sign.
The data revealed in this report will disturb and shock—but the report is not a counsel of despair. It is call to action. Failure would be fatal, but it is not inevitable. Ending AIDS will cost much less money than not ending AIDS. Importantly, the actions needed to end AIDS will also better prepare the world to protect itself against the threats of future pandemics.
What we need to do is not a mystery. We know it from what we’ve repeatedly seen succeed across different contexts: shared science, strong services and social solidarity. This is the pledge made at the United Nations General Assembly High-Level Meeting on HIV/AIDS in June last year: end the AIDS pandemic by ending the inequalities that perpetuate it.
We can end AIDS by 2030. But the curve will not bend itself. We have to pull it down.