Four years ago, governments around the world committed to achieving targets in testing and treating the vast majority of people with HIV to the point where the AIDS pandemic would end.
The tools to do this have been available for 20 years. In 2010, the National Institutes of Health, under the leadership of Dr. Anthony Fauci, found that HIV-negative men whose partners were positive, significantly reduced their chances of becoming infected by taking a daily pill that combined anti-AIDS medication. This has become known as pre-exposure prophylaxis or PrEP.
PrEP can now be given as an injection. And people with HIV can take a single pill that makes the human immunodeficiency virus (HIV) in the blood undetectable.
Under Dr. Demetre Daskalakis' direction, the goal by the United Nations in 2016 was achieved in New York City, but Dr. Chris Beyrer, an AIDS researcher at Johns Hopkins University, says it is way off track elsewhere. Beyrer spoke to VOA recently. His questions have been edited for brevity and clarity.
VOA: Where are we in achieving the universal goals of having 90% of people with HIV diagnosed, 90% of those diagnosed on treatment, and 90% of those on treatment being able to suppress the virus to undetectable levels?
Beyrer: "The 90-90-90 targets were based on the assumption that achieving those goals would also bring down the rate of new infections, because as more people are treated, and are successfully virally suppressed, they will be less infectious for sex partners or maternal-to-child transmission.
"2020 was supposed to be the year in which we were going to see significant declines in new infections down under 500,000 worldwide, and we had more than 1.7 million new infections in 2019. So, we are way off the targets of actually getting control of HIV transmission."
VOA: Why are we way off track?
Beyrer: "We're still seeing people acquire HIV when they're relatively young … and then they are not starting therapy until quite a bit later. So there's that long period where they are living with HIV and not being treated and remaining infectious. That's the first problem.
"The second problem is that we have seen a significantly lower engagement of men in HIV testing and treatment than women. The reason for that is that in much of the world, women have much more interactions with health care in early adult life and that is because of contraception, pregnancy, child care. … but men from 18 to 45 have much less interaction with health care.
"If we're going to really get control of the HIV pandemic, we have to do much better with engaging men in care.
"Then I think we have to think about the key populations: people who are most at risk for HIV. … People who inject drugs, men who have sex with men, transgender women and trans men who have sex with men. We are talking about sex workers of all genders. … These are the folks who now account for 62% of all new infections, globally.
"And … that is because of stigma, discrimination against these folks and criminalization — laws against sex work, laws against being gay, punitive approaches to drug use instead of drug treatment. And this has been true for many years, but now It is so starkly clear that with 62% of all new infections worldwide happening [in this] population, we are failing to do the basics that are needed to control HIV."
VOA: To get men into health care, there are some barber shops where men can have their blood pressure taken. Are there similar ideas to get men into HIV treatment earlier?
Beyrer: “Yes. One great example was a large project that was joint U.S. with Kenya and Uganda, a large collaborative study called the Search Study, and Search really tried to provide services screening for things like blood pressure for diabetes, diseases that men care about and that are much less stigmatized than HIV and to integrate HIV services into those services, and to do so in ways that also work for men.
"So mobile vans going to workplaces, having evening and weekend hours. … It's very difficult if you ask men, particularly in low- and middle-income countries, to take days off of work and sit in the clinic all day. It's just not an option.”
VOA: Has COVID-19 in any way prevented people from going in and getting tested or getting treatment?
Beyrer: “We're just really starting to understand the impacts that COVID has had on HIV and also on TB. The leading cause of death worldwide for people living with HIV infection is tuberculosis. … What we've seen … is things that were not an emergency, like HIV testing for example, were postponed or those clinics were closed all together. That had a very big impact on HIV testing and also on prevention.
“We have, from the medical perspective, a powerful tool kit now to get control. But what we haven't done is get these essential tools and services to the people who need [them] the most. And as long as we continue to have this level of stigma and discrimination, criminalization of the people who are most at risk, we're not going to achieve our goals."