Is the end of AIDS in sight?

How Cotton Wool Can Help in the Fight Against AIDS

Many people who do not have HIV, the virus that causes AIDS, know they are at risk. They can take pre-exposure prophylaxis (PrEP), a kind of drug that reduces their chance of contracting it by 99% or so. This comes as a daily pill, and is popular among gay men in rich countries.

However, there is a much larger group of people at high risk, for whom a daily pill is far from ideal: heterosexual women in poor places where HIV is still very common. If their boyfriends discover they are taking the pill, they may conclude that their girlfriend does not trust them, or that she is planning to cheat on them. And a depressing number of boyfriends who suspect such things react violently.

A high-tech solution is on the horizon: cabotegravir, from ViiV Healthcare, a single injection that lasts for two months and is much more discreet than a daily pill. Alas, it is new, costly and not yet widely available, especially in Africa, where the virus is most widespread. So Patrick Mdletshe of the KwaZulu Natal Provincial Council on AIDS in South Africa offers a low-tech fix: stuff cotton wool in the bottle so the daily pills don’t rattle and your boyfriend won’t notice that you are taking them.

UNAIDS and the Sustainable Development Goals

UNAIDS, a UN body, hopes to end AIDS as a major public-health threat by 2030, building on the staggering success of the past two decades. AIDS, which weakens the immune system, has killed about 40m people—more than covid-19. However, the pace at which people are dying of it has fallen dramatically. In the early 2000s it was 2m a year, largely in poor countries, where hardly anyone could afford $10,000 a year for life-prolonging pills. In some African countries between a fifth and quarter of the adult population was infected with HIV; nearly all were expected to die of it. Life expectancy in Zimbabwe and Eswatini fell by two decades.

Then the price of antiretroviral pills plummeted, as drug firms offered steep discounts for poor countries and donors chipped in billions to pay for them. Today a year’s supply can cost a mere $45. Between 2001 and 2019 life expectancy in sub-Saharan Africa rose by 17%—and much more in the worst-affected countries (see chart). Globally, some 21m deaths have been averted, by one estimate. Today, three-quarters of those infected—roughly 30m people—are receiving treatment.

Unfortunately, triumph has bred complacency, argues Peter Sands, the head of the Global Fund to Fight AIDS, Tuberculosis and Malaria, a donor-financed body. “There’s a diminishing sense of urgency,” he says. Or worse. The biggest donor by far is America. Its global AIDS programme, PEPFAR, which was set up by President George W. Bush, expires on September 30th and some Republicans are trying to block its reauthorization.

An estimated 39m people are HIV positive—more than half of them in Africa. All will need lifelong treatment, unless a cure is found. Meanwhile, the virus is still spreading. Some 1.3m people were freshly infected last year. In Eastern Europe and the Middle East, the numbers of new infections in 2022 were 49% and 61% higher than in 2010, albeit from low bases.

Approaches to Tackling HIV

There are two main approaches to tackling the virus. One is to invent new medicines: ideally a cure or an effective vaccine. The other is to reach more people with existing technology. Both approaches—in the lab and on the ground—are being pursued in tandem by governments, private companies, donors and NGOs.

A cure seems a long way off. A vaccine may be closer, but HIV is an elusive target. It is highly mutable, and hides its DNA inside some of the immune cells that are supposed to destroy it. Nina Russell of the Gates Foundation, who has worked on HIV vaccines for “many, many, many, many” years, is nonetheless hopeful.

Past failures have taught scientists that they need to design vaccines that can teach the body to make antibodies to tackle a wide range of viral strains. They might have to create three, four or five different vaccines and jab people with all of them, in the correct order. Firms such as Moderna and BioNTech are using mRNA technology to speed up the process. However, even optimists do not expect success this decade. So hitting the 2030 target will depend largely on two things. First, finding and treating more infected people. Second, identifying those who are at risk of infection, and helping them avoid it.

UNAIDS urges countries to aim for “95-95-95”: where 95% of those who have the virus know they have it, 95% of those who know they have it are receiving treatment, and crucially that 95% of those in treatment are “virally suppressed”. If the drugs suppress the virus to a level where it is undetectable—and keep it there—it cannot be passed on sexually.

If the world were to reach 95-95-95, the disease would be brought under control, UNAIDS reckons, though tens of millions would still be living with it. In 2022 the figures were 86-76-71, a hefty improvement on 71-48-40 in 2015. But the “last mile” will be hard. “You have to be much more creative,” says Dr Quarraisha Abdool Karim of CAPRISA, a research centre in Durban.

Challenges and Solutions

One enormous, tricky group is men. They are less likely to get tested than women, not least because they do not get pregnant. Prenatal clinics are a wonderfully

SDGs, Targets, and Indicators

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being
• SDG 5: Gender Equality
• SDG 10: Reduced Inequalities

2. What specific targets under those SDGs can be identified based on the article’s content?

• Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases
• Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences
• Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory laws, policies, and practices and promoting appropriate legislation, policies, and action in this regard

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

• Indicator 3.3.1: Number of new HIV infections per 1,000 uninfected population, by sex, age, and key populations
• Indicator 5.6.1: Proportion of women aged 15-49 years who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care
• Indicator 10.3.1: Proportion of population reporting having personally felt discriminated against or harassed in the previous 12 months on the basis of a ground of discrimination prohibited under international human rights law

4. SDGs, Targets, and Indicators

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Source: economist.com

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