‘Equalize’ – A Slogan to Call Action!

Written by Dr. Shreyjit Kaur

While the world has been largely focused on the COVID pandemic for nearly three years, HIV has been increasingly receiving lesser attention. As a consequence, the global HIV response is in jeopardy, despite the grave reality that HIV remains a significant public health problem even today, mercilessly affecting millions of people throughout the world. Progression towards HIV goals has stagnated in recent years, resources have downsized, and millions of lives are at danger. Among the failures that allowed HIV to become and remain a global health crisis are discrimination, division, disparity, and disregard for the human rights.

Since 1988, every year the 1^st of December is observed as the World AIDS Day, as a day of opportunity for people all over the world to unite in the fight against HIV, to show support and solidarity to people living with HIV, and to commemorate those who have died from an AIDS-related illness. It is also designated as a day for bridging new and effective programs and policies across various sectors around HIV/AIDS. The red ribbon has become the international symbol of AIDS awareness, symbolizing compassion for people living with HIV as well as their care-takers.

On December 1, WHO and UNAIDS together join partners to mark World AIDS Day 2022, under the theme “Equalize”, aiming to recognize and address inequalities that are impeding progress toward the eradication of AIDS, as well as to equalize access to essential HIV services, particularly for children and key populations and their partners. Nearly 70% of infections occur in high – risk populations, including sex workers and their clients, men who have sex with men, intravenous drug users, transgender people and their sexual partners and people in prisons. Another important group is adolescent girls and young women in Sub-Saharan Africa, where nearly 5,000 are infected with HIV each week.

Brief history of HIV – AIDS

In the early 1980s in USA, there were unusual reports of rare pneumonias, opportunistic infections and cancers in young gay men leading to this mysterious disease being dubbed as Gay-Related Immune Deficiency (GRID). Later, it was also reported in injection drug users. Hence, it was renamed as Acquired Immune Deficiency Syndrome (AIDS). Over the time, cases of transmission were also reported in transfusion recipients, women through heterosexual contact, mother to child via breastfeeding etc. The causative retrovirus was recognized and named as Human Immunodeficiency Virus (HIV), traced back to be having simian origins. By early 1990s, this epidemic reached its peak and thereon, becomes a global health concern.

How far have we come?

Thirty years ago, being HIV positive was a virtual death sentence. With no effective treatment regime in hand, Zidovudine (AZT) was one of the first anti-HIV drugs approved by US-FDA in 1987. Years later, life-saving three drug combination antiretroviral therapy was introduced in 1996 consisting of – saquinavir, zalcitabine and zidovudine. Currently, Highly Active Antiretroviral Therapy (HAART) is a treatment regimen indicated to treat patients infected with human immunodeficiency virus type 1 (HIV-1) and also HIV-2 (although with some modifications). The standard of care for most treatment-naïve patients is a combination of two nucleoside reverse transcriptase inhibitors (typically tenofovir-emtricitabine) plus one non-nucleoside reverse transcriptase inhibitor or integrase inhibitor. Thus, giving people living with HIV(PLWH) a chance to lead longer, healthier and normal living. In fact, life expectancy of people living with HIV in high-income countries is very close to that of people without HIV. Early diagnosis with rapid tests for HIV has made it easier for people to get tested early and access the health-care they need.

Are there any newer options of prevention?

For many years, options for prevention of HIV infection were quite limited. Early campaigns consisted of the ABCs—abstinence, being faithful, and condoms. Later in early 2000s, male circumcision was added, but multiple attempts at developing a vaccine have been unfruitful. However, in 2012, there was a big buzz surrounding the introduction of HIV pre-exposure prophylaxis (PrEP). The first version of PrEP was an oral fixed dosed combination tablet that combined two antiretroviral drugs, emtricitabine and tenofovir. When taken on a regular basis, PrEP is indeed highly effective and extremely safe in preventing HIV infection. PrEP was viewed as a turning point and a game changer because it enabled people to take control of their sexual health. PrEP has also developed in the form of a vaginal ring, another safer option. The latest version of PrEP is an injection of another antiretroviral drug—cabotegravir (CAB-LA for cabotegravir-long acting). It is administered intramuscularly once in two months. Another injectable drug—lenacapavir—is currently undergoing clinical trials. It would need to be administered subcutaneously only once every six months. Although injectable PrEP seem to be a perfect solution, however; there are many drawbacks including high costs, lack of storage facilities, non-availability, lack of access, non-compliance etc.

Are we close to a vaccine against HIV?

The only way to put an end to the epidemic of HIV is with a vaccine but the progress has been significantly slower due to the unprecedented challenges posed by HIV such as its exceptional genetic variability, high rates of mutations, high content of sugars on its surface protein coat (leading to a very poor immunogenic response), ability to establish a quick and persistent lifelong infection, and the fact that not a single person has cleared HIV infection on their own. Moreover, most people infected with HIV do not develop broadly neutralizing antibodies, which are needed to fight the variants.

Nonetheless, there some ongoing and promising human clinical trials that aim at developing a vaccine against HIV: 

HVTN 301. This study, run by the HIV Vaccine Trials Network at the Fred Hutch Cancer Center, uses a tiny protein, or immunogen, to generate protective broadly neutralizing antibodies and stimulate the development of B cells which can themselves create the antibodies. 

HVTN 302. This study is funded by the National Institutes of Health and evaluates three experimental HIV vaccines based on the mRNA platform. Each vaccine developed by Moderna, contains a different spike protein found on the surface of the HIV virus that allows it to enter human cells so that it can induce a vigorous immune response.

IAVI G002. This is a clinical trial, sponsored by the International AIDS Vaccine Initiative, testing the safety and immune response of two mRNA vaccines on 56 healthy adults. Earlier research found that one of the vaccines was able to stimulate the production of rare immune cells needed to create antibodies against the HIV virus in 97 percent of patient participants. Another trial IAVI G003 has already begun in May 2022.

In addition, researchers are studying the use of some of these potential HIV vaccines as a means of not only prevention but also treatment.

Since, only eight years left before the 2030 goal of ending AIDS as a global health threat, WHO lays out key messages for World AIDS Day 2022 to put an end to inequalities that exacerbate the dangers for everyone:

1. Renew our commitment to end HIV: Persistent economic, social, cultural, and legal inequalities, as well as the challenges posed by the COVID-19 pandemic and other global crises, necessitate reinvigorated efforts to maintain the visibility of HIV and to end AIDS as a public health threat.
2. Focus on equality: Inequalities persist even in the most basic services, such as testing and treatment. It is important to ensure equal access to HIV prevention, testing, treatment, and care to everyone, everywhere. Health services should be tailored to reach and meet the needs of the most vulnerable and affected populations, including the implementation of a “zero tolerance” policy for discrimination and stigma in all areas of health care.
3. Elimination litmus test – children and key populations: WHO recommends refocusing on populations who have been overlooked in the global response to HIV and AIDS. Only 52% of HIV-infected children are receiving life-saving treatment. Also, if we can show progress in ending new infections among children and ensuring all are on quality antiretrovirals (ARVs), we will have more hope and political commitment to end AIDS in all populations by 2030. Globally, 70% of new HIV infections occur among marginalized and often criminalized population. Only by increasing HIV services and removing structural barriers, stigma, and discrimination against key populations in each country will we be able to end AIDS.

With pathbreaking and progressive research going on in the field of HIV/AIDS and newer treatment modalities in the pipeline, HIV still remains a major global public health issue, having claimed 40.1 million lives so far. In the year 2021, 650k people have died from HIV-related causes and 1.5 million people have acquired HIV. By the end of 2021, an estimated 38.4 million people were living with HIV, two-thirds of whom are in the WHO African Region. To reach the new proposed global 95–95–95 (95% of all people living with HIV to know their HIV status, 95% of all people with diagnosed HIV infection to receive sustained antiretroviral therapy, and 95% of all people receiving antiretroviral therapy to have viral suppression by 2025) targets set by UNAIDS, there is an urgent need to multiply and strengthen the ongoing efforts, to combat it with greater vigour and enthusiasm and finally put an end to this dreaded and inexorable malady.

REFERENCES:

1. https://www.who.int/campaigns/world-aids-day/2022 
2. https://canfar.com/awareness/about-hiv-aids/history-of-hiv-aids/ 
3. How far have we come on AIDS? By Dr Young-Soo Shin, Regional Director, WHO Western Pacific Region. Available from: https://www.who.int/westernpacific/news-room/commentaries/detail-hq/how-far-have-we-come-on-aids 
4. HIV prevention: new injection could boost the fight, but some hurdles remain by Jessica Haberer, The Conversation. Available from: https://medicalxpress.com/news/2022-11-hiv-boost-hurdles.html 
5. Will We Ever Have a Vaccine for HIV? by Hallie Levine. Available from: https://www.aarp.org/health/conditions-treatments/info-2022/hiv-vaccine.html 
6. Eggleton JS, Nagalli S. Highly Active Antiretroviral Therapy (HAART) [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554533/
7. https://www.who.int/news-room/fact-sheets/detail/hiv-aids 
8. https://www.unaids.org