Aids at 30

Today, 1st December, marks 30 years since Aids first appeared. In that time, the world’s perception of Aids has changed dramatically, from a guaranteed death sentence to a disease that today many see as “conquered.” From drugs developed 20 years ago and still in use today, to an unprecedented rush of therapeutic developments in the last five years, the story of Aids has been one of successive revolutions. Yet despite incredible advances in treatment, the disease remains incurable—and it represents a global health challenge on an unprecedented scale. In 2009, it killed over twice as many people as malaria.

Although it is virtually impossible to date its precise beginnings, it was in the spring of 1981 that doctors in America noticed some peculiar trends emerging. Kaposi’s sarcoma, an uncommon and usually harmless type of cancer, suddenly appeared in a group of men in New York who all became seriously ill. In California, meanwhile, gay men suddenly started falling ill with a hitherto rare lung infection, known as PCP. Reports of similar incidents begin to spread globally. Although initial prejudices assumed these problems were exclusive to the gay community, similar illnesses were soon seen among injecting drug users in Britain, heterosexuals in Haiti and haemophiliacs in the United States, amongst others. In July 1982, it was finally agreed that these illnesses were all being caused by the same underlying disease, which destroyed its hosts’ immune systems. It was christened Acquired Immuno-Deficiency Syndrome: Aids.

It took several more years to identify the virus that caused it but, in 1986, the virus was labelled the Human Immuno-Deficiency Virus, or HIV. It remains incurable, yet today, for those with access to the right drugs, HIV is no longer a death sentence, and revolutionary advances in its treatment continue to be made.

In 1985, when global records began, there were just over 20,000 cases of Aids reported worldwide. Today, around 34m people are infected. Yet, since the height of the epidemic in 1997, the number of new cases per year has fallen by almost 20 per cent. After three decades of concerted medical effort, the tidal flow of HIV has finally turned.

Perhaps most excitingly of all, in those countries that have been most severely affected by HIV—the majority of which are in sub-Saharan Africa—the epidemic is now either stable or in retreat. New strategies to prevent HIV include, remarkably, the realisation that circumcision can approximately halve the risk of being infected; and targeted interventions to reduce transmission from infected women to children at birth, via one-off doses of anti-HIV drugs and planned feeding strategies.

As treatment becomes more effective, too, the proportion of people living with HIV/Aids rather than dying from it continues to rise. The major breakthrough here came in the mid-1990s with the development of two new types of drugs which, when used in combination with earlier treatments, prevented the virus from creating new copies of itself, resistant to the effects of treatment. The effects were so astounding that the use of these combinations was dubbed the “Lazarus effect.”

This ushered in the modern era of highly-active combined therapy—and the first signs that the epidemic could be controlled. Today, for many patients in developed countries, HIV/Aids has become a “chronic disease”: one that cannot be cured, but can mostly be controlled with lifelong treatment, much like diabetes. The past five years has also seen the development of three new types of drugs, such as the integrase inhibitor, raltegravir, which attack the virus from yet more angles. These are valuable new weapons in the anti-HIV arsenal, offering fresh alternatives to those who cannot take the older drugs or in whom the virus has become resistant to all other options.

The global challenge of HIV/Aids remains vast—especially given that around half of those infected live in the developing world. Innovative anti-HIV therapies are expensive: raltegravir is priced by its manufacturer at £20.54 per patient per day in Britain. Thanks to changes in international trade law in 2001, however, the development of generic substitutes to branded drugs—and the subsequent massive reduction in price—have made universal access to treatment at least a possibility. The number of disadvantaged people able to access treatment reached 3m in 2007, and over the past four years has increased even further to around 6m.

Simply providing medication is not enough, however. Drugs do little good unless provided in the right combinations and taken regularly: with drugs, even a break in treatment of a few days can lead to drug-resistance developing in a patient’s individual disease. This means that healthcare infrastructure and support to help patients to manage their lifelong and burdensome cocktail of pills are crucial.

In my own experience of an HIV treatment centre in Kumasi, Ghana, people would come to the clinic having been handed out doses of medication like Smarties by a well-meaning local NGO—and, thanks to taking these haphazardly, had become resistant to virtually every drug we could offer them. The clinic created a “buddy” system between patients so that they could help each other in sticking to the often side-effect ridden treatment—a simple, inexpensive technique for offering vitally important support.

Perhaps the central problem in trying to treat HIV across the globe today is that, as our knowledge and research improve, the level of treatment required keeps being revised upwards. Recent research shows that it is important to start drug treatment even sooner after infection than previously thought, while drug treatment has also recently been shown to reduce the risk of infecting others.

Meanwhile, despite the overall decline, rates of new infections continue to rise by more than 25 per cent per year in some countries, mostly in eastern Europe and Asia. So far, for every two people who have gained access to treatment, five more have become infected. Despite the improvements, two thirds of the 15m HIV-sufferers requiring life-saving treatment today have no access to the drugs they need.

Moreover, does the political and popular will to beat Aids exist to match the rhetoric? At the UN General Assembly meeting on Aids in June, the international community dramatically pledged to halve HIV transmission by 2015 and provide treatment to the 15m in need. This requires an estimated increase in funding to over $22bn—yet a recent study reveals that international government funding for HIV/Aids has fallen by over 10 per cent in absolute terms since 2009. Philanthropic efforts, such as those of the Bill and Melinda Gates Foundation, continue rightly to prioritise HIV funding yet, despite their $2.2bn investment to date, their emphasis on funding research into a vaccine—a notoriously elusive goal for a virus which can change itself so easily—has potentially diverted these funds from more attainable targets.

If the UN’s ambitious goals are to be met, and the tide of HIV/Aids is to continue to ebb, then governments globally must recognise that the fight is far from over. As Michael Sidibe, Executive Director of UNAIDS recently commented: “Through shared responsibility, the world must invest sufficiently today, so we will not have to pay forever.”