In health care, we tend to spend a lot more time bemoaning failures than pondering successes. We too often lose sight of the fact that, while progress often comes gradually, the cumulative effect can be impactful.
HIV-AIDS is a case in point.
With 88.4 million people infected with human immunodeficiency virus over the past four decades, and 42.3 million of them having succumbed to AIDS, it remains one of the worst pandemics in history.
But new infections are down a remarkable 60 per cent since the peak – from 3.3 million in 1995 to 1.3 million in 2023. Deaths have dropped ever more sharply, 69 per cent, from 2.1 million in 2004 to 630,000 last year.
An astonishing 30.7 million people – 77 per cent of those of the 39.9 million living with HIV worldwide – are accessing antiretrovirals, drugs that keep the virus from replicating, and essentially made HIV a chronic, manageable illness.
Yet, much more remains to be done.
The campaign to rid the world of the scourge of HIV-AIDS by 2030 seems to be faltering. The other pandemic, COVID-19, took a lot of wind out of the sails, overwhelming public health in many parts of the world.
Still, glimmers of hope continue to arise.
At the 25th International AIDS Conference, held last month in Munich, there were two noteworthy developments: News of another patient who has been cured, and a big improvement in how preventive treatment can be delivered.
To date, only seven people have been cured of HIV: “The Berlin Patient,” Timothy Ray Brown, received a stem cell transplant to treat leukemia in 2007, and it ridded him of HIV. He lived 13 years before dying of cancer. The others include: The Dusseldorf Patient, Marc Franke; The London Patient, Adam Castillejo; The New York Patient, the only woman cured of HIV, has remained anonymous; The City of Hope Patient, Paul Edmonds; The Geneva Patient, known only as Romuald; The Next Berlin Patient, a 60-year-old man, was the latest patient cured, announced just weeks ago.
These cases are obviously unusual because, not only did the patients have HIV, but some form of blood cancer. The treatments they underwent were brutal and expensive. These treatments are not scalable, but provided researchers with important data.
Most of the patients received stem cell transplants from donors who carried a rare genetic mutation known as CCR5-delta 32, which makes them naturally resistant to HIV. But two of the donors did not have that mutation, and that’s important too.
Researchers speculate that chemotherapy might be poisonous to HIV, which provides new pathways for potential treatments. Some of the stem cell transplant recipients also suffered graft vs. host disease (where the body rejects the transplant), an autoimmune reaction and that may have destroyed HIV reservoirs.
The biggest challenge in curing HIV-AIDS is that, even when the virus is undetectable in the body, it can hide in reservoirs, and spring up again.
The treatments we have, antiretrovirals, keep the virus from replicating, but don’t kill the hidden virus. That means patients need to keep taking ARVs for life – often daily – to avoid illness. The drugs are a functional cure, but a tough slog.
But there are newer drugs that can be taken by injection every two months, or even twice a year. Better still, these drugs can be taken to avoid infection – known as pre-exposure prophylaxis, or PrEP.
A study released at the Munich AIDS conference found that one injection every six months was 100 per cent effective in preventing infections in women age 16-25 living in Africa. That study generated much excitement because young African women account for half of all new HIV cases.
However, the injectable drug lenacapavir (brand name Sunlenca) is expensive, a staggering US$42,240 annually, compared to $50 for ARVs in pill form.
The science behind these treatments and cures is of dazzling complexity, but it comes up against a harsh reality: Those who would benefit most are the hardest to reach, for economic and geopolitical reasons.
To be effective, prevention methods have to be affordable and accessible. The simplest methods, like condoms, are still highly effective – if they are used.
HIV-AIDS has never been strictly a medical or scientific challenge.
It is social and political aspects of the response that are the most bedeviling, the barriers that seem the hardest to overcome, and where we struggle the most to make progress.