Putting People First in the HIV Response: Reflections from AIDS 2024

Paula: The International AIDS Conference is the largest gathering on HIV and AIDS in the world, with thousands of scientists, policymakers, practitioners and activists sharing the latest advances. What was the most impactful thing you learned at AIDS 2024?

María: One of the most important scientific breakthroughs presented at AIDS 2024 was a study demonstrating the effectiveness of a long-acting injectable drug which can be used as a pre-exposure prophylaxis (PrEP) against HIV. PrEP has been a key strategy in preventing HIV for over a decade, but right now it comes in the form of a daily medication. The new drug is injected twice a year and has the same effect. The study was limited to cisgender women, but it raises a lot of hope, because the method is much more convenient and easier to remember than taking a daily pill.

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José: I echo what María has said. This was an impressive study and result. Once approved, the new drug will significantly improve adherence to PrEP, which is very important for HIV prevention efforts.

 

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Mario: I agree. Also, long-acting implants are being developed. They release antiretrovirals in a sustained manner for several months. This can revolutionize the HIV response by offering less invasive and more comfortable prevention and treatment options.

 

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Betty: Yes, these are really game changers, and my hope is that they will be available to the general population soon. Many activists who attended the conference expressed concerns about pricing of these new drugs. Medicine innovations are only meaningful when people who need them can actually access them.

Another innovation announced at the conference was an infusion of doxycycline – an antibiotic – into both PrEP and post-exposure prophylaxis (PEP), which is used to prevent HIV following an exposure to the virus. This integration can help mitigate the rising incidences of other sexually transmitted infections, such as syphilis, gonorrhea and chlamydia, among high-risk populations. 

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María: I was also excited to hear a story of another patient who was cured of HIV after receiving a stem cell transplantation. This is truly exceptional. It moves researchers closer to developing a vaccine and a cure.

 

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Betty: As of today, seven people are confirmed to have been cured of HIV in the world. This is different from undetectability. Being cured means that the virus is dead in the body, so these individuals no longer need treatment. Gene therapy is very promising, but right now it is extremely expensive and time-consuming, so it is not yet a scalable solution.

 

Paula: Beyond these remarkable scientific breakthroughs, what are the promising trends in achieving the HIV epidemic control goals? What sparks your hope?

Betty: The theme of the conference was “putting people first,” which generated a lot of excitement. It is incredibly important to focus on the individuals who live with HIV or are at high risk of acquiring HIV. We need to ensure that they know their status and can easily access HIV prevention, treatment and care. We need to provide them with accurate information in the language they can understand. We need to treat them with utmost respect and dignity. And finally, we need to meet them where they are on their journeys with tailored interventions. 

Putting people first is the cornerstone of client-centered approaches, which Global Communities and IntraHealth have championed for decades.

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José: Well said, Betty! HIV response is much more than science and people affected by HIV are much more than just patients. We need to put them first and reduce discrimination against them, while addressing psychosocial and economic determinants of their health. It was great to see a focus on human rights, inclusion and intersectionality at the conference.

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María: The official endorsement of the Undetectable Equals Untransmittable (U=U) message by the Public Health Agency of Canada sparked my hope and joy. When a person living with HIV reaches an undetectable viral load thanks to antiretroviral therapy (ART), there is zero risk of passing HIV to another person. 

Science clearly backs this message, but there are a lot of misconceptions about the U=U concept among healthcare workers. This makes it difficult for them to share evidence-based information with their patients. When national governments endorse this message, healthcare workers are more likely to internalize it, which is vital in HIV prevention efforts. It also helps reduce stigma and discrimination against people living with HIV.

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Mario: Advances in treatment that allow people to maintain an undetectable viral load are incredibly important, because they eliminate the risk of new infections. These treatments and vaccine research give me hope that the epidemic will end soon.

Paula: More than 40 million people have died of HIV-related causes since the beginning of the epidemic and nearly 40 million people are living with HIV today. What are the barriers to achieving an AIDS-free generation?

 

Betty: It has been more than 40 years since the first cases of HIV were reported. Yet criminalization, stigma and discrimination against people living with HIV and key populations, including lesbian, gay, bisexual, transgender and queer (LGBTQ+) people, are still prevalent. In fact, they are on the rise again. For example, earlier this year, Ghana – where Global Communities has worked for many years – passed a harsh anti-LGBTQ bill, which has increased criminal penalties for consensual same-sex conduct. This has catastrophic consequences for HIV response, because it pushes people underground. If people cannot access HIV services or face discrimination by health workers, the virus continues to spread. 

This really worries me because it prevents us from reaching the 95-95-95 goals established by the Joint United Nations Programme on HIV/AIDS (UNAIDS). These targets will be achieved when 95% of people living with HIV know their status; 95% of people who know their status receive treatment; and 95% of people on treatment are virally suppressed. Currently, we are at 86-89-93 and the clock is ticking!

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Mario: Inequitable access to health services because of poverty, stigma and discrimination continues to be a huge problem.

 

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María: I completely agree with Betty and Mario. It was a common concern during the conference that the anti-rights movement is rising all over the world. Many countries have really bad, punitive laws. In Canada, for example, HIV non-disclosure to a sexual partner may lead to aggravated sexual assault charges even if transmission does not occur. This is not helping to contain the epidemic because the fear of prosecution deters people from getting tested, knowing their status and seeking treatment.

Also, I am very concerned that scientific advances, including prospective vaccines, will continue to be mostly available in the Global North and not in the countries where they are most needed.

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José: Right, patent protections for HIV prevention and treatment drugs often mean that these life-saving medicines are not affordable in the Global South, for example in Central America where I work. There is always this tension between accessibility and profitability in the drug industry.

 

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María: Exactly. As Paula said, 40 million people are living with HIV around the world, but more than 20% of them are not receiving ART. This is a huge problem. We really need to improve access to medications, including generic drugs.

Paula: How confident are you that we can end the AIDS epidemic by 2030 and meet the relevant targets associated with the Sustainable Development Goals?

Betty: I believe a lot still needs to be done if we are to end the AIDS epidemic by 2030. We are supposed to achieve the 95-95-95 targets by 2025, which is next year. Aside from persistent stigma and discrimination, which continue to hamper the global HIV response, the world is still healing from the COVID-19 pandemic and many health systems are struggling to bounce back. Some countries are ahead and some still lag behind. There are also a lot of health disparities across the globe resulting from policy and institutional gaps.

We are all working extremely hard to reduce these barriers and strengthen health systems, and I believe we will continue to make progress. But 2030 is only five years away.

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María: I agree with Betty. We still have a long way to go. We can only reach these goals if we put people first, improve respect for human rights and allocate more resources to communities in need.

 

Paula: What can our combined organization – and our sector as a whole – do better to serve HIV-affected populations around the world?

José: As practitioners and opinion leaders, we need to keep raising our voice to improve the availability and accessibility of medications and new scientific advancements in the Global South. We also have the responsibility to strengthen the capacity of local actors to lead the HIV response in their communities. This includes increasing their participation in international conferences, like this one, for example through scholarships. 

I am a big believer in empowerment at the local levels. The real change comes from within the communities we work with.

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Betty: Yes, we need to advocate for equality and equity in healthcare. We also need to strengthen our multisectoral approaches. HIV, poverty, limited access to education, food insecurity, malnutrition: these issues are interconnected and must be addressed holistically. 

I also strongly believe in the importance of creating safe spaces for people living with HIV and key populations so that they are not left behind in the face of stigma and discrimination.

Finally, in my view, getting to the first 95% target is the hardest, so increasing consistent access to safe and stigma-free testing and counseling is really key.

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María: That’s right. And we need to take an intersectional approach to this work. Race, ethnicity, language, socioeconomic status, sexual orientation, gender and age are all factors that influence people’s health outcomes. Often, people living with HIV, or at high risk of HIV, experience multilayered discrimination. IntraHealth is currently training health personnel across Central America to prevent stigma and discrimination from an intersectional standpoint.

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Mario: I believe we must also continue working with national governments to facilitate access to all these medical advances we talked about earlier. Twenty years ago, the Global Fund to Fight AIDS, Tuberculosis and Malaria was purchasing HIV medicines in Honduras. Now, the state has assumed this responsibility.

Paula: Thank you for your insights!

Stay tuned for the next blog in which our colleagues will share key takeaways from their respective poster presentations at AIDS 2024.