The HIV epidemic: Progress and Setbacks

 There was a point in time (according to my father) when you couldn't turn on the TV without hearing about the AIDS epidemic. People were scared, and not without reason - very little was known about this mysterious new disease. Add to that all the stigmatization, the fear mongering, the outlandish misinformation, and it makes a pretty good recipe for a public health crisis. It's strange to look back at this period, especially taking into account all that has transpired since. For this piece, I wanted to take a look at where we are today, both the progress that has been made and the setbacks that we still face, and evaluate the lessons that we've learned along the way.

On the bright side: treatment has come a long way, and as a result an HIV infection is no longer a death sentence. With current combination antiretroviral therapies, a patient's viral load can be maintained at such a low level that it is undetectable in the plasma. This means that the patient is not only asymptomatic, but is also incapable of transmitting the virus to another person. This development alone has drastically reduced the disease burden across the world, especially here in the United States where these drugs are widely accessible. Globally, out of the 39.9 million people living with HIV in 2023, 30.7 million were able to access antiretroviral therapy. The annual rate of new infections has been declining since 1995 by about 60% (3.3 million new infections in 1995, 1.3 million new infections in 2023). The mortality rate from AIDS has also decreased by about 69% since its peak in 2004.

On the not-so-bright side: while the impact of this disease has drastically shrunk in certain parts of the world, the same cannot be said for less developed regions. In countries such as South Africa, Lesotho, and Eswatini, the prevalence reaches up to 25% of adults, and there remains a struggle to tackle this threat. Additionally, the spread of misinformation has compounded these difficulties. Rumors such as "having sex with a virgin will cure AIDS" or "antiretroviral therapy is harmful, lifestyle changes will suffice" have posed real setbacks, resulting in increased transmission and loss of life. In terms of the WHO targets (fewer than 370,000 new infections per year, fewer than 250,000 deaths per year, complete eradication by 2030), we have fallen short of each of these. Furthermore, despite the massive worldwide efforts, a vaccine against HIV remains elusive.

Amidst the failures, there is potential breakthrough on the horizon. A novel HIV drug, lenacapavir, received FDA approval in 2022 as an adjunct agent for treatment resistant HIV. It is administered as a subcutaneous injection every six months. It was later studied in the PURPOSE-1 trial as a prophylactic agent, which included 5,300 cisgender women in South Africa and Uganda. It displayed remarkable results; as of December 2024, the prevention rate within the sample group is 100%. Another international trial is ongoing, the PURPOSE-2, which includes participants with various gender identities with male sexual partners. So far, the prevention rate is 96%. This drug could truly be a game changer; there are oral prophylaxis agents, but they present issues with convenience, adherence, and stigma which limit use. A twice yearly injection could mitigate these problems if availability of the drug became widespread enough. Up to this point, complete eradication of the disease seemed all but impossible without a vaccine. Thanks to this exciting new development, this goal could be more realistic, perhaps a light at the end of the tunnel of this generation-defining epidemic.

References:

https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf

https://www.sunlencahcp.com/dosing-and-administration/sunlenca-dosing/

https://www.askgileadmedical.com/docs/sunlenca/sunlenca-mechanism-of-action

https://www.npr.org/sections/goats-and-soda/2024/12/12/g-s1-37662/breakthrough-hiv-lenacapavir

https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2024/july/20240710_lenacapavir


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