Follow the science

The message is clear: UN Member States must follow the science. To advance the HIV response, Member States must agree on an evidence-based political declaration, as well as implement evidence-informed national responses.

The United Nations High-level Meeting (HLM) on HIV and AIDS in mid-2021 marks 40 years since AIDS was first reported. Attention falls squarely on the progress made so far and what must still be done to strengthen the response to HIV. The UN HLM decides on the targets that will shape the next decade of the HIV response. Unavoidably, the impact of COVID-19 on the HIV response so far and to come is central to its discussions.

Four decades of responding to HIV demonstrate the importance of science. The COVID-19 pandemic is a stark reminder that following the science is an inherently political decision. The HIV response must seize the opportunity and capitalize on the political commitment towards public health generated by COVID-19. Here, we outline the science that should be followed, highlight the gaps that science has yet to fully address, and call attention to the policy and practice that should be adapted according to the science.

The power of science

Remarkable scientific progress has provided many of the tools we need to tackle the HIV pandemic. Landmark studies have shown that treatment saves lives and reduces onward transmission. People on effective treatment who have undetectable levels of the virus cannot transmit HIV to sexual partners; and the effectiveness of treatment on preventing perinatal transmission has been established for more than 20 years [1]. HIV treatment in the form of pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP) and other modalities has also proven to be effective in preventing HIV acquisition.

Timeline 1981 to 2021: The key scientific advances that changed the response

Reality check

37.6 million

people are living with HIV

690,000

died from AIDS-related causes in 2020

1.5 million

newly infected in 2020

Despite the advances and worldwide efforts over the past 40 years, around 37.6 million people are living with HIV and 1.5 million were newly infected and 690,000 died from AIDS-related causes in 2020 alone [2]. Only 10 countries met the UNAIDS 90-90-90 targets (that at least 73% of all people living with HIV are virally suppressed) by 2020 [3]. Tremendous progress has been made in developing effective treatments and prevention options, but we are still to develop a safe and effective HIV vaccine or cure.

In late 2019, a new pandemic, COVID-19, emerged. Disruption of essential health services during this pandemic is a global reality: 94% of countries reported disruptions in the first quarter of 2021 [4].

The response to COVID-19 has captured full attention and diverted political interest, funding [5], expertise and healthcare services [6] from people living with and affected by HIV.

Access to HIV prevention reduced and there were decreases in testing [7] and treatment initiation [8,9,10]. Among PEPFAR-supported programmes, voluntary medical male circumcisions reduced by 74% in April-June 2020 from the same quarter in 2019 [11]. In South Africa, lockdown was associated with decreases of 48% in HIV testing and 46% in ART initiations in April 2020 [12].

Tipping point

The impact of COVID-19 could be a tipping point for global health: an opportunity for improvement, innovation and investment in health systems or a risk of a colossal global scale if lessons are not learned for the future.

Following the science has never been more important. Many principles that have long been advocated for in the HIV response have also been important in following the science for the COVID-19 pandemic.

These include ensuring targeted, localized, context-specific responses that respect human rights and meaningfully engage communities.

An onslaught of misinformation has meant, in some cases, that the “defence of science” has been needed to strengthen the connection between science and policy to ensure an evidence-informed response for both COVID-19 and HIV. Varying national responses to COVID-19 are a reminder of the intersection and, often, tension between politics and following the science.

Seize the political commitment

The COVID-19 pandemic has also driven an unprecedented level of personal and political will – and urgency – to protect public health. The immediate public health emergency and long-term disruptions to economies triggered a high level of public and private commitment and, crucially, funding. This has helped drive logistical support and coordination and vaccine research and development unheard of in modern history.

COVID-19 has brought to the fore issues of health inequity and the importance of resilient health systems. It is essential to assess how some of the lessons learned from the COVID-19 response might strengthen pandemic preparedness and responses to infectious diseases in the future.

There is opportunity to adapt and enhance the approaches from the COVID-19 response to HIV and sustain political attention on public health.

This includes harnessing digital technology and community partnerships in research and health service delivery.

Learning from COVID-19

Financial barriers and the influence of vested interests in intellectual property must be removed if we are to protect global public health. As of March 2021, 78% of all COVID-19 vaccine doses had been administered in just 10 countries [13]. Through the Agreement on Trade-Related Aspects of Intellectual Property Rights, selected World Trade Organization (WTO) members have been called upon to waive intellectual property rights that prevent lower-income countries from manufacturing the vaccine [14].

We must heed critical lessons from the HIV response to address inequities in access to COVID-19 vaccines across the world.

Although the first effective HIV treatment was discovered in 1996, it took years before low- and middle-income countries could access combination therapy. In that time, many lives were lost as ARVs were not available and prohibitively expensive to the majority of people living with HIV [15].

It took unprecedented community mobilization, activism, global commitment, financing and political will, including the “3 by 5” initiative and subsequent 90-90-90 targets, to facilitate the rapid expansion of access to ART in resource-limited settings. We must not let history repeat itself and lose countless lives again due to inequitable access to scientifically proven and effective health interventions.

The coinciding of the WTO conversations with the HLM means that Member States’ interests relating to trade, intellectual property, access to COVID-19 vaccines and political priorities in the HIV response are inextricably linked. The denial of the basic human right to health in some countries poses the risk of failure in the responses to both HIV and COVID-19 [16]

The challenge

The HIV response must build on 40 years of robust science and also incorporate important lessons from the COVID-19 pandemic. The challenge is ensuring that the results of scientific research inform policies implemented at scale and enhance the delivery of programmes and healthcare practices. This can be achieved in three main ways: promote science, support action and empower people.

Promote Science

Support Action

Empower People

Promote
Science

Know your epidemic, know your response

The “know your epidemic, know your response” approach remains crucial. Unless programmes are implemented within an implementation science framework and the impact of interventions are measured, we don’t know where to do more, scale up, develop further innovation or stop if an intervention does not work.

Science tells us that accessible HIV testing, with rapid linkage to care and treatment, is vital in controlling the HIV pandemic and reducing AIDS-related deaths. Globally, fewer than 60 countries were able to monitor all aspects of the 90-90-90 targets in 2019, with even fewer doing so among key populations – men who have sex with men, people who inject drugs, sex workers and transgender people. UNAIDS reports that only 47 countries can measure ART coverage among gay and bisexual men, 29 among people who inject drugs and 33 among prisoners [17]. This means that we don’t know how many people in key populations are unaware of their HIV status and if they need life-saving treatment or further support to attain viral suppression.

Invest in research and development

For decades, a safe and globally effective HIV vaccine has remained elusive, hampered by complex challenges, including viral diversity and the virus’s ability to evade immune responses. However, new approaches, including passive immunization and candidates designed to trigger a better immune response, are in early stages of development, with some showing promising results [18].

HIV vaccine research enabled the rapid development of the COVID-19 vaccines through existing vaccine technologies, clinical trial infrastructures and collaborative networks. In turn, the success of technologies developed for a COVID-19 vaccine, such as the messenger RNA (mRNA) vaccines, has triggered a heightened interest in exploring the potential of these technologies for future HIV vaccine candidates. Increased global investment in HIV vaccine research is pivotal as only a vaccine is likely to provide durable control of the HIV pandemic [19].

Follow the science: Invest in knowledge gaps

Global research investments must address key knowledge gaps to advance the most critical scientific issues in HIV, including biomedical prevention, such as vaccines and long-acting technologies and progress towards a cure, as well as social science and evaluations of innovative and stigma-free models of healthcare.

Support
Action

Address structural barriers

UNAIDS points out that the translation of science into policy and then policy into action are key gaps in our HIV response [20]. These gaps are hard to close.

Removing legal and structural barriers to accessing HIV and other services, which include laws and policies that criminalize or discriminate against key populations, has been shown to improve health outcomes for specific populations [21]. A total of 67 UN Member States nonetheless have provisions that criminalize same-sex contact [22].

Migrants, particularly those who are undocumented, rarely have access to healthcare. People who inject drugs and sex workers are criminalized in many settings, which means that they can’t access services. Higher rates of incidence of ill-health, such as mental illness or drug and alcohol dependence, have been documented in specific groups, such as people who are homeless [23] and in prisons or other closed settings [24], than in the general population.

Gender-based violence and gender inequalities also drive the HIV pandemic. In sub-Saharan Africa, young women and adolescent girls make up about 10% of the total population and accounted for one in four new infections in 2019. Keeping girls and teenagers in school in high HIV-prevalence countries prevents new HIV infections by increasing knowledge and providing more life opportunities [25].

Political leaders must recognize and address structural barriers to health, repeal punitive laws and policies, end discrimination and reduce the effects of stigma. India recently passed comprehensive laws setting out a human rights-based approach to managing its HIV response. This followed extensive stakeholder consultation about how to address needs of stigmatized and marginalized groups [26]. An IAS-Lancet Commission [27] is reviewing and revitalizing critical issues in health and human rights, including in the HIV response. Science can help fill knowledge gaps and inform better policies; yet it is governments’ responsibility to create environments that enable the realization of the right to health for all.

Change policies

COVID-19 has accelerated policy support for and implementation of differentiated service delivery (DSD) for HIV. Delivery of PrEP was adapted in Ethiopia with extended refills and online education, in Thailand with extended refills and increased telehealth, and in South Africa through mobile clinics and home delivery [28]. DSD for HIV treatment was expanded in response to COVID-19, including eligibility, ART refill duration and prescription length, community-based ART options and expansion of HIV services with non-communicable diseases [29].

In over 50 countries, harm reduction services were adapted quickly to mitigate disruptions and service delivery challenges during COVID-19 movement and other restrictions. Models of service delivery were innovated by simplifying prescribing requirements, offering take-home opioid agonist therapy and increasing access to naloxone and harm reduction services through mobile services [30].

We must bolster the evidence base for the adaptations to service delivery that were implemented as emergency measures in response to COVID-19. The innovations to HIV and other health services that are proven to increase acceptability, uptake and adherence should remain in place.

Follow the science: Accelerate the uptake of evidence

The uptake of evidence must be accelerated to achieve specific evidence-based policy changes at the global, national and sub-national levels through tailored engagement, dialogues and advocacy on priority areas in the HIV response.

Empower
People

Bridge the digital divide

Use of digital devices and platforms can support people to look after their health. In some places, HIV self-testing kits and PrEP can be ordered online and digital platforms are used to facilitate the creation of peer support groups for adherence. During the COVID-19 pandemic, an initiative in Jamaica disseminated information through social media, using animated cartoon characters to reach adolescents [31].

Central to the success of digital interventions is internet access, with innovations that are designed and implemented to protect client confidentiality and privacy. However, countries where the HIV burden is highest, like in sub-Saharan Africa, experience irregular internet service and exorbitant pricing for mobile data [32]. Despite progress towards e-delivery of health, people in internet-poor settings are being left behind. Governments must recognize that internet access is rapidly becoming essential to healthcare and opens a range of public health opportunities.

Enable community leadership

During the COVID-19 pandemic, community-based models for ART delivery were used more extensively in HIV services in Cote d’Ivoire, Eswatini, Ethiopia, Kenya, Lesotho, Mozambique, South Africa, South Sudan, Tanzania, Uganda and Zimbabwe [33]. In South Africa, as of October 2020, more than 1.3 million people living with HIV were receiving ART refills at community pick-up points, including private pharmacies, community venues and lockers. Community-led research has been key in improving access to HIV tests [34] and informing the tailoring of harm reduction services [35].

The HIV response has shown the impact of communities demanding access to information, leading research, monitoring impact to ensure accountability, and advocating until policies and interventions reflect evidence and people’s choices and preferences.

Community leadership is critical for understanding the social context and how to deliver interventions. Vaginal rings have been shown to be effective in reducing the risk of HIV acquisition. However, recent work in four southern African countries found that women frequently had to negotiate their use [36]. If the rings are not as empowering as intended, it will reduce uptake and their potential in decreasing risk of HIV acquisition.

In challenging situations, communities can often be the first to organize. In Mexico, despite governmental funding cuts to HIV services, civil society is working to obtain alternative funding, including setting up online donations and partnerships with industry [37].

Follow the science: Engage communities in HIV research

Support must be provided to people and communities living with and affected by HIV to effectively engage in the HIV response. This includes empowering communities to lead and critically engage with cutting-edge science and strengthening the capacity of researchers in resource-limited settings to lead HIV science across all disciplines.

Conclusion

Following the science is key to achieving health equity and universal health coverage for HIV and other disease areas. Innovation must be accessible and equitable, science must inform policy, and community leadership must be taken seriously at every step. The greatest victories over the past 40 years have not been from HIV scientific breakthroughs alone, but from forming a common front that united scientists, activists and policy makers. The IAS, and its members, must call for the world to follow the science as we gather for the UN HLM and also lead the global HIV community in continuing to innovate and follow the science of tomorrow.

1 Connor EM, et al. Reduction of Maternal-Infant Transmission of Human Immunodeficiency Virus Type 1 with Zidovudine Treatment. N. Engl. J. Med. 331, 1173–1180 (1994)

2 UNAIDS, Global HIV Statistics. June 2021. https://www.unaids.org/en/resources/fact-sheet

3 UNAIDS, AIDSinfo. June 2020. https://aidsinfo.unaids.org/

4 WHO, Second round of the national pulse survey on continuity of essential health services during the COVID-19 pandemic, March 2021. https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS-continuity-survey-2021.1

5 Kowalska JD, Skrzat-Klapaczyńska A, Bursa D, et al. HIV care in times of the COVID-19 crisis – Where are we now in Central and Eastern Europe? Int J Infect Dis. 96:311-314 (2020). doi:10.1016/j.ijid.2020.05.013

6 Shiau S, Krause KD, Valera P, Swaminathan S, Halkitis PN. The burden of COVID-19 in people living with HIV: a syndemic perspective. AIDS Behav. 24:2244–2249 (2020)

7 The Hans India, COVID-19 has disrupted HIV care in India, says survey, December 2020. https://www.thehansindia.com/bengaluru/covid-19-has-disrupted-hiv-care-in-india-says-survey-659534

8 Gatechompol S, Avihingsanon A, Putcharoen O, Ruxrungtham K, Kuritzkes DR. COVID-19 and HIV infection co-pandemics and their impact: a review of the literature. AIDS Res Ther. 18(1):28 (2021 May 5). doi:10.1186/s12981-021-00335-1

9 Pinto RM, Park S. COVID-19 pandemic disrupts HIV continuum of care and prevention: implications for research and practice concerning community-based organizations and frontline providers. AIDS Behav. 24:2486–2489 (2020)

10 UNAIDS, Global Commitments, Local Action. June 2021. https://www.unaids.org/en/resources/documents/2021/global-commitments-local-action

11 amfAR, PEPFAR Monitoring, Evaluation, and Reporting Database, 2021. https://mer.amfar.org/

12 Dorward J, et al. The impact of the COVID-19 lockdown on HIV care in 65 South African primary care clinics: an interrupted time series analysis. Lancet HIV 8: e158–65 (2021)

13 Bloomberg, More than 447 million shots given: Covid-19 Tracker, March 21, 2021. https://www.bloomberg.com/graphics/covid-vaccine-tracker-global-distribution/

14 World Trade Organization, Members discuss intellectual property response to the COVID-19 pandemic, 20 October 2020. https://www.wto.org/english/news_e/news20_e/trip_20oct20_e.htm

15 Chigwedere P, Seage GR 3rd, Gruskin S, Lee TH, Essex M. Estimating the lost benefits of antiretroviral drug use in South Africa. J Acquir Immune Defic Syndr. 1;49(4):410-5. doi: 10.1097/qai.0b013e31818a6cd5. PMID: 19186354 (Dec 2008)

16 International AIDS Society. Human rights and fair access to COVID-19 vaccines: the International AIDS Society–Lancet Commission on Health and Human Rights. The Lancet 3971524-1527 (2021)

17 UNAIDS, AIDSinfo. June 2020. https://aidsinfo.unaids.org/

18 IAVI, First-in-human clinical trial confirms novel HIV vaccine approach developed by IAVI and Scripps Research, February 2021. https://www.iavi.org/news-resources/press-releases/2021/first-in-human-clinical-trial-confirms-novel-hiv-vaccine-approach-developed-by-iavi-and-scripps-research

19 NIH, Durable end to the HIV/AIDS pandemic likely will require an HIV vaccine, October 2017. https://www.nih.gov/news-events/news-releases/durable-end-hiv-aids-pandemic-likely-will-require-hiv-vaccine

20 UNAIDS, The Gap Report, July 2014. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_Gap_report_en.pdf

21 ILGA World, State Sponsored Homophobia report – Global Legislation Overview update, December 2020. https://ilga.org/state-sponsored-homophobia-report

22 ILGA World: Lucas Ramon Mendos, Kellyn Botha, Rafael Carrano Lelis, Enrique López de la Peña, Ilia Savelev and Daron Tan, State-Sponsored Homophobia 2020: Global Legislation Overview Update. Geneva: ILGA, December 2020. https://ilga.org/downloads/ILGA_World_State_Sponsored_Homophobia_report_global_legislation_overview_update_December_2020.pdf

23 Fazel S, et al. The prevalence of mental disorders among the homeless in western countries: Systematic review and meta-regression analysis. PLoS Medicine, Volume 5, Pages e225 (December 2008)

]24 Todrys KW, Amon JJ, Malembeka G, Clayton M. Imprisoned and imperiled: access to HIV and TB prevention and treatment, and denial of human rights, in Zambian prisons. J Int AIDS Soc. (2011 Feb) 11;14:8. doi: 10.1186/1758-2652-14-8.

25 UNAIDS, Keeping girls in school reduces new HIV infections, April 2021. https://www.unaids.org/en/resources/presscentre/featurestories/2021/april/20210406_keeping-girls-in-school-reduces-new-hiv-infections

26 UNAIDS, Legal and policy trends impacting people living with HIV and key populations in Asia and the Pacific 2014–2019, January 2021. https://www.unaids.org/sites/default/files/media_asset/legal-and-policy-trends-asia-pacific_en.pdf

27 IAS-Lancet Commission on Health and Human Rights, 2021. https://www.iasociety.org/HIV-Programmes/Programmes/IASLancet-Commission-on-Health-and-Human-Rights

28 http://differentiatedservicedelivery.org/Resources/differentiated_PrEP_slides

29 Grimsrud A & Wilkinson L. Acceleration of differentiated service delivery for HIV treatment in sub-Saharan Africa during COVID-19. JIAS, 2021, in press.

30 IAS President Adeeba Kamarulzaman at the 64th session of the Commission on Narcotic Drugs, 14 April 2021. https://www.iasociety.org/The-latest/News/ArticleID/265/Remarks-from-IAS-President-Adeeba-Kamarulzaman-at-the-64th-session-of-the-Commission-on-Narcotic-Drugs

31 UNAIDS, Digital HIV education for Jamaican young people during COVID-19 and beyond, March 2021. https://www.unaids.org/en/resources/presscentre/featurestories/2021/march/20210322_education-jamaican-young-people

32 Research ICT Africa, Despite reduction in mobile data tariffs, data still expensive in South Africa, June 2020. Tapiwa-Chinembiri-Mobile-Data-Pricing-Policy-Brief2-2020-FINAL.pdf

33 Grimsrud A & Wilkinson L. Acceleration of differentiated service delivery for HIV treatment in sub-Saharan Africa during COVID-19. JIAS, 2021, in press.

34 Indravudh PP, Fielding K, Kumwenda MK, et al. Community-led delivery of HIV self-testing to improve HIV testing, ART initiation and broader social outcomes in rural Malawi: study protocol for a cluster-randomised trial. BMC Infect Dis 19, 814 (2019)

35 International Network of People who Use Drugs (INPUD), Drug Decriminalisation: Progress or Political Red Herring?, April 20201. https://www.inpud.net/en/drug-decriminalisation-progress-or-political-red-herring

36 Pleasants E, Tauya T, Reddy K, et al. Relationship Type and Use of the Vaginal Ring for HIV-1 Prevention in the MTN 020/ASPIRE Trial. AIDS Behav. 24(3):866-880 (2020)

37 EL CEO, Cómo financiar una Organización de la Sociedad Civil con dinero privado, October 2019. https://elceo.com/politica/como-financiar-una-organizacion-de-la-sociedad-civil-con-dinero-privado/

Centers for Disease Control and Prevention. Pneumocystis pneumonia—Los Angeles. Morbidity and Mortality Weekly Report. 30, 250–252 (1981)

Barré-Sinoussi F, et al. Isolation of a T-lymphotropic retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS). Science 220, 868–871 (1983)

Clumeck N, et al. Acquired immune deficiency syndrome in Black Africans. Lancet 1, 642 (1983)

Alexander TS. Clinical and Vaccine Immunology. 23, 249–253 (2016)

Broder S. The development of antiretroviral therapy and its impact on the HIV-1/AIDS pandemic. Antiviral Research. 85, 1–18 (2010)1

Connor EM, et al. New England Journal of Medicine. 331, 1173–1180 (1994)

Baker R. FDA approves 3TC and saquinavir. Food and Drug Administration. BETA. 5, 9. PMID: 11363011 (1995 Dec)

Mann JM. Health and human rights: if not now, when? Health and Human Rights. 2(3):113–120 (1997)

Allers k, et al. Evidence for the cure of HIV infection by CCR5Δ32/Δ32 stem cell transplantation. Blood. 117 (10): 2791–2799 (2011)

Vernazza Pietro, Hirschel Bernard, Bernasconi Enos, Flepp Markus. HIV transmission under highly active antiretroviral therapy. Lancet372 (9652): 1806–1807 (November 2008)

Grant RM, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine. 363, 2587–2599 (2010).

Cohen MS, et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. 365:493-505 (2011)

INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. New England Journal of Medicine. 373, 795–807 (2015)

Rodger AJ, Cambiano V, Bruun T, et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA. 2016;316(2):171–181.

PARTNER 2 presented at AIDS 2018, published in 2019

Rodger AJ, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet. (2019)

Evidence for Contraceptive Options and HIV Outcomes (ECHO) Trial Consortium. HIV incidence among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: a randomised, multicentre, open-label trial. Lancet. 394(10195):303-313 (2019 June 13)

Swindells S et al. Long-acting cabotegravir + rilpivirine as maintenance therapy: ATLAS week 48 results. Conference on Retroviruses and Opportunistic Infections, Boston, abstract 139 LB (2019)

Overton ET et al. Cabotegravir + rilpivirine every 2 months is noninferior to monthly: ATLAS-2M study. Conference on Retroviruses and Opportunistic Infections, abstract 34 (March 2020)

Jaeger H et al. Week 96 efficacy and safety of cabotegravir + rilpivirine every 2 months: ATLAS-2M. Conference on Retroviruses and Opportunistic Infections, abstract 401 (2021)

Long-acting injectable form of HIV prevention outperforms daily pill in NIH study. Presented at HIVR4P 2021.

https://www.nih.gov/news-events/news-releases/long-acting-injectable-form-hiv-prevention-outperforms-daily-pill-nih-study