As the International AIDS Conference took place in Paris this week, UNAIDS issued a report with an encouraging statistic.For the first time, more than half of the 36.7 million people with HIV have access to treatment. That means most people with HIV are taking the antiretroviral medicines needed to suppress the virus. The report cited 53 percent, compared to roughly 27 percent in 2012.The news is a reminder of how the HIV/AIDS epidemic is ever-changing. There are promising trends. And there are setbacks as well. We talked with Annemarie Hou, chief of staff at UNAIDS, the United Nations program focused on HIV/AIDS, and Sharonann Lynch, HIV and TB policy adviser for Doctors Without Borders' Access Campaign.
Fewer people are dying in traditional epidemic hot spots.
In 2010, there were roughly 760,000 AIDS-related deaths in eastern and southern Africa. In 2016, the number had dropped almost by half, to 420,000. The improvement is due to no one single cause. Governments have increased domestic funding for testing and treating HIV, self-tests have made diagnosis easier, and government campaigns have worked with traditional leaders to mobilize communities to get tested for HIV and to start antiretroviral treatment if they test positive. The daily regimen of pills can prevent the virus from worsening and prevent transmission to others."Improvements in countries like South Africa, which has the largest number of people with HIV in the world, is what's driving these results," says Hou.She said the South African government has invested significantly in its AIDS response; the country spent more than $1.5 billion in 2014. To help people with HIV learn their status, South Africa rolled out self-testing and has supported community-based health groups to get people to get treatment and stay in it."It shows we're getting better at making sure we can find people," says Hou. "We're getting them right away."
But HIV infection and AIDS death rates are increasing in Eastern Europe and Central Asia.
The numbers in these regions are far lower than in eastern and southern Africa. But they are on a steady uptick: from 32,000 in 2010 to 40,000 in 2016. And just as governmental spending has helped bring down the numbers in Africa, the lack of commitment is a cause for the increase. "The rates are going up because of pure government neglect in terms of addressing the needs of key populations," says Lynch.The other reason for the increase is a problem that has been a part of the AIDS epidemic since it began in 1981: stigma. In Eastern Europe and Central Asia, people who inject drugs tend not to come to clinics or be tested for HIV, according to UNAIDS. One reason is that they want to conceal their drug use for fear of criminal penalties or other repercussions. For example, in Russia, public health services must add patients to public drug user registries, which can lead to loss of employment or child custody. Men who have sex with other men are also under-tested, in part because of stigma around being gay in the region.But there are promising developments. In 2017, Ukraine's capital, Kiev, became the first city in Eastern Europe or Central Asia to commit formally to ending the AIDS epidemic. Ukraine's government also announced at the end of 2016 it would increase its budget to fully fund a national opioid substitution program for people who use drugs, a population at high risk for HIV, In some countries, babies are no longer born with HIV. In the not too distant past, a pregnant woman with HIV would almost certainly pass the virus on to her child. That is no longer the case. "I think a lot of people would be surprised to learn there are countries that have reached zero transmission from mother to child for HIV," says Hou. "That's pretty big."The World Health Organization has certified that mother-to-child transmission has been eliminated in Armenia, Belarus, Cuba, Moldova and Thailand, Hou says.The key to preventing transmission, according to Lynch of Doctors Without Borders, is treating the mother for HIV with antiretroviral medicine. When mothers are treated, the concentration of the virus goes down in their blood, their birth canal and their breast milk. Many countries have ramped up efforts to make sure pregnant women get care and continue to do so after the child's birth. "That's why there are virtually no HIV-positive babies born in the U.S. anymore," Lynch says.The efforts to stop mother-to-child transmission are leading to another initiative, UNAIDS report. Health-care providers are getting contact information for male partners and testing them.
Women and sex workers have a tough time getting treatment.
"Everywhere in the world there are fragile communities, no matter how well off the country is, where people have very little political, economic, or social capital," says Hou. "And when you don't have either of those three, it's sometimes very difficult to get access to treatment." She lists prison populations, migrant workers and sex workers as groups that may struggle to get tested and get treatment.UNAIDS notes that discrimination in the health care system can take many forms. Health providers may deny service to patients who are gay, who use drugs or who are sex workers.Hou says marginalized groups need extra outreach and support. For example, if a clinic treats someone living below the poverty line for HIV, the clinic should make sure the person can obtain nutritious food. Similarly, if a patient has mental health issues, clinics should be able to offer mental health treatment as well as treatment for HIV.Nonprofits can also help access marginalized groups. UNAIDS highlighted one nonprofit in Cape Town, South Africa — "Women's Legal Centre." In weekly workshops for sex workers, the group teaches them about their rights if detained or arrested. It has also trained four sex workers as paralegals. Among their duties: taking sex workers to medical clinics.
TB is a major threat to people with HIV.
People with HIV/AIDS can die from many types of infections because of their weakened immune systems. But one infection is responsible for far more deaths than other causes: Tuberculosis accounts for 1 in every 3 deaths of people with AIDS.TB is usually curable with pills. If untreated, it can accelerate HIV's progress in the body and can be fatal."Governments need to get their heads out of the sand as far as the willingness and amount of energy that they're using to look for TB," says Lynch. "There have to be early outreach programs at the community level."
People with HIV are growing older — and that means new challenges.
HIV has long been a young person's disease. In 1990, for example, UNAIDS estimates say that of the 130,000 people with HIV in South Africa, only 1,700 were age 50 or older.Improvements in treatment allow more people with HIV to live longer. And fewer young people are contracting HIV, in part because they're becoming sexually active later and using condoms more in areas like Sub-Saharan Africa.So the population of people living with the virus is aging. The year 2012 was the first time people age 50 or older accounted for 10 percent of the adult population living with HIV in low and middle-income countries, according to UNAIDS. In high-income countries, this group accounts for 30 percent of the population."Older people are more susceptible to diseases," says Lynch, again referencing TB as an example. "We should be doing more [testing] for infection in these groups."Natalie Jacewicz is a freelance writer and law school student. Follow her @NatalieJacewicz.
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