Abstract
In a Commentary, appearing in this journal in May of last year, I reviewed the good news from the Global Fund to Fight AIDS, Tuberculosis and Malaria, presented by Winnie Byanyima, Under-Secretary-General of the United Nations and Executive Director of UNAIDS. 1 Over the past two decades, new HIV infections declined internationally by 54%, and AIDS-related deaths by 65%, a consequence of initiatives in antiretroviral treatment (ART) and prevention. These initiatives were supported by the Global Fund and the President's Emergency Plan for AIDS Relief (PEPFAR), both established 22 years ago. Yet the world did not meet 2020 HIV targets ambitiously set by UNAIDS 5 years earlier or the Global Fund replenishment funding goals in 2022. Thus, although the Global Fund strategy for the next 5 years asserts: “End Inequalities. End AIDS,” there are real obstacles to reaching those goals.
“The Path That Ends AIDS,” an interim progress report from UNAIDS related to “Sustainable Development Goals,” including an end to AIDS by 2030, notes that five countries, Botswana, Eswatini, Rwanda, Tanzania, and Zimbabwe, have reached 95-95-95 targets: 95% of people living with HIV know their HIV status, 95% of those so aware are receiving ART, and 95% of those on ART are virally suppressed. 2 Another 16 countries representing 65% of the global HIV population are near those targets. This should be highly encouraging save for two things: countries achieving the most progress have established and sustained programs which address societal and structural factors, including stigma and human rights violations, but this is not typical of many regions of the world; 2 and reauthorization of PEPFAR is by no means guaranteed.
Dramatic increases in new HIV infections, from 49% to 61% over the past decade, are now centered in Eastern Europe, Central Asia, the Middle East, and North Africa. 2 Many of these regions lack a variety of HIV prevention and treatment services. The International Epidemiology Databases to Evaluate AIDS network found the lowest scores for retention in HIV clinical care among adults in the Asia-Pacific region: only 54% of person-time was retained in care. 3 Other regions also impose barriers to their implementation. Watchdog groups including the International Lesbian, Gay, Bisexual, Trans and Intersex Association report that most African countries impose restrictive policies against LGBTQ+ communities and offer few basic protections. 4 Nigeria permits flogging, and several African countries allow the death penalty—the latest such legislation is from Uganda—though it is unclear that it has been actually carried out. 4 Thirty-two of the 54 African countries currently criminalize same-sex sexual activity, yet that high number is said to reflect progress, down from 39 countries in the 1990s. 4 South Africa is the only African nation to explicitly protect LGBTQ+ people in its constitution.
The proliferation of such discriminatory laws has been attributed to beliefs among fundamentalist Christians and interpreters of Islamic law in Africa, as well as inferences that “some African politicians demonize LGBTQ+ identities as a Western import that threatens social cohesion.” 4 Fear of being ostracized or imprisoned if identified as LGBTQ+ prevents individuals from seeking HIV care and accessing HIV pre-exposure prophylaxis (PrEP). 5 In addition, under new Uganda legislation passed this year, health care workers are required to identify and report patients suspected of being gay to the government or face prosecution themselves. In countries that criminalize homosexuality, HIV prevalence is five times higher among men who have sex with men than in countries without such laws. 6 It is also 12 times higher in settings with recent prosecutions than in settings without such prosecutions.
This is not only a concern for resource-poor countries. In 2021, US President Joe Biden issued a National HIV/AIDS Strategy encouraging reform of state HIV criminalization laws and policies. 6 But in 2023, there has been a “tide of anti-LGBTQ+ legislation and repressive government policies and practices in the USA,” according to John Nkengasong, the PEPFAR director. 6 More than 75 anti-LGBTQ+ bills have been signed into law in the US thus far in 2023 alone, a country where two thirds of new HIV infections yearly are among men who have sex with men (MSM). 7 An underappreciated consequence of such restrictions is the added burden to HIV care providers. The US South is particularly vulnerable, with 81% of counties having no access to an HIV care provider. 6 The HIV Medicine Association, one of the largest professional society of US HIV providers, stresses the need for advocacy in the face of such political obstacles: “issues related to the social determinants of health such as racism, housing, food insecurity, substance use disorders, xenophobia, homophobia, transphobia, and mental health are health care.” 8
International and domestic declines in funding of HIV initiatives must also be addressed; that will require stronger political will. 2 The outlook is not great. In 2022, there was a 90% funding gap for prevention programs in low- and middle-income countries, compared to the funding required by 2025. 2 PEPAR reauthorization for the next 5 years is in jeopardy, linked to accusations that its funds are supporting abortion-providers. 9 Instead, antiabortion advocates and some politicians have pushed for a 1-year reauthorization that includes explicit abortion restrictions. If lawmakers do not reauthorize PEPFAR, most of the program's funding would remain intact, but with two critical consequences. First, as Jennifer Kates, director of global health and HIV policy at Kaiser Family Foundation recently said, “If PEPAR doesn't get reauthorized … it could send some pretty chilling messages to people in the field who depend on PEPAR for life support.” 9 Second, several important provisions will end, including ensuring that some funds can be used for treatment, and others will be earmarked for vulnerable children. George W. Bush, 43rd president of the United States and author of PEPFAR, recently admonished that “there is no program more pro-life than one which has saved more than 25 million lives. I urge Congress to reauthorize PEPFAR for another five years without delay.” 10 Hopefully his words will carry weight.
Finally, existing pathways to accelerate access to HIV prevention and treatment despite these roadblocks must be promulgated. Telehealth availability and expansion of mobile health devices, important in facilitating access to HIV testing and ART adherence in both resource-rich and resource-poor settings 11,12 are critical. But technical barriers, unfamiliarity and patient distrust, and consideration of culturally significant absence of human contact and connection will need to be addressed. Similarly, biomedical interventions, including PrEP, both on demand and in the form of long-acting injectables, HIV self-testing, and promotion of U = U (HIV viral load undetectable equals untransmittable), offer new means to expand services to vulnerable populations, but only if stigma and access issues are confronted and resolved. Health care providers are key “implementation actors” in this regard, but in certain regions some providers fear reprisals or, with regard to PrEP, believe that it would “increase immorality.” 10
Director Nkengasong recently warned that “In 2023, HIV/AIDS threatens global health security and economic development. Governments need to address the inequities—including, crucially, legal and policy barriers—that stand in the way of progress in the HIV/AIDS response.” 6 His words need to be considered with much urgency.