Introduction

Held against the backdrop of a faltering HIV/AIDS prevention and treatment trend worldwide, this year’s AIDS 2022 conference call to re-engage and follow the science remains crucial to ending AIDS. According to the 2022 UNAIDS report, 650, 000 lives were lost to AIDS-related causes in 2021, more than 10 million persons living with HIV (PLHIV) did not have access to the live saving antiretrovirals (ARVs), and more than 1.5 million people were infected with HIV in that year alone. Children, adolescents and young women are the most affected, mostly due to poor access to medicines and prevention interventions. Coupled with disruption in HIV treatment and prevention due to COVID-19, the call to re-engage science was a timely reminder that science has given us the tools to end AIDS.

Our overarching takeaway from AIDS 2022 is that the science presented at the conference reaffirmed a few germane messages. In this blog post, we describe these key messages. First, priority interventions that have been positioned to bring us to the end of AIDS are effective. Second, conclusions from implementation science presented at the conference showed that implementation approaches, including differentiated service delivery (DSD) models work and should be scaled up rigorously. Third, community engagement is key to success and there should be nothing about us, without us. Lastly, our final takeaway message is both a reminder and a warning: epidemiological realities – the ageing population of persons living with HIV, comorbidities, colliding epidemics, emerging diseases, and neglected diseases – bring new challenges that require continuous learning from the mistakes of the early HIV/AIDS response.

Priority interventions are effective and can bring us to the end of AIDS, but we must reengage the science to sustain progress

We have made so much progress in controlling HIV since the ‘80s. From being a death sentence at the time, HIV infection today is a chronic illness that can be well managed with markedly improved quality of life. This progress has been facilitated by science – research into prevention, treatment and cure – that has provided us with a toolbox of interventions that continues to evolve with better solutions. At the conference, the world was reminded to reengage with the science as this would usher in the next phase of our fight against this disease. Evidence from large studies around recently introduced ARVs such as dolutegravir, showed that we have the right tools to achieve viral suppression. Effectiveness shown from studies on newer ARVs continues to confirm that long-acting agents are here to stay – for both prevention and treatment.

In addition to ARVs keeping PLHIV alive and healthy, a potent message reiterated by the conference co-chair, Adeeba Kamarulzamanis, is that when PLHIV are undetectable they will not transmit to their sexual partners (U=U), which is crucial for prevention. Moreover, science presented at the conference reaffirmed that pre-exposure prophylaxis (PrEP) works. The newer long-acting agents for ART and PrEP will help make ART and PrEP less burdensome from reduced dosing to addressing challenges of suboptimal adherence from pill fatigue, protection of health privacy (accidental disclosures when medicine bottles are discovered), convenience during travel and more choices for ART and PrEP delivery.

AIDS 2022 also showed us that we have grounds for continued hope as research into novel treatment strategies, including cure strategies continue to explore multiple approaches. The quest for HIV vaccines is gaining momentum with advances in RNA vaccines for COVID-19 renewing hope for an HIV vaccine. However, significant differences between the two viruses exist and were described. Nonetheless, science showed that HIV broadly neutralizing antibodies (BNAbs) have moved further along the pipeline to becoming available for general use.

Implementation approaches that we have in our toolbox, including DSD models work and we must reengage the science to ensure effective reach

Having the right interventions would come to naught if they do not reach the persons who need them. We have long known that PLHIV have diverse needs and delivery of services should be person-centered to meet preferences and expectations.

Science at AIDS 2022 showed that DSD models can improve patient care and outcomes. Indeed, data showed that service adaptation in different settings, especially during the peak of the COVID-19 pandemic, helped to ensure minimal disruption to services. COVID-19 accelerated the scale up of DSD models, especially decentralized drug distribution and multi-month dispensing (MMD) of ARVs. However, attention needs to be paid to contexts in interpreting and adapting science from one setting to another.

Additionally, coverage of DSD models was expanded as eligibility criteria in many countries expanded to populations who were initially excluded, including pregnant women, children and newly initiated PLHIV. At the same time, reduced number of visits to health facilities, decentralized drug distribution models that brought ARVs closer to people’s homes, out-of-facility ART initiations and service delivery, telehealth services were some of the innovations that recipients of care were highly satisfied with and helped reduce the impact of COVID-19 disruptions on HIV services. Similar gains were made for PrEP as a result of COVID-19 adaptations.

However, despite the above adaptations, implementation challenges of new science, scale-up and expanded access persist. For example, in sub-Saharan Africa, the epicenter of HIV/AIDS, the affordability of long acting ARVs, the prerequisite tests needed to enroll or switch patients to new medicines, supply chain issues that limit DSD models (6 -MMD) are a few of those challenges that require further support.

Community engagement is critical to success in HIV control

Sessions held at the global village of the conference and multiple data driven presentations reiterated the importance of community engagement, especially to ensure effective research. Evidence highlighted the importance of engaging with communities in research design, implementation, dissemination, uptake, and translation to policy. For example, engaging with research participants, especially children living with HIV in the design and conduct of research was an item that came to the fore.

Several presentations and panel discussions also highlighted evidence from research that explored how to engage youth and adolescents. Outcomes were typically more desirable when the young persons were actively engaged through dedicated strategies. The satellite session hosted by FHI 360 on expanding access to and increasing uptake of COVID-19 vaccinations among key populations was another one of the sessions that presented evidence that showed the importance of engaging and building trust with communities.

The epidemiology of HIV is evolving, and emerging infections present additional challenges

Reengaging with science will help us define the epidemiological realities as well as apply science to control colliding epidemics. As the population of PLHIV continues to live longer and age, it is important to look back to science to understand the challenges faced and how best to provide care at later stage of life.

Evidence around comorbidities, approaches to managing them and implementation science around integration of services all pointed to the fact that, from a person-centered perspective, and from efficiency standpoint, it makes sense to build programs that provide integrated holistic care for persons living with HIV.

Sessions at the conference also discussed the innovations needed to sustain care in the face of new challenges to the HIV program. Implementation science around these innovations will help ascertain whether we are treading the right course.

In this respect, AIDS 2022 paid a decent amount of attention to emerging diseases with COVID-19, monkeypox and female genital schistosomiasis featuring in different sessions. This widened focus on emerging diseases was especially welcome given how easily a new pandemic can roll back years of progress made in the journey to the end of HIV/AIDS.

Beyond disruptions and reversal of progress made with the HIV response however, it seems that the world is making the same mistakes made at the start of the HIV epidemic with the new epidemics. Stigmatization, inequalities, disparities and human rights violations seem to be widening and are appearing once again, especially in the response to COVID-19 and monkeypox, as if the world is not learning anything. In this regard, presenters at the conference concluded with a note of warning to not repeat the mistakes of the early HIV/AIDS response. That way, emerging and neglected diseases that may set us back can be addressed effectively. In the same vein, approaches to leverage existing platforms as a springboard to address emerging diseases were described in many sessions. We believe that both implementers and researchers can benefit from such approaches to inform long-term strategy for disease control.

Conclusion

We celebrate the progress made so far in efforts to control HIV and reaffirm that science holds the key to getting us to the end of AIDS. We urge the global community to indeed remain hopeful and enthusiastic by ensuring partnerships are resuscitated and following the science to scale-up evidence-based interventions. We must also continue our work to eliminate inequalities, uphold human rights and ensure greater and more equitable collaboration between communities and scientists.

Photo credit: DC Studio/Adobe Stock

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