Ending AIDS and stopping pandemics through closing inequalities.

This year marks 40 years since the first AIDS cases were reported. It was in 1981 that an unusual pneumonia was noticed in San Francisco and New York among gay men and people who inject drugs; the underlying cause was later found to be HIV. At the time, few imagined the HIV pandemic to come—one that grew, needlessly, to take the lives of ∼36 million people worldwide since its start.

Today, the HIV pandemic has collided with the COVID-19 pandemic—showing yet again that the world is unprepared for a global response to an urgent infectious disease. UNAIDS and Global Fund data show that the AIDS response, which was not on track before COVID-19, has proved remarkably resilient in some contexts but in others has been blown far off course—with HIV testing and prevention programs particularly undermined (1, 2).

This is hardly the first example of colliding pandemics. Tuberculosis (TB), an ancient infectious disease that also thrives on marginalization within our society, was identified early on as a common infection among people living with HIV. Soon HIV was recognized as the strongest risk factor for progression of latent tuberculous infection to active tuberculosis of the lungs. The combination of HIV and tuberculosis led to a quadrupling of rates of tuberculosis in much of Southern and East Africa, and tuberculosis quickly became the most important cause of death among people living with HIV. Today, people living with HIV are 18 times more likely to develop active TB, with over 95% of TB cases and deaths in low-income countries (3).

Now, under COVID-19, deaths from tuberculosis have risen for the first time in a decade (3). We cannot afford to be this unprepared for a pandemic and we can no longer afford to ignore the inequalities at the heart of pandemics. This World AIDS Day is dedicated to the theme of ending inequalities that drive TB, AIDS, and COVID-19 and that will almost certainly help outbreaks of the future become pandemics. Without bold action against inequalities, the world risks missing the targets to end TB and AIDS by 2030. We will face a prolonged COVID-19 pandemic and a spiraling social and economic crisis.

A bold new “Global AIDS Strategy 2021–2026—End Inequalities, End AIDS,” adopted earlier this year, leverages four decades of experience, and sets out what needs to be done to end the inequalities that are preventing people from benefitting from HIV services (see https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026). It spells out changes that are required across laws, policies, social norms, and services to uproot inequalities and get us back on track to ending AIDS by 2030.

Importantly, much of what is needed to end the AIDS pandemic is also critical for building pandemic-prepared and pandemic-resilient communities in the future. Indeed, if we start with human beings and build out pandemic-preparedness they need, we end up in a very different place than if we start with a question of novel pathogens. What we see, quite quickly, is that what is working on HIV, what needs to be taken to scale worldwide, will also help protect countries and communities in the future.

Not long ago, the success we have seen from the AIDS response was deemed impossible by many in the medical and global health world. We set the ambitious goal, amidst a pandemic with no cure and no vaccine, to ensure that all people living with HIV get access to effective treatment and could suppress the HIV virus to both save their lives and stop HIV transmission. As of 2020, two vastly different countries—Switzerland, home of UNAIDS and WHO headquarters, and tiny Eswatini, home to some of the highest rates of HIV in the world—had both passed a key threshold. Ninety-five percent of people living with HIV know their status, 95% of those are on treatment, and 95% of those are virally suppressed (1). Malawi has reduced new HIV infections by 64% since 2010. Thailand has more than halved its HIV deaths.

In the past decade, we have learned a lot about what human-centered pandemic response looks like—and it centers on closing inequalities. Where we have done that well, people are living long, healthy lives with HIV. Where we have built strong, people-centered efforts, HIV programs have withstood COVID-19. We now need to take these lessons worldwide—not just to end AIDS but to end COVID-19 and prepare for future pandemics.

One key is focusing our efforts where intersecting inequalities make some people far more vulnerable to pandemic disease. United Nations (UN) Member States this June adopted a bold Political Declaration on HIV and AIDS at the UN General Assembly that includes a range of new and ambitious targets. It calls on countries to define those populations central to their HIV epidemic and who are considered key. The Declaration (para 25) sets out that these include “people living with HIV, men who have sex with men who are at 26 times higher risk of HIV acquisition, people who inject drugs who are at 29 times higher risk of HIV acquisition, female sex workers who are at 30 times higher risk of HIV acquisition, transgender people who are at 13 times higher risk of HIV acquisition, and people in prisons and other closed settings who have six times higher HIV prevalence than the general population” (4). Only by focusing our efforts on addressing the specific needs, and protecting the rights, of key populations will we make tangible progress in reaching the ambitious Sustainable Development Goals (SDG) target to end AIDS.

Data are a critical tool to help us tackle pandemics when it can reveal the inequalities that exist. Take, as an example, people in prisons, who are disproportionately vulnerable to a range of infectious diseases, including HIV, COVID-19, TB, and multidrug-resistant TB (MDR-TB) due to overcrowding, poor ventilation, inadequate snatiation, poor nutrition, and lack of services. Among countries that reported to UNAIDS between 2017 and 2021, few are implementing HIV prevention programs in prisons and other closed settings, despite these being both cost-effective and evidence-based. Fifty-two of 137 reporting countries said that condoms and lubricants were made available to prisoners, only 32 of 140 reporting countries said that opioid substitution therapy programs were operational in prisons, and just 11 of 141 reporting countries said that needle-syringe programs were operational in prisons (1).

Laws and policies can help dismantle inequalities or make them worse. For example, during the past five years, countries that criminalized key populations experienced significantly less success in achieving the HIV testing and treatment goals than those with laws and practices that avoided criminalization (5). On the other hand, where countries’ policies allowed civil-society organizations to deliver HIV treatment in drop-in centers for key populations or in community-based cites, progress was often much faster even in the face of COVID-19.

This key community-based and community-led infrastructure is another critical factor that will help end AIDS and prepare for future pandemics. During COVID-19, for example, community leadership and service delivery have proved critical. In Côte d’Ivoire, Indonesia, Kenya, and elsewhere, community groups have delivered antiretroviral and tuberculosis medicines to people’s homes or local drop-in centers; in Eswatini and Kenya, civil-society groups have delivered condoms, lubricants, and HIV self-testing kits to key populations. Not only has this infrastructure been mobilized to ensure service continuity, it has also helped fight stigma and misinformation—about HIV and now about COVID-19. This is critical for pandemic response, and too often overlooked.

And ensuring affordable access to new medical technology is at the center. The lowest point in the global AIDS response may have come in the early 2000s when AIDS drugs all but halted HIV deaths in wealthy nations while millions died in low- and middle-income countries because drugs were unaffordable and unavailable. But generic production brought that price down to where today cutting-edge antiretrovirals are available for less than $100 per patient per year. Today we see disturbing echoes of the early AIDS failures in COVID-19 vaccine access. As of this writing, more third COVID-19 booster shots had been delivered in rich countries than the total number of shots given to anyone in low-income countries (6). Just 3.6% of people in sub-Saharan African countries have been fully vaccinated. These are problems that can be solved—not just with funding but by sharing technology to ensure that new medical breakthroughs are produced and made affordable in Africa, Asia, and Latin America (7).

This World AIDS Day comes in a pandemic moment. While we do not yet have a vaccine or a functional cure when it comes to HIV, we do have the knowledge and tools that could have prevented every single of the 1.5 million new HIV infections and avoided every one of the 680,000 AIDS-related deaths that occurred last year. We could be driving TB deaths down instead of up. Yet in times of crisis come the seeds of hope. With growing attention to the ways in which inequalities drive pandemics, we have the opportunity to build rights-based, human-focused responses to save millions of lives—not only to halt HIV and COVID-19 but to make the world more pandemic-resilient for the future.

DISCLOSURES

No conflicts of interest, financial or otherwise, are declared by the authors.

AUTHOR CONTRIBUTIONS

M.M.K. and H.N.-K. drafted manuscript; edited and revised manuscript; and approved final version of manuscript.