The world’s experts on HIV/AIDS are gathered this week in Amsterdam for the 22^nd International AIDS Conference as a collective anxiousness has set in. The 2016 optimism that fueled a United Nations declaration that the end of AIDS was near has been replaced by a gnawing fear among experts. If properly treated with available drugs, today’s 37 million infected people no longer face mortal illness as did their counterparts in the pre-treatment days of the 1980s and 1990s. That much is true.

But given the rest of the equation, it’s remarkable that the mood in Amsterdam isn’t one of panic. Danger surely looms.

For years, humanity had the virus on the run, and death tolls plunged to joyously low levels. But the disease is now poised, for the first time in recent memory, to add massively to its global death toll of 35 million since 1981. Three factors are contributing to its runaway resurgence: flawed public health strategy, rapidly shifting demography, and diminished resources.

A flawed strategy for HIV control

Let’s start with strategy. In 1996, researchers from multiple institutions and pharmaceutical companies announced the discovery that a combination of drugs, taken daily, could drive HIV levels down so dramatically that the treated individuals could live normal lives. And more than a decade ago, it was shown that the anti-HIV drugs worked so well that viruses were forced into hiding in parts of the body from which they couldn’t spread to other people sexually, through shared needles or blood, or in utero from mother to child.

A worldwide strategy for HIV control was set upon, aiming to place all HIV-positive people on the drugs, both to spare their lives and to stop the spread of the virus. The year 2030 was set as the world’s deadline for halting the spread of HIV, stopping AIDS deaths, and having the first generation since 1980 born and raised completely free from infection. To make the dream a reality, a cocktail of anti-HIV drugs was manufactured cheaply, bringing the annual cost down from a 1996 high of well over $10,000 per person to less than $75. And a multibillion-dollar infrastructure was created to find infected individuals, provide them with those drugs, and monitor their health.

But the strategy was a gamble. The drugs didn’t cure anybody—HIV still lurks in the bodies of the nearly 22 million treated individuals. Any interruption in taking the medicine allows hidden viruses to flood into the individual’s bloodstream, endangering the health and survival of the patient and making him or her a contagious risk to others. War, a transport breakdown, government financial glitches, loss of international donor support, patient migration, individual forgetfulness—hundreds of personal, financial, and political factors can interrupt treatment.

Moreover, 15 million people are still untreated and therefore infectious to others. Worse, most of these individuals are unware that they carry the virus, do not see any reason to get a HIV test, and are unlikely to take precautions to protect others, such as using condoms during sex. As a result, the pandemic is continuing to grow. Last year, 940,000 people died of HIV-related causes, while 1.8 million were newly infected with HIV.

And new infections are increasingly showing up in forms that are very hard to treat because the strains of HIV spreading today are more likely to be resistant to those $75-a-year treatments. Drug resistance forces the use of more expensive medicines, and the supply chain for second- and third-line treatments in poorer countries is minimal, in some cases nonexistent. When an individual is infected with a strain of HIV that is already resistant to available drugs, all aspects of the patient’s treatment and survival are affected.

Between 2014 and 2016, the World Health Organization (WHO) surveyed new infections in 11 poor countries, finding in six of the countries more than 10 percent were drug resistant. A 63-nation survey funded by WHO and the Bill & Melinda Gates Foundation found anywhere from 6 to 11 percent of new infections involved drug-resistant forms of HIV, and the trend was dire, with resistance increasing as high as 23 percent annually. Once individuals were put on their daily treatments, in 2017 failure rates due to drug resistance were as high as 90 percent in some countries, meaning new infections in those regions could no longer be controlled with the $75-a-year first-line therapies. The first such survey conducted in Cameroon, recently published, found that the majority of patients failing their primary treatments—up to 88 percent of them—were infected with resistant strains of HIV, and overall drug resistance rates in the West African nation in 2018 approach 18 percent.

Meanwhile, preventing HIV infection has fallen off the priority list, both in funding and individual action. A new UNAIDS-Lancet Commission report on defeating AIDS calls for an all-fronts urgent increase in prevention efforts worldwide. Rates of sexually transmitted diseases (STDs)—syphilis, gonorrhea, chlamydia, herpes, various forms of hepatitis—are skyrocketing, especially among young gay men in Europe and North America and heterosexual youth in much of sub-Saharan Africa, often in antibiotic-resistant forms. A type of essentially incurable gonorrhea—so-called XDR, or extensively drug resistant—has emerged in Australia and the United Kingdom, prompting alert across the European Union. If sexually active young adults were using condoms and following the sorts of safe sex guidelines that would protect them from HIV, these other STD trends would not be the new normal.

Laurie Garrett

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