LONDON: The virtual 23rd International AIDS Conference (AIDS 2020), organised by the International Aids Society (IAS) with the participation of the World Health Organisation (WHO) from July 6 to 10, came at a time when another pandemic, the novel coronavirus (COVID-19), is ravaging the world.
The IAS, founded in 1988, is the world’s largest association of HIV professionals, with members in more than 170 countries, with the mission to advocate and drive urgent action to reduce the impact of HIV. The timing and relevance of AIDS 2020 comes against the background of a new WHO survey that some 73 countries have warned that they are at risk of stock-outs of antiretroviral (ARV) medicines (to treat HIV) as a result of the COVID-19 pandemic. Twenty-four countries have reported having either a critically low stock of ARVs or disruptions in the supply of these life-saving medicines.
The theme of the conference, ‘Resilience,’ and the dire statistics of HIV defines the global war against HIV/Aids for 36 years – one which has claimed a staggering 33 million lives and infected 74.9 million people globally since the pandemic’s onset in 1984 till end 2018.
According to WHO data, there were an estimated 38 million people living with HIV at the end of 2019, of which 25.7 million people living with HIV are in Africa. Of these, South Africa had the single largest prevalence of people with HIV in the world with 7.7 million, followed by Mozambique with 2.2 million, Nigeria with 1.9 million, Kenya and Tanzania with 1.6 million each, Uganda with 1.4 million, Zimbabwe with 1.3 million, Zambia with 1.2 million and Malawi with one million respectively.
Malaysia, in contrast, has a very low prevalence of HIV. According to the Department of Statistics, Malaysia, as reported to WHO, of 1.1 million people tested in 2018, there were 5,600 new infections. HIV prevalence amongst adults (15-49) was only 0.4%.
As a result of concerted international efforts to respond to HIV, coverage of services has been steadily increasing. In 2019, some 68% of adults and 53% of children living with HIV globally were receiving lifelong antiretroviral therapy (ART). These statistics of despair are a sobering reminder of the devastation and human cost this pandemic has wreaked on a suspecting if not complacent world, which is still in search of a cure let alone a vaccine. A major setback came in February when an experimental HIV vaccine tested in South Africa failed.
Has HIV/AIDS become the forgotten pandemic in the wake of COVID-19 and what are the implications going forward? HIV activists are indeed concerned that with the preoccupation in fighting COVID-19, financial and other support for containing the other epidemics would be diverted. Bill Gates had to reassure the HIV communities especially in Africa that his Bill & Melinda Gates Foundation, contrary to reports, would continue to support their work.
As far as pandemics are concerned, HIV stands shoulder to shoulder with others such as Malaria, Tuberculosis (TB) and Ebola, which continue to ravage the world, especially the developing countries with their limited resources and underdeveloped health systems.
They put into context the latest pandemic sweeping the world, COVID-19 which by July 17 had claimed a reported 592,778 deaths and 13,953,342 confirmed cases globally. The US had the highest number of confirmed cases at 3,695,025 confirmed cases and 141,118 deaths; followed by Brazil with 2,014,738 confirmed cases and 76,822 deaths; India with 1,005,760 confirmed cases and 25,619 deaths; Russia with 752,797 confirmed cases and 11,937 deaths, and Peru with 341,586 confirmed cases and 12,615 deaths.
In comparison, Ebola is one of the most virulent viruses. In a recent article in Science, virologist Peter Piot, director of the London School of Hygiene & Tropical Medicine, who contracted COVID-19 in mid-March, stressed that he was glad to have coronavirus instead of Ebola. He is one of the ‘discoverers’ of Ebola in 1976 in the Democratic Republic of the Congo (DCR). According to Piot, Ebola has a high mortality rate and has a habit of resurfacing periodically. The West African Ebola epidemic in 2014 was the most widespread outbreak of the virus in history, resulting in 11,323 deaths and socio-economic disruption in Guinea, Liberia and Sierra Leone.
TB too remains a major killer, especially multidrug-resistant TB (MDR-TB), which has led to a public health crisis in Asia and Africa-affected countries, including Nigeria and South Africa, and a global health security threat. The WHO estimated 10 million people getting TB worldwide in 2018, of which 1.5 million died (including 251,000 people with HIV). WHO estimates that there were 484,000 new cases in 2018 with resistance to rifampicin – the most effective first-line drug, of which 78% had MDR-TB.
These figures are dwarfed by the sheer prevalence of Malaria. In 2018, there were an estimated 228 million cases worldwide with an estimated number of 405,000 deaths. The WHO African Region accounted for 93.5% of all Malaria cases and deaths in 2018.
Learning the lessons of one epidemic to another is complex given specificities, similarities and differences especially in the transmission of each pathogen. Pandemic pundits including economist Professor Jeffrey Sachs; the Executive Director of UNAIDS, Ugandan-born Winnie Byanyima; organisations such as WHO and IFRC, some epidemiologists and virologists have suggested that countries like South Africa are in a better position to contain COVID-19 because of the lessons learnt in fighting HIV and Ebola.
South Africa, according to Byanyima, “has the best government response to COVID-19 in Africa guided by lessons learnt from the HIV epidemic. They involved engaging various stakeholders in the battle against HIV. In other African countries, COVID-19 responses are dominated by epidemiologists and science with hardly any input from community, civil society and NGOs.” That remains to be seen.
Winnie Byanyima, UN Under-Secretary General and Head of UNAIDS, could not help singing the praises to President Cyril Ramaphosa when she met him in March for talks on Pretoria’s HIV/Aids eradication plans. Her message to the president was loud and clear, to renew the government’s commitment in the fight against HIV and to end gender-based violence, including rape, especially affecting adolescent girls and young women.
So, what are the lessons learnt from HIV and Ebola? The IFRC (International Federation of Red Cross & Crescent Societies) identified several lessons to be learnt from the 2014 Ebola outbreak in West Africa:
1.Communities play a vital role in preventing and responding to epidemics. There are strong traditional beliefs and stigmas around Ebola, therefore effective communication was crucial to helping communities abandon deep-rooted beliefs and take actions to prevent disease or treatment for illnesses. This includes listening to people’s fears, perceptions and beliefs about Ebola and by tailoring key messages and social mobilisation activities to address these fears.
2.Interactive radio programmes played a vital role in addressing stigmas and risky practices.
3.Community-based response can be the difference between an isolated outbreak and a national catastrophe.
4.Responding to epidemics is much costlier than preventing them. Using the locally based Red Cross and Red Crescent volunteer network to share clear information in an epidemic was vital, albeit their protection is vital.
British Red Cross mapping specialist, Kareem Ahmed, who worked on the Ebola (2014) and Zika (2015) virus outbreaks, concurs that there were several mistakes made including “lack of a clear communications strategies by the authorities, no community preparedness, and poor protection and security of health/frontline personnel.
“Of course, the necessary investment in healthcare is much less costly than an ill-prepared response. From a mapping/epidemiological perspective in West Africa, because of a lack of standardised village names and accurate to-scale maps, it was much more difficult to do contact tracing of cases, and this is one area our team focused on.”
UNAIDS’s Byanyima, in a podcast stressed that “what we learned from HIV and Ebola, is that a pandemic is not merely a health issue. It is about how society is structured; to what extent communities are empowered; about science and finding solutions, politics and how health is prioritised in our countries; about human rights and legal systems. It’s not a case of just finding the medicine and solving the issue. You have to bring the whole of government and society together.”
A crucial truism is that pandemics feed on inequality especially between rich and poor countries. The people hurt are the most vulnerable. It took five years to get the ARV drugs following campaigns by the HIV movement to get prices down. But the delay cost millions of lives during the period. In the case of COVID-19, history seems to be repeating itself. African countries are at the back of the queue after the rich countries for testing kits, masks and ventilators.
The correlation between COVID-19, HIV and TB is clear and present especially on its impact on the respiratory system. Of the1.5 million people who died from TB in 2018, according to WHO, some 251,000 were patients with HIV, which today remains a highly infectious disease with 1.7 million new cases reported in 2019 albeit mainly from Eastern Europe, Russia, some Asian countries and the Americas. Due to gaps in HIV services, 690 000 people died from HIV-related causes in 2019. Not surprisingly, IAS’s AIDS 2020 conference was followed by a special COVID-19 and HIV Conference on July 10 & 11, aimed at sharing the latest scientific evidence and recommendations on HIV prevention, diagnosis and treatment, and the impact of COVID-19 on HIV/Aids.
There is no cure for HIV infection. However, effective ARVs can control the virus and help prevent onward transmission to other people. At the end of 2019, says WHO, an estimated 81% of people living with HIV knew their status. Some 67% were receiving ART and 59% had achieved suppression of the HIV virus with no risk of infecting others. At the end of 2019, 25.4 million people were accessing antiretroviral therapy.
The good news is that between 2000 and 2019, new HIV infections fell by 39% and HIV-related deaths fell by 51%, with 15.3 million lives saved due to ART. This achievement was the result of great efforts by national HIV programmes supported by civil society and international development partners.
However, such gains are in real danger of being undermined by COVID-19. In May the WHO and UNAIDS did a modelling exercise which forecast that a six-month disruption in access to ARVs could lead to a doubling in AIDS-related deaths in sub-Saharan Africa in 2020 alone.
In 2019, an estimated 8.3 million people were benefiting from ARVs in the 24 countries now experiencing supply shortages. This represents about one third (33%) of all people taking HIV treatment globally. While there is no cure for HIV, says WHO, ARVs can control the virus and prevent onward sexual transmission to other people. A failure of suppliers to deliver ARVs on time and a shut-down of land and air transport services, coupled with limited access to health services within countries as a result of the pandemic, were among the causes cited for the disruptions in the survey
“The findings of the WHO survey are deeply concerning,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Countries and their development partners must do all they can to ensure that people who need HIV treatment continue to access it. We cannot let the COVID-19 pandemic undo the hard-won gains in the global response to this disease. HIV prevention and testing services are not reaching the groups that need them most. Improved targeting of proven prevention and testing services will be critical to reinvigorate the global response to HIV.”
For a country such as South Africa, with the single largest prevalence of HIV, the Ramaphosa government has designated HIV/Aida “as a strategic priority and an essential element of the UN’s 2030 Agenda for Sustainable Development,” which targets the eradication of the disease as a public health threat by 2030. But whether the country will achieve its stated target of expanding HIV treatment to at least 6.1 million people by end 2020, given the unexpected disruption caused by COVID-19, remains doubtful.
Co-mingling of government grants designated for managing HIV, TB and Malaria with new funds for fighting COVID-19 too has raised concerns that the former would get compromised in translation. In the case of South Africa for instance, Finance Minister Tito Mboweni’s 2020 Supplementary Budget Review in April precisely does this albeit R2 billion has been added to boost the total grant for the four pandemics to R3.4 billion, which includes the cost of hiring Cuban doctors to work especially in rural hospitals and clinics in South Africa.
So, what is the current status of HIV in Africa? One specialist who thinks that South Africa has made tremendous gains and has a compelling story to tell (warts and all) is Dr Nadia Ahmed, Consultant in HIV & Genitourinary Medicine at the Mortimer Market Centre, part of the Central North West London Trust, which is the largest HIV Unit in the UK if not the EU. The Centre is the only place in the world to have HIV and Hepatitis as a specialty service.
“Much is about just getting on with the job of tackling HIV. Countries that are on the right policy trajectory will succeed. Combatting HIV in Africa remains a ‘work in progress’,” she maintains. Dr Nadia, who has a special interest in adolescent HIV and its impact on young girls, has done a fair share of field work in Africa and Asia and recently returned to the UK after more than two years of frontline work at the Desmond Tutu HIV Foundation which is attached to the University of Cape Town.
Over the last decade she has worked in HIV clinics in Durban, for Doctors Worldwide in Malawi, with the Desmond Tutu HIV Foundation in the Western Cape, participated in workshops in Rwanda, Uganda, Ghana and Tanzania and has ongoing contacts with colleagues in Kenya, and Nigeria. Outside Africa she has worked on clinical attachment in Iran, Iraq and more recently in the Rohingya camps at Cox’s Bazaar in Bangladesh.
“In Africa, we have the potential to prevent transmission. We have effective ARVs, with even an injectable form on the horizon. South Africa has the highest prevalence of HIV in the world. Wins are being made and ARV programmes have been rolled out across Africa. People are getting access to it and life expectancy is going up. We have the means and evidence to say that we have effective treatment if a patient is on treatment and provided his/her medical management plan is controlled, they are not going to transmit HIV. We have good HIV prevention tools. We almost have the right ingredients to get to zero transmissions subject to the above caveats. This applies everywhere, including Africa,” adds Dr Nadia.
The caveats for getting it right in Africa remain challenging – the right political leadership and government policy, the support organisations, the commitment of clinical and allied staff, and adequate resources. “We have the ingredients but not the glue that binds them. Too much of the resources are spent on conferences. Last year there were over 20 on HIV. Yes, conferences can contribute to research, but some of these resources can be diverted to frontline services and education,” she laments.
Her interest in adolescent HIV is partly driven by the fact that HIV, according to Sentebale, remains the leading cause of death among 10-19 years old in Africa and that globally 82% of adolescents living with HIV are from Sub-Saharan Africa (SSA). Sentebale is the southern Africa-registered charity founded by Princes Harry of the UK and Seeiso of Lesotho in 2006, which supports the mental health and wellbeing of children and young people affected by HIV.
She is particularly pleased about the progress Botswana, Kenya and, to a lesser extent, Malawi are making. “Countries on the right trajectory will succeed,” maintains Dr Nadia. “Here Kenya and Botswana are good examples. Even Malawi, one of the poorest countries in my experience is making progress in the rural areas. It was empowering to see random lay people helping with triage in rural clinics. Countries will continue to do well, but unfortunately, they will plateau. People are pinning hope on an HIV vaccine, which if it does come out may lead to a cure.”
But how realistic is a vaccine? “I’d like to think it will happen. But it and a cure may take years.” While the search is on for a Covid-19 vaccine in record time, there was great disappointment when an experimental HIV vaccine tested in South Africa in February 2020 failed. “Vaccines against HIV historically are difficult to find,” explains Dr Nadia, “because you need a part of the virus that doesn't change at all. HIV is notorious for mutating in patients not on treatment or with poor adherence.
“It may have failed because the vaccine it was based on which showed some efficacy was to a different strain. Another theory is that the vaccine may have been over-stimulated given the high prevalence of HIV compared to the one it was based on where prevalence was lower. Yes, a vaccine would have helped but they already have the ARVs to help fight infection. Prevention management needs a combination approach not just one strategy. It would have taken years to see the full impact of a vaccine.”
She is confident that HIV can be eradicated in some of parts of the world in her lifetime. In the next decade Kenya and Botswana will continue to do well. There is the drive in Kenya, which is a good model for care. Others will slowly follow them, and others still will stay as they are if they do not change their policies.
Dr Nadia’s cautious optimism is underpinned by several factors. Firstly, access to ARVs is a thing of the past and should not be an excuse. Drug patents have expired and prices have come down considerably. ARVs are now common even in rural Malawi. However, there are still shortages especially in rural South Africa, and the cost of new drugs remains prohibitive, for example for Hepatitis C, which are 90% effective. If a patient is co-infected with HIV, the cost of a single treatment is around GBP90.
Secondly, the rolling out of new drugs for HIV at best can be erratic in Africa. Take for instance, Dolutegravir (DTG), a new drug which has been used in Britain for five years. “Botswana and Kenya have rolled it out, despite earlier concerns in a trial in the former that it could lead to foetal abnormalities. Further trials have shown no such causal link. But in South Africa it was introduced recently after a few years delay with the caveat that healthcare professionals are required to fully discuss the ARV with women patients, who may decide to get pregnant. In Malawi they have rolled out DTG even in the rural areas,” added Dr Nadia.
DTG compared to other ARVs has a very high barrier to resistance, especially if patients forget to take one or two of the other drugs. “There is some scepticism that this is a new drug and we still don’t know the full resistant patterns compared with other drugs in use longer than 10 years.”
Thirdly, African countries are lagging behind in meeting the '90-90-90 goals' adopted in 2014 by the Joint United Nations Programme on HIV and AIDS (UNAIDS) and partners. These goals aim to diagnose in a respective country 90% of all HIV positive people, provide antiretroviral therapy (ART) for 90% of those diagnosed and achieve viral suppression for 90% of those treated, by 2020. Britain has already superseded these goals, while South Africa has yet to do so.
Looking ahead, her message is clear: “HIV is eminently treatable and preventable.” Apart from the standard ‘protection’ of using condoms, educating the young especially and changing behaviour, the ARV called PREP has been very successful not only in treating HIV but also in preventing it. While both Kenya and South Africa have successfully rolled out PREP free of charge, it needed the UK-based Aids charity The Terence Higgins Trust to take the British Government to court to get the ARV free of charge under the NHS. Treatment for HIV, according to Dr Nadia, is free in most of the African countries where the public healthcare systems are not as developed as in the UK. Africa essentially is ahead of the game in PREP at least in accessibility but not necessarily in uptake.
She is also keen to dispel myths. Contrary to popular misconception, HIV is not imported through migrants. “I have seen data on South Africa that it is mainly acquired when somebody comes into the country. Persons from conflict zones may have been raped and acquired it through that. True there is extra pressure on resources especially if you don’t treat the additional risk of transmission.”
Currently, in South Africa, HIV treatment is accessible to foreigners and migrants, largely from Zimbabwe, Lesotho, Swaziland, Mozambique and DRC. However, under the proposed National Health Initiative (NHI) of President Ramaphosa, the initial provisions are that HIV treatment may not be free for refugees and asylum seekers but will be free for their children.
Then why is Africa so prone to HIV? The highest risk of transmission apart from blood transfusions in general is homosexual sex. In Africa, explains Dr Nadia, the reason is not really about sexual behaviour but a manifold of other factors - multiple partners ; non-condom use; the stigma of HIV; delay in getting ARVs which means always catching up with the rest of the world; rape and sexual violence which are very prevalent in South Africa because the infection can be transmitted quicker with greater friction; peer educators often find communication hurdles explaining the origin of HIV; pan-African cooperation in HIV is very much conference-based; poverty; and the prevalence of sugar daddies where older men are having sex with younger girls permitted by families, where these men would provide money for the families.
Currently adolescent girls have the highest rate of infection and are the biggest agents of transmission of HIV acquired from men.
Dr Nadia would like to see more money in public healthcare services, which she contends are too “physician and resource-focused as opposed to patient-focused.” Africa needs more specialised HIV care centres and the guidelines at least in South Africa are too lax on people whose viruses are not controlled, which means a risk of infecting new partners. She would also like to see a widespread use of another drug – PEP (Post Exposure Prophylaxis) – like a ‘morning after pill’ for HIV. In South Africa PEP is only given to people who have been raped or assaulted.
Mushtak Parker is a London-based independent economist and writer.
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