The findings were startling. Not a single newborn in the District of Columbia, the nation’s HIV capital, was diagnosed with HIV last year. And new HIV diagnoses in D.C. plummeted 74% from 2007 to 2018. D.C., which has a rate of HIV diagnosis per 100,000 residents nearly double Tunisia’s, is far from alone in making stunning progress. New infections and deaths have plummeted roughly 50% from their 2004 peak. In the wake of World AIDS Day on December 1, it’s important to recognize the remarkable global headway in combatting HIV and AIDS--and how we did it.
In a groundbreaking study in the July issue of Health Affairs, Steven Forsythe of Avenir Health and coauthors found that from 1995 to 2015, antiretroviral therapy (ART) averted 9.5 million deaths from AIDS worldwide, with global economic benefits of $1.05 trillion. Every $1 spent on ART generated $3.50 in benefits. And the authors project an additional 25.4 million deaths averted and $2.97 trillion in economic gains by 2030. They assumed achievement of the UNAIDS 90-90-90 goal for 2020: 90% of people with HIV know they have it, 90% of them receive treatment and 90% suppress the virus.
This is the Holy Grail for social policy: hard economic data justifying better health services. The data show how far we have come since 1981, when a mystifying and deadly immune deficiency disease first penetrated the public consciousness, thanks to some articles in the New England Journal of Medicine. By the end of 1992, 250,000 Americans had developed AIDS, and 200,000 had died.
How has the world made such advances? By attacking the problem on multiple fronts.
Back in 1985, when the epidemic was growing rapidly, researchers knew little about who was most vulnerable, how they contracted the disease, how to stop its spread and how to treat it. So the government asked us to launch a three-year outreach, education and intervention program for women involved in behavior posing a high risk of HIV transmission, such as sex work. The government also hired us to track the incidence of HIV among prison inmates, whose infection rates are roughly five times higher than in the general population.
When infections spiraled out of control in the early 1990s, prevention took on more prominence. We led the HIV Network of Prevention Trials, which enrolled 20,000 individuals in 17 scientific protocols to assess vaccines and other prevention strategies.
The federal Ryan White HIV/AIDS Program, several aspects of which we analyze, provides HIV care and treatment services for more than half of those diagnosed with HIV. In 2017, the suppression rate for program clients was 85.9%, well above the 58.9% national average. Suppression of the HIV virus means it’s unlikely to be transmitted.
Basic gumshoe work combined with technology also produced payoffs. In-person interviews, reviews of event postings from popular dating websites and mapping analysis led us to discover that HIV testing isn’t always available near where men having sex with men engage in high-risk behavior. That, in turn, led to development of informal referral networks to get the men to testing sites.
Practitioners made progress overseas, too. In Mozambique, our comprehensive HIV and AIDS program strengthened the health systems of three provinces so that they could tackle staff shortages, supply chain disruptions and inefficient management. In Namibia, an Abt project expanded access to voluntary medical male circumcision services through the private sector. In Ivory Coast, our program helped a network of private providers expand HIV services offerings. And in Vietnam, we’re helping mobilize financing for HIV programs.
Today the focus is on swapping lessons learned across ponds. For example, the U.S. President's Emergency Plan for AIDS Relief has made the effective test-and-treat approach a standard process in Africa. That is, someone who tests positive for HIV can’t leave without getting treatment. The U.S. should adopt that practice. In the U.S., our researchers found that social factors such as homelessness or domestic violence reduce adherence to treatment, a lesson other countries need to recognize.
In the future, technology such as artificial intelligence and biometrics could pave the way for further gains, especially among hard-to-reach populations such as long-distance truck drivers. Take South African truck drivers, an estimated 56% of whom had HIV in 2014-2016. Give them a unique digital identity linked to their electronic health records in clinics along truck routes, and they can get care almost anywhere they stop.
As the D.C. report and Health Affairs study show, progress has been remarkable. But a staggering 36.9 million people worldwide still live with HIV. The work is far from done. But we now know what to do to break the back of this scourge.