On This World AIDS Day, Experts Worry That Recent Gains May Be Lost

On this World AIDS Day, experts extol recent advances in combating the four decade-old global HIV epidemic. Indeed, the goal of eliminating HIV/AIDS as a major public health threat by 2030 remains a possibility. But these same experts acknowledge that the recent progress may be lost. Increased LGBTQ discrimination in countries throughout the world, disruptions of services due to regional conflicts, and uncertainty about the continued U.S. support of the President’s Emergency Plan for AIDS Relief are among the greatest concerns.

Recent advances in HIV treatment and prevention

Dramatic advancements in the treatment and prevention of HIV/AIDS have occurred over the past few decades. Highly active antiretroviral therapy, introduced nearly thirty years ago, switched the paradigm for people infected with the virus. Rather than dying of AIDS, they could live with HIV. And access to those life-saving drugs became more accessible to people throughout the world when then-President George W. Bush initiated PEPFAR.

HAART is so effective that the amount of virus in the blood of an HIV-infected person can become undetectable. And several large studies have shown that someone with an undetectable viral load cannot transmit the virus sexually. Undetectable equals untransmissible. U=U. In other words, treatment is a method of prevention.

These same drugs also can protect a person from becoming infected if exposed to the virus. When taken regularly, pre-exposure prophylaxis medications like Truvada and Descovy offer significant protection to uninfected people. According to the CDC, PrEP can reduce the risk of sexual transmission by 99% and reduce the risk of infection among people who inject drugs by 74%.

Ending the HIV epidemic by 2030

With programs like PEPFAR and medical interventions like U=U and PrEP, ending the HIV epidemic is a very real possibility. HIV/AIDS will not go away. No one is arguing that it will. But the number of new infections can be reduced such that we can move past the crisis stage of the epidemic. In the U.S., for example, public health officials hope that the number of new infections can be reduced to about 3,000 per year, a ten-fold drop from the current level.

But public health researchers also note that ending the HIV epidemic by 2030 will not be easy. Many structural barriers remain. And these impediments may be getting worse.

Continued stigma, discrimination, and criminalization

Stigma, discrimination, and criminalization remain major barriers to ending the HIV epidemic. As Helen Clark, the former Prime Minister of New Zealand noted at the International AIDS Conference in July, “The HIV/AIDS pandemic is rooted in inequality and marginalization.” Indeed, as part of their plan for ending HIV/AIDS, UNAIDS in 2021 put forth the 10-10-10 goals. Less than 10% of countries have policies that limit or deny access to HIV services, less than 10% of people living with HIV experience stigma and discrimination, and less than 10% of girls, women, people living with HIV, and other key populations experience gender-based violence or inequality. These goals are not being met. Even in the U.S., the data are disturbing. According to the Human Rights Campaign, over 20% of hate crimes in the U.S. are associated with anti-LGBTQ stigma. And 34 states have HIV criminalization laws, many of which are outdated and not consistent with current data.

Uncertainty about U.S. support of PEPFAR

Established by President George W. Bush in 2003, PEPFAR has reshaped the global HIV/AIDS landscape. Providing much needed aid to countries hardest hit by HIV/AIDS, PEPFAR has saved millions of lives. Writing recently in The Hill, Nathaniel Weixel noted that, “It’s been widely regarded as one of the most successful global health programs in U.S. history.”

But its future is in doubt.

In March 2024, Congress provided a one-year extension to funding PEPFAR. This is the first time since the program’s creation two decades ago that Congress has not agreed to a five-year reauthorization. This program cannot survive with one-year extensions. The initiatives supported by PEPFAR are not short-term. Ending HIV/AIDS requires long-term projects, long-term vision, and long-term guaranteed funding. Uncertainties associated with temporary funding could cripple many programs. These funding uncertainties could result in tragic losses in our efforts to end HIV/AIDS.

On this World AIDS Day, we can be thankful for the progress that has been made. The HIV/AIDS landscape has improved dramatically, both in the U.S. and globally. But HIV/AIDS is not over. Much still needs to be done. As former New Zealand Prime Minister Clark remarked at the end of her talk at the International AIDS Conference, “It’s clear that we do not live in the best of times. But we can’t give up on the challenges we face like ending AIDS. Lives and well-being literally depend on it.” Today, we have the tools to ending HIV/AIDS. We need the political will.