For the general public in the west it is understandable that most people may assume that HIV is not really a problem or a risk anymore. HIV is rarely in the news but if it is, it will likely to have been with headlines that herald that people living with HIV can have a ‘normal’ life expectancy and that adhering to treatment leads to viral suppression and a minimal risk of passing on HIV. It is true that dramatic advances are being made against the disease in the wealthier countries with universal health coverage and many in these countries are living full and healthy lives. In low and middle-income countries, important progress is also being made in securing access to treatment for those that need it and, as the UNAIDS report launched last week on progress towards the 90-90-90 treatment targets lays out, we are ‘on track’ to meet the global 2030 target of 30 million people on treatment.
However, this good news should not mask the scale of the task still ahead. As the same UNAIDS report points out: globally half of people in need of antiretroviral (ARV) drugs still do not have access and only half of people on ARVs are virally suppressed. We will only stay ‘on track’ to meet the 2030 treatment targets if several critical assumptions hold true – some of these include: that global leadership and resourcing for HIV from donors and domestic governments sustains; that prices of ARVs, particularly 2nd and 3rd line, continue to fall; that we can make the same progress in prevention and care and support as we are in treatment; that we can make progress in failing regions like Eastern Europe and in West Africa; that we can provide quality accessible services for key populations, young people and women and girls; and that we can address HIV drug resistance (HIVDR) so that it doesn’t undercut all the progress we have made.
It is this latter under-reported issue of HIVDR that I want to highlight in this blog.
Earlier this year I joined World Health Organisation (WHO) representatives on a panel on HIVDR at an event hosted by the All-Party Parliamentary Group on HIV & AIDS. The WHO spoke about the growing levels of HIVDR and I highlighted the role of civil society is responding to this threat to our goal of ending AIDS by 2030. A few months on and yesterday the WHO launched a timely and critically important Global Action Plan on HIV Drug Resistance, new WHO Guidelines on responding to HIVDR and a report with new data on the rising incidence of HIVDR at the International AIDS Conference in Paris. It will guide the global community toward co-ordinated and focused action on a largely unknown but potentially catastrophic challenge for individuals living with HIV and the HIV response as a whole.
The impact of HIVDR
HIVDR occurs when the HIV virus is able to replicate in the body, despite the use of medication. This occurs when the genetic structure of the HIV virus mutates due to inconsistent use of antiretroviral therapy (ART). Current ARVs are at risk of becoming less effective or even fully inactive due to this. HIVDR can occur due to a range of factors surrounding the patients’ adherence of HIV medication, issues with programmes, inadequate drug and treatment regimens and nature of the HIV type or sub-type.
There are 3 types of drug resistance:
Transmitted Drug Resistance (TDR) occurs when an individual who has not yet undergone treatment is infected with a drug-resistant virus.
Pre-treatment Drug Resistance (PDR) is resistance detected in individuals starting ART and is acquired due to previous ARV drug exposure.
Acquired Drug Resistance (ADR) occurs when an individual is on ARVs and genetic mutations form which leads to resistance to the treatment.
HIVDR leads to poor virological outcomes, and increased likelihood of morbidity and mortality. HIVDR has the biggest impact on the most vulnerable. HIVDR is on the rise in several low and middle-income countries. In sub-Saharan Africa levels of pre-treatment PDR are already above 10%. It is predicted that 450,000 new HIV infections will be attributable to HIVDR in the next 15 years. This would result in an excess of 890,000 deaths and nearly $6.5 billion additional ART costs. With first line drugs failing, there is no option but to either use expensive second and third line drugs or leave patients on drugs which are not working. In low and middle-income countries, second-line ARVs cost US$330 per patient and are around 3 times more expensive than first-line ARVs at US$120 per year. Third-line ARVs cost US$2000 per patient, per year, and so are nearly 18 times more than the lowest price first-line drugs. As a result, there will be a reduction in options and an increase in the cost of treatment for many patients. This is why investing in research and development is critically important. Investing in quality generics will reduce the costs of all ARVs and low and middle-income countries will be able to provide their patients with optimal treatment without being financially burdened. This will ensure there are resources available to provide for other crucial HIV investments.
If levels of HIVDR are not contained it will be impossible to achieve the global target of having 90% of people on ART with viral suppression by 2020 or 95% by 2030. HIVDR will lead to fewer effective drugs, treatment cost increases and reduced funding for other critical interventions. It is emerging as a serious barrier to reaching the target of ending AIDS by 2030 at a time when many donors are deprioritising HIV financially, politically and programmatically. HIVDR is yet one more reason for donors to hold fast in their support for ending this terrible pandemic while we have the chance.
Taking action against HIVDR
The Global Action Plan on HIVDR is a pivotal piece of work that highlights most of the key actions we need to take to address this emerging issue. The fight against HIVDR hinges on us listening to and acting on the recommendations of this plan before it is too late. As more time passes the greater resistance will increase, as will the cost of the treatment response.
The Global Action Plan’s recommendations are clear and precise:
Prevention and response: Implement high-impact interventions to prevent and respond to HIVDR.
Monitoring HIVDR through surveillance and routine programme data: Obtain quality data on HIVDR from periodic surveys, while expanding the coverage and quality of routine viral load and HIVDR testing to inform continuous HIVDR surveillance; monitor quality of service delivery, and collect and analyse data recorded as part of routine patient care for the purpose of evaluating programme performance to prevent HIVDR.
Research and innovation: Encourage relevant and innovative research, leading to interventions that will have the greatest public health impact on minimizing HIVDR; fill existing knowledge gaps on the risk of HIVDR for newer ARV drugs and the impact of service delivery interventions to increase viral load suppression and contain HIVDR.
Laboratory capacity: Strengthen laboratory capacity and quality to support and expand use of viral load monitoring and build capacity to monitor HIV drug resistance in low and middle-income countries.
Governance and enabling mechanisms: Ensure that enabling mechanisms (awareness/advocacy, country ownership, coordinated action and sustainable funding) are in place to support action on HIVDR.
We need to make changes and we need to do it fast. But what is the role for civil society in all this?
First of all, to play a central role in tackling resistance, civil society and affected communities must be engaged and supported. Raising awareness of the burden and impact of HIVDR among all partners, people living with HIV and communities is key to driving action.
Secondly, once civil society is aware and engaged we need to drive forward advocacy and accountability on HIVDR by national governments, donors and multilaterals. To fight HIVDR we need national leadership and sustainable funding in place. Current funding for research into HIVDR is coming to an end and no additional funding is currently available. We must also be holding service providers to account where the worsening quality of care for people living with HIV results in higher rates of HIVDR. Uncovering the extent of the problem is essential. We need more data on the rise of HIVDR. Communities should be a key actor in this through mobilising people to advocate on this issue and demand that governments monitor HIVDR at a national level.
Thirdly, civil society must be supported to build its crucial role delivering community level services to optimize ART service delivery and to eliminate the programming gaps that allow HIVDR to take hold. Good quality programmes ensure adequate adherence support; particularly for adolescents, women and key populations living with HIV who can face significant barriers. Programmes should appropriately use the recommended ARVs and have effective strategies to maximise retention in care. We must fully utilise the WHO’s guidelines on the use of ARTs for treating and preventing HIV infection. These present new recommendations for creating an enabling environment for community engagement in the delivery of ART. In many of the countries with the highest HIV prevalence, most adherence and care and support services are provided by the community organisations and local caregivers. We must have global recognition and increased funding for comprehensive care and support that underpins treatment adherence.
If we follow the priorities drawn together in the WHO’s Global Action Plan on HIV Drug Resistance, and support civil society’s key role as described above, we can control HIVDR and end this epidemic. We must act immediately. While we are deciding if we should or not respond, HIVDR is thriving and undercutting all the great progress we have made so far. Our commitment is that STOPAIDS will work with its members and partners such as the WHO to shout this message from the rooftops.
Mike Podmore, Director