[Editorial] HIV 40: inequalities fuel pandemics

June 5 marked 40 years since the first cases of HIV were documented in the US CDC Morbidity and Mortality Weekly Report. Such a milestone offers an opportunity to reflect on progress made and barriers still to be overcome four decades on from these first reported cases in 1981. To mark this anniversary, the Lancet family of journals has commissioned and curated Lancet HIV-40, a series of reports, profiles, and interviews highlighting the strides made in HIV research, care, and prevention, and the impact of HIV/AIDS on global health and advocacy.

Four decades later, there is still no vaccine and no cure. Despite effective prevention interventions and treatments, such as pre-exposure prophylaxis (PrEP), which reduces HIV acquisition, and antiretroviral therapy that renders the virus undetectable and untransmissible, progress towards ending the AIDS epidemic as a public health threat has been slow and extremely uneven. Intermediate targets for 2020 have been missed and time is running out on the global effort to reach the Sustainable Development goal to end AIDS by 2030.

The latest UNAIDS report, published on June 3, estimates that, in 2020, 1·5 million people were newly infected with HIV, 37·5 million people were living with HIV, and 690 000 people died of AIDS-related illnesses. Although the number of people with HIV on treatment more than tripled since 2010—from 7·8 million to 27·4 million—this leaves an estimated 10 million people untreated. More than half (62%) of all new HIV infections worldwide are in so-called key populations—including men who have sex with men, sex workers, transgender people, people in prison, and people who inject drugs. These individuals remain vulnerable because, in many countries, they are marginalised, stigmatised, or criminalised. Indeed, almost 70 countries criminalise same-sex sexual relations and more than 90 countries criminalise HIV exposure, transmission, and non-disclosure. The UNAIDS report underscores that countries with progressive policies and strong health systems—offering access to HIV testing and services, PrEP, harm reduction approaches, and quality care—were most successful in fighting HIV, whereas countries that do not take a rights-based approach to health leave key populations out of reach of HIV services. Moreover, the situation of young women in sub-Saharan Africa should also be a cause of concern according to UNAIDS data: AIDS-related illnesses are the leading cause of death among women aged 15–49 years in sub-Saharan Africa.

Slow and uneven progress in defeating HIV as a public health threat is, today, a human rights and social justice issue. The impact of HIV/AIDS is following along the lines of social and political determinants of health.

Against this backdrop, the UN General Assembly fifth high-level meeting on HIV and AIDS held on June 8–10, 2021, which looked at the HIV epidemic through an inequality lens, could be crucial to get the world back on track to end AIDS by 2030. In a political declaration, Ending Inequalities and Getting on Track to End AIDS by 2030, Member States adopted a new set of targets to be reached by 2025: provide 95% of all people at risk with access to HIV combination prevention options, ensure that 95% of people living with HIV know their status, and get 95% to be on HIV treatment. These goals aspire to reduce the annual number of new HIV infections to less than 370 000 and AIDS-related deaths to 250 000, and to provide HIV treatment to 34 million people. Importantly, a target to reduce the number of countries that have measures discriminating against at-risk groups to less than 10% has been included—despite wording disagreements—with all but four countries voting for this progressive new effort.

“The stark inequalities exposed by the colliding pandemics of HIV and COVID-19 are a wake-up call for the world to prioritize and invest fully in realizing the human right to health for all without discrimination”, said Winnie Byanyima, UNAIDS Executive Director. Indeed, over the past 18 months, the COVID-19 pandemic has added urgency to the fight against HIV. In many parts of the world, COVID-19 has led to the disruption of critical services to prevent, detect, and treat HIV, to an increase in violence against women, and has exacerbated inequalities and social injustices, which increase vulnerability to HIV/AIDS. There are clear parallels between the two pandemics: inequalities fuel pandemics, and pandemics fuel inequalities. Therefore, there is an urgent need to do more to prepare for and respond to pandemics in a way that addresses inequalities and does not deepen them.

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DOI: https://doi.org/10.1016/S2468-2667(21)00139-0

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© 2021 The Author(s). Published by Elsevier Ltd.

User License Creative Commons Attribution (CC BY 4.0) | ScienceDirectAccess this article on ScienceDirect Linked ArticlesHIV pre-exposure prophylaxis: scaling up for impact now and in the future

More than a decade after the first efficacy evidence for oral HIV pre-exposure prophylaxis (PrEP) was reported, PrEP uptake globally has been inadequate and global HIV prevention targets have been missed. Access to PrEP is still highly concentrated in a fairly small number of countries and, even within countries with widespread PrEP access, inequalities have emerged. More ambitious, high-priority global targets for PrEP uptake are required and could accelerate the HIV prevention response in a similar way to the success of the 90-90-90 testing and treatment targets.

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