Millions of People Living with HIV Are Alive, Thanks to a 20-Year Public Health Effort

PEPFAR’s progress shows that stopping a deadly and devastating global epidemic is not impossible. Since the George W. Bush administration launched his ambitious plan in 2003, PEPFAR has poured more than $110 billion of his money into HIV/AIDS treatment and resources. It is the largest joint public health effort by a single country to tackle a single disease and has changed the global course of HIV/AIDS, a devastating disease once considered terminal. It is rated with

The year PEPFAR was released, the World Health Organization reported an estimated 40 million people were living with HIV. Countries in sub-Saharan Africa, where the epidemic was most severe, had the majority of cases, with an estimated 26.6 million people infected. Most of Africa’s health facilities and universities lacked the testing, medication and patient monitoring resources needed to care for the sheer number of HIV/AIDS patients. Phyllis Kanki, a professor of immunology and infectious diseases at Harvard University, says that for people in many parts of the continent, it simply wasn’t a disease they could survive.

“We used to have a global health problem of having a disease that affects an entire population..but HIV was a more dramatic scourge of pathogens. In 2000, he started an AIDS prevention initiative in Nigeria and served as principal investigator for the PEPFAR program at Harvard University from 2004 to 2013. [HIV drugs] In the past. I think that’s a big change and why it’s being hailed as a huge global health success story. “

Scientific American How PEPFAR helped make HIV/AIDS a livable disease, how the program can inform other global health crises, and ending the global HIV/AIDS epidemic We spoke with Kanki to understand what stubborn barriers remain to this end.

[An edited transcript of the interview follows.]

What was the status of the HIV/AIDS epidemic in Africa in 2003?

Many parts of Africa had already reported cases in the mid or late 1980s. At that point, it was already recognized that parts of the African continent, such as Botswana and South Africa, were under heavy strain. Infections of 20-25% of the general population were documented in these areas.

It is commonly believed that, unlike the United States and Europe, it was in sub-Saharan Africa that HIV infection was actually found in certain risk groups (probably at that time male-male sex and intravenous drug users). I think I had a real understanding of it. , it was a much more heterosexual young adult population. It was real horror. Because there really wasn’t a good program and infrastructure in place to rapidly diagnose these people and give them complex treatments.

There was a lot of variation across the continent, but generally there weren’t many programs that would allow you to receive medication if you were found to have HIV. Those who had the means could find themselves testing positive and end up having to pay a lot of money to get medicine or go to Europe or America. [for treatment]But that was certainly only a small minority of people.There was no [known] Government programs readily set up to help people. And this was especially true in places already known to have the worst hits and the highest rates of infections.

Why did PEPFAR start?

As a minimum of care, an appropriate diagnosis is necessary. You must bring your own medicine. All drugs should be there. You have to give it to them every month. You have to have a system so they know you’re giving it to them. And we need a way to monitor them. And none of that was in place.

One of the reasons HIV has been so difficult to tackle in the global health arena is that it has been such a complex disease. [It’s] Difficult to diagnose. If you don’t know someone has it, you can’t treat it. Once someone is treated, it is a lifelong treatment.at the time [patients] I had to take 6-12 tablets once, twice, three times a day. Taking a pill is one thing, but taking it daily is absolutely essential. Because if you stop taking it, the virus that’s still there can come back and make you sick or even die. Some tablets cannot be taken until you have finished eating. In some of our clinics, if the population was food-deficient, we had to provide food. should be monitored. [facilities] was not equipped.Who was going to pay for these tests? You couldn’t ask [patients] We had to pay and we couldn’t ask labs without equipment to run the tests. There are many comorbidities. Another disease seen alongside HIV, such as tuberculosis (TB), is a real killer in its own right. I needed to administer two different therapies for two different complex diseases.

At that time the government [of Nigeria] They tried to provide treatment for some of the first HIV-infected people by purchasing generic drugs in India.government [in Africa] I was already trying to start these programs, but PEPFAR was really a blow. Using PEPFAR funds, we were able to actually strengthen what was just the beginning of the US government’s program.

Today, PEPFAR is active in more than 50 countries, providing healthcare infrastructure and resources, including antiretroviral therapy (ART), to stop the spread of HIV. What is ART and how has ART changed HIV/AIDS care?

The virus itself invades vital cells that protect the body from outside pathogens. Those cells are lymphocytes. A type of white blood cell that circulates in the body and in certain organs. It’s an important player that protects you. Therefore, one of the malicious properties of viruses is synthesizing. It inserts that genetic material into yours. That is why infections with retroviruses like HIV are perpetual.

There are different classes of antiretroviral drugs that act on different parts of the viral life cycle. Essentially, some stop viruses even before they integrate. Other drugs inhibit the consolidation step. Some even block virus intrusion.

When we started, it showed slides of people with piles of pills and people with their hands together. Now maybe he is on 1 tablet a day. In other words, one tablet contains multiple drugs. Those pills are far more effective than anything that could be handed out before.

What are the prospects for HIV/AIDS treatment?

There is PrEP (pre-exposure prophylaxis). This means that if you are not infected, this pill will help prevent you from getting infected from others. , there are different modalities and methods to reduce the virus.There are ongoing efforts to develop a vaccine.

A lot of research is being done on what is called an HIV cure [a few people reportedly have been cleared of HIV or considered to be in long-term remission after receiving HIV-resistant stem cells] And the different ways researchers think they can try to get rid of [the disease]But certainly it is still a work in progress.

What inequalities and stigma still exist around HIV/AIDS? What efforts are being made to identify and provide access to treatment for those in need?

There is stigma associated with many diseases, but in Africa some people don’t want people to know they have HIV. Maybe because she carries the stigma of having multiple sex partners or using drugs. Even just being unhealthy can be stigmatizing for certain groups.

We have been involved in a project in Nigeria for men who have sex with men, a highly stigmatized population. Very difficult to find. Part of the reason is that those countries have laws against sexual orientation.

Africa has the highest number of children infected at birth. Those kids are grown up, and many of them are stigmatized — they’re 12 and have just been told by their mother that they’re on the pill, and those pills are for HIV. I don’t want my mates or the rest of the community to know it’s what I have. So they don’t want to go to the clinic and be seen. Adolescents have a lot of trouble because they are grappling with many other issues in life and have to deal with the fact that they are supposed to go to the clinic every month. They will have to do it for the rest of their lives.

What do you see as the key next steps in achieving PEPFAR’s goal of ending the HIV/AIDS epidemic as a public health threat by 2030? How realistic is that?

Many of these international goals are like pie in the sky, but we must continue. You may not stop 10 feet from the goal line.In many countries they are very close [to providing treatment to every person with HIV]For example, I think Botswana is very close. They have a large infected population but have been very successful in identifying and treating all those affected. And…with the goal of preventing and treating all pregnant women who test positive. can really make a difference in getting rid of HIV infection in infants. Because that is the starting point.

Can lessons learned from PEPFAR be applied to other epidemic and disease prevention strategies?

It was a whole new approach to global health problems. I think PEPFAR was different, mainly because they put so much money into one disease in the most affected regions of the world.[those that] At the time, it was the poorest part that could have done nothing with what was available. PEPFAR was really an ambulance with medicine. Its size and scope were enormous. Working in Africa at the time, we were kind of stunned by the idea that a US program would put so much money into African people. We had never seen anything like it. So it was a really tremendous opportunity, and no one knew if it would really work. In all these countries, they have made a big difference, not just in HIV care, but in health care as a whole.

AIDS is caused by one virus, but it affects others, such as tuberculosis. So I think the PEPFAR program has provided many important lessons about how to deal with the Global TB Program. We have strengthened the infrastructure available for tuberculosis and have steadily improved its care. Many of the labs developed to provide HIV services are [mpox]So I think all of this will have a trickle-down effect of improving health services as a whole. I think it will be accepted. There were many other health care issues dealt with on the side, and we are certainly in a better position to deal with HIV than he was in 2004.