HIV, what was once a death sentence has become a manageable chronic condition. (Baylor College of Medicine Children's Foundation–Malawi, Robbie Flick)
  • While there is still no cure for HIV, there have been huge advances in treatment options over the past 40 years, which have improved the quality of life of people living with HIV.
  • These expanding treatment options have also created a new arsenal for HIV prevention, bringing us closer to controlling the Aids epidemic.
  • Even with the disruptions to health services during the COVID pandemic, available medications for HIV have helped protect people from developing severe cases of COVID-19.

The fourth HIV Research for Prevention (HIVR4P) conference wrapped on Thursday — but there’s still so much to learn and unpack on the advances made in HIV research.

This is the first in a series of Bhekisisa resources which bring you some of the pre-conference programme. Presented to journalists across the world these HIVR4P videos, and our coverage of them, will help explain some of the developments in prevention research and how best to report on them.

First up: a session from 12 January on ending the HIV epidemic while still maintaining progress during the COVID-19 pandemic.

The session was presented by the medical advisor to the United States president and the director of the American National Institute of Allergy and Infectious Diseases, Anthony Fauci.

How advances in HIV treatment have transformed people’s lives

It’s been 40 years since the first cases of Aids were reported. In that time, what was once a death sentence has become a manageable chronic condition. Scientists have been hard at work pushing the boundaries in HIV research and with that improving the life outcomes of people living with HIV. This work has led to huge strides forward and substantial changes in the life expectancy of a 20-year old person newly diagnosed with HIV. 

In the 1980s, Fauci explained, the expectation was that a 20-year old person with HIV would only live for one to two years following their diagnosis with advanced disease, or Aids. Today, however, a newly diagnosed 20-year old can live for roughly an additional 53 years.

The factor influencing this change? The menu of treatment options we now have available to respond to HIV.

While there was little that could be done for someone diagnosed with HIV in the 1980s, there are now several different types of medications, called antiretrovirals (ARVs), which can be used to treat HIV.

These drugs have helped save countless lives. Even though there is still no cure for HIV, ARVs can help control the virus and, if taken correctly, can allow a person to continue living their lives as normal.

#BhekisisaBites: Drop in infections follows ARVs’ success

In the early 2000s adult life expectancy in rural KwaZulu-Natal drastically declined to 49.2 years. But, with ART (antiretroviral treatment) becoming available at public health facilities the average life expectancy in the community began to increase, and reached 60.5 years by 2011. “Before ART became widely available, most people were dying in their 30s and 40s. Now people are living to pension age and beyond,” said Jacob Bor, the lead author of a 2013 study published in Science

Read more about how ARVs helped slow down the rate of new HIV infections

What are antiretrovirals?

First, let’s clear up some of the terminology: antiretroviral treatment (ART) refers to the combination of different antiretroviral medicines or drugs (ARVs) which are taken daily by a person with HIV.  
We currently have seven classes of ARVs. These drugs are grouped together in terms of how they respond to, or fight, HIV.

ARVs make it difficult for HIV to replicate — in other words, make copies of itself. This reduces the amount of the virus in someone’s body, which is called the viral load.

So why do these drugs matter?

Without treatment, HIV attacks and weakens the body’s immune system. It does this by destroying a part of your natural defence system called CD4 cells or T cells.

Think of CD4 cells like your body’s fire marshals: they help fight against fires (infections) by alerting colleagues to the threat and coordinating them to safety. In a similar way, CD4 cells coordinate and stimulate other immune cells in the body to fight against infections. In our analogy, ARVs would be the different types of protective gear that help our fire marshal stay safe while fighting fires.  

Generally, a well functioning immune system would have about 500 to 1 500 CD4 cells in a drop of blood (a cubic millimeter). We call this measure the CD4 count. When this count drops to less than 200 CD4 cells per drop of blood the HIV infection has progressed to its most advanced stage — Aids. At this stage the body would be vulnerable to opportunistic infections, such as pneumonia and TB, which increase the risk of illness and death.

But if someone takes ARVs, and is able to lower the amount of virus in their system, these fire marshal cells have a better chance against the infection.

How, and when, people take these drugs has changed over the years.

Initially, people were only prescribed ARVs when they had a low CD4 count — indicating that their immune system was weakened and its functioning compromised, explains Kevin Rebe, an infectious diseases physician, in a 2016 piece for Bhekisisa. This changed when new research in 2015 showed that the best treatment plan for someone living with HIV was to start a course of ARVs as soon as possible after their diagnosis, regardless of their CD4 count, Rebe writes.

These drugs (ARVs) and their combination in different treatment plans (ART) won’t cure HIV. But, when taken as intended, they help keep the HIV viral load low, the body’s CD4 count up, lower the risk of death and keep the risk of transmitting the virus down.

What do we need to end the HIV epidemic?

Aside from just being used to treat people living with HIV, ARVs also play an important role in preventing the transmission of HIV from person to person.

Ultimately, ending this epidemic means providing people with more options and the “optimisation of the HIV treatment and prevention toolkit”, Fauci explained.

This needs to involve “the continuous development of new and improved tools, because even though we have extraordinary tools, we always can do better. And in fact, we are doing better.”Read more about the search for an HIV vaccine.

As research in this field has progressed, we have learnt more about HIV, and treating it. Over time, scientists have figured out the best way to use medications for the biggest impact. One such breakthrough was evidence confirming the idea that Undetectable equals Untransmissable (or U=U). 

Here’s the basic thinking behind U=U: when a person living with HIV has a viral load so low that the virus can’t be detected in their blood using standard tests (undetectable), they can’t transmit the virus to another person (untransmissable). Most people with HIV who use their ARVs correctly have undetectable viral loads. So, by getting as many people with HIV on ARVs, we don’t just make it possible for people with HIV to live longer, healthier lives; we also help curb the spread of the virus. 

Here are more examples of how ARVs are being used to help prevent the spread of HIV:

To prevent mother-to-child transmission pregnant women living with HIV will take ARVs. After birth, their babies will be put on a course of HIV medicines too.

Someone who has been exposed to HIV can be put on emergency ARVs within 72 hours of their exposure. This is called post-exposure prophylaxis (PEP). 

Pre-emptive prevention measures are available too. People who don’t have HIV but have a high risk of being exposed to the virus can take HIV medicines before the possible exposure. This is called pre-exposure prophylaxis (PrEP).

Within PrEP, there are also a number of options available, and some on the horizon — including a new eight-weekly injection.

How is COVID-19 impacting people living with HIV?

Part of the global goals outlined by the United Nations Development Programme aims to end the HIV epidemic by 2030. The idea was to do this by reducing new HIV infections and Aids-related deaths by 90% over a 20-year time span.

Although the number of new infections are the lowest they’ve been since 1988 and there has been a historic reduction in deaths, there is still more to be done.

Many countries, who were already off-track for their targets, have faced further setbacks amidst the COVID-19 pandemic.

The effects of this new public health threat have both direct and indirect implications on the global HIV treatment and prevention programmes, outlined Fauci. 

What are the indirect effects? — Disruption of services.

As Fauci explained the COVID-19 pandemic interrupted and interfered with the provision of essential health services — including those that people relied on for treating and preventing HIV.

A 2020 interim report by the World Health Organisation (WHO) found that 32 of 101 countries (32%) with established ART programmes experienced some form of disruption in providing these services. About 31 of these countries reported partial disruptions, while 1 country said the disruptions were severe.

More about the WHO “pulse survey on continuity of essential health services during the COVID-19 pandemic” interim report (27 August 2020)

The report’s findings are based on survey questionnaires filled out by key informants in national health ministries. Each of the participating countries submitted one survey between May and July 2020. 105 countries completed and returned these surveys back to the WHO.

What you need to bear in mind when looking at the report’s data:

  • Each of the countries would be at different stages of the COVID-19 pandemic.
  • “Key informants” could be a single person using their own observations and assessments to complete the questionnaire or a consultative group of people. 
  • The roles of “key informants” could be different across countries too (i.e. a health policy advisor in one and health systems director in another).

So what’s the potential impact of these health service disruptions?
One study estimates that low- and middle-income countries with a high burden of HIV, could see HIV-related deaths increase by 10% over the next five years because of disruptions like these (compared to a hypothetical scenario with no COVID pandemic).

What about the direct effects — Are people living with HIV at higher risk of developing severe COVID-19?

According to Fauci: Yes and no.

One of the concerns about COVID-19 is that underlying medical conditions, like diabetes, can put you at higher risk of developing severe disease, Fauci explained. There is also some risk associated with people who have compromised immune systems — which is where HIV comes in.

“You might expect that with HIV, that you would be immunocompromised,” says Fauci. “But many people with HIV are on antiretroviral therapy, they have normal CD4 counts, and undetectable viral load.”

So, the initial expectation may have been that people with HIV would have weaker immune systems and, therefore, be more vulnerable to complications from COVID. But what we have seen instead is that HIV-positive people aren’t at higher risk as a result of their diagnosis — because of the successful implementation of ARVs to control their viral load.

Rather, what puts people at higher risk is having more than one medical condition, or comorbidities.

So while there have been a higher number of people with HIV dying of COVID-19, this is not as a direct result of their HIV status. Instead, this higher mortality rate is because people with HIV have a larger burden of comorbidities.

Fauci explained: “It’s the high morbidities that are the potential risk factor for severe COVID-19, especially in older individuals. In other words, people with HIV have some of the same comorbidities that other individuals who don’t have HIV [have]. Only, you have it in a more prevalent way.”

But ultimately, when we keep all factors the same, a person living with HIV and someone who is HIV negative would have the same risk of being infected with SARS-CoV-2. Additionally, COVID-19 disease would progress in the same way for both individuals, and both would face the same outcomes of COVID disease.

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