What has been the biggest success and biggest failure of the HIV/AIDS response?
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Click here to read the Cover Story, "PrEP at 10: Medication ‘added a lot of energy to HIV prevention’."
Since the first report of AIDS more than 40 years ago, the fight to end the pandemic has seen successes and failures.
We asked Sten H. Vermund, MD, PhD, the Anna M.R. Lauder Professor of Public Health at the Yale School of Public Health and professor of pediatrics at the Yale School of Medicine, and Annelys Roque, MD, infectious disease doctor at Emory University Hospital Midtown, what they consider the biggest success and biggest failure of the HIV/AIDS response. PrEP factored in both of their answers — in good and bad ways.
Success: The marriage of ART and prevention
Failure: PrEP uptake
The marriage of ART and prevention has been a huge success.
We think that radically expanded ART access and use around the world is likely contributing to diminished incidence (everywhere except Eastern Europe and Central Asia) because persons living with HIV are minimally infectious on ART. Early diagnosis and treatment are best for the patient and also best for the community, making HIV diagnosis and treatment highly cost effective, with both clinical and preventive benefits. Staying the course with a committment to expanded testing, linkage to ART services and help with adherence to ART will pay off in global HIV control.
Although PrEP has been a biological success in antiretrovirals and can block HIV acquisition, it has been a failure in stemming the HIV pandemic globally because uptake and adherence have been high only in high-income countries and typically only among men who have sex with men (MSM). A major research challenge is how to create demand for PrEP in venues of greatest need, notably in sub-Saharan Africa and among especially vulnerable populations around the world. Black MSM and transgender women in the U.S. are examples of subgroups who could benefit disproportionately if PrEP access and use could be increased.
Success: PrEP, where it is available
Failure: PrEP accessibility
I think the biggest success and biggest failure are two sides of the same coin.
This is my first year in Atlanta as an Emory physician, but I previously trained in San Francisco. The reason I say two sides of the same coin is because one of the biggest successes has not occurred in certain parts of this country. In New York and San Francisco, for example, PrEP is widely available, easy to get and is reaching the populations that it should reach — that’s a huge success for the last 5 years that I’ve been in infectious diseases. The other side of that coin, however, which I see now that I am in the Southeast, is that PrEP is wholly underused. Part of that is because that same mainstream accessibility has just not reached the South. I think that is probably the biggest failure that we have because there are so many new infections that could have been prevented by PrEP.
I have seen both ends of the spectrum. I have seen people who can get PrEP at their local pharmacy, who don’t need a consultation with a physician, which in certain cases is how it is in San Francisco, and I have seen young men aged younger than 25 years who are newly diagnosed with HIV who, in a different world, should have been on PrEP.
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