Following up on a national strategy to fight HIV, England’s national medical director recently told The Guardian that the country is on track to eliminate new cases of the virus by 2030. The publication declared that the country was investing its hopes into becoming the first in the world to “defeat” HIV.
It would be a groundbreaking achievement, especially for combatting a disease that has no cure. But contrary to popular belief, no new cases does not mean the virus will have been eliminated, in the U.K. nor elsewhere. Experts warn that eliminating HIV will take international efforts to make effective therapies affordable, enhance care for vulnerable populations, and hunt for a cure or vaccine. Some of these endeavors are further along than others, but there is still a long way to go .
“It’s a highly laudable and aspirational goal,” Kenneth Mayer, the medical research director of The Fenway Institute in Boston, told The Daily Beast. “The question is whether it's realistic.”
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A few factors, said Mayer, do make the U.K.’s goal possible, even if it remains improbable. Antiretroviral therapy, the gold standard for HIV treatment today, has fewer side effects than ever before, and HIV-positive patients who take their medication as prescribed will suppress their viral loads to the point where they can no longer transmit the virus through sex. (According to the U.S. Centers for Disease Control and Prevention, having an undetectable viral load reduces but does not completely eliminate the risk of HIV transmission through breastfeeding and sharing needles.)
In recent years, large clinical trials of pre-exposure prophylaxis (PrEP) have shown that daily pills or semi-monthly injections greatly reduce one’s risk of acquiring HIV. PrEP is recommended for people who are at risk of getting HIV through sex or injection drug use. In the U.K., PrEP pills are available for free through the National Health System.
In fact, nationalized health care is one of the reasons that the country is progressing faster on its campaign against HIV and AIDS than the U.S. is, Mayer said. The U.S. has a similar plan to reduce new HIV infections by 75 percent by 2025 and 90 percent by 2030.
But even with effective treatments and prophylaxis to reduce the spread of HIV, barriers to access still exist, particularly for vulnerable populations. The term “social determinants of health” describes the factors outside of biology that influence how a person lives—systemic racism, housing inequality, unemployment, and addictive substance use, and more can affect a person’s ability to manage their HIV status. Additionally, simply nurturing health literacy among people to take medications as prescribed is a key first step, Mayer said.
“If the medication is there but if it sits in the pill bottle, it's not going to do anybody any good,” he added.
In the U.S. policies exist to help cover the cost of medications like PrEP, but depending on one’s insurance status, clinic visits and lab tests may wind up being paid out of pocket. Sharing needles during injected drug use is the second-riskiest behavior for getting HIV, and effective interventions like needle exchange programs and safe injection sites have become politicized, Mayer said, putting drug users at risk based on where they live. And globally, nearly 10 million people are HIV-positive but are not accessing antiretroviral therapy, meaning they are at risk for transmitting the virus to others.
The COVID-19 pandemic has also thrown a wrench in HIV care and prevention by disrupting people’s access to in-person health care and life-saving antiretroviral therapy, though it remains unclear what the full extent of the pandemic will be on case numbers going forward.
Importantly, one positive development from the pandemic has been the demonstrated success of mRNA vaccines, which has direct bearing on a preventative vaccine for HIV. In March, the National Institutes of Health launched a Phase I clinical trial to study three mRNA vaccines for HIV, expected to be completed next summer. Even so, if the pandemic was any indication, public health leaders will have to overcome vaccine hesitancy to convince people to get a safe and effective shot to prevent HIV.
Once the U.K., or any other country, reaches zero new HIV infections in a given year, that still does not mean the fight is over, Mayer said. Until a preventative vaccine or cure exists for the virus, people with formerly undetectable viral loads may transmit the virus if they lose access to medication or do not take it as prescribed—not to mention the ongoing challenge of making existing treatments accessible globally.
“No new infections as of 2030 doesn't mean that you have no infections as of 2031 or 2032,” he said.
