Fauci: Steadfast Focus on HIV Disparities Needed

Dr Anthony S. Fauci

Decades before becoming the go-to authority in the US on the COVID-19 global pandemic, Anthony S. Fauci, MD, found himself witnessing the earliest perplexing cases of what would become another devastating global pandemic — HIV/AIDS. And while extraordinary advances have transformed treatment and prevention, glaring treatment gaps and challenges remain after 40 years.

"I certainly remember those initial MMWRs [the CDC's Morbidity and Mortality Weekly Reports] in the summer of 1981 that introduced us to what would turn out to be the most extraordinary and devastating pandemic of an infectious disease up until that time in the modern era," said Fauci when addressing the 2021 United States Conference on HIV/AIDS (USCHA) this week.

"Now, 40 years into it, we are still in the middle of a global pandemic despite the fact that there have been extraordinary advances," said Fauci, who is director of the National Institute of Allergy and Infectious Diseases (NIAID) and chief medical advisor to the President of the United States.

Specifically, it was on June 5, 1981, that the Centers for Disease Control and Prevention (CDC) issued its fateful report on the first five cases of what would soon become known as Acquired Immune Deficiency Syndrome.

By 2020, the five cases had grown to 79.3 million HIV infections since the start of the HIV/AIDS pandemic, claiming 36.3 million lives, according to the NAIDS Global AIDS update, Fauci reported.

At the end of 2020, there were 1.5 million new infections, as many as 37.7 million people living with HIV, and 680,000 deaths, according to the report.

The fact that so many people are living with HIV — and not dying from it — is largely attributable to "breathtaking" advances in treatment, Fauci said, underscoring the fact that there are now 13 single-tablet, once-daily, antiretroviral (ART) regimens approved in the United States to replace the multidrug cocktail that has long been necessary with HIV treatment.

"I can remember when the combination therapies were first made available, we were giving patients literally dozens of pills of different types each day, but that is no longer the case," Fauci said.

"We can say, without hyperbole, that highly effective antiretroviral therapy for HIV is indeed one of the most important biomedical research advances of our era."

Furthermore, HIV prevention using pre-exposure prophylaxis (PrEP), when used optimally and consistently, has further transformed the HIV landscape with 99% efficacy in preventing sexual HIV acquisition.

Troubling Treatment Gaps

Despite the advances, disparities and challenges are abundant, Fauci said.

Notably, the majority of those infected globally — 65% — are concentrated among key populations, including gay men and other men who have sex with men (23%), clients of sex workers (20%), sex workers (11%), people who inject drugs (9%), and transgender people (2%), according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

According to UNAIDS, among the 37.7 million people living with HIV at the end of 2020, 27.5 million were being treated with life-saving ART, leaving a gap of 10.2 million people with HIV who are not receiving the treatment, Fauci pointed out.

And of those who do receive treatment, retention is suboptimal, with only about 65% of patients in low- and middle-income countries being retained in care at 48 months following ART initiation.

Fauci underscored encouraging developments that could address some of those problems, notably long-acting ART therapies that, in requiring administration only every 6 months or so, could negate the need for adherence to daily ART therapy.

Likewise, long-acting PrEP provided intermittently over longer periods could prevent transmission.

"We're looking at [long-acting PrEP] with a great deal of enthusiasm as providing protection with longer durations between doses to get people to essentially have close to 99% protection against HIV acquisition," Fauci said.

While several efforts to develop vaccines for HIV in long-term clinical trials have had disappointing results, Fauci says he stops short of calling them failures.

"We don't consider the trials to be failures because, in fact, they tell us the way we need to go — which direction," he said.

"In fact, COVID-19 itself has given us new enthusiasm about the use of vaccine platforms such as mRNA that are now being applied in the vaccine quest for HIV," Fauci noted.

Ultimately, "we must steadily and steadfastly move forward to address critical research gaps and unanswered questions [regarding HIV]," Fauci said. "The scientific advances have been breathtaking and it is up to us to [achieve] greater scientific advances, but also to translate them into something that can be implemented."

Dr Paul Kawata

USCHA Executive Director Paul Kawata, MD, commented that he shares Fauci's optimism — and his concerns.

"NMAC [formerly the National Minority AIDS Council, which runs USCHA] is very excited about the science," he told Medscape Medical News. "Our ability to make treatment easier should be a pathway to success."

"Our concern is that we need more implementation science to know if long-acting ART will be used by the communities hardest hit by HIV," he said.

Kawata noted that NMAC agrees that vaccine trial "failures" can offer important lessons, "but we are getting impatient," he said. "Back in the 80s, Secretary Margret Heckler said we would have a vaccine in 5 years."

Furthermore, ongoing racial disparities, left unaddressed, will hold back meaningful progress in the fight against HIV, he noted. "We are always hopeful, [but] the reality is that race and racism play an outsized role in health outcome in America."

"Unless we address these inequalities, we will never end HIV."

NMAC receives funding from Gilead, Viiv, Merck, and Janssen.

2021 United States Conference on HIV/AIDS (USCHA). Presented December 2, 2021.

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