At the turn of the century, the best HIV therapies were available only in developed countries. Now, the increasingly global availability of powerful new treatments is helping to bring the HIV epidemic to heel
The impact of HIV in Africa in the 1990s and 2000s was profound. “It was a horrendous time,” says Kenly Sikwese, who has lived in Zambia for most of his life. One report found that, in 1999 alone, 5.4 million people were infected and 2.8 million died.
“I lost two of my own brothers to HIV, and I was one of the lucky ones – there were families of 10 that only had two members left,” says Sikwese, who coordinates an HIV treatment advocate network called AfroCAB, which campaigns for the speedy development and approval of life-saving treatments. “It was a time of no hope; if you had HIV, all you could do was wait to die.”
The rapid spread of the virus, combined with a lack of access to treatments, was especially felt by African nations. “Zambia became a country of funerals,” says Sikwese.
Since then, things have changed thanks to a huge surge of financial support from foreign governments and smart licensing deals by pharmaceutical companies.
On the decline
Much of the early funding was made available via the President’s Emergency Plan for AIDS Relief – an initiative launched by George W. Bush, US president at the time. This programme released $15 million to fund HIV prevention, care and treatment in developing countries between 2004 and 2008. Together with the Global Fund to Fight AIDS, Tuberculosis and Malaria, these organisations are still the mainstay for global HIV funding.
“Global AIDS-related deaths peaked at 1.9 million in 2005 but had halved by 2016”
“Things changed in the 2000s,” says Linda-Gail Bekker, who in 1995 founded the Desmond Tutu HIV Foundation in Cape Town, South Africa, in response to the lack of available treatments. “We said to pharmaceutical companies that we needed access to their drugs on the grounds of compassionate use,” she says.
Part of that change was led by Gilead Sciences. The company has pioneered the development of medicines for HIV. “Their drugs have been the first-line agents from the get go,” says Bekker.
Gilead was also one of the first to introduce tiered pricing of the antiretroviral treatments that had become so effective at tackling HIV. This made key medicines available in low- and middle-income countries for a fraction of what they cost in high-income countries. Having lower prices for drugs in Africa “has really been a game changer,” says Sikwese.
In another move to make treatments more accessible, Gilead began entering into generic drug licensing agreements with manufacturers in India and elsewhere. This means that since 2006, these drug makers have been allowed to make their own, generic versions of Gilead’s HIV drugs, and sell them cheaply in low-income countries.
Five years later, Gilead became the first pharmaceutical company to sign an agreement with the newly formed Medicines Patent Pool – an organisation formed to coordinate the licensing of patent-protected medicines so that they can be produced in generic form for low income countries.
Today, numerous drug manufacturers based in India, South Africa and China produce Gilead-developed medicines at low cost. The greater the number of manufacturers, the better it is for countries like Zambia, says Sikwese. “You have more competition, which means you have a lower price, which means you have more accessibility,” he says.
HIV self-testing kits are helping people get treatment earlier
The impact has been huge. In 2006, just 30,000 people received Gilead’s HIV medicines. By 2011, this number had risen to 2.4 million. By 2016, the company achieved a long-standing goal of treating 10 million people. At the same time, the price of these drugs has fallen by 80 per cent since 2006.
Other companies have since followed Gilead’s lead, making a range of medicines available at affordable prices; “21 million people are now on treatment,” says Bekker.
The wait for drugs is shrinking, too. In the early days, treatments for HIV that were developed in the US or Europe took a long time to be approved for use in developing countries. Sikwese remembers one drug that was approved for use in the US in 1996, but didn’t make it into Africa until 2010. But Gilead’s latest agreement with the Medicines Patent Pool aims to have new drugs ready for generic manufacturers as soon as they are available in high-income countries.
On the whole, there has been a huge turnaround in the availability of HIV treatments. According to the latest statistics from UNAIDS, the UN body that coordinates global action on HIV, 20.9 million people now have access to antiretroviral drug treatments. And that’s led to ambitious plans to build on that success, tackling the disease on an even larger scale.
In 2014, UNAIDS launched the 90:90:90 goal – aiming to make 90 per cent of people with HIV aware of their status, to give 90 per cent of those people HIV treatment, and for 90 per cent of those on treatment to have the virus so suppressed that it is undetectable in a blood test. And all by 2020.
There are encouraging signs. Global AIDS-related deaths peaked at 1.9 million in 2005, and had halved to 1 million by 2016, for example.
But the epidemic is far from over (see “On the decline“). Today, around 36.7 million people globally are living with HIV, and there were 1.8 million new infections in 2016. “There are still more than 1 million deaths,” says Sikwese. “That’s unacceptably high.”
One of the key challenges faced by public health practitioners is ensuring that everyone who is infected knows their status. “More people need to be tested at an early stage, without clinical symptoms,” says Papa Salif Sow, who helps oversee Gilead’s efforts to improve access to treatments in Africa.
Self-testing kits are proving helpful here – people can receive and use the kits at home, allowing them to learn their status without the stigma and time commitment associated with attending a clinic.
Improvements are still needed, however. “HIV mother-to-child transmission remains high in some sub-Saharan African countries,” says Salif. “And mortality in children living with HIV remains high.” He says better paediatric formulations of antiretroviral drugs are urgently needed.
But the tide seems to be turning. “Over time, we’ve seen a huge difference in mortality as more people have access to antiretroviral therapy,” says Sikwese. “Drugs companies including Gilead have become more proactive,” he adds. “In terms of making drugs available, and ensuring widespread uptake, they’ve played a critical role in levelling the playing field.”
For more see: @GileadSciences