On World AIDS Day (1 December 2022), we reflect on the HIV/AIDS pandemic journey and on the status quo of the quality of life of people living with HIV(PLHIV).

The HIV pandemic officially dates to 1981, when the US Centers for Disease Control and Prevention (CDC) reported five young men diagnosed with unusual cases of opportunistic infections in Los Angeles, California.^1,2 All died of their disease. Shortly thereafter, the causative agent of their ‘mysterious’ disease was identified to be the human immunodeficiency virus (HIV) which develops into AIDS (acquired immunodeficiency syndrome).³ Later it was discovered that the HIV pandemic had started around the 1920s in Kinshasa,⁴ the Republic of Congo, and that HIV originated from a chimpanzee.⁵

Today HIV still affects many people worldwide. New HIV infections have been reduced by 52% since their peak in 1997, but there are still 1.5 million individuals who were newly infected with HIV in 2020, and an average of 37.7 million PLHIV in 2020.⁶ Global summaries mask the regional variations, however. East and southeastern Africa continue to be the epicentre of the HIV pandemic, and certain key populations carry a higher burden of HIV infections.⁷ The HIV pandemic is therefore not over, and infection is still more common in certain regions and target populations.

Nevertheless, AIDS is no longer listed in the top 10 death causes globally, instead it is widely seen as a chronic disease.⁸ Healthcare for PLHIV has improved in the last 20 years, due to the development of more efficient treatment and improved adherence, preventive measures, and comorbidity management.⁹

Treatment

HIV infection can be treated using antiretroviral therapy (ART).¹⁰ ART advancements have changed the status quo of this disease from a death sentence into a manageable chronic condition.¹¹ ART has reduced HIV morbidity and mortality rates, leading to a life expectancy approaching that of the general population.¹² Thus, PLHIV are surviving longer, and much of the remaining excess mortality in PLHIV is not caused by AIDS, but due to risk factors such as smoking, injecting drugs, and comorbidities.¹³ However, life-long adherence to ART is necessary for PLHIV.

Life-long adherence to ART remains a challenge for PLHIV due to several behavioural and socioeconomical hurdles. Treatment fatigue and pill burden are some of these hurdles, although the ART regimen may nowadays be combined into a single pill. In addition, ART is not free of adverse effects.¹⁴ Socioeconomic factors such as education level, employment status, financial status, housing, and health insurance are additional hurdles, which have shown to be associated with the virological and immunological response of PLHIV, and with adherence to ART.¹⁵

Prevention

To date, there is no practical cure for HIV and prevention remains the best “cure”. While the ideal prevention would be via an effective HIV vaccine, this remains a scientific challenge yet to be overcome. A promising HIV vaccine is currently being investigated by Moderna, International AIDS Vaccine Initiative, and Scripps Research Institute.¹⁶

There remain other preventive measures for HIV such as adopting a healthy lifestyle and better habits (e.g. safe sex). HIV can also be prevented via pre-exposure prophylaxis (PrEP), a medication for those at higher risk of HIV exposure. Post-exposure prophylaxis (PEP) is a medication which is given immediately after a known exposure, so HIV infection might still be prevented with prompt treatment.¹⁷

Global initiatives & campaigns

In 2013, UNAIDS set up a global initiative called 90-90-90, which set new targets to end the HIV pandemic. This global initiative was aimed to achieve the following by 2020:

• 90% of PLHIV know their HIV status
• 90% of those diagnosed with HIV receive sustained ART
• 90% of those receiving ART achieve viral suppression

In 2021, 85% of PLHIV were aware of their HIV status, among which 88% were accessing treatment, and among which 92% were virally suppressed.¹⁸ The updated target is set by UNAIDS as 95-95-95, which is to be achieved by 2025,¹⁹ although progress has been remarkable more effort is still needed to achieve these goals globally.

Numerous awareness campaigns are actively involved in public education on HIV, which help among others in detaching the disease from the associated stigma.²⁰ As we have also witnessed with the juxtaposing COVID-19 pandemic, spreading awareness is of utmost importance. The so-called “infodemic” (i.e. epidemic of information) and misinformation impact the course of a pandemic.²¹

Take-home message

Based on current scientific literature and recent data on global statistics on HIV/AIDS, the mortality rate of PLHIV is decreasing significantly with improved awareness and control measures. This would be reflected in the improved insurability of PLHIV. While an HIV cure or vaccine are still scientific challenges, research in this direction is promising.

Advances in ART and international initiatives to prevent and control HIV have already contributed to improving the quality of life for PLHIV. Gen Re’s CLUE guidelines are being updated accordingly.

Endnotes

1. The HIV/AIDS Epidemic: The First 10 Years [Internet]. [cited 2022 Nov 14]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/00001997.htm
2. Pneumocystis Pneumonia – Los Angeles [Internet]. [cited 2022 Nov 16]. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/june_5.htm
3. A Timeline of HIV and AIDS [Internet]. [cited 2022 Nov 16]. Available from: https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline
4. Faria NR, Rambaut A, Suchard MA, Baele G, Bedford T, Ward MJ, et al. The early spread and epidemic ignition of HIV-1 in human populations. Science (1979) [Internet]. 2014 [cited 2022 Nov 14];346(6205):56–61. Available from: https://www.science.org/doi/10.1126/science.1256739
5. Gao F, Balles E, Robertson DL, Chen Y, Rodenburg CM, Michael SF, et al. Origin of HIV-1 in the chimpanzee Pan troglodytes troglodytes. Nature 1999 397:6718 [Internet]. 1999 Feb 4 [cited 2022 Nov 14];397(6718):436–41. Available from: https://www.nature.com/articles/17130
6. Global HIV & AIDS statistics – Fact sheet|UNAIDS [Internet]. [cited 2022 Aug 29]. Available from: https://www.unaids.org/en/resources/fact-sheet
7. de Cock KM, Jaffe HW, Curran JW. Reflections on 40 Years of AIDS. Emerg Infect Dis [Internet]. 2021 Jun 1 [cited 2022 Aug 31];27(6):1553–60. Available from: https://pubmed.ncbi.nlm.nih.gov/34013858/
8. Ibid.
9. Trickey A, May MT, Vehreschild JJ, Obel N, Gill MJ, Crane HM, et al. Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies. Lancet HIV [Internet]. 2017 Aug 1 [cited 2022 May 3];4(8):e349–56. Available from: https://pubmed.ncbi.nlm.nih.gov/28501495/
10. FDA-Approved HIV Medicines|NIH [Internet]. [cited 2022 Oct 5]. Available from: https://hivinfo.nih.gov/understanding-hiv/fact-sheets/fda-approved-hiv-medicines
11. Moranguinho I, Valente ST. Block-And-Lock: New Horizons for a Cure for HIV-1. Viruses [Internet]. 2020 Dec 1 [cited 2022 Sep 7];12(12). Available from: https://pubmed.ncbi.nlm.nih.gov/33334019/
12. Bukenya D, Mayanja BN, Nakamanya S, Muhumuza R, Seeley J. What causes non-adherence among some individuals on long term antiretroviral therapy? Experiences of individuals with poor viral suppression in Uganda. AIDS Res Ther [Internet]. 2019 Jan 21 [cited 2022 Oct 10];16(1):1–9. Available from: https://aidsrestherapy.biomedcentral.com/articles/10.1186/s12981-018-0214-y
13. Trickey A, van Sighem A, Stover J, Abgrall S, Grabar S, Bonnet F, et al. Parameter estimates for trends and patterns of excess mortality among persons on antiretroviral therapy in high-income European settings. AIDS [Internet]. 2019 Dec 15 [cited 2022 Jul 14];33 Suppl 3(Suppl 3):S271–81. Available from: https://pubmed.ncbi.nlm.nih.gov/31800404/
14. Adverse Effects of Antiretroviral Agents | NIH [Internet]. [cited 2022 Nov 16]. Available from: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/adverse-effects-antiretroviral-agents
15. Burch LS, Smith CJ, Phillips AN, Johnson MA, Lampe FC. Socioeconomic status and response to antiretroviral therapy in high-income countries: A literature review. AIDS [Internet]. 2016 May 15 [cited 2022 Apr 26];30(8):1147–61. Available from: https://journals.lww.com/aidsonline/Fulltext/2016/05150/Socioeconomic_status_and_response_to.1.aspx
16. IAVI and Moderna launch trial of HIV vaccine antigens delivered through mRNA technology [Internet]. [cited 2022 Oct 10]. Available from: https://www.fredhutch.org/en/news/releases/2022/01/mRNA-hiv-vaccine-trial.html
17. DeHaan E, McGowan JP, Fine SM, Vail R, Merrick ST, Radix A, et al. PEP to Prevent HIV Infection. Post-Exposure Prophylaxis (PEP) to Prevent HIV Infection [Internet]. 2022 Aug 11 [cited 2022 Oct 10]; Available from: https://www.ncbi.nlm.nih.gov/books/NBK562734/
18. Ibid, endnote 6.
19. Frescura L, Godfrey-Faussett P, Ali Feizzadeh A, El-Sadr W, Syarif O, Ghys PD, et al. Achieving the 95-95-95 targets for all: A pathway to ending AIDS. PLoS One [Internet]. 2022 Aug 1 [cited 2022 Oct 14];17(8):e0272405. Available from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0272405
20. Awareness Campaigns [Internet]. [cited 2022 Nov 16]. Available from: https://www.hiv.gov/federal-response/campaigns
21. Banerjee D, Meena KS. COVID-19 as an “Infodemic” in Public Health: Critical Role of the Social Media. Front Public Health. 2021 Mar 18;9:231.