We know how to end AIDS

This article is part of Telescope: The New AIDS Epidemic, a deep-dive investigation into the modern face of a disease that transformed the world.

Greece was never known for the quality of its health system. But in 2009, at least among drug users, HIV was not a major threat — just 15 were diagnosed with the virus that year.

Then came the financial crisis and the harsh austerity that followed. In 2011, another 256 drug users learned they had HIV. In 2012, the number was 484. The reason for the explosion: the Greek financial crisis and the harsh austerity measures that followed.

The ballooning epidemic illustrates the importance that politics and policy plays in the fight against AIDS. Though there’s still no cure, experts say we already have the tools to eliminate HIV as a threat to human health.

The problem is not the science. It’s the political will — and the fact that the most vulnerable tend to live on the margins of society. Lingering homophobia in some countries holds back men who have sex with men from getting care. Where they’re accepted, sex workers and migrants are still at risk — and blamed for the spread of the epidemic.

“These groups are generally discriminated [against] and stigmatized,” making them less likely to seek help with prevention and treatment, said Nedret Emiroglu, the chief for communicable diseases in the World Health Organization’s European Region. HIV isn’t just a medical condition; it’s "a social disease," she added.

Marios Atzemis was one of the Greek drug users diagnosed with HIV in 2011. He had been addicted to heroin and a regular in Athens’ open-air drug markets well before the crisis. Then in 2010, street services to help drug users stay safe lost a third of their funding. Atzemis stopped seeing the vans that used to distribute fresh syringes, even as new users were entering the scene, shooting newer, cheaper drugs.

“As a community of drug users, we didn’t have an effective means of defense,” said Atzemis, now a harm-reduction coordinator with the Association of People Living with HIV Greece (Positive Voice). “It was very easy for us to be targeted and to be scapegoats.”

The doctor refused to put him on anti-AIDS antiretrovirals medication until he got clean at a rehab clinic — even though the clinic was on the brink of being shut down for lack of funding.

For Atzemis, now 44, this was enough motivation to wean himself off the drugs. “It didn’t work the same for other people,” he said.

Whether it’s inconsistent funding for programs that are working or social stigma blocking help from getting to the people who need it most, activists and public health professionals say even relatively wealthy countries are struggling to close the remaining gaps in the fight against the epidemic. Worldwide, just four countries — Burundi, the Dominican Republic, the Democratic Republic of Congo and Portugal — are on track to meet the global goal to reduce AIDS deaths by 75 percent between 2010 and 2020, according to UNAIDS.

AIDS is in many ways a 21st century success story. The epidemic tore communities apart in the 1980s and 1990s. In 2000, only 680,000 people were on antiretroviral therapies. Today, 62 percent of people with HIV — some 23.3 million people — have access to the life-saving drugs. New infections are down 40 percent since their peak in 1997, according to UNAIDS.

Early diagnosis and speedy treatment create their own virtuous side effect. The drugs that prevent HIV from exploding into full-blown AIDS also prevent HIV-positive people from transmitting it to others.

London serves as an example of what is possible. An estimated 95 percent of people with HIV in the British capital have been diagnosed with the virus. And of those, 97 percent of them have such low levels of the virus that it's undetectable (and therefore not contagious).

On top of that, some antiretrovirals taken in advance of exposure, a treatment known as PrEP, can actually drastically reduce people's chances of getting infected in the first place. Lower-tech methods like condom campaigns and needle-exchange programs help prevent HIV’s spread further. There's justified optimism that London can end HIV transmission in the coming years.

Then there's what happened among drug users in Greece. Backsliding threatens progress worldwide. Complacency is another major threat.

Funding to fight HIV dropped in 2018 compared with the previous year, the NGO Doctors Without Borders warned in a report published this month. This dip in donations, the first since the turn of the century, could trigger an “epidemic rebound” in some poor African countries that can’t afford to pick up the slack left by the loss of international aid.

HIV diagnoses are down in the EU as a whole; however, in a third of the bloc's countries, the trend is moving the wrong way. Ireland, for example, saw a record high number of diagnoses in 2018. Public health officials pointed the finger at migrants, but activists argue the country needs better access to PrEP and self-testing kits.

Indeed, late diagnosis is a problem around the EU, where about half of patients don’t find out they’re HIV positive until several years after infection, according the the European Centre for Disease Prevention and Control.

Sex between men is still the top mode of transmission in the EU, but it’s also a bright spot: Diagnoses among this population are down 20 percent between 2015 and 2017. PrEP has the potential to drive further improvements, but it’s not reimbursed in many countries, and the principal developer, Gilead, has found itself in some bitter pricing disputes.

Russia represents a horrifying story of complacency, denial and discrimination. The epidemic there didn’t take off until the mid-1990s, and then mainly among people who inject drugs. But the country refused to fund harm-reduction measures, and in 2013, it outlawed targeting information to gay men. More recently, its rate of infections has been increasing by 10 to 15 percent annually, with 100,000 infected in 2017 alone, and most transmissions are between heterosexual couples.

In Greece, government officials, civil society and activists were relatively quick to acknowledge the problem. While the government faced heavy criticism from human rights advocates when it posted photos of alleged HIV-positive prostitutes, the public health community also rallied, doubling the number of needle exchanges in 2011 and cutting wait times for addiction treatment. Greece also introduced a novel system of paying drug users €5 to get tested and €3 for referring others, while connecting them with treatment and other services. That approach is now considered a model for responding quickly to outbreaks.

For better or worse, Greece shows that a country doesn't need to fix its entire health system to deal with HIV. As a case in point, its progress on AIDS hasn't translated into progress on correlated problems like hepatitis C. Those rates rose during the debt crisis and haven't ebbed much; based on 2017 data, around 62 percent of drug users in Greece have tested positive for hepatitis C.

The crisis-era HIV outbreak marked "the first time that all the stakeholders — NGOs, state structures, every single one — worked together to face this epidemic,” said Atzemis. "And probably the last time."

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