40 years of HIV/AIDS: a painful anniversary

40 years ago, on June 5, 1981, the US Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report included a report of a cluster of pneumocystis pneumonia cases among gay men in Los Angeles. Rare life-threatening conditions among men, women, and children were also being seen outside the USA but had not yet been reported—precursors to the coming HIV/AIDS pandemic. Since then, UNAIDS estimates that HIV/AIDS has killed 32·7 million people, with 75·7 million HIV infections globally. Today, the tools exist to eliminate HIV. Combination prevention interventions, such as pre-exposure prophylaxis, are highly effective at reducing HIV acquisition through sex, and antiretroviral therapy for those who have HIV can render the virus undetectable and untransmissible. Yet in 2019 alone, 690 000 people died from HIV/AIDS. Why are we so far off track in achieving the UN 2030 global target of ending AIDS?

There remains unfinished business. The success of the HIV response is predicated on equality—not only equality in access to prevention, care, and treatment for HIV infection, but also equality under the law. Yet, key populations and their partners, including men who have sex with men (MSM), transgender women, sex workers and their clients, and people who inject drugs (PWID), remain disproportionately affected by HIV, comprising 62% of all new HIV infections globally. Well into the 21st century, 67 UN member states still criminalise consensual same-sex conduct and 92 continue to criminalise HIV exposure, transmission, and non-disclosure of HIV infection. 18 criminalise transgender people. With sex work and injection drug use also illegal across much of the world, it is not surprising that effective health interventions are not reaching vulnerable and marginalised people at risk for HIV.

The last of our three HIV Commissions, convened by the International AIDS Society and The Lancet in 2017, called for the repeal of criminalisation laws as well as accountability for measuring progress towards repealing these laws. Sufficient progress has clearly not been made in the past 4 years. Countries such as Russia, United Arab Emirates, Ethiopia, and Chad still do not report on the numbers of MSM in their countries. Donors should do more to put pressure on governments that discriminate against key populations, but the threat of losing the chance to provide any HIV services at all in such settings must be carefully weighed against the benefits of expanding services.

The Commission also looked at how the broader global health landscape has changed since the start of the HIV pandemic. Universal health coverage (UHC), the idea that everyone has the right to a package of services for a range of diseases and health conditions without going into debt, is an equally important UN goal to achieve by 2030. Siloed global disease initiatives cannot continue indefinitely. Achieving UHC—truly universal coverage that addresses the needs of marginalised populations without judgment or prejudice—is essential to ending HIV.

An opportunity to accelerate greater equality and reduce discrimination comes on June 8–10, 2021, when the UN Secretary General António Guterres will convene the fifth High Level Meeting (HLM) on the Implementation of the Declaration of Commitment on HIV/AIDS, with equality as the central theme. The latest draft of the Declaration calls specifically for ending stigma and discrimination against key populations. However, The Lancet understands that some member states are pushing to remove even the mention of MSM, sex workers, and PWID from the Declaration text. These manoeuvres are counter-productive and morally wrong. As was the case 40 years ago, civil society—representing key and other affected populations—has mobilised to fight back ahead of the HLM, calling for key populations to remain clearly specified in the UN Declaration. The Lancet stands with civil society’s request.

Ending HIV cannot be achieved without targeted programmes that are tailored to key populations. Urgent concerns such as the climate crisis and its effects on migration, food insecurity, water resources, and conflict might only serve to increase vulnerabilities to HIV. Yet, here we are again, as if no progress has been made. The HIV/AIDS pandemic cannot be brought under control without recognising and ensuring the human rights of all, most fundamentally the right to health. If it continues to be a struggle even to acknowledge who is at risk for infection, HIV/AIDS will remain a public health concern for another 40 years and many more lives will be lost.

Editorial