Combination prevention manages to stop HIV in some countries; understand how – 07/20/2022

40 years ago, the first cases of HIV appeared. A lot has changed in relation to the epidemic that, even today, in 2022, is a challenge for the scientific community and governments around the planet. Some countries, however, have achieved good results in adopting combined prevention strategies to reduce the incidence of the disease.

A report by UNAIDS (Joint United Nations Program on HIV/AIDS) shows that the best results are in places with access to services such as HIV testing, PrEP (Pre-Exposure Prophylaxis), medication that prevents HIV, harm reduction, in addition to monitoring by health authorities.

As of June 30, 2021, 28.2 million people have accessed ART (Antiretroviral Therapy). In 2010, there were 7.8 million and, in 2020, 73% of those living with HIV (37.6 million) had access to treatment. It is estimated that the implementation of affordable and quality therapeutic resources has prevented 16.2 million AIDS-related deaths since 2001.

Fabio Mesquita, PhD in public health and epidemiologist, points out that the main obstacle to ending the epidemic is keeping investments in science, technology and public health as a priority.

“There are great examples of combat. We could cite some like Australia, Sweden and Norway. Some middle-income countries did very well, like Thailand and Brazil itself. Of course, for the rich countries the situation is easier. They weren’t afraid to adopt bold strategies such as harm reduction and were able to advance quickly in new technologies, especially PrEP”, says Mesquista.

positive examples

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Australia, for example, has adopted a population-wide distribution of HIV drugs and currently has only 633 cases. In Sweden, an estimated 90% of people living with HIV are diagnosed, 97% of them are on treatment and 95% of those on treatment have an undetectable viral load.

In Norway, 80% of those infected take medication and, in 2020, there was a decrease of 62% in the occurrence of HIV since 2010. Thailand is another positive case. If in 2010, 34% of those infected received antiretrovirals, currently, 79% have access, in addition to a 56% lower number of cases than in 2010.

In Brazil, there are 930,000 people living with HIV and 70% use ART, with a decrease in the number of deaths of 11% since 2010.

Global change helps reduce cases

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Fabio Mesquita, who has been a member of the WHO (World Health Organization) Technical Staff for 12 years, currently working in Myanmar, Southeast Asia, and former director of the then Department of STD/AIDS and Viral Hepatitis of the Ministry of Health ( 2013-2016), points to a radical change that took place in 2011 in the fight against AIDS globally and was essential for the decrease in cases.

“It was concluded that the treatment of HIV with antiretrovirals not only brought benefits to the people being medicated, but that there was a tremendous impact of prevention in the use of these drugs that we have known since 1989 and have been perfected over time. Science has advanced in the knowledge that people with viral load suppression no longer transmit HIV.”

The epidemiologist cites specific measures at that time that were effectively adopted in combined prevention strategies.

Vertical transmission: the introduction of antiretroviral drugs in the mother suppressed the viral load and the baby was born without the virus.

PEP (Post Exposure Prophylaxis): initially used for health professionals exposed to HIV and later introduced as a conduct for victims of sexual violence. Then it started to be used for anyone who had confirmed sexual exposure (either the condom broke or the person had sex without a condom).

“PEP became known as a kind of pill for the next 28 days and the person was protected from contracting the virus. From there it was a leap for science to develop PrEP putting those at high risk of contamination on antiretroviral medication to protect transmission”, mosque account.

These and other guidelines form combined and currently form the Combined Prevention Mandala with guidelines recommended by the WHO:

Treat all people living with HIV/AIDS;

  • Regular testing for HIV, which can be performed free of charge in the SUS (Unified Health System);
  • Post-Exposure Prophylaxis (PEP);
  • Pre-Exposure Prophylaxis (PrEP);
  • Prevention of vertical transmission;
  • Immunization for hepatitis A and B and HPV;
  • Harm reduction for users of alcohol and other drugs;
  • Diagnose and treat people with STIs (sexually transmitted infections) and viral hepatitis;
  • Use male and female condoms and lubricating gel.

Eradication in 2030?

Countries that have committed to the goals of the SDGs (Sustainable Development Goals) may be able to eradicate the epidemic by 2030, says Fábio Mesquita. The doctor refers to the UN (United Nations) pact of 2015, with several signatory countries, including Brazil.

With 17 global goals, number 3, which deals with health and well-being, aims to end the AIDS epidemic by 2030.

In the opinion of infectious disease specialist Pablo Eliack, from the HSJ (São José Hospital for Infectious Diseases) in Fortaleza, there are numerous obstacles to achieving the UN proposals: “We have educational, behavioral and financial problems. Each nation has a reality in relation to HIV, which impacts on the spread or decrease of the virus”.

Evaldo Stanislau, an infectious disease specialist at the HC (Hospital das Clínicas) at FMUSP (Faculty of Medicine at the University of São Paulo), points out that, although these are fundamental measures, there is an urgent need for changes: “An epidemic of this magnitude depends a lot on people. , we observed erratic behaviors, such as not using condoms and even a high dropout rate from PreP”.

Infectologist Vinicius Borges, known on Instagram as Doutor Maravilha, says that PreP, in addition to preventing HIV, is the gateway to carrying out other combined prevention actions, such as constant testing, vaccines and a whole line of care.

A pandemic in the middle of the epidemic

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According to Fábio Mesquita, new challenges appear daily when talking about HIV and it is complex to ensure that the richest countries maintain their priority contribution to actions.

“The most recent example is covid-19, an unusual event – there has been nothing like it since the Spanish flu – and which took the scientific and financial agenda for the global threat it caused”, says the epidemiologist.

As Evaldo Stanislau remembers, the covid caused what is called all hands on deck (literal translation of everyone with their hands on the deck), but which is an expression used in situations that require everyone’s commitment. “The teams were all destined for covid and many people stopped taking medicine correctly. HIV suffered side effects due to lack of manpower, since teams were assigned to take care of the pandemic, due to difficult access and lower adherence”, he explains. .

Mesquita cites other problems, such as the distribution of antiretroviral drugs, which were previously distributed monthly, are now distributed every 3 months or 6 months depending on the countries and global stocks: “One of the biggest impacts (besides the prevention) was the quality of clinical follow-up, since machines that detect viral load have become more used for covid-19”.

Brazil can go further

Even so, this strategy is what has saved lives, guarantees Eliack, who cites as examples Brazil and the SUS, which provides the medications (which are expensive) and finances the tests: “Of course we have a very big educational problem. there are very backward nations that use outdated strategies, such as some places on the African continent”.

For Stanislau, Brazil needs to think about new tactics to fight HIV: “There are vulnerable populations discovered in which we observe rates remain high, as in the case of men who have sex with young men, women and elderly people”.

The eternal hope of healing

From July 27 to August 2, the 24th International AIDS Conference of 2022 takes place, organized by International AIDS Society (IAS) in Montreal, Canada.

The cure for AIDS, obviously, is one of the highlights. Fabio Mesquita recalls that research is being carried out all over the world looking for ways to catch the virus that hides in the immune system of people living with HIV, remove it from hiding and exterminate it: “One of the promising studies is being carried out in São Paulo, but there is still a lot to be done”, he says.