AIDS-related deaths have declined worldwide except in Eastern Europe and Central Asia region. The latest data from joint United Nations programme on HIV/AIDS (UNAIDS) released last month shows that as compared to 2010, AIDS-related deaths have declined globally by more than half (51%) by 2023 but increased by 34.4% in Eastern Europe and Central Asia region.

The steepest decline in AIDS-related deaths during the period 2010-2023 among all the regions globally was in Eastern and Southern Africa (59%), followed closely by the Caribbean (57%) and Western and Central Africa (55%). This drop in AIDS-related deaths was 51% in Asia and the Pacific, 34% in Western and Central Europe and North America, 28% in Latin America and a mere 6% in Middle East and North Africa.

AIDS-related deaths are declining in all but one region – Eastern Europe and Central Asian region. This is a proxy for successful dissemination of lifesaving antiretroviral treatments across affected communities.

Not just AIDS-related deaths, even the number of new HIV infections has risen by 20% in Eastern Europe and Central Asia which is home to 2.1 million people living with HIV (5% of global population of people with HIV). There were 140,000 newly infected people with HIV in 2023 in Eastern Europe and Central Asia (out of 1.3 million people who got newly infected in 2023 worldwide). HIV adult prevalence in the region has increased from 0.5% in 2010 to 1.2% by 2023.

The number of new HIV infections in 2023 has increased in the Middle East and North Africa and Latin America regions also. However, in the rest of the regions the number of new HIV infections have shown a decline.

"In Asia and the Pacific region, there was a 14% decline in new HIV infections in 2022 but in 2023 it was 13%. So, the decline is stagnating. That is the challenge," said Eamonn Murphy, Director of UNAIDS Regional office of Eastern Europe and Central Asia and of Asia and the Pacific.

"What is going wrong in access and adherence (to the full cascade of HIV prevention, testing, treatment and care services)?" rightly asks Eamonn in regions where HIV rates and/or death rates have shot up.

The scientific evidence-backed WHO recommendations call for ensuring that everyone knows their HIV status, all those who are living with HIV should receive lifesaving antiretroviral therapy and remain virally suppressed (undetectable viral load). If viral load of people with HIV is undetectable then there is a zero risk of any further HIV transmission (that is where treatment works as prevention too!). This is commonly referred to as Undetectable Equals Untransmittable or #UequalsU.

All governments globally have promised to end AIDS by 2030 – which implies that #UequalsU should be a reality in the lives of all people living with HIV – and all others need to have access to full range of HIV combination prevention options in arights based and dignified manner.

"At the 25th International AIDS Conference (AIDS 2024), one of the major issues we talked about constantly is U=U (Undetectable Equals Untransmittable), where science is clear that if people are able to access effective treatment and remain on it, they achieve viral suppression. WHO has confirmed there will be zero sexual transmission. They can lead normal life like anyone else. That is a very powerful tool for both: why we need to get people into testing early, take themselves into treatment services and be supported to stay there. It is also a way to show the community that HIV is not what it was thought to be 30 years ago. It is not a death sentence,” said Eamonn.

Deadly gap between what we know-works and what-we-do

“Wherever we have seen strong investments by the governments working in partnership with the community and science, we have seen success. In Asia Pacific, there are many countries going the right way. But political leadership and commitment has either reduced or plateaued. That is the big challenge,” said Eamonn Murphy of UNAIDS.

Prevention and treatment services will only reach people if human rights are upheld, and unfair laws against women and against marginalised communities are scrapped, and discrimination and violence are tackled. Equitable access to medicines and innovations, including long-acting technologies is critical.

He added: “In Eastern Europe and Central Asia, we do not have enough commitment from governments to provide the right level of testing, treatment and prevention services. We also have a few laws in both these regions that are holding us back as they are actively used in some of the countries of these regions to stop people from coming for testing or treatment. Such laws criminalise the potential risk or the transmission of HIV. In Asia and the Pacific region, we have such laws in some countries as well. But there is a whole range of criminalisation of people by way of who they are, their work or their behaviours. This must stop."

A legal environment that facilitates access to effective, equitable and people-centred HIV services is essential for ending the pandemic.

As per the latest UNAIDS report, in 2024, only 4 countries (Venezuela, Colombia, Netherlands, Uruguay) did not have laws criminalising any of the 4 key populations of HIV. Key Populations refer to sex workers, gay men and other men who have sex with men, transgender people, people who inject drugs, among others. Key populations are not only at heightened risk of HIV but also have demonstrated that they are critically important to reach the unreached with full cascade of HIV services.

AIDS response is at the crossroads: Would governments take the right path?

"As we have these challenges and some countries taking the wrong path, we do have countries that are taking the right path. In Asia and the Pacific region, there are countries that are treating more than 80% of people living with HIV- such as Cambodia, Nepal, New Zealand, and Thailand. In Nepal, they have reduced new infections by more than 75% and could easily reach the 90% target (currently the drop in new HIV infections in Nepal is 79% by 2023 as compared to 2010)," said Eamonn.

“Other countries are not investing in the right programmes at the right time for the right people, or else they have legal barriers and legislative frameworks that are keeping people away from the services. In the Philippines new infections have risen significantly by over 500% during 2010- 2023. The Philippines also shows a very high AIDS-related death rate. And yet the government is trying hard. They are doing a catch up now but did not maintain the programmes earlier,” he added.

Rays of hope too in Eastern Europe and Central Asia

“There are some good examples of HIV response from Eastern Europe and Central Asia too. Armenia is doing well as it is investing and paying for 97% of the treatment for people living with HIV. But at the same time, we also have countries enacting laws that are making people afraid to go near a health service. So, if they have got HIV, they are going to be extremely unwell (because they may not seek timely care) and at risk of transmitting it to others, because they are afraid of the new laws,” said Eamonn– who has devotedly worked in health sector for over 30 years now.

Access to full cascade of HIV prevention, testing and treatment services is critically important

At AIDS 2024, a new HIV prevention medicine – Lenacapavir - when taken as Pre-Exposure Prophylaxis (PrEP) was also in the news. Studies have shown that there was 100% protection from HIV acquisition when it was used by young girls and women. But the price we heard at this conference was over US$ 40,000 per person per year (this medicine is to be taken as an injection every six months).

Eamonn Murphy calls for investment in new health technologies, such as the long-acting injectables both for HIV treatment and prevention – and ensuring that they are accessible to all. “They are significant game-changers. But currently the price is way too high. But we have also seen the modelling and science that Lenacapavir can be produced for as low as US$ 40 per person per year. Think of the savings governments can make if they invest in that type of technology. Resources can be saved and redirected to other health issues.”

More focus on the young people

Eamonn calls for increased political commitment to end AIDS with renewed or re-energised commitment in most of the countries in Asia Pacific, Eastern Europe and Central Asia.

“In addition, we also need a right programmatic mix (not the old-fashioned programmes). 47% of the new HIV infections in many countries- such as Thailand, Indonesia, Laos, Cambodia, and Myanmar - are in young people (aged under 24 years). This means we must have programmes targeted for the young people as well. It means governments investing more resources in new and more effective ways of combating HIV,” rightly says Eamonn. It also means engaging young people at every level of HIV programming aimed to reach them with full cascade of HIV services.

Eamonn highlights other barriers in accelerating HIV response. When science has proven a tool to work then why is there a need for yet another in-country pilot? Such steps delay translating scientific gains into public health outcomes. Likewise, mandatory confirmatory test requirement after self-testing, community-based testing or rapid testing, comes with the risk of people dropping off the care cascade. “A person does not want to wait for a month to get results. We really need to reform the system.”

Leaders and policy makers urgently need to act to provide access to treatment and prevention services to reduce AIDS related deaths and onward transmission of HIV.

“Asia Pacific was at the forefront of the HIV response at the beginning. It has been well overtaken by other regions in the world. Eastern Europe and Central Asia has a big catch-up to do too. These countries need to change and shift their approaches to get their programmes on the right path. Right now, we are at the crossroads, and we are going in the wrong direction in many countries. We can end AIDS as a public health threat by 2030. We have countries like Botswana that can achieve that - we are not talking of countries with a lot of resources. It means having political leadership, the right programmes with the resourcing put behind it by the governments for the people. Everyone has the right to health and full enjoyment of their lives and contribute to society. We can do it,” says Eamonn.