HIV in the Modern Era: Growing Old Together

As I walked down the halls of the 22nd International AIDS Conference in Amsterdam (AIDS 2018) in July, I could have never imagined that I would be entering my third decade of working in HIV. This conference, of all conferences, reminded me of how long, tiring, daunting, and at times triumphant and joyful these past three decades have been since HIV was first discovered in 1983 and potent combination antiretroviral therapy was introduced in 1996.¹

I listened to Tony Fauci, National Institute of Allergy and Infectious Disease director, our public health rock star of sorts, who is slightly graying and yet stronger than ever in translating the most technical terminology explaining sustained ART-free HIV remission. He described the use of broadly neutralizing HIV antibodies and the use of intermittent and continual non-ART interventions. He also discussed stimulating the immune system to independently exert long-lasting control over HIV.

His passing age is a marker in how far we have come. As was so eloquently described by one of the speakers in the What Types of Activism are Needed 30 Years into the AIDS Response? panel, co-chaired by ACT UP activists Eric Sawyer and Robin Gorna, “None of us could have imagined that there would be one pill to take daily in the late 1990s when the first ART drug was established in the mid-1990s.” It is thanks to doctors like Tony Fauci and Kenneth Mayer, the Fenway Institute/Harvard/Beth Israel Deaconess Medical Center—who presented on emerging issues regarding the global HIV and STI response at the PEPFAR preconference—that so many persons living with HIV (PLHIV) had access to ARVs and doctors who believe in the human rights of all of their clients.

When I started working in HIV in the late 80s, there was no PEPFAR, only mono-therapy, and stigma and denial left so many to spend their last days alone with little contact from their birth families. I was barely out of college. A little more than three decades later, we are discussing vaccine developments. I have a child entering college and yet, unfortunately, inequality still exists for PLHIV and discrimination laws against LGBTQI are ever present. Global AIDS Coordinator Ambassador Deborah Birx and so many others reminded us that policies and political will at the in-country level remain critically important.

We’ve come a long way

Many leaders who have contributed to the movement for decades were also present. Peter Piot, London School of Hygiene and Tropical Medicine, inspired the conference with a rousing plenary speech on Global Health and the HIV Response. He outlined the past 26 years since the last conference had been in Amsterdam in 1992 when there was no ART and when Jonathon Mann envisioned HIV as a human rights issue.

Piot reminded us that we are not on track to end the epidemic (in Eastern Europe and Central Asia—new infections were up by 29 percent, 2010-2017). And that we must continue to devote resources to low-income countries since even with lowering costs of ARTs and cost efficiencies, there are other costs, such as comorbidities that cause countries, such as Zambia, to devote approximately 3 percent of their gross domestic product each year to HIV-related costs.

Other researchers, such as Connie Celum, University of Washington, discussed how the epidemic is disproportionately affecting adolescent girls between ages 14 to 24 in southern Africa. She outlined the results of the HPTN082 trial and oral pre-exposure prophylaxis use with adolescent girls during the Prevention Solutions for the Next Generation: Highlighting Adolescent Research in the NIH HIV/AIDS Clinical Trials Networks and the Adolescent Trials Network panel. Sandy Thurman, chief strategy officer at the Office of Global AIDS Coordinator (OGAC), who we know continues to be the gentle guiding voice of OGAC and the voice of civil society, was holding court in the hallways with activists and ministers of health alike.

But there is still much to learn, and much to accomplish

Running into David Bryden, tuberculosis (TB) advocacy officer at RESULTS and the coordinator for US advocacy and co-chair for the TB Roundtable—who was one of the organizers of the TB 2018, An Official Preconference—I was reminded of how even though we may age, our sense of urgency may not wane. He was as passionate as ever in terms of the intersection between HIV and TB. With good reason, since we now know that TB is the leading cause of death among PLHIV.

David Malbranche, associate professor of medicine at Morehouse School of Medicine in Atlanta, Georgia, bravely told a plenary audience that he was old enough to have been an HIV prevention specialist and to have contracted HIV halfway through his career in HIV. As he schooled us on the different ways that we must adapt our everyday language as health care professionals, such as not labeling people “hard to reach,” I was again reminded that 30 years into the epidemic, I have much to learn even in the basics.

I hope that I, and that we all, may continue to learn and grow older with this amazing group of men and women who have dedicated their lives to this epidemic. I remarked to my old colleague, Jen Kates, Kaiser Family Foundation vice president and director, “I feel like we are all growing old together,” and she quipped back, “Well, we are not such a bad group to grow old with.”

^{1 Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. Aug 11, 2011;365(6):493-505.}