Southern Africa's solutions to the HIV epidemic

The southern region of Africa, the epicentre of the epidemic, faces unique problems - including a very high caseload amongst adolescents and young women. So, what are the solutions? We put in a call to Boghuma Titanji - a Cameroonian-born doctor and infectious disease specialist at Emory University - to tell us what we do and don’t have in our arsenal when it comes to fighting the spread of HIV…

Boghuma - One of the biggest barriers remains the fact that we don't actually have a vaccine that effectively prevents HIV acquisition. So what we really have at our disposal remains, getting as many people who are living with HIV on antiretroviral therapy, but also being able to provide Pre-Exposure Prophylaxis modalities to individuals who are at higher risk for acquiring HIV, and we are not hitting the targets where these are concerned.

Chris - What sort of levels are we getting to?

Boghuma - Most countries in Africa are approaching the 80% treatment coverage targets for adults, but it's important to note that when it comes to paediatric HIV, that number and those targets are unfortunately not being met with only about 50% of children living with HIV in Africa currently being on antiretroviral therapy. Where pre-exposure prophylaxis is concerned, the numbers there are a little bit more dire in terms of the regions hitting their targets and actually getting pre-exposure prophylaxis readily available to populations that are most likely to benefit. In Eastern and Southern Africa, these targets are on track to meet the goals that were set to be achieved by 2025, but in Western and Central Africa we still have significantly low levels of PrEP coverage. The target for PrEP coverage set for 2025 was the hope to get 21.5 million people on PrEP, but currently there are only about 3.5 million people who are receiving pre-exposure prophylaxis for HIV.

Chris - What's the barrier to getting to the number we want, why are we at the number we currently are?

Boghuma - I would think that one of the biggest barriers is really there's still a lot of stigma and discrimination that is associated with having HIV or being, someone who is in a group that may be at higher risk for acquiring HIV. Additionally, there have been issues around funding for pre-exposure prophylaxis with some countries not necessarily having the requisite resources to actually make these prophylactic treatments available on a broad scale. In terms of meeting the targets for treatment, the biggest barriers remain testing people and actually having people know their HIV status.

Chris - What do you think we can do about this? Where do you think the solution lies? Because you've outlined what the frustrations are but it's not obvious what we do then to solve that.

Boghuma - One of the key developments that gives me a lot of hope is the advent of long-acting PrEP modalities, which bring with them a layer of flexibility in terms of options and choice for people who are likely to benefit from pre-exposure prophylaxis. Now having this degree of flexibility and choice means that you are removing barriers, either people having to go to a healthcare facility to be able to pick up medication or just being able to use pre-exposure prophylaxis in a manner that is more discreet than having to take a pill a day.

Chris - Is this a short-term sticking plaster or is this part of a longer term strategy to try to bear down on transmission and ultimately stop it or is it both? Because one could see that if we could drive the number of people who are actively acutely infected right down, we actually really do slow down the transmission of the disease because people are most infectious with HIV when they're first infected.

Boghuma - That is absolutely correct. I think that it is both, but I would caveat that with the fact that we've now had pre-exposure prophylaxis for 12 years in the form of a once daily pill and still we are seeing approximately 120,000 new infections of HIV in Western and Central Africa per year. Now, although the modalities that I have described hold the potential of reducing the transmissions, they would only be able to have maximum impact if we are actually able to get them to the people that need them. Additionally, to your point about people with low viral loads or undetectable viral loads not being able to pass on the virus, that's why it's important that even if we're focusing on pre-exposure prophylaxis to prevent acquisition of HIV, we must also ensure that we are effectively treating the people who have HIV, to make sure that their viral loads are undetectable so that they also cannot transmit.

Chris - Is there a risk when we give wide scale use of drugs in the same way that with antibiotics, the more we use antibiotics, the more antibiotic resistance that we're going to see. If we are not careful with how we deploy drugs at this problem, there is a chance we could accelerate the rate of antiretroviral drug resistance and therefore we could pull the rug from under the use of those agents, not just in the African countries where they're being deployed, but potentially all over the world if those resistant forms spread.

Boghuma - That is absolutely correct and we have already seen reported in the clinical trials for some of the long-acting preventative modalities that exist, reports of individuals who have acquired drug resistance to these medications when they acquired an HIV infection while using them reassuringly, the rates of this occurrence have been low and I think that with having long-acting, pre-exposure prophylaxis, the one thing that we get is we know that the individual is taking the drug, because unlike the pills where you are really relying on an individual being able to take one pill every day, oftentimes in unsupervised settings, and you're trusting them to adhere to the therapy to maximise its effectiveness.

Chris - Are you optimistic in terms of where we are at the moment with the interventions we do have and the challenges that you have outlined that we need to surmount but are surmountable? Do you think we're going to get there?

Boghuma - I am cautiously optimistic. I think that we have the tools to effectively stop HIV transmission, but whether we have the will is something that remains to be seen and I think that a huge part of that will is being able to bridge the funding gap that would allow us to actually implement these tools and strategies and get them to where they are able to have maximal impact.