Antiretroviral therapy (ART) has dramatically modified the natural history of HIV disease. At the individual level it has transformed an otherwise fatal disease into a chronic manageable condition.1–3 At the community level there is now a compelling evidence that ART virtually eliminates HIV transmission.4–9 Further, early initiation of ART not only prevents morbidity, mortality and new infections, but it is also cost-saving.10–13 This has led to calls to scale-up access to HIV care and treatment worldwide as an effective means to curb and eventually control the growth of the AIDS pandemic, commonly referred to as “Treatment as Prevention” (TasP).14–16
As of December 2013, more than 12 million individuals worldwide were receiving ART, demonstrating that we are on track to meet the 2015 MDG goal of providing access to ART to 15 million individuals by 2015.15 Despite these extraordinary achievements, challenges remain, as late HIV diagnosis, poor linkage to and retention in care, as well as incomplete long-term adherence to ART remain relatively frequent. Of particular concern is the fact that many at-risk and marginalized populations continue to face multiple barriers to HIV diagnosis and care. Sadly, such barriers stand to undermine national and global HIV responses, as it will not be possible to end the AIDS pandemic without universal facilitated access to high quality HIV services.
Migrants are one of such highly vulnerable populations, particularly those who are undocumented or uninsured. In 2012, a report from GESIDA warned about the potential unintended negative consequences associated with the implementation of the Royal Decree (RD) 16/2012 on the health of immigrants living with HIV in Spain.17 The report projected that limiting access to health care to immigrants would likely lead to increased morbidity and mortality among this population. However, given what we now know about the impact of ART on transmission dynamics, it is obvious that not only immigrants living with HIV would be affected by this restrictive policy. Indeed, a lack of access to ART and other preventive services could fuel HIV transmission in a broader sense, as new HIV infections would spread beyond immigrants, and could include for instance newly infected newborn Spanish nationals, and the sexual contacts of said immigrants. In the same report, GESIDA investigators estimated that these cuts in public health expenditure would not only have devastating consequences in Spain public health, but would also lead to greater health expenditures in the medium-long term.
In a new follow-up study,18 GESIDA investigators show that only two years after the implementation of the Royal Decree (RD) 16/2012, there are already emerging signs of worsening health outcomes among immigrants living with HIV. According to this analysis, one out of three health providers reported difficulties in providing care to illegal immigrants living with HIV, and one out of six had to interrupt ART provision to their patients due to financial or administrative barriers. This is highly concerning; and failure to abandon this course might have serious public health consequences in Spain. The example of Greece should serve as a reminder of how extreme austerity measures could dramatically damage the health of a population, as demonstrated by the rise in new HIV infections among people who inject drugs from less than 10 in 2008 to almost 500 in 2012, following cuts in prevention and treatment programmes.19
On the contrary, the evidence from our HIV treatment programme in British Columbia, Canada, demonstrates the long-term effectiveness and sustainability of aggressively expanding access to HIV treatment and care.20 Between 1996 and 2012, with the support of the provincial government, ART coverage in British Columbia increased from 11% to 57%. During the same period, AIDS incidence rates and HIV-related mortality decreased by greater than 80%. Further, mother-to-child HIV transmission was virtually eliminated and overall new HIV infections decreased by more than 60%. Similar population-level benefits of TasP have been now documented in different settings, from Vancouver,6,8 to Taiwan,21 to Kwazulu-Natal in South Africa.7 Importantly, mathematical models consistently predict that expanding access to ART generates both individual and public health benefits, and economic savings.10–13
The world is moving towards universal access to HIV treatment and care. With the 2015 goals within the reach, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has released a new proposed target for 2020.15 The ambitious new target calls for 90% of people living with HIV worldwide to be diagnosed, 90% of people diagnosed with HIV to be on ART, and 90% of people receiving ART to have sustained viral suppression – all by 2020. Meeting the proposed target would ensure that by 2020, at least 73% of all people living with HIV worldwide will be virally suppressed, a nearly three-fold increase over current rough estimates of global viral suppression. This new target seeks to maximize the effectiveness of existing tools in order to virtually eliminate (i.e., ≥90% decrease below 2010 levels) progression to AIDS, premature death and HIV transmission by 2020; and thereby transform the HIV/AIDS pandemic into a low level sporadic endemic by 2030. The “90-90-90” target has already been formally endorsed by several countries, including the US, Brazil, South Africa, Argentina, Panama and Switzerland among others. The challenge remains to secure the necessary political will to meet the “90-90-90” global target by 2020 as the cornerstone of the global control of HIV transmission and AIDS. An AIDS- and HIV-free generation is possible; however, this will not be attained if we fail to fully capitalize on the promise of “Treatment as Prevention”.
HIV/AIDS is a winnable fight. We will not win this fight, though, unless all populations, including the most disadvantaged ones, have full and equitable access to HIV care and preventive services. Saving money by restricting access to HIV-related services to anyone is simply a bad public health and economic policy. The ultimate goal of ending the AIDS epidemic is within reach. The world cannot afford to miss this historic opportunity.
