A little more than 40 years ago, clusters of a rare type of pneumonia (Pneumocystis carinii) and cancer (Kaposi’s sarcoma) were being reported in young gay men in New York and Los Angeles. It was almost two years later before Professor Françoise Barré-Sinoussi, Dr Luc Montagnier and their colleagues at the Pasteur Institute in France isolated a retrovirus and established it as the cause of the disease that became known as AIDS. It then took another ten more years before effective therapy became available for people living with HIV (PLHIV) in high-income countries and another four years before the world galvanised at the International AIDS Conference in Durban in 2000 to ensure that this life-saving treatment became available to those in low- and middle-income countries as well. In the four decades, more than 75 million individuals and 32 million deaths from HIV and AIDS have been reported globally.
Recent advances in antiretroviral (ARV) treatment have dramatically improved the outcome of patients living with HIV and have turned this once fatal disease into a chronic manageable condition. In PLHIV receiving and adhering to treatment, the lifespan resembles those without infection. Furthermore, in patients achieving viral suppression, the chances of transmitting the virus to their sexual partners or unborn child is close to zero. Undetectable equals untransmissible. This, coupled with other effective prevention tools such as prevention pills also known as PrEP (pre-exposure prophylaxis), and more traditional interventions such as condoms, clean needles and syringes as well as treatment of substance use, have made it possible for the global HIV community to aim for the end of AIDS by 2030.
Fast forward 40 years, since the first reported cases of a cluster of severe pneumonia in Wuhan in December 2019, more than 330 million cases of COVID-19 have been reported. Although the official number of deaths has been reported at 5.5 million, estimates have put the number of people who have died from the disease to be between 12.3 and 23.3 million. In contrast to the length of time it took to discover the causative agent of AIDS and for diagnostic tests and effective treatment to be developed for the disease, advances in medical science and global scientific collaboration saw a rapid response to the COVID-19 pandemic. Within days of the report of the cluster of pneumonia and the identification of the causative agent named SARS-CoV2, sharing of the genomic sequence of the virus by Chinese researchers enabled scientists around the world to design test kits that enabled diagnosis of the infection and the race to develop vaccines. To date ten vaccines have been approved for use by the World Health Organization and more than 9 billion people have been vaccinated around the world, giving hope that the pandemic can soon be brought under control.
Santiago Vazquez Prison, Uruguay
The COVID-19 pandemic has drastically shifted attention towards the longstanding issue of overcrowding and poor hygienic conditions in prisons. As of March 2021, it is estimated that more than 527,000 prisoners have been infected with the virus in 122 countries, with more than 3,800 fatalities in 47 countries. In Uruguay, prisoners are among the priority groups in the country's vaccination plan that was rolled out in March 2021. Photo: Matilde Campodonico / AP Photo
These two devastating pandemics have not only led to a large number of deaths and chronic complications but have also generated massive socio-economic upheavals all around the world. They involve two quite different biological agents and have different transmission patterns and clinical manifestations, yet also share some commonalities and raise common themes, questions and challenges. Central to both is the disproportionate impact the pandemics have had on the vulnerable and the marginalised. In the case of HIV, key populations who include men-who-have-sex-with-men (MSM), transgender people, people who use drugs, sex workers and prisoners are at elevated risk for acquiring HIV infection, in part due to discrimination and social exclusion. Although the SARS-CoV2 virus infects those exposed indiscriminately, exposure risk and the severity of its health, social and economic impacts are not being felt equally. COVID-19 and its containment measures have exacerbated these and created new vulnerabilities. Those
who are at greater risk from the virus include those who live in crowded conditions, work in service jobs that put them in close proximity to others, take public transportation to work, or lack access to protective gear at work. They are also more likely to lack access to health care and health insurance, and to have pre-existing health conditions that increase the risk for severe diseases and mortality. In Malaysia and the region, the population at higher risk includes the urban poor living in crowded multi-generational housing, migrant workers and refugees and prisoners. Both Malaysia and Singapore saw large clusters of infections arising from migrant workers living in crowded dormitories or less-than-ideal housing arrangements. Additionally, in Malaysia, more than 50,000 cases of COVID-19 were recorded amongst prisoners, prison staff and their families.
COVID-19 VACCINE RECIPIENTS BY CONTINENT
Only 1.7% of global vaccines have been administered in Africa despite the continent making up 17% of the world’s population.
Both pandemics have also highlighted inequalities that exist at the global level that have been and will be responsible for the deaths of many living in low and middle-income countries (LMIC). Although PLHIV in high-income countries almost immediately benefited from antiretroviral treatment when they were licensed in the mid-1990s, the majority of patients in LMIC countries, particularly in Sub-Saharan Africa, where more than 90% of all HIV infections were occurring, had little or no access to these life-saving medications. It was estimated that more than 330,000 lives were lost to HIV/AIDS from 2000 to 2005 in South Africa alone because a feasible and timely antiretroviral treatment programme was not implemented. Additionally, an estimated 35,000 babies were born with HIV during that same period in the country because a mother-to-child prevention programme was not implemented. Millions of people in LMICs who could have been saved were needlessly dying. Sadly we are witnessing the same pattern with the global COVID-19 vaccine roll-out. Whilst in high- and upper-middle-income countries 77% of the population has received at least one dose and many countries are well on the way to providing booster doses for their population, in low-income countries only 10% of the population has received at least one dose of a vaccine. Clearly we are repeating the same mistakes that we did with the HIV response two decades ago.
The mental health pandemic
In Gulu, Uganda, a community-based counselling group is helping people living with HIV by providing psychosocial therapy to better cope with and overcome mental health conditions. Adjusting to living with a chronic infectious disease can be difficult. People living with HIV face a greater risk of developing mental disorders, with depression and anxiety among the most common comorbidities they face. Source: World Health Organization AfricaPhoto: Dan Freeman / Unsplash
Science has delivered not one but multiple highly-effective COVID-19 vaccines in less than one year, and effective treatments for severe COVID-19 that has reduced the mortality to this disease globally. Four decades of the HIV response have also shown us the important role that science has played to change the trajectory of the pandemic. For both pandemics, science must continue to play an important role in guiding the response. Countries that have crafted national policies and programmes guided by science have generally seen a decline in HIV incidence and progress towards the goal of ending AIDS, for example the implementation of the harm reduction programme in Malaysia. The late 1990s saw a rapid escalation of infections amongst people who injected drugs in Malaysia. Despite early global evidence showing that distribution of clean needles and syringes and treatment of opiate addiction can reduce the incidence of new infections, for many years this evidence-based programme was not implemented given the punitive approach taken when it comes to drug use. Failure to achieve the Millennium Development Goal (MDG) to reverse the HIV epidemic during the mid-term review of the MDG finally saw the government agreeing to the implementation of the harm reduction programme. From a peak of 6,500 new infections annually, the number of new infections has dropped to 200 cases per year amongst people who inject drugs. Similarly with COVID-19, failure of the global scientific and political community to acknowledge the airborne transmission of SARS-CoV2 has led to delayed initiation of mask mandates and inadequate attention being paid to the importance of ventilation to this day. Countries that have allowed science to guide the policy response to the COVID-19 pandemic have by and large fared better in their outcomes.
Whilst both HIV and COVID-19 have highlighted health systems and societal shortcomings, the two pandemics have also highlighted a number of positive actions. These include the importance of community health workers and acceleration in innovations and implementation of digital health that, moving into the post-pandemic period, should continue to play a major role in health systems in high- and LMIC.
The massive scale-up of antiretroviral treatment in the last two decades in Sub-Saharan Africa and other low-income countries has been made possible by innovations to overcome chronic health workforce shortages including empowerment and mobilisation of community healthcare workers and task-shifting. For example, a Community HIV Epidemic Control (CHEC) model in Zambia, a country with very high HIV prevalence, utilises a peer-to-peer approach to conduct health education, provide targeted HIV testing services in the community, refer and link HIV-infected clients to treatment services as well as HIV-uninfected clients to preventative health services, and deliver antiretrovirals to eligible PLHIV in the community to ensure adherence and sustain viral suppression. To date, the CHEC model has provided health services to over one million Zambians, with over one million HIV tests conducted since 2015 in both the community and at the facility, and linked over 90% of the population to health services and receiving ARVs. Similarly, community health workers have played an important role in providing home-based care and helped relieve the substantial burden the COVID-19 pandemic has placed on healthcare systems worldwide. Community health workers also played an important role in the massive vaccination roll-out programmes across the world. Clearly lessons learnt from successful community engagement and empowerment will be important moving forward in the post-pandemic era to support healthcare systems around the world to deal with both communicable and non-communicable diseases.
Undoubtedly, the COVID-19 pandemic has heralded the era of digital health. Public health restrictions, in particular lockdowns, have necessitated the use of digital technology in all spheres of medicine, from education and awareness messaging to telemedicine and home monitoring. In many countries, public health responses were supported by digitally-aided public health surveillance and dashboards to track the pandemic. This investment in digital technology is here to stay and will undoubtedly contribute to improved health delivery services and outcomes.
The remarkable scientific achievements that have led to the discovery of multiple highly effective vaccines and treatment for severe and more recently early COVID-19 have been possible through global scientific collaboration, sharing of knowledge and data, public-private partnerships and investments from governments, investors and philanthropy. As we transition to a newer world and learn to live with COVID-19 as we have done with HIV, dengue and many other infectious diseases, let us hope that the lessons learnt from both these pandemics will be replicated and embraced as we continue our efforts to end AIDS, learn to live with COVID-19 and ensure that we are truly prepared for future pandemics. However, scientific advances alone will not ensure future pandemic preparedness nor effective response to other health challenges including climate change, the rise in non-communicable diseases, and health issues associated with an ageing population. In addition to adopting evidence-based programmes and be guided by science, policymakers and health systems must also pay attention to the social determinants of health and address inequities, social injustice and adopt a rights-based approach – a key principle in the HIV response – in all health interventions, for the benefit of individuals and society.
PROF ADEEBA KAMARULZAMAN
Prof Adeeba Kamarulzaman is Dean of the Faculty of Medicine, University of Malaya (UM), and Adjunct Associate Professor at Yale University. She established the Centre of Excellence for Research on AIDS (CERiA) that conducts multi-disciplinary research on HIV ranging from clinical to public health and policy research.
She is also Chairman of the Malaysian AIDS Foundation, President of the International AIDS Society, and a member of the WHO Science Council.
Notably, Prof Kamarulzaman was conferred the Tun Mahathir Science Award (2007) and the Merdeka Award (2008) for her crucial role as part of UM’s Nipah Investigative Team, and a Doctor of Laws (honoris causa) from her alma mater Monash University (2015).