The Art of HIV Elimination: Past and Present Science

Abstract

Introduction As the HIV epidemic approaches its fourth decade, effective prevention remains elusive in the communities most affected by the virus. An estimated 36.9 million people were living with HIV globally by end 2014 [1] of whom 70% in sub-Saharan Africa. In 2014, an estimated 1.4 million people acquired HIV infection; 66% of these new infections and 66% of all HIV-related deaths occurred in sub-Saharan Africa, a region disproportionately affected by the epidemic. Remarkable strides have been made recently towards combating the epidemic and increasing antiretroviral therapy (ART) coverage with considerable reduction in mortality and morbidity [2], such that in 2014, 40% of all people living with HIV were receiving ART. Following the results of the START [3] and TEMPRANO [4] trials, the World Health Organisation (WHO) now recommends ART regardless of CD4 count [5], a policy that would maximise both the individual and population health benefit of ART. This aligns with the recent UNAIDS target of 90:90:90 (90% of people living with HIV aware of their HIV status, 90% of people diagnosed HIV-positive on ART, 90% of people on ART virologically suppressed) in 2020 [6], but will require huge financial investments and commitments from governments to bear fruit. It is now well-recognised that prevention approaches need to be combined to accelerate the effective prevention of HIV acquisition and transmissions [7]; HIV programme planning have now moved from the implementation of single preventive methods to combination context-specific prevention approaches, for which evidence of effectiveness exists. This paper reviews currently available HIV prevention methods, highlighting the strengths and weaknesses of past prevention approaches, draws attention to the present array of prevention armamentarium available and conceptualises how these could be combined towards the goal of HIV elimination. Abstract Introduction: Remarkable strides have been made in controlling the HIV epidemic, although not enough to achieve epidemic control. More recently, interest in biomedical HIV control approaches has increased, but substantial challenges with the HIV cascade of care hinder successful implementation. We summarise all available HIV prevention methods and make recommendations on how to address current challenges.