It is often said that the HIV pandemic and its evolution during the 80s and 90s is a powerful tool of collective memory in the field of health from which to learn for other epidemics. The fear of the initially unknown, the stigmatization and discrimination of entire population groups, the inequalities in access to therapeutic and diagnostic innovations, the clashes between patent rights and patients’ rights or the constant protagonism of organizations Social policies and community leadership are examples that can be extrapolated to other epidemics that we have to face.
However, it is often forgotten that the HIV pandemic is an element of memory and learning in itself, and this is something we are seeing today. The arrival of long-acting antiretrovirals and studies that seem to show a very significant reduction in transmission when used preventively to avoid it, suggest that for the first time in two decades we are facing a new advance that can completely change the rules. of the game, at a time when achieving the goal of reducing new cases of HIV by 90% seems increasingly complicated.
The arrival of antiretrovirals in the 90s represented a monumental advance in making HIV infection chronic. Furthermore, the suppression of the viral load slowed the transmission capacity (undetectable = untransmittable). We are now faced with the possibility of drastically reducing new infections thanks to the appearance of long-acting pre-exposure prophylaxis that, with a few injections throughout the year (6 with cabotegravir and 2 with lenacapavir) has the ability to practically completely eliminate the possibility of contracting the infection.
Lenacapavir, the drug whose results were presented at the International AIDS Conference in Munich a few months ago and which has changed the global board of expectations regarding HIV, has been named this year as the scientific breakthrough of the year by Science magazine. However, although science has done its part, there is still a long way to go before this advance can materialize in a change in people’s lives and in the global panorama of the infection.
In 1996, at the International AIDS Conference held in Vancouver, data on highly active antiretroviral therapy (HAART) were presented. These were data that showed the effectiveness of a treatment that could change the lives of millions of people. However, it was not until 9 years later, 2005, when this therapy reached the first million people in low- and middle-income countries. These inequality gaps, which represent a delay of a decade in the adoption of innovations in low- and middle-income countries, have been a constant throughout the history of HIV, as recently shown in an article published in the journal New England Journal of Medicine.
The question now is, given the arrival of an innovation that could completely change the evolution of the HIV pandemic in the world and even make real the aspirations of ending it as a global public health concern, what can we do to that what happened with antiretrovirals does not happen again? How can we ensure that an innovation that is going to change everything does not end up being just a reproducer of inequality with no real impact on the evolution of the pandemic at a global level for several years and many millions of new infected people?
The answer to this lies in the realm of politics. The company that owns the patent for lenacapavir (Gilead) has announced the issuance of voluntary licenses with marketing agreements that would cover a total of 120 countries. Beyond the conditions of these licenses, the problem lies in which countries are left out. In an analysis published by Salud Por Derechowe can see how many middle-income countries, especially in South America, where the number of new cases of HIV is considerable and, furthermore, where the epidemiological dynamic is far from descending, would be left out of this agreement, making it very difficult that could guarantee accessibility to lenacapavir effectively.
The challenge before us is, once HIV infection has become chronic and viral suppression of a very high percentage of the population has been achieved, to continue advancing along this path while putting an insurmountable barrier to new cases. We are not talking about marginal survival gains or small improvements in dosing or adherence. We are talking about the greatest milestone since the proof of the effectiveness of HAART; the greatest milestone in the fight against HIV in this century and that may make us think about turning the page in terms of the global importance of HIV.
To achieve this, the response cannot be oriented only to low-income countries and focused on Africa. Access must be addressed as a condition of necessity for the value of innovation, and from a framework of universality. The only way for countries like Peru, Argentina or Brazil not to be left out is to understand that Central America and South America are one of the hot spots for the HIV epidemic dynamics in the last decade and, furthermore, they are also one of the hot spots for its possible political response. Strengthening the initiatives that their governments can carry out in the field of local-regional production of generics and the implementation of universal access programs, as Brazil did more than two decades ago, is a responsibility for the so-called global North.
In 10 years we will ask ourselves what we were doing in 2024 when the possibility of ending HIV as a global health concern was put before us: were we guaranteeing access to lenacapavir or dolutegravir for all low- and middle-income countries? Were we proposing mechanisms to decouple the R&D and commercialization process to guarantee global access? Were we promoting a global alliance that would reject financing in high-income countries until the company that owned the innovation reached an access agreement in low- and middle-income countries? Without a doubt, the only thing we should not be doing is as if nothing were happening, as if we were talking about a treatment other than getting into the wheel where access gaps are generated, as if we did not know what things to do to avoid it.
The time is now, furthermore, because there is a group of countries with the capacity to propose politically brave and effective alternatives, such as Brazil, South Africa or Colombia. Guaranteeing that this window of political opportunity becomes an epidemiological reality is the responsibility of all countries, not just those that fear that the inequality gap will affect their inhabitants.
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