The HIV/ AIDS pandemic exposed global health inequalities and inspired transformative strategies that continue to shape healthcare access today
The HIV/ AIDS epidemic emerged in the early 1980s, characterized by immune system failure of unknown causes. By the mid-1990s, the disease had become a global crisis. At its peak, HIV/ AIDS was responsible for millions of deaths annually, with sub-Saharan Africa being among the hardest hit regions.
The introduction of anti-retroviral therapy (ART) in 1996 radically improved the prognosis of people living with HIV. Without treatment, patients with HIV tend to die within 10 years, but on ART they can have a normal life expectancy. However, its high cost — upwards of $10,000 per patient per year — meant it was out of reach for most patients in low- and middle-income countries (LMICs).
The pandemic has exposed inequities in healthcare access and profound stigma which hindered testing and care, although AIDS-related deaths have dropped by 69% since its peak in 2004, and by December 2023, approximately 30.7 million people were accessing ART, up from 7.7 million in 2010.
Lesson 1: The importance of partnerships and multilateral action
The HIV/ AIDS pandemic highlighted the necessity for stakeholders such as governments and pharmaceutical companies to collaborate on a global scale to tackle the multifaceted challenges posed by the disease.
Research has shown that international coordination in responding to outbreaks brings greater overall benefits compared to when each country independently pursues its own interests.
In 1996, 15 years since the first case of AIDS was identified, the World Health Organization (WHO) identified the need for a joint program to expedite global response to the disease, resulting in the formation of the Joint United Nations Program on HIV/ AIDS (UNAIDS). UNAIDS is constituted of six United Nations (UN) system co-sponsors, reflecting the multisectoral response required for the crisis. Previously, as HIV/ AIDs was not well recognized or understood, there were no guidelines for diagnosing and managing the disease, and doctors often treated patients independently.
According to Dr Joseph Saba, Chief Executive Officer (CEO) of Axios International, who was previously a part of UNAIDS’s Prevention of Mother-to-Child Transmission of HIV/ AIDS (PMTCT) group, “The geopolitics scene in the mid-90s involved much cross-sector and cross-country collaboration, eventually resulting in the advent of UNAIDS. UNAIDS became a key driver and player as a result of the substantial political will driving the unified global response to HIV/ AIDS. Till this day, it is still the only co-sponsored joint program within the UN.”
Following that, organizations such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) and the US-led President's Emergency Plan for AIDS Relief (PEPFAR) were established in 2002 and 2003 respectively. These initiatives provided financial support to countries which had been heavily impacted by the HIV/ AIDS pandemic and mobilized resources in unprecedented ways, enabling the scaling up of treatment in settings where resources were limited.
PEPFAR, for instance, has provided over US$110 billion in funding, and as of 2023, has provided ART to over 26 million people. One of the keys to its success lies in integrating ART distribution with local healthcare infrastructure, training over 300,000 healthcare workers and establishing treatment centers across sub-Saharan Africa. Similarly, the Global Fund operates on a multilateral funding model, gathering resources from governments, private donors, and foundations to support healthcare programs in more than 100 countries.
Lesson 2: Differential pricing and generic medications
While the introduction of ART revolutionized HIV treatment, the majority of patients in LMICs could not afford treatment until a shift in policies determining the prices of drugs and drug patents.
Differential pricing, also known as ‘equity pricing’ or ‘preferential pricing’ was introduced during the HIV/ AIDS pandemic; it is a concept where drugs are priced according to each country’s ability pay. Differential pricing enables companies that make patented drugs to recover most of the costs of research and development (R&D) from wealthier markets, while selling or licensing production of drugs in LMICs at lower prices.
In May 2000, the Accelerated Access Initiative (AAI), a collaboration supported by many international agencies and pharmaceutical manufacturers, was launched. Dr Saba explains, “Pharmaceutical companies faced extreme pressure over the high pricing of the ART. With the AAI, pharmaceutical companies together with United Nations partners, i.e., UNAIDS, WHO, World Bank, UNICEF and the United Nations Population Fund, worked together to bring down the cost of drugs to only 10% of the commercial price for patients in sub-Saharan Africa. This was a major milestone for the pharmaceutical industry as differential pricing was uncommon then.”
The next turning point came in 2001 when Cipla, an Indian pharmaceutical company, announced it would produce generic ART for just $350 per patient annually, a dramatic reduction from the original $10,000 price tag. This catalyzed global efforts to increase the availability of generic drugs, aided by concessions in the World Trade Organization’s (WTO) Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement. In the agreement, WTO allowed countries to bypass patents in health emergencies, which provided them with the flexibility of producing the drugs locally, or importing the drugs at the same low price if they lacked manufacturing facilities to produce them on their own.
Following the agreement, more than 60 LMICs have procured generic versions of patented medicines on a large scale.
The success of differential pricing and generic medications has influenced healthcare access for other conditions, with similar strategies currently being applied to treatments for hepatitis C, cancer, and diabetes.
Lesson 3: Advocacy drives change
Governments were slow to respond when HIV/ AIDS first emerged; among highly stigmatized groups of people such as homosexual and bisexual men. As such, the face of AIDS activism of the time was not that of a professional lobbyist or advocate, but rather people suffering from AIDS themselves. The success of HIV/ AIDS activism was driven by the formation of AIDS Coalition to Unleash Power (ACT UP) groups in several major cities in the United States and Europe.
Dr Saba explains, “The tactics of these activist groups made it impossible for governments and the pharmaceutical industry to ignore the situation. For instance, when a pharmaceutical company declared a 50% reduction in the drug price, some of these groups quickly organized a sit-in outside the home of a competing pharmaceutical company’s executive to pressure them into lowering their antdrug prices too.”
He adds, “Thanks to the activism in the West, HIV/ AIDS advocacy gained traction throughout Africa and other LMICs. The media also played a role in pressuring governments and pharmaceutical companies by highlighting the major gaps in access to treatment in LMICs.”
Advocacy also changed the global dynamic of fundraising for healthcare. The total investments channeled to the HIV/ AIDS pandemic in LMICs more than quadrupled from US$4.5 billion in 2000 to US$20.6 billion in 2017. Today, the HIV/ AIDS advocacy space is no longer dominated by patients and has since been occupied by policymakers, scientists, celebrities, and even religious leaders who promote evidence-based information on prevention and treatment.
Building a legacy for the future
The lessons learned from the HIV/ AIDS pandemic have fundamentally reshaped how the world approaches healthcare access. However, the work is far from over. Global health inequities persist, and the gains made in HIV/ AIDS prevention and treatment must be sustained through continued investments and advocacy.
Dr Saba states, “The HIV/ AIDS pandemic showed us the power of collective action and innovation, but it also reminds us that achieving healthcare equity is an ongoing struggle as the incidence of chronic diseases continue to rise within our populations.”
*Quotes from Dr Joseph Saba were adapted from his book, “A World Undivided – A Quest for Better Healthcare Beyond Geopolitics”.
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