The story of HIV: the past 44 years and the road ahead

The human immunodeficiency virus (HIV) epidemic began in 1981, when previously healthy men presented with Pneumocystis jirovecii pneumonia, cytomegalovirus disease and Kaposi sarcoma.[1] Of the 337 reported cases in 1981, 130 patients died within that year. The virus HIV was first identified in 1983 and the world’s first dedicated HIV clinic was opened in 1983 at San Francisco General Hospital, which provided refuge and compassionate care at a time when fear gripped the world and patients were stigmatised and denied care. World AIDS Day was first celebrated on 1 December 1988,[2] and we continue to commemorate it every year to raise awareness, honour the lives of those affected by the epidemic and remind ourselves of the challenges we still face today. The remarkable progress made in transforming a disease that was once a near-certain death sentence into a manageable chronic condition is a testament to decades of scientific advancement, sustained global commitment and relentless community advocacy. Today, HIV treatment for most patients entails taking a single-tablet regimen consisting of two to three well-tolerated drugs. This is a welcome departure from the complex pill combinations often accompanied by debilitating side effects in the past. With good adherence to treatment, the estimated life expectancy of people living with HIV is only slightly lower than that of the general population, especially for those who start treatment early.[3] Significant progress has also been made in HIV prevention. Daily and on-demand pre-exposure prophylaxis (PrEP) with tenofovir and emtricitabine effectively reduces the risk of HIV acquisition when taken as prescribed. More recently, two long-acting injectables, cabotegravir and lenacapavir, have also been added to the armamentarium. With these advances, the UNAIDS (Joint United Nations Programme on AIDS) 95–95–95 strategy has become a realistic global initiative to end AIDS as a public health threat by 2030. It aims to ensure that by 2025, 95% of all people living with HIV are aware of their diagnosis, 95% of all people living with HIV are on sustained antiretroviral therapy (ART) and 95% of people receiving ART have a suppressed viral load. In Singapore, a total of 7137 residents were living with HIV as of the end of 2024. The number of new cases diagnosed each year has been declining, from 300–500 per year between 2009 and 2019 to 200–250 between 2020 and 2023 and 151 in 2024. However, we still fall short of achieving the 95–95–95 targets. As of 2024, 85% of people living with HIV are aware of their diagnosis, 94% are receiving treatment and 94% have achieved viral suppression.[4] What have we done well and what more can we do? The biggest gap in Singapore is the first ‘95’ target. The main challenge lies in encouraging people who may be living with HIV to come forward for testing. In 2024, an amendment was made to Section 23(1) of the Infectious Disease Act to remove the requirement for people living with HIV to disclose their diagnosis to sexual partners. For the law to apply, they must have maintained an undetectable viral load for at least 6 months, have test results confirming this within 9 months of the encounter and be compliant with treatment. The amendment seeks to remove the fear of persecution and stigma associated with HIV testing and diagnosis. Active steps have also been taken to lower barriers to testing, including introducing anonymous HIV test sites, rapid HIV testing at general practitioner clinics, and most recently in January 2025, making HIV self-testing kits available for purchase at retail pharmacies.[5] However, while the structural framework is in place, greater efforts are needed to increase awareness and testing uptake, particularly among key populations. Singapore’s world-class healthcare system has ensured good linkage to care for newly diagnosed patients. We have almost achieved the second and third ‘95’ targets. To further increase accessibility to treatment, antiretroviral medications were included in the Standard Drug List and Medication Assistance Fund scheme in September 2020.[6] Singaporeans who are unable to afford subsidised medications can rely on MediFund. This ensures that no Singaporean is unable to access medications due to cost concerns. The availability of and adherence to ART have enabled the majority of patients to maintain virological suppression. The barriers to retention in care among the rare minority are often related to complex sociobehavioural circumstances, which may not be resolved even with intensive case management. Recent advances in HIV treatment offer new opportunities to improve adherence and virological outcomes for this subset of patients. Long-acting injectables, such as cabotegravir and rilpivirine given every 2 months and lenacapavir given every 6 months — even when used out of their approved indications — have shown promising efficacy and acceptability in individuals facing adherence challenges with daily oral ART. Access to these medications is currently limited because of the prohibitive cost. Providing subsidies for these novel agents may bring us closer to achieving the second and third ‘95’ targets, which are well within our reach. While we have done well in ensuring access to HIV treatment, more resources are needed to scale up our preventive efforts. As part of a comprehensive preventive strategy, PrEP is highly effective and evidence-based. Increasing access and financial assistance for PrEP, the cornerstone of modern HIV prevention, may well be one of the final pieces of the puzzle required to significantly reduce the number of new diagnoses locally. In a 2024 qualitative study among people living with HIV in Singapore, participants shared their experiences of institutionalised discrimination in educational institutes, workplaces and healthcare settings, and described how this fear of judgement prevented them from seeking medical care.[7] Indeed, progress towards social acceptance and destigmatisation of HIV has lagged behind scientific progress. Stigma and discrimination prevent people from accessing essential prevention, testing and treatment services. Continuous efforts to improve public education, challenge misconceptions and spread the unequivocal message of ‘Undetectable=Untransmittable’ (U=U) — that people living with HIV on ART who achieve and maintain an undetectable viral load cannot transmit the virus to their sexual partners — are crucial. Decriminalisation is also critical, as punitive laws deter access to HIV services and increase acquisition risk. To end the HIV epidemic, we must first end stigma, an epidemic in itself. The recent USA funding cuts for global HIV programmes have caused major alarm. Across Kenya, Uganda and Nigeria, an estimated 2.2 million people have lost access to HIV prevention services.[8] Modelling studies estimated that the cuts could cause an additional 4.43–10.75 million new infections and 0.77–2.93 million HIV-related deaths by 2030.[9] Singapore remains vulnerable to the downstream effects, including increased transmission risk and exposure to drug-resistant strains, given the ease of international travel. Undoubtedly, these cuts threaten decades of progress made and reverse hard-won gains. Such events also serve as a reminder against complacency and reinforce the need to strengthen healthcare systems to withstand global uncertainties and minimise service disruptions. Despite the looming uncertainty, the show of resilience demonstrated by the global community is encouraging. The successes since 1981 have shown that with solidarity, the world can move forward in the fight against HIV. World AIDS Day stands as both a tribute and a reminder of this arduous journey. In Singapore, achieving the 95–95–95 targets remains a monumental yet attainable goal. As we commemorate World AIDS Day this year, let us pledge to foster inclusivity, challenge stigma, and in doing so, work towards ending the HIV epidemic. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.