October / November 2011
by Regan Hofmann
Thirty years after people first started dying from a then-unknown virus, we face a thrilling tipping point in AIDS history. Leading scientists say the end of the pandemic is possible, maybe even in our lifetime. Now, the question is: How do we seize this moment? Here, we spell out our suggestions for what we need to lay HIV to rest.
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In September of 2010, Thomas Frieden, MD, MPH, director of the U.S.
Centers for Disease Control and Prevention (CDC), named HIV one of “six
winnable battles” the CDC will wage under his command. His claim that
AIDS can be beaten may prove prescient.
Global health leaders agree that scientific breakthroughs indicate the
end of AIDS could be in sight—possibly in the near future if we
strategically apply our resources to capitalize on recent discoveries.
What’s different now? Primarily, new data from U.S.-funded research
showing that antiretroviral treatment (ARVs) serves as prevention—in
both people living with the virus and those who are not. A recent study
known as “HPTN 052” offers evidence that treating people with HIV can
lower the risk of viral transmission by a whopping 96 percent. When we
put people with HIV on ARVs, we save their lives—and stop the spread of
HIV. Several other studies show that when people at risk for HIV take
treatment daily (a practice called “PrEP” for “pre-exposure
prophylaxis”), or when they take ARVs after potential exposure (a
practice known as “PEP” for post-exposure prophylaxis), their chance of
contracting the virus is reduced.
The long-waged battle between the treatment and prevention camps is
prevention. Bill Gates, one of the most generous funders in
the fight against AIDS, has said, “We can’t treat our way out of this
epidemic.” Indeed, ultimately, the answer is having a vaccine—and a
cure. But while we develop them, it appears the tools already in our
possession can begin to end AIDS. Perhaps we can at least partially
treat our way out of AIDS after all.
Anthony Fauci, MD, head of the National Institutes of Health’s National
Institute of Allergy and Infectious Diseases, said recently in Science: “The fact that
treatment of HIV-infected adults is also prevention gives us the
wherewithal, even in the absence of an effective vaccine, to begin to
control and ultimately end the AIDS pandemic.”
Putting a lot more people with HIV on ARVs is the equivalent of capping
the well in a large oil spill. It doesn’t completely solve the problem,
but it’s a first—and necessary—step to doing so. Treating people who are
living with HIV stops the spread of disease, keeps the world safer and
saves billions of American dollars—these facts provide new justification
for the cost and effort required to achieve our goals of universal
access to care for all who need it. The United Nations’ new goal for
universal access is 15 million people by 2015. Currently, only 6 million
of the 33.3 million people estimated to be living with HIV globally are
on ARVs. Having so few on pills is like trying to clean up an oil spill
while the well is still a geyser.
Once, the notion of universal access smacked of giving endless,
expensive medications to an eternally growing pool of people who
couldn’t afford them themselves and relied on the largesse of
governments and pharmaceutical companies to save them. New data suggest
that doing the right things today could enable us to get the upper hand
on AIDS forever.
The critical question is no longer, “Can we end AIDS?” but “Will we end
AIDS?” Will we garner the political and financial capital to do what
science suggests we can?
For years, we have tried various approaches to behavioral and
non-biomedical prevention, with some success. But, since people
continue, and likely always will, to have unprotected sex and share
injection drug equipment, incidence of new infection rates is not
declining and will never decline unless we stop HIV dead in its tracks.
The best way to do that is to provide ARVs to the bulk of people living
with HIV who need them. Modeling in several countries shows a direct
correlation between increased access to care and decreased rates of new
There are many barriers to care. Drug prices alone are not keeping
people from pills. In some nations, political unrest, lack of
infrastructure and/or a shortage of medical workers mean that even if
governments could afford the pills, the meds still wouldn’t get to the
people. In the United States, impending federal budget cuts, inadequate
state contributions to Medicaid and recent changes in eligibility
requirements for Medicaid, lack of childcare and transportation,
homelessness, substance addiction, mental health issues, comorbidities,
health disparities, misperceptions and language barriers also present
impediments to care.
And of course, fear of stigma, discrimination, homophobia,
criminalization, deportation, physical harm and death undermine HIV care
efforts around the world.
While these challenges are daunting, it pays to overcome them. We need
to greatly expand our testing efforts and do a much better job of
linking people to and retaining them in care. If many more people become
aware of their HIV status earlier, and if they access care and lower
their viral load to an undetectable level, then they not only improve
their own health but they contribute to better public health. Connecting
people to medicines before they inadvertently pass along the virus will
reduce community, and possibly global, viral loads. This is how the
spread of AIDS begins to slow. This is how we cap the well.
Having 27.3 million people with HIV globally (about 1 million of them in
America) remain untreated with existing drugs that can save their lives
and prevent AIDS from spreading is a humanitarian crime of epic
proportion. It’s also no way to stop the AIDS pandemic.
Expanded access to HIV treatment, while a lynchpin in any strategy to
end AIDS, will not, by itself, solve the problem. We also need to
develop and distribute biomedical prevention tools (like PrEP, PEP and
microbicides), scale up male circumcision and continue to distribute
more male and female condoms and clean syringes. The question is one of
relative proportion. Current levels of resources applied in newly
focused and optimally strategic ways to reflect the insight of recent
medical breakthroughs will maximize their impact and hasten doomsday for
We can make major headway by employing our complete arsenal of tools in a
way that ensures we get the biggest bang for our buck. But we can’t get
blood from a stone. If we are to end AIDS, we eventually will need more
money. And it needs to come from fresh sources. No nation has applied
more currency to the fight against AIDS than America. At its peak, the
budget for the President’s Emergency Plan for AIDS Relief (PEPFAR) was
$48 billion dollars. The United States spends about $19 billion a year
to fight AIDS at home. But that’s about to change as our government now
faces cutting $1.5 trillion from the federal budget. That’s not a
budgeting haircut. That’s a buzz cut.
As budget cuts are made, all discretionary spending and entitlement
programs (which comprise the bulk of domestic and global AIDS funding)
are at risk. The community of people living with HIV/AIDS and our
friends must convince political, economic and global health leaders not
to slash AIDS funding. We are up against those fighting for support for
other diseases, education, the military’s fight against terrorism, and
the dollars needed to keep Social Security secure, to name a few causes.
Our cry must be particularly pointed. If we fail to defend AIDS
spending, tens of millions of people will perish needlessly in the next
In his opening keynote speech at the International AIDS Conference in
Rome, UNAIDS executive director Michel Sidibé called gaps in access to
HIV treatment an affront to humanity that can and must be closed by
innovations in developing, pricing and delivering treatments and
commodities. “History will judge us not by our scientific
breakthroughs,” he said, “but how we apply them.”
Ending AIDS won’t be easy, it won’t be cheap, and it won’t happen
overnight. But if we develop a smart, sound, strategic plan—one that
uses existing resources better and secures new funding from other
nations—and if we sell it all the way up the political line to the
president himself and across both sides of the Congressional aisle, it
can be done.
This Congress and this president have the chance to kill one of the
world’s worst killers and in the process save tens of millions of people
and billions of dollars. If we rapidly increase access to care, and if
infection rates and deaths decline, then the resources needed to fight
global AIDS could shrink in as few as five years. And, significantly
expanding access to care will make the pharmaceutical companies who make
the drugs even richer. I know, I know. But the answer to bankrolling
the end of AIDS is not as simple as dropping drug prices. The prices set
by for-profit companies are only likely to go down if the volume of
drugs sold goes up. And for that to happen, we need to find more
guaranteed payers. This is why the rest of the world needs to help come
up with the cash to expand access to care for people with HIV.
We have a rare opportunity to rewrite the ending of one of the world’s
worst tragedies. We didn’t give up when we didn’t have the answers for
what can end AIDS—we certainly shouldn’t now that we do.
The bottom line? If the HIV community can encourage the world to up the
antes of international financial and political will, if global advocacy
efforts are bolstered and expanded, if we correctly position the
arguments for why the world should spend the money to stop AIDS, if we
put AIDS back in the spotlight and take it out of its silo, if we
utilize existing health care and faith-based infrastructure to deliver
care, if we make health care a human right that is equally offered to
all, if we protect the human rights of people with HIV, if we put our
money where we know it works best, and if these things result in more
people getting educated, protected, tested, treated and linked to care,
HIV’s days could be clearly numbered.
With that in mind, POZ outlines seven key areas where we need to
focus global efforts if we are to end AIDS, and we suggest specific
tactics within each of those areas.
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