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HIV and AIDS: The End of the Beginning

Chinua Akukwe, December 27, 2011

U.S. President Barack Obama, on the occasion of the 2011 World AIDS Day, called this the end of the beginning of the AIDS global epidemic. Obama's statement correlates with the comprehensive push by UNAIDS for a future free of HIV infections and AIDS deaths. Unquestionable gains have been made in the fight against AIDS, but huge difficulties remain.

 
Unquestionable gains
 
According to UNAIDS, an additional 1.35 million individuals clinically qualified to receive lifesaving medicines in low- and middle-income countries were placed on antiretroviral medicines in the last two years. From less than 500,000 in the late 1990s, more than 6.6 million individuals living with HIV/AIDS in low- and middle-income countries are now on antiretroviral medicines. At least 400,000 new HIV infections among children have been prevented since 1995 as a result of access to lifesaving medicines.
 
The rate of new HIV infection worldwide declined by 21 percent between 1997 and 2010, according to UNAIDS, averting at least 2.5 million deaths. Botswana continues to record one of the most spectacular success stories. In 2000, one of every three adults in Botswana lived with HIV/AIDS. By 2010, the new number of HIV infections had declined by two thirds due to an aggressive information, education and communication campaign against HIV transmission and the extraordinary, rapid scale-up of access to antiretroviral medicines from 5 percent in 2000 to more than 80 percent in 2010. It helped that Botswana is one of the richest and best-governed countries in Africa.
 
In the last decade, new HIV infections declined by more than one third in the Caribbean. Between 1996 and 2010, new HIV infections decreased by 56 percent in India and by 40 percent in Southeast Asia.
 
Advances in HIV research signpost potential further gains in the fight against the global epidemic. New research suggests that early and timely access to antiretroviral medicines can reduce HIV transmission by 96 percent among partners of individuals living with HIV/AIDS.
 
In the race for a "cure" for AIDS, two recent developments indicate that a breakthrough may not be as implausible as once thought. First, an individual currently known as the "Berlin patient," after multiple, expensive bone-marrow transplants, no longer shows evidence of HIV infection. Reportedly, this individual has been free of HIV for four years. Unfortunately, so far, researchers have failed to replicate this result. Another individual, the "Trenton patient," after a gene-therapy procedure, stopped HIV in its tracks for about 12 weeks. However, researchers are still struggling to replicate the gene-therapy outcome in other similar patients.
 
The U.S. National Institutes of Health, multiple medical research centers and research pharmaceutical companies are actively engaged in AIDS research. The quest for an HIV vaccine remains a top priority, with the public-private, civil-society International AIDS Vaccine Initiative backed by the Gates Foundation playing a pivotal roll in mobilizing financial, technical and logistics resources.
 
The last decade has also shown that bilateral and multilateral global efforts to fight AIDS can work. The U.S. PEPFAR program reportedly provides 4 million individuals worldwide with antiretroviral therapy. In the last year, PEPFAR support reportedly provided 600,000 HIV pregnant mothers with antiretroviral medicine, potentially averting HIV transmissions to 200,000 newborns. Obama announced a new PEPFAR goal of putting 6 million individuals on antiretroviral therapy by 2013. The Global Fund to fight AIDS, tuberculosis and malaria through its operations in 150 countries reportedly saves 100,000 lives a month. The Fund is responsible for one fifth of global AIDS financing.
 
Steep challenges remain
 
Currently, 34 million individuals live with HIV/AIDS. At least 7.6 million individuals who clinically qualify to receive antiretroviral therapy (53 percent of all eligible individuals) are not on treatment, and there is no immediate, rapid, comprehensive plan to put these individuals on antiretroviral therapy. Most of these individuals live in Africa where AIDS kills at least 1 million people a year. Most of these individuals die due to lack of access to lifesaving medicines that are widely available and utilized in rich nations. The recent suspension of new AIDS grant awards until 2014 by the Global Fund, due to shortage of donor funds, is another ominous sign of tough times ahead. Even the promise to put an additional 2 million people on antiretroviral therapy by Obama will not drastically change the scenario.
 
The 6.6 million individuals already on antiretroviral therapy require lifetime treatment. At this time, no contingency plan exists on how to keep individuals in low and middle income on lifetime access to antiretroviral medicines. Since more than 80 percent of all individuals on antiretroviral medicine in low- and middle-income countries rely on donor-supported supplies, the fate of these individuals when donor supply inevitably runs out cannot be imagined. Even at a drastically reduced annual cost of $100 in Africa, lifetime cost of antiretroviral treatment will be insurmountable for most low-income countries that spend less than $30 a year on health per individual.
 
With clear evidence that early treatment dramatically reduces the chance of HIV transmission, considerable pressure will soon mount on policymakers around the world to make antiretroviral medicines available to all individuals living with HIV/AIDS. Until a cure is found, an HIV vaccine becomes available or a scientific process is discovered that drives the HIV virus into long-term remission, the road to 96 percent reduction in HIV transmission is likely to pass through the expensive route of early onset of treatment for all individuals living with HIV/AIDS. This may be the ultimate challenge in the coming decade.
 
The UNAIDS estimates that global financing for HIV/AIDS program declined in the last year from $8.7 billion to $7.6 billion after exponential growth since 2001. Although $15 billion was spent globally on AIDS in 2010 (global, domestic and regional expenditures), this is still far short of the $22 billion to $24 billion a year that UNAIDS estimates it would take to wage a comprehensive battle against HIV/AIDS by 2015. Nothing in the immediate future global economic climate suggests that donor countries currently mired in economic doldrums will significantly raise their contributions.
 
For every two individuals put on antiretroviral therapy, three new HIV transmissions occur. It is not surprising that the incidence of HIV is rising in Eastern Europe, the Middle East, North Africa, Central Asia and Oceania where services for at-risk populations remain tenuous. Part of the problem has been the vertical orientation of organizations that did not anticipate sustained direct interface with at-risk populations during the early years of the fight against AIDS.
 
The next decade in the global fight against HIV/AIDS must now become community oriented. In this regard, the mobilization effort will remain global but implementation activities will be focused locally. This process requires rebuilding of community health systems, community social protection mechanisms and community empowerment programs. It would require investments in outreach services, community-participation mechanisms, and community-based research and evaluations.
 
Reoriented global attention and resource mobilization against HIV/AIDS requires new partners and operations outside traditional channels. South-South cooperation should receive top priority. China, India, Brazil and South Africa should provide more financial, technical and logistics assistance to poorer nations. Poverty alleviation should become as important as strengthening health systems in the fight against HIV/AIDS. Regional political and technical leadership will be indispensable as donors consolidate program support.
 
Today, HIV/AIDS remains an eminently discriminating global epidemic that exacts cruel and unusual punishment depending on your geography or social and economic status. The fight against HIV/AIDS in the next decade will be gritty and hard fought, but it is one where progress can continue to be made.

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