In 10 years, will we look back on President Obama's 2011 World AIDS Day speech and see it as a turning point in the AIDS pandemic, or cringe at the lost opportunity of a singular moment? The president's December 1 speech could be pivotal, but only if it is followed by changes in how we tackle global AIDS.
Why was the Obama speech important? The president declared that "we can end this pandemic," calling out the enormous potential following 18 months of startling scientific progress on AIDS. He laid out ambitious new targets for delivery of effective interventions, which, if accomplished, could substantially reduce rates of HIV infection and mortality. And in setting those targets, Obama signaled a renewed U.S. commitment to funding for global AIDS programs at a time when resources at home are constrained and other countries are backing away from the fight.
Now it's time to plot a course for implementing the president's vision. We need to act quickly to take advantage of reinvigorated leadership, aligning resources for tangible impact. Four things are critical to success and deserve immediate attention: strategic decision-making, increased funding, balancing global targets with attention to the most vulnerable, and research.
First, a new era of efficiency and strategic resource allocation is needed. An increased share of AIDS resources needs to reach programs on the ground, and that funding needs to be used for maximum impact. An AIDS-free generation requires a shift in resource allocation approaches; ideally, each country would start each year with a clean-slate budget and determine how to use money most effectively based on the latest science, epidemiology, and evidence of impact.
We also need more widely and better use economic modeling to make evidence-based decisions about recourse allocation. These models are increasingly influential, and they need to be designed thoughtfully. Choosing the questions and assumptions that are punched into the computer makes all the difference. It is not enough for models to focus simply on how we might reduce incidence when the goal of the global AIDS response is broader: to reduce infections, morbidity, and death.
No one intervention in isolation will move us toward an AIDS-free generation; it's going to take a combination of approaches. That said, using a more strategic lens will lead to changing priorities. For example, in countries where the epidemic is largely centered on certain populations investments should be focused there. Regardless of epidemic profile, investments in all countries should be submitted to this test: What public health impact can they be expected to achieve?
The new AIDS treatment target set by President Obama in his December 1 speech captured most of the media attention, but the president set specific goals in four areas that day: treatment, voluntary medical male circumcision, prevention of vertical transmission, and condom delivery.
Those four interventions will be central to any successful campaign against AIDS. Other interventions will be necessary, too, including behavior change, syringe exchange, and structural approaches. And it's long past time to better integrate TB, sexual and reproductive health, and other services with AIDS programming.
But now that the HPTN 052 study has conclusively demonstrated that AIDS treatment dramatically reduces the likelihood HIV will be passed to a partner, scientific leaders are pointing to treatment delivery as a central ingredient of progress. While more research is needed to understand the population-level prevention impact of AIDS treatment, there are already signals worth noting.
The UNAIDS annual report from November 2011, for example, cites four countries where expanded access to HIV treatment appears to be boosting the effectiveness of combination prevention. In all of this, we cannot forget an obvious point: Treatment is a public good beyond its potential for reducing incidence -- people thrive, support their families, raise their children, and contribute to the economy.
There are critical opportunities in the coming months to drive strategic efforts as countries supported by the President's Emergency Plan for AIDS Relief (PEPFAR) submit their Country Operational Plans (COPs), and grants through the Global Fund to Fight AIDS, TB and Malaria are reviewed for continuation. The next round of COPs is due in March, and its success in allocating resources effectively will determine whether the President's targets are met. The discussion about smart use of resources needs more attention, with more civil society engagement in developing COPs and other programming. The Office of the Global AIDS Coordinator (OGAC) and its implementing agencies, the Centers for Disease Control and Prevention (CDC) and USAID, must be clear with countries about the president's new PEPFAR targets, and the implications for resource planning.
There is a tension here, as donors, including the U.S., emphasize increased "country ownership" in decision making around health. There's no question donors should be transitioning to more country ownership. But the first mission of America's global AIDS effort is to alleviate suffering and end AIDS; those goals should drive resource allocation.
The second big challenge is finding new resources. It's a cruel irony that the same summer the results of the 052 study were released, a report from the Kaiser Family Foundation found that, for the first time, global resources dedicated to fighting AIDS had actually fallen over the last year. In November, the Global Fund cancelled a grant round for lack of funding. And in December, the U.S. Congress passed an annual appropriations bill that increased funding for many areas of global health, yet shaved global AIDS by 2 percent.
As a report from AVAC observed last year, if ending AIDS were a business, the CEO would recognize that this is the time to invest. Donor nations must reinvigorate their commitments to the Global Fund, as well as their own bilateral programs. Heavily affected countries should follow the lead of South Africa and dedicate more of their own resources to the health of their own people.
The U.S. needs to keep to the administration's three-year pledge to the Global Fund, but not by undermining the overall response to AIDS by simply shifting PEPFAR resources to the Fund. That approach would be foolhardy, undercutting the president's new PEPFAR commitments and divesting from an enormously successful program with bipartisan support that has brought international good will to the U.S. In fiscal year 2012, spending on global health amounts to just one-quarter of one percent of the U.S. federal budget. We can afford to begin to end AIDS, and, conversely, we won't solve our debt problem by slashing global health.
A third priority is achieving global targets while addressing the needs of the most vulnerable populations, including MSM, IDUs, and sex workers. These groups are often invisible, their needs disregarded, and their rights and safety openly abused. Doing better to tackle AIDS among them requires promoting their human rights and providing safe, tailored health services. This will require resource allocation that reflects the epidemic profile of a country, and adequate investment in the needs of most-at-risk populations even where epidemiological studies have ignored their existence.
Ambitious global targets can drive accelerated service delivery and development of more efficient systems. Is there a contradiction between such targets and attention to those at greatest risk, who may be harder to find and serve? Not if the goal is truly and AIDS-free generation. As a World Bank/Johns Hopkins report released last year demonstrated, in many places bringing overall HIV incidence down depends on doing better at addressing the needs of heavily affected populations such as MSM. It's also true that because MSM, IDUs, and sex workers are only now beginning to receive the attention they need, a slowdown in the response to global AIDS would harm them most.
Finally, as always, research is essential to success. It's possible to begin to end the AIDS epidemic now, but it won't truly be over without a cure and a vaccine. Research is also crucial to better understand how to implement interventions in combination, to improve HIV diagnostic and treatment options, and to successfully link newly diagnosed individuals to care and treatment.
We have entered a time of huge promise in the AIDS epidemic, but with it exists the very real threat that we will squander this opportunity by under-investing or failing to use money wisely. Now is the time for governments rich and poor, donors, providers, researchers, and advocates to find new resources -- and make smarter use of them -- to begin to end the most deadly epidemic of our time.