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New Achievements on AIDS Show Targets Matter -- So Let's Set New Ones

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On Monday at the White House, President Obama reported the latest accomplishments of the U.S. Government's response to HIV. The progress he cited was impressive. As a result of work funded through the President's Emergency Plan for AIDS Relief (PEPFAR), an estimated 1 million children have been born free of HIV and 6.7 million people now receive lifesaving anti-retroviral treatment.

Strangely, though, there was little mention of one the most impressive turnarounds in the global response to AIDS. By the end of this year, PEPFAR reports that it will have supported 4.7 million voluntary medical male circumcisions (VMMC), meeting a goal the President announced in 2011. Nearly all of these procedures, almost four million, were performed in just the past two years.

This is noteworthy not only for the potential impact on HIV transmission, but because VMMC efforts were, until recently, drastically off course. The turnaround shows that setting ambitious targets -- and backing them up with funding and political leadership -- can have a transformational effect.

In 2006, clinical trials showed that VMMC can reduce a man's chances of acquiring HIV from a female partner by nearly two thirds. Especially in sub-Saharan African countries with high rates of HIV and low rates of circumcision, this simple, life-long approach promised to prevent millions of HIV infections. Yet as recently as last year, only a handful of countries had made significant progress in scaling up the intervention. My organization AVAC, along with our partners, called for a dramatic increase in attention and resources for this vastly underutilized prevention option.

To be fair, VMMC is not always an easy sell, especially in places without a cultural history of male circumcision. This hesitance, combined with the logistical hurdles of scaling up a sensitive surgical procedure, left many to wonder if the U.S. government would ever achieve its 2013 target. But today, it appears the goal will be reached.

That achievement cannot, of course, be entirely chalked up to a numerical target, or even to an influx of funding. In the past year, several African countries themselves have established rollout plans and made substantial investments of their own. Marketing efforts have gotten under way to generate understanding of, and demand for, VMMC among men who can benefit. New, non-surgical devices have recently come onto the scene, providing an additional option that may eliminate the need for surgery and improve recovery times for some men.

But having a clear global objective was instrumental. It signaled to partners that this effort was important, that major progress was possible, and that the U.S. government, the world's largest funder of HIV prevention efforts, was ready to commit resources to meet its goals.

Even with this impressive success, we remain a long way from where we need to be. The ultimate goal of global VMMC efforts is for 80 percent of men to be circumcised in 14 priority African countries. That requires some 20 million circumcisions, meaning that we're just a quarter of our way to the goal. But we can't afford not to reach it: achieving this target would avert as many as 3.4 million new HIV infections and save $16.6 billion in future healthcare costs.

As we pass the targets that PEPFAR set for itself two years ago, it's time to establish new goalposts. PEPFAR -- and, for that matter, other global health leaders -- must commit to achieving much more ambitious targets over the next two years.

Other steps are needed, too. For example, we need to invest in better, more timely data reporting so that VMMC efforts -- and all other aspects of the AIDS response -- can be evaluated and refined in nearly real time. With 2012 data on VMMC roll-out only now becoming available, we're already missed valuable opportunities to support countries with effective programs and trouble-shoot with those that are falling behind. Non-surgical devices also need to be made available wherever appropriate, and their prices - which haven't been established - need to be truly affordable for the African nations that need them.

Meanwhile, we need to remember that none of the progress on VMMC would be possible if not for investments in research early in the last decade -- the kind of investments that will still pay off in other areas of HIV prevention and care.

On Monday, the President rightly noted the huge potential of research towards a cure for HIV, and committed $100 million to a new HIV Cure Initiative at the National Institutes of Health. By continuing to build our knowledge through clinical and early stage research for a cure, AIDS vaccines, microbicides and other ARV-based prevention, we lay the groundwork for the next generation of advances, and for the AIDS-free generation that we all hope to achieve.

AVAC will be releasing its annual "state of the field" report - this year entitled Research and Reality - on Monday, December 9. It will be available at www.avac.org and will include updates on VMMC, AIDS vaccines, microbicides, PrEP and treatment as prevention and a range of additional crosscutting issues.