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Making AIDS History: Achieving an HIV-Free Generation

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Written in collaboration with Michelle Moses-Eisenstein, M.P.H.

This week marks the return of the International AIDS Conference to the United States for the first time in more than two decades. From July 22-27, The International AIDS Society will convene more than 25,000 delegates from nearly 200 countries in America's capital. The meeting is being held this year in Washington, D.C., as a result of President Obama's decision in October 2009 to lift the 22-year-old U.S. government travel and immigration ban that prohibited people with HIV/AIDS from entering the United States. This important change in public policy is a reflection of the Obama Administration's leadership on eradicating HIV/AIDS, its adoption of evidence-based policies, and its rejection of the stigma that has surrounded HIV/AIDS.

Convening the International Conference this year in Washington, D.C. also shines a spotlight on the epidemic in America's capital city, where nearly 1 out of 40 people are living with HIV/AIDS -- a rate higher than 14 African countries, including Angola and Sierra Leone. In the U.S. there are 1.2 million people living with HIV, with more than 50,000 new HIV infections and 18,000 deaths from AIDS-related causes annually. Globally, 34 million people are living with HIV/AIDS, 2.6 million were infected with the virus last year, and nearly 30 million people have died from HIV/AIDS since the beginning of the epidemic.

But 30 years after the emergence of HIV/AIDS, there are many reasons to be hopeful that we are finally on a pathway to ending the epidemic. Around the world, the rate of new infections is decreasing, the numbers of people on treatment are increasing, and HIV-positive people who receive effective treatment can achieve nearly normal life expectancies. In the United States and other developed nations, mother-to-child transmission has been virtually eliminated. Scientific progress, new initiatives such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB and Malaria, and other partnerships among public and private sector organizations are revolutionizing the treatment and prevention of HIV/AIDS in America and worldwide.

The International AIDS Conference will highlight opportunities for achieving an AIDS-free generation. For the first time in the history of the epidemic, dramatic advances in science have brought the possibility of a world where no child will be born with HIV and where the risk of infection will be dramatically reduced with a combination of powerful prevention tools. There is real hope that a vaccine and, ultimately, a cure will emerge in our lifetimes. To achieve these goals, conference participants from around the world will underscore that nations must: 1) invest in research and accelerate the translation of science into services, 2) eradicate mother-to-child transmission of HIV worldwide, 3) scale-up evidence-based treatment and prevention strategies globally, and 4) eliminate the discrimination and stigma surrounding HIV/AIDS.

As a public health doctor, I have worked on HIV/AIDS issues since the beginning of the epidemic. In the 30 years since those dark days when people were dying rapidly of HIV/AIDS in America and there was minimal knowledge about how HIV was transmitted, we have made tremendous strides, and we have also realized that the epidemic affects every population. Investments in research have produced lifesaving antiretroviral medications (ARVs) that have revolutionized HIV/AIDS treatment. Today, nearly 7 million people are receiving these drugs globally, transforming what was once lethal into a chronic, manageable condition for many. However, of the more than 14 million people with HIV/AIDS worldwide who require medications, less than half receive ARVs.

In the United States, several thousand people are currently on a waiting list -- the AIDS Drug Assistance Program (ADAP) -- to receive medications. However, last week, the U.S. Department of Health and Human Services announced it would provide $80 million in grants to increase access to HIV/AIDS treatment and care across the United States. About $69 million will be sent to 25 states and territories through the ADAP to eliminate any waiting lists. The passage of the Affordable Care Act (ACA) health care reform legislation will help ensure that 14,000 patients living with HIV/AIDS will receive medical services. In sum, this new funding and the new law will ensure that low-income Americans living with HIV/AIDS will have access to life-saving health care and medications. Providing increased funding to boost the numbers of people on treatment in America fulfills an objective of the U.S. National HIV/AIDS Strategy released two years ago. Additionally, under the strategy, resources are being targeted more effectively to communities that are most affected by the disease.

Now we must intensify efforts to ensure that globally all HIV-positive people in need receive treatment and care. On World AIDS Day 2011, President Obama pledged a 50 percent increase in the number of HIV-infected people getting treatment through PEPFAR -- from approximately 4 million now to 6 million by the end of 2013. If progress continues to be made in reducing the costs of drugs and health service delivery, then even more people will receive lifesaving therapy. An acceleration of treatment for HIV-positive people worldwide would also help prevent transmission of infection and speed an end to HIV/AIDS.

A recent advancement in prevention came with landmark studies that revealed that oral pre-exposure prophylaxis (PrEP) -- a "prevention pill," combining two ARVs -- can reduce viral transmission by 92 percent if taken as prescribed. The FDA just approved this medication for preventing HIV/AIDS in populations at high risk of sexually transmitting the virus, including men who have sex with men (MSM) and couples where one person is HIV-positive and the other is HIV-negative. The agency will require periodic HIV testing for people using PrEP to help ensure that this biomedical tool is used safely and effectively. The FDA just approved a home HIV test kit that should increase the numbers of people who learn their HIV status. Other breakthrough research has found that early treatment of an HIV-infected partner decreases transmission to an uninfected partner by 96 percent, underscoring that treatment is also prevention. These advances can now be combined with other proven measures, including education, safe-sex practices, voluntary medical male circumcision, reduction of mother-to-child transmission, the availability of syringe exchange programs, and blood supply screening to save countless lives.

Scientists are making significant progress in developing an HIV vaccine. HIV's ability to mutate has thwarted vaccine development, but recent studies are showing partial efficacy of new vaccines. An important study was conducted in Thailand with the support of the Army's Walter Reed HIV Research Program. Recently, the National Institute of Allergy and Infectious Diseases (NIAID) selected Duke University and the Scripps Research Institute to lead the new Centers for HIV/AIDS Vaccine Immunology and Immunogen Discovery (CHAVI-ID) and awarded this new program $31 million in FY2012, with approximately $186 million or more in projected funding over the next six years. The initiative will support a consortium of multi-disciplinary researchers at universities and medical centers focused on multi-pronged approaches to accelerate HIV vaccine development. The team will address key immunological pathways and roadblocks, including immune responses that might protect against HIV infection or suppress it in people living with the virus, providing scientists with a foundation for designing a safe and effective HIV vaccine in the future.

Research is also underway to find a cure for AIDS, fueled by the experience of the "Berlin patient," a man who had both leukemia and HIV. He was treated in 2007 with a bone marrow transplant from a person with natural immunity to AIDS found in 1 percent of Caucasian blood marrow donors. The procedure not only cured this patient's leukemia but also appears to have eliminated the HIV virus from his body, and he no longer requires medication to treat the illness. This landmark case has provided important clues in the quest for a cure and a glimmer of what increased funding and intensified leadership might yield. amfAR, the Foundation for AIDS Research, is providing important scientific direction in supporting innovative work to discover a cure including establishing multi-site collaborations to achieve this goal. The NIH is funding studies to find a cure and has established research consortia to facilitate new discoveries. However, cure research must receive a significant boost in funding if we are to achieve a world without HIV/AIDS in the years ahead.

Another important research focus must be on behavioral health issues, including factors that promote adherence to medications and the use of preventive measures, as well as on the effects of mental illness and substance abuse on HIV/AIDS progression. Also, more studies are needed on sex differences in the disease. Behavioral interventions must be delivered that optimize prevention and treatment outcomes and ensure the effectiveness of social marketing messages so they are culturally competent to meet the needs of diverse population groups worldwide.

Of great concern right now is that the remarkable progress toward ending AIDS that has been made over the past decades is being threatened by a decline in resources and the threat of budget cuts to support HIV research and services worldwide. The lack of initiatives that target vulnerable populations presents a roadblock to achieving an HIV-free generation as well. However, today at the International AIDS Conference, Secretary Hilary Rodham Clinton announced a $35 million Challenge Fund to support country-led plans to provide services for these key populations. While U.S. global health investments today represent less than 1 percent of America's budget, these funds support lifesaving research and services for millions of people in developing nations and help build a world with more friends and fewer enemies, a critical tool of "smart" power in our nation's foreign policy.

Furthermore, a provision in the Budget Control Act of 2011 would enact a process called sequestration if Congress does not achieve deficit reductions of $1.2 trillion by the end of this year. Sequestration would cut government spending by a uniform percent across all affected programs. According to recent estimates, such cuts would reduce spending on non-defense discretionary federal government programs by 7.8 percent. The result would have life-threatening effects on vulnerable populations, many of whom are affected by HIV/AIDS. Recent estimates of the human impact of decreases in U.S. global health program funding as a result of the proposed sequestration process include:

  • 273,000 fewer people receiving AIDS treatment worldwide.
  • 62,000 more AIDS-related deaths globally.
  • 122,500 more children becoming orphans.
  • 111,000 fewer HIV-positive pregnant women receiving services to prevent mother-to-child transmission.
  • 21,000 more infants being infected with HIV.
  • 354,000 fewer children receiving food, education, and livelihood assistance.
  • 2.2 million fewer insecticide-treated nets procured.
  • 3.7 million fewer people receiving malaria treatment.
  • 6,000 more malaria-related deaths.
  • 65,000 fewer people receiving tuberculosis (TB) treatment.
  • 8,000 more TB-related deaths.

So, what can be done to ensure that the U.S. and the world are on track to realize an AIDS-free generation -- a goal President Obama announced on World AIDS Day 2011? If we are going to eradicate AIDS in America and worldwide, then a global strategic plan for achieving an HIV-free generation is needed that mobilizes all sectors of society across countries, scales up interventions that work to reach more people, makes programs more efficient and accountable, and invests in research to accelerate progress in ending HIV/AIDS, including intensifying efforts to discover both a cure and a vaccine. Public/private sector partnerships must be expanded with a wide range of community-based organizations, NGOs, businesses, faith-based groups and foundations. We must also work to eliminate stigma, violence, and poverty that are drivers of the disease worldwide. Numerous advocacy organizations are calling for the U.S. government to establish its own five-year strategic plan through an interagency process that would reflect recent developments in programmatic experience, the Global Fund reform process, technological breakthroughs, and new science, and make this goal a policy priority for America.

And what can you do to live in a world without HIV/AIDS? Learn more about HIV/AIDS in America and around the world. Know your HIV status and take steps to protect yourself or others from transmission. Contact your policymakers and urge them to make ending the HIV/AIDS epidemic a priority by investing in more scientific research to discover a cure and an effective vaccine. Urge them to provide the global health funding needed to increase the number of people on lifesaving treatment, to eradicate mother-to-child transmission, and to prevent HIV from occurring at all. As the International AIDS Conference convenes in Washington, D.C. today let us, together, help make AIDS history.

Rear Admiral Susan J. Blumenthal, M.D., M.P.A. (ret.), the Public Health Editor of the Huffington Post, is Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. She served as a leading U.S. government health expert and spokesperson for more than 20 years in the Administrations of four American Presidents. She was Assistant Surgeon General of the U.S.; the first-ever Deputy Assistant Secretary for Women's Health; Senior Global and e-Health Advisor in the U.S. Department of Health and Human Services; Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health; and a White House advisor on health issues. Dr. Blumenthal is currently a Clinical Professor at Georgetown and Tufts Schools of Medicine. She is also the Chair of the Global Health Program at the Meridian International Center. Admiral Blumenthal is the recipient of numerous awards, medals, and honorary doctorates for her pioneering leadership and landmark contributions to improving health. She was named the 2009 Health Leader of the Year by the Commissioned Officers Association and as a Rock Star of Science by the Geoffrey Beene Foundation. Her work has included a focus on HIV/AIDS since the beginning of the epidemic in the early 1980s.

Michelle Moses-Eisenstein, M.P.H., is currently an Allan Rosenfield Health Policy Fellow with amfAR, the Foundation for AIDS Research in Washington, D.C. This coming fall she will serve as a Health Policy Fellow for the Association of Schools of Public Health, working in a public service position in Washington D.C. Michelle earned her Master of Public Health in Health Policy and Management at the Mailman School of Public Health at Columbia University.

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