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Making AIDS History

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By Susan Blumenthal, M.D.
Written in collaboration with Melissa Shive

It was unusual 25 years ago for a world-famous movie star to fight for a health issue in the halls of the U.S. Congress. Yet, Elizabeth Taylor made history on May 8, 1986, when she entered the Dirksen Senate hearing room and took her seat at the long wooden table, center-stage, in front of members of the Senate Committee on Appropriations. Though she exuded the elegance, beauty and confidence of an internationally acclaimed actress, that day she testified in her role as the national chairman of the American Foundation for AIDS Research (amfAR). She was there to speak out about "a national scandal, a scandal of neglect, indifference and abandonment." Elizabeth Taylor was shattering the silence and stigma surrounding AIDS.

Only five years after HIV/AIDS emerged in America, Dame Taylor had become a leading advocate and champion for those affected by this disease, calling for increased research and access to services. Her dear friend Rock Hudson had died of AIDS less than one year prior, making the battle very real and personal for her. Her testimony that day was a major force in ensuring the passage of the monumental Ryan White CARE Act -- the largest federally funded program for people living with HIV/AIDS -- just four years later. Her words conveyed a wisdom and knowledge about the fight against HIV/AIDS that remain hauntingly true today: "The infection continues to spread uncontrolled. Some experts estimate that more than 1,000 additional people are now becoming infected with the AIDS virus every single day. AIDS can strike people of all races and all ages, including children, and the unborn. Women as well as men."

Though research has led to dramatic advances over the past 30 years since the first case of AIDS was reported in the United States, the epidemic has rapidly spread since Elizabeth Taylor testified more than two decades ago. At that time, 1,000 people became infected every single day in the U.S. Now, worldwide, a staggering 7,100 people are newly infected every 24 hours, more than 33 million people are living with HIV globally, and 1.8 million die annually from the disease.

But Dame Taylor's words offered hope as well: "An unprecedented health crisis is upon us, one that threatens in one way or another virtually all of our lives. A heroic, 'round-the-clock fight is being waged by our scientists against AIDS to find methods of prevention and treatment. Truly promising leads have been discovered that offer hope. Future therapies may even make possible a cure for those already afflicted." She spoke of the urgent need for greater investments in HIV/AIDS research, prevention and treatment -- and she called for a cure for the disease as well.

Twenty-five years later, we are at a turning point in the eradication of the epidemic. This year, UNAIDS released a new report, "AIDS at 30: Nations at a Crossroads," which contains three bold objectives: zero new HIV infections, zero discrimination and zero AIDS-related deaths. Our successes toward achieving these goals are finally within reach. The number of new infections -- 2.6 million in 2009 -- represents a 19 percent decrease from the peak incidence in 1997. The number of deaths from HIV also continues to decline, from 2.1 million in 2004 to 1.8 million in 2009.

Groundbreaking research has produced lifesaving antiretroviral medications (ARVs) that have revolutionized HIV/AIDS treatment and lengthened life expectancy worldwide for those people who have access to this therapy. As a result, there is a rapidly increasing number of people living with HIV who grow into old age and pass away from causes unrelated to HIV -- a testament to the power of these therapies. The use of ARVs has virtually eliminated maternal-to-child transmission of HIV infection in the United States; if there were resources for every nation to expand access to these medications, the same could be achieved globally, producing an HIV-free generation for the first time in the history of the epidemic worldwide.

Prevention technologies have also advanced dramatically and are cost-effective as well. The Institute of Medicine (IOM) recently released a report that underscored the importance of prevention in the long-term response to HIV/AIDS and its return on investment underscoring that every prevented HIV infection saves an estimated $355,000 in medical treatment costs.

At the beginning of the epidemic, since there were no ARVs at that time, preventing the spread of the virus focused on avoiding infection through education, safe-sex practices, syringe exchange programs as well as ensuring an HIV-free blood supply. However, in recent years, the tools in our prevention toolbox have grown significantly. From 2005-2007, important studies showed that adult male circumcision could reduce the risk of HIV infection. A study conducted in African women demonstrated that a 1 percent tenofovir microbicidal vaginal gel reduced overall HIV infection by 39 percent and by 54 percent among women who regularly used the compound . In December 2010, research demonstrated that the commonly used, once-daily emtricitabine−tenofovir (FTC−TDF) ARV combination pill could be used as pre-exposure prophylaxis (PrEP) to prevent acquisition of the virus in men who have sex with men (MSM). This randomized, placebo-controlled, double-blind trial demonstrated a 44 percent decrease in the incidence of HIV infection between the control and study groups. Efficacy grew to 92 percent among men who fully adhered to the prevention regimen, as confirmed by medication blood levels.

Just this month, findings from two other studies confirmed that this drug combination used as PrEP was also effective in preventing HIV infection in heterosexual couples. Moreover, advances from groundbreaking research released in May found that early treatment of an HIV-infected partner with ARVs dramatically decreased the risk of transmission to the uninfected partner by 96 percent, underscoring that treatment is also prevention. This means that the drugs responsible for saving the lives of millions of HIV-infected people over the past two decades appear to have the power to prevent new infections as well. And some scientists believe that if access were greatly expanded to these medications worldwide, the disease could potentially be eradicated within decades.

Additionally, after more than 80 unsuccessful clinical trials, scientists are finally making significant progress in the quest to develop a HIV vaccine to prevent the disease from occurring in the first place. The secret behind HIV's treacherous ability to elude the immune cells that police the body for unwanted infections lies partly in the virus' rapid mutations. While a person may become infected with one HIV strain, that single virus type can rapidly mutate into a million different iterations, effectively making it unrecognizable to disease-fighting immune cells. This ability to quickly mutate has thwarted vaccine efforts thus far. However, recent studies are showing partial efficacy of new vaccines, and with innovative developments in state-of-the-art three-dimensional viral modeling, scientists have discovered a section of the virus that does not appear to mutate, providing a potential target for an effective HIV vaccine in the future.

Lastly, the discovery of a cure for AIDS is finally on the horizon. Recently, a man nicknamed the "Berlin patient" has become the first person to whom the word "cure" has ever been applied. This formerly HIV positive man appears to have been functionally cured through a bone marrow stem-cell transplant for his leukemia using cells from a donor immune to HIV (about 1 percent of Caucasians carry this immunity). During the transplant process, the patient's own HIV infected white cells were wiped out and the donor's bone marrow stem cells took their place. Since that time, the patient has become HIV negative and no longer requires treatment with antiretroviral medications, providing evidence that a cure may have been achieved. This unique and fascinating case is providing clues in the roadmap to discovery of a cure and a glimmer of what continued leadership and funding might yield. amfAR, The Foundation for AIDS Research has spearheaded multi-site research collaborations and awarded grants to find a cure for AIDS, and the NIH recently provided $14 million in new funding to foster public-private partnerships toward this goal.

Three decades of scientific successes with rapidly accelerating progress in recent years underscores that we can end AIDS and provides strong evidence for why increased investments in treatment and prevention strategies are urgently needed. While U.S. funding for global health including HIV/AIDS accounts for only one-quarter of one percent of America's budget, this strategic investment saves millions of lives annually. Alarmingly, however, this year, the global fight against HIV/AIDS is facing the first decline in international resources in a decade, despite the huge unmet need that still remains. The world continues to face challenges in finding a way to ensure access to lifesaving HIV/AIDS treatment for all those who need them in the United States and worldwide. Shamefully, as of 2008, only 42 percent of people globally who needed treatment had access to lifesaving therapy. Today, fewer than 50 percent of HIV positive women who require services to prevent transmission to their infant can get this treatment. That means 10 million people in low and middle income countries, including 1 million children, do not receive the HIV/AIDS therapies that they urgently need. A recent amfAR report projects the human impact of proposed cuts to global health funding in the FY2012 budget by the US House of Representatives Budget Committee. The proposed funding cuts could potentially put lives at stake resulting in more than 47,000 infants globally becoming infected with HIV as a result of reductions in services to prevent mother-to-child transmission. Furthermore, these proposed budget decreases could result in the elimination of AIDS treatment for an estimated 654,254 people in the developing world, putting lives at stake. In the United States, up to 30 percent of HIV-positive Americans are not receiving care, and there are more than 8,000 people on the National AIDS Drug Assistance Program (ADAP) waiting list who need antiretroviral therapy. Furthermore, the proposed FY2012 budget cuts could result in a $400 million funding decrease for AIDS research at the National Institutes of Health, a significant setback for the prospect of new scientific discoveries.

The bottom line: in just the last five years, research has shown that the possibility of combining proven public health approaches (e.g. education, safe sex practices including condom use, syringe exchange programs and ensuring the safety of the blood supply) with new breakthrough prevention strategies (including pre-exposure prophylaxis with oral and topical ARVs, male circumcision and early treatment-as-prevention to reduce HIV transmission), is no longer just a goal, but a reality. Already, medications can prevent mother-to-child transmission of HIV, meaning an HIV-free generation is within our grasp, and we have new evidence that these medications can prevent transmission from infected to uninfected partners as well. ARVs are extending lives to old age -- almost unimaginable when this epidemic began. These important scientific advances provide evidence that there can be an end to the pandemic globally.

If there is to be a world without AIDS, then countries must work together to strengthen efforts and commit the resources that are needed to achieve this goal. Innovative initiatives like the President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the U.S. National AIDS Strategy are integral in the progress against HIV/AIDS. These initiatives must be fully supported and strategically deployed in the scale-up to their programs, including implementing treatment as prevention and targeting interventions to population groups most at risk. Global investments in research are the foundation of these efforts, paying lifesaving dividends. Landmark new findings must be put into practice now. Science must also be expanded in the years ahead to discover effective, lower cost, innovative approaches to treatment, testing and prevention, including a vaccine and a cure. Additionally, the drivers of the epidemic -- poverty, lack of education, stigma, gender inequities and discrimination -- must be eliminated. As Dame Taylor testified 25 years ago, "It is my hope that history will show that the American people and our leaders met the challenge of AIDS rationally and with all the resources at their disposal, for our sake and that of all humanity."

Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. She is also a Clinical Professor at Georgetown and Tufts University Schools of Medicine and Chair of the Global Health Program at the Meridian International Center. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. She is the Public Health Editor of the Huffington Post. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the US Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. She is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association and was named a 2010 Rock Star of Science by the Geoffrey Beene Foundation.
Melissa Shive is a medical student at the University of California, San Francisco and will be pursuing a Master of Public Health Degree (M.P.H.) at Harvard University this fall. She served as a Research Assistant at amfAR, The Foundation for AIDS Research in Washington, DC, was a Fulbright Fellow, and graduated with honors from the University of Pennsylvania.

References

Karim QA, Karim SSA et al. Effectiveness and Safety of Tenofovir Gel, an Antiretroviral microbicide, for the Prevention of HIV Infection in Women. Science. 2010; 329 (5996): 1168-1174.
Grant RM, Lama JR, et al. "Preexposure chemoprophylaxis for HIV prevention in men who have sex with men." N Engl J Med. 2010 Dec 30;363(27):2587-99.
3 amfAR, The Foundation for AIDS Research, FY2012 Global Health Funding Proposals: Projecting the Human Impact, July 2012.