Written in collaboration with Melissa Shive
Now more than ever, this year's World AIDS Day marks unprecedented progress toward ending HIV/AIDS and providing proof that investments in research, treatment, and prevention are yielding lifesaving dividends. While there still remain significant challenges in achieving a world without AIDS, we now have roadmaps to get us there. This week, the U.S. Department of State released the "PEPFAR Blueprint: Creating an AIDS Free Generation," and last year, the United Nations signed the 2011 Political Declaration on HIV/AIDS, which is a global strategy to achieve universal access to HIV prevention, treatment, and care by 2015. These documents are historic milestones and underscore that we are at a tipping point -- the beginning of the end of AIDS -- if we intensify efforts, work together, and commit the needed resources.
Here's why: As a result of global initiatives and programs, AIDS-related deaths have dropped by more than 25 percent between 2005 and 2011 worldwide. There are now 700,000 fewer new HIV infections in the world annually than there were a decade ago. In 25 low- and middle-income countries (most located in southern Africa), rates of HIV infection have dropped by 50 percent or more since 2001. In sub-Saharan Africa, AIDS-related deaths have decreased by one-third in the past six years and the number of people on HIV medication has increased by 59 percent in the last two years alone. Recent studies have demonstrated that treatment of HIV/AIDS with antiretroviral (ARV) medication reduces transmission rates by 96 percent, underscoring that treatment is also prevention. By ensuring that more people have access to ARVs, new HIV infections can be dramatically reduced.
Furthermore, several other milestones herald the hope for a world without AIDS in the future: the discovery and FDA approval of ARV drugs to use as pre-exposure prophylaxis (PrEP) to prevent HIV infection in high risk groups, significant declines in mother-to-child transmission of HIV, expansion of comprehensive education programs, testing and counseling, and the scale-up of other proven prevention measures, including regular condom use and medical circumcision.
However, despite these advances, the epidemic of HIV/AIDS is far from over. According to the most recent statistics from UNAIDS, there are still 2.5 million new HIV infections worldwide and 1.7 million deaths annually from this disease. Globally, there are 34 million people living with HIV and half do not know their HIV status. Nearly half of the people in need of antiretroviral treatment (6.8 million) do not have access to these life-saving medications, and as many as 50 percent of them will die within 24 months if they do not receive therapy. Sub-Saharan Africa continues to carry a disproportionate burden of disease, representing 69 percent of all people infected with the virus worldwide. The United States and countries across the globe must continue to take action against this deadly virus.
Moving forward, an effective vaccine and a cure for HIV/AIDS will be needed to finally end the global pandemic. On this front, scientists are making significant progress in developing an HIV vaccine. HIV's ability to mutate has thwarted vaccine development, but recent studies have shown 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 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, which is 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 efforts 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 and commitment from countries around the world if we are to achieve a world without HIV/AIDS in the years ahead.
To provide a roadmap for further accelerating progress toward a world without HIV/AIDS, on Thursday, U.S. Secretary of State Hillary Rodham Clinton released the U.S. government's "PEPFAR Blueprint: Creating an AIDS Free Generation," which provides a roadmap to achieve this goal. The PEPFAR blueprint's aim is to control the AIDS epidemic in the next 4-5 years by providing more people with medications to treat the disease, circumcising men in countries that have a high HIV prevalence, and ensuring that all pregnant women who are HIV-positive receive treatment. When these interventions are provided in combination, the number of new HIV infections annually could be reduced below the number of people who are put on ARVs. This would tip the scales on the epidemic and set a trajectory to achieve an HIV-free generation with zero new AIDS-related deaths, zero new infections, and no children who are orphaned because their parents have died of this disease. The blueprint includes five primary goals with action steps to achieve them:
1. Scale up combination prevention and treatment:
- Work toward the elimination of new HIV infections among children by 2015 and keeping their mothers alive.
- Increase coverage of HIV treatment both to reduce AIDS-related mortality and to enhance HIV prevention.
- Increase the number of males who are circumcised for HIV prevention.
- Increase access to and uptake of HIV testing and counseling, condoms, and other evidence-based and appropriately-targeted prevention interventions. PEPFAR now provides 5.1 million people with medications and the Global Fund has provided 4.2 people with these drugs since it was established in 2002.
2. Going where the virus is: Target evidence-based interventions for populations at greatest risk
- Target HIV-associated tuberculosis and reduce co-morbidity and mortality.
- Increase access to and uptake of HIV services by key populations.
- Partner with people living with HIV to design, manage and implement HIV programs responsive to and respectful of their needs.
- Strengthen PEPFAR 's continued focus on women, girls, and gender equality.
- Reach orphans and vulnerable children (OVC) affected by AIDS and support programs that help them develop to their full potential.
- Strengthen programmatic commitment to and emphasis on reaching and supporting young people with HIV services
3. Promoting sustainability, efficiency, and effectiveness
- Strengthen PEPFAR supply chains and business processes to increase the efficiency of U.S. investments.
- Increase efficiencies through innovation and greater integration of services with other U.S., bilateral and multilateral global health investments, including the Global Fund.
4. Creating an AIDS-free generation requires a global effort
- Partner with countries in a joint move to country-led, managed, and implemented responses.
- Increase support for civil society as a partner in the global AIDS response.
- Expand collaboration with multilateral and bilateral partners.
- Increase private sector mobilization toward an AIDS-free generation.
5. Science must continue to guide our efforts
- Leverage greatest impact by continuing to invest in implementation science.
- Support implementation research.
- Evaluate the impact of optimized combination prevention.
- Support innovative research to develop new technologies for prevention (e.g., microbicides, vaccines) and care (e.g., new treatments or treatment regimens).
- Develop evidence-based approaches to reaching people early enough in their disease progression to help maintain a strong immune system, stave off opportunistic infections, particularly TB, and reduce new HIV infections.
- Support the deployment of suitable technology for measurement of viral load, both through tiered laboratory networks and "point-of-care" tests as they become available.
- Assist countries in adopting breakthrough new technologies with proven impact, such as new molecular-based TB tests that have dramatically reduced time to diagnosis and treatment for people living with TB and HIV.
The PEPFAR Blueprint reflects the Obama Administration's investments in "smart power," with the tools of health, education, and development as essential components of our national foreign policy. It underscores that we now have the tools to end the epidemic, but we must scale-up what works and deploy these tools strategically to reach the most vulnerable populations worldwide. Investments in ending AIDS are also building the health systems to address and prevent other infectious and chronic diseases -- saving lives and resources as well.
In this regard, it is important to note that foreign aid has traditionally been the major source of funding to fight the AIDS epidemic worldwide, but for the first time in history, UNAIDS reports that domestic investments by low- and middle-income countries to address their own HIV/AIDS epidemics surpassed global giving for these programs. From 2001-2011, 81 countries have assumed more shared responsibility in addressing the disease by increasing their own nation's contributions by more than 50 percent despite the global economic crisis.
The United States, however, is the largest source of global health funding to end the AIDS epidemic. While surveys show that many Americans believe that 25 percent of our nation's budget is spent on global health and development, the amount is actually less than 1 percent. Congress is now debating an 8.2 percent across-the-board funding cut to most non-defense discretionary programs using FY 2012 appropriations levels. amfAR, the Foundation for AIDS Research, has conducted an analysis that applies sequestration cuts to U.S. government global health programming, and it reveals there would be minimal impact on deficit reduction, but it would devastate the lives of tens of thousands of people globally. For example, the report estimates that if the sequestration of U.S. government bilateral global health support should occur:
- HIV/AIDS treatment for 276,500 people will not be available, potentially leading to 63,000 more AIDS-related deaths and 124,000 more children becoming orphans.
- 112,500 fewer HIV-positive pregnant women will receive services to prevent maternal-to-child transmission, leading to more than 21,000 infants being infected with HIV.
- Funding for food, education, and livelihood assistance will not be available for nearly 359,000 children.
- About 60,000 fewer people with tuberculosis (TB), the leading cause of death for HIV positive people, will receive treatment, leading to 7,000 more deaths due to TB, and 300 fewer people with multi-drug-resistant TB will receive treatment. About 1.3 million fewer pentavalent vaccines for children will be available through GAVI, leading to 14,000 more deaths from diphtheria, tetanus, pertussis, Haemophilus influenza type B, and hepatitis B.
On the global front, leaders convened last year for the 2011 U.N. General Assembly High Level Meeting on AIDS and adopted the 2011 Political Declaration on HIV/AIDS. Listed below are 10 specific targets in the declaration that are critical components of a global strategy to achieve universal access to HIV prevention, treatment, and care by 2015. Turning the tide on HIV/AIDS in the next 1,000 days to meet these 2015 targets will require increased research, financial investment, and political commitment to finally end the epidemic in the years ahead by 1) making the needed scientific discoveries, 2) scaling up effective interventions, and 3) building the health systems infrastructure needed to transform what has been an emergency response to the epidemic into a sustained multi-faceted, multi-sector response in all countries.
1. Reduce sexual transmission of HIV by 50 percent by 2015.
Sexual transmission remains the primary route of new HIV infection globally and is a key area of focus for eliminating new HIV infections. Female sex workers are 13.5 times more likely to be living with HIV than women in the general population. Based on a survey conducted in capital cities worldwide, HIV infection among men who have sex with men (MSM) is, on average, 13 times higher than that of the general population. A median of only 38 percent of MSM have been tested for HIV in the prior 12 months. Condoms are essential tools to prevent sexual transmission of HIV, yet it is estimated that low- and middle-income countries procured only 2 billion condoms in 2010, far short of the estimated 13 billion condoms required to reach the HIV prevention goals for 2015. PrEP must be considered as strategy for preventing HIV/AIDS among these high risk groups.
2. Reduce transmission of HIV among people who inject drugs by 50 percent by 2015.
About 3 million of the estimated 16 million people who inject drugs are living with HIV, and these individuals have an HIV prevalence rate that is 22 times higher than the general population. In particular, women who inject drugs are at a much high risk of exposure to HIV because they are also more vulnerable to other risk factors like partner violence, homelessness, and comorbid mental disorders that increase vulnerability to infection. In the U.S., an important step forward is to lift the federal ban on syringe exchange, which is an evidence-based, proven intervention that decreases transmission rates of blood-borne diseases including HIV and hepatitis.
3. Eliminate new HIV infections among children by 2015 and substantially reduce AIDS-related maternal deaths.
In just the last two years, rates of new infections in children have dropped by 24 percent, but 72 percent of children living with HIV who are eligible for HIV medications still do not have access to them. Pregnancy-related deaths in women living with HIV have declined from 46,000 to 37,000 globally from 2005 to 2010. However, still only 30 percent of treatment-eligible pregnant women received antiretroviral treatment in 2011. To achieve an AIDS-free generation, it is essential to provide ARV therapy to pregnant women to prevent transmission to their babies as well as to ensure that all children worldwide who are HIV-positive receive treatment.
4. Reach 15 million people living with HIV with lifesaving antiretroviral treatment by 2015.
Antiretroviral therapy has saved an estimated 14 million life years in low- and middle-income countries, and the number of people accessing antiretroviral treatment has increased by 63 percent from 2009 to 2011. However, 7 million people eligible for HIV treatment still do not have access to these life-saving medications. The U.S. has pledged to ensure that 6 million people are on ARVs through PEPFAR programs by 2013 to help reach this goal.
5. Reduce tuberculosis deaths in people living with HIV by 50 percent by 2015.
While tuberculosis-related deaths have fallen by 25 percent from 2004, it remains the leading cause of death for people living with HIV, even though it is known that starting antiretroviral therapy immediately upon diagnosis can reduce the risk of TB illness by up to 65 percent.
6. Close the global AIDS resource gap by 2015 and reach annual global investment of $22-24 billion in low- and middle-income countries.
Spending on HIV/AIDS programs increased by 11 percent from 2010 to 2011, with domestic spending by low- and middle-income countries rising by 15 percent and now accounting for the majority of total HIV spending globally for the first time in the history of the epidemic. However, global investment on the disease in 2011 was $16.8 billion, which is still significantly short of the $22-24 billion goal for 2015.
7. Eliminate gender inequalities and gender-based abuse and violence and increase women and girls' ability to protect themselves from HIV infection.
Women account for 58 percent of people living with HIV in sub-Saharan Africa and represent 68 percent of people with access to antiretroviral therapy in low- and middle-income countries. Gender inequalities and power imbalances in relationships between men and women make it difficult for women to negotiate safer sex practices or use interventions that could protect them from HIV infection. In 26 of 31 countries with generalized epidemics, fewer than half of young women have accurate knowledge about HIV transmission, treatment and prevention. And while 57 percent of pregnant women living with HIV in low- or middle-income countries received antiretroviral medicines to prevent maternal-to-fetal transmission, only 30 percent of them receive these medications to treat the disease to safeguard their own health. Ensuring that women receive treatment after giving birth to a baby is essential for advancing women's health in the developing world as well as to prevent a generation of children growing up without mothers who have died from HIV/AIDS.
8. Eliminate stigma and discrimination against people living with and affected by HIV through promotion of laws and policies that ensure the full realization of all human rights and fundamental freedoms.
Fear, ignorance, stigma, and discrimination continue to undermine efforts to provide services to prevent, diagnose, and treat HIV/AIDS, and these social and structural barriers to care continue to be major hurdles for many vulnerable populations. For example, 52 percent of people living with HIV in Zambia reported verbal abuse because of their HIV status, and 1 in 5 people living with HIV in Nigeria and Ethiopia reported suicidal thoughts and behaviors. As of 2012, about 60 countries have laws that specifically criminalize HIV transmission, and 40 percent of U.N. member states criminalize same-sex sexual relations. Nearly 40 percent of countries do not have laws in place that protect people living with HIV from discrimination and the laws that do exist are often inadequate. Efforts to shatter stigma surrounding HIV/AIDS, particularly among high-risk vulnerable populations including MSM, LGBT, sex workers, and people who inject drugs are needed to support a human rights-based AIDS response.
9. Eliminate HIV-related restrictions on entry, stay, and residence in countries around the world.
Current restrictions on the entry, stay, and residence of people living with HIV in countries lack a scientific basis and are often relics of the fear and discrimination dating from early in the epidemic. While many countries have lifted these outdated policies, including the United States in 2010, 45 countries still have laws restricting entry, stay, and residence for people living with HIV and will require concerted efforts to educate policymakers and the public to enact legislation that permits travel and immigration for people who are living with HIV.
10. Eliminate parallel systems for HIV-related services to strengthen integration of the AIDS response in global health and development efforts, as well as to strengthen social protection systems.
A comprehensive approach to ending AIDS means integrating HIV-related services into existing health systems structures, allowing countries to leverage HIV-related achievements into broader health and development programs, which will, in turn, improve the long-term sustainability of these programs and interventions in nations globally. Furthermore, intensified efforts are needed to address the social and economic drivers of the epidemic including improving essential services like housing, education, and employment opportunities.
Global achievements on these 10 U.N. targets and on the goals for the PEPFAR Blueprint thus far demonstrate that with continued funding for research, treatment, care, and rapid scale-up of programs that have proven effective, the goal of universal access to medication and care as well as elimination of new HIV infections is attainable. While global progress is accelerating toward these goals, there is still much more work left to be done. Greater effort must be made to reach vulnerable populations who are disproportionately affected by the epidemic that programming has failed to effectively reach (including MSM, sex workers, and people who inject drugs) thus far. Investments in science are needed to discover a cure for AIDS as well as to develop a safe, effective vaccine to prevent HIV infection.
This World AIDS Day is a celebration of the achievements that have been made and the acceleration of progress in recent years, providing proof that ending the HIV/AIDS epidemic is not only feasible but achievable. The PEPFAR Blueprint is an important roadmap to get us there. However, continued public and policymaker support and increased resources are urgently needed to scale-up programs that work and to invest in innovative research so that we can achieve a world without AIDS in the future.
amfAR. "September 2012 Update: The Effect of Budget Sequestration on Global Health: Projecting the Human Impact in fiscal year 2013." The Foundation for AIDS Research. September 25, 2012.
UNAIDS. "2012 UNAIDS Report on the Global AIDS Epidemic." Nov. 20, 2012.
UNAIDS. "Global AIDS Epidemic Facts and Figures." Nov. 20, 2012.
United States Department of State. "PEPFAR Blueprint: Creating an AIDS-free Generation." Nov. 29, 2012.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the public health editor of The Huffington Post. She is also the senior policy and medical advsior at amfAR, the Foundation for AIDS Research, a senior fellow in health policy at the New America Foundation in Washington, D.C., 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, and as senior global health advisor in the U.S. Department of Health and Human Services. She also served as a White House advisor on health. Prior to these positions, Dr. Blumenthal was chief of the Behavioral Medicine and Basic Prevention Research Branch and head of the Suicide Research Unit at the National Institutes of Mental Health and chair of the Health and Behavior Coordinating Committee at the National Institute of Health. She has chaired numerous national and global commissions and conferences and is the author of many scientific publications. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association and was named 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.
Melissa Shive is currently a medical student at the University of California, San Francisco and a Master of Public Health Degree candidate from Harvard University. She served as a research assistant at amfAR, The Foundation for AIDS Research and was a Fulbright Fellow. Ms. Shive is an honors graduate from the University of Pennsylvania.
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