How Close Are We to an AIDS-Free Generation?

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Where we stand on what President Obama has declared an achievable goal -- and a top U.S. global priority

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Sydney Opera House on World AIDS Day 2011 [Rick Rycroft / AP]

Ending the AIDS pandemic isn't "merely visionary," says the Joint United Nations Program on HIV/AIDS (UNAIDS). "It is entirely feasible."

There has certainly been enormous progress in curbing the spread of HIV and reducing the number of deaths from the cancers and infections associated with advanced, untreated HIV disease known as AIDS. In 2011, "only" 2.5 million people worldwide were newly infected with HIV, 20 percent fewer than in 2001. "Only" 1.7 million died from AIDS in 2011, a big drop from the peak of 2.3 million in 2005.

Essays and ideas to mark the 24th annual World AIDS Day See full coverage

The number of HIV-positive people receiving lifesaving antiretroviral therapy has increased dramatically, from a mere 50,000 worldwide a decade ago to an estimated eight million today. UNAIDS reports that in the last 24 months alone, the number of HIV-positive people being treated (with antiretroviral therapy) worldwide has increased by 63 percent.

Nevertheless, UNAIDS estimates that 34 million men, women and children are infected with HIV. This means that more than 75 percent of them are not receiving therapy. They remain at extreme risk for serious medical challenges--and are still capable of spreading the virus to others.

Many don't know they are infected because they haven't been tested. In the United States, the federal Centers for Disease Control and Prevention (CDC) estimates there are 1.2 million people living with HIV. As many as one in five of them are believed not to know they are infected.

Of those who do know, the CDC estimates that only 28 percent are receiving and adhering to the medications that can keep their viral level at the optimal undetectable level needed to prevent illness--and reduce their infectiousness by almost 100 percent.

Statistics released by the CDC during the last week of November offer reason for continuing concern about HIV. In 2010 young Americans, 13 to 24 years old, accounted for 26 percent of new HIV infections. Some 57.4 percent were African-Americans, 19.6 percent Latinos, and 19.5 percent whites. Overlapping all the racial/ethnic categories, the vast majority (72.1 percent) of infections, were attributed to male-to-male sexual contact. More than half the youths did not know they were infected.

While an AIDS-free generation may be "feasible," we can't reasonably claim to be "close."

What you mean by 'AIDS-free'

When she first referred to an "AIDS-free generation" in a speech on November 8, 2011, Secretary Clinton was envisioning a world in which "virtually" no children would be born with HIV infection, there would be lowered risk of infection in general, and everyone with HIV would get treatment to keep them well and prevent them from transmitting the virus to others.

A new "Blueprint" from the State Department, unveiled November 29 for World AIDS Day, lays out the U.S. government's vision for creating the AIDS-free generation. The report details how the President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. global HIV/AIDS program and the world's single largest source of funding to combat HIV, will help achieve what it terms "an ambitious, but reachable goal."

The Blueprint's vision statement hones with a poet's precision, and license, the steps and strategies needed to attain this worthy goal: "The United States believes that by making smart investments based on sound science, and a shared global responsibility, we can save millions of lives and achieve an AIDS-free generation."

Ariel Pablos Mendez, assistant administrator for Global Health at the U.S. Agency for International Development (USAID) said in a November 28 statement, "Tipping points are occurring in many countries, where the number of annual new HIV infections is below the annual increase in new patients on treatment, marking the beginning of the end of AIDS."

If the end of AIDS is beginning, what will it take to get to the end?

Time to act

Charles "Chip" Lyons, president and CEO of the Elizabeth Glaser Pediatric AIDS Foundation, a global leader in the effort to eliminate HIV and AIDS among children and their mothers, told me the tools and data now exist to virtually eliminate pediatric AIDS.

"So how important is that to people?" he asked.

He described his earlier work with UNICEF's efforts to achieve universal childhood immunizations. In 1980, only 20 percent of the world's children were fully immunized. By the end of the decade, the number reached 80 percent. Lyons attributed the increase to a "very dramatic policy strategy" and funding that followed the persuasive marshaling of data "demonstrating the do-ability of things" to finance ministers and political leaders.

Lyons called the Blueprint "a very strong promise to the next generation." The challenge, of course, is to keep the promise. "The scientific and research communities have done their jobs," said Lyons, "discovered a number of medicines, drugs, combination therapies that have had and are showing dramatic results. So it's the policy and strategy and funding leadership that is required to make the tools available to the widest number of people."

He added, "The shorthand for that is 'political will.' " Which, of course, is a fancier way of saying "get it done."

Gregory Pappas, MD, PhD, administrator of the District of Columbia Health Department's HIV/AIDS, Hepatitis, STD and Tuberculosis Administration, said the time for planning and personal agendas is past. "Now is the time to act," he said.

Pappas said funding needs to be committed to scale up the National HIV/AIDS Strategy rolled out by the Obama administration in 2010. "A lot of smart people worked really hard to make the [strategy] happen. Get on with the show and implement the National Strategy."

In a 2012 article, David R. Holtgrave, PhD, professor and chairman of the Department of Health, Behavior and Society at Johns Hopkins University Bloomberg School of Public Health, and his colleagues estimated it will cost $15.2 billion to achieve the National HIV/AIDS Strategy's 2015 goals of substantially increasing the nation's HIV prevention efforts and the number of Americans who are tested for HIV and, if positive, linked to treatment.

"We have more political will than we've ever had," said Nancy Mahon, Global Executive Director of the MAC AIDS Fund and chair of the Presidential Advisory Council on HIV/AIDS. "But what we need to do is connect the political will to the appropriations process. Those are very big dots."

Do more of what we know works

"What is the business plan for 'Getting to Zero?' " asked Mahon, referring to the theme of this year's World AIDS Day on December 1. "It's a great tag-line, but how do we actually operationalize that?"

The businesswoman recommends that a group of people--perhaps the Presidential council would be well-suited to the task?--"really think through" the implementation of the Affordable Care Act and what it will mean for people with HIV, and the pending 2013 reauthorization of the $2 billion Ryan White Program which supports primary medical care and essential support services for low-income Americans living with HIV.

Mahon said it's high time to focus on groups hardest hit by HIV--gay and bisexual men, injection drug users and sex workers--and to direct efforts and resources proportionately to programs that focus on reaching them with HIV testing and, importantly, retaining those who test positive in treatment.

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The author of Victory Deferred, John-Manuel Andriote has specialized in HIV/AIDS reporting since 1986. His research materials, correspondence, and recorded interviews are part of a special collection curated by the Smithsonian.

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