How Close Are We to an AIDS-Free Generation?

For now, however, Mahon said the same people most affected by HIV are also those most poorly served by both the existing prevention and medical systems.

Robert C. Gallo, MD, the microbiologist who in 1984 proved HIV causes AIDS and created the first HIV blood test, said the first thing political leaders should do is not make promises. He recalled President Richard Nixon's 1971 war on cancer and President Bill Clinton's 1997 call for an HIV vaccine within a decade.

Gallo said "the most rapid and surest way to really do something" is to "test and treat, and more testing and treating." If done extensively, he said it "could lead to a major decline in the epidemic, and epidemics not kept 'kindling' tend to end."

In fact, the U.S. Preventive Services Task Force, which advises the Department of Health and Human Services and the nation's physicians on the medical evidence for preventive health measures, recommended that nearly everyone between ages 15 and 65 should be tested for HIV, even if they are not at high risk of infection. Evidence suggests that learning of their infection as early as possible leads people who have HIV to access treatment and adopt safe-sex behaviors. The guidelines currently are open for a 30-day public comment period. Final recommendations will be released next year.

A truly successful vaccine "will of course end the epidemic," said Gallo. "It would halt new infections, period." For those with the virus, molecular-based approaches are being researched "which could, in theory, lead to real and total cures."

But, Gallo added, "I have no idea when, and these approaches will likely be limited for the industrial nations, and application for all is impossible to predict. It will heavily depend upon the simplification of the approaches and economics."

Measuring success

"In this field, success breeds success," said Stefano Bertozzi, MD, PhD, director of the Bill and Melinda Gates Foundation's HIV program, one of the world's largest private funders of HIV vaccine, diagnostics and biomedical research. He said the "aspirational goal" is to stop people from dying from HIV.

Even without a vaccine or cure, Bertozzi said a transformation is needed "in the provision of HIV services away from how many people receive a service to how many people derive a benefit from what is produced." He explained, "It's insufficient to count the number of people taking antiretrovirals. That is not our goal. Our goal is to extend life through the use of [medications]."

In 2013, the Global Fund to Fight AIDS, Tuberculosis and Malaria--a public-private partnership and international financing institution--will begin a new funding cycle. In the U.S., both the global PEPFAR program and domestic Ryan White Program will be up for reauthorization. "A huge part of the equation is making sure they are funded into the future," said Bertozzi.

But it's not only that. "There is an opportunity to invest more intelligently," he said, "to make sure that we are investing in the most effective interventions and make sure they are most focused on populations at greatest risk."

Success is possible only with supportive policies, political will in action, including the potential new mandate for universal HIV testing and the Affordable Care Act's guarantee of access to medication for those who test positive. But even with the right policies, the tools that are available to curb HIV are only effective when they are actually used.

As Carl Schmid, deputy executive director of the Washington, D.C.-based AIDS Institute, put it, "The policies are in place, but now we need to implement them. The doctor still has to offer the HIV test."

Success also requires the update of archaic state policies and laws, such as those that criminalize HIV-positive people for not disclosing their HIV status to sexual partners, even if their virus is medically managed at an undetectable level, they practice safe sex, and there is no actual harm (HIV infection) to an HIV-negative partner.

Catherine Hanssens, executive director and founder of the New York-based Center for HIV Law and Policy, said by e-mail, "It is difficult to see how we can effectively encourage early diagnosis and treatment, and prevent new cases of HIV, while we have government policies and laws that single out HIV for punitive treatment." When people risk an extremely long prison sentence simply for not telling--even if he or she also wasn't asked--about their HIV status, regardless of what actually went on, too many prefer not to know, risking their own health and that of their partners.

It is also difficult to see how, short of achieving the Holy Grail of a vaccine, success can be possible when current policy in the U.S. now accepts the status quo of 56,300 new HIV infections a year. Without seriously reimagining prevention interventions, those numbers will continue, thousands more will struggle and suffer and perhaps infect others with what is, after all, still a deadly virus.

Yet innovation in prevention is stifled by equally archaic laws limiting federal funding for HIV prevention to only the least "offensive" materials possible. Rather than the 'targeted, explicit' prevention messages public health experts advocated as early as 1986, the 1987 "Helms Amendment" continues to limit what is considered acceptable. The result is inoffensive--and ineffective, as new HIV infection rates attest. Clearly those most at risk are not being effectively reached.

B.R. Simon Rosser, PhD, professor and director of the HIV/STI Intervention and Prevention Studies Program at the University of Minnesota School of Public Health, told me, "Clearly if you only fund mediocre safer programming, then you only have mediocre safer intervention outcomes." For example, he said that instead of assuming--as is currently common--that "behavioral interventions don't work for gay men" it would be more accurate to say "mediocre, boring and non-controversial interventions don't work for a community which is not mediocre, sanitary boring or non-controversial."

Stephen F. Morin, PhD, director of the Center for AIDS Prevention Studies and the AIDS Policy Research Center at the University of California-San Francisco, who has worked on HIV policy issues since the beginning of the epidemic, also advises greater articulation where it comes to talk about the AIDS-free generation.

"Essentially what people are really talking about is the ability to control the epidemic, not get rid of it," said Morin. "Since we don't seem to be able to get much more than 25 to 30 percent of the U.S. [HIV+] population virally suppressed, there is a lot of work to be done. Even in a control strategy, you would have to detect more cases. You would not only have to link them to services, but get them in the kind of specialty care and support services that would result in long-term viral suppression. All that is tough."

Morin echoed Mahon in calling for political leaders to risk political capital to actually fund and implement their blueprints and road maps.

"I love the National HIV/AIDS Strategy," said Morin. But right now, he added, Washington's budget priorities don't reflect the level of commitment it will take to implement it.

"Budgets are statements of your values," explained the former staffer for Representative Nancy Pelosi. "If you really wanted an AIDS-free generation, you would have a budget for it."

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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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