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.
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."
"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.