Debating an End to AIDS

The July 2012 International AIDS Conference brought together thousands of advocates looking to achieve an end to the virus’s epidemic spread. But though some conference participants, including U.S. officials, seemed hopeful that could be achieved in the next decade, a number of worrying trends suggests "we’re beginning to see real trouble in a number of ways that we not necessarily anticipated," says CFR Senior Global Health Fellow Laurie Garrett. With funding pressure growing in the United States and Europe, Garrett says, U.S. officials seemed to be directing their message at Capitol Hill that the money spent so far has been successful and now is not the time to "walk away from this fight." She says "the real challenge in the next period will be to frame HIV appropriately so that the momentum that is specific to this epidemic continues."

Can you lay out the big issues at the International AIDS Conference that have been discussed?

It boils down to two things: The first is the U.S. government perspective that the end of AIDS is attainable--that through a combination of country ownership of their own programs and U.S. government commitment and other donor commitments, we can indeed achieve, as Secretary of State Hillary Clinton put it, "an AIDS-free generation," starting with kids being born today.

The second theme running though the entire meeting is one of deep anxiety about where the money will come from to keep the AIDS effort going forward, since funding has stagnated since the 2008 financial crisis, and for many programs [it] has plummeted. And third: Does the science really support this idea of the end of AIDS? In fact, a lot of the scientific presentations would say quite the opposite--that we’re beginning to see real trouble in a number of ways that we not necessarily anticipated.

You noted in several blog posts that the talk at the conference seems overly optimistic. How much is the discourse disconnected from the situation on the ground?

First of all, let’s be fair to them. They are not claiming that what is in sight is the eradication of the HIV virus. What they’re saying is that they think they can achieve, or they envision in a near future--meaning in the next five to ten years--the end of the epidemic spread of HIV, [with] the actual incidence of new cases starting to not only go backwards but really drop off sharply, heading toward something on the order of only one million new infections a year as opposed to the current 2.5 million new infections worldwide a year. [They are talking about] seeing a complete block in transmission from HIV-positive mothers to their babies, and using some of the new toolkits--like male circumcision and the provision of what’s called prophylaxis treatment, or PREP--to give to HIV-negative people in relationships with infected people.

All these things, plus the belief--and it is a belief, rather than a case of proven science--that by getting a large percentage of a population on treatment, you will so lower the amount of virus circulating in the bodies of all these people that you’ll render it essentially non-infectious. So treatment, they say, equals prevention.

The source of my skepticism--and I believe I reflect the skepticism of scientists all over this meeting--[is that] in the United States, with all the resources we have at hand, we have only managed to actually identify about half of the HIV-infected population in America. More than half don’t even know [they’re infected], so they are not accessing treatment in any way. And even when they get in treatment, we’re only seeing effectiveness in that they’re not infectious to their partners in the 28 percent of the Americans that we get in treatment.

We’re seeing some very disturbing presentations at this meeting that give me plenty of cause to be concerned. One study in Uganda shows there was no protection provided by giving people with HIV plenty of drugs and hoping that being in treatment would eliminate the possibility that they would pass the virus to their sexual partners. A study in Thailand tried giving the prophylaxis form of the drug to injection drug users, heroin users in Bangkok, and found that they were only taking the drugs properly about half the time. If you only take drugs properly half the time, you promote the emergence of drug resistance forms of the virus, and this is a great cause for concern. There’s a lot of concern on why can’t we manage to get to that zero point on the numbers on babies born HIV-positive. The toolkit has essentially been employed since the 1990s; it’s very cheap and easy to do, yet the vast majority of HIV-positive mothers is still not getting access to treatment and therefore they are not able to protect their children from being infected. So we have a long list to go, and the science here says, "Well, let’s hold our horses, it’s time to declare the epidemic is on its way down."

What is this really saying about the state of the fight against HIV?

Since 2008, we’ve seen donor after donor step away from the plate. About half of the European donors are not putting any money at all toward the international effort. The United States is carrying the burden, and by far. We’re not just the number one donor, we are the mega donor. If you combine the private givings of Bill and Melinda Gates with our federal government givings, the majority of the eight million people now receiving antiretroviral treatments for their HIV infection throughout the world are getting it as a result of U.S. support--in fact, six million out of the eight million.

A lot of the rhetoric of this meeting is speaking more to Capitol Hill than to anybody inside the conference. It’s an attempt to say, "This is money well spent, you will get thanked, you will be saving lives. We’ve already saved millions of lives, and we can save millions more." This is not the time to say, "As part of reducing our national debt and reducing our deficit, we should walk away from this fight against the HIV virus."

The problem is that many of these messages get taken quite literally overseas, and there could be a sense [from] communities all over the world where HIV is diminishing, "Oh my goodness, the end is in sight, I don’t need to use a condom anymore, I don’t need to be so worried, we’re going to bring an end to AIDS." Of course, nothing could be further from the truth at this time.

South Africa made an effort to become self sufficient, taking over treatment and prevention programs from the international community. How well has that worked?

South Africa is committed to achieving self-sufficiency not only in its HIV struggle, but also tuberculosis and in providing universal health coverage to its population. They are committed on a course that will certainly increase the percentage of their national budget each year that goes for health, and they are building a vast infrastructure of clinical services even in the most remote areas of the country. There are some great successes and some really sharp warning signs.

They are getting more and more of the population to get tested and to get into treatment [for HIV], and there are some dramatic results in key provinces of the country. However, [there are] two big problems: first, their ability to control the pharmaceutical [supply chain] is turning out to be an issue. They recently have had a stock-out of a number one anti-HIV drug, tenofovir, and it affected access to treatment for 6,000 people. And for many, it meant that their treatment was interrupted, and as we know, the virus is able to mutate when you are not suppressing it properly with medicine. [Second,] they also have shown that the allocation of funding domestically does not meet the needs level, so that politically powerful parts of the country are still getting far more money to fight AIDS, even if their epidemics are very small, than places like KwaZulu-Natal, where the infection rate of young women is well over 50 percent.

Regarding the gender gap, the incidence of HIV among women is very high. What do you see going forward? Is there a glimmer of hope?

The female face of AIDS is a much more visible face than it was a couple of these meetings ago. Women are angry. We’ve had speakers making it clear to the men in the meeting that if there’s going to be any further conversation about any policy related to HIV, the women better be in the room. That goes all the way down to the local level, where in many parts of the world more than 70 percent of new infections are female, because men have many ways to protect themselves but women have no way to protect themselves but by having no sex. For women, if you add in their far lower status in most societies, they are far more likely to be a victim of rape and brutalization; they are unable to control the funds in their families because men control the pockets, and [therefore they are unable] to purchase any ways to protect themselves, including leaving a marriage. These are all issues that have risen very high in the agenda.

What happens going forward?

The next big thing on the global health landscape is going to be 2015, when the Millennium Development Goal (MDG) deadline will arrive but the targets will not have been achieved. This includes three health targets, one of which is to bring the number of infected babies down to zero, cut the epidemics growth rate by half, and have universal access to HIV treatment for at least fifteen million people. We may reach the fifteen million people on treatment, but we will not reach any of the other targets I listed. And the danger is that 2015 will turn into a sense of defeat around the MDGs.

But active debate is going on now about what should be the next MDGs. It looks as though the likely next big thing will be a call for universal health coverage. The real challenge in the next period will be to frame HIV appropriately so that the momentum specific to this epidemic continues and isn’t swallowed up into a much larger health landscape and perhaps loses its energy and its urgency.