THE END OF AIDS?

People made a brazen proclamation last year: The end of AIDS is approaching.

The fight against AIDS is not yet over and still requires a

lot of funding and resources at a time when both are at

a premium. Photo by: Jamison Wieser / CC BY-NC-SA

What began as a mysterious affliction of the few and eventually infected 59 million people globally will be the topic of discussion for around 25,000 participants at this year’s International AIDS Conference in Washington, D.C. In between scientific presentations, high-level speeches and rowdy side debates, two strands will weave throughout the events: hope that the disease can finally be stopped and fear that no one will do it.

The fight against AIDS is indeed at a critical juncture, with more tools than ever at our disposal for prevention and treatment. But with every success comes the lingering fear that achievement will breed complacency — or disinterest manifested as resources withheld. A push for country ownership is welcome for some aspects of development, but leaves health ministers fretting over the amount of domestic money required if the United States — which funds almost half of the global AIDS effort — claims mission complete and starts winding down support.

In fact, the mission is not complete at all. HIV is the leading cause of death for women of reproductive age, and 2,400 young people aged 15 to 24 were infected with the virus daily in 2011, according to a Joint U.N. Program on HIV/AIDS fact sheet.

African countries are increasingly being asked to find — and fund — their own solutions to the pandemic despite their lack of capacity to do so, experts at Médecins Sans Frontières said in a statement. “Just as success is within reach, we’re up against a great financial squeeze,” Malawian health official Stuart Chuka said. “I truly believe we can end AIDS. But we can’t do it alone.”

The myriad goals of the conference include this recognition that AIDS is not over, and still requires a lot of funding and resources at a time when both are at a premium.

The science of AIDS

The conference will also be a scientific meeting — an opportunity to promote the availability of new prevention tools and share information and experience gleaned from implementing these tools in different settings. The U.S. Food and Drug Administrationannounced July 16 that it approved a pill called Truvada, the first drug shown to reduce the risk of HIV infection.

Conference organizers received 11,715 scientific abstracts for a peer-reviewed selection process covering clinical science, epidemiology and preventive science, and other fields.

Scientists and practitioners alike are keen to celebrate the success achieved in recent years. Last year’s announcement forecasting the “end of AIDS” has been supported by small global decreases in new infections and AIDS-related deaths, and increases in the number of people receiving antiretroviral therapy. New infections in children fell by nearly a quarter since 2009.

“The conference comes at a time when we have the opportunity to make a final effort in reducing or eliminating HIV,” Abt Associates HIV and AIDS expert Liza Solomon said. “The question of course is, are we able to take advantage of these opportunities?”

The economic crisis in general, and the stagnation of HIV and AIDS funding in particular, are major concerns for those who recognize that despite having more tools than ever at our disposal, applying them costs money and requires difficult choices.

Money matters

Questions over funding will be front and center at the conference. Global health resources peaked a few years ago at around $27 billion per year, and are now contracting with near-term growth unlikely, according to an essay by J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies.

Nontraditional donors, including BRICS countries, will be on the spot to step up and help diversify funding for HIV and AIDS. They’ve actually done just that in recent years: Low and middle-income countries invested $8.6 billion into the response in 2011, up 11 percent year on year. Meanwhile, international funding remained at 2008 levels ($8.2 billion), according to UNAIDS.

On a country level, there is a lot of interest in identifying how to use national funds in combination with donor funds to have the most impact, and how to allocate resources efficiently and strategically, according to Donna Sherard, senior HIV communications adviser at Population Services International’s sexual reproductive health and tuberculosis department.

Treatment versus prevention

While strategic distribution of resources sounds obvious, it’s extremely contentious when those resources are life-saving medications or prevention tools. 

Most countries currently get medicine to 50 to 60 percent of those eligible. With a new focus on treatment as prevention like Truvada, there will be a push to get medicines to people who aren’t even infected yet but are deemed “high risk.”

This reframing of the treatment versus prevention debate might preclude the shouting matches said to have erupted when the topic came up at the plenary session of the last International AIDS Conference in Vienna. “What we’ve learned is prevention is treatment and we can’t look at them as being in conflict with each other,” Solomon said.

But with too few resources to get medications to all those who could benefit from them, it isn’t clear who should decide the priorities.

That is a tough moral decision, and one that complicates programming with choices that could pit public health against clinical needs, according to John Palen, an international health expert also with Abt Associates.

Palen forecast controversy at the conference over the use of antiretrovirals for prevention. Some groups already strongly opposed Truvada, claiming it could reduce compliance with other preventive measures like wearing condoms or reducing the number of sexual partners.

Social constructs

More tension could arise over the “medicalization” of HIV, according to Solomon. People infected with HIV often have a lot of social issues requiring support, and giving them a pill and calling the problem solved would be naïve, she said.

These social issues are even more apparent when dealing with marginalized populations at high risk, like men who have sex with men, or commercial sex workers. Conference attendees may find themselves in the middle of contentious debates over how strongly donors should insist governments support a human rights-based approach to prevention.

By not mandating that certain countries reform the punitive policies they have toward certain populations — arresting women who are found in possession of condoms, or criminalizing homosexuality for example — much of what we’re trying to do will not be accomplished, Palen said. “For any of these policies to work there needs to be a change in the ways those populations are dealt with,” he said.

Palen believed the United States might be pushed to be more assertive on these issues, and take responsibility for human rights diplomacy. He thought the predicted absence of President Barack Obama at the conference was a missed opportunity for the United States to show leadership and support for AIDS issues.

It’s an agenda that the entire development community, and not just health professionals, should care about, agreed the experts. The conference provides a rare opportunity for people to come together and talk about these larger issues of economics, welfare and social service delivery. Discussions about creating or refining health systems that are responsive to the needs of individuals and marginalized groups can teach other sectors about providing holistic support.

Our collective ability to address HIV and AIDS also exposes a lot about our systems and ourselves, Sherard said. HIV is the “great revealer of all of our opportunities and deficiencies in terms of human rights, equity, marginalization, (and) our ability and willingness to take care of each other,” she said.

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