World AIDS Day 2011

The Broad Side has graciously allowed me to publish a guest post from Linda Distlerath, my colleague at APCO Worldwide and former Global Executive Director for The Partnership for an HIV-free Generation.

Having worked in the HIV/AIDS field for over twenty years, I find myself each December 1, World AIDS Day, reflecting on how far we have come in tackling the global HIV/AIDS pandemic and contemplating what the future will bring.

This past year marked the 30th anniversary of the first reports from U.S. Centers for Disease Control (CDC) of unusual cases of Kaposi’s Sarcoma and pneumocystis pneumonia in gay men, both later recognized as opportunistic infections associated with HIV infection and diagnostic of “full-blown” AIDS. Hence, 1981 is seen as the beginning of the HIV/AIDS epidemic in terms of public attention to a frightening and previously unknown infectious threat.

Over the next fifteen years, much effort was focused on the scientific, clinical and epidemiological aspects of HIV infection and AIDS with significant investment by the U.S. government through the National Institutes of Health and the CDC among other government agencies, along with the research-based pharmaceutical industry. Many results were clear: HIV was definitively identified as the cause of AIDS, HIV is transmitted through bodily fluids (blood, semen, vaginal secretions, breast milk) and not by casual contact, and the clinical course of infection from initial exposure to HIV to death from AIDS over an 8-10 year period was elucidated. But clear results did not deter the stigma and discrimination facing those with HIV/AIDS, nor the spread of misinformation about how HIV is transmitted, and unfortunately this continues to thwart more rapid progress in the prevention and treatment of HIV/AIDS today around the world.

But 1996, the 15 year mark of the HIV/AIDS epidemic, was a watershed year for science, the industry and people living with HIV/AIDS, at least in the U.S., Europe and other health resource-rich regions. In that year, the notion of the “triple combination cocktail” of antiretroviral drugs to treat HIV infection—taking viral load to undetectable levels for prolonged periods – came to life, and indeed brought life back to those ravaged by AIDS. The international AIDS conference that July in Vancouver was marked with a celebratory and jubilant mood among the 15,000 attendees. The tide had indeed turned after 15 years of effort and billions of dollars of investment in research laboratories both public and private, academic medical centers and regulatory agencies to transform HIV/AIDS from a death sentence to a manageable, chronic disease. And within a couple years, the mortality rates of AIDS plummeted in countries rich enough to afford the expensive antiretroviral drugs.

So we come to 2011, another fifteen years into the HIV/AIDS epidemic. Aren’t we ready for another watershed year? I say yes, and it’s about prevention of HIV/AIDS. This year has brought forth new evidence and the realization we have a very large toolbox to prevent HIV infection. No, we don’t have the desired magic bullet of a safe, efficacious and affordable HIV vaccine. And we don’t have a new, nicely packaged technology for HIV prevention that’s “plug and play” like the “triple combination cocktail” for treatment. And it’s unlikely that TIME will consider someone related to HIV prevention as Person of the Year this December, mirroring the naming of David Ho, Scientific Director and CEO for the Aaron Diamond AIDS Research center, as the 1996 Man of the Year for his work leading to the triple combination cocktail.

What we do have – and eloquently covered by U.S. Secretary of State Hillary Clinton in her talk at the NIH on November 8 – is the possibility of achieving an AIDS-free generation. This can be done because of our big tool box for HIV prevention filled with proven and durable interventions that can be combined to dramatically reduce new HIV infections—a strategy known as combination prevention. The big hammers include prevention of mother-to-child transmission, male circumcision, and extending treatment to reach all those with HIV, even those newly infected. The latter strategy is known as “treatment as prevention”, as the reduction of viral load in those infected will reduce the rate of transmission to HIV to their partners. Supporting tools include condoms, counseling and testing for HIV. If this combination prevention approach can be scaled up with as much vigor as was done for the triple combination cocktail launched in 1996, we can indeed achieve an HIV-free and AIDS-free generation.

But I am afraid that the enthusiasm, vigor and importantly, the funding, does not exist to achieve the goal of an HIV/AIDS-free generation. AIDS activists in the 1980s and 1990s were a major driving force in demanding attention, speed and funding to develop new treatments for AIDS, and that drive continued to bring access to treatment to millions in the developing world over the last 10 years. Today, as we are faced with the possibility of preventing millions of new infections, I don’t see a champion or a loud and annoying activist-fueled movement to demand scale-up this new combination prevention strategy for HIV. Why is that? Because it’s easier to “buy” a packaged antiretroviral treatment and count the lives saved, as compared to estimating the infections that never happened? Or the funding needed to scale up prevention – especially “treatment as prevention” – is so daunting, considering the current economic crisis has already reduced funding for current AIDS treatment programs? Or have we all just suffered from AIDS aid fatigue?

World AIDS Day 2011 is here. Looking back, we have accomplished much considering the obstacles in the science, politics and financing that HIV/AIDS posed over the last 30 years. Today, December 1, I’m hoping for the HIV Prevention Person of the Year on the cover of TIME – that’s not going to happen. Looking ahead, I will optimistically envision a World AIDS Day in 2016 or 2021, marking 35 or 40 years into the HIV/AIDS pandemic, where we will have achieved an AIDS-free generation.

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