AIDS

AIDS 2012: Science and the future of AIDS

Amid political statements and declarations of commitment, several sessions at the ongoing International AIDS Conference 2012 have shined a bright light on the future of the pandemic and the global response.

In one session, Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) at the U.S. National Institutes of Health, gave a keynote address, “Ending the HIV/AIDS Pandemic: From Scientific Advances to Public Health Implementation.”

According to Dr. Fauci, who has been at the forefront of the fight against HIV/AIDS since the discovery of the virus in the early 1980s, the scientific developments in the last three decades that have helped understand, treat and prevent HIV infection bode well for the promise of a world free of AIDS. He noted that the robust arsenal of nearly 30 antiretroviral drugs and scientifically proven interventions now available to treat and prevent HIV infection and improve people’s health and longevity, offer an unprecedented opportunity in the years ahead. However, he was clear in cautioning that this will not be accomplished without sustained global commitment and effort. This means that the international community cannot retreat in the face of the current economic slowdown, but rather build upon those advances, adjusting, adapting and strengthening the response on the basis of accumulated experience and lessons learned from across the world.

If we heed Dr. Fauci’s advice, it should be clear to all of us that while we need international funding from current and new donors to sustain the global effort, developing country governments also can and should step in and prioritize funding and investments to contribute to the fight against HIV/AIDS and for other health priorities. While some people argue that the unprecedented funding for AIDS in the last decades has created imbalances in the global health agenda, we should also remember that in previous decades the underfunding and underdevelopment of health systems in most of the world, and the resulting lack of or limited access to basic health services for the majority of the population, was a common phenomenon that came before the AIDS response.

Now that the XIX International AIDS Conference is in full swing this week in Washington, DC, it’s worth reflecting not only on past achievements but on future challenges.

As recounted by Dr. Peter Piot, the former executive director of UNAIDS, in his recently published memoire, No Time to Lose, after overcoming many obstacles and naysayers, the UN system, with its many organizations and agencies, working together with governments, civil society and religious organizations, groups representing people living with AIDS, and eventually the pharmaceutical industry, came together this past decade to redefine existing HIV/AIDS prevention and treatment paradigms.

There have been landmark political events as well, such as the UN Security Council Session held in January 2000 that for the first time focused on AIDS as a global health challenge, and the UN Special Session on AIDS held in June 2001, which paved the way for establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR).

Not only was the power of scientific and technological developments leveraged to confront the global epidemic, but an unprecedented commitment of funds helped scale up the international response.

Speaking ahead of the XIX International AIDS Conference, World Bank Group President Jim Yong Kim says that ending AIDS—an idea that seemed inconceivable only a few years ago—is within our reach thanks to international efforts by activists and communities. Kim, who will address the conference's opening plenary session July 22, says the lessons learned in the fight against AIDS can be used to eradicate poverty.

The World Bank, together with USAID, PEPFAR and The Lancet, will host a debate at 6:30 pm ET on Monday, July 23, on global health funding for HIV/AIDS. Watch the debate webcast, follow the live blog, or follow on Twitter at #WB Live or #AIDS2012.

Lors de la dernière conférence internationale sur le sida organisée à Washington, en 1987, les États-Unis étaient présidés par Ronald Reagan, l’Union soviétique tenait encore debout, un mur coupait Berlin en deux et la taille de l’économie chinoise était comparable à celle de l’Espagne. Personne n’aurait pu prédire les évolutions de notre planète ni celle de l’épidémie de sida.

En cette année 2012 décisive, la conférence est de retour à Washington. Le sida reste le plus grave défi de notre temps sur le front des maladies infectieuses, avec plus de 65 millions de contaminations et 30 millions de décès depuis le début de la pandémie, sans compter les quelque 3 millions de nouveaux cas et les 2 millions de victimes supplémentaires chaque année.

Ces statistiques sinistres ne doivent pas masquer les incroyables progrès accomplis. Lors de la conférence de 1987, le monde était démuni face à cette pandémie mortelle alors qu’il n’existait aucun médicament pour atténuer une lente et douloureuse agonie. Aujourd’hui, la palette des outils de prévention à l’efficacité avérée ne cesse de s’étoffer ; les infections sont en recul dans plus de 33 pays ; et jamais l’humanité n’a disposé d’autant de traitements pour lutter contre un virus. Les coûts de traitement annuels ont été divisés par 100 et ils atteignent désormais 8 millions de personnes à travers le monde, soit 60 fois plus. C'est, à ce jour, l'expansion la plus importante d'un traitement qui permet de sauver des vies.

Avec l’accélération des progrès scientifiques, des percées encore plus spectaculaires sont attendues.

C’est en Afrique surtout que ces progrès incroyables sont le plus visibles. En Afrique de l’Est et en Afrique australe, l’épidémie de sida était responsable à son paroxysme de 50 à 70 % des hospitalisations et des deux tiers des décès dans la population adulte. Imaginez un instant ce que cela signifierait à l’échelle de votre quartier. Dans mon pays, le Zimbabwe, les hôpitaux étaient remplis de mourants décharnés, le personnel soignant transformé en fossoyeurs, les hôpitaux en hospices et toute la vie sociale réduite à deux activités : visites aux malades et funérailles. Les marchands de cercueils, à l’activité florissante, s’installaient le long des routes menant aux cimetières surchargés.

When the International AIDS Conference was last held in Washington, D.C. in 1987, Ronald Reagan was U.S. president, the Soviet Union stood, a wall scarred a divided Berlin and China’s economy was roughly the size of Spain’s. The wider world – and the AIDS epidemic – has changed more than anyone foresaw.

The conference returns to Washington in a watershed year. AIDS remains the greatest infectious disease challenge of our age: more than 65 million people infected and 30 million deaths since the epidemic began, and roughly 3 million new infections and 2 million deaths a year.

These are grim statistics, but they belie the incredible progress made. When we met at the 1987 AIDS conference, the world had few tools to prevent deadly infections and no drugs to commute slow, agonizing, wasting death. Today, there is an expanding armory of proven prevention tools; new HIV infections have been reduced in more than 33 countries; and there are more drugs to treat HIV than for every retrovirus in history combined. Annual treatment costs have been reduced 100-fold and AIDS treatment has been expanded 60-fold to reach 8 million people worldwide in the largest-ever expansion of lifesaving treatment.

As the pace of scientific progress accelerates, even greater breakthroughs await us.

Nowhere is this amazing progress more evident than in Africa. At its peak in Eastern and Southern Africa, AIDS was responsible for 50-70% of bed occupancy and two-thirds of all adult deaths. Let each of us simply try to imagine experiencing this in our own neighborhoods. In my country, Zimbabwe, hospitals overflowed with emaciated, dying people, nurses and doctors were undertakers, hospitals were hospices, and an entire society’s social life rotated from hospital beds to funeral gravesides. Coffin-making was the fastest growing business, lining miles of roads to overcrowded cemeteries.

While participating in a study of HIV spending efficiency in South Africa, I met a young HIV-positive mother who had just received the joyful news that her new-born daughter was healthy and HIV-free. Wiping away tears of relief, she described the gratitude she felt for the antenatal clinic staff, who had helped start her on antiretroviral treatment (ART) and thanks to whom she now had the hope of a bright future for her daughter. This encounter was just one among many similar incidents during the study – and, as our preliminary data show, is representative of the positive impact of the Government’s strong commitment to bringing down rates of HIV.

South Africa has mounted one of the strongest responses to HIV in the world. Its most dramatic success has been the scale-up of ART since 2003, growing from almost nothing to the country’s largest health program that treated about 1.5 million people in 2011 (out of a total HIV-infected population of 5.6 million).

The impacts of this treatment drive are already showing, with overall mortality, maternal and infant deaths all on a downward trend following their HIV-related peaks in the early-to mid-2000s. However, the cost of sustaining this success is huge: South Africa has committed to putting an estimated target of almost 10% of the entire population on a life-long course of expensive drug treatment. And, even with government negotiators bringing down ART drug prices by 65% since 2008, successful testing campaigns coupled with the worrying increase in resistance to first-line therapies look set to further raise the financial risk.

These challenges extend beyond South Africa. An analysis of the fiscal dimensions of HIV/AIDS released by the World Bank earlier this year in a number of countries concluded that without significant additional investments in prevention starting now, the cost of treatment will rapidly become unaffordable for even the most cash-rich countries on the African continent.

The scaling up of voluntary medical male circumcision, particularly in high HIV prevalence settings, is a highly cost-effective intervention to fight the epidemic—randomized controlled trials have found a 60% protective effect against HIV for men who became circumcised.

But, the supply of this medical service is just one part of the picture. Without active involvement from individuals and communities to deal with social and cultural factors that influence service acceptability, the demand for this common surgical procedure will be low.

Indeed, on a recent visit to Botswana, a country with high HIV prevalence and low levels of male circumcision, my World Bank colleagues and I had a good discussion with the National HIV/AIDS Commission about ways to address the low uptake of voluntary, safe male circumcision services in spite of a well-funded program by the government. It was obvious to all that if the demand for, and uptake of, this service were not strengthened through creative mechanisms that foster acceptance, ownership, and active participation of individuals and community organizations, the program would not help control the spread of HIV through increased funding of facilities, equipment, and staff alone.

So, what do we need to do to ensure that need, demand, utilization, and supply of services are fully aligned to improve health conditions?

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A while ago, I was part of a mission to visit a new hospital in Lesotho. Warned in advance that this facility was intended to treat people with multi-drug resistant tuberculosis (TB)– and knowing the huge burden of HIV-TB co-infection in the country—I was expecting the patients’ demographic to match the profile of HIV: largely young and increasingly female.

What I wasn’t prepared for was the sight of two entire families—young and old, men, women and children—all confined together for the foreseeable future, to be monitored by health workers as they take their daily drugs.

We’re entering a phase where AIDS is moving from emergency crisis financing to sustainable development financing—which is a major challenge, but one that we’re continuing to tackle, with the goal of stronger national ownership and responsibility.

One of the Bank’s international mandates is to support countries to develop better national health plans and budgets. Today, the Bank released an important study, The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda, which is a part of this mandate. The study helps countries do the long-range planning that we so desperately need in HIV programs.

The Bank has a long-established partnership with ministries of finance and planning, and we understand country systems. We stand ready to help countries integrate HIV into their programs and plan for it in a sustainable way.

We’ve seen extraordinary progress in AIDS. Today, we have more antiretroviral drugs to treat HIV than every other virus in history combined. We’ve reduced treatment costs from tens of thousands of dollars to as little as $100. And we’ve expanded our understanding of effective HIV prevention, including the role of male circumcision and the important role that treatment can play in prevention under the right circumstances.

Many of us involved in HIV remember the days when 70% of beds in health facilities in Africa were occupied by people with AIDS. Our successes in treatment and prevention have removed this specter and have allowed health systems to focus on other important health priorities.

2012 is off to a sobering start for those of us in the global health community, against a backdrop of continuing global financial volatility coupled with complex reforms at the Global Fund to Fight AIDS, Tuberculosis and Malaria. New research from the Institute for Health Metrics and Evaluation (IMHE) shows a slowdown—and perhaps a plateauing—of the historical growth in global health funding to which we have been accustomed during the past decade. This new reality is, rightly, leading to questions about whether substantial—if not radical—changes are needed in the highly fragmented global health ecosystem. And yet, at the same time, there are signs of new initiatives.

I believe the slowdown in global health funding requires adjusting our expectations in the coming years. Last fall, after participating in a number of inspiring discussions during the UN General Assembly, I reflected about each one of the critical global health priorities to which we have all pledged our support in recent years: the Millennium Development Goals (MDGs) for nutrition, child and maternal health, and HIV/AIDS, TB, and malaria, as well as non-communicable diseases. It struck me that while most of these health interventions are destined to help the same mother or child, we have created very separate initiatives and institutions to deliver on each. We have been able to elevate the awareness and commitments for each of these priorities, but now the challenge is, like Humpty Dumpty, how do we now put them all back together again?

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