1 December is World AIDS Day. Here Kenneth Mayer, MD, explains what makes the 2012 observance different from all those before – and, hopefully, those to come. Dr. Mayer is Co-Editor of Clinical Issues in HIV Medicine, Co-Chair of the HIVMA/IDSA Center for Global Health Policy’s Scientific Advisory Committee, founding Medical Research Director of Fenway Health, a visiting professor at Harvard Medical School, and an attending physician and director of HIV Prevention Research at Beth Israel Deaconess Hospital in Boston.
By Kenneth Mayer
Last year, on World AIDS Day, U.S. President Barack Obama set ambitious goals to reach more people with treatment and fundamental prevention. Echoing U.S. Secretary of State Hillary Clinton’s call for an “AIDS-free generation,” he envisioned a tipping point in a 30-year battle to subdue the world’s costliest epidemic.
This World AIDS Day, the administration’s release of a global AIDS roadmap takes the vision into practice. Outlining the U.S. government’s commitment to apply research to reality, with the efforts of affected countries and other donors, it is as much a promise as a challenge.
The plan serves as a solid indication that three decades into a struggle that began without direction, and that sometimes seemed futile, the U.S. has set a course to continue the pace it has achieved in the last year, while giving partners encouragement and reason to match those efforts. It underscores, at a time of worldwide economic challenges and competing concerns, that this investment will yield gains, this is a battle that can be won, and this is not the time to stand still.
The global health community and its researchers, policy makers, donors, field workers, and affected populations know what to do to begin to end this epidemic, and now need to do it. To realize the magnitude of this opportunity, compare where we are now to where we were 31 years ago when fear, ignorance, and prejudice stymied responses while AIDS’ death toll multiplied exponentially as it circled the world. With little clue as to how the virus was transmitted from 1981 to 1985 rumors and mistrust also spread. Through epidemiological research we overcame the terror of those years, understanding that without blood exchange or intimate sexual contact the virus was not readily transmitted. Researchers’ discovery in the mid-1990s that combinations of antiretroviral drugs could arrest the virus changed it from a death sentence into a manageable disease, for many. Shamefully, the cost of those drugs kept the benefit of that breakthrough from being shared in the poor countries where relief was most needed. Finally, in the last decade, with the importation of generic medicines, the establishment of The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President’s Emergency Plan for AIDS Relief, work to confront the epidemic emerged from laboratories and wealthy countries, to what are now some of the most formidable front lines.
Yet we continue to fall short. We know that injection drugs are a major vector for HIV transmission, but many countries punish users of those drugs rather treat them with opioid substitution therapy and protect them with needle exchange programs. Homophobia and criminalization of gay sex threaten efforts to even count the toll in countries where HIV is most prevalent. Programs to prevent transmission of the virus from mothers to infants are hobbled by constraints on family planning commodities. Sex workers are marginalized by efforts that exclude their input. Treatment and prevention programs fail to reach people with physical and mental disabilities. While tuberculosis is the primary killer of people living with HIV, screening and treatment for the two diseases remain unlinked. While donors have imported some of the means to fight the epidemic, too often they have imported answers as well, failing to allow for the diversity of needs and affected populations in different countries.
With a plan that includes the needs of all affected populations, the tools we have now will be powerful. The study known as HPTN 052 showed that early initiation of antiretroviral therapy could decrease the transmission of HIV in couples in which only one partner was HIV-positive by 96 percent. The use of an antiretroviral drug as pre-exposure prophylaxis in combination with other risk-reduction measures, was shown to be effective in protecting men who have sex with men, and heterosexual men and women from acquiring the virus.
These discoveries will be useless, however, if people who need medicine to save their lives don’t get it. While eight million people are getting treatment, 34 million are living with the virus. Maintaining the momentum of treatment coverage that the U.S. has achieved in the last year in Africa is imperative to meet the original humanitarian mission of the response as well as to continued progress.
Then, with shared responsibility and political will, the next World AIDS Day can be one on which we can see the end of the road, far ahead but certain, when we can stop the further spread of HIV.
To raise awareness of World AIDS Day, Dr. Mayer and Daniel Kuritzkes, MD (Co-Editor of Clinical Issues in HIV Medicine) have selected recent, topical articles, which have been made freely available for a limited time by The Journal of Infectious Diseases and Clinical Infectious Diseases. Both journals are publications of the HIV Medicine Association and the Infectious Diseases Society of America.
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Image credits: World AIDS Day press images via worldaidsday.org media centre.