Much to celebrate in fight against AIDS

The rate of new infections has plummeted and the end of the epidemic is in sight. The challenge now is to maintain the funding needed to go the final mile. Elizabeth Finkel reports.

Sir Bob Geldof pulled no punches criticising the funding shortfall to end AIDS. – International AIDS Society/Steve Forrest

Despite the cloud over the AIDS 2014 conference cast by the loss of six researchers in the MH17 disaster, there was much to celebrate.

Since 2001 the rate of new infections has plummeted – this year it has halved to 2.1 million a year. In the past three years alone new HIV infections have fallen by 13%. And of the 25 million people currently in need of treatment 14 million – close to 60% – now receive it, something that was once thought impossible.

“There has been more achieved in the last three years than in the last 25 – we have picked up the pace,” Michel Sidibé, the Executive Director of UN AIDS, declared. And that has led to a bold vision: “We have the potential to end the epidemic by 2030.”

A statement of such ambition is crucial to galvanise the funding community, says Mark Dybul, the executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. “Policymakers aren’t content with doing what was done in the past.”

The major obstacle is funding. While millions now receive drugs, millions more will need lifelong treatment. But there are concerns that traditional donors are retreating from long-term funding. Australia’s recent budget flagged it would slash $7.6 billion from foreign aid over the next five years. This will inevitably impact HIV prevention. Dybul warns that international agencies are no longer willing to go it alone – national governments have to play their part too. This is especially so given that many of the countries that have benefited most from international aid, such as India and Brazil, have transitioned from being low-income to middle-income countries. “Everyone needs to be in the game, we need to have domestic finance or we won’t see an increase in international aid,” says Dybul.

That will also require a new narrative, he says. Fifteen years ago it was about getting treatment to those who needed it. The campaign was led by people like Festus Mogae, a former president of Botswana, under whose leadership the country became the first in Africa to provide free HIV therapy.

“When everyone said you couldn’t do it for southern Africa he stood up and did it,” said Dybul speaking on a panel that included Sidibé, Mogae and singer Yvonne Chaka Chaka. Now “we are at a different historic moment”, he added.

Today's galvanising narrative is about ending the epidemic – reducing new infections till the virus effectively stops spreading, he says.

That will be expensive. Of the 35 million people estimated to carry the virus only half know they are infected. Funds will have to be found for the lifelong treatment of all. And today’s treatments tend to kick in much earlier, which raises the cost. In the past people were treated only once their immune systems showed signs of damage, usually years after infection.

Today infected but otherwise healthy people take the drugs early to help prevent them from infecting their partners (treatment as prevention). There’s also evidence that early treatment leads to long-term remissions where people can be virus-free for years without drugs (e.g. the Mississippi baby). Uninfected sex workers may take the pills to prevent themselves from becoming infected (treatment as prophylaxis) and people who’ve had unprotected sex take the drugs as a morning- after pill (post-exposure prophylaxis).

The key message is that by strategically targeting these early treatments the spread of infection could be stopped completely, says Dybul.

Just 15 countries account for 75% of new HIV infections. And within countries, particular sub-populations such as sex workers or gay men are at the highest risk. “If we focus on geography and sub-populations we could get to the point of controlling the epidemic with a reasonable amount of money,” says Dybul, referring to a recent modelling study in the Lancet.

The models also show we are at a tipping point, he says. Infections have risen by 8% in Western Europe and North America, by 7% in the Middle East and North Africa and by 5% in Eastern Europe and Central Asia since 2005.

Overall the world will be worse off in terms of loss of life and long-term financial costs if the current opportunity to halt HIV’s spread is lost. “We have a fragile, five-year window of opportunity. If we are smart and scale up fast by 2020 we will be on track to end the epidemic by 2030,” said Sidibé. “If not we risk significantly increasing the time it will take – adding a decade, if not more.”

As musician and activist Bob Geldof put it in his gloves-off statement at the conference, "there is a great sense of triumph, commitment and vindication that you are on the last gasp on the journey to ending AIDS".

“The scandal underlying all of this is the preposterous reluctance to fund the last mile,” he said.

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