There’s something different this year about World AIDS Day. In years past, we’ve used the December 1 date to celebrate achievements and look with great hope toward the future. The path forward has been clear — backed by substantial support from the U.S. government. This year, successes continue to add up, but many are asking, do we still have the support that has been so critical? Can we continue to make progress without it?
Let’s start by looking back for some inspiration. The many people fighting the HIV pandemic around the world learned something new and important in the spring of 2011- we learned that HIV treatment, already heralded for its Lazarus-like effect of bringing back to life even the sickest patients, also prevented sexual transmission of the virus. And did so definitively in the NIH-funded HPTN 052 study, which showed a 96% reduction in transmission of HIV within couples in which one person had the infection and the other did not. And with that, the concept of treatment not just for health, but of “treatment as prevention,” was launched.
National governments, WHO, and PEPFAR, where I was working at the time, took notice, and took action. In fact, as noted in the new UNAIDS report released last week in Cape Town, we have seen almost a doubling of the number of people on antiretroviral therapy worldwide since 2012. This represents an acceleration in treatment access over the last five years, to nearly 21 million people today, driven by the compelling science, rapid development and adoption of new guidelines and policies supporting treatment for all, and funding to support implementation. It has cut deaths in half, and has played an important role in reducing new infections along with other prevention strategies.
As we detail in our chapter of the third edition of Disease Control Priorities (DCP3) released earlier this month by the World Bank, University of Washington and other partners, there was a role in this great achievement for everyone from the scientists who developed and tested the antiretroviral drugs, to the NIH and the FDA that supported clinical trials and regulatory pathways for emerging drugs, to PEPFAR, Global Fund and national programs that kept pace with emerging science and expanded treatment access.
We also describe the important role played by economic analysis. Although some early analyses suggested that treatment was too expensive for the developing world, a courageous humanitarian imperative led the world to “do it anyway.” And yet, as analyses progressed and took into account rapid decreases in drug prices, the remarkable life-saving benefits of treatment and the restoration of economic productivity, and economies of scale, treatment began to look more and more cost-effective in these settings. Now— with treatment’s additional effect of preventing sexual transmission of HIV is factored in— we find that treatment is “very cost-effective” based on international benchmarks for health interventions. This puts HIV treatment in range with some of the most cost-effective health interventions, including HIV prevention interventions such as voluntary medical male circumcision, pre-exposure prophylaxis (PrEP), condoms, and other interventions worth continued investment for the public good.
Even as these public health tools have allowed us to make great progress in the fight against HIV, surveys have revealed new challenges. In Zambia, where I lived for the last four years, we have seen distressingly high rates of HIV infection in adolescent girls and young women. The prevalence of HIV infection was 4-times higher in young women aged 20-24 than among young men, driven in part by low treatment coverage in similar age and older men. Country-led efforts are underway to reach these girls and women with protective approaches, including access to PrEP and other prevention interventions encompassed in PEPFAR’s DREAMS initiative, and we must move fast. We must also deploy better approaches to treatment access for HIV positive young people, only a third of whom have achieved the most important marker of health and prevention, virological suppression. There is a feeling of optimism in Zambia and other countries today, driven in part by the dual benefits of treatment, and now is not the time to draw back—we must rather double down on an investment that is paying off.
We have tackled and overcome many such challenges thanks to the bipartisan commitment of many leading members of the US Congress, and several US Presidents, who believed that relieving suffering and controlling a raging pandemic, both at home and abroad, was a fight worthy of US resources. In the minds of many policymakers, the further evidence of the exceptional cost-effectiveness of HIV treatment and prevention will only strengthen their resolve to continue demonstrating America’s leadership in this fight. A strong PEPFAR and US leadership in supporting the Global Fund, which leverages US dollars to increase the commitments of other donors, are in our national interest and will be judged well by history.
As World AIDS Day approaches on December 1, we’ll learn more about this administration’s ongoing role in this winnable war. The administration’s proposed funding cuts for HIV, TB and malaria programs are not encouraging, and one can only hope that this approach is rethought in light of the tremendous opportunities to advance this fight. Treatment for both health and prevention surely must continue to play a key role in plans to control the HIV pandemic — this includes lowering barriers to treatment access for the 15.8 million people still in need and achieving virological suppression for those already on treatment. We must also redouble efforts to ensure access to effective prevention to increase the likelihood that those not yet infected, remain free of the virus. These cost-effective approaches will continue to save lives every day, even as we buy time for further scientific discovery that is needed to deliver us vaccines and other innovations to truly end the pandemic. With all of the progress that has been made, and challenges yet to be faced, one might say, “there is no time to lose.” And this is no time for losing.