World AIDS Day has been observed on 1st December each year since 1988 and is one of
the longest-running disease awareness and prevention initiatives of this kind in the
history of public health. It is an opportunity to reflect on the global epidemic that
has claimed 30 million lives over the past 30 years, to stake stock and to strategically
move forward. For the 5-year period 2011-2015, World AIDS Day has adopted the bold
theme: ‘Getting to Zero. Zero new infections, Zero discrimination, and Zero AIDS-related
deaths.’ These words directly quote the United Nations Secretary-General Ban Ki-Moon
in June 2011 which he prefaced with, “Today we have a chance to end this epidemic
once and for all. That is our goal”.
The vision of a world with zero HIV infections, zero discrimination and zero HIV-related
deaths has captured the imagination of diverse partners, stakeholders and people living
with and affected by HIV. At the International AIDS Conference in Washington in July
2012, US Secretary of State Hillary Rodham Clinton called on Global AIDS Coordinator
Eric Goosby to create a blueprint for the US government to achieve an AIDS-free generation.
There is clearly a new era of optimism regarding the global response to HIV. Is this
ill-founded or are their grounds for such optimism?
The scale of the epidemic is greater now than ever before, with an estimated 34.2
million people living with HIV in 2011, including 3.4 million children1. However,
the continuing rise in the number of people living with HIV does not simply reflect
ongoing new infections but is also a result of increasing survival associated with
treatment (i.e. treatment success). The annual number of new infections each year
has been slowly declining with 2.5 million infections in 2011 (a 20% reduction since
2001). This includes 330,000 new infections among children, which have reduced by
24 per cent within the preceding 2 year period1. The number of people dying from AIDS-related
causes has decreased substantially from a peak of 2.2 million in 2005 to 1.7 million
in 2011. Thus, despite the daunting reality of almost 7,000 new infections and 4,600
deaths across the world each day, there is growing evidence that the course of this
epidemic is nevertheless changing and starting to head in the right direction.
Confidence is growing in the range of tools that we have at our disposal to address
the HIV epidemic. The global scale-up of antiretroviral therapy (ART) has been an
extraordinary success story. Implementation continues to accelerate, reaching more
than 8 million people in low- and middle-income countries by 20111. This represents
a 20 per cent increase within the preceding year and a 20-fold increase over 8-years.
Scale-up of ART is estimated to have averted 2.5 million deaths in low- and middle-income
countries between 1995 and 20102. Providing antiretroviral prophylaxis to pregnant
women has prevented more than 350,000 children from acquiring HIV infection since
1995. These successes are to be celebrated and built on. There is still a long way
to go, however, as coverage is just 54 per cent of the 14.8 million people estimated
to be eligible for treatment. The fact remains, that for the 1.5 million people who
started ART in 2011, there were 2.5 million new infections. We are neither keeping
pace with those needing treatment nor effectively switching off the tap. A new era
of effective HIV prevention is desperately needed.
In recent years, there has been a major shift in our understanding of the even greater
potential role of ART in tackling this epidemic. The goals of ART are now expanding
from simply preventing morbidity and death and mother to child transmission to also
include prevention of sexual transmission. Natural history data originally showed
that people living with HIV whose viral load is less than 1,500 copies/ml had a very
low risk of heterosexual transmission3, suggesting that ART might also be effective
for prevention. This was more recently confirmed by the HPTN052 study that demonstrated
that ART reduces HIV transmission between discordant couples by 96 per cent4. These
data strongly support a strategy of widespread use of early treatment as prevention
(TasP).
The goal of TasP strategies is to diagnose and start ART early in as great a proportion
of those living with HIV in a community as possible. Suppressing the overall ‘community
viral load’ would be anticipated to switch off transmission and thereby help stem
the epidemic5. The 2010 revision of the World Health Organization guidelines for ART
was a step in the right direction towards this, recommending earlier treatment and
use of less toxic drug regimens6. However, with increasing recognition of the preventive
benefit of ART, future policy changes may push this agenda towards even earlier treatment.
Many believe this to be the key strategy that is needed to make progress towards ‘Getting
to Zero’. In addition, this would potentially play a central role in tackling the
HIV-associated tuberculosis epidemic7.
There are other reasons for optimism. Recent years have also seen other significant
scientific breakthroughs in HIV prevention. A randomized trial of oral chemoprophylaxis
using a combination of two oral antiretroviral drugs (tenofovir and emtricitabine)
among men who have sex with men8 and a randomized trial of a vaginal tenofovir gel
among women in South Africa9 both showed partial efficacy. In July 2012, the WHO issued
its first recommendations on use of pre-exposure oral prophylaxis (PrEP)10. The first
evidence of efficacy for an HIV vaccine candidate has also been found in recent years11
, restoring a little confidence in the hitherto demoralized HIV vaccine field. Meanwhile
global scale-up of established prevention interventions such as prevention of mother
to child transmission, condom distribution and male circumcision continues to grow.
The first ever possible ‘cure’ of a patient living with HIV has been reported after
receiving a stem cell transplant from a donor who was homozygous for CCR5 delta32
as treatment for acute myeloid leukaemia12. In July 2012, the International AIDS Society
also published a document entitled ‘Towards a cure’ that outlines a global strategy
towards finding a cure for HIV infection13. Thus, the past few years have seen huge
progress in the overall scientific agenda.
Despite this progress, are we being over-optimistic or simplistic in thinking we can
tackle this epidemic that has ruled as the leading infectious cause of death for so
many years? Can we sustainably scale up the needed interventions to levels of coverage
sufficient to make a real impact on new infections? We should reflect on World AIDS
Day in 2003 when the WHO and UNAIDS launched the ‘3 by 5’ initiative, which was met
with not a small amount of pessimism in some quarters. This target of providing treatment
for 3 million people in low- and middle-income countries by the end of 2005 required
a fundamental shift in thinking. Despite the daunting challenges of feasibility, funding
and delivery, this goal provided a much-needed focus and vision to galvanize concerted
international action to tackling the enormous challenge of AIDS. Ultimately the ‘3
by 5’ goal was only met in 2007 and yet this provided huge momentum that has seen
continued expansion of ART access to reach more than 8 million people by 20111.
The world now has a choice between maintaining current efforts in scale-up of treatment
and prevention and seeing incremental progress over time, or investing more smartly
in the shorter term to achieve far greater gains. We are at a pivotal moment in the
global response where we have the opportunity to grasp UNAIDS 2011-2015 strategy for
‘Getting to Zero’14. This, of course, requires substantial international investment
of resources. Since 2008, budgetary constraints and ongoing uncertainty resulting
from the global recession have conspired to threaten existing hard-won gains. Global
resources made available to HIV programmes in low- and middle-income countries decreased
in real terms in 2009 and 20102 and this was compounded by the Global Fund's cancellation
of the 11th round of funding in November 2011. The global investment in HIV was $16.8
billion in 2011, falling short of the $22-24 billion projected to be needed annually
for the global response to HIV up to 20151. However, this shortfall of around $7 billion
per year is only a small fraction of the estimated clean-up costs of Hurricane Sandy
which hit the east coast of the USA in October 2012.
These financial challenges require that not only must the efficiency of HIV programmes
be maximized, but also that the investment is recognised as being ‘smart’. There are
much wider health benefits of HIV care and prevention, including positive impacts
on the HIV-associated TB epidemic, maternal and child health and strengthening of
the health system. The human and social benefits must also be understood, with the
economic gains of improved health substantially offsetting the costs of treatment15.
Simplistic and artificial debates regarding the competition between HIV and other
global health needs are unhelpful in this regard. The challenges to scale-up are not
only financial and logistical, however. Achieving high levels of coverage of interventions
will also require a societal change in thinking. ‘Zero discrimination’ is a critical
goal since stigma and discrimination are major barriers to uptake and utilization
of services.
The call to ‘Get to Zero’ is a global call, involving the whole international community
of nations. This includes India, with 2.4 million people (39% female) living with
HIV in 2009 - the third highest number of any country after South Africa and Nigeria16.
This represents 7 per cent of the global burden of HIV and half of Asia's epidemic.
There are around 140,000 new infection each year and 172,000 deaths. Incidence is
estimated to have decreased by 50 per cent between 2000 and 2009, which is a laudable
achievement and yet these are not grounds for complacency. Although HIV prevalence
among female sex workers declined to less than 5 per cent, prevalence remains high
among men who have sex with men (7.3%) and people who inject drugs (9.2%)16. Just
less than half a million people in India were reported to be alive and receiving ART
at the beginning of 201217. This represents about 20 per cent of all those living
with HIV and much greater ART coverage could contribute significantly to HIV prevention.
Investments have increased substantially to $2.5 billion during the National AIDS
Control Programme III (2007-2012) and the domestic contribution increased to 25 per
cent in 2011. There has been significant scale-up in coverage of focussed programmes
among key populations at higher risk. However, further progress in coverage is needed
as well as measures to reduce stigma and discrimination.
The story of AIDS over the past 30 years has been a truly remarkable one. There is
a sense that at long last we are in a season of opportunity when real progress can
be made. But this will require unity of purpose with scientists, policymakers, implementers,
civil society, the community and international donors pulling together like never
before with the unshakable belief that one day we can get to Zero.