Only Stronger U.S. Leadership Can End the AIDS Epidemic
Existing Treatment and Prevention Techniques Could Prevent Millions of New HIV Infections and Deaths From AIDS -- but Only If Obama Sustains Funding
Revise and revitalize the National HIV/AIDS Strategy (NHAS) to incorporate new scientific findings and to more rapidly scale up HIV prevention and treatment programs nationally. A recent paper by David Holtgrave, a department chair at the Johns Hopkins Bloomberg School of Public Health, and colleagues found that "[w]ithout expansion of diagnostic services and of prevention services for [people living with HIV], scaling up coverage of HIV care and treatment alone in the U.S. will not achieve the incidence and transmission rate reduction goals of the NHAS. However, timely expansion of testing and prevention services for [people living with HIV] does allow for the goals to still be achieved by 2015, and does so in a highly cost-effective manner." The goals of the NHAS include:
- lowering new HIV infections by 25 percent and HIV incidence by 30 percent
- increasing Americans' knowledge of their own serostatus from 79 percent to 90 percent
- increasing the proportion of newly diagnosed Americans linked to clinical care within three months from 79 percent to 90 percent
- increasing the proportion of Ryan White HIV/AIDS program clients who are in continuous care (at least two visits for routine HIV medical care in 12 months at least 3 months apart) from 73 percent to 80 percent
- increasing the percentage of Ryan White HIV/AIDS program clients with permanent housing from 82 percent to 86 percent, and
- increasing the proportion of HIV-diagnosed gay and bisexual men, Blacks, and Latinos/Latinas with undetectable viral load by 20 percent each
all by the end of 2015.
Recent scientific discoveries have shown that earlier initiation of antiretroviral therapy can reduce HIV transmission by a whopping 96 percent among couples with differing HIV status.
This led Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health (NIH) to write:
The fact that treatment of HIV-infected adults is also prevention gives us the wherewithal, even in the absence of an effective vaccine, to begin to control and ultimately end the AIDS pandemic. ... For the first time in the history of HIV/AIDS, controlling and ending the pandemic are feasible; however, a truly global commitment ... is essential. Major investments in implementation now will save even greater expenditures in the future; and in the meantime, countless lives can be saved.
Revising the National AIDS Strategy to incorporate these new findings could enable the administration to set more ambitious targets of reducing HIV transmission and incidence by 50 percent or more -- as South Africa has committed to doing by 2016 -- increasing linkage to care to 95 percent, increasing Ryan White care retention to 95 percent (the program funds care for those who cannot otherwise afford it), increasing Ryan White clients' access to housing to 95 percent, and increasing the proportion of blacks, Latinos and Latinas, and gay men with an undetectable viral load to at least 90 percent.
Of course, this revised National AIDS Strategy would cost more money up front. But as Fauci pointed out above, and as Bernhard Schwartländer of UNAIDS, who first proposed the scale-up efforts that led to PEPFAR and the Global Fund in a pivotal paper in Science magazine in 2001, and colleagues pointed out in their global strategic investment framework for HIV: "[t]he yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US $22 billion. Implementation of the new investment framework would avert 12.2 million new HIV infections and 7.4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29.4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone."
Increase funding for the National Institutes of Health (NIH) by 15 percent annually for the next five years. The NIH budget has been flatlined since 2004, with the exception of two years of stimulus funding in 2010-2011. The rate at which new grant applications are funded has fallen to 10 percent, meaning nine out of 10 applications are rejected. In his 2011 State of the Union address, Obama committed to reinvigorating the United States' commitment to and investment in scientific research:
This is our generation's Sputnik moment. Two years ago, I said that we needed to reach a level of research and development we haven't seen since the height of the Space Race. And in a few weeks, I will be sending a budget to Congress that helps us meet that goal. We'll invest in biomedical research, information technology, and especially clean energy technology -- an investment that will strengthen our security, protect our planet, and create countless new jobs for our people.
This year, his proposed 2013 budget flatlines NIH once again. We need increased investment in biomedical research to assure the discovery and development of the innovative tools we need to end the epidemic, cure HIV and find a vaccine to prevent its transmission.
Commit the administration to fully funding the research, prevention, care, and treatment scale-up required to end the pandemic. Some of the steps needed to end AIDS are discussed in a report issued this week by our colleagues at AVAC and amfAR, An Action Agenda to End AIDS.
President Obama has shown himself capable of the vision to create a National HIV/AIDS Strategy and continued to ensure that the United States is the leader in support for global HIV programs. Now is the time for him to embrace the newest scientific results, which give America the power to map out an endgame for the epidemic around the world.
Mark Harrington since 2002 has been the executive director of the Treatment Action Group, which he co-founded in 1992 after four years working with the Treatment + Data Committee of ACT UP/New York. He was awarded a MacArthur Fellowship in 1997.
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