From a special plenary session titled "Looking to the Future -- The Epidemic Steps to End the Epidemic in 2031, and New Directions in AIDS Research" at the XVII International AIDS Conference in Mexico City, August 6, 2008.
Twenty years ago this October, fifteen hundred AIDS activists from around the United States surrounded the headquarters of the U.S. Food and Drug Administration in Rockville, Maryland, to demand that it revolutionize its regulatory approach to the testing and approval of new drugs for AIDS. That demonstration was successful beyond our wildest dreams and we are living with its consequences still. Indeed, I and many thousands of others might not be living today had it not been for the unprecedented activism spawned by the AIDS epidemic over two decades ago.
Ten years ago at the Geneva AIDS Conference, mistitled "Bridging the Gap," I was asked to address the question: "Cure: Myth or Reality?" At that time it was evident that the scientific basis for a cure had not yet been established, despite the recent and revolutionary advent of HAART. In Geneva, I called on AIDS activists, community, leadership, and researchers to work to bring HIV treatment along with better prevention programs to the developing countries where most people with AIDS lived and died. Richard Horton summarized the clinical science news of the conference, and he was excoriating in his criticism of the deep divide he witnessed:
"This conference was about 'bridging the gap.' So why was it that every day this week, whenever a speaker from a developing world country rose to talk about an issue central to 'bridging the gap,' seats emptied and the halls began to bleed delegates through the aisles and out into the corridors of the conference centre? I watched this happen at least six times to speakers from Africa, India, and Thailand. It was nothing less than shameful.... If you walk out of a room when your own colleagues have travelled long distances ... to share their experiences with you: Why should any government bother to listen if you don't ...?"
Ten years later we are now all working together -- north and south, prevention and treatment, scientists and activists -- in an unprecedented global movement that has radically transformed the outlook for millions of people with HIV, saved millions of lives, and prevented millions of HIV infections. We are more unified than we were in 1998. Infighting is less common than it once was. We have some amazing short-term accomplishments to be very proud of. According to UNAIDS, deaths from AIDS might even have started to fall in the last two years.
But these gains are fragile, may be transitory, and may be undermined by forces viral, demographic, and political. We must not be lulled into slackening of our efforts. Rather, we must intensify our efforts, and overcome the threats that face us.
What is the state of the epidemic in 2008 and where should we be focusing our efforts?
We must seek a cure and a vaccine because lifelong triple-drug therapy for the currently infected will require 990 million patient years of antiretroviral drugs to be manufactured, delivered, and taken by the already infected 33 million -- even if all transmission were somehow magically stopped tomorrow.
Add to this the 2.7 million newly infected each year and over the next 30 years we add another 81 million people who would need lifelong therapy -- barring a cure -- and this will mean another 2.43 billion patient years of ART.
Accelerating scale-up is the foundation for our coming work. We must scale up faster so that we can put one person on therapy for each new infection. But we need massive investment in research on a cure and on better prevention methods if we are ever going to end the AIDS epidemic.
We must strive to continue to lower the numbers newly infected. There are several ways we could dramatically reduce infections rapidly if we are willing to take some radical steps around the world.
The U.S. government and its people are obliged to address this epidemic with the same urgency with which they are now addressing the global pandemic.
The United States must develop and implement a national AIDS strategy with specific targets, timelines, and the goal of reversing the epidemic, with special attention and resources targeted toward black Americans, Latino/Latina Americans, women, and men who have sex with men.
We must have access to much better, more accurate, and timelier information about where the epidemic is and where it is moving to. Recent revisions downward by UNAIDS on the global pandemic and upward by the CDC on the U.S. epidemic have left the impression that we are still far from having a clear enough picture of the size, scope, distribution, and movement of the epidemic in its 28th year.
Given the wealth of information that came from the unexpected results of the randomized SMART study it is urgent that we undertake a long overdue new study of when to start ART.
Routine screening for TB at every clinic visit should also allow healthy HIV-positive persons in pre-ART care to receive cotrimoxazole and isoniazid preventive therapies, which despite overwhelming evidence of efficacy are not routinely used in most sites due to overblown fears about resistance, toxicity, and adherence.
Better opportunistic infection prophylaxis and treatment are also needed. Key drugs must be added to the essential medicines formulary and their prices brought down: amphotericin-B for cryptococcosis, azithromycin for MAC and a host of other infections, rifabutin for tuberculosis, and valganciclovir for CMV retinitis.
Other rich countries in the European Union and the Organization for Economic Cooperation and Development must double or triple the amount they invest in biomedical research, including research for AIDS, TB, viral hepatitis, and other diseases. Emerging and developing countries need to increase investment in biomedical research five- to tenfold to help address persistent gaps in health research.
The AIDS movement -- made up of activists, scientists, health workers, and policy makers alike -- has shown that it is possible to scale up antiretroviral treatment to cover three million people in just five years.
Let's make this the vanguard of an unprecedented global citizens' movement for comprehensive universal primary health care for all. We owe it to our colleagues working in TB; malaria; sexual and reproductive health; maternal and child health; and food security and clean water, among many many others, to unite with them to demand the resources necessary to meet and surpass the millennium development goals and to provide not only universal access to HIV prevention, care, and treatment but universal and comprehensive primary health care for all.
Some will say that this is an impossible aspiration. Some of these naysayers said the same thing about ART scale-up in 2000. Some of them do not want to spend rich countries' resources on global health; some, regrettably, are simply jealous of the success of the AIDS movement in mobilizing resources and making an impact. We cannot afford to descend into quarrels with others who genuinely care about global health.