For the first time, the end of the global HIV epidemic is within reach. Recent breakthroughs in HIV prevention research have created unprecedented opportunities to curb new HIV infections, save lives and set the world on a path toward eliminating HIV transmission in our lifetimes. But ending the global pandemic won’t be simple or quick, and our success is far from assured. To capitalize on today's opportunities, the global AIDS response urgently needs a coherent, long-term plan.
The AVAC report is also available in PDF form.
In addition, we are pleased to introduce our new podcast series. We feature leading researchers, advocates and policy makers speaking candidly about the most pressing issues facing HIV prevention today. Give it a listen and let us know what you think.
This AVAC report presents a three-part agenda for ending the AIDS epidemic. It is intended as a vision and a challenge to the field, and a first step in holding all of us—civil society, researchers, governments, and funders—accountable for progress.
Each of the major priorities below demands action now—but the dividends will come in the short, medium, and long terms.
1. DELIVER today’s proven strategies at scale for immediate impact
- Model combination prevention programs to identify the parameters that are essential for scale-up to have a major impact on infections
- Mobilize demand for new tools among people who could benefit, through social marketing and other efforts
- Reprogram existing resources when evidence shows they could be used to greater effect
- Fund evidence-based scale-up today—and save money in the future—through substantial increases in commitments from U.S., European and developing country funders.
2. DEMONSTRATE and roll out newly available HIV prevention tools, including PrEP and microbicides, for even greater impact in 5 to 10 years
- Plan for the introduction of PrEP and microbicides in the next several years, and for follow-on research needed to address questions that remain unresolved in trials to date
- Pilot these interventions through demonstration projects that help define their optimal use and real-world impact
- Prioritize the use of these interventions in populations, and in combinations, where the potential benefits are greatest
3. DEVELOP long-term solutions—including an effective vaccine and a cure—that will enable us to close the door on AIDS
- Sustain funding for research, to capitalize on recent scientific insights that have begun to revitalize the search for a vaccine, while pursuing new leads that may eventually result in a functional cure for HIV infection.
We can end the AIDS epidemic in our lifetime. That’s the view from AVAC and, in an exciting movement, from civil society groups, scientists and top political leaders around the world.
To get where we need to go, the global AIDS response needs to align itself with some of the principles of business management. That’s why this letter is titled, in part, the essential business of ending AIDS in our lifetime. To save money and lives, the AIDS response needs to be guided by several principles.
To start with: invest in success.
If AIDS prevention were a business, there is no question that now would be the time to invest. We’ve had major breakthroughs, surprising proofs-of-concept of new prevention tools, and an exhilarating accumulation of evidence from clinical trials, epidemiological modeling and real-world practice, all of which would be foolish to ignore.
Smart businesses also know when to pull the plug on approaches that haven’t panned out. In the 30 years of the epidemic, there has been a significant increase in global funding and awareness. And many victories have been won. But funds have also been spent on redundant and poorly-coordinated research. On the implementation side, there’s a hefty price-tag associated with self-perpetuating projects and methodologies, both large and small, that fund salaries, per diems, meetings and workshops, but do not, at the end of the day, have a demonstrable impact on the trends of the epidemic. This type of “business as usual” has to change.
Determining how to end AIDS is surely hard, but it is doable.
We need to act on the promise of combination prevention—and debate less about the relative merits of one strategy versus another one. We must gather evidence about what effective combination prevention programs look like in different settings through impact evaluations and innovative clinical trials. Communities, researchers and advocates need to shift from advocacy for one specific intervention and work for well-defined combination packages.
We need to spend the money we do have more wisely—and not retreat from global commitments to the additional financial support required to see this effort through.
We need to prepare for disappointments—and not let bumps in the road detract from the critical goals, which range from an AIDS vaccine that prevents enough infections to be used on a wide scale, to the vision of a world in which innovative community-led models for treatment adherence are the norm.
Finally, we must talk less and do more. This year’s AVAC Report is shorter than in years past. The issues are clear. The road ahead is still long, but there is an end in sight. Let’s get going!
AVAC’s goal is to work with partners worldwide to ensure that the answer to the question: “Will we end the epidemic?” is a resounding yes.
If this is the goal, then we all need to examine our priorities. We need to do more of some things, less of others. And we need to be sure that we’re keeping track of what should happen in the next 12 months, the next few years and the next few decades.
AVAC Playbook 2012 focuses specifically the next twelve months. It includes our analysis of what top strategic goals should be are at a global level, and particularly in hard-hit countries, over the coming year. It also includes our own organizational priorities for contributing to these goals.
These are three key steps to getting on track to begin to end the AIDS epidemic in our lifetime. Each strategy has specific needs in terms of research, funding and implementation, and we’ve described them in separate sections of the Report.
But the reality is these and other interventions cannot be viewed as independent. They are the core elements of combination prevention packages that must also include condoms, clean needles and harm reduction programs and smart, strategic behavior change communication. (Male and female condoms and harm reduction are highly-effective, relatively inexpensive and still imperfectly deployed. While we haven’t devoted a specific section to these strategies, the resources and know-how invested in scaling up combination prevention must improve the logistics, communication and delivery of these strategies.
If the world is serious about implementing HIV testing, voluntary medical male circumcision (VMMC) and scaled-up antiretroviral treatment, then these three actions are of the utmost importance.
For the effort to end AIDS to remains on track over the next 10 to 15 years, today’s emerging prevention tools like PrEP, microbicides and an AIDS vaccine need to remain on track for introduction and delivery.
If the “test, circumcise, treat” agenda detailed in the previous section is fully implemented, rates of new HIV infections could drop significantly in the next decade, as will the number of people living with HIV who progress to and die from full-blown AIDS. As the epidemic comes under control, it will become even more apparent where new tools can be added to combination prevention packages to have the greatest impact and synergy.
The AIDS epidemic isn’t going to end tomorrow. Even with all of the strategies described in the preceding pages, it isn’t guaranteed to end at all. The success of the venture will depend in large part on the ability to operationalize—and fund—combination prevention in many different settings. Over the long term, there may also be breakthroughs in the search for a protective AIDS vaccine and a functional cure, strategies that would have an enormous impact on the shape of the epidemic and prevention needs. It is critical that this work be sustained with adequate funding, and a consistent focus.
As the world implements existing tools, we must also maintain scientific investigation. The AIDS vaccine field is as exciting as it has ever been. The results from follow-up work on the RV144 vaccine efficacy trial have framed a new research agenda. Basic scientific exploration of neutralizing antibodies is paying off as new potent antibodies are identified, and their structures and maturation processes are increasingly well defined.
Some might say that when we say we have the tools to end AIDS and urge continued investment in research, that we are trying to have it both ways. We think that, over the long term, focusing on both implementation and scientific investigation is needed if we are see the struggle through to the end.
If all the proposed steps outlined here are taken over the next 10 years, there will still be people living with HIV and new infections every day. But there will also be many people living longer, healthier lives with HIV—and many, many fewer HIV infections. The epidemic will be, finally, under control. This is the first step to ending it and for many of us, it is the goal we will live to see.
To control and, ultimately, end the epidemic, the world needs a comprehensive “Ending AIDS” agenda which spans research and implementation, vaccines, PrEP, microbicides, circumcision, ARV treatment and care. This agenda would constitute a strategic plan that lays out key milestones, budgets and roles, using science and evidence as the guide, AVAC—in concert with many players and stakeholders— looks forward to developing this strategy to end the epidemic.
As NIAID head Anthony Fauci wrote earlier this year:
“If one accepts the tenet that science should inform policy, then the scientific data are speaking loud and clear. Global policy makers must seriously consider these new data in their priority-setting and decision-making... For the first time in the history of HIV/AIDS, controlling and ending the pandemic are feasible; however, a truly global commitment, including investments by those rich and middle-income countries whose contributions have thus far been limited, is essential. Major investments in implementation now will save even greater expenditures in the future; and in the meantime, countless lives can be saved.”
Yet, as with all successful movements, the power to achieve is vested not just with the leaders but with all stakeholders . AVAC envisions a near future in which presidents, parliamentarians and policy makers; health professionals and researchers; advocates, people at special risk and people living with HIV and AIDS join in the movement to bring this pandemic to the end.