This is an exciting moment in the response to AIDS. Leading scientists, policy makers, advocates, and others believe we can begin to end the pandemic. But we will not realize this potential automatically. It will take choices: about increasing investment, using funds strategically, learning as we go, and holding ourselves accountable.

With this email, amfAR and AVAC are launching the first in a series of quarterly progress reports on actions taken to accelerate the end of the epidemic. These reports follow the Action Agenda to End AIDS (endingaids.org) our groups issued at the 2012 International AIDS Conference. That document called for specific steps in five critical areas: strategy, investment, accountability, research, and efficiency.

With each issue of the report we aim to ask: Are we following the evidence and making the critical decisions and commitments needed in each area to accelerate progress and begin to end the epidemic? Or are we missing opportunities to act strategically and thereby allowing the epidemic to continue?

For our first update, we hope to pass along what we consider to be key “take-home messages” about results over the past year, including progress under each of the five critical areas and links to relevant materials. We also preview what we will be looking for over the next quarter so that we—and you—can focus on the most important actions needed to lay the foundation for the end of AIDS.

A more detailed quarterly analysis is available at endingaids.org, along with the Action Agenda itself. We are interested in your input and feedback, and invite you to suggest data sources we may have missed and ways in which we can improve the usefulness of this report. Write us at info@endingaids.org.

A special note on data: Our ability to hold each other accountable for results suffers from serious data limitations—regarding investments, country-level decision-making, service coverage, and epidemiological trends. While these quarterly updates will report on what is available, they will also point out those places where data isn’t available, isn’t timely or complete, or is of questionable quality.

The Bottom Line

Results to date:

New infections and AIDS deaths continue to decline, but not at a pace sufficient to meet the global goals of halving new infections among adults and eliminating new infections in children by 2015.

• In 2011, the number of new infections among adults was 21% lower than in 2001.
• New infections among children fell by 42% from 2003 to 2011.
• AIDS deaths were 29% lower in 2011 than in 2006.
• Scale-up of voluntary medical male circumcision is finally picking up pace.

Overall progress still remains too slow:

• The coverage increase for services to prevent new infections in children was relatively modest in 2011;
• Crucial investments by donor countries are flat or in decline; and
• There is little evidence that countries are reorienting priorities to enhance the strategic focus and impact of limited funding.

The opportunity to move toward the epidemic’s “end game” is real, but we’ll need to “up our game” if we hope to get there. Read on for more detail on developments in the five priority areas.

Strategy: Scale up high-impact interventions

Gains in bringing key strategies to scale are genuine, but the pace of coverage scale-up needs to accelerate. Improvement is urgently needed with respect to the timeliness of coverage data. Scale-up remains far too slow for key marginalized populations.

• Antiretroviral treatment coverage and services to prevent new infections in children increased by 21% and 10%, respectively, in 2011.
• 2012 brought the most progress to date in scaling up voluntary medical male circumcision in the 14 priority countries—with about 2 million male circumcisions performed to date (about 10% of the amount needed)—but much more needs to be done.
• Many countries continue to fail to focus AIDS spending on the most cost-effective strategies.
• PEPFAR is developing a blueprint to ensure an “AIDS-Free Generation,” with an anticipated launch later this month.
• 40% of UN member states criminalize consensual same-sex sexual relations, undermining rights-based responses.

Investment: Mobilize sufficient resources

Current funding ($16.8 billion in 2011) remains more than $6 billion less than the $22−24 billion needed annually for an optimally effective AIDS response.

• Developing countries are increasing domestic outlays and now account for more than half of HIV spending worldwide.
• Donor HIV assistance increased in 2011, but reflects flat funding since 2008.
• European leaders took steps to implement a financial transaction tax to provide ongoing support for international health and development programs.

Accountability: For results

Genuine accountability in the AIDS responses remains lacking. Rather than wait 12−15 months to obtain essential coverage information, we need a real-time results monitoring system that measures outcomes. WHO, UNAIDS, and UNICEF should work with the Global Fund, PEFPAR, other leading donors, and national governments to generate more timely data on service coverage and epidemiological trends.

• Prior to World AIDS Day 2012, the ONE Campaign is launching its first annual monitoring report to track financial, programmatic and political commitments toward three global targets for 2015—eliminating mother-to-child transmission, reaching 15 million people with antiretroviral therapy, and reducing new HIV infections.

Research: Build the evidence base to end AIDS

Additional funding is focused on implementation research, although substantially greater efforts are needed to build the evidence base to increase the uptake, efficiency, and impact of HIV programs.

• Important gains have been made in developing simpler, affordable, point-of-care diagnostic tools for CD4 and viral load monitoring.
• PEPFAR awarded $60 million in implementation research grants to improve the effectiveness of HIV programs.
• Evidence presented at the International AIDS Conference increased optimism about the future prospects for a cure for HIV.
• Five demonstration projects are under way in the U.S. to inform roll-out of pre-exposure prophylaxis.
• After slow progress in prior years, strategic investments in HIV vaccine research are paying dividends and generating renewed optimism.

Efficiency: Use resources for maximum impact

It is now clear that delivery of antiretroviral therapy is far cheaper than originally believed, highlighting the feasibility of further, expedited scale-up.

Unfortunately, trade agreements being negotiated threaten to inhibit the production of essential generic antiretroviral medicines that will be needed in future years.

• The cost of antiretroviral treatment programs is falling, but clarity is lacking on how much or how fast costs are declining. There are several recent cost assessments, including a Clinton Health Access Initiative study that concluded that antiretroviral therapy programs in sub-Saharan Africa cost far less than previously understood.
• Further analysis of data from HPTN 052 finds that early initiation of antiretroviral therapy would result in substantial long-term reductions in HIV-related treatment costs.
• The Economist sharply criticized trade negotiation tactics being pursued by the U.S. and the European Union, urging donor governments and the pharmaceutical industry to show flexibility to ensure future access to essential HIV medicines.

What we’ll be looking for in our next quarterly update...

• Does the new PEPFAR blueprint lay out a clear plan of action to move steadily toward an AIDS-Free Generation?
• Does the new UNAIDS Global Report indicate that countries and their international partners are implementing more strategic national programs? Are the data in the new Global Report timely and reliable?
• Is the U.S. Congress on the right path to maintain vital support for PEPFAR and the Global Fund? What do the November election results say about the future of PEPFAR, including its reauthorization?
• Is the Global Fund effectively implementing its new five-year strategy? Are countries stepping forward to reprogram their Global Fund grants in line with investment principles? Now that the Global Fund has embarked on a promising new strategic direction, are donors stepping forward to ensure that it has the resources it needs to support strategic, evidence-based proposals from countries?