By Sonja Ausen-Anifrani
In the last several decades, HIV/AIDS has plagued populations, disrupted economic and family structures, and highlighted underserved groups. Since the first reported cases of HIV/AIDS, more than 25 million people have died as a result of complications from the illness. The disease has been particularly devastating in certain portions of Africa: out of the total number of people living with HIV worldwide in 2009, 34% of these lived in ten countries within South Africa. However, significant progress is being made towards lessening the effects of this disease; for example, in 2011 there were 1.7 million AIDS-related deaths as compared to 2.3 million in 2005. In addition, 25 countries have witnessed a 50% or greater drop in new HIV infections since 2001 and more than eight million persons with HIV had access to antiretroviral therapy.
It is this progress that has spurred movement towards an AIDS-free generation. Several of the most prominent organizations leading this initiative include UNAIDS “Getting to Zero” and PEPFAR’s “Creating an AIDS-free Generation.” On 8 November 2011, Hilary Clinton gave a speech at the National Institutes of Health in which she claimed the ability to achieve an AIDS-free generation and also defined what this means:
Now, by an AIDS-free generation, I mean one where, first, virtually no children are born with the virus; second, as these children become teenagers and adults, they are at far lower risk of becoming infected than they would be today thanks to a wide range of prevention tools; and third, if they do acquire HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.
Barriers to attaining this goal are very real; however, with concerted efforts, I believe reaching this target is feasible. Much thoughtful discussion and research has been poured into the alleviation of HIV/AIDS. The PEPFAR document referenced above provides a detailed outline of proposed steps:
- Work toward the elimination of new HIV infections among children by 2015 and keep their mothers alive.
- Increase coverage of HIV treatment both to reduce AIDS-related mortality and to enhance HIV prevention.
- Increase the number of males who are circumcised for HIV prevention.
- Increase access to, and uptake of, HIV testing and counseling, condoms and other evidence-based, appropriately-targeted prevention interventions.
- Target HIV-associated tuberculosis (TB) and reduce co-morbidity and mortality.
- Increase access to, and uptake of, HIV services by key populations.
- Partner with people living with HIV to design, manage and implement HIV programs to ensure that they are responsive to, and respectful of, their needs.
- Strengthen PEPFAR’s continued focus on women, girls and gender equality.
- Reach orphans and vulnerable children affected by AIDS, and support programs that help them develop to their full potential.
- Strengthen programmatic commitment to and emphasis on reaching and supporting young people with HIV services.
- Strengthen PEPFAR supply chains and business processes
- Increase efficiencies through innovation and greater integrations of services with other U.S., bilateral and multilateral global health investments.
- Partner with countries in a joint move toward country-led, managed and implemented responses.
- Increase support for civil society as a partner in the global AIDS response.
- Expand collaboration with multilateral and bilateral partners
- Increase private sector mobilization toward an AIDS-free generation.
- Support implementation research.
- Evaluate the efficacy of optimized combination prevention.
- Support innovative research to develop new technologies for prevention and care
- Develop evidence-based approaches to reaching people early enough in their disease progression to help maintain a strong immune system; stave off opportunistic infections, particularly TB; and reduce new HIV infections.
- Support the deployment of suitable technology for measurement of viral load, both through tiered laboratory networks and ‘point-of-care’ tests as they become available.
- Assist countries in adopting breakthrough new technologies with proven impact, such as new, molecular-based TB tests.
These Road Maps provide strategic steps that can assist in creating an AIDS-free generation. As with any well-thought out plan, we must consider the pitfalls that may prevent these aspirations from becoming reality. In a recent article in The Atlantic, John-Manuel Andriote analyzes the likelihood of these objectives reaching fruition. He states that barriers may be present in ineffective policies, implementation challenges, outdated state policies (criminalizing HIV-positive persons for not revealing HIV status to potential sexual partners, for example), and low priority status within budgets. Next, there are barriers around adherence to named ideals; for instance, condoms may abound, but their use cannot be enforced. The perpetual problems of food insecurity and poverty speak to the difficulties of implementing lasting change: enough food and enough money exist for all to have a decent quality of life and, yet, no one has been able to successfully mandate the equal distribution of food or money. Lastly, how much tenacity will be put forth in this effort? Public health professionals and others must commit to seeing these goals through, despite circumstances that will be difficult to combat.
There are other measures whose integration will be imperative in meeting this goal. Greater emphasis on STI prevention should be promoted. Certain groups of STIs increase the likelihood of HIV transmission. Providing education and working to empower women is an important step that relates to this goal. Sabarwal and Santhya illuminate the low levels of treatment seeking in India, particularly among young and unmarried women. Andriote’s article mentions making HIV testing mandatory, even in those instances when one does not present with risk-factors. This proposition could be quite useful in reducing transmission.
It seems that an AIDS-free generation is not unattainable..Or is it? Despite barriers, the reductions in the AIDS death and infection rates cited above are progress to be celebrated and used as fuel for achieving additional advancement. Approaches that consider multiple disciplines (medicine, economy, geography, political, and educational, for example) and how these disciplines can work most efficiently and creatively together in order to contribute to an AIDS free generation will be of utmost importance. The necessity and urgency of meeting and implementing these objectives can be measured in future lives saved, families kept intact, and economies kept running. AIDS-free can be in our future.