Now Is Not the Time to Retreat on HIV

Remember the infamous 2001 quote in a Boston Globe interview by then-administrator of USAID, Andrew Natsios, explaining that adherence to treatment would be impossible because Africans “don't know what Western time is?” At that point, only 400,000 people living with HIV were receiving antiretroviral treatment (ART) in the developing world—most of them in Brazil, the only developing country providing universal and free access to treatment.

In a little more than a week, thousands of scientists, clinicians, and activists engaged in the AIDS response worldwide will meet in Vienna for the XVIII International AIDS Conference. In a Science magazine opinion piece published today, Nathan Ford of Médecins sans Frontières; Julio Montaner, of the Division of AIDS at the University of British Columbia in Canada and the current president of the International AIDS Society (IAS); Pedro Cahn of the Fundacion Huesped in Argentina and the immediate past president of the IAS, Elly Katabira of Makerer Medical School in Uganda and the president-elect of the IAS; and I call on our colleagues from these diverse fields to unite their voices and continue to hold governments accountable for their promises to provide universal access to “comprehensive programs for HIV prevention, treatment, care and support by 2010.”

In little more than seven years, the AIDS community has prevailed against many obstacles to show what the human spirit can achieve when it acts in bold and generous fashion. As we note in today’s article, the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) in 2002 and the establishment of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 set the stage for rapid progress. Today, more than four million people are on ART in low and middle-income countries, alive, at work and in school, with their families and friends. Back in 2001, naysayers lined up to say this was impossible, unrealistic, or too costly.

Today, we know we can virtually eliminate transmission of HIV from mother to child, and save women’s lives, by appropriate use of ART. From 2001 to 2008, new HIV infections decreased worldwide by 17 percent, and by higher margins in sub-Saharan Africa. Against great odds, as we wrote in today's article,

The GFATM catalyzed the introduction of needle exchange and/or methadone programs to prevent HIV infection in people who inject drugs in countries such as Azerbaijan, China, Georgia, Moldova, Russia, Tajikistan, and Ukraine and has adopted forward-looking strategies to address the pandemic as it affects women and girls and sexual minorities. Progress toward universal access has directly advanced efforts to achieve several of the U.N. Millennium Development Goals (MDGs), especially those that relate to reducing child mortality and improving maternal health.

Clearly, the massive efforts deployed by the AIDS community have worked. Moreover, the increasingly recognized benefit of ART in reducing HIV transmission presents exciting scenarios for finally bending the curve of new infections and breaking the back of the epidemic.

Still, much more needs to be done by governments to support effective HIV prevention interventions, notably by stopping abuse and discrimination against socially marginalized populations, repealing laws and regulations that hamper their access to health services, and combating sexism and gender inequity. Care of persons living with HIV, including pain relief and treatment adherence support, remain severely underfunded. In too many places, HIV and sexual and reproductive health services are not integrated. Access to good, affordable, and appropriate drugs for second and third line ART, and to pediatric formulations, remains elusive. Developing countries, in particular, need to be able to use flexibilities in world trade agreements to produce needed drugs at prices they can afford without fear of retaliation by the U.S. and Europe. Now is not the time to stop or stall the response.

Yet, in the wake of the G8 and G20, all our governments appear to be poised to shrug off responsibility for HIV. The naysayers are back, invoking a range of arguments to justify this shameful retreat: that HIV funding has distorted and weakened health systems; that HIV is receiving too large a share of health funding; that ART is not cost-effective; and that the AIDS response is not sustainable. We looked at the evidence on these questions, and found these accusations wanting:

In fact, it is global health overall and the Millennium Development Goals (MDGs) that are underresourced. According to a recent report of the Organization for Economic Cooperation and Development (OECD), wealthy nations are falling billions short in fulfilling their commitments to the MDGs. Certainly, compared with the hundreds of billions of dollars delivered almost overnight to rescue Wall Street and Greece, funding for the HIV response ($5.5 billion by the GFATM and $26 billion by PEPFAR since 2003, for example) remains modest.

Increasing funding for maternal and child health, as the Canadian government proposed to do at the G8, will fail if it means flatlining or reducing funding for HIV services. These same women and children are now getting infected with HIV for lack of preventive measures, and are being placed on waiting lists for ART, from South Africa, to Uganda and even the United States. Rather than pitting critical health priorities against each other, we should instead be calling for an urgent increase in overall health funding.

This will be the subject of discussion and debate at several key sessions in Vienna, including a double symposia entitled "Future of Universal Access" on July 20 from 2:30 to 6:00 p.m., moderated by Mark Heywood of section 27 in South Africa and Stephen Lewis of AIDS-Free World, and featuring Michel Kazatchkine, the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Ambassador Eric Goosby, the head of the U.S. Office of Global AIDS Coordination, in charge of PEPFAR.

Activists, scientists, health providers: come and join us to say, loud and clear, that now is not the time to retreat on global commitments to HIV programs.