12/3/2016

TheendofAIDS

TheendofAIDS
JeffreyD.SachsinNewYork

The AIDS pandemic claimed around 36 million lives between 1981 and 2016, and a similar number
aroundtheworldcurrentlylivewiththeHIVvirus.Some1.2millionpeoplediedofAIDSlastyear,and
another1.8millionwereinfected.Thosestatisticsaredaunting,butthestartlingnewsisthatthegoalof
an"AIDSFreeGeneration"isrealisticallywithinreach.Therequiredpolicystepsshouldbeagreedin
theearlydaysofUSPresidentelectDonaldTrump'sadministration.
The key reason that the epidemic can be ended is a scientific finding back in 2011 that showed that
HIVpositive individuals receiving antiretroviral (ARV) treatment suppress the HIV virus in their
bloodstreams so dramatically that they are very unlikely to transmit the virus to others through sex or
shared needles. This finding confirmed the concept of "treatment as prevention." If a high enough
proportionofHIVpositiveindividualsreceiveARVtreatment,itispossiblenotonlytosavetheirlives,
butalsotobreakthetransmissionofthevirusitself,therebyendingtheepidemic.
Building on this idea, AIDS specialists developed two crucial ideas: "909090" and the "cascade of
AIDS care." The 909090 program aims to ensure that by the year 2020, 90% of all HIVinfected
individualsknowthattheyareinfected(thefirst90)90%ofallthosewhoknowtheyareinfectedare
receiving ARV treatment (the second 90) and 90% of all those receiving ARV treatment successfully
suppresstheHIVvirusintheblood.Theideaofthecascadeisthatifeachofthethree"90s"isachieved,
theproportionofallHIVinfectedindividualswithviralsuppressionwouldbe90%x90%x90%,which
isequalto72%.
If 72% of those infected today can no longer infect others, the HIV/AIDS epidemic will be curtailed.
Indeed, if 909090 in 2020 becomes 959595 by the year 2030, the proportion of HIVpositive
individualsthatcannotinfectotherswouldriseto86%.Theongoingepidemicwouldgrindtoahalt,just
as a measles epidemic among children in a metropolitan area ends when 80% of the children are
vaccinated, even if the other 20% of children remain unvaccinated. Some cases would remain, but the
AIDScatastrophewouldbeover.
Thegoalofreaching909090bytheyear2020and959595by2030isrealistic,ifcountriesstrivefor
success. Sweden recently announced that it has reached the 909090 targets. Many other highincome
countriesareclose.Withinternationalhelpandnationalefforts,909090couldbeachievednotonlyin
highincomecountriesbutindevelopingcountriesaswell.
For most of the world, the biggest challenge is ensuring that by 2020 at least 90% of HIVpositive
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individuals are tested and learn that they are infected the first of the three 90s. To reach this goal,
peoplewhoaresymptomaticorathighriskneedtobeconnectedtothehealthsystemfortesting.
Once an HIVinfected individual tests positive, achieving the second 90% (AVR treatment) depends
mainlyonfundingandstaffingwithasufficienthealthbudget,medicinescanbemadeavailableforall
infectedindividuals.
Achieving the third 90% (suppression of the viral load) depends mainly on whether AVRtreated
individualstakethemedicationsonschedule.Thatmayrequiresocialsupporttoencouragethepatients
to continue the medications even when they feel healthy, and to help ensure the timely and affordable
supplyofmedications.
The909090targetscanbereachedevenamongimpoverishedandhardtoreachpopulations,thanksto
a new and powerful publichealth solution: community health workers (CHWs) supported by
smartphones.CHWsarelocalcommunityresidentswithatleastahighschooleducation,whoaretrained
forafewmonthsinthemanagementofspecifichealthchallenges,suchasidentifyingpotentiallyHIV
infectedindividuals,bringingthemtotheclinicfortesting,andhelpingthemtoadheretotheirmedical
protocols.Newsmartphoneappshelpthemtodotheirjob.
InruralAfrica,wheredoctorsaretypicallyveryscarceandAIDSprevalenceisoftenhigh,thehighlife
savingpotentialofCHWshasbeenverywelldemonstratedanddocumented.Moreover,beingaCHW
offers a good way for young people to start their careers. Though initial compensation is very modest
(perhaps $100 per month), the experience and training can put these young workers on a path toward
furthereducation(suchasnursing),risingskills,andhigherincomes.
Yet,despitethepotentialtobringtheAIDSepidemictoanend,theworldiscurrentlystuckinlimbo.
Sadly, our governments operate not on the basis of bold goals and the means to achieve them, but on
"businessasusual."Sixteenyearsago,businessasusualmeantalmostnotreatmentofpoorpeoplewith
AIDS,becausefinancingwasnotavailable.Atthattime,Irecommendedanew"GlobalFund"tofinance
AIDStreatment,anideathatwasadoptedandthenhelpedtostartaneraofAIDScontrolinAfrica.
USPresidentGeorgeW.Bush'sadministrationmadeamajorUSfinancialcommitmenttoAIDS,andthe
GlobalFundandUSprogramstogetherhelpedmillionsofpeoplegainaccesstotreatment.Yet,afterthe
2008financialcrisiserupted,PresidentBarackObamaleveledofftheUSfinancing,andtheglobalAIDS
controleffortgotcaughtina"halfway"mode.Asof2016,roughlyhalfofallHIVpositiveindividuals
areonARVtreatment,farshortofthe90%target.
TheincomingTrumpadministrationshouldgraspthehistoricopportunitytohelpbringAIDStoanend
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throughamodestfinancialcommitmentbygovernmentsandotherfunders.Anextra$10billionperyear
fromallsourceswouldlikelybesufficienttogetthejobdone,withjust$3.04.0billionannuallyfrom
theUS.
SkepticswillscoffthatTrumpisanunlikelychampionofsuchaneffortbut,frankly,whowouldhave
guessed 15 years ago that Bush would be the key mover of the financial scaleup of the fight against
AIDS? History is full of positive as well as negative surprises the end of AIDS can be a historic
achievementofourgeneration,ifwereachforit.
JeffreyD.SachsisProfessorofSustainableDevelopment,ProfessorofHealthPolicyandManagement,
and Director of the Earth Institute at Columbia University. He is also Director of the UN Sustainable
DevelopmentSolutionsNetwork.ProjectSyndicate,2016.
distribution@projectsyndicate.org

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