AIDS: some answers, some questions

The battle to treat and prevent the spread of HIV/AIDS in sub-Saharan Africa is a colossal effort being undertaken by nongovernmental organizations, philanthropists, and governments. The battle’s success will depend on the right combination of scientific research and public health policy. “Who Will Live? Power, Politics, and the Future of Global AIDS Treatment” will address this topic as part of the two-day William J. Bicknell Lectureship in Public Health at the BU School of Public Health Thursday and Friday, September 28 and 29.

Jonathon Simon, director of the BU Center of International Health and Development, discusses the scope of the world effort and what steps should still be taken. Simon, who will speak as a panelist during Friday’s lecture session, is also chair and associate professor of the BUSPH Department of International Health.

BU Today: How deeply involved is the world in the fight against AIDS today?

Simon: Twenty-five years into the greatest infectious-disease event in history, the world has started to respond, with tremendous political attention at the highest levels of government—both among the G8 countries and in countries heavily affected by AIDS—trying together to mount a global response to the pandemic. Levels of funds that have never before been mobilized for a public health crisis are now available, including $15 billion from the United States, committed by the Bush administration; $8 billion from The Global Fund; and major sums of money from the World Bank and national governments.

The UN Millennium Development Goals initiative set 2015 as the year by which the world should halt the spread of AIDS. How are we doing on that goal?  

We are failing. Last year there were more new infections than there were people who died from the disease. What this means is that we added over a million people to the global burden associated with HIV. We are rolling out and scaling up treatment services and beginning to extend the lives of people who have the disease, but our failure to mobilize an effective global effort on the prevention side means that each year in the past five years, we have actually fallen further behind. If that trend continues, we will certainly fail to meet the Millennium Development goal of turning back the tide on HIV/AIDS by 2015.

What needs to be done differently?

At the International AIDS Conference in Toronto in August, there was tremendous attention put on the prevention side of the equation because it is clear from the surveillance data that there are approximately four million new HIV infections each year. We may now begin to see the start of a more balanced approach where prevention takes on greater importance. Much of our effort during the last three to five years has been to develop treatment programs to extend the lives of people who have the disease. And although great progress in the provision of treatment has been made during this time, we are nowhere near the goal of treating three million people by 2005, which was the stated goal of WHO’s 3 by 5 initiative, a global AIDS program headed by Harvard’s Jim Kim. Professor Kim, who will speak on Friday morning, has been a passionate and persuasive voice in urging a global response to AIDS.

How are researchers doing on scientific discoveries surrounding AIDS? Is there any good news?

Some of the most exciting work that has come out in the last year is the research that has shown the protective effect of circumcision. The science shows that circumcision has a major effect in preventing the transmission of the disease. This is a very difficult public health intervention for programs to deal with because of cultural issues surrounding circumcision, and other reasons. We’ve made less progress on creating behavioral change to prevent the transmission of HIV. Major investments are being made in trying to change patterns of sexual behavior, particularly in young people, but in fact, it is a very difficult behavioral-change goal to accomplish. The prevention side, by and large, has had very little good news with the exception of the circumcision story.

On the treatment side, we continue to roll out treatments to more populations; these are life-extending, not life-saving, drugs. In fact, the treatment program has shown that we can get these drugs to people who need them, even in remote areas. Antiretroviral therapy has been shown to save lives in many populations. But treating people and extending lives are only part of the equation.

We have little data on the nonclinical outcomes, such as reengagement in labor force participation, or reengagement in civil society, people going back to school or back to church. In my opinion, we need to extend the thinking on the purpose of treatment beyond raising CD4 counts [a measure of immune strength] and reducing viral loads and on to the issues that matter to people—am I able to work and support my family, and can I fully participate in the social life of my community?

Should Africa command most of the world’s attention on AIDS, or are there other places where we should also focus?

The bulk of the infections are on the African continent, so you can make a legitimate argument for the importance of providing a disproportionate amount of treatment services there. However, if you look forward, you will find that this epidemic is going to be an Asian epidemic and an epidemic in central Europe. The emergent epidemics in India, China, and Russia will continue to draw more and more of the world’s attention not only because of the large population bases in those parts of the world relative to Africa but because of their economic, strategic, and political importance to the countries in the West that are financing the global response.

There is an ongoing and deeply felt debate about the wisdom and ethics of rationing AIDS drugs. Can you talk a bit about this debate from your point of view?

The global response to the pandemic has been well served by the activist community in drawing attention to the issue and in lowering drug prices and getting governments to mobilize and respond. One of the issues that the activist community has taken on is a notion that treatment should be provided for all. While this is a moral and ethical position, it is ahistorical—we have never been able to deliver medical technology to every person who needs it—and there are insufficient budgets to support the goal. The costs associated with the six million people who could probably be on therapy today, let alone the millions of additional people who will come into the flow of need in the near term, is an extraordinary financial burden for the world, both for international donors and for national governments.

While it is noble to think that we will be able to provide antiretroviral therapy for everyone who needs it, the human-resource constraints, the infrastructural constraints, and the financial realities lead me to believe we are a long way from being able to provide treatment for all. That implicitly means that we are in a rationing environment. Some of the scientists in the world, including our group at the BU Center for International Health and Development, believe that an explicit debate about the rationing of access will lead to better social policy. There may be reasons governments may want to provide preferential access to treatment for their nurses or their school teachers, their military forces or other specific populations—mothers with children perhaps. In fact, because we are failing to have an explicit discussion about the rationing that is occurring, we have a situation of implicit rationing where urban populations and elites have greater access than others. Having no explicit discussion of rationing doesn’t make the issue disappear; it just means we have no thoughtful social policy on how to respond to the crisis. As a world community, we can do better.