Susan Blumenthal, M.D.: Ending the AIDS Epidemic: Toward an AIDS-Free Generation

Written in collaboration with Ashley Grosso, Ph.D.

On this World AIDS Day -- 30 years after the first cases of HIV were reported in the U.S. and with 34 million people currently infected worldwide -- there is finally a roadmap for ending the AIDS epidemic globally and achieving an AIDS-free generation. Today, President Obama is announcing that we are at the beginning of the end of AIDS and that the U.S. pledges its commitment and resources to maximize the unprecedented scientific opportunities currently available to us to achieve this goal.

An AIDS-free generation means no child will be born with HIV; risk of infection will be dramatically reduced thanks to a combination of powerful prevention tools and a possible vaccine in the future, and people living with HIV will enjoy long, healthy lives as early access to treatment prevents their disease from progressing to full-blown AIDS.

In order to achieve this, we must:

1) Invest in research and accelerate the translation of science into services;

2) Eradicate mother-to-child transmission of HIV worldwide;

3) Scale-up evidence-based treatment and prevention strategies globally;

4) And eliminate the discrimination and stigma surrounding the disease.

First, research. Science has given us the tools to begin to end the AIDS epidemic, but government and private sector commitment, international collaboration, political will, and leadership are needed to reach this goal. Secretary of State Hillary Rodham Clinton recently spoke at the National Institutes of Health (NIH), highlighting how American investments in research over the past 30 years have yielded lifesaving dividends that will help end the AIDS epidemic. Her remarks echoed the message of a recent Capitol Hill Conference convened in July, 2011 by amfAR, The Foundation for AIDS Research, that we can make AIDS history by applying scientific research advances and committing the necessary resources and leadership to achieve this goal.

In the past year alone, U.S.-funded studies have produced dramatic results that will contribute to making AIDS history. An NIH-supported clinical trial provided evidence that HIV/AIDS treatment with antiretroviral medications (ARVs) not only saves the lives of those receiving medication but also prevents new infections. [1] When people with HIV initiated ARV treatment early in the course of infection, they reduced the risk of sexual transmission of HIV to others by 96 percent. This is the reason the Scientific Advisory Board of the President's Emergency Plan for AIDS Relief (PEPFAR) has called for accelerating the scale-up of ARVs. [2] UNAIDS reports that ARV treatment has saved the lives of 2.5 million people in low and middle income countries since 1995, but less than 50 percent of people who need treatment have access. [3] Results of other studies reported this year have shown that HIV-negative men who have sex with men (MSM) and members of heterosexual couples who took a daily antiretroviral pill as pre-exposure prophylaxis (PrEP) dramatically reduced their risk of acquiring HIV as well. [4] [5] [6] The relative risk of acquiring HIV for MSM was reduced by 44 percent overall, and by 92 percent among those who took the drug as prescribed (documented by detectable levels of the medication in their blood). Risk of acquiring HIV was reduced by 49 to 75 percent among members of heterosexual couples. Additionally, NIH-supported research has found that medical male circumcision reduces the risk of HIV acquisition among men by 53 percent, and an antiretroviral microbicidal vaginal gel reduced HIV risk in women by 39 percent overall, and by 54 percent among those who used the product regularly. [7] [8] However, another major study of a microbicide gel containing tenofovir was recently discontinued because it was found to be ineffective at preventing HIV transmission in women. [9]

Even though there are so many recent scientific advances and new prevention and treatment strategies to celebrate, there is still much to do. The ultimate goal in public health is the discovery a vaccine and a cure for a disease. Now, 30 years after the first cases of HIV were identified in the U.S., a cure is finally on the horizon. A formerly HIV-positive man appears to have been functionally cured of AIDS through a bone marrow stem cell transplant for his leukemia using cells from a donor immune to HIV. [10] Since the time of the transplant, the patient has been HIV-negative and no longer requires treatment with antiretroviral medications. [11] This case has provided hope and fueled a new generation of studies including gene therapy research. It is why amfAR, The Foundation for AIDS Research has spearheaded multi-site research collaborations and awarded grants to foster scientific discovery aimed at finding a cure. Additionally, the NIH recently provided $14 million in new funding to establish public-private partnerships toward this goal. While progress has been made in developing a vaccine to prevent HIV infection in recent years, more research is urgently needed. [12] The bottom line is that America's investment in research saves lives and provides hope for an AIDS-free generation worldwide.

Second, eradicating mother-to-child transmission of HIV. PEPFAR and UNAIDS are leading a global partnership to end HIV among infants by 2015 through prevention of mother- to-child transmission (PMTCT) services. In 2010, 52 percent of pregnant women living with HIV did not receive effective PMTCT. [13] The virtual elimination of mother-to-child transmission of HIV in the United States demonstrates that it is possible to eradicate pediatric AIDS globally if we commit the needed sources worldwide. A key component of this effort is an increased focus on women and girls who represent 50 percent of HIV cases globally and an even greater percentage in sub-Saharan Africa and the Caribbean. [14] AIDS is the leading killer of women of reproductive age worldwide. [15] Implementing a woman- and girl-centered approach is one of the guiding principles of the Global Health Initiative, the U.S. government's strategy to improve health outcomes through the integration of investments in eradication and control of specific diseases like AIDS with the strengthening health systems worldwide. [16]

Third, scaling-up combination evidence-based prevention and treatment interventions. In addition to increasing the reach of effective PMTCT services, voluntary medical male circumcision and the scale-up of treatment for people living with HIV are essential components of the roadmap to end the AIDS epidemic. Studies have found that treatment is prevention, reducing transmission of the virus to others by more than 96 percent. Thus, treatment pays a dual dividend by saving lives as well as preventing new infections. These services must be combined with other proven effective practices including condom use, behavioral interventions, counseling and testing, and health systems strengthening. No one intervention can create an AIDS-free generation, but effective interventions that are used in combination with each other can move us closer to our goal. Mathematical models have demonstrated that scaling up prevention strategies and treatment in high prevalence countries would drive down the global infection rate by an estimated 40 to 60 percent. That's in addition to the 25 percent decline in new infections that has been achieved in the past decade. This would represent a significant tipping point in the epidemic toward ending AIDS.

Fourth, reducing stigma surrounding HIV/AIDS. Discriminatory laws that criminalize people's sexual orientation and prohibit syringe exchange programs for injection drug users (IDU) must be repealed. Studies have shown that HIV-related stigma is associated with transmission risk behaviors among MSM. [17] Research has also found a strong positive correlation between drug use stigma and HIV injection drug use risk behaviors. [18] Repealing laws that prohibit the operation or funding of syringe exchange programs will help reduce this stigma as well as decrease the 10 percent of HIV infections annually that are due to IDU around the world. Additionally, women face stigma and discrimination that increase their risk of HIV transmission. One model estimates that stigma is associated with as many as one-half of new HIV infections among children because women refuse to take HIV tests or fail to go back to the clinic to learn their results. [19] Secretary Clinton underscored that reducing discrimination against women and girls and stopping gender-based violence and exploitation are critical components of comprehensive HIV prevention.

The Path to Progress

The remarkable progress toward an end to AIDS made over the past 30 years is being threatened by a decline in resources to support HIV research and services. While U.S. global health investments represent only about 1 percent of America's budget, these funds support lifesaving research and services for millions of people in developing nations and help build a world with more friends and fewer enemies. If support for global health is cut through the automatic trigger for sequestration of funds under the Budget Control Act of 2011, a recent report by amfAR estimates that in fiscal year 2013:

? Treatment funding for 403,000 people will not be available, resulting in 92,000 more AIDS-related deaths and 181,000 more children becoming orphans;

? Funding for food, education and livelihood assistance will not be available for 419,000 children;

? 10,000 more infants will die of AIDS-related causes before the age of 1 due to a lack of services for PMTCT; and

? AIDS research at the NIH will lose $339 million in funding.

Additionally, because of limitations in funding from donor nations, the Global Fund to Fight AIDS, Tuberculosis and Malaria recently announced that it will not make any new grants until at least 2014. [20] Cuts in support for these programs will lead to significant morbidity and mortality from HIV/AIDS.

This potential loss in human life and scientific support is alarming for many reasons. Precious lives will be lost and human suffering will increase worldwide. Furthermore, the health security of the U.S. population is tied to the health of people in other countries and reflects our character as a nation. [21] As President John F. Kennedy once said, "Our most basic common link is that we all inhabit this planet. We all breathe the same air... And we are all mortal." Infectious diseases cross borders and pose real threats to the lives of Americans. [22] The National Intelligence Council (NIC) has examined the connections between global health and U.S. national security. [23] A 2008 NIC report noted the significant impact of infectious illnesses slowing economic growth in developing countries of strategic importance to the United States, potentially disrupting the process of democratization and affecting political stability in these nations. At the United Nations General Assembly in September 2011, President Obama emphasized, "To stop disease that spreads across borders, we must strengthen our systems of public health. We will continue the fight against HIV/AIDS, tuberculosis and malaria. We will focus on the health of mothers and children. And we must come together to prevent, detect and fight every kind of biological danger -- whether it's a pandemic like H1N1 or a terrorist threat or a treatable disease." [24]

It should be underscored that on this World AIDS Day 2011, AIDS is very much a treatable disease.

And that is why despite the funding challenges that exist as a result of the current economic recession, the United States -- by working more effectively and efficiently, joining forces with other nations and partners to scale-up treatment and high impact prevention programs, to target high risk populations, and to build sustainable health systems -- can translate scientific advances into lifesaving services to make AIDS history. We can achieve what was once thought impossible: an end to the global AIDS epidemic!

Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Senior Policy and Medical Advisor at amfAR, The Foundation for AIDS Research. She is also a Clinical Professor at Georgetown and Tufts University Schools of Medicine and Chair of the Global Health Program at the Meridian International Center. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the Federal government in the Administrations of four U.S. Presidents, including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, as a White House Advisor on Health, and as Chief of the Behavioral Medicine and Basic Prevention Research Branch at the National Institutes of Health. She is also the Public Health Editor of the Huffington Post. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. She is the recipient of the 2009 Health Leader of the Year Award from the Commissioned Officers Association and was named a 2010 Rock Star of Science by the Geoffrey Beene Foundation. She has been involved in the fight against AIDS since the beginning of the epidemic.

Ashley Grosso, Ph.D. serves as an Allan Rosenfield Fellow at amfAR, The Foundation for AIDS Research. She is a recent graduate of the Ph.D. Program in Public Administration at Rutgers University. Dr. Grosso founded the AIDS Museum, a nonprofit organization based in Newark, NJ, to educate people about HIV through art.

REFERENCES:

1. Cohen, M., Chen, Y.Q., McCauley, M., Gamble, T., Hosseinipour, M.C., Kumarasamy, N., ... Fleming, T.R. (2011). Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine 365: 493-505.

2. PEPFAR Scientific Advisory Board. (2011). Recommendations for the Office of the US Global AIDS Coordinator: Implications of HPTN 052 for PEPFAR's Treatment Programs. Available: http://www.pepfar.gov/documents/organization/177126.pdf.

3. UNAIDS 2011 World AIDS Day Report. Available: www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_WorldAIDSday_report_2011_en.pdf

4. Grant, R.M., Lama, J.R., et al. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine 363: 2587-2599.

5. Baeten, J. & Celum, C. Antiretroviral pre-exposure prophylaxis for HIV-1 prevention among heterosexual African men and women: the Partners PrEP Study. 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2011). Rome, July 17-20, 2011. Abstract MOAX0106.

6. Thigpen, M.C., Kebaabetswe, P.M., & Smith, D.K., et al. Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active young adults in Botswana: results from the TDF2 study. 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2011). Rome, July 17-20, 2011. Abstract WELBC01.

7. Bailey, R.C., Moses, S., et al. (2007). Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomized controlled trial. The Lancet 369(9562): 643-656.

8. Karim, Q.A., Karim, S.S.A., et al. (2010). Effectiveness and safety of Tenofovir Gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science 329(5996): 1168-1174.

9. Microbicide Trials Network. (November 25, 2011). MTN Statement on Decision to Discontinue Use of Tenofovir Gel in VOICE, a Major HIV Prevention Study in Women. Available: http://www.mtnstopshiv.org/node/3909.

10. H?tter G., et al. (2009). Long-term control of HIV by CCR5 Delta32/Delta32 stem-cell transplantation. New England Journal of Medicine 360:692-698.

11. Blumenthal, S., & Shive, M. (November 14, 2011). Making AIDS history. Huffington Post.

12. Rerks-Ngarm,E., et al. (2009). Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand New England Journal of Medicine 361: 2209-2220.

13. UNAIDS 2011 World AIDS Day Report. Available: www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2011/JC2216_WorldAIDSday_report_2011_en.pdf

14. UNAIDS Report on the Global AIDS Epidemic 2010. Available: www.unaids.org/globalreport/Global_report.htm

15. World Health Organization. (2009). Women and health. Today's evidence, tomorrow's agenda.

16. USAID. (2010). Fact Sheet: The U.S. Government's Global Health Initiative.

17. Hatzenbuehler, M.L., et al. (2011). Prospective associations between HIV-related stigma,
transmission risk behaviors, and adverse mental health outcomes in men who Have sex with men. Annals of Behavioral Medicine 42(2): 227-234.

18. Latkin, C., et al. (2010). The relationship between drug use stigma and HIV injection risk behaviors among injection drug users in Chennai, India. Drug and Alcohol Dependence 110(3): 221-227.

19. Watts C et al. Stigma and discrimination as an important barrier to universal access to PMTCT: model projections. XVIII International AIDS Conference, Vienna, Austria, 18-23 July 2010.

20. Global Fund to Fight AIDS, Tuberculosis and Malaria. (November 23, 2011). Important Update: Establishment of Transitional Funding Mechanism to replace Round 11. Available: http://theglobalfund.org/en/application/

21. Institute on Medicine. (2008). The U.S. Commitment to Global Health: Recommendations for the New Administration.Feldbaum, H. (2009). U.S. Global Health and National Security Policy. CSIS Global Health Policy Center.

22. Feldbaum, H. (2009). U.S. Global Health and National Security Policy. CSIS Global Health Policy Center.

23. National Intelligence Council. (2011). Strategic Implications of Global Health.

24. Remarks by President Barack Obama in Address to the United Nations General Assembly. September 21, 2011.

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Source: http://www.huffingtonpost.com/susan-blumenthal/world-aids-day-2011_b_1122377.html

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