Achieving the End: One year and counting

With this year’s AVAC Report, we’re setting the clock on the global drive to end the AIDS epidemic. It’s a goal that nearly all now agree is attainable. But it can only be achieved if an ambitious pace of funding, implementation and research is set—and maintained—starting now.

Current models tell us that the next 12 to 24 months are a critical window. As the graphic below illustrates, we are closing in on an epidemic “tipping point,” when the rate of ART scale-up will outpace the rate of HIV infections—proving global capacity to treat all in need.

But the world will only reach this crucial milestone if it moves more quickly. Quite literally, this has to be the year that global HIV prevention efforts expand more quickly than ever before.

We’ve subtitled this Report “one year and counting” because it has been just about 12 months since the world started talking in earnest about beginning to end the AIDS epidemic. For a planet gripped with economic crises and funding shortfalls, the vision was big, and rightly so, since 2011 brought some of the most encouraging scientific news the HIV prevention field has seen.

We’re not counting down; we’re counting up.

We’re just a year into an era of incredibly high stakes for the global AIDS response, and we know that there are years to go before we can say that the epidemic is moving conclusively towards an end. But what we can do is look at the pace we’ve set and say that while there’s still plenty of reason for optimism, there is already real cause for concern.

In AVAC Report 2011, titled The End?, we laid out a framework that incorporated short-, medium- and long-term goals for ending the epidemic (see graphic above). To realize this goal, we argued that it would be critical to deliver the interventions we have today and to demonstrate how the potential impact of emerging strategies in the coming years. Also, it would be key to continue efforts to develop essential and truly novel interventions, such as an effective AIDS vaccine and a cure over the long term.

The goals laid out in the Playbook and throughout AVAC Report 2011 are as relevant today as they were a year ago. In 2013, we need to get far more specific. In this year’s Report, we briefly examine the progress made over the past year and provide necessary updates to the Playbook, and then we turn to the question, “What now?”

What are the top priorities for the next year? What would make the greatest possible difference?

Our top five list is elaborated on throughout the Report, which concludes with an urgent call for amplified global and national leadership. In brief, the priorities are:

1. End confusion about “combination prevention”.
2. Narrow the gaps in the treatment cascade.
3. Prepare for new non-surgical male circumcision devices.
4. Define and launch a core package of PrEP demonstration projects.
5. Safeguard HIV prevention research funding.

The future of prevention innovation is more precarious than it should be. This is, in part, because we’re not yet defining the struggle to begin to end the epidemic as a struggle, above all, to provide truly effective HIV prevention. In 2013, let’s pick up the pace of this historic race. It is—at one year and counting—ours to win.

Over the past 12 months, several new buzz phrases have emerged in the AIDS world. Among them: “combination prevention”, “high-impact prevention”, “evidence-based prevention” and “highly active retroviral prevention”, a.k.a. “HARP”. At this year’s major events, especially at the International AIDS Conference in July, combination prevention—by whatever name—was a top priority. Many speakers spoke of the coordinated introduction or expansion of a range of core, highly effective strategies. Speaking about combination prevention in the sub-Saharan African context, for example, US Secretary of State Hillary Clinton has highlighted voluntary medical male circumcision (VMMC), antiretroviral therapy (ART) for HIV-positive adults, HIV testing and prevention of pediatric infection programs.

Advocates can help guide focused discussions about what combination prevention is—and is not:

• Combination prevention involves tough, risky choices.
• Combination prevention isn’t one or two high-impact strategies plus business as usual.
• Combination prevention requires a holistic approach to planning, implementation and evaluation.
• Combination prevention is a work in progress.

A graphic illustrating of the declining numbers of people who move from testing HIV-positive to entering care to starting, and staying on effective ART factors into virtually every substantive discussion of the potential impact of treatment as prevention. This referred to as the treatment cascade. The gaps and absolute numbers differ by country and population—there isn’t a single cascade. But there are recurring patterns in attrition at every stage. And these patterns, as the graphic below illustrates, are sobering.

This current state of affairs must change if the world is going to make effective use of treatment as prevention as a tool for ending the epidemic. Therefore, in this arena, one priority for 2013 is to articulate and fund a retention science agenda that narrows the gaps in the treatment cascade.

Over the past 12 months, the state of voluntary medical male circumcision (VMMC) for HIV prevention started to change for the better. Rollout efforts in many of the 14 countries prioritized by PEPFAR and UNAIDS accelerated or got underway in earnest, and WHO/UNAIDS launched the Joint Strategic Action Framework, a document that is designed to provide ministries of health and other key stakeholders with a common approach to rapid implementation of a “catch up” phase of adult VMMC.

For key countries, the target is 80 percent of adult men undergoing the procedure over a finite period of time—a total of 20 million procedures in sub-Saharan Africa. Prior to 2012, progress had been relatively slow (see figure below). But the pace of implementation has now begun to pick up quite dramatically. Zambia, which had had a relatively lackluster national program since its launch in year 2009, published a detailed national plan in mid-2012 and exceeded its targets for July/August, performing 45,000 procedures in six weeks.

This past year brought major developments in pre-exposure prophylaxis (PrEP) research. In July, the US Food and Drug Administration (FDA) approved Gilead Sciences, Inc.’s application for a label change for TDF/FTC (marketed by Gilead as Truvada), indicating that the drug could be used for HIV prevention in HIV-negative adults. Less than a week later, WHO issued a document to guide low– and middle-income countries decision-making about PrEP demonstration projects.

To say that we can begin to end AIDS does not mean that we have all the tools we need to actually end it. Today’s tools are powerful enough to make a start at ending the epidemic. Implementation of what we have today will “buy time”—and reduce infections and save lives on an unprecedented scale—until additional tools, like a vaccine and a cure, can be developed. Progress toward a vaccine and a cure has been exciting. But it cannot continue without sustained funding for research. The top priority related to AIDS vaccine and cure research in 2013 is to safeguard research funding.

No action on the priority items described in the preceding pages is possible without action on one fundamental issue: the leadership gap. Execution of each of the five priorities put forward in this report depends on true leadership through word, dollar (and euro, pound, rand and shilling...) and deed.

There are gaps in global and national leadership. By World AIDS Day 2012 there was were new documents and new commitments from PEPFAR, Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and UNAIDS among others. PEPFAR has released a promised blueprint for an AIDS-free generation. GFATM has overhauled its grant-making structure and says it is focusing on high-impact interventions and may soon have a new leader. UNAIDS has released its World AIDS Day Report, WHO/UNAIDS is currently developing a comprehensive guidance document on using ARVs for treatment and prevention expected in 2013...

Looking more broadly, leadership at every level must emphasize that prevention is essential to ending the epidemic. This emphasis should guide decision making today and articulate a vision for what expanded, innovative prevention will or should look like in the future, as a microbicide, a vaccine and a cure come within reach—and finally become available.

The world’s leaders—with AIDS activists and advocates at the forefront—have the power to define the next year of the response in a way that will have impact far beyond the next 12 months. We can begin to articulate, together, the contours of a prevention revolution—and to ensure that there is funding, monitoring, ongoing research and continuous improvement. It is necessary work, and work that will serve us well in the years to come.