UNAIDS Reports Progress, PEPFAR Blueprint Looks Towards AIDS-free Generation

The latest global report from UNAIDS, release ahead of World AIDS Day on December 1, highlights progress in stemming the epidemic, including lower rates of new infection in many countries and a growing proportion of HIV positive people on antiretroviral treatment. Continued progress requires adequate funding, however. To that end, U.S. Secretary of State Hillary Clinton this week released a "Blueprint" detailing recent advances and future plans for achieving a generation free from AIDS.

2011 statistics:

• 34 million people globally living with HIV
• 2.5 million people newly infected with HIV 
• 1.7 million people died due to AIDS-related illnesses

This year's World AIDS Day Report: Results, shows a greater than 50% reduction in the rate of new HIV infections across 25 low- and middle-income countries, the majority of them in Africa. Some of the largest decreases have been seen in the most heavily impacted countries, for example a more than 70% reduction in Botswana and Malawi, a 50% drop in Zimbabwe, and a 40% decline in hard-hit South Africa and Swaziland.

The picture is not uniformly bright, however. The report notes that half the global reduction in new HIV infections during the past 2 years has been among newborn infants. While the goal of zero children born with HIV is within sight, the epidemic is increasingly concentrated among marginalized populations that face stigma and criminalization, including men who have sex with men, sex workers, and drug users.

UNAIDS also reports that the number of people with access to antiretroviral therapy (ART) worldwide has increased by more than 60% over the past 2 years, contributing to the number AIDS-related deaths falling by more than 25% since 2005. South Africa, for example, scaled-up treatment by 75% -- putting 1.7 million people on ART.

"The pace of progress is quickening -- what used to take a decade is now being achieved in 24 months," said UNAIDS Executive Director Michel Sidibé. "We are scaling up faster and smarter than ever before...Now that we know that rapid and massive scale up is possible, we need to do more to reach key populations with crucial HIV services."

But there is no time to waste: the 2015 target for achieving the Millennium Development Goals and UN Political Declaration on HIV/AIDS is just 1000 days away. The unmet need includes an estimated 6.8 million people who are eligible for but do not have access to ART, and an additional 4 million serodiscordant couples who could benefit from treatment as prevention.

The report highlights that low- and middle-income countries are picking up an increasing share of the cost of HIV prevention, care, and treatment, leaving them less dependent on international aid at a time when budgets are under pressure due to the ongoing global financial crisis. For the first time, domestic investments for HIV by low- and middle-income countries surpassed international donations.

PEPFAR Blueprint

The most heavily affected countries cannot meet the need alone, however. According to the report, US$ 22-24 billion will be required to meet the need for 2015, while funding in 2011 reached just under $17 billion. The U.S. accounts for approximately half of all international assistance for HIV, and together with the Global Fund for AIDS, Tuberculosis, and Malaria, provides the "lion’s share of investments in HIV treatment."

On November 29, U.S. Secretary of State Hillary Rodham Clinton unveil a new PEPFAR Blueprint: Creating an AIDS-free Generation, offering a detailed "roadmap" for how the U.S. government plans to help achieve an AIDS-free generation.

"Now, make no mistake about it: HIV may well be with us into the future," Clinton explained. "But the disease that it causes need not be. We can reach a point where virtually no children are born with the virus, and as these children become teenagers and adults, they are at a far lower risk of becoming infected than they are today. And if they do acquire HIV, they have access to treatment that helps prevent them from not only from developing AIDS, but from and passing the virus on to others."

The Blueprint "reflects lessons learned from almost ten years of experience in supporting countries to rapidly scale-up HIV prevention, treatment, and care services," according to a State Department press release. "It demonstrates the opportunity for the world to help move more countries toward and beyond the tipping point in their epidemics and put them on a path to achieving an AIDS-free generation. The blueprint makes clear that the United States’ commitment to this goal will remain strong, comprehensive and driven by science."

PEPFAR -- the President's Emergency Plan for AIDS Relief launched by George W. Bush in 2003 -- based its blueprint on the following principles:

• Make strategic, scientifically sound investments to rapidly scale-up core HIV prevention, treatment, and care interventions and maximize impact.
• Work with partner countries, donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations, and multilateral institutions to effectively mobilize, coordinate and efficiently utilize resources to expand high-impact strategies, saving more lives sooner.
• Focus on women and girls to increase gender equality in HIV services.
• End stigma and discrimination against people living with HIV and key populations, improving their access to, and uptake of, comprehensive HIV services.
• Set benchmarks for outcomes and programmatic efficiencies through regularly assessed planning and reporting processes to ensure goals are being met.

More specifically, this roadmap outlines PEPFAR’s plan to:

1. Target HIV-associated tuberculosis (TB) and reduce co-morbidity and mortality.
2. Increase access to, and uptake of, HIV services by key populations.
3. Partner with people living with HIV to design, manage and implement HIV programs to ensure that they are responsive to, and respectful of, their needs.
4. Strengthen PEPFAR’s continued focus on women, girls and gender equality.
5. Reach orphans and vulnerable children (OVC) affected by AIDS, and support programs that help them develop to their full potential.
6. Strengthen programmatic commitment to and emphasis on reaching and supporting young people with HIV services.
7. Strengthen PEPFAR supply chains and business processes to increase the efficiency of our investments.
8. Increase efficiencies through innovation and greater integrations of services with other U.S., bilateral and multilateral global health investments.

"[O]ur second goal is that the blueprint says we have to go where the virus is, targeting the populations at the greatest risk of contracting HIV, including people who inject drugs, sex workers, and those trafficked into prostitution, and men who have sex with men," Clinton said Thursday. "When discrimination, stigma, and other factors drive these groups into the shadows, the epidemic becomes that much harder to fight. That’s why we are supporting country-led plans to expand services for key populations, and bolstering the efforts of civil society groups to reach out to them. And we are investing in research to identify the interventions that are most effective for each key population."

"As part of our effort to go where the virus is, we are focusing even more intently on women and girls, because they are still at higher risk then men of acquiring HIV because of gender inequity and violence," she continued. "So we are working to ensure that HIV/AIDS programs recognize the particular needs of women and girls, for example, by integrating these efforts with family planning and reproductive health services. We are also working to prevent and respond to gender-based violence, invest in girls’ education, address gender inequality, and take other steps that have been proven to lower their risk of contracting the virus."

The Blueprint has been well received so far, but with an emphasis that resources must follow words in order to achieve these ambitious goals.

"With the support of adequate funding, this plan has the potential to turn the trajectory of the AIDS epidemic among children, men who have sex with men, people making their livings through commercial sex, and those who use injecting drugs, while continuing effective efforts that have shown results," the HIV Medicine Association and Center for Global Health Policy of the Infectious Diseases Society of America said in a statement.

"Achieving an AIDS-free generation is within our grasp," said HIVMA chair Michael Horberg. "While we celebrate this plan and what it can accomplish, we now look to Congress to ensure that it is executed, with critical funding for the work ahead and for continued research to carry the fight forward."

"Never in the history of the AIDS response have we been so aligned in our priorities, our mutual respect and in our shared motivation for results," said UNIADS' Sidibé in response to the Blueprint. "We must commit to immediately bring countries and resources together -- to close the capacity gap between where we are today and where we must be tomorrow."

11/30/12

References

UNAIDS. World AIDS Day Report 2012: Results. November 2012.

U.S. Department of State/Office of the Global AIDS Coordinator. PEPFAR Blueprint: Creating an AIDS-free Generation. November 2012.

Other Sources

UNAIDS. UNAIDS reports a more than 50% drop in new HIV infections across 25 countries as countries approach the 1000 day deadline to achieve global AIDS targets. Press release. November 20, 2012.

UNAIDS. UNAIDS commends United States’ commitment to achieving an AIDS-free generation. Press statement. November 20, 2012.

U.S. Department of State. The President's Emergency Plan for AIDS Relief (PEPFAR) Blueprint: Creating an AIDS-free Generation. Press release. November 29, 2012.

HIV Medicine Association and IDSA Center for Global Health Policy.HIV Clinicians and Researchers Applaud Release of Global AIDS Blueprint. Press statement. November 29, 2012.