The End of AIDS

The AIDS epidemic (“Acquired Immunodeficiency Syndrome”) claimed the lives of about 36 million people between 1981 and 2016, and a similar number of people around the world today are living with the human immunodeficiency virus (HIV). Last year alone, approximately 1.2 million people died from AIDS, and another 1.8 million were newly infected. These statistics are horrifying — but the remarkable news is that the goal of achieving “an AIDS-free generation” has become realistically attainable. What is needed now is agreement on the necessary political steps in the early days of President-elect Donald Trump’s administration. The main reason why ending the epidemic is now possible stems from a scientific breakthrough in 2011. It showed that individuals living with HIV who receive antiretroviral (ARV) therapy suppress the virus in their bloodstream to such an extent that it becomes extremely unlikely for them to transmit it to others through sex or shared needles. This discovery confirmed the concept of “treatment as prevention.” If a sufficiently high percentage of people living with HIV receive antiretroviral therapy, it becomes possible not only to save their lives but also to break the chain of transmission itself — ultimately ending the epidemic. Building on this idea, AIDS specialists developed two crucial concepts: the “90-90-90” target and the “HIV care cascade.” The 90-90-90 target aims to ensure that by 2020: 1. 90% of all people living with HIV know their status (the first 90), 2. 90% of those diagnosed receive antiretroviral therapy (the second 90), 3. 90% of those on treatment achieve viral suppression (the third 90). The second idea is that if these three targets are achieved, the percentage of all HIV-positive individuals who successfully suppress the virus becomes 90% × 90% × 90% = 72%. ________________________________________ Epidemic Decline If 72% of people living with HIV are no longer capable of transmitting the virus, it means the epidemic will begin to shrink. And if the 90-90-90 target for 2020 is increased to 95-95-95 by 2030, the share of HIV-positive individuals unable to transmit the infection would rise to 86% — almost stopping the epidemic altogether. This is similar to how measles outbreaks end in cities once vaccination rates reach around 80%, even if 20% of children remain unvaccinated. Some cases may persist, but the AIDS catastrophe would effectively come to an end. Reaching the 90-90-90 target by 2020 and then 95-95-95 by 2030 is realistic — if countries commit to it. Sweden recently announced it has already reached the 90-90-90 target, and many other high-income countries are close. With international assistance and national efforts, these goals are achievable not only in wealthy nations but also in developing countries. In most parts of the world, the challenge lies in ensuring that at least 90% of those living with HIV are tested and informed of their status by 2020 — the first 90. To achieve this, individuals with symptoms or those at high risk must be connected with the health system for testing. Once individuals test positive, achieving the second 90 (access to antiretroviral treatment) depends on funding and trained personnel. With sufficient health-care budgets, it becomes possible to provide treatment for all who need it. Achieving the third 90 (viral suppression) mainly depends on whether individuals on ARV therapy take their medications consistently. This may require social support to encourage patients to stay on treatment even when they feel healthy, as well as ensuring reliable and affordable supplies of medication. The 90-90-90 target can even be reached among poor and hard-to-reach populations thanks to a powerful new public-health solution: community health workers supported by smartphone technology. ________________________________________ Community Health Community health workers are local residents with at least a secondary-school education who receive several months of training to handle specific health challenges — such as identifying individuals who may have HIV, guiding them to clinics for testing, and helping them adhere to medical protocols. They now have smartphone applications to support their work. In rural Africa — where doctors are scarce and the AIDS epidemic is widespread — the high potential of community health workers to save lives has been proven and documented. Moreover, community health work offers young people a valuable entry into their careers. Although starting compensation is extremely modest (around $100 per month), their experience and training put them on a path toward further education (such as nursing), professional development, and higher income. However, despite the possibility of ending the AIDS epidemic, the world is currently stuck in a state of paralysis. Unfortunately, governments are not acting on bold goals or providing the means to achieve them; they merely continue “business as usual.” Sixteen years ago, business as usual meant that almost no treatment was available to poor people with AIDS because funding was not provided. At that time, I recommended the creation of a new “Global Fund” to finance AIDS treatment — an idea that was adopted and helped launch the era of fighting the AIDS epidemic in Africa. President George W. Bush’s administration provided major financial commitments from the United States for AIDS treatment, and the programs of the Global Fund and the U.S. together helped millions of people receive care. But after the 2008 global financial crisis, President Barack Obama reduced U.S. funding, leaving global anti-AIDS efforts stuck at “halfway.” By 2016, only about half of all people living with HIV were receiving antiretroviral therapy — far below the 90% target. The incoming Trump administration should seize the historic opportunity to help end the AIDS epidemic with a modest financial commitment from governments and other donors. An additional $10 billion per year from all funding sources would likely be enough to finish the job, with the United States contributing only about $3–4 billion annually. Skeptics may say that Trump is unlikely to support such an effort. But honestly, who would have predicted 15 years ago that Bush would become the leading driver of the financial escalation in the fight against AIDS? History is full of positive and negative surprises — and ending the AIDS epidemic could become the historic achievement of our generation, if we choose to pursue it.