Hillary Rodham Clinton: “Creating an AIDS-Free Generation”

The US Secretary of State Hillary Rodham Clinton spoke earlier this week at the National Institutes of Health on “A vision for the next steps in the fight against HIV/AIDS”. Her speech shed a very encouraging light on the fight against HIV/AIDS and the goal of an AIDS-Free Generation by 2015. The Foundation for AIDS Research, amfAR, welcomed the Secretary’ remarks.

The full transcript can be found here, below follow some important excerpts:

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What’s more, our efforts have helped set the stage for a historic opportunity, one that the world has today: to change the course of this pandemic and usher in an AIDS-free generation.

Now, by an AIDS-free generation, I mean one where, first, virtually no children are born with the virus; second, as these children become teenagers and adults, they are at far lower risk of becoming infected than they would be today thanks to a wide range of prevention tools; and third, if they do acquire HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus on to others.

Now, HIV may be with us well into the future. But the disease that it causes need not be. This is, I admit, an ambitious goal, and I recognize I am not the first person to envision it. But creating an AIDS-free generation has never been a policy priority for the United States Government until today, because this goal would have been unimaginable just a few years ago. Yet today, it is possible because of scientific advances largely funded by the United States and new practices put in place by this Administration and our many partners. Now while the finish line is not yet in sight, we know we can get there, because now we know the route we need to take. It requires all of us to put a variety of scientifically proven prevention tools to work in concert with each other. Just as doctors talk about combination treatment – prescribing more than one drug at a time – we all must step up our use of combination prevention.

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Even as we recognize all these crucial elements, today I want to focus on the three key interventions that can make it possible to achieve an AIDS-free generation. First, preventing mother-to-child transmission. Today, one in seven new infections occurs when a mother passes the virus to her child. We can get that number to zero. I keep saying zero; my speechwriter keeps saying “Virtually zero.” (Laughter, applause.) And we can save mother’s lives too.

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In addition to preventing mother-to-child transmission, an effective combination prevention strategy has to include voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent, and that the benefit is life-long.

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In the fight against AIDS, the ideal intervention is one that prevents people from being infected in the first place, and the two methods I’ve described – mother-to-child transmission, voluntary medical male circumcision – are the most cost-effective interventions we have, and we are scaling them up. But even once people do become HIV-positive, we can still make it far less likely that they will transmit the virus to others by treating them with the antiretroviral drugs. So this is the third element of combination prevention that I want to mention.

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For years, some have feared that scaling up treatment would detract from prevention efforts. Now we know beyond a doubt if we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to prevention. So let’s end the old debate over treatment versus prevention and embrace treatment as prevention.

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Finally, we’re calling on other donor nations to do their part, including by supporting and strengthening the Global Fund. Consider just one example of what the Global Fund has already done. In 2004, virtually none of the people in Malawi who were eligible to receive treatment actually received it. As of last year, with significant help from the Global Fund, nearly half did.

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Much of what we do will depend upon the people in this room and the hundreds and thousands like you – the researchers and scientists, the public health docs and nurses and other personnel, the community health workers, the funders and donors, the government officials, the business leaders, philanthropies, and faith communities that have all joined together in this quite remarkable way to combat this disease.

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Let’s not stop now. Let’s keep focused on the future. And one of those futures that I hope we can be part of achieving is an AIDS-free generation. Thank you all very much. (Applause.)

Bjørn Lomborg: The Five Best Ways to Fight AIDS

Bjørn Lomborg is the author of The Skeptical Environmentalist and Cool It, head of the Copenhagen Consensus Center, and adjunct professor at Copenhagen Business School. This article was originally published on Project Syndicate.

Making HIV/AIDS Investments Count

It is dangerous to believe that the end of AIDS is in sight. About 30 million people around the world live with HIV, and another 30 million are likely to become infected in the next decade if current trends persist. Funding from developed governments is dropping—a trend that must be reversed. But we also need to acknowledge that billions of dollars have been spent on well-meaning attempts to save lives, and there has been an alarming lack of high-quality evaluation of how these investments have performed.This is true not only of abstinence campaigns, for which there is no evidence of effectiveness, but also for many other mainstays of the AIDS response. On a systemic level, we do not know what works, where, and why—or how to replicate our successes.

In the project RethinkHIV, the Copenhagen Consensus Center and the Rush Foundation asked 30 of the world’s top HIV economists, supported by epidemiologists, demographers, and medical professionals to analyze the most promising responses to the epidemic in the world’s worst-hit region, sub-Saharan Africa. They were asked to examine what could be achieved with extra investments in six key areas: prevention of sexual transmission, reduction of nonsexual transmission, treatment of those who have the disease, initiatives to use social policy and health-system strengthening to fight HIV/AIDS, and vaccine research.

The resulting research papers offer the first-ever comprehensive attempt at cost-benefit analysis of AIDS priorities. Economics can offer a fresh perspective by showing us the overall value to society of competing spending options. Among worthwhile investments, some are very costly and achieve little good; others are remarkably cheap and incredibly effective. Whether on AIDS or other problems, additional funds should be spent first where we can achieve the highest return for our money.

To spark a dialogue about HIV/AIDS priorities based on the RethinkHIV research, the Copenhagen Consensus Center and the Rush Foundation asked five world-class economists—including three Nobel laureates—to form their own conclusions about how best to spend additional funding. The panel zeroed in on five investments that they believe should be at the top of policymakers’ lists.

Most important, they identified an urgent need for increased investment in developing an HIV vaccine. This is clearly a longer-term response to the epidemic: Research by Dean Jamison and Robert Hecht (PDF) for RethinkHIV suggests that we are about 20 years away from large-scale vaccination, and that increasing current funding by around 10 percent, or $100 million a year, would meaningfully shorten that projection. This would save millions of lives and potentially end the epidemic in the long run, while dramatically improving scientific understanding of the disease in the near term. For every dollar spent, it is likely that the benefits would run into the tens of dollars.

As a shorter-term response to the epidemic, the Nobel laureates were convinced by research by the economist Lori Bollinger (PDF) that we could practically wipe out mother-to-child transmission of HIV by 2015 with additional expenditures of just $140 million a year. About 350,000 infants became HIV positive in 2008, through pregnancy, labor, delivery, or breast-feeding, accounting for approximately 20 percent of all new infections. Since we have such cost-effective programs to halt this tragedy, the Nobel laureates concluded, this is a compelling investment.

So, too, is spending more to make blood transfusions safer. Bollinger calculates that annual investment of $2 million over five years would achieve 100 percent safe blood transfusions by 2015 and avert more than 131,000 HIV infections, while alleviating fears of infection for the almost half-billion people who would otherwise receive blood that was not comprehensively screened.

The Nobel laureates also found that male circumcision is an excellent use of funds. They focused particularly on the longer-term benefits of infant-male circumcision, arguing that there is massive untapped potential to introduce this very cheap practice across Africa. We know that adult-male circumcision reduces the odds of transmission from a woman to a man by up to 60 percent. Research by Jere Behrman and Hans-Peter Kohler (PDF) of the University of Pennsylvania makes clear that the real focus needs to be on working out the best ways to broaden adult circumcision efforts across the region, and to convince men that getting circumcised is a good idea. We also need to introduce counseling to ensure that men do not treat circumcision as a vaccine, and engage in riskier behavior as a result.

Finally, the panel of Nobel laureates concluded based on research by Mead Over and Geoffrey Garnett (PDF) that additional resources for treatment should go first to patients who are the sickest and most infectious. Because treatment is very expensive, coverage rates remain woefully inadequate. But treatment is not only an ethical imperative; it also is important in preventing and reducing sexual transmission.

The expert panel did not just identify the top-priority uses for additional funds. It also highlighted promising areas where more research is needed. As Anna Vassall, Michelle Remme, and Charlotte Watts of the London School of Hygiene and Tropical Medicine point out (PDF), gender inequalities and domestic violence are both associated with a significant increase in risk of HIV infection. So, if gender training programs were to piggyback on current income-boosting microfinance and agricultural-support programs, we could undermine norms about gender roles that entrench women’s dependence on men or condone domestic violence. It’s a proposal that deserves further investigation, as is the proposition from William McGreevey of Georgetown University (PDF) to increase efforts to focus treatment of HIV-positive patients to reduce opportunistic infections of cryptococcal meningitis.

We need to arrest the recent drop in AIDS funding and secure additional resources in order to make further headway against the disease. By highlighting sound investments—including some that are not currently at the top of policymakers’ to-do lists—RethinkHIV makes the case in economic terms for doing just that.

“Australia should lead a global HIV prevention revolution”

Today Bill Whittaker had an opinion piece in the ABC’s DRUM, arguing that Australia should lead a global HIV prevention revolution.

The global fight against AIDS is at a crossroads. On the one hand we have exciting new scientific evidence which could dramatically reverse the pace of the HIV epidemic and prevent millions of new infections, sickness and deaths.

On the other hand, there is weariness and complacency after 30 years of the epidemic as well as a global financial crisis putting tremendous pressure on national budgets around the world and threatening funding essential to reverse the relentless spread of HIV.

Mind-numbing statistics speak for themselves about the scale of the HIV epidemic and the work to be done: 30 million lives lost; another 33 million people living with HIV; and 7000 new infections occurring every day, mostly among young people.

New HIV treatments are having a tremendous impact in reducing illness and AIDS-related deaths, but the sustainability of providing HIV treatment – especially in low to middle-income countries – is threatened by the reality that for every one person put on HIV treatment, another two people become infected.

Recently, the United Nations agreed to a bold new Declaration to fight AIDS which Australia played a leading role in getting all UN Member States to endorse. A centrepiece of the UN Declaration are bold new HIV prevention targets for the global community to reach by 2015.

These global targets include reducing sexual transmission of HIV by 50 per cent; reducing HIV transmissions through injecting drug use by 50 per cent; and eliminating mother-to-child HIV transmissions – all by 2015.

So how would these targets be achieved under the UN Declaration?  Firstly, by dramatically scaling up prevention programs; by freeing up access to HIV testing; by increasing HIV education alongside wide availability of condoms and sterile injecting equipment; by promoting male circumcision in certain contexts; and by fully exploiting the potential of new technologies for communication and connecting people – such as social media, mobile phones and the internet.

The UN Declaration also calls for global action to ensure prevention programs properly focus on the three populations which are universally at higher risk to HIV, specifically men who have sex with men, sex workers and their clients and people who inject drugs.

Finally, the Declaration calls for new scientific evidence about the additional prevention benefits that HIV treatment can deliver to be capitalised on. So just as HIV treatment was revolutionised 15 years ago by combining different drugs – termed “combination treatment” – the Declaration heralds an era of “combination prevention”, where proven prevention programs and communication innovation are combined with wide availability of HIV treatment to help drive down rates of new HIV infections.

So what should this mean for Australia? Our rate of new HIV infections is running at around 1,000 new infections per year, mostly among gay men. But should we be satisfied with this level of new infections – the personal and community impact of this – and the something like $1 billion plus price-tag that comes with each 1,000 new infections? Of course not.

Australia’s current National HIV strategy and most state and territory strategies continue a lamentable drift away from setting bold, time-bound HIV prevention targets so essential to generate momentum and monitor progress.

Now is the opportunity for us to embrace “combination prevention”, re-double our efforts and set bold HIV prevention targets aligned with the 2011 UN Declaration to really drive down Australia’s HIV infection rates.  These targets should include:

• Reducing sexual transmission of HIV among men who have sex with men by 80 per cent by 2015.
• Eliminating HIV transmission from injecting drug use by 2015.
• Eliminating HIV transmission among sex workers and clients by 2015.

These prevention targets should be complemented by a treatment target of having 90 per cent of people with HIV in Australia on HIV antiviral treatment by 2013.

These are the kind of bold actions that the 2011 UN Declaration calls for and that all countries, including Australia, have pledged to implement.

Australia has shown great leadership and innovation in HIV prevention. One of the best things Australia can do to support a global HIV prevention revolution is to lead by example and champion what we are doing.  We must not miss this opportunity to re-vitalise our HIV prevention strategies and to help lead global efforts to stop the spread of HIV and its devastating impact on so millions of people around the world.

Bill Whittaker is one of the architects of Australia’s response to AIDS and has worked in HIV policy and strategy for more than 25 years. Bill is a member of Pacific Friends of the Global Fund’s Coordinating Committee.

Michael Kirby: Summing up the UNAIDS meeting on the criminalisation of HIV

In Geneva, from the 31 August to the 2 September, UNAIDS organised an expert meeting to review the scientific, medical, legal and human rights issues related to the criminalization of HIV exposure and transmission. Justice Michael Kirby, a retired judge of the High Court of Australia and member of Pacific Friends’ Coordinating Committee, was one of the experts to review the application of the criminal law to HIV.

Here an excerpt from an interview with Michael Kirby at the UNAIDS expert meeting in Geneva:

There are some exceptional cases where the criminal law has a role to play. However, the criminal law has been pushed into a whole range of other activities which are counter-productive from the point of view of a public health response to HIV. The use of criminal law is also likely to lead to disproportionate and highly punitive measures which are not helpful in responding to the epidemic in a way that prevents the spread of HIV.

After the meeting Michael Kirby did a wonderful job in summing up the key points and views from the high-level meeting in this report.

Visit of UNAIDS Executive Director

Executive Director of UNAIDS, Michel Sidibé, visited Australia on 27-31 August. Mr Sidibé spoke at the Lowy Institute for International Policy on the challenges and responses to the global HIV epidemic, addressed the plenary at the UN DPI/NGO conference in Melbourne, opened The Michael Kirby Centre for Public Health and Human Rights at Monash University, and spoke to several government officials in Canberra.

Michel Sidibé addressing the Lowy Institute on the global HIV/AIDS pandemic:

Prior to visiting Sydney, Melbourne and Canberra Mr Sidibé spent two days in Papua New Guinea where he discussed the just released HIV estimates and the country’s declining HIV rates.

In Sydney Mr Sidibé started the day with radio and television interviews (see ABC media coverage below). After that he addressed the Lowy Institute as part of the Distinguished Speaker Series on the challenges and responses to the global HIV epidemic and participated in a lunch roundtable hosted by the Lowy Institute. After that Mr Sidibé visited Sydney’s Medically Supervised Injecting Centre in Kings Cross, where the centre’s Director Dr. Marianne Jauncey showed him around. At the end of the day Michel was welcomed by the community at a reception in Darlinghurst.

ABC media coverage of Michel Sidibé’s visit to Sydney: