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Africa: Towards the End of AIDS
AfricaFocus Bulletin
Dec 5 2012 (121205)
(Reposted from sources cited below)
Editor's Note
"[Despite significant advances} the epidemic of HIV/AIDS
is far from over. According to the most recent statistics
from UNAIDS, there are still 2.5 million new HIV
infections worldwide and 1.7 million deaths annually from
this disease. Globally, there are 34 million people
living with HIV and half do not know their HIV status.
Nearly half of the people in need of antiretroviral
treatment (6.8 million) do not have access to these lifesaving
medications ... Sub-Saharan Africa continues to
carry a disproportionate burden of disease, representing
69 percent of all people infected with the virus
worldwide." - Susan Blumenthal, M.D. and Melissa Shive
According to the most recent UNAIDS factsheet on SubSaharan
Africa (http://tinyurl.com/cebkbg9), the number
of new AIDS infections a year declined from 2.4 million
to 1.8 million over the decade from 2001 to 2011. Between
2005 and 2011, the number of people dying from AIDSrelated
causes went down from 1.8 million to 1.2 million
a year. Progress has been significant, and, as the
article included in this AfricaFocus Bulletin makes
clear, the pathways for future progress are well-defined.
But the human toll remains enormous. Africa remains the
most heavily affected region, with 23.5 million people
living with AIDS, more than two-thirds of the global
total. And, while many African countries are now funding
a larger portion of their anti-AIDS efforts from their
own resources, global funding is still falling short, by
some $6 billion a year, of the target needed for
accelerated progress against the pandemic. U.S. budget
cuts could impose further shortfalls.
The article below, by Susan Blumenthal, M.D., and Melissa
Shive, provides a very clear summary of both the progress
and the significant tasks that lie ahead before victory
can be declared over the AIDS pandemic.
For previous AfricaFocus Bulletins on AIDS and other
health issues, along with guides to additional resources,
visit http://www.africafocus.org/healthexp.php
There are also additional references at the end of this
article and even more embedded links in the original full
version of this article on http://www.huffingtonpost.com/susan-blumenthal/
++++++++++++++++++++++end editor's note+++++++++++++++++
World AIDS Day 2012: A Roadmap for Ending HIV/AIDS
December 4, 2012
Susan Blumenthal, M.D.
Written in collaboration with Melissa Shive
[Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is
the public health editor of The Huffington Post. She is
also the senior policy and medical advsior at amfAR, the
Foundation for AIDS Research, a senior fellow in health
policy at the New America Foundation in Washington, D.C.,
a clinical professor at Georgetown and Tufts University
Schools of Medicine, and chair of the Global Health
Program at the Meridian International Center.
Melissa Shive is currently a medical student at the
University of California, San Francisco and a Master of
Public Health Degree candidate from Harvard University].
Now more than ever, this year's World AIDS Day marks
unprecedented progress toward ending HIV/AIDS and
providing proof that investments in research, treatment,
and prevention are yielding lifesaving dividends. While
there still remain significant challenges in achieving a
world without AIDS, we now have roadmaps to get us there.
This week, the U.S. Department of State released the
"PEPFAR Blueprint: Creating an AIDS Free Generation," and
last year, the United Nations signed the 2011 Political
Declaration on HIV/AIDS, which is a global strategy to
achieve universal access to HIV prevention, treatment,
and care by 2015. These documents are historic milestones
and underscore that we are at a tipping point -- the
beginning of the end of AIDS -- if we intensify efforts,
work together, and commit the needed resources.
Here's why: As a result of global initiatives and
programs, AIDS-related deaths have dropped by more than
25 percent between 2005 and 2011 worldwide. There are now
700,000 fewer new HIV infections in the world annually
than there were a decade ago. In 25 low- and middleincome
countries (most located in southern Africa), rates
of HIV infection have dropped by 50 percent or more since
2001. In sub-Saharan Africa, AIDS-related deaths have
decreased by one-third in the past six years and the
number of people on HIV medication has increased by 59
percent in the last two years alone. Recent studies have
demonstrated that treatment of HIV/AIDS with
antiretroviral (ARV) medication reduces transmission
rates by 96 percent, underscoring that treatment is also
prevention. By ensuring that more people have access to
ARVs, new HIV infections can be dramatically reduced.
Furthermore, several other milestones herald the hope for
a world without AIDS in the future: the discovery and FDA
approval of ARV drugs to use as pre-exposure prophylaxis
(PrEP) to prevent HIV infection in high risk groups,
significant declines in mother-to-child transmission of
HIV, expansion of comprehensive education programs,
testing and counseling, and the scale-up of other proven
prevention measures, including regular condom use and
medical circumcision.
However, despite these advances, the epidemic of HIV/AIDS
is far from over. According to the most recent statistics
from UNAIDS, there are still 2.5 million new HIV
infections worldwide and 1.7 million deaths annually from
this disease. Globally, there are 34 million people
living with HIV and half do not know their HIV status.
Nearly half of the people in need of antiretroviral
treatment (6.8 million) do not have access to these lifesaving
medications, and as many as 50 percent of them
will die within 24 months if they do not receive therapy.
Sub-Saharan Africa continues to carry a disproportionate
burden of disease, representing 69 percent of all people
infected with the virus worldwide. The United States and
countries across the globe must continue to take action
against this deadly virus.
Moving forward, an effective vaccine and a cure for
HIV/AIDS will be needed to finally end the global
pandemic. On this front, scientists are making
significant progress in developing an HIV vaccine. HIV's
ability to mutate has thwarted vaccine development, but
recent studies have shown partial efficacy of new
vaccines. An important study was conducted in Thailand
with the support of the Army's Walter Reed HIV Research
Program. Recently, the National Institute of Allergy and
Infectious Diseases (NIAID) selected Duke University and
the Scripps Research Institute to lead the new Centers
for HIV/AIDS Vaccine Immunology and Immunogen Discovery
and awarded this new program $31 million in FY2012, with
approximately $186 million or more in projected funding
over the next six years. The initiative will support a
consortium of multi-disciplinary researchers at
universities and medical centers focused on multi-pronged
approaches to accelerate HIV vaccine development. The
team will address key immunological pathways and
roadblocks, including immune responses that might protect
against HIV infection or suppress it in people living
with the virus, providing scientists with a foundation
for designing a safe and effective HIV vaccine in the
future.
Research is also underway to find a cure for AIDS, fueled
by the experience of the "Berlin patient," a man who had
both leukemia and HIV. He was treated in 2007 with a bone
marrow transplant from a person with natural immunity to
AIDS, which is found in 1 percent of Caucasian blood
marrow donors. The procedure not only cured this
patient's leukemia but also appears to have eliminated
the HIV virus from his body, and he no longer requires
medication to treat the illness. This landmark case has
provided important clues in the quest for a cure and a
glimmer of what increased funding and intensified efforts
might yield. amfAR, the Foundation for AIDS Research, is
providing important scientific direction in supporting
innovative work to discover a cure, including
establishing multi-site collaborations to achieve this
goal. The NIH is funding studies to find a cure and has
established research consortia to facilitate new
discoveries. However, cure research must receive a
significant boost in funding and commitment from
countries around the world if we are to achieve a world
without HIV/AIDS in the years ahead.
To provide a roadmap for further accelerating progress
toward a world without HIV/AIDS, on Thursday, U.S.
Secretary of State Hillary Rodham Clinton released the
U.S. government's "PEPFAR Blueprint: Creating an AIDS
Free Generation," which provides a roadmap to achieve
this goal. The PEPFAR blueprint's aim is to control the
AIDS epidemic in the next 4-5 years by providing more
people with medications to treat the disease,
circumcising men in countries that have a high HIV
prevalence, and ensuring that all pregnant women who are
HIV-positive receive treatment. When these interventions
are provided in combination, the number of new HIV
infections annually could be reduced below the number of
people who are put on ARVs. This would tip the scales on
the epidemic and set a trajectory to achieve an HIV-free
generation with zero new AIDS-related deaths, zero new
infections, and no children who are orphaned because
their parents have died of this disease. The blueprint
includes five primary goals with action steps to achieve
them:
1. Scale up combination prevention and treatment:
- Work toward the elimination of new HIV infections among
children by 2015 and keeping their mothers alive.
- Increase coverage of HIV treatment both to reduce AIDSrelated
mortality and to enhance HIV prevention.
- Increase the number of males who are circumcised for
HIV prevention.
- *Increase access to and uptake of HIV testing and
counseling, condoms, and other evidence-based and
appropriately-targeted prevention interventions. PEPFAR
now provides 5.1 million people with medications and the
Global Fund has provided 4.2 people with these drugs
since it was established in 2002.
2. Going where the virus is: Target evidence-based
interventions for populations at greatest risk
- Target HIV-associated tuberculosis and reduce comorbidity
and mortality.
- Increase access to and uptake of HIV services by key
populations.
- Partner with people living with HIV to design, manage
and implement HIV programs responsive to and respectful
of their needs.
- Strengthen PEPFAR 's continued focus on women, girls,
and gender equality.
- Reach orphans and vulnerable children (OVC) affected by
AIDS and support programs that help them develop to their
full potential.
- Strengthen programmatic commitment to and emphasis on
reaching and supporting young people with HIV services
3. Promoting sustainability, efficiency, and
effectiveness
- Strengthen PEPFAR supply chains and business processes
to increase the efficiency of U.S. investments.
- Increase efficiencies through innovation and greater
integration of services with other U.S., bilateral and
multilateral global health investments, including the
Global Fund.
4. Creating an AIDS-free generation requires a global
effort
- Partner with countries in a joint move to country-led,
managed, and implemented responses.
- Increase support for civil society as a partner in the
global AIDS response.
- Expand collaboration with multilateral and bilateral
partners.
-
Increase private sector mobilization toward an AIDS-free
generation.
5. Science must continue to guide our efforts
- Leverage greatest impact by continuing to invest in
implementation science.
- Support implementation research.
- Evaluate the impact of optimized combination
prevention.
- Support innovative research to develop new technologies
for prevention (e.g., microbicides, vaccines) and care
(e.g., new treatments or treatment regimens).
- Develop evidence-based approaches to reaching people
early enough in their disease progression to help
maintain a strong immune system, stave off opportunistic
infections, particularly TB, and reduce new HIV
infections.
- Support the deployment of suitable technology for
measurement of viral load, both through tiered laboratory
networks and "point-of-care" tests as they become
available.
- Assist countries in adopting breakthrough new
technologies with proven impact, such as new molecularbased
TB tests that have dramatically reduced time to
diagnosis and treatment for people living with TB and
HIV.
The PEPFAR Blueprint reflects the Obama Administration's
investments in "smart power," with the tools of health,
education, and development as essential components of our
national foreign policy. It underscores that we now have
the tools to end the epidemic, but we must scale-up what
works and deploy these tools strategically to reach the
most vulnerable populations worldwide. Investments in
ending AIDS are also building the health systems to
address and prevent other infectious and chronic diseases
-- saving lives and resources as well.
In this regard, it is important to note that foreign aid
has traditionally been the major source of funding to
fight the AIDS epidemic worldwide, but for the first time
in history, UNAIDS reports that domestic investments by
low- and middle-income countries to address their own
HIV/AIDS epidemics surpassed global giving for these
programs. From 2001-2011, 81 countries have assumed more
shared responsibility in addressing the disease by
increasing their own nation's contributions by more than
50 percent despite the global economic crisis.
The United States, however, is the largest source of
global health funding to end the AIDS epidemic. While
surveys show that many Americans believe that 25 percent
of our nation's budget is spent on global health and
development, the amount is actually less than 1 percent.
Congress is now debating an 8.2 percent across-the-board
funding cut to most non-defense discretionary programs
using FY 2012 appropriations levels. amfAR, the
Foundation for AIDS Research, has conducted an analysis
that applies sequestration cuts to U.S. government global
health programming, and it reveals there would be minimal
impact on deficit reduction, but it would devastate the
lives of tens of thousands of people globally. For
example, the report estimates that if the sequestration
of U.S. government bilateral global health support should
occur:
- HIV/AIDS treatment for 276,500 people will not be
available, potentially leading to 63,000 more AIDSrelated
deaths and 124,000 more children becoming
orphans.
- 112,500 fewer HIV-positive pregnant women will receive
services to prevent maternal-to-child transmission,
leading to more than
- 21,000 infants being infected with HIV.
- Funding for food, education, and livelihood assistance
will not be available for nearly 359,000 children.
- About 60,000 fewer people with tuberculosis (TB), the
leading cause of death for HIV positive people, will
receive treatment, leading to 7,000 more deaths due to
TB, and 300 fewer people with multi-drug-resistant TB
will receive treatment. About 1.3 million fewer
pentavalent vaccines for children will be available
through GAVI, leading to 14,000 more deaths from
diphtheria, tetanus, pertussis, Haemophilus influenza
type B, and hepatitis B.
On the global front, leaders convened last year for the
2011 U.N. General Assembly High Level Meeting on AIDS and
adopted the 2011 Political Declaration on HIV/AIDS.
Listed below are 10 specific targets in the declaration
that are critical components of a global strategy to
achieve universal access to HIV prevention, treatment,
and care by 2015. Turning the tide on HIV/AIDS in the
next 1,000 days to meet these 2015 targets will require
increased research, financial investment, and political
commitment to finally end the epidemic in the years ahead
by 1) making the needed scientific discoveries, 2)
scaling up effective interventions, and 3) building the
health systems infrastructure needed to transform what
has been an emergency response to the epidemic into a
sustained multi-faceted, multi-sector response in all
countries.
1. Reduce sexual transmission of HIV by 50 percent by
2015.
Sexual transmission remains the primary route of new HIV
infection globally and is a key area of focus for
eliminating new HIV infections. Female sex workers are
13.5 times more likely to be living with HIV than women
in the general population. Based on a survey conducted in
capital cities worldwide, HIV infection among men who
have sex with men (MSM) is, on average, 13 times higher
than that of the general population. A median of only 38
percent of MSM have been tested for HIV in the prior 12
months. Condoms are essential tools to prevent sexual
transmission of HIV, yet it is estimated that low- and
middle-income countries procured only 2 billion condoms
in 2010, far short of the estimated 13 billion condoms
required to reach the HIV prevention goals for 2015. PrEP
must be considered as strategy for preventing HIV/AIDS
among these high risk groups.
2. Reduce transmission of HIV among people who inject
drugs by 50 percent by 2015.
About 3 million of the estimated 16 million people who
inject drugs are living with HIV, and these individuals
have an HIV prevalence rate that is 22 times higher than
the general population. In particular, women who inject
drugs are at a much high risk of exposure to HIV because
they are also more vulnerable to other risk factors like
partner violence, homelessness, and comorbid mental
disorders that increase vulnerability to infection. In
the U.S., an important step forward is to lift the
federal ban on syringe exchange, which is an evidencebased,
proven intervention that decreases transmission
rates of blood-borne diseases including HIV and
hepatitis.
3. Eliminate new HIV infections among children by 2015
and substantially reduce AIDS-related maternal deaths.
In just the last two years, rates of new infections in
children have dropped by 24 percent, but 72 percent of
children living with HIV who are eligible for HIV
medications still do not have access to them. Pregnancyrelated
deaths in women living with HIV have declined
from 46,000 to 37,000 globally from 2005 to 2010.
However, still only 30 percent of treatment-eligible
pregnant women received antiretroviral treatment in 2011.
To achieve an AIDS-free generation, it is essential to
provide ARV therapy to pregnant women to prevent
transmission to their babies as well as to ensure that
all children worldwide who are HIV-positive receive
treatment.
4. Reach 15 million people living with HIV with
lifesaving antiretroviral treatment by 2015.
Antiretroviral therapy has saved an estimated 14 million
life years in low- and middle-income countries, and the
number of people accessing antiretroviral treatment has
increased by 63 percent from 2009 to 2011. However, 7
million people eligible for HIV treatment still do not
have access to these life-saving medications. The U.S.
has pledged to ensure that 6 million people are on ARVs
through PEPFAR programs by 2013 to help reach this goal.
5. Reduce tuberculosis deaths in people living with HIV
by 50 percent by 2015.
While tuberculosis-related deaths have fallen by 25
percent from 2004, it remains the leading cause of death
for people living with HIV, even though it is known that
starting antiretroviral therapy immediately upon
diagnosis can reduce the risk of TB illness by up to 65
percent.
6. Close the global AIDS resource gap by 2015 and reach
annual global investment of $22-24 billion in low- and
middle-income countries.
Spending on HIV/AIDS programs increased by 11 percent
from 2010 to 2011, with domestic spending by low- and
middle-income countries rising by 15 percent and now
accounting for the majority of total HIV spending
globally for the first time in the history of the
epidemic. However, global investment on the disease in
2011 was $16.8 billion, which is still significantly
short of the $22-24 billion goal for 2015.
7. Eliminate gender inequalities and gender-based abuse
and violence and increase women and girls' ability to
protect themselves from HIV infection.
Women account for 58 percent of people living with HIV in
sub-Saharan Africa and represent 68 percent of people
with access to antiretroviral therapy in low- and middleincome
countries. Gender inequalities and power
imbalances in relationships between men and women make it
difficult for women to negotiate safer sex practices or
use interventions that could protect them from HIV
infection. In 26 of 31 countries with generalized
epidemics, fewer than half of young women have accurate
knowledge about HIV transmission, treatment and
prevention. And while 57 percent of pregnant women living
with HIV in low- or middle-income countries received
antiretroviral medicines to prevent maternal-to-fetal
transmission, only 30 percent of them receive these
medications to treat the disease to safeguard their own
health. Ensuring that women receive treatment after
giving birth to a baby is essential for advancing women's
health in the developing world as well as to prevent a
generation of children growing up without mothers who
have died from HIV/AIDS.
8. Eliminate stigma and discrimination against people
living with and affected by HIV through promotion of laws
and policies that ensure the full realization of all
human rights and fundamental freedoms.
Fear, ignorance, stigma, and discrimination continue to
undermine efforts to provide services to prevent,
diagnose, and treat HIV/AIDS, and these social and
structural barriers to care continue to be major hurdles
for many vulnerable populations. For example, 52 percent
of people living with HIV in Zambia reported verbal abuse
because of their HIV status, and 1 in 5 people living
with HIV in Nigeria and Ethiopia reported suicidal
thoughts and behaviors. As of 2012, about 60 countries
have laws that specifically criminalize HIV transmission,
and 40 percent of U.N. member states criminalize same-sex
sexual relations. Nearly 40 percent of countries do not
have laws in place that protect people living with HIV
from discrimination and the laws that do exist are often
inadequate. Efforts to shatter stigma surrounding
HIV/AIDS, particularly among high-risk vulnerable
populations including MSM, LGBT, sex workers, and people
who inject drugs are needed to support a human rightsbased
AIDS response.
9. Eliminate HIV-related restrictions on entry, stay, and
residence in countries around the world.
Current restrictions on the entry, stay, and residence of
people living with HIV in countries lack a scientific
basis and are often relics of the fear and discrimination
dating from early in the epidemic. While many countries
have lifted these outdated policies, including the United
States in 2010, 45 countries still have laws restricting
entry, stay, and residence for people living with HIV and
will require concerted efforts to educate policymakers
and the public to enact legislation that permits travel
and immigration for people who are living with HIV.
10. Eliminate parallel systems for HIV-related services
to strengthen integration of the AIDS response in global
health and development efforts, as well as to strengthen
social protection systems.
A comprehensive approach to ending AIDS means integrating
HIV-related services into existing health systems
structures, allowing countries to leverage HIV-related
achievements into broader health and development
programs, which will, in turn, improve the long-term
sustainability of these programs and interventions in
nations globally. Furthermore, intensified efforts are
needed to address the social and economic drivers of the
epidemic including improving essential services like
housing, education, and employment opportunities.
...
References
amfAR. "September 2012 Update: The Effect of Budget
Sequestration on Global Health: Projecting the Human
Impact in fiscal year 2013." The Foundation for AIDS
Research. September 25, 2012.
http://tinyurl.com/cgnextv
UNAIDS. "2011 Political Declaration on HIV/AIDS."
http://tinyurl.com/5to6ejd
UNAIDS. "2012 UNAIDS Report on the Global AIDS Epidemic."
Nov. 20, 2012.
http://tinyurl.com/avzncwv
UNAIDS. "Global AIDS Epidemic Facts and Figures." Nov.
20, 2012.
http://www.unaids.org/en/resources/presscentre/factsheets
/
Factsheet on Sub-Saharan Africa at
http://tinyurl.com/cebkbg9
United States Department of State. "PEPFAR Blueprint:
Creating an AIDS-free Generation." Nov. 29, 2012.
http://www.pepfar.gov/documents/organization/201386.pdf
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