Co-chair, Bill & Melinda Gates Foundation
Starting in the early 2000s, the world made a huge investment to address the crisis, especially through the Global Fund to Fight AIDS, Tuberculosis and Malaria and PEPFAR, the President’s Emergency Plan for AIDS Relief. In the history of global health, there had never been an increase of that magnitude in getting products and services to people who need them. That’s why the curve of AIDS deaths bends so sharply around 2005.
With 35 million dead, AIDS is the worst humanitarian disaster of my lifetime. But when you consider what would have happened if the curve had stayed on its original trajectory, the fight against HIV also has to be counted among our greatest successes.
But it’s a success at risk.
Governments in both donor and developing countries that responded so aggressively to the crisis 15 years ago are now focusing on other things. Funding for HIV control has been flat, and now there’s talk of cuts. In a world of competing priorities and limited resources, these conversations are mandatory, but I want to be sure that the people having them are clear about the consequences.
First, we can treat people more efficiently. Some countries, such as Zimbabwe, have implemented what’s known as differentiated care. Most patients adhere to the treatment regimen closely, so they receive longer-lasting supplies of drugs and go to the health facilities less regularly. More than two-thirds of Zimbabweans on treatment visit a health professional only once every three months. However, patients who are less likely to stick to the regimen get extra support. In this model, no one is wasting money by getting more services than they need, and no one is risking getting sicker by getting less than they need.
Second, the key to solving the AIDS crisis over the long term is prevention. The fewer people infected in the first place, the fewer who will need treatment. We don’t want to just control a disease when we can end it.
We need to identify and promote the best prevention practices so that we can get maximum impact from every dollar we spend.
Unfortunately, the outlook for prevention is also concerning. In the past decade, the rate of decline of new infections has slowed. The current rate of decrease is not nearly enough to offset the population increases we’ll be seeing in Africa over the next generation. Africa’s youth are a reason for optimism—more and more talented young people who want to solve big problems are coming of age every year—but making sure they’re cared for is also a challenge.
In 1990, there were 94 million people on the continent between the ages of 15 and 24, the age range when people are most at risk of contracting HIV. By 2030, there will be more than 280 million.
What that means is pretty clear. If we only do as well as we’ve been doing on prevention, the absolute number of people getting HIV will go up even beyond its previous peak.
We have to do better. Part of that is more funding, not less. And, as with treatment, we need to identify and promote the best prevention practices so that we can get maximum impact from every dollar we spend.
Kenya has been a leader in this area, emphasizing both voluntary medical male circumcision and pre-exposure prophylaxis, or PrEP, two of the most effective prevention methods currently available. Other countries can learn a lot from Kenya’s experience.
Over time, we will need better tools, such as long-acting drugs that prevent HIV infection and, eventually, a vaccine. But the pattern with research and development funding is the same as with delivery funding: it’s been flat, and now it’s targeted for cuts.
That’s a scary prospect. Without R&D investments, we won’t have the new discoveries that will make it easier to prevent transmission of HIV. In the meantime, if we don’t spend more to deliver the tools we have now, we’ll have more cases. If we have more cases, we’ll need to spend more on treatment, or people will die.
I’m not advocating for a blank check for HIV treatment, because I don’t think we need one. But this chain of causation works in the other direction, too. If we invest more, if we are more efficient, if we share what we learn, if we show more leadership, then we will write the story of the end of HIV as a public health threat.