November 27, 2012
Let's Step Up the Pace
by Mitchell Warren
The executive director of AVAC outlines five critical global HIV priority actions for 2013.
With this year’s AVAC report—Achieving the End: One Year and Counting—we’re setting the clock on the global drive to end the AIDS epidemic. It’s a goal that nearly all now agree is attainable. But it can only be achieved if an ambitious pace of funding, implementation and research is set—and maintained—starting now. Current models tell us that the next 12 to 24 months are a critical window. We are closing in on an epidemic “tipping point,” when the rate of ART scale-up out will outpace the rate of HIV infections—proving global capacity to treat all in need.
But the world will only reach this crucial milestone if it moves more quickly. Quite literally, this has to be the year that global HIV prevention efforts expand more quickly than ever before.
We’ve subtitled the report “One Year and Counting” because it has been just about 12 months since the world started talking in earnest about beginning to end the AIDS epidemic. For a planet gripped with economic crises and funding shortfalls, the vision was big, and rightly so, since 2011 brought some of the most encouraging scientific news the HIV prevention field has seen.
We’re not counting down; we’re counting up. Which begs the question: When will it end? Few concrete deadlines, with the exception of the push to eliminate pediatric HIV infection by 2015. Instead, the lexicon of ending AIDS has a range of vague milestones—in our lifetime, in a generation and so on.
There are reasons for this. As we discuss in the report, there just aren’t a lot of data on the impact of scaling up highly effective combination prevention. Without this information, it’s hard to predict outcomes. In order to get more specific, we need to start acting. Evidence of impact will help fine-tune models that are, for now, powerful but largely theoretical.
But even with this uncertainty, it is important to establish clear targets and check our pace. Consider the alternative. What will happen if, after a year of great hope, the global community doesn’t set an accountability clock for “ending AIDS”? What possible explanation could we give members of the next generation when they ask, “Why did you say it was possible and then fail to come up with a plan and act on it?”
Now is the time to accelerate. For so many athletic events—swimming, sprinting, horseracing—the speed set “off the blocks” or “out of the gate” is key. The AIDS response is, as many have said, a marathon and not a sprint. But even for such an endurance event, the start matters—a lot. Within the first five miles, or 10 kilometers, of a marathon—when the vast majority of the distance has yet to be covered— an experienced runner can tell whether she has set the pace she needs to beat a record, whether the record is her own or the world’s.
We’re just a year into an era of incredibly high stakes for the global AIDS response, and we know that there are years to go before we can say that the epidemic is moving conclusively towards an end. But what we can do is look at the pace we’ve set and say that while there’s still plenty of reason for optimism, there is already real cause for concern.
Which is why it is exactly the right time to start a clock, and shift global efforts into a higher gear.
In the 2011 AVAC report titled The End? we laid out a framework that incorporated short-, medium- and long-term goals for ending the epidemic. To realize this goal, we argued that it would be critical to deliver the interventions we have today and to demonstrate how the potential impact of emerging strategies in the coming years. Also, it would be key to continue efforts to develop essential and truly novel interventions, such as an effective AIDS vaccine and a cure over the long term.
In last year’s report, we also debuted the AVAC Playbook 2011, which articulated global goals in nine key areas of the AIDS response. These goals reflected what epidemiologists, modelers, advocates and other public health leaders have declared to be essential:
• Scale up ART coverage to maximize prevention and clinical benefits.
• Complete a “catch-up” phase of voluntary medical male circumcision in 14 priority countries as quickly as possible.
• Use every means necessary to improve and innovate HIV testing and linkage to care.
• Act on the results of several promising new strategies, and be mindful for the unique timeframes for development and introduction of different tools.
• Adopt a new “investment framework” for HIV/AIDS that focuses on high-impact, evidence-based spending and programs.
The goals laid out in the playbook and throughout the 2011 AVAC report are as relevant today as they were a year ago. They are big, long-term objectives that we must keep squarely in sight. That’s why we’ve included the original playbook—with notes on key developments—in the 2012 report.
In 2013, we need to get far more specific. In this year’s report, we briefly examine the progress made over the past year and provide necessary updates to the playbook, and then we turn to the question, “What now?”
What are the top priorities for the next year? What would make the greatest possible difference?
Our top five list is elaborated on throughout the report, which concludes with an urgent call for amplified global and national leadership.
In brief, the priorities are:
1) End confusion about “combination prevention.”
2) Narrow the gaps in the treatment cascade.
3) Plan for the impact of new non-surgical male circumcision devices.
4) Define and launch the “core package” of PrEP demonstration projects.
5) Safeguard HIV prevention research funding.
Throughout the report, we hope one message is loud and clear: prevention is fundamental—and must be at the heart of the effort to begin to end AIDS. The past year’s notable quotes include “treatment is prevention.” This statement is well-supported by clinical research—and turning it into a reality will change the world. But the greatest benefits of treatment as prevention will only be realized if other effective prevention strategies are rolled out at the same time, and new ones are pursued.
Taking voluntary medical male circumcision to scale in key countries could avert at least 20 percent of anticipated infections by 2025. This would change the trajectory of the epidemic and make the impact of treatment as prevention that much more powerful. And so one of our key messages must be: prevention is prevention too. This almost should go without saying. Yet, as we discuss throughout the pages of the report, there are many gaps in the current response that can and must be filled.
The future of prevention innovation is more precarious than it should be. This is, in part, because we’re not yet defining the struggle to begin to end the epidemic as a struggle, above all, to provide truly effective HIV prevention. In 2013, let’s pick up the pace of this historic race. It is—at one year and counting—ours to win.
To download the report, click here.
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