“Prioritization” has emerged as a central theme in the days leading up to the official July 22 start of the XIX International AIDS Conference (AIDS 2012) in Washington, DC. A prime example of this can be found in a report outlining a global action agenda aimed at accelerating progress towards the end of the AIDS epidemic, released July 19 by AVAC and amfAR, The Foundation for AIDS Research.

The report, dubbed An Action Agenda to End AIDS, is based on an analysis of modeling research and consultations with HIV prevention experts.  The visually detailed publication is available online and will be discussed at an AIDS 2012 satellite symposium on Monday, July 23.

“To begin to end the epidemic, we need to be strategic and ambitious in using what is available today,” the report explains. “There is evidence on the impact some of these core strategies can have when combined with other interventions. And there is modeling that shows that these strategies, taken to scale and with attention to key populations, will reduce deaths, new infections and the price tag for the AIDS epidemic over the long term.

“So there is agreement that the world can begin to end the epidemic. But there is an open and urgent question as to how?”

The answer, the report suggests, involves being strategic and ambitious in using prevention interventions that are available today. “This plan focuses on scaling up a limited number of core interventions that will have the greatest impact and offer the greatest value in epidemics driven by sexual transmission. We emphasize, too, that comprehensive harm reduction, decriminalization and human rights protections must be combined to effectively address the epidemics among injection drug users, men who have sex with men (MSM) and sex workers around the world.

“Failure to implement these strategies at scale remains a major missed opportunity of HIV prevention to date,” the report warns.

AVAC and amfAR recognize that as the concept of combination prevention takes hold, there will inevitably be debates about which interventions to prioritize. But the test, they say, should be to identify the cost-effective approaches that will reduce the number of new HIV infections and AIDS-related deaths.  

“Thirty years into the epidemic, we cannot afford—literally—to choose any other criteria for prioritizing our efforts,” the authors write. “Available evidence indicates [five] core interventions meet this test and deserve to serve as the backbone of efforts to begin to end the epidemic.”  These core interventions are:

  • HIV Testing—to dramatically increase the number of HIV-positive and negative individuals who know their status and access needed services
  • HIV Treatment—to move to global implementation of ART guidelines that optimize treatment and prevention benefits
  • Voluntary Medical Male Circumcision—to achieve 80 percent coverage among adult males, between 15 and 49 years of age, in 14 priority countries
  • Prevention of Mother-to-Child Transmission—to eliminate new infections in children by 2015
  • Focused, Evidence-Based Prevention Programs for Key Populations—to ensure that the full range of drivers of the epidemic are addressed; harm reduction, structural change aimed at gender equality and addressing domestic violence, economic empowerment, and rights-based health care for MSM, sex workers and other criminalized groups are essential.
These core interventions, the report explains, are the tools necessary to fulfill five essential steps that must be taken—year by year through 2015—by various stakeholders, including governments, international organizations, donors, civil society, researchers and technical agencies: These steps fall within five overarching priorities:
  • Make hard choices by emphasizing, above all other efforts, the rapid scale-up of core interventions that can have the greatest impact. These include HIV testing and treatment, VMMC, prevention of mother-to-child (vertical) transmission, and evidence-based, human rights-based interventions for gay men, sex workers, injection drug users and others at greatest risk.
  • Mobilize sufficient, sustainable resources to ensure the rapid scale-up of these core interventions.
  • Agree on clear roles and responsibilities and hold one another accountable for results, through agreed timelines, target outcomes, transparent reporting, and real-time assessment of results.
  • Build the evidence base to end AIDS by prioritizing research on the most effective ways to implement new prevention strategies, as well as the continued search for a preventive vaccine and a cure.
  • Use every dollar of funding as effectively as possible by lowering the unit costs of core interventions, improving program management, and strategically targeting services.
By steadily reducing annual new HIV infections and simultaneously continuing to expand access to HIV treatment, the report authors project that a global “tipping point” can be achieved within two to three years. At that time, roughly 1.75 million people would gain access to HIV therapy yearly, exceeding—for the first time ever—the number of annual HIV infections, which would fall close to 1.5 million. This shift would mark a critical step in controlling the global epidemic.

“At this historic moment, all stakeholders need to commit to a common goal,” the report concludes. “We must focus and hold ourselves accountable. And while working to deliver core interventions to broad scale, let our actions and investments continue to support the search for a preventive vaccine and a cure for HIV/AIDS, which will make permanent the favorable changes that strategic action in the next five years will generate.”