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AIDS 30 years old

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26 July 2011

Despite advances in treatment, funding remains a global issue, writes David Brown, June 2011.

The AIDS epidemic turns 30 this month. What began as a fatal new plague has become a treatable, if still incurable, chronic illness. That change counts as a triumph by any measure, but it also poses an unusually difficult question for the next 30 years: how many people do we want to save from a death by AIDS - and who's going to pay for it?

The global AIDS community now has tools that prolong the lives of people infected with the virus and prevent others from acquiring it. They range from antiretroviral therapy (ART), to circumcision and campaigns to reduce promiscuity. On the horizon are gels and pills that protect against infection during intercourse. Even the outlook for an AIDS vaccine is no longer as bleak as it used to be.

At least 6 million people in the developing world are now receiving life-extending ART. That is less than half the 14.6 million HIV-infected people who should be getting treatment under the World Health Organisation's latest guidelines, but it nevertheless represents an accomplishment that was inconceivable when the epidemic turned 20 in 2001. That number is likely to grow after a recent study showed that ART dramatically cuts a person's infectiousness, and thus is itself a tool for prevention.High-risk group ... a graveyard in Cape Town, which holds many people who have died from AIDS; an estimated 5.6 million people are infected in South Africa.

Bringing those tools to the people needing them - 90 per cent of whom are in developing countries - requires lots of money. Last year, the world spent $16 billion ($15 billion) on the task, half of which was donated by rich countries and charities.

A recent projection estimated that, by 2031, global AIDS costs could reach the equivalent of $US35 billion a year. A recent United Nations report declared frankly: ''The trajectory of costs is wholly unsustainable.''

The disease first came to public attention on June 5, 1981, in a report on a rare type of pneumonia in five gay men, but scientists now believe the virus entered humans early in the 20th century. In Africa, where the epidemic began and has had the most devastating effect, the rate of new infections - incidence - peaked in the late 1990s.

Today, the epidemic is an astonishing mixture of good news and hard-to-excuse failure. About 33.3 million people around the world are infected with HIV, the virus that causes AIDS. In 2009, the last year for which there are complete statistics, 2.6 million people became infected and 1.8 million people died. Those numbers are down from previous peaks.

The decline reflects great progress in the hardest-hit regions, especially in Africa. During the past decade, the HIV incidence declined in 33 countries, and HIV prevalence among young people fell in 15 countries - in both cases, by an astonishing 25 per cent - largely due to safer sexual practices.

Nevertheless, the number of people living with HIV is still on the increase. Part of the reason is that AIDS patients are surviving longer, thanks to the expansion of antiretroviral therapy in the developing world, where 200 times as many people are getting it now than were just eight years ago. But for every person who starts treatment, two others become infected.

Without more progress in preventing new infections, HIV incidence will eventually start rising again. By 2031, when the epidemic turns 50, about 3.2 million adults will become infected each year, a recent projection shows. By the middle of the century, there could be 70 million people living with HIV in Africa alone.

Without question, a big reason for the progress made in the past decade is the sums of money brought to bear by the President's Emergency Plan for AIDS Relief (PEPFAR), created by George Bush in 2003 and expanded by Barack Obama, and by the Global Fund to Fight AIDS, Tuberculosis and Malaria, a free-standing institution in Geneva that gets money from rich countries to fund grants to needy countries. PEPFAR spent $US6.7 billion last year on AIDS treatment and prevention, the Global Fund $US1.6 billion. Together, the two provide antiretroviral therapy to about 85 per cent of the people receiving it in the developing world - about 4.7 million people in all.

Faced with budgetary concerns, both are seeing the amount of money they have to spend on the problem level off. Everyone agrees that, from now on, low-income countries will have to devote more of their budgets to AIDS. But some fear they will be asked to shoulder too much too soon.

''It defies imagination to think that it's time for donors to pass the hot potato to the government of one of the poorest countries on Earth,'' said Asia Russell, who works in Uganda with the activist group Health Global Access Project.

Nearly everyone agrees the first thing that needs to be done is to get more bang for the billions of bucks now being spent. ''Money is important, but money alone will not make it,'' said Michel Sidibe, director of UNAIDS, the United Nations AIDS program. ''We need to have a solidarity around issues which are going beyond money. The solution will be found through a genuinely shared responsibility.''

The most important step in bringing AIDS treatment to people in the developing world has been the huge decline in the cost of antiretroviral drugs over the past 15 years. Three-drug ART combinations cost $US10,000 to $US12,000 a year in 1996 when they became standard therapy in the US. The Clinton Health Access Initiative, one of Bill Clinton's charities, recently announced a schedule of brokered prices in which a three-drug combination, which includes the highly favoured drug tenofovir, runs to $US159 a year. The price of an older triple combination is $US79 a year - less than 1 per cent of what it used to be.

The initiative has helped create a more sustainable market by bringing drug buyers (often national governments) and drugmakers (usually generics companies) together to encourage more rational, long-term planning. Recently, it has also begun helping manufacturers find cheaper sources of the chemical raw materials they need to make their products.

The result has been a proliferation of firms making AIDS drugs for poor countries (although not for rich countries, where patent restrictions forbid sales). In 2003, four companies in India made AIDS drugs. Today 10 do, and Indian companies supply more than 80 per cent of AIDS drugs used in developing countries.

''Prices are rock-bottom now for a lot of the older drugs. We can't keep squeezing, because it will become an unattractive market,'' said Brenda Waning, an economist at the World Health Organisation, in Geneva. For newer drugs, she said, ''there is still a lot of room for price reductions''.

Lowering drug prices is just one of several strategies to make money go further. ''We're still mining for those efficiencies,'' Eric Goosby, the physician who runs PEPFAR at the US State Department, said recently. But he added, ''My guess is that in the next 18 months to two years we will have found them all.''

What happens then is a big question.

Recently, a group of economists and epidemiologists convened a project called aids2031 that examined scenarios for what might happen between now and the epidemic's 50th anniversary.

The most expensive one, costing $US722 billion over that period, would ramp up to provide treatment and prevention services for 80 per cent of people by 2015. It would prevent 33 million new infections, although 1.3 million a year would still be occurring in 2031, modelling done by the Results for Development Institute, in Washington, shows.

The cheapest scenario would put almost the same number of people on AIDS drugs but would target prevention services only at high-risk groups, such as uncircumcised African men, infected pregnant women and drug users. It would cost much less - $US397 billion - but 1.7 million people would still be getting infected each year 20 years from now.

All of the scenarios make clear that, without better success at preventing infections, the problem of not enough money will go on. ''Prevention is the sine qua non for turning off the tap and reducing the need for treatment,'' said Robert Hecht, head of the institute.

So, the global AIDS epidemic is out of its youth. It seems unlikely that there will be easy ways to avoid hard decisions as it heads towards middle age.

The Washington Post

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