Editor’s note: The current issue of Health Affairs is a thematic volume focusing on the President’s Emergency Plan For AIDS Relief (PEPFAR).

Last week’s 19th International AIDS Conference in Washington, D.C. convened 25,000 scholars, activists, practitioners, policy makers, and members of the general public; people living with HIV and people living without the virus; students, bureaucrats, trade reps, job hunters, and story chasers; all eager to be made believers again. Keep the faith. Spread the news. Turn the tide. At the AIDS-world’s biennial extravaganza, it’s difficult to escape the feeling of a post-modern religious revival. Tens of thousands of people from all corners of the world – a crowd more ethnically, economically, and sexually diverse than you’d find on the 7 train to Flushing – coming together to worship at the temples of scientific advance and collective action.

Like any religious movement, we have our totems – the AIDS quilt, the UNAIDS display of inflated condoms; our personal salvation narratives – see testimony of Nigerian mother saved by AIDS drugs and daughter born HIV-free; even our choir – the D.C. Gay Men’s Chorus with their schmaltzy but genuine rendition of “I’ll be there”. Yes, some come for funding, for a job, to network, or to learn the latest scientific discoveries; but most come also to remember that we’re in this together and to recommit ourselves to the cause – at least until the next AIDS conference in Melbourne, 2014.

But the AIDS movement is no “shepherd and flock” church. Perhaps the most unique aspect of this conference was the multiple modes of participation taken on by delegates, and the safeguarding of space to contest power. Deserting the scientific sessions last Tuesday, thousands of people with HIV, activists, and supporters marched to the White House to demand access to medicines, evidence based prevention, and a financial transaction tax to support HIV and other health programs.

At the conference itself, not only did activists interrupt Secretary of State Hilary Clinton’s remarks to challenge a potentially-dangerous trade deal (more on this below), but they did so in coordination with the conference activist liaisons, whose job it was to keep the conference a safe space, while ensuring a safe space for dissent. As newly-minted World Bank President Jim Kim described in his opening address at the Conference, “at nearly every turn, it is the activists, and their communities, that have led the way”. And so, just dues were paid to Act-UP, TAC, HealthGAP, TASO and others, space was created for dissent, critical issues were put on the agenda (Trans-Pacific Partnership, Global Fund governance), and no one was led out in handcuffs.

The conference featured five days of plenaries, posters, oral posters, oral abstracts, late breaking abstracts, side sessions, satellite sessions, symposia, and debates, and that’s not to mention the myriad pre-conference meetings – this conference was long, tiring, a bit overwhelming, and yet (miraculously?) totally upbeat. Although no major scientific breakthroughs were presented for the first time, there is plenty of reason to be optimistic. As NIAID Director Dr. Anthony Fauci said, “Even without a vaccine, even without a cure, we have the [scientific] tools for treatment and prevention that we can have a substantial positive impact on the trajectory of this pandemic.”

This conference was an opportunity to take the pulse on where we are as a community of people living with the virus, activists, researchers, policy-makers, and others. The conference was hopelessly large – the program resembled the white pages for a mid-size city – and attendees with different interests could have completely different experiences and exposures. And so, with this caveat, let me share six things I learned at AIDS 2012:

1)  People with HIV on treatment can lead largely “normal” lives.

To say that HIV is not the death sentence it once was is a gross understatement. Several clinical cohort studies have now shown that people with HIV who start antiretroviral therapy on time have life expectancies that approach those in the general population. This is true in the U.S. and Canada; it is true in Uganda. Life expectancy on ART has improved as therapies have become less toxic and can be tailored to the needs of individual patients. People with HIV can have and raise healthy children, find and maintain employment, enjoy safe romantic relationships, and lead fulfilling lives. A recent and critically important line of research is to understand the long run effects of HIV infection and treatment on the process of aging.

Of course, only about half of people eligible for HIV treatment are currently receiving treatment, according to WHO. And the majority of people who have HIV (including nearly 20 percent of Americans with HIV) do not know their status. Letting people know that they can lead a “normal” life with HIV could have important positive impacts on HIV testing and recruitment into care. But of course, without further increases in funding, the dream of universal access will be just that.

In addition to the survival benefits for individual patients, we are beginning to understand the impact of ART scale up on larger communities in settings of high HIV prevalence. In a late-breaking presentation at the Conference, co-authors and I demonstrated that public sector ART provision has led to a 14 year increase in adult life expectancy for the typical young adult in a community in rural South Africa. Such enormous changes in survival may have important implications for savings and investments, e.g. in schooling or job training, and for risk taking behavior, e.g. crime, substance abuse, or reckless driving, which take the lives of many young people in South Africa. In ongoing research we are working to understand how these changes have impacted behaviors and norms in this community.

2) Continued AIDS investments by donors and governments are a sound investment… But who should pay for them?

The World Bank hosted a debate on the statement “Continued AIDS investments by donors and governments are a sound investment, even in a resource-constrained environment” last Monday evening (7/23), with Mead Over and Roger England taking on Jeff Sachs and Michel Sidibe, to debate the worthiness of future AIDS investments. This was an excellent discussion and worthwhile for anyone interested in debates on the strengths and limitations of cost-effectiveness as an approach to priority setting.

It’s an old debate, but a useful one to have over and again. The question boils down to whether you believe that there is a fixed budget constraint, and who is making the resource allocation decision. To paraphrase Mead Over, from the perspective of a finance minister in a low-income country, resources are clearly scarce, and investments in clean water, road safety, immunizations, etc. have much higher payoffs than HIV prevention or treatment. To quote Jeff Sachs in rebuttal: “The Proposition is a bit of a sham, because we are not in a resource constrained environment… This is a rich world in which rich people don’t pay taxes…. We’re talking about $40 billion or so to pay for all of this. That’s 20 days of Pentagon spending; 1 percent of the net worth of the 1200 billionaires on Forbes list.”

Over’s argument is valid if we are ministers of finance in low-income countries or technocrats advising them. But, looking at the massive expansion of global health funding over the last 15 years, it’s hard to maintain the belief that we are facing a fixed budget constraint for global health (and development). As health economists, our job may be to identify the most cost-effective policies, but as global citizens our job is also to advocate for greater resource shares for health, education, and social protection, in rich countries and throughout the world. AIDS programs should not be sacrificed on the altar of cost effectiveness, when there is no clear indication that funding for AIDS and other health priorities is a zero sum game.

If HIV/AIDS remains a worthwhile investment, who should pay for it? Bernhard Schwartländer, Director for Evidence, Strategy and Results at UNAIDS, raised an important point in his comments at Tuesday’s plenary session: funding for HIV should be getting easier, not harder. With rapidly rising incomes in middle-income countries, funding responsibilities can be shared more broadly. Indeed, this transition has already occurred in South Africa, Botswana, and elsewhere, and is crucial for long run political accountability and sustainability.

But, I would argue, this is no justification to take our hand off the throttle in rich countries. Funding can and should be maintained, expanded, and plowed into high-yield investments, big push interventions (such as treatment as prevention in high prevalence settings), and global public goods (such as scientific research).

3) HIV in the United States

Congresswoman Barbara Lee (CA, D) stated in her plenary address – “This conference shines an international spotlight on the epidemic in this country, just as it shines a national spotlight on the epidemic around the world.” Indeed, as shown in a 2010 New England Journal of Medicine article, HIV prevalence in Washington and some other U.S. cities rivals that in some sub-Saharan African countries that receive PEPFAR funds. Clearly there is a need to redouble efforts in the United States. This will require commitment to funding, but also a transition to evidence based public health and HIV education policy. To take one oft-repeated refrain: Abstinence works. Abstinence-only education does not.

For a poignant and detailed primer on the U.S. HIV epidemic among Black Americans, the lives it has touched, and the harmful unintended consequences of short-sighted public policy, check out the PBS Frontline special Endgame: AIDS in Black America. It is excellent and should be required viewing for students and practitioners in all health fields.

4) This is not a victory lap.

The first AIDS conference in the United States in 22 years provided occasion to say thank you, thank you, and thank you to the American people and its government for leading the world in funding the global expansion of HIV treatment. To hear such an acknowledgement from a person who is alive today because of U.S. taxpayer dollars, it is hard not to be moved.

And yet… not only is the work not done, but existing achievements have come under attack. One such achievement is an international trade regime that allows countries to break patents when faced with public health emergencies. This right was affirmed by the Doha Declaration, adopted by the World Trade Organization in 2001. Access to generic medicines and the pressure that generics have placed on brand name pharmaceuticals have led to dramatic declines in prices of ART, enabling large scale treatment provision. But now these rights may be threatened.

For the last several years, the US government has been engaged in closed-door negotiations with a dozen countries on a trade deal called the Trans-Pacific Partnership (TPP). Legal scholars and medical practitioners fear that the TPP would block access to generic medicines critical for the global response to HIV, as well as other diseases. According to Doctors Without Borders, “If the U.S.’s demands are accepted, the TPP agreement will impose new IP rules that could severely restrict access to affordable, life-saving medicines for millions of people.” In spite of (or perhaps because of) these fears, TPP negotiations have bypassed Congress, to the chagrin of legislators and in violation of democratic process.

And so, on Monday (7/23) protesters of the TPP interrupted Hilary Clinton’s speech with chants of “Trans-Pacific Trade Deal Blocks AIDS Drugs”, holding banners in front of the raised podium for the first 10 minutes of her speech. The following day, thousands of protesters marched to the White House and US Trade Representative’s Office with banners stating “Ron Kirk: Trans-Pacific Trade Deal Kills”. See this Huffington Post article for further information and links.

Their message was clear: this is not a victory lap.

5) Treatment as prevention is promising, but expensive, and there are other things we should be doing first (or in addition).

Hailed as a game-changer, evidence on the efficacy of treatment as prevention  (TasP) has captured the imagination of the AIDS community. The now well-known HPTN-052 study found that due to viral suppression, antiretroviral therapy reduced transmission of HIV in serodiscordant couples by 96 percent. If people can be recruited into treatment early enough, scaling up antiretroviral therapy is a promising prevention strategy. Indeed, a recent population-level analysis in rural South Africa, cited here, found that areas with higher treatment coverage had lower infection rates than areas with lower treatment density.

However, as Bärnighausen and colleagues showed in a presentation at AIDS 2012, by cost-effectiveness criteria, expanding TasP through test-and-treat programs should only be implemented after achieving full treatment coverage under existing therapeutic guidelines, and fully implementing voluntary medical male circumcision. The upshot is that TasP, though promising, is expensive and difficult to justify in settings that have yet to achieve close to full treatment coverage under existing guidelines. Of course, if there were no resource constraints, and we knew we were going to implement TasP, then circumcision would be largely redundant.

Similar to scientific advances in therapeutics, TasP implementation may widen health disparities, as populations that can afford TasP proceed whole-hog towards test-and-treat strategies, while other resource-constrained populations may be unable to “turn the tide” against new infections. In resource-poor settings with large HIV epidemics, a big push to end HIV transmission through TasP may only be possible with outside funds.

6) We should be optimistic; we have the tools; but we are a long ways off.

Turning the tide is not just a figure of speech. It implies moving from a world in which the number of people infected with HIV is increasing to a world in which the number of people infected with HIV is decreasing. As pointed out by Mead Over, in his book, Achieving and AIDS Transition, this requires that the number of people who are newly infected with HIV each year is below the number of people with HIV who die each year. Having achieved dramatic mortality reductions due to antiretroviral therapy – a critically important and morally justified achievement – we must now drastically reduce new infections. New infections have declined steadily since the late 1990s, but incidence is still very high in some regions. In rural South Africa, increased survival due to ART has led to substantial increases in HIV prevalence. The task for prevention, whether through TasP, circumcision, sex education, or structural interventions like cash transfers to young women, is enormous. While there is much to celebrate, the ebb tide is a long ways off. Advocacy to raise funds for TasP and research to identify additional effective prevention strategies is needed.

Correction: This post has been updated to correct the number of Americans with HIV who do not know their status.

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