The world committed to end the AIDS epidemic by 2030 with goals adopted this year by the United Nations. But is that realistic, or even possible?
There are a lot of reasons for optimism on this World AIDS Day. The number of new infections has dropped 35 percent since 2000, according to the World Health Organization. HIV-linked deaths, which peaked in 2004, have dropped 40 percent since. And wider access to antiretroviral medicines is extending lives, suppressing the virus, and preventing its spread.
The UN agreement isn't talking about eradicating the virus entirely in 15 years. Citing mathematical models that show what's possible, the goal is to stop widespread transmission and eliminate it as a public health threat.
"It’s doable based on the tools we have, but the challenges are enormous," says Carlos del Rio, chairman of the department of global health at Emory University's Rollins School of Public Health.
When patients stick to their drug regimen, they can almost eliminate the risk of passing the virus to partners. The WHO now recommends that everyone diagnosed with HIV begin treatment immediately, rather than waiting until symptoms develop. Today, almost 16 million people are on antiretroviral drugs, compared with 700,000 in 2000.
The bad news is that despite the progress, less than half of those infected with HIV are even getting treatment. To halt the epidemic by 2030, access to drugs "needs to accelerate markedly," the WHO said in a recent report. This would mean almost doubling the number of people getting HIV drugs to 30 million globally by 2020. Many countries, including the U.S., aren't able to test, treat, and maintain care of the majority of people who contract HIV. "Our health systems are broken around the world," del Rio says.
Ending AIDS as a major threat requires getting drugs not only to the world's poorest, but also to those cast off by some societies, and keeping them on their medication. "This is about delivering a drug to people in need, and almost by definition in this epidemic, we know that people who are infected are often those that are marginalized, stigmatized, and very often criminalized," says Mitchell Warren, executive director of AVAC, a global organization focused on HIV prevention.
Making matters worse, not all the statistics are headed in the right direction. Unicef recently announced that adolescent deaths from AIDS have tripled since 2000, the only age group in which HIV-linked mortality isn't declining. The statistic is a reminder that gains in any epidemic can be reversed—particularly as treatment makes HIV less lethal than it used to be. "People can get complacent," Warren says. "People don’t see it as the threat it once was." A significant halt to HIV transmission is unlikely to be sustained long-term without a vaccine or a cure, both medical advances not yet in reach, Warren says.
There are financial barriers, too. Total global funding to fight HIV was about $21.7 billion this year. That would need to increase by almost 50 percent, to $31 billion annually by 2020, to be on track to meet the UN's 2030 goal, says Jen Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation.
"The funding picture is not very good right now," she says, explaining that preventing new infections in the immediate term is crucial to making the 2030 goal. "More money needs to be provided now to save money later."
Still, with the science available, the world has the capacity to largely end the epidemic as a public health threat within a generation. The question is whether the practical, political, and financial barriers can be overcome.
"I don’t want to minimize the fact that doing it is going to be challenging," says Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS, who pioneered the idea of ''treatment as prevention.''
"There is now consensus that it can be done, it should be done, it must be done," he says.