As promised, today we bring you another commentary inspired by Secretary Clinton’s recent speech calling for an AIDS free generation by Matthew Basilico, Nworah Ayogu, and Arjun Suri of Harvard Medical School.
As students immersed in the study of biological sciences, and as future physicians anxious to provide care and improve lives, we can be frustrated when public health policy seems based on interests neither scientific nor beneficent. United States programs that fight global AIDS have accomplished tremendous good over the past eight years; however, recent stewardship by President Obama has been disappointing both scientifically and morally. Last fall, many of us at Harvard Medical School protested President Obama because we believed his failure to keep his promises to scale-up the fight against HIV/AIDS was proof that he was ignoring the science and neglecting his ethical obligation to save millions of lives around the world. However, on Tuesday, Secretary of State Hillary Clinton delivered an inspiring address that is at once evidence-based and morally laudable.
When we began our protests last fall, there was a growing body of research indicating that treating HIV also prevents its spread. Evidence from a localized study South Africa indicated that when people with HIV received antiretroviral treatment (ART), their partners were 92% less likely to contract the virus. [1] Initial modeling used this information to theorize that, with universal access to treatment, infections could plummet within 10 years. [2] With this growing evidence (as well as other studies), the phrase “treatment as prevention”—long used by health professionals working at the front lines of AIDS care—resonated in scientific communities. Not only does treatment save lives, but these recent studies show that treatment could dramatically reduce new infections, slowing or even halting the epidemic in the future. It was not until this year, however, that this could be said with such certainty. A multi-site, large-N, randomized control trial showed that ART reduces new infections by 96%. [3]
We have also been encouraged by the growing literature showing that investments in HIV treatment programs improve health systems and eases delivery of other life-saving interventions.[4,5] Dr. Paul Farmer, co-founder of Partners In Health, described HIV treatment as the “battle horse” to drive the necessary expansion in infrastructure and political will for addressing other global health priorities.
The evidence is clear: now, more than ever, we know that investing in AIDS treatment will save millions of lives and reduce new infections. Yet in the first years of his administration, President Obama fell dreadfully short on campaign promises to significantly improve resources for AIDS funding. Many fellow classmates from Harvard Medical School, as well as from colleges and medical schools across the east coast, joined in protests encouraging the administration to uphold its promises. It is impossible to forget the numbers—a year of AIDS treatment costs less than $100, and the treatment program makes up far less than 0.2% of the federal budget. Yet while hundreds of billions of dollars went to bank bailouts, no new money was found for the meager $1 billion dollar annual rise that was promised during the election cycle.
Secretary Clinton’s speech on November 8th, therefore, was encouraging. She declared that for the first time, it will be United States government policy to create “an AIDS-free generation.” She emphasized prioritizing high impact interventions—prevention of mother-to-child transmission, circumcision, and treatment. And she lauded the vital role of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has been an innovative and transparent engine for delivering resources where they are needed most. Secretary Clinton’s speech had much of what is needed, except for the numbers.
To transform the Secretary’s vision into a reality, we will need bold treatment targets and solid commitments to increase funding. Six million patients on treatment by the end of 2013 would be an appropriate goal for the United States government, which is on track to have four million on treatment by the end of this year. Congress and the administration have responsibility for the 2012 budget, while the Super Committee debates 2013 and beyond. We eagerly await President Obama’s address on World AIDS Day (December 1st). Lawmakers have the opportunity to transform one of the greatest human scourges of our generation, or to be held accountable for inaction by patients, activists and history books. As medical students, we have the ability to hold lawmakers accountable by calling and writing our elected officials, and communicating publically the cost of inaction.
-Matthew Basilico, Nworah Ayogu, Arjun Suri; Harvard Medical School
References
1. Deborah Donnell, Jared M Baeten, James Kiarie, Katherine K Thomas, Wendy Stevens, Craig R Cohen, James McIntyre, Jairam R Lingappa, Connie Celum, “Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis,” The Lancet 2010;375:2092-2098.
2. Reuben Granich, Siobhan Crowley, Marco Vitoria, Ying-Ru Lo, Yves Souteyrand, Christopher Dye, Charlie Gilks, Teguest Guerma, Kevin M De Cock, and Brian Williams “Highly active antiretroviral treatment for the prevention of HIV transmission,” Journal of International AIDS Society 2010; 13:1
3. Cohen MS, Chen YQ, McCauley M, et al. “Prevention of HIV-1 infection with early antiretroviral therapy.” New England Journal of Medicine 2011;365:493-505.
4. David Walton, Paul Farmer, Wesler Lambert, F. Léandre, Serena Koenig and Joia Mukherjee, “Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti,” Journal of Public Health Policy 2004:137-158.
5. World Health Organization, “An Assessment of Interactions Between Global Health Initiatives and Country Health Systems,” Lancet 2009;393:2137-2169.
