Secretary Clinton: How Will We “Transition” to an AIDS-Free Generation?

Yesterday, Secretary Clinton made an eloquent and morale boosting speech in support of the United States' continued leadership in the global effort towards an “AIDS-free generation.” Her remarks demonstrated a clear focus on prevention as the way forward, highlighting recent advances in prevention of mother to child transmission (PMTCT), male circumcision (see here, here and here), the prevention effects of antiretroviral therapy for AIDS (ART), and the need to employ a “combination” approach for effective HIV prevention. And then she proudly touted the US administrations investment of more than $100 million in research to formally test the hypothesis around whether combination prevention works.

I think US’s $100 million spent on understanding combination HIV prevention-- which is matched by almost as much investment from the Bill and Melinda Gates Foundation and other partners-- is money well spent to show whether combination prevention can work. But here’s the rub, the prospect of eventually having an AIDS-free generation depends crucially on the outcome of these rigorous multi-year research projects that are just now being launched. And none of the current PEPFAR funded trials will be able to untangle the separate contributions of the several prevention interventions being combined (to do so would require more “arms” for each study, which would increase costs almost commensurately). The fact is, we don’t yet know whether any of them will succeed in lowering rates of new infection in the community as a whole. But we do know their costs will be exorbitant.What is lacking in the Secretary’s vision of an AIDS free generation is the intermediate goal of an “AIDS transition” that I describe in my new book (which will be launched at CGD on November 16). The objective suggested by Secretary Clinton of reducing the number of new infections to match the number of new people placed on treatment is sadly not sufficient, as the people living on AIDS treatment are dependent on daily medication and require expensive lifetime support. Instead, the number of new infections must fall below the number of AIDS deaths, while ART is sustained and expanded. A country that accomplishes this objective will have achieved what I call the “AIDS transition”.So how can the U.S. promote the AIDS transition? A solid, clearly defined multi-year US commitment is the fair and incentive-compatible framework upon which the US can plan its own future engagement and the recipient government can grapple with a well-defined unmet need. As Secretary Clinton pointed out, the US has for the first time made a multi-year commitment to the Global Fund for AIDS, TB and Malaria. This is commendable, but recipient African countries are extraordinarily vulnerable to the ups and downs of volatile foreign assistance disbursements and need reliable commitments even more than does the Global Fund. To each country where the US has already granted virtual “entitlements” to AIDS treatment, the administration should promise that it will sustain financing for those thousands of patients and expand treatment to X percent of those will need each year until the AIDS transition is reached. By specifying concretely the value of X, which is likely to be well below 100%, the US will be guaranteeing the minimum rate of treatment expansion, a minimum on which other donors and the recipient government can build.How should the specific percentage for expansion of treatment be decided upon for a given country? The US should use the recent trends in new infections and the cost of treatment to estimate how much will be required to finance the given percentage of new patients until the AIDs transition is reached. Then with an eye on its overall budget, the US should only promise to treat the percentage of need that it is willing to finance from now until the projected AIDS transition, a decade or more in the future. The US and the recipient government will then share the savings if costs go down even faster. And the US can also promise that evidence of a faster-than-anticipated decline in new infections over the next few years will be rewarded with an increase in the US-funded rate of treatment expansion.I’m glad that Secretary Clinton has taken the stage to proudly champion the US’ leadership role in AIDS. The fact that the US government has been able to continue to expand the numbers it supports on ART despite a flat budget for PEPFAR since 2008 is a tribute to the Obama administration’s leadership and to hard work by Ambassador Goosby and the PEPFAR staff. To effectively lead into the future, the US should clearly articulate its willingness to keep on expanding treatment, but not without limit. The promise of an AIDS free generation does indeed lie before us. In today’s budget environment, the only feasible path to that promise lies through the AIDS transition.