Getting to Zero: HIV by the numbers

• 25 million: number of deaths caused by HIV/AIDS since 1981
• 2.5 million: number of HIV-related deaths averted by antiretroviral treatment (ART) in low- and middle-income countries (LMICs) since 1995
• 34 million: number of people living with HIV worldwide at the end of 2010
• 3.4 million: number of children under 15 years living with HIV
• 68%: percentage of HIV-positive persons living in sub-Saharan Africa
• 2.7 million: number of new HIV infections worldwide in 2010, a 21% decrease from 1997
• 50%: worldwide percentage of HIV-infected persons who aware of their status
• 96%: reduction in sexual transmission of HIV between serodiscordant partners with antiretroviral therapy observed in the HPTN052 trial

• 61%: percentage of new HIV infections in the United States occurring among men who have sex with men (MSMs) as of 2009
• 44%: percentage of new HIV infections in the United States occurring among Blacks as of 2009
• 2%: Adult HIV prevalence in Baltimore city in 2009; adult HIV prevalence in Haiti in 2009
• 5%: Adult HIV prevalence in Baltimore zip code 21205, directly northeast of the Johns Hopkins medical campus, in 2009; adult HIV prevalence in Gabon in 2009
• 37.5%: HIV prevalence among MSMs in Baltimore city; the proportion of new HIV infections among MSMs in Baltimore has increased to nearly the same levels as in 1985
• 76.9%: percentage of HIV-infected MSMs in Baltimore city who are unaware of their status
• 312: Median CD4 count at HIV diagnosis in the Baltimore-Towson metropolitan area (current guidelines recommend initiating ART at CD4 counts 350-500)
• 6,411: Number of HIV-positive people in the United States currently on AIDS drugs assistance program (ADAP) waiting lists

• 6.65 million: number of HIV-infected people currently receiving ART in low- and middle-income countries
• 3.3 million: number of people currently receiving ART through Global Fund grants
• $2.2 billion: unfulfilled pledges to the Global Fund to fight AIDS, TB and Malaria
• 2: number of countries (USA and UK) that have honored their pledges to the Global Fund

• ZERO: number of new grants that will be awarded by the Global Fund for the next two years in response to budget shortfall; UNAIDS goal by 2015 (0 new infections, 0 discrimination, 0 AIDS-related deaths)

Setbacks on the HIV front: A case for sustainability, capacity building, and a comprehensive approach to global health

Once touted as a shining example in the battle against HIV in Africa, Uganda was featured two days ago as the first–but not the last–example of “how the war on global AIDS is falling apart” in a New York Times series highlighting the shortfall in funding, the US’s (diminishing?) contributions, the failures of scientific efforts to develop vaccines and microbicides, and the behavioral/cultural factors that make it so difficult to control the spread of HIV.

Although Uganda had once managed to decrease its HIV incidence rates, it appears that new infections are on the rise again, caused in part by a recrudescence of unprotected sex due to enduring social patterns of transactional sex, poor education,  and a general lack of female empowerment, among other issues. This is particularly problematic at a time when funding is drying up due not only to Wall Street’s shenanigans but also to donor fatigue. As the article reports, hope soared in the last decade as efforts by MSF, the Clinton Foundation and others led to dramatic falls in the prices of drugs, presenting a tremendous opportunity for international donors to make an impact by making available  the life-extending drugs that hade been available for years in developed countries but remained out of reach for the vast majority of HIV patients.

This “golden window” is now closed; some of the funding initiatives and grants that helped to open clinics  are coming to an end, and no new money is coming in to increase the availability of treatment, at least not at the pace needed to seriously curb the epidemic. The result? HIV patients in Uganda are now being turned away from clinics. There is justified fear that this “Kampala situation” will only spread to other countries and set us back to where we were in the 90s, when so many died without any hope for treatment. This is particularly alarming in the case of the HIV epidemic, with success being heavily dependent on not only maintaining already existing treatment slots but also increasing treatment availability rapidly. The situation is alarming, but I hope that the alarm bells will lead not to panic but rather to a serious examination of the mistakes that have been made and a reformulation of how we practice global health.

The soft power of global health diplomacy

We think a lot about global health diplomacy from the U.S. or western European perspective — foreign aid, development, and so on. Much of the international health movement has been structured along these lines: top-down interventions created in Geneva, formalized as WHO (and other) guidelines, and implemented by clusters of dedicated professionals. On the other hand, grassroots organizations work with community leaders and health workers in developing countries to build upward. And then there are those renegade MSF people, who get in there and provide the sheer grit, skill, and manpower to save lives, day to day, through wars and natural disasters. All of this has led to some amazing outcomes.

Why, then, this lingering sense that global health efforts represent a black hole of time and money? Foreign aid is never quite enough, workforce restructuring never fully realized (“brain drain”, I would argue, often takes an unfair share of the blame for this; yes, it’s a problem, but aren’t there others?), and a significant portion of the world’s population remains without access to basic nutritional and medical care.