To acknowledge World AIDS Day, December 1, 2016, the Vanderbilt Institute for Global Health wishes to acknowledge the 78 million [UNAIDS estimated range of 69.5 million–87.6 million] people who have become infected with HIV through the end of 2015, reminiscing as to 35 million [29.6 million–40.8 million] people who have died from AIDS-related illnesses in this same time span. Personally, I have lost many patients, school and work colleagues, and close friends to this infection, and I remember them on this day with sadness, but with hope for the future.
Perhaps only pandemic influenza has come close in history to the devastating global impact of HIV/AIDS. HIV infection is mediated by human behavior; persons infected with HIV suffer considerable stigma and discrimination in most venues, and are in need of huge health resources to stay healthy and to reduce infectiousness to others. Happily, the global community, particularly the United States, has made major strides in funding a substantive programmatic response to the HIV pandemic. AIDS-related deaths have fallen by 45% since the peak in 2005, a direct result of these investments through PEPFAR, the Global Fund, and other activist initiatives. For example, in 2015, 1.1 million [UNAIDS estimated range 940 000–1.3 million] people died from AIDS-related causes worldwide, compared to 2 million [1.7 million–2.3 million] in 2005.
In the UNAIDS 2016 fact sheet, 2015 estimates suggest that US$19 billion were invested in the HIV response in low- and middle- income countries (LMICs) with 57% of this total coming from domestic budgets. Even as incidence has declined, prevalence has risen with more persons living with HIV. Hence, UNAIDS projects that US$26.2 billion will be required in 2020 and US$23.9 billion required in 2030. It seems improbable that the current funding climate in the US, UK, and other donor nations will commit to higher sums, but the need will exist nonetheless.
Hence, we need prevention NOW to turn off the flow of new cases into the overflowing clinical settings offering antiretroviral therapy. We also need efficiencies, respectful clinical care, and quality improvements in our clinical care settings. Discovery in the vaccine, cure, and diagnostic arenas can offer more tools for the future. Implementation science is essential for interventions that work, but are not adequately deployed, from male circumcision to the “continuum of HIV care.” We must not succumb to “AIDS fatigue” any more than experts in disease control and prevention of malaria, tuberculosis, cancer, or a myriad of historical or emerging infectious threats can afford to declare premature victory.
This World AIDS Day 2016, let us think how we can merge synergistic agendas, getting away from “siloed,” single disease responses. Can our HIV infrastructures in rural Africa be deployed more effectively to meet community needs in control of TB, parasitic diseases, or other chronic diseases? Might such deployment bring stronger government and local community support? Can the drumbeat announcing the ascendancy of non-communicable diseases in LMICs be combined with reality-based awareness that existing infectious disease threats remain? The temptation to continue business-as-usual in our vertical disease control campaigns invites inefficiencies and competition between legitimate health needs; we can integrate for efficiency to make a maximum footprint on health of LMICs. New political leadership around the globe may not have the historical perspective on the HIV pandemic; we must remind them.
Sten H. Vermund, MD, PhD
Vice President for Global Health
Director, Vanderbilt Institute for Global Health
Amos Christie Chair of Global Health
Professor of Pediatrics, Medicine, Preventive Medicine, Obstetrics and Gynecology