Secretary of State Hillary Rodham Clinton visited the NIH today to give a major speech, in which she presented a new vision for the fight against HIV/AIDS. Her words tied in with upcoming December 1st Federal World AIDS Day activities and served to promote the upcoming 2012 International AIDS Conference, happening in Washington, DC this July.
In two noteworthy nods to the LGBT community, Clinton made the surprise announcement that Ellen Degeneres will serve as US State Department's New Special Envoy for Global AIDS Awareness; and later she mentioned that we will only make effective progress against HIV stigma by "repealing laws" that criminalize and discriminate against people "based on their sexual orientation."
The overarching theme of her vision was that of an "AIDS Free Generation." To achieve this goal, Clinton charged the international community to join the US government in seizing this pivotal opportunity to turn the tide in the global HIV pandemic by redoubling our efforts and funding of HIV treatment and prevention programs, focusing on a combination of evidence-based interventions that will gain the most ground. In particular, Clinton mentioned three top priorities:
- Reduce mother-to-child-transmission rates to "zero" (not "virtually zero," as Clinton remarked her speech writer suggested she say).
- Scale up rates of voluntary medical male circumcision.
- Scale up global provision of HIV anti-retroviral treatment.
Thankfully, she also underscored the importance of continuing support of other (very effective and far less costly) modes of prevention, including use of condoms, microbicides, and regular HIV testing in concert with these larger efforts. I often worry that in the ongoing battle among HIV/AIDS advocates over the supremacy of the HIV prevention versus the HIV treatment strategy, a battle that Clinton claimed should now be settled, we've forgotten that tried and true modes of prevention from decades past are still effective and must remain in our armamentarium. Yes, HIV treatment is effective in lowering viral loads and by extension preventing future infections. And yes, it appears that in the long-term it is cost effective to supply drugs globally to offset tremendous economic costs otherwise shouldered by countries ravaged by HIV/AIDS. However, the promising data we're getting about many new treatment-based interventions still should not trump or overshadow other, equally effective "prevention-as-prevention" modalities (e.g. condoms and good ol' education).
Clinton was quick to acknowledge the misgivings that many may have about a more treatment-focused approach to this strategy, and did well to emphasize that older, evidence-based approaches will continue to be funded along side the need for ongoing counseling. She used this opportunity to to make well-justified jab at the Right's ongoing War on Science, saying that although many in Washington still believe we live in an "evidence free zone," following science and reason is the only way we'll ever win the fight against HIV/AIDS.
Her comments about using multiple evidence-based approaches highlighted the important concept of finding the optimal mix or combination of HIV interventions to reduce new rates of infection. Already mathematical models of the combination strategy she proposed demonstrate a theoretical reduction of new rates of infection by 40-60% over a relatively rapid timeframe. Moreover, she announced that an additional $60 million of PEPFAR money is to be invested in four African countries to further study the impact of combination HIV intervention strategies to better refine our efforts moving forward. As such, she has called on other nations to now join the US in this effort to further improve our global strategy.
The top three focus strategies are good ones. Modes of reducing mother-to-child-transmission prevented an estimated 114,000 new infections last year from PEPFAR funds alone. And yet, currently 1 in 7 new infections globally continue to occur through this vertical route of infection. So there's certainly a real opportunity for large gains yet to be made on this front.
As for circumcision, since 2007 more than 1 million men have received voluntary circumcisions for prevention of HIV transmission, three quarters of which were funded by PEPFAR. This intervention is known to reduce rates of HIV infection by as high as 44% in circumcised men.
Finally, it is true that treatment is prevention, and that the cost of providing one individual anti-retroviral drugs in Africa has dramatically decreased from an average of $1100/year in 2004 to about $300-400/year today. This is encouraging news, especially for proposed expansion of funds for international anti-retroviral provisions; but I'm certainly for reducing our reliance on medication as much as possible, if we are truly to have a future generation free of AIDS.
Moving forward, Clinton said that there will be increased transparency of multinational organizations, such as the Global Fund, to weed out corruption and fraud. Moreover, countries receiving aid will be expected to ante-up, with more limitations placed on governments using their domestic funds, otherwise appropriated for public health, for other projects, offset by incoming international aid.
Clinton's speech marked an exciting recommitment to the global fight against HIV/AIDS, drawing from the recent move towards more unified strategies to fight this pandemic, as reflected by the National HIV/AIDS Strategy. Above all, these strategies aim to focus our efforts and have us succeed where we have too often failed before: in working together, despite the tendency for HIV/AIDS to divide us.