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The End of AIDS? What are you smoking?

Posted on by Laurie Garrett

The End of AIDS? What are you smoking?

For the first time in 22 years the International AIDS Conference is underway in the United States, and the dominant mood is strangely optimistic. On the activist side, it is summarized as “Keep the Promise,” to provide HIV treatment to 15 million people living outside the wealthy countries, by 2015. For the clinical and political leadership of the pandemic response the upbeat mood features declarations that we have turned the corner -- the end is in sight.

“What was unthinkable just three years ago, is now in sight – an AIDS Free Generation and the end of this epidemic,” Ambassador Mark Dybul, former head of the President’s Emergency Plan for AIDS Relief or PEPFAR, told the conference on Sunday. “Today, that must become our singular goal.”

So far I have spent 31 years of my life witnessing and writing about our 21st Century plague, and nothing could possibly bring me greater joy than to see the beginning of the end of the damnable Human Immunodeficiency Virus. But rhetoric aimed at drawing funding during a global recession will not make it so. Perhaps the chronic disease management of HIV patients using antiretroviral drugs (ARVs) has lulled the collective leadership in this pandemic into forgetting the most salient point: HIV is a new virus on planet Earth, only in wide human circulation for three decades, against which virtually no human being has effective natural immunity. Unlike plagues of the past, HIV struck humanity with such lethal force that until 1996 when treatment drugs became available the equation for nearly every infected person was: HIV=Death.

HIV is not a chronic disease. HIV is a virus. And any let-up in control efforts guarantees a resurgence of the disease. There is no end in sight for HIV until a fully effective vaccine is invented. There isn’t even an end in sight for the disease the virus causes, AIDS, until a cure is discovered.

But the rhetoric at this XIXth International AIDS Conference is wildly optimistic. In her address to the Conference Secretary of State Hillary Clinton recalled her November 2011 speech advocating an AIDS Free Generation: “Now since that time I’ve heard a few voices from people raising questions about America’s commitment…wondering whether we are really serious about achieving it,” Clinton said. “Well, I am here today to make it absolutely clear: The United States is committed and will remain committed to achieving an AIDS-free generation. We will not back off, we will not back down we will fight for the resources necessary to achieve this historic milestone.” Thunderous applause followed.

U.S Senator John Kerry (D-MA) told the story of Thomas Jefferson’s enthusiasm about 1770s vacuolization treatments to prevent smallpox, noting that the American Revolutionary forecast eradication of the disease. "We are at a similar crossroads today," with HIV, Kerry insisted, referring to eradication. "If we stay strong we will tear down the wall of AIDS.” (Kerry might do well to recall that Jefferson praised the crude vacuolization procedure in the 1770s; smallpox eradication was achieved 200 years later using vaccination, a different procedure. If Jefferson saw an end in sight for that disease, his vision extended out two centuries.)

And conservative Senator Lindsey Graham (R-SC) spoke to U.S. taxpayers from the Conference on Monday, invoking baseball metaphors: "Your money is being well spent. Now’s the time to pour it on…I do believe we today, with AIDS, [it] is a test of mankind in the 21st Century. Let it be said that those who had the opportunity to help stepped up to the plate and hit it out of the park.”

Most of the rhetoric is aimed at a different crowd here in Washington – not the conferees in the Convention Center, but Kerry and Graham’s fellow politicians a few blocks away on Capitol Hill. Amid sincere concern that members of Congress and the Senate are weary of the $6.6 billion taxpayer bill for these achievements, the leaders of the U.S. Global Health Initiative and its various agency pieces recognize the need to promise American politicians that there is an endgame, and their dollars will turn the tide of HIV. As Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases put it, “Congress says, ‘OK, we’re going to give you this money, but when are you going to fix the problem?’”

Statistics show that the global burden of HIV did, indeed, peak back in 2003, has plateaued globally since, and declined markedly in some countries. If we stay our current course both strategically and financially, the pandemic of HIV will hold steady at roughly 2.5 million new infections annually, the current tally of 34 million living with HIV will rise steadily, and though death tolls will fall thanks to treatment access, AIDS casket makers won’t go out of business for decades. In 2010 there were 1.8 million AIDS deaths in the world: all of our advances improved that incrementally in 2011, when 1.7 million succumbed to the disease.

If, however, available scientific tools are aggressively applied, world funding scales up to pay for them, and countries both rich and poor give their epidemics the sort of priority attention and political commitment they merit the numbers of new infections could be cut in half within three years – at an additional cost over current spending of about $7 billion.

But let’s be clear: The end of HIV is not in sight. Even if that $7 billion and political commitment can be conjured, and the best-available treatment and prevention tools are implemented, the world will still witness some 1 million new infections every year, well into the 2020s.The top scientist at the UN AIDS Programme, Dr. Bernhard Schwartlander, reckons some 22 million more people will be infected with HIV by 2020 if we stick with current funding and control practices: Bumping up to new strategies and spending will still add 11 to 12 million new HIV cases to the world, bringing the total number of people living with HIV/AIDS to something like 46 million. That’s a mass of humanity equal to the combined populations of the states of New York, New Jersey, Pennsylvania and Maryland.

“Is the end clearly in sight? No. Do we have the tools that will bring about the end? No,” philanthropist Bill Gates told Reuters this week.

The pandemic will not be over until the number of new infections hits zero, and the annual death toll plummets to insignificant levels.

It is dangerous to make promises that cannot be kept. We have seen the energy and momentum created by realistic aspirations, as well as the reverse – a sort of despairing paralysis that comes from crushed dreams and lost lives.

NEXT: The End of AIDS? The science says not now