Let's not jeopardize 30 years of AIDS progress

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As chronicled in the latest issue of Health Affairs, much of this progress has been made – and the lives of millions of people saved – because of PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief. The largest ever global investment in health by the United States government – and the largest ever made in HIV/AIDS by any one country – PEPFAR has provided treatment to 4 million people and care to 13 million more, mostly in the hardest-hit countries.
 
PEPFAR has recently set aggressive new goals. By 2013, PEPFAR aims to provide antiretroviral drugs to 6 million people in low- and middle-income countries, tripling the number who received them in the first five years of the program. This bold treatment goal falls short of an even higher goal to treat 15 million people overall by 2015, set by the UN General Assembly last year. PEPFAR also seeks to fund 4.7 million male circumcisions and provide antiretroviral therapy to 1.5 million HIV-infected pregnant women by 2013. We need to ask: Are we setting ambitious goals that we’re not prepared to fund or meet? Are we setting up one of our country’s greatest successes for failure?
 
PEPFAR funding has flatlined despite these new targets and is not nearly enough to maintain progress and continue reducing new HIV/AIDS cases and deaths. In 2008, Congressional appropriations for PEPFAR rose from roughly $6 billion to $6.9 billion in 2010 – and have since dropped to $6.6 billion in 2012. These trends are worrisome when estimates show that the world will require up to an additional $6 billion a year to reach the global targets.
 
There is great uncertainty right now about ongoing commitment by Congress to the HIV/AIDS epidemic and to global health in general. The forthcoming U.S. presidential election creates an extra layer of uncertainty. More funding and strong political will are needed to meet the goals that we and the world have set for ourselves. Now is not the time to retreat from the bipartisan support of a program that has enabled us to move closer to an AIDS-free generation.
 
PEPFAR itself also needs to continue to adjust its priorities. It must focus on strengthening local leadership, public-private partnerships and building up of health systems so countries can better address their own challenges and take ownership of their programs. PEPFAR must also strongly support prevention measures – such as preventing mothers from passing HIV to their children, condom use and male circumcision – and not just on treatment. These effective prevention interventions are sometimes the most costly.
 
For the first time in 22 years – thanks to removal of entry restrictions into our country by the Obama administration – the international AIDS conference will be held in the United States. We will hear from political and scientific leaders that we can now prevent needless AIDS deaths. But treatment, prevention, care, health system capacity and scientific research to develop an HIV vaccine require financial commitment, strong political will and investment in resources from all stakeholders. Let us not fall behind now and bring back the suffering of the past. Let us not jeopardize the great progress we have made over 30 years against one of the world’s greatest threats to health and well-being.

Dr. Merson led the World Health Organization’s first Global Program on AIDS from 1990-1995. Currently he is the founding director of the Duke Global Health Institute, Vice President and Vice Provost for the Office of Global Strategy and Programs, and Vice Chancellor for Duke-National University of Singapore Affairs at Duke University. Merson is a graduate of Amherst College and the State University of New York, Downstate Medical Center. In 1995, Merson was appointed the first Dean of Public Health at Yale University and in 2001 became director of the Yale Center for Interdisciplinary Research on AIDS. He is senior editor of Global Health: Disease, Programs, Systems, and Policies, a leading global health textbook. He has advised UNAIDS, WHO, Global Fund to Fight AIDS, Tuberculosis and Malaria, World Bank, Doris Duke Foundation, and the Bill and Melinda Gates Foundation.