Hillary Clinton reveals blueprint for reaching 'Aids-free generation'

Hillary Clinton (Getty Images)

The world can control the AIDS epidemic in the next four years and set it on a trajectory to become a small, if permanent, problem, according to a State Department document.

An "AIDS-free generation" — a goal that Secretary of State Hillary Rodham Clinton touted a year ago — could be reached by starting more infected people on AIDS drugs, circumcising men in high-prevalence countries and making sure that every HIV-positive pregnant woman is treated.

Done in concert, the strategy could reduce the number of new HIV infections each year to below the number of people with the infection who are put on life-extending AIDS drugs. That is an important "tipping point" that would allow the epidemic to start burning itself out.

"An AIDS-free generation will be within our sight," Clinton said as she described the 54-page document that models various ways to quell the 30-year-old epidemic. But she warned: "Now we have to deliver. . . . The history of global health is littered with grand plans that never panned out."

The document, however, contains no specific targets or a schedule for achieving them. It also doesn't estimate how much more money it would cost to reach the "tipping point" in high-prevalence countries, and where the money would come from.

The document is called "PEPFAR Blueprint: Creating an AIDS-Free Generation." PEPFAR stands for the President's Emergency Plan for AIDS Relief, a program that President George W. Bush started in 2003 that today spends $6.6 billion a year to battle AIDS in more than 35 countries.

Foreign donors such as PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria, headquartered in Geneva, provide half the money spent on AIDS in the developing world. (The other half comes from the countries themselves.) The most visible activity is the provision of antiretroviral therapy to infected people.

PEPFAR now provides AIDS drugs to 5.1 million and the Global Fund has provided them to 4.2 million since its inception in 2002. Both programs do many other things, as well.

Clinton coined the term "AIDS-free generation" in a speech last November. At the 19th International AIDS Conference in July, where she was greeted like a conquering hero, she promised to have a roadmap ready by World AIDS Day, which is Dec. 1.

Sharing the lectern in the State Department's Benjamin Franklin Room with four other speakers, three of them African, Clinton was effusively praised for her support of PEPFAR, which is run by the State Department. Several noted her advocacy of women's rights and girls' education; women account for 58 percent of Africans living with HIV.

"You will be remembered certainly as a person who has been working to change the face of this world," Michel Sidibe, director of UNAIDS and a native of Mali, told Clinton, who has said that she will leave her job soon. "We know that you will not drop the ball. You will continue, because we need you."

In many high-prevalence countries, the number of people becoming infected with HIV each year exceeds the number starting antiretroviral therapy — a state that will lead to continued growth of the epidemic.

For example, in the Democratic Republic of Congo, 4.9 people become infected for every one infected person starting therapy. In Nigeria, the ratio is 4.8 to 1; in Tanzania, it's 3.8 to 1; and in Rwanda, 2.1 to 1. In a few countries, the tipping point has been reached. The ratio is 0.5 to 1 in the tiny southern African nation of Botswana, and 0.4 to 1 in nearby Zimbabwe.

"We've never had a metric like that," said Paul Zeitz, a physician who heads the global AIDS advocacy group Act V. "It gives us a sense of the countries that are on track or off track for achieving this goal."

Chris Collins, a vice president of the AIDS research foundation amfAR, said the blueprint "changes the conversation from hopefulness to the practical next steps we have to take."

There's been a big push in the past decade to bring antiretroviral therapy to HIV-infected people in the developing world. There are now about 8 million on treatment, which is slightly more than half the people who need it.

The trend has accelerated in recent years, with a 63 percent increase in treated patients between 2009 and 2011. That, along with other methods of prevention, has led to a 50 percent or greater drop in new infections in 25 countries over the past decade. Nevertheless, in many places the epidemic continues to grow, albeit more slowly than it once did.

The blueprint depends on prevention methods whose effects have been measured.

The most important is antiretroviral therapy itself. A study last year showed that treating an infected person reduces his or her chance of transmitting the virus through sexual contact by 96 percent. When HIV-positive pregnant women take antiretroviral drugs, fewer than 5 percent of their babies become infected. Circumcision reduces a man's chances of acquiring HIV sexually by about 60 percent.

"We see a kind of a synergy with all of them together that we don't see with any of them alone," said Eric P. Goosby, a physician who heads PEPFAR.

The document shows how the incidence of AIDS will change in four countries — Cambodia, Kenya, Uganda and Zambia — under three scenarios.

One is the current trend of treatment and prevention. The second is increasing treatment coverage to 80 percent in people with relatively advanced infection, as defined by a CD4-cell count of 350 or less. The third scenario is bringing that same treatment coverage to people in an earlier stage of infection (CD4-cell count below 550), which is the standard in high-income countries.

The graphs in the blueprint show a downward trend in incidence with the second and third scenarios — and more steeply with the third.