U.S. Secretary of State Hillary Clinton today declared that recent scientific advances in HIV/AIDS have created a "historic opportunity" to change the course of the pandemic and usher in a generation where no children are born with the virus, the risk of becoming infected plummets for teens and adults, and those who do become infected receive drugs that both ward off disease and make them less infectious. "Creating an AIDS-free generation has never been a policy priority for the United States government until today because this goal would have been unimaginable just a few years ago," Clinton told a packed auditorium at the U.S. National Institutes of Health in Bethesda, Maryland.
This new tack, which Clinton repeatedly acknowledged was "ambitious," grows out of several recent scientific advances, including evidence revealed in May that starting antiretroviral (ARV) treatment long before someone becomes ill from HIV can cut the risk of infected people spreading the virus to their long-term partners by 96%. In addition to this so-called treatment as prevention, she noted that trials of male circumcision have shown that it can cut the risk of transmission by 60% or more. "The finish line is not yet in sight, but we know we can get there because now we know the route we need to take," said Clinton. "It requires all of us to put a variety of scientifically proven prevention tools to work in concert with each other."
Clinton did not commit significant new money to ramping up treatment as prevention, male circumcision, or prevention of mother-to-child transmission programs. Instead, she said "no institution in the world has done more than the United States government" in the fight against HIV/AIDS, and she positioned the Obama Administration as taking the lead in the push to change the trajectory of the epidemic. "The world could not have come this far without us and it will not defeat AIDS without us," said Clinton.
The audience gave Clinton several standing ovations, and policy leaders, HIV/AIDS advocates, and nongovernmental organizations that focus on the epidemic praised what several called her "bold" vision about applying recent prevention advances. "For the first time we have a political leader taking the scientific evidence and putting it out there that we can use it to save lives," said Michel Sidibé, head of the Joint United Nations Programme on HIV/AIDS. Mitchell Warren, head of the AIDS Vaccine Advocacy Coalition based in New York City, noted that the timing of the speech was key, too, as World AIDS Day is coming up on 1 December and the next international AIDS conference will take place in Washington, D.C., in July 2012. "This is putting a stake in the ground that says U.S. policy is committed to ending the epidemic," says Warren. "That's a huge statement."
After noting the U.S. government has made major investments in scientific research, the President's Emergency Program for AIDS Relief (PEPFAR), and the Global Fund to Fight AIDS, Tuberculosis and Malaria, Clinton pointedly called on other countries to do more. She chided some donors who were considering reducing contributions, and well-off countries that currently give nothing. "Some emerging powers and nations that are rich in natural resources can afford to give but choose not to," said Clinton. She also called on countries that receive help to do more, both in funding and leadership, to address their epidemics. "Some countries have allowed money from outside donors to displace their own investments in health programs," Clinton said. "That has to change and we have to demand that it changes."
Clinton made no mention of using ARVs in uninfected people to protect them from the virus. Large-scale trials of this so-called pre-exposure prophylaxis, or PrEP, in the past year found that it could thwart transmission via anal sex by 44% and vaginal sex by 73%. But debate continues about whether to use PrEP in resource-constrained countries that still do not offer ARVs to HIV-infected people who are critically in need of treatment. Eric Goosby stresses that the PEPFAR program, which he heads, plans to soon use PrEP. "She was trying to highlight those interventions that have a big impact on dropping incidence," said Goosby. "PrEP will be used for high-risk populations. It won't be used for generalized epidemics."
Clinton said figuring out which combinations of proven prevention strategies will work best in a given locale will require more research, noting that the U.S. government recently has invested $50 million on clinical trials to address these questions. She announced that PEPFAR will also receive $60 million in new funding to scale up combination prevention in parts of four countries in sub-Saharan Africa. "To sit on the sidelines now would be devastating," said Clinton.
PEPFAR head Goosby says Clinton's speech is the first of many to come on the topic from the Obama Administration. "The leadership role that United States has placed on HIV/AIDS will continue to increase, and specifically to look, even in times of economic severity, at how we can increase our impact," says Goosby. "It really is time to say the opportunity's here, we need to do it differently, are you willing, world, to get to the table and do it differently. We are very much interested in that dialog."