End of AIDS--hype versus hope.

[Special section on HIV][1] Since 2001, HIV incidence has declined by 33% worldwide, and more than 9.7 million people with HIV have gained access to treatment.[*][2] The Joint United Nations Programme on HIV/AIDS launched the Getting to Zero strategy (2011–2015) that includes zero new infections, zero deaths from HIV, and zero discrimination. Aspirational statements such as “the end of AIDS” have also prevailed. However, do such pronouncements help or hurt? Do they motivate action, or do they risk incredulity, leading to inaction? Do such aspirations epitomize hype or hope? The history of public health is replete with aspirational campaigns, with varying success. In 1971, the United States launched a “war on cancer,” increasing funding for cancer research. Although great progress has been made in our understanding, diagnosis, and management of cancer, this war has not yet been won. With a few exceptions, cures are rare, disparities in cancer outcomes remain, and investments in research are in question. On the other hand, despite skepticism about eradicating smallpox, the World Health Organization began a campaign in 1958 that focused on vaccination, surveillance, and containment. Twenty years later, smallpox was successfully eradicated. As for HIV, there are certainly reasons to be optimistic. Many countries with high HIV prevalence have scaled up programs for preventing mother-to-child transmission, and new pediatric infections are rare in several countries. Changes in therapy include earlier initiation of antiretroviral therapy (ART) and the treatment of pregnant HIV-infected women for life. These approaches have the potential to provide individual benefit to those living with HIV and prevent further HIV transmission. Additionally, new investments in health systems offer a foundation on which prevention and treatment services can be expanded further. However, implying imminent success may be perceived as minimizing the challenges that remain, resulting in the withdrawal of resources and a consequent resurgence of the presumed “controlled” disease. This risk is particularly relevant, because HIV expenditures are currently well short of the annual global target of U.S. $22 billion to $24 billion. Donor complacency would have catastrophic consequences. ![][3] “a world without epidemic AIDS…Let this be the rallying call.” PHOTO: AFP/GETTY IMAGES/ADEK BERRY Historically, some earlier optimistic predictions related to HIV have not met with success. These include the announcement in 1984 that an AIDS vaccine was forthcoming and early hope that ART would eradicate HIV infection. The potential of ART to control the HIV epidemic through a “test and treat” approach faces stark realities. Only 33.6% of women and 17.2% of men in low- and middle-income countries, and 34% of those eligible for treatment, have access to it,[†][4] and gaps in the HIV care continuum limit the potential of such an approach. Additionally, although overall incidence has declined, new infection rates among people who inject drugs, men who have sex with men, and young women in southern Africa are alarming. Several high-burden countries lag behind in expanding programs for preventing mother-to-child transmission, and the uptake of other prevention methods remains limited. Disappointingly, progress toward an efficacious vaccine—a critically needed intervention—has faltered, and although there is intense interest in finding a cure, scalable interventions are far from reality. Why then have some scientists and advocates trumpeted the goal of an “end of AIDS”? We perceive that they are haunted by the fear of donor fatigue and a loss of momentum in the face of recognized challenges. However, despite these concerns, we believe that with concerted efforts and sustained commitments, we can make substantial advances toward the hope of a world in which AIDS is no longer an epidemic threat. The campaign against smallpox offers important lessons learned on how it is possible to maintain efforts despite many naysayers. Envisioning a world without epidemic AIDS is a deeply profound concept. Let this be the rallying call. [1]: http://www.sciencemag.org/site/special/hiv2014/index.xhtml [2]: #fn-1 [3]: /embed/graphic-1.gif [4]: #fn-2