Toward an AIDS-Free Generation
Authors: Anthony S. Fauci, Gregory K. Folkers
Journal: JAMA (2012)

SINCE THE FIRST CASES OF WHAT IS NOW KNOWN AS AIDS were reported in 1981, an entire generation has grown up under the constant cloud of this modern-day plague. Across the globe, more than 34 million people are living with the human immunodeficiency virus (HIV), the virus that causes AIDS, including approximately 1.2 million individuals in the United States. HIV/AIDS has been responsible for the deaths of an estimated 30 million individuals. Although the rate of new HIV infections has declined or stabilized in many countries, the disease continues to exact an enormous toll: 1.8 million deaths in 2010 alone, grief and hardship for countless families and communities, and deleterious economic effects as those in the prime of life who lack timely access to treatment are lost to parenting and the workforce. Depending on the region of the world, many die with little or no access to medical care, while others require and receive expensive medical and endof-life care. Despite these daunting statistics, the fight against HIV/AIDS is currently viewed with considerably more optimism than in years past because powerful interventions have been developed, scientifically proven effective, and refined. If these tools are made widely available to those who need them, an AIDS-free generation may be possible—that is, today’s children could one day live in a world in which HIV infections and deaths from AIDS are rare. Foremost among these interventions is combination antiretroviral therapy, which significantly improves the health and longevity of individuals infected with HIV. Since the advent of antiretroviral therapy, the annual number of deaths due to AIDS has decreased by two-thirds in the United States. Globally, an estimated 700 000 lives were saved in 2010 alone due to the increased availability of antiretroviral therapy in lowand middle-income countries. Important challenges remain—notably finding the resources and developing the infrastructure to provide antiretroviral therapy to the estimated 8 million individuals with HIV infection who need these drugs but are not receiving them. Moreover, in wealthy and lower-income countries, only a minor proportion of those with HIV can navigate the entire HIV care cascade, from testing and diagnosis to accessing and being retained in care, starting antiretroviral therapy at the appropriate time, and then adhering to prescribed regimens to adequately suppress the viral load. Resources and innovative strategies are essential to find, test, and counsel those with HIV infection; help them remain in care; and derive the maximal benefit from antiretroviral therapy and other HIV/AIDS– related services. Importantly, antiretroviral therapy can also prevent HIV infection by reducing the amount of virus in an infected person’s blood and other body fluids such as genital secretions, making it less likely that the virus will be transmitted to others. A pivotal clinical trial known as HPTN 052 demonstrated that when providing antiretroviral therapy to the infected partner in HIV-discordant heterosexual couples early in the course of disease, the risk of HIV transmission to uninfected partners is significantly reduced when compared with deferring therapy until the disease was more advanced. Modeling data and studies in communities in which antiretroviral therapy is widely available suggest that scaling up antiretroviral therapy for HIV-infected individuals likely will substantially reduce the incidence of HIV infection. Thus, it is imperative to strive for universal access to antiretroviral therapy, both to benefit individuals with HIV infection and to reduce the risk of their sexual partners becoming infected. Antiretroviral therapy also is highly effective in blocking mother-to-child HIV transmission and helped prevent more than 350 000 infant infections worldwide from 20052010. Still, 390 000 infants were infected with HIV in 2010. Clearly, efforts to test, counsel, and provide effective antiretroviral therapy regimens to pregnant women with HIV infection must be enhanced to benefit their health as well as that of their infants. Moreover, reducing HIV infections among reproductive-age women and meeting their family planning needs is essential to eliminate mother-to-child transmission of HIV altogether. In addition to medical and societal interventions, voluntary medical male circumcision—a simple surgical procedure—offers a highly effective and durable way to protect heterosexual men from HIV infection. In 3 large-scale studies conducted in Africa, this 1-time intervention reduced the risk of a man acquiring HIV