Lancet opinion piece examines progress made against HIV/AIDS

"Nearly 30 years into the AIDS epidemic, we are able to access our progress in tackling the disease with both increased knowledge and the benefit of hindsight," former UNAIDS Executive Director Peter Piot of Imperial College London, who also serves as an adviser on global health strategy to the Bill & Melinda Gates Foundation; Michel Kazatchkine, executive director of the Global Fund To Fight AIDS, Tuberculosis and Malaria; Mark Dybul of the O'Neill Institute for National and Global Health Law at Georgetown University and former U.S. Global AIDS Coordinator; and Julian Lob-Levyt of the GAVI Alliance write in a Lancet opinion piece.

They add that the piece aims to examine "what we -- the international community -- got right, what we got wrong, and why we need to urgently dispel several emerging myths about the epidemic and the global response to it."

According to the authors, when "HIV was emerging in the early 1980s, we clearly underestimated the global effect that the disease would have, and that in only a few decades, tens of millions of people worldwide would become infected." They add, "The epidemic nowadays is the result of what 30 years ago was an unpredictable -- but tremendously potent -- combination of intimate personal behaviors ... and socioeconomic factors ... that have affected nearly every country worldwide." In addition, the international community underestimated "the extent to which stigma and discrimination -- against people living with HIV/AIDS and those most vulnerable to it -- would remain formidable obstacles to tackling AIDS," the authors write, adding that the "sense of urgency and solidarity that would eventually develop in the global AIDS epidemic, leading to an unusual convergence of political will, money and science" also was underestimated.

Other aspects of the HIV/AIDS pandemic were overestimated, the authors write. They add that despite innovations and successes regarding antiretroviral treatment, "we have also overestimated our capacity to devise technological solutions to prevent HIV," and "continued investments in new prevention technology remain a crucial part of the AIDS research agenda."

The author's point to the common myth that HIV prevention has not been successful overall -- which they say is contradicted by evidence it has been effective in several countries, adding that prevention is about behavior in addition to technology. They add that sustaining changes in sexual behavior "remains a major challenge," citing the possible "complacency about AIDS and the sense that a treatable disease is somehow less threatening than are other diseases."

There is also a "recurrent" myth that there is one "silver-bullet" solution to HIV prevention; however, "no approach will be enough on its own, and the promotion of one solution is ... irresponsible," the authors write. They continue that another "prevailing" myth is that there is little heterosexual transmission of HIV outside Africa and note that HIV transmission among women is rising worldwide, with "[m]ethods of transmission and affected groups" being "many and varied."

The authors write, "Alarmingly, a myth has begun to emerge that too much money is spent on AIDS," as countries face new financial difficulties while "competing for the attention of political leaders and donors." The myth that investments in AIDS efforts have been at the expense of underfunded health systems also needs to be dispelled, the authors write, adding that funds for HIV/AIDS efforts "are making a major contribution to the strengthening of health systems." The authors also address the myth that HIV/AIDS "has somehow been solved, writing, "We need to recognize that AIDS is a long-term event. Tackling it is complex, but our successes so far indicate what is possible." Increased efforts to examine epidemiological trends, "develop long lasting links with broader efforts to strengthen health systems and health workforces," continue investment in research, and make a "serious, concerted effort" to address stigma and discrimination are needed to "be anywhere close to the point at which we can truthfully say the fight against AIDS is being won" (Piot et. al, Lancet, 3/20).