The next 25 years

Abstract

When I first joined the Editorial Board on AIDS, I assumed that the journal would have a relatively short life, as with so many others. I implicitly thought that this new epidemic would be a matter of at the most a couple of decades, and that the end was already in sight (as we hear again today). Thirty years into the epidemic, it is clear I was wrong. Following the discovery of HIV as the cause of AIDS, there was great optimism that a vaccine would become available that optimism was reinforced by the discovery of ‘highly active antiretroviral therapy’ in 1996, opening perspectives of eliminating HIV. The global response was – rightly – framed as an emergency response (the E in PEPFAR). Thanks to unprecedented global solidarity and strong national and community mobilization, HIV incidence and HIV-related mortality are declining, with the notable exceptions of the former Soviet republics and old and new epidemics in MSM. The demonstration that early antiretroviral treatment is highly effective in reducing HIV transmission in discordant couples has led to renewed optimism that the end of AIDS is in sight, and that HIV, according to some models, can even be eliminated in the foreseeable future. It is true that never before in the history of AIDS have so many effective interventions been available. However, there are still enormous gaps between efficacy and real-world effectiveness of these interventions – between coverage of interventions in key populations at highest risk and the desirable coverage rates, and between available and needed funding – with actually a serious decline in financing of the AIDS response since 2010. Even if all these issues are addressed adequately and immediately, we need to adapt our strategies to confront a protracted epidemic. HIV has become endemic with continuing low-intensity to high-intensity transmission in many populations, a highly effective vaccine is years away, a cure enabling elimination of the virus reservoir does not appear realistic on the short-term horizon, the underlying societal drivers of HIV spread have not diminished, and stigma, weak systems and civil unrest and wars are formidable obstacles to achieve the high coverage of interventions needed to stop the epidemic. In addition, growing AIDS fatigue and declining political leadership on AIDS has endangered long-term financing of the AIDS response. With a game-changing and affordable scientific breakthrough still pending, the reality is that HIV infection will be with us for decades, if not generations – albeit most probably at much lower levels than today. This implies that we need to take a long-term view of our response to the epidemic while addressing the continuing HIV crises. The aids2031 consortium [1] recommended a series of changes in approaches to the AIDS response in order to address its long-term needs. These included: multiyear financial commitments from both high-income and affected countries, focusing prevention efforts on populations and settings at highest risk, investing more in programme evaluation, sustaining AIDS research, getting serious about capacity strengthening, seeking synergies with other programmes for service delivery, and optimizing antiretroviral treatment to increase coverage, reduce costs, and avoid development of antiretroviral resistance. Some of these recommendations are being introduced nationally and internationally, whereas others will require some fundamental institutional behaviour change. I am not a pessimist, and believe that we have the ability to intensify the real achievements of the last decade. However, an exclusive emergency response against AIDS seems counterproductive, as it may become an obstacle to a sustainable response, which should ultimately stop this pandemic. Acknowledgements Conflicts of interest There are no conflict of interest.