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JAIDS Journal of Acquired Immune Deficiency Syndromes:
doi: 10.1097/QAI.0b013e31826028d5
Introduction

Engaging to End the Epidemic: Seven Essential Steps Toward an AIDS-Free Generation

Marlink, Richard MD*,†; El-Sadr, Wafaa MD, MPH, MPA‡,§,‖; Simao, Mariangela MSc, MD; Katabira, Elly MD, FRCP#,**

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Author Information

*Harvard School of Public Health

Medical and Scientific Affairs, Elizabeth Glaser Pediatric AIDS Foundation

Mailman School of Public Health and College of Physicians and Surgeons, Columbia University

§International Center for AIDS Care and Treatment (ICAP)

Harlem Hospital Center, New York, NY

Rights, Gender and Community Mobilization Department, UNAIDS Secretariat

#International AIDS Society

**Makerere University College of Health Sciences, Kampala, Uganda

Over the past three decades, nearly 30 million people have lost their lives to AIDS and the epidemic has transformed communities around the world. Today, an estimated 34 million people are living with HIV. The number of people affected leaves no doubt: AIDS remains an urgent global health crisis.

Despite these sobering facts, recent advancements have provided unprecedented hope for an end to the epidemic. A rapid scale-up of antiretroviral therapy and prevention efforts has saved millions of lives. In many of the hardest-hit countries, in certain settings, the rate of new infections is decreasing. The number of AIDS-related deaths is also on a consistent downward slope. Most notably, new research has definitively shown that antiretroviral therapy can prevent new infections. These historic developments, along with many local and national achievements, have changed the global conversation about the epidemic.

The end of AIDS is within our reach. The question that remains is how will we get there.

New investments–and renewed commitments–from countries around the world will be critical to fully implement proven treatment and prevention tools already at hand and to continue essential scientific research. Only then will an AIDS-free generation be possible.

Are we willing to pay the price to turn the dream into a reality?

Several hundred leaders from the front lines of the global AIDS response gathered at Harvard University on World AIDS Day 2011 to begin to answer that question. During the two-day symposium, AIDS@30: Engaging to End the Epidemic, attendees and session leaders began a rigorous dialogue about what we have learned from AIDS and how to create a viable plan to halt the epidemic. “The AIDS@30 initiative provided an opportunity to pause and reflect about what AIDS has meant for the world,” explained Harvard School of Public Health Dean Julio Frenk. “It also provided a chance to use those reflections to chart a path toward the future.”

The conversation continues in this special supplement.

In the articles that follow, key symposium leaders address seven core topics at the heart of the future global AIDS response—areas that must be addressed if we are to close the book on the epidemic. Examining emerging questions, the authors offer solutions specific to their fields of research or advocacy while also illuminating common challenges and often-interconnected questions. In this multidisciplinary conversation, the intent is to provide a broad, accessible, and timely assessment of where we stand and how to most effectively move forward. We hope that the concepts elucidated in this supplement will encourage future collaborations, decisions, and commitments to address the challenges we now face.

In “The Future of HIV Prevention,” Nancy Padian, Michael T. Isbell, Elizabeth Russell, and Max Essex, assess the emerging promise and potential challenges involved in using a regimen of antiretroviral drugs (ARVs) to prevent transmission of HIV. The authors put recent game-changing research in critical context, addressing the fundamental biological challenges of prevention via ARVs as well as existing gaps in prevention options and the necessity for behavioral interventions.

HIV treatment is also in focus in a compelling evaluation by Martin Hirsch and Daniel Kuritzkes, “The Future of HIV Treatment.” They begin with an update on the search for a cure for HIV, an ongoing global effort recently emboldened by news that a man living with HIV appeared to have been cured by a stem cell transplantation. Hirsch and Kuritzkes then turn their attention to the “ARV pipeline,” arguing that systemic repairs must take place to advance essential new therapies.

Although advances in treatment and prevention have given us great hope and continue to prompt important research, local and national leaders will ultimately bear the greatest responsibility for leading the effort to end AIDS. Phyllis Kanki, Pradeep Kakkattil, and Mariangela Simao illustrate this in “Scaling Up HIV Treatment and Prevention Through Bold National Responses and Innovative Leadership.” The authors present examples of successful national leadership in Brazil, Uganda, Nigeria, Uganda, and India—case studies that clearly illustrate the vital role of government leaders, the private sector, and nongovernmental organizations in driving local and national responses to the epidemic.

Kenneth Mayer, Jean William Pape, Phill Wilson, Dázon Dixon Diallo, Jorge Saavedra, Matthew Mimiaga, Serena Koenig, and Paul Farmer discuss global and local health disparities in “Multiple Determinants, Common Vulnerabilities, and Creative Responses: Addressing the AIDS Pandemic in Diverse Populations Globally.” The authors examine efforts to address a variety of health disparities, all largely resulting from economic disempowerment, discrimination, and stigma. Through examples of community-level responses in Haiti, the United States, and South Africa, the authors make the case that addressing disparities must be a critical pillar of the future global AIDS response.

Hopeful, yet cautious, Chip Lyons, Angela Mushavi, Florence Ngobeni-Allen, Robert Yule, and Elaine Abrams deliver a bold assessment of where we stand in the global effort to end pediatric AIDS in “Ending Pediatric AIDS and Achieving a Generation Born HIV-Free.” With new HIV infections in children virtually eliminated in high-income countries, programmatic efforts have shifted to low- and middle-income countries, particularly countries in sub-Saharan Africa, home to the vast majority of pediatric AIDS cases. The dramatic scale-up of programs for prevention of mother-to-child transmission of HIV has saved millions of lives. Yet globally, only roughly half of HIV-positive pregnant women have access to prevention of mother-to-child transmission services. The authors here discuss what it will take to achieve the recently adopted Global Plan to virtually eliminate new pediatric infections worldwide by 2015.

Bruce Walker and Julie McElrath discuss the search for an AIDS Vaccine, arguing that it is likely to be the most realistic path toward elimination and eradication, among the several prevention modalities currently available, including the use of ARVs to prevent infection. In their article, “Is an HIV Vaccine Possible,” Walker and McElrath, longtime global leaders in the quest to discover such a vaccine, discuss recent biomedical advances in the field and suggest reason for optimism. But to move forward, they say, more funding is needed to support a diversity of concepts at a time when the correlates of protection from acquisition and disease progression are still unknown.

Finally, in “The Way Forward: Maximizing Our Impact Through Shared Responsibility and Smart Investments,” U.S. Global AIDS Coordinator Ambassador Eric Goosby sets forth a compelling road map for maximizing—and growing—current investments in the global AIDS response. Goosby details key strategies for encouraging new investments and optimizing the impact of the multibillion-dollar US President's Emergency Plan for AIDS Relief, the Global Fund, and other bilateral, multilateral, and partner country investments.

Each of these articles provides a unique assessment of progress and a specific plan for moving forward. Together, the authors have created not only a valuable reference for the global AIDS response, but, most importantly, a provocative foundation for ongoing dialogue.

Now, as we continue contemplating and planning the end of the epidemic, there are critical questions to be asked about the future global AIDS response. How can we best deploy resources already at hand? How should new scientific research be prioritized? Most importantly, will the global community make the necessary political and financial investments to scale-up combination prevention and other proven solutions?

Harvey Fineberg, president of the Institute of Medicine and former dean of the Harvard School of Public Health, asked AIDS@30 symposium attendees, “Have we simply reached the end of the beginning? Or are we really prepared to make this the beginning of the end?”

With these questions in mind, guided by the ideas and solutions presented in the articles that follow, the conversation will continue. This supplement will be presented at the XIX International AIDS Conference (AIDS 2012), July 22–27, 2012, in Washington, DC.

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ACKNOWLEDGMENTS

Numerous institutions and dedicated leaders have generously provided their ideas and support for the International Symposium, AIDS@30: Engaging to End the Epidemic, and this resulting special supplement. Dean Julio Frenk and the staff at the Harvard School of Public Health stood behind the initiative and helped bring the effort to fruition. Throughout the development process, a team of leaders around the world provided invaluable guidance. The Global Advisory Council, Steering Committee, and Planning Co-chairs all enthusiastically shared their insights and helped create an agenda that was both dynamic and relevant. Many distinguished leaders also generously and skillfully served as session moderators, speakers, and contributors for the symposium, and as editors and authors for this supplement. The authors offer sincere thanks to each and every one of these individuals. They are deeply grateful for the collective enthusiasm, dedication, and spirit of collaboration that these individuals have brought to this critical conversation.

The authors also acknowledge the generous support for the AIDS@30 International Symposium and this special supplement provided by Janssen Global Services, Merck Company Foundation, ViiV Healthcare, Gilead Sciences, Harvard School of Public Health AIDS Initiative, Harvard University for AIDS Research (CFAR), MAC AIDS Fund, Sanofi US, Bristol–Myers Squibb, Beth V. and Carmine A. Martignetti, and Samuel P. Peabody and Elizabeth Peabody, in memory of Judith Peabody.

Additional input, perspective, and support were provided by multiple offices at Harvard University, as well as the Elizabeth Glaser Pediatric AIDS Foundation, Fenway Community Health Center, International AIDS Society, the Global Business Coalition, and the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Learn more about the international symposium and the leaders behind the initiative at AIDSat30.org.

© 2012 Lippincott Williams & Wilkins, Inc.

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