The Future of AIDS: A Still-unfolding Global Challenge
- Reflecting on the past, looking toward the future
- What the history of AIDS may tell us about the future
- AIDS in a changing world
- Scenarios for the pandemic's future
The world is approaching a moment of truth in the still-unfolding response to the AIDS epidemic.
The worldwide mobilization to combat a disease unheard of 30 years ago has generated historic achievements. For the first time, complex, lifelong management of a chronic disease has been widely implemented in low-income countries, averting millions of deaths.1 Prevention services have also been introduced in antenatal settings to prevent infants from becoming infected, and the overall number of new HIV infections in 2009 for both children and adults was more than 20% lower worldwide than in 1997.2
The pandemic has also elicited an unprecedented global mobilization of political and financial resources. For the first time in history, a United Nations program was established dedicated to fighting a single disease and the first-ever special session of the UN General Assembly was held devoted to a particular health condition. AIDS also led to the creation of a major new addition to global health financing architecture, The Global Fund to Fight AIDS, Tuberculosis and Malaria. As of 2008, total annual resources for HIV programs in low- and middle-income countries reached US$ 15.6 billion, an astonishing 53-fold rise in 12 years.3,4 And, by 2010 an estimated 5 million people in low- and middle-income countries were receiving antiretroviral treatment, a remarkable 12-fold increase in less than a decade.5
Against this historic progress, ominous signs suggest that the AIDS response is beginning to fracture. In May 2010, the New York Times profiled Uganda's biggest AIDS clinic, where stalled funding has prompted authorities to cap the number of patients enrolled in HIV treatment.6 Citing Uganda as the "first and most obvious example of how the war on global AIDS is falling apart," the Times reported that the "golden window" of worldwide generosity appears to be closing, consigning countless newly diagnosed Ugandans to an early death.
The world has traveled this road before. From the Green Revolution that made acute hunger a thing of the past in scores of countries throughout the world to major initiatives that eradicated malaria from large swathes of the world, the global community has repeatedly mobilized to address global health inequities, only to lose interest or to declare victory prematurely. The results have been catastrophic, especially in Africa, where conditions that have been unknown in upper- and middle-income countries for decades continue to cost millions of lives each year.
Will this same tragic story be repeated with AIDS? Or will decision-makers throughout the world learn from the mistakes of the past and chart a different, healthier, more enlightened course?
In 2031, the world will mark 50 years since AIDS was first reported. Recognizing the generations-long challenge posed by AIDS, UNAIDS launched aids2031 as an independent consortium, composed of experts in public health, economics, biomedicine, the social sciences, international development, and community activism. Organized into nine thematic working groups, the aids2031 Consortium has examined possible futures of the pandemic, the factors most likely to determine its future course, and the steps needed to sharply reduce the number of new HIV infections and AIDS deaths over the next generation.
AIDS: Taking a Long-Term View examines the AIDS challenge, using a future-oriented lens to identify successful strategies that need to be strengthened and ways in which the response to AIDS must change. It directly refutes the growing "AIDS fatigue" reported among key international donors, some national governments, and global opinion leaders, and rejects the either/or choice between focused initiatives to address specific diseases and strengthened broad-based health services. Both approaches are needed.
If the AIDS landscape is to undergo transformation by 2031, when the world marks the 50th anniversary of the initial recognition of the pandemic, AIDS must remain high on the global agenda. A long-term and sustainable response is needed that continues to generate and apply new knowledge.
Reflecting on the past, looking toward the future
The emergence of the epidemic more than a generation ago represented a historic and unexpected development. By the early 1980s, experts believed that the era of infectious disease was fast becoming a relic of an earlier era. While developing countries might continue to grapple with old diseases that had been largely banished from industrialized settings but never brought under control globally—including malaria and tuberculosis—it was assumed that the world overall was entering an epoch when chronic diseases associated with rising affluence would consume the efforts of health planners and medical researchers.
AIDS upset all these expectations and assumptions. In three decades, HIV has infected more than 60 million people worldwide.7 More than 27 million have died of AIDS-related causes. AIDS is the leading cause of death in sub-Saharan Africa and one of the leading causes of death worldwide among reproductive-age women.
The epidemic has inflicted the "single greatest reversal in human development" in modern history.8 In sub-Saharan Africa, home to two-thirds of all people living with HIV, average life expectancy has fallen by more than a decade during the last 20 years as a result of AIDS (see Figure 1.1).
Figure 1.1 Life expectancy at birth, selected regions 1950–1955 to 2005–2010.
Source: Population Division of the Department of Economics and Social Affairs of the United Nations Secretariat/World Population Prospects.
Although sub-Saharan Africa has been most affected, other regions have not been spared. Even though HIV prevalence in Asia is only a small fraction of that in Africa, the region experienced 300,000 AIDS deaths in 2009.9 Moreover, as Figure 1.2 illustrates, existing trends are not encouraging in Asia and the modes of transmission are changing. The pandemic costs affected Asian households more than US$ 2 billion annually and is projected to cause an additional 6 million Asian households to fall into poverty by 2015.10
Figure 1.2 Past and projected new HIV infections in Asia by population group.
Source: CAA: Redefining AIDS in Asia Technical Annex.
Much is certain about the epidemic's future. AIDS will remain an enormous global challenge. Even with a robust and much stronger effort to prevent new infections and deliver effective therapies, the disease will undoubtedly remain a major cause of death worldwide. In Southern Africa, AIDS will continue to pose an existential threat to national economies, agricultural sectors, and both urban and rural communities.
Yet much about the future of AIDS remains uncertain. In large measure, the pandemic's severity in 2031 will depend on choices to be made in the next few years. This chapter summarizes the sobering results of modeling undertaken by the aids2031 Modeling Working Group. If efforts to tackle AIDS become smarter, more focused, and more community centered, tens of millions of lives can be saved over the next generation. If actions to address AIDS instead remain static or weaken over time, the result will be millions of preventable new infections and AIDS will claim many more millions of lives.
Figure 1.3 Annual AIDS deaths (adults 15–49 years) comparing current trends against expanded scenario. The cumulative number of deaths avoided between 2008 and 2031 in the expanded scenario is more than 7 million.
Source: aids2031 Modeling Working Group (unpublished data)