by Kent Buse

Years ago, as the international community debated how to respond to Kofi Annan's call for a radical and new multilateral funding body for global health, sceptics questioned whether or not new money for AIDS treatment would be wasted. Africa, so the narrative went, didn't have the wherewithal to deliver medicines to those who needed them - moreover, Africans would not be capable of sticking to a demanding treatment regime. Then there was the issue of who would pay.

Now, with more than six and a half million people on life-saving treatment in lowand middle-income countries, the majority of whom are Africans, sceptics have been forced to reassess their views. Simply put, the AIDS response is rightly viewed as one of the greatest success stories in modern global public health. Over the same period, rates of new HIV infections have fallen by more than twenty percent - and 56 countries have seen a decline in new infections or stabilised their epidemics. In 2010, almost 60 percent of pregnant women living with HIV received antiretroviral therapy to prevent transmitting the virus to their child; up from just 15 percent in 2005 (and Botswana, Lesotho, Namibia, South Africa and Swaziland reached the goal of providing drugs to 80 percent of pregnant women living with HIV). In many countries, HIV prevalence has dropped dramatically among young people - largely due to changes in sexual behaviour.

Investments in science and innovation have started paying dividends. The ground-breaking HPTN 052 trial revealed that when a person living with HIV adheres to an effective treatment regimen, the risk of transmitting the virus to their partner(s) can be reduced by 96 percent.

Huge gains have also been made in addressing some of the HIV-related human rights agendas. Ignorance and fear of AIDS have given way to compassion and greater understanding. A range of discriminatory and punitive laws have been repealed - including on travel restrictions, prohibitions governing same sex relationships, the selling or buying of sex, and access to harm reduction services for people who inject drugs.

As we mark the 30th anniversary of the epidemic, we are poised on the edge of a historic opportunity. United States Secretary of State Hillary Clinton spoke recently of ushering in "an AIDS-free generation." Such a goal would have been unimaginable even a few years ago. Now the first AIDS-free generation is held up as a policy priority of the biggest donor of the AIDS response. How did this happen and what comes next?

The AIDS response has always been remarkable - and fundamentally different to the way other global health challenges have been tackled. People living with HIV and AIDS mobilised in unprecedented ways. In the early days, the gay movement (mainly in the global North) drove attention to the issue, but they were soon joined by people living with HIV in all corners of the world. Other groups of people at higher risk of infection - including sex workers and people who inject drugs, as well as the women's movement - also rallied around the cause. The early activists deployed a range of tactics including strategic campaigning, civil disobedience, direct action and litigation. As a result, clinical trials and drug registration were fast-tracked; international trade rules were reinterpreted to enable a flourishing trade in generics, thereby facilitating an unprecedented reduction in the prices of medicines; the pharmaceutical industry came under pressure to offer discounted prices to low-income countries; many private sector companies stepped in to treat their staff and family members; other firms contributed funds and logistics to national responses; and global solidarity resulted in a tenfold increase in funding for the response between 2001-2009. The movement managed to shift discourse on public health by focusing attention on the social, political and economic determinants of risk and vulnerability to disease and the need to address harmful social norms. It is a response marked by innovation. Currently, young people from the around the world are using social networking media and 'crowdsourcing' to develop a new global Youth HIV Strategy. Yet perhaps most importantly, people living with and affected by HIV demanded that their preferences and expertise be taken into account in the planning and delivery of services - "nothing for me without me" made services more responsive and kept policymakers on their toes.

A global AIDS movement emerged. The movement was politically astute and created a great many incentives for decision-makers to take action in a way that they had not been willing to for other global health challenges. Where the political leadership was responsive, great progress was made relatively early in the epidemic in countries as diverse as Brazil, Senegal, Thailand and Uganda. At the global level, the movement, working in alliance with sympathetic donor countries, civil society organisations and courageous leaders from low- and middle-income countries, as well as the private sector and foundation world, orchestrated to put HIV on the agendas of the UN Security Council and General Assembly - two firsts for a health issue. The slogan of 'Health for All' was translated into a political commitment to universal access to HIV prevention, care, treatment and support by world leaders ten years ago. Country by country progress, recorded through an exemplary monitoring and reporting system, is reviewed annually in the UN General Assembly, establishing a degree of international accountability and a virtuous circle of visibility, financing and results.

Despite these successes, challenges remain. An estimated 34 million people were living with HIV in 2010 - around nine million of whom require treatment but do not receive it. Two people are newly infected with HIV for every person that commences treatment, and the global costs of treatment are not sustainable. One hundred and six countries still report having laws, regulations or policies that present obstacles to access to HIV prevention, treatment, care and support for vulnerable people. These include some form of restriction on the entry, stay and residence of people living with HIV based on their HIV status, criminalisation of same-sex sexual relations between consenting adults - six countries apply the death penalty for such practices - and criminalisation of HIV exposure or transmission. One hundred and sixteen countries, territories and areas have laws deeming selling sex to be illegal - thereby presenting obstacles to HIV prevention services. In addition to these challenges, for the first time in a decade, external investments in the AIDS response flat-lined in 2009 and diminished in 2010. The AIDS response, despite its phenomenal success, has been buffeted by global economic uncertainty and the need to address budget deficits.

The challenges are considerable, yet the AIDS response is no stranger to adversity. Those living and affected by HIV have overcome considerable obstacles over the past three decades and triumphed against seemingly overwhelming odds. Calling for an AIDS-free generation may seem optimistic, but it is within our grasp with the right mix of strategies and investments and continued political leadership. Recent announcements and budget decisions from the leadership of China, Nigeria, South Africa and Russia, among others, provide grounds for optimism for a new investment climate and sense of shared responsibility.

UNAIDS has adopted an aspirational vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths which has inspired new energy for the AIDS response. UNAIDS strategy to 2015 sets a bold agenda which focuses on innovation, efficiencies and value for money - as a result of efficiency gains more people continue to be put on treatment despite declining investment - and contains a set of bold, outcome-oriented targets which serve as milestones to the longer-term vision. These goals were endorsed by the international community in a ground-breaking political declaration adopted at this year's UN High Level Meeting on HIV/AIDS. In the declaration, the international community acknowledged for the first time the specific vulnerabilities of key populations - men who have sex with men, sex workers and people who inject drugs - to HIV and the need to aggressively tackle stigma and discrimination. Importantly, countries have committed to reaching UNAIDS targets by 2015. By focusing resources on these targets, particularly in a set of high impact countries, a generation free of AIDS is not only a moral and economic imperative but has become feasible too. A set of five actions will hasten the pace: fostering a new generation and geography of leadership; forging a compact of shared responsibility; continuing to innovate in science and service delivery; taking the AIDS response out of isolation to deliver on a range of Millennium Development Goals; and further enhancing human rights and gender equality. With continued progress in these areas, there are good reasons to believe that this is the beginning of the end of the health challenge that has marked our era.

2011 United Nations General Assembly Political Declaration On HIV/AIDS: Targets And Elimination Commitments

Achieve universal access to HIV prevention, treatment, care and support by 2015 (51)

1. Reduce sexual transmission of HIV by 50 percent by 2015.

2. Reduce transmission of HIV among people who inject drugs by 50 percent by 2015.

3. Eliminate new HIV infections among children by 2015 and substantially reduce AIDS-related maternal deaths.

4. Reach 15 million people living with HIV with lifesaving antiretroviral treatment by 2015.

5. Reduce tuberculosis deaths in people living with HIV by 50 percent.

6. Close the global AIDS resource gap by 2015 and reach annual global investment of US $22-$24 billion in low- and middle-income countries.

7. Eliminate gender inequalities and gender-based abuse and violence and increase the capacity of women and girls to protect themselves from HIV.

8. Eliminate stigma and discrimination against people living with and affected by HIV through promotion of laws and policies that ensure the full realization of all human rights and fundamental freedoms.

9. Eliminate HIV-related restrictions on entry, stay and residence.

Kent Buse is Senior Advisor to the Executive Director, UNAIDS. Former faculty at Yale University and the London School of Hygiene and Tropical Medicine, he is author/editor of a number of books on the politics of health policy and governance. The views expressed are those of the author and do not represent United Nations policy.



"The Beginning of the End of AIDS?"