The AIDS epidemic turns 30 next month. What began as a fatal new plague has become a treatable, if still incurable, chronic illness. That change counts as a triumph by any measure, but it also poses an unusually difficult question for the next 30 years:
How many people do we want to save from a death by AIDS — and who’s going to pay for it?
The global AIDS community now has tools that prolong the lives of people infected with the virus and prevent others from acquiring it. They range from antiretroviral therapy (ART), to circumcision and campaigns to reduce promiscuity. On the horizon are gels and pills that protect against infection during intercourse. Even the outlook for an AIDS vaccine is no longer as bleak as it used to be.
At least 6 million people in the developing world are now receiving life-extending ART. While that is less than half the 14.6 million HIV-infected people who should be getting treatment under the World Health Organization’s latest guidelines, it nevertheless represents an accomplishment that was inconceivable when the epidemic turned 20 in 2001. That number is likely to grow in the wake of a recent study showing that ART dramatically cuts a person’s infectiousness, and thus is itself a tool for prevention.
Bringing those tools to the people needing them — 90 percent of whom are in developing countries — requires lots of money. Last year, the world spent $16 billion on the task, half of which was donated by rich countries and charities.
A recent projection estimated that, by 2031, global AIDS costs could reach the equivalent of $35 billion a year. A recent United Nations report declared frankly: “The trajectory of costs is wholly unsustainable.”
The disease eventually named AIDS first came to public attention on June 5, 1981 in a report on a rare type of pneumonia in five gay men, but scientists now believe the virus entered human beings early in the 20th century. In Africa, where the epidemic began and has had the most devastating effect, the rate of new infections — incidence — peaked in the late 1990s.
Today, the epidemic is an astonishing mixture of good news and hard-to-excuse failure. About 33.3 million people around the world are infected with HIV, the virus that causes AIDS. In 2009, the last year for which there are complete statistics, 2.6 million people became infected and 1.8 million people died. Those numbers are down from previous peaks.
The decline reflects great progress in the hardest-hit regions, especially in Africa. During the last decade, the HIV incidence declined in 33 countries, and HIV prevalence among young people fell in 15 countries — in both cases, by an astonishing 25 percent — largely due to safer sexual practices.
Nevertheless, the number of people living with HIV is still on the increase. Part of the reason is that AIDS patients are surviving longer, thanks to the expansion of antiretroviral therapy in the developing world, where 200 times as many people are getting it now than were just eight years ago. But for every person who starts treatment, two others become infected.
Without more progress in preventing new infections, HIV incidence will eventually start rising again. By 2031 when the epidemic turns 50, about 3.2 million adults will become infected each year, according to a recent projection. By the middle of the century, there could be 70 million people living with HIV in Africa alone.
Without question, a big reason for the progress made in the last decade is the sums of money brought to bear by the President’s Emergency Plan for AIDS Relief (PEPFAR), created by George W. Bush in 2003 and expanded by President Obama, and by the Global Fund to Fight AIDS, Tuberculosis and Malaria, a free-standing institution in Geneva that gets money from rich countries (including the United States) to fund grants to needy countries. PEPFAR spent $6.7 billion last year on AIDS treatment and prevention, the Global Fund $1.6 billion. Together, the two provide antiretroviral therapy to about 85 percent of the people receiving it in the developing world — about 4.7 million people in all.
Faced with budgetary concerns, both are now seeing the amount of money they have to spend on the problem level off. Everyone agrees that, from now on, low-income countries will have to devote more of their budgets to AIDS. But some fear they will be asked to shoulder too much too soon.
“It defies imagination to think that it’s time for donors to pass the hot potato to the government of one of the poorest countries on Earth,” said Asia Russell, who works in Uganda with the activist group Health Global Access Project.
Nearly everyone agrees the first thing that needs to be done is to get more bang for the billions of bucks now being spent.
“Money is important, but money alone will not make it,” said Michel Sidibe, director of UNAIDS, the United Nations AIDS program. “We need to have a solidarity around issues which are going beyond money. The solution will be found through a genuinely shared responsibility.”
The most important step in bringing AIDS treatment to people in the developing world has been the huge decline in the cost of antiretroviral drugs over the last 15 years. Three-drug ART combinations cost $10,000 to $12,000 a year in 1996 when they became standard AIDS therapy in the United States. The Clinton Health Access Initiative, one of former president Bill Clinton’s charities, recently announced a new schedule of brokered prices in which a three-drug combination, which includes the highly favored drug tenofovir, runs $159 a year. The price of an older, less desirable triple combination is $79 a year — less than 1 percent of what it used to be.
The initiative has helped create a more sustainable market by bringing drug buyers (often national governments) and drugmakers (usually generics companies) together to encourage more rational, long-term planning. Recently, it has also begun helping manufacturers find cheaper sources of the chemical raw materials they need to make their products.
The result has been a proliferation of firms making AIDS drugs for poor countries (although not for rich countries, where patent restrictions forbid the sales). In 2003, four companies in India made generic AIDS drugs. Today 10 do, and Indian companies supply more than 80 percent of AIDS drugs used in developing countries.
“Prices are rock-bottom now for a lot of the older drugs. We can’t keep squeezing, because it will become an unattractive market,” said Brenda Waning, a health economist at the World Health Organization, in Geneva. For newer drugs, she said, “there is still a lot of room for price reductions.”
Lowering drug prices is just one of several strategies to make money go further. A researcher from Boston University working in PEPFAR-funded programs in Africa reported recently that when hospital clinics staffed mostly by doctors handed stable patients over to community clinics run mostly by nurses, the cost of care fell 9 percent in South Africa and 21 percent in Zambia. A physician from Columbia recounted that when Rwanda merged its HIV and tuberculosis programs, the number of TB patients being tested for HIV went way up, and the time it took to get someone on TB treatment went way down.
“We’re still mining for those efficiencies,” Eric Goosby, the physician who runs PEPFAR at the State Department, said recently. But he added, “My guess is that in the next 18 months to two years we will have found them all.”
What happens then is a big question.
Recently, a group of economists and epidemiologists convened a project called aids2031 that examined four scenarios for what might happen between now and the epidemic’s 50th anniversary.
The most expensive one, costing $722 billion over that period, would ramp up to provide treatment and prevention services for 80 percent of people by 2015. It would prevent 33 million new infections, although 1.3 million a year would still be occurring in 2031, according to modeling done by the Washington-based Results for Development Institute. The cheapest scenario would put almost the same number of people on AIDS drugs but would target prevention services only at high-risk groups, such as uncircumcised African men, infected pregnant women and drug users. It would cost much less — $397 billion — but 1.7 million people would still be getting infected each year 20 years from now.
All of the scenarios make clear that, without much better success at preventing infections, the problem of not enough money will go on for decades.
“Prevention is the sine qua non for turning off the tap and reducing the need for treatment,” said Robert Hecht, head of the institute.
Is there a way to get lots of money for AIDS painlessly? Some people think so.
Since 2006, a charity based in Geneva, UNITAID, has collected $1.5 billion and used it for AIDS, malaria and tuberculosis projects. About two-thirds of the money comes from a small fee that is added to the price of airline tickets in eight countries.
A campaign called (RED) has raised $170 million since 2006 by partnering with companies that give the Global Fund a share of profits from the sale of computers, mobile phones, baby strollers and other products.
That’s all small change in the face of what’s needed.
However, there is one “innovative financing” scheme that could raise as much as $50 billion a year.
It’s called a “financial transaction tax.” It would collect a fixed amount — perhaps .05 or .005 percent — on stock purchases, currency trades or other specified activities. A group of 1,001 economists this spring signed a letter to the finance ministers of the G20 countries saying the tax “is an idea that has come of age . . . [and] is morally right.”
At least 23 countries have transaction taxes. In the United States such a tax supports the budget of the Securities and Exchange Commission.
But in recent decades there’s been a trend away from transaction taxes, experts say, because trading tends to move to places where a tax doesn’t exist, and because the cost of the tax is easily passed on to consumers.
“I have never seen a proposal that I think would generate significant revenues that is politically viable internationally and wouldn’t generate substantial distortions in the market,” said Adam LaVier, an official in the domestic finance office of the Treasury Department.
The global AIDS epidemic is out of its youth. It seems unlikely that there will be easy ways to avoid hard decisions as it heads toward middle age.