Tough decisions about money and treatment are ahead as AIDS turns 30

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.”

Peaked but far from over

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.