Two cheers for lower HIV incidence

UNAIDS published its annual Report on the Global AIDS Epidemic last week, and there is much to celebrate.  The 2012 numbers show a 52% decrease in the number of new HIV infections among children since 2001, and a combined reduction among children and adults of 33% over the same period.  In addition, TB-related deaths for those with HIV has declined 36% since 2001. This has led some in the media -- not UNAIDS, official agencies are more cautious -- to speak of a turning point, a possible end in sight of this epidemic. How did this come about? Probably a number of factors, where it is hard to pinpoint any crucial initiative or cause. The numbers of persons started on antiretroviral treatment has increased sharply over the last decade, and consistent use of antiretrovirals makes HIV-positive persons far less likely to spread the virus to others. But this is only a piece of the puzzle: for now, what we know is that there are falling numbers of infected persons, not so much precisely why they are falling.

Of course, any story of a steady march to epidemic control is likely to conceal less triumphal elements. UNAIDS itself admits that while it is committed to reducing the human rights abuse (particularly in regard to women and other vulnerable groups) that often accompanies HIV infection, there is no sense that we have seen equally substantial reductions in violence against women and children or in excessively punitive laws against injection drug users. And there is more: while UNAIDS cites successes, it does so selectively: the infection rates among men who have sex with men has not deceased over the last decade, to the contrary. Why, ask gay rights groups, is this not emphasized in the press releases? Do the rising infections of gay men matter less than the lowered HIV acquisition among kids and non-gay men? In addition, only a percentage of those in need of HIV treatment in low-income countries are receiving it, and much needs to be done to get close to universal coverage.

As I have mentioned before, the vast numbers of HIV-positive persons on antiretroviral therapy worldwide is an amazing, fragile and contested achievement. Amazing, because there is almost no historical precedent for the magnitude of efforts and funds thrown at this particular disease. Fragile, because if the money streams to keep millions on this lifelong life-saving therapy dry up, and there is a massive treatment interruption, all (possibly drug-resistant) HIV will break loose. Contested, because it is hard not to notice that the investment in HIV/AIDS is disproportional to what is devoted to other diseases that produce similar or worse morbidity and mortality numbers. There is, of course, no ethical way of going back. Just ethically messy ways of pushing forward.