Washington — "Turning the Tide Together" is the theme of the XIX International AIDS Conference, which has brought more than 23,000 delegates from 195 countries to Washington July 22-27. As professionals and activists plunged into their discussions in the first days of the meeting, an alternate slogan for the event might have been "doing what works."
"Prevention-as-treatment works in the field if you implement it," said Dr. Anthony Fauci in a July 23 presentation, describing research conducted in Africa demonstrating that the number of new HIV infections drops when a high number of HIV-positive people receive antiretroviral therapy (ART) to reduce blood viral levels.
"There's a 38 percent lower risk of acquiring HIV in those high [ART] coverage areas," Fauci said. As the director of the National Institute of Allergy and Infectious Diseases (NIAID), Fauci has been on the leading edge of AIDS research for 30 years and is a key figure in working to achieve the U.S. goal of moving to an AIDS-free generation.
Research also provides strong evidence that male circumcision can be very effective in reducing female to male transmission, Fauci said. One study documented "a 42 percent decrease of acquisition of infection among Muslim male populations after voluntary circumcision," Fauci said, quoting further research conducted in Africa.
Senior research scientist Dr. Nelly Mugo of Kenyatta National Hospital in Nairobi has led some of the African research on the use of treatment as prevention. She said the findings give doctors the chance to combat the disease in new ways.
"We finally have additional tools," said Mugo, speaking to a delegate meeting July 24. "We haven't been here before. How do we prioritize these tools?"
That's a challenge Secretary of State Hillary Rodham Clinton put to the convention delegates in a speech July 23. AIDS practitioners and health administrators need to pick up the tools that work in slowing the epidemic, she said, and drop those that haven't worked.
But learning where the infected and at-risk people are is the first step in defining what tools will work. Global AIDS Coordinator Eric Goosby points out that different characteristics of HIV transmission in various countries have resulted in many epidemics, not just one. Each city may find that the most new infections are occurring among different demographic groups, Goosby said in a panel discussion, whether that is transmission between heterosexual partners, men who have sex with men, sex workers or intravenous drug users.
Figuring out who they are and where they are must come first, Goosby said. "You then try to position your prevention intervention so they are in front of that population. It's a lot easier said than done."
Maintaining flexibility in a national or regional AIDS strategy to allow regular re-evaluation of where and how disease transmission is changing is important, Goosby said, though difficult. Governments must sustain both their political will to combat the epidemic and their capability to adjust resources and response as infection patterns change.
Howard Koh, U.S. assistant secretary for health at the Department of Health and Human Services, said the emphasis on what works has been an important component of the National Strategy to Save Lives, the HIV/AIDS plan implemented by the Obama administration in 2010. In a July 24 panel with Mugo, Koh, also a physician, said a comprehensive national strategy, developed with input from all the various groups affected by the epidemic, is critical for maintaining both efficiency and effectiveness in the effort to get ahead of the epidemic.
Koh said the capability to develop new ways to address disease issues is also important. He described a plan to encourage more people to be tested for the virus in Washington, the host city for the meeting and a city with a rate of infection among the highest in the country.
"The District of Columbia's Department of Health makes HIV testing available at the Department of Motor Vehicles," Koh said. "So customers waiting in line for a driver's license or other services can get a free HIV test."
Koh said the Obama administration's HIV/AIDS strategy increased testing by 13 percent in the United States in 2011 alone, expanded the availability of care for AIDS patients and eliminated waiting lists for ART everywhere in the country.
While many of the lectures and discussions among the thousands of AIDS conference delegates focus on the need to treat more people, raise more funds and build better care facilities, veterans of this long struggle remind how much has been accomplished.
"It was exactly 10 years ago in the conference in Barcelona that I put forward the goal of reaching 3 million people with treatment by 2025," recalled Bernhard SchwartlÃÂ¤nder, who now serves as the director for evidence, strategy and results at UNAIDS, the Joint United Nations Programme on HIV/AIDS. "We are at 8 million today. The global AIDS movement has achieved amazing results over the last 30 years, and there's no reason why it should not continue to drive change, innovation, health and human rights for all."