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Selling cat by Hare? End of AIDS to 2030? How? At what price? And for those who ...

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End of AIDS for 2030 By Benjamin Ryan

As the slogans anticipating the end of the AIDS epidemic gain popularity, skeptics worry that such promises are empty and an ambitious unrealistic, and that failure to comply will ultimately hinder the efforts to combat HIV.

The idea of ​​whether by date for the end of AIDS

The idea was born in a cell in Washington, DC Charles King, who heads the Housing Works, A service organization on AIDS in New York City, was locked up for several hours along with the executive director of the Treatment Action Group in Mark Harrington. The two veteran activists had committed his last act of civil disobedience, this front of the White House during the International AIDS Conference in July 2012. Waiting for time to pass, they took regretting what they saw as the ineffective nature of the Obama administration in the National Strategies for AIDS, which, King believes, "is a strategy to keep the epidemic, not end it."

But what if they could find a way to end the epidemic, at least one test kit on a smaller scale? New York seemed stirred by the possibility. Not only were epidemiological key trends in the state moving in the right direction, as well as a pending redesign of its Medicaid program that would eventually free up funds that could be spent in new and creative ways. Moreover, the full implementation of the Affordable Care Act was to break new ground in the fight against HIV.

Advancing by June 2014: Governor Andrew Cuomo announced the ambitious plan of his administration to "end the AIDS epidemic in New York." The idea is to "bend the curve" and reduce the number of people living with the virus in the Empire State for the first time on three main efforts: improved diagnosis of HIV and link to care, improved retention for those receiving care along with antiretroviral treatment (ARV) expanded, and a push to put New Yorkers with high-risk behavior in Truvada (tenofovir / emtricitabine) as pre-exposure prophylaxis (PrEP).

King's leadership succeeded in bringing numerous parties for a meeting, including LGBT groups, service organizations in AIDS, pharmaceutical companies, the public health sector and the state government of course. Upon arriving at the flagship of the end of AIDS, these groups came in line with forces working on an even larger scale on the way to an ambitious goal. This includes the Obama administration, the United Nations Joint Program on HIV / AIDS (UNAIDSIn English), and the Global Fund to Fight AIDS, Tuberculosis and Malaria. In recent years all these entities have tried to put an end not as far to the epidemic and have committed to the goal with a fervor and an optimism not seen since mid-1990 when combination antiretroviral therapy for HIV was introduced.

This enthusiasm that some eyes are cautious, but with sincere hostility. Skeptics worry that such grand promises will fall to the ground, leaving the once thrilled donors and other stakeholders disillusioned about to close their wallets and turn their eyes to other concerns.

In a long list he cursed the internal e-mail servers on the eve of the International AIDS Conference in July Melbourne, former student of ACT UP, Gregg Gonsalves, invoked the rhetoric of the end of AIDS as "a strange utopian effort "and" a mirage following leading in a bad way "about the very real difficulties of dealing with the global crisis of AIDS in this.

Waafa M. El-Sadr, MD, Master in Public Health, director of the organization in global health ICAP at Columbia University, led a group of three people who published an editorial in the journal Science 11 in July entitled "End of AIDS: Advertising versus Hope. "The article argues that campaigns that promise" imminent success "in the battle against AIDS" can be perceived as campaigns that minimize the challenges that remain, resulting in the removal of resources and consequent resurgence of 'control' assumed the disease. "

Old tools, a new discovery, new hope

Anyway, campaigns to end the epidemic have been on the rise lately. The movement received greater scientific impulse in May 2011 when the findings of the famous study HPTN 052 were announced. To the great joy of the large international community about AIDS, the study showed that ARVs cut the risk of heterosexual couples status mixed in 96 percent. Anthony S. Fauci, MD, Director of the National Institute of Allergy and Infectious Diseases wrote an editorial in Science which came out in July of that year in which he enthuses: "We finally scientifically validated methods of prevention that clearly work, suggesting that ending the pandemic is possible." Treatment as prevention (TASPIn English) has become a beacon of hope.

Around November 2011, the then Secretary of State, Hillary Clinton, spoke about the new efforts for a "free generation of AIDS", which remained the cornerstone of global strategic Obama administration in relation to AIDS. The fuel behind this effort are the three "modes of prevention" of Fauci, each of which has been scientifically proven to reduce the risk of HIV transmission: Expanded HIV treatment, voluntary medical male circumcision (which reduces the risk of transmission HIV from men to women in 60%) and the treatment of HIV-positive mothers to prevent transmission from mother to child virus (MTCT, In english). Furthermore, there are very old strategies in HIV testing and counseling and condom distribution.

In 1º December 2011, World AIDS Day, both President Barack Obama and the UN Secretary-General Ban Ki-moon also made specific calls for an end to AIDS.

The dialect had a "ripple effect". Adopting such languages ​​in their public relations strategies were groups such as amfAR, the Foundation for Research on AIDS, which often speaks of an end to AIDS in their fundraising fields. There is also the Whitman-Walker HealthThe organization of services in AIDS Washington, DC, which recently changed its name Walk for AIDS (AIDS WalkIn English) for "Walk the end of HIV" (The Walk to End HIV, In english). The advertising campaign this event is called "The End of the Road" (The Finish Line, In english).

A UNAIDS has been making more specific appeals to "end the AIDS epidemic as a public threat" to 2030, a shared objective and supported by the Global Fund.

All of which bring up the question: "What is the" end of AIDS "?

"At one extreme there would be more people in the world living with HIV, and at the other end there would be more people in the world living with advanced disease due to HIV, meaning AIDS," says El-Sadr. "Between these two extremes, there is everything in between."

Adjusting the message

Ultimately, the Slogans are about the art of selling, regardless of whether they are reminding us that "Coke is all" or "Only You Can Prevent Fires on Forests". Regarding the fields of view of AIDS, sloganAlthough more nebulous or illusory than its current meaning, is typically designed to prioritize the interests of those signing the checks or opening the necessary policies doors (or not closing, as the case may be). Then of course there is public behavior in general, which, when shaken by the effectiveness of the message, can help put an end to the epidemic (or perhaps a political favor they realize precisely or not, to be proactive). This field also consider which tools the group working with the slogan have or expect to have at your disposal. Therefore, every definition of "end of AIDS" is limited by the particular approach of each entity in achieving that goal.

According to Kevin Frost, CEO of amfAR, reach the end of AIDS will be a "journey very, very long and requires instruments that frankly we do not yet have. It requires a vaccine, it requires a cure, and it requires a number of things that simply do not exist. "

This position fits with a central focus of amfAR's efforts that is the cure for HIV. The collection message of nonprofit funds suggests that support this research will lead to the end of AIDS. The strategy worked: while other AIDS battle groups across the country have seen their funds decrease, amfAR has doubled during the seven years Frost mandate, which he attributes to how successful such aspirational message resonates in amfAR supporters.

The definition of an end to AIDS, Frost says, "I believe the goal should be to completely eradicate this disease. And just as smallpox, I believe it can be done. "

Meanwhile, UNAIDSThe Global Fund, and the Cuomo administration in New York are, every man for himself, in his position clear that we have the tools to end the AIDS epidemic and that this order would see many people live longer lives and healthy with HIV.

The various stakeholders helping to shape the details of the state plan of New York have two references that they hope to achieve in the near future and that they say will help announce the arrival of an end to the AIDS epidemic.

The first goal is to reduce the number 75% of new infections in the state of 3,000 2012 in to 750 in 2020. Whereas there 150.000 people in the state of New York living with HIV, this effort could end the "transmission rate" annual 2 percent to 0,5 percent and probably cause shrinkage of the epidemic in the state. The other reference in the state of the plan is to reduce the number of New Yorkers positive tested for HIV and who then receive an AIDS diagnosis within two years of 10 percent to 5 percent, also around 2020.

More objective and greater clarity in the precise meaning of the end of the AIDS epidemic in New York are to emerge as the details are forged in the preparation of the governor's budget proposal in January.

The plan of UNAIDS is turned around a pair of goals for the global epidemic of HIV. The first is to have 90 percent of people living with the virus aware of their status, 90 percent of this group in ARVs and 90 percent of this group reaching an undetectable viral load - all around 2020. (Which means that 72 percent of the global HIV population would have the virus completely suppressed.) This, according to a mathematical model, should put the world at a goal, around 2030, of reducing 90 percent of new infections - to 200.000 per year - and a reduction of 80 per cent in AIDS-related deaths compared to 2010 data. While Gonsalves in particular discovers flaws in the lack of more specific UNAIDSThere is, in fact, in other projects.

Frost is critical of the concept of UNAIDS the end of AIDS, saying, "If you take the concept of UNAIDS and replace the word 'polio' for 'AIDS' you could argue that we end up with polio. And by this definition, you can argue that you may be right, since 'end an epidemic' and 'eradicate a disease' are different. But with HIV, the definition of UNAIDS reflect my [position] that a definition that leaves thousands of people living with HIV, but only not dying of the disease does not reflect what a person on the street could interpret what "end AIDS."

Pay no attention to the man behind the curtain

But can these great goals be achieved in truth, and within the promised time limit? Take the Obama administration's goal of an AIDS free generation. In the words of Hillary Clinton, the expression means that "virtually no child is born with the virus. As these children become teenagers and adults, they are at much lower risk of becoming infected than they would be today thanks to a wide range of prevention tools. And if they get HIV, they have access to treatment that helps prevent them from developing AIDS and passing the virus to others. "

Four years after the announcement of the plan, this vision is already proving illusory. One of the initial objectives of management was to achieve a zero mother-to-child transmissions to 2015. But as of the 2001 2013 we saw a drop of 60 percent in the annual incidence of MTCT, about 500,000 200,000 for the trend is the appeal of far reaching zero next year. In addition, the American investment battle against the global epidemic stalled widely from 2011. The President's budget for the Emergency Plan on AIDS Relief, which includes contributions to the Global Fund, was in 6,725 billion four years ago and is estimated at 6, 756 billion dollars today. The proposed budget for 2015 is 6, 403 billion.

The Obama Administration is also guilty of serious logical lapses to make promises about the end of AIDS. During the speech at the World Day of 2013 of AIDS, the Secretary of State John Kerry proclaimed that an AIDS free generation was "within reach". But according to its many settings explained by its predecessor, the AIDS-free generation will not be born until the mother to child transmission is virtually eradicated; and a time, and will require two decades have passed so that these children grow and move it to all other references.

"You must have a really good sight to see" the free generation of AIDS, says sarcastically Mitchell Warren, executive director of AVAC.

Referring to HIV treatment goals UNAIDS to 2020, Warren says, "I am in favor of being bold and audacious, but be beyond what we can aspire, to say that we are in 72 percent of global viral suppression in less than a decade is not, I think, a target realistic. I want something that is possible, but ambitious. "

By comparison, only 28 percent of Americans living with HIV have full viral suppression. In the editorial of El-Sadr for ScienceShe and her co-authors point out that in countries of low and middle income, only 34 percent of women and 17 percent of men with HIV have access to treatment.

Warren is concerned with the accounting of these promises. As I said to the [chief executive UNAIDS] Michel Sidibé and others [the International Conference on AIDS] in Melbourne, 'None of you still have your job around 2030' he recalls. "This is here to 16 years. Whom I will blame when I do not hit the target? ".

Put a smile

According to Kent Buse, PhD, senior adviser to the executive director and head of strategic policy directions in UNAIDS, Its decisions to adopt such impressive campaign strategies by the end of AIDS occurred in the context of rewarding forces requested a break in the disease and raise funds UN programs. In addition, given the economically austere environment, critics say UNAIDS should be transferred to the World Health Organization. Meanwhile, the public interest in HIV waned, of course, as few saw the disease as a pressionadora question. So, in an ironic twist, convincing the world that AIDS is not over, if required, talk about how she could end, thus reminding the ordinary people of the ever-present threat.

"AIDS need to retain and maintain some visibility," says Buse, "and even in the health sector we see AIDS to some extent being pushed by non-communicable diseases and universal coverage in health. And this is not to say that we think this is a zero game to zero. "

"We think that if we do not we implement this type of language that we will be ignored," he says of the Slogans the end of AIDS. "I think the response to AIDS have reasonably been unprecedented in terms of the progress it is achieving. And we must continue to tell this story to continue to attract investment. "

The executive director of the Global Fund, Mark Dybul, MD, says that attract investments of nations requires a finesse which is informed by epidemiological trends and mathematical models and is, in fact, supported by the historical organizations in combating disease.

"If you say 'AIDS is over and we can go,' that is a problem," said Dybul. "If you're saying that we're on a path now, we're really at a tipping point where we have the ability to get to the end of the epidemic - an epidemic, not eliminate HIV, but to get to the level more low endemicity - that is reasonably attractive to donors. To say that we will pay for it the next 75, 100 years and say there is no output is not very attractive to resource mobilization. "

With regard to "low endemicity" HIV Dybul said global research community is still solving these details.

And with regard to the inflection point, and Buse Dybul point to the model which states that a fast attack model and the condition can immediately direct the downward trend. Wait even a few years to expand efforts, and the lot of time, money and effort required to achieve the same result will be much greater.

Meanwhile, the faction of New York is feeling especially confident that the message of the end of AIDS resonates among people and that efforts will prove successful in the final analysis.

"I think this conversation [about the end of AIDS] actually energizes people," said Dan O'Connell, Director of the AIDS Institute at the Health Department of New York State. "If you do that in a certain context where there is a point in the sky and is not realistic, you will definitely get some negative response and people will be concerned that you are trying to exaggerate something. But I think that where we are in New York is perfectly possible to do what we said we will do. "

"I really see this as a defining moment," says Charles King of Housing Works, "And I feel a tremendous sense of responsibility. Because the truth of the matter is that I honestly believe that if the state of New York actually implement a plan that will get the curve to zero, we will be paving the way for other states to do the same. And if we fail and this is just a slogan and no one take advantage of this, we'll probably be kicking movement in the United States for at least a decade. And if be long until another governor take a step forward and say 'Oh yes, we can "

Translation Rodrigo Pelegrini

Information added on 22 / 04 / 2018:

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