Defining an ‘AIDS-free generation’

WASHINGTON, DC — One of the big questions for the International AIDS Conference, which officially opens tonight: Is an AIDS-free generation just a dream? And what does it mean?

When Secretary of State Hillary Clinton called for an AIDS-free generation last November in a speech at the National Institutes of Health, she didn’t spell out exactly what she meant. Eight months later, the US government still hasn’t done so. There’s no long-term timeline for its strategy or a definition of what would be a success.

On Saturday, in a discussion at Center for Strategic & International Studies, a Washington think tank, several AIDS experts and US officials gave their views on what it meant to reach an AIDS-free generation – and when it would happen.

“We’re talking about really looking down the road at declining rates of new infections, and the idea that not our current generation, but the next one to come will not have high burdens of HIV infections,” said Chris Beyrer, a professor at the Johns Hopkins Bloomberg School of Public Health who has served as a consultant to several US agencies on AIDS issues. “Will there continue to be HIV infections? The answer clearly is yes.”

Difficulties in halting HIV in some populations

Beyrer said that the new scientific tools for the prevention of HIV infection could lead to “real declines” but that the spread of the virus could continue to spread in several stigmatized populations, such as injecting drug users, gay men, and sex workers. “The reason is political, social, and human rights related,” he said. “We have a very long ways to go in thinking about an AIDS-free generation in Ukraine, Kazakhstan” and other central Asian or eastern European nations with entrenched epidemics among those groups.

Kevin De Cock, director of the Center for Global Health at the US Centers for Disease Control and Prevention, agreed with Beyrer’s general conclusions on reaching an AIDS-free generation.

Time to define Clinton’s call

“The language is really important,” he said. “This term ‘AIDS-free generation’ is really part of the lexicon. It means a virtual elimination of mother to child HIV infection, a substantial reduction in HIV incidence, and third, the aspiration for anyone who is infected that they can access life-saving therapy in a timely fashion with the best available drugs.”

De Cock himself said it was time for the US to define Clinton’s statement.

He said one of the reasons for the success of the US President’s Emergency Plan for AIDS Relief (PEPFAR) was that it set “realistic but ambitious targets. We need to do that with the ‘AIDS-free generation.’ We need to balance aspirations with realism, and not make the mistake of overpromising. We shouldn’t over promise.”

How does the world get sharp reductions in HIV incidence? In addition to expanding treatment, which also prevents the spread of infection, he said that male circumcision efforts have “got to be part of our science-based approach.” He also said South Africa showed that it was possible to virtually end HIV infection from mother to child, after it cut the infection rate to 2.7 percent of all births from HIV-positive women.

Moderator Tom Quinn, the director of the Johns Hopkins Center for Global Health, pressed De Cock on why more hasn’t been done in expanding male circumcision. “What has prevented the scale up of circumcision?” he said. “What is holding this back? PEPFAR pays for male circumcision, and it is the most cost-effective intervention that is available now.”

The lessons from Kenya

De Cock turned the question around. He said it was important to study countries such as Kenya that had succeeded and to learn from their experiences. In Kenya, he said, political leadership from the Luo tribe, which traditionally does not circumcise men, was critical, as was the ability by the medical establishment “to hold ‘circumcision days,’ and circumcision camps. It shows it can be done.”

David Serwadda, a professor of public health at Makerere University in Uganda, and one of the pioneers of researching AIDS in Africa, said that the fact people are now talking about an AIDS-free generation is due to PEPFAR.

“This term is now coming around as a result of multiple biomedical interventions,” he said. “… If you asked me 10 years ago, whether in the next 15 years we would see a huge scale up of people on treatment, I would really be very skeptical. But PEPFAR has truly changed the scenario. It’s shown what leadership could do. I would go into the villages and people (once near death from AIDS) are surprised they are alive. And I am equally as surprised they are alive as they are themselves.”

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