The US government will continue to fund HIV/AIDS research, prevention and treatment efforts as part of a more comprehensive global health strategy, officials said on Monday at a special session at the Fifth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa.
Dr Anthony Fauci, director of the National Institutes of Allergy and Infectious Diseases, began by reviewing recent data showing that earlier antiretroviral therapy above the current threshold of 350 cells/mm3 in the current US and European guidelines leads to better outcomes. "Everything points to earlier HIV therapy," he said.
Starting treatment at a higher CD4 cell count leads to less illness, more complete immune recovery, longer survival and lower long-term costs. One study, for example, found that it cost nearly three times as much to treat a person who starts therapy with fewer than 50 cells/mm3.
Dr Fauci also noted that the concept of treatment as prevention, or testing everyone regularly and providing universal treatment regardless of CD4 count in an effort to drive down viral load and make it harder to transmit the virus, is being studied for feasibility.
But expanding testing and treatment will cost more money in the short term, both domestically and on a global scale. Even as wealthy countries consider earlier treatment, about two-thirds of people with HIV in the developing world still do not have access to needed treatment based on a lower threshold of 200 cells/mm3.
Newly appointed US Ambassador at Large and Global AIDS Co-ordinator, Eric Goosby, said the World Health Organization would look at scientific research when deciding whether to lift the global treatment threshold to 350 cells/mm3, but must also consider economic realities.
Dr Fauci said that the President's Emergency Plan for AIDS Relief (PEPFAR) program started by George Bush would continue under Obama, but would no longer require funding recipients to emphasise sexual abstinence. Domestically, there are many unknowns as legislators battle over healthcare reform.
He also indicated that the Obama administration is "very much in favour" of lifting restrictions on HIV-positive visitors and that there is a "clear intention" on the part of both the administration and Democrats in Congress to remove the federal ban on funding for needle exchange. He expressed confidence that both policy changes would soon go into effect.
International AIDS Society Director Craig McClure said that the organisation would hold the 2012 International AIDS Conference in Washington, DC, if the entry restrictions are removed.
Responding to a question at a press conference following the session, Dr Fauci said focusing on the larger picture – for example, improving maternal health – would complement rather than compete with HIV/AIDS for funding. Dr Goosby added that efforts would include support for expanding health-related infrastructure and work force.
"What the president understands very well is that you can't address diseases in a vacuum," Dr Fauci said. "We are not going to restrict what we study [at NIAID] to HIV, but also to other diseases in the context of HIV, like TB and hepatitis....I think that's going to make it better, because people with HIV are also dying of other diseases."
While humanitarian motivation is often short-lived, Dr Fauci suggested that the economic "pie" will grow when people realize that "a healthy world is essential for successful global development."
"When you reach a certain level in the scale-up you start seeing system-wide benefits beyond the individual," said moderator Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. "I wish the political world could hear that when they think about their investments."
Continuing this theme, Dr Goosby said "the best health care can only go so far when there is not an opportunity for patients and their families to be supported." While international assistance remains critical, he said the ultimate goal "is for each country to be in a position to control its response to HIV".
Dr Goosby also emphasised the central important of human rights in the fight against HIV/AIDS, including protections for men who have sex with men, transgender people, sex workers, and injecting drug users.
Further information
A Fauci and E Goosby Global HIV research and policy and programme implementation under the new United States administration. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention, Cape Town, MOSS1, 2009.