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Here in Vienna, at the crossroads of Europe, 20,000 people from 185 countries have gathered for the 18th International AIDS Conference. The Austrian physician who chairs the conference, Dr. Brigitte Schmied, greeted this throng by recalling that “In the past five years, the coverage of HIV treatment in low- and middle-income countries has increased tenfold to now reach five million people.” No question about it.  This is an amazing achievement by the international community, which has not only prolonged the lives of all five million patients, but also helped their families and strengthened aspects of the health systems in recipient countries.  Other benefits may have also accrued to the recipient societies, but are hard to demonstrate.

But, this increase in treatment has simultaneously spurred an enormous increase in cost.  And in entitlements.  

To sustain each of these five million lives for another year will cost somewhere between $500 and $5,000, depending on the country.  That’s about $5 billion dollars a year and covers only about a quarter of those needing treatment by WHO’s new definition.  Nevertheless, Dr. Schmied assured the conference participants, “We have shown the skeptics that universal access is achievable.”

Well, no.  No one has shown that universal access is achievable.  At current levels of efficiency, resources would have to at least triple to achieve universal access and in today’s world of financial crisis, that’s not in the cards.  Furthermore, incremental progress towards universal access is frustrated because, each time we take a step forward, starting another million people on lifelong treatment, WHO redefines need as a larger share of the 33 million global total of HIV-infected people.  On the conference agenda and already in the opening speeches, there is much discussion of the advantages that would accrue from putting all 33 million on treatment for their rest of their lives, the so-called “test-and-treat” or TNT proposal.

Is universal access achievable?  Clearly, dramatic reductions in treatment costs would help.  The World Health Organization is proposing a new model of treatment, dubbed “Treatment 2.0,” to deliver better quality of care at a much lower cost.  But it’s not here yet and it might not work.  PEPFAR is attempting to increase recipient country “ownership” of its programs, hoping thereby to reduce the cost of U.S.-based supervision and to persuade these poor countries to spend more on AIDS (and therefore less on other cash-strapped government-financed social programs like education, roads and judiciary systems.).  But countries that assume “ownership,” and therefore control, of their AIDS programs might feel even less commitment to universal treatment access than do donors like PEPFAR and the Global Fund.  In the absence of new funding sources, AIDS patients and their advocates will have to wrest finite resources from many other claimants in the international development arena.

In fact, there is only one way to demonstrate that universal access is achievable:  we must present verifiable evidence that the number of new infections is trending lower, on a path towards becoming smaller than the annual number of deaths.  Only by holding down mortality rates, while simultaneously pushing the rate of new infections even lower, will the total number of people living with HIV/AIDS begin to shrink.  And only then, when we’ve reached this milestone I call the “AIDS Transition,” will universal access be truly within the reach of expanded and strengthened health systems.

If you are one of the 20,000 people here in Vienna and would like to hear more about the AIDS Transition, we invite you to attend the CGD sponsored session with that title, which will take place on Tuesday evening.  Check in your program for Satellite Session TUSA17 or just come to Mini Room 3 at 18:30.