On World AIDS Day, infection rates are declining, but dwindling funds threaten progress

World AIDS Day on Wednesday is a chance to assess the impact of six years of heavy US and international donor funding.

This year on World AIDS Day, we’re likely to hear more of the bad news than the good. This is normal. One doesn’t call a fire department to report the 99 houses that are perfectly fine, but rather the one that is burning. Still, when it comes to the current state of the AIDS epidemic, the truth may be found in the balance between the two extremes.

First, the good news.

After several decades of explosive growth, particularly in Africa, there are signs that the AIDS epidemic is slowing. Over the past decade, new HIV infections have decreased by 20 percent, according to UNAIDS, the United Nations AIDS agency.

Here in South Africa – the country with the world’s highest number of people living with HIV, at 5.6 million – the drop in new infections is 25 percent. What this means is that all that money spent on education about condom use, abstention from sexual behavior, and being faithful to one’s partner seems to be working.

Much of the credit for this turnaround clearly belongs to funding from donor nations, and in particular, the US President's Emergency Plan for AIDS Relief (PEPFAR), the Global Health Initiative, and private donors such as the Bill and Melinda Gates Foundation. From its inception in 2004, PEPFAR funding has grown from $2.3 billion to $6.8 billion in 2010, allowing the US government to buy up and provide free-of-charge antiretroviral treatments to some 2.4 million people worldwide.

On Monday, UN Secretary Ban Ki Moon emphasized the positive trends in a speech.

“With commitment and solidarity, this movement is helping the world turn the corner on the AIDS epidemic,” Mr. Ban said. “We have finally reached the first part of Millennium Development Goal 6 – by halting and beginning to reverse the spread of HIV. We must continue to chart a new and bold path ahead.”

But Ban also acknowledged that there was still much work to be done: “Our common goal is clear: universal access to HIV prevention, treatment, care and support. We must also work to make the AIDS response sustainable.”

Which brings us to the bad news.

There are 33 million people around the world infected with HIV. HIV spreads through sexual contact, and also through blood transfusions and intravenous drug use. Of that 33 million, more than two-thirds (22.5 million) of all HIV-positive people live in Africa, and their access to health care and to AIDS treatment remains quite low. Some 12 million of those HIV patients will require immediate care through an expensive cocktail of drugs called antiretroviral (ARV) treatments, but only 7 million of them will actually receive treatment, according to a recent study by the US Institute of Medicine.

Hang in there. The news gets worse before it gets better.

Funding for AIDS research and treatment seems to have stalled, a sign of donor fatigue during the ongoing global economic slowdown. ARV treatments are costly and become even more expensive, far beyond the means of developing countries, where the AIDS epidemic is centered. Aid groups such as Doctors Without Borders warn of a growing funding gap, and a withdrawal of donor support precisely when those funds are needed the most.

"In South Africa and the whole of Africa, if we do see a decrease in funding, it will mean we go back on all of the progress made so far after six years of heavy support," says Gilles van Cutsem, medical coordinator for Doctors Without Borders in South Africa and Lesotho. "We currently have about 1 million people on ARV therapy and there are plans to expand that to 2 million by 2016. You will go back to the days when people were dying because they didn't have access to ARVs. People will have to wait much longer to get access to ARVs, and when they do come to get treatment, they will be much sicker patients."

"Even South Africa will not be spared," Dr. van Cutsem says, "but in poorer countries like Mozambique, Lesotho, Swaziland, Zimbabwe, and Malawi, this will affect people much more quickly and more severely."

Van Cutsem said in a report released in May by Doctors without Borders that poorer countries are estimated to need about $20 billion in private donations over the next three years, but only $11.7 billion has been raised so far.

Thus, even as overall donor funding is increasing for AIDS relief, it isn’t keeping pace with the AIDS epidemic itself. According to the US Institute of Medicine panel of experts, external donor funding won’t ever be enough to provide universal treatment for AIDS.

“Because treatment will only reach a fraction of those who need it ... preventing new infections should be the central tenet of any long term response to HIV/AIDS in Africa," Dr. Thomas Quinn, co-chair of the Institute of Medicine panel that wrote the report, said at a news conference in Washington. He is also a professor at Johns Hopkins University in Baltimore and the National Institutes of Health.