sciencemag.org SCIENCE 166 11 JULY 2014 • VOL 345 ISSUE 6193
Since 2001, HIV incidence has declined by 33% worldwide, and more than 9.7 million people with HIV have gained access to treatment.* The Joint United Nations Programme on HIV/ AIDS launched the Getting to Zero strategy (2011–2015) that includes zero new infections, zero deaths from HIV, and zero discrimination.
Aspirational statements such as “the end of AIDS”
have also prevailed. However, do such pronouncements help or hurt? Do they motivate action, or do
they risk incredulity, leading to inaction? Do such aspirations epitomize hype or hope?
The history of public health is replete with aspirational campaigns, with varying success. In 1971, the United
States launched a “war on
cancer,” increasing funding for
cancer research. Although great
progress has been made in our
understanding, diagnosis, and
management of cancer, this war
has not yet been won. With a
few exceptions, cures are rare,
disparities in cancer outcomes
remain, and investments in research are in question. On the
other hand, despite skepticism
about eradicating smallpox,
the World Health Organization
began a campaign in 1958 that
focused on vaccination, surveillance, and containment. Twenty
years later, smallpox was successfully eradicated.
As for HIV, there are cer-
tainly reasons to be optimistic.
Many countries with high HIV
prevalence have scaled up programs for preventing mother-to-child transmission,
and new pediatric infections are rare in several countries. Changes in therapy include earlier initiation of
antiretroviral therapy (ART) and the treatment of pregnant HIV-infected women for life. These approaches
have the potential to provide individual benefit to those
living with HIV and prevent further HIV transmission.
Additionally, new investments in health systems of-
fer a foundation on which prevention and treatment
services can be expanded further. However, implying
imminent success may be perceived as minimizing the
challenges that remain, resulting in the withdrawal
of resources and a consequent resurgence of the pre-
sumed “controlled” disease. This risk is particularly
relevant, because HIV expenditures are currently well
short of the annual global target of U.S. $22 billion
to $24 billion. Donor complacency would have cata-
Historically, some earlier optimistic predictions related to HIV have not met with success. These include
the announcement in 1984 that an AIDS vaccine was
forthcoming and early hope that ART would eradicate
HIV infection. The potential of ART to control the HIV
epidemic through a “test and treat” approach faces
stark realities. Only 33.6% of women and 17.2% of men
in low- and middle-income countries, and 34% of those
eligible for treatment, have
access to it,† and gaps in the
HIV care continuum limit the
potential of such an approach.
Additionally, although overall
incidence has declined, new infection rates among people who
inject drugs, men who have sex
with men, and young women in
southern Africa are alarming.
Several high-burden countries
lag behind in expanding programs for preventing mother-to-child transmission, and the
uptake of other prevention
methods remains limited. Disappointingly, progress toward
an efficacious vaccine—a critically needed intervention—has
faltered, and although there
is intense interest in finding a
cure, scalable interventions are
far from reality.
Why then have some scientists and advocates trumpeted
the goal of an “end of AIDS”? We perceive that they are
haunted by the fear of donor fatigue and a loss of momentum in the face of recognized challenges. However,
despite these concerns, we believe that with concerted
efforts and sustained commitments, we can make substantial advances toward the hope of a world in which
AIDS is no longer an epidemic threat. The campaign
against smallpox offers important lessons learned on
how it is possible to maintain efforts despite many nay-sayers. Envisioning a world without epidemic AIDS is a
deeply profound concept. Let this be the rallying call.
End of AIDS—Hype versus hope Wafaa M. El-Sadr is the director of
ICAP at Columbia
a professor at
School of Public
York, NY. E-mail:
– Wafaa M. El-Sadr, Katherine Harripersaud,
*UNAIDS, Global Report: UNAIDS Report on the Global AIDS Epidemic 2013 (UNAIDS, Geneva, Switzerland, 2013).
†WHO, UNICEF, UNAIDS, Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector.
Progress Report 2010 (WHO, UNICEF, and UNAIDS, Geneva, Switzerland, 2010).
“a world without epidemic
AIDS…Let this be the
SPECIAL SECTION STRATEGIES AGAINST HIV/AIDS
a staf member of
ICAP at Columbia
is a professor
at the Mailman
School of Public