Access to HIV treatment worldwide has expanded substantially over the past decade with a significant reduction in AIDS-related morbidity and mortality.1
This achievement is the result of a global commitment and broad partnership between funders, country leadership and institutions, implementing organizations, and communities of people living with and affected by HIV.
Access to treatment has changed HIV disease from a “death sentence” into a manageable chronic condition for millions around the world. Yet, it is acknowledged that only 47% of PLWH in LMICs have access to such lifesaving treatment and, thus, there is great urgency to expand HIV treatment programs. In addition, a number of recent scientific findings have changed the landscape for PEPFAR-supported treatment programs, including the results of the CIPRA Haiti 001 trial, which led WHO to recommend initiation of ART at a higher CD4+
cell count threshold (<350 cells/mm3
), and the groundbreaking findings from HPTN 052, which demonstrated the efficacy of ART in reducing HIV transmission by 96% in HIV serodiscordant couples.51,52
These studies provided compelling scientific rationale for accelerating treatment access at earlier stages of HIV disease, not only for individual health benefits but also to help turn the tide of new infections. Model-based analyses have demonstrated that expanded treatment coverage, as part of a broader combination prevention package, could reduce annual new infections by more than 50% in the next 3 to 4 years.53
Key challenges remain to be addressed. Most PLWH are not aware of their HIV status, and in most settings, PLWH access ART at an advanced stage of HIV disease, contributing to mortality and morbidity and missed prevention opportunities.1,54
Furthermore, linkage from HIV testing to HIV prevention and care programs, retention in HIV care, timely initiation of ART upon eligibility, and achievement of high ART adherence rates remain key challenges in optimizing prevention and treatment outcomes for the individual, their partner, and the community.54
Continuing to address issues of ARV quality and cost in a proactive manner will also be essential to ensuring that PEPFAR investments result in the greatest possible impact on the HIV epidemic while building efficiencies that will foster greater sustainability and country ownership. This is particularly important in an era of resource constraints, although recent work has shown that in addition to the employment and productivity gains from ART, cost savings are garnered in the form of avoided expenditures on orphan care and delayed end-of-life care costs from AIDS-related morbidity.55
All in all, these findings suggest that from a societal perspective, the economic benefits are likely to equal or even exceed the costs of treatment provision, thereby indicating a positive economic return to investments in ART.50
Nevertheless, continuing to build a robust implementation research agenda will be fundamental to furthering the learning from ongoing programming and identifying efficient and effective methods to further expand the work and build on the success of PEPFAR.
In an address coinciding with the 2011 World AIDS Day, the compelling evidence for the remarkable gains achieved by expansion of HIV treatment and its potential impact on stemming the epidemic and enhancing the lives of communities around the world motivated US President Barack Obama to affirm the United States’ leadership role in combating the global epidemic. He pledged to increase by 50% the number of people PEPFAR supports on treatment over the next 2 years. This strong commitment will ensure that PEPFAR continues to lead the world’s response to the global HIV epidemic while serving as the foundation and platform for broader impacts through the US Global Health Initiative.