July 17, 2012 | By Bill Gates
2012 Annual Letter: HIV/AIDS
Excerpt from 2012 Annual Letter from Bill Gates.
The AIDS community has three big goals:
- Reduce the number of people getting infected. By 2015, the goal is to cut infections to 1 million per year, which would represent a 68 percent drop from the peak a decade ago.
- Provide drugs for everyone who needs them, so those with AIDS can live longer and more productive lives. Last year, 1.8 million people died of AIDS.
- Find a cure. Although there are people working toward a cure, it is viewed as so difficult that we can’t count on ever having one.
There are many ways to tackle the first goal: reducing infection. These methods can work individually and in combination. One approach is to convince people to avoid risky behavior. Education efforts are important, and they are getting more targeted, but their impact is uncertain.
Nineteen-year old Bayeza Manzini speaks to soccer players about the benefits of circumcision (Mataspha, Swaziland, 2010).
A second approach is male circumcision, which reduces HIV transmission by up to 70 percent. Funding for circumcision is finally being prioritized, since the cost is quite low and the protection is lifelong. Over 1 million men ages 15–49 have been circumcised in 14 Southern and Eastern African countries with large AIDS epidemics, but that is only 5 percent of the total number who could benefit from the procedure. Even in the ancient practice of circumcision, innovation has the potential to make a big difference. The new PrePex and Shang Ring devices simplify the procedure and make surgery unnecessary. The first studies suggest that these devices are both safe and effective. (I will keep this letter G-rated by leaving out the pictures of how the devices work.) Botswana, Kenya, South Africa, and Tanzania are starting to show leadership by getting the message out to all young men that it is important to get circumcised. Kenya has made the most progress, circumcising 70 percent of eligible men. I will be very disappointed if, by 2015, any fewer than 15 million young men have chosen to protect themselves and their partners by getting circumcised.
A third approach to prevention is to come up with an injection or pill or gel that reduces an uninfected person’s chance of becoming infected. The final results of studies of a number of these tools were reported in the last 18 months. In studies where the patients used the tool as they were supposed to, the results were quite good. However, in most studies the levels of usage were low and thus the overall results were disappointing. This has the field thinking hard about how you could motivate better adherence or create a tool that requires less effort from the patient. One example in early development is an injection that lasts 30 to 90 days. I think we will solve the adherence problem, but we are going to have to get medical scientists, social scientists, community representatives, and regulators working together. We have to develop and test overall delivery systems, including communication, support, and incentives, in ways that go beyond what a medical trial alone typically does.
A fourth approach, called treatment for prevention, is to give antiretroviral (ARV) drugs to people with AIDS earlier in the course of their disease, greatly reducing the chance that they will infect others. This is already done for pregnant mothers to reduce the chance of infecting their babies during delivery or through breast-feeding. The field has a goal of getting drugs to 90 percent of HIV-positive mothers by 2015, virtually ending mother-to-child transmission. The main problem with treatment for prevention is that most people who are infected with and transmitting HIV don’t know they are infected, so you wouldn’t know to give them drugs. In order to realize the full potential of treatment for prevention, we need to encourage widespread HIV testing, which will require developing a reliable, inexpensive saliva test that can be used privately.
One further approach to prevention is an AIDS vaccine. On this topic, this year’s news is very similar to last year’s. The scientific understanding of the AIDS virus—its shape, how it enters cells, and how we can use antibodies to block it—has advanced more than expected. However, plans for conducting trials of different constructs are still not as aggressive as they should be, given how game-changing a vaccine would be. It is still possible to have a vaccine within 12 years, but it will take some luck and better planning.
It is exciting to have so many prevention approaches available, and to be making progress on most of them. Funding continues to be a serious concern, but I am optimistic that the field will develop combined approaches to significantly bring down the rate of infection.
Meanwhile, there has also been amazing progress on the second major goal for the AIDS community: scaling up treatment. This is due mostly to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and to a U.S. program called PEPFAR: the United States President’s Emergency Plan for AIDS Relief. More than 6.6 million people are alive today because they are taking ARV drugs. Ten years ago it looked as if almost all of these people would die because the drugs were available only in rich countries.
Between 2008 and 2010 the Global Fund gave $8 billion for AIDS (57 percent), malaria (29 percent), and tuberculosis (14 percent). Other than PEPFAR for AIDS, the Global Fund is the biggest donor for all three of these diseases. It provided the money for 230 million bednets, which have been key to the 20 percent decline in malaria deaths over the past decade. It also provided treatment for 8.6 million cases of tuberculosis. I am not doing a section on malaria or TB in this year’s letter, but there has been good progress in both diseases, with the Global Fund being key to this.
The Global Fund does a lot to make sure its money is spent efficiently. Given the places where the Global Fund works, it is not surprising that some of the money was diverted for corrupt purposes. However, the Global Fund found these problems itself and changed the way it handled training grants, where most of the problems were. Unfortunately, news of any corruption makes many citizens think the entire program is mismanaged and a huge portion of the money is being wasted. Some of the headlines that talked about two-thirds of specific grants being misdirected fueled this impression. In fact, less than 5 percent of Global Fund money was misused, and with the new procedures in place that percentage will be even lower. Our foundation is the biggest nongovernment supporter of the Global Fund, committing $650 million over the years because of the incredible impact its spending has. I am confident that this is one of the most effective ways we invest our money every year, and I always urge other funders to join us in getting so much bang for our buck.
Between 2011 and 2013, assuming that all donors honor their commitments, the Global Fund will disburse $10 billion. This is a $2 billion increase, but not nearly the $12–$14 billion that is needed and was hoped for. Citizens of donor countries should know about the difference their generosity has made. The cost of keeping a patient on AIDS drugs has been coming down, and it looks like getting it to $300 per patient per year should be achievable. That will mean every $300 that governments invest in the Global Fund will put another person on treatment for a year. Every $300 that’s not forthcoming will represent a person taken off treatment. That’s a very clear choice. I believe that if people understood the choice, they would ask their government to save more lives.