Pivoting to End the Epidemic: Can We Do It?

Lisa Fitzpatrick, M.D., M.P.H.
Lisa Fitzpatrick, M.D., M.P.H.

The last two years have been filled with wonderful news for HIV science, including the focus on treatment as prevention, the availability and endorsement of pre-exposure prophylaxis (PrEP) for high-risk populations, and efforts across the country to scale up testing and linkage to HIV care. Expansive discussions about each of these advancements have loomed large at each infectious diseases-related conference, including the recent 2012 International AIDS Conference (AIDS 2012).

The conference was well attended, with over 20,000 participants spanning the globe. It afforded many of us who have worked for many years in global and domestic HIV/AIDS the opportunity to reconnect with old colleagues, share ideas and network about potential collaboration opportunities. By many measures, AIDS 2012 was a resounding success.

However, as I reflected on whether the conference shifted our focus to achieve a more direct and positive impact on reducing new infections, increasing testing uptake and improving engagement in HIV care, my view dimmed a bit.

The week of AIDS 2012, our clinic registered six patients with newly diagnosed HIV infection. On one hand, these new diagnoses were clearly due to our testing expansion efforts. But at the same time, I asked myself: Why hadn't they benefited from any of the prevention messages and strategies that should have kept them from becoming HIV infected and having to walk through our doors?

I wondered about the magnitude of the financial and human resource investments we have committed to conferences like AIDS 2012, and whether or not these resources should instead be utilized to implement structural interventions that present barriers to prevention, testing, treatment and engagement in care. We know of these barriers because the HIV scientific literature is rich with information naming and describing these challenges. But at AIDS 2012, I didn't hear concrete conversations about a clear and specific strategy to address these challenges.

What is our responsibility to face these issues head-on? What will it really take to turn the tide of this epidemic? Can we really get to zero, and what concrete steps must we take to achieve this? These are the conversations we shun, because the answers are elusive and overwhelming -- and because, for obvious reasons, we like conferences.

Connecting with other HIV stakeholders and hearing about shared hardships, program challenges and concerns from across the country and around the globe lifts our spirits and boosts our morale. These connections remind us we are not struggling to fight this disease alone. That's positive.

But a recurring theme in these conversations is the need for more financial resources to "fight" HIV. The notion that a lack of funding presents the greatest barrier to addressing the epidemic feels shortsighted and uninformed. My experience collaborating within multi-lateral partnerships and with program implementation on the ground causes me to disagree with these ardent cries and demands for increases in funding.

In 2011, the U.S. funding allocation for HIV/AIDS was over $20 billion. That's substantial. We desperately need these funds to address the epidemic, but have we considered how much of this money directly impacts the availability of testing, treatment and engagement in HIV care? It's a fascinating question -- one we can no longer afford to evade.

I believe ending the epidemic is absolutely achievable. But doing so may require a sharp right pivot from current conversations and business as usual.