Throughout the XIX International AIDS Conference (aka "AIDS 2012"), which was held in Washington, DC this past July, speaker after speaker enthused that we were poised to create an "AIDS-free generation" and that we were on the verge of "ending AIDS." From UN Secretary General Ban Ki-moon and U.S. Secretary of State Hillary Clinton, who spoke at the beginning of the conference of 24,000 people, to incoming International AIDS Society President, Francoise Barré-Sinoussi and former U.S. President Bill Clinton, who spoke at its end, there was nearly unbridled enthusiasm from those at the podium that the end was in sight. Their hope and belief were based on a set of recent scientific breakthroughs that, when added to those already in the "toolbox", could reduce new HIV infections sufficiently to usher in the end of the pandemic. Chief among these recent discoveries are that voluntary male circumcision can reduce female-to-male HIV transmission, and that taking antiretroviral (ARV) medications both as treatment and prophylaxis - approaches known as "treatment as prevention" - can reduce HIV transmission and acquisition among men and women. Secretary Clinton singled these out, along with the pre-existing strategy of pregnant women using ARVs to prevent HIV transmission to their newborns, as the key elements in achieving an AIDS-free generation, which she defined as "virtually no child anywhere will be born with the virus" by 2015. Beyond Secretary Clinton, belief in treatment as prevention (or "treatment is prevention") was fervent at the conference, as it is in current AIDS science and policy discourse.
Although it became almost heretical to register any doubt at AIDS 2012 about achieving an end to AIDS in the near future, there were many scientists, practitioners, policy advocates, and community representatives who pointed out some of the challenges. These include the fact that even if new infections decline precipitously in coming years, there will still be millions of people living with HIV for quite some time. The financial and social implications of this will remain high. In the current global economic crisis, the question of who will pay for HIV prevention, treatment, care and support services for over 30 million people is paramount. The U.S. government, through its President's Emergency Plan for AIDS Relief (PEPFAR) and its contribution to the Global Fund for HIV, TB and Malaria, has been the biggest funder of programs throughout the world, but there is no guarantee that its level of support can be maintained.
Moreover, the success of HIV/AIDS programs is dependent on a host of other social factors besides direct funding of them. These include social/structural issues related to such things as the structure and capacity of health systems, equality or inequality in access to services, education and social marketing about HIV prevention and care, appropriate targeting of interventions to particular population groups, and the influence of local culture, religion, and law on stigma or acceptance of people living with or at risk of HIV. There are also psycho-social issues related to the perceptions individuals have about and the meanings they give to HIV prevention and treatment strategies. All research on both biomedical technologies (such as male circumcision, and ARV) and behavioral interventions (such as condom-use and sexual negotiation skills-building programs) concludes that they are only effective if used. "Adherence" - using methods correctly and consistently - is the key to the success or failure of any HIV prevention or treatment modality, and it is fundamentally a function of psycho-social dynamics - comfort, ease, and desire of use - that reside primarily with individuals. What this means is that, even if the new prevention technologies highlighted at AIDS 2012 and among "treatment as prevention" advocates show efficacy in somewhat rarified clinical trials, their effectiveness at a population level will be affected by complex social and behavioral conditions that exist in "the real world."
These realities did receive some attention at AIDS 2012 in the form of sessions devoted to the "social determinants of health". Speakers highlighted the ways in which macro and micro social factors, such as political economy, gender inequality, housing, migration, conflict and violence, human rights laws, organized religion, etc. affect HIV epidemics and responses to them. The causal chains between social forces and individual health outcomes are complex and often non-linear, and they operate through multiple intermediate factors at the institutional and individual levels. As such, it is quite difficult to devise interventions to change social factors and to evaluate their effectiveness on HIV outcomes in the short-term. But, as many scholars and advocates have argued, it is essential to address social/structural factors as both drivers themselves of HIV epidemics and as potential facilitators of the effectiveness of technological advances in HIV prevention and treatment.
What was both fascinating and troubling to observe at AIDS 2012 was that these two conversations - one focused on biomedical technologies (particularly "treatment as prevention") that will help bring about an "AIDS-free generation", and the other focused on the "social determinants of health" that will either facilitate or impede that outcome - took place on parallel tracks. Almost no one brought the two streams together. But this is precisely what must occur if we are to truly "end AIDS". New technological developments will only work if people who need them have unfettered access to them (including payment for them), believe they will help more than harm them, and are able to take them up without fear of discrimination or social marginalization, regardless of their sex, gender, class, age, religion, race/ethnicity, citizenship or immigration status. Getting to this place will require more cross-disciplinary discussions that genuinely value the contributions of social, behavioral, and biomedical sciences equally, and it will require more inter-sectoral discussions seeking ways to translate scientific evidence into social and structural changes that can truly facilitate the end of AIDS.
The views expressed in Research Watch commentaries are those of the authors and do not necessarily reflect the view of UNICEF
Dr. Judith Auerbach is a sociologist and independent science and policy consultant, who most recently served as Vice President, Research & Evaluation at the San Francisco AIDS Foundation. Her previous positions include Vice President, Public Policy and Program Development, at amfAR (The Foundation for AIDS Research), Director of the Behavioral and Social Science Program and HIV Prevention Science Coordinator in the Office of AIDS Research at the U.S. National Institutes of Health (NIH), Assistant Director for Social and Behavioral Sciences in the White House Office of Science and Technology Policy, and Senior Program Officer at the Institute of Medicine. Dr. Auerbach received her Ph.D. in Sociology from the University of California, Berkeley, and has taught, presented, and published in the areas of HIV/AIDS, social science and public policy, and sex and gender, with articles appearing in such journals as Global Public Health, American Journal of Public Health, Science, Health Affairs, and the Journal of Health and Social Behavior. She serves on a number of commissions, advisory, and editorial boards, including the Global HIV Prevention Working Group, the NIH Office of AIDS Research Advisory Council, and the Journal of the International AIDS Society. Dr. Auerbach has received a number of awards, including the 2004 Feminist Activist Award from Sociologists for Women in Society, the 2006 Research in Action Award from the Treatment Action Group (TAG), the 2008 Career Award from the Sociologists AIDS Network, and the 2010 Thomas M. Kelly Leadership Award from Project Inform.