Global Health Progress

Ambassador Mark Dybul, Former U.S. Global AIDS Coordinator
Co-director, O’Neill Institute for National and Global Health Law, Georgetown University

Today, on HIV Vaccine Awareness Day, we pay tribute to all those contributing to the pursuit of a safe, effective and affordable vaccine against HIV.  Much progress has been made globally to advance prevention, treatment and care because of the leadership, commitment and talent of leaders from all sectors in-country at the national, community and individual levels. However, with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) , the Global Fund to Fight AIDS, Tuberculosis and Malaria and the UN family though the co-sponsors that make up UNAIDS, we have only just begun.  We cannot reach the ultimate goal – an HIV Free Generation – without a safe and effective vaccine.

The U.S. is the global leader in HIV vaccine development.  Biomedical researchers in our nation’s world-class laboratories are funded by the pharmaceutical and biotech industries, the U.S. Government (which provided approximately 80 percent of public expenditures for HIV vaccines), and foundations, most notably the Bill & Melinda Gates Foundation. In addition to basic research, clinical research physicians are leading HIV vaccine studies, volunteers are enrolling in clinical trials, and the community voices are advocating for funding and partnerships to reach the goal of an AIDS vaccine. All deserve our recognition and appreciation.

Twenty-five years ago, the U.S. Health and Human Services Secretary predicted an AIDS vaccine would be in ready for testing in two years. Another 20 years and numerous promising HIV vaccine candidates have come and gone.  The past year was a difficult one, but that is the natural arc of scientific advance.  We have learned much, and from that learning we continue the movement and momentum to find a vaccine.  Now is not the time to back away because we do not have a vaccine – now is the time to redouble our efforts because we do not have a vaccine.

But without an unanticipated technological breakthrough, realistically, it will be years – 5, 10, or maybe another 20 – before we have an HIV vaccine. Meanwhile, we are still facing over 7,000 new HIV infections every day around the world. We know how HIV is transmitted and despite difficulties in measuring the success of specific programs, we know that HIV prevalence rates can drop dramatically.  Recently, Namibia reported a nearly 50 percent decline in HIV rates among 15-24-year-old persons, following previous reports of 30 percent reductions in Kenya, 23 percent in Zimbabwe, and an overall reduction in Africa.

So we don’t need to wait for a vaccine to prevent HIV infections –there are proven strategies and evidence-based approaches that can dramatically reduce the transmission of HIV today. Education and behavior change including delaying sexual debut, partner reduction – both casual and multiple concurrent – and use of condoms, counseling and testing, prevention of mother-to-child transmission, male circumcision, post-exposure prophylaxis and the rapid expansion of treatment that contributes to decreased transmission, need to be financed and championed for scale-up, penetration and coverage.  And we are hopeful that pre-exposure prophylaxis will contribute to the prevention arsenal in the near future.

There is no silver bullet.  Combination HIV prevention – just like combination antiretiroviral therapy for HIV infection – will be required to have an effective and long-lasting impact. And it is important to tailor interventions to the countries and communities at highest risk whether in a generalized or concentrated epidemic.  It is essential that the UNAIDS approach – “know your epidemic” — be implemented.

HIV prevention must also address the social, economic and cultural barriers that increase vulnerability to HIV and impede access to HIV prevention services. Largely because of gender inequality, the prevalence of HIV in girls in some areas of sub-Saharan Africa is 5 – 8 times that of boys, and a concentrated and concerted effort to reach girls would have enormous impact on the HIV landscape in the future.  Economic opportunities for youth in many countries ravaged by HIV/AIDS are bleak, offering few incentives or reasons to take more positive actions to ensure a healthy future. Effective HIV prevention must indeed look beyond biomedical and behavioral approaches alone and tackle the contextual issues that thwart HIV prevention efforts.

The key to HIV prevention is behavior change – especially among youth — and the marketing tools and communications technology of the private sector can be used to attract and motivate audiences, or to create economic opportunities that build a bright future for youth through education, skills training and employment.  All prevention interventions require behavior change, not just sexual behavior change.  Delivery of a safe and effective vaccine will require people to know about it, believe it is worthwhile and take the time to get it.

A new public-private partnership for HIV prevention is radically altering the HIV behavior change landscape.  While it is focused on sexual prevention, the tools and strategy have broad implications. The Partnership for an HIV-Free Generation was launched at World AIDS Day 2008 in Kenya, bringing together 18 private sector partners and youth groups with the U.S. government through PEPFAR.  HIV-Free Generation combines PEPFAR’s technical and programmatic capacity with the expertise of the private sector in messaging, branding, new communication and entertainment technologies, and real-time market research to promote and maintain behavior change. Iconic companies and organizations such as Hasbro, Intel, Microsoft, Nike Foundation, Warner Brothers and the MTV Staying Alive Foundation, Junior Achievement and Girls Scouts USA will take HIV prevention to new levels by promoting healthy living, positive behavior change, gender equality and links with economic skills and opportunities.

Today we commemorate HIV Vaccine Awareness Day and look to the future when safe, effective and affordable AIDS vaccines are available. But today’s proven HIV prevention strategies are just not a “holding pattern” until such an AIDS vaccine is available.  The effective use of available HIV prevention tools and technologies will build a much more stable, solid and embracing platform for the AIDS vaccines that come in the future, whether 5 years or 20 years from now.  And such HIV prevention strategies will continue to be necessary even in the advent of the successful AIDS vaccine. Let’s act now to ensure we can build a future free of HIV for generations to come.