Before Secretary of State Hilary Rodham Clinton passes the reins to her successor, she's got a few loose ends to tie up. One of them is mapping out the U.S.'s continuing efforts to combat AIDS around the world.
So today she unveiled a "blueprint" for what she called an "AIDS-free generation."
Now Clinton isn't talking about ending the HIV pandemic altogether. Rather, she hopes to prevent most new infections from occurring in the first place and to stop HIV-positive people from developing AIDS.
"As we continue to drive down the number of new infections and drive up the number of people on treatment, we will get ahead of the pandemic and an AIDS-free generation will be in sight," she told an audience of AIDS advocates and government officials at the state department.
Just last week UNAIDS said that over the past decade the rate of new HIV infections has dropped by more than half in 25 low- and middle- income countries, most of them in sub-Saharan Africa. And, the U.S. has helped to get 5.1 million people on antiretroviral treatment over the past four years.
Yet despite this encouraging news, some public health leaders are skeptical that an AIDS-free generation is a realistic goal right now.
"We are still a very long way from that," Dr. Helen Rees, an HIV specialist at the University of Witwatersrand in South Africa, tells Shots. "It's still at this point aspirational, and it's good to have aspirations."
The goal of stopping new infections became theoretically possible just a year ago when a study showed that antiretroviral treatments dramatically reduce a person's risk of transmitting the virus to others.
But the jury is still out on whether the drugs will have the same effect in the real world, outside of a study, Rees says.
"We certainly know that when you lower people's viral loads through treatment, the chance of their infecting another person is massively reduced," she says, referring to the amount of HIV in the blood. "[But] we don't know if that sort of scenario will occur at the same rate as if we did test-and-treat in the general population."
Clinton's AIDS blueprint hinges heavily on a "treatment as prevention" strategy. Indeed, the President's Emergency Fund for AIDS Relief, or PEPFAR is spending millions of dollars to see if it will in South Africa, Tanzania and Botswana, health economist Mead Over, of the Center for Global Development, tells Shots.
He says it will take several years to get the results. And that's one reason, he says, that "it's premature to have as an objective achieving an AIDS-free generation."
The tipping point for AIDS, Over says, will be when the number of new infections is lower than the number of people dying from HIV. Once that happens, the total number of HIV positive people would begin to decline.
"That's not the case now," he says. "In fact the gap is widening as we speak."
Over also worries that there aren't enough resources right now to treat enough people to achieve a decline in infection rates by treatment alone.
Indeed, Clinton's blueprint also involves other types of HIV prevention strategies, including male circumcision, condom distribution and stopping transmission from mother to child.
These approaches, in combination with treatment, "drops the number of new infections quite precipitously," the U.S. Global AIDS Coordinator, Dr. Eric Goosby, tells Shots. "So much so that we have dropped the percentage of new infections over the last 5 to 10 years from 25 to 90 percent in most of sub-Saharan Africa."
So what will all this cost the U.S.?
Secretary Clinton didn't say – nor does her blueprint.
Goosby says those numbers exist, but he couldn't get out ahead of the White House, which writes the budget.
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Last year, 1.7 million people around the world died of AIDS. The U.S. government wants to make that number zero. Today, Secretary of State Hillary Clinton unveiled what she calls a blueprint for achieving a generation free of AIDS.
But as NPR's Richard Knox reports, the plan leaves a lot of big questions unanswered.
RICHARD KNOX, BYLINE: Hillary Clinton left no doubt that she wants this blueprint to chart the way for whoever succeeds her as secretary of state and for a Congress that has to fund the plan. She stressed how far the world has come in the six years since the United States started pumping tens of billions of dollars into preventing and treating HIV infections through PEPFAR, the Presidents Emergency Plan for AIDS Relief.
SECRETARY HILLARY CLINTON: Just listen to these numbers: in Zimbabwe, a 50 percent reduction; in Namibia, a 68 percent reduction; and in Malawi, a 73 percent reduction in the rate of new infections.
KNOX: A year ago, President Obama set a goal of getting six million people treated with antiviral drugs by the end of next year, under the PEPFAR program. Officials say that goal will be met. But now the idea is to get five to 10 million more people on the life-saving medications.
CLINTON: Eventually, we will be able to treat more people than become infected every year. That will be the tipping point. We will then get ahead of the pandemic and an AIDS-free generation will be in our sight.
KNOX: But the secretary didn't say, nor did her blueprint, how much this will cost, nor would the PEPFAR director, Dr. Eric Goosby.
DR. ERIC GOOSBY: The numbers that were put out there were in the who-and-where we need to put those resources. And because this is not a budget document, it did not include any of those budget numbers.
KNOX: Those numbers exist. But Goosby said he couldn't get out ahead of the White House, which writes the budget.
It's important to understand that the blueprint doesn't aim to end the HIV pandemic. Clinton said people will get infected with the virus for many years to come. The goal is to prevent people from getting AIDS. That will happen if people with HIV get antiviral treatment so their infection never progresses to AIDS, and others don't get infected at all.
GOOSBY: You will reach the tipping point. We think that we're looking at a three to five-year period for most of the countries in sub-Saharan Africa who carry a heavy burden of disease - there's 22 of them in particular.
KNOX: Goosby acknowledges that this is not the best time to launch expensive new initiatives. But he thinks the fight against AIDS is special.
GOOSBY: This commitment, I believe, reflects the best of the American people. And I feel that the bipartisan support that is felt for PEPFAR is strong and growing.
KNOX: Still, not all AIDS experts think the time is right.
MEAD OVER: I think it's premature to have as an objective the achievement of an AIDS-free generation.
KNOX: Hat's Mead Over, an economist with the Center For Global Development, who has studied the pandemic for decades. He points out that the $30 billion PEPFAR has spent has not yet driven down HIV infections as fast as it has added to the millions now living with the virus.
OVER: So that's a very depressing observation, which suggests that the advent of all that money did not really succeed in changing the course of new infections.
KNOX: Dr. Helen Rees agrees. She's an AIDS specialist at the University of Witwatersrand in South Africa, which has the world's biggest HIV caseload.
DR. HELEN REES: As long as the number of new infections exceeds the number of people we're putting onto treatment, then the epidemic continues. So certainly in southern Africa, we have a lot of work to do to approach being able to talk about ending the epidemic.
KNOX: But there's one area she says is nearing the endgame. Within the next three years, she expects the number of babies being born with HIV will be approaching zero.
Richard Knox, NPR News. Transcript provided by NPR, Copyright NPR.