HIV and AIDS in 2030: A Choice Between Two Futures
HIV and AIDS in 2030: A Choice Between Two Futures

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Jonathan Quick: Barstow Is Both a Scientist and an Activist

On a balmy Sunday evening in July, 2000, President Thabo Mbeki of South Africa stood up to warmly welcome 12,000 of us gathered in Durban for the biennial International AIDS Conference.  He then proceeded to lay out his AIDS denialism manifesto, claiming that AIDS treatment was a CIA-Big Pharma plot.  That manifesto cost nearly a half-million South African lives before AIDS activists forced a policy reversal.  Today South Africa has the largest AIDS treatment program in the world.

In HIV and AIDS in 2030: A Choice Between Two Futures, Dr. David Barstow returns us to Durban three decades later for the 2030 International AIDS Conference.  He provides two parallel transcripts of a plenary panel of government officials, academics, and secular and faith-based NGO leaders.  One – set in a future in which AIDS has come back strongly – is a conversation of regret, frustration, disappointment, missed opportunities and feeling of failure for having the lost the war against AIDS. The other – set in a future in which AIDS is no longer a public health threat – is a conversation of joy, achievement and great satisfaction over having won the war against AIDS.

Dave and I met in June, 2018, when we were asked to lead a dialogue on ending AIDS at a conference we were both attending.  I’ve since come to greatly respect and admire Dave, who gave up a successful career in academia and business to fight the dehumanizing impact of HIV and AIDS stigma.  He attributes that determined shift to a remark by activist rock-star Bono at a 2006 Christian leadership conference. 

A self-described “computer scientist turned AIDS activist”, Dave deftly combines the meticulous attention to order and detail you would expect from a scientist with the persistence and passion for action you would expect from an activist.  The fruits of this combination are evident in Two Futures.

Dave’ s compelling and vivid approach lays out the implications of the choice confronting policy-makers, funders, and other world leaders today.  He worked closely with modeling experts and drew on published analyses, UNAIDS Fast Track projections, and the Global Fund Investment Case to ensure the win and lose scenarios and charts are plausible, well-supported, and based on the latest data.

In human terms the difference between the two futures couldn’t be more chilling:  The current 1 million annual AIDS deaths could be reduced to less than 340,000 in the best-case “Win” scenario or swell to nearly over 1.5 million deaths in the worse-case “loss” scenario.

Is such a resurgence possible?  I fear so, especially if “AIDS fatigue” and competing national and international priorities are allowed to undermined the gains from the unprecedented global response to AIDS over the last two decades.

We know how to end AIDS.  At the time of AIDS 2000, the range of proven prevention methods was limited, the cost of AIDS medicines was sky high, funding was limited, deaths were increasing, and families were on their own to care for the sick and orphaned.  Today we have a wide a range of tools and resources for prevention, care, and treatment, from post-exposure and pre-exposure prophylaxis, to established global and national supply systems, to effective approaches tailored to the circumstances of key populations.

The benefits of ending AIDS would be substantial.  The dramatic decrease in new cases would especially benefit youth and women, who would suffer the most from a resurgence of AIDS.   Reducing new cases and the resulting need for costly life-long treatment would also contribute to the viability of universal health coverage programs expanding in every region of the world.

Finally, ending AIDS is affordable.  Affected low- and middle-income countries are now bearing nearly two-thirds of the burden from public and private funding sources.  The remainder comes from the U.S. and other donor governments. To end AIDS by 2030 an additional $8 billion per year is needed from all sources.  Against this increase, economists calculate ending AIDS will generate economic returns of more that $460 billion.   

 If the AIDS epidemic has taught us anything, it is that the human and economic cost is huge each time national or world leaders deny, debate, and delay taking action, as President Mbeki did. Yet, as Martin Luther King reminds us, the greatest threat to social justice is the not its opponents but the “appalling silence” of its many supporters. 

 In Two Futures Dave Barstow makes it clear that we can win the war against AIDS – or lose it.  The outcome we reach is not a matter of speculation. It is a matter of choice:  take action or to sit back.  It is a choice that rests with our political and public health leaders.  It is choice that rests with each of us as global citizens to raise our voices. Ultimately, it is moral choice for which we have the know-how, the resources, and no excuse for not acting.

Jonathan D. Quick, MD, MPH

Author, The End of Epidemics: The Looming Threat to Humanity and How to Stop It

Adjunct Professor of Global Health, Duke Global Health Institute

David Barstow