Intended for healthcare professionals

Observations Yankee Doodling

The myth of an AIDS free world

BMJ 2012; 345 doi: (Published 14 August 2012) Cite this as: BMJ 2012;345:e5479
  1. Douglas Kamerow, chief scientist, RTI International, and associate editor, BMJ
  1. dkamerow{at}

Control isn’t the same as eradication

Two events here in Washington, DC, have got me thinking about HIV and AIDS. The first was a revival of Larry Kramer’s searing 1985 AIDS play The Normal Heart, which I saw recently. The second was the widely publicised 19th International AIDS Conference, held here at the end of July.1

Watching The Normal Heart I was reminded how grim things were in the early 1980s. Set in New York City, the play follows its hero, the gay activist Ned Weeks (a thinly disguised alter ego of the author), as he rants and raves about the unknown plague that is killing dozens and then hundreds of gay men every month. No one will listen, even fellow members of his activist organisation. Another major character is a physician who is caring for the dying men, basically serving as a palliative care doctor because she can isolate no pathogen and has no effective treatments. The city health department won’t pay attention, and the government won’t sponsor enough research to find the cause and its cure. It is a profoundly upsetting play. Many in the audience left the theatre in tears.

Flash forward to Washington, DC, in the summer of 2012. Twenty five thousand delegates attended the AIDS conference, held in the United States for the first time in 22 years because President Obama has now lifted the travel embargo against HIV positive travellers. An almost circus-like atmosphere filled the city: celebrity speakers, concerts, exhibits. World leaders addressed the crowd. People were talking about a vaccine and a cure. The US secretary of state, Hillary Clinton, spoke and said we can achieve an “AIDS free generation.”


Of course, there has been astonishing progress against AIDS. The vast majority of HIV positive people can expect to live a relatively normal life with a chronic disease—if they can get access to treatment and take it regularly. International charities and rich countries work closely with the developing world to sponsor successful HIV treatment programmes. New studies have shown that drugs used for treatment can also be used two ways as preventatives: to prevent HIV transmission when taken by HIV positive patients and to prevent HIV infection when taken by HIV negative people with risky behaviours.2 We have never had so many ways to treat and prevent HIV infection. The cost of keeping people on antiretrovirals has plummeted in the developing world, averaging as little as $200 (£130; €160) to treat one person for a year. These are huge accomplishments.

But two concerns immediately arise: the magnitude of the work remaining to find and continuously treat all those infected, and the confusion between that treatment (even if it is somehow universally successful) and actual eradication of the disease.

Almost 35 million people are currently living with HIV infection.3 Many of them don’t know it. Every time they have sex or have a baby they can pass the infection to others. Many of the infected are in often marginalised groups: injecting drug users, sex workers, men who have sex with men, some ethnic minorities, or some combination of these. Drugs and behavioural changes can prevent transmission, but they have to be used all the time to work.

Ninety per cent of people infected with HIV live in developing countries. Despite huge contributions of aid from rich countries, millions go without treatment. Slightly more than half of HIV infected patients in sub-Saharan Africa are undergoing treatment, fewer in Asia and Eastern Europe.

In the US, remarkably, the story is not much different. Right here in Washington, the proportion of the population infected with HIV is 2.7%, similar to that in Rwanda. Less than 30% of them have the virus under control (virally suppressed). Nationwide, only a quarter of all Americans with HIV infection have their disease under control.4 Given what we know and how much we already spend, what is the likelihood we will be able to control this epidemic in the near future? It seems small.

But what if somehow we succeeded in getting all HIV positive people in the world identified and under long term treatment? What if everyone followed behavioural recommendations about sex and drug use? In this welcome but very unlikely scenario, there would actually be, for the first time in 30 years, the possibility of a generation that could escape infection: an AIDS free generation. Babies would be born without HIV, and young people would be safe from infection from sex or needles. Furthermore, infected but asymptomatic patients would not progress to AIDS.

It is a rosy scenario, but even if it came true it still would not spell the end of the HIV story. HIV is not like smallpox or even like polio. We have no vaccine, and the virus keeps mutating. More widespread use of antiretrovirals will doubtlessly lead to inconsistent use and the resulting emergence of new drug resistant HIV strains, further complicating viral control. We will still be paying to keep 35 million people suppressed for the rest of their lives. And, lest we forget, we have no cure.

Sorry to be a “Debbie Downer” (as my children often label me), but these are the thoughts that come to me after the juxtaposition of The Normal Heart with the AIDS conference. How far we have come. How far we have to go.


Cite this as: BMJ 2012;345:e5479


  • Competing interests: DK, a former US assistant surgeon general, is the author of Dissecting American Health Care.


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