and infants. In overcoming the global disparity between the countries in which infants are rarely infected with HIV and those in which this is still common, eliminating infections among children and keeping their mothers alive (1) has become a rallying point for collective action and global solidarity.
Fourth, there is a new willingness to be inclusive and respectful of human dignity in AIDS responses, even in relation to taboo and stigmatized behaviour. In many places, AIDS has brought to light social fault-lines and made visible the places and populations where social exclusion and marginalization have allowed the virus to become endemic. Responses to vulnerability which have built a broad platform of respect for inalienable human rights and supported gender equality have made significant contributions to positive social transformation.
Investment in AIDS has benefited from an increasingly accurate picture of where new infections are occurring, what actions need to be in place to prevent them, and the most urgent steps to ensure people in need are able to access treatment. The transition from small scale projects and proof of concept studies, to mass treatment access programmes has been realized. With this transition, unit costs have declined as systems have expanded to meet need and economies of scale and scope have been realized. As the AIDS response has changed gears from a short-term emergency response to a sustained long-term programme, both effectiveness and efficiency have come to the forefront of programming efforts.
Do more of what works
Each of these signals of change must be amplified if we are to chart a course to end AIDS. This requires overcoming the barriers that restrict access to treatment (2). A system-wide approach is required to ensure that individual options to control HIV can be translated into impact at the population level.
Individuals have more options to manage their risk of HIV infection, as do couples to address their risk together. These include managing sexual and drug-use behaviour, using condoms or clean injecting equipment to avoid transmission, reducing the risk of acquiring HIV through male circumcision and using antiretroviral therapy to keep the virus in check for those who are living with HIV.
As Anthony S. Fauci and Elly Katabira write below, the latest additional option is to provide antiretroviral therapy to people who are not infected with HIV but at high risk of exposure. Clinical trials have shown a significant reduction in the number of HIV-negative people newly infected when they take daily antiretroviral therapy during a sustained period. However, these trials have also shown that healthy individuals face a major challenge in adhering to daily antiretroviral therapy, even in the closely monitored and supported setting of a clinical trial.
Options can transform the response
Setting the epidemic on a decisive downward course requires that new HIV prevention and treatment options build on and add to existing responses. Individual benefits need
to be converted into systemic responses with population-wide impact. UNAIDS is convening an array of partners to ensure that the AIDS response is transformed in the next four years. To realize this potential, barriers to access must be removed. Services need to be reoriented to be more accessible at the grassroots level, using community- and people-centred delivery. Treatment and prevention programmes need to be overhauled so that people are empowered to use existing biomedical tools to prevent and treat HIV and integrate these biomedical tools into individual and community strategies to minimise risk.
This report documents the steady rise in access to antiretroviral therapy and the increasing value for money that can be achieved as programmes have moved to scale. Integral to this progress has been decentralizing care. HIV treatment was once confined to tertiary hospitals with specialist facilities located only in the largest cities, whereas today treatment can be made available at local and district health centres. Treatment can be devolved because of
improved supply chains, which can reliably deliver diagnostics and treatment. Although drug stock- outs continue to be a concern, early-warning systems and stock control management systems are increasingly in place to minimize any disruptions.
As antiretroviral therapy regimens have become more stable and simpler, attention has turned to diagnostic systems. Developing and making
available these diagnostic technologies is a central plank of the Treatment 2.0 agenda developed by WHO, UNAIDS and diagnostic experts. This was designed to reduce prices and improve access while ensuring quality, reliability and accuracy. The key diagnostic steps in managing HIV are initially diagnosing and confirming HIV infection and monitoring CD4 cell count and viral load. Simplified diagnostic platforms for estimating the CD4 count at the point of care or in basic laboratory settings are starting to become commercially available and rapid testing for viral load is at an advanced stage of development. Technologies to test for multiple diseases such as HIV,
tuberculosis, sexually transmitted infections and viral hepatitis using one simple, reliable device are also in the pipeline.
There is a pressing need to address the bottlenecks in human resource capacity to support HIV services. This was a key element for progress in the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (1) in the 22 countries with the highest burden of infants acquiring HIV infection. Task-shifting has been critical to delivering HIV programmes on a wider scale. At the first annual progress meeting of the Global Plan in May 2012, health ministers from many countries, including Burundi, Chad and the Democratic Republic of the Congo, described advances in service delivery, including nurses delivering antiretroviral therapy. In the United Republic of Tanzania, all family planning services integrate HIV services and vice versa; Ghana has issued a policy to provide free family planning to everyone; and Botswana has