truth in advertsingPerhaps it is not advertising in the strictest sense of the term but when WHO puts out their five-year goals for ending the HIV epidemic it is communicating two things— a sincere call to bring the largest sexually transmitted infectious disease epidemic in modern history under control and, the need for funding to do it. Like any large organization, company, institution or non-profit you have to dig deep to know whether the requested funding will allow them to achieve their goals, especially in the context of previous failures. For an epidemic like HIV which has raged on for more than three decades in spite of billions of dollars expended by multiple organizations, it is not unreasonable to pointedly ask—is it possible to reach the goals set by WHO by 2020?

The HIV epidemic was first recognized in 1981 and has continued ever since. Remarkable progress has been made in identifying HIV as the cause of AIDS, the ability to diagnose infection, the development of more than 30 drugs and combinations of drugs to treat and prevent infection, and the identification of all known methods of prevention. Yet the epidemic has persisted at a level that in the early years of discovery was considered unimaginable but seems to now, in spite of its enormity, has moved into the realm of allowable.

WHO requires a lot of funding. WHO’s annual estimated budget of over $4.5 billion comes from a number of sources—$1.5 billion is derived from voluntary donations from member states, the UN, and other international institutions. WHO is required to do a lot for that amount of money and it often does, but it has also failed with the most recent notable examples being HIV and Ebola as well as the highly touted Millennium Goals. So it is important to closely examine the potential to achieve its most recent goals for HIV cleverly expressed as 90—90—90. (“By 2020, 90% of all people living with HIV will know their HIV status. By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.”)

To achieve this goal it will be necessary to identify 90% of those who are HIV-infected worldwide currently estimated at more than 35 million and provide antiretroviral treatment to all of them. The truth in advertising part comes in when examining what has happened over the past two decades and the glaring omission by WHO and other international health organizations of the fundamental public-health principle for preventing sexually transmitted infections—contact tracing. After more than two decades of recommending that all HIV-infected individuals be treated with highly active antiretrovirals ( HAART) by international HIV experts at the 1996 Vancouver IAS conference only 50% of those who are estimated to be infected are receiving treatment and the number of individuals who are infected but do not know it are estimated to be 19 million. A major contributor to these deficiencies is the continued failure to implement contact tracing. WHO has no rational explanation of how their 90—90—90 goal can be achieved without implementing it. WHO makes no mention of the fact that without contact tracing the HIV epidemic will not just continue but will soon run the risk of expanding as HIV drug resistance becomes more prevalent and newer antiretroviral drugs once again become too expensive for income poor countries.

The HIV epidemic began when the virus crossed over from nonhuman primates into humans and infected the very first individual somewhere in Africa. It then spread worldwide through sexual transmission. It is unrealistic to believe that an epidemic of the ongoing magnitude (1.5 to 2 million new infections each year) can be controlled without a large and sincere effort to conduct universal HIV testing on all sexually active individuals. A goal of diagnosing 90% of the 35 million HIV infected individuals means that there will be 3.5 million HIV individuals who will be undetected, fail to receive treatment and continue to transit HIV infection to others. Accepting a goal of 3.5 million simple resets the epidemic to a number that will insure that the epidemic continues. There is urgency to conducting contact tracing which must be done confidentially and with every effort to protect individuals form discrimination and stigma. But it must be recognized that failure to conduct contact tracing is discriminatory in and of  itself resulting in the failure to protect uninfected individuals from a potentially lethal infection and the failure to identify those already infected who would befit from lifesaving treatment with ARVs and, if treated, further reduce sexual HIV transmission.

WHO has the global health megaphone to advertise what is right in public health. Truth in advertising means letting everyone known that if their goal of 90—90—90 is to be achieve it must include contact tracing.

References

WHO/UNAIDS 90—90—90 http://www.unaids.org/en/resources/documents/2014/90-90-90

WHO and Ebola. Too big to {f]ail. http://www.economist.com/news/international/21636038-ebola-has-laid-bare-failings-worlds-health-authority-too-big-ail

UNAIDS report shows that 19 million of the 35 million people living with HIV today do not know that they have the virus.  http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2014/july/20140716prgapreport

WHO Budget. http://www.who.int/about/finances-accountability/budget/en/