AIDS in 2031: where will we be?

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AIDS experts looking towards the state of the epidemic in 2031 warned the XVII International AIDS Conference today that massive investment is needed to scale up the manufacture of antiretroviral drugs for up to 110 million people, and that international donors need to think in terms of `pension fund` type provision to plan for the scale of antiretroviral provision that will be needed by 2031.

Dr Tony Fauci and Dr Robert Siliciano also told the conference, in separate sessions, of the need to re-double efforts to find a way of curing HIV infection – or at least finding a way to manage the disease without expensive lifelong drug treatment.

AIDS 2031 is a research and advocacy project launched by UNAIDS that is gathering a wide range of expert opinion to take a long-range view of what is needed to respond to HIV between now and 2031. The programme will look at technologies, advocacy, financing and prevention, and will report in 2009.



The total elimination of a pathogen, such as a virus, from the body. Eradication can also refer to the complete elimination of a disease from the world.


To eliminate a disease or a condition in an individual, or to fully restore health. A cure for HIV infection is one of the ultimate long-term goals of research today. It refers to a strategy or strategies that would eliminate HIV from a person’s body, or permanently control the virus and render it unable to cause disease. A ‘sterilising’ cure would completely eliminate the virus. A ‘functional’ cure would suppress HIV viral load, keeping it below the level of detection without the use of ART. The virus would not be eliminated from the body but would be effectively controlled and prevented from causing any illness. 


In discussions of consent for medical treatment, the ability of a person to make a decision for themselves and understand its implications. Young children, people who are unconscious and some people with mental health problems may lack capacity. In the context of health services, the staff and resources that are available for patient care.


The Joint United Nations Programme on HIV/AIDS (UNAIDS) brings together the resources of ten United Nations organisations in response to HIV and AIDS.

viral rebound

When a person on antiretroviral therapy (ART) has persistent, detectable levels of HIV in the blood after a period of undetectable levels. Causes of viral rebound can include drug resistance, poor adherence to an HIV treatment regimen or interrupting treatment.

The conference today heard preliminary views on the challenges facing the world in its response to HIV between now and 2031.

Mark Harrington, executive director of the Treatment Action Group, New York, told the conference that over the next 23 years, if new infections persist at a rate of 2.7 million a year, a total of 81 million people will be added to the 33 million already infected with HIV and in need of antiretroviral treatment. That would require almost a forty-fold increase in drug manufacturing capacity compared with current production.

“The manufacturing and logistic implications strongly argue for massive investment in the search for a cure,” Harrington warned.

He also called for universal HIV treatment for women as the most effective means of ending mother-to-child HIV transmission, and called for a continued global movement towards universal primary health care as the only way to strengthen health systems sufficiently to cope with the burden of HIV and other infectious and chronic diseases.

Asking `where do we need to be by 2031?`, UNAIDS executive director Peter Piot listed a number of desirable developments:

  • The majority of individuals in communities at risk, or in generalised epidemics, need to know their HIV status;
  • Drug development needs to keep in step with the global evolution of drug resistance, and more durable and better tolerated first- and second-line drugs will need to be available to all who need them;
  • Use of effective pre-exposure prophylaxis with antiretroviral drugs, and the appropriate application of antiretroviral treatment for prevention purposes.

But above all, said Piot, what is needed is a cure, a theme pursued in two lectures by Dr Tony Fauci and Dr Robert Siliciano.

Given that it is unlikely we will have the logistical and financial capacity to reach and treat everyone for life who requires treatment, said Dr Fauci, there is a need to expand research into how HIV infection might be eradicated – or at least contained so that it does not require lifelong treatment.

Over the next few years we can expect to see more extensive research into the potentially huge number of virus–host protein interactions, using microarray gene assays. “There are scores and scores of potential intracellular targets that we can use to develop new therapeutic interventions,” said Dr Fauci.

More research into the very early events in HIV – particularly the first few days – will also be crucial in determining whether eradication is possible, and which patients stand the best chance of being cured.

Dr Robert Siliciano expanded on the research agenda for HIV eradication in a plenary lecture, explaining that all the reservoirs of chronically infected cells that contribute to viral rebound when treatment is stopped have probably not yet been identified. Similarly, the right combination of drugs for driving down viral load and restricting the size of these reservoirs in primary infection is still unclear, although integrase inhibitors in particular are likely to have an important role, due to their ability to stop HIV from integrating into immune system cells.

Financing and advocacy

Piot warned that there was growing concern over the financial sustainability of universal access, both among country programmes and among donors. Everyone needs to make the money work more effectively – which means looking towards business models, he argued.

“The business of HIV prevention needs to become a real business, using business management and solid marketing…it would probably help if we bring in people from the business world to our pretty amateurish public health world,” he said.

He also highlighted the model of pension funds – funds which plan for a known and certain financial outcome – as a way of thinking about how to manage the long-term costs of antiretroviral therapy for the developing world, rather than thinking about how to limit `entitlements`.

Vuyiseka Dubula of South Africa’s Treatment Action Campaign said that it was time to start growing a new generation of leaders and advocates worldwide in order to sustain campaigns for access and human rights. In particular the advocacy of the most marginalised and vulnerable communities will need to be stepped up, she argued, and alliances developed with other social movements that have common goals in order to achieve aims like economic empowerment of women.