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Scaling Up Treatment for the Global AIDS Pandemic: Challenges and Opportunities
More-effective methods are needed to increase recruitment, retention, and compliance with protocols for research on interventions aimed at HIV prevention and adherence to treatment. The efficacy of such interventions should be evaluated using rigorous research methods, including randomized controlled behavioral trials. Evaluations of behavioral interventions should use behavioral self-reports as outcome measures, as well as HIV seroincidence data and other biological markers. In addition to assessing efficacy, researchers should assess the cost-effectiveness of interventions. Finally, more research and debate are needed to address the pressing ethical issues involved in the conduct of such research.
Addressing Comorbidity and Poverty
It is increasingly being recognized that many individuals who are at risk of and become infected with HIV are also impoverished and afflicted with a number of comorbid conditions, including other infectious diseases (hepatitis, sexually transmitted diseases, TB, malaria, and other endemic diseases), substance abuse, and mental illness. The potential for negatively synergistic interactions between comorbidities and poverty is obvious. Research is needed to test the efficacy of interventions that simultaneously address multiple diagnoses and risks, including how to improve adherence to ART among those suffering from any number of other diseases and substance abuse problems. Means of mitigating the complications imposed by coexistent poverty should also be investigated.
Research is needed as well to better understand the underlying factors that contribute to the co-occurrence of HIV/AIDS and the progression of AIDS with other infectious diseases, substance abuse, alcohol abuse, and mental illness. Such research should encompass how to design efficacious and cost-effective strategies for addressing such comorbid conditions. It will be essential to better understand the intersection of HIV/AIDS with these related conditions if the treatment and prevention programs now being implemented are to be sustained for the decades that will be necessary to bring the pandemic under control.
ENSURING SUSTAINABILITY ALONG THE PATH FORWARD
Sustained action along the path forward presumes solutions to numerous discrete scientific and management challenges. At the same time, as wealthy, middle-income, and poor nations join together in perhaps an unprecedented way to tackle the overarching challenge of bringing the pandemic under control, it bears emphasizing that the global problem of HIV/ AIDS will likely be present for decades despite research findings and optimized interventions. In a few years, when it may be hoped that the initial