While policy makers’ decisions can have only a small effect on the magnitude of the HIV/AIDS epidemic and its burden1 by 2020, decision makers do have time to set a new course for the epidemic so that the prospects for 2020 onward look more optimistic than is the case today. Depending on decisions outlined in this chapter, morbidity, mortality, and resource and financial burdens faced in 2020 by the U.S. government and African countries for the ensuing decades could differ by a factor of 10 or more. Available policy choices include not only the rate at which HIV/AIDS treatment is scaled up, but also how it is scaled up and how scale-up is linked to the effectiveness of prevention. This chapter examines in turn the potential for reducing HIV incidence, the potential for reducing treatment need, and the key policy choices and associated trade-offs that decision makers must consider in formulating long-term strategies for responding to the epidemic.


As noted in Chapter 1, a guiding principle of this study is the need to reduce the incidence of HIV (defined as the number of new infections during a given period of time). The number of people needing treatment in the short term is driven mainly by those currently infected; over time, however, those acquiring infection will require treatment. Reductions in the incidence of HIV infection will take some time to alter the burdens of treatment and mortality but are necessary if these burdens are eventually to decline. Currently, people are becoming in need of treatment more rapidly than they are being placed on treatment. This means that, although the death rate from AIDS has fallen, deaths among those in need of treatment will continue. To improve this situation, two things must happen: treatment coverage must increase, and incidence must fall. The pattern of incidence of new HIV infections will determine the treatment need or, if treatment is not available, the death rate.

The ability to measure and monitor HIV incidence is critical to the capacity to monitor epidemiological trends within selected populations; assess the effectiveness of intervention programs; and appropriately direct limited resources for treatment, prevention, and care. Knowledge of HIV incidence is necessary both to understand transmission patterns and to project the burden of HIV infection in different demographic and at-risk populations. Reliable information on HIV incidence is especially important to support prevention programs in resource-


The burden of HIV/AIDS for a population in a given year can be defined to include five components: its impact on health, on national income, on donor and domestic spending, on the workload of health care providers and institutions, and on the dependence of patients on a daily dose of medication for their survival. The committee’s quantitative estimates of burden in this chapter and Appendix A focus on HIV prevalence as an indicator of the total health burden, on the total number of patients on treatment, on the total spending required to sustain treatment, and on spending as a share of projected national health expenditures. Chapter 4 considers in more depth the burden of HIV prevalence on the health sector in African states.

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