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I'm witnessing the near defeat of AIDS in Africa. But I fear what comes next.

Trump must continue to invest in AIDS relief to see us to the end of the epidemic.

A study team conducts HIV tests as part of a ICAP survey in Zimbabwe in 2015.
ICAP at Columbia University

In 2002, when I first started working on HIV/AIDS in southern Africa, my friends and colleagues devoted every weekend to attending funerals. At that time, the antiretroviral drugs that were keeping people alive in New York and San Francisco were almost nowhere to be found in Africa, and the disease swiftly ravaged its victims.

Fifteen years later, the epidemic has turned a corner in three African countries that are at the epicenter of the crisis. In Zimbabwe, Malawi, and Zambia, the estimated number of new HIV infections per year has decreased by more than half since 2003, according to new research presented recently at one of the world’s top HIV conferences by my colleagues from Columbia University, the Centers for Disease Control and Prevention, and the three countries’ ministries of health.

Likewise, in all three countries, nearly two-thirds of all people living with HIV are receiving treatment that suppresses the virus in their bodies. This means they will live longer and healthier lives and won’t transmit the virus to others.

In 2014, UNAIDS, the UN body responsible for leading and coordinating the global AIDS response, came out with a bold set of targets to end the HIV epidemic by 2030, called 90-90-90. First, 90 percent of people living with HIV must be diagnosed, second, 90 percent of people diagnosed must receive treatment for HIV and third, 90 percent of people on treatment must take it daily in order to effectively suppress the virus in their bodies. If these targets could be met and sustained by 2020, mathematical models predict new infections would dwindle to zero by 2030.

Our research suggests that in one of the hardest hit corners of Africa, we are much closer to these goals than many experts would have guessed.

But victory is not yet assured. Ending the epidemic will require us to reach people who have not yet benefited from lifesaving prevention and treatment. That will mean President Donald Trump will need to reinforce the US commitment to its AIDS relief program, the President’s Emergency Plan for AIDS Relief (PEPFAR). As Bill Frist, a former Republican Senate majority leader, recently highlighted in the New York Times, PEPFAR is Trump’s opportunity to contribute to the goal of an AIDS-free generation.

How the world started winning the fight against AIDS in Africa

In the PEPFAR-funded surveys of more than 76,000 people we conducted in Malawi, Zimbabwe, and Zambia, we found that 70 percent of adults living with HIV have been diagnosed, 87 percent of those diagnosed report being on treatment, and 89 percent of those on treatment have very little virus in their bodies. And we’re not the only ones who’ve documented these trends — UNAIDS has similar estimates of the percentage of treatment coverage in these countries.

The 89 percent of people with very low levels of virus in their bodies are not cured, but they’re unlikely to get sick and they’re very unlikely to transmit the virus to anyone else. With three years left to go before the 2020 milestone, these three countries, home to more than 3 million people living with HIV, have nearly achieved two of the three 90 percent goals. (Their neighbor, South Africa, which has the largest HIV epidemic of any country in the world, has also made strides — its antiretroviral coverage is now 48 percent, according to UNAIDS.)

Such progress was unthinkable not that long ago. Several critical factors helped turn the situation around:

In 2003, George W. Bush launched PEPFAR, and the US committed billions of dollars to HIV prevention, care, and treatment in Africa. It was an act of moral leadership that became a stunning success. PEPFAR funds daily lifesaving antiretroviral treatment for 11.5 million people — the entire population of New York and Chicago.

Continuity and bipartisanship have been critical to PEPFAR’s success. The Obama administration continued President Bush’s AIDS program as PEPFAR received support from successive Democratic and Republican Congresses. This allowed PEPFAR to keep building on its foundations, advancing its impact and setting an example by focusing on results.

But the US wasn’t alone. Around the same time that PEPFAR started, more than 50 donor countries (including the US) began pooling funds through the Global Fund for AIDS, Tuberculosis and Malaria. The Global Fund streamlines the flow of funds and leverages economies of scale by purchasing essential medicines in bulk for multiple countries at a time using multiple donors’ funds.

Perhaps most inspiring, however, is that millions of policy makers, health workers, advocates, families, and patients in communities affected by HIV have worked hard to turn funding and resources into results.

In the Central African country of Cameroon where I lived from 2007 to 2009, I worked with two doctors, barely out of their 20s, who managed a caseload of 400 HIV positive children out of two tiny rooms. Down the street at Cameroon’s medical supply center, I worked with a spirited chief pharmacist. She loved to brag that in the country’s Southwest region, a group of women regularly hiked over the hilly terrain carrying boxes of HIV medicine on their heads to supply rural health posts.

To be sure, the funding and prestige in HIV work also attracted people who were not as supremely committed, but the progress we see today would not have been possible without a determined, resourceful majority.

Some people are still slipping through the cracks. Here’s how we help them.

By the end of 2016, more than 18 million people were receiving HIV treatment globally, leading to the progress we see today in the three key countries.

But not all people are benefitting equally. If we want to see the end of AIDS, we have to reach the people who are slipping through the cracks. Most notably, this includes men overall and young adults, both men and women.

At each of the three critical steps of the 90-90-90 targets, men trail women by up to 10 percentage points in the three countries we have studied. Likewise, in these countries, young adults aged 15 to 24 are only about half as likely to be aware of their HIV infection as adults over 35.

There are several potential reasons why young people may be less likely to know they have HIV. They may not seek testing because they feel they are not at risk for HIV or fear revealing they are sexually active.

Health workers may also be less likely to suggest an HIV test for a healthy-looking young person the way they would for a pregnant woman or a person who has signs of a weakened immune system. Further analysis of the recent studies in Malawi, Zimbabwe, and Zambia will shed light on the reasons for the diagnosis gap in these three countries. This will be critical, as people between the ages of 15 and 24 make up 20 percent of the population in these countries, and are likely to be sexually active. Hundreds of thousands of sexually active people with untreated, uncontrolled HIV puts the goal of zero new infections in serious jeopardy.

Our new data is proof that we can effectively control the AIDS epidemic in Africa. If we build on the progress we have made and focus on reaching the people who are not yet diagnosed and treated, AIDS will be to our children what smallpox and polio are to us.

But this good news also throws down a gauntlet. We cannot become fatigued and lose interest. The US must stay committed to PEPFAR and the international collaboration through the Global Fund. We must build on what has been accomplished, otherwise we risk seeing the epidemic roar back. It’s our fight to win, but it’s also ours to lose — an AIDS-free generation hangs in the balance.

Elizabeth Radin is a lecturer in epidemiology at Columbia’s Mailman School of Public Health and a technical specialist at ICAP.

Further reading: Joseph Frankel at the Atlantic writes about what we know about the Trump administration’s support for PEPFAR so far.

Vox’s Julia Belluz on why Obamacare repeal would be devastating to people with HIV.

9 maps and charts that explain the HIV epidemic.

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