Speakers presented their visions for the necessary investments to ensure a sustainable response to AIDS until 2031. New challenges will emerge, while existing challenges remain to present barriers to the response in the long term. While the patents of many existing drugs will have expired by 2031, investment in treatment, diagnostics and vaccines must continue. The importance of combination prevention tailored to specific contexts and communities that also include efforts to address systemic social change was emphasised. The epidemic in Sub-Saharan Africa was identified in particular for needing society-wide mobilisation, using new and innovative approaches and increased partnerships with the private sector.

Speakers spoke about the importance of activism and advocacy in the long-term response– for advocacy to ensure political leadership, for it to be confrontational, constructive and to be based on optimism and ambition. While advocacy has brought many successes, advocate identified the need for a more proactive approach in the future, and for stronger alliances with other health and human rights movements. Key issues included advocacy for the establishment and implementation of supportive legal frameworks including the decriminalisation of homosexuality, sex work and HIV transmission, as well a sustainable level of adequate level of financing with efficient use of resources. Middle-income countries in particular will have to do much better in allocating more domestic spending. This is a political decision, which governments are shying away from in those settings where stigma and discrimination is preventing financial allocation to meeting the needs of marginalised groups. The World Health Organisation was singled out by two of the session’s speakers as lacking in political leadership and commitment, and its regional representation described as “centres of nepotism and corruption”. 

Despite the clear need for advocacy, and in particular advocacy led by those most affected, it faces challenges, including lack of funding, and the need for greater investment in capacity building of leaders and young emerging advocates.

Looking to the future- the epidemic in 2031 and new directions in AIDS research

Dr Anthony Fauci, director of NIAID, presented his vision for the future of HIV research. He focused on the potential for progress in five key areas: (1) Pathogenesis studies. Early events in HIV infection should be further characterized, as the first few days of infection determine whether or not a vaccine will succeed or fail in preventing viral spread. Structural studies will help devise immunogens that can induce neutralizing antibodies. High throughput genomic studies will help identify new drug targets among host gene products. Studies of immune activation will help understand how the pool of CD4+ T cells is destroyed. (2) Diagnostics and monitoring should be made easier, cheaper, and brought to point of care worldwide. (3) Therapy is a success in terms of the number of molecules developed (25 approved so far by US FDA) but has not resulted in a single individual being cured of the virus. Obstacles to a cure include persistence of the latent reservoir and residual viral replication in gut associated lymphoid tissues. (4) Prevention: while prevention of mother to child transmission and post-exposure prophylaxis (PeP) are proven strategies, pre-exposure prophylaxis (PreP) and antiretroviral containing microbicides hold promise. (5) Vaccines. Dr Fauci thinks that key issues in basic and applied immunology should be solved prior to launching new large scale vaccine trials. Research priorities include understanding of early events  (including the role of the innate immune response), devising immunogens that induce broadly neutralizing antibodies, devising appropriate animal models, and understanding the correlates of vaccine-induced immune protection.