T H E S O U T H E R N A F R I C A N J O U R N A L O F H I V M E D I C I N E A P R I L 2 0 1 1 Imagine a small gathering. Gradually, word spreads and the intimate affair turns into a fulcrum of activity. From a handful of friends, hundreds of people join, bringing strobe lights, powerful loudspeakers and copious amounts of food. The party, one of the most successful ever held, lasts through the night. Then the lights are turned on, the cops arrive and the party grinds to a halt. No more parties are allowed, ever again. It is perhaps crude to depict the struggle to get HIV/ AIDS on the global agenda as a successful party being busted. The HIV/AIDS ‘community’ – for lack of a better word to describe a disjointed group of people focusing on a common challenge – is, however, a victim of its own success. In the 2000s it managed to rally immense political support and mobilise unprecedented financial and human resources. Nowadays, the luxury of that precious capital is no longer there. New priorities are occupying the global community, and HIV/AIDS is being treated like a scolded child who has squandered both parental trust and pocket money. In this context, a contemplative book like AIDS: Taking a Long-Term View is particularly necessary. The short, easy-to-read monograph takes a critical look at the field of HIV/AIDS policy from 1981 until today, 30 years after the virus was first reported. It explains and summarises, in layman’s terms, what the road ahead for HIV looks like. It serves as a useful resource for students of health policy as well as engaged policy makers. ‘It is fair to ask whether the global AIDS effort has always achieved good value for its money,’ suggests one of the chapters. ‘Despite a more than 53-fold increase in AIDS funding in barely over a decade, the epidemic continues to outpace the rate at which programs are delivering.’ These are indeed sobering estimates. Not only are such mind-boggling increases in funding unlikely to recur, but needs for such funds will certainly keep escalating. In light of this, a healthy degree of soul-searching is needed, and the book provides just that. The book succinctly takes stock of what the world of HIV has achieved, what it could have done differently, and what it should do today to ensure that 2031, the anniversary marking 50 years since AIDS was first reported, will be a party and not a funeral. In so doing, the group of academics and high-level practitioners that authored it – the aids2031 Consortium – provides a much-needed vision going forward. The key argument is that the AIDS community needs to shift from its current short-term thinking to a longer-term action plan. Unlike the global campaign against climate change, which has always adopted a long-term view, the reaction to the HIV epidemic was initially framed as an emergency response. From the start, HIV was portrayed as a catastrophe waiting to happen; its complex social and behavioural determinants, which could only be addressed in the long run, were not deemed as crucial as the here-and-now. It is no coincidence, for instance, that the HIV/AIDS co-ordinating body for Swaziland, a country with one of the highest HIV prevalence rates in the world, was named the National Emergency Response Council on HIV and AIDS (NERCHA). Part of the HIV community’s success in mobilising unprecedented amounts of funds in such a limited time is no doubt due to this approach. Nevertheless, this strategy is now back-firing. Millions of people have been placed on ARVs and thousands of new programmes have sprung up as a result of PEPFAR and Global Fund money, but now that the tide has changed and future funding is uncertain, sustainability poses a massive challenge. The book brings together the work of nine working groups focusing on modelling, social drivers, programmes, financing and leadership, among other things. It compiles the current consensus – arrived at following a long and serious consultative process – on all the key aspects of the epidemic into a single document. In so doing, the book does not actually tell us anything new. As the authors suggest, we should focus on prevention, and improve the efficiency of spending on HIV. We must ensure greater donor co-ordination and come up with innovative financing mechanisms and incentive schemes such as advance market commitments, in order to encourage research and investments in the right places. We must devote ourselves to finding and funding more easily administered and longer-lasting first-line treatment. This is particularly important if we are to prevent resistance from developing, particularly in low- resource countries where affordability and availability of second-line drugs are particularly challenging. The authors also suggest that donor funding must focus on low-income/high-prevalence countries, while middle- income countries should be encouraged to finance their HIV/AIDS services using national resources. Given the extent of the HIV problem in sub-Saharan Africa, the book also highlights a need to institutionalise AIDS as a political issue. In high-prevalence countries like South Africa, an annual parliamentary debate on AIDS should be mandatory. Social activism, which AIDS: Taking a Long-Term View. The aids2031 Consortium. New Jersey: FT Press Science, December 2010. Pp. 224. ISBN-10: 0-13-217259-3. ISBN-13: 978-0-13-217259-2. B O O K R E V I E W 47 A P R I L 2 0 1 1 T H E S O U T H E R N A F R I C A N J O U R N A L O F H I V M E D I C I N E was instrumental in obtaining public provision of ARVs in the country, needs to play its role in ensuring that HIV remains at the forefront of political debate. The monograph also places the fight against HIV in historical perspective; the past teaches us that HIV must be tackled from all angles at once in order for it to be defeated. ‘Virtually every major public health success has been built on a combination of behavioral, biomedical, social and structural approaches,’ point out the authors, citing the campaign against smoking as a key example. In the absence of game-changers – such as the discovery of an effective vaccine, new drugs, or even a cure – our efforts to steer clear of ‘business as usual’ must be strengthened. In sum, none of these recommendations is revolutionary, and that is exactly what is most significant about the book. It tells us what we know we should be doing but aren’t doing. The greatest challenge in 2011 will be to ensure that these recommendations don’t fall on deaf ears. If they do, in 2031 we will find ourselves the victims of a bad hangover at the end of another busted party. Ilaria Regondi Alan Whiteside 48