On November 29th, two days before World AIDS Day, Secretary of State Hillary Rodham Clinton unveiled a “blueprint” for an AIDS-free generation. The blueprint consists of five goals:

  1. Rapidly scaling up the most effective prevention and treatment interventions.
  2. Targeting the populations at the greatest risk of contracting HIV, including injectable-drug users, sex workers, men who have sex with men (MSM), and those trafficked into prostitution.
  3. Promoting sustainability, efficiency, and effectiveness.
  4. Encouraging country ownership of HIV/AIDS treatment and prevention programs.
  5. Ensuring that science and evidence continue to guide the development of HIV/AIDS interventions.

When presenting this blueprint, Secretary Clinton cited a number of specific examples and steps that PEPFAR would be taking in the future to ensure the achievement of these goals. Conspicuously absent, though, was any elaboration of specific actions that would be taken to achieve Goal #3: sustainability, efficiency, and effectiveness. While the other blueprint goals received multiple paragraphs-worth of explanation and elaboration, only three sentences were allocatedto Goal #3:

Third, we will promote sustainability, efficiency, and effectiveness. We’ve already saved hundreds of millions of dollars by switching to generic drugs in our treatment regimen. And we will continue to ensure that we get the most out of every dollar spent. (http://www.state.gov/secretary/rm/2012/11/201198.htm)

Three sentences for what is arguably the most important – and most challenging – goal of the blueprint and the global fight against HIV/AIDS.

The issue of sustainability is of particular concern where I work in Malawi. According to the 2012 UNAIDS World AIDS Day Report, there has been a 73 percent reduction in the rate of new infections in Malawi over the past decade. That’s a huge reduction and an impressive achievement for a country with one of the top-ten highest HIV prevalence rates in the world (11%). But how sustainable is that achievement in a country that also has one of the lowest levels of GDP per capita (173 out of 180 according to the World Bank)and one of the lowest levels of government expenditures on public health (165 out of 182 at $65 per capita), particularly now that the Global Fund to Fight AIDS, Tuberculosis and Malaria has halted all new funding until 2014? In the absence of new and/or increased funding, how will Malawi continue to reduce its HIV prevalence when the annual cost of providing ARVs is the same as the country’s per capita GDP ($300-$400 per person)? Already, I hear almost daily complaints from the nurses and health sector staff at my organization about the chronic lack of HIV testing kits, the dearth of CD4 count machines, and the lengthy delays (up to two weeks) in getting test results back from the labs. Without new funding, many in Malawi, including Edith Mkawa, the newly appointed Secretary for Nutrition, HIV and AIDS, worry that all the hard work put in to reducing the rate of new infections by 73 percent “will be for nothing.”

Consistent funding for treatment and prevention programs is a key component to mounting a sustainable response to the HIV/AIDS epidemic. But funding in and of itself is not enough. To truly achieve sustainability, we must be smart about the types of programs being funded. International donors should target their funding towards strengthening the capacity of health care professionals and laboratory technicians in those countries with the highest HIV prevalence rates. Rather than flooding the countries most affected by HIV/AIDS with free condoms, cheap drugs, and behavior change materials, international donors should focus their attention (and money) on investing in the health care infrastructure of these countries and shifting the production of ARVs and testing materials to these most affected countries. These are just a few of the specific steps missing from Secretary Clinton’s three-sentence treatment of sustainability in her blueprint for an AIDS-free generation.

The word sustainability is derived from the Latin sustinere (tenere, to hold; sus, up). If we ever hope to reach what Secretary Clinton referred to as “the tipping point” of the HIV/AIDS epidemic – the point at which we will be able to treat more people than become infected every year – we must take the true meaning of “sustainability” to heart. We must equip those countries most affected by HIV/AIDS with the knowledge, tools, and capacity to “hold up” against the onslaught of this devastating disease so that their hard fought gains will not be for naught.


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