THE CENTRAL PROBLEM that the world faces with HIV and Aids today is this: it is the millions of people infected with HIV who, in spite of the medical advances and all the money poured in to help, remain untreated. The solution involves immensely more than the provision of extra antiretroviral drugs. UNAIDS estimate that about half of people living with HIV are also undiagnosed. That means that around eighteen million people in the world today are living in ignorance of their condition. Eighteen million. The danger is twofold. There is the obvious danger to those who are infected, but there is the additional danger to public health generally. People with untreated HIV can spread the virus further. It means that hospitals and clinics are involved in a perpetual struggle to catch up. For every person they put on treatment there are approaching two others somewhere in the world acquiring HIV for the first time. How on earth can you defeat Aids against that background? We need policies that meet the needs of those who are waiting for treatment but at the same time reduce the colossal number of the undiagnosed. No one should be under any illusion about the barriers that stand in the way.

We need first to radically reduce the number of the undiagnosed living in ignorance of their condition. The longer treatment is delayed the more difficult it is. Even those who reach treatment may find their life expectancy curtailed. And of course not knowing of their condition they can easily pass on the virus. Not everyone does but, as we have seen in London, a fifth of those with HIV are undiagnosed but that fifth is responsible for over half of new infections. London is one city which, by international standards, has a relatively low number of people living with HIV; in many other cities the numbers involved will be immense.

Then there are those who know they have HIV and who have begun treatment, but for one reason or another do not continue. The danger, as we saw in Washington, is that once they slip out of treatment their HIV becomes harder to treat when and if they eventually return, and in the meantime they become infectious again. This issue is given little publicity. The public assumption is that if treatment is given it will be accepted and automatically followed. Self-evidently that is not the case.

Lastly there are the men and women who have HIV and are waiting in a queue for treatment. The latest WHO guidance from Geneva brings forward the time when treatment should be started, but even those guidelines exclude most of the very newly infected. These people may be in no imminent danger themselves, but they are at their most infectious at this stage and pose the greatest danger to others.

The medical goal for people living with HIV is to achieve an undetectable viral load, which means that, to all intents and purposes, they cannot pass on the virus to others. The figures show just how far we are away from reaching that aim. In the United States less than a third of men and women living with HIV reach that goal. Across the Atlantic in Britain and France almost 60 per cent reach the goal, but that still leaves 40 per cent who do not. If this is the position in the rich West what is it in countries that do not have such wealth, where public health systems are undeveloped, and where travel difficulties are all too real?

It is difficult to see how, without further action around the world, HIV and Aids can be defeated. That is not a criticism of the dedicated work of clinicians, international and civil society organisations and volunteers. It is a recognition that they need more help and that they need it urgently if even more lives are not going to be squandered. That help must come from governments, for that is where responsibility lies. The need is for a renewed international effort. I would propose ten measures which would help avert at least part of the continuing tragedy:

First, there must be a new initiative on prevention. As a world we seem much more prepared to pay for the casualties of HIV than to prevent them. There are no demonstrations outside the White House in Washington, or the Parliament building in Cape Town, or down Whitehall in London, calling for more prevention. There have been plenty calling for more treatment. Although it is entirely right that those who already have HIV should insist on treatment, it is also right that the public should insist that every effort is made to stop the disease spreading. With over thirty-five million living with HIV and another thirty-six million already dead, our progress is painfully and tragically slow. One reason is that the resources devoted to prevention do not bear any comparison with the money devoted to treatment.

Let me give an example from Britain, which is obviously the country I know best. When I chaired the all-party House of Lords Select Committee on HIV which reported on the position in September 2011, we pointed out that although the nation spent approaching £1 billion a year on antiretroviral treatment and care, the Department of Health spent only £4.9 million a year on health promotion and advertising to prevent HIV. I found the prevention figure so incomprehensibly low that I asked for it to be checked three times. When we found it was accurate, the committee urged an increase. The response from the health department was to cut the amount to £4.45 million. It must rate as one of the most short-sighted policies ever, but the trouble is that it is exactly the kind of priority that is being given to health promotion around the globe.

We need to recognise that determined efforts on publicity in the past have not failed, but have been successful. Both in Britain and Australia the big advertising campaigns (although controversial with some) reduced the numbers contracting HIV as well as other sexually transmitted diseases. But, like all other campaigns, they needed to develop and be consistently put to the public. Coca-Cola would not mount a major campaign one year and then go off the air for the next quarter of a century. We need to use all the means open to us which were not available back in the 1980s, like the internet and social media, while not ignoring the more traditional means of communication. Over the years in New York and Washington I have seen posters and advertisements on the subways. In Kenya I saw the poster vans. I cannot remember a similar effort in Moscow – or, for that matter, in most cities in Western Europe. In short we need to return to public education and use some of the messages from the past. Risky behaviour still needs to be changed, the numbers of partners need to be reduced and condoms still need to be used.

Second, the highest priority in public education should go to increasing testing. If we can bring the number of the undiagnosed down then we will have taken a major step to reducing HIV – assuming that testing is followed by treatment. The aim must be to ensure that tests are provided in the places that are most convenient to the public and that results do not leak into an intolerant community. That is why home testing is so important. Testing takes place conveniently and privately with the offer of swift confirmation of the results and counselling. In every nation there are testing opportunities – like the tests offered to the drivers in Washington DC waiting for their licenses to be renewed, or patients in the waiting rooms of surgeries, or prisoners entering prison. HIV is no longer a death sentence but a long-term condition. A positive diagnosis can still be traumatic but is not the utterly shattering event of twenty-five years ago. The aim must be to make HIV tests a normal part of medical checks.

Third, sensible sex and relationship education should be introduced. In some parts of the world there is vast ignorance. In Yangon (previously Rangoon) I was told by one of the few campaigners there that the issue was that young people and many others still ask ‘What is HIV?’ In the West ignorance is not usually on that scale (although it can be), but everyone will tell you that the level of knowledge is nothing like what it was at the end of the 1980s. There is ignorance about how HIV is transmitted and there is ignorance about the precautions to be taken. In many countries efforts to change the position are defeated by the churches. The arguments used remain very much the kind of reservations that Margaret Thatcher had and which are described in my first chapter: that education will expose children to new knowledge that will be damaging and should be postponed until much later. The difficulty is that the ‘much later’ never comes. The assumption that parents carry out this part of education is highly optimistic. As I have travelled around the world I have been struck by the large numbers of parents, as well as clinicians, who instead favour action in schools.

Fourth, antiretroviral treatment should be offered to all people with HIV as soon after they are infected as possible. Up until very recently we have been giving treatment only when the patient enters the danger zone. This was defined by the WHO as when the CD4 count in the blood fell below 350 micro litres of blood. They have now adjusted that lower limit to a CD4 count of below 500. It is a major step forward, although I accept that some countries still cannot reach the old limit. But to my mind there seems no reason why there should be a limit of any kind. All clinicians agree that HIV is dramatically more infectious just after it has been contracted. Surely it makes no sense to exclude the most infectious from drug treatment.

The almost automatic reaction of governments is to shudder at the cost. But there is another way of looking at the position. If your aim is to reduce the amount of onward transmission, then clearly the greater the number on treatment and adhering to it the better. Other things being equal, prevention reduces the number with HIV and saves the onward and permanent cost of treatment. The greater access to generics over the next few years gives governments the cost opportunity to introduce this policy. Governments might remember that sooner or later they are going to have to put people with HIV on treatment in any event.

There has already been encouraging evidence about what can be achieved by extending treatment to anyone with HIV, regardless of their blood count, and more could be provided by pilot schemes. As for the argument that people given such treatment will need to adhere to it, that is an argument that already applies to the existing situation. Whatever happens, campaigns on improving adherence will be necessary and we will need more testing if such a change in policy is to stand any chance of success. There are obvious difficulties for countries which even now cannot reach everyone below the WHO limit, but for others there is the chance of getting off the escalator of ever-rising numbers of people with HIV.

Fifth, the ultimate goal is to develop a vaccine. The polio vaccine has eradicated that condition in my lifetime. After the war I remember the children who were crippled with polio, the warnings not to use public swimming pools and the pictures in magazines of the unhappy prisoners in their iron lungs. That has now been eradicated in virtually every nation of the world, the only exceptions being where there are religious and political objections to vaccination itself. An Aids vaccine could have an equally dramatic effect and mean that the vast cost of treatment would be progressively reduced. You would think that hardly anything could be more important, but the truth is that the search for an Aids vaccine has been under-resourced. More resources would speed up the process and mean that new avenues could be explored. The pharmaceutical industry shows little inclination to invest: the risk is too high and the likely financial reward too low. This means that any advance for the benefit of the public is down to governments and foundations. The United States shoulders the bulk of the burden, although in all conscience there is no reason why they should be so unsupported by other nations. It is time that all the rich countries of the world stepped up to the plate. They should remember the words of Peter Piot, speaking in 2014, who said, ‘Ending HIV without a vaccine will simply not be possible.’ My case rests.

Sixth, we must tackle in a much more determined way the corruption which scars so many nations today. It has been a constant complaint on my travels. Police taking pay-offs, officials creaming off government funds, politicians taking bribes. The lowest form of corruption is when it deprives patients of medicines and drugs which can save their lives. The successors to Harry Lime in Graham Greene’s The Third Man are alive today and thriving.

Corruption also has another effect. The fact that there is corruption at all deters governments from giving to overseas aid programmes (including aid to improve health systems) and provides a useful stick for the opponents of such aid. Even a squeaky-clean and open organisation like the Global Fund in Geneva gets tarnished by the generalised charges. Where possible, money should be directed straight to civil society organisations working on the ground, or through agencies like the Global Fund. The standards of the civil society organisations I have seen are high, as too is the motivation of those who work for them – often in the most difficult of conditions.

Seventh, if we are to tackle corruption then we must tackle the question of sex work, which also has a major impact on HIV. Around the world sex workers are exploited. They are exploited by their pimps, by their landlords and by the police. They are treated as outcasts and forced to work in the shadows. Health care is neglected and the inevitable result is that in all too many nations the prevalence of HIV infection among sex workers is way above that of the general population. Frequently, what makes this possible are the hypocritical and counter-productive laws that cover the area and which mean that around the globe sex work is overwhelmingly marked down as criminal. In reality it is widely tolerated, provided that as much as possible it is kept out of sight, and the usual official defence is that even though it is technically illegal the law is ‘lightly’ enforced. The trouble with this argument is that the lack of certainty gives the green light to corrupt policemen and anyone else who wants to take advantage of the position. New South Wales is one of the few exceptions to the general rule. In Sydney sex work is run under normal business controls and as a result there has been no recent case of HIV being passed on by a sex worker and police corruption in this area has been virtually eliminated. A debate has now started on the position in other countries. In Western Europe an argument that has gained ground is that only the client should be penalised – and that a determined new policy of this kind would much better protect the sex worker. The counterargument to that is that this will still push much sex work outside the law and will certainly require a police effort to enforce what will be a new criminal offence. Nevertheless, it is a debate which needs to be joined if we are ever to make any progress. We might remember that in Sydney the changes to the state law followed the exposure by official investigations of the deeply unsatisfactory position that existed while sex work remained illegal. Other cities would also benefit from such investigations, including not only New Delhi and Kiev, but also London.

Eighth, the success of the harm-reduction policies in drugs policy must be shouted loud. The provision of clean needles and syringes has been an undoubted success. As we have seen, where such policies are implemented, new infections from HIV by shared needles have been reduced to remarkably low figures and, in spite of some of the fears, neither crime nor drug taking has risen as a result. In Britain it is also an interesting supporting argument for those who think that drugs policy should be put under the charge of the Health Department and not the Home Office. Nothing I or anyone else says is likely to persuade Russia from its woeful and deadly path in refusing to countenance such a policy, but the United States is different. There, many states have their own clean-needle policies. Their success has been established. The message to Congress is to please look at the evidence again and then end the ban on federal funds being used for such schemes. Such a decision would not only bring in much needed resources, but would send a message around the world. At the same time all nations should note the initiative of the United Nations General Secretary, Ban Ki-moon, in calling a special session of the General Assembly on illicit drugs in September 2016. This initiative gives a perfect focus for the discussions that are already going on in so many countries and offers an opportunity for the introduction of new policies that more surely penalise the traffickers and not the users.

Ninth, a new dialogue must be attempted with the churches and the faith leaders. They have the power to change attitudes, but it has been one of the most depressing features of my travels to find so many churches arm in arm with the most reactionary political elements in the world. Goodness knows there are many religions but I would have thought that all were united in offering help to the disadvantaged – like the minorities who feature so prominently in the HIV area. Yet, we have the Orthodox churches in Russia and Ukraine that fail to challenge public intolerance on homosexuality. We have the Roman Catholic Church clinging to a policy of banning condom use, which has been responsible for a multitude of deaths from Aids and goes smack against any concept of a right to life. And then, perhaps worst of all for me personally, we find the Anglican Church in Africa, and particularly Uganda, supporting some of the most discriminatory laws in the world. As a church, the Anglicans seem to have a particular difficulty with homosexuality, and even in Britain you find the bishops deciding that the civil right of equal marriage should not be available to their own clergy. They should beware, lest their reputation for intolerance spread.

Tenth, politicians must start leading again. Enormous progress was made, particularly in the first years of the twenty-first century, thanks to the efforts of politicians, clinicians and activists of every conceivable hue working together. In 2003 we had a Republican President of the richest country on earth prepared to commit his nation to supporting the permanent medical treatment of millions of men and women, thousands of miles from his political base. For George W. Bush, there was almost no political advantage in establishing PEPFAR, but he did it all the same because it was right. In 2002 we had nations coming together to set up the Global Fund which would funnel resources to where they were most needed. The funds were not labelled by nation, but were given freely to be distributed according to need and without thought of commercial or national return. These were actions of principle. They recognised the duty that the comparatively rich have to the grindingly poor.

The commitment of the clinicians, the civil society organisations and the volunteers remains, but the commitment of the politicians is at worst absent and at best wavering. Politicians in countries like Russia and Uganda are content to preside over death and discrimination. Politicians in countries like Ukraine (certainly up to now) have done the very least they can get away with. And too many politicians in the United States and Britain either back their own prejudices or are nervous of being seen to espouse the cause of minorities who they believe are unpopular with the public and, of course, the brutish section of the media.

We should remember that most major failures have come about because of a lack of political leadership, a lack of political courage, or a refusal to look at the facts. As we have seen, in South Africa the issue was practically ignored by one leader and then steered on a ridiculously damaging course by his successor. But what South Africa also demonstrated was that when new politicians took over with new policies that were guided by evidence and not by unsubstantiated belief, then the results could be remarkably positive. It is an example to politicians in all nations of what can be achieved.

The world now stands at a tipping point. We can go forward and develop new policies that give us some hope of defeating HIV and Aids, or we can sink into a sea of complacence, wrongly believing it was all yesterday’s problem. If we go forward then we must overcome one last barrier which still stands in our way: the barrier of prejudice, which can defeat all our efforts.