On the other hand, the emergency could come back at any moment, and many fear it will if treatment stops. If the absolute number of patients on ARV treatment stays constant but the epidemic grows, the ranks of untreated patients could soar to dangerous levels, with potentially devastating consequences for their health, their families, and their societies.
Prevention is certainly key to bringing down those numbers. Yet the funding choice between preventing and treating is a false one. For starters, there is a preventive aspect to ARV treatment; a recent study cited by Joanne Carter, executive director of Results, an anti-poverty advocacy group, in her March congressional testimony found that ARV treatment lowered risk of infection 92 percent in discordant couples -- ones in which one partner is HIV positive and the other is not.
The prevention benefit goes further. "When you find out you are HIV positive, you have two choices," explains Joseph Amon, head of the global health program at Human Rights Watch. "You can do something with that knowledge -- and what people want is to get treatment and feel like they are being supported -- which leads to behavior change. The other option is to find out you're positive, but we don't have any drugs available for you, so come back in a few years. That doesn't lead to behavior change." One aid worker in Nigeria echoed that concern: "If we test 185,000 people [this year for HIV] and we find 7,400 positive [but have less than half that many treatment slots], what are we going to do with them?"
The gap between U.S. ability and patient needs is one reason that the administration has emphasized a need to get other donors on board, in addition to local governments. The $50 million cut to the Global Fund, however, has been met with concern by the same groups that have criticized Obama's global-health policy, and Kazatchkine calls it "a big test for the multilateralism and the move to multilateralism for the administration."
The bigger test will be whether Obama's health initiative can really build the environment that would be conducive to a shift from emergency to long-term HIV treatment, strengthening health-care systems where many have tried before and failed. In an ideal world, there would be enough money to fund both emergency and long-term solutions. But here's the truth: There isn't. So this was an inevitable juncture: A global recession, constrained budgets across the developed world, and a simple realization that treating HIV/AIDS is expensive have forced the U.S. government and other governments to answer hard questions about how their dollars will be spent. If Obama can make those hard decisions and manage the transition from emergency to long term, the fight against HIV/AIDS will be on a more sustainable footing. A wrong turn, however, could endanger the incredible gains made in recent years. And that's what advocates fear most of all.