It has been a wonderful yet wearing conference attended by over 23,000 people. We now look forward to the AIDS 2014 conference in our own Melbourne, Australia.

A key cross-cutting theme for me, wearing my hat as a general practitioner, has been the challenges current and in the future in managing the intersection caused by aging, HIV and non-communicable diseases (NCDs).

Australia continues to struggle with its approach to chronic and complex disease care. Does it increase verticalisation and place extra burdens on hospital based services? Many patients find the work of multiple presentations to specialists to be overwhelming and unachievable. Or can we continue to build comprehensive primary care level teams comprising general practitioners, practice nurses and community nurses along with various allied health professionals?

Will Australia be able to embrace the opportunities and challenges of task shifting? Can different tasks be reallocated? The appropriate balance between self management, primary, secondary and tertiary services is a question of great importance. This is both a challenge in Australia and even more so in low and middle income countries where the only part of their system oriented to chronic care is that modeled by HIV services. There are many opportunities in operational level research ahead.

The day held many highlights. There was ongoing discussion on the importance of the international community continuing to partner in the continuing challenges related to the epidemic. This is a time where national governments will be expected to continue to increase local contributions to local programs, however external assistance is a valuable and essential element in continuing to turn the tide. A great deal has been achieved. Yet there is much more to do. A way of contributing to this process is by signing the DC declaration.

Please could you consider signing this document. This is an important contribution you can make. Consider sharing it also with other friends and colleagues. 

Some of the world's leading HIV researchers have signed the D.C. Declaration. Community advocates have signed.  Have you?

The possibility of beginning to end the AIDS epidemic in our lifetimes is now a reality, but it requires a scale up of resources and efforts using the tools we have today to curb new infections and improve the health of tens of millions of people with HIV/AIDS. Turning the tide will take concerted leadership at all levels of government, health systems, and academic and non-governmental organizations. The Washington, D.C. Declaration calls for:

• An increase in targeted new investments
• Access for all to evidence-based HIV prevention, treatment and care
• An end to stigma, discrimination, legal sanctions and human rights abuses against those living with and at risk for HIV
• Marked increases in HIV testing, counselling and linkages to services
• Treatment for all pregnant and nursing women living with HIV and an end to peri-natal transmission
• Access to antiretroviral treatment for all in need
• Identification, diagnosis and treatment of TB
• Accelerated research on new HIV prevention and treatment tools
• Mobilization and meaningful involvement of affected communities.
• Sign the declaration online at www.dcdeclaration.org or www.2endaids.org
• You too can lend your name before the final number of endorsements is announced at the Closing Session!

Plummets in Vit D, increased kidney stones, increased fractures (more than half do not have osteoporosis, 13% vs 5%), direct cellular aging as measured by telomeres fraying, increased depression, these are some of changes associated with HIV and aging.

In 2015, over half of the HIV population in North America and Europe will be over fifty years of age.
We can now say to a young person who is recently diagnosed with HIV "Some day you will be old!".

In Uganda a 35 yr old Man starting ART with a CD4 greater than 100 has a life expectancy of more than 35 years. Life expectancy gains in sub Saharan Africa are similar to those in western settings. Aging adds chronic disease to the mix of issues to address in the list of HIV health challenges.

It was recognised the limits of a silo based approach - care needs communication and coordination. Disability, frailty - depletion in organ system reserve and functional status - are terms increasingly applicable to those ageing with HIV. Each is a consequence of a chronic disease burden.
 
Age is accentuated not accelerated for those with HIV. There is increased risk of various conditions at the usual ages. Polypharmacy (>5) increases risk of an adverse drug reaction, this increases by 10% with each additional drug. The principles and risks of polypharmacy are applicable here.
 
Falls are increased by a vast range of medicines.
Call for a patient centred approach. Risks are greatly increased after 65 yrs compared to those 50-64.

Over 60% of mortality is due to Noncommunicable diseases (NCDs) in the developed world and only a little less in developing countries. The challenge of NCDs are made more complicated by HIV. The workforce is being challenged to task shift, as part of these new situations. This is supported internationally but is less welcomed in Australia. There will be an increased demand for primary care service providers, especially GPs to better provide comprehensive, integrated team based care. The new ASHM Life Plans (led by Edwina Wright and others) will be an important contribution.  

We do not yet have good baseline markers for many NCDs in many, many countries especially in the 50+ age group- lots of research opportunities ahead.

Also see JAIDS, Vol 60, Supplement 1, July 1, 2012 And AIDS, Vol 26 Supplement 1, 2012-07-25 Both of these supplements focus on HIV and Aging.

It was the best of times, it was the worst of times (Charles Dickens, 1859, “The Tale of Two Cities”) ...
 
The incremental growth of HIV  science  year by year has accumulated many successes in many areas. This science has lead to a range of interventions, yet  biological efficacy will not be effective without adherence, and adherence is situated in the domains of cultural, economic and gender realities.
 
I have heard today that the issues of adherence in a Washington clinic,  in a Melbourne hospital, in a west African village, or in a Russian prison  demonstrate a  great diversity of challenges. Yet the discourse of human rights has been strengthened as the common  basis for empowering, authorising and allowing  people to be agents for the necessary changes in  these settings.  Though, of course, this does not diminish the difficulties in each setting.
               
A Ugandan colleague, Dr Musoke,  has highlighted the key roles  of political commitment, logistical problems such as stockouts, and the difference between capital city tertiary facilities and rural cities. There are still many difficulties. Concerns about long term resistance are real issues in many settings.
 
There is a move internationally to prioritise the disease burden due to non-communicable diseases (NCD). The NCD agenda is in one sense, I believe, rising to the top of the international health priorities. In this context, there were interesting studies from Uganda (Chamie et al) and from Nigeria (Gwarzo et al) indicating that HIV programs were also effectively integrating screening for non-communicable diseases, and also from Zambia (Mulanga et al) including cervical cancer services.
 
I learnt about the Gardner Treatment cascade which is an important new tool to allow us to picture the cascade of challenges of access and adherence that are now and future concerns. Let me share this example to illustrate how it works. 
For every 100 individuals living with HIV in the United States, it is estimated that:

• 80 are aware of their HIV status.
• 62 have been linked to HIV care.
• 41 stay in HIV care.
• 36 get antiretroviral therapy (ART).
• 28 are able to adhere to their treatment and sustain undetectable viral loads.

In short, CDC estimated that only 28 percent of the more than 1 million individuals in the U.S. who are living with HIV/AIDS are getting the full benefits of the treatment they need to manage their disease and keep the virus under control. Put another way, nearly 3 out of 4 people living with HIV in the U.S. have failed to successfully navigate the treatment cascade. Since a picture “is worth a thousand words,” see the included image.

... So said the former American president Roosevelt. The opening ceremony is going well. It is a hot Washington day.

It is now feasible once again for this conference to be held in the USA after more than two decades. The recent policy  change in allowing international openly positive HIV people to be welcomed in the USA is an important and much needed step forward.
 
The AIDS 2012 theme is "Turning the Tide Together".

The platform speakers - scientists, community leaders, faith based leaders, celebrities and importantly those infected and affected share much enthusiasm and encouragement as well as messages of hope. There is a repeated call that ongoing political and  community responses and resources are needed to allow science to continue to increase the knowledge needed to deliver progress in searching for cures and vaccines, and to continue to make available the essential education, prevention and treatment services. For me, the image of hope that most resonates is the image of the AIDS quilt panel - "The Last One". See attachment. I saw this yesterday at a preconference event.

Platform speakers included a 24 year old HIV infected woman from Zimbabwe, the Washington gay men's choir, two recently imprisoned Iranian physicians, an African - American pastor, HIV program leaders, the president of the World Bank, an actress and the UNAIDS director with more to follow...