Turning the Tide After AIDS 2012: Moving Toward an AIDS-Free Generation Together

President William Clinton at Closing Session of AIDS 2012. © IAS/Steve Shapiro - Commercialimage.net

President William Clinton at the closing session of AIDS 2012. © IAS/Steve Shapiro – Commercialimage.net

It’s been nearly two weeks since former President William J. Clinton closed the last session of the XIX International AIDS Conference(AIDS 2012) and delegates returned home.

This year’s conference featured commitment and calls for an AIDS-free generation, a growing interest in Option B+, and new research towards a cure.  Here are some reflections from what we learned at AIDS 2012, where we truly started “turning the tide together”.

Clinton calls for a blueprint toward an AIDS-free generation

Secretary of State Hillary Rodham Clinton at AIDS 2012. © IAS/Ryan Rayburn - Commercialimage.net

Secretary of State Hillary Rodham Clinton at AIDS 2012. © IAS/Ryan Rayburn – Commercialimage.net

Secretary Hilary Rodham Clinton announced significant funding towards preventing mother-to-child transmission (PMTCT) of HIV, South Africa’s plan for voluntary medical male circumcision, and money for “implementation research,” civil society, and country-led plans. Sec. Clinton also called on Ambassador Eric Goosby to provide a blueprint for achieving an AIDS-free generation during her plenary address. Numerous other stakeholders echoed her commitment. But, if we really want to achieve an AIDS-free generation, the $7 billion funding gap that stands between where we are now, and where we should be, will need to be erased.

Option B+ takes center stage

Dr Chewe Luo at AIDS 2012 (Photo credit: S. Holtz/MSH)

Dr Chewe Luo at AIDS 2012 (Photo credit: S. Holtz/MSH)

There is growing consensus that countries should embrace Option B+ to decrease or eliminate vertical HIV transmission. Option B+ — whereby HIV-infected pregnant women are put on antiretroviral treatment for life regardless of their CD4 count — originated in Malawi. In its first year of implementation, the country has seen a 6-fold increase in ART uptake among HIV-infected women. Many plenary speakers and presenters, including UNICEF’s Dr. Chewe Luo, praised the approach and encouraged uptake in other countries.

Elimination of pediatric AIDS by 2015

Along with Option B+, there is a renewed call to action to end pediatric HIV by 2015. MSH welcomes that discussion and the political commitment to achieve it. Great progress has been made toward this ambitious goal in the short history of preventing mother-to-child transmission of HIV: from 2009 to 2011, the number of new HIV infections in children decreased by 24% to 320,000 last year. That is still too many. It is clear that we will not achieve the goal of eliminating pediatric HIV unless we apply some serious innovations and new thinking.

Photo credit: AIDS 2012.

Key vulnerable populations face a growing epidemic

The epidemic is still growing in key vulnerable populations, including: men who have sex with men (MSM), sex workers, and injection drug users (IDUs). Participants discussed lessons learned and programming improvements to help stabilize and turn the tide on the growing HIV epidemic among MSM. For many years HIV care, treatment and prevention programming for sex workers has been less than effective. This year there seemed to be more momentum and reexamination on how we approach prevention in sex worker communities. The IDU population is perhaps still the most marginalized and difficult to reach in many countries. At AIDS 2012, we saw the beginnings of change as countries are starting to think about how to scale up national responses to reach this at-risk population.

Scott Kellerman (left) moderates a session at AIDS 2012. (Photo credit: S. Holtz/MSH)

Scott Kellerman (left) moderates a session at AIDS 2012; Erik Schouten (right), panelist. (Photo credit: S. Holtz/MSH)

Treatment is prevention

Our prevention toolkit is growing. The most promising prevention efforts currently include male medical circumcision and treatment as prevention, pre-exposure prophylaxis, with ongoing hope for further advances in microbicides and vaccines. Male medical circumcision has been shown to dramatically reduce the risk of HIV infection for men by about 60%. The HPTN 052 study that concluded last year definitively proved that initiation of antiretroviral therapy (ART) by HIV-infected individuals substantially protected their HIV-uninfected sexual partners from acquiring HIV infection, with a 96 percent reduction in risk of HIV transmission. New research presented shows that not only is treatment as prevention effective, its very cost-effective as well.

No longer do we have to qualify the term treatment as prevention, we now know that treatment is prevention. Now the hard work begins, how best to bring these innovations to scale

Tackling HIV & AIDS and chronic non-communicable diseases (NCDs)

Panelists at AIDS 2012 Satellite Session: Beyond MDG 6, July 22, 2012. (Photo credit: S. Holtz/MSH)

Panelists at AIDS 2012 Satellite Session: Beyond MDG 6, July 22, 2012. (Photo credit: S. Holtz/MSH)

Delegates discussed how to use the HIV & AIDS infrastructure to tackle chronic non-communicable diseases in low and middle income countries. One session, “Beyond MDG 6: HIV & NCDs” led by MSH, Pan American Health Organization (PAHO), and partners, focused on how the global health community can fight the dual epidemics by integrating health systems toward universal health coverage (UHC). In other sessions, experts noted the long neglected reality that is now upon us: with the phenomenal success of ART treatment programs, we’re now faced with an aging population of people living with HIV, and dying from tuberculosis (TB) and chronic NCDs.

Searching for a cure

Researchers released new findings at the conference, renewing a focus on finding a cure. Although all agree we’re not there yet, promising findings provide for some measure of optimism: We’re getting people on treatment; we’re getting viral loads down, maybe we can beat this.

“The science has been telling us for some time now that achieving a cure for HIV infection could be a realistic possibility,” said IAS President Françoise Barré-Sinoussi, PhD, Director of the Regulation of Retroviral Infections Unit at the Institute Pasteur in Paris. “The time is right to take the opportunity to try and develop an HIV cure – we might regret never having tried.”

Involving communities and countries for sustainability

XIX International AIDS Conference (AIDS 2012) Washington D.C. © IAS/Steve Shapiro - Commercialimage.net

XIX International AIDS Conference (AIDS 2012) Washington D.C. © IAS/Steve Shapiro – Commercialimage.net

Many presenters throughout the week reinvigorated discussions around bringing care, treatment and prevention services to the community via door-to-door testing, care, treatment and support — a not so subtle reminder that successful programs must adapt to suit the communities they serve and not the other way around. Also encouraging was the news that many countries, even those that extremely resource-limited, are contributing increasingly larger proportions of the resources to the HIV & AIDS response.

Other experts eloquently reminded us of the continued intersection of the HIV and TB epidemics, the role that social determinants of health (such as poverty) play in perpetuating the epidemic, and the unmet $7 billion funding gap needed to truly provide universal access for HIV & AIDS drugs. One session captured the unique challenges of improving HIV prevention, care and treatment in fragile states.

Kuala Lumpur & Melbourne: Looking to 2013 & 2014

Optimism filled the convention center during AIDS 2012. To be sure, challenges remain, and we have much to do to close the treatment gap and move sincerely towards elimination of pediatric HIV, but for the first time in memory, the hope that filled the halls was palpable and there was a sense that we can move forward and decrease the terrible hold that HIV has had on people these last 30 years.

As we reflect on what we learned, we also look to the future for HIV & AIDS treatment, prevention, and care. For the next two years, we look forward to being in Asia and hope to see much increased participation from our Asian colleagues. We’ll be meeting in Kuala Lumpur, Malaysia, in 2013 to discuss the scientific progress made by ourselves and our colleagues. The Kaiser Family Foundation and Center for Strategic & International Studies (CSIS) high-level panel said that key issues in Melbourne (AIDS 2014) will likely include country-level and human rights concerns, and more on the search for a cure, as well current results on implementation science and results of the HPTN052 studies.

"Turning the Tide Together" AIDS 2012.

We’re looking forward to seeing you there, and continuing this vital work together.

What was your favorite moment or lasting impression from AIDS 2012? What do you hope will be different in Kuala Lumpur (2013) or Melbourne (2014)? Tell us your thoughts below.

 

5 Days, 5 Plenaries, a World of Experience

The XIX International AIDS Conference featured five full days of plenaries with high-level speakers and community activists. The plenaries exemplified the diversity of topics covered throughout, and the global experience of people attending the July 22-27  conference. The plenary round-ups below are a great way to re-enter the experience of AIDS 2012, whether you attended the conference or just want to learn more.

Chioma Nwuba Wows the Crowd at AIDS 2012

Chioma Nwuba at AIDS 2012 discussing sustainability and local ownership.

Chioma Nwuba at AIDS 2012 discussing sustainability and local ownership. (Photo credit: S. Holtz/MSH)

The Kwara state of west-central Nigeria suffers many health-related challenges: an HIV prevalence rate of 2.2 %, a large geographic area, difficult terrain, a rural population, poor access to health facilities, long waiting time at facilities, and shortages of human resources for health. These are some of the factors thought to contribute to poor uptake of HIV testing and CD4 investigation (a test to determine whether or not a patient is eligible for HIV treatment) and the high level of attrition of patients living with HIV at all stages of the treatment process — from HIV testing to commencement of treatment to long-term treatment.

Enter Chioma Nwuba, laboratory specialist with the Prevention and Organizational Systems – AIDS Care and Treatment Project (ProACT) in Kwara state to the XIX International AIDS Conference. On Wednesday, July 25, Chioma presented “A laboratory-based approach to reduce loss to follow-up of HIV positive clients” to a standing-room only crowd at the oral abstract session on HIV linkage retention in care. She described the “MSH” leadership and management approach used by the ProACT project: The hospital management committee assessed the situation and made decisions that ultimately streamlined service delivery at the facility — ensuring sustainability and local ownership.

Thanks to the intervention: data clerks now fill laboratory request forms instead of clinicians; lab technicians collect and test blood rather than clinicians; escort services are strengthened so patients are enrolled and undergo lab tests on the same day; lab tests are provided Monday through Friday rather than just once a week; and test results are provided quickly to ensure initiation on treatment.

Twelve months after the intervention, the number of clients accessing CD4 investigations increased from 53.8% to 93.3%, the number of clients lost along the treatment process reduced from 58.7% to 10.7%, turnaround time for certain test results decreased from 7 days to 24 hours and the average client wait time decreased from 4 to 1.5 hours.

The project staff have found that strengthening laboratory systems helps increase uptake of CD4 investigations, shorten client waiting time and ultimately reduces loss-to-follow-up, especially among clients attending clinics from hard to reach communities with difficult terrains.

ProACT is a five-year, 60-million-dollar, follow-on project to the Nigeria Leadership Management and Sustainability (LMS) AIDS Care and Treatment Project (LMS-ACT). ProACT supports HIV & AIDS and TB services in six Nigerian states: Kogi, Niger, Kwara, Kebbi, Taraba, and Adamawa. The project places a strong emphasis on building the capacity of government and civil society organizations to strengthen health and HIV & AIDS systems for delivery of integrated health and HIV & AIDS and TB services.

 

Day 5: Living and Aging with HIV, Dying from TB and NCDs

Judith Currier speaking at Friday's plenary, XIX International AIDS Conference (AIDS 2012) Washington DC.  © IAS/Ryan Rayburn - Commercialimage.net

Judith Currier speaking at Friday’s plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn – Commercialimage.net

Volunteers were handing out t-shirts as we arrived at Friday’s plenary of the XIX International AIDS Conference. When Marie from Results South Africa asked all t-shirt recipients to stand, over a quarter of the delegates rose from their chairs. These individuals represented the percentage of people worldwide who are co-infected with HIV and tuberculosis (TB). This powerful metaphor — 25 % of the people in the room on their feet — highlighted the morning’s theme: integrating HIV/AIDS care and treatment into disease-specific and broader health services.

The “Bell Tolls” For HIV & TB

The session’s first presentation, “Science and Implementation to Turn the Tide”, was delivered by Dr. Tony Harries, senior advisor at the International Union Against Tuberculosis and Lung Disease. Dr. Harries began by stating that 350,000 people had died from HIV/TB co-infection in 2010, and that many of these deaths were preventable.

With evidence-based research and World Health Organization (WHO) recommendations, Dr. Harries argued that co-diagnosis, early ART, and isoniazid preventative therapy (IPT) are answers to the pressing problem of increasing HIV/TB co-infection.

Harries also emphasized a need for “better, cheaper, and quicker” TB diagnostic tests. He explained the benefits of two diagnostics: Xpert MTB/Rif, which provides TB test results in two hours, and Urine TB LAM, which derives a diagnosis in just 30 minutes. “Diagnosis is not just about accuracy,” Dr Harries explained. “It is also about feasibility, speed, costs, and overall impact in saving lives.”

Harris concluded his presentation by urging health professionals to address HIV/TB co-infection by advocating for improved policy and practice, conducting needed research, implementing evidence-based strategies, and tackling poverty, which drives the epidemic. After this call to action, Dr. Harris closed with powerful quote from the famous British poet, lawyer and priest, John Donne: “Any man’s death diminishes me because I am involved in Mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”

Aging with HIV — Dying from NCDs

Dr. Judith Currier from the University of California then took the stage to present her talk on “Non-communicable Diseases (NCDs) and Aging in HIV.” She began by praising the public health community for supporting improved access to ARVs, which has extended the lives of many people. She shared positive results that show half of all people living with HIV in the US by 2020 will be over the age of 50.

While enjoying the many benefits of longer lives, Dr. Currier also explained that this longevity puts HIV patients at risk for other health problems, including NCDs. The most prevalent NCDs impacting HIV patients today include cardio-vascular disease, cancer, diabetes, and chronic respiratory disease. In 2008, 36 million people died of NCDs. To address the crisis of NCDs among HIV patients, Dr. Currier suggested the following interventions: (1) improved screening and monitoring for NCDs; (2) early diagnosis of NCDs in TB patients and prompt care; (3) smoking cessation interventions; (4) dietary and exercise education; (5) earlier start of ART; (6) tailored ART regiments to reduce the risk of NCDs; (7) expanded global use of safer ART drugs; (8) evaluated treatment for NCDs in HIV patients; and (9) integrated screening and treatment of NCDs in HIV treatment programs.

“HIV and NCD epidemics are colliding on a global scale and failure to address these problems could lead to an erosion of ART benefits,” Dr. Currier warned. In her closing statement, Dr. Currier left the audience with a call to action, punctuated with a collective mandate to “Make healthy aging with HIV an achievable goal.”

Improving Health Systems for HIV

The final presentation, “Optimization, Effectiveness and Efficiency of Service Delivery” was facilitated by Yogan Pillay, Deputy Director General for South Africa’s Department of Health, Strategic Health Programs. Pillay began his speech with praise for South Africa’s recent success in testing 20 million residents for HIV, enrolling 1.7 million people in ART (since 2004), circumcising 500,000 men in the past year, and reducing the nation’s vertical transmission rate from 8% in 2008 to 2.7% in 2011. Despite these promising trends, Pillay cautioned that South Africa’s advances cannot be sustained without greater health system efficiency and effectiveness. “We are treating more people so we need a health and social system that can support [them],” he explained.

To improve health system efficiencies, Pillay urged the community to: increase spending on high impact interventions; improve efficiency of direct service delivery; and reduce spending on indirect costs. Pillay emphasized cost analysis as a means to help health leaders identify the correct spending mix to achieve optimal outcomes. To improve cost effectiveness, Pillay suggested service integration, resource tracking, and conducting an expenditure analysis across funders to identify inefficiencies. Pillay also recommended that the community work collaboratively to improve national health plans by optimizing service delivery models, harmonizing and improving different actors, identifying bottlenecks, highlighting equity concerns, developing research networks and conducting further research on sustainability.

Pillay concluded by emphasizing the importance of political will and collaboration in enhancing the quality and effectiveness of national health systems: “Countries need to take the lead!” he urged, “Partners and countries can fill the investment gap together!”

Yogan Pillay describing South Africa's health system at Friday's plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn - Commercialimage.net

Yogan Pillay describing South Africa’s health system at Friday’s plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn – Commercialimage.net

These speeches set the stage for an inspiring final day of the conference while also reinforcing the current global HIV needs and the evidence-based recommendations for an effective response. While the t-shirt exercise was daunting for some, the three presentations left conference participants with an urgency to act, strategies to employ, and evidence to motivate their continued response to the ever-evolving HIV pandemic.

Marie articulated this hope and call as she closed the t-shirt exercise saying: “Let’s move past one in four deaths from TB and celebrate together when we meet again in Melbourne!”

Jessica Charles is communications specialist at MSH’s Center for Health Services.

HIV and Health System Strengthening in Fragile States: Improving HIV Prevention, Care and Treatment

AIDS 2012 Fragile States panel

Panelists at the session HIV and health system strengthening in fragile states, July 26 at AIDS 2012 conference. (Photo credit: S. Holtz/MSH)

MSH in collaboration with the International Rescue Committee (IRC) and Physicians for Human Rights (PHR) sponsored a lively satellite session at the XIX International AIDS Conference in Washington DC discussing, “What are the keys to working on HIV & AIDS in fragile states?” Moderated by Susannah Sirkin of PHR, the session included an exciting interchange among panelists and delegates in the audience.

MSH President Dr. Jonathan Quick led off the discussion with a number of observations on fragile states, which included the point that a state which is not functioning effectively, (inadequate services, high levels of violence, etc.) — regardless of the cause — could be considered fragile. Each fragile state is unique, but all face similar challenges in that access to health services is difficult; often the population, at least in certain regions, must cope with considerable violence and insecurity.

The panelists, Peter Mutanda and Aminul Islam of IRC and I, contributed insights into the many vexing questions posed by dealing with HIV in fragile states where governments and society are overwhelmed by other problems and challenges that at times seem to dwarf the issue of HIV. In some fragile states, the prevalence of HIV is relatively low. These countries need to balance the immediate crises they face and the large numbers of preventable maternal and child deaths with the need to deal with HIV now to forestall a more serious epidemic down the road.

Members of the audience brought up fascinating examples of work that NGOs and ministries have done trying to deal with HIV in such fragile states as Democratic Republic of the Congo and Somalia. The discussion included these key issues:

  • What can we learn from fragile states where, despite overwhelming problems, some health programs are effective?
  • How should fragile states prioritize HIV amid other concerns?
  • What should be done when data are poor or non-existent?  How high a priority should fragile states place on obtaining better epidemiologic and surveillance data versus other pressing needs?
  • In fragile states where donors provide most health funding, how can country ownership of health programming be obtained? Who is ultimately responsible for deciding on health priorities, given the fact that ministries of health in many fragile states are barely functioning?

While we didn’t necessarily provide answers to these challenging questions, the discussion was stimulating and thoughtful for all who attended — and gave all of us a lot to think about as we return to work on strengthening health systems for HIV in fragile states.

Steve Solter, MD, MPH, is MSH’s country lead and technical lead on fragile states. MSH is currently working with partners in several fragile states, including South Sudan, Democratic Republic of the Congo, Afghanistan, Haiti, and Liberia.

 

MSH Supports Growing International Acceptance of Option B+, Encourages Country Adoption, Further Research

Drs Scott Kellerman (left) and Erik Schouten at "Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings?" a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Drs Scott Kellerman (left) and Erik Schouten at “Prevention of Vertical Transmission and Beyond: How to Identify, Enroll and Retain Children in Treatment Programmes in Resource-Limited Settings,” a satellite session at XIX International AIDS Conference on Sunday, July 22, 2012. (Photo credit: S. Holtz/MSH)

Cross-posted on MSH.org

July 31, 2012 – As the international community gathered for the XIX International AIDS Conference last week, HIV & AIDS experts and key organizations voiced their support for a new approach to preventing mother-to-child transmission of HIV: Option B+.

Option B+ calls for antiretroviral therapy (ART) for life for all HIV-positive pregnant women, regardless of CD4 levels.

The government of Malawi, with the support of MSH, adapted the World Health Organization (WHO) guidelines on preventing mother-to-child transmission, to the needs of Malawi. Current WHO guidelines (2010) distinguish between treatment and prevention (known as “prophylaxis”) and rely on accurate CD4 counts to determine ARV regimens.

Unable to quickly and accurately ensure results from CD4 counts on HIV-positive women, and struggling to adjust treatment regimens given the high fertility rates and frequent pregnancies, Malawi elected to combine ART with PMTCT in a new approach they dubbed Option B which offers lifelong treatment to all HIV-positive pregnant women, regardless of their CD4 levels. The Malawi Ministry of Health devised this approach with support of MSH’s Basic Support for Institutionalizing Child Survival (BASICS) program, funded by USAID.

Dr. Erik Schouten of MSH and colleagues described the bold, new approach in a Lancet article in July, 2011. Option B+ puts women and children first, and, as Schouten and colleagues argue, will likely be cost-effective for countries, like Malawi, in the long-term.

In April, 2012, the World Health Organization (WHO) released a programmatic update on “Use of ARVs for Treating Pregnant Women and Preventing HIV Infection in Infants” (PDF). In the executive summary, the WHO said:

Now a new, third option (Option B+) proposes further evolution—not only providing the same triple ARV drugs to all HIV-infected pregnant women beginning in the antenatal clinic setting but also continuing this therapy for all of these women for life. Important advantages of Option B+ include: further simplification of regimen and service delivery and harmonization with ART programmes, protection against mother-to-child transmission in future pregnancies, a continuing prevention benefit against sexual transmission to serodiscordant partners, and avoiding stopping and starting of ARV drugs. While these benefits need to be evaluated in programme settings, and systems and support requirements need careful consideration, this is an appropriate time for countries to start assessing their situation and experience to make optimal programmatic choices.

Since July, 2011, MSH has helped trained a cadre of 3,366 health workers in Malawi. Within the first year of implementation in Malawi, the number of HIV-positive pregnant women starting ARV treatment has increased six-fold from 1,200 per quarter prior to implementation, to 7,200 in the quarter ending in June 2012. MSH is currently working on a cost-benefit analysis, and is studying the efficacy and challenges of option B+ scale up for preventing vertical transmission in Malawi.

Now others are following Malawi’s lead, particularly in light of Ambassador Eric Goosby’s and UNAIDS’ Michel Sidibe’s call for eliminating pediatric HIV by 2015 (PDF). Earlier this year, Uganda announced its intention to adopt Option B+; UNICEF began a thorough review of the approach; and other countries have expressed a strong interest in moving toward including Option B+ in their strategies for decreasing vertical HIV transmission.

Throughout the XIX International AIDS Conference, researchers and global health leaders touted the benefits of Option B+, and discussed the potential for combining ART and PMTCT in other countries. At a satellite session on Sunday, July 22, leaders from UNICEF, the International AIDS Society (IAS) and MSH discussed Option B+ for preventing vertical transmission. Dr Chewe Luo, Senior Programme Advisor at UNICEF, discussed the topic in depth during her plenary speech on July 25. And in the closing words of the conference, two rapporteurs gave a hat-tip to Option B+, displaying early data from Malawi, provided by Dr Erik Schouten of MSH.

“Option B+ is a game-changer and one of the most exciting developments in decreasing vertical transmission and pediatric HIV in recent years. In short, it calls for treating the mother, preventing vertical transmission to the child, and continuing to treat the mother. It offers the promise of much reduced vertical transmission rates while simultaneously decreasing maternal morbidity and mortality from HIV,” says Dr. Scott Kellerman, MSH’s global technical lead on HIV & AIDS.

MSH is thrilled that the global momentum toward Option B+ is building. Option B+ may not be right for every country or every situation, but in Malawi – and likely in many more countries – Option B+ will prove efficacious and cost-effective in not only protecting babies, but also in treating HIV-positive women. MSH is proud to have been a part of the inception of this idea and looks forward to working with our broad network of HIV & AIDS programs throughout sub-Saharan Africa and the world, using our technical capacity and research ability to investigate the operational issues that need to be addressed and understood for optimal implementation and scale-up of this approach.

Learn more about Option B+:
For additional information or to arrange for a press interview, please contact Barbara Ayotte, Director of Strategic Communications, at 617.852.6011 or bayotte@msh.org.

 

Day 4: Listening, Learning from Marginalized Populations

After 3 days of plenaries — complete w/ scientists & rock stars, challenges & solutions, and a call for focusing on women & girls — Thursday’s plenary focused on some of the most vulnerable & at-risk populations: men who have sex w/ men (MSM), sex workers, injection drug users, and transgenders.

Related Reading: Reaching the Most Vulnerable Populations: A Health and Human Rights Imperative

Reaching the Most Vulnerable Populations: A Health and Human Rights Imperative

Debbie McMillan of Transgender Health Empowerment speaking at the Thursday plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Steve Shapiro - Commercialimage.net

Debbie McMillan of Transgender Health Empowerment speaking at the Thursday plenary. XIX International AIDS Conference (AIDS 2012) Washington DC — as delegates wearing “Statue of Liberty” crowns listen. © IAS/Steve Shapiro – Commercialimage.net

Related Reading: Listening, Learning from Marginalized Populations (via Storify)

After three days of plenaries — complete with scientists and rock stars, challenges and solutions, and a call for focusing on women and girls — the day four plenary focused on some of the most vulnerable, marginalized, and at-risk populations: men who have sex with men (MSM), sex workers, injection drug users, and transgendered people.

Men Who Have Sex with Men

Paul Semugoma of the Global Forum on MSM and HIV opened Thursday’s plenary with the stark facts about men who have sex with men (MSM). Semugoma urged delegates to “move from being friendly to MSM to being competent in getting them care.”

MSM are at particular risk of HIV, sexually-transmitted infections (STI), and high viral load partners. “If you don’t ask about sexual orientation in the examining room, then you don’t know the patient is high risk. Health workers are uniquely placed gate keepers, but when they don’t know about MSM, they are blind.”

Interventions needed to decrease HIV risk in MSM include: behavioral change, pre-exposure prophylaxis, condoms, and antiretroviral therapy (ART). MSM also are affected by criminalization and targeted by stigma.

Semugoma issued an urgent call to action to end invisibility of MSM in the epidemiology, service delivery, and decisionmaking. We must “take our heads out of the sand,” Semugoma implored. “We cannot achieve an AIDS-free generation without MSM. We need to fight stigma, ignorance, and stand in solidarity with colleagues who are beaten or killed for advocating for MSM, such as David Kato in Uganda.”

No drug users? No sex workers? No international AIDS conference

Cheryl Overs at the Thursday plenary, XIX International AIDS Conference (AIDS 2012) Washington, DC. © IAS/Steve Shapiro - Commercialimage.net

Cheryl Overs at the Thursday plenary, XIX International AIDS Conference (AIDS 2012) Washington, DC. © IAS/Steve Shapiro – Commercialimage.net

People distributed green Styrofoam “Statue of Liberty” crowns along with signs stating: “No drug users? No sex workers? No internat’l AIDS conference” as Cheryl Overs of the Global Network of Sex Work Projects, and a researcher from Melbourne, Australia, began speaking.

Drug users and sex workers have been banned from attending the XIX International AIDS conference due to travel restrictions currently in place in the US.

Overs spoke about the social exclusion, rejection, poverty, and lack of information facing sex workers. HIV tests can often lead to criminal prosecution of sex workers and sex workers have less rights and less choice. “The HIV epidemic is being fueled by repression,” said Overs. “The greatest threat to the health and human rights of sex workers is the inability to find a safe place to work.”

She showed a video taken of a “rescue” of sex workers and said these raids ignored the agony and the rights of the sex workers. “We need a law that gets commercial sex out of dangerous places and into safer ones.” She urged sex work to be made legal and called on governments to make the decision to do this — “the decision is free”.

She cited networks of sex workers helping other sex workers. “We need meaningful participation. Sex workers represent ‘real life’ — not epidemiological categories.” She called for a repeal of the PEPFAR Anti-Prostitution Pledge and for a revision to laws so that sex workers could legally enter the US.

Nothing About Us, Without Us

Debbie McMillan, risk counseling specialist at Transgender Health Empowerment, began by showing videotaped remarks from sex workers and injection drug users gathered in Calcutta and Kiev, because they were barred from entering the US to attend the conference. “We are all human beings, we all have rights.” Lifting the travel ban was not an achievement but a mistake that was fixed, she said.

Debbie is a transgender African-American woman who used to be a drug user and sex worker. She is convinced she contracted HIV in prison. She said that she represents people at the “height of the crisis” that should be included in the programs and conferences.

“I went to the street at age 14 and became a commercial sex worker because I thought it was the only place for someone like me. I got high to dull the reality.” She cited clean syringe programs as a key component to fighting HIV.

“My mother was the only person who completely accepted me. She had 1 cup, 1 fork, 1 spoon, 1 plate. At some point she got infected with HIV and died of complications from AIDS. I had to view my mother’s body while in shackles and handcuffs. Two months later, I was diagnosed with HIV at 20 years old.”

There is no bedside manner from health professionals for transgender people, noted McMillan. The Object Bridge LGBT Program for HIV people saved her life.

“I don’t want to be an outsider looking in. I collaborate with my peers in Calcutta and Kiev because they can’t be here. We need to have a conference where all can participate. Nothing about us, without us.”

Going Beyond 15 Million on Treatment by 2015

Gottfried Hirnschall, Director of HIV at the World Health Organization (WHO) in Switzerland, said that getting 15 million on treatment by 2015 was achievable and noted antiretroviral therapy (ART) scale-up successes in Rwanda, Malawi and Cambodia. He also noted that the evidence is now tipping toward earlier initiation of ART and said it has proven cost-effective.

Hirnschall said we need to work now to aaddress gaps for future scale-up, including considering Option B+, “test, treat and retain” method. He also noted the importance of provider initiated testing and counselling.

Reflections on AIDS 2012: Shameza David

Shameza David, AIDS 2012 Poster Presentation. (Photo credit: S. Holtz/MSH)

Shameza David, AIDS 2012 Poster Presentation. (Photo credit: S. Holtz/MSH)

The thrill of having the opportunity to participate in the XIX International AIDS Conference began some months ago. The International AIDS Society accepted an abstract I authored with colleagues for a poster exhibition. This excitement became more real when I learned that I was one of three winners of an MSH internal abstract contest, and would be given the chance to travel to Washington D.C. to attend the conference and present our poster, “Leadership and Management Training increasing male involvement in PMTCT.”

I could barely sleep on Sunday night. I was nervously thinking about presenting the poster at the conference the next day. (I would have been a lot more nervous had it not been for the practice session held by MSH that helped to prepare us for presenting our posters in a clear and concise manner!)

Coming from a small city like Georgetown, Guyana, I could not conceive the magnitude of the conference or the sheer size of the convention center structure.  From the opening day I was blown away by the number of delegates, presenters, exhibitors and speakers from literally all over the world — all involved in some way in the fight against HIV & AIDS — filling the Walter. E. Washington convention center.

I felt privileged to be part of Management Sciences for Health and be surrounded by warm, welcoming supportive colleagues from our global, hardworking family.

The theme of the AIDS 2012 conference, “Turning the Tide,” flowed throughout the week, from the opening plenary to the closing session. I had goose bumps listening to the passion and conviction with which panelists spoke about their personal experiences and struggles they fought and overcame in the pursuit of reducing the incidence and impact of HIV on lives and livelihoods. These plenary sessions were rich in content, and highlighted studies and interventions, and generated new perspectives that could enhance our existing programs at home to create stronger impact. For example, two plenary sessions on preventing HIV among commercial sex workers highlighted a key group that we’ve missed during our intervention: the regular clients of sex workers. The speakers underscored how initiating behavior change interventions with regular partners could make it easier for commercial sex workers to negotiate condom use in their regular relationships.

Being part of the MSH booth was an excellent way to get a picture of the diversity of people attending the conference. Interacting with those who stopped by revealed delegates from an array of organizations and groups: clinical, behavioral, social, academic, faith-based, and community-based, among many others. It was heartening to find that many people knew of our organization and took an interest in one or more of our several programs. Also, visiting the booths of other organizations was useful for knowledge exchange on programs and resources.

This week will resonate with me for a long time, and I will use the journey home to reflect on the wealth of information shared. I am grateful to MSH for affording me this opportunity, and I return home re-energized and invigorated to continue our work as we contribute towards the shared vision of an AIDS- free generation, and someday soon, the end of AIDS.

Shameza David is program officer for the second phase of the MSH-led Guyana HIV/AIDS Reduction and Prevention Program (GHARP II), funded by USAID.

Emerging World Powers: Leadership to Turn the Tide

XIX International AIDS Conference (AIDS 2012) Washington DC. Special Session: China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?  Aradhana Johri. © IAS/Ryan Rayburn - Commercialimage.net

Aradhana Johri speaking at the XIX International AIDS Conference (AIDS 2012) Special Session: “China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?” © IAS/Ryan Rayburn – Commercialimage.net

The similarities facing China, India, South Africa, and Brazil don’t necessarily jump off the page. However, important commonalities exist that the global health community needs to examine — and perhaps model in low income countries.

China, India, South Africa, and Brazil are emerging world powers that have made important advancements in changing the course of the HIV & AIDS epidemic in their countries.

At a special session of the XIX International AIDS Conference on Tuesday, July 24, hosted by Stephen Morrison of the Center for Strategic and International Studies and anchored by renowned economist, Jeffrey Sachs, high level speakers from each of these countries reflected on significant activities that changed their country’s course in HIV & AIDS management. The leaders also discussed how their countries can help lead the way in the fight against the epidemic.

Three themes developed from the conversation of how these countries were able to successfully manage the epidemic in their countries: (1) A country must invest in health not as the end goal, but as a critical instrument of economic development. (2) Reducing the cost of antiretrovirals (ARVs) is critical to get more people on treatment quickly (each country had a different approach). (3) A strong, educated leadership makes the difference. It is the Ministry of Health and global health professionals job to educate government leaders on health.

The South African Health Minister, Dr Pakishe Aaron Motsoaledi, said the focus on HIV & AIDS is what made the difference for his country. The government worked with partners to dramatically reduce the cost of ARVs by 53% which helped get 1.7M people on treatment. “2009 was our turning point,” he said. “There was a real commitment made by the Government at all levels to improve health impact.”

In China, over 80% of the AIDS budget is from the Chinese government directly, explained Dr Wu Zunyou, director of the National Center for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention. The trigger point was the SARS outbreak: leadership made rapid changes to control the outbreak and their mindset changed to focus on respecting health as a human right and protecting marginalized groups.

Dr Dirceu Greco, who has served as a member of the Brazilian Ministry of Health’s National Commission on AIDS, explains that Brazil set standards early, owned 100% of the response, and most importantly has developed the world’s largest public health system with over 100 million people in the system. Brazil invested in health, not just HIV and that was crucial to curbing the disease in Brazil.

India dramatically scaled up their HIV program to manage the HIV epidemic. From the beginning, they stuck to a scientific, evidence-based approach when addressing the concentrated epidemic in India. Aradhana Johri of India’s National AIDS Control Organisation, said that the key was to never lose the focus on prevention efforts.

As middle income countries, India, China, Brazil, and South Africa have had some advantages in managing the epidemic; the world’s poorest countries may be able to adapt some of these approaches to change the tide in their countries. As these four countries move forward, they must lead by example and show other countries how to face the challenges that still remain in ensuring sustainability, fighting stigma, and reducing drug costs and, hopefully one day soon, immunization prices.

Jeffery Sachs closed the discussion, saying: “We are at a vital crossroads; the Global Fund is in financial crisis.” He encouraged the presenters not only to be the voice in public health, but within the leadership of The Global Fund. He asked the countries to invest in The Global Fund, so the world can continue to see significant changes in the fight against AIDS, Tuberculosis, and Malaria.

Watch the special session: “China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?”

Margaret Hartley is MSH’s knowledge exchange associate.