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.

On Day 3, Three Women, Three Calls: Keep Mothers Alive, Make Women Count, Invest in Programs for Girls

XIX International AIDS Conference (AIDS 2012) Washington D.C. Wednesday Plenary Session Linda H.ScruggsAIDS Alliance for Children, Youth and FamiliesUnited StatesUSA and Canada © IAS/Ryan Rayburn - Commercialimage.net

XIX International AIDS Conference (AIDS 2012) Washington DC, Wednesday Plenary Session, Linda H. Scruggs. © IAS/Ryan Rayburn – Commercialimage.net

Day three of the XIX International AIDS Conference opened with an impassioned plenary by three powerful women speakers, calling for more concerted action for women and girls living with HIV, particularly adolescent girls.

Dr Chewe Luo, Senior Advisor HIV/AIDS, UNICEF, spoke about the Global Plan to Eliminate New HIV Infections in Children by 2015 and Keeping Their Mothers Alive. Targets of the plan include: 1) Reducing infections in children by 90%. (In 2011, 333,000 children were infected with HIV, with 29% of new infections in Democratic Republic of the Congo, Nigeria and Malawi.) 2) Reducing HIV-related maternal deaths of women during pregnancy, delivery or post-delivery, by 50% by 2015.  3) Eliminating mother-to-child-transmission.

Luo highlighted the benefits of giving triple therapy or single dose Nevirapene throughout breast feeding; this could reduce mother-to-child-transmission to less than 5%. She described pilot studies in 11 countries and improvements in access to antiretrovirals (ARVs) for women: from 48% in 2010 to 57% in 2011. Despite improvements in Eastern and Southern Africa, the Caribbean, Eastern Europe and Central Asia, “we still need to do better in Western Africa,” she said. The decline in HIV infections in children was roughly 10.8%  from 2010 to 2011 but, “this is not enough,” said Luo. “We should have reached 20% by now.”

She cautioned that treatment should have started earlier for pregnant women and cited several options that countries have, mostly based on cost: Option A and B which are treatment therapies for the mother for a limited time and the newer Option B+ which provides triple ART for pregnant women for life.

“We will not achieve the goal of eliminating PMTCT without some serious innovations. And that’s what this strategy [Option B+] is about,” said Luo.

OPTION B PLUS: BOLD CHOICE TO SAVE MOTHERS WITH HIV IN MALAWI

Malawi is the first country to implement Option B+. “We need to look at PMTCT as a component of ART and access treatment early,” said Luo. “This is the bottom line for me.”

“Option B+ must be scaled up. I applaud Malawi for being so bold.” Benefits of Option B+ include reduced infant HIV infection.

Luo then turned her attention to the “unacceptable” percentage of children not receiving ART. “We are failing to reach children,” she said.

She ended with a call to action. We need to: 1) simplify our prevention approach and integrate PMTCT and ART programs at the community level; 2) introduce innovative approaches to reach adolescent girls and pregnant teens; 3) change treatment regimens for children; and 4) collaborate with community groups.

GENDER EQUITY AND EMPOWERMENT: LINDA’S STORY

Linda Scruggs, a consultant and a woman living with AIDS, delivered an inspirational account of her own struggles and brought her rousing comprehensive agenda to “Make Women Count” and end gender discrimination and stigma to a standing ovation. Scruggs told many stories of both gender inequity and gender empowerment.

“For the last 20 years, women have been asking for an international platform for their rights, to count us in. Today I stand to give us direction and a recipe for change. We want women  to work with women that have the tools for us, by us, with us. … It is not enough to create a task force or write a paper, what we need is to be part of the solution. We are the Mothers of the Earth.”

Linda reflected: “What does a woman with no self- esteem look like?  What does a woman whose uncle molested her look like? What is a woman who can’t read or write, broken and voiceless? That woman was me.”

Linda told stories of women, broken or affected by disease. “We are at the table and a force to be reckoned with. We need a big change and need to create jobs and training for HIV positive women.”

UNFINISHED AGENDA: PROTECTING  ADOLESCENT GIRLS

Dr. Geeta Rao Gupta, Deputy Executive Director of UNICEF, also made the case to turn the tide for adolescent girls and highlighted the need for gender equality. Adolescent girls aged 15 to 24 bear the brunt of the epidemic. Of the 4.8 million young people with AIDS, 3 million of them are girls.

The challenges of adolescent girls are immense: early sexual debut, child marriage, increased risk of HIV and STIs, sexual violence, and risk of early pregnancy and HIV infection. Many are forced early into transactional sex to survive or they depend on older men to survive. Most lack basic information on condoms or sex education.

Geeta offered recommendations to accelerate the pace of protection for adolescent girls:

  1. We need relevant national plans for high impact with emphasis on girls. Few country plans include anything about adolescent girls.
  2. We need to educate girls — empower them to make choices.
  3. We need to start early; make adolescents visible in routine data systems and follow their health status after age 5. (Right now, they don’t appear in the data unless they get pregnant or contract HIV and then they are included with adult data.)
  4. We need to invest in innovations to reach adolescent girls through social media and networks.
  5. We need to engage with adolescents as partners.

As Anthony Lake of UNICEF has so eloquently said: “We invest so much in keeping girls alive in their first decade of life. We must not lose them in the second.”

We need a world that is AIDS-free and fair for all women and girls. That must be our legacy.

Barbara Ayotte is MSH’s director of strategic communications.