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.
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!”
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.
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: 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
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.
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:
- We need relevant national plans for high impact with emphasis on girls. Few country plans include anything about adolescent girls.
- We need to educate girls — empower them to make choices.
- 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.)
- We need to invest in innovations to reach adolescent girls through social media and networks.
- 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.
Tuesday’s (July 24) session at the XIX International AIDS Conference kicked off with a plenary session on HIV & AIDS “Challenges and Solutions”.
The first three presenters, Javier Martinez-Picado (Spain) from the AIDS Research Institute IrsiCaixa and ICREA; Dr. Nelly Mugo (Kenya) of the University of Nairobi and Kenyatta National Hospital; and Dr. Bernhard Schwartländer, (Switzerland) the Director for Evidence, Innovation and Policy at UNAIDS, each spoke about the possibilities for ending AIDS. Dr. Howard Koh, Assistant Secretary for Health for the US Department of Health and Human Services described US efforts to end AIDS.
A cure or eradication is necessary
Dr. Martinez-Picado launched the session with a list of reminders why a cure or eradication is necessary: (1) The HIV virus is suppressed with antiretroviral therapy (ART), and (2) the vast majority of patients who adhere to treatment will live long, healthy lives. However, (3) mortality and morbidity from chronic diseases such as heart disease and cancer is still higher in populations of HIV-positive patients in treatment than in the general population. In addition, (4) stigma and discrimination against people living with HIV continues to plague nearly every community. And (5) the cost of treatment is projected at $22 billion per year for universal access. For all of these reasons, a cure or eradication is preferable to lifelong treatment.
This cure or eradication will require, “a prolonged period of research,” said Martinez-Picado. But he urged the audience not to let that deter our efforts. He presented a series of scientific studies that are showing varying signs of promise for progress toward a cure. Though none of them is a silver bullet, it is clear that progress is being made in HIV science.
Science, Not the Only Answer
Science isn’t the only answer — though an important one — Dr. Nelly Mugo reminded us in her presentation. According to Dr. Mugo, 44 percent of new HIV infections in Kenya are among married or cohabitating couples, and 50 percent of HIV-positive couples are serodiscordant. Often a couple’s desire for children will overshadow their fear of transmitting the virus to their partner, thus preexposure prophylaxis and treatment as prevention are important strategies for keeping partners of people living with HIV free of the disease.
However, adherence to treatment and linking patients with care after testing are still major problems — not only in Kenya, but worldwide. The solution to these problems is not more advances in science, but rather community-based efforts to make sure both HIV-positive clients and their partners understand the necessity of accessing treatment and adhering to it for life. After all, treatment as prevention cannot work if treatment is not accessed.
Another $7 Billion
Neither science, nor social programming is free. And without increased funding, the number of new HIV infections per year will stagnate, said Dr. Bernhard Schwartländer. Though he believes we must “learn how to do more with what we have,” Dr. Schwartländer also urged countries to take ownership of their health and increase domestic funding for health, including HIV services. Though he believes another $7 billion is needed by 2015 in order to halve the rate of new HIV infections, he says that if low- and middle-income countries continue to fund health services at the same rate they are currently funding them, the gap will be closed as these nations emerge from low-income to middle- and high-income status over the next decade.
“None of this will be achieved without a strong activist voice,” Dr. Schwartländer reminded the crowd, and urged us to challenge our governments to rise to the challenge. “The world overall is getting richer,” he said, “We have to make it fairer.”
Dr. Howard Koh presented achievements made during the first two years of implementation of the United States’ HIV and AIDS strategy. He praised the FDA’s recent approval of Truvada for pre-exposure prophylaxis and the provisions the Affordable Care Act will make for HIV care — including ending insurance companies’ ability to cap lifetime care limits and preexisting condition exclusions. The US plans to decrease the number of new infections within our borders by 25 percent by 2015 through cutting-edge research on vaccines and microbicides and increasing the number of people who know their status through innovative programs, such as free HIV testing at the department of motor vehicles.
It is clear from this session that we will not end AIDS tomorrow. But with the vision of our leaders, the voices of our activists, and the hard work of those on the front lines living and working with people living with HIV a future free of HIV is within our reach.
Mary Burket is communications manager in MSH’s Center for Health Services.
Science was at the forefront of the opening event of the XIX International AIDS Conference on day two, but the “dream team” and a rock star also made an appearance, in a rousing plenary session attended by more than a thousand members of the global public health community in Washington, DC.
In an opening presentation entitled, “Ending the HIV/AIDS Pandemic: From Scientific Advance to Public Health Implementation,” Dr Anthony Fauci of the National Institute of Allergy and Infectious Diseases (NIAID) captured more than 30 years of the epidemic’s history in less than 20 minutes, from what he called the “dark years” of the 1980’s to the present day “new dawn of therapeutics.” Recapping the increasing evidence behind biomedical approaches from prevention of mother-to-child transmission, voluntary male medical circumcision, and treatment as prevention, Dr Fauci underscored the fact that those working in the field of HIV today must “marry the biological with the behavioral.” He closed his remarks by saying how proud he was, after attending 18 previous AIDS conferences, to be able to say, “We do have the scientific basis to implement!”
Fauci was followed by Phil Wilson, founder and executive director of the Los Angeles-based Black AIDS Institute, who also applauded the tools and knowledge available today, after 31 years of living with this epidemic. Wilson’s mood grew more sober, however, as he highlighted the dismal reality for black American men who have sex with men: at age 25, their odds are one in four that they will contract the virus; by age 40, 59.3% are infected. Wilson enumerated five steps to end the epidemic, starting with fully implementing the Affordable Care Act and ending with a plea to AIDS organizations to “re-tool” themselves – noting that community based organizations are central to the fight against the epidemic but are not in a position to deliver health services or implement the important, effective biomedical interventions that exist today.
UNAIDS Executive Director Michel Sidibé took the stage briefly, reminding the audience that he had called upon them on the conference’s opening day to “dream big dreams” and think of the opportunity that exists today to end this epidemic. He referred to his own dream team – mentioning President Obama, US Secretary of Health and Human Services Kathleen Sebelius, and US Global AIDS Coordinator Eric Goosby — and then called to the podium the woman that the New York Times referred to a few weeks ago as the “rock star diplomat,” US Secretary of State Hillary Clinton.
As chanting activists tried to drown out her voice, Secretary Clinton opened her remarks with the words, “What would an AIDS conference be without a little protesting?” and moved on, talking about how AIDS is no longer the death sentence that it once was, and highlighting the possibility that we are moving toward an AIDS-free generation.
Clinton spoke enthusiastically about the role that the US government has played in the global fight against HIV, lauding the creation of the Presidents Emergency Plan for AIDS Relief (PEPFAR), as well as the work of the US Centers for Disease Control and Prevention (CDC) and the US Agency for International Development (USAID).
Acknowledging that all the work “only matters if in the end we are saving more lives,” Clinton reiterated the US government’s commitment to the effort to fight AIDS, announcing an $80 million investment to help pregnant women in developing countries receive treatment and prevention services; $15 million in scientific research aimed at specific interventions for key at-risk populations; a $20 million challenge fund to support country-led efforts to target key populations; and a $2 million investment to reinforce civil society organizations’ efforts for those most at-risk.
More than 20,000 health workers, people living with HIV/AIDS, development specialists, and community activists are attending the AIDS conference, which concludes this Friday. For more on MSH’s presence at the event, visit MSH at AIDS 2012.
Elizabeth Walsh is director of communications in MSH’s Center for Leadership & Management.