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.

 

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.