31 Jul 2014
Dismantling 'critical disablers' critical to changing the face of the epidemic

After opening in sadness over the loss of friends and colleagues aboard Malaysian Airlines Flight #17, the 2014 International AIDS Conference in Melbourne, Australia, closed with renewed vigor and determination to put the most affected populations at the heart of the global response to the disease.

“There will be no end of AIDS without ensuring respect and dignity of all people, equity in access to health services and social justice. We need to shout out loud that we will not stand idly by when governments, in violation of all human rights principles, are enforcing monstrous laws that only marginalize populations that are already the most vulnerable in society," said outgoing IAC president Françoise Barré-Sinoussi . “I am very glad that the past week clearly reaffirmed that our engagement goes largely beyond HIV.”

In support of that renewed commitment, the assembled delegates, estimated at more than 14,000, endorsed and signed the Melbourne Declaration: a statement that "nondiscrimination is fundamental to an evidence-based, rights-based and gender transformative response to HIV".

Such a recommendation, however, only underscored the impact of structures that oppress key affected populations, specifically laws, policies and practices that are barriers to the implementation and scale-up of health care services for key populations.

Discriminatory laws enacted in Nigeria, Russia and Uganda were singled out not only for the draconian penalties they impose on people for exhibiting homosexual behaviors but also the chilling effect this has and will continue to have on health-seeking behaviors.

"We cannot allow homosexuals, drug users, sex workers to remain so vulnerable, just because governments persecute them, and stigmatize and discriminate against them. We know the results of repressive policies, we have the numbers," said the Global Fund's executive director, Mark Dybul. "As a researcher I can say that based on existing scientific data, we know the consequences of these ultra-repressive policies. These governments must take responsibility, because it is their policies that will be responsible for a new epidemic. Is that what they want?"

Conference delegates were also asked to commit to the ambitious target of ending the epidemic by 2030: meaning that those who are already infected will be able to prevent passing the disease to another person thanks to a combination of the existing tools -- including anti-retroviral drugs.

To do that, however, means a significant increase in the number of HIV cases detected and an even more substantive increase from 13 million in the number of people currently taking ARVs. UNAIDS estimates suggest that 19 million of the world's 35 million people living with HIV have yet to be diagnosed -- or even identified.

The new 90-90-90 strategy touted at the conference would expand testing so that 90% of HIV-infected people know their status. Of that population, 90% will receive regular treatment with ARVs and among those people, 90% will achieve sufficiently suppressed levels of the virus in their bodies so they will be unlikely to transmit it to others.

According to Dybul, this goal represents a historic moment "a moment where we can take the spread of HIV as an epidemic and turn it into low-level endemicity".

Achieving this will require a powerful shift in implementation, through better and smarter investments in interventions that consider cultural and community needs and that incorporate smart monitoring and evaluation of results and impact.

“If we continue with what we are doing, if we continue with what we started 12 years ago and do not change, we will begin to see the epidemic come back up,” Dybul said. “The question is no longer can we do it, the question is will we do it?”

But while the will was most certainly demonstrated at IAC, the way remains less clear, particularly with respect to funding. The development agenda that is expected to follow the achievement in 2015 of the UN's Millennium Development goals has yet to explicitly reference the HIV response: an oversight that is preoccupying many of the conference attendees as well as policymakers worldwide. The estimated $19 billion spent annually on prevention and treatment -- much of which comes from external financing mechanisms including the Global Fund -- has held flat for the past several years and is unlikely to increase in the next several years.

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