Research suggests policies are barrier to ending HIV
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Government policies can work against achieving an end to HIV by limiting access to prevention and treatment for the most heavily affected groups, according to research presented at the 22nd International AIDS Conference last week in Amsterdam.
An estimated 1.8 million people were newly infected with HIV in 2017 and nearly 1 million people still die of the disease annually. While the number of people on antiretroviral therapy has risen dramatically - reaching 21.7 million last year - an estimated 15.2 million still go without treatment.
Despite remarkable gains in HIV treatment and prevention, many barriers stand in the way of universal access. These include policies that criminalize or promote discrimination against people due to their HIV status, sexual orientation, gender identity, sex work, or drug use.
"The biggest barriers now to ending the epidemic are ideologically and politically driven," said International AIDS Society president and conference Co-Chair Linda-Gail Bekker. "Together, we will hold policy makers and donors accountable to the evidence - the end of AIDS will only come from prioritizing science-based policies, ensuring adequate funding and working hard together to be certain that no one is left behind."
The conference, which brought together more than 15,000 delegates, featured sessions devoted to the detrimental effects of the U.S. global gag rule, laws that harm sex workers, and criminalization of people living with HIV.
The global gag rule, also known as the Mexico City policy, prohibits funding of organizations that inform clients about the full range of reproductive options, including abortion, even if they do not use the money directly for abortion services. A growing body of evidence shows that HIV services for women are best provided in conjunction with reproductive and maternal health services, which is hampered by the policy.
Originally put in place under President Ronald Reagan, the policy has been rescinded and reinstated as Democrats and Republicans trade places in the White House. Advocates say hundreds of organizations that receive President's Emergency Plan for AIDS Relief, or PEPFAR, funding will be affected.
"The Trump-Pence global gag rule is an ideological crusade that denies lifesaving care to women around the world and threatens decades of progress in the global HIV response," said Congresswoman Barbara Lee (D-Oakland), who spoke at the conference. "The health care of women and children shouldn't be used as a pawn to placate right-wing extremists."
2020 confab controversy
Lee also addressed the continuing controversy around holding the next International AIDS Conference in July 2020 in San Francisco and Oakland. As reported last week, activists from the Bay Area and around the world are demanding that the confab be moved, citing President Donald Trump's recent policy barring people from certain countries as well as long-standing U.S. exclusion of sex workers and people who use drugs.
"Even within the same country some people have the best care and treatment and others are falling through the cracks. In the U.S. your health care is determined by the color of your skin or the dollars in your bank account, or the ZIP code in which you live," Lee said at the conference's closing session.
"In 2000, we brought the fight to South Africa under an AIDS denialist government and we can't shy away now," Lee added, referring to the 2000 AIDS conference in Durban. "My district is the heart and soul of the resistance movement against these terrible policies."
Delivering the conference keynote address, former president Bill Clinton also addressed the 2020 controversy.
"For those of us who care about this issue in the United States, San Francisco is a sacred place, where many people died and some of the first battles were fought. ... I think when you get there, you'll be glad to have the conference in San Francisco," he said to a mixed chorus of applause and boos.
Clinton, who started the Clinton Health Access Initiative after he left office, also stressed the importance of not cutting back on global funding for HIV and tuberculosis in order to increase resources for non-communicable diseases such as heart disease and cancer.
"There are still areas of this challenge that aren't really being addressed. We have to fight for more oral PrEP and continue development of promising tools like long-acting injectable PrEP," he said. "I'm somewhat perplexed at the opposition to this, which is part of the attempt to relitigate questions of sexual orientation and sexual identity in the context of a new politics of division that is sweeping the world. All I know is the only really pro-life answer is to save as many lives as possible."
Sex worker activists interrupted Clinton's speech to protest SESTA, the Stop Enabling Sex Traffickers Act, a recent federal law that makes websites, social media networks, and other online platforms liable for user content related to sex trafficking. But SESTA also expands federal law to cover online content intended to "promote or facilitate" consensual adult prostitution.
In the wake of the law's passage in March, several sites that sex workers use to find and screen clients have already shut down, which advocates say is driving people to street prostitution. Advocates also fear that "facilitation" could be deemed to include sites offering HIV prevention information, peer support, and "bad date" lists that warn workers about dangerous clients.
With multiple studies now showing that people on treatment with suppressed HIV cannot transmit the virus, 20 leading experts issued a consensus statement declaring that scientific evidence refutes the rationale for laws criminalizing HIV transmission. At least 68 countries - and some U.S. states - criminalize HIV non-disclosure, exposure, or transmission.
"Simply put, HIV criminalization laws are ineffective, unwarranted and discriminatory," said Bekker, a co-author of the statement. "In many cases, these misconceived laws exacerbate the spread of HIV by driving people living with and at risk of infection into hiding and away from treatment services."
The statement - a joint effort of IAS, the International Association of Providers of Care, and UNAIDS - stresses that there is no possibility of HIV transmission through biting or spiting, no possibility of transmission during vaginal or anal sex when the HIV-positive partner has an undetectable viral load, and no way to establish proof of HIV transmission from one individual to another.
"With all the new scientific advances now available, we need to continue to use science as evidence to deliver justice," UNAIDS Executive Director Michel Sidibé said. "No one should face criminalization because of a lack of information or understanding by the justice system about the risks of HIV transmission."
As the world makes strides towards controlling the epidemic, experts stressed the importance of integrating care to address all the needs of people living with HIV.
"We have not truly helped a child if we treat her for HIV, but do not vaccinate her against measles. We have not truly helped a gay man if we give him PrEP but leave his depression untreated. We have not truly helped a sex worker if we give her STI screening but not cancer screening," said World Health Organization Director-General Tedros Ghebreyesus. "Universal health coverage means ensuring all people have access to all the services they need, for all diseases and conditions."
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