By Reinhard Jacobsen

AMSTERDAM (IDN) – Since the first cases of HIV were reported more than 35 years ago, 78 million people have become infected with HIV and 35 million have died from AIDS-related illnesses, says UNAIDS, a United Nations organization that is leading the global effort since1996 to end AIDS as a public health threat by 2030 as part of the Sustainable Development Goals (SDGs).

According to the latest figures available, in 2017, 36.9 million people were living with HIV and 21.7 million with HIV on antiretroviral therapy. 1.8 million were newly infected with HIV in 2017.

More than 16,000 researchers, advocates, policy makers, funders and community leaders from more than 160 countries came together from July 23 to July 27, 2018 in Amsterdam, the Netherlands, to make the 22nd International AIDS Conference (AIDS 2018) a key milestone on the road to a world without HIV.

With a view to Breaking Barriers Building Bridges, nearly 3,000 abstracts were presented from more than 100 countries in the weeklong conference which organised dozens of satellite sessions, pre-conference programmes, demonstrations, performances and community meetings.

The Amsterdam Affirmation

AIDS2018 endorsed the Amsterdam Affirmation stressing what has been achieved in the past two years and what remains to be done. It said: Much has changed since the global HIV community convened at the previous International AIDS Conference in Durban in 2016. Advances in science have been significant, including widespread acceptance that HIV is untransmittable with an undetectable viral load, increased PrEP rollout, innovative treatment delivery methods and promising developments in cure and vaccine research.

But while there have been success stories, prevention efforts continue to lag and new HIV infections are still on the rise among key populations and young women and girls.

These groups continue to experience high levels of structural violence and stigma. Coupled with a rising tide of populism, questionable political commitment and leadership and declining financial resources, the HIV response is operating in a fragile environment. People, politics and power lie at the heart of the AIDS epidemic. How these intersect will continue to be critically important in achieving the agreed global targets and universal health coverage.

Focus on youth

Youth and junior investigators made up more than one-third of the submissions presented at the conference, and their work drew attention in every conference track. Besides, AIDS 2018 provided more scholarships to young people than any previous AIDS conference.

The AIDS 2018 Global Village featured the largest dedicated youth space of any International AIDS Conference – providing a critically important space for young people from around the world to network, collaborate and showcase their achievements.

Dozens of youth-focused programmes and events put young people and their experiences front and centre. Among these were sessions calling for a “youthquake” in HIV prevention and treatment, addressing innovative strategies to overcome barriers to access for young people and sharing strategies to amplify meaningful youth leadership for the HIV response.

Funding

Funding is essential to the AIDS response, and new data released at AIDS 2018 reveal a significant US$6 billion gap between what is available for the response and what is needed, now, to ensure global access to prevention, treatment and care.

After several years of flat funding, more than half of major donor governments decreased their HIV commitments in 2017, and no new significant commitments from international donors have been forthcoming. Treatment scale up has plateaued and is far short of what is needed to meet UNAIDS 2020 treatment goals. While domestic spending on HIV has risen significantly in recent years, it is not nearly enough to make up for gaps in donor funding.

With nearly 1 million people still dying of HIV annually, advocates warn that if the funding gap is not closed quickly, the shortfall could lead to millions of unnecessary HIV infections and deaths.

Condoms availability

Participants in a conference session learnt that 30 years into the response to HIV and despite increased use of condoms over the past three decades, condom availability and use gaps remain, in particular in sub-Saharan Africa where the gap between availably and need is estimated to be more than 3 billion condoms. The estimated condom need in 47 countries in sub-Saharan Africa in 2015 was 6 billion male condoms; however, only an estimated 2.7 billion condoms were distributed.

Participants also highlighted several barriers and inequities hindering access to, and the use of, condoms that continue to exist, including poor access, age restrictions, gender norms, religious norms, stigma, insufficient supply and, in some places, laws that make it an offence to carry condoms.

Many countries also prohibit condom promotion and distribution in schools and other venues where adolescents socialize. According to participants, of the 100 countries that reported having a national plan or strategy related to condoms in 2017, only 26 reported that the plan included condom promotion in secondary schools.

International funding for condom procurement in sub-Saharan Africa has decreased in recent years, and domestic funding has not sufficiently increased, participants noted. In several countries condom programming, in particular condom promotion and demand creation, has stalled due to lack of funding and decreased investment.

Comprehensive well-being

AIDS 2018 put a spotlight on the need to address the comprehensive health and well-being needs of people affected by HIV – from the Generation Now pre-conference on HIV and sexual and reproductive health and rights to calls to integrate care and treatment of HIV and TB, the #1 killer of people with HIV.

Throughout the conference, reports on programmes that integrate HIV diagnosis and treatment with care for hepatitis, STIs, hypertension, diabetes and other health concerns showed that these initiatives deliver better, more effective and more cost-effective care than programmes that look at single health issues in isolation.

As WHO Director-General Tedros Ghebreyesus reminded the conference opening session, “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. Universal health coverage means ensuring all people have access to all the services they need, for all diseases and conditions.”

Global gag rule

Researchers shared alarming evidence at the 22nd International AIDS Conference (AIDS 2018) today of negative impacts of the U.S. Government’s “Mexico City Policy”, also known as the “global gag rule”.

U.S. Representative Barbara Lee of California’s 13th Congressional District said: “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,” she said. “The health care of women and children shouldn’t be used as a pawn to placate right-wing extremists.”

First put in place by President Ronald Reagan and reinstated in 2017 by President Donald Trump, the policy denies U.S. aid to organizations that provide information, referrals or services related to legal abortion or advocate for abortion, even with their own money.

Past iterations of the policy applied solely to U.S. family planning assistance. Now, under the Trump Administration, it applies to almost all U.S. global health bilateral assistance, including the President’s Emergency Plan for AIDS Relief (PEPFAR).

“The reach of the global gag rule has been greatly expanded, and has the potential to roll back progress on HIV,” Anton Pozniak, President-Elect of the International AIDS Society and Executive Director of HIV research and Director of HIV services, Chelsea and Westminster Hospital in the United Kingdom, said. “The evidence is clear: we need better integration of sexual and reproductive health and HIV services, not policies that make it harder for people to access healthcare.”

A study presented on July 27 sought to understand the effect of the expanded Mexico City Policy on HIV programmes and services. The authors analysed data from ForeignAssistance.gov over the most recent three-year period for which such data were available (FY2013-2015) to estimate the number of non-governmental organization (NGO) recipients of PEPFAR funding that could be subject to the policy, as well as the amount of funding they receive.

Results, as presented by Jennifer Kates of the Kaiser Family Foundation, were that more than half of the countries that receive PEPFAR support allow for legal abortion. The authors identified 470 foreign NGO prime recipients of PEPFAR bilateral HIV funding, which received $873 million. In addition, they identified 274 US NGO prime recipients, accounting for $5.5 billion, which would be required to ensure that any foreign NGO sub-recipients were in compliance.

The researchers concluded that the expanded gag rule would likely affect hundreds of NGOs that receive PEPFAR support.

Another study assessed the global gag rule’s applicability in several African countries. Specifically, it looked at an exception in the US policy that applies when local laws affirmatively require healthcare providers to provide counselling and referrals for abortion.

The authors conducted a assessment of the applicability of the affirmative defence in several African countries. Findings, presented by Brian Honermann of amFAR, were that South Africa has particularly strong Constitutional protections for reproductive rights.

South Africa also has strong informed consent requirements in its National Health Act, ethical guidelines, and robust case law that compel healthcare providers – including PEPFAR partners – to continue counselling about and referring for abortion services that cannot be circumvented by the policy.

Evaluations in Mozambique, Zambia and Zimbabwe have found differing levels of protections. The study concluded that South African law provides a template for advocates to replicate. [IDN-InDepthNews – 29 July 2018]

Photo: A glimpse of AIDS2018. Credit: AIDS2018

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