AIDS 2012There has been much optimistic talk this past year about turning the tide of HIV and creating an AIDS-free generation. For this to translate to reality, we must address the high HIV prevalence rate among the most vulnerable populations: men who have sex with men (MSM), sex workers and transgender people. In addition, antiretrovirals—heralded as treatment and prevention—must be made available to millions more HIV-positive people. Is any of this possible in the real world, and if so—how do we do it? Four speakers addressed these topics in a plenary session titled “Dynamics of the Epidemic in Context” on Thursday, July 26, at the XIX International AIDS Conference (AIDS 2012) in Washington, DC.

MSM and HIV
“Men who have sex with men exist everywhere—I also am a man who has sex with men.” With this declaration, Paul Semugoma, MD, a practicing physician in Kampala, Uganda, opened his plenary discussion. Such a declaration was necessary and “mega important,” he said, because of the level of ignorance and denial across the globe concerning MSM.

Many countries that report HIV data fail to collect any information on MSM, as if these men don’t exist, he said. Yet the fact is that across the globe HIV prevalence among MSM is higher than other adults. The disparities are alarmingly stark among black MSM. African-American MSM are 72 times more likely to be HIV positive than the general U.S. population; in Canada, black MSM are 73 times more likely to be positive; and in the United Kingdom, they are 111 times more likely to be living with the virus. The disparities continue across the HIV health spectrum—MSM are more likely to be undiagnosed and uninsured, to have a harder time attaining and staying on meds, and they’re less likely to suppress the virus. “An AIDS-free generation?” Semugoma asked, in reference to a popular slogan, “Not without including MSM.”

We know that condoms, PrEP (pre-exposure prophylaxis), treatment as prevention, behavior changes and other interventions work, Semugoma said, so the question is how to apply them to the MSM population.

What are the main challenges in doing so? Criminalization of same-sex practices. Semugoma used Senegal and Uganda to illustrate this problem. Both countries have an HIV epidemic concentrated among MSM, but when health workers and advocates tried to reach these men, they were arrested and prosecuted for promoting homosexuality and gay rights. The fear, he noted, is that homosexuality will spread throughout the population, and the reality is that HIV is what is spreading.

What about solutions? Semugoma’s call to action is to end the invisibility of MSM, to include them in health care delivery, in epidemiology and decision-making. And to return to basics: condoms and (water-based) lube. If $134 million were invested in condoms and lubricant, it could avert 25 percent of the global MSM infections in the next 10 years. It’s also important to fight stigma and ignorance with data and information, and to include multi-stakeholders—governments, service providers, communities of MSM—in the fight against AIDS.

Semugoma wrapped up with a slide titled “Price of Advocacy.” It included the photos of Aim Mongoche in Cameroon, Steve Harvey in Jamaica, David Kato in Uganda and Thapelo Makutle in South Africa—advocates who were beaten, arrested and killed. “It’s tough to achieve comprehensive HIV prevention and treatment in these contexts,” Semugoma concluded, “but they have tried. And we continue to try.” The last slide, though, was an image of Semugoma and his partner in a happy and loving embrace—visible for all the world to see.

Sex Workers
The advent of PrEP—pre-exposure prophylaxis—along with treatment as prevention and rapid HIV home testing may be radically altering the field of HIV prevention, but how do these tools apply to sex workers?

The tide cannot be turned without including sex workers, said Cheryl Overs, a research fellow at Monash University in Australia and an advocate for sex workers rights. She was referencing not only the AIDS 2012 slogan “Turning the Tide Together” but also the fact that sex workers and drug users are denied entry to the United States—and thus to the AIDS conference and to the discussions, decisions and solutions regarding the epidemic.

Yes, sex workers want new technologies to help protect themselves, but biomedical tools such as PrEP—taking daily meds to prevent HIV infection—may also increase the pressure to have condomless sex and thus add an enormous risk for HIV to sex workers. Also, Overs noted, it will be the sex workers who will shoulder the responsibility of buying and using the new tool.

HIV tests, which are pivotal to getting more people aware of their status and into treatment, can backfire because sex workers are afforded less confidentiality. Positive tests can mean a loss of incomes—or that they can be legally prosecuted and find their photos and status published in newspapers by the police. As Overs noted: “Sex workers all say that their greatest threat is the law that makes it impossible to find a safe place to work.”

Another threat to sex workers is advocates—mostly religious fundamentalists and feminists—who are out to “rescue” them. To illustrate this phenomenon, Overs played digital footage recorded from a cell phone. It showed a group of adult female sex workers being “rescued” by being herded up and shoved onto a bus against their will. “Save us from our saviors” is a popular rallying cry in these instances.

Overs agreed with LGBT activist Peter Piot, who said, “What drives continued expansion of the pandemic is not the absence of effective preventative technologies, but discrimination, exploitation and repression of certain social groups.”

What can be done? Overs listed many needed steps. First, repeal laws that prohibit consenting adults from buying or selling sex. Ensure safe working conditions for sex workers. Stop police harassment and violence, and prohibit mandatory HIV and STI testing of sex workers.

It’s also imperative, she stressed, that sex workers be part of the solution, that they be included in all levels—from research to policy making. On this last note, Overs showed a film highlighting the success of Modemu, a group of Dominican sex workers who united to educate and advocate in their communities. The United Nations and other agencies should follow this example and listen to the knowledge and needs of sex workers. “Programs should be based on facts,” Overs said, “and the sex workers have the facts—not the moralists and fanatics.”

Regarding the promise of PrEP and new HIV interventions, Overs closed with a slide that read: “Talk of ‘allocating resources to where they will have the greatest impact’ is code for taking money away from social programs and spending it on biomedical interventions instead. Resist!”

Transgender Community and Drug Users

Debbie McMillan did not rely on slide shows or surveys or data to get her message across. She simply told her life story. “I am an Afrian-American transgender woman,” she said. “I used to be a drug user. I used to be a sex worker. I used to be incarcerated. For 20 years, I lived a life that guaranteed I would contract HIV. I represent people at the heart of the AIDS crisis. Small groups with a big problem.

“The solution [to the AIDS crisis] lies in people like me,” she said. “When we are included in the design of programs, they are more successful.” That message—that the minority groups affected by HIV must be included in every level of fighting the epidemic—was the heart of her story.

The details of that story, she acknowledged, are unpleasant but not uncommon. McMillan turned to the streets when she was 14. That led to sex work. Then to drugs. Then to prison, where McMillan is convinced she contracted HIV. At a low point, McMillan envisioned living one day as a woman. It was that possibility that gave her hope and led her to seek help.

She found a lifesaving program called Bridge Back. The reason it succeeded, she said, is that unlike previous doctors who insisted on calling her by her birth name, Bridge Back “accepted me 100 percent.” Alas, the program has since closed due to lack of funding.

Today, McMillan is a risk-counseling specialist with Transgender Health Empowerment in Washington, DC. To tackle the AIDS epidemic, transgender people must be included at all levels and with no judgments—include them in creating solutions, and you’ll get solutions that work. “I want to collaborate, I don’t want to be on the outside looking in,” she concluded. “Include us, let us help.”

Expanding Treatment

To everyone familiar with the “15x15” goal—the target of getting 15 million HIV-positive people on antiretrovirals (ARVs) by the year 2015—Gottfried Hirnshall, MD, MPH, of the World Health Organization, has a bit of news: It is achievable, we are on track to succeed, and now is the time to think about doing more!

For inspiration, Gottfried mentioned three success stories: Cambodia has scaled up ARV coverage 90 percent since 2003, Malawi did so by 67 percent in the same time period and South Africa by 66 percent. But why scale up ARV coverage? In rural South Africa, for example, every 10 percent increase in ARV coverage translates to a 17 percent decrease in individual risk for HIV. Questions remain about when to start ARV coverage—at what CD4 count—but Hirnschall says it’s strategic to offer ARVs earlier to more people and that modeling suggests doing so is cost effective in the short and long term.

But how to do it? Hirnschall offers key areas to optimize: Expand, simplify and diversify HIV testing—including self-testing; use simple and better drugs; use the just-developed diagnostic tests for CD4 counts and viral loads, which can be done at the point-of-care without having to go to a specialist; address the disparities and inequalities in high-risk populations; and take advantage of new technologies and opportunities such as PrEP and treatment as prevention.

Hirnschall closed with a reminder: ARVs for treatment and prevention are a powerful tool for ending the HIV epidemic.

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