AIDS: Small steps, big dreams

Progress in fighting the global HIV epidemic is hampered by gender-based violence and the criminalization of certain behaviors

By Paul Jeffrey

Published in Response magazine December 2014

As they have done every other year for decades, almost 20,000 researchers, activists and policy makers gathered for a week last July to talk about the progress they are making against the AIDS epidemic. Yet the 20th International AIDS Conference, held in Melbourne, Australia, didn’t include much conversation about a cure for HIV, as the wily virus has outsmarted every attempt to eradicate it from the human body. There is hope, however, that advances in treatment for HIV can mean an eventual end to the disease as we know it, eventually converting it from a global public health emergency to a manageable chronic disease.

The progress centers around the use of anti-retroviral drugs–ARVs in the lingo–that reduce the viral load in the body to undetectable levels, which also means infected people are less likely to pass the virus on to someone else. In lieu of a cure or a vaccine, such treatment becomes a key component of prevention, especially among children who acquire the infection from their mothers at birth. In 2013, about 240,000 children were newly infected, a decline of 58 percent from 2002, the year when mother-to-child transmission was at its worst. Providing pregnant women with ARVs has prevented almost one million new HIV infections in the last five years.

In all ages, new infections are declining. In 2013, some 2.1 million people were newly infected with HIV. That’s a horrible number, but it’s 38 percent less than in 2001. In some countries, new infections have fallen by more than 75 percent.

Deaths from AIDS-related illnesses are also declining. About 1.5 million AIDS-related deaths occured in 2013, down 35 percent from 2005. In the last three years, AIDS-related deaths are down 19 percent, the largest decline in the past ten years.

That’s the “good” news, obviously a relative term. There is also bad news. Of the 35 million people living with HIV, only 13 million were receiving ARVs at the beginning of 2014. Three of four children with HIV aren’t receiving treatment. Among women with HIV, about one-sixth are 15-24 years old. In sub-Saharan Africa, women acquire HIV infection at least five to seven years earlier than men. Gender inequalities and gender-based violence often prevent adolescent girls and young women from being able to protect themselves against HIV, and economic and cultural factors often keep them from accessing treatment.

In populations that are even more widely marginalized, the virus thrives unchecked. The infection rate among female sex workers around the world is 13.5 times greater than among women 15-49 years of age. Among intravenous drug users, HIV is 28 times more prevalent than in the general population.

Activists at the Melbourne conference outlined a new global strategy that aims to end the spread of HIV by 2020, and eliminate the disease altogether by 2030.

Often described as the 90-90-90 Plan, the straegy aims to insure that 90 percent of people who are infected are tested and diagnosed. Then, 90 percent of those who are diagnosed as HIV positive will receive antiretroviral drugs. Activists then aim to have at least 90 per cent of those getting ARVs to attain an undetectable level of virus in their bodies, essentially a functional cure.

Michel Sidibé, the director of UNAIDS, said the goal is obviously ambitious but history shows that clear targets are the best way to progress. “90-90-90 is not just a numeric target, it’s a moral and economic imperative,” he said. “It will drive the HIV-AIDS epidemic into history.”

Most of the obstacles to achieving that goal lie not in science, but in public attitudes toward those who live with the virus.

“We have the tools. We have the science that we need. Yet there is no way to treat people if they have no access to care because they are afraid, or because they are women, or because they are a migrant, or because they need to hide to survive,” Luiz Loures, the deputy executive director of program of UNAIDS, told a gathering of religious leaders on the eve of the conference.

People are scared

The global AIDS ambassador of the United States government, Deborah Birx, told faith leaders in Melbourne that their “compassion and passion for this work continue to be the heartbeat of the response to HIV,” yet she also expressed concern about the role of some religious groups in fomenting discrimination in Africa, where anti-gay legislation has led to violence against sexual minorities. Globally, same-sex sexual acts are criminalized in 78 countries and are punishable by death in seven.

The Rev. Phumzile Mabizela, a Presbyterian minister in South Africa, said anti-gay legislation is setting back the struggle against AIDS.

“The new laws and even the discussion of the new laws have promoted a lot of fear. People are scared of going to clinics or hospitals. They don’t know whom to trust,” said Ms. Mabizela, the executive director of the International Network of Religious Leaders Living with or personally affected by HIV and AIDS (INERELA+).

“We as a faith community should stand up and fight against this. It puts the lives of our most at-risk communities even more at risk. The more we discriminate against them, the more we stigmatize them, and the less likely they are to come forward for the resources they need.”

While homophobia is provoking violence in some areas, complacency has become a common problem in other parts of the world, primarily in the global north.

“In the United States, western Europe, Australia and New Zealand, complacency has become a problem,” said Father Robert Vitillo, the Vatican’s top AIDS expert. “Because we have relatively low levels of infection, and most people who are HIV positive are on medications, we think the problem is solved. But that’s not the case. High income countries have had a steady rate of new infections for several years, yet they’re lecturing everyone else on how to reduce their new infections.”

Mr. Vitillo said this “lack of awareness” takes on even more dangerous overtones when PrEP becomes available, a reference to Pre-Exposure Prophylaxis. “With PrEP people can develop a sense that they don’t have to worry about infection anymore. So they can have all the sexual encounters they want, or inject any drugs they want, with a perception that they’re protected from HIV. But there are other diseases that they can acquire. We’re in danger, but there’s widespread denial about the danger,” he said.

According to Ulysses Burley, a Lutheran physician and AIDS activist in Chicago, young people of color in the United States are at a particular risk of being left behind in the struggle against HIV and AIDS.

“If Black America were its own country, it would be ranked 16th in the world in terms of HIV infections, above countries like Botswana and Ethiopia and Haiti. So as we discuss the global epidemic, I don’t want the U.S. epidemic to be left behind, especially young African-American men who have sex with men,” he said.

Insuring their inclusion in the HIV response means churches have to establish new ways of reaching millennials. “You can’t do outreach to a population to which you don’t have access,” Mr. Burley said. “It also means the church has to deal better with sex and sexuality, not as a separate theme, but as something integral to our spirituality.”

Lalchhuanzuali, a young woman from Mizoram State in northeast India, says she wouldn’t be HIV-positive today if the church had helped her better understand sexuality.

“Inside the church I got training about drugs, but I didn’t get information about sex. I did’t get sex education anywhere. That’s why I became HIV-positive,” she said. “The church leaders need to speak out and do sex education inside the church in order to support young people.”

A Presbyterian whose presence in Melbourne was sponsored by the YWCA, Ms. Lalchhuanzuali faced severe discrimination when she learned her status. Her husband threw her out of the house. She says her local congregation, however, moved from seeing HIV-positive individuals as bad people to offering love and support. She spends much of her time today encouraging other churches to get involved. “We need to teach the youth, especially young women,” she said. “We need to support women’s rights. If we can do this, things can change.”

“There is plenty of money”

Changes in international funding for HIV testing, treatment and education will jeopardize continued progress against the virus, many religious workers in Melbourne warned. Of particular concern is a shift in funding, especially by the U.S. government, away from AIDS programs in countries where growing economies have moved the nations from being considered “poor” to now being labeled “middle income.”

Mr. Vitillo said that’s a mistake.

“It’s true that a small number of people are getting richer and richer, and a country’s GNP may have risen into the middle income category, but the situation of the poor is often worse. And some governments claim they can handle all of their own health care, but they really can’t, and what they do provide they tend to concentrate in the large cities. As a result, the churches that have been providing care in rural areas have less access to funding today,” he said.

Assuring that nobody gets left behind, Mr. Vitillo said, will require fundamental policy shifts.

“It means much more equitable sharing of resources. We keep hearing there’s no money. But there is plenty of money. Governments just have the wrong priorities in how to spend it. If we took some of the funding that now goes to weapons and spent it in the struggle for development, we could take care of HIV and AIDS much more quickly,” he said.

Financial decisions at national levels are also increasing the risk of leaving whole segments of the population behind. In India, for example, the government this year ended 13 years of collaboration and funding for church-run hospitals and community care centers.

“The government decided to close these and announced that people should go to the government health facilities. But those aren’t really capable of handling the complex multiple needs of HIV-infected people, especially complicated cases and those in the end stages of care,” said Father Mathew Perumpil, who coordinates HIV work for the Catholic Church in India.

Both Catholic and Protestant churches in India have struggled to keep the centers open, even without government funding.

“We were the first to open our doors to people living with HIV. We didn’t start these programs because of the government. We started them because of the people. So many of the centers remain open and continue providing services. But that puts us in a huge bind. Where do the resources come from? The patients can’t pay,” said Mr. Perumpil.

While the Indian government continues providing antiretroviral medications at no cost, church-run hospitals and centers are now struggling to raise their own funding for other services.

Mr. Perumpil said the people most at risk of being left behind in the HIV response in India are women living in the countryside.

“The poor, the people without voices, are always the ones who are left behind. They aren’t the key populations that get lots of attention and money from the international community. They are poor women in villages who still know nothing about HIV and end up getting infected by their husbands who are working elsewhere. They are the people who are still left behind,” he said. “You don’t see them in Melbourne because this conference is too expensive for any of them to attend. They are marginalized not because of their sexual orientation, but simply because they’re poor. The church is close to them, and the church has to do a lot more in solidarity with them.”

The Rev. Paul Jeffrey is a United Methodist missionary photojournalist and senior correspondent for response.