Senior Associate, Global Health Policy Center, CSIS
A session at the International AIDS Conference entitled “Dynamics of the Epidemic in Context” was a study in contrasts. First, Paul Semugoma, Cheryl Overs, and Debbie McMillan, three well-spoken representatives of groups at high risk of acquiring HIV, AIDS, and other burdens each described in some detail the myriad social, personal, economic and legal challenges that marginalized and stigmatized people and groups face in confronting HIV/ AIDS. They were followed by Gottfried Hirnschall of the World Health Organization (WHO) who provided a WHO perspective on the coming expansion of HIV testing and treatment.
The first three presentations were a reminder of the similar challenges faced by sex workers, intravenous drug users and MSM (Men who have Sex with Men). Within specific countries, each of these groups has an HIV prevalence that is usually significantly greater than that of the general population of their country. Individuals in these groups are often stigmatized, sometimes including rejection by their own families. Some of them may be unaware of their own HIV risks. Levels of violence they face are often greater than that faced by my members of the general population. Their activities may be criminalized and, if they are incarcerated as a result of these activities, they may face even greater violence. Finally, their economic circumstances may limit their access to care, including necessary medications.
The WHO presentation was a well-organized and thoughtful discussion of the need to begin long term planning to address the anti-retroviral treatment needs of the world’s HIV-infected population in a way that can also have an impact on preventing future HIV transmission. (Much of the information and guidance included in that presentation can be found in “The strategic use of antiretrovirals: to help end the HIV epidemic,” which WHO published just prior to the International AIDS conference.
Because of my interest in the HIV prevention impact of anti-retroviral drugs, I enjoyed the Hirnschall presentation itself but I was struck by what seemed to be a lack of connection between its mostly biomedical and epidemiologic content and the societal challenges highlighted by the first three speakers. Many of those existing societal challenges (e.g., violence, poverty, excess incarceration) are going to require addressing structural issues of the kind that are not very responsive to biomedical approaches.
One other common theme among the first three speakers was a sense that high risk groups were not being included in any significant way in the planning of HIV/AIDS-related programs. Although there has long been an intent and practice to include People Living with HIV/AIDS (PLWHA) as stakeholders in planning activities at various levels, this PLWHA preference has nearly always been interpreted to mean people who were already infected with HIV, as opposed to those people who were not yet infected but were stakeholders by virtue of living at higher risk of being infected than the general population in their countries. Whether broadening the program planning inclusion process to include stakeholders beyond PLWHA, i.e., to include more uninfected but ‘at risk’ people could be helpful to the planning of successful programs remains to be seen. (Its value seems obvious to me but….) However, since the HIV testing and anti-retroviral treatment activities will increasingly include explicit prevention goals, that kind of stakeholder group expansion could be worth a serious try.