Opening Plenary
The opening plenary session of the World AIDS Conference, 2006, Toronto featured two talks about the cutting edge of HIV. First, Chris Beyrer of Hopkins talked about the epidemic “news”, that is new information on individual and structural sources of HIV risk behaviors. He illustrated his point using several case studies. One of the case studies was Eastern Europe, where the epidemic is rapidly expanding due to individual actions (lack of condom use) and structural barriers to prevention (lack of access to information, to means of preventing transmission such as condoms, and the lack of needle exchange services for drug users. He stated that these means of prevention are clearly effective and supported by evidence, thus he called them “evidence-based” prevention methods. He noted that the expanding epidemic of HIV in Eastern Europe is also due to lack of access to means of prevention in prison settings, where HIV hits the hardest.
For his second case study, he discussed the epidemic among MSM not only in the United States but also in Africa and Asia, where MSM are extremely stigmatized. He noted that the prevalence and incidence of HIV infections among MSM in developing world countries reflected their lack of access to information about preventing HIV and their stigmatization – since no AIDS prevention messages address these groups, the prevalence can range as high as 10 to 20 fold higher than the prevalence in the general population. This is the certainly the case in Senegal – where the prevalence is 30% among MSM and less than 3% in the general population.
For his final case study, he took a look at the epidemic in South Africa. He mourned the persisting high rate of HIV transmission and the prevalence – 33% of women that are 30 years old in South Africa are HIV infected. This is due to lack of condom use despite education about condoms, and may also be due to the lack of circumcision among men, and the experiences of young women in regards to HIV – for most their first sexual encounter involves forced sex. These women also have cervical ectopy and their risk is also increased because of a belief that sex with a virgin will cure HIV/AIDS. Additional risks for HIV for women in subsaharan Africa include – marriage, intimate partner violence, and early coital debut. Lastly, Dr. Beyrer mentioned the risk of HIV infection that is associated with migration for labor. The main risk is for the man who migrates, and the risk derives from his outside partners. He then brings that HIV home to his wife, who is exposed and transmits the virus to her child.
Lastly, Beyrer mentioned the condom gap. He reported that global condom distribution is only as high as 6 to 9 billion and the global condom need is 24 billion (this is based on 3 condoms per man – probably a low figure). Beyrer closed with a call for evidence based prevention methods for all. He stated that access to evidence based prevention services must be extended to drug users, MSM, girls and young women (and here he failed to mention prisoners) if we are to improve the structural context for the reduction of individual HIV risk.
Anand Gover
The second talk was by Anand Grover, who was awarded the Johnathon Mann award this year for HIV and human rights. He talked almost exclusively about routine or “opt out” testing – where HIV testing is routine, with an option to refuse. He suggested that this may be effective, but raised issues about the ethics of this procedure. Apparently, his position is that more often than not the routine offering of testing would result in mandatory testing with patients failing to exercise their informed choice to test or opt out of testing because of lack of information and disempowerment.
A second important point made by Anand Gover was that stigma was the main damage done to HIV infected persons. That the law cannot protect them because laws deal with stigma after the event, and the damage has already been done. So we need to devote more effort to reducing stigma in our societies.
Lastly, he addressed the lack of access to means of prevention of HIV in American prisons. He specifically mentioned the fact that 94% of US prisons do not distribute condoms, even though transmission by sexual means has been proven to occur. In that context, he called upon the Bush administration to recognize the A B C’s of HIV prevention and to implement them where they are needed, including in prisons. He suggested that the US must lead in this arena and other countries would be sure to follow.
Women and AIDS
The last speaker of the morning session was Louise Binder – a woman living with HIV who is also a lawyer, an HIV activist and outspoken leader of women’s rights in HIV. She spoke forcefully about the disproportionate impact of power on the powerless of the world – the Power of the pharma companies, of developed world leaders, to ignore the epidemic of HIV that is running rampant among the Powerless – women, girls, drug users, transgender, sex workers, indigenous people and aboriginal people. She noted that the HIV incidence rate among aboriginals in Canada is 3 fold higher than the rate in the general population. And she mentioned that the impact of powerlessness can also be seen elsewhere in North America, where HIV is the leading cause of death among African American women in the US. She spoke long, and hard, about the need for “time for action” (which is the slogan of the conference) and said, that according to her watch, that time was long past, but perhaps if we acted now, we’d have a chance to save a few million women and girls.
Bill and Bill
Then, of course, we had the Bills speak to us. Bill and Bill in a cozy living room session. They chatted with an interviewer about the challenges and excitement of working on the front line of HIV, or, as the interviewer said, Knowing There by Going There. Bill Clinton discussed PepFar – and so did Bill Gates – and while they generally agreed that PepFAR was doing good work, they mentioned the fact that the A of the agenda, which is heavily funded (Abstinence before marriage) and for which 30% of the funds are earmarked, is one aspect of the program that gets a lot of attention. Bill Clinton went out of his way to point out that the evidence suggests that young people who are abstinent catch up in terms of risk as soon as they go ‘off the wagon’. During the question and answer session, one of Bill C’s comment that got a big chuckle from the audience was “While I made a few mistakes during my presidency, under funding AIDS initiatives was not one of them.”
Hope is Stamping out AIDS
Some fun notes – I went to a session on “Hope spreads faster than AIDS” a new project by the Global Fund – Richard Feachem introduced the project – the idea is to “Stamp out AIDS” using funds raised through stamps. I thought the most interesting aspect about this news is that “Hope” is going to be the main focus of the campaign – the idea being that there is hope for treatment. The stamps are really, truly, beautiful, so look for them – they will be rolled out in the US in early 2007. The new add for the project features an elephant (the elephant in the room is AIDS, get it?).
Another fun note— Act up is present in force, and their focus right now is the lack of health care workers available for HIV treatment in countries that are scaling up using global funds money. They have been unfurling banners, chanting on the escalators, and also holding up “empty white coats” during the meetings. These white coats say “Fund health care workers”. They look like so many ghosts in the midst of these large meetings – and they are in fact reminiscent of the absence of health care workers where they are most needed. The facts are these: over 4 million qualified health care workers are needed right now in developing world countries. In 10 countries, only enough health care workers to cover 10 percent of the population are available. One of these countries is, of course, Mali.
And Paul – the word on Community based Care.
Last but not least, I have to mention Paul Farmer. Our inspiration, our guiding light – he was here and talked about empowering community based health workers (Not doctors, not nurses) to teach about HIV, to help diagnose HIV, and to treat HIV in settings where no medical providers are available. We think this model has to work – there are not enough providers to go around – and so, just as we have learned to use available resources in US prisons, and in Mali, we need to think about different models of care. I should add here that this system of community based care will be discussed at our session tomorrow (Tuesday) where we’ll have a report from the Ukraine on “community based care” in correctional settings.
That’s it for today – I’ll send you another blog for the HIV/Prison session tonight.
Anne De Groot, MD
GAIA Scientific Director and Founder
The Warren Alpert School of Medicine of Brown University