World AIDS Day. It is that time of year again when attention focuses on the response to HIV, looking back at progress made and looking forward to the opportunities and challenges ahead. Much of the attention this year is positive, highlighting the unique opportunities before us. The UNAIDS annual report puts forward the lofty, but seemingly achievable goal of getting to zero: no new infections, no discrimination, no HIV-related deaths. Secretary Clinton’s recent speech putting forward the US government’s international response echoed many of the same messages: we have the science and tools needed to turn the tide of the epidemic, what is needed is the will. The response in the US, through the National HIV/AIDS Strategy places an emphasis on achieving measurable results with (and a renewed focus on targeting services for) those at greatest risk, particularly men who have sex with men, minimizing barriers to care and keeping people in care. However, tempered with the good news there are concerns. For the first time in years, the global economic situation and domestic budget battles have put U.S. and international HIV programs on the chopping blocks. There are challenges at the Global Fund, in management, implementation, and the willingness of governments to invest and meet their commitments.
I’m in a fortunate position, working on both domestic and international HIV programs. People often ask how one can shuttle between the two, given that the issues and available resources are so different. In fact, from where I sit, the differences really aren’t that great. For one thing, the focus must remain on engaging individuals and communities where they are, with programs that meet their needs, not just for HIV services, but broader health and social support services. There is a movement to medicalize the response, making clinics the “one-stop shopping” focal point of prevention, treatment, care and support services. While there are potential strengths in this approach, alone it will not completely turn the tide. In fact, we have had the greatest impact in reducing the number of new infections and enrolling people in care, be it in Massachusetts, South Africa or India, when community organizations and the medical establishment work in true partnership, focusing on the needs of clients. Community-based organizations, including associations of people living with HIV, have to be equal partners with the doctors and nurses who provide clinical care. Communities cannot be adjuncts to the medical response.
Second, we need to be mindful that while many people may be impacted by HIV, not all are equally at risk and in need. Prevention services need to target those at greatest risk, using every available combination of interventions that may minimize risk of acquiring or transmitting the virus. Treatment and care services need to meet the specific needs of diverse populations—one size does not fit all. Gender needs to be addressed in all programs. This means not solely focusing on the needs of women, but also looking uniquely at the health needs of men, including men who have sex with men and transgenders.
Third, integration is a strategy and a means, not an end. Careful consideration ought to be given to what is being integrated, for the benefit of whom, at what cost and benefit. More effort needs to be placed on evaluating these efforts.
Lastly, there is a desperate need for leadership at the community, state/district, national and international level. Political leaders must be held accountable for ensuring that comprehensive, combination services are available for those at greatest risk and in greatest need. Community and religious leaders need to address stigma, discrimination and myths about HIV and build supportive environments. Individuals and communities must hold their leaders accountable.
We live in interesting times. As we mark 30 years of the response to HIV, there is renewed hope that we can fundamentally change the course of the epidemic, decreasing the number of new infections, increasing continuous access to care for those living with HIV, eliminating stigma and discrimination and zeroing out the number of people who die of complications from the disease. The opportunities and challenges are increasingly similar whether you live in Boston, San Francisco, Washington, DC, Gulu, Lusaka, Addis Ababa, Ashgabat, New Delhi or Tegucigalpa and in this ever increasingly connected world, the opportunities to learn from one another are nearly limitless. Let’s make sure we seize those opportunities.