The International AIDS Conference ended two weeks ago. After reclaiming front page and radio feature status during the conference, HIV has begun to fade from the news cycle. Already, HIV has once again slipped off the front pages of the paper and isn’t a featured story on morning radio shows. There has been time to sift through the inspirational speeches, data, information and hallway conversations and think, “Where do we go from here?” I’ve come up with a few thoughts, based on my experience, tempered by twenty years of working in the field and living with the virus.
At no time since HIV was first identified have we had this much knowledge available to us about how to reduce new infections, effectively treat people living with HIV, and address the impacts of the disease on individuals and communities. But it is abundantly clear that these innovations—first there was treatment and PMTCT and most recently PrEP, treatment as prevention, male circumcision to name a few—will never reach their full potential unless we address the reasons why people don’t adopt prevention strategies that would greatly limit the risk of becoming infected, why people don’t want to know or disclose their status to others, and why they don’t enter or stay in care.
While at the conference, I saw more presentations than I can count that documented again and again missed opportunities. People get tested but don’t make it into care. They get into care, but don’t get on ARVs. They get on treatment, but don’t come back for visits or the drugs don’t reach their full potential. And I’m continually surprised that doctors and public health experts seem shocked that our good work and messages don’t quickly have the acceptance we expect.
Avoiding HIV in many communities can be very difficult. Abstinence isn’t an option for many. Reducing partners isn’t possible for many folks as they only have one. Condoms are difficult to discuss and using them consistently can be even tougher. It is easy to assume that if a partner doesn’t ask to use a condom, they must be safe. For many people at risk for or living with HIV, substance use and mental health are dealt with inadequately. Disclosure of HIV status is challenging and can result in serious repercussions. HIV care is complicated. Disclosure is complicated. Starting a drug regimen, even if it is just one pill a day, is hard. Staying adherent for years, if not decades, is infinitely more difficult.
As we herald this new era with a vast array of potential solutions I come away from the meeting more convinced than ever that something has to change in our approach. We have to better understand the behavioral and structural issues that put people at risk and limit their ability to access services at the individual, family, community, and societal level. Just because we create a better prevention approach or find a new drug for treatment, doesn’t mean folks are going to come. Treatment as prevention isn’t necessarily going to convince someone to start life-long HIV treatment. For someone newly diagnosed, the decision to start a lifetime of HIV drug treatment is unlikely to be affected by the public health argument that “treatment is prevention”. People will want to know the benefits for them personally, their health and the possible long term affects of the drugs. Getting circumcised isn’t going to happen if a man thinks his partners won’t approve.
There were discussions at pre-conference sessions, as well as throughout the five days, that started to address some of these challenges. Kevin Fenton from CDC presented a framework to address HIV in the black diaspora that calls upon all of us to consider history and the power structure in which services are offered and people live. A number of sessions focused on the growing number of children born with HIV who are reaching adolescence and the need to develop and implement programs that meet their unique challenges. There were also sessions focused on addressing stigma by eliminating antiquated HIV criminalization statues, as well as other laws which target sex workers, men who have sex with men, and transgender people. Efforts such as these and others that I’m sure I missed need to be front and center of our efforts.
I once again left the conference hopeful—guardedly so. The drum beat of bio-medical solutions to all things HIV continued. But there was a growing voice at the conference that if these solutions are going to get to people, be adopted and sustained, solutions to behavioral and structural issues have to be identified and addressed with funding and other support.