What will Melbourne be remembered for?

Every two years I am renewed and reinvigorated  by thousands of strangers; I have the privilege to attend the International AIDS Conference and, for one week,  be inspired, challenged, annoyed, frustrated and ultimately forced to look anew at how I approach my role in the effort to end HIV in my life time.  This year was no different.

I heard some bemoan the fact that this conference was flat—that there were no new scientific breakthroughs, no grand commitment, no seismic shifts in policy.  There is some truth in those statements.  I don’t think any one is likely to remember the Melbourne Conference like they do Vancouver, where the first results from triple combination trials were presented or Durban, the first meeting in Africa and the clarion call to provide treatment for all.

However, this was a critically important meeting for it sent a clear message that the times are changing and evolving,–as they always have–in the fight against HIV.  We can’t rest on our success if we are to achieve what we have all been working towards and what is tantalizing closer than ever before: radical and sustained reduction of new infections, long-term care for those living with HIV, and improved quality of life.

We have to think and act differently to be successful in this new world. The common themes that emerged from the many presentations I saw over the course of the conference gave us a sense of the direction this fight is headed.

Space and geography matter:  For too long we have talked in generalities: sub-Saharan Africa, India, The Caribbean, The Twelve Cities in the US.   We have to stop being so lazy.  We have data and information that clearly show that within countries, counties, provinces and cities, geography matters.  There are multiple epidemics in spatial settings and resources need to target these hot spots.   If resources are being diverted from these communities we have to ask why and demand change

HIV is a shared community responsibility:  Stigma and discrimination thwart our efforts at every turn.  Every day, hate, fear and potential legal punishment keep people from critical services.  Too often individuals, leaders, service providers and communities turn a blind eye.  Brave women, men, and adolescents risk their lives every day.  If they aren’t being supported we have to ask why and act.

Not everyone needs services:  Adolescent girls in sub-Saharan Africa, men who have sex with men, transgender women, sex workers, people who inject drugs, people living with HIV, pregnant women, children, prisoners, migrant workers, displaced people and people with disabilities everywhere.  These are the people who need to be our focus.  They are at greatest risk for HIV, most likely living with HIV and least likely to have access to services.  If programs aren’t serving the needs of at least one of these groups we have to ask why and do something to change it.

Resources must line up with epidemiological data,  be allocated to where services are being accessed, and address issues of quality.  The HIV field is flooded with data that we don’t use well.  Programs are required to collect it but often don’t have the time to use it.  Donors and their partners haven’t focused on using this data to align support.  That is all about to change as PEPFAR and the Global Fund move towards the use of site level data to make critical decisions.   This will likely lead to difficult decisions about what to fund and where but ultimately, if done strategically and well, will help bring more services to those people who need them most.

Many of the tools to prevent and care for HIV are there and more are coming. Condoms, Option B+ for prevention of mother to child transmission, treatment as prevention, PEP and PrEP, and medical male circumcision are all out there and becoming more widely available.  New prevention approaches, innovations to existing approaches, and whole new technologies are on the horizon.  We must continue to develop and improve systems that allow people to adopt and adapt prevention and treatment strategies that meet their needs as their life situations change.

Melbourne will be remembered as the point at which we made the pivot turn.  We began to laser in our tremendous wealth of experience, talent, passion, and compassion to refine our response as we have done before: evolving, adapting and stepping forward.

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