Ending AIDS: Reach Vulnerable Populations or Risk Erasing Gains Made Against HIV

By Michael Keller

Groups consistently pushed to society’s fringes aren’t receiving the support they need to successfully prevent or treat HIV infection, health officials and advocates declared during the United Nations (UN) High-Level Meeting on Ending AIDS in New York City last week. From China and Russia to Malawi and Middle Eastern countries, intravenous drug users, sex workers, prisoners, and men who have sex with men are key populations in which the spread of HIV continues in many regions.

 

And while AIDS has moved from a fatal diagnosis to a treatable, chronic disease in many parts of the world, protecting vulnerable and isolated populations will be key to achieving the ambitious goal set by the UN as part of the Sustainable Development Goals to end the AIDS epidemic by 2030. “For now, we’ve been sneaking condoms under the doors of prisoners,” said Namibian health and social services minister Bernhard Haufiku during the meeting, which took place June 8-10. “But I’ve been talking with the commissioner of the corrective service to change that policy, which dates back to the apartheid era. Other marginalized groups are starting to get access to more services—sex workers, truck drivers, and more.”

Such efforts by Haufiku and other health officials around the world to support these populations come at a critical time in the decades-long struggle to contain the spread of HIV. The world has clearly made huge strides. Since 2000, the number of new annual infections has fallen by 30 percent. This is largely due to the extraordinary scale-up of antiretroviral treatment since 2010. An estimated 17 million people were receiving therapy by the end of 2015, according to the latest report issued by the Joint United Nations Programme on HIV/AIDS (UNAIDS) just days before the UN meeting opened. More than 2 million people gained access to life-saving antiretroviral therapy since the previous year alone. Availability of these drugs has pushed down annual AIDS-related deaths by 43 percent since 2003.

Yet these advances remain on fragile ground. UNAIDS reports that the number of new HIV infections globally has plateaued, with around 2 million people becoming newly infected every year for more than five years despite unprecedented investment in HIV treatment programs. Even more troubling, Eastern Europe and Central Asia saw a 57 percent increase in new HIV infections over a five-year period ending in 2015.

“Declines in new HIV infections among adults have slowed alarmingly in recent years, with the estimated annual number of new infections among adults remaining nearly static,” write the authors of the 2016 UNAIDS Global AIDS Update. “Beneath this global figure lie multiple disparities—across regions, within countries, between men and women and young and old, and among specific populations being left behind. These disparities must be addressed in order to achieve the reductions required to end the AIDS epidemic as a public health threat by 2030.”

Remembering the forgotten

Experts warn that the reluctance by authorities to reach the most vulnerable populations is fueling HIV’s spread. Through criminalizing and stigmatizing same-sex relationships, transgender people, sex work, and drug use, those who fall into these categories get locked out of education and are also less likely to benefit from HIV prevention or treatment programs.

Marginalized people accounted for more than 90 percent of new HIV infections in 2014 in Central Asia, Europe, North America, the Middle East, and North Africa, and for 20 percent of new infections in sub-Saharan Africa, the UNAIDS data reveals. A Chinese AIDS activist at the High-Level Meeting said stigmatization of gay men was fueling a rising infection rate among that demographic. Pavel Aksenov, the director of Esvero, the Russian Harm Reduction Network, said antipathy from his country’s officials toward these ostracized groups is translating into real problems. “Russia dropped support for necessary programs by 75 percent, leaving many without funds overnight,” he said, the strain in his voice making clear his deep frustration. “The question is how can you work with people when you do not recognize their existence in the first place.”

Indeed, to many at the UN meeting it has become clear that not engaging these groups doesn’t just risk stalling advances made in controlling HIV, it also threatens the global commitment to rid the world of AIDS. Switzerland’s Ambassador for Global Health, Tania Dussey-Cavassini, said much progress has been made, but it is important to remember that around 37 million people are currently living with the disease and that number could easily grow. “If we continue to do the same thing, we will achieve nothing more than what we’ve already accomplished today,” she said. “We all must work constructively outside of our comfort zones.”

New financing

Many meeting attendees called for the same prescription to reach key populations and take the global AIDS response into its next phase: more money. Indeed, donors and middle- and low-income countries will need to increase investment in AIDS programs significantly to meet 2020’s US$26.2 billion target, which UNAIDS projects is the necessary amount to scale up ART treatment and prevention sufficiently to end AIDS by 2030. Outside analysts calculate that the program would cost $54 billion over the next 10 years.

Advocates and officials hailing from middle-income countries, whose relatively stronger economies exclude them from some of the stream of donor funds going to the poorest nations, voiced concerns that they would be unable to reach the key populations at risk of HIV within their borders. “So far, funding most programs for key populations has come from international sources,” said Lorena Castillo de Varela, the First Lady of Panama and a UNAIDS Special Advocate for AIDS in Latin America. “There needs to be a transition to domestic, sustainable funding for these people. And we still must help countries that don’t have the capacity to do it.”

To that end, during the meeting the US announced that it would bolster efforts around the world to reach these vulnerable groups with a $100 million Key Populations Investment Fund. The money is meant to fund community-based groups directly providing HIV prevention and treatment services to sex workers, gay men and other men who have sex with men, injection drug users, transgender people, and prisoners. Another goal of the fund is to reduce stigma and discrimination suffered by these individuals.

Jeffrey Sachs, a renowned economist and director of the Earth Institute at Columbia University who spoke about financing the end of AIDS, said that any hand wringing about the cost to get the job done should be brushed off. “This is not so hard, honestly,” he said. “It’s a matter of just a little bit of money. How much is needed? A rounding error so small—maybe another $5 to $10 billion a year. We’re talking small change.”

Michael Keller reports from the frontiers of science, technology, and international affairs. His writing has appeared online and in newspapers, magazines, and books, including the graphic novel Charles Darwin’s On the Origin of Species.