Charles Birungi_EV4GH2013Charles Birungi (EV 2013)*

As I prepare to return home this week after the ICASA conference in Cape Town, the heated discussions on the “end of AIDS” remain vivid in my mind.  Is the “end of AIDS” a myth or reality? At this year’s World AIDS day, the UNAIDS Executive Director, Michel Sidibe noted that: “For the first time we can see an end to an epidemic that has wrought such staggering devastation around the world. For the first time we can say that we are beginning to control the epidemic and not that the epidemic is controlling us.”

Looking at the journey walked so far, I fully agree with Michel Sidibe. Growing up in rural Uganda, I recall the stigma and discrimination that surrounded the disease ‘slim disease’ in the 1980s. It was an era of no treatment that left scores dead. From the vantage point of 2013, we seem to be at the brink of ending AIDS. UNAIDS has recently reported a 33% reduction in new infections since 2001; 52% reduction in infant infections since 2001; and 9.7 million on ARV treatment by end of 2012.

Is the world poised to end AIDS? In spite of the above stellar progress, it is clear that the battle is not yet over. In fact, putting the pedal off the accelerator now would be declaring victory too soon. There were 2.3 million new HIV infections in 2012 alone, with 70% of these occurring in sub-Saharan Africa; 1.6 million people died of AIDS related causes in 2012. Sixteen years after the advent of ARV therapy, this is unacceptable. Sadly, 13 million people in Africa are still waiting for access to treatment. The world is still grappling with gender inequality and violence that remain unchecked, HIV-related stigma and discrimination remain unchecked; “key populations” still under-served and discriminated against.

My friend Agnes Nanyonjo, a 2012 Emerging Voice who is a leading expert on malaria in Uganda always tells me how it is rare that diseases are eliminated. This is my experience. Prof Whiteside of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal has recently echoed the same sentiments. With intensified and focussed vigilance, monitoring and resources, at best, we should expect to prevent, contain and control HIV. Whereas smallpox was eradicated in the world, the end of AIDS will not be in a similar manner largely because we don’t have the same biomedical tools at our disposal. The notion that the virus would cease to exist and all infections would stop is not really relevant in the current context of AIDS. It is in this context that I have used the term “end of AIDS” in this blog post.

As an Emerging Voice for Global Health, the idea of ending AIDS is to take every tool we have available and to use them in a rational and optimum way that protects rights. This way, we could drop annual new infections from 2.3 million to just a few thousands, and the same for mortality. With few thousands or hundreds of new infections and AIDS-related deaths, would that define the end of AIDS? Whereas we seem to be at the beginning of the end of AIDS, there are some very dark clouds ahead. HIV and AIDS do not seem to be high on the agenda of the Post-2015 Development agenda.

Over the past 13 years, the MDGs have mobilised the world around the goal of reversing HIV and AIDS trends. Today, AIDS is not over. To maintain momentum towards ending AIDS, HIV needs to be prominently positioned in the post-2015 agenda, including ambitious, measurable targets. Treatment is important – stops people from dying and lowers viral load.  But the discourse on ending AIDS needs to be extended to encompass a societal and human rights response.

It is increasingly becoming clear that the next phase of the struggle against AIDS requires that we tackle the social and political determinants of inequality in access to health care systems, including addressing the big questions over the sustainability of the existing AIDS response among others. As AIDS remains an unfinished MDG business, I plead for a goal on HIV.  To the participants at ICASA, the litmus test for the Post-2015 development framework is whether it reflects HIV, in terms of a specific goal, and the associated targets, and indicators. Similarly, the UN Secretary-General Ban Ki-moon recently called for the post-2015 development agenda to ‘realize the vision of a future free of AIDS’.

Ending AIDS in my generation is possible. It takes more than a biomedical approach to realise this desired future. It requires political commitment, community mobilization, adequate funding, further integration of HIV with sexual and reproductive health and rights, addressing social determinants and rights-based approaches to reach the most marginalized and a strengthened accountability framework. These must be combined with biomedical advances achieved through investments in vaccine and cure research. Over the past 30 years, the AIDS response has ably demonstrated that better health reduces inequality and poverty and mobilizes people to build democratic accountability. The lessons learned and innovations of the AIDS response and movement, including inclusive, people-centred, participatory rights-based, multi-sectoral action, can be harnessed and leveraged for social transformation in the post-2015 development agenda (for more see for example the UNAIDS-Lancet Commission Working Group 2 Discussion paper). At the just concluded ICASA, there was a unanimous agreement that the AIDS agenda is relevant to all countries. It is a public health priority in high-burden countries and an entry point for social inclusion and rights-based development in all countries. Will the Post-2015 development agenda heed to these calls from Cape Town?

 

 

* Everything I say in this blog post and comments is in a personal capacity. You can follow me on Twitter at @C_Birungi

3 Responses to Ending AIDS in my generation? Some reflections from ICASA

  1. Staying the course of eradicating HIV/Aids
    WHAT WE NEED TO DO STRAIGHT AWAY
    We need to stop detaching the human face from the way we engage in HIV-related interventions. We need to understand that when we decide to work towards eradicating HIV/Aids there are human beings involved. “We must never forget that any woman or man always has a particular race or ethnic background, class identification, age, sexual orientation or preference and religion. The combination of these identities will inform and modify each of them separately and in combination with each other. Race, class and sexuality are each modified, qualified and informed by each other characteristics or identities that comprise the individual and no one of them can exist in isolation. In the fight to eradicate HIV/Aids there is need to ‘adopt a model for thought that posits continuums, complexities and embraces contradictions’,” (Rothenberg).
    SQUARELY FACING VULNERABILITIES UNIQUE TO HIV; IDEAS ON STAYING THE COURSE OF ERADICATING HIV/AIDS
    It is coming to four decades since the first HIV/Aids diagnosis. Many observations have influenced the way interventions are provided. Gone are the days when fear of sharing eating utensils with persons living with HIV/Aids formed basis for isolation, discrimination and neglect by those who were supposed to have given care. Gone are the days when it was thought coughing or sharing clothes or a mosquito bite causes HIV.
    SOME VULNERABILITY CASE SCENARIOS (BUILDING THE BROADER PERSPECTIVES)

    1. Juliet is a 22 year old pregnant woman with 2 other children. Both children were fathered by different men. Her recent male partner beat her that she had to be hospitalized. In the hospital, Juliet was diagnosed with HIV/Aids and TB. Planned interventions include: providing care for person; managing trauma; enrolling Juliet to medications and care that will stop transmission of HIV to the unborn; linking with welfare support, police and legal bodies.
    SCENARIO 2
    2. Koala is an HIV/Aids intervention organization. It is planning its HIV/Aids clinical trials networks partnerships. It is involved in extensive consultations with policy makers, religious bodies, researchers, clinicians, nurses, patient advocates, community care workers, community-based resource persons, activists, and people living with HIV or at risk for infection. The planned activities include: garnering support; building referral mechanisms,mobilizing and enrolling volunteers; the treatment and prevention of other opportunistic diseases such asmalaria, tuberculosis and hepatitis which are significant co-infections for people who are infected with HIV or at risk for infection.
    SCENARIO 3
    3. Shaka is a 35 year old man, an asylum seeker and is living with HIV/Aids. He sought the services for HIV-related illnesses but he is very irregular in getting his refills. He is not used to the new country and he finds it hard to break through the existing support clubs. He has defaulted many times. It is likely he is taking on a poor retention and adherence commitment path. Previously he had a high CD4 count. Only the next available test will show his true CD4 count now.
    SCENARIO 4
    4. Jerome is an activist and has just read a report from CDC: PrEP, or Pre-Exposure Prophylaxis, is breakthrough in HIV prevention medication to come out in the last two years. Truvada the first PrEP drug, was approved by the FDA last summer. When taken daily, it can prevent transmission of HIV 99% if taken every day. Even if taken only four times a week, its effectiveness remains as high as 96 percent. He is now wondering how to use this information to modify knowledge and practices. He is one of those who advocate for embracing the new trends fighting HIV.He wants to widely report and celebrate this breakthrough about PrEP.
    SCENARIO 5
    5. Monogamy, fidelity, delaying sex, testing, treatment, consistent condom use, use of lubricant in anal or painful sexual intercourse and care for persons living with HIV/Aids are some of the enduring HIV-related strategies and interventions.

    CONCLUSION:
    What we need to address:
    1. Address issues of domestic relations, male-female power and control.
    2. Address stigma and discrimination in the wider policy and program context.
    3. Address the minority, asylum seekers and immigrant issues in contemporary society.
    4. Establish infrastructure for dialogue, practices and the broader perspectives around sexual relations and lifestyles.
    5. Establish enduring partnerships and networks to address HIV/Aids beyond borders.

  2. Thanks Charles.
    When we meet in Melbourne I may share with you some more thoughts on this. Also read my blogs on: https://www.blogger.com/home

  3. Kristof says:

    Hi Charles,

    do you think HIV should be a global (‘universal’) post-MDG goal or a regional one ? HIV is a bigger problem in SSA than in Western-Europe, for example. In the health area, I personally favour a universal goal like UHC or healthy life expectancy, and would allow for 1 or 2 continent- or region-specific goals depending on the burden.

    Regards,

    Kristof

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