An AIDS free generation must be possible, I think to myself as I hear stories of triumph and strength from HIV orphans in Iganga, Uganda. An AIDS free generation can be possible, I think as I teach sexual health classes to adolescent girls in Riobamba, Ecuador. An AIDS free generation will be possible, I think as I listen to a bold rollout plan for HIV prophylaxis in Guatemala City, Guatemala.
What exactly would it take to wipe AIDS off the planet? We know the importance of preventing infection, improving how we diagnose the virus, and treating patients soon after they’re diagnosed. Each of those steps have been extensively researched and proven in “real world” settings. They have been translated into policy and programs around the world — including Kenya, San Francisco, and Thailand.
The global community has now redoubled efforts to treat AIDS patients as soon as they’re diagnosed. This is in line with recent research that has proven that an HIV-positive person with complete “viral suppression” — that is, a very low amount of the HIV virus in their blood — has an almost zero percent chance of infecting a sexual partner.
This plan, known as 90–90–90, relies on three levels of HIV treatment. First, 90 percent of people living with HIV must know their status. In the United States, undiagnosed and untreated cases contribute to the majority of the new infections. Second, 90 percent of HIV-positive individuals need care and treatment. And finally, 90 percent of individuals receiving treatment must be at the point of viral suppression.
The fate of this plan hinges upon the ability of all people to receive treatment, regardless of culture, ethnicity, or social grouping. I believe it can be done — as long as we embrace the social and moral changes this implies.
In many parts of the world, the HIV epidemic is concentrated amongst people who use drugs, commercial sex workers, and men who have sex with men (MSM). For example, three-quarters of new HIV infections in the U.S. occur among MSM. In Guatemala, the HIV prevalence rate for MSM is 11 percent, over ten times higher than the general population. Even in places where the epidemic is not as concentrated, like sub-Saharan Africa, MSM have a disproportionate share of the HIV burden. In Zambia and Malawi, HIV prevalence among MSM is about double that of the general population.
Populations like MSM, injecting drug users, and commercial sex workers are often stigmatized and ignored in health policy decisions. But ignoring populations at risk does not make them disappear. By abusing and disenfranchising them, governments are taking away their access to necessary healthcare resources. When a homosexual man does not have access to condoms — and is further afraid of someone discovering a condom and suspecting a same-sex encounter — he is succumbing to discrimination.
His disenfranchisement from the health system affects more than just his person. His entire social network becomes a direct byproduct of a biased national policy.
Uganda’s recently overturned Anti-Homosexuality Act is a prime example of the far-reaching impact of policy based on moral ground. When the act was passed in 2013, many LGBT people hid their private lives, or fled their country entirely, in order to be safe from physical harm. They knew questions from doctors and other community members could lead to accusations — and if accused to be homosexual, they could be persecuted or even killed. During my time in Uganda I came to know many MSM who lived in continual fear of discovery and persecution by their family and community. In hiding their sexual preferences, many LGBT Ugandans do not access the health services that are designed specifically for sexual minorities.
Aside from destroying families and lives, bigoted policy can in fact fuel national HIV epidemics. In the Russian Federation, nearly a million people are estimated to be infected today — compared to 500,000 in 2010. Laws prohibit opioid substitution therapy, which helps wean opioid users from their addictions. Clean needle programs are rare due to the enforced illegality of injecting drugs. Without sterilized needles and a path to getting clean, the epidemic is poised to grow further.
Far too often, hate, fear, and ignorance drive policies for stigmatized diseases and populations. In the case of HIV, higher infection rates in high-risk populations often directly correlates with higher incidence in the general population.
It therefore becomes impossible to speak of an AIDS free generation without the inclusivity and acceptance that needs to go hand in hand with an increase in diagnosis, care, and treatment.
As with the eradication of any contagious disease, we are in this together. In order to reach zero new infections, leaders in health and government must stop marginalizing and placing judgment on certain segments of the population. People from disenfranchised populations are first and foremost people. It is time that leaders in government and health treat them as such.
