The appalling lack of access to scientifically proven interventions for key populations at risk -- including sex workers, men who have sex with men and people who use drugs - and the lagging scale up of simple and inexpensive treatment regimens to prevent vertical transmission of HIV reflect persistent, underlying human rights violations that threaten future progress on AIDS, according to organizers of the XVIII International AIDS Conference taking place in Vienna this week under the theme of Rights Here, Right Now.
"To deny a woman the tools and information she needs to protect and care for her own health and that of her child is to deny the value of their lives," said Dr. Brigette Schmied, AIDS 2010 Local Co-Chair and President of the Austrian AIDS Society. "Gender inequality puts women at greater risk for HIV and also means that sufficient resources are not being provided to implement even the simplest and most effective interventions," she added. Fewer than one-half of pregnant women in low- and middle-income countries who require care to prevent vertical transmission have access.
The disconnect between currently available knowledge and access to HIV prevention and treatment services for people who use injection drugs in Eastern Europe and Central Asia has also emerged as a key conference theme. Though injecting practices fuel the region's epidemic, access to scientifically sound strategies, including needle and syringe exchange programmes and opioid substitution therapy, are scarce and even illegal in many locations, including Russia.
"In Eastern Europe, just a few kilometres from Vienna, drug use is driving the AIDS epidemic," said Dr. Julio Montaner, AIDS 2010 Chair, President of the International AIDS Society and Director of the B.C. Centre for Excellence in HIV/AIDS in Vancouver, Canada. "The Vienna Declaration calls on the world to move beyond fears and prejudices to take scientifically-proven steps to save lives," he added.
Laws that criminalize injecting drug users, men who have sex with men and sex workers remain widespread, though evidence presented at the conference and elsewhere indicates clearly that such approaches undermine, rather than advance, public health goals. As a result of such laws, as well as stigma and discrimination, members of these communities have significantly reduced access to both treatment and prevention services.
The consistent call throughout AIDS 2010 for the extension of human rights protections as a central tenet of the global response to AIDS was amplified by today's three plenary speakers, one of whom delivered the annual Jonathan Mann Memorial Lecture.
Combination HIV Prevention: Moving from Debate to Action
Dr. Carlos Cáceres (Peru) of the Institute of Studies in Health, Sexuality and Human Development presented examples of combination prevention initiatives, including aspects of their design, impact figures and cost. Combination prevention includes biomedical interventions, behavioural and structural approaches. The concept maintains that a single prevention intervention is less effective than a combination of efforts that address multiple issues on several levels.
He said that combination prevention is increasingly considered a "sensible" way to move toward universal access to HIV prevention, treatment, care and support. Cáceres argued that combination prevention is evolving into a rich concept that is comprehensive, strategic, and evidence- and human rights-based. The added value of combination prevention strategies would help the concept become a guiding principle of the HIV response.
Dr. Elaine Abrams (United States) of the International Center for AIDS Care and Treatment Programs at Columbia University's Mailman School of Public Health called for a new era in the prevention of mother-to-child transmission (PMTCT). While some countries have demonstrated more noteworthy successes in this area over the last several years, large numbers of children remain at risk for HIV infection in most high-burden countries. Abrams said that failure to attain more substantial achievements in this area can be attributed primarily to a constricted approach to PMTCT centered on HIV testing and simplified antiretroviral prophylaxis regimens. Although an estimated 60,000 to 70,000 pediatric infections were prevented through PMTCT in 2007, 1,200 children per day are still infected with HIV.
Abrams said that a shift from a narrow focus on preventing transmission to one that embraces the comprehensive, long-term health needs of women, children and families is necessary to reach a perinatal transmission rate of less than 5% by 2015. Key advances needed to achieve this goal include the rapid geographic expansion of prevention and treatment services, increased awareness of the human rights of PLHIV, and innovative strategies to prevent new infections in young girls and women.
No Excuses: A Living Experience of the Struggle for Rights - Jonathan Mann Memorial Lecture
Meena Saraswathi Seshu (India) of Sampada Grameen Mahila Sanstha (SANGRAM) presented examples of rights-centred responses to the HIV epidemic using real-life stories of programmes in western India shaped by the participation of sex workers, men who have sex with men (MSM), rural women living in poverty and young people. Too often, programmes that claim to be committed to rights-centred responses do not reflect that commitment, she argued.
Seshu said that the sex workers' involvement in shaping HIV education and health services helped them go from social pariahs to leaders in the HIV response while gaining community respect. Through this evolution, the community found the strength to challenge generations of entrenched discrimination and abuse against MSM, overturn social norms that impeded young people's access to comprehensive sexuality education, and bring to the centre of its collective consciousness the hidden problem of violence against women. Seshu noted that while the stories she presented arise from the Indian perspective, the challenges overcome using rights-centred language, tools and strategies are similar to those faced in many parts of the world.