On World AIDS Day, Myles Ritchie, Mott MacDonald team leader for a UK aid funded HIV prevention programme in eastern and southern Africa, argues that a back-to-basics approach is needed to fulfil UNAIDS’ ambition of ending AIDS by 2030.
In recent years, I have been a proponent of, and supported the hypothesis that we can treat our way out of HIV. If we can find and treat everybody who is HIV positive, and ensure good adherence and access to medicines, we can reduce the viral load at a population level and prevent ongoing transmission.
However, despite the increased number of people accessing treatment, the number of newly acquired infections every day remains alarming – in 2016 there were 790,000 new infections across eastern and southern Africa alone. I fear we have collectively taken our eye off the ball on primary prevention. We have assumed for too long that everybody has the knowledge and ability to protect themselves from HIV and the types of prevention tools necessary to do this. What we’re finding is that those assumptions don’t always hold true, due in part to a general apathy about the virus, and the fact that treatment is available. Prevention is still absolutely key to ending HIV, in combination with treatment.
Enduring stigma and discrimination
The notion that HIV has become a manageable, chronic disease is not understood or a reality in many lower income countries. Despite the years of raising awareness, cultural myths are sustained around HIV’s origins and acquisition, while those infected are still exposed to severe stigma and discrimination.
For the most vulnerable groups in society including adolescents, prisoners, men who have sex with men, and sex workers, stigmatisation contributes directly to the spread of the disease. Through research, our programme has seen many examples where those living with HIV from these groups are reluctant to access the health system. When they do, particularly in the public sector, many are denied services or made to feel unwelcome. MSM have difficulty accessing health services because in addition to discriminatory attitudes, nurses and clinical staff lack the expertise to treat anally transmitted infections.
Sexually active teenagers, who want to access contraception or condoms, are often driven off by nurses and told they should not be having sex in the first place. Likewise, where approved, they may have an interest in using PrEP (pre-exposure prophylaxis) to avoid infection, but medical staff are reluctant or not yet equipped to provide the necessary support and advice they seek.
Adherence to medication is another big issue for adolescents, both those who acquire HIV at birth through mother-to-child transmission, and those contracting HIV as teenagers. The commitment to be on antiretroviral therapy is lifelong - you only need to miss a few days for the virus to bounce back. If you don’t stick to your regimen, then you will become sick again, and be at risk of transmitting HIV. Poor adherence to the medication also leads to drug resistance. This results in a need for second line drugs because the first line drugs will stop working. Are we ready for this scenario when it hits?
Breaking social barriers to change
We must do more to support these vulnerable groups. Of course, it’s important to challenge countries and advocate for reform, especially around the decriminalisation of homosexuality and sex work. However, this rights-based approach may struggle to change legislation and conservative attitudes in the shorter term. Therefore, we should adopt a strong public health approach, as these marginalised groups continue to drive the epidemic. Donors, as much as possible, should get behind supporting local NGOs that are trusted by these groups in the communities in which they live.
Clinically, and from a research point of view, we’ve got a full prevention toolbox. We know how to prevent HIV, and we know how to treat it effectively. Ultimately, it is core structural barriers that stand in the way of ending HIV: discrimination and stigmatisation, as well as alcohol use; food insecurity; poverty; sexual, gender-based and domestic violence; and weak healthcare systems.
We’ve made much progress in recent years and we have what it takes now to end HIV and AIDS. Looking at the bigger picture, I’m excited that the HIV response may yet provide a blueprint for universal access to healthcare – a major ambition of the United Nation’s Sustainable Development Goals. Events like World AIDS Day provide an opportunity to regroup, reflect and recommit ourselves to ending this disease, now 37 years on.