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Africa/Global: Not Yet "End of AIDS"

AfricaFocus Bulletin
July 26, 2016 (160626)
(Reposted from sources cited below)

Editor's Note

At the 21st International AIDS Conference in South Africa last week, "optimism faded as delegates arrived to news that donor countries had reduced global HIV funding by more than $1 billion from 2014 to 2015. ... Nearly 20 million people are [still] in need of antiretroviral therapy. [and] nearly half of the $44 billion cost could be unfunded between 2016 and 2020." - Washington Post, July 25, 2016

Overshadowed by the U.S. presidential campaign and by acts of terrorism around the world, the 21st International AIDS Conference was held in Durban, South Africa earlier this month. Sixteen years after the previous International AIDS conference in Durban in 2000, which marked a turning point in international action on AIDS, there were successes to celebrate. In 2000, the only people receiving life securing antiretroviral (ARV) treatment in Africa and other developing countries were accessing medicines through clinical trials. The few that were rich enough purchased life through private healthcare. Sixteen years later, 17 million people across the world receive ARVs, mostly through public health care systems. This accomplishment is unprecedented, and UNAIDS has laid out the goal of putting "an end to AIDS."

But there were also dire warnings of the danger of reduced international commitment to confront the continued death toll. Africa, and in particular South Africa and neighboring countries in Southern Africa, continue to be the epicenter of the pandemic. Worldwide, the reality is that only 51 percent of people know their status and of the 37 million people living with HIV, only 17 million are on treatment. Almost one in five South African adults are living with HIV, and the percentages are even higher in Botswana, Lesotho, and Swaziland. And, noted International AIDS Society president Linda-Gail Bekker, "there is a horrible funding gap we have to address. We had so much money when we didn't have the tools. Now we have the tools and we don't have the money."

This AfricaFocus Bulletin contains one essay by South African AIDS activist Mark Heywood, and interviews with UNAIDS executive director Michel Sidibé and International AIDS Society president Linda-Gail Bekker.

For an excellent series of maps, tables, and charts on the current status of HIV/AIDS in Africa, visit http://www.afri-dev.info/ - Direct URL: http://tinyurl.com/hhzaln9

For coverage of the Durban conference by South Africa's Daily Vox, visit http://tinyurl.com/hfnjmns

For the Washington Post article quoted above, go to http://tinyurl.com/hjr4vf2

For previous AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/intro-health.php

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AfricaFocus Bulletin will be taking a break from publication for the next six weeks. Automated news feeds on the website (http://www.africafocus.org) will continue to be updated regularly. AfricaFocus social media will also be updated occasionally during this period.

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The response to AIDS has shown another world is possible

Mark Heywood

Daily Maverick, July 19, 2016

http://www.dailymaverick.co.za - Direct URL: http://tinyurl.com/hk6kosx

[Mark Heywood is Executive Direction of Section27 and an executive member of the Treatment Action Campaign]

We live in a nasty, fragmented, divided world, where hatred is more and more ruling the roost. Glorious bastards who have been pushed beyond the pale of civilised behaviour are on a killing spree. Their intention is to provoke new wars and civil wars where person fights person on the basis of differences based on race, or religion or ethnicity.

A gleeful arms industry has found a new market for drones with bombs. The indiscriminate 'fightback' against terror frequently make matters worse. Ironically groups like ISIS are aiming to push people into the hands of bigots like Trump, Marie Le Pen and Nigel Farage. They want more violence against marginalised people. They want racial and religious civil wars.

It's a zero-sum war game.

While reports of these horrors washed across our TV screens, the 21st International AIDS Conference began in Durban. Sadly, the energy and idealism that is evident here risks being eclipsed by global instability. Yet, in the AIDS activist movement and the 30- year response to AIDS, we have seen glimpses of another world; another way of living and loving, dying and doing business.

It is extraordinary.

Sixteen years ago the International AIDS conference first came to Durban. At that point, the only people receiving life securing antiretroviral (ARV) treatment in Africa and other developing countries were accessing medicines through clinical trials. The few that were rich enough purchased life through private healthcare.

Sixteen years later, 17-million people across the world receive ARVs, mostly through public health care systems. This accomplishment is unprecedented in the history of any medicine. Seventeen million deaths have been averted. Although activists are rightly critical of UNAIDS' (http://www.unaids.org) talk of the end of AIDS, the fact that an end can even be discussed – and that it is theoretically possible – indicates just how far we have come.

How did we come so far?

People who stood up for their human rights achieved this. Activists achieved this.

In the 1980s AIDS began its deadly rampage as an epidemic of recrimination and prejudice. Stigma is by no means over. Yet, the way in which people with HIV have stood up for each other has gone a long way towards breaking the stigma. Solidarity with people most at risk has won greater acceptance and recognition of sex workers, understanding of difference in gender and sexual orientation and the rights of drug users, prisoners, migrants.

Where once AIDS was marked by total hatred, there are now significant pockets of respect for love and diversity, solidarity and empathy, in every country in the world. A long way to go, yes, but a start.

Other profoundly important things have happened. Once upon a time almost every poor person with HIV was denied life by pharmaceutical companies intent on amassing vast profits from essential medicines. Activists shamed drug companies, challenged them in court, exposed their corrupt practices. Prices tumbled. As a result different business models began to emerge, ones that could make smaller profits from meeting the needs of larger numbers of people. Prices tumbled and tumbled.

Activists confronted the whole model of intellectual property 'rights' and by doing so were able to push back the WTO Agreement on Trade Related Aspects of Intellectual Property, an 'agreement' that had been forced on developing countries in 1995 at the height of capitalist triumphalism. As a result a massive market opened for generic companies based in India in particular. If similar challenges were mounted around drugs for cancer or other causes of illness millions more lives are there to be saved.

Learning how to make a market out of genuinely meeting needs and human rights is something other corporates must learn, including for decent food, housing and a hundred other of life's necessities. That battle must still be joined by other advocates, that wisdom still acquired by a short-sighted business community.

So, AIDS is about AIDS. But it's also about so much more than AIDS. It's about justice and social justice. In the words of Edwin Cameron: "AIDS has taken us on a journey of light."

In the weeks before this conference I warned that the job is only half done.

The global statistics remain frightening. According to UNAIDS:

  • There are 1.1-million deaths due to AIDS a year;
  • There are 5,700 new HIV infections a day;
  • Epidemics of TB and MDR-TB run largely unchecked.

My fears were not unfounded. As we sit in our padded seats, or rather as we march, sing, argue, meet, learn from each other, debate, shout, advocate, commiserate and occasionally cry, it's becoming clear that this glimmer of hope risks being snuffed out. Conferences like this that refocus human rights activism, where politicians come to account to people, might be the last kick of a dying horse.

In activist meetings a very different picture is emerging to the optimistic one that government officials, ours included, wanted to make the AIDS story. There are medicine stock-outs in many countries. Sex workers and drugs users are humiliated, imprisoned and sometimes murdered. Poor people in rich countries are being left behind by the artificial segmentation dreamed up by some bright spark in the World Bank that declares certain developing countries 'middle income', ignoring the local context of inequality, corruption and severe deprivation.

Try telling the 12-million hungry people in SA or 25% unemployed that ours is a middle income country. "Dream on", they will reply, "we would be happy if it was a 'some-income' country, rather than a no-income country."

Human rights respecting countries like South Africa are silent on the human rights abuses by our economic allies in countries like China, India and Russia. Attacks on civil society organisations and activists are growing. In India, the Lawyers Collective – an organisation that has shone a light for human rights for 35 years – and 15,000 other NGOs are under attack.

Finally donor funding from developed countries for preventing and treating HIV and TB is declining fast. As right wing governments rise in the West and as the unwinnable 'war on terrorism' consumes ever greater resources, the appetite for matters-just is declining. If we are to meet the target of universal access to ARV treatment UNAIDS has announce that there is a funding gap of $7 billion a year. But apparently taxpayers in developed countries feel that they have done enough now.

My answer to that, dear US Ambassador Gaspard and others, is to appeal to you that your governments try a little harder to talk to your taxpayers. Show your citizens how their investments in others' lives have brought us half way across the river to the "end of AIDS". Appeal to them to continue their largesse. Explain to them why their investment in AIDS is something they should take proud ownership of, how it has been an investment in humanity, health systems and social fabric. It has saved millions of lives. Tell them the job's not done. Tell them the world will be safer for it.

Try also to persuade them that today's way to win the war on tomorrow's terrorism is in large part with love and respect for human rights, solidarity and empathy, inclusion rather than exclusion.

If we do not arrest these developments the response to HIV risks evolving once more into one based on market calculations about profit and investment frameworks rather than fundamental human rights. We will never come back to Durban to celebrate.

The question we have to ask, the question you have to ask, is whether we will allow this recession?

There are 18,000 people at this AIDS conference. We are 0.00000000000000000000001% of the world's population. We are 0.000000001% of the 37-million people still alive with HIV in the world. We have a huge burden on our shoulders. But we also have the power of human rights law, of advances medicine and scientists, of morality, of love. In the words of the Deputy President Cyril Ramaphosa, who opened the conference, "We must throw ideas at each other, not stones. It is through human action that we will end this epidemic."

So, will this conference be the last kick of a dying horse?

It depends on you.


Step by step: The road to ending the AIDS epidemic

By Sophie Cousins

Devex, 18 July 2016

http://www.devex.com - Direct URL: http://tinyurl.com/jrfz3p8

Michel Sidibé has a big job ahead of him. By 2020, the executive director of UNAIDS wants 90 percent of people living with HIV to know their status, 90 percent of people who know their status to access antiretroviral treatment, and 90 percent of people on treatment to have suppressed viral loads.

While achieving these 90-90-90 goals would set the world on course to end the AIDS epidemic by 2030--in line with the Sustainable Development Goals--the reality is that only 51 percent of people know their status and of the 37 million people living with HIV, 17 million are on ART. As the 21st International AIDS Conference opens this week in Durban, South Africa, activists are calling for treatment for all.

Meanwhile, HIV infections among adults are not on the decline. In fact, infections are on the rise across some regions.

While there are promising new prevention tools such as pre-exposure prophylaxis (PrEP), it's not yet widely available in many settings, particularly for key populations.

And all this is happening while funding for response is on the decline, with more emphasis on countries most affected by HIV to finance their own responses, as many transition to middle-income country status.

Devex sat down with Sidibé at AIDS2016 to discuss the road ahead. Here are some highlights from that conversation:

Q: UNAIDS has set the very ambitious 90-90-90 targets to be achieved by 2020. There's 17 million people out of 37 million living with HIV on ART. What needs to be done to scale up people's access to ART?

We have been ambitious because during the last five years we've been able to double the number of people put on treatment, which means that countries were not overwhelmed by the problem and they were able to define their strategy, to reach people and make sure that treatment was available. The biggest challenge I personally feel will be this one: the health systems. The huge number of people [receiving] treatment is [shedding] light on the inefficiencies of our health systems and the capacity of the health system to absorb and to be able to scale up quickly, more than they have been able to do.

If we don't have a shift in the service delivery approach--to think about strengthening the community, reinforcing the interface between the last service provider and the community, and bringing civil society and others to become providers of services--it will be very difficult for us. That's why I'm calling for 1 million community health workers to be implemented really quickly.

[Secondly], financing will be critical. What I'm seeing right now has scared me, if we continue to harbor the flattening and reduction of funding. We cannot lie to each other. I cannot see how Malawi, Zambia, even South Africa can get to 6 million people on treatment without any financial support. We need to continue to call for global solidarity. I think financing will be a key issue.

[Thirdly], how we will reach hard-to-reach people--those key populations who are today representing 35 percent of new infections? If we don't have a strategy that can really quicken the pace and reach them and get them treatment services, then our ambitious goals will not be achieved.

Q: A recent UNAIDS report found that new HIV infections among adults have stalled, failing to decline for at least five years. In eastern Europe and central Asia, new HIV infections rose by 57 percent between 2010 and 2015. What role do you think PrEP can play in HIV prevention and how can you expand its use among countries that are against it?

We are completely supportive of PrEP. We are working with countries to try and introduce PrEP in countries such as South Africa among sex workers. We are [also] trying to see how in Eastern Europe and Central Asia we can start pushing to make sure they can have the appropriate policy reform which can help them to target people who inject drugs so it can reduce infections. I think they are not closed to that [idea], even though we face the dilemma that we continue to believe that harm reduction programs should be put in place, that people should not be criminalized, and that people should not be facing prejudice and exclusion.

Even if with PrEP, if you cannot come for services, you cannot get the pill … that is the trade-off we need to manage properly--not just making sure that a pill becomes the magic response but restoring the dignity of people, making sure they are not hiding and not discriminated against. There's a tendency to think that with PrEP pills will help us to resolve issues of infection. That's true, but if you don't reach people, if you have a series of bad laws that are not removed, it will be impossible for us to implement because the impact will be little.

Q: There's insufficient coverage of harm reduction programs across the globe and policies that criminalize people who inject drugs. The United Nations' target to reduce HIV transmission among people who inject drugs by 50 percent by last year was missed. How can UNAIDS better advocate for harm reduction programs?

A good example is China: It was [previously] zero tolerance for people who inject drugs previously. What we did, was really bring the leadership of China to really understand the evidence--the science and the strategy information--coming from other countries. China today has the biggest harm reduction program in Asia. I think groups that are put on those programs are close to zero new infections. So it means that the pragmatic approach of China helped to completely change the face of the epidemic among drug users.

And there's a lot of uncertainty around funding for AIDS response in the future. How will UNAIDS advocate for funding for key populations?

We are working closely with PEPFAR who in New York announced $100 million for key populations. I think it's a catalytic fund and, for me, that's what we need, to have the courage to say "these are targeted funds" [that] will help us to see how to better reach those people with a community network. I think it will certainly bring different modalities in the future--how to finance those groups and how to support them--because until now they were part of a package of financing.

Having the courage to say that we have $100 million behind you and want to succeed, that really could completely change the way we can leverage [the funding] to scale up. We will see a lot of community groups who will start to be more vocal because they can get small amounts that help them to demonstrate that they can have an impact if they are given more resources.

Q: Given that only 51 percent of people know their status, what role do think self-testing is going to play in the future? How can we increase its outreach?

I think we need to completely change our approach to testing. It's good to go for routine testing and make sure that we make testing more convenient. Self-testing can therefore play a very important role, on one condition: we need to think about our service delivery approach. It's not possible to have self-testing when you don't have a different health system, which can be really big not on just the health system per se but a system for health. We need to think about systems for health--the community approach, so we have community health workers, a subsystem of health, which will be able to really deal with this self-testing [and] go door-to-door because they are trusted, have the capacity and are close. But, if not, we cannot tell people to go self-test ... It will fail completely because again we'll have a lot of people who will test positive but will not have the ability to access services--they will be scared and they will not trust anyone.

What we need to think about in this period is how we electrify a different type of communication approach. Most young people are complacent. They don't see people dying of AIDS. So we have a bulk of young people that need not just to be protected, but becoming actors of transformation in terms of prevention. That is, for me, a future challenge.


Aids Conference 2016 - the Gains, the Gaps, the Next Global Steps

The Conversation (Johannesburg), July 22, 2016

http://allafrica.com/stories/201607220830.html

Interview

By Linda-Gail Bekker, University of Cape Town

As the 21st International AIDS Conference wraps up in Durban, South Africa, Professor Linda-Gail Bekker, incoming International AIDS Society President, talks to The Conversation Africa health and medicine editor Candice Bailey about what was achieved and what still needs to be done.

Q: What are the three interventions or innovations that stand out at the conference in terms of taking the fight against HIV forward?

There has been exciting work about how we do treatment better to make sure we get to the 34 million who are infected. And that's absolutely critical. We have to reach those 34 million people but we know that health systems, particularly in the sub-Saharan region, are struggling. So there was some wonderful work on differentiated models of care, how we can do business more effectively and efficiently and ways we can do the steps in the cascade more efficiently.

And I've loved some of the testing innovations. Addressing all the steps from testing is critical.

Secondly I'm passionate about primary prevention but I think we've got some gaps on how we can do it. I'm a great proponent of daily pre-exposure prophylaxis and I really think we should roll it out because it works. But I'm very excited about the prospect of what's coming down the road in terms of less frequent dosing for preexposure prophylaxis.

Number three is a fresh approach to adolescents. This conference has reinvigorated the notion that we have to get adolescents to the table. We have done well, I think, in getting adolescents to be really well represented. And it works. You feel their voice.

The message I have heard here is that we need to have an integrated approach. We can't just talk HIV treatment or just HIV prevention. It has to take into consideration structural issues, behavioural issues, rights, access -- a lot of issues. And I think it becomes a model of how we really look after our adolescents around the world and HIV is a great catalyst within that.

Q: Based on the discussions at the conference where are the gaps in the global HIV response?

At the moment it's money. There is a horrible funding gap that we have to address. We had so much money when we didn't have the tools. Now we have the tools and we don't have the money. I feel desperate about that.

In 2000 we missed opportunities because we didn't have our systems and our thinking right. I'm taking collective responsibility but there was a leadership gap and we lost lives because of that. Here we stand now and if we don't act in the way that we should, we will have lots of lost lives and infections that we don't have to. And I don't want that on my record.

When we get help from Sir Elton John, Prince Harry, Princess Mabel from The Netherlands and Charlize Theron to shine a focus on this we are eternally grateful. We need help from everyone to carry the message that the job isn't done. Otherwise we will miss the moment and we will have regrets. And I don't want to be in that camp.

I am very pleased that the Replenishment of the Global Fund Conference is being held in Canada because I think the Prime Minister of Canada is really showing that he can get the job done. Justin Trudeau's a great example of moving forward when he needs to move forward and doing uncomfortable things when they have to be done because it's right. I have a sense that he does what's right. So I'm excited about that because I think that's important.

We have to keep showing people that it's not only the right thing and the compassionate thing and the humane thing but that it makes good financial sense. We are bleeding where we don't need to bleed in terms of finance. And if we can shut it down earlier we will do the world a favour.

Q: What is the message that is coming out of this conference?

The job is not done. We have tools that can be deployed; we have a lot of work to do. We have the energy but this is not the time to not have the resources. It's a collective global effort. And we're excited. Durban has re­energised the whole sense of community and engagement. Now we need the rest of the world to get on board. And I think we can do it. The optimism that I have felt here is real. But the reality is that if we don't move forward from today that trajectory will flatten out.

...


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