Q&A: Attack inequities to beat HIV/AIDS, amfAR vice president says

SAN FRANCISCO — The 23rd International AIDS Conference was scheduled to take place this week in San Francisco, California — a city that would have served as a reminder of the uneven progress against HIV/AIDS. While infection rates have plummeted in San Francisco, new infections are on the rise just across the Bay Bridge — particularly among racial and ethnic minorities.

Now, the COVID-19 pandemic that forced AIDS 2020 to go virtual is also disproportionately affecting minority groups.

“We know that San Francisco is in the middle of an effort on HIV and they are making significant gains, which is great,” said Greg Millett, director of public policy at amfAR, the Foundation for AIDS Research.

He wore a Black Lives Matter shirt when he gave his opening plenary at AIDS 2020 this week, where he focused on racial disparities in both the HIV/AIDS and COVID-19 responses.

“But part of the reason that they’re making those gains is that the community that’s at highest risk of HIV no longer lives in San Francisco and is elsewhere,” Millett said.

Millett spoke with Devex about the disparities that link HIV/AIDS and COVID-19, what can be done to address these inequities, and how the HIV/AIDS community can turn progress into success.

Your keynote captured how the disease burden for both COVID-19 and HIV/AIDS is worse among marginalized populations in the United States. How do those same dynamics play out globally?

There are a lot of parallels there. Communities of color are most impacted by HIV as well as COVID, both on the domestic and the global stage. We know that there are specific marginalized populations where policies, such as criminalization laws, magnify disparities, particularly for HIV.

New research just came out during this conference looking at those nations in sub-Saharan Africa that criminalize homosexuality, where you find a much higher prevalence of HIV among men who have sex with men. We’ve seen what’s happened with Russia and the trajectory of criminalization of LGBT populations and the rise of HIV there. And we’ve seen the opposite. When Portugal decriminalized some of its drug use and implemented harm reduction programs, we saw decreases in HIV infection among people who inject drugs.

Then of course there is sexism. A big difference that we see between the domestic HIV/AIDS epidemic and what’s taking place globally, particularly in sub-Saharan Africa, is in the Americas it’s primarily an epidemic taking place among men and particularly men who have sex with men, but most of the infections globally are taking place among women, and particularly women in sub-Saharan Africa.

We see data from PEPFAR [the U.S. President's Emergency Plan for AIDS Relief] and others that a lack of education is associated with greater rates of HIV infection among adolescent girls and young women. And power dynamics are associated with higher rates of HIV infection as well from sexual abuse or having much older male partners.

So all of these contextual factors come into play to influence the disparities we see on the global stage.

What can the global health and international development community do to address these entrenched inequalities?

Communities need to be central in our response. Communities are central to coalition building and developing collaborations. That really has to have an intentional process. We can’t continue to pretend that just investing money and pushing agendas in top-down driven ways is going to change things unless there’s a specific intention to attack these underlying inequities that we continue to see.

And that really means at least two things. The first is that we have to fund grassroots organizations that have organized themselves to fight the socioeconomic battles that underlie these surface level inequities. And the second is to protect the individuals and organizations that do so through rigorous defense of international human rights standards and through protections in freedom of speech and transparency as well as accountability.

I think that’s perhaps the best way forward, and it’s clearly been one of the hallmarks of the HIV response. I get questions all the time from people from other disease fields asking: How has HIV been able to effectively mobilize the community response to decrease rates of HIV infection or decrease mortality in specific areas? And that has been our success story. And in many ways we need to make sure we build on that success both globally and domestically.

You also helped lead a session at AIDS 2020 drawing on lessons from the 2019 report “Translating Progress into Success to End the AIDS Epidemic.” How can the HIV/AIDS community learn from and build on the case studies you presented?

There were a lot of things that were helpful in that report.

One was campaigns to encourage HIV testing particularly among groups that were most affected. The second was free and easy access to treatment and diagnosis of HIV regardless of CD4 level [a test that mentions the strength of the immune system]. The third was scale-up of HIV testing and evidence-based HIV prevention such as voluntary medical male circumcision, preexposure prophylaxis, and harm reduction. And the fourth was concerted efforts to provide human rights-based services and social supports alongside programs to fight stigma and discrimination. And all of that ideally in the context of broad health care access.

So those were the things we saw that were really the glue in terms of the progress that was made and the success that was made in each one of those places. In terms of moving forward, there are several things we know we need to do.

We’ve already seen some of the successes that are being had in terms of long-acting agents both for antiretroviral therapy as well as for PrEP. We need to make sure we have those types of agents available.

In the short term, it’s going to be difficult for us to address a lot of these issues, due to the social determinants of health that magnify disparities. But if we have medications that allow people to weather these social determinants of health, such that people can still remain adherent to these medications, then that’s something that’s going to be helpful for us in the short term.

The one thing that this COVID-19 response has demonstrated is that our HIV expertise has been crucial globally for many people to understand exactly how we begin to address an infectious disease, because we’ve been so successful with HIV.

We not only need that scientific expertise, we need that expertise from community-based organizations as well who know how to deal with marginalized populations, they have the trust in marginalized populations, they know how to conduct testing as well as treatment in contexts that are very difficult. And we have not necessarily engaged many of these communities in doing that.