It’s been 33 years since the world first learned that the human immunodeficiency virus was the cause of AIDS. Many lives were lost to the epidemic in the decades that followed, but we’ve come a long way in combatting the virus. Globally, programs to provide antiretroviral treatment to people living with HIV have averted an estimated 7.8 million deaths between 2000 and 2014.
There are 17 million people living with HIV around the world currently on treatment, due in large part to the efforts of empowered communities coming together to demand access to treatment and resist and challenge stigma and discriminatory practices against people living with HIV. This accomplishment has greatly slowed the transmission of HIV, yet the virus persists due to our inability to reach vulnerable and key populations most at risk of HIV with prevention, care and treatment services.
Women, adolescent girls, migrants, men who have sex with men, sex workers, people who inject drugs and prisoners remain acutely at risk of HIV infection because of social factors such as harmful gender norms and stigmatizing attitudes and structural factors including discriminatory laws and policies and unequal access to HIV services. Interventions to remove these barriers that violate human rights to health information and services should be a priority, yet evidence-based strategies are few and far between.
The last three decades of research have elucidated how HIV is transmitted — through unprotected sexual intercourse, transfusions of contaminated blood, contaminated needles, and during pregnancy and childbirth — and what strategies and tools are most effective at preventing HIV transmission, such as condom use, pre-exposure prophylaxis, post-exposure prophylaxis, antiretroviral therapy, blood bank screening, and voluntary medical male circumcision. We’ve also worked tirelessly to prolong and improve the lives of people living with HIV.
But to truly “end AIDS” by 2030, as the Sustainable Development Goals call for, we have to do more.
Making HIV prevention and treatment interventions widely available and acceptable, the current focus of the global health community, is no longer enough. The number of new HIV infections being identified through current testing approaches is decreasing, yet HIV incidence has not dropped significantly. This means that the people we are reaching with testing and prevention services are not the people at highest risk of HIV infection. Only when we can access and engage in care people most at risk will we see large reductions in HIV incidence. Doing so will require that public health and outreach programs reduce stigma and discrimination of these vulnerable and key populations and remove the human rights barriers to prevention, care and treatment.
For example, laws that criminalize HIV transmission, sex work and same-sex relationships prevent people from testing for HIV for fear of being discriminated against or prosecuted for criminal behavior. The lack of training for health workers about how to provide stigma-free services to key populations or how to provide nonjudgmental sexual and reproductive health services to young people discourage visits to the health clinic and engagement in care.
On the flip side, supportive policies like those that allow syringe-exchange programs can actually cause further harm to people who inject drugs if police are not trained on the importance of the policy and discouraged from targeting drug users who are trying to utilize these programs. While a few promising interventions to address some of these barriers have been tested, more evidence is needed. The current evidence gap makes it difficult for governments to integrate human rights programs within a comprehensive response to HIV. As a result, well-intentioned efforts that could make a big difference often fall short.
So where do we go from here? As we head into the 21st International AIDS Society conference, it is critical that we sharpen our focus on human rights.
After more than three decades combating HIV, it is clear that we can’t simply treat our way out of this epidemic. We must make certain that those most vulnerable to HIV infection have equal access to high-quality prevention, care, and treatment options, and are supported to actively engage in these services. We can only accomplish this by using a human rights-based approach — one that places people who are marginalized, excluded or discriminated against as the central focus — to design, implement and evaluate human rights programs and national policies.
Only then will we truly be able to end AIDS in a generation.
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