Global Public Health Goals Thwarted by Human Rights Violations, Gender Inequality and Stigma

Mexico City -- As the XVII International AIDS Conference drew to a close, HIV experts from around the globe highlighted the dramatic negative impact that stigma and the denial of human rights, including gender inequality, continue to have on the effectiveness of HIV treatment and prevention scale up. Fear of violence, discrimination and unwarranted prosecution prevent many people living with or at risk for HIV from seeking testing and treatment, and drive others to place themselves at risk for infection.

"The voices of those who bear the brunt of this pandemic have been loud and clear in Mexico City this week," said Pedro Cahn, International Co-Chair of AIDS 2008 and President of the International AIDS Society and Fundación Huésped in Buenos Aires, Argentina. "If the world does not heed the call to ensure the human rights and dignity of every person affected by HIV, we will not achieve our goal of universal access."

"Those most at risk, including injection drug users, men who have sex with men and sex workers, as well as women and youth, must never be seen simply as patients or prevention targets," said Dr. Luís Soto Ramírez, Local Co-Chair of AIDS 2008 and Head of the Molecular Virology Unit at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán and Coordinator of the Clinical Care Committee of CONASIDA, Mexico's National AIDS Council. "Their experiences and contributions are central to the development and implementation of effective programmes. As we strive for universal access we must once and for all commit to the ideal that every life is worthy of respect."

Speakers in the final plenary session underscored the connection between public health and human rights, and also addressed the intersection of HIV and Tuberculosis (TB).

Confronting TB/HIV In the Era of Increasing Anti-TB Drug Resistance
Tuberculosis is the leading cause of death among people living with HIV in Africa and a major cause of death elsewhere. At least one-third of the 33 million people living with HIV worldwide are co-infected with TB, and these individuals have up to a 15% risk of developing active TB every year.

Dr. Chakaya Jeremiah (Kenya), Chief Research Officer of the Centre for Respiratory Diseases Research at Kenya Medical Research Institute, gave an overview of the challenges presented by the dual epidemics of HIV and TB. To reduce the burden of TB in people living with HIV, he urged the HIV community to take greater responsibility for implementation of the 3 "I"s recommended by the World Health Organization. The three "I"s include: intensified case finding; isoniazid preventive therapy; and TB infection control. Jeremiah noted good progress being made to decrease the burden of HIV in TB patients through HIV testing of TB patients and the initiation of preventive therapy for HIV-positive TB patients.

Jeremiah also profiled the emerging threats of multidrug-resistant and extensively drug-resistant TB (MDR/XDR-TB). The experience with XDR-TB in South Africa paints a bleak picture with very poor patient outcomes. According to Jeremiah, both MDR/XDR-TB are the consequence of sub-optimal TB control and inadequate infection control practices in health care settings.

HIV Prevention Lessons From Community Experiences in Concentrated Epidemics
In his plenary remarks, Bruno Spire (France) identified reducing stigma, combating prevention fatigue, and diversifying HIV testing as key steps to prevent sexual transmission of HIV in concentrated epidemics. Spire proposed a "triple therapy" strategy to combat stigma and discrimination rooted in evidence of stigma's negative impact on HIV risk reduction. The strategy includes fighting for better acceptance of people living with HIV (PLHIV), improving laws and policies to protect those most vulnerable to infection, and implementing prevention programmes that incorporate community mobilization and peer support. He cited examples of female sex worker mobilization efforts in India, Chile and France, and an initiative to mobilize men who have sex men in Africa, as important examples of this successful strategy. Spire is President of AIDES, France's primary nongovernmental HIV organization, and a researcher at the French National Institute for Medical Research.

To combat prevention fatigue, Spire called for pragmatic solutions for those who do not consistently use condoms, including risk reduction programmes adapted to individual and community needs. He pointed to data showing that access to antiretroviral therapy and perceived good health have a positive impact on consistent condom use among people PLHIV. Spire also emphasized the importance of a variety of HIV testing approaches. This includes routine testing with opt-out options, which Spire said demonstrates higher rates of HIV detection, as well as increased access to voluntary counseling and testing, particularly in community settings. In addition to facilitating earlier access to care, learning one's HIV status enables earlier adoption of safer behaviors. Spire noted that rates of unprotected intercourse are more than 50 percent lower among those who know their HIV status.

Criminalization of HIV is Costing Lives and Increasing Suffering
According to Edwin Cameron (South Africa), Justice of the Supreme Court of Appeal of South Africa, the enactment of laws that criminalize transmission of or exposure to HIV has become so widespread, and criminal prosecutions so frequent, that they have become a crisis in efforts to deal rationally and effectively with HIV. Citing examples from locations as diverse as the United States, Sierra Leone and Singapore, Cameron highlighted the irrational nature of these laws and their ineffectiveness in achieving their purported goal of preventing the spread of HIV. Rather, they radically increase HIV stigma and become barriers to testing and treatment. Prosecutions often single out already vulnerable groups such as sex workers, men who have sex with men and, in European countries, black males. Women are especially victimized by these laws, which expose them to assault, ostracism and further stigma.

Cameron stated that one of the outcomes of AIDS 2008 should be a major international pushback against such misguided criminal laws and prosecutions. He urged delegates -- strengthened in their resolve to fight against stigma and discrimination -- to return home committed to persuading lawmakers and prosecuting authorities of the folly and distraction of criminalization.

Road Map for Action on Women, Girls and HIV/AIDS
Citing violence against women as both a cause and consequence of HIV infection, Zonibel Woods (Canada) of the Ford Foundation highlighted the fear of violence from partners as a reason that some women do not seek treatment for HIV. Woods declared that providing access to treatment cannot be divorced from ensuring a woman's right to live free from violence, and that attempts to scale up HIV treatment, while ignoring stigma and discrimination, will not work. For real progress, the legal and policy environment to address violence against women must be strengthened along with the commitments to invest in, enforce, monitor and evaluate such policies.

Confronting gender-based violence is one of three priorities in Wood's roadmap for responding to HIV in women. She also outlined the importance of ensuring women's right to sexual and reproductive health, and investing in women's organizations so that women can participate effectively in decisions that affect their lives. Policies and budgets must support the full range of reproductive health services, including quality pregnancy and delivery care, and access to contraception. In addition, research and investment in technologies that put control of prevention in women's own hands also remain critical. In closing, Woods welcomed the recent decision by the Global Fund to Fight AIDS, TB and Malaria to invest in gender transformative programs. However, she emphasized that success in this regard depends on the engagement of women's organizations in setting in-country priorities, and the inclusion of experts in gender equality and women's empowerment funding on proposal review panels.

Conference Closes With Rapporteur Reports, Calls to Action
At the Closing Session, delegates heard summary remarks from AIDS 2008 Co-Chairs, Dr. Pedro Cahn and Dr. Luis Soto Ramirez, as well as from community representatives. Global Fund Executive Director Dr. Michel Kazatchkine gave a closing keynote address following a taped transmission from the official conference hub held at the Nelson Mandela School of Medicine of the University of KwaZulu Natal in Durban, South Africa. Incoming IAS President, Dr. Julio Montaner, Director of the BC Centre for Excellence in HIV/AIDS and Founding Co-Director of the Canadian HIV Trials Network, gave an inaugural address, followed by remarks from OXFAM Ambassador and singer Annie Lennox. To conclude today's Closing Session, Mexico City Mayor Marcelo Ebrard and Local AIDS 2008 Co-Chair Luis Soto Ramírez officially transferred the International AIDS Conference glass globe from Mexico City to Vienna, Austria, the host of AIDS 2010. Accepting the globe for Vienna were: Sonja Wehsely, Executive City Councillor for Public Health and Social Affairs; Frank Amort, from Aids Hilfe Wein; and AIDS 2010 Local Co-chair Brigitte Schmied, from the Otto-Wagner Hospital.

With more than 24,000 participants from over 190 countries, AIDS 2008 was the second largest in the history of the International AIDS Conference, and the first to be held in Latin America. The conference theme, Universal Action Now, emphasized the need for continued urgency in the worldwide response to HIV/AIDS, and for action on the part of all stakeholders.

During the conference, a team of 50 rapporteurs prepared written summaries of conference sessions to record what was discussed and identify next steps on a range of issues. Prior to the Closing Session, chief rapporteurs from eight topic areas presented weekly summaries. All reports and summaries are available online at www.aids2008.org.