We now have the science we need to totally end the spread of HIV worldwide.
But this is a mixed-up world. A world where people who know they are HIV positive are less of a problem than people who assume they are HIV negative.
It’s a world where some medical professionals are more worried about being put out of work than about preventing illness. Where parts of Africa are leading the way while Europe trails behind.
It’s a world where your prospects vary wildly if you are HIV positive, depending on where you live and who you are.
And while there’s enormous advances and cutting edge science, progress is fragile. Some conservatives are destroying lives to see their views triumph.
Give everyone access to testing
Even the simplest step, getting tested for HIV, can be fraught with problems.
Some people can easily pop into a clinic, take a test, and be on their way in less time that it takes to drink a coffee.
But for others it isn’t that easy.
Under 18s may be banned by law from taking a test without parental permission. You have to ask yourself if all sexually-active teens want to explain to their parents why they want one. And that’s not counting the parents who may simply refuse.
In the US, the most likely group to be positive and not know their status are young people between 13 and 24-years-old.
In much of the western world, migrants are at higher risk of being HIV positive. But some fear being deported if they come forward for testing.
Removing these barriers is essential.
Make testing as easy as possible
For others, testing is simply more of a hassle than it needs to be. In the US, people often receive routine blood testing for a range of conditions, like diabetes. But ordering an HIV test is a separate function, requiring different paperwork. In fact, the paperwork can even be different from that required for other sexual health screening.
In the UK, vast strides have been made in encouraging to test. But GSN recently reported on a number of sexual health clinics that have closed down, making tests harder to come by.
The most popular clinic for gay and bi men in Britain is 56 Dean Street in Soho, London. It now books out all of its appointments for the day within seven minutes of them being released.
It’s an urgent problem. In 2014, the US Center for Disease Control reported nearly 166,000 Americans were HIV positive and didn’t know because they weren’t testing. If all of those people knew their status, countless new HIV infections could potentially be prevented.
Despite that there has been huge progress.
The culture of testing has dramatically improved in many places in the world. A decade ago, many gay and bi men in the UK didn’t test regularly. Now many do at least once a year.
South Africa has gone from virtually zero testing and treatment 10 years ago to nearly 4 million people on treatment now. Given they will need to be on treatment for the rest of their lives, it’s an impressive public health commitment. And it shows countries can scale up their efforts dramatically.
Remove legal barriers to testing
In many countries, only doctors, phlebotomists (blood specialists) or other health professionals can test for HIV.
For example, when the HIV/AIDS Alliance in Ukraine lost their funding, they faced having to stop testing. By law, they had to use a doctor to test and they couldn’t afford to employ the doctors they needed.
So they asked a lawyer for help. They discovered lawmakers made the rule before HIV tests became so simple you can do them on yourself. Because of that, it was illegal for non-doctors to test other people, but not for people to test themselves.
The Alliance used that loophole. They taught their staff to help people test themselves, and give them support if they are positive. In 2015, the Alliance used this to carry out 200,000 tests and diagnose 4,000 people with HIV.
Roll out home testing
HIV can now be detected with a simple finger-prick blood test. In fact, it’s so easy that you don’t even need to be a doctor or nurse. You can use a home testing kit and get a result in minutes.
At least, that’s the theory. In practice there are huge barriers in the way.
Across Europe, home testing is illegal in the majority of countries. You can home test in Britain, France, Romania and Ukraine. But you can’t in Germany, Spain, Serbia or Italy.
Even when home testing is legal, it’s not easily available. No UK high street supermarket or pharmacist stocks HIV testing kits at present. In fact, GSN is working with partners to crack that problem with a trial project coming soon.
And perhaps it shouldn’t surprise us that some doctors oppose home testing – they fear it’s a job killer. We need to educate them to embrace this change.
Obviously, people who home test need appropriate support if the test is positive. But if that’s in place, home testing can take a lot of pressure off health services.
Get positive people on treatment
If you are HIV positive, your ‘viral load’ determines how likely you are to transmit the virus.
HIV treatment doesn’t remove the virus from your body – it’s not a cure. But it can control the virus so it doesn’t harm your health.
One of the other advantages of drugs to treat HIV, is they reduce your viral load. HIV positive people on effective treatment can have such low viral loads it is impossible for them to give someone else the virus.
Scientists have actually known about this for the best part of a decade. But it’s taken a while for officials, like the Center for Disease Control in the US, to endorse ‘treatment as prevention’.
It makes economic sense for governments and health insurers to get HIV positive people on to effective treatment. It will stop other people getting the virus, saving money in the long run.
And early treatment also improves the health outcomes for HIV positive people.
In some places, this works. The fall in new HIV cases in London is thought to be due in large part to people being tested for HIV early and then getting on treatment.
But in other places, the system fails people.
In Russia, only 32% of HIV positive people get treatment. And across Eastern Europe, governments are failing to provide adequate funding to treat people. That helps the virus spread and has potentially devastating consequences on positive people’s health.
Get treatment fast
HIV positive people are particularly likely to pass on the virus when they first get it. Their viral load is higher and they may assume they are HIV positive.
The sooner they can get on effective treatment, the better.
Not everyone will want to start antiretroviral drugs straight away. For some people, it takes a while and a lot of support to come to terms with their HIV status.
But for those prepared to start, health providers should have a policy to make sure they do.
Strange though this may sound, this is not how it works now. For example England’s National Health Service has no policy stating that all newly diagnosed HIV patients should start treatment quickly. It’s left to individual clinics and doctors to drive that.
And if you are in Britain, you are one of the lucky ones. Many parts of the world are still very slow in getting people who are very ill on treatment.
Make gay sex legal worldwide
LGBTI activists have argued for years that you will never eradicate HIV and AIDS until you have made gay sex legal worldwide.
Criminalising gay and bi men backfires. It makes them harder to educate about safe sex. It stops them coming forward for testing and treatment. And it leads to persecution, blackmail and corruption that actively disrupts efforts to tackle HIV.
Police raid clinics targeting gay men – and drug users, and sex workers. They ban publicity raising events.
One place where this may soon change is India. The country’s Supreme Court seems destined to strike down the British colonial law which criminalizes homosexuality as unconstitutional.
Criminalization in India prevents people from coming out or seeking health care or disclosing their orientation to healthcare professionals.
Sadly, the doctors reflect Indian society. There are even cases where doctors have refused to treat gay men with sexual health conditions because they would be ‘enabling further crimes’.
Decriminalization will give organisations and individuals greater courage to call out healthcare providers on homphobia, biphobia and transphobia.
If Indian gay and bi men have confidence to come forward, it could have a big impact on HIV. India does provide free testing and treatment, although some richer Indians choose private treatment.
There are around 80 countries worldwide that criminalize homosexuality. But far more persecute LGBTIs, and this too can be a barrier to tackling HIV, for the same reasons.
Russia’s law banning the ‘promotion’ of homosexuality to young people damaged HIV efforts.
The country fails to target men who have sex with men for prevention and testing. They leave that job to the few organisations who get national funding or some pockets of local money.
And the ‘propaganda’ law has created new obstacles for young people and others to get information about HIV and AIDS or services.
It’s yet another way where advancing LGBTI rights would save lives.
Show trans people respect
Trans women are 49 times more likely to become HIV positive than the rest of the population, according to the World Health Organization.
But government HIV prevention programs often ignore them. Back in 2014, only 49% of countries reported that their national AIDS strategies addressed trans needs.
Insultingly, trans women are often considered to be gay men by health officials. And HIV prevention campaigns targeted men who have sex with men, bypassing trans people.
Some countries don’t recognize their true gender at all. So they may have to use their ‘dead name’ – their name before transition – to access clinics. Some face so much stigma, including from the medical profession, and criminalization they fail to access healthcare generally – not just HIV.
Experts believe trans men are far less at risk than trans women. But that’s partly because there’s been hardly any research. And nothing is known about non-binary people and HIV risk. All this needs to be studied and understood.
Despite this, awareness is growing. HIV and trans organisations need to work together and to ensure progress doesn’t get derailed by a backlash, as so often happens.
Abandon the War on Drugs and deal with the reality
Injecting drug users have always been high risk for HIV.
Yet governments are as irrational to them now as they were when the AIDS crisis first hit.
In Russia, drug users are driving up HIV cases. But the country refuses to target them for prevention campaign. It won’t provide needle exchanges so they can inject safely. And it won’t help wean them off drugs by giving methodrone.
It’s getting worse. In 2009, 75 projects targeted 135,000 drug users – just 5% of the conservatively estimated 2.5 million in Russia. By 2016 just 16 projects remained. These reach only 13,800 people. That’s almost 90% down. And it means only one in 200 people injecting drugs are included.
Meanwhile, Russia is busy putting them in prison. There are about 150,000 Russian prisoners convicted of drugs offenses. The vast majority are in jail for possession of drugs for personal use. That’s about a quarter of the total prison population.
Inside the unhealthy prisons, tuberculosis is running wild. Naturally, people who are HIV positive, including many drug users, are particularly at risk. TB has always been a killer for HIV positive people. But even then they don’t get treatment. The Russian system simply hands them a death sentence with their prison sentence.
Pay attention to people of color
In white-dominated countries, there’s always been a tendency to target HIV campaigns at white people.
But that often means the campaigns fail to reach out to people of color, who are likely at higher risk.
And then a shift in policy can make things worse. When the US started cutting back on its Planned Parenthood program eight years ago, you started to see spikes in HIV among African Americans who relied on this service for their sexual health needs.
Meanwhile for men who have sex with other guys who are also black or Latino, the messages sent out to gay white Americans can be alienating. Even some of the simplest language fails to hit home – they may not identify as gay.
HIV positive people consistently highlight in surveys how they face stigma and prejudice from the rest of society.
This stigma prevents people from coming forward for testing and treatment. It stops people from talking openly about HIV.
In fact, if you have HIV, discovering your status is the best thing you can do. It will help you get on treatment and, once you are, you can enjoy a normal life expectancy. Plus you can’t pass on the virus if you are on effective treatment.
Educating people about what it means to be HIV positive will help end the stigma. And that will help end the virus.
Target sex workers
Sex workers are widely criminalized around the world, but are also at high risk of HIV.
Again, this stops them coming forward for testing and treatment, harming their health and helping the virus spread.
As a for example, only half of sex workers who test positive in Russia end up registering with officials so they can get treatment. They are just too afraid.
In many parts of the world, trans people can’t get a wide variety of jobs so are forced into sex work. And trans women in sex work are among the highest risk groups in the world for HIV.
Even among sex workers, trans sex workers are more likely to work on the street than in safer spaces. They are more at risk of criminalization and police brutality.
Helping sex workers stay HIV negative, test and get treatment is vital.
Educate the public
When Michael Friedman, a 41-year-old gay Broadway composer died of HIV related complications in September, it sent a shockwave through New York.
It took many in the city back to the dark days of the 80s when the gay community lost so many of our brightest and best.
And it illustrated why HIV education needs to continue. While some sexually active men test for HIV every three months, Freedman had not tested for several years.
Education is fundamental. But many still don’t know the basics.
How many infections could be prevented if every school child learned about sexual health – gay and straight? Remember that children now as young as 10 have smartphones and the ability to access gay hookup apps on the sly.
Communication is so poor that HIV experts are talking about white hetersexuals as being a hard group to tackle. They may be low risk but like anyone, they can get the virus. But they still think of it as a gay disease.
Make HIV something that all health services, not just specialist clinics
We need HIV and sexually transmitted infection clinics. They provide specialist health workers who know the virus back to front and inside out. Many hard-to-reach groups, like gay and bi men, see them as safer places to go and speak honestly about their sex lives.
But HIV should be everyone’s concern.
In the UK, GPs – or family doctors – have started to get more involved in HIV care.
Part of the reason is that HIV often comes alongside other health conditions, which makes them more aware of the issues. They need to be been trained and supported. But they are proving good at providing HIV tests and patients are taking them up on the offer.
Hospitals are also improving. They are recognising other conditions which may indicate HIV, like pneumonia in young people, and are testing.
It’s an opportunity to further drive down the virus.
Simplify health systems so they have open doors, not barriers
In some Eastern European countries, Soviet-era health systems still keep different disciplines in rigid silos. The result is a lack of expertise which may lead to HIV positive people falling through the gaps.
In the US, a mix of city, state and federal policies, plus various private insurance companies, complicate all aspects of HIV. Your prospects vary depending on who you are, how much money you have and where you live.
According to the law, treatment should be provided for free for all HIV positive people in Russia.
But gay and bi Russian men face a problem. They often move from their native cities to other regions. And now treatment is only free where you are registered. This policy means if you are registered in St Petersburg but you live in Moscow, you may have to go back to St Petersburg to get treatment.
Far too often, the system fights people trying to get help. It’s in everyone’s interests to untie these bureaucratic knots.
Educate the medical profession
You may expect medical professionals to understand HIV.
But there’s still confusion.
There are reports of doctors around the world declining to tell HIV positive patients they can’t pass on the virus if on treatment. They have a theory, without clear evidence, that people get confused and don’t adhere to treatment if they think that.
There’s an opportunity to educate the medical profession about how to spot HIV. They could help their patients avoid the virus in the first place. And they need to be aware more and more people are living long-term with the virus – and they’ll be having to give them general healthcare.
Understand the potential of PrEP
PrEP is the big new thing.
Put simply, by taking a tablet once a day or in enough time before you have sex, you can massively reduce the risk of getting HIV.
It is having a dramatic impact on HIV rates where it is available. And generic versions of the drug are making it more affordable.
Roll out PrEP worldwide
Currently an estimated 8,000 people in England are buying their own PrEP online. Now the National Health Service is providing it for 10,000 people to trial how it can contribute to HIV care long-term. It’s an open question how many of those ‘free’ PrEP places will be snapped up by the people currently paying for it.
In the US, PrEP is often available but not always easily. The drug company Gilead, who makes the main PrEP drug, provides free clinics. But equally some doctors charge large fees for consultations. It can be hard navigating the waters.
And in India, the country that makes generic – cheaper – PrEP drugs for the rest of the world, regular people can’t always get it. PrEP is not funded by the Indian government. And at around 3000Rs ($30 €25) a month, wealthier Indians can afford to buy it privately, while poorer people and students are priced out.
There is no publicly-funded PrEP at all across post-Soviet Union countries. After all, they typically aren’t funding enough treatment even for those with HIV.
But there is a brilliant example from Kenya and South Africa. PrEP is rolling out there for free, particularly targeting men who have sex with men, drug users and sex workers.
Sustained publicity campaigns are touting PrEP as a good option.
In fact, it’s so well done there’s a risk of a downside. Heterosexual men may assume PrEP is not for them. And none of the downsides of PrEP – the potential side effects and concerns some people have about its effectiveness are not being heard.
Don’t look down on people on PrEP, they’re saving us all
Of course, there’s always a backlash. And there’s been some stigma against people on PrEP.
In some countries, gay and bi men are being portrayed as sex maniacs who can’t be trusted to be responsible for using condoms so must take pills.
But that view misses the point.
Everyone who takes PrEP protects not only themselves, but also any HIV negative person they have sex with. If they can’t contract the virus, they can’t pass it on. Providing the drug to even those at most high risk can dramatically reduce HIV.
And it’s not necessarily the case they will pass on other sex infections, through not using condoms. The best PrEP schemes get users in for regular screening. They need to be monitored for side-effects. And they also get tested for other sexually transmitted infections.
If they get treated for those infections quickly, they can’t pass those on either. So it is just possible some of those conditions will drop too.
PrEP is not for everyone at every point in their lives. But by getting rid of the stigma, we can better educate people about who needs it and when. And they should then be encouraged to get on with it, without shame.
Give swift and easy access to PEP
There’s another treatment, Post Exposure Prophylaxis, or PEP. This is a series of drugs you can take immediately after being exposed to HIV. It can stop you getting the virus, even after it enters your body.
But it’s complicated. PEP treatment doesn’t always work. It’s not without side-effects. And it has to be started quickly – 72 hours after exposure to HIV is the limit.
People have to know where they can get PEP and have an open door to access it swiftly. That simply doesn’t exist everywhere.
Keep people using condoms
Of course, condoms remain the front line in preventing the spread of HIV.
Condoms are widely available but there is a lot of pressure on men, particularly via hook-up apps, to have bareback sex. The fetishisation of ‘raw’ sex through bareback porn has also contributed to risk-taking.
And there are still damaging messages going out.
In Kenya, for all the progress they’ve made, the government tends to portray their reason for giving gay men condoms as being to protect the heterosexual population.
We must continue to promote easy, affordable access to condoms and lube.
Fight back against conservative ideologies
In spite of all the evidence, there are still people who think ‘traditional’ or ‘Christian’ values are a better way to fight HIV.
Step forward US Vice President Mike Pence.
While governor of Indiana, he opposed needle exchange. The result was a spike in HIV cases in this country. He eventually had to back down, for a short time, to bring the problem under temporary control.
Janet Kainembabazi, the wife of Uganda’s President Yoweri Museveni, also put lives at risk to drive her own conservative agenda.
Influenced by US evangelicals, she got Uganda to slow down on proper HIV prevention work and push sexual abstinence. It was a disaster, so much so that Museveni eventually had to reverse the policy.
Attempts to get Russian sexual health programs to promote abstinence over condoms is having similarly devastating results.
We are at war, not just with a virus, but with ideologies that will let it flourish.
One country alone can never totally eliminate new HIV cases within its own borders. We all travel far too much for that to work.
We need international cooperation.
And we need to focus on supporting internal change in the countries where HIV is running rampant. For example, an incredible 50% of all new HIV cases in Europe stem from Russia. That’s vastly disproportionate to the country’s population.
But the world provides opportunities to learn as well as problems to be solved.
For example, Zambia and Zimbabwe have looked closely at the progress Kenya and South Africa have made tackling the virus.
International cooperation give us the opportunity to learn what the latest data is telling us more promptly. It can help us find solutions which are already working elsewhere. And global digital media can help us get out vital messages far more quickly.
Help women control their own sex lives
Of all the social problems preventing us tackling HIV, the greatest is the relationship between men and women.
In far too much of the world, women don’t have power to decide the sex they want. Even when sex puts them at risk. Women are seen merely as a source of pleasure for men.
We are not going to disable patriarchy overnight. But we can recognize that every HIV activist also has to be a feminist.
And there are opportunities. A number of countries have run education campaigns which show women making decisions about sex or have provided specialist targeted services.
Can we really end HIV?
The UN has set out ambitious targets for 2020.
First, they want 90% of all people living with HIV to know their status. Then they want 90% of those positive people to be sustained antiretroviral therapy. And they want 90% of people taking those antiretrovirals to be ‘undetectable’ and therefore unable to pass on the virus.
In reality, the world will move at different paces.
Russia and much of Eastern Europe appear to be going backwards. Huge change is needed before we can hope to end the virus.
But from India to the UK, experts are speaking positive about ending the virus – not today but in the foreseeable future.
In Britain, sustained investment could end new HIV infections in just a few years. There will still be ‘outbreaks’ of the virus, because of people coming from abroad. But these would perhaps be treated as ‘outbreaks’ to be swiftly damped-down by health authorities.
What everyone agrees on, is that we now have the best set of tools ever with which to stop new HIV infections. Policy, funding, prejudice are now the real unknowns.
Science has found a way to beat HIV. Society now has to take up the fight.