World AIDS Day 2009: Progress and Challenges (web article)

In a very public recognition of World AIDS Day 2009, Secretary of State Hillary Clinton announced the lifting of a 22-year-old immigration and travel ban that prohibited HIV-positive persons from coming to the U.S. On hand to share in this victory for public health and human rights was Epidemiology professor Chris Beyrer, one of five members representing North America on the International AIDS Society Governing Council, an elected body that represents professionals working on HIV/AIDS globally.

Beyrer, director of the Johns Hopkins Center for Public Health and Human Rights, says that the action clears the way for the U.S. to host one of the most prominent AIDS meetings in the world.

“We put forward that if the travel ban was lifted, the next meeting of the International AIDS conference (in 2012) should be in the U.S,” he says, “and it should be in the city with the highest AIDS rate in America, which is Washington, D.C.”

Every World AIDS Day presents an opportunity to reflect on the progress and challenges in the HIV/AIDS epidemic. A pledge of increased funding for the President’s Emergency Plan for AIDS Relief (PEPFAR) is tempered by the resurgence of HIV infection rates among MSM (men who have sex with men) and by the troubling trend of criminalization of homosexuality in some developing countries.

In the following Q&A with Jackie Powder from the Bloomberg School’s Office of Communications and Public Affairs (OCPA), Chris Beyrer discusses the latest issues in the HIV/AIDS arena.

OCPA: What are the benefits of lifting the ban on immigration and travel to the U.S. by HIV-positive individuals?

CB: For many years, since the first Bush presidency, we have not been able to hold the International AIDS Conference in the U.S. because there has been an immigration ban on HIV-positive persons coming here. This has clearly not been an effective public health strategy for a very long time. It’s not evidence-based; it’s also a restriction of human rights for HIV-positive people who have a right to visit.

The U.S. Congress repealed the law in 2008 under the [George W.] Bush administration, but it’s taken quite a while to get the policy formalized and to have the visa ban lifted. It is a real achievement of the Obama administration to have done so and what that means is that the International AIDS Conference can now come back to the U.S.

OCPA: Can you talk about PEPFAR under the Obama administration?

CB: One of the major issues that’s confronting everybody now is the rollout of antiretroviral therapy (ARV) in developing countries. President Obama has pledged to increase funding but potential major change is whether to continue that as a very disease-specific program or to try and integrate it more into the global health agenda. The President has made it clear that’s what he wants to focus on.

In the first years of PEPFAR the approach was that we’re doing an emergency plan for AIDS relief, and Obama is essentially saying that the program has to be seen not so much as an emergency plan for AIDS, but as an expansion of support for a whole range of global public health issues which would include things like maternal and child health, as well as AIDS, so there is that tension.

OCPA: What are the ramifications of such a change?

CB: It’s a very complicated question. PEPFAR separated itself very clearly from things like family planning and contraceptive services, particularly in Africa, and a lot of that was because of restrictive language around abortion services, which was such an important part of Republican support for the initial PEPFAR authorization.

The integration of HIV services into family planning is obviously the right thing to do. It’s evidence-based, and I think in the public health world everybody agrees it’s a very important step.

But there is a potential downside to this kind of approach. One of the reasons people feel that PEPFAR is as effective as it was in getting people in treatment was precisely because it was a well-resourced, targeted effort. When you start to talk about health care system-strengthening much more broadly, you run the risk of diluting the program and trying to integrate it into a very weak health care system. The potential is that you don’t necessarily strengthen the health care system you want to strengthen, and you weaken the HIV program.

OCPA:  From your perspective, what new statistics are especially important in the just-released UNAIDS 2009 AIDS Epidemic Update?

CB: I think one thing that’s very important is the number of new infections. It’s estimated at 2.7 million. It really speaks to the challenges we face in terms of prevention. Roughly for every person we put on treatment another 2 or so are becoming HIV infected. We’re still behind the curve in terms of ramping up universal access to care.

I think the very good news from that report is the tremendous increase in the number of people on ARVs. I think it’s over 4 million. So 2008 was a very good year in terms of expanding access to lifesaving ARV therapy, and a lot of that was PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

OCPA: What can you tell us about the troubling trend of increases in HIV cases in MSM populations?

CB: When we talk about new infections, one of the trends to emerge is a resurgence of  HIV infection rates among MSM in developed countries, the U.S., the U.K., Canada, Australia and so forth. In addition, we’re seeing the emergence of epidemics among MSM in  low- and middle-income countries in Southeast Asia,  Latin America, the Caribbean, Africa, Eastern Europe and Central Asia. These epidemics are very challenging to deal with because in many of these settings MSM are hidden, highly stigmatized and discriminated against in health care. In addition, in more than 80 member states in UN family, these behaviors are still criminalized, so we’re dealing with legal and human rights situations.

Here we are in 2009 and we are dealing again with HIV among gay and bisexual men, but now mostly in developing countries. We’re faced with enormous challenges in terms of providing prevention, treatment and care. There has to be international donor support, including through PEPFAR, for prevention and care services for MSM. That part of the picture is quite good. U.S. support has been strong and USAID has been a leader on the issue.

The biggest problem has been at the country level where ministers of health and governments in general are very reluctant to expend resources on this discriminated-against minority. In these cases, we’re been trying to strengthen grassroots organizations and human rights groups to really advocate for services and to partner with governments to push for decriminalization of same sex behaviors between consenting adults as an HIV prevention strategy. India just lifted its sodomy laws in a court case pushed by national AIDS control organizations. Nepal has just decriminalized, so there is some real movement. In Latin America  legal reforms are further along.

Where we see continuing challenges are in Africa, the Middle East and Central Asia. Right now Uganda is debating a law that would punish homosexuality with life imprisonment and aggravated homosexuality with the death penalty. That is a cause for real concern. And of course, Uganda has been a leader in AIDS prevention and treatment, so this is a real political struggle unfolding right now. 

OCPA: What’s behind the resurgence of high rates of HIV among MSM in the U.S.?

CB: There’s evidence of a return to high rates of infection, but I think it is extremely striking that there are really marked disparities in HIV rates in MSM by race and ethnicity. The highest rates are among African American men, then Hispanics, then non-Hispanic whites. And in Baltimore that disparity is really extreme with some of the highest rates of infection in the country for African American MSM. (According to a recent JHSPH study, in 2008 the HIV prevalance in Baltimore for minority MSM was 43.3 percent compared to 18.3 percent for white MSM.)

If you look at it at the level of the individual, you see that African American men are at somewhat less risk than white men. So individual  behaviors do not alone explain the disparities. We think more important is network- and social-level differences, and the fact that these men have such limited access to health care, higher rates of other STDs, and are much less likely to have HIV testing and to know their status than white men. And this is now such a more advanced epidemic that if individual-level risks are quite modest overall, the risk of acquisition is high. That’s the way HIV operates in networks.

OCPA: What is the status on millennium development goals with respect to HIV/AIDS?

CB: We’re not going to get there, particularly in terms of universal access to treatment in low- and middle- income countries. And if you look at G-8 commitment of 4 years ago, promises were made but the only 2 countries meeting the funding targets are the U.S. and the U.K. Other donors have really fallen very short, and none of them are close to 50 percent funding support for the commitments they made.

What it means is that the majority of people in developing countries who need ARV are not getting it. The Global Fund for AIDS, Tuberculosis and Malaria, which is a major international donor, is underfunded and is not going to be able to meet the next funding round, and we’re very concerned that there is going to be  insufficient funding to continue expanding of access to treatment and care. Many millions of people in the poorest countries and the hardest-hit regions are going to get sick and die of untreated HIV/AIDS.