21st International AIDS Conference, Durban, July 2016
Sr Alison Munro, OP
Hundreds of journalists present at the 21st International AIDS Conference ensured that the world was kept informed of the developments in scientific research into new drugs and vaccine trials, and of gains made in programmes reducing mother to child transmission of HIV, and of concerns around the adolescent epidemic now being experienced in sub-Saharan Africa.
There were sessions on the need to scale up prevention efforts alongside doubling the numbers of people on treatment, on the dangers of complacency, on TB co-infections and the co-morbidities of non-communicable diseases such as hypertension, cholesterol and diabetes, and certain cancers. The conference looked at why girls in particular are vulnerable to HIV, at how stigma and discrimination is an obstacle to effective prevention and treatment, and at difficulties in treating children. Common themes were the UNAIDS 90 90 90 strategy, where the money will come from to scale up programmes, human rights issues, and providing services to so-called hard-to-reach populations. There were marches and demonstrations led by activists, activities in the Global Village organised by various Non -Governmental Organisations and community organisations, and promotions of drugs and medical supplies by the major pharmaceutical companies.
South Africa was a pariah in 2000 when the International AIDS Conference was first held here; it is now a leader in the response to AIDS on various fronts.
A session on the role of faith communities highlighted some of the difficulties such organizations face in their particular responses to AIDS, as well as at how the faith community response is viewed by others. It was followed by a well-attended inter-faith service at Emmanuel Cathedral, aptly chosen as a venue given the late Archbishop Hurley’s commitment to human rights and to the AIDS agenda. There is a recognition that in the faith community as a whole services are often poorly documented and researched , that faith leaders and community workers need to be more knowledgeable regarding HIV, that the use of sacred texts , the understanding of gender laws and of the concerns of people of different sexual orientations can be problematic. We need gender justice, and we need to break down stigma. UNAIDS and PEPFAR are looking to faith communities to help deliver services to reach the 90 90 90 goals. Faith based organisations provide most of the health care services in some countries. But the world of faith is highly complicated, not homogeneous. Communities of faith need better connections with health care systems. Anglican Archbishop Makgoba suggested that “HIV has exposed gaps in our teaching, and we face a challenge to blend theology and practical implications, a theology of compassion blended with human rights. HIV has challenged the church to break its heart.” Faith leaders and representatives of faith communities are called to particular action in reducing stigma and discrimination, increasing access to health services, defending human rights and ensuring treatment for children.
According to UNAIDS statistics there were 2, 1 million new infections in 2015, bringing to 34 million the number of people infected with HIV and living with AIDS globally. Of these only 17 million are on anti-retroviral treatment, and the challenge is to get another 17 million people on treatment. Daily 4000 people die from TB, a common co-infection with HIV, often not diagnosed and not treated early enough. Men, so-called key populations (which include commercial sex workers, gay people, prisoners and drug users), and young people are missing at every level along the continuum of care and treatment. There are new challenges around HIV in migrant populations. And while between 2000 (when South Africa first hosted an International AIDS Conference) and 2016 there were successes regarding treatment, and in reduction in rates of mother to child transmission, “the face of the epidemic is becoming younger” and there is still “a long way to go to eliminate HIV infections”. (Luis Loures, UNAIDS).
In South Africa there are 7 million people living with HIV. Of these 4 million are women aged 15 and over. Prevalence among adults 14-49 is at 19, 2 %. . The number of children under 14 and living with HIV is less than 250 000. The percentage of orphaned children under the age of 17 is 2,1 % (cf UNAIDS). We need vaccines, the single most effective tool to prevent HIV transmission, while recognising that vaccine efficacy decreases over time, influenced by “distracting” antibodies. Vaccine trials are “open for business” with a new trial beginning in several countries, including South Africa, later this year. Some vaccines have failed and some trials have regrettably had to be stopped.
South Africa in partnership with UNICEF is “embarking on the last mile” in the quest to eliminate the transmission of HIV to infants according to Dr Yogan Pillay of the Department of Health. South Africa’s Prevention of Mother to Child Transmission programme has had great successes leading to a great decline in the transmission rate, now at 1,1% at birth. There are 800 000 mothers in support groups on the Mom Connect Programme. Exclusive breast feeding as a means of protecting infants, and adherence on treatment, are being promoted and stigma being addressed. And at the same time children under 15, undiagnosed and untreated, are falling through the cracks.
AIDS is the leading cause of death among adolescents. While today we experience the prevention of mother to child transmission programme gains of the past years, we also experience an HIV cascade among adolescents. Why girls are so vulnerable to HIV infection has been shown to be associated with bacteria in the genital tract which facilitate inflammation and genital tract infection. In Southern Africa men in their 30s are exposing young girls to HIV, the same men themselves infected by women in their thirties. Testing and treatment needs to be scaled up to break the cycle of HIV, and medical male circumcision rolled out to men by the age of 25. Education and the changing of community norms are key. There were passionate pleas for young people and by young people that they not be left out. They want recognition as agents of change and as partners in the fight against AIDS. There were calls for stigma and discrimination to be addressed, for infections in young people to decrease, for more adolescents to go on treatment, for issues of sexuality to be talked about, for support around adherence. Difficulties around treatment because of stigma are real, and drug resistance among adolescents is set to become a major problem.
Aging of people on anti-retroviral treatment and the associated non communicable diseases are also being studies in different countries. People on ARV treatment are living longer, but there are co-morbidities, with cardio-vascular disease seen as a leading cause of death. The need for good nutrition, and exercise, for reducing drug intake, alcohol consumption and obesity, is as important in people living with AIDS as it is in the general population.
A new treatment paradigm is needed. Because it is not easy for someone to take medication daily over the course of a lifetime it is recognised that long acting drugs would help ease the pill burden that many patients struggle with. There are viral reservoirs in the body which never forgets its exposure to HIV. AIDS rebounds within two to three weeks when treatment is stopped no matter how long one has been on treatment. Ideally an infected infant should be started on treatment within 48 hours. HIV latency is a major barrier to treatment in children as is the availability of suitable drugs for children. TB is a leading cause of death among people with AIDS and there is need to start TBHIV treatment quickly. While anti-retroviral treatment prevents TB, patients should be given drugs for both AIDS and TB to maximise prevention.
There was a number of presentations on the funding needed globally, $ 26 billion a year to end AIDS by 2030 according to some estimates , and alongside that the stark reality of the funding gaps. 73% of the world’s poor live in middle income countries. There were calls for the re- politicization of the AIDS agenda since while we know the solutions (prevention, treatment, adherence, vaccines) governments are aligned to private sector interests; services are privatised and denied to 90% of the people. The next four years, it was said, are critical if AIDS is to end by 2030, and we are not to revert to where we were in 2000 when the benefits of treatment arrested the numbers of deaths amongst people with AIDS.
And at the same time governments must deliver on human rights and gender equality and do away with laws that criminalise AIDS. “We need enraged activists,” said Justice Edwin Cameron, and “we have to test, test, test – the gateway to knowledge and treatment.”