July 21, 2014

HIV: Science and stigma

This article originally appeared in The Lancet here. Reposted with permission.

Today’s issue of The Lancet is dedicated to HIV to coincide with the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia (July 20—25, 2014). This year, the biennial meeting—the biggest global gathering of HIV scientists, health-care workers, and activists—has made stigma and discrimination one of its main concerns. Such an emphasis is sadly as necessary today as it was in the very early days of the disease. Worldwide, discriminatory environments that fuel HIV epidemics have remained entrenched in some countries and resurged in others. Russia, for example, has continued its anti-harm reduction policies for people who inject drugs and extended them to Crimea. Meanwhile, Uganda and Nigeria have taken backward steps in their response to HIV, introducing hugely discriminatory anti-gay legislation. True to its history of activism as well as of science, AIDS 2014 has produced the Melbourne Declaration under the banner “no one left behind”, which affirms “that non-discrimination is fundamental to an evidence-based, rights-based and gender transformative response to HIV and effective public health programmes”.

There are five marginalised populations, in particular, who have been left behind in the HIV response in many countries. These groups are disproportionally affected by HIV, have an increased risk of infection, and yet are the least likely to have access to HIV prevention, testing, and treatment services because of widespread stigma and discrimination. They are: sex workers, men who have sex with men (MSM), transgender people, people who inject drugs, and people in prison. Worldwide, one in two new HIV infections is in these populations. HIV/AIDS will never be controlled without respectful and targeted engagement with these communities.

The best approaches for their care are known. Last week, WHO released new consolidated clinical guidelines on HIV prevention, diagnosis, treatment, and care for these key populations. As well as bringing together existing guidance for these communities into one document, some recommendations are updated. For the first time, WHO is strongly recommending pre-exposure prophylaxis (PreP) as part of a package of prevention services for MSM. PreP is a remarkable scientific advance that increases the options for MSM to protect themselves from the virus but has largely only been offered in pilot projects in north America. Modelling by WHO estimates that, worldwide, 20—25% reductions in HIV incidence in MSM could be achieved through PreP, averting up to 1 million new infections over 10 years.

The guidelines go beyond HIV, providing a welcome holistic view of care, covering possible co-infections such as hepatitis and tuberculosis, sexual and reproductive health, and mental health. They also tackle stigma and discrimination. Legal and social environments play a part in making these groups marginalised, but so does the health sector. Health workers have an ethical obligation to provide optimum, confidential care to all individuals without judgment about their gender identity, sexual orientation, or life choices and behaviours. Care must always be humane and respectful, as well as being based on evidence. However, too often it is not. Training initiatives can sensitise health workers to provide better, friendlier services for marginalised groups, as they have done in parts of South Africa. Sometimes simple common sense and compassion is all that is needed in clinical settings. For example, understanding that a transgender woman might want health staff to address her by her female, social name rather than the male name that could appear on medical records, especially in public areas, is not difficult to realise.

The potentially powerful public health effect of turning the tide of discrimination and stigma against these groups is borne out by science published in today’s issue. An Article and a Public Health paper show that focusing on key populations and geographies as well as the interventions that are likely to have the largest effect in different epidemics provides a smarter return on investment and could reduce HIV from a pandemic level to low-level endemicity.

The Lancet will continue to publish the best research we receive to inform the HIV response, including for key populations. Two new initiatives will aid this ambition. On July 22, at AIDS 2014, we will launch a new Series focusing on health issues specific to sex workers. And in the coming months, we are launching a new online journal dedicated to HIV/AIDS science and health research, The Lancet HIV. These developments will, we hope, help improve care for all people at risk of, or living with, HIV, and endeavour to ensure that no one is left behind.