Alvaro Bermejo: Removing the social and structural barriers impeding the global HIV response will advance medical efforts no end

This week the world’s largest gathering of HIV experts, policy makers, activists, and people living with HIV will convene in Washington for the 19th International AIDS conference, brimful of optimism at recent biomedical advances and heralding the end of AIDS.

At the International HIV/AIDS Alliance we applaud the progress made to stem the epidemic; getting six million people worldwide access to ART including in some of the remotest corners of sub-Saharan Africa is not to be sniffed at and there is a very real belief that we can—and will—achieve universal access to treatment.

But to do so we need to go beyond the “silver bullet” approach and look at the legal and cultural barriers that lead to a failure to protect those who are most vulnerable to HIV, in particular marginalised groups like men who have sex with men, transgender people, sex workers, and people who inject drugs.

Let’s take the example of two countries that have been able to avail themselves of similar technologies and know how, yet their HIV response has evolved very differently and are now poles apart when it comes to new infection rates.

One of the first out of the starting blocks to react to and manage the epidemic, Australia is widely acknowledged to have one of the world’s most successful harm reduction and public health education programmes, and as a result has maintained a low rate of HIV infection among drug users and in the general population. In the US, where the International AIDS conference is taking place, a ban on needle exchange funding has made it difficult for injecting drug users to protect themselves and the epidemic has soared.

It’s no coincidence that the areas with the highest infection rates in America are those that have the most aggressive drug policies and effectively criminalise drug users. A recent report by the Global Commission on Drug Policy found that when access to needles and methadone treatment is expanded—and when drug users do not have to fear arrest for possession of needles—HIV infection rates fall.

Eliminating legal barriers to access and enshrining human rights within the HIV response is a crucial step in encouraging the uptake of treatment and prevention services. Another is to address the structural barriers that are responsible for people who test positive not accessing care and/or preventing adherence to treatment. The Alliance Ukraine and partners struggle daily to ensure consistent access to treatment for injecting drug users when there is no comprehensive package of care available.  Yes of course we need “the medical bit,” the opioid substitution therapy, but that has to be matched with other forms of support such as information and education outreach for health workers and the police, legal aid, and psychosocial programmes. Try telling that to the Ukrainian government who is on the verge of shutting down its leading AIDS clinic in a country that sees 25,000 new infections a year.

In developing countries, we have seen that the most successful public health approaches have been those which have involved communities in both the decision making processes and in the service delivery. But the role of the community in contributing to health systems is often not sufficiently recognised in government, donor, and UN definitions of “health systems strengthening.” We also need to recognize the importance of addressing health service stigma and discrimination—a key obstacle to access—in ensuring well-functioning health services and achieving universal access. If we can remove all of these barriers then, and only then, will we have a very real chance of bringing about an end to AIDS.

Alvaro Bermejo is Executive Director of the International HIV/AIDS Alliance: He is a Global Fund board member, as the Developed Country NGO representative.