December 3, 2012 Liz Borkowski, MPH 0Comment

December 1 was World AIDS Day, and this year’s theme is “Working Together for an AIDS-Free Generation.” In the 2011 United Nations Political Declaration on HIV and AIDS, countries set ambitious goals to reach by 2015:

  1. Reduce sexual transmission by 50%.
  2. Reduce HIV transmission among people who inject drugs by 50%.
  3. Eliminate new infections among children and substantially reduce the number of mothers dying from AIDS-related causes.
  4. Provide antiretroviral therapy to 15 million people.
  5. Reduce the number of people living with HIV who die from tuberculosis by 50%.
  6. Close the global AIDS resource gap and reach annual global investment of US$22 billion to US$ 24 billion in low- and middle-income countries.
  7. Eliminate gender inequalities and gender-based abuse and violence and increase the capacity of women and girls to protect themselves from HIV.
  8. Eliminate stigma and discrimination against people living with and affected by HIV by promoting laws and policies that ensure the full realization of all human rights and fundamental freedoms.
  9. Eliminate restrictions for people living with HIV on entry, stay and residence.
  10. Eliminate parallel systems for HIV-related services to strengthen the integration of the AIDS response in global health and development efforts.

This year, 186 coutnries submitted reports on their progress, and the UNAIDS Report on the Global AIDS Epidemic summarizes the situation:

Globally, 34.0 million [31.4 million–35.9 million] people were living with HIV at the end of 2011. An estimated 0.8% of adults aged 15-49 years worldwide are living with HIV, although the burden of the epidemic continues to vary considerably between countries and regions.

Sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living with HIV and accounting for 69% of the people living with HIV worldwide.

… Worldwide, the number of people newly infected continues to fall: the number of people (adults and children) acquiring HIV infection in 2011 (2.5 million [2.2 million–2.8 million]) was 20% lower than in 2001. Here, too, variation is apparent. The sharpest declines in the numbers of people acquiring HIV infection since 2001 have occurred in the Caribbean (42%) and sub-Saharan Africa (25%).

…The number of people dying from AIDS-related causes began to decline in the mid-2000s because of scaled-up antiretroviral therapy and the steady decline in HIV incidence since the peak in 1997. In 2011, this decline continued, with evidence that the drop in the number of people dying from AIDS-related causes is accelerating in several countries.

In 2011, 1.7 million [1.5 million–1.9 million] people died from AIDS-related causes worldwide. This represents a 24% decline in AIDS-related mortality compared with 2005 (when 2.3 million [2.1 million–2.6 million] deaths occurred). The number of people dying from AIDS-related causes in sub-Saharan Africa declined by 32% from 2005 to 2011, although the region still accounted for 70% of all the people dying from AIDS in 2011.

In The Atlantic, Treatment Action Group founder Mark Harrington describes a bold and ambitious Blueprint for an AIDS-Free Generation from the Obama administration. The President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria is supporting antiretroviral therapy of millions of people worldwide, contributing to global achievements in fighting the disease. Harrington contrasts this progress to what’s happening in the US:

Here at home, however, the epidemic is at a stalemate. New HIV infection rates have hovered around 50,000 per years for two decades — long before the introduction of effective HIV treatment. And the Obama administration is still committed to an under-resourced National HIV/AIDS Strategy. Not only is the U.S. plan not on track to achieve its goals, but they are themselves far less ambitious than what has already been achieved in the past decade in some of the world’s poorest countries, such as Cambodia, Ethiopia, or Zambia.

At a White House briefing which followed Clinton’s festive Blueprint launch, a diverse group of administration and community speakers discussed the domestic epidemic, but there were no new announcements save for Health and Human Services Secretary Kathleen Sebelius’ relatively anodyne tribute to the promise of the Affordable Care Act and its potential to help push forward the U.S. strategy … Because the Supreme Court decision upholding the ACA turned Medicaid expansion from a mandate into a state option, the state-by-state struggle for equitable HIV treatment access will continue.

At the White House all speakers — Valerie Jarrett, Secretary Sebilius, PEPFAR’s Eric Goosby, and NIAID AIDS supremo Tony Fauci — expressed obvious relief that the election was over and that ACA implementation could proceed. Agreeing but broadening the point, a diverse and motivated group of community representatives spoke for young black women, young black gay men, Latinos, researchers, and providers. They cautioned that ACA implementation would not cover the needed housing, mental health, and other essential services required to deliver high quality HIV services.

It was good to be among a group of people committed to ending AIDS. But no one from the administration mentioned drug users. The ban on federal funding of needle exchange continues. No one mentioned the urgent upcoming need to reauthorize PEPFAR or the Ryan White Care Act, which will provide vital services, especially in states which decline to provide full HIV coverage under the ACA, and to provide community support, housing, and other services unlikely to be covered by insurance exchanges.

In the United States, only 25 percent of the 1.2 million HIV positive people are on effective ART with an undetectable viral load. Only 33 percent are retained in care. Only 82 percent even know their HIV status — a number that’s much lower among young people with the virus.

Funding for these and other public-health programs depends on Congress. One positive step President Obama has been able to take on his own is ending the 25-year ban on HIV-positive non-residents entering the US — and action that addressed UN Declaration goal #9 and that allowed the International AIDS Conference to be held in the US earlier this year. (via SFist) has posted “The Photo that Changed the Face of AIDS“: Therese Frare’s photo of AIDS victim David Kirby on his deathbed in 1990, surrounded by his family. It ran in LIFE magazine in November 1990, and “quickly became the one photograph most powerfully identified with the HIV/AIDS epidemic.” Editor Ben Cosgrove explains:

While the world has become more familiar with HIV and AIDS in the intervening years, Frare’s photograph went a long way toward dispelling some of the fear and willful ignorance that had accompanied any mention of the disease. Barb Cordle, the volunteer director at [AIDS hospice] Pater Noster when David Kirby was there, once said that Frare’s photo of David “has done more to soften people’s hearts on the AIDS issue than any other I have ever seen. You can’t look at that picture and hate a person with AIDS. You just can’t.”

It seems like a very long time ago that AIDS victims were shunned and despised, and that touching photographs like this one were an essential antidote to fear and hatred. We’ve made a lot of progress, but around the world many HIV-positive people are still stigmatized and victimized, whether overtly or subtly. In many cases, the battle is no longer against prejudice, but against complacency and budget cuts (for examples, see Kim’s post on cuts to HIV prevention and screening services). But families losing loved ones to AIDS still grieve just as deeply as David Kirby’s family did, and will keep grieving until we achieve the goal of an AIDS-free generation.

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