Forty years ago, on June 5, 1981, the U.S. Centers for Disease Control and Prevention 's Morbidity and Mortality Weekly Report included a report of a cluster of pneumocystis pneumonia cases among gay men in Los Angeles. Rare, life-threatening conditions were also being observed outside the United States among men, women, and children, but had not yet been reported—precursors to the coming HIV/AIDS pandemic.
Since then, UNAIDS estimates that HIV/AIDS has killed 32.7 million people, with 75.7 million new HIV infections worldwide. Today, the tools to control HIV exist. Combined prevention interventions, such as pre-exposure prophylaxis (PrEP), are highly effective at reducing HIV transmission through sex, and antiretroviral therapy for those living with HIV can make the virus undetectable and untransmittable. Yet, in 2019 alone, 690,000 people died from HIV/AIDS.
Why are we so far from achieving the UN's 2030 global goal of ending AIDS? There are still unfinished issues. The success of the HIV response hinges on equality: not only equality in access to HIV prevention, care, and treatment, but also equality before the law. Yet key populations and their partners, including men who have sex with men (MSM), transgender women, sex workers and their clients, and people who inject drugs (PWID), continue to be disproportionately affected by HIV, accounting for 62% of all new HIV infections globally. Well into the 21st century, 67 UN member states still criminalize consensual same-sex conduct, and 92 continue to criminalize HIV exposure, transmission, and non-disclosure. Eighteen criminalize transgender people. Given that sex work and injecting drug use are also illegal in much of the world, it is not surprising that effective health interventions fail to reach vulnerable and marginalized people at risk of contracting HIV.
The last of our three HIV commissions, convened by the International AIDS Society and The Lancet in 2017, called for the repeal of criminalization laws, as well as accountability mechanisms to measure progress toward their repeal. Clearly, insufficient progress has been made in the last four years. Countries such as Russia, the United Arab Emirates, Ethiopia, and Chad still do not report on the number of men who have sex with men (MSM) in their countries. Donors should do more to pressure governments that discriminate against key populations, but the threat of losing the opportunity to provide any HIV services in these settings must be carefully weighed against the benefits of expanding services.
The Commission also analyzed how the overall global health landscape has changed since the start of the HIV pandemic. Universal health coverage (UHC)—the idea that everyone is entitled to a package of services for a range of illnesses and health conditions without going into debt—is an equally important UN target to be achieved by 2030. Isolated global initiatives on diseases cannot continue indefinitely. Achieving universal health coverage—truly universal coverage that addresses the needs of marginalized populations without judgment or prejudice—is essential to ending HIV.
An opportunity to accelerate greater equality and reduce discrimination arises from June 8-10, 2021, when UN Secretary-General António Guterres will convene the fifth High-Level Meeting (HLM) on the implementation of the Declaration of Commitment on HIV/AIDS , with equality as its central theme. The latest draft of the Declaration specifically calls for an end to stigma and discrimination against key populations. However, The Lancet understands that some member states are pushing to remove even the mention of MSM, sex workers, and PWID from the text of the Declaration. Such maneuvers are counterproductive and morally wrong. As was the case 40 years ago, civil society, representing key and other affected populations, has mobilized to campaign ahead of the HLM, calling for key populations to remain clearly specified in the UN Declaration.
The Lancet supports the call from civil society. It is not possible to end HIV without targeted programs tailored to key populations. Urgent concerns such as the climate crisis and its effects on migration, food insecurity, water resources, and conflict can only serve to increase vulnerability to HIV. Yet here we are again, as if no progress has been made. The HIV/AIDS pandemic cannot be controlled without recognizing and guaranteeing the human rights of all, fundamentally the right to health. If it remains difficult even to identify who is at risk of infection, HIV/AIDS will remain a public health problem for another 40 years, and many more lives will be lost.
In: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01213-7/fulltext