Reprinted from Harvard Health and Human Rights Journal.
For decades, the International AIDS Conference has successfully convened a massive biannual meeting, bringing together a diverse community of scientists, researchers, activists and officials, as well as a smattering of celebrities. At a turning point with a battered global strategy and the devastation caused by a second global pandemic, COVID-19, the global AIDS movement has never been in more urgent need of such frank and diverse conversations. Sadly, the conference which launched online this week has never been more divided: while scientists and UN officials gather in the official meeting, AIDS 2020 Virtual, community activists have broken away to hold a parallel conference, HIV 2020.
Normally, the sober business of the International AIDS Conference is frequently interrupted by raucous—if peaceful—human rights protests and vocal debates from the floor of the plenary, as well as lively events and parties in the civil society booths in the Global Village. This culture began to develop in 1989 when, feeling excluded, early AIDS activist protesters stormed the International AIDS Conference meeting, took the stage, and demanded access to scientific information. The following year, in San Francisco, protesters shouting “Shame! Shame!” went further, drowning out the US Secretary of Health and Human Services, prompting some to wonder whether ACT Up had finally “gone too far”. But instead, this culture of protest became institutionalized, so routine that plenary speakers were given tips on how to manage protests gracefully and get on with their talks. The conference began offering scholarships to enable civil society participation. While there were sometimes tensions, the scientists, officials, pharma reps, and activists somehow coexisted—albeit increasingly preaching to their own sub-groups of loyal followers. As the conference grew into a behemoth of tens of thousands, the Global Village seemed to get farther away from the main plenary hall, both literally and figuratively.
2020 is obviously far from a normal year, thanks to the COVID-19 pandemic. The Global Fund recently released a report that suggested that its impacts could see deaths from HIV, TB, and malaria as much as double, wiping out nearly two decades of progress in the worst-hit regions.
But even before COVID-19, this year was already a moment of reckoning for the global AIDS response. As UNAIDS warned last year, the world was already off track to meet the 2020 targets towards the end of AIDS, and COVID-19 is having a devastating impact, especially for the so-called “key populations”: sex workers, men who have sex with men, transgender people, people who use drugs, and prisoners. According to the new update by UNAIDS, launched this week, 62% of new global HIV infections last year were among key populations and their sexual partners. This percentage is increasing rapidly: in 2018, it was 54%, and in 2017, 40%. The world is clearly failing to prevent HIV infections among key populations.
This year-on-year increase points to what I’ve argued elsewhere is a weakness in UNAIDS’ Fast Track strategy which aims to achieve the “end of AIDS by 2030”: it prioritized global scale-up of treatment and commoditized the global response, leaving prevention, community mobilization, and advocacy to reform punitive laws a poorly-resourced afterthought. The premise behind Fast Track, justified by mathematical models, was that rapid global scale-up of treatment would trigger a “phase change” or “epidemic transition” and bring about an “end of AIDS”. In order to try to achieve this, aid agencies focused their investments on treatment scale-up in a few high-prevalence countries, divesting from middle-income countries where HIV is concentrated among key populations.
The result in practice is that while AIDS-related deaths did drop in some high-prevalence countries, we increasingly have a global pandemic driven by discrimination and criminalization of key populations everywhere else. Stark differences in HIV incidence and mortality across locations and populations were overlooked by focusing on a narrow set of indicators, at national scale, of progress toward the control of HIV epidemics instead of defining and monitoring a broader set of rights-based indicators that could reveal structural barriers and government actions (including laws, policies and practices) that restrict universal access to prevention, care, and treatment.
The COVID-19 pandemic has only worsened these problems with loss of employment, lockdowns and school closures that have driven more women and girls into child marriage and sex work, and increased police harassment of key populations and migrant workers driving them further underground, away from government health services. In her AIDS2020 presentation, Meg Doherty (WHO) shared modelling demonstrating that COVID-related disruptions of ART for six months could also lead to more than 500,000 AIDS-related deaths. Supply chain disruptions are further impeding access to condoms, PrEP, opioid substitution therapy (OST), and other critical services.
Under the circumstances, it’s never been more critical to have key populations and other people living with HIV front and center at the AIDS conference. Unfortunately, many are absent. They were alienated by the International AIDS Society’s decision to convene the meeting in the United States for the second time in eight years. Sex workers and drug users cannot gain entry to the United States, and there are now also travel bans against several countries. Further rights abuses against people of color, migrants, and gender diverse people raised serious concerns about their ability to meaningfully participate or even get US visas. So instead, those networks have organized a breakaway meeting at the same time, HIV 2020, to “reclaim the response and amplify the voices of people living with HIV and key populations”.
The first few days of AIDS 2020 Virtual have been weaker as a result of this split, with a strange silence around many of the presentations. The virtual platform designed for the meeting does not permit any questions from the floor for most plenary and satellite sessions. A chat box functioned poorly the first day, then quietly disappeared, shutting down the usual questions, let alone challenges to authority. Even tweets critical of the conference using the official hashtag #AIDS2020Virtual quietly melted into silence.
Meanwhile, a few clicks away on Zoom and Facebook, the HIV 2020 meeting proceeds with a lively celebration and informality, with speakers presenting from the front seats of their cars, speaking multiple languages, performing music, swapping virtual hugs in the chat boxes. They have issued a list of recommendations to the International AIDS Society, including disqualification of countries with poor human rights records for key populations from hosting the International AIDS Conference in the future (though that may leave a very short list of countries as options). In the face of crumbling health systems, lack of food security, and a growing sense of stark inequality and crisis, community-based networks have been a lifeline in many parts of the world. They provide emotional support, financial aid, share life-saving health information, and inspiration to those otherwise marginalized and abandoned. Let’s hope they can reinvigorate the global HIV response as well.
UNAIDS. 2018. Miles to Go: Closing gaps, breaking barriers, righting injustices. Geneva, CH. https://www.unaids.org/en/20180718_GR2018.
UNAIDS. 2019. Communities at the Centre: Defending rights, breaking barriers, reaching people with HIV services. Geneva, CH. https://www.unaids.org/en/20190716_GR2019_communities.
UNAIDS. 2020. Seizing the Moment: Tackling entrenched inequalities to end epidemics. Geneva, CH. https://aids2020.unaids.org/report/.