If We Act to Remove Structural, Behavioral and Social Barriers, We Can End the HIV Epidemic With the Medicines We Already Have
A Conversation With Benjamin Young, M.D., Ph.D.
August 22, 2016
To optimize the care continuum for people living with HIV, we must optimize the environments where HIV care is practiced. That means repealing laws that criminalize and stigmatize people living with HIV and members of key populations vulnerable to acquiring HIV. For the International Association of Providers of AIDS Care (IAPAC), these are the first steps in facilitating wider access to life-saving HIV treatment, care and prevention services.
"Doctors aren't just care providers," says IAPAC chief medical officer Benjamin Young, M.D., Ph.D.; "we're the guardians of the health, and health as a human right, of the people we serve and represent." Following Beyond Blame, a pre-conference to AIDS 2016 in Durban, South Africa, bringing together HIV decriminalization advocates from around the globe, I spoke with Young about the need to change perceptions of harm from HIV exposure, the role of providers as activists and his work updating the global knowledge base to reflect the 21st-century realities of HIV.
How has IAPAC, which represents the global community of HIV care providers, been involved in anti-criminalization work?
IAPAC has been very firmly grounded in the idea of health, HIV and human rights since its inception 30 years ago. At the end of last year we published the world's first evidence-based literature review and recommendations for improving the care continuum for people living with HIV. It's not coincidental that out of 36 recommendations the first three directly address the issues of stigma, discrimination, criminalization and the legal environment in which we practice medicine, and practice the care of people living with HIV.
They also address the role that stigma, discrimination and criminalization play in the lives of people that are represented in key populations, who may or may not be living with HIV. This is germane in the context of HIV prevention and PrEP [pre-exposure prophylaxis] because, if we marginalize those populations, we hobble our abilities to effectively do things such as HIV testing and offering preventive services.
The recommendations acknowledge the legal environment, and therefore the human rights environment, around migrants and their rights as human beings to be able to move from one place to another -- which are embodied in many, many UN documents.
This is an association that has been deeply grounded in the notion of health as a human right, that marginalized populations have equal human rights, and that that extends to health and access to HIV testing, care and treatment.
I'm a proud HIV care provider. I'm an HIV doctor. And it's often orthodox to think that doctors shouldn't be activists. But this construct that I've laid out actually says, if anything, doctors aren't just care providers; we're the guardians of the health, and health as a human right, of the people we serve and represent: our patients and the patient communities. We don't often practice that but, in fact, we are human rights activists. Whether we accept it overtly or not, I think we have the opportunity to be.
Talk more about the connections between optimizing the HIV care continuum and addressing HIV-related stigma and criminalization.
In understanding the care continuum, we understand that a lot of people have difficulty navigating it. That means that we have to be doing more than we currently are to facilitate access to the life-saving therapies that we now have.
To the extent that IAPAC is an umbrella organization, I represent global health providers: physicians, nurses, nurse practitioners, physician assistants, pharmacists, case managers, lay health workers and village health workers; and I would add to that the receptionists and the janitors and the person that opens the door at the clinic. I would even extend this to elected officials, in this context. Anyone involved in care delivery, in facilities of care is, to some extent, part of the constituency that I try to represent. I try to articulate and advocate for their needs, but also to steer their activities in a way that is productive to executing the nonjudgmental, human rights-based care of people living with HIV or affected by HIV.
Central to my participation in the Beyond Blame HIV criminalization pre-conference was to inject into the more orthodox view of human rights as kind of an aspirational, humanistic thing, the message that there's now quantitative science around this, as well.
There are two notions in the context of criminalization of HIV and HIV exposures that I try to simplify to a few statements.
One is that the 21st century of HIV is different than the 20th century of HIV. We need to update our knowledge base. To do that requires understanding that HIV treatment works. Hard stop.
What does it do? HIV treatment prevents death. It prevents tuberculosis. It prevents cancer. It prevents progression to AIDS. It prevents serious infections. It prevents opportunistic infections. Hard stop.
It does so in people who are sick, who have symptoms, who have high CD4 counts, in a way that's comparable to the way it works in people who do not have symptoms but are at unknown or unperceived risk of serious things, including death. Hard stop.
We also know that HIV therapies prevent new infections to babies, to sexual partners and so on. These things are categorically different than they were just a few years ago.
We also know from an HIV infection exposure perspective that HIV exposure sexually -- or even in drug use -- is not "high risk." The highest risk is in the neighborhood of less than 1%. It's not a done deal. That's even before we start talking about treatment. We actually know that now, in ways that are very robust and quantitative.
The science around this will continue to become more robust. But I argue strongly that it's sufficiently robust to say that sexual exposure, especially in the context of being on treatment, is essentially zero risk. We know from data that have been presented in the last year or two, including publications this week.
Second, when we look at it from the perspective of harm and the criminal law environment, it means that if someone acquires HIV, then the harm done in the 21st century is not what it used to be.
We used to say, "HIV infection is a death sentence"; it rolls off the tongue so easily.
Exactly; it's a sound bite.
HIV infection is not a death sentence. The harm done by HIV infection is present -- meaning that, yeah, it's better not to [acquire HIV], by all means -- but it is no longer a death sentence. In fact, people living with HIV who have access to testing, care and treatment and are willing to take treatment have, for all intents and purposes, a normal life expectancy and a near-normal, if not normal, quality of life.
Those scientific statements need to be wrapped around the humanistic view of human rights and stigma, and human rights and migration, and human rights and health. That's very different than the way we did before. It's a new junction of science and the humanities that really makes the argument for understanding the impact of undue stigma, discrimination and criminalization on the prosecutorial, judicial environment, which we must address if we are going to deliver on the promise of making death from AIDS a rare event, making new infections from HIV a very rare event and making long-term, healthy, asymptomatic survival with HIV commonplace among those 37 million people today who are living with the virus.
This article was provided by TheBodyPRO. It is a part of the publication The 21st International AIDS Conference (AIDS 2016).
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