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21st International AIDS Conference (AIDS 2016)

Interview

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

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Is IAPAC involved in training and galvanizing providers to become advocates?

IAPAC is involved at a number of levels. First is this larger policy and advocacy microphone -- to make sure that elected officials, policymakers, clinical providers and community members understand the new parameters of the 21st century of HIV. Because without understanding that, then:

  • If people don't get tested, that's just the way it is.
  • If people present with end-stage AIDS when they're first diagnosed, well, that's just the way it is.
  • If people just have treatment failure because we haven't talked to them about adherence, or we practice in a care environment that's stigmatizing, well, that's just the way it is.
  • If people just die, that's just the way it is. Right?

No, it's not. None of that is acceptable in the 21st century. Some of that was the way it was, because of our unfortunate ignorance and the unavailability of the tools that we currently have. So, we need to recalibrate that. To a large extent, that's a lot of what I do. I correct this.

We're involved in a range of educational activities to help reset those understandings, including quite a bit of work here in Africa. We're involved in capacity-building exercises to train trainers who will go back to their cities and their countries to "spread the gospel." We're involved in 16 countries right now, where we're training hundreds of providers in the 21st century of HIV -- and for that matter, the 21st century of hepatitis B and hepatitis C [HCV] -- which we're not talking about right now, but I will say that all cases of HCV should be cured. Our inability to mobilize the political and professional and community will to achieve that will cause thousands and thousands of deaths -- much like the 3,000 or 4,000 deaths from HIV today, while we're pleasantly enjoying the company of our colleagues here in Durban.

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In a different but related activity, IAPAC is one of four core partners of the Fast-Track Cities Initiative, which is a joint project between IAPAC, UNAIDS, UN-Habitat and the City of Paris to get smaller municipalities -- that is to say, not nations but cities, and city governments, and city communities, and city health care providers -- to agree to achieving the initial goals of 90-90-90 [that by 2020 90% of people with HIV will know their status, 90% of those will be on treatment and 90% of those will achieve viral suppression] -- so that we get 73% of people in these jurisdictions on treatment and virally suppressed by the end of 2020. That's three and a half years from now. Four cities have released initial data here at AIDS 2016.

So, imagine the end of epidemic AIDS in New York: That's actually not so hard to imagine anymore. San Francisco, right? Denver. We're on our way. London, Amsterdam, and so on.

But now imagine the end of AIDS as an epidemic in Nairobi. Imagine Johannesburg. Imagine Durban. Imagine Kinshasa, Accra, Mumbai, Bangkok. Well, those cities have committed, and they're on their way, too. Imagine a Nairobi without AIDS. Now, don't imagine it; demand it.

In this process we engage not just government, not just public health; we're engaging key local medical leaders in those cities, and key community and civil society leaders in those communities, to recalibrate the understanding and the expectations and to create the demand and giving them the tools by which they can do that.

Many of the tools we already have. That is to say, we have effective antiretroviral therapies. We have very effective rapid HIV testing. But today there are many places that don't have rapid testing because the legal environment doesn't allow people to use rapid tests (rapid tests can only be administered by physicians) where there are no physicians, and so on.

We have to understand all the structural, behavioral and social barriers to delivering the things that we have. We don't need new medicines to do this. The medicines are not perfect, but they're pretty darn good, right? We need to demand that those things that we have actually get used because we can save thousands of lives today with the tools we have. Those failures to fully exploit those tools today aren't just bad for people or for patients; those are human rights violations.

That's the call to action for care providers to be activists. I'm proud to call myself a physician-activist -- maybe an activist-physician, in that order -- and an inheritor of the legacy of our departed colleagues Jonathan Mann and Joep Lange and all of the community activists who have come before me and taught me and provided the tools we have today.

In our current context, in which laws criminalizing people living with and affected by HIV still exist, what is a provider's responsibility to protect their clients regarding potential risk of criminalization? We say, "Get tested, get tested" -- but there is the chance that, once a person knows their HIV-positive status, they are vulnerable to being criminalized under these stigmatizing laws.

It's conflicted, right? If I know that I test somebody, and I actually put their lives or their wherewithal at risk, that's a problem. We as providers need to be mindful of that and of the extent that an HIV diagnosis may render that happening.

First and foremost, that means we need to be very protective of the confidentiality of the information that we are privileged to have access to -- in this case an HIV status. Being very mindful shepherds of protected, private, confidential information is very important.

Then, sometimes we have to be very careful about navigating these tricky shoals and working within patient communities to create a safe place -- to ask about safety, first and foremost. Inquire about and understand the environment. It's not as simple as saying, "What is it like in my city?" It's actually asking an individual. Because it's where they live. It's the house that they live in, metaphorically. It's the family and friends that they live among that comprise safety or non-safety.

There's also a larger judiciary, legal or criminal environment in which they live. We need to be mindful of that, as well. Sometimes that means putting clinic doors in different places, or not making "HIV" part of the name on the door, and so on. There are different solutions in different places. It depends a little bit on that.

It also means that, when possible -- as we have recently, very successfully and proudly, in the state of Colorado, where I live and practice medicine -- we work carefully and diplomatically with lawmakers to address inconsistencies in the law, where the laws are in the 20th century or -- even worse -- the 19th century, to try to modernize those laws. It was marvelous to see the efforts of Senator Pat Steadman and the Colorado Mod Squad to modernize the Colorado statutes.

We recognize where we are not perfect and try to move the dialogue forward. Rather than saying that this is just the way it is -- that death is just the way it is, that criminalization and stigma are just the way it is -- we acknowledge that we have this shortcoming. Let's see what we can do today and tomorrow to fix it.

Any final thoughts before we sign off?

Here at AIDS 2016, the Fast-Track Cities Initiative launched its first informational effort to help identify and neutralize some of these issues around the care continuum, around resources, around stigma, discrimination and criminalization. The first five of many city-specific data dashboards are now available. Those cities are Amsterdam, Netherlands; Denver, United States of America; Kyiv, Ukraine; Paris, France; and San Francisco, USA. By World AIDS Day, just a few months from now, we should have, I believe, around 25 cities.

We hope that public health officials, health providers and, most importantly, communities of people living with or affected by HIV will help report into that database about where our data are accurate and, perhaps more importantly, where they're not -- so that we can identify stigma, discrimination and criminalization; where there are medication stock-outs; where there are policies and laws that make it difficult for providers to do the job they want to do, that make it difficult for people who are living with HIV to get tested or into care; and so on.

Ending AIDS as an epidemic is going to require everybody believing that it can happen, and everybody doing a small, and sometimes a larger, part in making sure that our communities ultimately benefit from all of the tools that we have today.

This transcript has been edited for clarity.

Olivia Ford is a contributing editor for TheBody.com and TheBodyPRO.com.


Copyright © 2016 Remedy Health Media, LLC. All rights reserved.

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