From Pragmatic to Profound, It's All Powerful: Snapshots as AIDS 2014 Begins to Close

The 20th Conference on AIDS

As the clock moved forward on the final full day of the conference, fervent and final arguments were made, souvenirs were tucked away for the return trip, and the flow of posts with the #AIDS2014 slowed to a trickle.

Even as the conference uploaded a greater number of actual session webcasts to the Internet -- partially rectifying a gripe voiced by at least a few journalists and advocates seeking to follow the proceedings from afar -- the conference itself began to end.

The closing sessions of the conference still lie ahead, but they tend to be notoriously ill-attended as people make their way back to the vital work and the cherished families and communities that await them at home.

At the closing, hard-working "rapporteurs," the diligent summarizers and synthesizers of the conference set, will deliver summaries of each of the five conference tracks.

Mark S. King took to the streets with fellow activists, serving as a rapporteur of sorts in his most recent video installment as he interviewed "awesome advocates." Here's just a few more examples of the important words and ideas we've heard, seen and read in recent hours:

Words Well Said

JoAnne Keatley, in center without sign. (Photo: International AIDS Society/Elisabetta Fino)
JoAnne Keatley, in center without sign. (Photo: International AIDS Society/Elisabetta Fino)

JoAnne Keatley: "We are transgender women and men, and we have our own community, and our own ability to respond to the issues that are facing us."

The Star Observer of Australia captured the voice of JoAnne Keatley calling for more recognition of transgender leaders:

At the opening plenary session on the fifth day of the International AIDS Conference in Melbourne, trans woman and researcher JoAnne Keatley said trans people should be representing themselves. "Consider inviting a trans HIV profession to represent our own response to these important updates and issues," she said to the packed audience, who responded with applause. "I think that many of the people on the panel recognize that trans women and men are not men who have sex with men, we are transgender women and men, and we have our own community, and our own ability to respond to the issues that are facing us."

Keatley, who runs the Center of Excellence for Transgender Health in the U.S., told the Star Observer she was concerned about the blanket use of the term "transgender" by WHO (World Health Organization) and others, even though trans women are disproportionately affected by HIV.

She explained that a draft of the recent WHO guidelines for HIV prevention, diagnosis, treatment and care for key populations "kept speaking about transgender people as if we didn't have male or female identities ... So my argument was that, to say that transgender people were a key population when really the incidence resided among trans women, the fact that we don't call out the fact that HIV is having this profound impact on transgender women, and that we reduce it to transgender women is just another way of erasing our gender. It dehumanizes us and in effect it erases our gender identity."

Paul Semugoma: "Today I was very powerfully reminded that people still die of AIDS."

Dr. Paul Semugoma, a physician from Uganda who has been a leader in the fight for HIV prevention, care, and treatment among gay men and other men who have sex with men (MSM) in Africa, received the 2014 Elizabeth Taylor human rights award from amfAR, just hours after the loss of a family member to AIDS:

Today I was very powerfully reminded that people still die of AIDS when they drop through the cracks. My sister-in-law, in the last few hours, passed away from AIDS. It's 2014, it's 30 years since the epidemic started, we have the drugs, we have quite a lot of things. But we have structural issues that stand in the way. I'm a gay man, I'm an African, I'm an Ugandan, each of these things can stand in the way of one's access to health ... For a person like me, quite a lot of things stand against you, in work, in advocacy, in just plain saying I also want to live the happy life that other people do.

U.S. Ambassador, on HIV criminalization: "Time to remedy our mistakes."

Introducing the panel "Criminalization of Key Populations: How to Respond to HIV," the U.S. Ambassador to Australia delivered a hard-hitting statement that condemned a range of criminalization measures, including those in his home nation:

We know that criminalization is bad health policy. It is bad public policy. It doesn't work to prevent the spread of disease -- in fact, it does the opposite.

While the United States still has laws that criminalize HIV status -- as one of today's panelists, Nick Rhoades, can tell you from painful experience -- we are working to be better, to do better, and to remedy our mistakes. ...

Criminalization laws undermine public health approaches to fighting the disease and limiting its spread. These laws do not reflect current scientific knowledge about HIV. They undermine our ability to get people into screening and treatment programs. More fundamentally, these laws wrongly stigmatize and marginalize those who are living with HIV and AIDS. We believe that one of the most productive public policy actions that we can take is removing outdated HIV criminalization laws from the books.

Indonesian Health Minister, on drug criminalization: "Do we want to kill them? Or do we want to save them?"

Meanwhile, at the Melbourne town hall, the popular Q&A panel discussion featured a panel of notables, including Indonesian Health Minister Nafsiah Mboi, currently also chair of The Global Fund to Fight AIDS, Tuberculosis and Malaria.

As reported by Australia's The New Daily, Mboi arguably stole the show, as she answered a question about facing religious and political opposition to the distribution of condoms and sterile syringes:

"When the President appointed me Secretary of the National AIDS Commission, the first thing I did was indeed invite all of them who were against [fighting AIDS], as well as the ones who were for it.

"But we knew this was a very difficult question, because the law criminalized drug use, so there was a big resistance. So I said okay, let's stop for a moment. We have 330,000 young people who are injecting drugs. Previously in some districts it's already 67 per cent HIV positive, Hep C, as well as syphilis, etc. What do we want to do? Do we want to kill them? Or do we want to save them? The easiest way is to kill them.

"Because if you don't do anything, we keep on fighting among us, they will die. They will die of overdose, they will die of AIDS, they will die of Hep C. And if they get imprisoned they will die even faster. Because they get beaten up.

"But we are the government. Where were we when our kids became victims of the drug pushers? And there was total silence. Then a policeman came and said, 'You're right. We have to save them if we can. Because my son is a drug user. And I don't know what to do.'

"And that, my friends, changed the whole atmosphere."

View her testimony on YouTube.

Risk Compensation Continues to Be Non-Revealed

The big news from the iPrEx Open-Label Extension (OLE) was that even those who took as few as four doses of tenofovir/emtricitabine (Truvada) a week had complete protection from HIV. But as reported by TheBodyPRO.com's Warren Tong, the study also revealed no evidence of risk compensation, with participants reporting safer sexual practices and a similar syphilis incidence (a marker of sexual risk behavior) between both groups in the study.

The ever intrepid Gus Cairns of aidsmap.com was hot on the trail of compensatory risk analyses at AIDS 2014.

He notes that three different methods of statistical analysis detected no rise in risk among men who underwent circumcision in Zambia, a nation on the path to circumcising 80% of eligible men by next year. And in a presentation titled "Is use of antiretroviral treatment (ART) associated with decreased condom use?" the answer was also a very clear "nope!"

Cairns explains that the latter presentation's meta-analysis of every study of new ART users that tracked sexual behavior found "not a single instance" of risk compensation. Actually, he notes, "in 15 studies that met inclusion criteria for the analysis, starting HIV treatment was consistently associated with a fall in sexual risk behavior, as measured by increased condom use. This association held true for both genders; for committed relationships and casual sex; and for partners both known, and not known, to be HIV negative." The studies evaluated condom use in heterosexual people in sub-Saharan Africa.

Adoption of Russian Policies Against Opiate Substitution Has Had Deadly Consequences in Ukrainian Conflict

Back in April, Norman Fowler warned in The Independent that the occupation of Crimea by pro-Russian forces was bad news for methadone users:

For Crimea's 805 registered methadone users, the future is bleak. Its health ministry confirmed on Thursday the ban on methadone therapy. In the next few weeks, the drug will have run out and the likelihood is that most of the users will be forced back to injecting. From the point of view of HIV prevention, this is disastrous.

At a conference panel, Ukrainian delegates to AIDS 2014 confirmed that the change has indeed been disastrous, and "almost 60 people had been forced to move to continental parts of Ukraine to continue to access the healthcare, some have committed suicide and many more are living in pain and suffering," according to Melbourne's Herald Sun:

International HIV/AIDS Alliance in Ukraine executive director Andriy Klepikov said it was a fragile situation where a health policy that was saving human lives had changed "literally and unexpectedly" overnight.

"Patients are facing pressure from Russian authorities not to move from their families, so several of them committed suicide, because psychologically they faced huge pressure: on one side they were forced to stop the treatment, which can be considered as torturing, from the other side they have huge pressure from the environment to stay in Crimea," he said.

Russian Activist Offers Strategies for Survival in "Non-Supportive Climates"

Ivan Varentsov of the Andrey Rylkov Foundation in Russia delivered a compelling presentation on "strategies of survival" despite unrelenting conditions in his nation that work against human rights, harm reduction and HIV efforts:

Traumatic Rumors: The Number of AIDS 2014 Delegates on Flight MH17 and How the Media Got It Wrong

 (Credit: International AIDS Society/James Braund)
International AIDS Society/James Braund

No matter how many AIDS 2014 conference-goers were aboard, the loss of life in the crash in Ukraine was unsparing, sudden and devastating to the friends, families and communities of all involved, including those of the six delegates whose loss has been confirmed.

But the early estimate of a higher toll -- sometimes said as around 100, or even more precisely as 108 -- spread as fast as Twitter, and as far as the White House, with President Obama citing it in a speech. It caused much turmoil and specific pain and grief at the conference itself. But how did it happen?

According to the Australian site Crikey, the number was first heard at the International Indigenous Pre-Conference, and came at a moment of "extreme grief":

The figure came from attendees at the Friday session of the International Indigenous Pre-Conference on HIV and AIDS held in Sydney, a precursor to the 20th International AIDS conference in Melbourne, which started on Sunday. Crikey spoke to several pre-conference attendees who said they first heard the number during a moment of silence for the victims of the crash as well as those who had died of HIV/AIDS. "During the welcome, there was an announcement about the crash, and we were told that there were fears up to 100 passengers might have been AIDS conference delegates," a conference attendee told Crikey. But we've also been told, through people involved in organizing the conference, that they were under strict instructions not to give total figures, and that the minute of silence did not put the death toll at a specific number. The figure, says one, was seized upon "in a moment of extreme grief".

It's worth stressing that. Those early hours, with news of the crash and possible deaths slowly leaking out, were full of chaos and confusion for the attendees at the pre-conference. Some people were sobbing -- terrified for their colleagues and friends in the close-knit HIV research community. People's recollections can often be imprecise in times of emotional trauma.

May everyone at AIDS 2014 have safe travel home, and may we all continue to move forward in the days, weeks and months ahead on the road to the end of the epidemic.

Julie "JD" Davids is the managing editor for TheBody.com and TheBodyPRO.com.