response: December 2018 issue

AIDS and the Vulnerable

As AIDS treatments continue to improve, shifting demographics show that economic inequality and lack of education keep vulnerable women and children from prevention and care.

AIDS and the Vulnerable
A woman gestures during a demonstration by sex workers and their allies during the 2018 International AIDS Conference in Amsterdam.

Human viruses spread where they can, infecting people when possible without caring about gender or social status. Yet as the AIDS epidemic moves toward its fifth decade in a world plagued by inequality, HIV more than ever demonstrates a clear preference for the poor. If you have money or live in a country whose government cares about public health, effective treatment is available. More than ever before, those without resources or power—including women and girls—are the ones who increasingly bear the burden of the disease.        
 
“We know that HIV is linked to the second-class status of girls and women worldwide,” actress Charlize Theron said during the opening of the International AIDS Conference in Amsterdam in July. “And we know HIV targets communities that our societies have exploited, discarded and shamed.”
 
The Academy Award-winning South African said combating the spread of HIV goes far beyond medicine. “The fight against HIV is linked to a centuries-long fight for equality, dignity and human rights, and the only way to win this war is by shifting power to the people who have been shut out, by elevating local leadership, especially young people, and by spreading opportunity and access,” she said.

The three zeros

Researchers at the biennial conference had positive news, including what’s been dubbed “U equals U”—research showing that HIV-positive individuals under treatment with antiretroviral medications who have achieved an undetectable viral load cannot pass on the virus to others. Thus, “undetectable” equals “untransmittable.”
 
“It’s a miracle. And the data is irrefutable,” said Richard Bauer, a Catholic priest who works with a large AIDS program in Nairobi.
 
“We call this the three zeros. Zero missed doses. Zero missed clinical appointments. Zero viral load. If you can get the three zeros, the virus becomes undetectable in the body and it’s virtually impossible to physically transmit it to others. That has huge implications, especially for married couples where one person is HIV positive and their partner is not. And couples no longer have to be afraid of conception because the virus can’t be transmitted to the baby as long as we keep those three zeroes going,” Bauer said.
 
“We still need to be talking about healthy human sexuality and values, because even though you may be undetectable and untransmittable with HIV, there are other sexually transmitted diseases,” he said. Indeed, the growth in complacency about HIV transmission may have helped spur a rise in chlamydia, gonorrhea and syphilis infections in many places, including the United States.
 
The demographics of the AIDS epidemic are slowly shifting. While the number of new global HIV infections per year has dropped from 2.2 million in 2010 to 1.8 million in 2017, a reduction seen most dramatically in eastern and southern Africa, long the regions most affected by HIV, new infections are on the rise in some 50 countries. The annual number of new infections has doubled in eastern Europe and central Asia, for example.
 
Because of the expanded availability of antiretroviral medications, the number of AIDS-related deaths worldwide dropped to 940,000 in 2017, the lowest this century. And the number of people on treatment was way up; of 36.9 million people living with HIV in 2017, 21.7 million were on treatment.
 
Yet huge gaps remain, especially for children. New HIV infections among children have declined by 35 percent since 2010, down from around 270,000 in 2010 to 180,000 in 2017 according to UNAIDS—but that still means around 180,000 children became infected, and only 52 percent of children living with HIV are getting treatment. Although 80 percent of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission of HIV to their child in 2017, 180,000 children acquired HIV during birth or breastfeeding.

Speaking for children

One factor contributing to worse numbers for kids is that few children in the developed world get infected with HIV anymore. Children do continue to get infected in poor countries, however, but there’s little profit to be made selling them drugs. Pharmaceutical companies have no financial incentive to develop pediatric treatments.
 
Enter Pope Francis, who in 2016 convened the first of several meetings in the Vatican, bringing church leaders, international health officials and CEOs of some of the largest drug companies into the same small room.
 
“It’s like being sent to the principal’s office,” said Sandra Thurman, the chief strategy officer for the President’s Emergency Plan for AIDS Relief, a U.S. government program that funds AIDS response around the globe. “It’s the power of someone standing before you who looks at you with authority and says, ‘This is the right thing to do, this is the moral thing to do, this is the ethical thing to do. And you, Company X and Organization Y, you are doing the right thing by making sure we get treatment to children.’”
 
According to a consultant for the World Council of Churches, which is collaborating with the Vatican initiative, someone needs to speak on behalf of children.
 
“Children have always been the missing link in the AIDS response,” said Stuart Kean. “Getting children onto the agenda has been difficult because they’re not physically here and they’re not making noise. So it’s other people who have to speak up for them. Which is why the meetings in Rome are great. We finally got all the people who need to listen into the same room.”
 
Several child-specific dosages and formulations of antiretroviral medications are now available as a result of the coordinated church push. Yet some of the most important medications still need to be refrigerated, and many places lack dependable electricity. Some of the formulations still taste bad, and companies are working to develop medicines that parents can sprinkle like granulated sugar on top of porridge and other foods.

Rapid diagnosis saves lives

In the last year, the Rome meetings have expanded to include manufacturers of diagnostic devices that allow for a quick diagnosis of a child’s HIV status.
 
“We now have machines at testing sites which return test results in about 90 minutes, instead of the average of 50 days it takes when they send a blood sample off to be tested somewhere else,” said Chip Lyons, president and CEO of the U.S.-based Elizabeth Glaser Pediatric AIDS Foundation.
 
Lyons, who has participated in the Rome meetings, helped get 1,700 diagnostic machines placed at clinics and testing sites in eight African countries, many of them in church-run facilities.
 
“Going from 50 days to zero days to get the results is a really big deal. That means immediate counseling and initiation of [antiretrovirals] for the child. The difference for the caregiver, usually the mom, is dramatic. She gets the meds right away that she and her infant need, instead of coming back several times over two or three months,” Lyons said.
 
The diagnostic machines in Lyons’ pilot program are all located in sub-Saharan Africa, home to 86 percent of the world’s HIV-positive children and adolescents. In West and Central Africa, 80 percent of infected children are not receiving any antiretroviral therapy. And it’s getting worse. The number of 15- to 19-year-olds dying of AIDS in West and Central Africa increased by 35 percent between 2010 and 2016, even while it fell elsewhere in Africa.
 
Participants in the Vatican meetings last year adopted a 41-point “Rome Action Plan” with specific milestones for corporations and international organizations. A monitoring group meets monthly and updates a public website displaying progress toward those goals. A meeting at the end of 2018 will discuss what more needs to be done.
 
“We are constantly monitoring progress. We try to tick the boxes to see what has happened and not happened and figure out how to follow up. We still don’t have all the formulations we need for children, drugs that kids want to take and mothers can easily give. There are some companies we need to push harder,” said Gottfried Otto Hirnschall, director of the Department of HIV/AIDS of the World Health Organization.

Fighting stigma and discrimination

It’s not just Big Pharma that needs to be pushed to do more. AIDS activists are adamant that the church has to fight harder against the stigma and discrimination that can be just as deadly as the virus.
 
“Stigma is very high in West and Central Africa. There are clinics with space, but the people aren’t there,” said Deborah Von Zinkernagel, who directs the Community Support, Social Justice and Inclusion Department for the United Nations Joint Program on HIV/AIDS (UNAIDS).
 
“Religious leaders getting publicly tested and speaking from the pulpit about HIV will go a long way in breaking down the barriers to testing and treatment.”
 
One-quarter of those living with HIV do not know their status, so the World Council of Churches, of which the United Methodist Church is a founding member, has pushed religious leaders to get publicly tested as a way of encouraging others to do the same. The campaign seeks to change public attitudes, starting with the stigma around simply taking the test, which is now as easy as wiping a swab along your gums.
 
Organizers point out that HIV is a virus, not a moral condition, and that religious leaders of all faiths have unique influence on attitudes at the grassroots. The idea has caught on far and wide. The National Council of Churches in the Philippines, for example, has sponsored a “Testing the Clergy” poster campaign, with roadside posters showing bishops who have taken an HIV test.
 
Despite such campaigns, the virus is spreading rapidly around the globe in several key populations, including people who inject drugs, sex workers, prisoners and men who have sex with men. Negative public attitudes toward these groups, and, in the worst case, outright criminalization, make them harder to reach with testing and treatment. In a globalized world, good public health policy needs to be more inclusive than ever.
 
Leaders of the fight against AIDS recognize the vital role of faith leaders.
 
“It is impossible for us to reach those who are difficult to reach and really remove the barriers of stigma and discrimination,” Michel Sidibé, the executive director of UNAIDS, told religious leaders at the Amsterdam conference. “We need people who all their lives have been building bridges between people. That is who you are.”

Educating girls is key to reducing risk

Women have long suffered in inordinate numbers from HIV infection, for physiological as well as political and cultural reasons. In 2017, 48 percent of newly infected adults were women. Globally, HIV is the leading cause of death among women aged 30–49.
 
Increased vulnerability to HIV is linked to inequality of power, education and income. Studies in several countries, including the United States, have shown that financial insecurity increases HIV risk.
 
Gender-based violence also plays a role. Several studies have shown that in some regions, women who are exposed to intimate partner violence are on average 50 percent more likely to acquire HIV than women who have not experienced such violence. And once women are infected, according to studies in the United States and Haiti, intimate partner violence is associated with significantly lower adherence to treatment and lower levels of viral suppression.
 
This disparity is particularly evident in sub-Saharan Africa. For every three new HIV infections among young men (aged 15-24) in eastern and southern Africa, there were seven new infections among young women of the same age. In western and central Africa, for every three new infections among young men, there were five new infections among young women. 
 
Gender-based imbalances of power mean that many young women are not able to make decisions about their own lives, limiting both their choices and opportunities as well as their access to information, health and social services, education and employment. For example, in 29 countries women require the consent of a spouse or partner to access sexual and reproductive health services. And 75 percent of women aged 15-19 do not have a final say in decisions about their own health.
 
Studies have repeatedly shown that increasing educational achievement among women and girls is directly linked to better health outcomes, including lower rates of HIV infection, delayed childbearing and safer births. Yet in some settings, cultural and social norms mean that girls in HIV-affected families are the ones who drop out of school to care for sick parents or generate income for the family. As a result, less than one in three girls in sub-Saharan Africa are enrolled in secondary school.
 
Poor women may have little choice but to adopt behaviors that put them at risk of infection, including transactional and intergenerational sex, earlier marriage and relationships that expose them to violence and abuse. Education, on the other hand, allows girls to gain better knowledge about HIV and their own sexual and human rights. It lowers exposure to intimate partner violence and increases their chances of becoming financially secure and independent.
 
Not surprisingly, the most effective interventions to reduce the risk of HIV infection among adolescent girls in Africa are the ones that keep them in school. These include making education free for girls, supporting orphans and other vulnerable children to stay in school  and cash transfers that reward parents for keeping their daughters in school. In Malawi, for example, such a program reduced the dropout rate of girls by 35 percent. It also resulted in a 40 percent reduction in early marriages, a 30 percent reduction in teenage pregnancies and a 64 percent reduction in HIV risk within 18 months.

“Who will love them?”

A common complaint among health workers is the difficulty in getting adequate funding for the AIDS response. (Despite efforts by the Trump administration to cut HIV and AIDS funding, U.S. government funding has remained fairly stable due to broad bipartisan support in the Congress.) While money often continues to be available for purchasing antiretroviral pills, funding for social workers and counselors—the software of the AIDS response—is an endangered species.
 
That worries many on the front lines of the faith community’s HIV response who often provide the necessary environment in which pills can work.
 
“People living with HIV only take medicine twice a day. What do they do the rest of the day? Who will be with them and who will talk to them when they are in crisis? Who will walk with them in their journey, and as they get healthy, who will love them? This is especially true with children and adolescents who have grown up without a family or their family has rejected them,” said John Toai, a Catholic priest who directs the HIV and AIDS work of the Archdiocese of Saigon.
 
“People living with HIV, especially children, need more than just medicine. They need love. They need acceptance. They need to see the value of their life, no matter their HIV status. And this is where the church must reach out and say that we accept you, that you are loved by God and we are here to accompany you.”
 
Toai’s program, which recently lost some of its U.S. funding, houses HIV-positive children in a shelter and works with hundreds of others living with the virus in the city. About 1,500 adults receive treatment in a church-run outpatient clinic, many of them internal migrants who don’t have the proper documents to receive treatment in government clinics.
 
“If people are sad and lonely and have no one to help them, if the community rejects them, they will not continue to take their medication,” Toai said. “Why should they take medication if no one loves them, if they only experience judgment and prejudice from others?” 
 
The Rev. Paul Jeffrey is a United Methodist missionary and senior correspondent for response. He lives in the Pacific Northwest.

Posted or updated: 12/3/2018 12:00:00 AM
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