Four messages from AIDS 2014, and what they mean for HIV in the UK
Today is the final day of AIDS 2014, the 20th International AIDS Conference hosted in Melbourne this week. Despite the devastating start to the conference, with the loss of delegates on board flight MH17, the week has been revitalising for the international HIV community and we end AIDS 2014 with a strong sense of current priorities in the fight against HIV. Here are my four top messages from the conference, and what I think they mean for the UK's efforts to tackle HIV:
1. Structural, legal and policy drivers of HIV
A thread throughout all the plenary talks and much of the research presented was the importance of the structural factors that affect individual and communities' risk of HIV. These include poverty, gender inequality, homophobia, transphobia, racism and HIV-related stigma.
We also saw numerous examples of how laws and policies - often motivated by these structural factors - can serious impede our ability to fight HIV. In particular, we saw the disastrous impact that certain criminal laws targeting homosexuality, drug use and sex work can have on harm reduction efforts and on human rights and wellbeing of groups most affected by HIV.
This is the global picture. In the UK we are fortunate to have had largely successful harm reduction efforts. But we must still be vigilant about the broader policy context to ensure it does not undermine HIV prevention, testing and treatment efforts in our country. For example, in the past year NAT has been campaigning actively against new NHS charging rules introduced with the Immigration Act 2014, which if implemented could create a real barrier to HIV testing for at-risk migrants.
There was a session at the conference called "Sexier than you think: HIV policy, regulation and legislation". At NAT we could not agree more, and this is why we work exclusively on HIV policy issues in the UK
2. There is no single "HIV epidemic"
The Melbourne Declaration, one of the legacies of AIDS 2014 is entitled "Nobody left behind". This has been a catchphrase of the week, applied to key populations who experience a greater burden of HIV globally. Each of these populations is affected by HIV in a different way. In addition, the impact of HIV differs geographically, not just between nationals but between regions, cities and neighbourhoods.
On Tuesday, Mark Dybul of the Global Fund reminded delegates that "all epidemics are local" and must be tackled in line with their unique characteristics. This is very relevant to the current situation in England, where HIV prevention is now the responsibility of local government. We know that in England gay and bisexual men and African-born people are our 'key populations' in terms of disproportionate impact of HIV. People who use drugs also need tailored HIV services. But successful prevention depends on individual councils understanding the diversity within these populations and beyond, engaging with their population, being across the unique needs of their local population and investing appropriately.
3. Combination prevention
'Combination prevention' has been another popular concept this week. It is about giving people living with and at risk of HIV a choice of prevention approaches and access to the tools which work for them and their partners.
There are really exciting developments in HIV prevention approaches. Kenneth Mayer's Thursday morning plenary talk on new prevention technologies (NPTs) showcased a range of potential methods under development in the form of pills, gels, films, vaginal rings, diaphragms and injections. There is also still real optimism about the development of an effective HIV vaccine.
On Tuesday the iPrEx OLE study announced findings that PrEP (pre-exposure prophylaxis) was 100% effective in preventing HIV transmission when taken as prescribed. As highlighted in this recent blog from our Director of Policy & Campaigns, Yusef Azad, PrEP is not a replacement for condoms, but an additional strategy.
And condoms were very present at the conference, with free distribution and daily demonstrations of new products with a particular emphasis on the new generation of female condoms.
Of course one size does not fit all (!), there is no single prevention option that works for everyone and combination approaches work best for most - so it is great to see the menu getting much longer.
4. The cure
Delegates at the conference have welcomed these scientific advances but we have also had to start thinking about what our current best shots at a cure really means for people currently living with HIV.
For example, if the best we can currently manage is an undetectable viral load without the need to take treatment for a period of some years, perhaps we should start talking about 'remission' from HIV? If we do achieve a 'functional cure' (where someone living with HIV is able to stay permanently off-treatment with an undetectable viral load) will they also be 'cured' of HIV stigma?
These are important questions to start thinking about now, as sadly experience has shown us that public knowledge and attitudes have not kept up with the medical advances that make HIV a manageable, long-term condition for most people living in the UK today.