Fast-Tracked or Foiled?

A U.N. declaration to accelerate the end of AIDS may not be up to speed

by Chael Needle

sexworker_en[dropcap]L[/dropcap]ast month, the Member States of the United Nations adopted the “Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight against HIV and to End the AIDS Epidemic by 2030” at the High-Level Meeting on Ending AIDS.

Calling for a global push to ensure a collective and concerted response to the pandemic, the General Assembly’s declaration seeks to implement this acceleration over the next five years in order to meet the 2030 deadline for the Agenda for Sustainable Development, which encompasses issues beyond HIV/AIDS but understands health as a precondition as well as an outcome and indicator of sustainability. Taking a multifactorial and people-centered approach, the goals address HIV/AIDS in the context of development, injustice, inequality, poverty, and conflict as well as health. The Joint United Nations Programme on HIV/AIDS (UNAIDS), with the help of eleven U.N. agencies and national and global partners, leads the implementation of these guidelines.

Dependent on engaged leadership in all sectors of society, including among individuals living with HIV, the short-term (2020) goals include decreasing new HIV infections to fewer than 500,000 globally; decreasing AIDS-related deaths to fewer than 500,000 globally; and the elimination of HIV-related stigma and discrimination.

Among its many commitments, too numerous to list here, the declaration advocates for providing targeted comprehensive HIV prevention services (including condoms, PrEP, and male circumcision) for all women and adolescent girls, migrants, and key populations—sex workers, men who have sex with men, people who inject drugs, transgender people, and prisoners; eliminating mother-to-child transmission of the virus; revising laws that create barriers for and promote the stigmatization and discrimination of individuals living with HIV/AIDS; promoting health as a human right (for example, calling for universal health coverage); assuring input from PLWHAs in monitoring and accountability practices; and increasing funding to close resource gaps. The declaration also calls for national and regional tailoring of approaches (making special note of hard-hit regions like sub-Saharan Africa and the Caribbean, among others), as well as a new focus on social and legal protections for youth as well as girls and women, who often experience violence and discrimination that exacerbate HIV risk and prevents HIV care.

The declaration’s commitment to treatment goals covers three primary areas.

Closing treatment gaps. Building on earlier success, namely, the fact that the number of people on HIV treatment reached 17 million at the end of 2015, exceeding the target, the U.N. seeks to double the number of people receiving HIV medications so that 30 million are receiving lifesaving care.

Promoting an integrated health approach. The declaration reiterated its commitment to approach HIV/AIDS within an integrated health framework, working to respond to a number of health issues—such as tuberculosis, hepatitis B and C, cervical cancer, human papillomavirus, noncommunicable diseases, and emerging and re-emerging diseases—that sometimes intersect with HIV.

Financing the end of AIDS. As the proposed goals need funding, leaders made robust financing and allocation commitments appropriate to a fast-track level of delivery; Member States called for $13 billion to replenish the Global Fund to Fight AIDS, Tuberculosis and Malaria; and Member States also promoted a stepped-up and strategic engagement of the private sector. The declaration also addressed barriers to affordable, gold-standard generic medications, diagonostics, and health technologies related to ending AIDS.

While many of the progressive goals were lauded, some advocates point to the declaration’s failure to make visible populations most in need of prevention and treatment resources and to spell out practices that would ensure health as a human right across the board.

Considering that the declaration includes a “[c]all for urgent action over the next five years to ensure that no one is left behind in the AIDS response,” the declaration fails to call for comprehensive sexuality education, as activists, organizations, and others who collaborated on the draft, have pointed out. Contrary to the overall principles of UNAIDS, the declaration reaffirms heterosexual and gender normative relationships at the expense of LGBT and gender-nonconforming youth: “Commit to accelerate efforts to scale up scientifically accurate age-appropriate comprehensive education, relevant to cultural contexts, that provides adolescent girls and boys and young women and men, in and out of school, consistent with their evolving capacities, with information on sexual and reproductive health and HIV prevention, gender equality and women’s empowerment, human rights, physical, psychological and pubertal development and power in relationships between women and men, to enable them to build self- esteem, informed decision-making, communication and risk reduction skills and develop respectful relationships, in full partnership with young persons, parents, legal guardians, caregivers, educators and health-care providers, in order to enable them to protect themselves from HIV infection.”

The declaration also fails to substantially address key populations, such as gay men, people who use drugs, transgender people, sex workers and other criminalized and excluded populations. Men who have sex with men, for example, are mentioned once. Transgender people are mentioned once. Sex workers are mentioned once. These key populations are in fact reduced to a single sentence. Activists have called out countries like Russia, Poland, and Iran, among others, for editing out these populations in order to sustain their own bigotry. The exclusionary language will cost lives and further nurture stigma, discrimination, and criminalization of individuals who need prevention and treatment, say critics. It begs the question: How can the global fast track be up to speed if healthcare as a right that encompasses all human beings is at a dead-stop or slow to progress in some countries?

Chael Needle wrote about a call to action to address the needs of long-term survivors in the June issue.