tag:theconversation.com,2011:/fr/topics/aids-855/articles
AIDS – The Conversation
2024-02-09T13:35:58Z
tag:theconversation.com,2011:article/206375
2024-02-09T13:35:58Z
2024-02-09T13:35:58Z
Lack of access to health care is partly to blame for skyrocketing HIV rates among gay Black men
<figure><img src="https://images.theconversation.com/files/573871/original/file-20240206-20-wvuls8.jpg?ixlib=rb-1.1.0&rect=453%2C91%2C3636%2C2624&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man takes a free HIV test during the Harlem Pride parade in New York City.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/man-takes-a-free-hiv-test-during-the-harlem-pride-parade-in-news-photo/1152819582?adppopup=true">Kena Betancur/AFP via Getty Images)</a></span></figcaption></figure><p>Over the past 20 years, people living with HIV in the United States have seen a drastic improvement in their overall <a href="https://www.thebodypro.com/article/hiv-life-expectancy-in-u-s-matches-general-population-with-some-differences">quality of life</a>. But the medical achievements that have made those lives better and created longer <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(23)00028-0/fulltext">life expectancies</a> have not benefited all communities. </p>
<p>In fact, some communities still have higher rates of new cases of HIV, the virus that causes AIDS. This is especially true for <a href="https://www.cdc.gov/hiv/group/msm/bmsm.html">Black gay and bisexual men</a>. Black queer men are <a href="https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=21">six times more likely</a> to die as a result of HIV-related complications when compared with queer men of different races.</p>
<p>In addition, in the <a href="https://www.cdc.gov/hiv/group/msm/bmsm.html">most recent available data</a>, Black queer men made up 26% of all new cases of HIV in 2019 despite making up <a href="https://williamsinstitute.law.ucla.edu/publications/black-lgbt-adults-in-the-us/">less than 3% of the total</a> U.S. population. </p>
<p>Finally, <a href="https://www.cdc.gov/nchhstp/newsroom/2016/croi-press-release-risk.html">data released in 2016</a> revealed that if the rates then of new HIV cases persisted, an estimated 1 in 2 Black queer men would acquire HIV in their lifetime. </p>
<p>For comparison, those rates mirror the <a href="https://www.prb.org/resources/the-status-of-the-hiv-aids-epidemic-in-sub-saharan-africa/">prevalence of HIV in sub-Saharan Africa</a> in 2003 when the international community began sending help, including then-<a href="https://www.cgdev.org/page/overview-president%E2%80%99s-emergency-plan-aids-relief-pepfar">President George W. Bush</a>, who approved and implemented his <a href="https://www.npr.org/sections/goatsandsoda/2023/02/28/1159415936/george-w-bushs-anti-hiv-program-is-hailed-as-amazing-and-still-crucial-at-20">Emergency Plan for AIDS Relief</a> program.</p>
<p>To this day, sub-Saharan Africa is still considered the epicenter of the AIDS crisis and accounts for <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2023/july/unaids-global-aids-update">nearly 70%</a> of the world’s HIV infections.</p>
<p>The <a href="https://doi.org/10.1353/hpu.2023.a903345">prevalence of HIV</a> in the Black queer community has been well documented in <a href="https://doi.org/10.1080/09540121.2023.2189223">academic research</a>, including <a href="https://doi.org/10.1177/00027642221145027">my own</a>, which demonstrates that when patients’ <a href="https://doi.org/10.5744/rhm.2023.6012">treatment plans</a> include access to health care and other social services, the patients stay healthy longer. </p>
<h2>The question of risky behavior</h2>
<p>The wide reach of HIV in the Black queer community is not due to members of that community having more sex, or using protection less, or having more partners than queer people of other racial or ethnic backgrounds.</p>
<p>In fact, long-standing studies have shown that when Black queer men have access to appropriate health care, they use condoms more often, and test themselves for HIV more often, than queer men of other races.</p>
<p>For example, <a href="https://www.contagionlive.com/view/hiv-rates-in-young-black-gay-men-strikingly-higher-despite-fewer-risk-behaviors">a study</a> conducted in 2018 found that young Black gay men reported lower rates of sexual risk behaviors, fewer sexual partners and more lifetime HIV tests, but still maintained the highest number of new cases.</p>
<figure class="align-center ">
<img alt="A Black man sits at a table surrounded by a group of other men at a large gathering." src="https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=367&fit=crop&dpr=1 600w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=367&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=367&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=461&fit=crop&dpr=1 754w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=461&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/574193/original/file-20240207-22-snwbsu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=461&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Black man sits among the audience at the annual World AIDS Day commemoration on Dec. 1, 2023, in Long Beach, Calif.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/long-beach-ca-the-audience-was-deeply-moved-by-the-singing-news-photo/1825635482?adppopup=true">Brittany Murray/Long Beach Press-Telegram via Getty Images</a></span>
</figcaption>
</figure>
<p>Studies published in <a href="https://doi.org/10.2105/AJPH.2012.301003">2012</a>, <a href="https://doi.org/10.1007/s10461-014-0842-8">2015</a>, <a href="https://doi.org/10.1007/s10461-018-2270-7">2019</a> and <a href="https://doi.org/10.1007/s10461-021-03430-6">2021</a> have shown that the increase in HIV infections in the Black queer community is not about the number of sexual encounters.</p>
<p>According to those studies, Black queer people have a higher risk of contracting HIV than those others because their communities are more tightly knit – despite behaving more safely than others.</p>
<p>As a result of social stigma and discrimination, Black queer men are more likely to have sexual relationships within their own racial group. Given the already high prevalence of HIV in this group, this concentration increases the likelihood of encountering a partner living with HIV and increases the risk of HIV infection.</p>
<h2>A perfect storm of racism and homophobia</h2>
<p>Preventive measures such as preexposure prophylaxis, or <a href="https://www.cdc.gov/hiv/basics/prep.html">PrEP</a>, have completely revolutionized the field of HIV treatments.</p>
<p>Available as an <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention">injection</a>, a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935218/">daily pill</a> or <a href="https://endinghiv.org.au/blog/prep-on-demand-dosing-guide/">on-demand dosage</a>, PrEP is known to be 99% effective in reducing the risk of acquiring HIV when taken as prescribed.</p>
<p>But in order to receive PrEP, for instance, one must first locate a provider who is willing to prescribe the medicine. <a href="https://www.nbcnews.com/feature/nbc-out/unequal-hiv-prevention-pill-use-puts-minority-men-higher-risk-n1059016">There are examples</a> of doctors simply refusing to prescribe it out of fear of “<a href="https://sph.cuny.edu/life-at-sph/news/2018/07/31/prep-perception-promiscuity/">increased promisciuty</a>.”</p>
<p>This sentiment is often rooted in racism and homophobia.</p>
<p>Even if one locates a provider, there is also the ever-looming issue of insurance and affordability. A <a href="https://www.webmd.com/hiv-aids/how-much-truvada-for-prep-costs">month’s supply</a> of Truvada, one of the two FDA-approved PrEP drugs, is nearly $2,000 without insurance, while a generic version costs $30 to $60 per month. </p>
<p>Though HIV care and <a href="https://www.healthaffairs.org/content/forefront/new-guidance-prep-support-services-must-covered-without-cost-sharing">PrEP</a> are broadly covered under the Affordable Care Act, that often means only the cost of the prescriptions. Patients are frequently surprised to learn that the lab costs of blood tests and analysis of PrEP are <a href="https://kffhealthnews.org/news/article/prep-hiv-prevention-costs-covered-problems-insurance/">not always covered</a>, nor are additional tests for other medical conditions, such as diabetes or high blood pressure. </p>
<p>This is problematic because in order to stay on PrEP, you must engage in quarterly check-ins and bloodwork. </p>
<h2>Lowering the risks</h2>
<p>HIV prevalence is highly <a href="https://www.mdpi.com/1660-4601/18/18/9715">concentrated in the South</a>, which accounts for over 50% of new HIV cases. The region also has the highest fatality rate for Black queer men.</p>
<p><a href="https://doi.org/10.3389/fcomm.2020.00026">My research</a> typically uses interviews of Black queer men to better understand how Black gay men experience and face structural barriers such as access to testing and <a href="https://health.gov/healthypeople/priority-areas/social-determinants-health">adequate housing</a>.</p>
<p>Most men I interview are living with HIV and offer insights on their lived experiences and professional expertise with great vulnerability and power.</p>
<p>For example, Travis – a pseudonym – is from Little Rock, Arkansas, and is living with HIV. “If I’m worried about where I’m going to sleep or how I’m going to afford medicine, I don’t care about getting tested,” he explained. “I am not gonna come to my appointment to get poked with needles.” </p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509742/#:%7E:text=For%20example%2C%20Peterson%20and%20Jones,reduce%20HIV%2Drelated%20racial%20disparities.">Research</a> shows Travis is not an outlier. </p>
<p>Issues such as <a href="https://www.hud.gov/program_offices/comm_planning/hopwa">housing</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7716244/">employment</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/23876086/">transportation</a> and concerns <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305389">about costs</a> of health care are major obstacles in staying healthy.</p>
<p>Another man I interviewed lives in Los Angeles and pointed out that the younger generation has had limited education about the risks of <a href="https://www.cdc.gov/hiv/group/msm/brief.html">Black gay life</a>. </p>
<p>“We don’t even think about the fact that so many young Black gay men were never taught about HIV and condoms in school,” he said. “We don’t learn that.”</p><img src="https://counter.theconversation.com/content/206375/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deion Scott Hawkins does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
When appropriate care is available, several studies have shown, gay Black men are more likely to test themselves for HIV and engage in less risky sexual behaviors than gay men of other races.
Deion Scott Hawkins, Assistant Professor of Argumentation & Advocacy, Emerson College
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/218918
2023-12-01T13:38:30Z
2023-12-01T13:38:30Z
Who is still getting HIV in America? Medication is only half the fight – homing in on disparities can help get care to those who need it most
<figure><img src="https://images.theconversation.com/files/562804/original/file-20231130-23-mq7ite.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Access to life-saving HIV prevention medications varies by race and other sociodemographic factors.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/aids-awareness-red-ribbon-royalty-free-image/1445701859">David Talukdar/Moment via Getty Images</a></span></figcaption></figure><p>As the globe marks another <a href="https://www.who.int/campaigns/world-aids-day/world-aids-day-2023">World AIDS Day</a> on Dec. 1, it’s crucial to both acknowledge the significant strides made in the global battle against HIV and recognize the persistent challenges that remain. While the United States had seen a <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">slow decline</a> in the overall number of new HIV infections from 2017 to 2021, a closer look at the data reveals <a href="https://www.cdc.gov/hiv/statistics/overview/in-us/incidence.html">persistent disparities</a> largely borne by LGBTQ people and <a href="https://theconversation.com/use-of-hiv-prevention-treatments-is-very-low-among-southern-black-gay-men-170794">communities of color</a>.</p>
<p>As a <a href="https://scholar.google.com/citations?user=DbZMkzUAAAAJ&hl=en">social epidemiologist</a> who proudly identifies as a gay Latino, I have a vested interest both personally and professionally in understanding and addressing the HIV disparities my communities face. It’s disheartening to realize that, despite available medical advances that can end the AIDS epidemic, these resources aren’t reaching those who need them the most.</p>
<h2>Tools in the HIV prevention arsenal</h2>
<p>When HIV/AIDS first emerged in the U.S. in the 1980s, <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline/">condoms were the only prevention strategy</a> available other than behavioral changes like abstinence. Since then, the development of effective medications has made it possible to live with HIV.</p>
<p>In the 1990s, researchers adopted the model of “<a href="https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/arv-therapy-as-prevention">treatment as prevention</a>,” which recognized that an HIV-positive person with a reduced viral load from taking their antiviral therapy medications had a lower likelihood of passing the virus to their sexual partners. This messaging was changed in recent years to <a href="https://www.idsociety.org/science-speaks-blog/2021/u--u-the-evidence-is-in.-spreading-the-word-that-undetectable--untransmissable-is-the-next-crucial-step/">“undetectable = untransmittable,” or U=U</a>, when a landmark study concluded that people living with HIV who are virally suppressed, or undetectable, through medications are not able to pass the virus on to a sexual partner.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/8q21PG1CdNs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">People who have undetectable levels of the virus are deemed to have untransmittable HIV.</span></figcaption>
</figure>
<p>In 2005, researchers introduced <a href="https://www.hiv.uw.edu/go/prevention/nonoccupational-postexposure-prophylaxis/core-concept/all">non-occupational postexposure prophylaxis, or nPEP</a>, which aimed to prevent infection in someone exposed to HIV by initiating antiviral therapy. </p>
<p>In 2012, the U.S. Food and Drug Administration approved the first <a href="https://www.hiv.uw.edu/go/prevention/preexposure-prophylaxis-prep/core-concept/all">preexposure prophylaxis, or PrEP</a> drug, which is an antiviral therapy that someone who has not been exposed to HIV takes daily to prevent infection. In 2021, the FDA approved the use of a <a href="https://www.hiv.uw.edu/go/prevention/preexposure-prophylaxis-prep/core-concept/all#recommended-regimens-dosing-hiv-prep-long-acting-injectable-">long-acting, injectable form of PrEP</a>, providing an alternative to daily pills. </p>
<p>While medical advancements have enhanced the options to prevent HIV, many aren’t reaching the people they are intended to treat. Of the estimated <a href="https://www.cdc.gov/hiv/group/racialethnic/other-races/prep-coverage.html">1.2 million people eligible for PrEP in the U.S.</a>, only 30% received a prescription in 2021.</p>
<h2>Racial disparities</h2>
<p>Gay and bisexual men continue to comprise around <a href="https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics/">two-thirds of new HIV infections</a> in the U.S. <a href="https://www.cdc.gov/hiv/policies/data/transgender-issue-brief.html">Transgender people</a>, <a href="https://www.vice.com/en/article/pkgnny/homeless-hiv-treatment">people who inject drugs</a> and <a href="https://www.cdc.gov/hiv/group/sexworkers.html">sex workers</a> also have disproportionate new infection rates. But cases are not distributed evenly by race. </p>
<p>The Centers for Disease Control and Prevention’s 2021 HIV Surveillance Report on groups at risk of HIV in 13 U.S. cities found that <a href="https://www.cdc.gov/hiv/pdf/library/reports/cdc-hiv-surveillance-special-report-number-31.pdf">nearly 80% of gay and bisexual men</a> engaged in condomless anal sex, with higher rates among white men than among both Black and Latino men.</p>
<p>However, between 2015 and 2019, white gay and bisexual men experienced a <a href="https://www.cdc.gov/hiv/group/msm/msm-content/diagnoses.html">17% decrease in HIV cases</a>. Black and Latino gay and bisexual men experienced no significant reductions. This is likely due to disparities in access to HIV prevention medication. Among those who were HIV negative, <a href="https://www.cdc.gov/hiv/pdf/library/reports/cdc-hiv-surveillance-special-report-number-31.pdf">only a little over 40% had used PrEP</a> in the past 12 months, with white men reporting higher use than both Black and Latino men. Among those who were HIV positive, 95% were actively using antiviral therapy, and there was little variation by race.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Hand holding orange PrEP pills above a clothed table with an open pill bottle" src="https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/562805/original/file-20231130-25-n3chgy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The first PrEP drug was approved in 2012, but access remains uneven across the U.S.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-latina-woman-taking-medicine-royalty-free-image/1320349143">Sara Jurado/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>Factors such as stigma, lack of access to and mistrust in health care, socioeconomic status, and cultural nuances that restrict access to PrEP likely contribute to the unchanging HIV burden <a href="https://www.cdc.gov/hiv/group/bmsm/prevention-challenges.html">Black</a> and <a href="https://www.cdc.gov/hiv/group/gay-bisexual-men/hispanic-latino/prevention-challenges.html">Latino</a> men, <a href="https://www.cdc.gov/hiv/policies/data/transgender-issue-brief.html#systemic-factors-that-contribute">trans people</a> and <a href="https://www.vice.com/en/article/pkgnny/homeless-hiv-treatment">people experiencing homelessness</a> face.</p>
<h2>Closing the PrEP access gap</h2>
<p>A recent systematic review of 42 different interventions to promote PrEP among gay and bisexual men in the U.S. found that the most promising involve addressing <a href="https://doi.org/10.1186/s12981-022-00456-1">various social and environmental factors</a> that restrict access and adherence. </p>
<p>Tackling access barriers at the community and health care levels can enhance public health initiatives to expand PrEP access, including addressing issues like stigma and medical mistrust. This can help effectively promote PrEP use among Black and Latino gay and bisexual men and reduce racial disparities in HIV infections.</p>
<p>It is also important to note that while HIV disproportionately affects certain groups, <a href="https://www.cdc.gov/hiv/group/racialethnic/africanamericans/diagnoses.html">people having heterosexual sex</a> are still at risk and need to be part of the HIV prevention solution.</p>
<p>World AIDS Day serves as a poignant reminder that the fight against HIV is not only a global endeavor but also one that requires a nuanced understanding of the unique challenges different communities face. Addressing disparities and tailoring interventions can help move humanity closer to a world where HIV is no longer a pervasive threat.</p><img src="https://counter.theconversation.com/content/218918/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angel Algarin receives funding from the National Institutes of Health. </span></em></p>
Two-thirds of new HIV infections are among gay and bisexual men. Although cases have decreased among white men, they have stagnated among communities of color.
Angel Algarin, Assistant Professor of Health Promotion and Disease Prevention, Arizona State University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/213310
2023-10-24T13:12:46Z
2023-10-24T13:12:46Z
HIV-positive parents in Zimbabwe struggle to manage their children’s education – study shows how
<p>Over the past three decades researchers have explored various aspects of the impact of the HIV pandemic. One focus area has been children who have lost their parents to AIDS. Less attention has been given to children who are raised by parents living with HIV. This group has become much bigger as more people have <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2021/september/20210906_global-roll-out-hiv-treatment">access to antiretroviral therapy</a> and are therefore expected to raise their children. </p>
<p>Our research in Zimbabwe looked at the effects the HIV status of parents had on their children’s education. </p>
<p>In Zimbabwe, the current HIV prevalence rate among adults is about <a href="https://www.unicef.org/zimbabwe/hivaids">13%</a>. In 1997 it was at its peak at <a href="https://pubmed.ncbi.nlm.nih.gov/20406793/">29.3%</a>. Nevertheless, Zimbabwe still has the <a href="https://www.statista.com/statistics/270209/countries-with-the-highest-global-hiv-prevalence/#:%7E:text=Among%20all%20countries%20worldwide%20those,rate%20of%20almost%2026%20percent.%20**link%20is%20behind%20a%20paywall**">sixth highest HIV rate</a> in the world. Eswatini has the highest rate (19.58%) and South Africa ranks fourth (14.75%).</p>
<p>Our research focused on mothers in Harare, Zimbabwe’s capital city, who had access to treatment. We were interested in the impact of HIV on their investment in their children’s education. We conducted <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">interviews</a> at <a href="http://mashambanzou.co.zw/">Mashambanzou Care Trust</a>, a local non-profit organisation that provides care to about 5,000 HIV-positive low-income individuals in Harare. Thirteen HIV-positive mothers were interviewed to discuss the key reasons behind the disruption of their children’s schooling .</p>
<p>We found that the HIV status of low-income parents in Zimbabwe severely affected their children’s education, in four ways.</p>
<p>Firstly, HIV worsened the financial barriers parents faced when trying to get their children educated. Secondly, children missed school because they needed to take care of sick parents or siblings. Thirdly, sick parents were not involved with their children’s <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">academic achievement</a> because they were physically, mentally and emotionally incapable of helping. Lastly, children of HIV-positive mothers did not always have birth certificates, a major barrier to school and exam registration in Zimbabwe.</p>
<h2>Financial barriers</h2>
<p>The research showed that HIV in Zimbabwe is not only a health issue but also a socioeconomic problem that can force people into <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">poverty traps</a>. </p>
<p>HIV-positive women expressed the view that the Zimbabwean economy, their partner’s health and their own health affected how they supported their children’s educational needs. </p>
<p>We found children with parents who could not afford to pay school fees or buy school uniforms could be sent home until the payments were made. Other low income families experienced this too but parents with HIV could not work and so had more difficulty paying school fees.</p>
<p>HIV-affected families could also face the burden of raising other children from deceased or ill family members. Some of the mothers had siblings and close family members who had died of AIDS. In one case, a <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">single HIV-positive mother </a> had three biological children and three orphans from relatives.</p>
<h1>Missing school</h1>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">Girls</a> were particularly affected because they were expected to care for siblings, help sick parents with daily activities such as eating and toileting, and make sure they had a place to live and food to eat. </p>
<p>Mothers spoke about the heavy burden their daughters had to <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">carry</a>. </p>
<blockquote>
<p>My eldest child was the one who took care of me and cooked for me. When I got sick, my daughter stopped going to school. She is the one who took the responsibility of taking care of me. </p>
</blockquote>
<p>Some children were forced to drop out of school to earn an income. </p>
<blockquote>
<p>He dropped out of school after finishing his Form 3. He is currently selling bananas at Mbare and the money he is getting is not enough. Most of the time he brings home some food after selling bananas. </p>
</blockquote>
<h2>No time to help</h2>
<p>Most HIV-positive mothers told us that they did not <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">spend time</a> with their children because they spent a lot of time on income-generating activities, attending to their own health, or their husband’s health. These tough conditions led to even more illness and stress.</p>
<blockquote>
<p>All my seven children stay at home as none of them is in school right now. Each day of their lives is difficult as in some cases we fail to get some food to eat. After having failed to get food for the family, it then stresses me more as the mother. Given my condition that I am HIV-positive I end up getting continuous headaches and sometimes I get sick as a result of the stress. </p>
</blockquote>
<h2>Birth certificates</h2>
<p>Some HIV-positive parents were too sick to obtain birth certificates for their <a href="https://www.tandfonline.com/doi/full/10.1080/00346764.2023.2214126">children</a>. Without birth certificates, children risk being sent home and cannot benefit from programmes that target poor children. One mother told of trying to get birth certificates for her children in Mutare, almost 300 kilometres away from Harare.</p>
<blockquote>
<p>I once went to Mutare to secure birth certificates for my children. I was told to bring my national identification card which was in Harare during that time. I am yet to go back to Mutare and collect birth certificates for my children. I am only being stopped from travelling because I am currently sick and receiving treatment. </p>
</blockquote>
<h2>Looking to the future</h2>
<p>Our research highlights a vulnerable group of children who should also benefit from social assistance programmes that target HIV-affected orphans, given that their parents are too sick to care for them. </p>
<p>They should be included in the <a href="https://www.ajol.info/index.php/ajsw/article/view/194113#:%7E:text=Zimbabwe%20adopted%20the%20National%20Orphan,social%20safety%20nets%20for%20OVC.">National Orphan Care Policy</a>, which seeks to provide basic care and protection to orphans and vulnerable children, and the <a href="https://www.unicef.org/esa/media/11846/file/Unicef_Zimbabwe_Education_Budget_Brief_2022.pdf">Basic Education Assistance Module</a>, which pays school fees for this group of children.</p><img src="https://counter.theconversation.com/content/213310/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tatenda Zinyemba does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Some children of HIV-positive parents drop out of school to look after their mothers and fathers. Others skip class to earn cash for the family by selling goods.
Tatenda Zinyemba, Researcher in Economics, Health and Governance, Maastricht Economic and Social Research Institute on Innovation and Technology, United Nations University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/215314
2023-10-12T13:39:33Z
2023-10-12T13:39:33Z
Jerry Coovadia remembered - a champion of science, children and compassionate public health
<p>Deeply saddened as we in the South African health community were by the loss of Professor Jerry Hoosen Coovadia on 4 October 2023, I reflected on what he had come to mean in my medical career and in my life. </p>
<p>“Prof Jerry”, as we called him, was an internationally renowned South African paediatrician, public health and justice activist and clinician scientist. He made a lasting impact on child health, the response to HIV in South Africa and the region. He died, aged 83, at his home in KwaZulu-Natal, leaving his wife, Dr Zubeida “Zubie” Hamed. </p>
<p>What stands out for me is his principled, pragmatic and compassionate approach to paediatrics and child health. And then how these principles were brought to bear in response to the HIV epidemic. </p>
<h2>Earlier years</h2>
<p>In 1988 I found myself working to repay a government bursary at the quaint but very busy Eshowe Provincial Hospital in northern KwaZulu-Natal. There were three of us fresh new medical officers who, guided by a few key and wonderfully committed specialists, worked day and night in the emergency unit, outpatients and wards of this bustling public sector hospital serving rural communities. </p>
<p>Those “bush doctoring” days were some of my most fulfilling and exciting. It was satisfying to be carrying out emergency medicine or administering anaesthetics on two out of three nights. At the same time it was terrifying to put the mostly theoretical information we had gained in the last seven years to urgent and critical, practical use.</p>
<p>Paediatrics was no less terrifying than surgery or obstetrics. But we had the wonderful duo of Jenny Chapman guiding us in paediatrics and John Larson in obstetrics and gynaecology, and a library of important manuals and textbooks in the hospital boardroom. </p>
<p>Jenny, who was one of the most dedicated and caring paediatricians I have ever met, simply swore by Prof Jerry, his books and his teaching. I had not yet met Professor Coovadia in person, but I certainly came to intimately know his textbook (as I recall mine was a green version, much dog-eared and underlined) and his teachings not only at medical school but then under Jenny’s tutelage. </p>
<p>What set this book, <a href="https://global.oup.com/academic/product/coovadias-paediatrics-and-child-health-a-manual-for-health-professionals-in-developing-countries-9780199053940?cc=za&lang=en&">Paediatrics and Child Health</a>, apart was how it so practically but compassionately spoke to our setting and the African child. It dealt with the dilemmas and quandaries we faced daily in getting the best care to every child with our constrained resources. Jenny also taught me that it was wise to call and consult when the dilemma needed more than one opinion. And no opinion was more important than Prof Jerry’s.</p>
<p>When I later had the great good fortune to meet Prof Jerry in the 1990s as the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754430/">HIV epidemic was taking off in KwaZulu-Natal</a>, I was thrilled to discover the author was just as I had imagined him from his book: principled, passionate and pragmatic. </p>
<p>Throughout the next decade, our paths crossed frequently as we all took up the business of getting lifesaving HIV treatment to Africa. This meant building clinical evidence, writing guidelines and taking to the <a href="https://assets.publishing.service.gov.uk/media/57a08cc840f0b6497400143c/long_live_zackie.pdf">streets and courtrooms</a> as activists. His resolute and strong stance against <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61581-6/fulltext">AIDS denialism</a> was critical and inspiring. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/jerry-coovadia-the-south-african-doctor-who-led-the-fight-against-hiv-in-children-215080">Jerry Coovadia: the South African doctor who led the fight against HIV in children</a>
</strong>
</em>
</p>
<hr>
<p>With the <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2009/november/20091101southafrica">end of the denialist era</a>, from 2008 onwards, Prof Jerry’s wisdom continued to be greatly valued. I always enjoyed hearing his opinion or proposed solution to a challenge. True to his nature, the proposal first and foremost had the child, the patient, their family and their community at the heart. </p>
<p>Thereafter, it was carefully considered with the known current evidence available and finally it was pragmatic and feasible in our setting and considerate of the primary health system. </p>
<p>That opinion was always delivered with a quiet but firm voice and his active eyebrows and ready smile providing the right amount of emphasis and exclamation. A recent interview that captured Prof Jerry so wonderfully quoted him as saying <a href="https://www.dailymaverick.co.za/article/2021-05-30-be-true-to-science-and-kind-to-patients-says-healthcare-giant-jerry-coovadia/">“be true to science and kind to patients”</a>, an instruction that should be given to every healthcare professional as they embark on their careers. </p>
<p>Prof Jerry was, and remains, an inspiring model.</p><img src="https://counter.theconversation.com/content/215314/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
His teaching spoke practically but compassionately to the needs of the African child.
Linda-Gail Bekker, Professor of medicine and deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine, University of Cape Town
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/212177
2023-09-08T12:25:59Z
2023-09-08T12:25:59Z
Anemia afflicts nearly 1 in 4 people worldwide, but there are practical strategies for reducing it
<figure><img src="https://images.theconversation.com/files/546721/original/file-20230906-33614-a4o8yh.jpg?ixlib=rb-1.1.0&rect=15%2C7%2C5126%2C3484&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Anemia symptoms include shortness of breath, dizziness and fatigue.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-holding-blood-in-test-tube-royalty-free-image/1180192054?phrase=anemia&adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>Anemia is a major health problem, with <a href="https://doi.org/10.1016/S2352-3026(23)00160-6">nearly 2 billion people</a> affected globally. It afflicts more people worldwide than low back pain or diabetes – or even anxiety and depression combined. </p>
<p>Despite this, investments in reducing anemia have failed to substantially reduce the massive burden of anemia globally over the last few decades.</p>
<p>People <a href="https://www.ncbi.nlm.nih.gov/books/NBK499994/">become anemic</a> when their blood lacks enough healthy red blood cells to carry oxygen throughout the body. This decreased oxygen delivery causes many of the most <a href="https://www.nhlbi.nih.gov/health/anemia/symptoms">common symptoms of anemia</a>, including fatigue, shortness of breath, lightheadedness, difficulty concentrating and challenges with work and daily life tasks. </p>
<p>In addition to its direct health effects, anemia can <a href="https://doi.org/10.1111/nyas.14105">inhibit brain development and fine motor skills</a> in children and heighten the <a href="https://doi.org/10.3390/jcm10122556">risk of stroke</a>, <a href="https://doi.org/10.1681/ASN.2005030226">cardiovascular disease</a>, <a href="https://doi.org/10.1212/WNL.0000000000008003">dementia</a> and other chronic illnesses in older adults. <a href="https://doi.org/10.1111/nyas.14093">Anemia during pregnancy</a> can lead to increased rates of anxiety and depression, early labor, postpartum hemorrhage, stillbirth and low birth weight. Infections for both mother and baby are also more likely when the mother is anemic.</p>
<p>We are <a href="https://scholar.google.com/citations?user=LbtdQcsAAAAJ&hl=en">global</a> <a href="https://scholar.google.com/citations?user=0kfiPK8AAAAJ&hl=en">health</a> <a href="https://www.healthdata.org/about/people/nicholas-kassebaum">researchers</a> with expertise in epidemiological modeling of anemia alongside other maternal, neonatal and nutritional disorders. </p>
<p>Our work is part of the <a href="https://www.healthdata.org/research-analysis/gbd">Global Burden of Disease Study</a>, a large research study comprehensively estimating health loss due to hundreds of diseases, injuries and risk factors around the globe. Through our analysis, we have produced annual estimates of anemia prevalence by underlying cause for 204 countries and territories, by age and sex, from 1990 to the present. We have collected thousands of data points across hundreds of sources to produce the most comprehensive picture of anemia burden.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/z0Z1QMouVgE?wmode=transparent&start=29" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Anemia is often measured by the amount of hemoglobin – an oxygen-carrying protein within red blood cells – that a person has in their blood.</span></figcaption>
</figure>
<h2>Anemia is a widespread problem</h2>
<p>Anemia is diagnosed by a simple blood test and can be caused by a number of underlying conditions. </p>
<p>Decreases in healthy red blood cells can occur due to excessive loss of existing red blood cells, such as through bleeding or destruction by the body’s immune system. Anemia can also occur due to decreased production of new red blood cells or changes in the normal structure or lifespan of red blood cells that make them less effective.</p>
<p>Globally, anemia is the third-largest cause of disability: Our recent study found that <a href="https://doi.org/10.1016/S2352-3026(23)00160-6">nearly 1 in 4 people has anemia</a>. This burden is concentrated among children younger than 5 years and adolescent girls and women, one-third of whom are anemic. Anemia rates are particularly high in sub-Saharan Africa and South Asia, where we estimated that 40% – or two out of every five people – have anemia.</p>
<p>Reductions in anemia rates have been slow and uneven, dropping from 28% to 24% globally from 1990 to 2021. Adult males have fared better, with young children and adolescent girls and women – who bear the highest burden of anemia – showing the least progress. On the positive side, there has been a shift toward milder forms of anemia, which result in much less disability compared to severe anemia.</p>
<h2>Reducing anemia means tackling underlying causes</h2>
<p>Substantially reducing anemia globally is complicated by its many underlying causes. Dietary iron deficiency is the <a href="https://doi.org/10.1016/S0140-6736(15)60865-0">most common cause</a> across the globe. But other important drivers of anemia include blood disorders such as <a href="https://www.cdc.gov/ncbddd/sicklecell/index.html#">sickle cell disease</a> or <a href="https://www.cdc.gov/ncbddd/thalassemia/facts.html">thalassemias</a>, infectious diseases like <a href="https://theconversation.com/locally-transmitted-malaria-in-the-us-could-be-a-harbinger-of-rising-disease-risk-in-a-warming-climate-5-questions-answered-208726">malaria</a> and <a href="https://theconversation.com/parasitic-infections-hit-the-health-of-low-income-black-communities-where-states-have-neglected-sewage-systems-205616">hookworm</a>, gynecologic and obstetric conditions, <a href="https://theconversation.com/what-is-inflammation-two-immunologists-explain-how-the-body-responds-to-everything-from-stings-to-vaccination-and-why-it-sometimes-goes-wrong-193503">inflammation</a> and chronic diseases. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three-dimensional illustration of human artery anatomy, showing normal red blood cells and sickle-shaped blood cells flowing away from the heart." src="https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=478&fit=crop&dpr=1 754w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=478&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/547067/original/file-20230907-9809-nfpk9n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=478&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sickle cell disease – characterized by crescent or sickle-shaped red blood cells that can block blood flow to the rest of the body – is a well-recognized cause of anemia.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sickle-cell-cardiovascular-royalty-free-image/1130415446?phrase=sickle+cell+disease&adppopup=true">wildpixel/iStock via Getty Images</a></span>
</figcaption>
</figure>
<p>Anemia in adolescent and adult women often occurs due to loss of blood from menstruation and increased needs for blood for the developing baby during pregnancy. Much of the anemia burden in this group is <a href="https://doi.org/10.3390/nu13082745">likely related to</a> <a href="https://theconversation.com/the-us-lacks-adequate-education-around-puberty-and-menstruation-for-young-people-an-expert-on-menstrual-health-explains-187501">lack of menstrual education</a>, inadequate options for effectively managing menstrual problems in those who have them, and unmet needs for family planning services. These are also important drivers among transgender men and nonbinary people who menstruate. </p>
<p>Young children <a href="https://doi.org/10.1016/j.jpeds.2015.07.014">have increased requirements</a> for iron as their bodies grow, and malnutrition is a common cause of anemia in this group globally.</p>
<p>Iron supplementation has historically been the primary form of treatment and prevention of anemia. This includes large-scale addition of iron to foods such as flour, rice or milk, as well as providing oral iron tablets and intravenous iron, depending on the context and severity. </p>
<p>Some research has suggested that less than half of people with anemia will <a href="https://doi.org/10.1111/nyas.14175">fully respond to supplemental iron</a> if the underlying causes of iron deficiency remain untreated. For example, cells in our bodies <a href="https://doi.org/10.1016/j.beha.2004.08.020">sequester iron</a> as part of the immune response to some infections. Supplementing with iron without treating the underlying infection will do little to solve the iron deficiency in the long run, and it <a href="https://doi.org/10.1016/S0140-6736(06)67962-2">may even be harmful</a>.</p>
<p>Additional interventions include <a href="https://www.cdc.gov/hiv/risk/art/index.html">HIV treatment and prevention</a>, with <a href="https://theconversation.com/long-acting-injectable-prep-is-a-big-step-forward-in-hiv-prevention-190225">pre-exposure prophylaxis</a> and <a href="https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html">anti-retroviral therapy</a>. Preventing initial infection with HIV or suppressing the effects of the virus once infected will reduce the anemia burden related to HIV/AIDS.</p>
<p>Other strategies include malaria control methods, such as insecticide-treated bed nets and vaccination, and monitoring and prevention of chronic illnesses such as <a href="https://www.cdc.gov/kidneydisease/basics.html#">chronic kidney disease</a> and <a href="https://www.niehs.nih.gov/health/topics/conditions/inflammation/index.cfm">inflammatory conditions</a>. In combination with a robust supplementation program, these interventions could meaningfully reduce the global burden of anemia.</p>
<p>Anemia makes it hard for nearly 2 billion people worldwide to learn in school, perform at work and take care of their families. We hope our findings will allow for more comprehensive intervention and treatment plans, especially for the most vulnerable – adolescent and adult women, children and the elderly.</p><img src="https://counter.theconversation.com/content/212177/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicholas Kassebaum receives funding from the Bill & Melinda Gates Foundation. </span></em></p><p class="fine-print"><em><span>Theresa A McHugh and William Gardner do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Among young children, adolescents and adult women, anemia strikes 1 in 3 globally. Most cases are driven by dietary iron deficiency, red blood cell disorders and untreated tropical diseases.
William Gardner, Researcher in Neonatal and Child Health at the Institute for Health Metrics and Evaluation, University of Washington
Nicholas Kassebaum, Adjunct Professor in Health Metrics Sciences and Professor of Anesthesiology and Pain Medicine, University of Washington
Theresa A McHugh, Researcher and Scientific Writer at the Institute for Health Metrics and Evaluation, University of Washington
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/207836
2023-07-13T11:46:33Z
2023-07-13T11:46:33Z
Fungal infections in the brain aren’t just the stuff of movies – Africa grapples with a deadly epidemic
<figure><img src="https://images.theconversation.com/files/532417/original/file-20230616-19-tunqcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The fungus Aspergillus fumigatus. This fungus can cause a number of disorders in people with compromised immune function or other lung diseases.</span> <span class="attribution"><span class="source">Kateryna Kon/Science Photo Library/GettyImages</span></span></figcaption></figure><p>In the 2023 American post-apocalyptic drama television series <a href="https://www.hbo.com/the-last-of-us">The Last of Us</a>, humans are plunged towards extinction as a fungal infection of the brain zombie-fies most of the species. This may seem far-fetched but fungi can, and do, infect human brains.</p>
<p>Fungi are present everywhere in our environment: in the air, in the soil, in decaying plant material, on our skin, and even in the gut as part of our natural flora.</p>
<p>Microscopic, disease-causing fungi can invade various parts of the body, leading to a range of symptoms and health problems. In fact, fungal infections contribute to <a href="https://doi.org/10.3390%2Fjof7050367">about 1.5 million deaths</a> every year. </p>
<p>I am a neurobiologist who has been studying fungal infections of the brain for 10 years. I was part of a team that recently <a href="https://doi.org/10.1111/pim.12953">published a review</a> discussing the emergence, and re-emergence, of fungal infections in Africa, especially in sub-Saharan Africa. We conclude that Africa is suffering from a silent, but costly, epidemic of fungal infections. We found that the emergence of deadly fungal infections in the region is primarily driven by a high burden of HIV infections, lack of access to quality healthcare, and unavailability of effective antifungal drugs.</p>
<h2>What are fungal infections?</h2>
<p>For the greater part of the history of humankind, fungal infections were never a threat to human health. This is mainly because most fungi cannot survive the warm human body temperature of 37°C. However, climate change and other environmental pressures <a href="https://doi.org/10.1016/j.joclim.2022.100156">have led</a> to the emergence of species of fungi that are capable of surviving at human body temperatures. </p>
<p>Even then, our immune systems are quite capable of fighting against fungal infections. For instance, our bodies can create localised acidic environments, limit micronutrient availability and release antimicrobial agents. </p>
<p>However, when the immune system is weakened, fungi are able to evade the body’s defences and avoid detection. They can generate bioactive agents which help them evade or adjust to the host immune response. Some adapt to survive in hostile, low-nutrient and low-oxygen environments. </p>
<p>Immunocompromised people are at risk of developing serious or life-threatening fungal diseases. Africa accounts for <a href="https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf">67%</a> of the global burden of HIV, and opportunistic fungal diseases <a href="https://doi.org/10.1111/pim.12953">are on the rise</a>.</p>
<h2>Some examples</h2>
<p>One example of opportunistic fungal diseases is <a href="https://www.ncbi.nlm.nih.gov/books/NBK525986/">cryptococcal meningitis</a>, which emerged with the HIV pandemic in the late 1980s. Today, sub-Saharan Africa contributes about <a href="https://doi.org/10.1016/s1473-3099(17)30243-8">73%</a> of all global cases and deaths resulting from the disease. Cryptococcal meningitis is caused by the fungus <em>Cryptococcus neoformans</em>, which is found in soil and bird droppings. Infection by the fungus occurs when someone inhales fungal spores. It first leads to the development of a lung infection and later a fatal brain infection. Cryptococcal meningitis is a leading cause of adult meningitis in sub-Saharan Africa and it’s associated with <a href="https://doi.org/10.1016/S1473-3099(22)00499-6">almost 20%</a> of all AIDS-related deaths. </p>
<p>Effective treatments for cryptococcal meningitis are unaffordable and inaccessible for most affected people. Costs <a href="https://doi.org/10.1093/cid/ciy971">range between</a> US$1,400 and US$2,500 per patient for a full two-week antifungal treatment course. </p>
<p>The development of cheaper drugs has been hindered by a limited understanding of how the fungus causes such extreme damage in the brain. </p>
<p>Another example of an HIV-related opportunistic fungal disease is pneumocystis jirovecii pneumonia. It’s caused by a ubiquitous, airborne fungus <em>Pneumocystis jirovecii</em>, which is passed on from person to person. Pneumocystis hardly causes trouble in people with healthy immune systems, but they act as reservoirs and pass the infection to those with poor immune systems, who may develop serious symptoms including fever, a dry cough and trouble with breathing. Pneumocystis jirovecii pneumonia occurs in <a href="https://doi.org/10.1186/s12879-016-1809-3">15%-20%</a> of HIV patients who present with respiratory problems. </p>
<p>The diagnosis of pneumocystis jiroveci pneumonia is expensive and requires a well-equipped laboratory. In Africa’s poor urban and rural healthcare facilities this will be a challenge. The fungus, <em>P. jirovecii</em>, is also extremely difficult to culture, which limits diagnosis and research. </p>
<h2>Growing burden</h2>
<p>In our review, <a href="https://doi.org/10.1111/pim.12953">we found</a> various factors driving the emergence and reemergence of fungal threats. They include climate change, the spread of immunosuppressive diseases, medical advances such as organ transplants (the immune system is suppressed to minimise rejection), the use of immunosuppressants to manage inflammatory diseases, and the use of antibiotics. </p>
<p>While these factors are not unique to Africa, the burden of fungal diseases and the number of people who succumb to them is much greater. </p>
<p>The COVID pandemic seems to have made the global fungal burden worse. For instance, <a href="https://doi.org/10.1016/j.gr.2021.12.016">recent studies</a> have <a href="https://doi.org/10.4103%2Fijd.ijd_17_22">shown</a> that people who were infected with COVID and have recovered are vulnerable to infection with a fungus called mucormycosis, also known as the black fungus. COVID-induced lung damage, high blood sugar, and the steroids often used to treat it are all predisposing factors to black fungus infection. With a reduced capacity to clear fungal spores and a reduced immune response, thanks to the steroids, the fungus can gain entry and infect the sinuses and facial bones, eventually moving to the brain. </p>
<h2>But don’t we have antifungal drugs?</h2>
<p>Most of the population affected by fungal infections live in rural or poor urban settlements. </p>
<p>With poorly funded and overburdened healthcare systems, many African countries are not well prepared to deal with fungal infections. Additionally, some of the WHO-recommended antifungal drugs – such as flucytosine – are <a href="https://gaffi.org/antifungal-drug-maps/">unavailable</a> in most African countries. Ineffective and even rather toxic drugs are sometimes used instead. </p>
<p>The emergence of drug-resistant fungal strains is also a growing threat. Of great concern is the rise in multi-drug resistant Candida species, <a href="https://doi.org/10.1007/s11908-019-0702-9">azole-resistant Aspergillus</a> species and clinically resistant <a href="https://doi.org/10.1007/978-1-60327-595-8_20">Cryptococcus</a>. </p>
<h2>Management strategies</h2>
<p>Fungal threats are adding pressure to overburdened health systems with a limited arsenal of treatment options. </p>
<p>Healthcare professionals, scientific researchers, policymakers and governments must address the gaps in the diagnosis and management of fungal infections. This will help to improve capacity to deal with them.</p><img src="https://counter.theconversation.com/content/207836/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rachael Dangarembizi is a scientific researcher in the field of neuroscience and medical mycology and her research is funded by several funding bodies including the Gabriel Foundation and the UK Medical Research Council. </span></em></p>
Africa is suffering from a silent, but costly, epidemic of fungal infections.
Rachael Dangarembizi, Neuroinfections Researcher, Neuroscience Institute, University of Cape Town
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/204263
2023-04-26T12:28:46Z
2023-04-26T12:28:46Z
Challenging the FDA’s authority isn’t new – the agency’s history shows what’s at stake when drug regulation is in limbo
<figure><img src="https://images.theconversation.com/files/522817/original/file-20230425-28-sxmbmf.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2048%2C1370&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In addition to evaluating new drug applications, the FDA also inspects drug manufacturing facilities.</span> <span class="attribution"><a class="source" href="https://flic.kr/p/bCZpCD">The U.S. Food and Drug Administration/Flickr</a></span></figcaption></figure><p>Political pressure is nothing new for the U.S. Food and Drug Administration. The agency has <a href="https://theconversation.com/the-fdas-big-gamble-on-the-new-alzheimers-drug-162396">frequently come under fire</a> for its drug approval decisions, but attacks on its decision-making process and science itself have increased <a href="https://www.statnews.com/2020/08/27/trump-has-launched-an-all-out-attack-on-the-fda-will-its-scientific-integrity-survive/">during the COVID-19 pandemic</a>.</p>
<p>Recent challenges to the FDA’s authority have emerged in the context of reproductive rights.</p>
<p>On Nov. 18, 2022, a group of anti-abortion doctors and medical groups <a href="https://adflegal.org/sites/default/files/2022-11/Alliance-for-Hippocratic-Medicine-v-FDA-2022-11-18-Complaint.pdf">filed a lawsuit</a> against the FDA, challenging its approval from more than 20 years ago of <a href="https://theconversation.com/mifepristone-is-under-scrutiny-in-the-courts-but-it-has-been-used-safely-and-effectively-around-the-world-for-decades-204163">mifepristone</a>, a drug taken in combination with another medication, misoprostol, to <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">treat miscarriages</a> and used to induce <a href="https://www.guttmacher.org/article/2022/02/medication-abortion-now-accounts-more-half-all-us-abortions">more than 50% of abortions</a> in early-stage pregnancies in the U.S.</p>
<p>It is widely believed that the plaintiffs filed the lawsuit in the Northern District of Texas so District Judge Matthew J. Kacsmaryk, a <a href="https://www.nytimes.com/2023/04/07/us/politics/texas-judge-matthew-kacsmaryk-abortion-pill.html">well-known abortion opponent</a>, could oversee the litigation. While Kacsmaryk did issue a preliminary injunction ruling that the FDA lacked the authority to approve mifepristone, an appeal <a href="https://storage.courtlistener.com/recap/gov.uscourts.ca5.213145/gov.uscourts.ca5.213145.183.2_1.pdf">partially reversed</a> the decision and the Supreme Court <a href="https://www.supremecourt.gov/opinions/22pdf/22a901_3d9g.pdf">stayed Kacsmaryk’s order</a>. The case now sits at the 5th U.S. Circuit Court of Appeals and will likely return to the Supreme Court.</p>
<p>The FDA is the government’s oldest consumer protection agency. The effects of this lawsuit could reach far beyond mifepristone – undermining the agency’s authority could threaten its entire drug approval process and change access to commonly used drugs, ranging from amoxycillin and Ambien to prednisone and Paxlovid.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=Yeg0EUgAAAAJ&hl=en">legal scholar</a> whose research focuses in part on the law and ethics of the FDA’s drug approval process. Examining the FDA’s history reveals the unprecedented nature of the current challenges to the agency’s authority.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chart titled 'Data for Decisions' depicting sources the FDA considers in its decision-making" src="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=381&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=381&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=381&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=479&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=479&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522844/original/file-20230425-14-2hs75n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=479&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Then FDA Commissioner George Larrick used this chart during 1964 Senate testimony to illustrate the range of sources the agency uses in evaluating proposals.</span>
<span class="attribution"><a class="source" href="https://flic.kr/p/dv6CFV">The U.S. Food and Drug Administration/Flickr</a></span>
</figcaption>
</figure>
<h2>Events shaping FDA’s focus on safety</h2>
<p>In its early years, the FDA focused primarily on balancing the competing goals of consumer safety with access to experimental treatments. The priority was strengthening consumer protection to prevent tragedy from recurring. </p>
<p>For instance, at the turn of the 20th century, Congress passed the <a href="https://ncjolt.org/articles/volume-23/volume-23-issue-4/fdas-accelerated-approval-emergency-use-authorization-and-pre-approval-access-considerations-for-use-in-public-health-emergencies-and-beyond/">Biologics Control Act of 1902</a>, providing the federal government the authority to regulate vaccines. This law was introduced after 13 children died from inadvertently contaminated diphtheria antitoxin, which was made from the blood of a horse infected with tetanus. </p>
<p>A few years later, after investigative journalists publicized the unsanitary conditions and food-handling practices in meatpacking plants, Congress passed the <a href="https://ssrn.com/abstract=3237889">Pure Food and Drug Act of 1906</a>, which prohibited the marketing and sale of misbranded and contaminated foods, drinks and drugs.</p>
<p>Similarly, in 1937, approximately 71 adults and 34 children died from ingesting <a href="https://doi.org/10.7326/0003-4819-122-6-199503150-00009">S.E. Massengill’s antibacterial elixir</a>, which contained a poisonous raspberry flavoring added to sweeten the taste. In response, Congress passed the <a href="https://www.fda.gov/about-fda/fda-history/milestones-us-food-and-drug-law">Federal Food, Drug and Cosmetic Act of 1938</a>, requiring manufacturers to show that drugs are safe before they go on the market. This act marked the beginning of modern drug regulations and the birth of the FDA as a regulatory agency. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/4wIBCoxuOJ0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">FDA scientist Frances Oldham Kelsey’s decision to not approve thalidomide for use in the U.S. protected Americans from the birth defects that swept newborns in other countries.</span></figcaption>
</figure>
<p>Then, in 1962, Dr. Frances Oldham Kelsey, a pharmacologist, physician and medical officer working at the FDA, <a href="https://www.fda.gov/about-fda/fda-history/milestones-us-food-and-drug-law">refused to approve thalidomide</a>, a drug marketed in Europe, Canada, Japan and other countries to alleviate morning sickness in pregnant women but later found to cause severe birth defects. Shocking revelations of children born without limbs or suffering from other debilitating conditions motivated Congress to pass the <a href="https://theconversation.com/could-thalidomide-happen-again-46813">Kefauver-Harris Drug Amendments of 1962</a>, which ushered in a more cautious approach to the drug approval process.</p>
<h2>FDA’s turn toward expanding access</h2>
<p>During the 1970s, questions about the limits of safety versus an individual’s right to access arose when cancer patients who wanted access to an unapproved drug derived from apricots, Laetrile, sued the FDA. The agency had blocked the drug’s shipment and sale because it was not approved for use in the U.S. At that time, the Supreme Court <a href="https://tile.loc.gov/storage-services/service/ll/usrep/usrep442/usrep442544/usrep442544.pdf">upheld the FDA’s protective authority</a>, holding that an unproven therapy is unsafe for all patients, including the terminally ill.</p>
<p>The 1980s, however, marks the FDA’s shift toward increasing access following reports of an emerging disease – AIDS – which primarily affected gay men. In the first nine years of the AIDS epidemic, <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/00001880.htm">over 100,000 Americans died</a>. AIDS patients and their advocates became <a href="https://dx.doi.org/10.2139/ssrn.2739121">vocal critics of the FDA</a>, arguing that the agency was too paternalistic and restrictive following events like the thalidomide scare.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="ACT UP protestors lying on the ground with tombstone-shaped signs demanding the FDA allow access to experimental HIV/AIDS drugs" src="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=412&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=412&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=412&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=518&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=518&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522846/original/file-20230425-3279-zhlvri.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=518&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protests from HIV/AIDS activists like ACT UP spurred the FDA to develop expedited drug approval tracks to meet urgent public health needs.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/protesters-close-the-federal-drug-administration-building-news-photo/1213566352">Mikki Ansin/Peter Ansin via Getty Images</a></span>
</figcaption>
</figure>
<p>After massive protests, Dr. Anthony Fauci, then director of the National Institute of Allergy and Infectious Diseases, proposed a <a href="https://www.washingtonpost.com/outlook/2020/04/29/fight-against-aids-has-shaped-how-potential-covid-19-drugs-will-reach-patients/">parallel track program</a> allowing eligible patients access to unapproved experimental treatments. This, along with other existing FDA mechanisms, helped lay the path for other alternative approval pathways, such as <a href="https://theconversation.com/what-are-emergency-use-authorizations-and-do-they-guarantee-that-a-vaccine-or-drug-is-safe-151178">Emergency Use Authorization</a>, which played a large role in permitting use of vaccines and medications pending full FDA approval during the COVID-19 pandemic.</p>
<h2>Future of the FDA</h2>
<p>Despite the FDA’s shift toward increased access, the <a href="https://www.statnews.com/2018/05/31/right-to-try-ron-johnson/">political right has in recent years argued</a> that the agency remains too bureaucratic and paternalistic and should be deregulated – an argument seemingly contrary to the reasoning underlying Kacsmaryk’s recent order that the FDA did not sufficiently evaluate the safety of mifepristone in its approval.</p>
<p>Mifepristone, which has <a href="https://www.ama-assn.org/delivering-care/public-health/ama-court-don-t-overturn-fda-approval-mifepristone">overwhelming data supporting its safety</a>, could remain available to some people in some states regardless of the outcome of this lawsuit. While the FDA approves drugs for consumer use, it does not regulate the general practice of medicine. Doctors can <a href="https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label">prescribe FDA-approved drugs off-label</a>, meaning they could prescribe a drug with a different dose, in a different way or for a different use than what the FDA has approved it for.</p>
<p>The mifepristone case has broad implications for the FDA’s future and could have devastating effects on health in the U.S. Due in part to FDA involvement, public health interventions have led to a <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6019a5.htm#">62% increase in life expectancy</a> in the 20th century. These include vaccines and medications for childhood illnesses and infectious diseases such as HIV, increased regulation of tobacco, and <a href="https://theconversation.com/fda-approval-of-over-the-counter-narcan-is-an-important-step-in-the-effort-to-combat-the-us-opioid-crisis-198497">over-the-counter Narcan</a> to combat the opioid crisis, among others.</p>
<p>The FDA needs to be able to use its scientific expertise to make data-driven decisions that balance safety and access, without the ability of a single judge to potentially gut the system. The agency’s history is an important reminder of the need for strong administrative agencies and ongoing vigilance to protect everyone’s health.</p><img src="https://counter.theconversation.com/content/204263/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Coughlin is affiliated with the Foundation for Prosecutorial Accountability.</span></em></p>
As the government’s oldest consumer protection agency, the FDA has long butted up against drugmakers, activists and politicians. But undermining its work could be harmful to patient health and safety.
Christine Coughlin, Professor of Law, Wake Forest University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/202354
2023-03-28T00:31:23Z
2023-03-28T00:31:23Z
The ABC’s In Our Blood shines a light on lesbian activism during the AIDS crisis – but there’s more to their story
<figure><img src="https://images.theconversation.com/files/517581/original/file-20230327-14-y6a0wp.jpg?ixlib=rb-1.1.0&rect=11%2C5%2C3982%2C2652&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">ABC</span></span></figcaption></figure><p>The recent ABC mini-series, In Our Blood, offers a fictionalised account of Australia’s response to AIDS, focusing on the development of a <a href="https://unsw.press/books/learning-to-trust/">partnership</a> between impacted communities, health professionals and government. </p>
<p>Lesbians are placed at the centre of this narrative, but more needs to be done to ensure these representations capture the complex histories of AIDS <a href="https://www.dukeupress.edu/information-activism">information activism</a> in Australia.</p>
<p>The series features two lesbian characters: activist Deb (Jada Alberts) and high-school teacher Mish (Anna McGahan). Deb and Mish are shown attending activist rallies, speaking up in meetings with government representatives, transforming their home into an office for AIDS activists, and caring for people living with HIV.</p>
<p>Their inclusion serves to historicise lesbians’ immense contribution to Australian AIDS activist movements – but it perpetuates a well-established trope of the “altruistic” <a href="https://researchers.mq.edu.au/en/publications/the-fabric-of-resistance-care-domestic-objects-and-hiv-self-narra">lesbian carer and advocate</a>. </p>
<p>In this re-telling, we risk forgetting that lesbians also protested their own exclusion from epidemiological, medical and public health information about AIDS.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/6F70kankd6Q?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>Are lesbians at risk of HIV?</h2>
<p>The answer is complicated. </p>
<p>While sex between cisgender women is thought to be low risk, several studies suggest that <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(87)93071-6/fulltext">transmission is possible</a>. </p>
<p>It is, however, important to understand how HIV risk transmission hierarchies can render lesbian and queer women invisible in our surveillance data. </p>
<p>When a person is diagnosed with HIV, risk transmission hierarchies are used to record their most probable source of exposure to the virus. <a href="https://www.tandfonline.com/doi/full/10.1080/14680777.2020.1837907">In Australia</a>, these risk hierarchies have never recognised female-to-female sex as a potential route for HIV transmission.</p>
<p>This means, for example, that if a woman reports having sex with both men and women, her exposure to the virus is recorded as “heterosexual contact”. If she has never had sex with a man but uses injecting drugs, her exposure is recorded as “injecting drug use”. And if she has never had sex with a man or used injecting drugs, her exposure is recorded as “undetermined”.</p>
<p>Yet, even if we understand sex between cisgender women as low risk, lesbians are not a homogenous group. Some lesbians use injecting drugs, have sex with men or could become infected with HIV through another source of transmission. </p>
<p>But for these lesbians to be included in HIV surveillance data, their sexual identities <a href="https://www.tandfonline.com/doi/full/10.1080/13691058.2012.738430">must be obscured</a>.</p>
<p>Because of this, we have no way of knowing how many lesbian and queer women are living with HIV or have died from AIDS-related illness in Australia. Although, anecdotally, we do know that <a href="https://www.positivelife.org.au/wp-content/uploads/2021/01/plnsw-talkabout-46.pdf">four of the first seven</a> women diagnosed with HIV were lesbians.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=837&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=837&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=837&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1052&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1052&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517814/original/file-20230327-26-7xlsk0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1052&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Part of the safe-sex campaign during the 1980s.</span>
<span class="attribution"><span class="source">Act Up Melbourne</span></span>
</figcaption>
</figure>
<h2>Untold histories of lesbian AIDS activism</h2>
<p>Since the 1980s, when In Our Blood takes place, lesbians have advocated for their inclusion in Australia’s public health, medical and epidemiological response to AIDS. </p>
<p>Much lesbian AIDS activism occurred from within Australian AIDS organisations, such as the AIDS Council of New South Wales (now known as ACON). In 1988, ACON’s Women and AIDS Working Group produced the organisation’s first lesbian information pack, entitled <a href="https://www.positivelife.org.au/wp-content/uploads/2021/01/plnsw-talkabout-46.pdf">Sapph Sex</a> – its title a pun on safe and sapphic sex.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=584&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=584&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=584&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=734&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=734&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517813/original/file-20230327-28-e21gsy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=734&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">ACON’s Women and AIDS Working Group produced the organisation’s first lesbian information pack.</span>
<span class="attribution"><span class="source">ACON</span></span>
</figcaption>
</figure>
<p>Outside the context of Australian AIDS organisations, activists used lesbian magazines to produce, debate and circulate lesbian-specific information about HIV. Lesbian magazines published articles <a href="https://nla.gov.au/nla.obj-881421990/view?partId=nla.obj-881436490#page/n5/mode/1up">contesting the dominant assumption</a> that lesbians were “immune” to HIV, and provided a platform for HIV-positive lesbians to write on their experiences. </p>
<p>Readers of Australia’s largest lesbian magazine, Lesbians on the Loose, were also encouraged to write in to the magazine’s resident doctor, Doctor on the Loose, to request guidance on a range of health-related concerns.</p>
<p>During the height of the epidemic, Doctor on the Loose provided readers with advice on the risks associated with specific practices: sex, injecting drug use, sperm donation, and blood sharing rituals. In their responses, Doctor on the Loose worked to dispel <a href="https://nla.gov.au/nla.obj-884067310/view?partId=nla.obj-884070012">common misunderstandings</a> about HIV transmission:</p>
<blockquote>
<p>you can’t catch it from toilet seats, sharing food, sharing joints, shaking hands or kissing (there is no evidence that tongue kissing passes on HIV).</p>
</blockquote>
<p>HIV-positive lesbians were, of course, at the forefront of these activist endeavours. One such lesbian was Jennifer Websdale. As one of the first seven women diagnosed with HIV in Australia, she was committed to ensuring lesbians were visible as a distinct population in the global AIDS epidemic. </p>
<p>In 1991, Websdale received funding to attend the Ninth National AIDS/HIV Forum in New Orleans. When she returned to Australia, she coined the term “<a href="https://nla.gov.au/nla.obj-888349986/view?partId=nla.obj-888383459#page/n11/mode/1up">cuntaphobia</a>” to describe the complex intersections of sexism and homophobia that work to silence HIV-positive lesbians in wider conversations about HIV.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=717&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=717&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=717&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=901&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=901&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517819/original/file-20230327-26-7u5zkr.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=901&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">AIDs campaigning in Australia 1985.</span>
<span class="attribution"><span class="source">ACON</span></span>
</figcaption>
</figure>
<p>Websdale died from AIDS-related illness in 1994 at the age of 33. Three decades on, her activism retains an enduring relevance. </p>
<p>As we move toward <a href="https://www.afao.org.au/our-work/agenda-2025/">ending HIV</a> in Australia, it is imperative for us to interrogate how our ingrained re-tellings of the Australian AIDS epidemic foreground some histories, and marginalise others. </p>
<p>After all, the project of ending HIV will require us to ensure that HIV prevention, testing and treatment information and services are available to all Australians – including lesbian and queer women.</p><img src="https://counter.theconversation.com/content/202354/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Manlik received funding from a Research Training Program (RTP) Scholarship while undertaking this research.</span></em></p>
The ABC mini-series, In Our Blood, offers a fictionalised account of Australia’s response to AIDS – but more can be done to remember lesbians’ immense contribution to AIDS activist movements.
Kate Manlik, Casual Academic and PhD Candidate, Macquarie University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/195997
2023-01-08T08:47:21Z
2023-01-08T08:47:21Z
HIV remains a leading killer in Africa despite medical breakthroughs – how to eliminate it
<figure><img src="https://images.theconversation.com/files/500741/original/file-20221213-13937-sc773c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p><em>About <a href="https://www.unaids.org/en/resources/fact-sheet">38 million</a> people around the world are living with HIV. About 70% of them live in Africa. This shows that there is no solution to the AIDS pandemic without a solution in Africa. In 2021, there were 1.5 million <a href="https://www.unaids.org/en/resources/fact-sheet">new cases</a> of HIV – just over 4,000 cases per day around the world. At the same time, close to <a href="https://www.unaids.org/en/resources/fact-sheet">700,000 people died</a>. The big challenge is to address the dual realities of people still dying from HIV in large numbers, and the large numbers of new infections. The upside is that there is a clear plan with clear goals on how to address this. In 2016, countries came together at the United Nations to <a href="https://www.unaids.org/en/resources/909090">agree</a> on what the world’s strategy should be. The goal is to end AIDS as a public health threat by 2030. We spoke with leading scientist Professor Salim Abdool Karim about how to close the gaps.</em></p>
<hr>
<h2>What are we getting wrong?</h2>
<p>It’s not like we’re doing something wrong, but you can always do better than what we do now. Most new infections are coming from two different groups.
The first is key populations. The largest number of new infections is occurring in <a href="https://www.unaids.org/sites/default/files/media_asset/2022-global-aids-update-summary_en.pdf">men who have sex with men</a>. Especially young men – often young black men. These infections occur largely in Eastern Europe and in Russia.</p>
<p>The second high priority is the large numbers of new infections in <a href="https://www.sciencedirect.com/science/article/pii/S2772707622001035">young women in Africa</a>. If we don’t address those two groups, we won’t solve the problem.
But to address those two groups is not easy. The challenges in much of Eastern Europe and Russia relate to their marginalisation and discrimination as much as they are about services for key populations.</p>
<p>In Africa, we have simply not been able to stem the number of new infections in young women to the extent we had hoped. The problem is the way in which society has supported or entrenched age disparate sex, where teenage girls are having sex with men about eight to 10 years older than them.</p>
<p>And the means we have to slow the rate of new infections in young women is not well suited to the need. It’s not feasible for a young woman who is not thinking about HIV and aware of her risk regularly to take a tablet every day or even to get an injection. So we have to develop new technologies.</p>
<p>We need a combination of new approaches in our society to reduce age disparate sex. And we need new technologies to protect young women. And thirdly, we need to get more young men and more men in their 20s and 30s into health services so that they test and they go on to treatment before they infect young girls.</p>
<h2>How do we change this?</h2>
<p>There are three things we have to think about.</p>
<p>The first is we must appreciate that each of us is mutually interdependent: each person’s risk affects the risk faced by others. Hence, we need solutions that involve everyone working towards a common purpose. We saw that very clearly in COVID-19. Omicron was first described in South Africa in November 2021 – within a week this variant was detected in 16 countries. Within two weeks omicron was in several countries on all continents. This shows that we are all interconnected and dependent on each other. We have a shared responsibility to deal with the problem. </p>
<p>We can’t take the attitude that it’s somebody else’s problem. In many ways, in HIV, the response has taken our interdependence into consideration. For example, wealthy countries put resources into the <a href="https://www.theglobalfund.org/en/">Global Fund to Fight AIDS, TB and Malaria</a> for poor countries to benefit. It’s a shared responsibility. The countries are not saying, “It’s Africa’s problem, we don’t care.” No, they’re saying, “We understand that if we don’t get HIV under control in Africa, it affects the whole world.”</p>
<p>Second is that we have to mobilise the resources to at least get treatment up to the levels that we have set in our targets. That means we have to get 95% of people knowing their HIV status, 95% of people with HIV on treatment, and 95% of them virally suppressed. This is the global target for 2025. We need to help each other to get to that target.</p>
<p>We’re going to need to do better with prevention. That’s the third point. Treatment is not going to be enough on its own to enable us to reach the 2030 target. We need to improve prevention. That means we’re going to need to continue our efforts in circumcision and condom promotion, and to do better with pre-exposure prophylaxis.</p>
<h2>What are the next steps?</h2>
<p>We need to build on the momentum from the COVID-19 pandemic. The introduction of new technologies such as <a href="https://medlineplus.gov/genetics/understanding/therapy/mrnavaccines/#:%7E:text=Currently%20vaccines%20for%20COVID%2D19,as%20the%20%E2%80%9Cspike%20protein%E2%80%9D.">mRNA</a> is a good example. This is technology we can tap to improve the research on vaccines against tuberculosis and malaria, particularly in HIV.
We don’t have a vaccine for HIV yet, but there are now new candidates being made with mRNA. At least we can do better with existing TB vaccines and existing malaria vaccines with a new platform such as using mRNA technology. It is also an important platform for HIV vaccines in the pipeline.</p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195997/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Salim Abdool Karim does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
We need a combination of new approaches to reduce age disparate sex. And we need new technologies to protect young women.
Salim Abdool Karim, Director, Centre for the AIDS Program of Research in South Africa (CAPRISA)
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/195479
2022-12-13T13:27:56Z
2022-12-13T13:27:56Z
Hypertension, diabetes, stroke: they kill more people than infectious diseases and should get a Global Fund
<figure><img src="https://images.theconversation.com/files/499986/original/file-20221209-19531-9yfpxs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">shutterstock</span> </figcaption></figure><p>Noncommunicable diseases such as diabetes, hypertension and cardiovascular conditions account for <a href="https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases">41 million deaths</a> each year. That’s more than 70% of all deaths globally. Most of these deaths (77%) are in low-income and middle-income countries – including those in Africa. </p>
<p>These conditions are currently <a href="https://www.researchgate.net/publication/356360474_Tanzania_Non-communicable_Diseases_and_Injuries_Poverty_Commission_Findings_and_Recommendations">more prevalent</a> than infectious diseases. Sixty-seven percent occur before the age of 40. Besides being the leading causes of death worldwide, noncommunicable diseases carry a <a href="https://apps.who.int/iris/handle/10665/274512">huge cost</a> to individuals. These also undermine workforce productivity and threaten economic prosperity.</p>
<p>Healthcare provision in much of Africa still relies on <a href="https://www.brookings.edu/blog/future-development/2019/03/01/closing-africas-health-financing-gap/">external donors</a>. There’s insufficient funding to help low-income and middle-income countries control noncommunicable diseases. Most <a href="https://jamanetwork.com/journals/jama/fullarticle/2320320">development assistance for health funding</a> provided by international donors is allocated for infectious diseases and maternal and child health. In <a href="https://vizhub.healthdata.org/fgh/">2019</a>, funding for HIV amounted to US$9.5 billion. The amount allocated to noncommunicable diseases was US$0.7 billion. </p>
<p>Evidence suggests that addressing the noncommunicable disease pandemic can also mitigate other challenges like HIV, tuberculosis (TB), maternal and child health, and universal health coverage. </p>
<p>The <a href="https://www.theglobalfund.org/en/">Global Fund</a> to Fight AIDS, TB and Malaria is an international partnership. The fund invests US$4 billion a year to fight these three diseases. </p>
<p>I believe it’s now time to think of establishing a Global Fund for noncommunicable diseases, or expand the mandate of Global Fund beyond AIDS, TB and malaria. The epidemics of these conditions overlap. For example, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8872228/#:%7E:text=The%20most%20prevalent%20HIV%20comorbidities,and%20hepatitis%20C%20%5B14%5D.">research</a> has shown that <a href="https://jamanetwork.com/journals/jama/article-abstract/2757599">comorbidities</a> such as diabetes and cancers are common in people living with HIV. </p>
<h2>Broadening healthcare provision</h2>
<p>Disease specific programmes have <a href="https://academic.oup.com/heapol/article/33/3/381/4812662">limitations</a>. As public health practitioners we should learn from our mistakes. We must build integrated programmes and health systems that address the interlinkages and co-morbidities. One example would be to include diabetes screening in TB treatment programmes. </p>
<p>In addition to integration, noncommunicable diseases require increasing investments. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=352&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=352&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499973/original/file-20221209-22427-6zj374.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=352&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>The Global Fund is seeking US$18 billion this year. At the same time <a href="https://www.thelancet.com/ncd-countdown-2030">The Lancet NCD Countdown 2030</a> projects that interventions for noncommunicable diseases need US$18 billion a year. That’s what it would take to meet the UN target of reducing noncommunicable diseases by a third by the year 2030. </p>
<p>I would argue that the case for <a href="https://pubmed.ncbi.nlm.nih.gov/35339227/">investment</a> in noncommunicable diseases has never been stronger. </p>
<h2>A roadmap</h2>
<p>The World Health Assembly recently <a href="https://www.who.int/news-room/feature-stories/detail/world-health-assembly-approves-a-global-implementation-roadmap-to-accelerate-action-on-noncommunicable-diseases-(ncds)">approved</a> the World Health Organization’s roadmap for the prevention and control of noncommunicable diseases covering the period 2023-2030. </p>
<p>The roadmap recommends actions to: </p>
<ul>
<li><p>promote “best-buys” interventions with a high return for every dollar spent, such as smoking cessation programmes </p></li>
<li><p>strengthen health systems </p></li>
<li><p>reduce noncommunicable disease risk factors such as tobacco use and unhealthy diets </p></li>
<li><p>embed noncommunicable diseases within primary healthcare and universal health coverage. </p></li>
</ul>
<p>This roadmap needs to be followed in line with the commitments to reduce air pollution and promote mental health and well-being.</p>
<p>The lessons learned from the COVID-19 pandemic offer opportunities for strengthening emergency preparedness and responses beyond pandemics. Emergency risk management and continuity of essential health services for all hazards – addressing the foundational health system gaps – can improve health security.</p>
<h2>What should be done</h2>
<p>How should Africa respond to the increasing burden of noncommunicable diseases? There needs to be a strong political will and buy-in from governments, with strong multi-stakeholder participation. </p>
<p>The <a href="https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025">UN General Assembly</a> decision on HIV and noncommunicable diseases commits governments to identify and address the comorbidities of HIV and other links to pressing global health challenges. These include links to noncommunicable diseases, learning from the perspectives of people living with these conditions and underscoring the importance of focusing on comorbidities. </p>
<p>The WHO’s <a href="https://www.who.int/initiatives/global-noncommunicable-diseases-compact-2020-2030#:%7E:text=The%20Global%20NCD%20Compact%202020,of%20people%20living%20with%20NCDs.">noncommunicable disease compact</a> proposes concrete actions. These actions need to be data-driven and supported by noncommunicable disease-related indicators in health systems performance and access to healthcare metrics. </p>
<p>Monitoring systems need to be more diverse. The systems should capture and monitor progress made through sectors that affect health, such as housing and sanitation. Doing this would strengthen the monitoring of national systems and the capacity to address noncommunicable diseases comprehensively.</p>
<p>Health system strengthening and quality of care will improve significantly with additional resources for noncommunicable diseases through an entity like the Global Fund. </p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2022 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/195479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaushik Ramaiya is Honorary General Secretary of Tanzania Diabetes Association and we work with Ministry of Health (Tanzania) in implementing National NCD program which has been funded by World Diabetes Foundation (WDF) and Novo Nordisk Foundation. </span></em></p>
Addressing the noncommunicable disease pandemic can also mitigate challenges facing people living with HIV and complement efforts against TB.
Kaushik Ramaiya, Honorary Professor of Medicine & Global Health , Liverpool School of Tropical Medicine
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/195542
2022-12-01T21:03:51Z
2022-12-01T21:03:51Z
On World AIDS Day, Canada must lead the way in combating HIV-AIDS
<figure><img src="https://images.theconversation.com/files/498368/original/file-20221201-12-91tm7n.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C3888%2C2566&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Provinces like British Columbia have reduced infection rates thanks to successful treatment and prevention measures. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Dec. 1 marks <a href="https://www.worldaidsday.org/">World AIDS Day</a>. As researchers focused on fighting the HIV-AIDS epidemic, we are increasingly concerned all the progress made in the fight against the virus is at risk. </p>
<p>In 1996, the first remarkable breakthrough against the HIV-AIDS epidemic came with the novel combination of drugs that became known as <a href="https://www.ncbi.nlm.nih.gov/books/NBK554533/">Highly Active Antiretroviral Therapy (HAART)</a>.</p>
<p>For the first time, HAART was able to stop viral replication and render the virus undetectable in blood and bodily fluids, and consequently promote immune reconstitution. This in turn would prevent an HIV infection from developing into AIDS, significantly reducing premature deaths.</p>
<h2>Treatment as prevention</h2>
<p>The next major breakthrough came in the early 2000s. Through close monitoring of the epidemic in British Columbia, our research documented that HIV infected individuals who have consistent viral suppression with HAART are virtually unable to transmit the infection. This led us to recommend initiating HAART immediately following HIV diagnosis to accelerate overall HIV/AIDS control. </p>
<p>We called the strategy <a href="https://bccfe.ca/tasp/about">Treatment as Prevention</a> (TasP) to illustrate the fact that HAART simultaneously stops progression to AIDS, premature death and HIV transmission.</p>
<p>TasP was enthusiastically embraced by the Joint United Nations (UN) Programme on HIV/AIDS (UNAIDS), in 2010. However, it soon became apparent that the TasP strategy was too ill defined, and this open the door for it to be inconsistently deployed between regions.</p>
<p>In 2014, <a href="http://www.unaids.org/sites/default/files/media_asset/JC2670_UNAIDS_Treatment_Targets_en.pdf">UNAIDS unveiled two sequential TasP-inspired targets</a> to quantify the proportion of people living with HIV who need to be diagnosed, the proportion of diagnosed people who need to be on HAART, and the proportion of people on HAART who need to be <a href="https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treatment/viral-suppression">virologically suppressed</a> by 2020 and 2025. Viral suppression is defined by having less than 200 copies of HIV per milliliter of blood.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&rect=0%2C300%2C3085%2C1958&q=45&auto=format&w=1000&fit=clip"><img alt="A white flag with the words World Aids day and a red ribbon flies in front of the peace tower." src="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&rect=0%2C300%2C3085%2C1958&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Canada has made breakthroughs in the fight against HIV-AIDS, but more must be done to make access to treatment more equitable.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>These targets were specifically designed so that by 2030 the world would see a 90 per cent decrease in AIDS mortality and new HIV infections, and meet the goal of ending the HIV-AIDS pandemic. In 2015, the UN <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/june/20210608_hlm-opens">formally endorsed</a> the <a href="https://doi.org/10.7448%2FIAS.19.1.20917">90-90-90 by 2020</a> target. It endorsed our subsequent <a href="https://bccfe.ca/blog/united-nations-adopts-ambitious-95-95-95-95-target">95-95-95 by 2025</a> target in 2021. </p>
<p>However, a lack of leadership and resources have hampered progress towards the UN targets around the world. This has been exacerbated by the COVID-19 pandemic, which disrupted some medical services, decreased HIV testing, interrupted the provision of HAART and diverted funding. </p>
<h2>Differing success rates across Canada</h2>
<p>In 2020, the Public Health Agency of Canada (PHAC) released a much-awaited <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/hiv-canada-surveillance-report-december-31-2020.html">epidemiological HIV/AIDS update</a>. The update came ahead of the <a href="https://aids2022.org/2022/04/29/the-international-aids-conference-returns-to-montreal/">International AIDS Conference</a> held in Montréal in July 2022. </p>
<p>Unfortunately, the results were rather concerning. HIV cases in Canada have remained flat since the 1990s, but there is a marked contrast between British Columbia and the rest of the country. While B.C. saw a steady decline in cases between 1996 and 2020, the rest of Canada saw no further reduction in cases over the same period. </p>
<p>HIV cases peaked throughout Canada in the early 80s. But a decrease in high-risk sexual practices led to a substantial reduction in cases. After that, the course of the epidemics diverged. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="HIV incidence across Canada and B.C. from 1980-2020" src="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=263&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=263&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=263&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=330&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=330&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=330&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">HIV cases from 1980 until 2020 in Canada and British Columbia.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<p>The reason for this discrepancy can be explained by the success of TasP in B.C., where the strategy originated. The graph below compares progress toward the UN’s 2020 target across Canada’s provinces and territories.</p>
<p>B.C., Nova Scotia, Newfoundland and Labrador and the three territories are the only Canadian jurisdictions that surpassed all three components of the <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html#s10">benchmark target</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A chart showing Canadian provinces' progress towards the UNAIDS 90-90-90 targets" src="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Estimated percentage of people living with HIV diagnosed, on treatment and virally suppressed by selected regions in Canada at the end of 2020.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<p>A failure to optimally implement TasP nationally has led to markedly different <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html">HIV rates</a> across the country. In 2020, the national HIV incidence rate was 4.8 per 100,000 people. B.C., which had the highest domestic incidence rate at the peak of the epidemic in the 1980s, was well below the national average, at 2.5 per 100,000 population. The province is now at the low end of the national spectrum, together with the territories and Atlantic provinces at 2.1 and 2.2 per 100,000 population, respectively. </p>
<p>Alberta and Ontario were within the range of the national average at 4.2 and 4.1 per 100,000 population. At the other end, Saskatchewan, Manitoba and Québec were above the national average at 23.0, 7.7 and 5.8 per 100,000 population, respectively. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Map of Canadian provinces & territories showing HIV incidence rates in 2020." src="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=497&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=497&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=497&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=625&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=625&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=625&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">HIV rates in Canada by province and territory in 2020.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<h2>What Canada needs to do</h2>
<p>Clearly, Canada has the tools and the means to end the epidemic. The question remains, are we up to the task? The key requirements are well known: </p>
<ol>
<li>Normalize HIV testing to ensure everybody knows their HIV status.</li>
<li>Remove barriers to <a href="https://www.ohtn.on.ca/out-of-pocket-costs-associated-with-hiv-in-publicly-funded-high-income-health-care-settings/">accessing health services</a>. </li>
<li>Expand support for affected populations, with particular emphasis on harder-to-reach and most affected populations (men who have sex with men, people dealing with substance use, sex workers, inmates, immigrants and First Nations Peoples).</li>
<li>Make free harm reduction services widely available (condoms, lubricants, injection and smoking paraphernalia, supervised injection and smoking consumption sites and safer drug supply programs).</li>
<li><a href="https://doi.org/10.9778/cmajo.20180058">Free HAART</a> for all HIV-positive people.</li>
<li>Free <a href="https://www.cdc.gov/hiv/risk/prep/index.html">pre-exposure prophylaxis (PrEP)</a> to all people at heightened HIV risk.</li>
<li>Free relevant laboratory monitoring for all those on HAART or PrEP. </li>
</ol>
<p>In addition, we must demand full transparency and accountability from our health-care system. That starts with PHAC annually reporting progress towards the UN 95-95-95 by 2025 target, HIV prevalence and AIDS-related mortality. </p>
<p>Finally, the federal government should sponsor a yearly independent summit of all relevant stakeholders to promote accountability and transparency, compare regional progress and share lessons learned in the process. </p>
<p>As a leader in treatment and prevention, Canada has a global responsibility to optimally implement a strategy to effectively combat HIV-AIDS. That will require a major commitment from the provinces given that health care is a provincial responsibility. </p>
<p>Canada knows how to end the HIV-AIDS epidemic. It is high time to get it done.</p><img src="https://counter.theconversation.com/content/195542/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julio Montaner has received support, paid to his institution, from the BC Ministry of Health, Health Canada, the Public Health Agency of Canada, Genome BC, Vancouver Coastal Health and the VGH Foundation. Institutional grants have been provided by Gilead, Merck and ViiV Healthcare.</span></em></p><p class="fine-print"><em><span>Viviane Dias Lima receives funding from the Canadian Institutes of Health Research (PJT-148595; PJT-156147), and the Canadian Foundation for AIDS Research (CANFAR Innovation Grant – 30-101). </span></em></p>
Dec. 1 marks World AIDS Day. Canada has the tools and means to end the epidemic. The question remains, are we up to the task?
Julio Montaner, Killam Professor, Department of Medicine, University of British Columbia
Viviane Dias Lima, Scientist, Senior Methodologist & Associate Professor, Department of Medicine, University of British Columbia
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/195381
2022-11-30T13:43:40Z
2022-11-30T13:43:40Z
COVID deepened inequalities in HIV treatment: what we learnt in Nigeria
<figure><img src="https://images.theconversation.com/files/498217/original/file-20221130-12-u3ona4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/closeup-woman-hand-holding-red-ribbon-hiv-world-royalty-free-image/1219095637?phrase=HIV%2FAIDS%20in%20Nigeria&adppopup=true">Suriyawut Suriya/Getty Images</a></span></figcaption></figure><p>The 2022 World AIDS Day theme is <a href="https://www.who.int/europe/news-room/events/item/2022/12/01/default-calendar/world-aids-day-2022--equalize#:%7E:text=On%201%20December%20WHO%20joins,under%20the%20theme%20%E2%80%9CEqualize%E2%80%9D.">Equalize</a>. The reason for this focus is that HIV reflects economic and social inequity. People with low socio-economic status <a href="https://www.apa.org/pi/ses/resources/publications/hiv-aids#:%7E:text=A%20lack%20of%20socioeconomic%20resources,et%20al.%2C%202013">are worst affected</a> by the epidemic. Also, the worst impacts of <a href="https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/publication/wcms_120468.pdf">the HIV epidemic are found</a> in the least developed countries and the most impoverished neighbourhoods. </p>
<p><a href="https://news.un.org/en/story/2022/01/1110192">In West Africa</a>, the proportion of people living on less than $1.90 a day jumped from 2.3% in 2020 to 2.9% in 2021 and more than 25 million across the region are struggling to meet their basic food needs. </p>
<p>Nigeria has the <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-12865-y#:%7E:text=Nigeria%2C%20the%20most%20populous%20country,burden%20%5B9%2C%2010%5D.">third highest burden</a> of HIV in the world. <a href="https://www.statista.com/statistics/1127055/people-living-with-hiv-receiving-treatment-in-nigeria/#:%7E:text=As%20of%202021%2C%201.9%20million,growing%20in%20the%20past%20years.">As of 2021</a>, 1.9 million people in Nigeria were infected with HIV. About 90% of them were receiving antiretroviral therapy. </p>
<p>The country seems to be moving successfully towards <a href="https://www.pedaids.org/2014/11/20/unaids-issues-new-fast-track-strategy-to-end-aids-by-2030/">the 95-95-95 target for ending AIDS by 2030</a>. This means 95% of people living with HIV knowing their HIV status; 95% of people who know their status on treatment; and 95% of people on treatment with suppressed viral loads. The target was launched by UNAIDS in November 2014. </p>
<p>But COVID-19 has threatened the progress that’s been made so far.</p>
<p>We explored this in two studies. <a href="https://pubmed.ncbi.nlm.nih.gov/35901294/">One was about</a> access to health services in Nigeria for women and girls living with HIV during the pandemic. It sought to know how easily they could access HIV, tuberculosis, sexual and reproductive health services. <a href="https://pubmed.ncbi.nlm.nih.gov/36189755/">The second</a> was about food insecurity, financial vulnerability and housing insecurity among women and girls living with – or at risk of – HIV in Nigeria. It set out to assess the impact of the COVID-19 pandemic on those likely to be worst affected by the multiple epidemics: vulnerable and stigmatised women. </p>
<p>Both pieces of research show that the COVID-19 pandemic disrupted access to essential health services. </p>
<h2>Poor access to HIV services during COVID-19</h2>
<p>For the first research, we recruited 2,076 adolescent girls and women living with HIV in different parts of Nigeria. We then assessed their ease of access to HIV, tuberculosis, sexual and reproductive health services during the pandemic. </p>
<p>We found that over 6 in 10 women and girls living with HIV had limited access to HIV services during the COVID-19 pandemic. Almost 2 in 10 had limited access to TB services. And almost 4 in 10 had limited access to sexual and reproductive health services.</p>
<p>Our study showed that because of the closure of HIV services and sexual and reproductive health service points during the pandemic, pre-existing financial and non-financial barriers to accessing services increased significantly. Having no money, having to pay additional unofficial fees and the lack of security on the road to the health facility were the barriers with the greatest impact on access to health services. </p>
<p>Transgender women, women who engaged in sex work and women who injected or used illegal drugs were severely affected. </p>
<p>Our findings suggest that some vulnerable populations may have fallen through the cracks despite efforts to improve access to HIV services during the pandemic in Nigeria. </p>
<h2>COVID increases vulnerability of people living with HIV</h2>
<p>Our second <a href="https://pubmed.ncbi.nlm.nih.gov/36189755/">study</a> sought to assess how the pandemic had further created differential food, financial and housing insecurity among vulnerable and stigmatised women in Nigeria. </p>
<p>Women and girls with disability, transgender women, sex workers, persons engaged in transactional sex, substance users and people on the move are all vulnerable. We found that a significantly high proportion of the study population had to deal with food insecurity (76.1%), financial vulnerability (83.6%) and housing insecurity (36.2%). Some women were particularly badly affected by the pandemic: women and girls who transacted sex were more than four times as likely to face housing insecurity and more than twice as likely to face food insecurity and financial vulnerability compared with other vulnerable women and girls who did not transact sex. </p>
<p>This suggests the need to monitor and plan better to avert negative impacts and increased HIV infection.</p>
<h2>The way out</h2>
<p>The results of both studies suggest that people who are affected by inequity may be the worst affected by pandemics like COVID-19. Emergency preparedness needs to happen well ahead of emergencies. It should include mapping out which populations are most likely to need care. </p>
<p>For Nigeria, it’s critical to plan ahead so that people living with HIV – as well as others – can get essential life-saving services. The combined effect of the disruption of access to HIV services and other essential services may have had an overall negative impact on the HIV response in Nigeria. </p>
<p>Emergency preparedness efforts include improving the access of vulnerable women and girls to essential service access. This can be done through active engagement of civil society organisations working with the target populations worst affected by the pandemic. Also, HIV programming in Nigeria needs to include housing, economic and financial insecurity mitigation measures for women and girls living with HIV.</p><img src="https://counter.theconversation.com/content/195381/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Morenike Oluwatoyin Folayan received funding from the Joint United Nations Programme on HIV/AIDS (UNAIDS) for this research. </span></em></p>
Some vulnerable populations may have fallen through the cracks despite efforts to improve access to HIV services during the pandemic in Nigeria.
Morenike Oluwatoyin Folayan, Professor of Paediatric Dentistry, Obafemi Awolowo University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/187924
2022-08-04T20:19:21Z
2022-08-04T20:19:21Z
New Zealand’s plan to eliminate HIV transmission ignores deepening inequities in health outcomes for Māori women
<figure><img src="https://images.theconversation.com/files/477520/original/file-20220803-17-j47fup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">AIDS</span> </figcaption></figure><p>The New Zealand government plans to spend NZ$18 million on becoming the first country to <a href="https://www.beehive.govt.nz/release/government-sets-out-plan-eliminate-hiv-transmission-new-zealand">eliminate transmission</a> of the human immunodeficiency virus (HIV) within a decade. </p>
<p>In a <a href="https://www.health.govt.nz/have-your-say-aotearoa-new-zealands-hiv-action-plan">draft action plan</a> launched last week, associate health minister Ayesha Verrall set out key measures to increase prevention and testing, improve access to treatment and address stigma.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1553293964463439872"}"></div></p>
<p>These are ambitious targets, but the plan fails to take account of the changing pattern of the HIV pandemic. It does not reflect the <a href="https://pubmed.ncbi.nlm.nih.gov/24038370/">mounting evidence</a> that Māori, and Māori women in particular, have disproportionately high rates of HIV and are more likely to be diagnosed late. </p>
<p>If Māori women are not identified as a group at increased risk of HIV and progression to AIDS as a result of late diagnosis, the plan’s effectiveness in stemming the spread of HIV infection will be severely limited. This glaring omission could easily derail minister Verrall’s goal and instead exacerbate current HIV disparities.</p>
<p>Since national HIV surveillance was established in Aotearoa New Zealand in 1985, 5,430 people have been diagnosed with the virus and 757 have died of AIDS. The number of people diagnosed with HIV has <a href="https://www.otago.ac.nz/aidsepigroup/otago840423.pdf">declined</a> recently (from 195 in 2016 to 122 in 2021), but inequities in health outcomes are deepening.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hiv-40-years-on-four-action-points-to-end-aids-as-a-health-threat-162260">HIV 40 years on: four action points to end AIDS as a health threat</a>
</strong>
</em>
</p>
<hr>
<p>The pattern of the HIV pandemic globally has changed dramatically with the advent of antiretroviral therapy (<a href="https://www.healthnavigator.org.nz/medicines/a/antiretroviral-therapy/">ART</a>) more than two decades ago. With timely access to ART, people with HIV can expect to enjoy the same health outcomes as everyone else. </p>
<p>ART has become a key plank in preventing the spread of HIV. But to be effective, ART must be initiated soon after a person becomes infected with the virus. If New Zealand is to achieve elimination of HIV by 2032, ART must be made readily available to everyone and we must remove the barriers caused by stigma, discrimination and racism. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1538429758371155968"}"></div></p>
<h2>HIV inequities are increasing</h2>
<p>At the recent <a href="https://aids2022.org/">24th International AIDS Conference</a> in Montreal, a consistent message was that the HIV pandemic is far from over, and that HIV inequities have increased. </p>
<p>The world will not eliminate HIV any time soon if governments and decision makers fail to recognise the adverse impact of HIV on disadvantaged populations such as Indigenous peoples, and especially Indigenous women. </p>
<p>At the conference, I presented five steps for developing action plans to prevent HIV transmission among Indigenous peoples. This provides a highly relevant framework for setting realistic and achievable goals for Māori living with HIV.</p>
<ol>
<li><p>Recognise the impact of colonisation and historical trauma</p></li>
<li><p>ensure access to culture</p></li>
<li><p>identify and resource protective factors such as whānau and family support</p></li>
<li><p>ensure health services are free from stigma and discrimination </p></li>
<li><p>understand and address the impacts of social determinants on health and wellbeing.</p></li>
</ol>
<p>UNAIDS leads the <a href="https://www.unaids.org/en/Global-AIDS-Strategy-2021-2026">global effort to end AIDS</a> as a public health threat by 2030. It recently set a 95-95-95 target: 95% of people living with HIV knowing their HIV status; 95% of HIV-positive people receiving treatment; and 95% of people on treatment with suppressed viral loads.</p>
<p>New Zealand cannot ignore the fact we are part of the global community. If the international community fails to eliminate HIV within the next eight years, this will seriously hamper efforts in our country.</p>
<h2>Health reforms provide opportunity to enhance equity</h2>
<p>In 1994, more than a decade after the onset of the HIV pandemic, New Zealand’s ministry of Māori development Te Puni Kōkiri produced the first <a href="https://natlib-primo.hosted.exlibrisgroup.com/primo-explore/fulldisplay?vid=NLNZ&docid=INNZ7114110320002837&context=L&search_scope=INNZ">report</a> into the likely impact of HIV on Māori. </p>
<p>It warned Māori were vulnerable to HIV and the government needed to implement measures to prevent the spread of the virus among Māori. Just as has <a href="https://www.bmj.com/content/376/bmj.o180">happened with COVID-19</a>, the government paid scant attention to those warnings. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/research-shows-maori-are-more-likely-to-die-from-covid-19-than-other-new-zealanders-145453">Research shows Māori are more likely to die from COVID-19 than other New Zealanders</a>
</strong>
</em>
</p>
<hr>
<p>As we enter the fifth decade of the HIV pandemic, Māori continue to be adversely affected by HIV, with higher rates of late diagnosis increasing the <a href="https://pubmed.ncbi.nlm.nih.gov/22093231/">risk of poor health outcomes</a>. </p>
<p>Māori women have been rendered invisible in the draft action plan, despite the fact they have <a href="https://www.otago.ac.nz/aidsepigroup/otago840423.pdf">high rates of locally acquired HIV</a>.</p>
<p>Action plans play an important role in managing and controlling all manner of illnesses. This plan is no exception. But to be effective, plans need to be in tune with the needs of communities and based on consultation processes that engage with them respectfully. </p>
<p>New Zealand’s current <a href="https://www.rnz.co.nz/news/national/440988/health-system-reform-what-the-experts-are-saying">health reforms</a> are designed to lead to long overdue improvements in equity for Māori. But this is not reflected in this draft action plan, which may well undermine efforts to address HIV disparities. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/with-closer-ties-to-gps-nzs-new-central-health-agency-could-revolutionise-treatment-of-major-diseases-159434">With closer ties to GPs, NZ's new central health agency could revolutionise treatment of major diseases</a>
</strong>
</em>
</p>
<hr>
<p>The reforms require health services and professionals to put Te Tiriti o Waitangi and equity at the forefront of health policy and services. In its current form, the action plan fails to take advantage of the opportunities in the new health sector. </p>
<p>If New Zealand wants to stop the transmission of HIV among Māori, the HIV elimination action plan must set out strategies to address inequities. An overwhelming message from the AIDS conference was that affected communities, and especially people living with HIV, must be front and centre of efforts to prevent the transmission of the virus.</p><img src="https://counter.theconversation.com/content/187924/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Clive Aspin has received funding from the Health Research Council of New Zealand. He is a founding member of the International Indigenous Working Group on HIV and AIDS. </span></em></p>
The omission of growing evidence that Māori, and Māori women in particular, have worse health outcomes after HIV infection could derail New Zealand’s elimination plans and exacerbate disparities.
Clive Aspin, Associate Dean Māori, Faculty of Health; Senior Lecturer in Health, Te Herenga Waka — Victoria University of Wellington
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/176466
2022-05-16T19:59:36Z
2022-05-16T19:59:36Z
Class, queerness and illness in the ‘post-crisis’ era: rewriting the narrative of HIV
<figure><img src="https://images.theconversation.com/files/462919/original/file-20220513-15-56onz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Jonathan Bazzi photo by Claudia Beretta</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>I often read a book’s acknowledgments to see who an author thanks for supporting the creation of their work and how they go about thanking them.</p>
<p>Among those mentioned at the end of Jonathan Bazzi’s <a href="https://theconversation.com/the-end-of-eddy-and-why-writing-about-life-can-be-a-dangerous-game-72211">autofiction</a> is the award-winning Italian novelist Viola Di Grado. Bazzi thanks Di Grado for “curbing my wild proliferations of thought”, though frankly it’s hard to fathom a version of this memoir that’s even more wild and proliferating. </p>
<hr>
<p><em>Review: Fever by Jonathan Bazzi (Scribe Publications)</em></p>
<hr>
<p>In <a href="https://scribepublications.com.au/books-authors/books/fever-9781922310903">Fever</a>, the 37-year-old Milanese author meditates on illness and <a href="https://theconversation.com/wellness-is-not-womens-friend-its-a-distraction-from-what-really-ails-us-177446">wellness</a>, sex and death, families and their undoing, <a href="https://theconversation.com/love-violence-and-class-wounds-in-thatcher-era-glasgow-what-booker-winner-douglas-stuart-did-next-179095">class</a> and Italianness, mothers and sons, desire, art, education and more. When they land in a psychiatrist’s office, Bazzi is “a river that’s overflowing. I can’t stop.” Their account of growing up poor and queer in Northern Italy and of coming to terms with HIV in the era of undetectable viral counts is a veritable explosion of ideas. </p>
<h2>The story of an illness</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=933&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=933&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=933&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1172&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1172&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462917/original/file-20220513-110-mha5ii.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1172&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>“Three years ago the fever came over me and never left … One week, two weeks.” Midway through the first page, we’re already months into the story of an illness, plunged into a life of anxious visits to clinics and puzzling test results.
Jonathan, 31. Boyfriend called Marius, two Devon Rex cats, casual job as a yoga instructor. Then, suddenly, a fever that will not subside.</p>
<p>Bazzi’s spare, efficient prose feels urgent, as if narrated by a frank and fast talker who gets intermittently bored. They wrap up one story, only to pick up the thread of another. This pace belies the hours, weeks and months of a life spent in waiting rooms and in bed, languishing in the chronic uncertainty of not knowing what’s wrong. </p>
<p>It also recalls the political urgency of earlier AIDS diaries and <a href="https://theconversation.com/holding-the-man-and-bringing-hiv-aids-in-australia-to-a-mainstream-audience-43250">memoirs</a> from the “plague years”. Although Bazzi will soon understand that they are HIV positive, and that there is a clear – and highly effective – treatment trajectory proceeding from that diagnosis, the body conceals other unsolved mysteries, and so the sense of urgency and uncertainty remains. </p>
<p>Alternating with these breathless chapters of autopathography (a patient’s account of illness) are episodes from Jonathan’s childhood and adolescence in the working-class city of Rozzano. Rozzano is on the “extreme Southern periphery of Milan”, and is peripheral in other ways, too. Women wear nightgowns to the supermarket and kids with fake tans whip past on Vespas. A bit “like the Bronx of Northern Italy”, Rozanno is a place into which “poverty and disadvantage are pumped […] like wastewater.” </p>
<p>The Rozanno effect infuses every facet of Jonathan’s life. Their parents, Tina and Roberto, had a “Rozzano love story” – that is, a relationship that didn’t last long, “a love that quickly soured into hate and spite”. </p>
<p>When teenage Jonathan starts meeting friends and lovers outside the city, they always ask to be dropped off several blocks from home. They don’t want anyone to see the “crumbling plaster façade” or the “appalling inhabitants leering from the balconies” of the public-housing tower in which they live. These “big, drab” towers that dominate the city have basements full of rats where drug users go to shoot up.</p>
<p>It’s a place “full of weirdos”, but not one that celebrates or nurtures them. Gender roles are rigidly policed; “men are made a certain way – they like Vespas, football, pussy – and women are made a different way”. </p>
<p>Jonathan prefers reading and drawing; at school he’s bullied relentlessly. “Rozzano hates me. I have hated Rozanno. Why was I born here?” Developing a stutter and a passionate interest in art doesn’t help, and he eventually drops out.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-beautiful-hiv-positive-community-queer-eyes-jonathan-van-ness-shines-a-spotlight-on-the-changing-face-of-hiv-123993">'The beautiful HIV-positive community': Queer Eye's Jonathan Van Ness shines a spotlight on the changing face of HIV</a>
</strong>
</em>
</p>
<hr>
<h2>The social construction of disease</h2>
<p>“Nothing could be more meaningless than a virus”, wrote Judith Williamson about HIV/AIDS in 1989. “It has no point, no purpose, no plan; it is part of no scheme, carries no inherent significance.” And yet every disease, especially if it is new, mysterious and potentially life-threatening, offers opportunities for storytelling and interpretation. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Grey-haired woman in front of bookselves, wearing a waistcoat over a striped shirt." src="https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=575&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=575&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=575&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=723&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=723&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462923/original/file-20220513-20-unr546.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=723&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Susan Sontag photographed in her home, 1979 ©Lynn Gilbert.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Reflecting on their diagnosis, Bazzi parses the social meanings of HIV: “HIV confirms two things: you’re gay, and you’ve had sex. Maybe too much sex, and in a promiscuous manner.” Another story: HIV is part of a family curse. “Bazzi men are unlucky; they always die young”. </p>
<p>Recalling Susan Sontag’s two famous essays on disease, <a href="https://www.nybooks.com/articles/1978/01/26/illness-as-metaphor/">Illness as Metaphor</a> (1978) and <a href="https://www.nybooks.com/articles/1988/10/27/aids-and-its-metaphors/">AIDS and its Metaphors</a> (1988), Bazzi contrasts the metaphors used to understand <a href="https://theconversation.com/goodbye-georgia-blain-a-brave-and-true-chronicler-of-life-70329">cancer</a>, which his father has, and HIV.</p>
<blockquote>
<p>Cancer is a crazed proliferation of cells. HIV is cell death. Cancer is internal revolt, the body wanting too much, growing, expanding. HIV is an attack, an invasion, a capitulation. </p>
</blockquote>
<p>The various stories Bazzi tests out reflect the abundance of social meanings produced in response to disease. </p>
<p>Much like <a href="https://theconversation.com/australia-risks-relying-on-pfizer-and-moderna-for-its-covid-vaccines-3-ways-to-break-free-182147">COVID-19</a>, HIV has never been a simple collection of virological or biomedical facts. HIV/AIDS was the first global pandemic of the media age and since it first came to public attention in 1981, it has been extremely fertile territory for a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265931/">wild proliferation</a> of stories. </p>
<p>AIDS as a Communist plot to bring down the United States; AIDS as a virus developed in CIA laboratories to kill homosexuals. While compulsively researching online, Bazzi discovers that many of these outlandish ideas continue to circulate: </p>
<blockquote>
<p>HIV is a hoax […] The biggest conspiracy of the twentieth century […] HIV and AIDS were invented by Big Pharma.</p>
</blockquote>
<p>The stories we tell about disease, including the supposedly neutral language used by doctors, scientists and public health professionals, give structure and meaning to our understanding of it. </p>
<p>In the case of HIV, the proliferation of stories has been of particular interest to researchers, activists, people living with HIV and many others. Because the way these stories are told – particularly in the public sphere – can influence the way <a href="https://theconversation.com/from-plagues-to-obesity-how-epidemics-have-evolved-96109">epidemics</a> play out, including who does and doesn’t receive appropriate care.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=286&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=286&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=286&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=360&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=360&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462937/original/file-20220513-15-y0ozfu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=360&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One of a series of safe sex posters from an Italian ‘Stop AIDS’ campaign by the AIUTO AIDS Svizzero in collaboration with the Federal Office of Public Health.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Performing illness, from the dramatic to mundane</h2>
<p>“HIV has its own history, its own traditions”, Bazzi writes. </p>
<blockquote>
<p>Destinies, statistics, organisations, clinical cases, media stories. A long sequence of narratives that predate me, that I know very little about.</p>
</blockquote>
<p>Despite these claims to ignorance, Fever is particularly illuminating on the social experience of illness – the way a set of rituals and performances play out around the sick body, and how these operate to confer a set of social roles.</p>
<p>At the centre of the plot is the sick body, which provides evidence, clues that propel the narrative of illness along and so must be monitored and traced, described and surveilled. “I am preparing my bodily fluids for examination. My body is invested with new meaning.”</p>
<p>Doctors are the other core protagonists in this drama, and they possess a crucial storytelling role. They are “priest-like”, with the power to assign the sick person “to a community”, allocating them “a narrative, a case study”. And of course, the key setting for such performance is the hospital, “the place where either you’re reborn or you die”. </p>
<p>Despite its urgent pace, Fever is a reminder that the story of sickness isn’t all dramatic climaxes. <a href="https://theconversation.com/people-with-chronic-illness-short-changed-by-fragmented-system-federalism-paper-35393">Chronic illness</a> also involves very mundane and administrative tasks. Appointments, referrals, tests, prescriptions; the keeping and processing of medical records, payments, insurance paperwork. This is the everyday work of being unwell. Bazzi captures it in snatches of conversation overheard in waiting rooms. </p>
<blockquote>
<p>“Do you have a health insurance card? Excuse me, have you provided a urine sample?”
“That’ll be 27 euros and 80 cents.”</p>
</blockquote>
<p>Importantly, the dramaturgy of illness creates and re-creates interpersonal roles and relationships. For example, Jonathan’s partner Marius tests negative and this powerfully changes their relationship. </p>
<p>The couple are now <a href="https://www.verywellhealth.com/serodiscordant-couple-3132908">sero-discordant</a> (where one person is HIV-positive, the other HIV-negative): “An asymmetry is established.” Marius’s blood “has been interrogated, and it tells a different story”.</p>
<p>And what if, in spite of existing narratives and social roles, your own illness disregards the established parameters? For Jonathan, HIV is a “catalyst” and their body an “ampitheatre”, but there will be more to the story of their fever before it’s resolved – if indeed it ever can be.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hiv-aids-on-screen-by-focusing-on-history-we-ignore-the-present-28972">HIV/AIDS on screen: by focusing on history, we ignore the present</a>
</strong>
</em>
</p>
<hr>
<h2>The HIV and AIDS memoir</h2>
<p>Fever is being hailed as one of the “first contemporary personal narratives of living with HIV”. In spite of the upwards of 37 million people in the world living with the infection, this is a fair description. </p>
<p>During the 1980s and 90s, a large body of HIV/AIDS diaries and memoirs were published. The most famous were written by white gay men living through extreme physical suffering and often social isolation in the early years of the AIDS crisis. </p>
<p>Among them are works by David Wojnarowicz and Paul Monette in the United States, and Derek Jarman in the United Kingdom. In Australia, there was the extraordinary AIDS diary <a href="https://www.dukeupress.edu/unbecoming">Unbecoming</a> (1990) by Griffith University anthropology lecturer Eric Michaels. Far better known is Timothy Conigrave’s <a href="https://www.penguin.com.au/books/holding-the-man-9781742284064">Holding the Man</a> (1995), which was adapted for the stage and eventually the screen.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An ill man, bald and in pyjamas, sits at breakfast with a healthier looking man." src="https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=249&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=249&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=249&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=313&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=313&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462918/original/file-20220513-110-gc9eud.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=313&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ryan Corr and Craig Stott in Holding the Man (2015).</span>
<span class="attribution"><span class="source">IMDB</span></span>
</figcaption>
</figure>
<p>HIV/AIDS was – and remains – a carrier of heavily political meanings and these works served a testimonial function. They offered the experience of an individual but also paid witness to experiences of political abandonment and the failure of state institutions to properly respond to HIV/AIDS. Such testimonies enabled the expression of grief and mourning, but also provided a foundation for activism and political action. </p>
<p>These works also developed new experiential and expressive languages for thinking about illness. In so doing, they helped to transform public understandings of HIV. Alongside incendiary activist campaigns and other forms of cultural production, they played an important role in changing phobic and discriminatory narratives about HIV.</p>
<p>Fever is an inheritor of this tradition, but it’s a story about HIV in the “post-crisis” era. </p>
<p>Today, HIV positive people on treatment have a negligible viral load and largely cannot transmit the virus. Treatments are so significantly advanced that they have fewer and fewer side effects; new developments promise drugs that only need to be taken once a month or every two months. And yet, older ideas about HIV cast a lingering shadow. As Bazzi writes, “people living with the condition are still subject to a toxic blend of invisibility and guilt”. </p>
<p>A <a href="https://theconversation.com/hiv-aids-on-screen-by-focusing-on-history-we-ignore-the-present-28972">lack of conversations and stories</a> addressing the contemporary experience of living with HIV may contribute to and exacerbate this stigma. </p>
<p>Bazzi is explicit in their refusal of this state of affairs, “rejecting the tradition of shame and discretion”. </p>
<p>Fever is indeed a landmark in this sense, because while the stories of the crisis era were prolific across genres and forms, very little media and literature has captured the experience of living with HIV now.</p>
<p>“My HIV diagnosis is an incontrovertible fact”, Bazzi concludes. </p>
<blockquote>
<p>I have HIV – all that means is I have to see my doctor a lot, and do lots of tests. Like millions of other people in the world, for all kinds of reasons. Everything else is extrinsic. Put there by you, by us.</p>
</blockquote><img src="https://counter.theconversation.com/content/176466/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dion Kagan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
One of the first contemporary personal narratives about living with HIV in the 21st century, Fever urgently interrogates the social meanings of HIV, and how they’ve evolved in the era of treatment.
Dion Kagan, Research Officer, La Trobe University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/180489
2022-05-06T20:50:46Z
2022-05-06T20:50:46Z
The Catholic saint who dedicated his life to a leprosy colony in Hawaii – and became an inspiration for HIV/AIDS care
<figure><img src="https://images.theconversation.com/files/461138/original/file-20220504-20-mhvgtd.jpg?ixlib=rb-1.1.0&rect=18%2C21%2C976%2C659&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The headstone of Father Damien, a Catholic saint who was canonized in 2009.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/news-photo/1081384530?adppopup=true">Richard A. Cooke III/Corbis Historical via Getty Images</a></span></figcaption></figure><p>On Jan. 3, 1865, the Kingdom of Hawaii, then a sovereign state, <a href="https://www.capitol.hawaii.gov/session2021/bills/SB697_CD1_.HTM">enacted “An Act to Prevent the Spread of Leprosy</a>.” Any person suspected of having the ancient disease – which is mentioned <a href="https://theconversation.com/quarantines-have-tried-to-keep-out-disease-for-thousands-of-years-130680">as far back as the Bible</a> – would be inspected and, if deemed incurable, permanently exiled to a peninsula on the island of Molokai.</p>
<p>More than 8,000 people with leprosy fell victim to this policy of permanent segregation over the next century. Native Hawaiians renamed leprosy “ma'i ho'oka'awale ‘ohana”: <a href="https://www.barnesandnoble.com/w/the-separating-sickness-mai-hookaawale-ted-gugelyk/1114591870">the sickness that separates family</a>. Surrounded by steep cliffs and treacherous ocean, the peninsula served as a natural prison and soon gathered a reputation as a de facto death sentence.</p>
<p>But in the Catholic Church, May 10 commemorates the day one man moved to Molokai willingly: Father Damien. Born <a href="https://www.vatican.va/news_services/liturgy/saints/2009/ns_lit_doc_20091011_de-veuster_en.html">Jozef De Veuster</a> in Belgium, he came to Hawaii as a young Catholic missionary and spent the last 16 years of his life <a href="https://www.nps.gov/kala/learn/historyculture/damien.htm">voluntarily living in the leprosy colony</a>, before contracting the disease himself and dying in 1889.</p>
<p><a href="https://www.vatican.va/content/benedict-xvi/en/homilies/2009/documents/hf_ben-xvi_hom_20091011_canonizzazioni.html">Canonized as a saint</a> in 2009, Father Damien was designated the patron saint of people with leprosy, or Hansen’s disease.</p>
<p><a href="https://divinity.uchicago.edu/directory/mark-lambert-1">My research</a> focuses on how Christian theology views socially stigmatized diseases, such as leprosy. Since the HIV/AIDS epidemic began in the 1980s, Damien has also become linked with the virus and inspired many Catholic groups that care for patients. His legacy
illustrates the church’s complicated, often harmful views on HIV/AIDS – but has also helped people see those who suffer from stigmatized diseases with more agency and dignity.</p>
<h2>Joining the community</h2>
<p>Damien <a href="https://www.damien-hs.edu/apps/pages/index.jsp?uREC_ID=2177609&type=d&pREC_ID=2182501#:%7E:text=I%20">landed at Molokai</a> on May 10, 1873. In a now famous letter to his brother, he wrote that he would make himself “a leper with lepers,” to “gain all to Christ.”</p>
<p>For over 2,000 years, “care” for people with leprosy has often been <a href="https://doi.org/10.1086/344062">reduced to segregation</a>. This was the case <a href="https://uhpress.hawaii.edu/title/kalaupapa-a-collective-memory/">in Hawaii</a>, where the Board of Health offered bounties to those who turned in suspected patients. The widespread belief that leprosy was an advanced stage of syphilis added an air of moral condemnation to the policy.</p>
<p>According to accounts such as “<a href="https://uhpress.hawaii.edu/title/kalaupapa-a-collective-memory/">Kaluapapa: A Collective Memory</a>,” which documents residents’ experiences in the colony, Damien employed his carpentry skills to build two chapels, new shelters for the residents, and a multitude of coffins. He provided rudimentary medical care, secured a fresh water supply, and established an orphanage. At a time when fear of being near people with leprosy was the norm, the priest also ate with residents from the same pot, and shared his pipe with them.</p>
<p>By the beginning of 1885, Damien began to show signs of <a href="https://doi.org/10.1515/9780824865801-017">having contracted leprosy</a>, and in 1886 the priest formally became known as Admission #2886 to the settlements. Three years later, he succumbed to the disease. </p>
<figure class="align-center ">
<img alt="A black and white photograph shows a small group gathered in front of a church in front of a misty mountain." src="https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=444&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=444&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=444&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=558&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=558&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461143/original/file-20220504-23-u8dw70.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=558&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Father Damien stands with patients outside his church on Molokai Island.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/father-damien-stands-with-patients-outside-his-church-on-news-photo/615231942?adppopup=true">Corbis Historical via Getty Images</a></span>
</figcaption>
</figure>
<h2>Patron saint</h2>
<p>Damien’s ministry garnered an international audience, elevating him to something of a celebrity, and his death prompted an immediate response. The future king of England, Edward VII, <a href="https://www.barnesandnoble.com/w/the-spirit-of-father-damien-jan-de-volder/1123972273?ean=9781586174873">proposed</a> to erect a monument to Damien on Molokai, to establish a ward devoted to leprosy in a London medical institution and to fund research on leprosy in India. Damien’s example inspired the creation of several other organizations devoted to the study and treatment of leprosy, from <a href="https://www.charitynavigator.org/ein/222066044">the U.S.</a> and <a href="https://damiaanactie.be">Belgium</a> to Congo and Korea.</p>
<p>In 1967, the French journalist and humanitarian Raoul Follereau presented the pope with <a href="http://fides.org/en/news/23980-EUROPE_FRANCE_Raoul_Follereau_Foundation_rejoices_at_the_canonization_of_Belgian_missionary_Fr_Damien_De_Veuster_Apostle_of_the_Lepers">a petition</a> signed by almost 33,000 leprosy patients, calling for the beatification of Father Damien. In 1977, Pope Paul VI declared Damien “venerable,” the first <a href="https://theconversation.com/who-becomes-a-saint-in-the-catholic-church-and-is-that-changing-81011">step toward canonization</a> – which eventually occurred <a href="https://www.vatican.va/content/benedict-xvi/en/homilies/2009/documents/hf_ben-xvi_hom_20091011_canonizzazioni.html">in 2009</a>, under Pope Benedict XVI.</p>
<figure class="align-center ">
<img alt="Three women wearing flowers in their hair and dressed in yellow smile at the camera." src="https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461141/original/file-20220504-19-kn49f4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hawaiian pilgrims attend a 2009 ceremony at the Vatican to canonize five new saints, including Father Damien.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/hawaian-pilgrims-attend-pope-benedict-xvis-a-new-saints-news-photo/527601302?adppopup=true">Alessandra Benedetti/Corbis Historical via Getty Images</a></span>
</figcaption>
</figure>
<h2>From leprosy to HIV/AIDS</h2>
<p>But how did <a href="https://www.cbsnews.com/news/father-damien-aid-to-lepers-now-a-saint/">the patron saint of people living with leprosy</a> become, informally, a patron saint of people living with HIV and AIDS? Given the Catholic Church’s traditional stances against homosexuality, condoms and extramarital sex, the notion can seem paradoxical.</p>
<p><a href="https://www.nytimes.com/1988/02/28/magazine/when-fear-conquers-a-doctor-learns-about-aids-from-leprosy.html">Comparisons between the two diseases</a> were made from the early days of the AIDS crisis: Both were considered mysterious and frightening and severely stigmatized, with sufferers often viewed as “dirty” or “sinful.” Many caregivers were afraid to even touch AIDS patients. </p>
<p>Invoking Father Damien’s example became a way for religious organizations to legitimize their HIV/AIDS outreach in the eyes of the church and to emphasize their concern for patients’ social stigma – even if the Catholic Church itself was helping to perpetrate that stigma, and <a href="https://www.npr.org/2019/12/01/783932572/how-the-catholic-church-aided-both-the-sick-and-the-sickness-as-hiv-spread">arguably the disease itself</a>.</p>
<p>In 2003, for example, Cardinal Alfonso López Trujillo, president of the Pontifical Council for the Family, <a href="https://www.vatican.va/roman_curia/pontifical_councils/family/documents/rc_pc_family_doc_20031201_family-values-safe-sex-trujillo_en.html">wrote that</a> “the use of condoms goes against human dignity. Condoms change the beautiful act of love into a selfish search for pleasure – while rejecting responsibility. Condoms do not guarantee protection against HIV/AIDS. Condoms may even be one of the main reasons for the spread of HIV/AIDS.”</p>
<p>Even in 2009, the year Damien was canonized, Pope Benedict <a href="https://doi.org/10.1016/S0140-6736(09)60627-9">remarked</a> that the AIDS epidemic “cannot be overcome through the distribution of condoms; on the contrary, they increase it” – an attitude out of touch with <a href="https://www.upi.com/Archives/1992/06/19/Poll-says-Catholics-support-female-priest/8826708926400/">most U.S. Catholics’ views</a>, not to mention <a href="https://www.cdc.gov/hiv/basics/hiv-prevention/condoms.html">medical science</a>. The pope’s statement provoked <a href="https://doi.org/10.1016/j.rbmo.2011.02.007">such outrage</a> that the Belgian Parliament even <a href="https://www.thetimes.co.uk/article/belgium-condemns-pope-over-condom-issue-bk3kzgzbnrb">condemned it</a>.</p>
<p>But many in the Catholic Church <a href="https://www.barnesandnoble.com/w/after-the-wrath-of-god-assistant-professor-of-religion-and-womens-gender-and-sexuality-studies-anthony-m-petro/1132140644?ean=9780190064778">responded to the AIDS crisis</a> with empathy. In 1985, for example – just a few years after the disease <a href="https://www.ucsf.edu/news/2021/06/420686/40-years-aids-timeline-epidemic">had been identified</a> – the New York Archdiocese <a href="https://www.nytimes.com/1987/11/22/nyregion/aids-helps-rescue-ailing-hospital.html">opened a treatment facility</a> at St. Clare’s Hospital, the state’s first specialized AIDS unit.</p>
<p>A number of ministries turned to Father Damien as inspiration for AIDS-related work, years before the church officially made him a saint. Likely the oldest is <a href="https://damienministries.org/">Damien Ministries</a>, founded in 1987 “to serve the poorest of the poor living with HIV and AIDS, as inspired by the life of the Blessed Father Damien.” The Washington, D.C.-based ministry adopted a solidarity approach modeled after Damien’s ministry on Molokai, citing parallels between leprosy and HIV/AIDS.</p>
<p>Other Damien-inspired organizations include the <a href="http://www.albanydamiencenter.org/our-history.html">Albany Damien Center</a>, <a href="https://damien.org/about/our-history">the Damien Center of Indiana</a> – founded as a collaboration between Catholics and Episcopalians – and <a href="https://saintdamienhospital.nph.org/history/">St. Damien Hospital in Haiti</a>.</p>
<figure class="align-left ">
<img alt="A tapestry with a colored border depicts a portrait of Father Damien, wearing a hat and glasses." src="https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=758&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=758&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=758&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=953&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=953&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461144/original/file-20220504-13-wdr2j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=953&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A tapestry depicting Father Damien, born Jozef De Veuster, hangs from the St. Peter Basilica facade during a canonization ceremony at the Vatican.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/HIYEYearender/81db85f170ae4bbc9579419ffd9ee866/photo?Query=father%20damien&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=16&currentItemNo=9">AP Photo/Alessandra Tarantino</a></span>
</figcaption>
</figure>
<p>Damien serves as what <a href="https://history.northwestern.edu/people/faculty/affiliated-faculty/robert-orsi.html">religion historian Robert Orsi</a> calls an “<a href="https://press.princeton.edu/books/paperback/9780691127767/between-heaven-and-earth">articulatory pivot point</a>”: a way people – HIV/AIDS patients, in this case – can use their faith to reshape their experience and gain agency, even as that same religion stigmatizes them as powerless “others.”</p>
<p>As a canonized saint, Damien is embraced by the highest levels of the church. Yet as a man who embraced those the rest of society had rejected, joining them and even dying for them, he also represents people at the margins.</p>
<p>
<section class="inline-content">
<img src="https://images.theconversation.com/files/338598/original/file-20200529-78871-1g5gse5.jpg?w=128&h=128">
<div>
<header></header>
<p><a href="https://www.ats.edu/">University of Chicago Divinity School is a member of the Association of Theological Schools</a></p>
<footer>The ATS is a funding partner of The Conversation U.S.</footer>
</div>
</section>
</p><img src="https://counter.theconversation.com/content/180489/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark M. Lambert does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Father Damien’s legacy has inspired health providers and humanitarians for over a century.
Mark M. Lambert, Teaching Fellow, University of Chicago
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/179793
2022-03-24T14:26:49Z
2022-03-24T14:26:49Z
Left to die: the fate of thousands of people living with HIV in Tigray
<figure><img src="https://images.theconversation.com/files/453826/original/file-20220323-27-9phr1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People receiving medical treatment at the entrance hall of Ayder Referral Hospital in Mekele, the capital of Tigray region, Ethiopia</span> <span class="attribution"><span class="source">YASUYOSHI CHIBA/AFP via Getty Images</span></span></figcaption></figure><p>People with human immunodeficiency virus (HIV) on regular treatment are now experiencing similar <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767138">life expectancy</a> to people without the virus. This is thanks to the innovation of <a href="https://pubmed.ncbi.nlm.nih.gov/25310317/">antiretroviral therapy</a> which can prevent the progression to AIDS. This is the late stage of HIV infection that occurs when the body’s immune system is badly damaged because of the virus. </p>
<p><a href="https://emedicine.medscape.com/article/211316-overview#a6">Evidence</a> shows that the survival period for HIV patients who progress to AIDS is usually less than two years in untreated patients. If patients do not have access to ART, the <a href="https://www.medscape.com/answers/211316-6065/what-is-the-prognosis-of-untreated-hiv-infection">prognosis</a> is poor, with an overall mortality rate of more than 90%.</p>
<p>A key factor that limits access to antiretroviral therapy is conflict or war. </p>
<p>For this reason, we are deeply concerned about people living with HIV in Ethiopia’s Tigray region, an area that’s been the focus of <a href="https://bmjopen.bmj.com/content/11/6/e043943">our work</a>. Currently, there’s <a href="https://www.hrw.org/tag/tigray-conflict">a conflict</a> between Ethiopia’s central government and the regional Tigrayan government. </p>
<p>We’ve <a href="https://www.researchgate.net/profile/Fisaha-Tesfay">carried out</a> <a href="https://www.researchgate.net/profile/Hailay-Gesesew">research</a> for over 12 years on HIV in Tigray. This includes <a href="https://pubmed.ncbi.nlm.nih.gov/28107430/">research</a> on the consequences of not taking antiretroviral therapy over short periods of time. </p>
<p>We believe that little attention is being given to HIV programmes or to the people who live on this medication. This is because the <a href="https://www.devex.com/news/opinion-in-tigray-we-are-demanding-food-and-medicine-not-bombs-102621">Ethiopian government</a> had imposed a siege and was withholding all basic services and blocking all forms of humanitarian assistance, including food aid and medical supplies. On March 24 2022 the Ethiopian government announced an indefinite humanitarian truce. A day later, the Tigray government <a href="https://www.aljazeera.com/news/2022/3/25/ethiopia-tigrayan-fighters-agree-to-cessation-of-hostilities">agreed</a> to the call for the humanitarian truce, calling on the federal government to take concrete steps to facilitate unfettered humanitarian access to Tigray.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/decades-of-progress-gone-in-one-year-tigrays-healthcare-system-has-been-destroyed-170406">Decades of progress gone in one year: Tigray's healthcare system has been destroyed</a>
</strong>
</em>
</p>
<hr>
<p>Patients receiving care for noncommunicable and communicable <a href="https://gh.bmj.com/content/6/11/e007328">chronic diseases</a> will be among the ones suffering due to lack of medical care. These include patients in HIV care.</p>
<p>Access to antiretroviral therapy is just one of the challenges. The war on Tigray will substantially impact the entire HIV care continuum, from diagnosis, enlisting for antiretroviral therapy and retention in HIV care. This is a great worry for those living with HIV in Ethiopia’s Tigray region. </p>
<h2>New HIV infections</h2>
<p>The starting point of positive outcomes of HIV care continuum is <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17051-7/fulltext">prevention</a> through a number of activities. These include condom use, prevention of <a href="https://apps.who.int/iris/handle/10665/96350">mother to child</a> transmission, and prevention of <a href="https://www.unaids.org/sites/default/files/media_asset/jc1601_policy_brief_criminalization_long_en.pdf">deliberate</a> transmission of HIV. </p>
<p>In Tigray, promotion of good health and disease prevention activities were provided through the health extension programme at health posts and through routine morning sessions at health centres and hospitals. But the region faced a <a href="https://rusi.org/explore-our-research/publications/rusi-newsbrief/international-community-struggles-address-ethiopian-conflict">full scale war</a> from November 2020 to June 2021. This was followed by a de facto blockade for ten months. Signs that it might be lifted came with the Ethiopian government’s announcement an <a href="https://www.aljazeera.com/news/2022/3/24/ethiopia-declares-truce-to-allow-aid-into-tigray">indefinite humanitarian truce</a>.</p>
<p>As a result, the health extension programmme was completely non-functional for more than a year, and about 70% of hospitals and 87% of health centres were <a href="https://gh.bmj.com/content/6/11/e007328">non-functional</a> within the first six months of the war. </p>
<p>Health facilities have run out of condoms and <a href="https://www.devex.com/news/tigray-the-deliberate-destruction-of-a-health-system-102252">pre-exposure medicines</a> used to prevent people from getting HIV. The Tigray health care system has <a href="https://gh.bmj.com/content/6/11/e007328">collapsed</a> because of the war. Reproductive health services – including HIV care services – have also collapsed. These potentially increase the rate of new HIV infections. The stories of sexual violence and wider and systematic gang <a href="https://www.telegraph.co.uk/global-health/women-and-girls/make-hiv-positive-hundreds-women-rush-tigray-hospitals-soldiers/">rape</a> involving deliberate HIV transmission are among the most heinous acts.</p>
<p>HIV in the <a href="https://pubmed.ncbi.nlm.nih.gov/30810344/">Ethiopian military</a> is high, and the rate of HIV among <a href="https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf">women</a> was already 1.2% (versus 0.6% in men) in Tigray. The Tigray regional health bureau showed that 7.3% of the women who have been raped have been diagnosed with various sexually transmitted infections and <a href="https://www.facebook.com/dimtsiweyane/posts/4853278724770265">5% have been infected with HIV</a>.</p>
<p>The fact that <a href="https://www.unhcr.org/refugeebrief/the-refugee-brief-5-november-2021/">over two million</a> Tigrayans were internally displaced also potentially increases the rate of new HIV infections in the region.</p>
<h2>HIV treatment linkage and retention</h2>
<p>Before the war, Tigray had <a href="https://bmjopen.bmj.com/content/11/6/e043943">147 health facilities</a> providing HIV care services, where 13 health facilities provided an oral HIV self-testing services. Each health facility had <a href="https://bmjopen.bmj.com/content/11/6/e043943">one to five peer educators</a> to promote ART adherence. </p>
<p>There were more than <a href="https://tigrayeao.info/tigray-health-bureau-tigray-health-sector-annual-bulletin-2021-january-2022/">43,000 HIV patients and 2,363 pregnant mothers</a> taking ART prophylaxis, with 867 HIV exposed infants in Tigray before the start of the war. These patients are at risk of AIDS related deaths because of the frequent interruption, and later, stoppage of antiretroviral therapy for more than ten months. This was due to the complete collapse of the HIV care system. </p>
<p>The war, and its aftermath, has had a devastating effect.</p>
<p>On January 2022, a group of health workers from Ayder Referral Hospital, the biggest specialised hospital in Tigray, reported <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00054-X/fulltext">running out of</a> basic medicines. Clinics have also run <a href="https://www.nasdaq.com/articles/doctors-say-lives-are-lost-in-hospitals-in-ethiopias-tigray-due-to-dwindling-supplies">out of stock</a>.</p>
<p>Up to <a href="https://www.theguardian.com/global-development/2022/mar/02/patients-dying-as-conflict-prevents-supplies-reaching-tigray-hospitals">half</a> of infants infected with HIV die within their first two years if they did not take ART. The survival status of women who were on ART prophylaxis is high likely to dwindle because of the high rate of malnutrition. The <a href="https://www.france24.com/en/africa/20211001-un-reports-unprecedented-malnutrition-in-tigray-amid-indications-of-siege">United Nations</a> has released data showing that 79% of 15,000 screened pregnant and lactating women in Tigray were diagnosed with acute malnutrition.</p>
<p>If the <a href="https://www.medscape.com/answers/211316-6065/what-is-the-prognosis-of-untreated-hiv-infection">mortality rate</a> of untreated HIV patients is more than 90%, the rate is even higher for HIV patients in Tigray.</p>
<h2>The transition</h2>
<p>In Tigray, 85% of the population are rural dwellers and rebuilding basic infrastructure such as road, water, and electricity will take the priority. Rebuilding the health infrastructure such as hospitals and health centres and replacing the <a href="https://www.reuters.com/article/ethiopia-conflict-health-idUSL1N2KE11S">90%</a> of lost ambulances will therefore take time. </p>
<p>This gap in the transition will result in further new HIV infections, delayed linkage to and interruptions of treatments, resistance to treatments, AIDS and deaths. </p>
<p>A preliminary report of damage assessment conducted by <a href="https://tigrayeao.info/tigray-health-bureau-tigray-health-sector-annual-bulletin-2021-january-2022/">Tigray Regional Health Bureau</a> between July to September 2021 showed that the rate of lost-to-follow up of people living with HIV and TB was 81% and 90%. </p>
<p>The existing inequity in poor HIV outcomes for rural dwellers and among women is an additional challenge to the unfolding tragedy as they make up the largest numbers of victims of war and conflicts.</p>
<p>Unless special attention is given to conflict and HIV the war will undermine the achievement of the 2030 goals to end AIDS, discrimination, and new infections.</p>
<p>The statements of global leaders for 2021 World AIDS Day contained messages of the ambitious goal of 2030. But they missed a core factor, namely the war or conflict that changes the likelihood of ending AIDS. </p>
<p>When the war is fought in one of the HIV prevalent areas, the goal of ending AIDS will simply be wishful thinking. </p>
<p>Access to HIV medicines is a basic human right and should not be denied, as experienced by the people with HIV in Tigray, especially in an era when the life expectancy of people with and without HIV is relatively <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2767138">similar</a>. </p>
<p>We urge leaders of countries and influential HIV institutions such as the World Health organisation and UNAIDS to bring meaningful action and save those people living with HIV in Tigray who are left to die. </p>
<p><em>Dr Joanne Flavel from the Stretton Institute at The University of Adelaide, South Australia, contributed to the writing of this article.</em></p><img src="https://counter.theconversation.com/content/179793/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Hailay Abrha Gesesew is a principal investigator in a project sponsored by an Australian National Health and Medical Research Council (NHMRC) and is a Senior Research and Teaching Fellow at Research Centre for Public Health Policy at Torrens University Australia in Adelaide. The views expressed in this opinion piece are only the author, not necessarily the funder. </span></em></p><p class="fine-print"><em><span>Dr Fisaha Tesfay is a Postdoctoral Research Fellow at the Institute For Health Transformation, Deakin University Australia. The views expressed in this piece are only the author’s </span></em></p>
Unless special attention is given to conflict and HIV the war will undermine the achievement of the 2030 goals to end AIDS, discrimination, and new infections.
Hailay Gesesew, NHMRC Research Fellow (Public Health), Flinders University
Fisaha Tesfay, Postdoctoral Research Fellow, Deakin University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/175960
2022-02-02T16:13:58Z
2022-02-02T16:13:58Z
Cancer drug could help fight HIV – new research
<p>A cancer drug called pembrolizumab might also help people with HIV, according to a <a href="https://www.science.org/doi/10.1126/scitranslmed.abl3836">new study</a>. </p>
<p>On the face of it, cancer and Aids have little to do with each other. One is caused by an excessive division of cells in the body, the other is caused by infection with a virus (HIV). But there is a link – the human immune system – which is where this drug acts. In fact, the story behind this medicine is full of surprising <a href="https://www.penguin.co.uk/books/110/1109946/the-beautiful-cure/9781784702212.html">twists and turns</a>.</p>
<p>The journey began in 1992 when a certain receptor protein on T-cells (a type of white blood cell) was discovered by Japanese scientist Tasuku Honjo. Instructions for making proteins are encoded by genes, and this particular protein was brought to Honjo’s attention as a result of a search for genes that cause cells to die. </p>
<p>It was therefore given the name “programmed cell death 1” or “PD-1”. It later turned out that it had been misnamed – this receptor has nothing to do with T-cells dying – and for many years, the role of the PD-1 receptor remained mysterious.</p>
<p>A big clue came when mice were genetically modified to lack the gene that contains the instructions for making the PD-1 receptor. Without PD-1 the mouse immune system reacted more vigorously, meaning immune cells multiplied more when stimulated. And some of the mice, especially those that were elderly, spontaneously developed an autoimmune disease. </p>
<p>This fitted with the idea that PD-1 sends a switch-off signal to immune cells, acting as a brake on the system. And that without it the immune system is more reactive, overly so when autoimmune disease develops. We now know that PD-1 works like this in many kinds of immune cells, including T-cells.</p>
<figure class="align-right ">
<img alt="Tasuku Honjo" src="https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/443487/original/file-20220131-23-t05j0r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tasuku Honjo discovered programmed cell death protein 1.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=74898195">Bengt Nyman/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Clinical trials have established that blocking PD-1 can be effective in treating some types of cancer in some patients. In other words, we can fight cancer by making sure the immune system doesn’t turn off. For this, Honjo, together with Jim Allison who discovered another brake receptor in the immune system and showed that blocking its action could work as a medicine, won the <a href="https://www.nobelprize.org/prizes/medicine/2018/press-release/">2018 Nobel prize</a> in physiology or medicine.</p>
<h2>HIV hides in a latent state</h2>
<p>This brings us back to HIV. One reason it has proved very hard to cure people with Aids is that a small amount of HIV hides in the body’s T-cells in a latent state. </p>
<p>Most of the time, when HIV enters one of the body’s T-cells, it will use that cell’s machinery to make copies of itself, sending new HIV particles out into the bloodstream. But a few T-cells harbour the viral genes while not actively producing the virus or viral proteins, and the virus within these T-cells is very hard to target. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3234450/">Latent virus persists</a> even in patients who are able to keep Aids under control with antiretroviral therapy because that type of therapy can only work on the active virus.</p>
<p>This <a href="https://www.science.org/doi/10.1126/scitranslmed.abl3836">new study</a>, published in Science Translational Medicine, looked at 32 cancer patients being treated with medicines that block PD-1, who also happen to be infected with HIV. Amazingly, HIV latency was reversed. The latent form of the virus was reawakened in these patients, which should make it targetable again.</p>
<p>As the virus gets reactivated in cells where it was once latent, then viral proteins would start to get made in that cell, which would, in turn, make these cells more visible to the immune system to be killed directly, and the newly unleashed virus could also be controlled with anti-retroviral therapies.</p>
<p>Scientists still need to find out if this approach will also work for patients who don’t also have cancer. More importantly, these types of medicines that unleash the immune system are associated with side-effects that can be serious for some patients, because unwanted immune responses can sometimes also be triggered, leading to symptoms of autoimmune disease.</p>
<p>As I’ve recently written about in a book, <a href="https://www.penguin.co.uk/books/111/1117386/the-secret-body/9781847925695.html">The Secret Body</a>, countless exciting new medicines are being developed now to nudge the activity of immune cells up or down. A major next goal is to find ways to be more precise with this type of medicine, to trigger the right type of response to fight disease, be it cancer, Aids or other illnesses, but avoid the side-effects of triggering unwanted immune responses elsewhere in the body.</p><img src="https://counter.theconversation.com/content/175960/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel M Davis is the author of three books published by Penguin Random House: The Compatibility Gene, The Beautiful Cure and most recently, The Secret Body. He receives research funding from The Medical Research Council, Cancer Research UK, The Wellcome Trust, GSK, Bristol Myers Squibb and Continuum Life Sciences. He tweets at @dandavis101</span></em></p>
The drug pembrolizumab reveals where latent HIV is hiding.
Daniel M Davis, Professor of Immunology, University of Manchester
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/172945
2021-12-20T11:47:33Z
2021-12-20T11:47:33Z
‘HIV Made Me Fabulous’ film relies on science and embodied storytelling to counter stigma and discrimination
<figure><img src="https://images.theconversation.com/files/438226/original/file-20211217-15-11va8uv.jpg?ixlib=rb-1.1.0&rect=170%2C45%2C2667%2C1485&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">We need a new script about women and HIV. </span> <span class="attribution"><span class="source">(Allie Carter)</span>, <span class="license">Author provided</span></span></figcaption></figure><blockquote>
<p>“We can’t demonize the very stuff that sometimes has made us be the people that we are.” </p>
</blockquote>
<p>So says <a href="https://www.unitedagents.co.uk/juno-roche">Juno Roche</a>, <a href="https://uk.jkp.com/products/gender-explorers?_pos=2&_sid=7b3772f93&_ss=r">a writer, activist</a> and trans woman who has lived with HIV for over 25 years. Roche wrote and narrated the film <a href="https://www.lifeandlovewithhiv.ca/film"><em>HIV Made Me Fabulous</em></a>, a 10-minute piece that combines narrative and dance, and was directed and produced by filmmaker and dancer <a href="https://www.edmondkilpatrick.com/bio">Edmond Kilpatrick</a>. </p>
<p>As researchers who aim to improve responses to gender, social justice, sexual and reproductive health and rights and HIV, we co-produced the film, in collaboration with women living with HIV. We released it to commemorate <a href="https://www.worldaidsday.org/about/">World AIDS Day</a>, Dec. 1, a day to show support for people living with HIV and mourn those who have been lost. </p>
<p>We intend to promote hope and celebrate the lives and resilience of women living with HIV globally. Our research also seeks to understand the effect watching the film has on viewers, to consider future uses of film as a tool for combating stigma and discrimination and promoting empathy for women living with HIV.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CWjLhHjsfo-","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<h2>Extraordinary HIV advances</h2>
<p>This year, the world <a href="https://www.cdc.gov/museum/online/40yearsofprogress.html">marked 40 years</a> since the first five cases of what later became known as AIDS were officially reported. </p>
<p>Since that era, which began in illness, fear and death, science has yielded extraordinary HIV advances that would have been unthinkable <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4309625/">a few decades</a> ago.</p>
<p>With the right treatment and care, people living with HIV can expect to live a long and healthy life with zero risk of transmitting HIV to their sexual partners if their viral load <a href="https://www.cdc.gov/nchhstp/dear_colleague/2017/dcl-092717-National-Gay-Mens-HIV-AIDS-Awareness-Day.html">is undetectable</a> — meaning that the virus isn’t showing up on blood tests. </p>
<p>This finding underpins the stigma-reducing “<a href="https://preventionaccess.org/">Undetectable equals Untransmittable</a>” (U=U) campaign endorsed by more than 1,000 organizations in more than 100 countries.</p>
<p>Researchers, advocates and people living with HIV hope that medical advancements like this can be liberating for people living with HIV, offering more agency over <a href="https://doi.org/10.1111/1467-9566.12347">sexual choices</a> and turning outdated attitudes and beliefs about HIV on their head.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/QamnyGc0gtY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">‘HIV Made Me Fabulous.’</span></figcaption>
</figure>
<p>But not everyone knows the U=U message. And the benefits of this HIV prevention science <a href="https://doi.org/10.1007/s13178-020-00432-2">for women</a>, in a world where women still aren’t equal to men, is hindered by on-going <a href="https://doi.org/10.1371/journal.pmed.1001124">discrimination</a>, harassment and <a href="https://www.who.int/reproductivehealth/topics/violence/hiv/en/">violence</a>, particularly for groups already marginalized on the basis of sex, sexual orientation, gender identity or expression, racialization, Indigeneity, disability or experience as a sex worker.</p>
<h2>Evoking emotions, changing thinking with film</h2>
<p>Some public health researchers have documented a growing interest in drawing on <a href="https://doi.org/10.1177/1049732319871251">the capacity of film as a tool to evoke emotions, change thinking and transform society</a> for better health outcomes.</p>
<p>In creating <a href="https://www.lifeandlovewithhiv.ca/film"><em>HIV Made Me Fabulous</em></a>, we explore the question of whether combining science with art could do more than communicate the shift in scientific understandings of HIV infectiousness. </p>
<p>In <a href="https://doi.org/10.1075/sin.18.15hyd">embodied storytelling</a>, a storyteller uses the body as a communicative medium, and may also enable viewers and listeners to tap into sensations experienced in their bodies. By employing this approach, we are seeking to use the film to measure whether the artful telling of Roche’s experiences of stigma and HIV, using dance, can help <a href="https://doi.org/10.1080/19443927.2017.1327884">promote empathy and compassion by arousing felt emotions in viewers’ bodies</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2-h2B55qYu0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Collaborators involved in ‘HIV Made Me Fabulous’ discuss the film.</span></figcaption>
</figure>
<p>We hope the film allows viewers to engage with the information presented more fully, and expands viewers’ capacities to understand and relate to the experiences of women living with HIV. And in turn, we hope this alters people’s learned prejudices surrounding the disease. </p>
<h2>Reclaiming sexual pleasure</h2>
<figure class="align-right ">
<img alt="Black and white photo of a trans woman with medium length light hair looking up and smiling." src="https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438227/original/file-20211217-17-1l4rdkz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Writer Juno Roche narrates both struggles and triumphs.</span>
<span class="attribution"><span class="source">(Allie Carter)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The film shares a story, often unheard, about the experiences of women living with HIV — both the struggles and the triumphs. Roche’s words are enacted by three performers (Jacky Essombe, Quanah Style and Joleen Mitton) who incorporate movement and dance. During the film, the women prepare to meet a potential lover, find the courage to knock on their door, and ride the ensuing emotional journey.</p>
<p>Kilpatrick, <a href="https://www.youtube.com/watch?v=ll66u0P_Uhc">whose work has explored dance as a vehicle for expressing life with HIV</a>, describes how he used movement, dance and storytelling in the film as a way to invite a physical and emotional response in the viewer, while hearing stories that may be associated with unconscious bias. “If Juno’s words are delivered with images that provide a visceral empathetic reaction,” he asks, “could old, embodied biases that lead to stigmatized reactions to people living with HIV be replaced by new, kinder ones?”</p>
<h2>Changing behaviours, attitudes</h2>
<p>To measure the impact of the film in addressing stigma, we’re inviting people to watch it and complete a <a href="https://forms.gle/HQYemm2HUPFKZEAd8">short, two-minute survey</a> sharing their reflections. The data we glean from surveys will inform the use of film in public health practice to change behaviours and attitudes toward sex and HIV — and ultimately improve people’s health.</p>
<p>We want communities to know that science has turned HIV into a treatable, chronic condition and that stigma has consequences to health and quality of life. We also want women to know that if they are HIV-positive, they still have the right to enjoy all aspects of life, including sexuality, on an equal basis to people without HIV.</p>
<p>We also invite people — from peer support workers and service providers to university professors, sex educators, people living with HIV and engaged citizens — to consider hosting a group screening and discussion using <a href="https://www.lifeandlovewithhiv.ca/wp-content/uploads/2021/11/HIV-Made-Me-Fabulous-Discussion-Guide_v1-Colour-Spreads.pdf">the film facilitation guide</a> and more <a href="https://www.lifeandlovewithhiv.ca/film">resources on our website</a>.</p>
<p>The arts can catalyze dialogue, <a href="https://theconversation.com/from-depression-to-parkinsons-disease-the-healing-power-of-dance-123748">awareness, action</a> and advocacy, while simultaneously contributing <a href="https://theconversation.com/how-theatre-can-help-young-nigerians-who-are-living-with-hiv-150378">to reducing stigma</a> and discrimination. These are essential features to end inequalities and also help end barriers that prevent people from getting treatment for HIV and living fuller lives.</p><img src="https://counter.theconversation.com/content/172945/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Allie Carter has been awarded research funding from the Canadian Institutes of Health Research, the Michael Smith Health Research BC, the National Health and Medical Research Council, and the Australian Government Department of Health.</span></em></p><p class="fine-print"><em><span>Angela Kaida has been awarded research funding from CIHR, SSHRC, Grand Challenges Canada, and the Michael Smith Health Research BC. She does not work for, consult, own shares in or personally receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Can a film’s artful telling of experiences of stigma and HIV, using dance, help promote empathy and compassion?
Allie Carter, Adjunct Professor, Faculty of Health Sciences, Simon Fraser University
Angela Kaida, Associate Professor and Canada Research Chair in Global Perspectives in HIV and Sexual and Reproductive Health, Simon Fraser University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/172842
2021-12-06T13:41:58Z
2021-12-06T13:41:58Z
Why addressing racism against Black women in health care is key to ending the US HIV epidemic
<figure><img src="https://images.theconversation.com/files/435449/original/file-20211202-20099-1a4zath.jpg?ixlib=rb-1.1.0&rect=7%2C202%2C5184%2C2981&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When Black patients are treated by Black doctors, they have better health outcomes – but fewer than 6 in 100 American doctors are Black.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/smiling-senior-doctor-talking-to-patient-in-royalty-free-image/1309073221?adppopup=true">The Good Brigade/Digital Vision via Getty Images</a></span></figcaption></figure><p>Forty years into the HIV/AIDS epidemic, Black women continue to bear the highest burden of HIV among women.</p>
<p>Although Black women represent only <a href="https://www.census.gov/quickfacts/fact/table/US/LFE046219">13% of the female population</a>, they accounted for over half of HIV diagnoses among all females in the U.S. in 2018, according to <a href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/women.html">data from the U.S. Centers for Disease Control and Prevention</a>. White women, who are 62% of the female population, <a href="https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-31/content/women.html">accounted for 21%</a> of HIV diagnoses. </p>
<p>Black women are also <a href="https://doi.org/10.1371/journal.pone.0189973">less likely</a> than white women to <a href="https://www.cdc.gov/mmwr/volumes/67/wr/mm6741a3.htm">receive the antiretroviral therapies</a> that are highly effective at preventing HIV infection and are more likely <a href="https://www.idsociety.org/news--publications-new/articles/2021/study-shows-black-women-with-hiv-had-highest-rates-of-premature-mortality-between-1998-2018/">to die of causes related to HIV</a>. </p>
<p>This year’s World AIDS Day theme included <a href="https://www.unaids.org/en/World_AIDS_Day">ending inequalities</a> in HIV and AIDS care. But in order to address the inequities, it will require examining the root causes of them. In the United States, the most prominent reasons for these disparities are <a href="https://doi.org/10.1056/NEJMms2025396">structural and systemic racism</a>. </p>
<p>I am the co-founder and director of a research center at Columbia University, <a href="https://sig.columbia.edu/content/get-involved">the Social Intervention Group</a>. In the past 30 years, more than a thousand Black women living with or at risk for HIV have participated in the center’s studies of the <a href="https://scholar.google.com/scholar?q=nabila+el+bassel&hl=en&as_sdt=0,39&as_vis=1">causes and dynamics of HIV, substance abuse and gender-based violence</a>. These include <a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C39&as_vis=1&q=nabila+el+bassel+HIV&btnG=">intervention studies</a> to put new strategies into practice and evaluate their impacts.</p>
<p>We have identified three approaches that can help improve the health of this population of at-risk women, as well as their access to health care.</p>
<h2>Addressing life contexts and experiences</h2>
<p>Many women who participated <a href="https://doi.org/10.1001/jamanetworkopen.2021.5226">in our studies</a> told us that their health providers rarely pay attention to their life context.</p>
<p>Life context includes racism, discrimination, poverty, a history of homelessness, incarceration, partner violence, stigma and trauma. Black women often <a href="https://doi.org/10.1001/amajethics.2021.156">lack integrated health services</a> to address these co-occurring issues, and simultaneously <a href="https://doi.org/10.1073/pnas.1516047113">their needs are often ignored</a> by their health care providers, which means <a href="https://dx.doi.org/10.2105/AJPH.2008.140541">they do not receive the treatment they need</a>.</p>
<p>The data affirm these women’s personal experiences. Black women are almost <a href="https://www.americanprogress.org/article/basic-facts-women-poverty/">three times as likely to live in poverty</a> and to <a href="https://www.cdc.gov/healthequity/features/maternal-mortality/index.html">die from pregnancy-related causes</a> than white women. They are also more likely to <a href="https://www.nationalpartnership.org/our-work/resources/health-care/black-womens-health-insurance-coverage.pdf">hold low-wage jobs that do not provide health benefits</a>.</p>
<p>Black Americans overall remain more likely to <a href="https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/">lack health insurance</a> than their white counterparts. They often <a href="https://dx.doi.org/10.1007%2Fs11113-016-9416-y">lose insurance coverage more quickly</a>. </p>
<p>To help overcome these inequities, the Social Intervention Group has developed an intervention called “Empowering African American Women on the Road to Health,” <a href="https://sig.columbia.edu/research-projects/eworth">or E-WORTH</a>. This study was designed by and for Black women to decrease HIV transmission and improve access to care, and it evaluated whether its methods improve participants’ health outcomes in practice.</p>
<p>E-WORTH is a new cultural adaptation of an HIV intervention for Black women called <a href="https://doi.org/10.1371/journal.pone.0111528">Project WORTH</a>, which was selected as <a href="https://www.cdc.gov/hiv/pdf/research/interventionresearch/compendium/rr/cdc-hiv-worth_best_rr.pdf">a best practice by the CDC</a>. </p>
<h2>Culturally tailored HIV care</h2>
<p>A total of 352 women participated in <a href="https://dx.doi.org/10.1001/jamanetworkopen.2021.5226">our E-WORTH intervention study</a>, which started in November 2015 and concluded in August 2019. The intervention included a one-hour individual HIV testing and orientation session, and four weekly 90-minute group sessions. </p>
<p>These sessions included raising awareness about HIV and other sexually transmitted infection risks, proper condom use, sexual negotiation skills, risk reduction goal settings, increasing social support and linkage to services, intimate partner violence screening, safety planning and referral to violence prevention services. </p>
<p>The participants were provided with opportunities to discuss their experiences of barriers to health care and other services, and how racism affected their access to services. </p>
<p>These unique intervention components had a positive effect. We found at the 12-month follow-up that compared with women participating in a one-session HIV testing intervention, the women in the five-session E-WORTH intervention had 54% lower odds of testing positive for any sexually transmitted infection. They also reported 38% fewer acts of condomless vaginal or anal intercourse.</p>
<p>The findings suggest that implementing an HIV/sexually transmitted infection intervention that is culturally tailored and designed for Black women holds promise for reducing the disproportionate burden of these infections in this population.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A Black female doctor peers into the mouth of a patient." src="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435664/original/file-20211203-21-vc7qqa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Culturally tailored health care shows promise for improving health outcomes for Black women.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-receives-a-physical-the-daybreak-community-health-news-photo/540612512?adppopup=true">Gregory Smith/Corbis Historical via Getty Images</a></span>
</figcaption>
</figure>
<p>Research shows that Black women often don’t receive adequate care because <a href="https://doi.org/10.1073/pnas.1516047113">care providers frequently do not believe their pain is real</a>. Several participants in E-WORTH <a href="https://sig.columbia.edu/news/new-publication-protocol-prevent-hiv-and-violence-among-black-women">reported that</a> in their overall experiences with the health care system, “No one ever believes me.”</p>
<p>In contrast, because of the trust and respect shown by facilitators and study staff, women participating in E-WORTH reported <a href="https://sig.columbia.edu/news/new-publication-protocol-prevent-hiv-and-violence-among-black-women">feeling heard and believed</a>.</p>
<p>These same women have also told us that sometimes clinical staff blame them for contracting HIV and <a href="https://www.healthline.com/health-news/the-discrimination-black-americans-face-when-it-comes-to-pain-management#Racial-bias-in-medical-care">fail to discuss or offer treatment and care options</a>, which prevents them from accessing or staying in care. </p>
<p>To address life context, E-WORTH is interwoven with Afrocentric themes of trauma and resiliency. These draw on Black Americans’ historical and lived experiences, from slavery to Jim Crow to the mass incarceration of Black individuals. Multimedia sequences in the sessions are intentionally infused with conversations about historical oppression, race and culture as well as systemic issues such as the overpolicing of Black communities and <a href="https://www.sentencingproject.org/issues/racial-disparity/">disproportionate sentencing laws</a>. </p>
<p>The facilitators of the intervention sessions led discussions exploring how intersecting identities related to race and ethnicity are at the heart of the HIV epidemic for Black women. The scripts used by facilitators featured Afrocentric language, based on input from prior focus groups of Black women, including character names. Afrocentric graphics were used, such as purple for royalty. </p>
<h2>A need for Black doctors and structural racism training</h2>
<p>Researchers have found that <a href="https://www.scientificamerican.com/article/we-need-more-black-physicians/">the health outcomes of Black patients improve</a> when they are treated by Black doctors. Further, Black women are more likely to trust doctors who <a href="https://doi.org/10.1353/hpu.2018.0036">live in their communities</a>.</p>
<p>However, a <a href="https://doi.org/10.1007/s11606-021-06745-1">recent study</a> found that only <a href="https://www.usnews.com/news/health-news/articles/2021-04-21/little-progress-in-boosting-numbers-of-black-american-doctors">5.4% of American doctors are Black</a>, and only <a href="https://www.usnews.com/news/health-news/articles/2021-04-21/little-progress-in-boosting-numbers-of-black-american-doctors">2.8% of them are women</a>. </p>
<p><a href="https://doi.org/10.1001/jamanetworkopen.2020.15220">Another recent study</a> suggests that creating medical education programs at <a href="https://theconversation.com/us/topics/hbcus-38001">historically Black colleges and universities</a> could increase the number of Black doctors. This supports other studies confirming <a href="https://dx.doi.org/10.3934%2Fpublichealth.2017.6.579">the importance of these schools</a> in expanding America’s ranks of Black doctors.</p>
<p>Increasing the number of Black providers is only part of the solution, however. <a href="https://www.aamc.org/media/37286/download?attachment">Fewer than half of U.S. medical schools</a> provide some sort of instruction or training on addressing structural racism and racial disparities in medical care. </p>
<p>[<em>Get the best of The Conversation’s politics, science or religion articles each week.</em><a href="https://memberservices.theconversation.com/newsletters/?source=inline-best">Sign up today</a>.]</p>
<p>Over the past few years, medical schools as well as schools for allied health professions have made greater commitments to <a href="https://www.aamc.org/news-insights/medical-schools-overhaul-curricula-fight-inequities">training the next generation of health professionals</a> to address racism. </p>
<p>While research has shown structural racism to be <a href="https://doi.org/10.1056/NEJMms2025396">a powerful driver of health disparities</a>, a <a href="https://doi.org/10.1016/S0140-6736(17)30569-X">wide gap exists</a> in the literature on the <a href="https://dx.doi.org/10.1007%2Fs40615-021-01137-x">impact of these trainings</a> on medical staff practices and their patients’ health outcomes. This underscores the need for more attention to <a href="https://doi.org/10.1177/0002764213487341">this type of research</a>. </p>
<h2>Underpinnings of racism in the medical system</h2>
<p>In late 2020, the American Medical Association declared <a href="https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health">structural racism a public health threat</a> and emphasized the urgent need to prepare the U.S. health care workforce to redress it.</p>
<p>“Without systemic and structural-level change, health inequities will continue to exist,” <a href="https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health">wrote AMA Board member Willarda V. Edwards</a>. “Declaring racism as an urgent public health threat is a step in the right direction toward advancing equity in medicine and public health.”</p>
<p>The Social Intervention Group continues to develop and evaluate solutions to curbing the HIV crisis among Black women. Our research findings suggest that when these women are actively engaged in all stages of their health care services and research, they can improve their health and lives. But this will require that medical professionals also address the health care system’s inherent structural racism.</p><img src="https://counter.theconversation.com/content/172842/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nabila El-Bassel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>
Black American women have disproportionate HIV infection rates – in part because of systemic and structural racism in the health care system.
Nabila El-Bassel, Professor of Social Work, Director of Social Intervention Group, Columbia University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/170852
2021-12-02T13:43:30Z
2021-12-02T13:43:30Z
Why COVID-19 must be included in safer sex messaging on college campuses
<figure><img src="https://images.theconversation.com/files/432516/original/file-20211117-21-ov80nw.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C3464%2C2300&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Little information is available to college students on stopping the spread of COVID-19 within an intimate relationship.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-couple-kissing-with-face-protective-mask-royalty-free-image/1265180786?adppopup=true">DisobeyArt/iStock via Getty Images Plus</a></span></figcaption></figure><p>With college students back on campus, and COVID-19 with us <a href="https://theconversation.com/is-covid-19-here-to-stay-a-team-of-biologists-explains-what-it-means-for-a-virus-to-become-endemic-168462">for the foreseeable future</a>, it has become increasingly clear that educators need to develop a <a href="https://www.healthline.com/health/healthy-sex/safer-sex-tips-positions-during-covid-19#covid-19-tips">new definition</a> of safer sex. </p>
<p>Although the virus is <a href="https://www.avert.org/coronavirus/covid19-sex">not a sexually transmitted infection</a>, students can <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html">spread COVID-19</a> through <a href="https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html">droplets and particles</a>, especially when within 6 feet of each other. That includes being intimate. </p>
<p>This is why sex education efforts need to inform students not only about sexually transmitted infections, HIV and unintended pregnancy, but also about ways to <a href="https://bestlifeonline.com/new-coronavirus-sex-guidelines/">reduce COVID-19 transmission risk</a>.</p>
<p><a href="https://profiles.ucla.edu/tamra.loeb">As psychologists</a> and <a href="https://www.researchgate.net/profile/Michele-Cooley-Strickland">educators</a> at the University of California, Los Angeles, who <a href="https://www.semel.ucla.edu/profile/gail-wyatt-phd">design interventions</a> to promote the health and well-being of college students, we are aware of the work that has gone into reopening campuses during the pandemic. But despite all the effort, some critical health needs of those students have been entirely overlooked. </p>
<figure class="align-center ">
<img alt="A group of college students on campus." src="https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432529/original/file-20211117-27-iq3bqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Much can be done to reduce COVID-19 risk for sexually active students.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/diverse-group-of-college-friends-royalty-free-image/887132600?adppopup=true">Ariel Skelley/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>The CDC missed a chance</h2>
<p>The Centers for Disease Control and Prevention produced <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/colleges-universities/considerations.html#section4">a lengthy document</a>, last updated in November 2021, about college campuses and COVID-19 transmission. The document offers suggestions on how to stop the spread of the virus in all kinds of scenarios, from communal eating to sporting events. But stunningly, we could not find a word about the potential for spreading COVID-19 within an intimate relationship. </p>
<p>This is particularly disturbing when one considers that college students could use some expert advice. Their decision-making skills are not <a href="https://doi.org/10.1016/j.jadohealth.2009.05.016">fully developed</a>, and many college-age students are <a href="https://doi.org/10.1016/j.jadohealth.2009.05.016">impulsive</a>. </p>
<p>Pleasurable and perhaps risky behaviors often win out over possible long-term negative consequences. Just look at the <a href="https://mashable.com/article/how-to-have-safe-sex-during-covid-pandemic-smarter-hookups">rates of STIs</a>, <a href="https://doi.org/10.1080/17538068.2017.1385575">HIV</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/19278182/">unintended pregnancy</a>: Compared with other age groups, the rates are <a href="https://doi.org/10.1080/07448481.2018.1549554">higher among college students</a>. </p>
<h2>Ways to avoid COVID-19</h2>
<p>The irony is that there is much to say and to promote about <a href="https://bestlifeonline.com/coronavirus-sex-new-york-guidelines/">reducing COVID-19 risk</a> for sexually active students. </p>
<p>Here are some evidence-based recommendations: Limit the number of sexual partners. Avoid sexual contact with anyone who has COVID-19 or symptoms. Use condoms and <a href="https://www.cdc.gov/condomeffectiveness/Dental-dam-use.html">dental dams</a>.
Avoid activities involving transmission of fecal-oral material. Wear masks during intimate acts. Avoid kissing. </p>
<p>Also: Wash hands before and after sexual activity. Use clean sex toys. Sanitize areas where sexual activity occurs. Engage in <a href="https://www.avert.org/coronavirus/covid19-sex">self-pleasure</a>. And understand that those who are not symptomatic can still transmit <a href="https://www.cdc.gov/library/covid19/pdf/public_pdfs/2020-06-12-Science-Update_FINAL_public.pdf">COVID-19</a> and some <a href="https://www.aafp.org/dam/AAFP/documents/patient_care/sti/hops19-sti-manual.pdf">STIs</a>. </p>
<h2>Abstinence programs don’t help</h2>
<p>Many <a href="https://mashable.com/article/how-to-have-safe-sex-during-covid-pandemic-smarter-hookups">abstinence programs</a> are based on the premise that abstinence until marriage is the acceptable <a href="https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/human_rights_vol35_2008/human_rights_summer2008/hr_summer08_kantor/">standard of human sexual behavior</a>. </p>
<p>But research has shown that <a href="https://aspe.hhs.gov/reports/impacts-four-title-v-section-510-abstinence-education-programs-1">abstinence programs are ineffective</a> and often lead to increased rates of <a href="https://doi.org/10.1371/journal.pone.0024658">unintended pregnancy</a> and other high risk behaviors. That’s because they limit discussions of STI prevention and birth control; this effectively <a href="https://doi.org/10.1371/journal.pone.0024658">withholds information</a> from young people who are in the midst of making crucial decisions about their health and future.</p>
<p>Instead, <a href="https://doi.org/10.1097/GCO.0b013e3282efdc0b">research shows</a> that programs that provide accurate information in a nonjudgmental way about abstinence, contraception and STI prevention work better, particularly if they also promote communication, decision-making and <a href="https://www.americanbar.org/groups/crsj/publications/human_rights_magazine_home/human_rights_vol35_2008/human_rights_summer2008/hr_summer08_kantor/">negotiation skills</a>. </p>
<p>These same programs could also add information about preventing the spread of COVID-19 while sexually intimate.</p>
<figure class="align-center ">
<img alt="A young woman on her bed is looking at her smartphone." src="https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432538/original/file-20211118-28-1i2jhps.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">By accessing COVID-19 test results via smartphone, students can easily share them with their intimate partners.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/woman-in-bed-texting-on-phone-royalty-free-image/1311283313?adppopup=true">martin-dim/E! via Getty Images</a></span>
</figcaption>
</figure>
<h2>How schools can help</h2>
<p>Instead of ignoring the issue, university administrators should make sure students have the tools they need to avoid both COVID-19 and STIs. </p>
<p>For example, with just their smartphones, students can easily <a href="https://www.studenthealth.ucla.edu/services/covid-19-testing">schedule COVID-19 tests</a>, get the results and then share them with those they are intimate with. The same can be done with <a href="https://doi.org/10.1007/s10461-019-02718-y">STI, HIV</a> and pregnancy results. </p>
<p>Sharing those results with respect for confidentiality requires widespread promotional campaigns to normalize this new behavior. Schools or campus-based student organizations could ignite a trend on Twitter with a simple but memorable slogan. Here’s one we suggest: “Show me yours and I’ll show you mine.” That’s one of many Twitter-friendly lines that would encourage students to exchange electronic health records. </p>
<p><a href="http://95.138.156.120/article/06/01/2021/UC-San-Diego-offers-students-COVID-test-kits-by-vending-machine">Some campuses</a> already have vending machines <a href="https://newscenter.sdsu.edu/sdsu_newscenter/news_story.aspx?sid=78531">that contain free COVID-19 self-test kits</a>. Results are sent to students electronically. At UCLA, the self-test kits are placed near <a href="https://healtheducation.ucla.edu/what-we-offer/programs/bruin-love-station">sexual health vending machines</a>, which are stocked with condoms, lubricant, emergency contraception and other reproductive and sexual aids. </p>
<h2>Learning to interact again</h2>
<p><a href="https://doi.org/10.18865/ed.30.2.261">Communication between students</a> is critical, particularly when sharing intimate information. But after 18 months away from campus because of COVID-19, some have experienced <a href="https://doi.apa.org/fulltext/2021-00489-001.html">serious social and emotional impacts</a>. For many, peer-to-peer communication skills have declined. This awkwardness makes it particularly difficult when discussing sensitive subjects. </p>
<p>Again, the school can help. One way is to offer students breakout sessions in small groups. This could be done in-class or as extracurricular assignments. Either approach gives <a href="https://www.premiumschools.org/social-anxiety-disorder-college/">socially anxious students</a> – or those recovering from COVID-19 isolation – the outlet they need to interact in person with others. </p>
<h2>How parents can help</h2>
<p>Young people have been bombarded with sexual misinformation from both peers and media. But studies show that intergenerational communication about sexual activity can reduce <a href="https://doi.org/10.1542/peds.2015-0305">risky sexual behaviors</a>. And while sexual health education is <a href="https://www.cdc.gov/healthyyouth/whatworks/what-works-sexual-health-education.htm">effective at reducing unwanted outcomes</a>, it’s enhanced when <a href="https://doi.org/10.1016/j.pcl.2016.11.002">parents are involved</a>. </p>
<p>With the widespread impact of COVID-19, now is a great time to <a href="https://eisnerfoundation.org/">bring parents into the conversation</a>. But they are often an underutilized resource. Many haven’t had sexual health education themselves, they may not know what’s appropriate to share with their children and they may simply be <a href="https://doi.org/10.1016/j.pcl.2016.11.002">uncomfortable with sex topics</a>. </p>
<p>We are still in a time of considerable ambiguity, mistrust and confusion. That applies to both COVID-19 and sexual health. But there is one certainty: Young people need responsible adult guidance to secure a healthy future. And the sooner the better. In the grip of a pandemic, their lives may depend on it.</p><img src="https://counter.theconversation.com/content/170852/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamra Burns Loeb receives funding from the National Heart, Lung, and Blood Institute of the National Institutes of Health.</span></em></p><p class="fine-print"><em><span>Gail Wyatt, Phd works at University of California, Los Angeles(UCLA). She receives funding from National Heart, Lung, and Blood Institute of the National Institutes of Health, Cal Wellness Foundation, and Gilead Pharmaceutical Sciences. </span></em></p><p class="fine-print"><em><span>Michele R. Cooley-Strickland is the co-principal investigator of a grant with pending funding from the Eisner Foundation at UCLA. The title of the grant is "Plan A: Intergeneration STI, HIV, and Pregnancy Prevention – ‘Sex, Cookies, & COVID’.”</span></em></p>
Schools have not adequately educated students about the increased risks of virus transmission when it comes to being sexually intimate.
Tamra Burns Loeb, Adjunct Associate Professor, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
Gail Wyatt, Dena Bat Yaacov Endowed Chair and Distinguished Professor of Psychiatry & Biobehavioral Sciences, University of California, Los Angeles
Michele R. Cooley-Strickland, Project Scientist and Clinical Psychologist, Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/168909
2021-09-29T10:40:27Z
2021-09-29T10:40:27Z
Head of UNAIDS unpacks the knock-on effects of COVID-19. And what needs to be done
<figure><img src="https://images.theconversation.com/files/423801/original/file-20210929-28-j14zmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">UNAIDS Executive Director Winnie Byanyima.</span> <span class="attribution"><span class="source">Fabrice Coffrini/AFP via Getty Images</span></span></figcaption></figure><p><em>The COVID-19 pandemic has deepened global inequities. The world’s poor have borne the brunt of national lockdowns and will struggle to recover and poorer countries have been unable to rollout comprehensive vaccination campaigns because of a grossly unequal distribution of vaccines. On top of this COVID-19 has also derailed progress against diseases that affect poor people. Imraan Valodia sat down for a conversation with Winnie Byanyima, the Executive Director of UNAIDS.</em> </p>
<hr>
<p><strong>Imraan Valodia:</strong> What impact has COVID-19 had on the fight against HIV in countries, particularly those in the global South, carrying the biggest burden of the disease and with significantly weaker healthcare systems?</p>
<p><strong>Winnie Byanyima:</strong> Firstly, we must recognise the successes of the AIDS response. We have achieved what many once said was impossible. Of the <a href="https://www.unaids.org/en/resources/fact-sheet">38 million</a> people living with HIV, 27.5 million are accessing lifesaving antiretroviral therapy. We have cut the rate of new HIV infections by more than half and averted 16.6 million deaths.</p>
<p>But let us be clear: fighting a pandemic with <a href="https://theconversation.com/why-ending-hiv-still-rests-on-a-working-cure-as-well-as-prevention-113592">no cure and no vaccine</a> is hard.</p>
<p>Hundreds of thousands are still dying of AIDS and 1.5 million people were newly infected last year. AIDS remains a crisis and COVID-19 is making it worse.</p>
<p>Even before COVID-19, we were <a href="https://www.unaids.org/en/resources/909090">off track</a> in meeting the global AIDS targets and the COVID-19 pandemic has pushed us back even further. COVID-19 related restrictions have hurt the most vulnerable, including marginalised and stigmatised communities and has disrupted access to HIV services.</p>
<p>Since COVID-19 hit, the Global Fund to Fight AIDS, TB and Malaria <a href="https://www.theglobalfund.org/en/news/2021-09-08-global-fund-results-report-reveals-covid-19-devastating-impact-on-hiv-tb-and-malaria-programs/">estimate</a> that the number of mothers receiving prevention of mother to child transmission services dropped by 4.5%, people reached with HIV prevention programmes declined by 11%, HIV testing declined by 22% and medical male circumcision to prevent HIV dropped by 27%.</p>
<p>In very high prevalence settings in Africa, it is estimated that the effects of COVID-19 could contribute to a 10% increase in HIV deaths over five years. </p>
<p>Amid unprecedented global disruptions, we must act urgently to prevent a resurgent global AIDS pandemic and to quickly recover our progress toward ending AIDS. To get fully back on track on HIV we absolutely have to get on top of COVID-19.</p>
<p><strong>Imraan Valodia:</strong> COVID-19, like HIV, has deepened inequalities in society and disproportionately affected women while widening the long-existing gender pay gap. How do we begin to address this gender economic and inequality pandemic?</p>
<p><strong>Winnie Byanyima:</strong> Both COVID-19 and HIV are feeding off inequalities: women whose rights are not respected; women who do not have economic security or access to the most basic health or education services. These are the people that pay the heaviest price of our inaction on inequality. They pay the price in insecurity, in poverty, in sickness, and too often in death.</p>
<p>Five in six African adolescents newly acquiring HIV are <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30404-8/fulltext">girls</a>. The reason is power. Research <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2021/april/20210406_keeping-girls-in-school-reduces-new-hiv-infections">shows</a> that completion of secondary education reduces a girl’s risk of acquiring HIV by up to half, and by even more if this is complemented by a package of rights and services. Yet as countries struggle with the current fiscal challenges, education and girls’ empowerment are among sectors that are suffering the biggest budget cuts.</p>
<p>Governments also have a responsibility to shift the <a href="https://theconversation.com/unpaid-care-work-still-falls-on-women-seven-steps-that-could-shift-the-balance-163908">burden of care</a> away from women’s invisible unpaid labour. Affirmative action is essential to counteract the legacy of discrimination against women.</p>
<p>Economic interventions are needed to overturn the gross imbalance of wealth. But ending the age of inequality requires the strengthening of emancipatory social and cultural forces to overturn the gross imbalance of power in all its interconnecting forms.</p>
<p><strong>Imraan Valodia:</strong> You say that extreme inequality is not inevitable – it’s a policy choice – explain what you mean by this? What roles can individuals, communities, and nations play to end it?</p>
<p><strong>Winnie Byanyima:</strong> There is a pandemic of inequality – between men and women, between the South and the North; between dominant and marginalised communities, between the elite and the majority – which hold back our enormous potential.</p>
<p>Inequalities are perpetuated by laws, by informal rules (social norms), by national social and economic policies and resource allocation, and by global policies and finance. And key to determining all those outcomes are inequalities of voice and power.</p>
<p>In the face of the colliding crises, it has become clear that we need bold new approaches to how we survive and thrive. Action is needed at all levels – not to build a perfect world but to enable a resilient one.</p>
<p>The answers are being articulated by activists and organisers, particularly young people from the most marginalised communities. They are showing how to build societies able to overcome any crisis and to unleash the potential of all. They have done so because the people most impacted are those who understand it best.</p>
<p>As a UN leader, I have experienced the power of the pressure of communities, women’s groups and grassroots movements, pushing us; at times that pushing is uncomfortable for us; but my message to you is: </p>
<blockquote>
<p>Keep pushing!</p>
</blockquote>
<p><strong>Imraan Valodia:</strong> What lessons can we learn for the management of future pandemics from the triangle of science, government and communities that was in place in dealing with HIV?</p>
<p><strong>Winnie Byanyima:</strong> We have learned a lot about how to fight pandemics. This year marks <a href="https://theconversation.com/africa/search?q=AIDS+40+years">40 years</a> that we have been fighting AIDS and our successes and failures have taught us that we cannot successfully conquer a pandemic without working together to end inequalities, promote people-centred approaches, engage communities, and respect human rights.</p>
<p>This is one of the most challenging moments in the history of HIV and global health. We need greater urgency in our response to pandemics, global solidarity behind a data-driven global plans to end AIDS and to end COVID-19, and partnerships to prepare to respond to the next threat.</p>
<p>We need to draw from the collective experience, brilliance and value set of the AIDS response. If we apply the hard-earned lessons of AIDS up front, we will increase our odds of winning.</p>
<p><em>This article is part of a media partnership between the Southern Centre for Inequality Studies’s and The Conversation Africa for its 2021 annual Inequality Lecture, which was presented on Thursday, 30 September. You can watch the full lecture <a href="https://www.facebook.com/conversationAfrica/videos/660007621560449?_rdc=1&_rdr">here</a>.</em></p><img src="https://counter.theconversation.com/content/168909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Imraan Valodia receives funding from a number of local and international organizations that support research.</span></em></p>
Greater urgency is needed in the response to pandemics, to end AIDS and to end COVID-19.
Imraan Valodia, Dean of the Faculty of Commerce, Law and Management, and Head of the Southern Centre for Inequality Studies, University of the Witwatersrand
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/165353
2021-09-23T14:08:37Z
2021-09-23T14:08:37Z
Children are losing caregivers to COVID-19: they need support
<figure><img src="https://images.theconversation.com/files/419974/original/file-20210908-15-ktc1cp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">As the pandemic progresses, many more children will experience devastating losses.</span> <span class="attribution"><span class="source"> SDI Productions/GettyImages</span></span></figcaption></figure><p>Children have a very <a href="https://www.nature.com/articles/d41586-021-01897-w">low risk of death or severe disease</a> from COVID-19. As a result, they have not been a core focus in the pandemic response priorities of prevention, detection, and response. But this approach doesn’t take into account the secondary impacts of the pandemic. These include children being orphaned or bereft of their caregivers.</p>
<p>Children are among the most vulnerable members of any society and are thus disproportionately affected by the devastation of this pandemic. If every adult death represents a child who has lost a member of their care network, we are on the cusp of a crisis of care for those children left behind. Without support, these children are set to face adverse consequences, including poverty, abuse, and institutionalisation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-19-in-children-the-south-african-experience-and-way-forward-164586">COVID-19 in children: the South African experience and way forward</a>
</strong>
</em>
</p>
<hr>
<p>A first step in supporting these children is to figure out how many have lost guardians to COVID-19. We <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01253-8/fulltext">worked with experts</a> at the Centers for Disease Control and Prevention, the World Health Organisation, the World Bank, and the United States Agency for International Development to estimate this number. </p>
<p>We used mathematical modelling and mortality and fertility data from 21 countries that account for 76% of the reported global deaths from COVID-19. </p>
<p>Our <a href="https://www.cdc.gov/coronavirus/2019-ncov/downloads/community/orphanhood-report.pdf">findings</a> uncovered a hidden, secondary pandemic. Over the first 14 months of the COVID-19 pandemic, 1.5 million children around the globe lost primary caregivers, including at least one parent or grandparent, to the virus. We also created an <a href="https://imperialcollegelondon.github.io/orphanhood_calculator/#/country/Brazil">online calculator</a> that shows minimum estimates for every country in the world.</p>
<p>As the pandemic progresses, many more children will experience such devastating losses. By September 2021 the number had already risen to 2.3 million. Evidence-based responses to this caregiver loss are urgently needed within global and national responses to COVID-19.</p>
<h2>Crisis of care</h2>
<p>More than 1.1 million children around the world experienced the death of <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01253-8/fulltext">a primary caregiver</a>, such as a parent or custodial grandparent, between March 2020 and April 2021. More than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)01253-8/fulltext">1.5 million</a> children experienced the death of primary caregivers as well as co-residing grandparents (or kin).</p>
<p>Considering custodial grandparents as caregivers in our research is particularly important for an African context. Grandparents <a href="https://www.un.org/development/desa/pd/data/living-arrangements-older-persons">often</a> serve as guardians, caring for children whose parents migrated for work, have died, or are separated by conflict or war. </p>
<p>Countries with the highest numbers of children losing primary caregivers were South Africa, Peru, the USA, India, Brazil, and Mexico. The number of children orphaned in these countries ranges from 94 ,625 to 1, 562, 000. On the African continent, South Africa has experienced the greatest loss of primary caregivers. Although it is likely that other countries may be under-reporting COVID-19-associated deaths and may have many more orphaned children than we were able to measure. But we know that one in every 200 children in the country lost their primary caregiver. In sum, estimates suggest that every 12 seconds, a child around the world loses a caregiver to the coronavirus pandemic.</p>
<p>As long as the COVID-19 pandemic continues, this devastating toll of caregiver loss will increase daily. For those of us working in child protection, these figures representing the scale of COVID-19-associated orphanhood are deeply concerning. They present serious long-term challenges to the well-being of children.</p>
<p>Children experiencing COVID-19-associated deaths of parents or caregivers are at greater risk of family separation and institutionalisation. Institutionalisation <a href="https://www.thelancet.com/pdfs/journals/lanchi/PIIS2352-4642(20)30060-2.pdf">should be avoided</a> because of its clear damage to psychosocial, physical and neural development.</p>
<p>Accelerating equitable vaccine delivery is key to developing a response to this crisis. Over half a billion COVID-19 vaccine doses have been administered worldwide. But <a href="https://www.nytimes.com/interactive/2021/03/31/world/global-vaccine-supply-inequity.html">more than 75%</a> have been used by the world’s richest countries. To this day, less than <a href="https://www.afro.who.int/news/eight-10-african-countries-miss-crucial-covid-19-vaccination-goal">3%</a> of Africa’s population has been fully vaccinated. This moment is all too reminiscent of when AIDS first rampaged through sub-Saharan Africa. It was a time when lifesaving medicines were available in the United States and Europe, but still years away for other countries.</p>
<h2>Lessons from HIV</h2>
<p>Lessons from mass-fatality outbreaks such as HIV might pave a way forward. </p>
<p>In 2003, the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) programme made <a href="https://crsreports.congress.gov/product/pdf/IF/IF10797">a ground-breaking commitment</a> to children worldwide affected by the AIDS epidemic. It mandated that 10% of the programme’s funds would support children whose primary caregivers had died of AIDS or had acquired HIV. This programme, through evidence-based interventions and clinical services, continues to support families caring for children who lost caregivers to AIDS. This helps prevent children being placed in institutions.</p>
<p>Such evidence-based responses should inspire the thinking around how best to care for bereaved children. It is essential to help families caring for these children. Psychosocial support groups should be established. Surviving caregivers must be empowered to facilitate grieving and open communication with children about the trauma of losing loved ones. We must advocate for resources to be allocated to this.</p>
<p>Investments are also urgently needed for accelerator programmes adapted to COVID-19, which combine economic interventions, positive parenting, and education support. Our earlier <a href="https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(19)30033-1/fulltext">research</a> shows that low-cost approaches focused on family strengthening can improve multiple outcomes for children with deceased caregivers.</p>
<p>Our <a href="https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642(19)30033-1/fulltext">research</a> on development accelerators on the African continent has also shown that programmes like these are feasible and can be affordable. For example, cellphone-based parenting support programmes that help caregivers to manage stress, give them strategies for nonviolent discipline and teach ways to keep children safe from sexual violence can cost as little as about $8 a child.</p>
<p>The grief of these children and their future are the global community’s responsibility. An all-encompassing response to these losses is urgent.</p><img src="https://counter.theconversation.com/content/165353/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lorraine Sherr has received various research grants over the course of my academic career.</span></em></p><p class="fine-print"><em><span>Lucie Cluver receives research grants to the University of Oxford and the University of Cape Town from the Oak Foundation and Global Challenges Research Fund (UK) for this work. </span></em></p>
Estimates suggest that every 12 seconds, a child somewhere in the world loses a caregiver to the coronavirus pandemic.
Lorraine Sherr, Professor of Clinical and Health Psychology, UCL
Lucie Cluver, Honorary Professor in Psychiatry and Mental Health, University of Cape Town
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/166230
2021-09-22T12:58:23Z
2021-09-22T12:58:23Z
Spreading HIV, the virus that causes AIDS, is against the law in 37 states – with penalties ranging up to life in prison
<figure><img src="https://images.theconversation.com/files/417668/original/file-20210824-19578-1mmip0.jpg?ixlib=rb-1.1.0&rect=56%2C0%2C6240%2C4082&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Medical experts have recommended that HIV criminal laws be revised.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/prisoner-at-the-bolivar-county-correctional-facility-waits-news-photo/1315034536">Spencer Platt / Staff / via Getty Images News</a></span></figcaption></figure><p>Despite the fact that HIV is now a treatable medical condition, the majority of U.S. states still have laws on the books that criminalize exposing other people to HIV. Whether or not the virus is transmitted does not matter. Neither does a person’s intention to cause harm. A person simply must be aware of being HIV-positive to be found guilty. </p>
<p>These laws are <a href="https://doi.org/10.1007/s10461-013-0408-1">enforced mainly on marginalized people living in poverty</a> who cannot afford lawyers. The penalties – <a href="https://www.hivlawandpolicy.org/news/chlp-releases-date-analysis-us-laws-criminalize-disease-2020">felony convictions and being placed on sex offender registries</a> – are severe and life altering. </p>
<p>It is difficult to know exactly how many people are affected by HIV criminal laws, since a central <a href="https://doi.org/10.1007/s10461-016-1540-5">database of such arrests does not exist</a>. The HIV Justice Network has collected a <a href="https://www.hivjustice.net/country/us/?">partial list of 2,923 HIV criminal cases</a> since 2008 based on media reports. </p>
<p>I am a <a href="https://scholar.google.com/citations?hl=en&user=pR7k3XQAAAAJ">professor of social work</a> who studies the impact of HIV criminal laws <a href="https://doi.org/10.1080/15381501.2021.1963385">from the perspective of people who have been arrested</a>. My research shows such statutes are outdated, harm people living with HIV and exacerbate the spread of the virus by driving people into hiding and away from treatment services. </p>
<h2>The early years of AIDS</h2>
<p>In 1981, the U.S. Centers for Disease Control and Prevention reported <a href="https://pubmed.ncbi.nlm.nih.gov/6789108/">the first cases</a> of what later would be called acquired immune deficiency syndrome, or AIDS. By 1982, researchers had strong evidence the disease could be transmitted through blood and sexual activity. At the time, the <a href="https://doi.org/10.1126/science.7089584">death rate for AIDS patients was estimated to be 65%</a>. </p>
<p>In 1983, scientists discovered the <a href="https://doi.org/10.1126/science.6189183">retrovirus that causes AIDS</a> and named it the human immunodeficiency virus, or HIV. Initially, HIV infection was reported mainly in gay men, but as time went on, <a href="https://ari.ucsf.edu/about-us/history-aids-ucsf">it was diagnosed in other populations, including women and children</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three people at cubicle desks under a banner reading 'National AIDS Hotline - Information, Education, Referrals.'" src="https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/421401/original/file-20210915-16-1tynro6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Operators at the National AIDS Hotline run by the American Social Health Association in 1991.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AIDSEPIDEMIC1991/9c157ac90ce8da11af9f0014c2589dfb/">AP Photo/Karen Tam</a></span>
</figcaption>
</figure>
<p>In 1994, <a href="https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline">AIDS was the leading cause of death</a> for all Americans ages 25 to 44. Medical treatment for the disease was in its infancy. Both factors fueled the public’s fear of being exposed to AIDS. A diagnosis seemed like a death sentence.</p>
<h2>Criminal laws</h2>
<p>The 1988, Ronald Reagan’s <a href="https://doi.org/10.1111/j.1746-1561.1988.tb00559.x">Presidential Commission on the HIV Epidemic</a> recommended that states establish criminal penalties as a way of deterring people with HIV from engaging in behavior likely to transmit the virus. The <a href="https://www.govtrack.us/congress/bills/101/s2240/text">1990 Ryan White CARE Act</a>, which provided major funding for HIV services, required states to certify they had adequate laws in place to prosecute individuals who knowingly exposed another person to HIV.</p>
<p>In 1990, 14 states had HIV criminal laws. By 2005, <a href="https://doi.org/10.1007/s10461-006-9117-3">23 states had them</a> – even though the <a href="https://bibleandbookcenter.com/read/ryan-white-care-act-reauthorization/">reauthorization of the Ryan White CARE Act in 2000</a> removed the criminalization requirement. Today, these laws are <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">on the books in 37 states</a>.</p>
<h2>Unintended consequences</h2>
<p>From the outset, experts across many disciplines <a href="https://www.ucpress.edu/book/9780520291607/punishing-disease">voiced concern about the effectiveness of using punitive criminal laws</a> as a way of deterring the spread of HIV.</p>
<p>Indeed, HIV criminal laws have backfired from a public health perspective. A 2017 study found people living in states with HIV criminal laws are <a href="https://doi.org/10.1097/QAD.0000000000001636">less likely to get tested and know their HIV status</a> than those in states without HIV laws. Stigma and fear of prosecution discourage people from seeking information or help.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People in a parade carrying a banner that reads 'HIV Stigma Stops Here.'" src="https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418103/original/file-20210826-25-1vjp2pq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Minnesota AIDS Project banner at the Twin Cities Pride Parade in Minneapolis in 2013.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/87296837@N00/9180874836">Tony Webster/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>This lack of knowledge is significant because pharmaceutical treatments, beginning in 1996 with highly active antiretroviral therapy, or HAART, have steadily <a href="https://www.niaid.nih.gov/diseases-conditions/hiv-treatment">transformed HIV into a chronic manageable condition</a>.</p>
<p>Medical experts have <a href="https://doi.org/10.1007/s10461-016-1540-5">recommended that HIV criminal laws be revised</a>. However, <a href="https://scholarship.law.cornell.edu/clr/vol94/iss3/13">most state legislatures have not done so</a>. </p>
<p><a href="https://www.hivjustice.net/global-hiv-criminalisation-database/cases/">These laws are regularly enforced</a> – most often on members of stigmatized groups, including those who are <a href="https://doi.org/10.1007/s10461-013-0408-1">homeless or suffering from an addiction or mental illness</a>. Research has also documented that HIV criminal laws are <a href="https://www.thebody.com/article/hiv-criminalization-and-people-of-color">disproportionately applied to people of color</a>. In fact, the majority of people arrested for an HIV crime <a href="https://doi.org/10.1007/s10461-013-0408-1">are members of multiple minority communities</a>. </p>
<p>Being arrested for an HIV-related crime is often devastating for individuals – beginning with the permanent exposure of personal health information to the public. For indigent defendants, felony charges pursued by a county’s district attorney will result in the appointment of a <a href="https://vanderbiltlawreview.org/lawreview/2020/05/plea-bargaining-and-collateral-consequences-an-experimental-analysis/">public defender, who will most likely counsel a guilty plea</a> – regardless of whether the individuals believe they are guilty or even understand the consequences of such a plea. </p>
<p>Sentences for violating HIV exposure statutes are comparable to sentences for vehicular homicide and <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">can be as severe as life in prison</a>. A 2017 analysis of 393 convictions in Arkansas, Florida, Louisiana, Michigan, Missouri and Tennessee found the <a href="https://www.ucpress.edu/book/9780520291607/punishing-disease">average sentence for an HIV-related crime was 92 months</a> – or nearly eight years in prison. </p>
<p>Incarceration can result in <a href="https://www.brennancenter.org/sites/default/files/2020-09/EconomicImpactReport_pdf.pdf">permanent restrictions on employment, housing, education and voting</a>. </p>
<p>Additionally, six states currently <a href="https://www.hivlawandpolicy.org/resources/chart-state-state-criminal-laws-used-prosecute-people-hiv-center-hiv-law-and-policy-2012">place people convicted of an HIV-related crime on the sex offender registry</a>, which results in lifetime sex offender status – a relentless and unending punishment. </p>
<h2>Treatment lowers risk</h2>
<p>The HIV epidemic in the U.S. has changed tremendously in the past 40 years. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Three people hold signs saying 'Free HIV testing now' and 'Ask about Prep/Pep now.'" src="https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417666/original/file-20210824-17640-4ofpwm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Volunteers hold signs promoting free HIV testing and information during the Harlem Pride parade in New York City on June 29, 2019.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/volunteers-hold-signs-as-they-promote-free-hiv-testing-news-photo/1152819576">KENA BETANCUR / Contributor / AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>HIV exposure laws have not kept up with the changes in HIV science and treatment. People with knowledge of their HIV status can <a href="https://www.cdc.gov/hiv/risk/art/index.html">receive treatment that makes them unable to transmit the virus</a>. Proven prevention methods such as <a href="https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/HIV-Proven-Prevention-Methods-508.pdf">HIV testing, treatment and preexposure prophylaxis, or PrEP</a>, are tools that remove the justification for HIV criminal laws.</p>
<p>Scientists can identify solutions to public health challenges, but it takes action by <a href="https://www.annualreviews.org/doi/pdf/10.1146/annurev.publhealth.25.101802.123126">politicians to turn solutions into policy</a>. HIV criminal laws are largely ignored because the people they directly affect are not connected to political power. </p>
<p>Bipartisan support is needed to replace existing laws with proven public health interventions.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p><img src="https://counter.theconversation.com/content/166230/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Lennon-Dearing has recieved funding from the University of Memphis Foundation and currently receives funding from the National Institutes of Health under Grant 2P30AI042853-21. She is a member and consultant for the Tennessee HIV Modernization Coalition.</span></em></p>
Current HIV criminal laws increase HIV stigma and discrimination against marginalized people – and negatively affect public health.
Robin Lennon-Dearing, Associate Professor of Social Work, University of Memphis
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/166735
2021-09-01T20:09:53Z
2021-09-01T20:09:53Z
Watching It’s a Sin under lockdown: a different kind of home shaped by life-saving queer friendships
<figure><img src="https://images.theconversation.com/files/418781/original/file-20210901-17-5xxtyp.png?ixlib=rb-1.1.0&rect=136%2C10%2C959%2C645&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Olly Alexander (Ritchie) on left, Omari Douglas (Roscoe) and Callum Scott Howells (Colin) in It's a Sin.</span> <span class="attribution"><span class="source">Red Production Company</span></span></figcaption></figure><p><em><a href="https://theconversation.com/au/topics/lockdown-tv-108838">Our writers nominate</a> the TV series keeping them entertained during a time of COVID.</em></p>
<p>Binge watching a gut-wrenching story about the early years of the HIV/AIDS epidemic might seem like a strange choice in Sydney right now. What possible solace could be found in a story about a group of young friends in 1980s London who found their joyful steps towards the creation of a queer world fractured by fear and death? </p>
<p>I rewatched the five-part British TV series It’s a Sin in lockdown recently, and the sorrow that reverberates through the show resonated a little more potently than it did on my first viewing earlier this year. It also, though, in its elaboration of joyful possibilities fractured by an epidemic, helped me make sense of some of the intangible losses of lockdown. </p>
<p>As counsellor <a href="https://theconversation.com/its-ok-if-you-have-a-little-cry-in-lockdown-youre-grieving-165329">Neeraja Sanmuhanathan has written</a>, many in lockdown are feeling “disenfranchised grief”. Yet even naming these feelings risks insensitivity, because others are dealing with grief much more difficult to bear.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/hnR5DxP2e2g?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>New South Wales Premier Gladys Berejiklian speaks from a rhetorical playbook of unity, discipline and shared citizenship obligations to compel Sydneysiders to stay at home under lockdown. It’s a Sin can help us consider how the sorrows and hardships of these obligations are unevenly distributed, for they depend on what your home looks like, and whether it is your primary source of nourishment and care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/think-of-it-this-way-at-least-youre-not-locked-down-with-drunken-misanthropic-bookshop-owner-bernard-black-166173">Think of it this way: at least you're not locked down with drunken, misanthropic bookshop owner Bernard Black</a>
</strong>
</em>
</p>
<hr>
<h2>Queer networks</h2>
<p>It’s A Sin opens in 1981. A group of young Londoners find their way to each other and a queer life as new forms of social visibility are being carved out from the grip of homophobic discrimination and sentiment. </p>
<p>We soon come to love, even if they sometimes behave a little poorly, Olly (a star-making turn from <a href="https://ew.com/tv/olly-alexander-pride-its-a-sin-years-and-years/">Year and Years frontman</a> Olly Alexander), Roscoe (Omari Douglas), Colin (Callum Scott Howells) and Jill (Lydia West) as their lives converge in a share house, “the Pink Palace”, which becomes the emotional centre of the story.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=596&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=596&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=596&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=749&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=749&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418362/original/file-20210830-20-11nor0j.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=749&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Omari Douglas in It’s a Sin.</span>
<span class="attribution"><span class="source">Red Production Company</span></span>
</figcaption>
</figure>
<p>They are a diverse lot, both in ambition and background. All, in different ways, seek to escape the futures mapped for them by others, although what they would like to become is much less clear.</p>
<p>Exuberant confusions and experiments are at the centre of the first few episodes. I challenge anyone not to be totally undone by Colin’s endearing uncertainties as he takes tentative steps into homosexual worlds. We see parties, drinks at the pub, exciting intimacies. And The Pink Palace develops its own tender traditions and vocabularies; the housemates exclaim “La” to each other as they enter and exit the house. These are the everyday familiarities that feel like a hug of recognition.</p>
<p>Rather than a world organised by biological family and the romantic couple, friendship is sovereign here. These new kinds of friendship prioritise pleasure and joy. They are full of disordering excitements that produce new ways to understand their world.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=304&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=304&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=304&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=382&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=382&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418779/original/file-20210901-15-mxfbuv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=382&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Friendship is sovereign in The Pink Palace.</span>
<span class="attribution"><span class="source">Red Production Company</span></span>
</figcaption>
</figure>
<p>This is why the emergence of HIV/AIDS, which haunts the show from the first episode, feels so tragic. Just as historical change produced the possibility of forging queer public worlds — spaces for dissident desires — an epidemic ravaged them, unleashing fresh waves of homophobia. </p>
<p>Created by Russell T. Davies, each episode of It’s a Sin takes place a few years apart, tracing the impact of the epidemic on queer lives over a decade. We watch these tentative worlds shattered first by fear, then by death, doubly punished by a state that refused to help. In the UK and US, gay men in the early years of the epidemic were seen as a problem to be managed and a sin to be expunged rather than partners in the possible response.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=440&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=440&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418777/original/file-20210901-13-1pm7ea9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=440&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">New intimacies are forged.</span>
<span class="attribution"><span class="source">Red Production Company</span></span>
</figcaption>
</figure>
<p>There are lessons here about the importance of engaging with — rather than disciplining and policing — communities. The <a href="http://press-files.anu.edu.au/downloads/press/n5314/pdf/ch02.pdf">“Australian-Response”</a> to HIV/AIDS was hailed as a success because the state engaged with and learnt from those vulnerable to the disease to develop community-led policy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-recognising-the-unsung-heroes-of-australias-aids-crisis-81030">Friday essay: recognising the unsung heroes of Australia's AIDS crisis</a>
</strong>
</em>
</p>
<hr>
<p>Part of the mastery of the show is that we, as viewers, share the fears of these young men and their friends. We know what is coming, even if they don’t. We find ourselves wondering who from the Pink Palace and their friends will be struck down. </p>
<p>In one episode, one of the housemates is forcibly and legally detained in hospital after his diagnosis. His mother and friends hire a lawyer to release him so he might be cared for by those who understand him.</p>
<p>Watching this makes for difficult viewing. Queer networks, however, power the show. They hold those who are sick, comfort those who are stricken by loss, and politically mobilise to force the state to act. They share grief with parents who lose their sons, holding to account families whose love turned out to be conditional. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=289&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=289&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=289&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=363&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=363&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418363/original/file-20210830-31-z6v7lv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=363&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Queer networks power the show, politically mobilising where needed.</span>
<span class="attribution"><span class="source">Red Production Company</span></span>
</figcaption>
</figure>
<p>This is queer intimacy as life-saving. </p>
<p>This is friendship as primary nourishment and radical politics.</p>
<h2>Less rigid boundaries</h2>
<p>The emotional and narrative centre of It’s a Sin is a home. But this home looks quite different to the one our leaders today might imagine when they issue stay-at-home orders — almost always referring to a family when doing so. It’s certainly not organised around a couple (and the children).</p>
<p>The boundaries around the Pink Palace are porous, people come and go, and you never know who might be at the breakfast table. It is, however, affirming in its instabilities. For Roscoe, this home is an escape from a familial home that was a place of violent rejection.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=435&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=435&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418780/original/file-20210901-17-1u6d80s.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=435&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Roscoe (Omari Davis) flees a violent, rejecting familial home.</span>
<span class="attribution"><span class="source">Red Production Company</span></span>
</figcaption>
</figure>
<p>And that, I think, highlights the challenge facing so many queers in lockdown today. Queer lives are often organised around friendships, (as indeed are many others not oriented around a romantic couple). Boundaries around queer homes may be less rigidly drawn. The intimacies and communities that sustain living queer, enabling joyful exploration of who we might become with each other, are often forged both within and beyond the walls of our home. </p>
<p>This is why so many queer friends I know are struggling. Lockdown hasn’t simply shut down our capacity to dance and have fun, or to have casual (and thus apparently meaningless) sex. It has turned the spaces beyond our homes, in which we nourish our queer selves, into sites of danger. It has turned having your friends over and snuggling on the couch into a breach of duty. </p>
<p>Which is to say, much like the HIV/AIDS epidemic, the impact of lockdown is being felt unevenly and with different effects. </p>
<p>On the release of It’s a Sin, there was much public discussion about the ways in which this show re-imagined the experience of HIV/AIDS for a generation far enough removed from the early years of the epidemic to understand it as history rather than experience. </p>
<p>Watching this series now, though, I find myself mourning the everyday, public, and non-familial intimacies of queer life lost to us during lockdown. It might not have provided solace, but it has helped me to explain my sense of loss. </p>
<p>It also made me wail. And perhaps having a good cry is what many of us need.</p>
<p><em>It’s a Sin is showing on Stan.</em></p><img src="https://counter.theconversation.com/content/166735/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leigh Boucher receives funding from the Australian Research Council.</span></em></p>
The emotional centre of British TV series It’s a Sin is a home. But this home looks quite different to the one our leaders might imagine when they issue stay-at-home orders.
Leigh Boucher, Senior Lecturer – Modern History, Macquarie University
Licensed as Creative Commons – attribution, no derivatives.
tag:theconversation.com,2011:article/165443
2021-08-09T12:25:55Z
2021-08-09T12:25:55Z
People living with HIV face harmful stigma daily – DaBaby’s rant was just more public than most
<figure><img src="https://images.theconversation.com/files/414424/original/file-20210803-25-pwt48e.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4256%2C2822&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">HIV stigma manifests in many ways, including microaggressions that could lead to a higher risk of depression, PTSD and suicidality.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/awareness-royalty-free-image/1282556694">ASphotowed/iStock via Getty Images Plus</a></span></figcaption></figure><p><a href="https://apnews.com/article/entertainment-music-arts-and-entertainment-dababy-248557a1d881dbb6e1f0c7bbc2ccd589">Rapper DaBaby drew sharp criticism</a> after he delivered a rant during a concert on July 25, 2021, insulting people living with HIV or sexually transmitted illnesses. He not only disrespected women and same-gender-loving men, but also falsely equated HIV with a death sentence.</p>
<p>As an <a href="https://scholar.google.com/citations?user=IG4tFvMAAAAJ&hl=en">associate professor of psychology and a clinical psychologist</a> at the University of Miami, I investigate and develop strategies to address the psychosocial and structural factors driving HIV health disparities. My research shows that not only were his comments disrespectful, but also directly harmful and dangerous to people living with HIV.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1419745351163076612"}"></div></p>
<h2>HIV is a chronic illness, but stigma rages on</h2>
<p>HIV is a chronic illness. As a result of <a href="https://www.cdc.gov/hiv/clinicians/treatment/index.html">highly effective medications</a> that first became available over 20 years ago, people living with HIV can take just <a href="https://www.cdc.gov/hiv/risk/prep/index.html">one pill per day</a> and live healthy and long lives. I know many advocates, colleagues and friends who have been living fulfilling lives with HIV for decades. Further, HIV medication can reduce the amount of virus in someone’s body to levels so low that it’s suppressed or <a href="https://www.niaid.nih.gov/diseases-conditions/10-things-know-about-hiv-suppression">undetectable</a> - this means that a person cannot transmit HIV to someone else.</p>
<p>While ongoing medical advances have made living normal lives and thriving with HIV possible, stigma, racism and homophobia are persistent forces harming both people currently living with HIV as well as people who may contract HIV in the future. </p>
<p><a href="https://www.cdc.gov/hiv/basics/hiv-stigma/index.html">HIV stigma</a> appears in a variety of ways, including harmful words and behaviors; hostile home, work and social environments; and discriminatory policies and laws. One way stigma manifests is through <a href="https://www.npr.org/2020/06/08/872371063/microaggressions-are-a-big-deal-how-to-talk-them-out-and-when-to-walk-away">microaggressions</a>, which include subtle words and behaviors that insult and demean a marginalized group.</p>
<p>These microaggressions often cut across the multiple identities that people have. Examples are comments suggesting that women living with HIV look a certain way (“She doesn’t look like she has HIV”) or acting surprised when women with HIV are thriving in work, relationships and other areas of life. Such words and behaviors can negatively affect the mental and physical well-being of people living with HIV. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/8q21PG1CdNs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Medication can lower the levels of HIV in someone’s blood until it’s undetectable and therefore untransmissible to other people. This concept is called U=U.</span></figcaption>
</figure>
<p>My team and I in the <a href="https://shine.psy.miami.edu">SHINE Research Program</a> found that among Black women living with HIV, those who endured more microaggressions about being Black and female tended to experience more <a href="https://doi.org/10.1089/apc.2018.0258">barriers to HIV care</a>, <a href="https://doi.org/10.1007/s11524-020-00432-y">depression</a>, <a href="https://doi.org/10.1037/tra0000467">PTSD symptoms</a> and <a href="https://doi.org/10.1007/s40615-021-01009-4">suicidality</a>. Similarly, higher levels of HIV-related discrimination were associated with higher levels of depression, PTSD symptoms and barriers to HIV care. </p>
<p>The COVID-19 pandemic and racial unrest further increased distress from microaggressions, according to <a href="https://dx.doi.org/10.1007%2Fs10461-021-03321-w">preliminary findings</a> in our <a href="https://news.miami.edu/as/stories/2019/10/dale-project-mmagic.html">Monitoring Microaggressions and Adversities to Generate Interventions for Change (MMAGIC) study</a>. We found that the likelihood that a Black women living with HIV would experience distress because of microaggressions about her HIV status, race, gender or LGB identity increased by 28% from the start of the COVID-19 pandemic in March 2020 through July 2020. Conversely, women who had suppressed levels of HIV were 64% less likely to experience microaggressions than those without suppressed levels. This may be because microaggressions can <a href="https://www.wiley.com/en-us/Microaggression+Theory%3A+Influence+and+Implications-p-9781119420040">adversely affect mental health</a> and make it <a href="https://dx.doi.org/10.2105%2FAJPH.2017.303744">more difficult for people to take their daily medication</a>.</p>
<p>Microaggressions can also have a negative effect on the lives and well-being of both people living with and without HIV. HIV stigma is the No. 1 challenge my team faces when we engage individuals in HIV testing and provide information about the HIV prevention pill <a href="https://www.hiv.gov/hiv-basics/hiv-prevention/using-hiv-medication-to-reduce-risk/pre-exposure-prophylaxis">PrEP</a>. Because of <a href="https://www.glaad.org/endhivstigma">widespread stigma and inaccurate information about HIV</a>, some people are anxious about getting an HIV test or even being seen near an HIV testing vehicle.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People participating in the 2017 Keep the Promise Concert & March in Fort Lauderdale for National Black HIV/AIDS Awareness Day" src="https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414425/original/file-20210803-25-weevn1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One way people living with HIV deal with stigma is participating in advocacy efforts.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AHFHostsKeepthePromiseConcertMarchinFtLauderdaleforNationalBlackHIVAIDSAwarenessDay/670e6dff5bff4e2b81a5b491ce16877a">AP Photo/Jesus Aranguren</a></span>
</figcaption>
</figure>
<h2>Larger systemic issues drive stigma</h2>
<p>Based on my work with people living with HIV, I found DaBaby’s words problematic and hurtful because he used his platform to further reinforce HIV stigma. This jeopardizes the well-being and lives of people living with HIV and the LGBTQ community. However, his individual words are a reflection of larger systemic issues including <a href="https://www.cdc.gov/hiv/policies/law/states/exposure.html">HIV criminalization</a>, <a href="https://www.hrc.org/press-releases/2021-officially-becomes-worst-year-in-recent-history-for-lgbtq-state-legislative-attacks-as-unprecedented-number-of-states-enact-record-shattering-number-of-anti-lgbtq-measures-into-law">anti-LGBTQ policies and laws</a> and <a href="https://www.nbcnews.com/nbc-out/out-health-and-wellness/-will-shut-us-hiv-prevention-clinics-brace-gilead-reimbursement-cuts-rcna1346">inadequate financial support</a> behind efforts to tackle HIV stigma and empower people living with HIV, members of the LGBTQ community and women.</p>
<p>In the face of stigma and discrimination, however, many people living with HIV use <a href="https://doi.org/10.1037/cdp0000165">adaptive coping strategies</a>. One way Black women living with HIV have <a href="https://www.positivelyaware.com/articles/weathering-many-storms">coped with stigma</a> is through <a href="https://doi.org/10.1080/09540121.2018.1503225">social support</a> from their peers, friends, family and health care providers, and by seeking mental health services. Some women also <a href="https://doi.org/10.1037/cdp0000165">selectively disclose their HIV status</a> and <a href="https://doi.org/10.1037/cdp0000165">strategically avoid harmful spaces and individuals</a>. In addition, women actively fight against stigma by <a href="https://doi.org/10.1037/cdp0000165">sharing accurate information about HIV</a>, <a href="https://doi.org/10.1037/cdp0000165">engaging in advocacy</a> and claiming their power to not let HIV stigma dictate their lives.</p>
<p>Accountability and change are needed at the structural, institutional, interpersonal and individual levels to combat stigma. And centering the voices of people living with HIV, the LGBTQ community and women is required to achieve sustainable and meaningful change.</p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/165443/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sannisha Dale receives funding from the National Institute of Health. </span></em></p>
Microaggressions are more subtle than outright discrimination. But they can directly affect HIV treatment outcomes.
Sannisha Dale, Associate Professor of Psychology, University of Miami
Licensed as Creative Commons – attribution, no derivatives.