tag:theconversation.com,2011:/global/topics/aids-epidemic-46431/articlesAIDS epidemic – The Conversation2023-10-12T13:39:33Ztag:theconversation.com,2011:article/2153142023-10-12T13:39:33Z2023-10-12T13:39:33ZJerry 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>
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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>
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<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 TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1662302021-09-22T12:58:23Z2021-09-22T12:58:23ZSpreading 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>
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<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>
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<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>
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<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>
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<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>
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<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>
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<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 MemphisLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1442822020-08-27T00:10:52Z2020-08-27T00:10:52ZShame and fear: lessons to learn as COVID-19 collides with a growing HIV epidemic in Indonesia<figure><img src="https://images.theconversation.com/files/354294/original/file-20200824-22-1tkrvmi.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C4000%2C2832&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An Indonesian police officer gets tested for COVID-19 in Tangerang, Banten.</span> <span class="attribution"><span class="source">ANTARA FOTO/Muhammad Iqbal/aww</span></span></figcaption></figure><p>The nation with the world’s fourth-largest population, Indonesia, has become a target of criticism for its poor COVID-19 mitigation response that <a href="https://duckofminerva.com/2020/08/indonesias-half-hearted-response-to-covid-19-the-role-of-politics-and-historical-legacies.html">“does not value policy advice from external experts”</a>. This has contributed to the country having the <a href="https://covid19.who.int/table">highest recorded COVID-19 death toll in Southeast Asia</a>. </p>
<p>A failure to handle <a href="https://www.thejakartapost.com/academia/2020/06/19/covid-19-kills-as-stigma-harms-families-and-society.html">stigma</a> associated with COVID-19 has also contributed to the surge in cases in Indonesia. The number of cases is the <a href="https://www.csis.org/programs/southeast-asia-program/southeast-asia-covid-19-tracker-0">second highest in Southeast Asia</a>. </p>
<p>Globally, we are witnessing how stigma is taking its toll on affected communities, including in Indonesia, and how <a href="https://www.thejakartapost.com/news/2020/07/08/stigma-precarity-deter-indonesians-from-getting-tested-for-covid-19.html">fear is preventing COVID-19 testing</a>. </p>
<p><a href="https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30477-8/fulltext?dgcid=raven_jbs_aip_email#.Xy0DSTx1Dao">Stigma and discrimination</a> have historically accompanied many infectious disease epidemics.</p>
<p>Similarly to what has been observed with the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197953/">HIV epidemic</a>, we are seeing how shame and fear resulting from stigma and discrimination can drive increased transmission of COVID-19 and prevent vital public health control.</p>
<h2>Shame and fear help disease spread</h2>
<p>AIDS-related deaths fell in most countries, including in the developing world, following widespread improved access to anti-retroviral treatment <a href="https://ourworldindata.org/hiv-aids">by the early 2000s</a>. </p>
<p>However, AIDS-related deaths have never fallen in Indonesia. The toll has <a href="https://www.unaids.org/en/regionscountries/countries/indonesia">increased by 60% since 2010</a>. </p>
<p>Among many challenges that Indonesia has to deal with in its HIV epidemic, stigma and discrimination are the greatest barriers. The COVID-19 pandemic in Indonesia presents similar challenges. </p>
<p>Shame, a negative emotion of unworthiness and inferiority linked to <a href="https://pdfs.semanticscholar.org/72f5/bec99bf961fd8cf3ac2558fad01317ec099d.pdf?_ga=2.205921178.849042126.1595759625-1145901093.1595759625">one’s core identity</a>, is a specific consequence of stigma. </p>
<p>Shame leads people to behave in ways that may be against their best interests. It can lead people to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239200/">seek belonging in riskier environments</a> and communities. </p>
<p>Regardless of the method of transmission and major differences in the viruses, HIV and COVID-19 are both potentially fatal. However, the <a href="https://mh.bmj.com/content/43/4/257#ref-59">threat of shame</a> can feel worse than the threat of death itself. Public health responses to infectious diseases must also tackle and prevent shame.</p>
<p>Fear of persecution and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4672457/">negative outcomes</a>, such as violence, abandonment and relationship breakdowns, due to the <a href="https://data.unaids.org/publications/irc-pub06/jc999-humrightsviol_en.pdf">stigma</a> associated with HIV lead people to avoid getting tested or treated.</p>
<p>Similarly, if people know that a positive COVID-19 diagnosis for themselves or a family member negatively impacts or isolates them from their community or prevents them from making a living, this fear can prevent them from getting tested. </p>
<p>Residents in Penjaringan, North Jakarta, “<a href="https://www.thejakartapost.com/news/2020/07/08/stigma-precarity-deter-indonesians-from-getting-tested-for-covid-19.html">shut themselves in when COVID-19 swab tests were being administered in the neighbourhood’s community hall</a>”. They did this for fear of being stigmatised and losing opportunities to make a living.</p>
<p>Social stigma has worsened <a href="https://www.aidsmap.com/news/sep-2018/indonesia-tackling-hiv-one-worlds-fastest-growing-epidemics">HIV rates</a> among men who have sex with men and other marginalised groups. The stigma has pushed risk underground. This then further increases HIV risk and vulnerability in these groups. </p>
<p>Back in April, it was reported that a patient diagnosed with coronavirus in Indonesia was subjected to <a href="https://globalnews.ca/news/6779349/coronavirus-shaming-stigma-covid/">cruel innuendo</a> suggesting she contracted it through sex work. </p>
<p>Public fear often creates stigma against those infected as a protective mechanism. Beliefs that put the blame and responsibility on those infected, however unfounded, can enable people to feel better off and negate their own risk.</p>
<p>Similar impacts have been observed for populations affected by <a href="https://gh.bmj.com/content/2/4/e000515.long">tuberculosis</a>, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154499/">leprosy</a> and <a href="https://www.tandfonline.com/doi/full/10.3402/gha.v7.26058">Ebola</a>, for example.</p>
<h2>Misinformation makes it worse</h2>
<p>Myth and misinformation and the spread of fake news compound these issues. </p>
<p>A Global Fund report highlighted that in Surabaya, East Java, patients presenting for HIV tests have been asked to seek forgiveness by health workers because of <a href="https://www.theglobalfund.org/media/8721/crg_humanrightsbaselineassessmentindonesia_report_en.pdf?u=637165999520000000">perceived sins</a> before they will be seen. Many people living with HIV are asked to wait for hours for treatment, implying they are not worthy of health care.</p>
<p>In one <a href="https://e-journal.unair.ac.id/JAKI/article/view/18848">study</a> of public understanding and misinformation about COVID-19 in Indonesia, 28% of 530 respondents believed COVID-19 is a deliberately created biological weapon and 20% believed gargling salt water or vinegar could kill the virus. </p>
<p>Indonesian government ministers have themselves suggested <a href="https://theconversation.com/indonesia-was-in-denial-over-coronavirus-now-it-may-be-facing-a-looming-disaster-135436">unconventional and non-evidence-based</a> methods, such as prayer, to beat COVID-19.</p>
<p>Government leadership guides such public understanding; an understanding that prayer protects one from COVID-19 can translate to a belief that those infected are not abiding by religious teaching, undermining their worth in society.</p>
<p>Governments and institutions that encourage blame or false beliefs about an infectious disease drive stigma. </p>
<p>This cycle of stigma prevents affected individuals and communities from thriving and <a href="https://mh.bmj.com/content/43/4/257#ref-39">drives poor physical and mental health</a>. </p>
<p>Public health strategies that perpetuate <a href="https://pubmed.ncbi.nlm.nih.gov/31156079/">stigma are not successful</a> in controlling any infectious disease epidemic. Structural power and mechanisms should be used to educate people and generate positive behavioural change.</p>
<h2>Public health strategies</h2>
<p>We can learn from strategies that have reduced HIV-related stigma to manage COVID-19. </p>
<p>Countries that have strategically reduced institutional stigma have observed better HIV testing and treatment rates and engagement in care. As a result, new HIV infections are reduced. </p>
<p>These trends have been observed, for example, in neighbouring Southeast Asian countries <a href="https://www.unaids.org/sites/default/files/media_asset/confronting-discrimination_en.pdf">Thailand and Vietnam</a>.</p>
<p>Thailand has been a pioneer in reducing HIV-related stigma and discrimination in health-care settings through an innovative health system-wide response. </p>
<p>This <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2018/july/zero-discrimination-health-care-settings-thailand-viet-nam">involved</a> a strategy to reduce stigma and discrimination based on global measuring tools. The strategy includes a permanent monitoring system, evidence-informed actions at health facilities and instructed community engagement at all levels. </p>
<p>Thailand has also had greater success than most Southeast Asian countries in averting COVID-19 deaths and cases by adopting a “<a href="https://news.un.org/en/story/2020/08/1069191">whole-of-society</a>” approach. This enables understanding and appropriate responses to the needs of vulnerable populations. </p>
<p>To counter growing COVID-19 infection rates, public health endeavours must aim to understand the needs, priorities and fears of populations and prevent stigma. The most <a href="https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30757-1.pdf">vulnerable populations</a> must not be left behind.</p>
<p>The Indonesian government should learn from the impact its policies have had in fuelling HIV-related stigma so as to avoid perpetuating stigma during the COVID-19 pandemic.</p>
<p>It is vital that governing bodies and policymakers discourage misinformation and follow robust local and international data. They must also translate the data for public understanding to minimise fear and promote compliance with public health interventions. </p>
<p>This should include <a href="https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(20)30477-8/fulltext?dgcid=raven_jbs_aip_email#.Xy0DSTx1Dao">risk communication strategies</a> to fill knowledge gaps in the general population and prevent the spread of “fake news”.</p>
<p>Government public health endeavours should provide clear, robust, evidence-based information; promote equitable health strategies; reduce stigma and encourage community cohesion. By building public trust and confidence, these measures will have far better success.</p><img src="https://counter.theconversation.com/content/144282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keerti Gedela is a Consultant Physician and researcher for the National Health Service in the UK.
She has received funding from the UK Medical Research Council (MRC)/Newton Fund.
Keerti Gedela and Professor Irwanto are chief investigators within a UK-Indonesia Joint Partnership in Infectious Diseases.</span></em></p><p class="fine-print"><em><span>Evi Sukmaningrum dan Irwanto tidak bekerja, menjadi konsultan, memiliki saham, atau menerima dana dari perusahaan atau organisasi mana pun yang akan mengambil untung dari artikel ini, dan telah mengungkapkan bahwa ia tidak memiliki afiliasi selain yang telah disebut di atas.</span></em></p>Shame and fear resulting from stigma and discrimination can drive increased transmission of COVID-19 and prevent vital public health control.Keerti Gedela, Consultant Physician and Researcher (56 Dean Street, Chelsea & Westminster NHS Trust), Honorary Senior Clinical Lecturer, Imperial College LondonEvi Sukmaningrum, Dosen Dosen Fakultas Psikologi, Universitas Katolik Indonesia Atma Jaya Irwanto, Professor, Department of Psychology, Universitas Katolik Indonesia Atma Jaya Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1190752019-06-27T12:46:47Z2019-06-27T12:46:47ZShould you be tested for HIV? Why June 27 is a good day to do it<figure><img src="https://images.theconversation.com/files/281442/original/file-20190626-76709-kph9eg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman whose blood is being drawn to test for HIV.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/hudopa/27865119191/in/album-72157670314267485/">U.S. Dept. of Housing and Urban Development/flickr</a></span></figcaption></figure><p>June 27 is <a href="https://www.hiv.gov/events/awareness-days/hiv-testing-day">National HIV Testing Day</a>. Have you been tested? </p>
<p>The Centers for Disease Control and Prevention report that of the estimated 1.1 million people in the United States who have the HIV infection, <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">1 in 7</a> don’t know their status.</p>
<p>That is especially true for youth ages <a href="https://www.cdc.gov/hiv/group/age/youth/index.html">13 to 24 that make up 21%</a> of the nearly 40,000 new HIV diagnoses made in 2017. <a href="https://www.cdc.gov/hiv/group/age/youth/index.html">More than 50% of youth</a> who have HIV don’t know about their infection.</p>
<p><a href="https://www.cdc.gov/healthyyouth/data/yrbs/index.htm">Only 9% of high school students</a> report having been tested for HIV. Many people do not get tested because of lack of access to health care, fear and misperceptions about HIV risk and the testing process, and health care settings that lack HIV testing as a <a href="https://www.cdc.gov/hiv/library/factsheets/index.html">routine part of care</a>. </p>
<p>As a nurse at a clinic that treats sexually transmitted infectious diseases, I frequently saw patients visit the clinic requesting HIV testing because their provider did not want to test them for HIV, or their provider said they did not offer HIV testing. We would also see young people at the clinic because they could not always be assured of confidentiality at their doctors’ offices.</p>
<p>Nurse practioners play a valuable role in testing of HIV in youth. A colleague and I recently published an <a href="http://dx.doi.org/10.1097JNC.0000000000000014">article</a> on HIV testing that showed nurse practitioners are less likely to perform HIV testing on people younger than 18 years of age. That may be in part because of issues related to patient confidentiality, consent, and linkage to care when a person tests positive. </p>
<p>Nurse practitioners are in a <a href="https://www.aanp.org/about/all-about-nps/whats-a-nurse-practitioner">unique position</a> to educate youth about HIV, refer youth to health services including HIV testing and perform HIV testing. But currently, nurse practitioners do not have full practice authority in all states. One way to increase HIV testing for all persons might be to include giving nurse practitioners the full authority under state regulations and practice acts to test for HIV.</p>
<h2>Testing a major breakthrough</h2>
<p>The development of <a href="https://www.cdc.gov/hiv/testing/laboratorytests.html">testing technologies</a> has been one of the two leading breakthroughs to the possibility of ending the <a href="https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview">HIV epidemic</a>; the other is <a href="https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/58/fda-approved-hiv-medicines">pharmacological interventions</a> that effectively manage the disease and prevent transmission. Our nurse practitioner study concluded that nurse practitioners have an important role to increase HIV testing rates and could help put an end to HIV.</p>
<p>Nevertheless, many people don’t know if they should be tested, and so they are not.</p>
<p>Although it has been nearly 40 years since the beginning of the HIV crisis, the CDC reports that the infection continues to affect <a href="https://www.cdc.gov/hiv/group/index.html">gay, bisexual and other men who have sex</a> with men of all races and ethnicities; black and Latino men and women; people who inject drugs; people aged 25-34; and people in the Southern U.S. disproportionately. </p>
<p>There are <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm">national recommendations</a> and <a href="https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/human-immunodeficiency-virus-hiv-infection-screening">practice guidelines</a> for nurse practitioners to test for HIV. However, the rate at which they screen for HIV is low, as my colleague Gale Spencer and I reported in our <a href="http://dx.doi.org/10.1097JNC.0000000000000014">recent study</a>. </p>
<p>We found that the strongest predictor of nurse practitioner HIV testing behavior was the practice setting’s social pressures that influence HIV testing. In other words, when office staff supported routine HIV screening, then nurse practitioners were more likely to test for HIV, even when it took more time.</p>
<p>Also, nurse practitioners believed that when “consent from a parent/guardian should be obtained before screening for HIV in a person younger than 18 years,” they were less likely to screen for HIV. This means that better policy and procedures are needed to help guide providers for testing those younger than 18. We believe this is pivotal, given that among young people between the ages 13 and 24 with HIV, nearly <a href="https://www.cdc.gov/hiv/group/age/youth/index.html">half are not aware of their status</a>. </p>
<h2>Testing guidelines for all</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/281462/original/file-20190626-76717-1g5i8zz.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A blood test can reveal the presence of the HIV virus.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sample-blood-screening-test-hiv-syringe-523216012?src=-4BUG5bkwSc47igT8V2Nvw-1-1&studio=1">Room's Studio/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>According to the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm">CDC recommendations</a>, everyone should be tested at least once between the ages of 13 and 64 as part of routine health care. </p>
<p>Also, if you are pregnant or planning to get pregnant, the CDC recommends that you should get tested as early as possible. </p>
<p>You should also get tested at least once a year if:</p>
<ul>
<li>You are a sexually active gay or bisexual man</li>
<li>You have had sex with an HIV-positive partner</li>
<li>You have had more than one partner since your last HIV test</li>
<li>You have shared needles or “works” to inject drugs</li>
<li>You have exchanged sex for drugs or money</li>
<li>You have another sexually transmitted disease, hepatitis or tuberculosis</li>
<li>You have had sex with anyone who has done anything in this list, or with someone whose sexual history you do not know. </li>
</ul>
<p>Also, the CDC recommends testing before having sex for the first time with a new partner. The agency also recommends that you talk about sexual and drug-use history.</p>
<p>In January, 2019, the <a href="https://www.who.int/">World Health Organization</a> made the proposal to declare 2020 the “<a href="https://www.who.int/hrh/news/2019/2020year-of-nurses/en/">Year of the Nurse and Midwife</a>.” Nurses provide the essential link between the people of the community and the complex health care system. With their help, more youth – and others – can get tested.</p><img src="https://counter.theconversation.com/content/119075/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jodi Sutherland 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>June 27 is National HIV Testing Day, and an expert suggests it’s a good time to think about testing, especially for youth. And, a recent study suggested that nurses have a role in reaching youth.Jodi Sutherland, Clinical assistant professor, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1123402019-02-22T22:49:01Z2019-02-22T22:49:01ZThe Freddie Mercury story that goes untold in ‘Bohemian Rhapsody’<figure><img src="https://images.theconversation.com/files/260447/original/file-20190222-195853-m1l7o7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The film glosses over the bigotry Mercury faced as a queer man with HIV.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Queen-amp-Mercury-Freddie/080baead9ef74492a088148878186c29/2/0">AP Photo</a></span></figcaption></figure><p>Millions of people tuned in to the Oscars to see “Bohemian Rhapsody,” the biopic of Queen frontman Freddie Mercury, compete for best picture, which “Green Book” ended up winning. </p>
<p>There were a lot of people cheering against “Bohemian Rhapsody.” The film has been dogged by accusations of <a href="https://www.vox.com/2018/11/16/18071460/bohemian-rhapsody-queerphobia-celluloid-closet-aids">homophobia</a>, and the film’s director, Bryan Singer, <a href="http://www.dailycal.org/2019/02/21/bohemian-rhapsody-bryan-singer-allegations/">was accused of rape and sexual abuse</a>.</p>
<p><a href="https://twitter.com/l_marhoefer?lang=en">But as a gay historian</a>, I keep coming back to something else – the tragic history that’s glaringly absent from this movie. </p>
<p>Mercury, along with all the other men and women who tested positive for HIV in the 1980s, was a victim not just of a pandemic but of the failures of his own governments and of the scorn of his fellow citizens. The laughable initial response to the HIV pandemic helped seal Mercury’s fate.</p>
<p>None of that is in the movie. </p>
<h2>Governments turn their backs</h2>
<p>In the early 1980s, when an epidemic of HIV first struck a few population centers in the U.S., U.K. and elsewhere, governments mounted almost no public health response. </p>
<p>Doctors initially noticed the virus in groups of people who happened to already be stigmatized for other reasons: men who had sex with men, drug users and, due to racism, <a href="https://www.nytimes.com/1985/04/10/us/haitians-removed-from-aids-risk-list.html">Haitians and Haitian-Americans</a>.</p>
<p>The <a href="http://www.worldcat.org/oclc/993349150">prejudiced initial public health response</a> assumed that many of these people were getting the virus because of whatever was already supposedly wrong with them. Gay men, the thinking went, were getting it because of “risky” behaviors like having lots of partners. HIV was not, therefore, a threat to most straight people. The medical profession’s view of HIV was so colored by the idea that it was intrinsically gay that at first they named the virus “<a href="https://www.nytimes.com/1982/05/11/science/new-homosexual-disorder-worries-health-officials.html?pagewanted=all">GRID</a>,” an acronym for “gay-related immunodeficiency.”</p>
<p>That was bad science, as we know now. Especially in the absence of good public health information about <a href="https://www.plannedparenthood.org/learn/stds-hiv-safer-sex/safer-sex">how to have safer sex</a>, your risk of contracting any sexually transmitted infection goes up when you have more partners. But there was nothing about gay sex in particular that caused AIDS. Lots of straight people <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1802108/">had multiple partners in the 1970s and 1980s</a>, but initially, by chance, some communities of gay men were hit harder.</p>
<p>Governments and the general public quietly left people with HIV to their fate. <a href="http://bilerico.lgbtqnation.com/2011/06/larry_kramers_historic_essay_aids_at_30.php">As one activist pointed out</a>, two years into the crisis, the U.S. government had spent more to get to the bottom of <a href="https://www.upi.com/35-years-after-landmark-recall-Tylenol-deaths-still-unsolved/9661507150232/">a series of mysterious poisonings in Chicago</a> that killed seven people than to research AIDS, which had already killed hundreds of people in the U.S. alone. </p>
<p>The first report of HIV in the U.K. was in 1981. There was no test for the virus until 1985, and there was no really effective treatment <a href="https://www.poz.com/article/antiretrovirals-transformed-hiv-epidemic-timeline">until 1996</a>.
In 1985, Prime Minister Margaret Thatcher <a href="https://www.theguardian.com/politics/2015/dec/30/thatcher-tried-to-block-bad-taste-public-health-warnings-about-aids">tried to block a public health campaign</a> promoting safe sex; she thought it would encourage teenagers to have sex, and, she claimed, they were not at risk of infection.</p>
<p>All told, it was an absurd response to the major public health catastrophe of our time and to a disease that would go on to kill <a href="https://www.who.int/en/news-room/fact-sheets/detail/hiv-aids">36 million people</a> around the world – about as many as <a href="https://www.facinghistory.org/weimar-republic-fragility-democracy/politics/casualties-world-war-i-country-politics-world-war-i">died in World War I</a>.</p>
<h2>Glossing over the era’s homophobia</h2>
<p>All this left Mercury and other queer men in a terrible place. Without good public health information, and with research lagging, they were unnecessarily exposed to the virus. Diagnosed in 1987, Mercury didn’t live long enough for the development of <a href="https://aidsinfo.nih.gov/understanding-hiv-aids/fact-sheets/21/58/fda-approved-hiv-medicines">antiretroviral combination treatment</a> that could have saved his life.</p>
<p>He faced not just a deadly disease but vitriolic prejudice against people with HIV and AIDS. Two years before he was diagnosed, a Los Angeles Times poll found that <a href="http://articles.latimes.com/1985-12-19/news/mn-30337_1_times-poll">a majority of Americans wanted to quarantine HIV-positive people</a>; 42 percent wanted to close gay bars. As Mercury <a href="https://www.rollingstone.com/music/music-news/queens-innuendo-remembering-freddie-mercurys-last-masterpiece-223856/">fought to keep making music</a> as he grew sicker and sicker, the lead singer of the then-popular band Skid Row wore a t-shirt that said, “<a href="https://www.washingtonpost.com/archive/lifestyle/1990/01/24/on-the-beat/e1eb4a66-afe1-43cd-a5f5-de0096b05377/?utm_term=.7aa0b22c5fee">AIDS kills faggots dead</a>.”</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260446/original/file-20190222-195879-mx81zr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Anti-gay protesters heckle marchers during the 1990 Gay Pride Parade along Fifth Avenue in New York.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Watchf-AP-A-NY-USA-APHS230965-U-S-Protest/8eb24213beb9484692d35e2eb4b5c0e9/11/0">AP Photo/David A. Cantor</a></span>
</figcaption>
</figure>
<p>You won’t see this in the movie, either. No one in “Bohemian Rhapsody” is overtly homophobic; when homophobia appears at all, it’s in subtler forms. For example, a bandmate tells Mercury that Queen is emphatically not the openly queer disco act The Village People.</p>
<p>In real life, Mercury faced rampant homophobia – he never really came out publicly, and it’s easy to see why. In 1988, the U.K. passed <a href="https://www.pinknews.co.uk/2018/05/24/what-was-section-28-homophobic-legislation-30-years-thatcher/">a notorious anti-gay law</a> that declared, officially, that homosexuality shouldn’t be promoted and that same-sex couples had “<a href="https://doi.org/10.1177/136346000003004001">pretend</a>” families, not real families. The law stayed on the books for over a decade.</p>
<p>The era’s glam rock and disco music scenes had queer moments, but it was all predicated on everyone being straight in real life. David Bowie <a href="https://www.theguardian.com/music/2006/jan/22/popandrock.davidbowie">told the press he was queer in 1972</a> and then loudly <a href="https://www.rollingstone.com/music/music-news/david-bowie-straight-time-69334/">took it back in 1983</a>, saying “the biggest mistake I ever made” was telling the press “that I was bisexual.” </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=804&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=804&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=804&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1011&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1011&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260444/original/file-20190222-195861-1hr2zm0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1011&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">When Freddie Mercury changed his look to mimic a style popular among gay men, not all of his fans were on board.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/AP-KU-AUS-LON101-ROCK-STAR-MERCURY-CONCERT-SYDNEY/c4e87918c3e0da11af9f0014c2589dfb/34/0">AP Photo/Gill Allen</a></span>
</figcaption>
</figure>
<p>The Village People were unique because they were unabashedly out and proud, but they weren’t a hit act because of that. They were a hit because the straight public <a href="https://www-jstor-org.offcampus.lib.washington.edu/stable/44706140?socuuid=f62803ea-995a-4c36-a1b5-c4d7b00becfc&socplat=twitter">either didn’t realize it or didn’t want to know</a>.</p>
<p>Ask yourself: When you danced to “<a href="https://www.youtube.com/watch?v=Vc0gYbTNctU">YMCA</a>” at your high school talent show, did you know it was about gay culture? I’m going to guess the answer is no.</p>
<p>The same was true of Queen. How many of the rock fans who packed stadiums to see them play “We Are the Champions” knew that the heroic singer was not just a rock god, but a fabulous queer icon, too? Not many. </p>
<p>In the 1980s, Mercury ditched his glam rock look and cut his hair in a style popular in gay subculture, donning a black leather jacket and sporting an enviable, gorgeous mustache. Many fans hated it. In the U.S., <a href="https://www.rollingstone.com/music/music-news/queens-tragic-rhapsody-234996/">they threw razors onstage</a>.</p>
<h2>No one to blame but himself?</h2>
<p>When Mercury died in 1991, his bandmates felt it necessary to do <a href="https://youtu.be/q-YirPyS47I">a TV interview</a> to dispute what the media was saying – that Mercury had brought AIDS upon himself with his decadent partying.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/q-YirPyS47I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Freddie Mercury’s bandmates try to set the record straight.</span></figcaption>
</figure>
<p>The movie also quietly makes it seem as if Mercury’s debauchery was to blame for his fate. </p>
<p>In the film, Mercury abandons the band to make a solo album in Munich with <a href="https://slate.com/culture/2018/10/bohemian-rhapsody-fact-fiction-freddie-mercury-movie-accuracy.html">his diabolical boyfriend</a>, who lures him <a href="https://nursingclio.org/2018/11/19/bohemian-rhapsody-review/">into a shady queer world</a>. His ex-girlfriend rescues him and he returns to the band. But by then, it’s too late: He has HIV.</p>
<p>In real life, Mercury didn’t break up the band, he wasn’t the first of the bandmates to make a solo album and, of course, partying doesn’t cause AIDS. </p>
<p>I hope someday, someone makes a better Freddie Mercury biopic, one that accurately depicts the historical moment he lived in and the challenges he dealt with. He deserves it.</p><img src="https://counter.theconversation.com/content/112340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laurie Marhoefer 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>In the film, the real tensions of gay life in the 1980s – from government apathy towards the AIDS crisis, to rampant anti-gay prejudice – don’t get their due.Laurie Marhoefer, Associate Professor of History, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/876402017-11-27T06:37:30Z2017-11-27T06:37:30ZSouth Africa still has four critical gaps to fill before it sees the end of AIDS<figure><img src="https://images.theconversation.com/files/195571/original/file-20171121-18533-nx4wn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There are several challenges that South Africa needs to address to bring HIV under control.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa has the <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">largest number of people living with HIV</a> in the world. It accounts for up to one third of new HIV infections globally. In 2016 there were an estimated <a href="http://sanac.org.za/wpcontent/uploads/2017/05/NSP_FullDocument_FINAL.pdf">7.1 million people living with HIV</a> In the same year close to 10 million people were tested for HIV. </p>
<p>But huge strides are being made in line with the country adopting the UNAIDS’ <a href="http://www.unaids.org/en/resources/documents/2017/90-90-90">90-90-90 strategy</a>. Under the plan the aim is for:</p>
<ul>
<li><p>90% of all HIV positive people to know their HIV status </p></li>
<li><p>90% of people who know their HIV status to be on treatment, and</p></li>
<li><p>90% of those on treatment to have suppressed viral loads by 2020. Viral suppression is when a person’s viral load – or the amount of virus in an HIV-positive person’s blood – is reduced to an undetectable level.</p></li>
</ul>
<p>South Africa has made tremendous progress towards meeting the 90-90-90 targets. <a href="https://www.statssa.gov.za/publications/P0302/P03022016.pdf">In 2016</a>, South Africa’s National Aids Council estimated that 86% of all HIV positive people in the country knew their HIV status, 65% of the those who knew their HIV status were taking antiretroviral therapy and 85% of those taking antiretroviral therapy were virally suppressed. </p>
<p>To complete the last leg South Africa has four important things to do. It must address the gaps in HIV testing; it must start people on antiretroviral treatment and make sure that they remain on it; it must ensure that people maintain virological suppression and, lastly, it must strengthen its strategies around prevention.</p>
<p>All these areas have challenges that may prevent South Africa from taking the last few steps to meet the target.</p>
<h2>The challenges</h2>
<p><strong>The HIV testing:</strong> the <a href="http://www.health.gov.za/index.php/gf-tb-program/332-national-hiv-testing-services">country’s guidelines</a> recommend that all adults are tested for HIV at least once a year. Groups that are at a higher risk of being infected should be tested every three to six months.</p>
<p>But HIV testing programmes show that certain groups are <a href="http://www.health.gov.za/index.php/gf-tb-program/332-national-hiv-testing-services">tested much less</a> than this. For example, a significant proportion of men go untested as do adolescents, young people, and men-who-have-sex-with-men. </p>
<p>To narrow this gap and increase access to HIV testing and treatment, community and workplace based HIV testing and counselling should be strengthened and HIV self–tests should be improved. </p>
<p><strong>Antiretroviral treatment:</strong> this is the most powerful tool in South Africa’s response to HIV. Treatment has reduced illness and death from a peak of 325 000 in 2005 to 126 000 AIDS related deaths in <a href="https://www.statssa.gov.za/publications/P0302/P03022016.pdf">2016</a> as well as the number of <a href="http://science.sciencemag.org/content/339/6122/966">new infections</a> at population level in some settings. </p>
<p>And improvements are being implemented all the time. For example, last year amendments to the <a href="http://www.sahivsoc.org/Files/22%208%2016%20Circular%20UTT%20%20%20Decongestion%20CCMT%20Directorate.pdf">national treatment programme</a> meant that all HIV positive people could receive ARVs regardless of their CD4 count. </p>
<p>But there are still disparities in starting treatment particularly among men, young people, female sex workers and other key populations. These groups are more likely to start treatment late in the course of HIV infection. </p>
<p>Community based ART initiation as well as high quality client-centred HIV care and treatment services will be essential to address these gaps.</p>
<p><strong>Suppressing the virus:</strong> staying on HIV care and maintaining viral suppression is essential if the 90-90-90 targets are going to be met. </p>
<p>But in South Africa there are still high numbers of people who stop taking treatment and attending care. People stop taking their medication for lots of reasons. The reasons range from being pregnant at start of ART or having a low CD4 count at entry into care, a lack of disclosure of HIV status, and inflexible clinic hours.</p>
<p>The national HIV care and treatment programme has <a href="https://www.nacosa.org.za/wp-content/uploads/2016/11/Integrated-Adherence-Guidelines-NDOH.pdf">recommended</a> various strategies to improve adherence to medication and these are being implemented across the country. These include clinic visits to help monitor people on treatment as well as community based adherence clubs and peer groups. Another has been the recommendation that chronic medicines are delivered through private pharmacies. </p>
<p>What is needed are for programmes to better understand and address the provider, individual and community factors which determine why some people living with HIV can remain in care for a long time and why some cannot. </p>
<p><strong>Prevention:</strong> Primary prevention focuses on people who are HIV negative and aims to keep them that way. The weapons in the prevention arsenal are diverse and include: </p>
<ul>
<li><p>behavioural change (abstinence, reducing the number of sexual partners as well as correct and consistent condom use), </p></li>
<li><p>male circumcision, </p></li>
<li><p>pre-exposure prophylaxis and post-exposure prophylaxis.</p></li>
</ul>
<p>But these interventions vary in effectiveness at population level depending on coverage and for some adherence. </p>
<h2>Next steps</h2>
<p>By implementing the 90-90-90 strategy South Africa is expecting to reduce the number of new HIV infections dramatically in the next five years. This will involve scaling up a combination HIV prevention interventions as well as maintain high levels of viral suppression and reduce time spent with unsuppressed viral loads. With all this in place the number of new HIV infections is expected to fall from 270 000 in 2016 to less than 100 000 by 2022.</p>
<p>But ending AIDS as a public health threat will require a sustained focus on health promotion by creating conditions that allows communities and individuals to make informed choices regarding HIV prevention, care and treatment - and empowering of communities and individuals to act on those choices.</p><img src="https://counter.theconversation.com/content/87640/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tendesayi Kufa-Chakezha is an employee of the NICD but the views expressed in the article are her own.</span></em></p>South Africa has made tremendous progress towards meeting the 90-90-90 targets but there are some challenges preventing it from reaching the goals set by UNAIDS.Tendesayi Kufa-Chakezha, Epidemiologist and Public Health Specialist, National Institute for Communicable DiseasesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/867362017-11-23T14:24:02Z2017-11-23T14:24:02ZFour big insights into HIV/AIDS that provide hope of finding a vaccine<figure><img src="https://images.theconversation.com/files/195865/original/file-20171122-6027-1oe0fkn.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>HIV remains one of the continent’s most intractable health challenges.
Tremendous progress is being made to understand the virus, the immune mechanisms that contribute to its control and for new antiretroviral drugs and vaccines to be developed to treat and prevent HIV. </p>
<p>But much remains to be done to overcome the health and economic devastation of the epidemic. African researchers have been performing cutting-edge research to contribute to addressing these problems. The sub-Saharan African Network for TB/HIV Research Excellence has been at the forefront of this research and has provided some important insights into how the virus spreads as well as the immune mechanisms that enable some people to control the virus without antiretroviral drugs. </p>
<p>This knowledge could be translated into effective vaccines or other novel interventions to prevent the spread of the virus or achieve a functional cure where people are able to live without antiretroviral drugs at least for a while. </p>
<p>Although the goals of a vaccine or cure remain elusive, the research being done makes these goals appear increasingly likely.</p>
<hr>
<h2>Immune systems are critical</h2>
<p>A major plank of <a href="http://jvi.asm.org/content/early/2016/05/12/JVI.00276-16.abstract">our research</a>, in collaboration with others, has been around understanding what mechanisms the body uses to control HIV – particularly in the early phase of infection. </p>
<p>Our research shows that within a few weeks of becoming HIV infected, almost all people have a very robust immune response through cells known as<a href="https://www.ncbi.nlm.nih.gov/pubmed/26362266"> cytotoxic T lymphocytes, or killer CD8 T cells</a>. These cells are able to partially suppress HIV. </p>
<p>But when most people are exposed to the virus, their immune systems are mostly skewed to respond to regions of HIV that are highly variable. This allows the virus to easily change to escape immune recognition. </p>
<p>The killer CD8 T cells produced during the acute phase are also<a href="http://journals.lww.com/aidsonline/Citation/2015/01020/Broad_and_persistent_Gag_specific_CD8__T_cell.4.aspx"> highly defective</a>. They become exhausted and die off easily, which enables the virus to persist. </p>
<p>But we’ve discovered an interesting twist. Some people have a genetic makeup that facilitates development of very good CD8 killer T cell immune responses. These rare individuals can control the virus without antiretroviral drugs. These are also a few people who appear to control the virus without using CD8 killer T cells, and we are in hot pursuit of the mechanisms that control the virus in such individuals. </p>
<p>This ground-breaking research is vital because understanding how the immune system is able to control the virus – either by killer T cells or other mechanisms – could lead to effective HIV vaccines or cures.</p>
<h2>HIV evades or adapts to immune pressure</h2>
<p>Our work has shown that HIV is very adept at evading the body’s immune responses to the virus. The main way it does this is by <a href="http://jvi.asm.org/content/86/6/3193.abstract">developing mutations</a> that enable the virus not to be recognised by a person’s immune system. At the same time it continues to replicate and reproduce itself. </p>
<p>Our work shows that although this immune escape is common, in some cases the virus develops mutations that cripple it, making it unable to continue <a href="http://jvi.asm.org/content/85/8/3996.abstract">replicating efficiently</a>. </p>
<p>We have identified some of the regions of virus that are vulnerable that cripple the virus if it is targeted by the immune system. These regions of viral vulnerability could be included in HIV vaccines so that the body makes an immune response against these regions of the virus ensuring that the immune system cripples the virus. This may be an effective way to make an HIV vaccine or achieve natural control of the virus in those already infected. </p>
<p>But that’s not the end of the story. There’s a further complication because we’ve also discovered that the virus can acquire new mutations that <a href="http://jvi.asm.org/content/84/20/10820.abstract">restore its ability to replicate</a> efficiently. But we think that there may be ways to block or limit escape. The viral regions of vulnerability that we have identified could be good candidates for vaccines designed to disable virus replication.</p>
<h2>Genetic and viral factors matter</h2>
<p>There is a lot of variability in HIV disease progression. </p>
<p>Without antiretroviral therapy, most HIV infected people develop full blown AIDS within 10 years. But some people succumb more rapidly, within two years. There is also a rare group of individuals known as elite controllers who have been shown to live with HIV for more than 20 years with almost undetectable viral load and without developing AIDS. </p>
<p>Our group and others have shown that <a href="https://www.ncbi.nlm.nih.gov/pubmed/19996938">variability in disease progression</a> can be explained by differences in genetic factors that govern the immune response. </p>
<p>Some people are naturally equipped with better genetic makeup that enables them to develop a very good immune response that can fight off the virus and control it. But in almost all cases, a robust and good immune response eventually leads to immune escape in the virus, which means that the virus acquires changes that enable it to hide from the immune system. </p>
<p>But some of these mutations can <a href="https://www.nature.com/articles/nature07746">cripple the virus</a>. </p>
<p>People infected with HIV but with superior immune responses – or with a virus that has been crippled by the immune system end up living long healthy lives without antiretroviral drugs. </p>
<p>This kind of knowledge is very useful for the potential development of vaccines.</p>
<h2>The influence of viral genetic factors</h2>
<p>One of the defining characteristics of the HIV/AIDS epidemic is that there are multiple genetic strains (known as subtypes or clades) that are unevenly spread throughout the world. </p>
<p>We have demonstrated that some regions of HIV differ in biological activity according to HIV subtypes, and these differences are consistent with reported differences in rates of disease progression. </p>
<p>For example, our work shows that there are <a href="http://jvi.asm.org/content/early/2017/06/15/JVI.00518-17.abstract">characteristics in the Gag region</a> (a specific part of the HIV virus) that make subtypes B and D able to replicate more efficiently than subtypes A and C, which may explain why subtypes B and D are associated with <a href="http://jvi.asm.org/content/early/2017/04/13/JVI.00253-17.short">faster disease progression</a> compared to A and D in some population-based studies. </p>
<p>Paradoxically, it appears that the subtypes that <a href="https://www.ncbi.nlm.nih.gov/pubmed/25013080">replicate less efficiently</a> such as A and C are more successful in infecting more people, perhaps because infected people live longer with these viruses. </p>
<p>The work helps to explain how HIV affects the rate of disease progression in individuals and how in general epidemics spread and change over time. This kind of knowledge is important for predicting the spread of epidemics and how to combat outbreaks so that they do not cause massive suffering as has been the case with HIV and viruses such as Ebola.</p><img src="https://counter.theconversation.com/content/86736/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thumbi Ndung'u receives funding from the Gates Foundation, Gilead Sciences, the South Africa National Research Foundation, The National Institutes of Health, the Victor Daitz Foundation and the Wellcome Trust. He is affiliated with the University of KwaZulu-Natal, the Africa Health Research Institute and the Ragon Institute of MGH, MIT and Harvard University. </span></em></p>To get an effective vaccine for HIV/AIDS, scientists need to understand exactly how the virus works and immune system responds to it. African scientists have come one step closer.Thumbi Ndung'u, Programme Director for the Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE), University of KwaZulu-NatalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/875492017-11-22T12:17:48Z2017-11-22T12:17:48ZThree decades on, stigma still stymies HIV prevention and treatment<figure><img src="https://images.theconversation.com/files/195175/original/file-20171117-7545-1xb416z.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>There have been great strides and many important victories in the fight against HIV. <a href="https://theconversation.com/rings-and-things-other-ways-to-prevent-hiv-are-on-the-cards-69192">Scientific innovations</a> and <a href="https://www.gatesfoundation.org/Media-Center/Press-Releases/2002/11/HIVAIDS-Prevention-Effort-in-India">sustained investment</a> have been the most important weapons in this ongoing battle.</p>
<p>Nevertheless the epidemic retains a powerful grip – especially on people in Africa. In sub-Saharan Africa, 19.4 million are living with the virus. In 2016 an estimated 15 000 new infections occurred every week in the region.</p>
<p>Treatment and prevention of HIV are twin endeavours; they rely universally on two elements. The first is the interaction of HIV positive and negative people with HIV services. The second is the willingness of people to modify their risky behaviour and avoid negative health consequences.</p>
<p>Adherence is the cornerstone of these processes: a commitment to taking medication or adopting a risk-reducing behaviour consistently over time. By adhering to their antiretroviral (ARV) regimens those living with the virus are able to lead long, healthy lives. They are able to eliminate the chance of passing on the virus to their partner(s). The concept of an <a href="https://www.preventionaccess.org">undetectable virus is an untransmissable</a> one is now acceptable. </p>
<p>With good adherence to an HIV prevention pill or pre-exposure prophylaxis (PrEP) or consistent use of condoms, HIV negative people can protect themselves from infection.</p>
<p>But real and perceived stigma can undermine all these efforts. This is because stigma stops people from getting tested, stops them discussing their test results with intimate partners when they do test, and then staying on their treatment. Unless stigma is addressed, the aim of ending the AIDs epidemic by 2030 – one of the United Nations’ Sustainable Development Goals – is unlikely to become a reality.</p>
<h2>The logic behind stigma</h2>
<p>Stigma happens when disgrace and shame become associated with an attribute, such as being HIV positive. It results in the person with the attribute being discredited or socially renounced. When stigmatised beliefs are widely held in a community, hostility and discrimination towards stigmatised people becomes common.</p>
<p>A stigmatised person can start to believe these views as well and develop a self-depreciating internal representation of themselves. This is known as internalised stigma. It can lead to diminished mental health and emotional distress. Both general and internalised HIV-related stigma can compromise a person’s ability to seek and stay on treatment. And it can prevent people from taking steps to prevent infection.</p>
<p>For instance, a woman living with HIV could choose not to go back for more medication because she’s scared someone from her community will see her and learn her status.</p>
<p>Conversely, a sexually active teenager might not ask a healthcare professional how she can prevent HIV if she is afraid of being judged for having sex.</p>
<p>There is evidence that these scenarios still play out. The HIV Stigma Index conducted in South Africa in 2014 found that about 45% of the respondents experienced internalised stigma. And 39% lived in fear of potential stigma. Young people between the ages of 15 and 24 were particularly affected by all types of stigma.</p>
<h2>Stigma on top of stigma</h2>
<p>Stigma has the negative psychological consequence of making it more difficult for people to cope and find social support. It also reduces their ability to overcome other barriers to adherence, such as unfriendly healthcare services or side effects from medication.</p>
<p>The research shows that people who do not experience internalised stigma tend to be more successful in adhering to treatment and more capable of overcoming other barriers to access treatment and prevention services.
HIV stigma poses additional difficulties for positive people who already belong to stigmatised population groups, such as men who have sex with men transgender people, sex workers, and people who inject drugs.</p>
<p>Stigma against these groups already reduces access to healthcare services and social support. But disclosure of being HIV positive can result in people facing even more stigma, discrimination and hostility.</p>
<p>This is especially the case in African countries where homosexuality and sex work are criminalised.</p>
<p>Moralistic support for criminalisation often interferes with public health initiatives. As a result, stigmatised populations are frequently made more vulnerable to HIV infection due to this discrimination and restricted access to healthcare services.</p>
<h2>Changing the tide</h2>
<p>The good news is that stigma can be reduced if three basic interventions are put in place.</p>
<p>Firstly, through the implementation of effective and sustained mass media campaigns and health promotion aimed at dispelling the common myths. These campaigns should involve HIV positive people as message bearers.</p>
<p>Secondly, normalising and promoting the interaction with HIV prevention services. What is needed here are more people openly engaging about HIV testing and taking PrEP (pre-exposure prophylaxis).</p>
<p>And thirdly laws and policies that protect those living with the virus from discrimination and promote them being able to access healthcare services.
These are especially important for key population groups living in countries where criminalisation disrupts public health strategies.</p><img src="https://counter.theconversation.com/content/87549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Linda-Gail Bekker receives funding from a number of academic funding agencies including the NIH (USA). She is currently the President of the International AIDS Society.</span></em></p>Stigma stops people from getting tested for HIV, and staying on their treatment. Unless it’s addressed, the AIDS epidemic will persist.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 TownLicensed as Creative Commons – attribution, no derivatives.