Last spring, a German man named Timothy Brown made international headlines for being cured of HIV. Despite the controversy that soon engulfed his story, it nevertheless ignited new hopes that the war against AIDS, the disease caused by the human immunodeficiency virus (HIV), could soon be won. Optimism may not be unwarranted.
First, advances in science and medicine, from new uses of antiretroviral drugs to clearer evidence on prevention strategies such as circumcision, are providing innovative options for stemming the tide of transmissions. Second, UNAIDS data suggests that global infections are beginning to level off. In 2009, 2.6 million people were newly infected with HIV, 19% fewer than in 1999, and 21% fewer than the peak of 3.2 million in 1997. Although these are certainly welcome signs of progress, science and medicine alone cannot accomplish the goal of eradicating new infections. Without broader changes in the way many governments and societies conceptualize AIDS and the populations it affects — particularly gay men and sex workers — the war will never be won.
In much of the developing world, heterosexual sex is the dominant mode of HIV transmission, but marginalized groups shoulder a greater burden of infections. In Kenya, where 1.2 million people are estimated to be living with HIV, nearly two-thirds of new infections are attributed to either casual heterosexual sex or heterosexual sex within a regular partnership. Fifteen percent of new infections, however, are from men who have sex with men; 14% are from sex workers and their clients. Even though only 6% of the Kenyan population is HIV-positive, infection rates among gay men and sex workers are dramatically higher. The continued suffering of these communities is often masked by statistics aggregated at the national level.
What does this mean for effective policymaking? Targeting heterosexual couples with prevention and treatment efforts certainly makes sense. But ignoring marginalized communities does not. Gay sex is illegal in 31 sub-Saharan African countries — Kenya included — and subject to the death penalty in four. Needless to say, governments that criminalize homosexuality tend to do relatively little when it comes to providing prevention and treatment services for HIV-positive gay men. Even worse, many governments either explicitly prevent or not so subtly impede the ability of NGOs to work with these groups.
In addition to legislation, stigma often discourages gay men from seeking medical attention and encourages risky behavior. Sexual encounters between men, for instance, often occur in clandestine or hurried situations to avoid detection, reducing the likelihood of condom use. New medicines will do little good if gay men and sex workers are too afraid to seek out doctors, fearing legal prosecution or personal judgment. Although new scientific breakthroughs carry a lot of promise, large segments of the population are likely to be excluded in the absence of broader value changes that address these issues.
The argument for doing more to help these populations is not just a moral one. Because sexual networks often overlap (many married men also have sex with other men or sex workers), HIV transmission can occur between different groups. As a result, even if prevention and treatment strategies targeted at heterosexual couples are 100% effective — a completely unrealistic target — most-at-risk populations can still be a major driver of new infections in the general population. Senegal offers a clear example of this interaction. In the early stages of the epidemic, sex workers were specifically targeted with treatment and prevention strategies. Today, sex work is both legal and regulated, making it substantially easier for sex workers to access health services. This is a major contributing factor to the country’s overall HIV prevalence of less than 1%.
The international community can do more to push ill-advised laws off the books. Foreign aid could be tied to the recognition of gay rights. Diplomatic pressure could be applied to governments that make it difficult for NGOs to provide services to sex workers. While Secretary of State Hillary Clinton’s recent speech on gay rights is a step in the right direction, there is still much more work to do. For perhaps the first time in history, we have the right tools to end AIDS altogether through comprehensive prevention strategies, a feat that will never occur if marginalized communities continue to suffer in silence because of stigma and discrimination.
Photo Credit: resurge international