Cathy Watson
25 August 2008
opinion
Kampala — THOUGH I think about HIV every day at Straight Talk, attending the world AIDS conference in Mexico this month came as a shock. It was like having my brain prised open, taken apart and then re-assembled.
The first thing that hit me was the passion. Did you know that the US has no national AIDS policy, that one in every 20th person in Washington DC has HIV and that AIDS has become a disease of African-Americans? I didn't but it is true. In fact, if black America were a country it would rank sixteenth in the world for HIV.
"Shame," shouted a group of demonstrators, before settling down to hear CDC director Dr. Kevin Fenton, himself a black American, give the newest statistics on the US epidemic.
There was more passion on the T-shirts. "We are part of the solution" said a T-shirt worn by sex workers. Other T-shirts read "Science against stigma", "Anger =Action,", "Silence = Death", "Obama has tested" and perhaps my favourite: "We are all equal, we are all positive".
The second thing that struck me was the pride and visibility of groups that are sometimes referred to as "marginalised".
There were native Latin Americans -the continent's original people -dressed in traditional costume, some with feathers in their hair. There were also transvestites and transgender people, some of whom looked like men dressed as women.
I watched the women who identified themselves as commercial sex workers (CSWs) and thought that their tired faces told the story of appalling lives from which they needed rescue. But they were demanding that their work be recognised as as a job like any other and simply made safer.
"We do not want to cook or knit! We are not dying for lack of sewing machines," shouted Elena Reynaga, founder of the Argentine Association of Female Sex Workers and the first sex worker to ever address an International AIDS Conference.
Did you know that in many countries sex workers who carry condoms are more likely to get arrested as police take the condoms as proof that they are selling sex? Then once arrested that they often have to have sex with the police to get released?
As David Wilson of the World Bank presented data to show that India, Cambodia and Thailand had reversed their AIDS epidemics by working with sex workers, I made a mental note to think about adolescents who sell sex in Uganda.
I attended sessions on men who have sex with men (MSM) and injecting drug users (IDU), thinking that if I learnt about HIV epidemics that do not resemble Uganda's, it might unlock new insights for me about an epidemic that I think I know well. What I found is that MSM and IDU are likely to be Uganda's issues soon if they are not already.
Doctors now have a new way of analysing the epidemic. This "modes of transmission" process examines the last 1,000 HIV infections and asks: where did they come from? Which populations contributed the infections? This analysis shows where cases of HIV are going to occur and compares what is being done to prevent infections with what should be done.
In a session on this process, we heard that in Kenya, men having sex with men and injecting drug users contributed more to the last 1,000 infections than female sex workers. Yet there are no national programmes for those two groups.
Some MSM is "situational" -the men do not think of themselves as homosexual but they have sex with other men because of the situation they are in. Prisons, of which Uganda has its normal share, are the prime places where situational MSM occurs.
On the first day of the conference Uganda's Alex Countinho, who is in the running to be the next Director General of UNAIDS, gave a stunning plenary address.
Among other things, he argued that: "Prisons are semi-porous membranes. Men come in, acquire HIV from other men, leave and infect females in their community. If you go to prison, you are more likely to die of AIDS than anything else. Yet what are we doing about it?"
Finally, in Mexico I was struck by the gleaming science and intellectuality of the conference. What a lot of research HIV has provoked!
Did you know that sexual fluids can contain hundreds of millions of HIV copies, but we get infected by only one single virus?
Did you know that ARVs can completely prevent viral replication but that no patient has ever had HIV eradicated from his or her body? The virus persists as genetic information in resting T cells that live as long as 70 years. Eradication requires an agent that could turn on latent HIV so that it can be flushed out of the resting cells without causing toxicity. As yet no such agent exists.
But despite the tremendous advances in knowledge, there remains one single terrible fact. After a-quarter of a century, success against HIV/AIDS is slipping spectacularly out of our grasp.
It is true that two million people are now on ARVs out of the 33 million who are infected worldwide. But that is only 50% of those who need treatment and, as Coutinho noted in his speech, treatment is also not straight forward: one out of every three people who start treatment drops out within two years.
A turning point would be if more people were starting on ARVs than are getting infected. But we are far from that. In fact, for every two people starting treatment, another five are getting infected. So we have an ever growing burden of infection. Most people currently living with HIV will die without treatment.
Prevention must be urgently "ramped up". The good news is that in Uganda the thinking on how to do this has begun. Prof. Fred Wabwire Mangen of Makerere's Institute of Public Health has completed Uganda's "modes of transmission" analysis. He presented the results in Mexico and will present them to the Uganda AIDS Commission next month. We need to heed them.
HIV prevalence has not declined since 2002 in Uganda. And because Uganda has one of the world's fastest growing populations, it will have increasing numbers of newly infected people each year even if the rate of new infections remains the same.
Much is known about what works in HIV prevention. What remains, as one speaker said in Mexico, is for us to: "Do the right things, do them right, and do enough of them."
The writer is the Director of the Straight Talk Foundation
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