HIV remains a global health problem, thanks to ignorance and prejudice

http://www.theguardian.com/commentisfree/2014/jun/08/hiv-aids-gay-healthcare-africa-russia

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Are we winning the battle against HIV and Aids around the world? It would be a very brave man who said with certainty that we were. In spite of the reassuring words of some politicians, the position is that worldwide there are still more than 1.5 million deaths from Aids every year and about 2.3 million new infections. But the worst, and most shocking, figures are the following.

More than 35 million people are living with HIV but about half of those do not know they are infected. In other words, around 18 million live in ignorance of their condition. That is potentially disastrous for them, for the longer treatment is delayed the worse the prospects for a successful outcome. What it also spells out is a massive global public health problem.

Many of the 18 million will go on living in the way they always have; having sex and spreading the virus. Too many drug users will continue to share needles and too many sex workers will not take basic precautions. New cases of infection vastly exceed the numbers going on to treatment for the first time.

The scandal is that one of the main reasons why people with HIV do not come forward for testing is that they know they will come up against a wall of discrimination and prejudice. As I have gone around the world over the last two years looking at the HIV situation, what has shocked me most has been the depth of feeling that exists against gay men, lesbian women and transgender people. If anything, the position has become worse over that period. If I were a gay man living in many countries today, I would compare my position to that of being black and living under apartheid in South Africa or being a Jew living under the Nazis in Germany. That is the shame of the world.

The worst discrimination is in the almost 80 countries of the world where homosexuality is illegal and is punished by imprisonment and worse. Gay people will not come forward for testing if they risk prosecution and an amendment to their official records. Uganda, Russia, and Nigeria are just three countries where the laws have become more repressive and the barriers for testing made higher. Extraordinarily, India still clings to an anti-gay law passed by the British in 1860.

Even worse, such laws are widely – often overwhelmingly – supported by the public in those countries. The prejudice is a political card to be played by governments when the public needs distraction. All too few fight the injustice. Even the churches play no serious part in combating the prejudice. Anglican and Catholic ministers in Uganda support the laws rather than fight them; the Orthodox church in Russia does nothing to stem the tide. The attitude of the churches in too many countries of the world is a stain on religion.

Nor is it just the law that acts as a deterrent. In many countries, families and communities turn against men who are gay and women who have acquired HIV from a husband or partner who has ignored all precautions. Young gay men are thrown out of their homes by their families who are fearful of the local reaction; women with HIV are ostracised. There could hardly be a worse background in which to promote testing.

This is all bad enough, but there are two other groups who face discrimination, damaging both them and the cause of public health. The first are drug users who all too often are treated with contempt and face prosecution rather than any realistic hope of rehabilitation. It has been established for the last 25 years that providing clean needles and methadone is a certain way of virtually eliminating the transmission of HIV.

Yet a country such as Russia persists in a policy that denies this sensible harm reduction route. Instead, they pursue a policy of trying to get people off drugs – often with force. It is balefully unsuccessful policy and new cases multiply.

Officials in Moscow say that the public is well satisfied with the government's policy, but all this means is that at best the public does not care and at worst believes that drug users should be left to their fate. Ironically, Russia's cold war foes, the United States, has also now cut off funds for harm reduction policies. Can Congress really be happy to be part of the Russian conga of death?

The second group are sex workers who are in the lowest place in almost every nation's table of priorities. It is an area that politicians avoid. Governments express distaste and go to great lengths to keep sex work out of sight. Yet if you are concerned about HIV and sexual disease, there could hardly be a more important group.

Sydney has tackled the issue in an entirely pragmatic way. In effect, sex work can be run as a business – subject to the normal rules of health and safety. The result has been that there has been no known case of HIV being transmitted through sex work for many years.

Before the retired colonels reach for their shotguns at the prospect of such a change in Britain, they might remember this. In London, it is entirely legal for a sex worker to work from a single flat as long as she is a single operator. You can be a small business – you just cannot grow any bigger. In Britain, this area was most memorably investigated by the Wolfenden committee in 1957. Surely the time has come for a fresh independent examination of our position and the position around the world, including the evidence from Scandinavia that it is the customers who should be prosecuted, not the women. Better health will not come from shutting our eyes.

In my view, HIV will not be defeated until there is a vaccine. The polio vaccine shows just what can be achieved. A vaccine will not end the prejudice with HIV but it will give us the means to go around it. The trouble is that a vaccine is still some distance away. There are encouraging signs but we will have to be patient and finance the research.

For the next years, we will have to make do with the measures we have. There is opportunity for expanding treatment as the older drugs come off patent. But none of this will work if prejudice and discrimination continue to prevail in so many parts of the world that you cannot persuade men and women living with HIV even to take a test. For those who believe that the issue of Aids has gone away I would say: think again.

Aids: Don't Die of Prejudice by Norman Fowler is published on 10 June (Biteback Publishing £14.99).