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Fact: Treat All policies could help avert more than 21 million deaths and 28 million new infections by 2030. 

In September 2015, the World Health Organisation (WHO) issued a new policy which stated that anyone infected with HIV should begin antiretroviral treatment as soon after diagnosis as possible. With its “treat-all” recommendation, WHO removed all limitations on eligibility for antiretroviral therapy (ART) among people living with HIV; all populations and age groups are now eligible for treatment.

The expanded use of antiretroviral treatment is supported by recent findings from clinical trials confirming that early use of ART keeps people living with HIV alive, healthier and reduces the risk of transmitting the virus to partners.

WHO now also recommends that people at “substantial” risk of HIV should be offered preventive antiretroviral treatment. This new recommendation builds on 2014 WHO guidance to offer a combination of antiretroviral drugs to prevent HIV acquisition, pre-exposure prophylaxis (PrEP), for men who have sex with men. Following further evidence of the effectiveness and acceptability of PrEP, WHO has now broadened this recommendation to support the offer of PrEP to other population groups at significant HIV risk. PrEP should be seen as an additional prevention choice based on a comprehensive package of services, including HIV testing, counselling and support, and access to condoms and safe injection equipment.

New recommendations on early use of ART and expanded offer of PrEP are contained in WHO’s “Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV.” The new guideline stresses that, in order to effectively implement the recommendations, countries will need to ensure that testing and treatment for HIV infection are readily available and that those undergoing treatment are supported to adhere to recommended regimens and are retained in care.

The recommendations were developed as part of a comprehensive update of the “WHO consolidated guidelines on the use of antiretroviral drugs for preventing and treating HIV infection”.

Based on the new recommendations, the number of people eligible for antiretroviral treatment increases from 28 million to all 37 million people who currently live with HIV globally. Expanding access to treatment is at the heart of the set of targets for 2020 with the aim to end the AIDS epidemic by 2030. These targets include 90% of people living with HIV being aware of their HIV infection, 90% of those receiving antiretroviral treatment, and 90% of people on ART having no detectable virus in their blood.

According to UNAIDS estimates, expanding ART to all people living with HIV and expanding prevention choices can help avert 21 million AIDS-related deaths and 28 million new infections by 2030.

CLICK HERE for the Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. 

Global LGBTIQ advocates will once again convene this December at OutRight’s annual Advocacy Week in New York City. The ten-day event will have advocates amass for trainings and meetings with U.N. representatives to discuss global LGBTIQ issues. This invaluable collaboration between advocates will culminate at OutSummit, the capstone meeting where attendees are invited to discuss unique social and political issues that LGBTIQ people face in a diverse range of nations.

Martha Carrillo is a lesbian women engaged in HIV work in Belize, and Latin America and the Caribbean more broadly. She was the co-founder of the first ever NGO providing support to persons living with HIV, in particular men who have sex with men. She has also served as the Director of the National AIDS Commission and owns her own consultancy company providing technical assistance in the areas of human rights, advocacy training, and capacity building for key affected populations. She is the founder of an online support/social group for lesbians and bi women called W4W Belize (women4women) and a Counseling Psychologist by profession.

OutRight Magazine interviewed Martha on what led her to become an advocate for LGBTIQ rights and her current work in the Caribbean.

OutRight: What experiences first made you aware of the need to advocate for LGBTIQ rights? How did you first get involved with your earliest experiences and current organization?

Martha: Being a lesbian in a highly discriminatory society such as the one I grew up in was an everyday challenge. Coming to the realization that I was a lesbian as a young high school teacher (20yrs), I felt guilty and dirty among young persons who were looking up to me as a role model. When I went away to study in the US my whole life changed. I fell into a society where the topic of being gay was not a taboo. I was able to find myself, explore my sexuality and form important LGBTI networks. Upon returning to Belize I promised that I would be visible and available to help all young LGBTI persons in their coming out process so that they would know that our reality in Belize was based on ignorance, lack of exposure and a violation of our human rights.

OutRight: How have global politics impacted your work?

Martha: As a psychologist and an HIV consultant, I have had the opportunity to see HIV and its impact on our community from different perspectives including support services, addressing prevention for affected populations like men who have sex with men (MSM), addressing stigma and discrimination, human rights and creating an enabling environment. I have regional and global exposure to platforms that have educated, inspired and moved me to do as much as I can as a consultant, activist and advocate for the LGBTI community to decrease their vulnerabilities to the epidemic.

OutRight: Why is it important to be a part of advocacy week and how will that impact the work that you will do at home?

Martha: Every opportunity to learn and network is an important opportunity. I have heard from other LGBTQI colleagues and peers of their experience in Advocacy Week and have seen their growth because of this process. I want and need that for myself so that I may be better equipped and greater inspired to continue my work.

OutRight: What are some local social or political obstacles you and your organization currently face?

Martha: High-level institutionalized stigma and discrimination; high level of self-stigma among the community itself; high level of resistance and opposition from fundamentalist churches.

The Third Latin American and Caribbean Forum on Sustainability of the HIV Response (LAC III), “Road to Ending AIDS in LAC: Towards Sustainable Regional Fast Track Targets” was held in Port-au-Prince, Haiti, from 6 to 8 November 2017.

The forum was organized as a collaborative effort by the Government of Haiti, in coordination with the Horizontal Technical Cooperation Group (GCTH), the Pan Caribbean Partnership against HIV and AIDS (PANCAP), the Minister of Health of Brazil, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the Pan American Health Organization, the Global Fund Against AIDS, Tuberculosis and Malaria, the President’s Emergency Plan For AIDS Relief (PEPFAR), AIDS Healthcare Foundation (AHF), the Latin American Network of People Living with HIV (REDLA+) and the Caribbean Network of People Living with HIV and AIDS (CRN+).

As part of civil society representation, CRN+ made a poster presentation by the Interim Secretary, Mr Devon Gabourel, which focused mainly on the Greater Involvement of People Living with HIV in Ending AIDS.  The CRN+ Interim Chair, Mr Winfield Tannis-Abbott ended the forum with some closing remarks that resonated with participants.  He called for the scale-up of the Greater Involvement of People living with HIV (GIPA), ensuring support and full involvement and ownership by networks and communities of people living with HIV and the investment in age-appropriate comprehensive sexuality education and youth-friendly services for in-school, out-of-school and at-risk youth.

The overall objectives of the third forum were to review the progress and challenges towards meeting international and national targets; to discuss strategies to sustain the response in the medium and long-term including reflection on how to improve health systems effectiveness, efficiency and appropriate resource allocations; and to identify recommendations on how to close the resource gaps, specifically by increasing domestic investments.

PANCAP’s Youth Advisor, Dr Astel Collins (Hon.), recently represented PANCAP at a workshop aimed at building capacity for the implementation of the Global Accelerated Action for the Health of Adolescents (AA-HA!) guidance.  The workshop was implemented by PAHO/WHO, UNFPA and UNICEF.  The purpose of the workshop was to assist governments in deciding what they plan to do – and how they plan to do it – as they respond to the health needs of adolescents in their countries. The AA-HA! is intended as a reference document for national-level policy makers and programme managers to provide them with step-by-step guidance for setting their national priorities, and translation of these priorities into plans and programmes. The training focused on how to conduct a proper needs assessment, how to do a landscape analysis, how to set national priorities, how to identify key areas for programming and then monitoring and evaluation.

Participants of AA-HA!

The discussion at the workshop focused on adolescents being central to the overall success of the 2030 Agenda. Furthermore, the Global Strategy for Women’s, Children and Adolescents’ Health is leading the way in articulating the actions needed to capitalise on existing achievements from the MDGs, operationalise the Sustainable Development Goals (SDGs) and assure that the unfinished MDG agenda is addressed within one generation. Therefore, investing in adolescents brings a triple benefit: 1) healthy adolescents now; 2) Healthy adults in the future and 3) healthy future generations. Moreover, any nation that successfully implements the AA-HA! guidance to develop their adolescent will have a reduction of preventable adolescent and youth morbidity and mortality, their risk factors and determinants, and the risk factors for premature adult mortality. As well as the promotion of positive adolescent and youth health and development.

PANCAP Youth Advisor, Dr Astell Collins

Dr Collins reported that the team from Guyana will create a multi-sectoral, multi-agency steering committee and appoint a focal point which is likely to be from the Ministry of Public Health and then subsequently create a work plan for the AA-HA strategy development in Guyana. The first meeting is scheduled to be held in January 2018.

Last year, Chris Kimmenez and his wife asked their doctors a simple question. Could Chris, who has been HIV-positive since 1989 but keeps the virus in check through medication, transmit it sexually to Paula?

They were pretty sure they knew the answer. Married for more than 30 years, they had not always practiced safe sex, but Paula showed no signs of having the virus.

Their physicians were less certain. “They had a conversation and they did some research on it,” Kimmenez said. “They came back to us and said there may still be a risk, but we’re comfortable enough” that unprotected sex is safe.

“We knew that all along,” said Kimmenez, 56, who works with sex-offenders in Philadelphia.

Simple acknowledgments like that one, spoken quietly in the privacy of doctors’ offices, mark the arrival of a historic moment in the history of HIV: Medical authorities are publicly agreeing that people with undetectable viral loads cannot transmit HIV.

The policy change has profound implications for the way people view the virus. It promises not just unprotected sex for couples like Kimmenez and his wife, but also reduced stigma for the 1.2 million Americans living with HIV. The change also offers the hope that more people will be tested and begin treatment if they are found to have the virus rather than live in denial.

“There was something in me that said I’m damaged and I made a mistake and people see it and I’m a danger,” said Mark S. King, 56, a writer and activist who tested positive for HIV in 1985. But now treatment has fully suppressed the virus. “When I finally internalized this message . . . something suddenly lifted off of me that is hard to describe. It was almost as if someone wiped me clean. I no longer feel like this diseased pariah.”

Once considered a death sentence, HIV infection can now be managed via medication, much like chronic diseases such as diabetes, and people with the virus live full lives. The rate of new infections in the United States dropped by 10 percent from 2010 to 2014, to 37,600 in 2014, according to the U.S. Centers for Disease Control and Prevention. Fewer than 7,000 people died of HIV/AIDS that year.

In July, Anthony S. Fauci, head of the National Institute of Allergy and Infectious Diseases and one of the world’s leading authorities on HIV, publicly agreed at an international conference that people with undetectable viral loads in their blood cannot transmit the virus.

On Sept. 27, the CDC followed, releasing a letter that said people who take medication daily “and achieve and maintain an undetectable viral load have effectively no risk of sexually transmitting the virus to an HIV-negative partner.”

The influential British medical journal the Lancet HIV endorsed the idea in an editorial this month. All told, more than 500 organizations in 67 countries now agree, according to Bruce Richman, who is leading the “Undetectable = Untransmittable” (U=U) campaign credited with beginning to change public perception of HIV transmissibility.

Like many developments in the four-decade history of HIV, this one has been slow to gain acceptance among mainstream health-care providers. Many are not aware of it or must unlearn the habit of drilling safe-sex lessons into patients, as they have been doing almost since the AIDS epidemic began. HIV-positive people also must alter deeply-ingrained beliefs that nothing good can come of revealing their status.

The change in philosophy also has sparked concerns, for which there is some evidence, that more condomless sex will lead to an increase in other sexually transmitted infections. And experts acknowledge that a few people whose viral load is not truly suppressed will eventually transmit HIV to others.

Laws in many states also are out of date. Many still criminalize the failure to reveal HIV status to a sex partner, even when there is no danger of transmissibility.

But on balance, authorities said, the agreement that people with HIV can prevent sexual transmission by taking a single pill each day is nothing less than revolutionary.

“Nothing is completely risk free,” Fauci said in an interview. “What the community feels is that all of the good that will come from the lack of social stigmatization” is worth the risk. “This means a lot to them. This has a lot to do with their self-worth, their identity.”

An undetectable viral load is defined as fewer than 200 copies of the virus in a milliliter of blood. Generally, people with HIV should maintain that level or a lower level for six months before beginning to consider themselves incapable of transmitting the virus sexually.

Many who faithfully take antiretroviral medication and lead healthful lifestyles can bring their viral loads considerably lower, to 50 or even 25 copies.

But progress raises other questions, said Jonathan Mermin, director of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. What if a person forgets to take medication for one day? What about two, or more? How long after resuming therapy should someone wait before once again considering himself or herself incapable of transmitting the virus? And what about people who go above and below the 200-copy threshold over time? Studies show that to be the case for about 10 percent of the people with HIV, Mermin said.

As yet, there are no evidence-based answers to these questions, he said. “The public-health challenge now is moving from theory to implementation,” he said. “Many questions arise following the information that when a person with HIV has an undetectable viral load, he has effectively no risk of transmitting the virus.”

In 2008, Swiss experts announced that people with undetectable levels of HIV could not transmit HIV through sex. But the world was not ready to hear the message then.

Starting in 2011, three large studies confirmed the idea, tracking more than 75,000 vaginal and anal condomless sex acts without finding a single HIV transmission to an HIV-negative partner from someone whose viral load was undetectable. The initial 2011 study was named “breakthrough of the year” by Science magazine.

Now the challenge is to get the message out to HIV-positive people, caregivers and the public. And that process has been slow.

“I would tell everyone about this, friends and family and people I wanted to date and I was coming across so much resistance, because major institutions were saying this is wrong,” Richman said.

He launched U=U last year, initially a lonely and sometimes controversial campaign to let the world know something that many people with HIV had concluded for themselves. His breakthrough moment came in August 2016 when New York City’s health department signed on. Soon, other cities and organizations were joining.

Still, the message is moving mainly from people with HIV to health authorities and policymakers, rather than in the other direction, Richman said.

“This is a radical challenge to the status quo and to 35 years of HIV and fear of people living with HIV,” Richman said.
Brigitte Charbonneau, 71, of Ottawa, found out this year that she could not transmit the virus after 23 years of being HIV positive. “I thought, ‘My God, I’ve been living with my man for 20 years and we’ve been using condoms,’ ” the retired hairdresser recalled. “And I phoned him right that afternoon.”

Jennifer Vaughan of Watsonville, Calif., vividly remembers the moment she learned she could not transmit the virus to her boyfriend. The mother of three tested positive in February 2016 after she became critically ill with what was finally determined to be AIDS. HIV was not among the possibilities she or her doctors considered, until a blood test revealed the virus. She thinks she was infected by a previous boyfriend with a history of intravenous drug use.

She attended a speech Richman gave and was speaking with him in a parking lot outside a Starbucks.

“I’ll never forget him saying those words, ‘You can’t transmit the virus if you’re undetectable,’ ” the 47-year-old substitute teacher recalled. “And I said, ‘Wait, what?’

“It was like the sky opened. Are you kidding? There’s, like, zero risk? I don’t feel like I’m a threat anymore. I don’t feel like I’m dirty. I don’t feel like I’m a dangerous person.”