Since the identification of Pneumocystis (carinii) jirovecii pneumonia in five homosexual men in San Francisco in 1981, which led to the first description of what has become known as AIDS, our understanding of the syndrome has come a long way. Although the disease briefly acquired the somewhat divisive monikers gay-related immune deficiency (GRID) and 4H (after the populations affected: Haitians, homosexuals, haemophiliacs, and heroin users), the story in the past three decades has been one of a pandemic that has touched most social groups in every country.
The major gains in the past 30 years have been in both knowledge and care of HIV/AIDS: from the identification of the virus to development and refinement of diagnosis and treatment. Global campaigns such as 3 by 5 and Universal Access might not have achieved their main goals but certainly have ensured that HIV/AIDS is high on the agendas of global, national, and local governments. The recent 2009 AIDS Epidemic Update reported that the number of new infections has fallen by 17% globally and AIDS-related deaths have fallen by 10% in the past 5 years, with 2·9 million lives saved since 1996. Further gains are being made in the targeting of particular groups. As emphasised in a news story in this issue, programmes aimed at Latin Americans in the USA target a specific group with needs that differ from those of the majority population of the country.
Despite these gains, prejudice, discrimination, and stigmatisation of people with HIV/AIDS, and key groups most affected by and at most risk of the disease, continue to hamper efforts to tackle the pandemic. The welcome news that the USA has at last lifted a 22 year travel restriction that prevented people with HIV/AIDS entering the country, and that South Korea has removed a similar ban, reminds us that almost 30 countries worldwide still block entry by and repatriate foreign nationals with HIV/AIDS. And in Uganda, the attempt to introduce the death penalty for people known to have engaged in homosexual acts and further criminalise individuals, including health workers, who support such people is a terrifying sign that addressing issues of vulnerability, discrimination, and human rights will be key to future gains in the battle against the pandemic.
About a third of people living with HIV/AIDS in countries without generalised epidemics are men who have sex with men, sex workers, and injecting drug users, and in countries with generalised epidemics people in these key groups have a higher prevalence of HIV/AIDS than do the general population. The WHO Towards Universal Access report, released last year, identified these as target populations in the fight against HIV, since infections in these groups are likely to drive epidemics in the future.
Despite the recognition that vulnerable groups are key to addressing the ongoing HIV/AIDS pandemic, tackling the problem in these people is hampered by their exclusion from access to prevention and treatment. In a study by the AIDS Alliance, key populations in Latin America were underrepresented in the allocation of grants from the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Only US$8 million of $170 million reached organisations specifically representing key vulnerable populations, and no grant was specifically awarded to organisations representing transgender people, despite the prevalence of HIV in this group reaching 45% in some cities.
But funding bodies can help to improve the situation of key populations, not only by providing funds directly, but also by putting conditions on donations to ensure that countries act to remove discrimination and improve the health of people in vulnerable groups. Over the past 5 years, the Ukraine has managed to turn the tide in a rapidly escalating HIV/AIDS crisis by opening needle exchanges and offering counselling for drug users with donations from the Global Fund given on the condition that the country legalised methodone replacement therapy.
People who are marginalised in many societies and health systems are now central to the fight against HIV/AIDS. Only by improving the rights of these people can they have better access to prevention, treatment, and management. Funding organisations can help to address these issues, by asking governments for legislation that removes barriers to accessing care and by encouraging local advocacy for these vulnerable groups. The fight against HIV/AIDS is no longer a battle against the virus, it is, and will increasingly be, a battle for human rights.
