Impact Magazine No. 17 by Impact Magazine

THE MAGAZINE OF PSI

No. 17

STEMMING HIV A Focus on those

at Greatest Risk

7 QUESTIONS

› MARK DYBUL,

Global Fund to Fight AIDS, Tuberculosis and Malaria

› MICHEL SIDIBÉ,

UNAIDS

DEBT FREE

Noemi’s Story

PSI’S GUIDE TO I C 2014

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EDITOR’S NOTE

THE MAGAZINE OF PSI

EDITOR-IN-CHIEF Marshall Stowell Director, External Relations and Communications mstowell@psi.org

MANAGING EDITOR Mandy McAnally Manager, External Relations and Communications amcanally@psi.org

CONTRIBUTORS Laura Dominick Rena Greifinger Janie Hayes Brittney Kramer Laetitia Lemoine Regina Moore Thayer Rosenberg Janelle Santiago Beth Skorochod Petra Stankard

PSI is a global nonprofit organization dedicated to improving the health of people in the developing world by focusing on serious challenges like a lack of family planning, HIV and AIDS, barriers to maternal health and the greatest threats to children under five, including malaria, diarrhea, pneumonia and malnutrition. psi.org

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A SECOND CHANCE TO DO IT RIGHT. No doubt the topic of conversation at the 20th International AIDS Conference in Melbourne, Australia, will be ‘key populations.’ In other words, how do we reach those at greatest risk for infection – men who have sex with men, people who inject drugs and sex workers. These have always been the people at greatest risk. They have been the most ignored, stigmatized, marginalized, dehumanized and politicized. The world has made great progress in slowing transmission among the general population in high prevalence countries, but it has made shockingly little progress among key populations. Here we are, decades in, discussing a focus on key populations, as if it were new. As we head back to the future, we have a second chance to do right by people. Yes, people. People with names. People with loved ones – not simply those defined by what they do, or by more polite and tolerable words like ‘key.’ In the past 20 years, I have heard countless politicians and high-level government officials give impassioned speeches about the exemplary corporate response to the AIDS epidemic and the impressive scale of the U.S. government’s response. There have been numerous awards recognizing the media and people like Elizabeth Taylor, who fought for the world’s attention when AIDS was nothing more than ‘gay cancer.’ The accolades are well deserved. But with a very few notable exceptions from people like Michel Sidibé, few have publicly and repeatedly acknowledged the gay community for the lonely, devastating fight for answers and action that formed the world’s response. We’ve heard even less about people who inject drugs and sex workers. Where are the accolades for these people? It’s not been politically expedient, nor particularly popular to talk about the people most of society would rather forget. Things are slowly changing for the LGBT community, but there is still little empathy for people who inject drugs and sex workers. It still plays much better on Main Street to talk about ‘innocent victims.’ The irony is not lost considering that Uganda, Nigeria and other countries with repressive anti-LGBT laws are directly benefiting from funding, prevention efforts and medicines fought for by the gay community in the early days of AIDS. As we make our way to Melbourne, and we have the chance to hit the reset button, let’s do it right. Let’s make the best of this opportunity to talk less about key populations and talk more about people, dignity and basic human rights. n

Population Services International

MARSHALL STOWELL Editor-in-Chief, Impact follow @PSIimpact

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impact | No. 17

PSI NETWORK

CONTENTS

TH E MAGA Z I N E O F P S I | N O. 17 | 2014

DEBT FREE: NOEMI’S STORY

7 QUESTIONS WITH DR. MARK DYBUL Executive Director Global Fund to Fight AIDS, Tuberculosis and Malaria

STEMMING HIV: A FOCUS ON THOSE AT GREATEST RISK

INTERVIEW WITH MICHEL SIDIBÉ Executive Director, UNAIDS

STEPPING UP THE PACE PSI’s Guide to the 2014 International AIDS Conference

SHARING HER TRUE IDENTIT Y: KHOM’S STORY

ANTI-GAY LAWS, POLICIES AND HIV

LOST AND FOUND: P’BOY’S STORY

By Dr. Paul Semugoma, ANOVA Health Institute

POLICY MAT TERS: NO TURNING BACK Kevin Fisher and Catherine Connor, co-Chairs, Global AIDS Policy Partnership

FINAL WORD: WE CANNOT SEPARATE HEALTH FROM RIGHTS By Karl Hofmann President & CEO, PSI COVER PHOTO: © RITA VILLANUEVA

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7 QUESTIONS

DR. MARK DYBUL Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria

impact | No. 17

Marshall Stowell, editor-in-chief of Impact, talks to Mark Dybul about Global Fund game-changers, prioritizing stigmatized populations in HIV efforts and the role of emerging economies in global health. MARSHALL STOWELL:

The Global Fund experienced a difficult period preceding your appointment in 2012. You had a unique chance to hit the reset button. What has changed?

➜ M A R K DY B U L : The Global Fund is a 21st century organization, and we are constantly learning and improving. I came to the Global Fund in early 2013, just as we were in the process of shifting our funding model to have an even bigger impact on HIV, tuberculosis and malaria. The new funding model is a game-changer. It is allowing us to work more closely with countries, serve our partners better and reach the most vulnerable populations. It is also allowing us to take a more holistic approach to health, and address gender inequalities and human rights barriers to health. In many ways, we are reinvigorating the spirit of partnership.

MS:

You speak about a “window of opportunity” for defeating AIDS over the next generation by focusing on specific populations. Which populations and what are today’s most effective tools to reach them?

➜ M D : Scientific innovation and implementation experience over the last decade give us an historic opportunity to end this epidemic as a threat to public health. We’ve made huge progress, and millions of lives have been saved already. But these gains are fragile. If we want to defeat HIV, we need to take the scientific advances to the most vulnerable populations and the people who need them most and put them at the center of our prevention, treatment and care efforts. These include women and girls, men who have sex with men, sex workers, people who inject drugs, transgender people, prisoners and migrants, among others.

D R . M A R K DY B U L has worked on HIV and public health for more than 25 years as a clinician, scientist, teacher and administrator. After graduating from Georgetown Medical School in Washington D.C., Dybul joined the National Institute of Allergy and Infectious Diseases. Dybul was a founding architect and driving force in the President’s Emergency Plan for AIDS Relief. He led the agency as the U.S. Global AIDS Coordinator from 2006 to 2009. Before coming to the Global Fund, Dybul was co-director of the Global Health Law Program at the O’Neill Institute for National and Global Health Law at Georgetown University.

don’t make sure the trajectory of HIV infections accelerates downward, we could lose all our hard-fought gains. We also need to make sure we don’t leave anybody behind. There have been incredible scientific innovations in the last decade, but we need to take them to the ground for everybody. There is no single bullet, so we need to be smarter with our investments, deploying all the tools we have, from harm reduction to circumcision, to prevention, to making sure that all those who need it receive antiretroviral treatment. Antiretrovirals not only save lives, but dramatically reduce the chances of infecting others, so there is a huge prevention value in this. Everything is connected.

MS:

You are a medical doctor, ran PEPFAR, have collaborated with some of the world’s leading global health experts, and now you are leading one of the world’s largest donor organizations. What lessons have you learned that shape your leadership philosophy?

➜ M D : The biggest lesson is that there

MS:

Emerging economies are increasingly involved in the HIV/AIDS response. How is the Global Fund engaging them from a policy and funding perspective?

is no single institution or organization or collection of organizations that is going to do this job. That has to come from all of us. We will only defeat HIV if we create an inclusive human family and if we treat everyone in the world with dignity and

responsibility and mutual accountability can bring real change. Governments, multilateral organizations, civil society and philanthropists came together to say with one voice: “We can defeat HIV, TB and malaria.” That is pretty awesome. But now we have to do it.

MS:

What impact do anti-LGBT laws have on the HIV epidemic, and what role should the international community play in addressing them?

➜ M D : Laws that criminalize LGBT people, organizations, activities, or people who support them severely affect access to essential HIV services. Besides suffering from discrimination and stigma, gay men have a disproportionally high burden of HIV. Anti-gay laws drive these communities further underground, stopping them from getting the prevention, treatment and care they need. We need to continue engaging with our partners to make sure we remove all forms of homophobia and stigma undermining global efforts to control and defeat the epidemic. It is also critically important that we support community-based organizations as a vital component of the HIV response. n

➜ M D : Emerging economies are becoming increasingly engaged in the global health dialogue. They can have an enormous positive impact in development. The Global Fund is engaging with emerging economies so that they can share their experience and technical knowledge in the regions where they sit. They also play an important role in our governance structures. Some of these emerging economies are leading the way in their regions. But here it is important to add that the global community needs to craft a new development framework between high-income countries and low-income countries so that emerging economies can unlock their full potential for effecting positive impact regionally and globally.

Our latest replenishment was an example of how partnership, shared responsibility and mutual accountability can bring real change.”

respect. We all need to come together. It will take commitment and shared responsibility from all of us – external funders, governments, NGOs, communities affected by the disease, faith-based organizations, activists and community groups, and the private sector.

MS:

At the International AIDS Conference, you’ll speak on a panel addressing, “What is Holding Us Back and How Do We Move Faster?” What are some of the major challenges facing us as a community? What are the innovations that will get us there faster?

MS:

In December, the Global Fund’s Fourth Replenishment process saw the largest amount of funding ever committed by its donors. To what do you credit this significant commitment?

➜ M D : The major challenge we face is

➜ M D : Our latest replenishment was

making everyone understand that if we

an example of how partnership, shared

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STEMMING HIV A FOCUS ON THOSE AT GREATEST RISK

HIV CARE CONTINUUM

female sex worker in Tanzania. A woman who injects drugs in Vietnam. A man in Nicaragua who has sex with men. A young person in Liberia who cannot read. These individuals and millions like them are often left behind in the fight against HIV. Around the world, key populations – men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID) – run an inordinately high risk of contracting HIV. HIV prevalence among PWID1 is 22 times higher than the general population. MSM and FSWs are 19 and 13.5 times more likely to contract HIV, respectively.2,3 Young people, ages 15 to 24, accounted for 40 percent of new adult HIV infections in 2012, with young women becoming infected at twice the rate of young men. While these groups run the highest risk of infection, they are also the least likely to access comprehensive services across the HIV care continuum. PSI is addressing that, by identifying where vulnerable populations are and reaching them with messages, products and services they understand and can afford – from prevention to treatment. The programs highlighted here demonstrate how PSI’s approach – applying data-driven design, high-quality services and advanced technology at every stage of the HIV care continuum – is helping to stem the tide of HIV among the people who need it most.

G ENERATING DEMAND FOR SERVICES T ESTING AND COUNSELING R EFERRALS AND LINKAGES C ARE AND TREATMENT

1. UNAIDS (2012) Report on the global AIDS epidemic. 2. Baral S et al (2007). Elevated risk for HIV infection among men who have sex with men in low and middle income countries. 3. B aral S et al (2012). Burden of HIV among female sex workers in low income and middle income countries. A systematic review and meta-analysis.

GENERATING DEMAND FOR SERVICES V I E TN A M: Marketing ‘Low Dead Space’ Syringes to People

Who Inject Drugs In Vietnam, PWID are at high risk of contracting HIV and Hepatitis C. The common practice of using shared, contaminated needles and syringes facilitates transmission. In Vietnam, nearly a quarter of people who inject drugs are HIV positive, and an estimated six out of 10 are living with Hepatitis C – highlighting the crucial need for efforts to reduce the sharing of contaminated injecting equipment. Since 2005, PSI/ Vietnam has worked with a range of partners, including the Government of Vietnam, to conduct outreach and education to motivate safer injecting behaviors and encourage regular HIV testing and counseling among PWID. In 2012, based on WHO evidence that HIV is more readily transmitted through the sharing of traditional low dead space syringes – which retain relatively large amounts of infected blood even after they are used and rinsed – PSI/Vietnam developed the world’s first social marketing program for low dead space syringes. Once the plunger is depressed and the syringe is rinsed, low dead space syringes retain nearly 100 times less blood than high dead space syringes, reducing the chance of HIV and Hepatitis C transmission. The pilot program has focused on increasing awareness of, and access to, the new syringes among PWID and generating evidence to inform national and international programs. Sales have shown promising signs to date. 4

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% of PWIDs in Vietnam estimated to be living with HIV

1.6X

females who inject drugs and who have been exposed to PSI’s face-to-face outreach campaign are 1.6 times more likely to have used sterile injecting equipment than females not exposed

2,300 vs. 60,800

# of low dead space syringes sold in three key Vietnamese provinces in September of 2012, prior to PSI’s social marketing program

# sold in those same provinces eight months later after PSI/Vietnam began its social marketing program

G ENERATING DEMAND FOR SERVICES

HIV TESTING AND COUNSELING L I B E R I A : Harnessing Mobile Technology to Encourage

6,225 # of MSM reached in Nicaragua in 2013

2.68 # of times more likely MSM in Nicaragua who are reached by cyber-educators are to use a condom than those who are not

N I C A R A G U A: Using Online Chat

Rooms to Reach Men who have Sex with Men In Latin America, many MSM are not open about their sexuality due to high levels of stigma and discrimination in their communities. This stigma and discrimination puts them at greater risk of contracting HIV compared to the general population. Many MSM in Latin America connect with sexual partners through online chat rooms and social networking websites. As a result, they are often difficult to reach with HIV services via typical channels, such as faceto-face outreach in openly gay clubs or other gathering spots. In 2012, PSI and its local network member, the Pan American Social Marketing Organization (PASMO) began a unique combination-prevention program in Central America that reaches MSM with HIV prevention information where they are – online. A trained team of cyber educators conduct online chats and provide electronic vouchers for free or discounted HIV testing and counseling and screening for sexually transmitted infections (STI) at partner healthcare facilities. These partners are trained by PSI to provide MSM-friendly services. Recent evaluation studies show that the men reached by the program are much more likely to use a condom than those not reached, and many have utilized vouchers for HIV services.

In Liberia,a country still recovering from the effects of civil war, rates of youth unemployment, illiteracy and pregnancy are high. Few young people are well educated about sexual health, and myths about HIV and contraception abound. Available data from Liberia show that only about 5 percent of the population has tested for HIV, and among those with only a primary education, that number decreases to 1 percent.4 Young women are at particularly high risk for HIV as they have little education, face high rates of sexual violence, and rely heavily on transactional sex. This means they have little ability to negotiate condom use. In 2013, PSI/Liberia launched a pilot peer education program called HealthyActions. Implemented in an Alternative Basic Education project run by partner Educational Development Center (EDC), the program includes a five-day curriculum that aims to build knowledge and skills related to HIV and STI prevention and contraceptive use, with a focus on delivering services at ABE sites. The success of the program in increasing rates of HTC and contraceptive use among young people has been augmented by a peer educator training with 200 graduates of the HealthyActions program. The peer educators use mobile phones to report the number of young people reached through their sessions and provide referrals for HTC and contraceptive services. The peer educators also use their phones to communicate the pre-recorded audio curriculum to deliver HIV-prevention and sexual and reproductive health education to peers in their youth clubs and communities. The program is successful at engaging and motivating young people to know their HIV status. Each week’s HealthyActions classes are followed by a Clinic Celebration Day – a pop-up clinic staffed by government health workers and open to the entire community – where nearly two thirds of the program’s youth receive HIV testing and counseling.

“ HealthyActions is directly contributing to improved health outcomes as well as increased use of modern family planning methods,” says Lisa-Hartenberger-Toby, EDC’s chief of party in Liberia. “This is beneficial to individual Liberians, their families and communities, and Liberia as a whole.”

% of Liberian women have had a child or are pregnant by age 19

% of program participants who received testing and counseling during the HealthyActions “Clinic Celebration Day,” far above the national average.

4,600

# of Liberian youth participated in the HealthyActions program 4. Liberia Demographic and Health Survey, 2007. http://dhsprogram.com/what-we-do/survey/survey-display-271.cfm

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Youth to Seek HIV Testing and Counseling

STEMMING HIV A FOCUS ON THOSE AT GREATEST RISK

1.6

million

6,000 # of HTC sites in Kenya

# of people living with HIV in Kenya

HIV TESTING AND COUNSELING KE NYA: Building the Evidence Base for HIV Self-Testing Recent research indicates that HIV oral self-testing could significantly increase the number of people who know their HIV status, especially in areas where stigma and discrimination are high or access to traditional HIV testing is limited. In Kenya, self-testing could improve access to routine HTC, lower its costs, increase confidentiality and empower users. However, as with any new product, research gaps exist that must be filled before the product can see widespread introduction. In 2013, with support from the International Institute for Impact Evaluation, PS/Kenya began a set of research studies to help fill two knowledge gaps about how to effectively bring these products to market more quickly. One study examined the feasibility of oral HIV self-testing among the general population, including FSWs

+-+-+-+-+-+-+-+ -+-+ +-+-+-+-+-+-+-+-+-+ +-+-+-+-+-+-+-+-+-+ +-+ -+-+-+-+

% of FSWs in the study who said they would use an oral HIV self-test kit

% of Kenyans who report knowing their HIV status

and MSM. Another focused on product packaging for the oral self-test kit. The first study found high potential for self-test promotion in Kenya. Over half of the MSM respondents and nearly all of the FSWs reported that they would use the HIV oral self-test kits if they were made available. More than half of the MSM and more than 9 out of 10 FSWs indicated they were willing to pay for the kit. Key advantages of the test for both MSM and FSWs included privacy and ease of use. The second study found that the packaging of the test is critical to whether and how the product is used. For both MSM and FSWs, packaging and labeling affected potential users’ confidence in the product, as well as how accurately they used and interpreted the test. The results of both of studies will be used to inform an upcoming pilot program on self-testing in Kenya, which could open new options for HIV testing for marginalized populations in both Kenya and across sub-Saharan Africa.

REFERRALS AND LINKAGES E TH I O P I A: Mapping Key Populations to Improve Referrals and Linkages

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2,659

# of venues found with at least one FSW in Addis Ababa

# of towns and cities where HIV prevention, HTC, and care and treatment services have been mapped thus far using GPS

High quality mapping data are critical for effectively targeting activities to reach key populations and for referrals to HIV care and treatment services. PSI/Ethiopia is using global positioning system (GPS) data to better orient the use of program resources by identifying the size and whereabouts of the country’s female sex workers, and then strengthening nearby existing public and private referral points to offer comprehensive reproductive health services. Using teams of data collectors, PSI/Ethiopia has mapped over 30,000 FSW venues with over 70,000 FSWs, as well as thousands of public, private and NGO-supported service outlets in 83 priority project towns and cities. The PSI/Ethiopia team then brought this information to life for local decision-makers by layering the data into interactive Google Earth maps that allow for a bird’s-eye view of service coverage in and around “hot spot” areas in each project town or city. As part of the USAID-funded MULU HIV Prevention Program, PSI/Ethiopia is using this visual representation of the GPS data to help outreach workers provide FSWs, previously neglected by critical services, with more accurate and convenient referrals to HTC, care and treatment services. This visual representation is also used to identify health service coverage gaps near “hot spots” and has informed efforts to petition Regional Health Bureaus to strengthen services at facilities in or near these areas. Based on its success, the program is expanding to strengthen the capacity of area program teams and partners so they too can use the data for programmatic decision making.

REFERRALS AND LINKAGES

CARE AND TREATMENT Z I M B A B W E : Integrating HIV Treatment and other

– District AIDS Control Coordinator, Tanzania Ministry of Health

HIV+

3out of10 # of FSWs in Tanzania who are HIV positive

% of FSWs in Tanzania younger than 25

TA NZ A N I A: Increasing HIV Prevention and Treatment

Health Services for Underserved Populations The recent practice of integrating HIV treatment with other health services – including contraception and maternal and child health – has shown success in moving more clients from HTC to treatment, leveraging efficiencies in service provision and costs. In 2013, PSI/Zimbabwe began providing female sex workers, pregnant and breastfeeding women, and serodiscordant couples (in which one partner is HIV positive and the other is HIV negative) with additional options to access CD4 cell count testing and antiretroviral treatment (ART) services through its New Start clinics. Four outreach teams also provide ART at clinics specifically serving FSWs. This approach is implemented closely with partners and complements the Zimbabwe Ministry of Health and Child Care’s increasing interest in using treatment as prevention in its combination-prevention strategy. The program is designed to reduce morbidity and mortality, and support HIV-prevention efforts by reducing HIV viral load among FSWs who are HIV positive. PSI/Zimbabwe is also establishing ART services in rural mines for FSWs and their clients, especially casual mine laborers, who have no access to public health services. The program fills a gap among high-risk populations in Zimbabwe and provides an important option for these groups to access HIV treatment.

Among Female Sex Workers Around the world, female sex workers are 13.5 times more likely to be infected with HIV than other women. In Tanzania, though sex work is illegal, the country has a relatively large FSW population, with 7,000 working in Dar es Salaam alone. This population of women can be difficult to reach through traditional HIV outreach services because they work secretively and are often suspicious of outsiders. Once an FSW knows she is HIV positive, these same challenges make it difficult to ensure that she enrolls in quality care and treatment services. Through its “Shosti” program, PSI/Tanzania has trained and mobilized nearly 100 female sex workers as peer educators. Shosti is a Swahili feminine name for a close friend or role model. These women provide one-on-one and group outreach to other FSWs to encourage correct and consistent condom use, regular HIV testing and counseling, and STI screening and treatment. Since 2012, these peer educators have reached 25,000 FSWs in Tanzania, and 5,559 have undergone HIV testing. Of these, 1,051 tested HIV positive and were linked to treatment using a paper-based referral voucher. Moving forward, PSI/Tanzania and its partners will strengthen the linkages between HTC and HIV care with the introduction of an electronic referral system that will help enroll more HIV positive FSWs into HIV care programs.

2,038

# of individuals in HIV care after the first 10 months of the program

90 % of clients with suppressed viral load after six months of treatment in PSI/ Zimbabwe’s program

“ This innovative program, with PEPFAR support, includes one of the first ART-as-prevention initiatives undertaken in the country under the auspices of the Ministry of Health and Child Care and is helping to define how ART-as-prevention services can best be offered to commercial sex workers, as well as other vulnerable populations.” —USAID Zimbabwe

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“ The Shosti program has helped us reach a group that we hadn’t considered how to reach before.”

➜ INTERVIEW WITH MICHEL SIDIBÉ

MICHEL SIDIBÉ,

EXECUTIVE DIRECTOR, UNAIDS,

talks with Impact about the 20th IAC, addressing stigma and discrimination, and the AIDS epidemic in 10 years. MICHEL SIDIBÉ Since his appointment as Executive Director of UNAIDS and Under-Secretary-General of the United Nations in 2009, Michel Sidibé’s vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths has echoed around the world. Mr. Sidibé has spent more than 30 years in public service. He worked to improve the health and welfare of the nomadic Tuareg people in his native Mali. He served UNICEF for 14 years, overseeing programs across 10 francophone African countries and serving as country representative in a number of countries. He holds two Post-Master’s diplomas from the University of Blaise Pascal, ClermontFerrand, France. He also holds a Masters degree in economics.

IMPACT:

Tell us about one moment from your 30-year career that fuels your passion to address AIDS?

➜ M I C H E L S I D I B É : I often think back to 2001, when the United Nations convened the General Assembly’s Special Session on HIV/AIDS. At that time, HIV was spreading out of control in Africa and in some other developing countries. While people in lowand middle-income countries were dying of AIDS-related illnesses in a large and growing tragedy, a few privileged people living with HIV in developed countries were already accessing life-saving treatment. Some critics at the UNGA said that it would be impossible to bring HIV treatment to people in developing countries because it was too costly and too difficult to take. The cover of The Economist referred to Africa as “The Hopeless Continent.” But many of us refused to take no for an answer. Instead, civil society and the private sector rallied. What followed – the UN Declaration of Commitment on HIV/AIDS, and then the creation of the Global Fund to fight AIDS, Tuberculosis and Malaria, and PEPFAR – set the world on course to a new era of partnerships, accountability, scientific innovation and scale-up. The results have distinguished the global AIDS response as one of the most rapid and successful breakthroughs in the history of global health.

IMPACT:

To meet your call for “zero new HIV infections, zero discrimination and zero AIDSrelated deaths” where should the HIV and AIDS community focus?

➜ M S : At a time when the world is finally talking about ending the AIDS epidemic,

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we will never reach this historic milestone if we do not focus on the needs of people who are still being left behind. More than 30 years into the epidemic, there are many reasons that certain populations are still disproportionately becoming infected with HIV and dying of AIDS-related illnesses. The AIDS response must enhance our understanding and response to address poverty and social drivers of infection, such as gender-based violence, discrimination, lack of harm reduction programs for people who use drugs and punitive laws. Young people everywhere, especially young women and girls in sub-Saharan Africa, continue to be at high risk of HIV infection when they cannot access reproductive and sexual health services and rights. AIDS programs must integrate health and social issues in a coherent, holistic manner, and these issues should be approached with the benefit of lessons learned in the AIDS response.

IMPACT:

The AIDS 2014 Melbourne Declara-

tion states, “An end to AIDS is only possible if we overcome the barriers of criminalization, stigma and discrimination that remain key drivers of the epidemic.” What forms of discrimination most hinder progress? What impact will the anti-LGBT laws in Uganda and Nigeria have on HIV, and what can be done internationally and locally?

➜ M S : Progress in the AIDS response is still being undermined by gender inequity, violence against women and girls, discriminatory homophobic attitudes, and punitive laws and practices. In Eastern Europe and Central Asia, the HIV epidemic continues to grow because of the ways some

governments and societies treat people who inject drugs. When people at high risk of HIV infection have to hide underground due to discrimination and criminalization, the virus spreads. That is bad for vulnerable people and it is bad for society, because in such contexts, it will be difficult, if not impossible, to end the AIDS epidemic. For everyone, everywhere, we must advocate for unrestricted access to lifesaving HIV services. This also requires that we support civil society to ensure they have a strong voice and a place at the table where policies are made. We also have to leverage the full potential of human rights and gender equality to serve as critical pillars of the AIDS response – through political leadership; strategic, evidencebased programs; and empowerment of people most affected.

IMPACT :

The HIV treatment and care cascade

provides a clear process for ensuring that people living with HIV receive appropriate care and that further transmission of HIV is limited. How has its articulation impacted prevention and treatment efforts?

routine, door-to-door offers of HIV testing and family testing, and HIV testing integrated into multi-disease campaigns. HIV testing campaigns need to focus on areas with high HIV prevalence and ensure safe and confidential access to testing. Successful campaigns require good integration and trust between community and health systems.

IMPACT:

Populations at increased risk of HIV infection, like men who have sex with men, people who inject drugs, sex workers and youth, often lack basic legal protections. What can we do to increase legal protections and change social norms so that these populations have better access to HIV prevention, treatment and care?

➜ M S : The Global Commission on HIV and the Law has done some innovative work in this area. The Commission is an independent group of eminent political and social leaders from around the world who conducted an exhaustive two-year exploration into laws, law enforcement and

new HIV infections among children. Ending the AIDS epidemic to me is about ending AIDS as a global health threat. Why do I think we can end the AIDS epidemic? First, science is marching into positive new territories: microbicides, vaccines and a cure are real agendas where dramatic progress has already been made. We do not expect a magic bullet, but science is now giving us new hope for reaching the end of the AIDS epidemic. Second, the countries most affected by HIV are themselves changing. From South Africa to China to Brazil, many countries have adopted the UNAIDS vision of the three zeros – zero new HIV infections, zero discrimination and zero AIDS-related deaths. They are also mobilizing more of their own domestic resources. Over the past five years, many African countries have been using the African Union Roadmap on AIDS, TB and Malaria to increase their domestic investments in AIDS by over 150 percent. South Africa is now putting $2 billion domestic resources into its

➜ M S : Prevention is critical. Testing is critical. Eliminating mother-to-child transmission is critical. Condoms, voluntary male circumcision and traditional and new HIV prevention technologies are all essential parts of an integrated, strategic global response to HIV. There is no more debate – HIV treatment is also effective in preventing new HIV infections. This has enabled us to move the polemic from prevention versus treatment to a new approach of combination prevention in which treatment plays an important role. But we know that we cannot treat our way to zero. Ending the AIDS epidemic requires a renewed push on combination HIV prevention to ensure that we are using all the tools at our disposal, doing all we can to prevent new HIV infections.

IMPACT :

The successful implementation of the treatment and care cascade relies on well-designed HIV testing programs that reach populations at highest risk of HIV infection. What are key innovations in finding people living with HIV and linking them to the health system?

On the last mile of our journey to ending the AIDS epidemic, we must walk in solidarity with the most vulnerable groups.” access to justice issues in the context of HIV. The Commission looked into the legal and structural fabrics that sustain inequality, injustice and human rights violations. The evidence is clear. African and Caribbean countries that do not criminalize same-sex sexual activity have lower HIV prevalence among men who have sex with men. Countries that treat people who use drugs as patients instead of criminals – including Australia, Germany, New Zealand, Portugal and Switzerland– have increased access to HIV services and dramatically reduced HIV transmission rates among people who use drugs. The evidence is there, and we need to maintain the pressure, support civil society and stay engaged.

IMPACT:

Where will we be in 10 years as an HIV/AIDS community?

➜ M S : Around half of all people living with

➜ M S : Due to the dramatic progress with

HIV do not know their status, so innovative HIV testing efforts are urgently needed. HIV testing can be scaled up through new community-based initiatives, including

the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, I am convinced that we will soon achieve zero

response to HIV – the largest domestic AIDS investment in the world. We are also going to see a transformation in how health is financed and delivered globally. People around the world are challenging the status quo, demanding change, condemning inequity. They want a bigger agenda – beyond AIDS. When the MDGs were established, almost 90 percent of the world’s poor lived in low-income countries. Today, three out of four poor people live in middle-income countries. The entire paradigm for health and development has to be reconstructed. Neither AIDS nor health can be addressed in isolation. On the last mile of our journey to ending the AIDS epidemic, we must walk in solidarity with the most vulnerable groups. Our greatest challenge to ending the AIDS epidemic will be to reach people who remain hidden beyond the reach of life-saving services. The AIDS epidemic will not be over until we are sure that no one is left behind. n

psi.org | impact

PSI’S GUIDE TO THE 2014 INTERNATIONAL AIDS CONFERENCE ➜C HECK OUT TH E W E E K O F S AT E L L I T E S E S S I O N S A N D P R E S E N TAT I O N S .

An HIV testing and counseling session at the Society for Family Health’s (SFH) New Start clinic in Lusaka, Zambia. SFH is a PSI network member.

STEPPING UP THE PACE

INTERNATIONAL AIDS CONFERENCE 2014:

PSI SATELLITE SESSIONS

SUNDAY, JULY 20

HIV/AIDS and Youth: Presenting Biomedical,Behavioral and Structural Interventions that Work

There are over 2 billion adolescents and young people in the world today; the largest population of youth to date. An estimated 7 million young people are living with HIV, 70 percent of whom contracted HIV through sexual activity or drug use. This satellite session will bring together leading voices in HIV prevention among young people, to share evidence and experiences from programs and advocacy that work. Designed around the combination prevention framework, the session will highlight biomedical, behavioral and structural interventions to prevent HIV among adolescents and young people, with particular focus on vulnerable populations. Speakers will discuss the advent of vaccines and microbicides, social media outreach, prevention with young people living with HIV and youth-led advocacy initiatives that are reshaping the discussion about HIV prevention and youth. DETAILS: 9:00-11:00am, Room 103 HOSTS: Youth Health and Rights Coalition members: Pathfinder International, PSI, PPFA and LinkUS (a partnership of the Global Youth Coalition on HIV/AIDS, MSI, and the International HIV/AIDS Alliance) PANEL: The Honorable Barbara Lee, Congressmember, from California’s 13th District (opening remarks); Purnima

Mane, Pathfinder International (co-chair); Cedric Nininahazwe, The Burundian National Network of Young People Living with HIV (co-chair), Prince Ngongo Bahati, IAVI; Jorge Rivas, PSI/PASMO; Dessie Ayalew, MSI/Ethiopia; Caitlin Horrigan, PPFA; Musah Lumumba, CYSRA-Uganda and the Y+ Programme

SUNDAY, JULY 20

PANEL: Leslie Mancuso, Jhpiego (opening remarks); Alain Damiba, Jhpiego (chair, panel 1); Emil Asamoah-Odei, WHO/ AFRO (chair, panel 2); Kelly Curran, Jhpiego (chair, panel 3); Emmanuel Njeuhmeli, USAID; Naomi Bock, CDC; Mitchell Warren, AVAC; Gissenge J. I. Lija, Tanzania Ministry of Health and Social Work; Yogan Pillay, South Africa Department of Health; Dino Rech, Centre for HIV/AIDS Prevention Studies; Virgile Kikaya, Jhpiego; Mehebub Mahomed, Jhpiego; Karin Hatzold, PSI;

DETAILS: 6:30-8:30pm, Melbourne Room 1 HOSTS: PSI, FHI360, Population Council PANEL: Emmanuel Njeuhmeli, USAID/Washington and Susan Kasedde, UNICEF (co-chairs); Karin Hatzold, PSI; Timothy Mastro, FHI360; Erica SolerHampejsek, Population Council; Dino Rech, CHAPS; Mafuta Tshimanga, ZICHIRE; Rebeca Plank, Harvard University; Webster Mavhu, CESSHAR

New voluntary medical male circumcision (VMMC) devices have the potential to rapidly accelerate VMMC scale up by making the procedure faster, simpler and more acceptable. This session will provide updates from male circumcision device research and pilot implementation. Presentations from researchers from several African countries will discuss new advances and these advances’ potential impact on HIV-prevention programming. These will include presentations on the latest clinical profiles and acceptability of male circumcision devices in adult and early infant circumcision, as well as other VMMC-related operations research to increase efficiencies for rapid scale up.

how the potential for HIVST can be realized.

From Research to Practice to Impact: TUESDAY, JULY 22 Lessons and Tools Realizing the Potential TUESDAY, JULY 22 from the Voluntary HIV Self-Testing Can New Technologies for Medical Male HIV self-testing (HIVST) has huge potential to scale-up Circumcision Scale Up Improve Efficiency to HIV testing. This In 2007, WHO and UNAIDS in Voluntary Medical access session features research recommended countries developments and the launch Male Circumcision with high HIV prevalence and of an AIDS and Behavior special low male circumcision rates and Early Infant issue. The session will include add voluntary medical male a series of presentations on circumcision (VMMC) to their Male Circumcision opportunities and challenges HIV-prevention programScale Up? for HIVST and a discussion of ming. Subsequently, President Obama set a goal of 4.7 million PEPFAR-funded circumcisions by December 2013. Countries in the East and Southern Africa (ESA) region set ambitious scale-up goals and some 6 million men have been circumcised to date, with funding from ESA governments, PEPFAR and the Bill & Melinda Gates Foundation. This threepanel session will present tools developed and lessons learned during the accelerated scale-up of VMMC, including a presentation by PSI/Zimbabwe’s Karin Hatzold during a panel focused on the importance of partnerships and collaborations. DETAILS: 3:45-5:45pm, Room 104 HOSTS: JHPIEGO, MCHIP

DETAILS: 6:30-8:30pm, Rm 101-102 HOSTS: WHO PANEL: Rachel Baggaley, WHO, and Paul Semugoma, ANOVA Health Institute (co-chairs); Cheryl Johnson, WHO; Joseph Tucker, UNC School of Medicine; Nicola Desmond, LSHTM; Roger Peck, PATH; Annette Brown, 3ie; Margaret Zulu, SAT; Petra Stankard, PSI

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INTERNATIONAL AIDS CONFERENCE 2014:

PSI PRESENTATIONS

Biomedical Services in a Generalized Epidemic ➤ Safety and efficacy of the PrePex™ device for male circumcision performed by non-physician clinicians: A onearm, open-label prospective study among adult males in 3 urban settings in Zimbabwe LOCATION: Exhibition Hall,

Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE152 TYPE: Poster ➤ Safety and efficacy of the PrePex™ device for male circumcision performed by primary care nurses at primary health care level in Zimbabwe LOCATION: Exhibition Hall,

Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE149 TYPE: Poster ➤ Estimating the cost efficiency of introducing the PrePex™ circumcision device in Zambia CO-AUTHORED BY: PSI and CHAI LOCATION: Room 109-110 DATE: 7/25/2014 TIME: 11:00am-12:30pm TYPE: Oral

➤ Safety profile of PrePex™

➤ Lessons learned from

➤ Use of a unique identifier

male circumcision device in

integration of point of care

code system to track key

adolescents aged 13-17 years

CD4 cell count testing at PSI/

populations reached under

in Zimbabwe

Zimbabwe HIV testing and

a combination prevention

LOCATION: Exhibition Hall,

counseling sites

program in six countries of

Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE150 TYPE: Poster

LOCATION: Exhibition Hall,

Central America

Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE217 TYPE: Poster

LOCATION: Exhibition Hall, Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE458 TYPE: Poster

Key Population Size Estimation and Tracking

➤ Comparison of direct and

➤ Scaling up voluntary male medical circumcision through effective demand creation strategies in Malawi LOCATION: Exhibition Hall,

Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE330 TYPE: Poster ➤ Achieving scale-up through strategic capacity building and integration of voluntary medical male circumcision services in routine public healthcare delivery channels in Southern Province of Zambia LOCATION: Exhibition Hall,

Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE349 TYPE: Poster ➤ Predictors for uptake of voluntary medical male circumcision in Zimbabwe: Analysis using the adoption

➤ If you aren’t counted, you don’t count: Estimating the number of sex workers in Mandalay and Yangon, Myanmar LOCATION: Room 109-110

indirect methods for estimating the size of the female sex worker population in Addis Ababa, Ethiopia LOCATION: Exhibition Hall, Ground Level DATE: 7/24/2014 TIME: 12:30-2:30pm NUMBER: THPE117 TYPE: Poster

DATE: 7/23/2014 TIME: 1:00-2:00pm NUMBER: WEPDC0105 TYPE: Oral Poster Discussion

Female Sex Workers ➤ Gatekeepers’ influence

➤ Challenges and lessons

on female sex workers’ HIV

learnt in estimating the

prevention and service seeking

number of men who have sex

behaviors in Ethiopia

with men in Yangon, Myanmar

LOCATION: Exhibition Hall, Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE267 TYPE: Poster

LOCATION: Exhibition Hall,

Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE107 TYPE: Poster

stairway LOCATION: Exhibition Hall, Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE157 TYPE: Poster

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Men who have Sex with Men

➤ Prevalence of and factors

with female sex workers in

associated with HIV, Syphilis

Yangon and Mandalay

and HSV-2 among female

LOCATION: Plenary 2

sex workers: Findings from

DATE: 7/23/2014

a national biological and

TIME: 4:30-6:00pm

➤ The effectiveness of PSI

America

behavioral survey in Tanzania

NUMBER: WEAE0204

outreach activities among

LOCATION: Exhibition Hall,

TYPE: Oral

men who have sex with men

LOCATION: Exhibition Hall, Ground Level DATE: 7/24/2014 TIME: 12:30-2:30pm NUMBER: THPE142 TYPE: Poster

Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE138 TYPE: Poster

regarding condom use and HIV testing and counseling in

interventions effective? Impact

Central Asia

evaluation of combination

LOCATION: Exhibition Hall, Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE356 TYPE: Poster

condom use among female sex

risk behaviors among men who have sex with men and transgender women in Central

➤ Are combination prevention

prevention on increasing

➤ Social vulnerability and HIV

People Who Inject Drugs

➤ Social vulnerability predicts

workers in Central America

consistent condom-use

LOCATION: Plenary 2

among female sex workers

DATE: 7/24/2014

in Tanzania: Findings from

TIME: 2:30-4:00pm

the 2013 HIV Biological and

NUMBER: THAC0302

➤ Can a combination

➤ Assessing social marketing

Behavioral Survey in 7 regions

TYPE: Oral

prevention strategy reduce

of low dead space syringes in

HIV risks for men who have

Vietnam

➤ Knowledge, empowerment

sex with men? Evidence from

and positive social norms as

a quasi-experimental, mid-

drivers of consistent condom

term evaluation in Central

use among female sex workers

America

in 5 provinces of Angola

LOCATION: Exhibition Hall, Ground Level DATE: 7/24/2014 TIME: 12:30-2:30pm NUMBER: THPE143 TYPE: Poster

LOCATION: Exhibition Hall, Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE201 TYPE: Poster

LOCATION: Exhibition Hall,

Ground Level DATE: 7/24/2014 TIME: 12:30-2:30pm NUMBER: THPE116 TYPE: Poster

LOCATION: Exhibition Hall,

➤ Effectiveness of interpersonal communication activities and TV advertisements on HIV risk reduction behaviors among

Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE317 TYPE: Poster

female sex workers in 5

➤ Association between

provinces of Angola

➤ Geographic coverage of

exposure to social marketing

LOCATION: Plenary 2

comprehensive clinical services

and HIV prevention behaviors

DATE: 7/24/2014

for female sex workers in

among men who have sex with

TIME: 2:30-4:00pm

Ethiopia

men in Vietnam

NUMBER: THAC0304

LOCATION: Exhibition Hall,

TYPE: Oral

Ground Level DATE: 7/24/2014 TIME: 12:30-2:30pm NUMBER: THPE118 TYPE: Poster

LOCATION: Exhibition Hall, Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE202 TYPE: Poster

➤ Can community-based HIV prevention have a positive effect on HIV testing

➤ Factors associated with needle and syringe sharing in Vietnam LOCATION: Exhibition Hall, Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE117 TYPE: Poster

behavior? Findings from a quasi-experimental study

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INTERNATIONAL AIDS CONFERENCE 2014:

PSI PRESENTATIONS

Youth ➤ Expanding access to critical HIV and reproductive health services to low literacy youth in Liberia LOCATION: Exhibition Hall,

Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE354 TYPE: Poster ➤ Branding free condoms to

Biological and Behavioral

➤ Quality of care to key

➤ Could the definition of

Survey

populations by private health

comprehensive knowledge of

LOCATION: Exhibition Hall,

service providers in Central

HIV prevention be a possible

Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE216 TYPE: Poster

America

Stigma, Discrimination and Legal Context

increase acceptability and use among youth in Malawi

➤ Creating an enabling

LOCATION: Exhibition Hall,

environment for HIV

Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE287 TYPE: Poster

intervention: Lessons from

Gender-Based Violence and HIV

Police Action Committee on AIDS in Abuja LOCATION: Exhibition Hall,

Ground Level DATE: 7/21/2014 TIME: 12:30-2:30pm NUMBER: MOPE330 TYPE: Poster ➤ Prevalence and correlates

➤ Barriers and motivators to

of stigma and discrimination

accessing HIV post-exposure

index in Nigeria

prophylaxis services among

LOCATION: Exhibition Hall,

adult female survivors of

Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE258 TYPE: Poster

sexual violence in Zimbabwe: Mixed methods results LOCATION: Exhibition Hall,

Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE156 TYPE: Poster

➤ Effect of anti-stigma legislation on the level of stigma directed towards persons living with HIV in

➤ Prevalence and determinants

Nigeria

of physical and sexual violence

LOCATION: Plenary 3

among female sex workers

DATE: 7/22/2014

in Tanzania: Findings from

TIME: 11:00am-12:30pm

the 2013 National HIV/STI

NUMBER: TUAD0103

PRESENTED BY: IPPF/WHR with support from PSI/PASMO LOCATION: Exhibition Hall, Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE274 TYPE: Poster

barrier to the achievement of

Other Research of Interest

➤ HIV testing uptake, social

zero new infections? Evidence from Nigeria LOCATION: Exhibition Hall, Ground Level DATE: 7/24/2014 TIME: 12:30-2:30pm NUMBER: THPE209 TYPE: Poster

norms and condom use trends among adult men and women 15 to 49 years old in Zimbabwe

➤ Analysis of factors promoting use of sexual and reproductive health care services among most at risk populations: Evidence from a mystery client survey in Nigeria LOCATION: Exhibition Hall, Ground Level DATE: 7/22/2014 TIME: 12:30-2:30pm NUMBER: TUPE295 TYPE: Poster

LOCATION: Exhibition Hall, Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE156 TYPE: Poster

➤ Reducing on-going transmission risks among people living with HIV in Central America: Findings from an HIV combination prevention evaluation

➤ Factors associated with consistent condom use with non marital partners among truck drivers and their assistants in 5 provinces of Angola

LOCATION: Exhibition Hall, Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE158 TYPE: Poster

LOCATION: Exhibition Hall, Ground Level DATE: 7/23/2014 TIME: 12:30-2:30pm NUMBER: WEPE316 TYPE: Poster

TYPE: Oral

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▲ Noemi, a former sex worker and peer educator, teaches women in her community in Guatemala how to protect themselves from sexually transmitted infections and negotiate condom use with their male clients.

DEBT FREE

oemi’s life was marked by hardship from an early age. Her grandmother sent her away at 14. Shortly after, she became pregnant and had a son. She needed work to support herself and her child, so she moved from her small town in El Salvador to Guatemala City with the promise of a waitressing job. But that promise was a lie – she realized too late that she had been sold into the sex trade. She was forced to work to repay the “debt” owed for clothes and makeup the brothel owners forced her to wear. Initially, Noemi didn’t know her rights or how to protect herself, but she met peer educators from PASMO, PSI’s network member in Central America, and local partner organizations and learned how to prevent sexually transmitted infections (STIs) and negotiate condom use with clients. Armed with knowledge, Noemi started to volunteer as a peer educator and stopped practicing sex work. Now, she teaches women about HIV and STIs through games and one-on-one visits, offers HIV testing and counseling, and provides vouchers for free health services. Noemi is much more than an educator to the community she serves. PASMO and their partners gave her the knowledge and confidence to eventually exit the sex-work industry. Now she is debt free and paying it forward. n

psi.org | impact

ANTI-GAY LAWS, POLICIES AND HIV B Y D R. PA U L S E M U G O M A

“I

t is our way of fighting HIV!” The speaker, a member of Uganda’s Parliament, hurled those words into the crowded room. His tone defiant, he was looking directly at me. It was May 9, 2011; the Parliament building in Kampala. The occasion: a hearing on Uganda’s proposed Anti-Homosexuality Bill by the Committee on Legal and Parliamentary Affairs. A number of groups had attended to oppose the bill, which criminalized “homosexual touch,” punished “promotion of homosexuality,” criminalized renting housing to gay people. I was there with the Civil Society Coalition for Human Rights and Constitutional Law, discussing public health implications of HIV prevention and care, citing research from Uganda. Earlier, the Uganda Human Rights Commission had offered objections to the bill. Colleagues weighed in on legal grounds,

D R . PA U L S E M U G O M A is a medical doctor and advocate. He currently works with ANOVA Health Institute in South Africa on its Health4Men Programmes.

impact | No. 17

and UNAIDS Country Representative, Mr. Musa Bungudu, reminded everyone of Uganda’s huge HIV burden. I was nervous. Gay and Ugandan, I was not ‘out’ at the time. Mine was a professional presentation, but the subject was risky, the audience potentially hostile. I spoke directly to the Parliament member. “This bill is not an HIV-prevention measure,” I said. Despite the arguments that day, Parliament passed the bill. President Museveni signed it into law in February 2014. At the time, the health minister asserted there would be no discrimination in health care. Within two months, an HIV clinic run by an international research organization was raided. Police suspected it of “recruiting young men,” and “training them into homosexuality.” The organization’s stellar international reputation and world-class research didn’t matter. That Ugandans were receiving life-saving HIV treatment and volunteered for research didn’t matter. That relevant oversight bodies had cleared it didn’t matter. Police declared their research “unethical” and “a promotion of homosexuality.” Homosexuality is taboo in many countries. HIV has made us confront our tendency to keep sex and sexuality from public discourse. With friends, relatives, and neighbors dying, we needed to talk openly. Yet, increased visibility of socially marginalized populations has led to backlash. Some legislators are reacting with knee-jerk laws to keep these “un-African,” “Western” imports in check. Concerns for HIV are forgotten in a rush to ban and banish people not fitting the norm. Uganda has an estimated 1.2 million people living with HIV, half a million of them on treatment. Our health system is

in shambles, stock-outs of drugs common. Across southern Africa, generalized HIV epidemics have stabilized at high levels, hiding high rates of infections among gay men. In Senegal, where overall prevalence of HIV is less than 1 percent, prevalence among men who have sex with men (MSM) is over 20 percent. Communities are invisible. They are stigmatized, criminalized and punished by prison and death. Oppressive legal and social ramifications force MSM underground, un-reached and under-researched. In many places, programming for care and prevention is absent, or meager. But organizations, agencies and researchers must not give into complacency and fear. With dwindling resources, we need to prioritize what is available and use it effectively. We need to self-educate. It is not enough to be MSM-friendly. We need to know why MSM are a key population, why they need targeted HIV prevention and care, how they can be reached, and best practices. There are many African educational MSM resources available, free and online. They range from sexuality education, MSM sensitivity training, programming, and monitoring and evaluation. Health workers need MSM cultural competence, to appreciate the range of concerns of MSM clients. Knowledge enhances our effectiveness at advocacy, and advocacy is necessary even in the toughest environments. Research is crucial. Local epidemics need to be studied, quantified and understood. Yet, across Africa, this research is lacking. Anti-gay laws and policies make research harder, necessary permissions almost impossible to get and respondents harder to access. Targeted, prioritized funding is also necessary. Broad programming for heterosexual majorities doesn’t trickle down. Targeting key populations is both responsible and cost-effective because this is where the disease burden lies. In Uganda, the raided clinic re-opened with scaled-back services. MSM clients dispersed. In communities, a few outreach services are continuing muted. We are challenging the law in Constitutional Court, hoping to scale it back. We must not stop advocacy. Silence is death. n

SHARING HER TRUE IDENTITY B Y S I H A M A N O B A N N AV O N G , P S I/L A O S

orn a boy, Vongphachanh “Khom” Temmelath knew from an early age that she was different. Khom’s family worried that their small community in Vientiane, Laos, would judge them. Early on, they urged her to act more masculine, but she insisted this was her true identity. With time, they accepted her as a male-tofemale transgender, or katoey. Khom began wearing make-up in high school. By university,

▲ Khom (left) sits at a hotspot with a fellow peer educator.

she grew her hair long and wore women’s clothing. She was active on campus, organizing events and activities. But eventually, the discrimination from fellow students and faculty caused her to drop out. As a transgender person with no degree, she found it nearly impossible to find a job. Unemployed, she felt alone and adrift. Khom’s health was also at risk. HIV prevalence among the general population of Laos is 0.1 percent, but it is 5.6 percent among men who have sex with men, who include transgender individuals. In response, PSI/ Laos opened three New Friends Drop-in Centers in 2008 in the country’s largest urban areas. They provide a range of HIV and sexually transmitted infection (STI) prevention education and services, including free, anonymous rapid testing for HIV, for an estimated 6,000 transgender individuals and their partners. Khom found a sense of community at New Friends. She began mentoring youth who visit the center. “Before working at New Friends, Khom had heard of HIV and STIs, but fearing discrimination, she rarely saw a doctor and had never been tested. Now, she says of her work at New Friends: “I can protect myself and protect others.” n

psi.org | impact

policy matters

Experts hope to circumcise more 14 African countries to reduce

VOLUNTARY MEDICAL MALE CIRCUMCISION FOR HIV PREVENTION: Scale-up Progress in Priority Countries

NO TURNING BACK B Y K E V I N F I S H E R A N D C AT H E R I N E C O N N O R, C O -C H A I R S, G LO B A L A I D S P O L I C Y PA R T N E R S H I P

he 20th International AIDS Conference marks a pivotal moment in the fight to end the AIDS pandemic – one that captures both the promise and the challenge of the years to come. The past decade of financial and political commitment has resulted in a major expansion of access to HIV prevention and treatment services around the world. The public health impact of this commitment is both significant and unprecedented. Nevertheless, the gains are fragile and more must be done to reach everyone in need. Almost three years ago, the United States government revitalized its commitment to ending AIDS through the ambitious goal of reaching an AIDS-free generation. Bipartisan support for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria, continues to bring us closer to meeting this goal. Last year, President Obama announced that his target for supporting 6 million people on treatment by the end of 2013 was ahead of schedule. And Secretary of State John Kerry announced that

1 million babies globally have been born HIV-free thanks to PEPFAR support. PEPFAR has been instrumental also in one of the most impressive turnarounds in the global response to AIDS, providing access to voluntary medical male circumcision (VMMC). VMMC has been shown to reduce a man’s chances of acquiring HIV from a female partner by nearly two thirds. PEPFAR had supported 4.7 million circumcisions by the end of 2013. This support has been critical. Investments in the global AIDS response are working. In 2012, there were 2.3 million new HIV infections, the lowest number of annual new infections in almost a decade. Twenty-six countries have seen a 50 percent or greater drop in new HIV infections since 2001. Globally, new partnerships are emerging – 53 percent of all HIV-related spending in 2012 came from the governments of countries tackling the epidemic domestically. Costs of treatment have also decreased dramatically. In the mid-1990s first-line antiretroviral therapy was $10,000 per person per year. In some low- and middle-income countries today it is $140. Through this

ABOUT

The Global HIV Treatment Gap: Existing people on ART versus people eligible under past and current WHO guidelines AVAC Report 2013: Research & Reality; www.avac.org/report2013

impact | No. 17

The Global AIDS Policy Partnership is a coalition of over 70 U.S.-based advocacy and implementing organizations committed to expanding and improving global HIV and AIDS programming. Kevin Fisher is Policy director for AVAC: Global Advocacy for HIV Prevention, and Catherine Connor is director of Public Policy and Advocacy for the Elizabeth Glaser Pediatric AIDS Foundation.

than 80 percent of men in their risk of HIV infection

AVAC Report 2013: Research & Reality; www.avac.org/report2013

efficient use of resources and an increased investment, we stand poised to reach an important ‘tipping point’ in the fight against HIV and AIDS, in which the number of individuals receiving HIV treatment exceeds the number of new HIV infections.

Sadly, the challenges ahead of us remain daunting. To date, 16 million people in Africa who are eligible for antiretroviral therapy cannot access treatment. The treatment-eligible children living with HIV in sub-Saharan Africa are only about half as likely to receive antiretroviral therapy as HIV-positive adults. And though HIV rates are declining globally, rates for certain key populations appear to be rising in several regions. Yet international support for HIV efforts has remained flat or – as in the case of PEPFAR – dropped in recent years. Without expanded and sustained investment in cost-effective treatment and evidence-based prevention, there is a very real danger that we will reverse the prevention gains of the last decade. As Secretary Clinton said when she launched the US Blueprint for an AIDS Free Generation: “The goal of an AIDS-free generation may be ambitious, but it is possible with the knowledge and interventions we have right now.” It would be a great tragedy to miss that opportunity. Rather than fall behind, we must step up the pace and end this once and for all. We’ve come too far to turn back now. n

VOLUNTARY MEDICAL MALE CIRCUMCISION: Isaac Ishmael shares his experience in Malawi

eet Isaac Ishmael, a 28-year-old electrician who recently underwent VMMC. One day in late Spring, Isaac saw a group of people on the road near Waterguard, a small trading center in the Mpemba area of Malawi’s southern state of Blantyre, named after a nearby billboard that advertises water safety products. Curiosity got the best of him, and he joined the group to find his fellow community members talking to others about VMMC. These ‘mobilizers’ are trained by PSI/Malawi to provide information and referrals to high-quality VMMC services. PSI runs these programs in 10 countries in sub-Saharan Africa, equipping front-line educators who often partner with local celebrities to answer questions about VMMC. With a steady partner to whom he is engaged to marry in October, Isaac had questions and concerns about the procedure. He had heard about VMMC, but wasn’t quite convinced. Isaac found the PSI mobilizers to be knowledgeable: They shared the benefits of VMMC, information about the stages of the procedure, reassurance about the quality and location of services, and details about recovery. Isaac felt more confident after the discussion, and was inspired by the number of Isaac Ishmael talks with a other men in his community who planned to undergo PSI health provider in Malawi the procedure. before he undergoes voluntary Isaac talked it through with his fiancé. Together medical male circumcision. they decided he would have the procedure. VMMC provides partial protection from HIV for Isaac and reduces his fiancé’s risk of cervical cancer. After the successful procedure, Isaac convinced four of his friends to do the same and took them to the clinic. Beyond the immediate health benefits, the experience has challenged Isaac to see and think differently. “It changed the way I see the future,” he says, “because I feel I acted like a modern man, thinking not only about my future but also my partner’s future.” n

psi.org | impact

P’boy conducts a peer education session at the O-zone Drop-in Center in Bangkok.

LOST AND FOUND

ife was not always as it is now. Stable and happy. There were 15 years when P’boy was lost, injecting drugs nearly every day with unsterlized needles he kept in the fold under a roof or somewhere near a pile of garbage. These were lost years. Now, he is a peer educator at PSI/Thailand’s O-zone Drop-in Center in Bangkok. O-zone is a branded network of centers that provides people who inject drugs with health services, information, clean injecting equipment and condoms. It was by chance that he joined a friend for an activity at the center, and later he applied to volunteer. In 2006, he was offered a job, trained and given a chance to help others. Every day he visits neighborhoods he knows from a past life to talk to fellow drug users about ways to protect themselves. “I used to have another lifestyle,” said P’boy. “I was arrested 27 times with charges on thievery and drug use. But I was able to change all these things, because I had a chance to help other people.” n

impact | No. 17

final word

Karl Hofmann PSI President and CEO

WE CANNOT SEPARATE HEALTH FROM RIGHTS

▼ Karl Hofmann talks with a shopkeeper in Burundi.

ne of the beauties of PSI’s single-minded focus on health outcomes and measurable results has been our ability over many decades now to avoid getting entangled in the politics that sometimes accompanies foreign assistance. Yes, our work in family planning and reproductive health creates its share of controversies in some places. And the fight against HIV and AIDS, with which we’ve been associated since the 1980s, is certainly not without its conflicts. But by being focused on health, we’ve been able to develop programs of national scale and impact even in locations where other forms of international engagement and assistance have been rejected. Zimbabwe. Myanmar. Cuba. ‘We’re not a rights organization – we’re a health organization.’ For many years we’ve pretended that this was a distinction that mattered, and one that allowed us to

keep working even where others weren’t allowed to. The reality is, of course, it’s impossible to separate health from rights, and it’s foolish to pretend that one is possible without the other. This is now more obvious than ever in the context of HIV, where our continued progress hinges on effectively reaching with prevention, care, treatment and advocacy those key populations whose rights are most at risk. Offensive legislation in Uganda and Nigeria echoes the many ways, formal and informal, that stigma and discrimination have helped to propel the virus we’ve spent so much time and energy fighting, whether in Africa or America or anywhere. We can’t legislate our way out of HIV and AIDS. We’re a health organization that cannot achieve its mission without advancing the rights of those we seek to serve. Appreciating the connection between rights and progress – particularly in the context of HIV and AIDS – has been part of PSI’s own maturation. n

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