Ending HIV Transmission: What Babies Have Taught Us

The 90% reduction in HIV transmissions to infants is one of the greatest public health success stories in recent history, made possible by advances in HIV medications. Success toward ending all HIV transmission is possible if we put recent discoveries to work on a massive scale.
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Co-authored by Robert Grant

Members of CDC's Elimination of Mother to Child Transmission of HIV Stakeholder's hold hands as a message of collaboration and solidarity.

Recent advances in HIV science have brought a new bold possibility: Ending sexual HIV transmission. Both the city of San Francisco and New York State have launched ambitious "Getting to Zero" and "Ending HIV" initiatives that have served as cornerstones goals to significantly reduce HIV transmission. Other cities and states are discussing their own local initiatives. Success toward ending all HIV transmission is possible if we put recent discoveries to work on a massive scale. Why do we think this is possible? In a new article published in the Journal of the Association of Nurses in AIDS Care, we suggest how lessons learned from preventing HIV infection in babies show us the way.

Celebrating success, toward new possibility. In 1991, during the peak of the HIV/AIDS epidemic, 1650 babies were born with HIV in the United States. By 2010, that number had declined to 162. This 90% reduction in HIV transmissions to infants is one of the greatest public health success stories in recent history, made possible by advances in HIV medications, which provide treatment for the mother and prevention for her infant. Though the numbers of women living with HIV who give birth each year continue to rise, the numbers of infants born with HIV continue to decline. Vital work remains to maintain these successes and achieve the elimination pediatric HIV infections. What have years of reducing HIV transmissions to infants taught us about ending all HIV transmission?

Whole people with sexual and reproductive desires. Today, 50,000 new HIV infections occur each year in the U.S. - the vast majority from sex. Initial approaches to curbing infant HIV infections focused on the transmission from the mother to her infant, not on the women's overall health or life experience. In time, this focus shifted from the womb to a broad view of supporting women in living fulfilling lives and achieving their natural reproductive and life goals. Expanding our current view of HIV transmission would shift our language to a framework of sexual and reproductive wellness, not just an absence of disease or the use of condoms. This reframing of the conversation requires recognizing sexual and reproductive desires and sexual fulfillment as goals worthy of support. This is not just about the science of eliminating sexual HIV transmission, it is also about fostering sexual health, engaging with people, and leveraging our shared motivations to lead satisfying sexual lives.

Champions and change-makers are everywhere. Local and national change-makers emerged to create the initiative needed to decrease the numbers of babies born with HIV. Local heroes worked beyond grant objectives, their job descriptions, and their budgets. Champions can create individual and systems change and are found in unexpected places - the front desk receptionist, a physician, a lab technician, a social worker, a patient, and their friends. Champions for ending sexual HIV transmission are emerging, and are welcome regardless of social position or level of education. As with other innovations, the first followers, have a key role in transforming a good idea into a social movement. Celebrate champions, welcome them as pioneers, and follow them.

Creating a compelling story. Saving infants from HIV infection is a compelling story. Pediatric HIV infections continue to occur at an unacceptable rate, highlighting how the last mile is sometimes the most difficult and sustaining enthusiasm until the goal is reached is a challenge. Rising to this challenge calls for a broader scope. We now have the possibility of ending sexual HIV transmission - itself a compelling story. Although sex and sexuality are, at times, ensnared in stigma and suspicion, we can collectively reframe the story to be one about our shared desires for human connection.

What can we do together? We could speak with each other kindly, using inclusive words. President Nelson Mandela spoke about the importance of words amidst turmoil and possibility at the 2000 International AIDS Conference in Durban, South Africa.

It is never my custom to use words lightly. If twenty-seven years in prison have done anything to us, it was to use the silence of solitude to make us understand how precious words are and how real speech is in its impact upon the way people live or die.

Stigma about HIV and sex divides us. Such stigma is embedded in our language, however kind or charitable our intent. Talk of "their need for services" instead of "our desires," and "risk behavior" instead of "sex" is rooted in the notion of a reasonable and responsible us who are trying to care for a needy and dangerous them. This notion is the essence of stigma no matter how well intentioned. No one wants to be "targeted for high impact interventions." A new, more gentle and inclusive lexicon could begin to heal the divisions between us and carry us further in our mutual efforts to end HIV transmission. It is time to change the story from one of risk reduction to one of possibility.

Robert Grant is Chief Medical Officer at the San Francisco AIDS Foundation, the Betty Jean and Hiro Ogawa Investigator at the Gladstone Institutes, and a Professor of Medicine at the University of California, San Francisco (UCSF).

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