Whenever AIDS has won, stigma, shame, distrust, discrimination and apathy was on its side. Every time AIDS has been defeated, it has been because of trust, openness, dialogue between individuals and communities, family support, human solidarity, and the human perseverance to find new paths and solutions.
If we don't leverage the power of innovation to transform how health services are provided and utilized, efforts to stop new HIV infections and AIDS-related deaths can reach a stalemate. Many of the advances in HIV prevention and treatment have come through innovation and applying knowledge in new ways. Today, male circumcision is not just a cultural practice, but a potentially lifesaving health procedure that protects men against HIV.
At the start of the HIV epidemic, women living with HIV had no way of reducing the risk of transmitting HIV to their unborn child. The introduction of antiretroviral therapy for people living with HIV showed that the immune system was bolstered and HIV viral loads came down. This knowledge was applied to give pregnant women an opportunity to protect their newborns from becoming infected with HIV. Now the same knowledge has been proven to stop new HIV infections among sexually active people.
Couples in discordant relationships -- where one partner has HIV and the other does not -- can dramatically reduce the risk of HIV transmission if the partner with HIV takes antiretroviral treatment. In fact, the risk of passing on the infection can be reduced to below 5 percent. New guidance released by the World Health Organization (WHO), "Couples HIV testing and counselling, including antiretroviral therapy for treatment and prevention in serodiscordant couples," is a significant step forward in this area. WHO now recommends that antiretroviral therapy be offered to HIV-positive people in discordant relationships even when they do not require it for their own health.
Unfortunately, about half of people living with HIV still do not know they have the virus. This is where couples can make a difference. It starts with couples knowing their HIV status -- together. Many people who know their HIV status do not disclose it to their partners or healthcare providers for fear of stigma and discrimination. This has to change. Couples need to be able to discuss their HIV status with the confidence that they will be supported by their partners, families and by society. They need to know they won't be met with shame and stigma.
Studies show that nearly half of people living with HIV who are in a long-term sexual relationship have an HIV-negative partner. Gender-wise, the split is 50-50. Half of the infected partners are male and the other half female. Data also shows a large proportion of new HIV infections come from HIV transmission within established couples and not from one-night stands -- a common misconception.
In China, three-quarters of HIV infections in couples attending pre-marital counselling and testing were diagnosed in serodiscordant couples. In countries with a low HIV prevalence, nearly 75 percent of partnerships with HIV infection have only one partner living with HIV. And in countries with high HIV prevalence, up to three out of 10 people living with HIV were in a stable sexual relationship with a partner who did not have HIV. A study conducted across 14 sites in eastern and southern Africa showed that the source of the HIV infection could be traced to the long-term sexual partner in 64 percent of the cases.
For the AIDS response, couples testing and counselling should be one more turning point to expand options to strengthen the impact of HIV prevention and treatment. Modelling from Zambia and Rwanda show that by providing HIV testing and counselling for couples together, the rate of new infections among serodiscordant couples can be reduced from 20 percent to 7 percent in Zambia and 3 percent in Rwanda. Regardless of who is infected, if the infected partner is on antiretroviral treatment, he or she will protect their partner and their children from HIV infection at the same time.
Couples need to talk with each other. By choosing to start antiretroviral treatment, even when they do not need it for their own health, the partner with HIV can protect their partner. Access to antiretroviral therapy can become a vital entry point for enabling discussion -- including disclosure of HIV status and removing the fear and stigma associated with HIV transmission.
Of course, couples can also choose to use condoms, which remain the most cost-efficient option and also stops other sexually transmitted infections and unwanted pregnancies. Both options -- condoms and antiretroviral medicines -- need to be used consistently and couples will need each other's support.
The power of couples to make a difference is immense. By providing couples with the option to test together and access antiretroviral treatment for prevention purposes, UNAIDS estimates that about an additional four million couples can be given this life-saving option. This potential must be unleashed. It will make a difference to their lives and that of their children. It will take us one more step forward in our quest for zero new HIV infections, zero discrimination and zero AIDS-related deaths.
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"Guidance on couples HIV testing and counselling including antiretroviral therapy for treatment and prevention in serodiscordant couples: recommendations for a public health approach." World Health Organization HIV/AIDS Programme. April 2012. [link]