The inclusion of all populations

I wanted to celebrate with colleagues and friends the enormous progress we have made in responding to the epidemic.
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Last week´s United Nations General Assembly (UNGA) High Level Meeting (HLM) on Ending AIDS in New York was both inspiring and painful. The exclusion of civil society organizations was profoundly wrong - but the commitment of so many great activists, scientists and political leaders was so heartening. The Political Resolution, which finally emerged was weak on inclusion, and arguably a setback for our global efforts to end AIDS. But then, Ambassador Debbie Birx, the United States President's Emergency Plan for AIDS Relief (PEPFAR) lead, announced US$ 100 million for a Key Populations Investment Fund, giving renewed hope to the fight for full inclusion of LGBT, sex workers, and people who inject drugs in the HIV response.

I wanted to celebrate with colleagues and friends the enormous progress we have made in responding to the epidemic. Some 17 million people are now on antiretroviral treatment (ART) and some 80% of those people live in sub-Saharan Africa. Two decades ago people said it just could not be done but as we know events at the International AIDS Conference in Durban, South Africa in 2000 largely changed all that, and it will indeed be a source of pride to many who attend the conference on its return to Durban in a month´s time to reflect on just how far we have come. But there is still a long way to go.

Although the new UNAIDS data released this month demonstrated the progress we have made, there is indeed a flip side, that I, and many of my colleagues have long been arguing: unless we address the acute prevention, treatment and care needs of key populations, including men who have sex with men (MSM), sex workers, people who inject drugs, and transgender people, we will miss this current window of opportunity to end the epidemic once and for all.

In my mind, key populations are defined by two connected factors - communities facing elevated risk of HIV due to living a vicious circle of a high burden of HIV, which is exacerbated by denial of services based on social factors and discrimination by their country. Currently, key populations account for 52% of new infections worldwide, and 62% of infections in the United States occur in the MSM community. Transgender people are 49 times more likely to be living with HIV than the general population, and sex workers and people who inject drugs face similar risks. Exclusion of these communities to health services goes against the basic principles of human rights and hinder a strong public health response.

This is not me just saying that - it is a scientific statement, backed by evidence. We have seen a measurable increase in viral load among MSM in Nigeria after the passage of an anti-LGBT law there. In much of the same way, we have also seen decreases in testing uptake in countries where criminalized sexual preferences or drug use behaviours have driven communities underground, making it harder for outreach workers to get services to those communities most vulnerable.

In countries like Russia, the intimidation of civil society, and subsequent withdrawal from the country of some, is making service provision untenable there. A dramatic lack of harm reduction services, such as clean needle exchange provisions together with the banning of opioid substitution therapy like methadone, is fueling an expanding epidemic in Russia - directly attributing to over one million people infected with HIV and is now the fastest growing HIV/AIDS epidemic in the world.

The HIV response was built on the engagement and inclusion of a strong, diverse community working towards a common goal. The exclusion by some member states of the LGBT community at the HLM goes against the very principles that the AIDS response is built upon. That is why it was so painful for many of us, as it was harmful to those much lauded public health efforts that we were all gathered in New York to both celebrate and mobilize. Without the inclusion of all stakeholders, including key populations, we will never be able to finish the job.

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