Including sex workers, drug users and MSM in prevention and treatment

Fabulous plenary session in more way than one this morning. The first three speakers spoke passionately about the inclusion of marginalised populations in the response to HIV, reminding us that strategies that are developed without the full participation of affected communities are likely to fail.

Dr Paul Semugoma from Uganda highlighted how many countries are failing to provide adequate access to prevention and care for men who have sex with men, resulting in higher rates of HIV among most MSM populations, particularly in the developing world. Prejudice and homophobia remain major barriers to effectively working with MSM, and Semugoma argued we need to "fight stigma with data" to counter misinformation. Dr Semugoma argued that donors should insist that countries' HIV strategies address MSM and paid tribute to activists who have suffered and died trying to achieve rights for MSM, including the late David Kato.

Cheryl Overs (Monash), founder of the Global Network of Sex Work Projects, sounded a warning note about rolling out new prevention and testing technologies without adequate consultation with and protections for sex workers. She suggested that developments such as PrEP and rapid testing could be used to coerce sex workers into having unprotected sex, with the industry seeing a market opportunity to use new technologies to sell unprotected sex. Overs reminded the conference, to much applause, that although the US decision's to allow entry of HIV-positive people into the country is long overdue and welcome, people who admit to being current sex workers or injecting drug users remain barred from entry. This means that the conference is failing to represent affected populations, undermining the response.

This criticism, summed up in the slogan, "No drug users? No sex workers? No International AIDS Conference", was taken up by Debbie McMillan. As McMillan put it, as an African American transgender woman, former drug user and sex worker who has been incarcerated, her chances of avoiding HIV were slim - but that does not mean she could not or cannot address HIV, which she now does as a counsellor. McMillan criticised the continuing US ban on federal funding for needle and syringe programs, despite the overwhelming research showing their beneficial effects - as she put it, "I don't need the research to know this is true." Debbie's testimony of growing up in poverty, wrestling with her sexual identity, doing sex work, becoming drug addicted and being incarcerated was powerful, and starkly illustrated the inequities faced by many in the US. McMillan spoke convincingly about the value of non-judgmental drug treatment programs, specifically designed for LGBT people, that helped her manage her addiction, come to terms with being a transgender woman, and fire her enthusiasm for activism.

The final speaker, Gottfried Hirnschall (WHO), gave an overview of the achievements to date in promoting global treatment access for HIV, suggesting that while current targets are aiming for 15 million people on ART by 2015, we need to start thinking about bigger and bolder targets. Acknowledging the previous speakers, he noted the huge disparities in roll-out and access, particularly among stigmatised groups. For example, it is estimated globally no more than 10% of HIV-positive IDU have access to treatment. Hirnschall went on to discuss another hot topic - treatment guidelines and when to initiate treatment. He noted that even a compromise guideline to initiate treatment at ≤350CD4 with treatment as prevention for people in discordant couples (for example) would include 23 million people globally - which is why scale-up needs to be considered now. Hirnschall noted that none of this will work without universal access to HIV testing, and that it has become vital to broaden access to testing. He referred the audience to the WHO's new strategic policy framework for HIV testing and counselling, released today (download here). The framework emphasises that all countries trying to boost uptake of testing need to consider a range of approaches in addition to clinic-based testing, most notably community-based testing and self-testing. I think this framework will be a valuable tool as we plan for Australia to offer rapid testing in a range of settings, and consider the merits and risks of home-based testing.