Op-ed: A Closer Look at Hillary Clinton's AIDS Strategy

Secretary of State Hillary Clinton made a landmark speech on Tuesday declaring a new direction in the U.S. response to the global AIDS epidemic.  Citing a number of recent studies on the efficacy of different biomedical approaches for preventing HIV, Clinton announced that an HIV-free generation is now within reach. 

“While the finish line is not yet in sight,” she said, “we know we can get there, because we know the route we need to take.”

The new U.S. commitment to an “HIV-Free Generation” — and the accompanying three-point action strategy centered around prevention of mother-to-child transmission, medical male circumcision, and treatment-as-prevention — represents one of the first attempts to translate this new HIV prevention science into a broad-scale policy priority.

It remains unclear, however, exactly how this new strategy will impact epidemics among gay men and other men who have sex with men, as well as other key populations like transgender people, sex workers and people who use drugs.  In fact, the speech hardly mentioned them at all.

Global epidemiological data paints a clear picture of where the epidemic is concentrated.  HIV prevalence rates among these key populations are higher than those of the general population in nearly every country that accurately collects and reports this data, including countries with generalized epidemics such as those in Sub-Saharan Africa. 

HIV prevalence rates among MSM are skyrocketing around the world, surpassing 20% in countries as diverse as Jamaica, Mexico, Myanmar and Zambia, and infection rates of more than 70% have been observed in some transgender communities.  UNAIDS currently estimates that people who use drugs account for 80% of all HIV infections in Eastern Europe and Central Asia, and in parts of Africa, sex workers and their clients are believed to make up as much as half of all infections. 

It is unfortunate that Clinton, herself a powerful ally who has championed LGBT rights as human rights, failed to discuss the new strategy in relation to MSM or any other key population. This omission was not lost on those of us who understand and bear witness to the disproportionate HIV disease burden being shouldered by key populations around the world. 

Any viable global AIDS strategy must take into account the needs of key affected populations if it is going to effectively reduce HIV burden.  Even the most promising evidence-based intervention cannot succeed if it neglects the social, legal and structural barriers faced by key populations.

Despite the fact that the virus was first discovered in gay men over 30 years ago and continues to have an extreme impact on this population, fewer than one in 10 MSM are reached by HIV prevention programs worldwide today.  Fewer than 40 out of 184 countries report to UNAIDS that they have national targets for HIV program coverage for MSM, and less than 2% of international funding for HIV is targeted to MSM.  Moreover, 78 countries still criminalize homosexuality.

Without explicitly targeting MSM and other key populations, it is unlikely that any new strategy to address the global AIDS epidemic will make a dent in these figures.  Stigma and discrimination remain high around the world, driving MSM and other key populations away from life-saving prevention and treatment services offered to the general population.  A recent survey of more than 5,000 MSM worldwide showed that, among all variables, the strongest predictor of compromised access to HIV prevention services was the level of homophobia experienced by participants.

Stigma, discrimination, and criminalization are extremely important and complicated issues; they cannot be an afterthought.  While biomedical approaches may present useful new tools in the fight against HIV, we cannot use them as an excuse to skirt the hard work of addressing the social, legal and structural barriers that have prevented gay men and other key populations from accessing services since the beginning of the epidemic.

Earlier this year, the President’s Emergency Plan for AIDS Relief (PEPFAR) issued technical guidance on combination HIV with MSM, one of the first documents of its kind.  The U.S. State Department has also been a powerful force in the fight for LGBT rights abroad.  This work is commendable and must be continued as the United States begins to roll out its new global AIDS strategy.

The new AIDS strategy must be targeted and tailored to the specific needs of communities most affected by HIV.  To accomplish this, we must be able to openly name and respectfully engage those communities.  All eyes now turn to President Obama to lend his support to reinforcing U.S. commitments to the global HIV response, especially in the lead up to next July’s International AIDS Conference in Washington D.C. 

The conference returns to U.S. soil for the first time since 1990, bringing with it 20,000 delegates and the expectations of millions.  This presents a vital opportunity for the president to take leadership in directly addressing the needs of those most impacted by HIV and AIDS, including MSM, both in the U.S. and around the world.

GEORGE AYALA is executive officer of the Global Forum on MSM & HIV (MSMGF) www.msmgf.org