Last week the High Level Meeting on HIV/AIDS took place in New York, in which the Member States of the United Nations adopted (not without controversy) a new Political Declaration on HIV and AIDS that, according to UNAIDS, it is ambitious and achievable, aiming to end inequalities and be in a position to end AIDS by 2030.
To find out what happened there and analyze the situation of the pandemic globally and also in Spain, we spoke with Ramón Espacio, president of CESIDA, the state coordinator for HIV.
First of all… How are you feeling after the end of the High-Level Meeting on HIV? Is the Political Declaration that came out of it convincing? Does it include the items sought by civil society?
There are some highs as well as lows to the Declaration; however, this year was generally a bit of a disappointment. For the first time ever, there was no consensus for the Political Declaration. The vote was forced by the Russian Federation which proposed many amendments to the text, almost entirely. In addition to Russia, three other countries voted against it: Nicaragua, Belarus and Syria. It passed in the end, but with a much lighter tone than the first draft which was much more ambitious. Some areas were watered down or even deleted from all the texts in the Declaration referring to sexual and reproductive rights, sex education, harm reduction, rights and decriminalization as well as the necessary legal changes. The same occurred with measures included in the TRIPS on access to innovation and medicines. There was even some resistance to naming key populations as we had called for as civil society representatives, yet they included them in the end.
As far as the highs… For the first time ever, this Declaration includes specific commitments and measurable targets such as the 10-10-10 targets which aim to ensure by 2025 that the number of women, girls and people living with HIV experiencing gender-based inequalities and sexual violence is no more than 10%; there are 10% less countries with restrictive policies on access to services; and that there are 10% less people with HIV suffering from stigma. The 95-95-95 targets from the Global HIV Strategy were also included and there’s a commitment to increasing financing to reach 29 billion dollars by 2025.
Following the 2016 High-Level Meeting, the international community has spent 5 years consistently failing to meet the goals for prevention, diagnosis, treatment and financing established and, thus, endangering the end to AIDS as a public health problem by 2030. Do you think it will be different this time, especially considering the focus on COVID-19? Will we be able to reach that goal?
Unfortunately, the 90-90-90 targets for 2020 were not met. It’s difficult to meet them and I don’t believe we’ll end HIV as a global public health problem by 2030. Right now, we’re seeing the problem with COVID-19 vaccines as far as access, the implementation of measures on Intellectual Property Agreements, etc. The good thing is that we continue insisting upon it all… there continue to be events like this High-Level Meeting, there’s a certain level of commitment and we can see how some countries -especially in Africa as well as some areas of the Caribbean, Central Asia and Eastern Europe- have made a lot of progress towards these global targets. But it’s difficult. I highly doubt we’ll achieve them worldwide.
In 2019, the key populations and their partners accounted for 63% of all new HIV infections. We’re talking about female sex workers, gay and bisexual men and other men who have sex with men, transgender people, people who inject drugs and prisoners and other incarcerated people. Will it be possible to end HIV as a public health problem when there continues to be stigma surrounding these populations and their human rights continue to be denied in so many countries?
No, of course not. You can’t work with drug users when you’re criminalizing the use of drugs. You can’t work with the LGBTI population when you’re criminalizing them. It’s impossible. And that’s where this Political Declaration came up short. There are countries where the death penalty continues to be enforced for people with sexual identity issues. Progress has been made and some countries are decriminalizing these things, such as Angola; however, we’re never going to meet the goal of eradicating HIV as a health problem if there is no progress in the area of human rights.
A few months ago, the Global Fund released some very worrisome data in the fight against other pandemics in the era of COVID-19, saying that testing to diagnose HIV had dropped 41% in African and Asian low-income countries. The incidence is expected to rise in the coming months. Will COVID-19 lead to an increase in AIDS deaths, thus rolling back all these years of progress?
This was precisely one of the topics most heavily discussed at the HLM. Just imagine: If we’re expecting it to have an impact in Spain due to the problem of access to early testing during the first few months of the lockdown, the impact is and will be immense in developing countries. And the worst thing about it is the vaccines aren’t getting where they need to be and if we can’t get them to those countries, they’re going to have an ongoing crisis with a brutal impact on HIV, tuberculosis, resources, laboratories, testing, treatments, healthcare centres…
Going back to Spain and COVID-19… Last year during the lockdown, you all denounced the situation facing the most vulnerable populations with the lack of assistance and how the problem was affecting the healthcare being received by people with HIV and, in general, the resources that were available for people’s sexual health. How has that situation evolved over these past months?
The lockdown had a brutal impact on everything and even more so on vulnerable populations because, in the end, they’re always the ones most affected by any crisis. CESIDA organizations worked to connect people with the healthcare system, offering assistance with basic resources for sex workers, trans people, recently-arrived migrants… Cases were gradually resolved and all the obstacles were cleared little by little in order to get treatment for people without public health insurance cards, for example. There were no face-to-face appointments for months yet the infectious disease units went to great lengths to assist people remotely. The greatest impact was not on HIV-related care in and of itself as the monitoring is rather simple; it was really on co-morbidities .
And what happened to all the people without public health insurance cards as far as their healthcare? CESIDA has truly insisted on the need for universal healthcare access.
And we continue to do so. What CESIDA organizations are doing is getting appointments and care for undocumented migrants and those who need treatment. But the ease of getting that care or lack thereof really depends on each individual autonomous region. That’s why we continue saying that a national law guaranteeing universal healthcare access is necessary: a law that truly guarantees cover for all the shortcomings in Spanish Royal Decree Law 16/2018. There continue to be problems with people who have come through family regrouping processes because their children live in Spain. In fact, we’re now waiting to see what’s going to happen with COVID-19 vaccines for people in irregular situations, including this group of people. In general, however, we’re seeing a certain will to find solutions to these cases. For example, we’ve been able to resolve cases of people with HIV who were blocked because they came as tourists and could not leave and thus ran out of medication and were given medication for one month in the hospitals. But I have no idea what ever happened to all the people who did not seek help from an NGO. We’ll never know.
What is the status of the fight against AIDS in Spain right now? As far as policy, financing, etc. What are the demands from Spanish civil society?
In Spain, there has been progress in the response to HIV which was obviously affected by the pandemic. As far as prevention and early testing, the most significant progress came with the approval of Pre-exposure prophylaxis (PrEP), yet the implementation has been delayed and there is a need for investment. There are many autonomous regions where nothing has yet been done and others where there just aren’t enough resources not to mention huge waiting lists like in Madrid and Barcelona. Another measure that was approved was the inclusion of Affective Sexual Education in the new national Education Law, but it needs to be implemented. The attention given to HIV and to sexual health and other sexually transmitted diseases (STDs) in the various autonomous regions is quite deficient. We still don’t have a clear strategy and there just aren’t many resources for STDs. For example, easy-access clinics which sometimes work by respecting people’s anonymity is one model that works very well; however, depending on the autonomous region, they’re often saturated or simply don’t exist. There need to be many changes in order for this to become a part of primary healthcare as is intended. And it’s essential to eradicating HIV and other STDs because early testing and immediate treatment are fundamental to cutting the chain of transmission.
We’ve seen progress on issues related to stigma and discrimination with the Social Pact and the Council of Ministers Resolution for Public Service. Yet changing the regulatory framework just isn’t enough: it has to be applied. One important issue that keeps popping up is the lack of access to insurance for people with HIV. We’ve had a regulation in place since 2018, but they’re hardly ever approved. And this is where we can see stigma still exists. And the financing available to community organizations continues to be scarce. The Spanish National AIDS Plan must be strengthened with material and human resources and we need a more specific strategy for vulnerable populations which again depends on the autonomous regions in many cases.
With respect to the role of Government in the international fight against the pandemic, Spain not so long ago re-joined the Global Fund with 100 million. It’s been making good on its commitments and has also contributed more money during the pandemic. Is this enough or should it do more over the next few years?
I think we all see this as a positive step. Spain had stayed outside the Global Fund since 2011 and was disappearing from all international forums. Now, there’s a will to get back in. The Spanish National AIDS Plan has re-connected with UNAIDS, Spain has gotten back to the table and it can offer experience with the best practices we have here. It’s something that should never have been allowed to happen.
5th June marked 40 years since the first clinical description of the cases that were later known as acquired immunodeficiency syndrome (AIDS). It’s estimated that nearly 40 million people have died from AIDS around the world. Some 38 million are now living with HIV and nearly a million people continue to be infected each year with 700,000 dying each year. Even after so many years, there’s still no effective vaccine to prevent it. In the meantime, in just under a year and half, we’ve seen the impressive development of vaccines, testing and tools for a whole new pandemic with unprecedented public investment from the most developed countries. Does it seem like some diseases are more important than others? Or are the clinical complexities of HIV truly the problem in finding a successful vaccine?
It’s a mix of the two. They’re obviously two very different diseases. HIV is a much more difficult virus; there have been many attempts at producing a vaccine but, at the same time, a lot less has been invested. It’s clear that if HIV had caused such an impact on developed countries as COVID-19 has and there was a prevalence of HIV as has been and continues to be seen in African and Sub-Saharan countries, a whole lot more would have probably been invested. It’s really a combination of both factors. Right now, there’s a lot of hope with the new Janssen vaccine being developed. The trials are already in phase 3. Hopefully, they’ll find it soon and hopefully when it is found, it will get where it needs to go. This vaccine has to be for Africa and for vulnerable populations.
In spite of everything… Are there any lessons to be learnt from this public health crisis in a view to improving access to HIV treatments, testing and prevention? Can it be a challenge as well as an opportunity?
What is now evident is that we can all be vulnerable. Whether or not we’re capable of applying any of the lessons… only time will tell. What is clear is that what’s been learnt and developed in order to deal with HIV has really made many things easier with COVID-19 as far as infrastructures, laboratories for virus loads and tests, the networks and capabilities of community organizations in supporting vulnerable populations… it was all helpful. COVID-19 has highlighted the need to reinforce our systems and invest globally because we’re either all doing well or no one will.