Addressing Human Rights Is Central to U.S. Leadership on Global HIV
November 30, 2018
World AIDS Day 2018, marked annually on December 1, brings with it increased urgency to accelerate progress toward the 2020 deadline to dramatically reduce new HIV infections, eliminate stigma and discrimination, and increase the numbers of people on anti-retroviral treatment (ART). However, we are off track to achieve the 2020 goals globally and at risk that the pandemic will resurge out of control. There is a crisis of prevention hindered by infringement on human rights that challenges our ability to reach many with services and bring down the new infection rate. At the same time, U.S. government leadership on these underlying human rights issues has eroded. To be successful before the 2020 deadline, the Trump administration and Congress will need to directly address the human rights issues affecting global HIV, which will help sustain its leadership position heading into the United States hosting the International AIDS Conference in July 2020.
It has been four years since the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched its Fast Track goals on World AIDS Day 2014. Modeling at the time demonstrated that the world had a limited window—just five years—to accelerate prevention and treatment progress to keep the pandemic from spinning out of control. Many are familiar with the most famous of the Fast Track goals—the 90-90-90 goal to get 90 percent of those living with HIV tested and knowledgeable of their status, 90 percent who know they are living with the virus on ART, and 90 percent of those on ART virally suppressed. Fewer are familiar with the other two goals to reduce new infections to 500,000 per year and eliminate stigma and discrimination.
The biannual International AIDS Conference, held in Amsterdam in July, exposed quite vividly that we are not close to achieving those targets. UNAIDS’s Miles to Go report, released on the eve of the conference, provided a reality check: as of the end of 2017, progress toward 90-90-90 stood at 75-59-47. Meaning that while tremendous strides have been made to increase the number of people on ART, overall, only 47 percent of those living with HIV are virally suppressed. We know this is crucial because those with undetectable viral loads are unable to pass on the virus to others.
The challenge in reaching the treatment and viral suppression coverage rates is that the denominator keeps increasing. New infections have not come down, especially for adults. Despite incremental declines each year, adult infection rates are stuck at approximately 1.8 million per year—far from the goal of 500,000 needed to break the pandemic. The “Miles to Go” report was blunt in its assessment: “There is a prevention crisis. The success in saving lives has not been matched with equal success in reducing new HIV infections. New HIV infections are not falling fast enough. HIV prevention services are not being provided on an adequate scale and with sufficient intensity and are not reaching the people who need them the most.”
While tremendous strides have been made to increase the number of people on ART, overall, only 47 percent of those living with HIV are virally suppressed.
The ability to reach those prevention and treatment targets is affected by a variety of factors including human rights constraints that hinder delivery of and access to services. Adolescent girls and young women are particularly vulnerable to HIV infection. Girls are up to 14 times more at risk for HIV infection than boys their same age in some countries. Societal and gender norms around girls’ education, for example, and limitations on women’s rights and access to sexual and reproductive health services add to the susceptibility.
The third Fast Track goal—eliminating stigma and discrimination—is intended to address some of the human rights constraints. Societal discrimination persists in many countries, as does institutionalized discrimination in the form of laws criminalizing certain behavior and rhetoric from political leaders condemning the behavior and threatening the individuals with prison or worse. Such laws push populations into hiding and make it difficult or even criminal to reach them with HIV services. At a time when more prevention services are needed to reduce new infections dramatically, laws and rhetoric have a chilling effect and hinder access to these vulnerable groups. More than 45 percent of annual new infections occur among key populations who are at much greater risk of HIV infection than those in the general population: female sex workers and transgender women are at 13 times greater risk, while people who inject drugs are 22 times and men who have sex with men (MSM) are 28 times more at risk of infection. Many key population groups choose to avoid health care services due to stigma and discrimination, thus limiting opportunities to prevent and treat HIV and meet the overall Fast Track goals.
One would expect the U.S. government to be at the forefront of challenging these laws, policies, and rhetoric. U.S. leadership in the global fight against HIV/AIDS has been transformative, and the U.S. government remains the top funder of global HIV programs through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the U.S. government supports approximately one-third of its funding). U.S.-supported programs have largely driven the increases in treatment access and preventive services over the last 16 years. To its credit, the U.S. government has supported many activities to advance human rights for the benefit of HIV goals and specifically increase access and services for key population groups through both PEPFAR and the Global Fund. PEPFAR states unequivocally on its website that it “stands firmly and unequivocally with and for key populations.” PEPFAR also supports the DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) initiative targeting reductions in new infections among adolescent girls and young women in 15 African countries.
But there are overarching concerns about how broader U.S. policy or inaction regarding human rights may affect PEPFAR’s ability to reach its target populations. Under the Trump administration, we have seen overt undermining of human rights protections as well as passive ignoring of alarming abuses occurring in other countries that would have triggered reactions from previous administrations. Some of these do not have direct health ramifications, but others do, such as the Trump administration’s reinstatement and expansion of the Mexico City Policy. Removal of protections for transgender students under Title IX in February also sends signals to other governments that they will not be condemned for discrimination against such populations.
The White House has not directly addressed the recent controversy in Tanzania affecting the health services to MSM. In early November, Paul Makonda, the regional commissioner of Dar es Salaam, announced the creation of an anti-gay surveillance squad charged with rounding up homosexuals. Sodomy is already illegal in Tanzania and punishable by up to 30 years in prison. Makonda’s announcement follows other anti-gay and anti-human rights rhetoric and policies from President John Magufuli and his administration since he was elected in 2015. In 2016, the government of Tanzania banned HIV/AIDS outreach and services to MSM, including by PEPFAR-supported partners, such as the distribution of lubricants that are core components of HIV prevention campaigns. There have been other attacks on human rights such as forced pregnancy tests for secondary school students that have resulted in pregnant girls being banned from attending school and returning post-partum.
The U.S. Department of State’s spokesperson did issue a statement about the recent issues in Tanzania on behalf of the U.S. government stating deep concern over “escalating attacks and legislative actions by the Government of Tanzania that violate civil liberties and human rights, creating an atmosphere of violence, intimidation, and discrimination.” The statement said the U.S. government is “troubled by the continued arrests and harassment of marginalized persons, including lesbian, gay, bisexual and transgender people, and others who seek to exercise their rights to freedom of speech, association, and assembly. Legislation is being used to restrict civil liberties for all.”
However, the statement does not address the likely effects on health and HIV/AIDS of the regional commissioner’s rhetoric, including on U.S.-supported programs, nor was there an associated statement from the White House condemning the actions like we have seen previously, such as President Obama’s condemnation of Uganda’s Anti-Homosexuality Act in 2014. There also have not been any statements by members of Congress condemning the Tanzanian actions. However, we have seen action by other governments and multilateral institutions. Tanzania’s second-largest donor, Denmark, is withholding nearly $10 million in development assistance to Tanzania and the European Union withdrew its ambassador. The World Bank suspended visits to the country as well as a $300 million education loan because of the ban on pregnant girls attending school.
Beyond overt targeting of key population groups like what we see in Tanzania, legislation in many countries restricts non-governmental organization (NGO) and civil society activity and limits free speech, press, and organization. These restrictions on vulnerable groups and civil society organizations that seek to advocate for them along with attacks on journalists are on the rise globally. These restrictions have an impact on the ability of U.S.-supported health programs to operate freely and meet the needs of affected populations. The challenge of reaching marginalized groups is likely to grow, not diminish, particularly if the United States does not exercise leadership.
I have written in the past, as have others, that now is not the time to take our foot off the gas in the fight against HIV/AIDS and that the U.S. government must sustain its leadership. Usually, the focus of those arguments is to sustain and expand funding to continue to scale up services, especially ART access. But human rights have to be a core tenant of those arguments as well, especially when it comes to preventing new HIV infections, which is going to make or break our success globally. We are not going to be successful if we don’t reach those who are most at risk of infection and that means tackling head on the societal and institutional stigma, discrimination, and criminalization that stand in the way to reaching those individuals.
This year’s World AIDS Day falls 13 months shy of the start of 2020. The U.S. government and Trump administration have a tremendous opportunity to push toward achievement of the Fast Track goals over this period. It’s an opportune time to demonstrate financial and moral leadership because the United States will host the July 2020 International AIDS Conference in San Francisco and Oakland, which will put U.S. policies and funding front and center.
We are not going to be successful if we don’t reach those who are most at risk of infection and that means tackling head on the societal and institutional stigma, discrimination, and criminalization that stand in the way to reaching those individuals.
For the Trump administration and executive branch, HIV funding must remain a priority in the fiscal year 2020 budget. Attempts again to cut the annual funding for PEPFAR and the Global Fund will have a detrimental impact on the ability to reach the Fast Track goals. The White House should speak up and take action against human rights violations that undermine PEPFAR and the Global Fund’s HIV activities. And PEPFAR’s Key Population Investment Fund, which has languished for two years, must be implemented successfully through the U.S. Agency for International Development (USAID) and Centers for Disease Control and Prevention (CDC) in 2019 as promised.
The new Congress should also make a concerted stand to protect global HIV funding, as the current Congress has done for the last two fiscal years, and for human rights writ large. Incoming members of Congress can look for opportunities in legislation, hearings, and public statements to keep a focus on human rights and hold the executive branch and other governments accountable for actions and activities that restrict access to essential health services. Congress also has an oversight role in ensuring UNAIDS is at the forefront pushing for human rights protections and service access for all populations affected by the virus.
As we pause to reflect on this World AIDS Day, we must commit to putting prevention at the top of the agenda and addressing the underlying human rights issues to keep more from being afflicted by this terrible disease. We have less than two years to make the 2020 Fast Track goals a reality. If we miss that window and push back achievement to 2025, we face an estimated 2.1 million additional HIV infections and 1 million additional deaths. We owe it to those individuals to make the concerted effort we know is needed now.
Sara M. Allinder is executive director and senior fellow with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.
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