Pawan Dhall does a photo round-up of the ‘21st International AIDS Conference’ held at Durban, South Africa from July 18-22, 2016

The international biennial on HIV (human immuno-deficiency virus) and AIDS (acquired immune deficiency syndrome) returned to Durban after 16 years. In 2000, a breakthrough was made in worldwide commitment towards HIV treatment on a large scale. This time around, the catchword was ‘90-90-90’, an ambitious treatment target to help end the HIV epidemic.

Elaborated, the 90-90-90 target means that “by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART); and 90% of all people receiving ART will have viral suppression”. But what unfolded in Durban this year doesn’t inspire unqualified hope for the achievement of the 90-90-90 target.

One part of HIV treatment consists of treatment for opportunistic infections (tuberculosis or TB, for instance) that affect the body as the immunity weakens because of HIV. The other component is ART that tackles the virus itself by blocking its multiplication in the body. The buzzword today is an early start of ART for  everyone infected with HIV. The earlier approach of delaying the start of ART till a certain immunity threshold – mainly to minimize side effects and costs of a lifelong ART regimen – is on its way out because of availability of smarter and cheaper drugs.

An unprecedented 17 million people worldwide are on ART today, but that still leaves another 20 million yet to be provided with ART. On what count does this seem achievable four years from now? Global rhetoric (never mind who started it) that the end of HIV epidemic maybe around the corner needs a serious reality check. Speaker after speaker at the opening ceremony of the Durban conference exhorted governments, multilateral agencies and donors to not allow cutbacks on funds for the HIV response.

Prominent among the speakers were Archbishop Desmond Tutu (who spoke through video conference) and South African actor Charlize Theron, who said: “We value some lives more than others and till this stops, the epidemic won’t!” More often than not the lives less valued are those of girls, women, sex workers, queer people and religious, racial or caste minorities, and more so in the global South.

So, like the proverbial horse on a chess board, we move forward when more and more people start on ART, improve their own health, and become less infectious to others because of reduced viral loads in the body. But then we slide sideways when the stigma, discrimination and violence we unleash on those on ‘society’s margins’ deny them vital information and services to protect themselves from HIV. No wonder then that most new HIV infections in the world today are among transgender women, men who have sex with men, and sex workers.

Prevention of mother to child transmission of HIV is counted among the success stories of the worldwide HIV response. Paediatric HIV rates have plummeted as almost 80% of HIV positive pregnant women are on ART today. But why do so many women become infected in the first place? Why do we lose many of them even today?

Thought provoking reminders these, but humour wasn’t in short supply either at the conference. In a rousing speech, Cyriaque Ako, gay and HIV activist from Ivory Coast, said: “I’m gay, but not too hard to reach as many governments insist. I have three cell phone numbers, a Facebook profile, a WhatsApp number, and a Skype ID!”

The point being that the ‘hard to reach’ label on some of the most vulnerable populations should no longer be a smokescreen for governments to hide behind and to cover up their prejudices and non-performance. Point well made, but how many were really listening? A key symposium on transgender health issues later in the conference drew only a handful in the audience.

Another key to the achievement of the 90-90-90 target is the supply of cheap generic drugs for ART. For long, India has played a vital role in this regard as a ‘pharmacy of the developing world’. According to some estimates, India supplies 92% of the ART drugs in current use in developing countries. The credit for this goes to the Indian patent law that has several safeguards against monopolistic pricing by pharmaceutical companies.

But there are disturbing signs that the Indian government might give in to the demands of the western governments and corporate sector to change its patent law. This will likely make life saving drugs for HIV, cancer and other diseases exorbitantly expensive and out-of-reach for the masses the world over. Activists from the Treatment Action Campaign and other networks led a protest march through the conference venue and on to the Indian Consulate in Durban to hand in a petition that demanded that status quo be maintained on India’s patent regime. They also wanted an end to the harassment of human rights lawyers working to ensure affordable treatment and medicines for all.

On the somewhat brighter side, the conference managed to draw the spotlight on crucial intersectional issues. Co-infection of HIV and TB, challenging enough on their own and more so together, was the centre of attention as advances in clinical and treatment strategies were reported. The role of violence, mental illness and disability in increasing the vulnerability to HIV infection was visible throughout the poster presentation arena, the networking zone and in the dance, theatre and film presentations in the  Global Village section of the conference.

The author had an opportunity to present a poster on the link between the ‘ability to provide informed sexual consent’ and ‘HIV vulnerability among queer people’. This was on behalf of the International Center for Research on Women and Varta Trust, and the author was happy to note that his was not an isolated concern. Many other presenters highlighted similar concerns, and clearly sex education for the young remains an elusive goal not just in India.

On the HIV cure front, the clinical research questions seemed to have become better defined. As is well known, ART blocks the multiplication of HIV in the body but does not eliminate it. The virus hides in specific tissues in the body, and if ART is stopped, it rebounds. Researchers are now focused on finding means to eliminate the latent reservoir of HIV in the body as well as to prevent a rebound of the virus if for some reason ART is stopped.

It does sound as if the pursuit for a cure is becoming smarter. In the meantime, prevention of HIV remains the smartest thing to do. Yes, by encouraging and teaching people to put on a condom, or perhaps through the intake of pre-exposure prophylaxis (providing ART to people not yet infected with HIV). Then again, ART helps also people already infected with HIV become less infectious to others.

But none of these will happen if something more fundamental doesn’t take place. Till we – as individuals, communities and societies – have attitudes, laws, policies and systems that discriminate and dehumanize, many among us will never be interested in or capable of access to HIV prevention information and services. Let’s turn the microscope on ourselves well ahead of 2020!

Since this article was published, the guidelines for starting ART have been revised in India. According to an office memorandum issued by the National AIDS Control Organisation, Ministry of Health & Family Welfare, Government of India on May 5, 2017, starting ART will no longer be dependent on CD4 count and other criteria like clinical stage of HIV infection, age and population. All people who test positive for HIV will be treated with ART at the earliest – Editor.