Resumenes de Conferencia AIDS 2018

AIDS 2018 International Congress. Rapporteur Summaries related Prisons, drugs, key populations.

Tuberculosis in Prisons

AUTHOR: Sean Wasserman

Session Summary

TB rates in prisons are much higher than in the general population and may represent a reservoir of TB in the community. The session highlighted new research related to the public health burden of TB among prison populations. Themes included transmission, screening and prevention strategies, implementation challenges, and community perspectives.

Session Highlights

To support the hypothesis that prisons serve as reservoirs of TB epidemics in LMICs, Jason Andrews showed that the risk of incident TB disease in South-Western Brazil remains higher amongst ex-prisoners for up to 7 years after leaving prison and demonstrated that prison and community epidemics are genetically interrelated, suggesting transmission spillover. A mathematical model predicted that exit screening would be more beneficial than entry screening, and that a combined intervention would result in > 60% reduction in TB incidence in prisons, and > 30% reduction in community TB burden. Julio Croda presented data from a cohort study involving 12 prisons in South-Western Brazil showing that biannual screening is predicted to result in substantial reductions in new TB cases. In preliminary data from a prospective mass TB screening study, only 27% of new TB cases were identified using traditional screening approaches plus chest X-ray with automated interpretation.

Critical Assessment

The presenters showed compelling data to support the hypothesis that TB in prisons is a major public health issue, and a potentially important driver of TB in the community. Current strategies for screening, diagnosis, and prevention appear to be inadequate, and this new evidence should be used to inform updated screening recommendations. This session highlighted the importance of finding ways to address the TB epidemic in prisons, including advocating for this issue at the upcoming UN High Level Meeting on TB.

Mortality trends in the ART era

AUTHOR: Michael Marco

Session Summary

Mortality from AIDS has markedly decreased since the advent of ART in most countries. Here, longitudinal mortality trends and cause of deaths were presented. As individuals on ART age, causes of death are now increasingly attributed to NCDs, malignancies, HCV, and the biggest risk factors are smoking and alcohol misuse.

Session Highlights

All studies sampled individuals on ART. A Canadian study in women documented current alcohol and tobacco use as well as depression were independent, robust risk factors of mortality. A London study including men and women confirmed alcohol and tobacco use as a significant risk factors of mortality. Other papers noted NCDs, malignancies, and HCV as the largest contributors of death in their patients stable in ART. Lastly, a South African study analyzing trends in AIDS mortality pre-and-post ART roll-out documented that females 25-34 years had higher death rates compare to males; however, this pattern was reversed in males >45 years.

Critical Assessment

The methodology of all papers in this session were sound, and data were presented in a clean and concise manner. Conclusions were quite sobering and shed light on the fact that while countries continue to test people for HIV and rapidly initiate them on ART, it does not mean that all of these individuals will live late in life. In a majority of these studies, HIV treatment factors (i.e., ART use, VL, CD4) were not predictive of mortality. Hence new funding is sorely needed for managing the prevention and treatment of HCV, NCDs, malignancies and mental health issues in ART patients in high-, middle-, and low-income countries. Likewise funding for campaigns to quit smoking and curb alcohol misuse is essential to the longevity of all PLHIV. The sole goal in treating PLHIV should not simply be meeting UNAIDS’ 90-90-90 targets. There must be a more holistic, patient-centered approach.

 

It’s raining men: Key statistics for engagement

AUTHOR: Ayden Scheim

Session Summary

Presenters focused on cisgender men’s HIV risks and engagement in prevention. Results highlighted strong retention of men, benefits of PrEP for MSM, provided the first data on MSM in South Sudan, and showed mixed effects of interventions to engage heterosexual men in prevention and treatment across multiple African countries.

Session Highlights

Among Bangkok MSM, mathematical modeling predicted large reductions in HIV incidence with high PrEP adherence—up to 1183 infections per 10000 averted with 90% adherence and no condom use among MSM who use drugs during sex. In a U.S. cohort, PrEP-using MSM had more condomless sex while on PrEP. Rectal STI incidence didn’t increase during PrEP and was lowest after discontinuation. The first biobehavioral survey of South Sudanese MSM found 3.3% HIV prevalence (compared to a 2.6% national average). In 5 high-burden African countries, testing, circumcision, and treatment funding for men aged 15-49 was added to the PEPFAR DREAM intervention for young women. For each outcome, PEPFAR program data improved in 2-3 countries, particularly for treatment initiation. A microfinance and peer leadership intervention to prevent HIV and IPV among young Tanzanian men had high retention (82% at 30 months) and positive effects on secondary outcomes of HIV testing and gender norms.

Critical Assessment

Jonathon Rendina noted the U.S. PrEP results indicate that PrEP is “working as it should”: MSM are using PrEP when they are at high risk and stopping when they are no longer at risk. Much work remains to address HIV prevention capacity among MSM in other settings—only 42% of South Sudanese MSM had ever seen lubricants for sex. The microfinance intervention for Tanzanian young men was innovative and informed by community input, but men were skeptical. The intervention was theoretically-based (intending to increase men’s time horizons), but other approaches might be more gender-appropriate.

 

The new high risk populations: Who are they?

AUTHOR: Tonia Poteat

Session Summary

Emerging data were presented on reducing stigma against key populations in health services in Malaysia, use of gay social networking apps in China, extended risk networks HIV testing in Ukraine, timing of HIV acquisition among sub-Saharan migrants in France, and substance use among MSM in the U.S.

Session Highlights

Peer case management approaches and sensitivity training at government clinics in Malaysia successfully reduced stigma against key populations. Men using gay social networking apps in China are more likely to test for HIV than non-users and demonstrated a trend toward lower HIV prevalence. Machine learning algorithms to improve HIV case finding among PWID in Ukraine were 83% accurate in predicting which seeds would recruit someone living with HIV; and the best predictor of such recruitment was network size, not the HIV status or vulnerability of the recruiter. Social vulnerabilities experienced early after migration to France are responsible for increased HIV vulnerability prior to settlement; however, migrants who are infected after being fully settled in France have increased risk likely related to local sexual networks. Young Black MSM in the US experience elevated STI prevalence compared with other racial groups despite lower HIV risk behavior (eg. substance use and sexual behavior).

Critical Assessment

Despite a title suggesting that new key populations would be discussed, the session provided data on known key populations. The strength of the session was the provision of data from regions that get less attention in the HIV response (eg. Malaysia) as well as information on emerging technologies (eg. machine learning) that can improve the ability to reach hidden populations with HIV interventions. The Q&A included a robust discussion of the lack of presentations about transgender men and the need for the conference and researchers more broadly to include data on HIV among this population.

 

Sex and drugs: Ongoing syndemics in the PrEP and treatment era

AUTHOR: Ayden Scheim

Session Summary

Presentations focused on syndemics, co-occurring psychosocial conditions that synergistically impact risks for HIV transmission and disease progression. Studies characterized syndemics among U.S. PLHIV in care and among Indian MSM and evaluated interventions to improve substance use and HIV outcomes for U.S. cisgender MSM and South African cisgender women.

Session Highlights

Three presentations examined impacts of syndemics on HIV risks. Within-patient increases in syndemic burden were associated with onwards transmission risk behavior among U.S. HIV clinic patients. Violent victimization, drug use, and frequent drinking interacted synergistically to predict condomless sex for Indian MSM. Intimate partner violence, depression, and non-injection crystal methamphetamine had interactive effects on inconsistent condom use, survival sex work, and STI symptoms among Indonesian women who inject drugs. Two talks addressed syndemics interventions. The Women’s Health Co-Op Plus intervention in South Africa led to improved viral suppression among substance-using women, while binge drinking was associated with detectable VL. An initial RCT evaluated a behavioral activation intervention to help crystal methamphetamine-using MSM identify and participate in pleasurable goal-directed activities other than sex and drug use. At 6 months, intervention participants had less CAS with serodiscordant or unknown-status partners and had more meth-free days.

Critical Assessment

Presentations reinforced the need to address the psychosocial conditions of people living with or at risk for HIV to reduce new infections and improve treatment outcomes. There was rich discussion about the challenges of modeling syndemics – an exposure variable that counts the number of ‘syndemic’ conditions has been criticized for not evaluating interaction, but complex multi-way interactions may be difficult to interpret and apply to practice. In addition, the role of stigma in syndemic theory and interventions requires greater attention. As per the original theory, stigma is an upstream cause requiring structural interventions, but most current interventions are individual-level.

 

Building bridges from scientific innovation to implementation

AUTHOR: Robert Newells

Session Summary

Session included the announcement of a new anti-stigma award from ViiV, updates on HIV cure and vaccine research, review of integrase inhibitors for treatment and prevention, and a call for a “differentiated” prevention approach.

Session Highlights

Dr. Pedro Cahn, Scientific Director of Fundacion Huesped in Argentina, discussed the use of Integrase Strand Transfer Inhibitors (InSTIs) such as dolutegravir in treatment and cabotegravir in PrEP; a drug class could help “succeed” with goals of 90-90-90 as they are superior or non inferior compared to today’s first line regimens. He reviewed current guidance questions related to a possible association between dolutegravir use in pregnancy and risk of neural tube defects identified in a Botswana study. What he called “unprecedented rollout in low-income countries” highlights the need for implementation research. Dr. Nduku Kilonzo of the National AIDS Control Council in Kenya talked about the need for differentiated models of HIV prevention, including scaled up primary prevention to address persistently high rates of HIV incidence, noting huge gap in harm reduction services in epidemics driven by drug use and that “success in VMMC [was] not celebrated enough or leveraged enough.”

Critical Assessment

With progress but significant time to go before a vaccine or a cure, there is urgent need for scaled up primary prevention and access to effective, well tolerated ART regimens. This work must happen in the context of research, monitoring and stakeholder engagement that addresses unanswered questions, identifies best practices to support informed choice, along with advocacy to ensure adequate funding for this work.

 

Occupy the epidemic: Economic inequality and HIV

AUTHOR: Robert Newells

Session Summary

Housing, poverty, food insecurity, other economic determinants of health were discussed as challenges to achieving viral suppression, reducing risk factors for PWID, and accessing sexual health and outreach services.

Session Highlights

A presentation by Keshet Ronen (US) on a cross-sectional study of food insecurity and virologic suppression among pregnant Kenyan women living with HIV found that over half experience some insecurity, almost one third severe, this was associated with older age, lower income, more children, lower social support, depression, and unsuppressed VL (16% of food insecure women vs 9% of those with food security). A Ukrainian study presented by Alyona Mazhanya (US) found independent association between housing insecurity and likelihood of using needles/syringed after someone or sharing injection equipment.
Dr. Shira Goldenberg from the Gender and Sexual Health Initiative at the BC Centre for Excellence in HIV/AIDS presented on a four year study that tracked changes in land use, sex workers’ neighborhood of residence and rates of access to HIV, STI sexual health services. Gentrification meant sex workers had to move further away from health services; access declined.

Critical Assessment

What’s happening socioeconomically in our communities (i.e., housing and food insecurity) needs to be out front when we talk about what’s happening with HIV in our communities. Adherence interventions and retention in care require larger policies around housing and supporting people. Post-gentrification, mobile interventions need to be scaled up to meet people where they are. Income is less of a factor than the availability (or lack) of supportive services in the ability for PLWHA to achieve viral suppression.

 

Justice on the margins: Legal strategies to address barriers to HIV services

AUTHOR: Yvette Raphael

Session Summary

Human rights violations happens to mostly the poor, and the already-marginalised in our communities and in the world. People living with HIV, IDU and Sex workers are in that category; legal strategies and/or strategies aimed at law workers can be used to remove or address some of these barriers.

Session Highlights

Presentations emphasized the need to strengthen the role of community paralegals and legitimise their work, to train judges, and ensure that people at risk of legal persecution understand their rights and how to protect them. In a project from Russia reported on the work of “street lawyers” to inform empower and give judicial protection. A southern African “judges forum” is designed to a long term judicial capacity building on scientific and medical information. Another presentation reviewed the situation in Indonesia, where drug users, transgender and homosexual identity, and sex work are all criminalized.

Critical Assessment

It is often the governments and the Legal and Justice systems that violate human Rights; this is exacerbated in situations where people under attack do not know their rights or have access to legal workers to help counter persecution. This session highlighted a range of strategies that can be used to ameliorate this situation.

 

Epidemic transition: How will we achieve it while ensuring equity and quality?

AUTHOR: Mitzy Gafos

Session Summary

The session was a panel discussion on epidemic control and epidemic transition. It addresses issues of the definition of ‘control’, the programmatic needs to achieve ‘control, and the types of data matrix needed to allow monitoring of movement to epidemic control and transition to sustainable control.

Session Highlights

Measures of progress to ‘control’ available for ‘zero infections, zero deaths’. Need better measures of zero stigma e.g. key population access to services, criminalisation, marriage equality, qualitative assessments of social norms. Addressing social factors, i.e. stigma, key to achieving 90-90-90 and delivery of prevention services i.e. PrEP. U=U potentially powerful stigma reduction tool. Clear need to include service users in planning i.e. young people, MSM, injecting drug users, and in some cases provide platform and ‘get out of their way’ so they can implement. Need granular data among key populations to avoid overemphasising progress to control. Ongoing need to address social factors in implementation of programmes and measure progress in order to support sustainability of ‘control’. Need to plan for backwards movement from target and ensure programmes are adaptable to change. SDGs provide framework to advance ‘control’ in multisectoral manner and in political sphere.

Critical Assessment

Clear recognition across all panellists of the need to build civil society involvement into the design, implementation and monitoring of programmes, to address structural and social drivers of the epidemic that also impact on related factors such as other SHRH services and the NCD agenda, and the need to measure our progress at the granular level to understand inequalities of services and achieve ‘leaving no one behind’. The session wasn’t able to provide examples of how best to achieve many of these recommendations and that will be a useful next step.

 

Drugs, drug policy, harm reduction: A reality check

AUTHOR: Mauro Guarinieri

Session Summary

The AIDS response is failing people who use drugs. HIV transmission increased by one third between 2011 and 2015, while global targets were aiming at reducing transmission by 50%. Funding is just 13% of the 1.5 billion that UNAIDS estimates is needed annually. The session tried to answer why.

Session Highlights

Ruth Dreyfus, GCDP opened the session by saying how “easy and cheap is to prevent HIV among people who use drugs”. And yet only 1 out 6 people globally receive services, donor funding fell by 24% since 2007, and just four countries have managed to bring harm reduction to scale, according to Julia Buxton. As a result, the global community is falling behind all targets. All panelist argued that a combination of factors contributes to this massive failure. The failed war on drugs has been unfolding into wars on people in the Philippines, most of Latin American, Asia and the US; the over reliance on biotechnologies, biometrics, e.g. PreP, increase costs and shift people away from the basic message of harm reduction, that is to focus on “people needs, not health interventions” (Daniel Wolfe, OSF). Judy Chang, INPUD, emphasised the role of communities as key to getting back on track.

Critical Assessment

“It is not people who use drugs who are broken, but the systems that fail to address their needs” (Judy Chang, INPUD). The session made a powerful case for moving away from drug prohibition and abstinence as the key outcome of interest. Examples from the Czech Republic, Portugal, and other 25 countries experimenting decriminalization show that if we are to reach our 2030 goals we need to end mass incarceration, mass killings, and mass criminalization of drug use and drug possession. Most importantly, we are not going to do it without working with people who use drugs.

 

Why do we fail in responding to the epidemic among people who inject drugs?

AUTHOR: Mauro Guarinieri

Session Summary

The session brought together science, law enforcement and community in a panel that tried to answer a recurring question: why we are failing to respond to skyrocketing epidemics among PWID, particularly in Eastern Europe, where the lack of appropriate responses is accounting for unprecedented levels of HIV transmission?

Session Highlights

“Changing the police behaviour may be the single most important factor affecting the success of any response to HIV among PWID”. Nick Croft, Universtiy of Melbourne, Australia, pointed out that while decriminalization should be always the ultimate end game, law enforcement can either be our best ally of worse enemy in implementing sensible responses to HIV and drug use. M-J Milloy, from the BC Centre or Excellence in HIV/AIDS, Canada, shared data from multiple studies showing how incarceration can reduce access to ART among PWID by almost 50%, “PWID is the only key population where life expectancy has declined over the last years. Something we should be ashamed of”, he said. Anya Sarang shared powerful stories from Russia, the third largest growing HIV epidemic in the world, accounting for over 2/3 all HIV transmission in Europe, where harm reduction is still considered “a threat to the HIV national strategy”.

Critical Assessment

It is disheartening to keep hearing the extent to which the global response to HIV is failing people who use drugs. Some of the stories shared by Anya Sarang, Andrey Rylkov Foundation in Russia and SKOSH in the Netherlands, are simply hearth-breaking. A country where the only response to drug use is still violence and mass-incarceration, and where basic rights are denied as a matter of course, Russia did not face HIV until fifteen years into the global pandemic. Instead of benefiting from the experiences of other countries in confronting it, Russia has systematically rejected all well established lessons.

 

Leaving no one behind: Stigma interventions for youth

AUTHOR: Jenelle Babb

Session Summary

The session presented the outcomes of Project Shaan, implemented by the Indian NGO, GAURAV. The project aimed to: reduce HIV-related stigma among health providers, facilitate an enabling environment amongst duty bearers and support social mobilization in support of the LGBT and sex worker communities.

Session Highlights

GAURAV supports HIV prevention, health and rights of young LGBT and young sex workers including through their group, Rainbow Tigers. This is a platform across India that provides a safe space and networking zone for the LGBT and sex work communities while carrying out advocacy to shift negative public attitudes.
LGBT youth in Maharashtra, India, are disproportionately likely to be HIV positive and face distinct challenges. Understanding the unique socio-cultural issues and how they relate to HIV risk could maximize prevention efforts.
Programme strategies and objectives include to: increase access to justice; reduce stigma and discrimination through capacity building of youth community leaders; advocacy and networking with law enforcement officers; advocacy with and orientation of health care workers; youth community mobilization; awareness sessions with educational institutions; sensitizing and engaging media and mass communication sectors.

Critical Assessment

The session offered up useful information on GAURAV’s programme experience on multi component approaches to preventing and responding to stigma and discrimination faced by young LGBT and young sex workers. The presentations focused on what was done (activities) rather than processes, outcomes or lessons learned. All of these would have been valuable additions. As the session was poorly attended there was also no audience interaction to provide other opportunities to draw out this information.

 

Display the red umbrella: Creating media about sex work and HIV

AUTHOR: Bakita Kasadha

Session Summary

Session led by J Leigh Brantly, Monica Jones and P J Starr, flagging the dehumanising ways sex workers are portrayed in the media, as well as sharing success stories on reframing and controlling the sex worker narrative, with tips on creating sex worker media simply and effectively.

Session Highlights

P J Starr facilitated a discussion on how sex workers and those profiled as sex workers (migrants, people of colour, etc.) are portrayed in media. Most delegates examples centred on vilification and dehumanisation. A couple of examples mentioned the framing of sex workers as victims/passive. The positive and humanising narrations were directly from sex workers.
Monica Jones shared how she gained control of reframed her story within the media and gained the support from the general public, “It’s very important to use our own voices to tell our own stories and then other people will pick up on it”.
J Leigh emphasised the importance of self-reflection; how one feels about their sex work will reflect in their interviews. When self-creating media J Leigh advised: letting go of fear; reaching out to tech savvy people; familiarising yourself with your phone capabilities.
Session closed with delegates creating and sharing their own media.

Critical Assessment

The facilitators were great at contextualising each discussion. Frequently they made reference to “walking whilst trans” and normalised communication structures that are rooted in colonial practices. This informed delegates on what they should self-reflect on when creating their own media.
Facilitators successfully created and interactive and responsive space. It was clear that an inclusive dynamic underpinned their facilitation styles, from sitting with delegates (rather than on stage) to talking about Dragon software, which helps Monica Jones share her story (she is a woman living with her disabilities that impacts her written communication).

A longer session would have been beneficial.

 

South-South learning for a more inclusive and integrated Caribbean

AUTHOR: Jenelle Babb

Session Summary

This video captures the learning experience of CBO and local authority representatives from the islands of the Eastern Caribbean as they learn, through a training organized by CVC, about outreach, programming, advocacy, care and treatment and safe spaces designed by CBOs for key populations in the Dominican Republic.

Session Highlights

Documenting through film, a training approach innovation to bring together different country lessons and experiences and build capacity, especially in smaller country contexts, in HIV programming with key populations: MSM, sex workers, persons who use drugs, trans women and young people living with HIV.
It captures feedback and perspectives from workshop participants on the training and their opinion of key population programming in the Dominican Republic including how they would apply the training in their home country. Programming elements being showcased were diverse, covering prevention, treatment, community mobilization and economic empowerment as well as site visits to treatment centres, laboratories, public education and behavior change communication community spaces.
The video was appreciated by the viewers present. A short discussion session following the film screening further enabled discussion on south-south exchange in the Caribbean.

Critical Assessment

The video really was a showcase of HIV programming in the Dominican Republic as told through the voices and opinions of eastern Caribbean practitioners working with key populations and who took part in the training. The objective was to highlight that learning and exchange of experiences was possible and something to be pursued between neighbouring countries of the Caribbean, rather than importing and adapting programmes developed outside of the region.

 

Tuberculosis in prisons

AUTHOR: Peter Wiessner

Session Summary

TB rates are 30 times higher in prisons than in the general population. However, few countries perceive prison health as a public health priority. The session addressed setting-based TB risks factors for prisoners, such as overcrowding, poor air-ventilation, lack of sunlight, poor access to health services, identified knowledge-gaps and best-practices.

Session Highlights

Prisons are an amplifier of tuberculosis. The growth of incarceration rates by 275% globally between 2000-2016 adds to the problem. Studies in Brazil demonstrate a 42% likelihood to get infected within a single year in prison. Prison health authorities often do not follow WHO guidelines. Establishing TB programs in prison reduces the TB burden in the general population. In many regions, prisons are the key driver of TB and MDR-TB that spill over to general population. Reason are poor adherence, discontinuation of treatment upon release and lack of access for NGOs delivering services in prison. To tackle the situation good screening practices were identified. However, prisons remain disconnected from the general health system, leading to double standards, disregard of guidelines and lacking sufficiently-trained health personnel. Better cooperation between Ministries of Health, Justice and Interior are needed to change the situation.

Critical Assessment

The TB situation in prisons is a public heath emergency, a crisis and a scandal. The session made it clear that nothing much will change, as long as the prison health is siloed. Ministries responsible for prison health need to cooperate and change the underlying political factors that cause the problems identified above. To break the barrier between realities inside and outside prison, sessions like this should include those working in prison, in prison health administrations and relevant ministries.

 

Breaking barriers of inequity in the HIV response

AUTHOR: Parinita Bhattacharjee

Session Summary

The session focused on understanding the inequity in HIV response and stressed to need to focus on specific populations who are left out. Innovations to scale up HIV prevention and treatment for drug users, community involvement specially women drug users and need for decriminalisation of HIV was stressed.

Session Highlights

Stephan Baral focused on the epidemiology of HIV and using case studies shared that there exists inequity in distribution of HIV across geography and population. This evidence made a compelling case to address the unmet prevention and treatment needs of adolescent girls, PWID, MSM, FSWs and indigenous people. Anna Deryabina and Olena Stryzhak maintained the focus on drug and substance users. Their presentations shared the need to scale up programmes for PWID using innovative interventions like incentivised chain referral and HIV self-testing to increase HIV testing and yield, PrEP for prevention, nurse led home based support and integration of OST and ART to increase adherence. Olena specially advocated for equal coverage of women who use drugs with integrated services, community involvement and decriminalisation of drug use. Allan Maleche and Robert Suttle stressed the need to decriminalise HIV by repealing criminal laws and increased funding for structural remedies based on science.

Critical Assessment

The session focused on inequity and used evidence to make the case. The message that risk of HIV is not evenly distributed and most infections are emerging from unmet prevention and treatment needs was clear. The need to address structural inequities and systematic barriers to increase coverage of HIV services in specific populations was stressed. Integrated approaches, gender oriented services and service delivery models and active community engagement and participation is essential. Decriminalisation of HIV and use of science to interpret and apply laws was also a key message. The personal stories of two speakers added life to the presentations.

 

Creating danger: Impact of end-demand laws and policing of sex work

AUTHOR: Emily Bass

Session Summary

This session featured five presentations on the impact of policing practices and laws aimed at sex workers and their impact on health, HIV risk and access to health services, as on non-sex work specific laws used to prosecute sex workers in southern Africa, and strategies for mounting legal challenge.

Session Highlights

A pair of presentation from France (Helene Lebail) and Canada (Elena Argento) looked at the impact of
end demand laws that support the “Nordic model” of seeking to eradicate sex work, criminalizing the purchase of sex and targeting third-parties and clients. The Canadian study was a longitudinal project that looked at access to services among sex workers pre- and post- law reform that included end-demand statutes. Access to health services and sex work services such as drop in centers and supports decreased after passage of the law. In France, a mixed method qualitative/quantitative approach found that enactment of end demand laws led to an “acute increase in [sex workers] socio-economic vulnerability.” A Baltimore-based study (Katherine Footer) found that the intensity and frequency of sex worker contacts with police–whether “routine” policing or explicitly abusive contacts–increased risk of SWs experiencing client violence; this was particularly true for heroin-using SWs.

Critical Assessment

Elena Argento summarized the implications of this research well, saying,”It is critical that legal interventions and policies follow evidence – that end demand criminalization exacerbates barriers to health and services.” This is true in multiple contexts, including supposedly sex-worker friendly Netherlands, and requires work on multiple levels including direct legal challenge that is developed in collaboration with and responsive to sex worker needs and environment, as described by Tashwill Esterhuizen of the Southern African Litigation Center.

 

Falling off the HIV cascade: Autonomy as a determinant of ART retention among sex workers

AUTHOR: Emily Bass

Session Summary

A session looking at the range of social, structural, individual and community level issues that can affect sex worker engagement in ART services, and that can be addressed through collaborative program design and implementation.

Session Highlights

Two researchers from Johns Hopkins (Carly Comins and Lauren Parmley) described the socio-ecological model (SEM) of barriers for sex workers to accessing and staying ART programs developed by interviews with nearly 40 sex workers or key informants in South Africa. The SEM looked at issues at the individual, network and structural levels and captured a range of actionable insights. Serena Cruz (University of Amsterdam) spent three years on ethnographic research with sex workers in Kampala and described the ways that these women and men build and present their social capital and how the steps that reinforce their connections to valuable social networks can be at odds with those recommended or dictated by the health facility. “The intimacy that goes into how you survive is risk bound,” she said. Robin Eakle (WRHI, South Africa) presented qualitative research with South African SW reinforcing the need to involve SW in program design/implementation.

Critical Assessment

With the increasing emphasis on finding, linking and achieving virologic suppression for people living with HIV, it is becoming crystal clear that the multiple factors that help or hinder a person from seeking health care need to be examined–ideally in research and programs designed by and with the people who need the services. These presentations provided insights into how to gather this information and suggestions about what to do with it. A session co-chair emphasized the need to foreground sex workers themselves in this work.

 

Dignity has no nationality: HIV and migrants’ rights

AUTHOR: Emily Bass

Session Summary

A set of presentations on the impact of criminalization of irregular migration and undocumented migrants in terms of health-seeking behavior and HIV risk, as well as an examination of the components of a successful campaign against bad policy in the UK.

Session Highlights

Yusuf Azad (National AIDS Trust, UK) told the story of a successful evidence-driven campaign to challenge British government policy that dictates that undocumented migrants are not eligible for free care and are charged for accessing certain services, and highlighted the critical role of high quality evidence (time of arrival in country, time of diagnosis, CD4 cell count) in building a counter argument to the claim that migrants are “health tourists.” Phillip Marotta from the Global Health Research Center of Central Asia showed that criminalization of migration status increased sexual risk among market workers in Kazakhstan, with the largest magnitude of effect for incarceration followed by arrest, while two presentations, one from US and one from Canada, demonstrated that the fear of raids (Canada) or perceived immigration laws (US) had a negative impact on health seeking behaviors.

Critical Assessment

Presentations in this session filled in gaps in evidence and documentation of the specific links between criminalization of migration and individual and public health; while only one presentation provided an example of the means to combat such policies, all of the presentations yielded data that is actionable in making arguments for better policies and programs.

 

Rise against violence: Coming together to end inhuman humanity

AUTHOR: Khatchig Ghosn

Session Summary

The session shed the light on acts of violence faced by the LGBTIQ+ communities and drug users. Four speakers from four continents shared experiences related to violence from their community and personal perspectives, and elaborated on possible solutions.

Session Highlights

Jay Mulucha, Fem Alliance, Uganda focused on how the laws and policies are restricting transgender people from accessing to services. Health care providers are reluctant to serve in fear of being repercussions. Mulucha talked about the link between self-stigma, drug use and depression. Bikas Gurung from ANPUD mentioned the crises faced by drug users: overcriminalization, overdose, high prevalence of HIV/TB/Hepatitis/STIs, compulsory detention centers across Asia. War on drugs in the Philippines claimed >12,000 lives of drug users. Steve Letsike from National AIDS Council, South Africa talked about how societies use culture and religion to silence discussion about same sex practices and human rights. Vitaly Djuma from ECOM elaborated on how politicians use policies to spread homophobia. Funding for HIV services among LGBTI need budget advocacy. To rise over violence collaboration across groups experiencing violence and social justice movements are needed, along with raising awareness, advocating for changes in policies.

Critical Assessment

The different communities’ stories brought so many similarities: “People are being killed by bullets and silence of the world”, as Bikas put. Hearing the stories helped to understand issues, however, little space was left for discussing what are the ways forward. Further discussion could use bringing government side – ombudsman, parliamentarians law and order authorities etc. – to discuss if not practical solutions then at least the first steps. It would be useful to understand what help is needed for current movements to build the bridges of solidarity that they briefly mentioned in closing remarks.

 

Building bridges for the next generation

AUTHOR: Robert Newells

Session Summary

Youth-focused session started with a description of neurocognitive reasons for ways that adolescents process and respond to information compared to young adults and adults. The session ended with results from a study that showed improved knowledge and attitudes, increased HIV testing, and reduced risky sex among viewers of MTV Shuga.

Session Highlights

The adolescent neurocognitive development work of Dr. Anne-Lise Goddings from University College London concluded that adolescents are particularly susceptible to social influence. Minister of Foreign Affairs Reina Buijs described the involvement of parents, communities, and health services in comprehensive sexuality education in the Netherlands focused on teaching children that it’s okay to make choices. Reinforcing those narratives were preliminary results from a study conducted in Nigeria showing that MTV Shuga effectively transmitted information, changed attitudes, increased HIV testing, and among women, led to fewer sexually transmitted infections. O’Cindy Cynthia Samuels of the Guyana Sex Work Coalition explained that “Sex work is work which is both formal and informal.” It is a misconception to think of all sex workers as victims. Sex work is not sexual exploitation, human trafficking, or violence against women. Framing all sex work in these ways feeds stigma that violates human rights and impedes the HIV response.

Critical Assessment

Children have lamented for generations that adults don’t understand them. It’s true! If we are truly concerned about building bridges for the next generation, we are required to communicate in ways that will engage the next generation. And we may be required to have some uncomfortable conversations in the process.

 

Hidden in plain sight: Meeting the needs of young people from key populations

AUTHOR: Resty Nalwanga

Session Summary

Six young people from key population groups shared insights and skills how to meet the needs of their peers: create safe-spaces, enable youth-led support, assist non-youth organizations/services to address unmet needs including together advocate for lifting age-related restrictions and enable youth to speak-out – but not in tokenistic way.

Session Highlights

Six young people from around the world –living with HIV or gay or using drugs, of different genders – covered 3 areas how to address young people’s needs. First, self-support and youth-organizing mean creating safer spaces, engaging young people in activities that benefit their livelihoods, and peer-to-peer approach. Secondly, services, for example, for key populations need to talk and include youngsters and integrate tools on young key populations. Last but not least, when it comes to international organisations, there is a lot of tokenism. Young people need legit representation and ability “to say what we want instead of what is expected from us to say”; instead during development of guidelines they could be given “scripts that don’t belong to us”. Opiyo Consolata shared her experience when she was given an opportunity on hands on skills with the UN; this improved her representation as a young person and gave technical knowledge.

Critical Assessment

Many HIV & TB programmes ignore young people, their diversity, especially when they are from key populations. It is based on fear. Majority of young people cannot access SRH information, drug-related harm reduction and HIV prevention because of legal restrictions, social marginalization, prejudice to key populations, poverty, etc.
Safe spaces are crucial to bring young key populations on board: in public, they can’t openly express themselves. The workshop showed how to use evidence-based reporting to inform policy-makers and to adapt services to the needs of youth “hidden in the plain sight”. One global approach cannot be work in all cultures.