December 1 is World AIDS Day: the one day in the calendar when we are expected to mark the devastation caused by the global AIDS pandemic. The most recent numbers are so large they numb the senses—nearly one million deaths worldwide and 1.8 million new infections in 2017 alone. The scientific tools clinicians have to fight HIV have never been more powerful, so why in 2018 are people with HIV still dying?
Digging deeper, grave country realities reveal the contours of a crisis where life-saving treatment scale up is not coming fast enough, and where human rights are under attack. In Mozambique, for example, a country with the second highest rate of AIDS deaths in East and Southern Africa, essential tests that measure whether or not a person’s treatment is working by suppressing HIV replication are still not routinely available. Homophobia and discrimination at the highest levels of government recently triggered censorship of gay men and sex workers at a high-level prevention conference in Uganda, a country where less than half of young people know how HIV is transmitted and how to prevent HIV infection. Across West and Central Africa, only 40% of people with HIV have access to antiretroviral therapy. Yet instead of aggressively accelerating roll out of new standards of care for treatment and prevention of tuberculosis—the leading killer of people with HIV worldwide—countries are struggling with sub-standard diagnostic and therapeutic tools.
Major funding gaps are fueling these deadly inequities in coverage and quality. The U.S. is by far the biggest donor funding the global AIDS response, and despite years of powerful successes of the U.S. bilateral AIDS program, Congress has failed to deliver the funding increases that will unlock life-saving treatment and prevention access for all. At least $850 billion is needed in FY 2019, in addition to Congressional action during the lame-duck session to enact the Senate’s commitment to a down payment of $50 million in additional funding—enough to begin to undo the harm caused by programs being denied the ability to accelerate life-saving coverage, though not enough to make up for lost time after years of flat funding. Likewise, the Global Fund to Fight AIDS, Tuberculosis and Malaria will replenish its coffers in 2019, and donors are poised to dodge their global commitment to fully fund the HIV response. Instead of delivering the three year, $18 billion renewal of funding needed to fight these three pandemics, the threat of flat funding is rearing its ugly head—again.
Second, harmful AIDS policies are pouring salt on the wound caused by AIDS budget austerity. Most prominent is President Trump’s expanded Global Gag Rule, which is hobbling groups that provide HIV services alongside comprehensive reproductive health care services—unless those implementers pledge to “gag” themselves, and stop providing women information about access to abortion, abortion services, or advocacy to change laws to increase access to abortion—using non-U.S. sources of funding.
In sub-Saharan Africa, where unsafe abortion is a leading cause of preventable maternal mortality, this cruel restriction stands in the way of women getting the HIV prevention and treatment alongside family planning support they desperately need. As programs that provide comprehensive family planning services—including access to legal abortion–shrink and disappear, reactionary and fundamentalist providers are taking root. Likewise, governments around the world, including the U.S., are attacking gay and transgender communities that face a disproportionately high risk of infection and poor clinical outcomes—from recent arbitrary arrests and detention of gay Tanzanians providing HIV prevention services, to transphobia from the White House including President Trump’s proposed changes to immigration rules that would obstruct treatment access for HIV-positive immigrants seeking permanent residence in the U.S. and their families. These dangerous policies and practices not only undermine fundamental health rights of communities in urgent need of quality treatment and prevention, they threaten to erode all of the fragile gains and victories that have been secured since the first World AIDS Day, thirty years ago.
Ironically, these obstacles also point to real hope: they are all problems that can be solved with political will. Casting aside flat funding and overturning evidence-defying policies are within our grasp, but they require leadership. This World AIDS Day, it’s the 116th Congress that must show its spine, stand up to a White House that is attempting to snatch defeat from the jaws of victory, and do right by 36.9 million people living with HIV around the world.