What comes after START? We’re reading about a projected cost of universal access and other barriers to treatment

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NewWWRTreating HIV Patients Before They Get Sick – This New York Times editorial follows the newspaper’s reporting on findings from the Strategic Timing of AntiRetroviral Treatment study, which found that treating people for HIV upon diagnosis averts illnesses without adding negative impacts. The findings, the editorial says, raise the question of: “whether global and national organizations can find the will — and the resources — to protect millions of people from deaths and diseases that could be prevented,” Good question, although perhaps it’s not a matter of “finding,” as much as prioritizing, resources to fulfill the promise made more than a decade ago with the launches of the U.S. President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS Tuberculosis and Malaria. When describing the resources needed, however, the editorial gets confusing. “Currently,” it says, “fewer than 14 million people of the estimated 35 million people in  the world infected with HIV are taking antiretroviral drugs. Treating all the infected people in the world’s poor and middle-income countries immediately would cost almost $20 billion, roughly triple the current expenditures.” The math is hard to follow, and unexplained — why would treating all 35 million people who live with HIV cost $20 billion? Is that figure based on current costs, and does it factor in economies of scale that have lowered costs throughout treatment rollout? The reasoning behind citing a figure based on the unlikely event — regardless of guidelines —  of immediately treating all who need treatment also is hard to follow, considering the large numbers of people eligible for treatment under current guidelines but not getting it, and the large numbers receiving their diagnoses only when their immune cell counts have plummeted below those of the current and previous guidelines.  Currently too many other barriers to treatment exist to make it likely that the world will face the price tag of universal coverage overnight. The fact remains that all people living with HIV will need treatment, the sooner the better, (and the START results add more proof that sooner also is less expensive than later). And while it seems likely that effective HIV responses will always require more than is allocated for them, inflating estimates of universal HIV treatment access is in itself a barrier to making it a reality. We’re reading about some of the other barriers to universal treatment access, this week, including criminalization, discrimination, and neglect of populations with some of the highest rates of HIV, and laws criminalizing HIV exposure and transmission.

Key Affected Population Engagement in Cameroon – It is nearly two years ago that following the unsolved torture and murder of Cameroonian HIV treatment and gay rights advocate Eric O. Lembembe, a coalition of civil society organizations striving to link sexual minority populations to health services said they could no longer work without support, and adding “we reject a partnership that reduces our associations to simply a labor force that must work in precarious, dangerous conditions.”  A $1.4 million dollar project supported by the Global Fund at the time that included outreach to gay men measured success in numbers of condoms distributed, and numbers of peer educators trained — in an environment where clergy organized anti-gay campaigns, clinics offering services to gay men were vandalized, and violence against men suspected of having sex with men was rife. Now, this report from MSMGF tells how, with technical assistance from the Global Fund, and support from an international collaborative group, civil society in Cameroon put together a Global Fund application reflecting the real needs of Cameroon’s most affected and vulnerable populations. Conditions, however, in a country that has one of the highest reported arrest rates on anti-homosexuality charges worldwide, and where prison conditions fuel HIV and other epidemics, remain challenging and under-supported, this 76 Crimes post reports.

How the Prohibition of Human Trafficking and Sexual Exploitation Infringes the Right to Health of Female Sex Workers – This study, reported in Health and Human Rights Journal began as an attempt to gather information on HIV and HPV prevalence among Cambodian women engaged in sex work, as well as on their access to prevention measures. But as anti-sex trafficking efforts led to laws and police actions that disrupted social and safety networks of women involved in voluntary sex work, researchers found, those women lost access to support systems and protections they needed to access healthcare. This is particularly poignant in the wake of revelations this year that Somaly Mam, a galvanizing icon in anti-sex trafficking crack downs had mobilized her campaign around stories that turned out not to be true. Then, this week, the Phnom Penh Post and Voice of America reported the U.S. Embassy in Cambodia was aware the stories were untrue two years before the rest of us did, but stayed silent because of the support she generated for anti-sex trafficking efforts.

The Reckless Prosecution of ‘Tiger Mandingo’ – This piece by Rod McCollum for The Nation discusses the “clinic to prison pipeline” that HIV criminalization means, particularly for black gay men in this country. The article looks at the case of Michael Johnson, a Missouri men tried by a jury among whom some were reported to believe “homosexuality is a sin,” and sentenced to 60 years in prison on a conviction of “recklessly infecting” one man with HIV, and having sex with four others. McCollum is one of only a handful of American journalists covering international HIV issues, and while this piece examines the scope and inequities of U.S. laws, he also highlights a global problem: The great majority of people infected with HIV are exposed to the virus by people unaware of their own infection. And HIV criminalization laws discourage, rather than encourage ascertaining one’s status through a test. Criminalization is another barrier, then to treatment. In turn, with laws against HIV exposure or transmission in at least 32 states, the status of the United States as a leader in criminalization is a barrier to the world’s largest HIV responder being in a position to provide an example of good policy around the issue.

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