Advocates from around the world came together at the U=U Global Summit at the 24th International AIDS Conference (AIDS 2022) in Montreal last month to share successes and challenges that continue to hamper full-scale integration of the ‘Undetectable = Untransmittable’ (U=U) message in diverse global contexts.
A central theme was that structural barriers – especially poverty, limited access to treatment and viral load testing, stigma, and widespread inequalities – continue to shape health outcomes. HIV criminalisation is also a formidable barrier in many contexts, and advocates discussed the possible role of U=U in challenging HIV criminal laws.
The Caribbean
Judy-Ann Nugent, from the Jamaican Network of Seropositives (JN+), spoke about challenges in the Caribbean, where there has been limited U=U buy-in from healthcare providers and people living with HIV. She emphasised the role of stigma, poverty, weak health systems and low levels of literacy in limiting treatment uptake and adherence.
“Simply put, if people are not fed, paid – have enough money or food – if their basic needs are not met, taking HIV medication will not be a priority for them,” she said.
[embedded content]Led by activist Michael Ighadoro the entire AIDS 2022 conference stands up for U=U.
However, there has been progress, with 70% of all people living with HIV in the region accessing treatment in 2021 and incidence continuing to drop. According to the latest UNAIDS data, 84% of people living with HIV in the Caribbean know their status, 83% are on treatment and 87% are virally suppressed.
To promote more widespread awareness of U=U, Nugent recommended that U=U messaging is embedded in funding agreements with PEPFAR and the Global Fund so that countries are required to take proactive steps to integrate U=U into national programmes in order to receive funding. PEPFAR’s updated country guidance for 2022 does just this, making extensive mention of the need for countries to integrate U=U messaging along the HIV care continuum.
Latin America
Dr Franco Bova, from the Argentinian organisation Asociación Ciclo Positivo, shared that only 60% of those on treatment are virally suppressed in Latin America, falling far short of the previous 90 and the current 95 targets for viral suppression. It is also one of the regions where HIV incidence has increased since 2020. Bova said poverty and inequality perpetuate new infections and are barriers preventing people living with HIV from achieving viral suppression.
Various approaches have been successful at creating awareness of U=U in the region. In Argentina, activists have worked with community-based organisations, NGOs, universities, and local government to spread the U=U message at large public events, such as Pride, and through social media. Bova spoke about some successful strategies used in other Latin American countries, such as storytelling in Mexico, music videos and concerts in Venezuela and official government campaigns in Brazil. He also highlighted important gaps that make it challenging to speak about U=U at all. For instance, in Peru, the Ministry of Health does not collect any data on viral suppression.
Bova’s organisation is promoting a virtual platform, Indetectable LAC, to bring stakeholders in Latin America and the Caribbean together to share information and to enable better networking in the regions.
The Middle East and North Africa
HIV infections increased by 33% in this region from 2020 to 2021. It is one of only three global regions, along with Latin America, and eastern Europe and central Asia, where HIV is still on the rise. In 2021, only 67% of people living with HIV knew their status, 50% were on treatment and 44% were virally suppressed.
“The Middle East and North Africa is the region where the international HIV community has failed,” stated Arda Karapinar, founder of Red Ribbon Istanbul, Turkey’s leading HIV civil society organisation. He emphasised the distinct contextual challenges in the region. HIV-related stigma, combined with conservative religious attitudes towards sex and limited human rights, present formidable challenges in getting the U=U message out.
However, he also spoke of how passionate local activism can result in change and create awareness. “I know from my own experience in Turkey how sometimes, just one activist from a country or a region, dedicated to creating a change in society for the benefit of all, may be highly sufficient. There are great activists in the region who are defending U=U. They continue to work despite countless risks.”
Karapinar argued that Turkey is uniquely positioned between Europe and the Middle East, and can act as a meeting point and a safe harbour for those hoping to improve HIV outcomes and U=U awareness in the Middle East and North Africa region.
United Kingdom
Activist Fungai Murau spoke about the gaps that still exist in U=U awareness, even in the UK. She shared the story of a young woman who had acquired HIV vertically and had never heard about U=U. “Children who acquired HIV vertically in the UK are being transferred from adolescent clinics to adult clinics without being told about U=U,” she said. “Because we are assuming that paediatric doctors should not be talking to young girls about sex. This is not correct. We need to change that. We need to ensure that by the time they transfer to adult clinics, we have closed that gap.”
She advocated for integration across different healthcare services in the UK. “My HIV clinic is my champion, but my GP or my dentist may not know about U=U.”
Criminalisation in the United States
The US is one of the leading countries criminalising people with HIV under laws ranging from non-disclosure to alleged transmission. Convictions under these laws can result in lengthy prison terms and registration as a sex offender.
[embedded content]Krishen Samuel, Florence Anam and Professor Linda-Gail Bekker discuss U=U in our aidsmapLIVE AIDS 2022 special.
While some activists have argued that U=U should be used as a basis for decriminalisation, Catherine Hanssens, founder of the Center for HIV Law and Policy, spoke about the potential pitfalls of being overly reliant on U=U when advocating for HIV decriminalisation, particularly because of the structural barriers to achieving viral suppression in the US.
Hanssens emphasised that advocacy on behalf of an individual is very different from advocacy for equitable policy and law reform. While it may certainly be beneficial to show proof of undetectability (and subsequent lack of ability to transmit HIV) in individual cases, there might be unintended negative consequences if advocates call for undetectable status to be codified into laws – especially for the groups most likely to be targeted by HIV criminalisation.
U=U stands for Undetectable = Untransmittable. It means that when a person living with HIV is on regular treatment that lowers the amount of virus in their body to undetectable levels, there is zero risk of passing on HIV to their partners. The low level of virus is described as an undetectable viral load.
Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.
Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged.
In HIV, usually refers to legal jurisdictions which prosecute people living with HIV who have – or are believed to have – put others at risk of acquiring HIV (exposure to HIV). Other jurisdictions criminalise people who do not disclose their HIV status to sexual partners as well as actual cases of HIV transmission.
If viral load is a factor in determining whether a person is guilty, it can lead to using a person’s failure to stay in health care or to achieve viral suppression as evidence of guilt. It can also lead policymakers and prosecutors to believe, and argue, that people living with HIV who are not undetectable pose a significant risk of transmission to sexual partners. “Current science makes it clear that HIV is not easy to transmit,” Hanssens said. “And even when transmitted, it is easily survivable with appropriate treatment.”
She argued that efforts to reform HIV criminal laws should be based on whether intent to harm was present or not, and the fact that HIV is a manageable chronic illness with appropriate treatment, not a death sentence.
HALIFAX – The Nova Scotia government says it could be months before it reveals how many people are on the wait-list for a family doctor.
The head of the province’s health authority told reporters Wednesday that the government won’t release updated data until the 160,000 people who were on the wait-list in June are contacted to verify whether they still need primary care.
Karen Oldfield said Nova Scotia Health is working on validating the primary care wait-list data before posting new numbers, and that work may take a matter of months. The most recent public wait-list figures are from June 1, when 160,234 people, or about 16 per cent of the population, were on it.
“It’s going to take time to make 160,000 calls,” Oldfield said. “We are not talking weeks, we are talking months.”
The interim CEO and president of Nova Scotia Health said people on the list are being asked where they live, whether they still need a family doctor, and to give an update on their health.
A spokesperson with the province’s Health Department says the government and its health authority are “working hard” to turn the wait-list registry into a useful tool, adding that the data will be shared once it is validated.
Nova Scotia’s NDP are calling on Premier Tim Houston to immediately release statistics on how many people are looking for a family doctor. On Tuesday, the NDP introduced a bill that would require the health minister to make the number public every month.
“It is unacceptable for the list to be more than three months out of date,” NDP Leader Claudia Chender said Tuesday.
Chender said releasing this data regularly is vital so Nova Scotians can track the government’s progress on its main 2021 campaign promise: fixing health care.
The number of people in need of a family doctor has more than doubled between the 2021 summer election campaign and June 2024. Since September 2021 about 300 doctors have been added to the provincial health system, the Health Department said.
“We’ll know if Tim Houston is keeping his 2021 election promise to fix health care when Nova Scotians are attached to primary care,” Chender said.
This report by The Canadian Press was first published Sept. 11, 2024.
ST. JOHN’S, N.L. – Newfoundland and Labrador‘s chief medical officer is monitoring the rise of whooping cough infections across the province as cases of the highly contagious disease continue to grow across Canada.
Dr. Janice Fitzgerald says that so far this year, the province has recorded 230 confirmed cases of the vaccine-preventable respiratory tract infection, also known as pertussis.
Late last month, Quebec reported more than 11,000 cases during the same time period, while Ontario counted 470 cases, well above the five-year average of 98. In Quebec, the majority of patients are between the ages of 10 and 14.
Meanwhile, New Brunswick has declared a whooping cough outbreak across the province. A total of 141 cases were reported by last month, exceeding the five-year average of 34.
The disease can lead to severe complications among vulnerable populations including infants, who are at the highest risk of suffering from complications like pneumonia and seizures. Symptoms may start with a runny nose, mild fever and cough, then progress to severe coughing accompanied by a distinctive “whooping” sound during inhalation.
“The public, especially pregnant people and those in close contact with infants, are encouraged to be aware of symptoms related to pertussis and to ensure vaccinations are up to date,” Newfoundland and Labrador’s Health Department said in a statement.
Whooping cough can be treated with antibiotics, but vaccination is the most effective way to control the spread of the disease. As a result, the province has expanded immunization efforts this school year. While booster doses are already offered in Grade 9, the vaccine is now being offered to Grade 8 students as well.
Public health officials say whooping cough is a cyclical disease that increases every two to five or six years.
Meanwhile, New Brunswick’s acting chief medical officer of health expects the current case count to get worse before tapering off.
A rise in whooping cough cases has also been reported in the United States and elsewhere. The Pan American Health Organization issued an alert in July encouraging countries to ramp up their surveillance and vaccination coverage.
This report by The Canadian Press was first published Sept. 10, 2024.
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