By Peter Reiss, Local Scientific Chair of the 22nd International AIDS Conference (AIDS 2018)
We are at a critical juncture in the HIV response. The biggest impediment to AIDS is leaving people behind. If we are serious about ending AIDS, we must ensure that the incredible achievements we have made reach all settings and populations.
In July 2018, Amsterdam will host the 22nd International AIDS Conference (AIDS 2018) under the theme, Breaking Barriers Building Bridges. This is only fitting because while Amsterdam’s epidemic is much less severe than in many parts of the world, our city in many ways highlights how values of tolerance and respect for human rights are essential to an effective AIDS response.
When AIDS first emerged in Amsterdam in the 1980s, the early signs were concerning. New cases of AIDS were rapidly increasing, especially among gay men. Transmissions were also occurring as a result of injecting drug use. And a large and vibrant gay community was understandably concerned that public health efforts would attempt to roll back hard-won civil rights gains in the name of prevention.
As one of the most free, open and tolerant cities in the world, Amsterdam opted not to adopt the coercive stance recommended by some during the epidemic’s early years. Instead, our city leveraged, rather than suppressed, our local culture of freedom, inclusion and tolerance. Gay communities demanded a seat at the table of AIDS-related decision making, and soon gay men were in large measure leading and shaping a response to an epidemic that primarily affected gay men.
Amsterdam grounded its AIDS response in scientific evidence and worked to elevate common sense and inclusion over prejudice and scapegoating. After evidence emerged of rising HIV infections among people who use drugs, Amsterdam created the world’s first needle exchange programme. Today, HIV transmission through injecting drug use has been virtually eliminated in Amsterdam due to the city’s continued commitment to this approach. Amsterdam’s experience offers lessons that are especially valuable for Eastern Europe and Central Asia, where new HIV infections have increased by an alarming 60% since 2010, largely due to the failure to make harm reduction services readily available.
Consistent with the ethos of Amsterdam, the city has remained a beacon for human rights and tolerance throughout the history of the AIDS response. In 2001, the Netherlands became the first country in the world to recognize same-sex marriage. At the United Nations and in other international forums, the Netherlands has used diplomacy to champion the right of every person to live in safety and dignity.
More recently, Amsterdam has signed on as a Fast-Track City, with the aim of ending the city’s epidemic once and for all. We have already seen major progress towards this goal with the number of new diagnoses in Amsterdam falling by approximately 50% since 2010. This plunge in new infections reversed trends seen in the previous decade when new HIV infections were increasing among gay and bisexual men. It is believed that these more recent, favourable trends in the response stem from improved HIV treatment outcomes. In 2015, 79% of the estimated 6,150 people living with HIV in Amsterdam were virally suppressed, a level that exceeds the ultimate outcome for the 90-90-90 target (73% viral suppression).
These gains are encouraging, but getting to the “end game” of AIDS in Amsterdam will not occur overnight and will require years of hard work. We will need to keep people in care for decades. And we will also need to expand utilization of key prevention methods, such as pre-exposure prophylaxis (PrEP), as we have done for treatment. In the case of PrEP, as with other prevention methods, scaling up is slow and challenging as we need to link PrEP to those who need it most and help them take it regularly.
In Amsterdam, nearly 400 people living with HIV have yet to be diagnosed. Late diagnosis of HIV can worsen long-term treatment outcomes, increase risk of death or hospitalization, and contribute to continued transmission of HIV. Amsterdam’s challenge mirrors Europe’s broader challenge. Across the European region, nearly half of new HIV diagnoses are among people who are diagnosed late in the course of infection, years after becoming infected and only after the virus has seriously damaged the body’s immune system.
We have seen successful outcomes when we have addressed this by making better use of data to intervene with appropriate, community-centred strategies for building demand for testing services in underserved communities and offering testing in ways that are sensitive and tailored to each community’s needs. Over the past few years, our city-wide health campaign targeting gay men to encourage early testing and diagnosis has led to increasing the number of gay men who are entering care at an early stage of HIV infection.
Although we still have progress to make, we need to remember that it’s not just about Amsterdam, or even the Netherlands; it is about a global commitment to work both within and beyond our borders. We are, as the theme of the 1996 International AIDS Conference in Vancouver emphasized: One World, One Hope. We truly are all in this together. If we end AIDS for some but allow the epidemic to rage on among others, we will have failed.
This World AIDS Day, join the AIDS 2018 movement and let us all pledge to remain true to the principles that have defined the AIDS response. As I’ve said before, every new diagnosis is one too many. We will leave no one behind.