Australasian Society for HIV Medicine

At the end of the IAS conference a colleague asked me what my three take home messages were; I had to think for a moment, but not because there was a paucity of information to choose from. Rather, quite the opposite; IAS 2008 was very much better than I expected. The program had substance and many of the presentations had a passion and depth of critique and analysis that was sorely needed. The only caveat I put to this assessment of the conference is that a program so vast and varied is bound to have strengths and weaknesses, and it may just be that I got lucky this time and chose good sessions to attend. However, most colleagues I met and spoke to were of a similar view: this was a good meeting.

There are a few reasons for this I think and they include the venue, the strong content and focus on the absurdly titled ‘marginal populations’ in the HIV epidemic, the input of our colleagues from Central and South America and plenaries that went beyond the general overview of things and tackled needs and challenges head on.

Centro Banamex is a vast conference centre about 20 minutes from central Mexico City, if you beat the morning peak hour traffic. If not, you spent anything up to an hour, or more, getting there. The venue stretches the length of an adjacent race track and is next to one of the sites of the 1968 Olympic Games. It was easy to negotiate and find session rooms. After the labyrinth of Toronto and the excessive time it took to get to sessions, this made a big difference to just how much of the conference program you could get to.

One of my three ‘take- home’ messages is certainly the welcome though belated acknowledgement that while we ignore the needs and rights of so called marginalized populations in the epidemic, we are ignoring the epidemic itself. Governments and donors were criticized for allocating the majority of efforts and resources to general populations, when in fact the epidemic exists in populations people would rather ignore: gay men, injecting drug users, sex workers and their clients. As one speaker stated, while we have neglected to address the epidemic amongst men who have sex with men, we have compromised the entire global response to this virus. On Tuesday morning, Dr Jorge Saavedra gave the Jonathan Mann memorial lecture and began by saying “At last, a plenary on gay men.” Could this really be true? Seventeen bi annual world conferences into this epidemic and we’ve not had a plenary devoted exclusively to sex between men? That’s where it all began; this fact, arguably above all others, has stigmatized HIV globally, and we haven’t put it front and centre till now? As a friend remarked, shame on us. As gay men working in this field we have to accept some of the blame for this. Saavedra, like many other speakers at this conference who addressed needs of most affected populations, emphasized the need to research and understand the social and structural determinants of people’s lives and behaviours if we are to change norms, and reduce the risks, stigma and discrimination these people face and bring down transmission in meaningful degrees.

Appropriately, given its location, there was a strong participation by colleagues from Central and South America. On Wednesday morning, the session, “From Risk to Vulnerability: Caribbean and Global Perspectives” picked up on the theme of better understanding structural drivers of epidemics if responses are to be successful. One of the pertinent points for me from this and other Caribbean sessions was a similarity of elements between the Caribbean and the Pacific: a number of different post colonial spheres of influence across small island nations; an approach by international ngos and donors to them as ‘one region’ that ignores social and cultural differences and determinants; small populations where issues of confidentiality and access to services are critical; mobility between islands and states; strong masculine role models that value risk. I think we might do well to look more closely at some of the responses and research from the Caribbean and consider how it might apply to HIV in the Pacific.

Finally, a very strong theme in many sessions I attended was the absolute need to analyse and use data to support our positions and arguments, particularly to counter the persistent generalised, one-size –fits-all policies of international bodies such as UNAIDS and including WHO’s promotion of provider initiated testing…oh, and counseling. In many places we have gathered data as part of our programs, but we have been less rigorous at analyzing and using that data to better inform our practices and adapt these to the needs and conditions of local populations. This theme arose again and again in many sessions. Global targets may sell well to politicians and leaders, but when, as so often happens, they become the ends that justifies the means, the rights and needs of people with and affected by HIV suffer. Two blatant examples stood out at this conference. A strong human rights program ran throughout the conference and contributed many excellent considerations; however there was a disturbing theme from some quarters that the human rights of people with or at risk of HIV are best interpreted as the ‘right to life’. Now where have you hard this phrase before? By taking this line, advocates immediately assumed the right to make decisions for people with and affected by HIV. I found this position arrogant, presumptive and extremely unsettling. The other instance of ends overriding means was the bizarre campaign, linked to ‘your rights to life’ to have a million people test by December 1. Quite who is driving this I am not sure, but it seemed to be emanating from somewhere in North America. Speakers from the floor took to the microphones after presentations to declare “the ultimate human right is the right to life! So test! Sign up now! 1 million by December 1” At one session, a presenter from the Philippines responded to this ‘fulfil my target’ plea by noting that in fact, in the Philippines at least 1 million people have been tested already. All migrant workers; All against their will; All without access to counseling, support or if they needed it, treatment.

A much better conference than I expected, but still there are individuals and organizations who presume to decide the rights and choices of people we have neglected in order to meet targets. The strongest message I heard at IAS 2008 was that success in prevention, support and care lies in listening to people tell us what they need and working together to provide that. This is evidence based practice.