UNAIDS: behind schedule and behind the eight-ball

Doctors Without Borders/Mario Travaini  

One of the United Nations’ Sustainable Development Goals is the disappearance of AIDS by 2030, 12 years away. The end of the epidemic can’t come too soon. As UN Secretary-General António Guterres said for World AIDS Day on December 1, 30 years since it was first celebrated, “More than 77 million people have become infected with HIV, and more than 35 million have died of an AIDS-related illness.”

And they are still dying. In 2017, according to UN statistics, 940,000 died of AIDS-related illnesses and 1.8 million people became infected. AIDS is now the leading cause of death among adolescents (aged 10–19) in Africa and the second most common cause of death among adolescents around the world. 

Is it going to succeed?

The first benchmark is only 13 months away. The year 2020 is the date set for UNAIDS to reach its 90-90-90 goal. This means that 90 percent of all people living with HIV will know their HIV status, 90 percent of all people with a diagnosed HIV infection will receive sustained antiretroviral therapy; and 90 percent of all people receiving antiretroviral therapy will have viral suppression. 

And how’s that going? Not too well.

Notwithstanding the optimistic rhetoric of UNAIDS chief Michel Sidibé, the scorecard was 75-79-81 for 2017. Even in the United States, where the disease has lost much of its stigma and resources are abundant, the figure is about 86-62-49.

UNAIDS knows that this is far from enough. Its 2018 report, Miles To Go, states that:

As we reflect on our progress, some satisfaction is warranted. But on balance, the world is slipping off track. The promises made to society’s most vulnerable individuals are not being kept. There are miles to go in the journey to end the AIDS epidemic. Time is running out.

UNAIDS has set an ambitious target. It will not reach it. It cannot reach it. Humiliating failure is only a few months away. The question that the UN must ask is: what went wrong?

UNAIDS points a finger at the selfishness of donor countries. “Achieving the 2020 targets will only be possible if investments from both donor and domestic sources increase,” it says.

But what if its strategy is wrong? Albert Einstein reportedly said, “The definition of insanity is doing the same thing over and over again, but expecting different results”. But that is exactly what UNAIDS has been doing. It has placed all of its faith in technological solutions like distributing 20 billion condoms a year in low- and middle-income countries and has neglected the principal driver of the epidemic, behaviour.

Back in 2004 a consensus statement by dozens of AIDS expert was published in The Lancet, one of the world’s leading medical journals. It pleaded for more emphasis on modifying behaviour to decrease the prevalence of AIDS spread through sexual contact. It endorsed the so-called ABC approach: Abstain, Be faithful, use Condoms correctly and consistently.

... when targeting young people, for those who have not started sexual activity the first priority should be to encourage abstinence or delay of sexual onset, hence emphasising risk avoidance as the best way to prevent HIV and other sexually transmitted infections as well as unwanted pregnancy. After sexual debut, returning to abstinence or being mutually faithful with an uninfected partner are the most effective ways of avoiding infection. 

This message of abstaining before marriage and being faithful after marriage was ridiculed in the media and by the AIDS establishment.

But with failure of the 90-90-90 goal on the horizon, isn’t it time to take a second look at common sense? If you don’t have sex or if you are faithful to your partner, you won’t get AIDS. You won’t need condoms.

True, sexual behaviour is affected by gender norms and social and economic conditions which are not always under a person’s control. But with the Grim Reaper cutting a swathe through Africa’s teenagers, it’s worth taking the ABC approach seriously. 

Condoms do not work. Or rather, this particular condom may work, but 20 billion won’t. Why not? Because breakage and slippage will happen, even within correct and consistent usage.  Broadcasting the message that condoms offer complete protection gives people an illusion of complete safety, thus leading to the phenomenon of “risk compensation”: earlier onset of sexual relations or to a higher number of sexual partners and other risk behaviours.

Even in the US, the number of new HIV/AIDS cases actually rose slightly in 2017 because young people are becoming complacent, thus leading to the phenomenon of “risk compensation”. "People are reverting to their old practices and not being careful about their behaviour,” Donna Futterman, an adolescent AIDS expert at Montefiore Medical Center in New York told ABC News.

The AIDS epidemic would end if UNAIDS were able to distribute a 100 percent effective vaccine with 100 percent distribution– but that is La-La Land. After decades of working to eradicate smoking, public health authorities are still struggling to stop tobacco consumption and addiction.

It is risk-taking behaviour which fuels the AIDS epidemic. The UN’s strategy does not deal with this effectively. Why?

First, because the AIDS bureaucracy is patronizing. It “knows” that youth can´t defer sex until they find someone to share a lifelong project with. So instead of delivering a sound message of abstinence in sex education, it distributes condoms.

Second, after 30 years of a failed strategy, it is stuck in a rut, repeating the mantra of more condoms, more funding, more medicine. It is inflexible and unimaginative.

And third, its strategies have stopped being truly evidence-based. They are based on an ideology of sexual freedom which is killing young people.

The message of World AIDS Day is that AIDS will be beaten, “will be history”, by 2030. But as every day passes, this is looking more and more like a con job.

As Jokin de Irala, an AIDS expert at the University of Navarra in Spain, told MercatorNet, “As long as public health is used as an instrument of ideological activism, we will never get to the truth of the problem and therefore will never achieve health for all. Real compassion for persons at risk entails both caring for them but also respectfully and kindly telling them the truth about the reality of the risks of certain behaviors, even if condoms are used.”

Michael Cook is editor of MercatorNet


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