By Nabila El-Bassel

The advent of World AIDS Day on December 1st provides a chance to reflect on how far we’ve come in combatting HIV/AIDS since the world’s first cases were reported over thirty-five years ago—and how far we still need to go to reach the UNAIDS goal of ending this pandemic by 2030.

As a scientist at Columbia working in HIV research for over twenty-five years, I have witnessed a great deal of progress. Advances in both clinical research and prevention science have led to a significant reduction in transmission of HIV around the world. Now, thanks to pre-exposure prophylaxis (PrEP), people at high risk for HIV can lower their chances of getting infected. Mother-to-child transmission of HIV has been substantially reduced in many parts of the globe through early and effective antiretroviral treatment (ART). And with the finding that circumcised men are 60 percent less likely to become HIV infected, more than a million men have opted for medical circumcision.

However, all of this good news masks a growing problem. UNAIDS has set the ambitious goal of achieving “90-90-90” targets by 2020—which call for 90 percent of people living with HIV to know their status, 90 percent of those diagnosed to start and stay on ART, and 90 percent of those on ART to have viral suppression. As we approach the year 2018, the facts remain grim.

According to a 2017 UNAIDS report, an estimated 30 percent of people living with HIV do not know that they have been exposed to the virus and have become infected. An estimated 18.8 million worldwide do not have access to antiretroviral treatment. Only around 10 percent of high-risk individuals are actually receiving PrEP.  While we have witnessed a 16% decrease globally since 2010 in the number of new HIV infections each year, Central Asia and Eastern Europe have seen a 60 percent increase in the number of new HIV infections.

Thus for 2030 to be a realistic goal, I would propose the following five steps to connect those left behind to HIV testing, treatment and care, both within the United States and globally.

1) Address the root causes of HIV transmission.

One day, a gay man of color approached a member of our research team at the Columbia University Social Intervention Group (SIG) and said, “For the first time, I feel like people here see me as a person, not just as someone who might give you HIV/AIDS.”

Stigma, discrimination, insufficient access to comprehensive sexuality education, racism, heterosexism, poverty, unemployment, and discriminatory government legislation—all of these prevent key affected populations from obtaining information and prevention services and medical treatment that will protect them and their sexual partners from HIV transmission. Particularly in a political climate where many of the most marginalized populations are being stigmatized and ostracized, we must work to end this situation by building sophisticated, culturally-congruent programs for those who need to get tested to know their status, and for high-risk individuals who could avoid a positive diagnosis through use of the preventative PrEP.

2) Provide access to couple and community-based prevention tactics beyond the individual.  

Early in my research career I noticed an important piece missing from HIV prevention for individuals. Often, women bore the responsibility for protection from HIV transmission, leaving her male partner out of the equation. To address this gap, our research team at SIG developed and conducted the first couple-based HIV intervention called “Connect.” The results were so powerful that the Center for Disease Control adapted our intervention to diverse groups and cultures and disseminated it globally.

Approaches like this promote a couple’s mutual responsibility for engaging in safer sex behaviors and create a safe environment where women can raise concerns about barriers that may increase her risk of HIV transmission such as partner violence, sexual coercion, refusal to use condoms, or issues of reproductive health. Further, group-level interventions, such as one we developed for drug-involved female offenders under community supervision, helps these women increase condom use and decrease HIV transmission and other STDs.

3) Target regions of the world where HIV rates are rising.

As mentioned, while global cases of HIV are decreasing, in Central Asia they are on the rise. Over ten years ago, the Social Intervention Group launched the Global Health Research Center of Central Asia (GHRCCA) to serve some of the most marginalized and vulnerable populations who suffer from HIV/AIDS. We work with the governments of Central Asian nations to provide funding and resources to address structural barriers that prevent people who inject drugs from accessing and engaging in HIV care, involving local communities, NGOs and the police in implementing the intervention for this affected population.

During the next few years, we need to see more global efforts of this kind in the hardest-hit regions, both to reduce HIV incidence in these countries and to prevent further global spread.

4) Use multiple strategies in prevention interventions and address structural causes. 

One or two strategies alone will not be effective in reducing the HIV/AIDS pandemic. Ideally, prevention programs would always include a combination of biomedical, behavioral, and structural strategies. Biomedical interventions consist of ART, PrEP, male circumcision, access to syringe exchange programs, and medical interventions to prevent mother-to-child transmission. Behavioral interventions comprise drug use and sexual risk reduction and comprehensive sexual education. Structural interventions include poverty alleviation and reductions in stigma, gender inequalities, and sexual violence.

In Central Asia, for example, many sex workers are HIV positive but continue exchanging sex for money or drugs even when they know they are infected. Accordingly, GHRCCA adapted a structural intervention for our NOVA Project to support behavioral change and income-generating activities for sex workers in Kazakhstan. We provided micro-finance and job skills training programs to empower women and reduce their reliance on sex work. In another project, we worked with 24 local needle-exchange programs and trained nurses and outreach workers to deliver HIV services and help motivate their clients to stay in treatment and link them to care.

5) Allocate more funding to fight the HIV epidemic.

We have made tremendous progress in the AIDS epidemic. In part due to this progress, funding is declining, and key populations tend to be left behind whenever funding is cut or diverted through political will. In order to end the AIDS epidemic by 2030, governments must continue to prioritize the allocation of funding for those who are at highest risk of becoming infected with HIV and transmitting the virus to others.

* * *

Taking these five steps will help put us on track to ending the pandemic by 2030. And now I invite you all to join me on November 30th, where five global AIDS researchers will share their views on how we can address the political and social barriers these populations face, both in the US and abroad.

Re: PrEP access: UNAIDS, 2017, Giler, RM, 2017, CDC, 2016
Re: Funding declining


Dr. Nabila El-Bassel is the Willma and Albert Musher Professor of Social Work at Columbia University’s School of Social Work. She leads the Social Intervention Group and the Global Health Research Center of Central Asia, which have a research mission of targeting women and girls, along with other key underserved populations, in the United States and Central Asia. More recently, she has been stewarding a Columbia University-wide initiative called ASPIRE: Advancing Solutions in Policy, Implementation, Research, and Engagement for Refugees.

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  1. Mary Lutz says:

    With a commitment that spans decades, Dr. Nabila El-Basel has had substantial impact on the HIV epidemic through her research investigations of risk behaviors and program evaluations. One of the first researchers to recognize issues related to HIV-discordant couples, her authority in the field is unquestioned and speaks to the need to combat ignorance, prejudice and stigma through global and local education and compassion.