AIDSImpact 2019 special issue – Promises to keep and miles to go … 

The 14th AIDSImpact conference was held in London in July 2019. The rallying call for this meeting was “Promises to keep and miles to go … ”. The meeting provided an opportunity to look forward, bringing an essential dialogue at a crucial time in the epidemic, and a time to reflect, update, plan and to reaffirm the promises made and the many needs still to be fulfilled.

Delegates from 49 countries included academics, caregivers, researchers, policymakers, activists, user groups and programmatic leaders. The conference was coordinated by AIDSImpact, a non-profit UK-based charitable organisation which ensured that over a third of delegates attending did so with support.

The global community is still facing a virus whose spread is often determined by psychosocial drivers. As the current Coronavirus, Covid-19, epidemic highlights, stigma and discrimination remain part of the picture and the psychological ramifications of the epidemic need as much understanding as the virological challenge. Human behaviour, reaction and understanding are key, and the educational and prevention roles played by all are crucial ingredients for progress. The HIV epidemic has shown that the response requires multiple perspectives and actors; activists and health care workers together with those affected by HIV can provide a model for future global epidemics.

The conference noted advances but also highlighted that the world still has much to learn and to do. The success achieved in recent years in terms of effective treatment of HIV infection and also in its prevention by means of PEP and PrEP is very encouraging, but can lead to a sense of complacency when in fact there are still major “Promises to keep and miles to go”. These include the increasing problems of ageing with HIV, the mental health impact of the infection, the consequences of chemsex and IDU, and the complexities of successfully implementing biomedical prevention. Key populations have specific needs and a comprehensive response has to accommodate and understand these. Many groups may not be recognised, or overlooked, from young children to those ageing with HIV, from sex workers to those who inject drugs; women, men, MSM, all need to be understood and provided for if the global epidemic is to be addressed.

This special issue represents a selection of papers from the conference where approximately 400 oral, 300 poster, and 5 video presentations covered a very broad range of global considerations. It provides a brief insight, and although not comprehensive in any way, it includes diverse papers, with the shared theme of addressing the biopsychosocial drivers of the HIV epidemic and a taster of the vibrant meeting.

Stigma continues to be a major hurdle – directly and by contemplation, through the misery and burden, it causes. The effects of stigma become more complex as it contributes to poor access to treatment, care, support and prevention. There is a close link between stigma and mental well-being and quality of life. Stigma is the silent killer in the HIV epidemic, affecting not just those living with HIV, but also those who are not infected, and thus less able to access the very treatment they require for all levels of prevention. During the conference, a number of studies examined the challenges and problems associated with stigma – such as the impact of stigma on psychosocial well-being (Yang et al., 2020) and interventions to reduce health care provider stigma in India (Ekstrand et al., 2020).

As PrEP is making its way into the mainstream of preventive options, we face new emerging challenges worldwide in shaping the access, uptake and experiences of PrEP use among specific key populations. Access to PrEP needs to be increased and made attractive for those populations with current low uptakes, such as the youth, transgender persons, ethnic minorities, and those living in rural areas. We distinguish between pull and push strategies. On the pull side, we need to empower key populations, by, for example, increasing the response efficacy concerning PrEP use and include self-support interventions to increase the self-efficacy of PrEP uptake. On the push side, we need to make PrEP globally available and easily accessible throughout all communities. In addition, the normative acceptance of PrEP use as an HIV prevention tool needs to be significantly expanded. In this special issue, 5 papers from Belgium, France and Malawi addressed questions about PrEP including results from a large Internet European study. (Kidman et al., 2020; Puppo et al., 2020; Kelly et al., 2020; Annequin et al., 2020; Nöstlinger et al., 2020).

A paper on ageing with HIV (O’Brien et al., 2020) explored the lessons from rehabilitation in chronic disease to the healthy ageing with HIV population. Co-morbidities and syndemics such as Hepatitis C among men, transwomen and transmen (Grov et al., 2020), and HCV among people with HIV who use drugs in Vietnam (Li et al., 2020a) are important to consider. As people age with HIV, multiple comorbidities need to be understood.

Breaking evidence presented at the conference provided new knowledge towards achieving the proposed 4th “90” (adding 90% experiencing the optimal quality of life for people living with HIV to the original targets of 90% diagnosed, 90% on treatment and 90% with viral suppression) by 2020. Data from the USA revealed higher sexual trauma among women living with HIV compared to men, and that such trauma was associated with poorer quality of life (Harrison et al., 2020).

That care and capacity building are vital components of a strong HIV response, was clearly set out in different settings such as in Russia (Amirkhanian et al., 2020) or by the use of a simple, person-centred community-based intervention in Ghana (Abboah-Offei., 2020), that provided evidence that a training course and mentorship for existing staff has the potential to improve communication and perceived relevance of care. A study from China reported major concerns with the quality of care, discrimination perpetrated by providers, and poor utilisation of community-based organisations in services that should be working to optimise the quality of care (Li et al., 2020b).

Caregivers have needs themselves – with examples of support for the supporters (Hay et al., 2020) and capacity building among HIV Activists (Greenhalgh et al., 2020). Disclosure remains a challenge with a pensive paper exploring the balance between need and want (Lim et al., 2020). Four papers on prevention explored some examples of the multiple issues involved, such as the potential of injectable medications (Carillon et al., 2020), protected anal intercourse (Duchesne et al., 2020), an mHealth prevention programme in South Africa (Visser et al., 2020) and risk reduction among MSM (den Daas., 2020).

There is both increasing knowledge of risks and new promises for solutions. A paper by Zhao Gu et al. (2020) examines brain oscillation amongst children who are not infected with HIV but were orphaned by parental AIDS. They find differences in brain functioning that are related to higher levels of learning and behavioural problems, suggesting a need for increased support at school and with peers. A study using DHS data from Zambia by (Mwaba et al., 2020) to explore factors associated with adolescents testing for HIV finds being older, female, more educated and married or partnered and with greater HIV knowledge and older sexual initiation were more likely to have tested. Thus, there is still a substantial need for testing support amongst the most vulnerable groups. Violence and victimisation are hazards experienced by adolescent mothers (Gebrekristos et al., 2020) and maternal mental health is related to child cognitive development in a Zimbabwe study of caregivers living with HIV and their children (Mebrahtu et al., 2020).

HIV testing still marks the entry into the HIV cascade and the issue of self-testing in Malawi was studied (Lora et al., 2020). Encouragingly, a new meta-analysis finds that social support is a key component to ART adherence – with higher rates of adherence and viral suppression in community-based settings (Nyoni et al., 2020). However, a study from Hay et al. (2020) in the UK, found that interventions based on new technologies and social media may discriminate according to socioeconomic status, and therefore delivery of social support must also take account of the effects of social disadvantage on access. If we are to develop evidence-based strategies that encourage people to enter and remain in routine HIV care, such data will assist us to understand patients’ concerns, identify the challenges in delivery, and implement feasible and acceptable interventions.

The AIDSImpact conference prides itself on high-quality content, but also provides excellent opportunities for sharing, networking and inspiration. The conference was the culmination of input by a wide variety of individuals and organisations. The scientific committee provided ongoing support, including peer reviews of the scientific contributions and planning the conference structure. Much of the input was through gracious support, volunteer contributions and dedication to the ideals of dignity and knowledge. The Organising Committee would like to thank all those who supported the London 2019 conference. In particular, Ari Sherr, who coordinated a small army of local volunteers, Yoni Sherr for technological expertise, Kathryn Roberts and Veronica Murrey for enabling support, the Local Committee for their knowledge and helpful suggestions; the international board for guidance, wisdom, direction and endeavour. Such gatherings could not be possible without the support of sponsors, large and small, among whom we wish to thank the following:.

Educational sponsorship from our major donors, Gilead and Viiv Healthcare was pivotal. Wide support was given in many different forms from AIDSCare, Routledge, National AIDS Trust UK, Human Sciences Research Council (South Africa), CeSHHAR Zimbabwe, RTI International, The London School of Hygiene and Tropical Medicine, University College London, Avert, Terrence Higgins Trust UK, National AIDS Manual, AIDSMap, The Bill and Melinda Gates Foundation, HIE (Health Innovation Ecosystem). Artistic insights inspired our audiences from The Catwalk and Chiva (Life Growing Up), Joyful Noise choir, and Light Fantastic who truly were fantastic.

Disclosure statement

No potential conflict of interest was reported by the author(s).

ORCID

Lorraine Sherr http://orcid.org/0000-0002-5902-8011

Richard Harding http://orcid.org/0000-0001-9653-8689

Udi Davidovich http://orcid.org/0000-0002-4921-0346

Lucie Cluver http://orcid.org/0000-0002-0418-835X

Bruno Spire http://orcid.org/0000-0002-3546-8020

Barbara Hedge http://orcid.org/0000-0002-5637-0516

Jose Catalan http://orcid.org/0000-0003-4636-0012