The AIDS conference 2018: a critical moment

International AIDS conferences have been important markers in the AIDS response since their inception in 1985. Occurring every two years, they bring together researchers, advocates, policy makers, programme implementers, funders and community leaders from all corners of the globe for discussion, debate, and importantly, the introduction of new evidence concerning all aspects of the AIDS response, from basic science to what makes for good policy and effective advocacy. There really is no other gathering quite like it, encompassing not only plenaries and abundant scientific sessions, but scores of pre-meeting and satellite sessions, as well as marches, demonstrations, music and theatre. With one of the authors (SG) having attended every one of these conferences since the last time this conference was held in Amsterdam in 1992, we note that the tenor changes each time, reflecting not only advances in science, but on-the-ground realities and larger geopolitical concerns.

The 22nd International AIDS conference took place 23–27 July in Amsterdam, Netherlands.¹ According to conference publicity, more than 16,000 people from over 160 countries attended the event, and it certainly felt like it as we seemingly took over not only the conference facility but much of the city of Amsterdam. While much of the information presented can ultimately be found online, the reason so many of us continue to attend is for what these gatherings tell us, not only about HIV, but about the state of the world we live in. This year was no exception. As populist and right-wing movements grow across all continents, the solace and good feelings that came not only from seeing old friends, but so many like-minded people sharing key concerns and willing to truly engage with one another on the hard questions we face, cannot be over-stated. In our RHM pages,² using video clips, we share the voices of some of the participants at the conference, who gave us insights and thoughts on the conference. They articulated their concerns regarding targets being off-track for the prevention and treatment of HIV, and about a lack of resources overall, including for specific areas such as concerns about the realisation of sexual and reproductive rights for trans people.³ The problems of discrimination and stigma came up repeatedly, as did developments regarding criminalisation. We reiterate and expand on some of these important themes below.

Many things were heartening to see. First, the record number of young people from all regions of the world, not only as participants, but as thought leaders with platforms from which they could speak and be heard at every turn. Second, the unprecedented attention to the harmful effects of HIV criminalisation, including a consensus statement from leading HIV scientists. The consensus recommends the use of up-to date scientific evidence in criminal hearings related to HIV and reaffirms that good scientific and medical evidence can help to limit unjust prosecutions.⁴ Do watch RHM’s video interview with Justice Edwin Cameron from South Africa, speaking on this topic.⁵ The overwhelming attention to U=U (undetectable equals untransmissible),⁶ shines a light on the links between science, rights, advocacy and attention to issues beyond the biomedical in ways that have not been seen since the 2012 release of the report of the Global Commission on HIV and the Law.^7,8 U=U is a global campaign launched in 2016, giving a clear, scientifically sound message that people living with HIV who are virally suppressed cannot sexually transmit the virus to others.⁶

Also on the positive side, access to treatment appears to be increasing in all corners of the world, even though people who are hardest to reach and whose behaviours or activities are criminalised, remain those least likely to access treatment. It is sobering that there are an estimated 1.8 million people around the world who were newly infected in 2017, and nearly 1 million people who died.⁹ 1.8 million people newly infected, 1 million people who died! Given established prevention and treatment initiatives, these numbers are simply unacceptable, and reflect how even proven strategies are failing to reach those who most need them. All this to say that even as there are many advances, HIV remains a major health, rights and development issue in all parts of the world. At the conference, it is of incredible concern that presentation after presentation made clear that treatment scale up has plateaued and is far short of what is needed to meet UNAIDS 2020 treatment goals.¹⁰

Perhaps of most concern, with impacts on every dimension of the AIDS response, was the news that after several years of flat funding, more than half of major donor governments have decreased their HIV commitments, with no new significant commitments from international funders forthcoming. With an estimated US$6 billion shortfall reported at the meeting, it isn’t rocket science to realise that if the funding gap is not closed quickly, there will be millions more people unnecessarily infected, let alone who will suffer and die. A major concern going forward then is not only the amount of money that is needed but how it will be spent. With shrinking resources, vigilance will be needed to ensure monies are not limited to biomedical interventions, but that sufficient attention is given to the larger legal, policy, social and human rights issues that may not be as immediately obvious as an HIV testing kit or a dose of anti-retro viral treatment. These broader aspects are necessary to bring the epidemic under control and ensure people can live healthy lives and must also be addressed to ensure biomedical and other interventions are effective.

Looking forward, there are two overriding considerations in any reflection for the future. First, concerns the question of Michel Sidibe, the director of UNAIDS, and the prospect of UNAIDS more generally. Corridor discussions were filled with what seemed to be fairly unanimous agreement that Sidibe’s time had come and that he must resign, not simply because he failed to adequately address the cases of sexual harassment brought to him involving UNAIDS staff members, but because of his apparent inability to truly hear and understand the global call for him to resign as necessary, not simply because of his actions (or lack thereof), but for the good of UNAIDS and the AIDS response more generally.

The second, ironically, concerns the location of the next international AIDS conference two years from now. This is the second AIDS conference to take place in Amsterdam. The first, in 1992, was put together in just one year, as the conference was moved out of the US, because of its policies to ban HIV-positive travellers from entering the country. The next conference in 2020 is meant to take place in California. Noting that one of the authors is from California, a US state that is doing all it can to distinguish itself from the horrors imposed by the Trump administration in so many domains, there are many reasons to applaud the decision to hold the conference in California. Yet, there is no question that internal US political reasons for having the conference in CA are insufficient. The conference must be accessible to all those who want to attend, especially people coming from communities and countries most impacted, and for that reason the conference must be moved.

As with so many issues, we are at a critical moment in the AIDS response. We must move forward, despite increasingly conservative ideologies around the world, and ensure that two years from now we are able to reflect on progress achieved – wherever the conference physically takes place, and whoever will serve as the head of UNAIDS.