I am writing this letter from the XIX International AIDS Conference in Washington, D.C. It has been 22 years since the International AIDS conference was held in the United States (mainly due to the unwillingness on the part of the United States to grant visas for HIV-infected individuals- only recently lifted).
Here 25,000 scientists, policy makers, health and education ministry officials, advocates, and activists from around the world are gathered with a renewed determination to stem the tide of this epidemic. Medical advances, improved access to care, prevention initiatives, and our nation's revived determination are all good signs, but as a culture we will need to shift our perspective to stop the spread of HIV.
Recent news of pre-exposure and post-exposure prophylaxis treatment has been encouraging. Last week, the Food and Drug Administration (FDA) approved Truvada (emtricitabine and tenofovir disoproxil fumarate) for Pre-Exposure Prophylaxis (PrEP) to prevent the spread of HIV to high-risk, healthy individuals. Other similar preparations are under investigation and HIV therapeutic drugs are being developed for prophylactic use. These drugs are very costly and require individuals to adhere to rigid compliance in order to be effective.
Also, last week, Health and Human Services (HHS) Secretary Kathleen Sebelius announced nearly $80 million in grants to increase access to HIV/AIDS care across the United States. The funding will ensure that low-income people living with HIV/AIDS continue to have access to life-saving health care and medications. This effort stemmed from President Obama's determination to create an AIDS-free generation.
In addition, there is reduced stigma for HIV infected individuals. The CDC just launched "Let's Stop HIV Together" a new campaign that is part of the 5-year initiative started in 2009 to reduce stigma around HIV and advocate for more access to testing and treatment "Act Against AIDS."
The United States, through its National AIDS Strategy, has outlined a "prevention" strategy through early detection and early treatment, focusing on vulnerable populations.
These new strategies are overdue. In the United States, we continue to experience 50,000 new infections a year. And, there are serious health disparities. People of color, youth, and sexual minorities are much more likely to become infected than other groups.
Over the last 30 years, where have we failed? We know that HIV is still mostly spread by sexual behavior. Yet, the disease is rather easily preventable through the use of condoms. Condoms are reasonably inexpensive, potentially readily available, easy to use, and highly effective in preventing HIV and other sexually transmitted infections (and unintended pregnancy). What a bargain! So, why are they not used more?
Behavioral HIV prevention strategies and interventions have tried to get people to reduce risky sexual behavior and promote condom use. While reasonably effective, there needs to be continuous implementation of these interventions, and they are costly. Investment in prevention strategies has always been difficult. With the recently adopted National Prevention Strategy, National AIDS Strategy, and the Affordable Care Act, there is new hope that these investments will be made.
But a fundamental problem remains. We remain a sexually dysfunctional culture. We live in a culture that is still uncomfortable talking about sex and sexuality in a mature and honest fashion. We continue to debate and hold back on providing comprehensive sexuality education. It is very clear that what distinguishes the United States from other developed countries in sexual health indicators is the existence of (or lack thereof) early and sustained comprehensive sexuality education. When kids are educated early they grow up to be more comfortable with talking about sexuality, more likely to be sexually responsible, and have lower rates of sexually transmitted infections and unintended pregnancies. They contribute to a cultural climate that is sexually healthy. That climate then insists on comprehensive sexuality education and thereby creates a cycle of healthiness. In the United States, we are still caught up in a negative and unhealthy vicious cycle. The goal of the Joycelyn Elders Chair in Sexual Health Education is to reverse this negative cycle.
Both Walter Bockting and I, along with over 600 delegates from around the world attended the "Global Forum on Men who Have Sex with Men (MSM) and HIV" as part of the International AIDS Conference. While 60% of new infections around the world are found in gay and bisexual men, only 2% of the global prevention budget is directed at this group. Also, transgender individuals are an overlooked population at major risk for HIV, due in large part to continued stigma and discrimination. This disparity in funding efforts represents the institutionalized stigmatization, heterosexism, and homophobia that exist in our cultures as well as in our public health systems. If we do not attend to this population as well as other marginalized populations such as sex workers and drug users, we will fail in our efforts to stop the spread of infections.
Walter Bockting and I also attended two important meetings pertaining to transgender health and HIV. The first was called "The Great TRANSformation: Towards a Holistic Approach for Healthier and Happier Trans Communities in Latin America and the Caribbean." Walter Bockting talked about "Avenues for Action for the Provision of Care and the Promotion of Well-Being." This symposium represented some of our ongoing work with the Pan American Health Organization in developing and finalizing a "Blueprint for the Provision of Prevention and Care for Transgender Individuals through Latin American and the Caribbean." We also participated in a second special session on "Addressing Stigma in Transgender & Other HIV-Vulnerable Communities" sponsored by the Human Rights Campaign, the International Association of Physicians in AIDS Care, the International Treatment Preparedness Coalition, and the Pan American Health Organization.
As the current Chair in Sexual Health, I was happy to participate in this conference and push a sexual health agenda in HIV prevention. I was very pleased that the Program in Human Sexuality was a co-sponsor along with the Pan American Health Organization and the Centers for Disease Control and Prevention of a satellite session on "Addressing Sexual Health and Evidence-based Sexual Health Education: Evolving Opportunities." I spoke on "Towards a Broader Vision of Sexual Health in the New Millennium." I emphasized the need for a broad sexual health approach to stem the tide of the HIV epidemic, which emphasizes a positive and respectful approach to sexuality and sexual expression throughout the lifespan and that acknowledges sexuality as a basic and fundamental aspect of our humanness and that the pursuit of sexual pleasure is natural and desirable. A broad sexual health approach combats sexual coercion, shame, discrimination, and violence. But a sexual health approach must go beyond venereology and, on an individual level, promote positive sexual identity and esteem, honest communication and trust between partners, the possibility of having pleasurable, fulfilling and satisfying sexual experiences, taking responsibility of the consequences of one's sexual choices and their impact on others, and optimizing reproductive capacity and choice. At the community level, it is achieved through access to developmentally appropriate, comprehensive and scientifically accurate sexuality education, clinical and preventative sexual health services, and respect for individual differences and diversity and a lack of societal prejudice, stigma, and discrimination.
The Chair in Sexual Health will continue to work with our faculty at PHS and with partners around the world to promote a sexually healthier culture - not only to address the sexual problems in the world -- but to advance the opportunity for everyone to lead sexually healthier lives which are pleasurable and satisfying.
Eli Coleman, PhD
Professor and Director
Academic Chair in Sexual Health
PHOTO: Omar Banos (Impacto at AIDS Project Los Angeles), Rafael Mazin (Pan American Health Organization), and Eli Coleman