For me this is something of an anniversary . It is almost 40 years to the month that I came to Geneva to discuss an issue causing increasing alarm and concern throughout the World – HIV and Aids. I still have the records of that meeting . As my wife will confirm I do not throw away papers lightly . At that moment in 1986 some 36,000 cases of Aids had been reported from 75 countries – but as the excellent Jonathan Mann said (with considerable understatement ) many reports were not reliable . The WHO’s estimate of the scale of the epidemic was 100,000 cases and forecast a toll of anywhere between 5,000 to three million deaths within five years . We were at the foothills of one of the worst epidemics to effect the world .
What I remember most clearly of those years was our impotence in helping people who had contracted HIV. There were no drugs; no medicines. Contracting HIV was almost certainly a death sentence. I remember at the beginning of December going to Berlin and meeting a consultant who had lost 8 patients in the last 2 weeks. Everywhere I went I met doctors and nurses working under the strain of knowing that there was nothing they could do but provide the best possible care- care not cure .
The United States who had one of the most serious challenges was a prime example of what was happening . In Los Angeles I went to the leading hospital there. There was one large ward which was full to capacity with young men all of whom were infected. I was introduced there to a shipping clerk and for the benefit of the television cameras we were pictured shaking hands. The idea was to show that Aids was not infectious and could not be contracted in the same way as the common cold. It was the prelude to a much more influential photograph which went around the world of Princess Diana doing the same a month or two later in a London hospital. The aim was to fight some of the ignorance and prejudice which surrounded this whole area.
For those who were already infected the challenge was to provide the best possible care and I pay tribute to the doctors and nurses who so often provided this . The much bigger task in terms of numbers was to prevent the many millions of others in the public from contracting it . You might have thought that such a policy of prevention – using all the devices of modern communications then available –television, posters, newspaper advertisements - would have been universally welcomed. Not so I fear. There were counter arguments . A popular argument was that this was not a public health crisis but a so called moral one . Homosexuality was condemned ; and much of the public health measures with it . The chief Rabbi in Britain said the campaign “tells people not what is right but how to do wrong and get away with it – like sending people into a contaminated atmosphere but providing them with gas masks and protective clothing, or instructing thieves how to escape being caught”. A much supported solution on both sides of the Atlantic was that all those infected should live in total isolation – flying in the face of everything we knew even then about how HIV was passed on .
Another policy was to ignore that there was a problem at all. When I went to the United States no one I met could recall a single word that President Reagan had uttered about the challenge of Aids. In Britain Mrs Thatcher was better than that but was not an enthusiast of my health campaign – I could put it stronger than that. In the main we managed to go around the Prime Minister. Broadly she took the view that the publicity was introducing the subject to many teenagers who new nothing of it. If in the implication was that this would lead to an increase in infection it was wide of the mark – not only HIV came down but so did sexually transmitted disease generally. Giving some proof oft the effectiveness that advertising can have.
Now the easiest thing for me to say at this point is that all this is just history . But it would not be true . First and most obvious the prejudice - not just of the public but of political leaders and politicians - continues to this day . Why else do we have a position where 68 countries criminalise gay men - a disastrous policy if your aim is to reduce infection. It is an obvious barrier to men coming forward for testing.
But for those of us campaigning against such restrictions seem some encouraging signs. I remember being in India a few years ago and being told that Britain was responsible for the prejudice against the gay population and there was some justice in the charge then. But look at the position in Britain today. The laws against homosexuality have been long-scrapped but what is significant is how rights have been extended most notably to enable equal marriage. The position is not perfect but a small revolution has been achieved with overwhelming political support. What we now need are many more small revolutions.
So let us be frank . Although we have made fantastic progress since those days, thanks to the efforts of clinicians, nurses, researchers and organisations crossing national borders like UN AIDS we face today fresh crises.
AIDS is the deadliest pandemic of our time. 36 million people have so far died from AIDS-related illnesses – 36 million.
AIDS is an emergency with deaths continuing at a rate of 650,000 people a year. Every minute a life is lost to AIDS.
The fallout from COVID-19, and from the war in Ukraine, have hit the AIDS response worldwide.
The result is progress against the HIV pandemic has stalled, risks have increased, and resources for the response have shrunk.
The Global Fund for AIDS, TB and Malaria reported that HIV testing fell by 41% across 502 health facilities in Africa and Asia. Harm reduction services for people who use drugs were disrupted in nearly two thirds of 130 countries UN AIDS surveyed.
Over 168 million children have lost access to school for at least a year. 11 million girls may never return to school. Surges have been reported in gender-based violence, forced child marriages, and teenage pregnancies. In a UN Women Survey, 7 in 10 women said they think the COVID-19 pandemic has increased domestic violence. Almost 1 in 2 women reported that they or a woman they know experienced violence since the COVID-19 pandemic. Calls to helplines have increased five-fold in some countries during the pandemic. These factors increase girls and women’s risks of acquiring HIV.
Violence against and harassment of LGBT people has increased, as has stigma and discrimination against marginalised communities. In such a context, LGBT people are pushed further away from vital health services. These factors increase LGBT people’s risk of acquiring HIV.
As the HIV response still reels from the COVID-19 crisis, now the war in Ukraine has dramatically increased across the world the cost of living including food prices, worsening food insecurity for people living with HIV, making them much more likely to experience interruptions in HIV treatment.
Debt repayments for the world’s poorest countries have reached 171% of all spending on healthcare, education and social protection combined, choking countries’ capacities to respond to AIDS. Domestic funding for the HIV response in low- and middle-income countries has fallen for two consecutive years.
In 38 countries, new HIV infections are actually rising.
Eastern Europe and central Asia, Middle East and North Africa, and Latin America have all seen increases in annual HIV infections over several years. In Asia and the Pacific – the world’s most populous region – UNAIDS data now shows new HIV infections are rising where they had been falling. Climbing infections in these regions are alarming. In eastern and southern Africa rapid progress from previous years significantly slowed in 2021. There is some positive news, with notable declines in new HIV infections in western and central Africa and in the Caribbean, but even in these regions, the HIV response is threatened by a tightening resource crunch.
Stalled progress meant approximately 1.5 million new infections occurred last year – over 1 million more than the global targets.
Progress in ensuring all people living with HIV are accessing life-saving antiretroviral treatment has also stalled. The number of people on HIV treatment grew more slowly in 2021 than it has in over a decade.
That is some list of what is going wrong. But it is not a counsel of despair, it is call to action. We have come a very long way in the last 40 years. No longer is HIV something like an automatic death sentence. The advances in antiretroviral drugs mean that people who are infected can live long lives like the rest of us. We can end AIDS. We know how this can be done.
So we are not remotely in the same position as we were when I was a minister. But let me pick out three challenges where today the need for progress is particularly urgent.
The first is the education of girls and young women.
One thing which has certainly changed since the early days is the position of girls and young women One key component required for the end of AIDS is the education and empowerment of girls. For years past we have been used to conduct much of the political discussion in terms of men = when in fact it is a challenge which effects women just as profoundly – a position that goes little recognised in the general discussion.
Right now, around the world, an adolescent girl or young woman acquires HIV every two minutes. Six in seven new HIV infections among adolescents in sub-Saharan Africa are occurring among girls. Enabling girls to stay in school until they complete secondary education reduces their vulnerability to HIV infection by up to 50%. When this is reinforced further with a package of empowerment support, their risks are also reduced.
It’s key that all children – including those who dropped out in COVID and those who were out of school even before COVID – get to complete a full secondary education, and that this includes comprehensive sex education and girls’ empowerment. Yet as countries struggle with the current fiscal challenges, education and health are too often amongst sectors that worldwide are suffering the biggest budget cuts.
That is why the Education Plus initiative, co-convened by UNICEF, UNESCO, UNFPA, UN Women and UNAIDS, with governments, civil society and international partners, is pressing leaders to accelerate the actions and investments needed to ensure that every African girl is in school, safe and strong.
That is point one – point two is to recognise that marginalisation and discrimination perpetuate pandemics. Laws that punish consensual same sex relations, in addition to contravening the human rights of LGBT people, are a significant obstacle to improving health outcomes, including in the HIV response. Such laws help to sustain stigma and discrimination against LGBT people and are barriers to LGBT people seeking and receiving healthcare for fear of being punished or detained.
When people fear the state, many will hide from it. When people fear public shaming, many will seek to prevent themselves from being seen.
68 countries still criminalise gay men. The repeal of all such laws worldwide will help the world end AIDS.
The data proves that the maintenance of punitive laws is hurting countries’ ability to end the AIDS pandemic.
In countries whose laws criminalise them, gay men have at least twice the risk of acquiring HIV compared to countries which do not. This applies even when such laws are not operationalised into arrests.
Countries that criminalize gay men saw less progress towards HIV testing and treatment targets over the last five years — with significantly lower percentages of people living with HIV knowing their HIV status and achieving viral suppression than in countries that avoided criminalization.
In times of crisis, some in power have shown a tendency to treat human rights as “in the way”. But the evidence is clear: human rights are not only intrinsic, but they are also the very means by which governments can successfully beat a pandemic.
Vibrant independent human rights organisations are vital as advocates for reform, in bringing rights violations to judicial, political and public attention, and in strengthening accountability. We will beat AIDS by valuing the rights and dignity of every person. Decriminalisation saves and changes lives.
So my third point is that we can end AIDS, if leaders act courageously. On current trends, we will miss the UN target of ending AIDS as a public health threat by 2030, resulting in additional AIDS-related deaths. But there is no inevitability that we stay on current trends. We can end AIDS, by 2030, as promised. Last year leaders agreed a roadmap, set out in the Political Declaration on HIV and AIDS.
The manifesto to achieving success includes the empowerment of girls and women, and it includes the removal of punitive and discriminatory laws.
But it also includes international cooperation and support. But sadly at this moment too many high-income countries are cutting back aid, and resources for global health. In 2021, international resources available for HIV were 6% lower than in 2010. When you exclude the United States (whose contribution has been the most generous) international assistance for the AIDS response from other bilateral donors has plummeted by 57% over the last decade.
And wealthy countries need to remember what is at stake. What is at stake is hundreds of thousands of deaths and millions of new infections - all preventable. What is at stake is end of a pandemic at the end of this decade not a pandemic that goes on and on.
Beating pandemics is ultimately a political challenge. We can end AIDS by 2030 but only if we are bold in our actions and our investments. We need courageous leadership. And we need people worldwide to insist that their leaders be courageous. Whether we end AIDS is up to all of us. It is ultimately an issue of life and death.
Note
Lord Fowler was Health and Social Security Secretary in the UK from 1981 to 1987. He led the Don’t Die of Ignorance campaign in 1986/87 and is a past Chairman of the Conservative Party and Lord Speaker of the House of Lords. He is now a Crossbench peer and an Ambassador for UNAIDS.