Volume 19, Issue 6 , Pages 409-411, November 2008
“Universal Action—Now”
Article Outline
Simplifying what is complex is just as dangerous as making complex that which is simple.
—Peter Piot, MD, at the opening ceremonies of the XVII International AIDS Conference in Mexico City, August 3, 2008
The weather was cool and damp in Mexico City last August as more than 20,000 delegates from all over the world arrived for the 17th International AIDS Conference. I must admit that I arrived with a lot of trepidation. I get nervous in large cities; I don't like heat and humidity; I'm embarrassed by my lack of language skills (I grew up in New Mexico—I should speak Spanish!); I hate conferences with too many people and too many choices. Except for the heat, all of those prejudices were borne out. But I also know that the International AIDS Conference provides an opportunity every 2 years for people to come together to discuss advances and continuing barriers to dealing with HIV infection, the biggest public health problem of our time. And Mexico City provided a functional venue for those discussions.
A Quick Look…
A conference of this magnitude cannot be adequately synopsized in an editorial. I spent 5 days attending meetings and special events, talking to colleagues, and wandering around the Global Village. I took 40 pages of notes. A month later, I spent time reviewing those notes and browsing through the abstracts on a CD provided by the conference organizers. I then listed the conference themes that were noteworthy for me. The following is a quick overview of those themes.
Testing for HIV
Not that much was said about testing—there were no plenary sessions dedicated to it and few concurrent sessions, although many of the prevention sessions certainly stressed the need for testing. The key here, however, and the reason I put it first on my list, was evident in the frequently cited statistics: 80% of people living with HIV in low- and middle-income countries and 25% of people living with HIV in the United States do not know they are infected (Marks et al., 2005, Steinbrook, 2008). Most don't have access to testing, but many others fear finding out they are infected or live in a constant state of denial about their personal risks. HIV-related stigma and discrimination continue to support barriers to HIV testing, barriers that also decrease access to treatment and prevention services.
Treatment
Reports from the treatment experts led me to believe that we are doing pretty well in this area. Recent advances have decreased morbidity and mortality. Debates are now focused on when to start therapy and how the host immune system interacts with HIV and antiretroviral therapy (ART). New treatment options are in development and will eventually contribute to existing combination therapies. On paper we are doing well. In reality, however, drugs don't work if you can't get them. All of the advances don't make much of a difference to the 9.7 million HIV-infected people who are not in treatment (Steinbrook, 2008).
Prevention
The new buzzwords in the area of prevention were combination prevention. I've been preaching combination prevention for years on the premise that one size does not fit all. Combination prevention gives a name to the philosophy that many different prevention methods, used in individually determined combinations, work better than one dogmatic approach, whether that approach is condoms or abstinence. At this conference, condoms, needle and syringe exchange, and drug replacement therapy were joined by calls for safe syringes to protect health care workers (in an ANAC/Physicians for Human Rights session), male circumcision, and the use of ART for prevention.
ART for prevention, based on a Swiss study (Vernazza, Hirschel, Bernasconi, & Flepp, 2008), got a lot of press. Preliminary reports from that study showed that adequate viral suppression significantly decreased the risk of HIV transmission. Further research needs to be done, but this result added to the idea of medical management of transmission (Mascolini, 2008). Given the success of prevention of mother-to-child-transmission and postexposure prophylaxis, preexposure prophylaxis has gained additional credence. All of this optimism about using antiretrovirals for prevention must obviously be tempered by what I reported earlier—ART is simply not yet available to most of those who need it. We still cannot treat our way out of this epidemic. We still need barriers and behavior modification and evidence-based prevention methods.
The bad news for prevention was—once again—the lack of progress on a vaccine or on effective microbicides. The overwhelming opinion of the scientists in this effort was that we cannot give up; we need to regroup and be creative. Until there is success, however, we must continue. As Festus Gontebanye Mogae, the former President of Botswana, said at the opening ceremonies on August 3, “Prevention of new infections should be our number one priority, our number two priority, and our number three priority.”
Human Rights
The issues of human rights in the HIV epidemic were on prominent display at the conference. I attended a couple of compelling sessions on criminalization of HIV where “bad laws with good intentions” (those that try to decrease HIV transmission by prosecuting people with HIV) were discussed. I learned of laws that would incarcerate HIV-infected people for engaging in consensual sex with full disclosure in which no transmission occurs. Many of these laws put pregnant women at risk of legal repercussions even if they take ART during pregnancy and/or if the infant is not born infected. Some laws would apply even if the “offender” is not aware that he or she is infected. And lest you think that these things only happen outside of the United States, a recent case in Texas in which an HIV-infected man was sentenced to 35 years in prison for spitting on another person was discussed. Justice Edwin Cameron, an eloquent speaker on this topic, stated, “He was punished not for what he did, but for the HIV he carried” (plenary session, August 8).
The human rights agenda is important in this global epidemic because the loss of human rights is directly related to fear, stigma, discrimination, closeted behavior, health care worker prejudices, barriers to care, and increased risks for HIV transmission. Human rights was a key cornerstone of the conference as evidenced by the array of plenary speakers who addressed these issues, including several young people (the youngest was 14 years of age), an injection drug user, men who have sex with men, and—for the first time—a sex worker. The universal messages from these activists were: tell us the truth, don't ignore us, involve us in meaningful ways in all plans that affect us, respect us, and give us responsibility.
…And the Punch Line(s)
When I look at all of these issues, I am compelled to comment on the problem of scarce resources. We do not have adequate funding, resources, or health care systems to deal with this epidemic. We do not have governments with the political will to do what must be done to prevent HIV transmission or to allocate the resources needed to care for those with the infection. This is a global issue—no country has done enough to make the needed differences. As Pedro Cahn, the outgoing president of the International AIDS Society and co-chair of the conference, said, “It should never be a question of either/or, but a question of how” (opening ceremonies, August 8). Unfortunately, it is still either/or and will probably remain so for the discernable future.
A large factor in this scarce resource debate is the very real shortage of all kinds of health care providers. Consider these facts: (a) physicians have always been a scarce resource in the geographic areas most highly impacted by HIV, and (b) nurses are the largest group of health care workers in the world. Add these together and it doesn't take much to figure out that nurses are an invaluable resource. When educated and trusted to take on expanded tasks in the HIV epidemic, nurses become more valuable. Task shifting describes the process that occurs when physician tasks such as prescribing ART, managing treatment, and monitoring side effects are taken on by others, and nurses are the most logical clinicians to take on those tasks.
We already knew the value of task shifting. Research in the United States from 2005 showed that nurse practitioners and physician assistants who specialized in HIV care were able to provide care equal to HIV-specialist physicians and better than nonspecialist physicians (Wilson et al., 2005). Three years later, 41 abstracts presented at the International AIDS Conference addressed the issue of task shifting and described the positive influence that nurses have on HIV care in resource-poor settings. Two of those studies were widely reported as showing that nurses could provide care at the same level of quality as physicians; and one of those studies reported that patients in the nurse-run clinics were more confident in their abilities to adhere to ART than those in the physician-care centers (Kaiser Daily HIV/AIDS Report, 2008).
And so I am left with a question: Where were the nurses in Mexico City? Oh sure, there were a lot of us in attendance. Some nurses presented posters and a few gave oral presentations. Of more than 7,800 abstracts, however, only 303 even mentioned nurses. And—even more important—not one nurse gave a plenary presentation. Speakers in the plenary sessions ranged from national and international political figures to social and laboratory scientists to epidemiologists to physicians (lots of physicians) to a sex worker to a drug user to a lawyer to activists of all stripes. Plenary speakers occasionally mentioned the health care provider shortage and a few talked about the need for task shifting. One even mentioned the role of nurses in this process. But at no time during the entire conference was one single nurse seen on the plenary stage. Here we have a group of care providers with demonstrated abilities to contribute in significant ways to the care of people with HIV infection, and not one of them was asked to address the conference. The theme of the conference was Universal Action—Now. How can you have universal action when you omit one entire group of care providers? It just doesn't make sense to me.
References
- Kaiser Daily HIV/AIDS Report2008, August 11AIDS2008: Studies find few differences in health outcomes for HIV-positive patients cared for by nurses.Retrieved August 112008, from www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=53874
- . Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: Implications for HIV prevention programs. Journal of Acquired Immune Deficiency Syndromes. 2005;39:446–453
- . One overlooked HIV prevention tactic: Antiretrovirals for all. International AIDS Society Newsletter. 2008, August;6–7
- . The AIDS epidemic: A progress report from Mexico City. New England Journal of Medicine. 2008;359:885–887
- . Les personnes seropositives ne souffrant d'aucune autre MST et suivant un traitment antiretroviral efficie ne transmettent pas le VIH par voie sexuelle [Seropositive individuals who have never had another STD that are on effective antiretroviral therapy will not transmit HIV sexually]. Bulletin Medical Suisses. 2008;89:165–169
- Quality of HIV care provided by nurse practitioners, physician assistants, and physicians. Annals of Internal Medicine. 2005;143:1729–1736
PII: S1055-3290(08)00189-1
doi:10.1016/j.jana.2008.09.001
© 2008 Association of Nurses in AIDS Care. Published by Elsevier Inc. All rights reserved.
Volume 19, Issue 6 , Pages 409-411, November 2008
