The short session also served to debunk some myths about the sex worker population. For instance, Swadhin Mondal and Indrani Gupta of the Institute of Economic Growth in Delhi, India, conducted a survey of sex workers to learn whether sex workers were being pushed to engage in sex without condoms in exchange for more money from prospective clients. But, according to Mondal, 72 percent of sex workers in the study were consistent condom users, particularly those who were brothel-based sex workers. In addition, the study seemed to indicate that sex workers received higher premiums for engaging in safe sex with regular clients.

The session also looked at the infrastructure for providing services in certain countries with respect to sex workers, particularly the work of community service organizations and local task forces. One study, from Ukraine, found that non-governmental organizations that contract with local pharmacies to provide medications, condoms and syringes to sex workers and intravenous drug users seem to be effective in reaching marginalized populations an connecting them with appropriate resources to avoid contracting HIV. 

But another study, from South Africa, looked at the problems posed by countries accepting PEPFAR funds, which seemed to indicate that PEPFAR's "anti-prostitution pledge" has forced the gradual phase-out of services once available to sex workers, thereby increasing their isolation and making it harder to access preventative or treatment services.

Moderator Cheryl Overs, of Australia, emphasized to the audience the importance of acknowledging the human rights and dignity of sex workers so they would not be forced to the margins of society. She also said that because sex work is a form of employment, it was likely that the problems associated with the testing and regulation of sex workers were more likely to be resolved through labor laws than through public health initiatives.

But it was Dr. Paul Semugoma of Uganda who provided the most powerful message: MSM exist everywhere, in every nation, and success in combating the HIV pandemic depends on addressing the virus's impact on this population.

"We are able to turn the tide, but there are barriers to progres," Semugoma said. "In the fourth decade of the AIDS pandemic, we still have countries that do not have statistics on MSM. What is the problem? They are ignorant, and they are in denial."

Semugoma's speech highlighted the societal and political situation in his native Uganda, where homosexuality is criminalized. He also made indirect references to other countries where gays may be persecuted. Semugoma asserted that the criminalization or stigmatization of MSM "due to imported homophobia" only drives the HIV epidemic underground by discouraging MSM from getting tested or seeking treatment out of fear.

For example, he said, in Uganda, some health professionals never ask patients about their sexual orientation, which means they may overlook potential health risks, resulting in some at-risk patients possibly never getting tested or being treated for HIV. Semugoma said because these populations are essentially invisible, they rarely receive the amount of funding needed for biomedical and behavioral interventions to curb the spread of HIV/AIDS. Only by addressing the homophobia in society and institutions, and dealing directly with MSM, Semugoma said, will countries be able to reduce the prevalence of HIV, as this population bears the greatest HIV burden, in both developing and developed countries.

While the group shouted down Frist with chants of "Repeal the pledge, reform PEPFAR" and "Sex workers' rights are human rights," Rep. Barbara Lee turned the tide by speaking about recently introduced legislation that seeks to remove that pledge, HR 6138. Her comments were answered with a new chant, "We love Barbara Lee!" 

Audacia Ray, Brooklyn-based founder of the Red Umbrella Project, a sex worker advocate and media specialist has posted video of the July 25 protest on her site. The video also features comment from Kelli Dorsey of D.C.'s Different Avenues organization, a local advocacy organization serving youth and young adults affected by HIV and violence, particularly homeless LGBT youth engaged in sex work as a means of survival.

The announcement, includes a link to the full report. 

Among the District's successes were reducing the number of AIDS-related deaths by almost half and linking pregnant mothers with treatment, ensuring no babies were born with HIV.

Coming a month after the release of the 2011 District of Columbia HIV/AIDS, Hepatitis, STD and TB Epidemiology Annual Report, D.C. officials, including several from the Disrict's Department of Health, told delegates that cooperation among government bodies, community activists and private businesses were essential to "turning the tide" on the HIV/AIDS epidemic. 

"We turned the tide together," said A. Toni Young, of the Community Education Group, which seeks to reduce the spread of HIV and eliminate health disparities among District neighborhoods by emphasizing education, testing and training for community health workers.

Young said the D.C. Department of Health, community groups, academics, researchers and scientists and the federal government all played a role in D.C.'s successes, which also included reducing the number of infections among intravenous drug users. Young said those combined efforts allowed the District to set up an infrastructure to test, track and manage cases where people contracted HIV. 

"When we talk about research, there was none," Young said. "In D.C., it was like turning around the Titanic in the Potomac."

Dr. Mohammad Akhter, the former director of the D.C. Department of Health, echoed Young's comments on collaboration between different entities and community stakeholders in promoting and carrying out policies relating to the care of HIV/AIDS.

Akhter cited four main "pillars" that were essential to fighting HIV in a successful way: robust research, particularly focusing on where, when and how to give patients treatment; political leadership, to provide both monetary resources and support services, as well as political cover; qualified staff, who are trained to provide culturally competent and holistic care, as well as track patients to ensure they can get as close to full viral suppression as possible; and a vocal and engaged activist community that could push for action and demand accountability from higher-level politicians, scientists or organizations working on fighting the disease.

Dr. Gregory Pappas, of the D.C. Department of Human Health, said that D.C. is sending out representatives to meet with medical providers in the same way that pharmaceutical representatives do, with the intent of incorporating measures like routine HIV testing, including for patients older than 40, and ensuring that doctors and nurses can provide culturally competent and quality care. Akhter also noted that, under a new law set to take effect later this year, all health providers in the District will be required to have training on HIV/AIDS in order to recertify as licensed medical professionals. 

Marcia Ellis, of Community Advisory Boards for HIV/AIDS Research, told delegates that medical professionals must build upon long-standing relationships with community organizations in order to create a space for open and honest dialogue where community feedback can be sought. She also advised HIV/AIDS experts to address what seems like "small" problems among patients and study participants so they do not adversely impact or inhibit the success of research, interventions and treatment. 

Speaking to thousands of delegates attending the XIX international AIDS Conference Monday morning, Clinton and HIV/AIDS advocates shared stories of sucesses in research, prevention and treatment of HIV and their vision of "an AIDS-free generation."

In keeping with the theme of this year's conference, which was "Turning the Tide" against the disease, the speakers focused on positive developments and promising scientific advances that could help in the development of a vaccine or cure for the disease. But, positive attitudes aside, they also warned the activists in attendance that much work is left to be done.

"Part of the reason we’ve come as far as we have is because so many people all over the world have not been satisfied that we have done enough," Clinton said in addressing the conference's delegates. "And I am here to set a goal for a generation that is free of AIDS."

Specifically, Clinton focused on defining "an AIDS-free generation" that begins with no child being born with the virus, then access to quality treatment for those who may later become infected that helps prevent them from developing AIDS and passing the virus to others.

"I know that many of you share my passion about achieving this goal," Clinton told the audience. "In fact, one could say I am preaching to the choir. But right now I think we need a little preaching to the choir. And we need the choir and the congregation to keep singing, lifting up their voices, and spreading the message to everyone who is still standing outside. ... This is a fight we can win. We have already come so far – too far to stop now."

Clinton also announced three new monetary efforts to reach key populations: $15 million, to go towards implementation research to identify specific interventions that are the most effective for at-risk populations, and $20 million to support country-led plans to expand HIV services.  She also pledged $2 million to help civil society groups that do outreach in those communities.

Prior to Clinton's speech, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, reviewed the history of HIV and the epidemiology of the disease. Both Fauci and Clinton mentioned biomedical and behavioral intervention advances that showed progress on combating HIV/AIDS, including sucesss in having adult males get circumcised; the success of antiretrovirals, with particular emphasis on the successes in treating HIV-positive pregnant women, who give birth to seronegative children; and the success of microbicides and pre-exposure prophylaxis (PrEP), which, when used correctly, seem to be successful in reducing the incidence of HIV.

Phill Wilson, founder and executive director of the Black AIDS Institute, described the situation in the United States, particularly the struggles facing black men who have sex with men (MSM), among whom HIV infection rates are rising rapidly. He also raised issues of funding for and access to quality health care, which is one of the factors driving the epidemic, especially among young people, the black community, and communities with a high incidence of poverty. Wilson told the stories of two men - Luis and Lawrence - who both died of AIDS due to the challenges they faced in being able to access testing and treatment for their disease.

"The AIDS epidemic is definitely a tale of two cities," Wilson said. He also cited statistics showing where the fight against HIV/AIDS has failed: in getting people tested, as almost 20 percent of HIV-positive people are thought to be unaware of their status; and in moving HIV-positive patients from testing and into treatment, preferably with antiretrovirals. As the epidemic stands, less than a third of HIV-positive individuals are able to regularly adhere to antiretroviral therapy and achieve full viral suppression.

Wilson also called upon AIDS activists and patient advocates to defend the Obama administration's signature health care law, the Affordable Care Act, due to its provisions that allow people with HIV and other pre-existing conditions to obtain health insurance that will provide them access to care.

"For people with HIV, these provisions are lifesaving," Wilson said.

In addition to pushing for full implementation of the health care law, Wilson also provided the delegates with a checklist of four other actions. First, he said, HIV-positive people must come out in order to inform HIV-negative people of how important funding and research are, and in order to reduce stigma that often prevents people from getting tested or seeking medical help when infected.

Wilson also called for HIV/AIDS activists to demand treatment for all those who need it, as well as calling for health providers to integrate biomedical interventions with behavioral preventative methods, and stress the importance of a combined approach to their patients. Lastly, he said, AIDS organizations must retool their strategies in order to find more innovative ways to engage people in knowing their serostatus and pursuing treatment if they test positive. He stressed that information and education, of at-risk people, patients and providers, was essential to combating the epidemic. 

"We're going to squeeze out every drop of information we can," he said. "Together, we are greater than AIDS."

A series of experts and advocates on HIV/AIDS examined the status of HIV among MSM around the world, starting with statistics related to infection and survival rates among MSM and touching on the structural and institutional challenges, including societal homophobia, stigma, discrimination against gay men, and a lack of attention and resources targeted to or alloted for MSM.

Some speakers focused on health disparities among different communities of MSM, particularly among MSM of color, which exist not only in the United States, but across the globe. Even though black MSM are less likely to use drugs or engage in riskier sexual behavior in many Western nations, structual inequalities in access to education and health care, lower incomes and a likelihood of self-segregating in partner choice lead to higher rates of infection among black MSM than among their white counterparts. In addition, MSM of color are less likely to be engaged at all steps of detection and treatment when they are HIV-positive, meaning they are less likely to end up on treatment, adhere to antiretroviral therapy and achieve full viral suppression.

Stefan Baral of the Johns Hopkins Bloomberg School for Public Health classified three levels of risk facing MSM: individual-level risks, such as engaging in unprotected sex, which focus on traditional biological and behavioral interventions like condom use and PrEP; network-level risks, such as the prevalence of HIV in lower-density networks and among marginalized groups, such as racial minorities; and structural risks related to issues like criminalization, government action, societal stigma and widespread homophobia. Several other speakers echoed these points in their presentations.

Australian academic and gay-rights activist Dennis Altman, in addressing how homophobia affects MSM, looked at four major causes at the root of societal homophobia: authoritarianism, political homophobia as a way of asserting a national or cultural identity, prevailing attitudes that rely on traditional gender roles, and religion.

Altman noted that while countries that criminalize homosexuality are hostile to MSM, so, too, are countries that do not (by law) discriminate, but do not acknowledge the public health risks facing MSM. He insisted that advocates must fight against allowing tradition, culture or religious beliefs to impede human rights or human dignity. Other speakers noted that HIV prevalence is higher in countries that criminalize or prosecute homosexual acts, as such governmental actions drive the epidemic underground and make people less likely to seek appropriate prevention or treatment methods. 

Nicole Styles, MTA’s community outreach coordinator, will be onsite talking about female condoms and encouraging visitors to take part in the Universal Access to Female Condoms Paper Doll Campaign, aiming to break the Guinness record for longest paper-doll chain.

“It’s been used all over the world,” she says of the campaign to raise awareness about female condoms, adding that her team has made more than 160 dolls so far. “It’s interesting to see the dolls from other countries. It’s cool. It’s empowerment.”

Also cool is the 3:15 p.m. event she just can’t talk about – but it rhymes with “crash knob.”

Entrance to the Global Village, at 9th and M Streets NW, is free. But while admission is free, Metro TeenAIDS would really like to know you’re coming. Please RSVP to geetha@metroteenaids.org.

A panel of researchers sharing the findings of studies of these at-risk populations said that while PrEP and greater access to HIV testing was favored by a majority of those surveyed, much more research was needed. The researchers also warned that the availability of PrEP or over-the-counter HIV tests could lead some people to engage in riskier sexual behavior.

As most in the scientific community seem to be embracing PrEP as one of many tools that could aid the fight against HIV/AIDS, others – including some audience members – expressed skepticism. One week after the Food and Drug Administration (FDA) announced it had approved the antiretroviral drug Truvada for daily use as a PrEP component, in combination with safer-sex practices, to reduce the risk of HIV infection among adults considered at high risk of acquiring the virus, some critics remain wary of fully endosing PrEP over concerns that, in practice, high-risk populations will continue to engage in behavior that increases their chances of becoming infected.

Still, because PrEP does not require consensual action by both parties, it is viewed as a tool that could help particularly those who are the receptive partner in sexual intercourse regardless of sexual orientation.

In one study that looked at the acceptability of oral intermittent pre-exposure prophylaxis, or iPrEP, in South Africa, focus groups revealed a high degree of acceptability due to a lower frequency of dosing and the ability to use it without disclosing to one's partner, according to Linda-Gail Bekker, chief operating officer of the Desmond Tutu HIV Foundation. Bekker noted that men in the focus groups were more likely to be able to "plan" their next sexual encounter, relative to women, thereby highligting the possible benefits for women, who may have less control or say over when sex occurs.

In another study, which surveyed men who have sex with men (MSM) in Washington and Miami, Lisa Metsch, a professor of epidemiology and public health at the University of Miami, revealed that neary half of all MSM in the Miami cohort expressed a willingness to try PrEP if it was made available to them, while 61 percent of the D.C. cohort said the same. In D.C., those with fewer sexual partners and those older than 33 were less likely to want to use PrEP, compared to other groups. 

A third study, of mostly heterosexual HIV-negative men, revealed most were willing to use PrEP if available. However, more than a quarter of the subjects indicated that the use of PrEP would make them more likely to engage in unprotected sex with an HIV-positive person, indicating that there may be some loss of sexual inhibition, despite information that PrEP is recommended to be used in combination with safer-sex practices. Critics of the FDA approval of PrEP say findings like these concern them, fearing that such behavior will increase outside of clinical-trial settings.

A fourth study looked at the availability of over-the-counter at-home HIV testing, following the FDA's July 3 approval of the OraQuick rapid-HIV oral test, which is expected to be available in October. In a survey of men considered at high risk due to engaging in unprotected anal intercourse, 80 percent said they were interested in testing a potential sexual partner prior to engaging in sex. in the second part of the study, where the men were given the test to use in the field for a three-month period, the men in the study asked 124 of 150 partners if they'd be willing to take the test. Of those asked, 101 complied and 23 refused. According to the subjects of the study, a refusal to get tested was taken as a sign not to engage in unprotected sex with that particular person.

Researcher Alex Carballo-Diequez, of the HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, said the results seemd to indicate that available testing modifies people's sexual behavior, prompting some audience objections and questions about the reliability of the test, given a possible "window period" during which a person may be infected but has not yet developed the HIV antibodies that produce a "positive" test result. 

Carballo-Diequez pushed back, saying that while the availability of testing was not a guaranteed protection against HIV, it could still reduce the infection incidence by making people aware of partners' HIV statuses.

"Sometimes, because we want something that is optimal, we don't use something that is good enough," he said. 

Because of fears of discrimination or mistreatment, she said, many transgender people avoid needed medical attention or reporting crimes to police. Employment discrimination may also lead transgender people into survival sex work. Other factors include intravenous drug use or injecting themselves with silicon or hormones without the guidance of medical professionals. 

Because of these very community-specific problems, Keatley said, transgender people cannot simply be classified as "men who have sex with men" (MSM) in anti-HIV efforts, but need a distinct category with outreach and prevention strategies specially tailored. 

Marcela Romero, a Colombian-born transgender activist, said that governments are complicit in the challenges faced by trasngender communities. Marginalization and a lack of resources to address health and well-being contribute to a higher incidence of HIV and sexually transmitted infections, and lower life expectancy among transgender people. 

"A person without an identity ceases to exist," Romero said of governments who ignore transgender citizens. 

Manisha Dhakal, a Nepalese activist with the Blue Diamond Society, added that even when transgender communities mobilize, they often lack the capacity and skills needed for efforts like proposal writing, and have fewer resources to lobby international organizations or governmental bodies for funding. 

Keatley reiterated the importance of employment as the key to solving many of the problems facing transgender people. Gainful employment (as well as protections against discriminatory hiring and firing), she said, is what is needed for transgender people to access insurance, health care, better educational opportunities and housing.

During a Monday, July 23, workshop event, speakers and attendees illustrated both the support and suspicion of using antiretrovirals as a method of preventing HIV-negative people from becoming positive. Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS, argued in favor of "treatment as prevention" through antiretrovirals, while Kenneth Mayer, medical research director and co-chair of Boston's Fenway Institute, countered that more research needs to be done before the medical community endorses pre-exposure prophylaxis (PrEP). Audience members – on both sides of the issue – also spoke passionately.

The debate comes one week after the FDA announced it had approved the antiretroviral drug Truvada for daily use as a PrEP component, in combination with safer-sex practices, to reduce the risk of HIV infection among adults considered at high risk of acquiring the virus, such as men who have sex with men (MSM), serodiscordant couples where one partner is positive and one is negative, and sex workers.

Montaner cited statistics from a study done in British Columbia that showed as access to antiretrovirals was expanded, new HIV diagnoses decreased. He said that the success that HIV/AIDS medical professionals have had in treating HIV-positive pregnant mothers with antiretorvirals to ensure their children are born without the virus shows the promise of using such treatments for uninfected adults.

“We need to do this without any further delay,” Montaner insisted.

Mayer, however, spoke of unknown effects of such therapies in healthy individuals with normal CD4, or T-cell, counts. He mentioned the possibility of resistance to the medications over time among people with normal CD4 counts as a possible side effect, particualry in cases where adherence is lax.

Mayer and Sean Strub, founder and advisory editor of POZ magazine, also warned that while linking people with care is an admirable goal, public health officials may use antiretrovirals as a crutch of sorts, recommending it for all people regardless of the nature of their serostatus, instead of basing their recommendations on science. Strub, as well as some audience members, also raised questions about the ethical issues that accompany scientific advances such as antiretrovirals.

Other considerations discussed and debated were the cost of such medications, the prioritization of patients who would be able to access those treatments, and the toxicity of the drugs. In addition, medications used as prevention could only be completely effective if they were used along with other prevention methods, such as using condoms during sex. To ensure that resistance to the drugs would not develop, health care providers would also need to stress the importance of interventions, such as regular HIV testing, and would have to be appropriately trained to do risk assessment or to provide the appropriate counseling to patients seeeking treatment.

The explained that homophobia or childhood trauma may contribute to “syndemics" – meaning a series of interconnected epidemics, such as poverty, bullying and abuse, intimate partner violence, depression and substance abuse – which, in turn, drive riskier sexual behavior that can increase chances of acquiring HIV, the panelists shared.

Dr. Keith Rawlings, of the Dallas-based AIDS Arms Inc., said the existence of disparities in health care is not a new phenomenon, but that because of those existing disparities, simply expanding the system and giving people access to health care through measures like the Affordable Care Act is not going to be enough to effectively detect and treat HIV/AIDS in this American YMSM population, among the hardest hit by the epidemic.

Rather, Rawlings said, the challenge is dependent on engaging this population, who rarely interact with health care providers, and get them to make wiser health care decisions, such as getting regular checkups. He also said providers should remain vigilant for signs of underlying problems that might require counseling or mental health treatment, an issue for which he was critical of the African-American community, arguing that, as a whole, this community has been reluctant to embrace mental health and counseling treatments. 

Looking at those who provide health services to this YMSM popluation, Dr. Ron Stall, professor and chair of the Department of Behavioral and Community Health at the University of Pittsburgh, said those providers must adopt a more holistic approach to treating young gay men of color, rather than focusing on HIV and STDs alone.

“Scientists are just obsessed with the area between the knee and the navel when it comes to gay men,” Stall said, citing a study showing that the more psychological/emotional health problems a person has, the more likely it is he will engage in high-risk sex, leading to greater HIV prevalence.  

Dr. David Malebranche, an HIV/AIDS specialist and an assistant professor at Emory University School of Medicine, said that the attitudes of health care and service providers and their interactions with patients need to be changed to address any underlying trauma or feelings of self-hatred, inadequacy or depression that could place them at risk of acquiring HIV.

For instance, Malebranche said health care providers often lecture patients about the need for safe sex but may overlook or fail to ask questions relating to a patient/client's state of mind. After a patient discloses they have been involved in riskier sexual behavior, health care professionals need to ask why.

The panelists agreed that, while there is needed improvement from all parties, health care providers must find innovative ways to engage the younger MSM population – particularly those of color – and connect them with whatever treatment is necessary, stressing the importance of combining biomedical and behavioral interventions, such as medication partnered with the use of condoms.

Sunday afternoon, July 22, ahead of the evening's opening session of the XIX International AIDS Conference (AIDS 2012) in Washington, thousands took to D.C. streets and the grounds of the Washington Monument for the "Keep the Promise" rally and march.

The rally, hosted by actress and comic Margaret Cho, featured a number of prominent figures, such as the Rev. Al Sharpton, activist Cornel West, and Haitian-American singer Wyclef Jean. Among the "call to action" points released by Keep the Promise advocates were lower prices for AIDS drugs globally, and "leveraging treatment as prevention in concert with a scale-up of rapid HIV testing and access to care." 

Video/Editing: Aram Vartian
Producer: Randy Shulman