Chasin' The P's in Mexico City

P is for Prevention, Policies & Pink Elephants

I was in Mexico City with 23,000 other people for the first International AIDS Conference in Latin America. The event was grand, to say the least.

The conference opened up in full regalia on Sunday, August 3rd, with an event hosted at the Auditorio Nacional near the center of el De Efe- the Federal District, Mexico City (if such a behemoth has a center). As always, this opening session really set the stage and tone for the conference in the days to come. After a beautiful performance of the ballet folklórico, with a mariachi band from Guadalajara, we awaited addresses from several key leaders from all over the world including, Peter Piot, Executive Director of UNAIDS, Felipe Calderon, President of Mexico and Ban Ki-Moon, the UN Secretary General.

The conference theme was Universal Action Now (¡Acción Universal Ya!) which underscored the key message from each of the speakers - increasing access to antiretroviral (ARV) therapy for some of the most vulnerable and marginalized communities. It quickly became apparent that the conference sought to focus on certain communities in particular: men who have sex with men (MSM), intravenous drug users (IDUs), commercial sex workers (CSWs), and to a lesser extent, Latin American migrant workers.

Later, back in my room, I realized this was no coincidence. Looking at the conference program it was clear that session after session would focus on these same groups.

Focus can be good, or can be bad. For instance, funders might say, "Hey, lets try and include other 'hard to reach populations.' " Which is good. But, on the other hand, funders might also say, “Hey, we only have a few dollars, lets only focus on these few 'hard to reach populations.' ” Which could be bad. Well, I’m no Nostradamus so we’ll just have to wait and see about all that.

That first night also brought the first discussions of top US and Mexico initiatives - initiatives that were heavily applauded. And why not? Let me list them, Letterman-like, as my Top 5 P's. (Drum roll, please).

1. P is for PEPFAR and getting $$$ - and more $$$$$!

Do you remember back in 2003 when George Bush didn't want to be known as just a war president? That's the year the president (maybe as a distraction from the troubles in Iraq?) authorized the first President's Emergency Plan For AIDS Relief (PEPFAR) - $15 million dollars over 5 years to fight the global HIV/AIDS pandemic. We had problems with the details- especially in that program appeared to be influenced too heavily by American political and social groups with "moral" rather than public health agendas. But, hey, it was a first step in the right direction.

Well, 5 years is up (and we're are still in Iraq) and presto, PEPFAR has been reauthorized and the money is way up - a whopping 48 billion dollars! Gotta clap for that!

While nowhere in PEPFAR are the words ‘family planning’ mentioned, folks on the ground here talked about this re-authorization with cautious appreciation. Hey, no language is better than repressive language. And some folks hoped that a maybe a new presidential administration will interpret PEPFAR more broadly.

2. P is for People Living With HIV/AIDS traveling into the US

Okay, check on hell and make sure it hasn’t frozen over, because I am going to praise President Bush twice in one day. During the opening plenary and again during former President Bill Clinton’s speech on Monday, August 4th, President Bush was applauded for lifting the travel ban that previously prevented people living with HIV/AIDS (PLWH/A) from entering the United States. (Not the slightest of reasons why the AIDS conference has not been held in the U.S. since its inception in San Francisco, 17 years ago). Tucked into the PEPFAR language are provisions that repeal a 1993 ban preventing PLWH/A from entering the country or from being eligible for legal status.

That's great, right? But not too fast. The measure, at the moment, is purely de jure. As the Washington Blade points out, for now, HIV is still listed as a communicable disease by Health and Human Services- which prevents positive folks from entering the country or adjusting their legal status. Sound like Catch 22 to you?

3. P is for Lifting Pharmaceutical Plant Restrictions

Mexican President Felipe Calderon promised to follow Brazil's lead by lifting plant and manufacturing restrictions and thereby allowing Mexico to produce their own generic HIV meds. He barely took a breath before adding that such modifications would be rolled out slowly as to prevent a crash in the market. (This should be interesting to see the roll out - remember that pharmaceuticals are available without prescriptions in Mexico!)

Mexico continues to show how far from US movie stereotyping it really is. Far from the machismo, hyper-Catholic conservative city, Mexico city has shown it's progressive streak by legalizing abortion, greatly improving it's contraceptive uptake rates and, hopefully soon, producing its own antiretroviral generics. (Go ‘head on now!)

4. P is for Prevention Reducing Prevalence

President Bill Clinton addressed a plenary session of roughly 3,000 people on Monday 4 August 2008 [he is such a rock star!]. He departed from the party platform of universal access to return the focus back to the United States and it's own HIV/AIDS epidemic.

He cited the national Black AIDS Institute's report on HIV in the Black community, noting that were Black Americans a nation on our own, our HIV prevalence would rank us 16th in the world. He went on to push for a national AIDS strategy to address structural issues for PLWH/A domestically - issues including housing, poverty and substance abuse. (He joked that he did not coordinate such sound bites to coincide with the protesters below him calling for ‘Housing for People Living with HIV.’)

Later these same issues were echoed by Congresswoman Barbara Lee (D- California) and by Dr. Kevin Fenton, the director of the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention (CDC). Dr. Fenton reiterated the need for a national strategy to tackle AIDS domestically. He highlighted new prevalence and incidence estimates from CDC novel methods for calculation. Essentially, the numbers pointed to an steady increase of incidence for, and only for, the MSM community; a disproportionate burden borne by men, and Black men in particular.

Other encouraging news also came via Laura Kann, also of the CDC. She presented results from the Youth Behavioral Risk Surveillance Survey from 1991 to 2007. For the first year since the start of the epidemic, HIV incidence has dropped- indicating that prevention efforts have started to turn the tide on the epidemic.

But, she went on, young people engaging in sex has been on the rise since 2001 (with quadratic increases over the 16 years- meaning, decreases then increases again). One woman from the audience asked to what would Kann attribute this. As Dr. Kann hesitated to speculate on the data, I sat in my chair thinking only of the failure rate of so-called Abstinence-Only programs.

5. But P is really for the Pink Elephants in the room: Big Pharma

So reeling from all the wonderful people I met, all the informative sessions I participated in and all the cool pens pilfered from the exhibit hall, I awaited the delayed flight in Mexico City’s Benito Juarez airport with new-found colleagues. We talked and debated. Was all this money being spent worth it? Are we going to ensure universal access? And I am going to have to call out the pink elephant in the room: by saying universal access, we have to know the hidden discourse. It reminds me of the myth of meritocracy - that in America if you “work hard, you will get far.” What no one adds to that story is that the road narrows the further you along you go. And for some the road starts to narrow sooner than for others.

In the end, and call me a cynic, if you like, I believe that we will not treat all people. But we need to keep the heat on and keep calling for universal access. Truth is, Big Pharma cannot afford to give access to everyone who live with HIV/AIDS. The point of seeking out particular target populations, is just that, to target some folks. Either those with the highest prevalence (like MSM) and who would therefore stand to make the most money for Big Pharma once they are on ARVs, or those with the greatest incidence rates (like IDUs and sex workers) who would be most likely to start ARVs. Lets be real, universal access is not universal. That Big Pharma is a necessary evil is a given- that disease translates to dollars for some is the way of the world. But we can’t take on Big Pharma alone AND we really do need the meds!

We just need to keep creating small cracks in the system that props Big Pharma up - cracks that include innovative prevention approaches and policies that align with scientific evidence.

And we need to start serving people, not profits and private agendas.