IAPAC Supports Formation of UN Group of Friends for Hepatitis Elimination

IAPAC Supports Formation of UN Group of Friends for Hepatitis Elimination

Statement by Dr. José M. Zuniga, President/CEO, IAPAC and Fast-Track Cities Institute

20 September 2022 – UNGA Side Event: Building Solidarity for Hepatitis Elimination

Thank you for inviting me to join you for this United Nations General Assembly side event focused on building solidarity for hepatitis elimination. I wish I could be with you in New York City, but I am grateful to the Coalition for Global Hepatitis Elimination and the Task Force for Global Health for making my virtual participation possible.

For reference, the International Association of Providers of AIDS Care (IAPAC) is a global medical association representing more than 30,000 clinicians delivering care and treatment services for people living with HIV and comorbid diseases, including viral hepatitis. We are also the core technical partner to the Fast-Track Cities network, which numbers more than 400 cities and municipalities. These cities and municipalities are also supported by the Fast-Track Cities Institute through implementation science and operational research activities. While at its launch in 2014 the Fast-Track Cities network was initially focused on ending urban HIV epidemics with some cross-over into addressing TB coinfection, in 2019 the network’s mandate was expanded to ending urban TB irrespective of coinfection as well as embracing and urbanizing the WHO’s goals of eliminating HBV and HCV by 2030.

Our mandate’s expansion into urban HBV and HCV responses was a natural evolution for two reasons: First, given the significant advances in HIV treatment, we have the tools to guarantee people living with HIV near-normal lifespans. Why then would we wish for them to succumb to comorbid diseases and syndemic conditions? And, second, why not leverage the HIV response to facilitate greater progress in closing gaps across HBV and HCV care continua, for example? Given progress is sadly lagging to the detriment of millions of people, and because a high tide can lift all boats, we have been leveraging the HIV response across the Fast-Track Cities network to accelerate urban HBV and HCV responses.

Are we succeeding? We have been monitoring, collecting, and disseminating best practices from urban viral hepatitis elimination efforts that we posit are innovative, replicable, and scalable. Here are three examples:

  • Our Fast-Track Cities colleagues in Lisbon are using community pharmacies to offer point-of-care tests for HIV, HBV, and HCV infections to expand opportunities to diagnose these three diseases outside of clinical settings, which some who accessed the testing viewed as stigmatizing.
  • In Madrid, our colleagues have implemented an HIV/HCV screening program with embedded linkage to a care nurse, thus actioning differentiated service delivery in an attempt to both optimize care since, as a rule, nurse-delivered care tends to be much more person centered, and strategically expand the health workforce engaged in HCV care. Notably, the quality of care did not suffer. Indeed, only 3% of those diagnosed with HCV were lost to follow-up.
  • And, in Amsterdam, our colleagues are offering testing and linkage to HCV care to clients attending homeless services as a means of conducting outreach to a hard-to-reach at-risk population. Most recent data indicate 71% of homeless people who inject drugs linked to care and 57% initiating treatment.

These are but a few examples of the urban public health leadership on display in cities and municipalities around the world, from Bangkok to Kigali and New York City to Tel Aviv. Yet, these cities and municipalities alone cannot achieve the global goals of eliminating HBV and HCV.

The new World Health Organization (WHO) Global Health Sector Strategy calls for 90% of people living with HCV to be diagnosed and of those 80% to be on treatment. My concern is that the baseline (based on 2020 data) is 30% for diagnosis and 30% on-treatment. Similarly progress towards the ambitious HBV targets when compared against baseline also reflects a need to re-focus and accelerate our efforts to eliminate HBV. Those are significant gaps requiring business unusual. In fact, we need a whole of government (including city and municipal governments) and whole of society approach, and I believe that it is in our cities and municipalities where we can be the most innovative, responsive, and timely efforts to curb morbidity and mortality related to HBV and HCV.

Bottomline, though, achieving the global goals HBV and HCV elimination requires political leadership at all jurisdictional levels, and most notably national levels, with national investments to match and adequate to the task at hand. Many countries, such as India and Egypt, and, as already noted, many cities and municipalities, are already taking bold actions, including through interventions ranging from timely administration of birth dose HBV vaccination to scaling up access to diagnostic tests and direct-acting antivirals to treat and cure HCV. But more can and must be done to avert millions of unnecessarily premature HBV- and HCV-related deaths by 2030. In fact, given the reality we have a cure for HCV, it is a public health failure of a colossal magnitude that we are not more rapidly closing gaps across the HCV continuum and thus failing to cure millions of people.

What is needed today is a re-commitment by UN member-states to work in solidarity in this common cause. That is why IAPAC and the Fast-Track Cities Institute unequivocally support the formation of a UN Group of Friends focused on attaining the attainable goal of hepatitis elimination.

IAPAC Response to Draft HIV Action Plan for Wales

IAPAC Response to Draft HIV Action Plan for Wales

The Fast-Track Cities initiative started as a global partnership between the Joint United Nations Programme on HIV/AIDS (UNAIDS), International Association of Providers of AIDS Care (IAPAC), United Nations Human Settlements Programme (UN-Habitat), and the City of Paris. Since its launch on World AIDS Day 2014 in Paris, more than 400 cities and municipalities from every region of the world have joined the initiative by signing the Paris Declaration on Fast-Track Cities, pledging to end urban HIV epidemics by getting to zero new HIV infections, zero AIDS-related deaths, and zero HIV-related stigma. The partnership also advances efforts to end tuberculosis (TB) epidemics, eliminate viral hepatitis (HBV and HCV) and other sexual transmitted infections (STIs) in urban settings by 2030.

Joining the Fast-Track City network simply requires a city or municipality leader to sign the Paris Declaration on Fast-Track Cities. However, being a Fast-Track City requires actioning the goals, objectives, and targets to which all Fast-Track Cities commit, including:

  • Ending urban HIV, viral hepatitis, TB, and other STIs epidemics by 2030
  • Putting people at the center of the HIV, TB, viral hepatitis, and other STIs responses
  • Addressing the causes of HIV, TB, viral hepatitis, and other STIs risk, vulnerability, and transmission
  • Using the HIV, TB, viral hepatitis, and other STIs response for positive social transformation
  • Building and accelerating HIV, TB, viral hepatitis, and other STIs responses that reflect local needs
  • Mobilizing resources for integrated public health and sustainable development
  • Uniting as leaders by committing to an accountability framework

Currently, there are 8 Fast-Track Cities in the United Kingdom, including Aberdeen, Brighton and Hove, Bristol, Cardiff and Vale, Glasgow, Liverpool, London, and Manchester. More UK cities are set to join before the end of 2022. Fast-Track Cardiff and Vale together with partners in Cardiff and across Wales have pioneered the Fast-Track Cities initiative in Wales with a strong focus on engaging and empowering communities and collecting and understanding data to drive innovation and improvements in services as demonstrated by innovative interventions such as the Texting 4 Testing project.

The International Association of AIDS Care Providers (IAPAC) welcomes the draft HIV Action Plan for Wales that was released for public comment and awaits a final revision. We applaud the plan for its overarching action to establish Wales as a Fast-Track Country through the co-creation of an all-Wales coalition, Fast Track Cymru. In this, HIV Action Plan both fosters alignment between the national HIV agenda and urban HIV responses and demonstrates a clear understanding that moving from to the commitments in the Paris Declaration on Fast-Track Cities to actioning them requires consistent political buy-in, public health leadership, data-informed interventions, and community leadership. The forthcoming launch of a national HIV action plan with a clear integration of the Fast-Track Cities initiative and a national coordinating body is unprecedented in the initiative’s history and sets an important example and precedence for other Fast-Track Cities in the United Kingdom and globally.

Recommendations

With this integration of the Fast-Track Cities initiative into the proposed Welsh HIV Action Plan, the Welsh government honors several of the seven core commitments in the Paris Declaration on Fast-Track Cities, including using the HIV, TB, viral hepatitis, and other STI responses for positive social transformation by building on the highly successful interventions advanced by Fast-Track Cities Cardiff and Vale; mobilizing resources for integrated public health and sustainable development, and uniting as leaders by committing to an accountability framework. Nevertheless, IAPAC puts forward four recommendations for further refining the HIV Action Plan’s core commitments on stigma, involvement of people living with HIV, and monitoring and evaluation of the plan.

1. Measuring HIV-Related Stigma
HIV-related stigma can negatively impact on prevention, testing and treatment efforts and lead to adverse health outcomes. IAPAC is thus pleased to see that ‘tackling HIV-related stigma’ is one of the five priority areas for action in the plan in alignment with the Paris Declaration on Fast-Track Cities’ stated goal of achieving zero HIV-related stigma; Goal 3.3. of the Sustainable Development Goals; and the UNAIDS Global AIDS Strategy, 2021-2026. However, the draft Welsh HIV Action Plan’s outlined steps for to achieve the goal of zero tolerance towards HIV-related stigma does not include a clear monitoring framework to track progress. Without a monitoring framework, it will be difficult to understand how best to intervene and address individual and institutional drivers of stigma, and to assess whether the implanted interventions work as intended.

Stigma is a complex social phenomenon that is operationalized across several domains at the micro-, meso- and macro- level, and survey instruments that aim to meaningfully describe and assess how and in which contexts stigma unfolds thus necessarily need to capture this complexity. IAPAC therefore recommends the steps of actioning on the priority to ‘tackling HIV-related stigma’ to include the development of standardized and validated HIV-related stigma indicators that capture individual level drivers in and outside of healthcare setting such as fear of infection, prejudice, blame and social judgement and organizational level drivers such as social/cultural norms, policies, and practices.

2. Including People Living with or affected by HIV in all Five Priority Areas
One of the core commitments in the Paris Declaration on Fast-Track Cities is to ‘put people at the center of everything we do.’ This commitment includes not only focusing efforts on all people who are vulnerable to HIV, TB, viral hepatitis, and other diseases but also to meaningfully include people living with HIV in decision-making around policies and programs that affect their lives. Following through on this commitment is to realize the rights and responsibilities of people living with HIV, including their right to self-determination, and to let personal lived experiences shape the HIV and AIDS response.

While IAPAC acknowledges the clearly stated involvement of voluntary and community groups and people living with HIV in the Action Plan Oversight Group, the five priority areas – Prevention, Testing, Clinical Care, Living Well with HIV, and Tackling HIV-Related stigma – mainly position people living with HIV as the (passive) beneficiaries of the action HIV Action Plan’s steps and interventions outlined to action on the priority areas rather than the decision-makers and drivers of these steps and interventions.

The benefits of meaningfully involving people living with and affected by HIV are multi-levelled. For the individual, involvement can improve self-esteem, decrease isolation, and improve health through access to better information about prevention, treatment, and care initiatives. For organizations, involvement of people living with HIV can change perceptions, and provide valuable experiences and knowledge. For communities and societies, public involvement of people living with HIV can break down fear and prejudice by showing the faces of people living with HIV and demonstrating that they are productive members of, and contributors to, society.

IAPAC therefore encourages the intentional and active inclusion of people living with to ensure that representation of people living with and affected by HIV are present in the planning, implementation, and monitoring stages of all aspects of the five priority areas, and furthermore to use strategies to guarantee diverse representation within the group of people living with and affected by HIV in all their diversity. In other words, IAPAC encourages the formulation of clear steps to ensure that the attainment of the five priority areas is by people living with and affected by HIV and not primarily for or about them.

3. Facilitating Community-Led Monitoring
IAPAC commends that one of the draft HIV Action Plan’s three core principles is to have ‘All new initiatives and services be subject to ongoing monitoring and evaluation to make sure they meet the actions and principles laid out in the plan.’

IAPAC encourages these monitoring and evaluation initiatives to be community-led, ensuring that the collection, analysis, and utilization of data involves the community itself with support from our public health institutions – even if this necessitate making changes to policies within the authority at the city or health board level. This will in turn facilitate a data-driven, equity-based accountability mechanism for the Welsh Government’s communities inherent in the HIV Action Plan.

4. Developing an Accountability Framework for the Actions in the HIV Action Plan
While it is commendable that each of the five priority areas is operationalized through various concrete actions, amounting to 26 concrete actions within the draft HIV Action Plan, IAPAC notes that each of the actions are not matched with corresponding KPIs, timeline, or metrics for monitoring and evaluating on the progress towards attaining them.

IAPAC recommends the development of a clear accountability framework for each of the actions set within the HIV Action Plan. Pivotal to a comprehensive accountability framework is not simply setting quantifiable metrics and tangible milestones but furthermore a clear communication’s strategy for the action plan and for the achievements.

An accountability framework combining clear indicators to monitor progress and a corresponding communication strategy would arguably enable all stakeholders to stay informed on the progress of the actions set within the plan, facilitate stakeholder coordination, improve accountability, identify gaps, inform priorities, mobilize resources, allow for action course corrections, and enable political and community stakeholders to use the HIV Action Plan as an advocacy tool towards our shared vision of a world with zero new HIV infections, zero AIDS-related deaths, and zero HIV-related stigma.

IAPAC Condemns Federal Court Ruling Restricting PrEP Access

September 9, 2022 (WASHINGTON, DC) – A federal judge in the US District Court for the Northern District of Texas ruled earlier this week that the Affordable Care Act’s (ACA) provision requiring employers’ health insurance plans to provide access to pre-exposure prophylaxis (PrEP) for the prevention of HIV acquisition violates the religious rights and freedoms of employers afforded under the Religious Freedom Restoration Act (RFRA).

 

The International Association of Providers of AIDS Care (IAPAC) and its clinician-members in the United States condemn this egregiously odious ruling, which only serves to permit blatantly homophobic discrimination in the guise of “religious freedom.” In violation of nondiscrimination law, and contrary to scientific evidence about HIV prevention, the employer who brought the challenge falsely claimed that providing PrEP access violates its religious freedom because such access would “encourage homosexual behavior, prostitution, sexual promiscuity, and intravenous drug use.” Moreover, the ruling jeopardizes the United States’ efforts to decrease new HIV infections by 75% by 2025. When taken as prescribed, PrEP can reduce by up to 98% the possibility of HIV-negative individuals acquiring HIV. Access to all US Food and Drug Administration (FDA)-approved medications, including those approved for HIV prevention and treatment, must remain free from partisan judicial activism.

 

Additionally, Judge O’Connor’s ruling in Braidwood Management v. Becerra that the US Prevention Services Task Force (USPSTF) was unconstitutionally delegated Congressional power(s) threatens to upend preventive medicine in the United States. Pre-exposure prophylaxis for HIV is only one of nearly 100 preventive services recommended by the USPSTF. Health plans are required to provide coverage of these preventive services without copays or other similar cost-sharing burdens placed on the insured. If this ruling is allowed to stand, it subjects crucial health screening services such as testing for sexually transmitted infections and HIV, diabetes screening, and cancer risk assessments to unlawful discrimination and makes Americans vulnerable to the whims of employers seeking to skirt the patient rights afforded by the ACA – all in the name of “religious freedom.”

 

“We stand united with like-minded medical and patient advocacy allies across the United States in declaring that the ruling in Braidwood Management v. Becerra is a threat to the health of all Americans and an unacceptable interference in efforts to prevent new HIV infections in the United States,” said Dr. José M. Zuniga, IAPAC President/CEO. “Access to PrEP in no way bridges religious freedoms but instead honors the right of every person to dignity, health, and wellbeing. We call upon the ruling’s reversal on appeal. Additionally, we call for leadership in Congress to pursue legislative remedies to RFRA – up to and including repeal – to ensure individuals and institutions wishing to blatantly discriminate cannot hide behind a false shield of religious freedom.”

IAPAC Defines Person-Centered HIV Care Priorities at AIDS 2022

Statement on IAPAC’s Priorities for Person-Centered HIV Care

Dr. José M. Zuniga, President/CEO, @IAPAC and @FTC2030

IAS Consultation Meeting – 30 July 2022 (#AIDS2022)

Good morning and thank you to the IAS for inviting IAPAC to participate in today’s consultation meeting on person-centered HIV care. I am Dr. José Zuniga, President/CEO of IAPAC as well as the Fast-Track Cities Institute.

I am happy to share IAPAC’s priorities for actioning person-centered HIV care through our 30,000-member clinician-members and the 400-plus Fast-Track Cities:

  • We advocate universal standards of care that are competency-based and developed with significant input from people living with and affected by HIV. These standards should address the pervasive issue of stigma, including by formalizing U=U as a clinical competence.
  • We urge greater integration between the clinical, behavioral, and social dimensions of HIV responses. Silo-ing continues to be a major barrier for people living with or affected by HIV to access and utilize the whole-person care they need to succeed beyond achieving viral suppression or avoiding HIV acquisition.
  • Moreover, we welcome the scale-up of innovations to make HIV services more affordable, accessible, and convenient. However, these innovations must be framed within the context of person-centered care and reflect the voice of those most affected by HIV.
  • We call for health systems strengthening focused on continuous quality improvement that prioritizes whole person-centered care. We note, however, that support for and an augmentation of the health workforce is critically needed, including due to significant burn-out resulting from the dual HIV and COVID-19 pandemics.
  • And, to strengthen our responses, we recommend the use of metrics to inform decision-making. Relevant indicators could include the proportion of people living with HIV who are involved in decision-making about their care, who are satisfied with their relationship with health professionals, and who are satisfied with services provided by their health facilities.
  • We must also prioritize community engagement in planning, delivering, and monitoring HIV services. True engagement that avoids tokenism is critical to facilitate accountability, build mutual trust, improve health outcomes, and contribute to our efforts to stem new HIV infections and avert AIDS-related deaths.
  • We advocate a disruption of a culture within health systems that facilitates inequities, stigma and discrimination, and poor health outcomes. We welcome, too, efforts to correct dominant (or malignant) narratives about race, gender identity, and sexual orientation so that we center care around lived experienced without reinforcing labels, objectification, stigmatization, and marginalization.
  • On that note, we place extraordinary value on a collective commitment to equity and the concept of leaving no one behind. When “patients” are seen as people rather than numbers, serving the most marginalized becomes a prerogative rather than a liability.
  • And, relatedly, we advocate a focus on the dignity of people living with and affected by HIV. We must honor the human right to dignity just as much as we honor the right to health and well-being. In doing so, we will gain the added benefit of better health outcomes and improved quality of life.

Those are IAPAC’s priorities as we progress on a trajectory from disease-oriented to patient-centered and now to person-centered HIV care. The distinction between the latter two may be more subtle, but it is nonetheless critical. Just as people are not experiencing HIV in a vacuum, they also do not experience life in a vacuum. Health is one part of their whole person – a star in a constellation of needs, hopes, strengths, and challenges – that we must strive to optimize a person’s within a holistic context.

#ZeroHIVStigmaDay

July 21: New International Awareness Day with an Aim to End HIV Stigma

21 July 2022 (LONDON, ENGLAND, UK, and WASHINGTON, DC, USA) – Commemorating the birthday of late South African AIDS activist Prudence Mabele (1971-2017), a consortium of community, medical, and urban health organizations today announced their joint effort to create #ZeroHIVStigmaDay (July 21), a new international awareness day calling attention to the persistent levels of stigma experienced by people living with and affected by HIV.

The four organizations comprising the consortium are NAZ (a UK-based sexual health charity whose services are dedicated to people experiencing better sexual health) and the International Association of Providers of AIDS Care (IAPAC, a global network of clinicians and allied health professional working to end the HIV pandemic), in collaboration with the Global HIV Collaborative and Fast-Track Cities Institute.

“In this fifth decade of the global HIV pandemic, stigma continues to undermine progress and, in combination with fear and shame, is still driving late diagnosis of HIV in a way that is unacceptable and entirely preventable,” said Parminder Sekhon, Chief Executive Officer of NAZ. “Building on the legacy of Prudence Mabele, a fearless and irrepressible activist, we pledge to work towards a collective day of action in her name. We have 365 days to work together to shape a seminal day of global action. If we are to have any hope of ending HIV and crossing the finishing line together, we must join forces, voice by voice to end HIV stigma.”

A recent IAPAC LBGTI Health Equity Survey across 50 cities and municipalities worldwide found that HIV stigma remained a serious concern for 91% of respondents [1]. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), people living with HIV who perceive high levels of HIV stigma are 2.4 more times likely to delay enrollment in care until they are very ill [2], which leads to premature death and negates the prevention benefit of successful HIV treatment. Modern antiretroviral therapy (ART) adhered to as prescribed and resulting in an undetectable viral load both slows disease progression and offers people living with HIV an opportunity to live a near-normal lifespan. Additionally, people living with HIV who are on ART and have an undetectable viral load for six months or more and take their medications as prescribed pose no risk of transmitting HIV to their sexual partners, which is the basis of the U=U (Undetectable = Untransmittable) public health message.

“HIV stigma is jeopardizing our ability to end AIDS as a public health threat by 2030. By eliminating HIV stigma, we can dismantle the barriers people living with and affected by HIV confront when accessing testing, prevention, and treatment services. But we must also root out inequities and inequalities exacerbated by the ‘otherness’ ascribed to communities affected by HIV,” said Dr. José M. Zuniga,
President/Chief Executive Officer of IAPAC and the Fast-Track Cities Institute. “Zero HIV Stigma Day, and its full year of affiliated actions, represents a concerted global effort to harness our collective power towards the aim of realizing the human right to dignity, health, and well-being for everyone everywhere.”

For more information about #ZeroHIVStigmaDay, please visit: https://www.ZeroHIVStigmaDay.org

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About Prudence Mabele
Prudence Mabele was the first Black South African woman to publicly share her HIV status. She advocated for the rights of women and children living with HIV and against gender-based violence. She was diagnosed with HIV in 1990 and went public with her status in 1992. She set up the Positive Women’s Network in 1996. She died in 2017. For more information about her, please visit: https://en.wikipedia.org/wiki/Prudence_Nobantu_Mabele

About NAZ
NAZ is a minority-led HIV and sexual health agency with over 30 years grassroots experience of delivering HIV care and support and evidenced-based sexual health programs to Black and Brown and minoritized communities. Its mission is to achieve true parity in sexual health outcomes for racially minoritized communities living with and at elevated risk of HIV. For more information about NAZ, please visit: https://www.naz.org.uk/

About IAPAC
Representing 30,000 members, IAPAC is the largest association of clinicians and allied health professionals working to end the epidemics of HIV and tuberculosis, as well as eliminate HBV and HCV, by 2030. IAPAC is also a core technical partner to the Fast-Track Cities network and the Secretariat for its Fast-Track Cities Institute. For more information about IAPAC, please visit: https://www.iapac.org/

About the Global HIV Collaborative
The Global HIV Collaborative (GHC) is a partnership of strategic global leaders and activists that strives to improve the HIV outcomes for Black communities globally. GHC works to address the current global trajectory of HIV outcomes in Black populations and seeks to prioritize the persistent issue of unequal HIV outcomes rooted in ethnic disparities. For more information about GHC, please visit: https://hiv-collaborative.org/

About the Fast-Track Cities Institute
The Fast-Track Institute was created to support cities and municipalities worldwide in their efforts to achieve Sustainable Development Goal (SDG) 3.3 (ending the epidemics of HIV and TB), the World Health Organization goal of eliminating HBV and HCV, and SDG 11 (making cities and municipalities inclusive, safe, resilient, and sustainable). For information about the Fast-Track Cities Institute, please visit: https://www.ftcinstitute.org/