Forward to AIDS 2014: Now is the Time to Unite for the Global HIV/AIDS Epidemic

From 22-27 July 2012, the XIX International AIDS Conference (AIDS 2012) was held in Washington DC, USA-the nation's capital. The meeting of International AIDS Society (IAS) had not been held in the United States in 22 years because of a ban on travel of HIV+ people into the United States which began after the 1990 meeting held in San Francisco. During the early days of the Obama administration the ban was lifted. Then, in recognition, the IAS planned its return to DC. The theme of the conference was “Turning the Tide” seizing the moment when so much science has made the end of AIDS a realistic goal.

AIDS 2012 was the premier gathering for sci-entists, policy makers, and advocates working on HIV/AIDS science, policy, and advocacy to end the epidemic. Much of the planning and content of the program was done by people living with the virus. The meetings presented recent scientific develop-ments and lessons learned from around the globe, and gave a collective direction to the global fight against HIV/AIDS.

The meeting included abstract-driven presentations to symposia, bridging and plenary sessions. The Global Village was free and open to the public and provide, satellite viewing of the meetings, exhibitions and affiliated independent events. The Global Village was held inside the Washington Convention Center, in a space below where the scientific portion of the meeting was held. Because the space was public, it was a favorite for demonstrations and advocacy events, which have been a part of IAS meetings since their beginnings.

As the host city, the District of Columbia, United States capital, was in the global spot light-not for what was going on in the United States Congress or the White House-but instead for what was hap-pening in neighborhoods and the local government's fight against the virus. I had a unique opportunity to help plan and participate as the director of the city government's HIV/AIDS program. The Mayor of DC launched a Host Committee to work with IAS to ensure the meeting went smooth and was well sup-ported by city services, that the program and sci-entific work done in DC were used as show cases, and that financial benefit come to the city through hosting the meeting. I was the executive director of the Host Committee and a member of the IAS organizing committee. From this unique perspective I reflect on the HIV/AIDS epidemic in DC and the way that the global becomes local and local becomes global.

First, the meeting was an opportunity to reframe the fight against HIV in the nation's capital which has been compared to African epidemics and claims were often repeated that DC had the highest rates of HIV in the nation. This narrative was familiar to many and promoted both by critics of the city and those who sought to dramatize the depths of the epidemic. In fact, DC has emerged as a model local response and leader in the implementation of the US National HIV/AIDS Strategy. According to a US Centers for Disease Control and Prevention (CDC) study, half of the people living with HIV in the US resided in twelve cities: although DC was not at the top of that list, it hovered between 3^rd or 4^th position depending on the measures.^[1]

DC exemplified the theme of the meeting, Turning the Tide, by cutting new diagnoses of HIV in half over a five year period and decreasing disparities.^[2] This happened during an era when the number of US national infections had stagnated at about 55,000 a year for a decade. DC made these strides by following the evidence base that guided the US National HIV/ AIDS Strategy. The strategy emphasized aggressive and early testing; rapid connection to care; and suppression of viral load through adherence. The DC Mayor's HIV/AIDS Commission had endorsed “Treatment on Demand” in the District and every-one in the city has access to antiretrovirals regardless of ability to pay or immigration status. Following this initiative, testing for HIV has increased dramatically over the past years with HIV testing available through the city, routine in most clinics, and available in non-clinical settings including the Department of Motor Vehicles where people waited for driver's license and other related purposes. By 2012, over 80% of newly diagnosed were connected to care in three months, a dramatic increase from 2008. The standard expected by the city with the contracted community based organization was to have a newly diagnosed person into a doctor's office within 48 hours. While sustained adherence remains a problem, rates of viral suppression increased over the same period. Movement towards greater coordination between providers and progress toward better care through Patient Centered Medical Homes has begun.

Activism and advocacy were also important at AIDS 2012. The meetings demonstrated again that the local has truly become global and that global is always local. A year in advance to the meeting, when consciousness of the meeting had just begun, international activists from many aspects of the fight against AIDS reached out to local counterparts in DC and local activists from around the world were in contact. The movement to promote safe infections (also known as needle exchange) provides a vivid example of the complexities and opportunities these dynamics provide. DC has a very successful needle exchange program which cut new diagnoses among intravenous drug users (IVDU) in half since the program started to scale up in 2007. City tax dollars are used to support community based programs to provide clean needles and other services to IVDU including a van that travels in neighborhoods late into the night, distributing educational materials, condoms and clean needles. This happens in the shadow of the federal government which forbids use of federal dollars for needle exchange. Because of the unique relationship between DC and the federal government, the city budget, including allocation of taxes collected by the city, must go through a federal committee for approval. Sensitive national social issues (abortion, needles exchange) are frequent flash points between the city and the federal govern-ment.

The success of DC's needle exchange program is in large part due to the thoughtful way in which the program was designed and executed. Those who request needles must register with the community based organization that provides them with a card. This card can be shown to law enforcement officers who are educated about the program, in a city in which these needles are illegal outside of the medical prescription context.

The global activists were aware of the local program and some of them had helped create the original local policy. When the planning for AIDS 2012 began, they started planning for advocacy to draw in the thousands attending the conference and the hundreds of journalists from around the world. Initially the global activists had agreed with the local activists to distribute clean needle in and around the conference. Safe infection was an emotional issue for many local and global HIV/AIDS activists. The proposed demonstration would have clearly been in violation of city law and could possibly draw the notice of federal law makers opposed to the pro-grams.

After considerable negotiations at many levels (including highest federal) it was agreed upon that the DC Van would be parked inside the Global Vill-age but that needles would not be distributed or on display. Special sessions on safe infections and attention to the city's successes were highlighted in the Global Village and in a number of media opportunities. Global became local and may have disrupted the city program and success. Local global collaboration ensured a successful conference for all parties.

The 20th International AIDS Conference (AIDS 2014) will be held from 20-25 July 2014 in Australia at the Melbourne Convention and Exhibition Cen-tre. The meeting will spotlight diverse nature of the epidemic and the response to it in the Asia Pacific region. As the world turns its attention to AIDS 2014, lessons learned from our experience planning and hosting AIDS 2012 raise a number of programm-atic, policy, and advocacy issues.

The global IAS meetings continue to be an exciting opportunity for scientists, program and service providers, the media, and activists to come together. The epidemic and medical response to the disease has changed so much advocacy and activism. While the desperation of activism in earlier IAS meetings has waned, activism still has a critical role to play in promoting science, policy, and funding. Activism continues to play the watch dog role on public and private actors, governments, and drug companies. The time may have come, however, for consolidation of efforts that are disparate and uncoordinated. In an era of waning funds available to activist organization many of these organizations have folded or have weakened. It is better that they merge and find common voice. In the US alone there are still dozens of different organizations working on HIV/AIDS. This may be the time for emergence of a unified voice for HIV/AIDS, analogous to the American Cancer Society, and for other disease areas. The epidemic in the US and in many parts of the globe continues to spread and people still die prematurely. AIDS 2012 was a time to reconsider advocacy and explore new ways to work together to fight the epidemic. AIDS 2014 should be the time for all to come together.