In Marin County, there are some 648 individuals living with HIV while in the Republic of Malawi, a country in southeastern Africa, about a million people are believed to be infected.
Despite the vast difference in the number of people affected, those fighting the disease and caring for the sick in both locations agree the biggest obstacle to ending the HIV/AIDS epidemic is the stigma associated with sex.
Global AIDS Interfaith Alliance, a San Rafael nonprofit, is part of an international effort to reduce the number of HIV/AIDS cases to below epidemic levels by 2020. The alliance does most of its work in Malawi, where it employs 67 Malawians who try to identify their HIV-infected countrymen and get them to start taking antiretrovirals.
Unlike years ago, the medicines needed are readily available, said Todd Schafer, the alliance’s chief executive.
“There are shortages of all kinds of medicines but the HIV drugs have been consistently available,” Schafer said.
The biggest problem, Schafer said, is convincing Malawians, particularly men, to be tested.
“There is still a lot of stigma relating to HIV because of its connection with sex,” Schafer said.
AIDS is rampant among heterosexuals in Malawi so the stigma isn’t due to a prejudice against homosexuals — even though homosexuality was outlawed in Malawi in 2010, Schafer said.
“The bigger concern regarding stigma is the sense that you are promiscuous and that you have been sexually active outside your marriage,” Schafer said.
Andy Fyne, prevention and testing manager at the Spahr Center in San Rafael, said stigma is also the biggest roadblock to identifying and treating Marin residents infected with HIV.
“We’re just not where we need to be in eliminating the stigma around substance abuse and same-sex love,” Fyne said. “I can accept it within myself, but when my neighbors or my family or my church cannot accept it then I can’t go that extra step and be open and go to the doctor.”
Marin service
On Friday, Dec. 1 — World AIDS Day — the Spahr Center is hosting an event at 3 p.m. to memorialize people who died from AIDS and honor long-time survivors.
Since the first Marin AIDS case was reported in 1982, 1,431 Marin residents have been diagnosed with the disease and 824 have died. In 2016, there were 24 new cases of HIV infection and four deaths due to AIDS reported in Marin. Between 2005 and 2016, Marin County averaged 19 new HIV infections per year.
According to UNAIDS, an estimated 1.8 million people worldwide became newly infected with HIV and 1 million died from AIDS in 2016. UNAIDS estimates there are 36.7 million people globally living with HIV; almost an equal number, 35 million, have died from AIDS-related illnesses since the start of the epidemic.
There is, however, plenty of reason for hope. New combination therapies have proven remarkably effective, and the prices of vital antiretroviral drugs and diagnostics continue to be driven down.
Schafer said medications that cost $10,000 a year for a single individual in 2000 now cost just $75 a year.
“That has changed the equation enormously,” he said.
The expansion of antiretroviral therapy worldwide resulted in a 45 percent drop in AIDS-related deaths between 2005 and 2015, according to UNAIDS.
Reduce cases
Since 2000 when Global AIDS Interfaith Alliance was founded and began its work in Malawi, the annual rate of new HIV infections there has decreased by 60 percent and the rate of AIDS-related deaths has decreased by 65 percent. Malawi is among the sub-Saharan African countries that have been hit the hardest by the HIV/AIDS epidemic.
Sensing that the epidemic is nearing a tipping point, UNAIDS has developed a strategy to dramatically reduce the number of cases to below epidemic levels by 2020. To achieve this goal, UNAIDS has focused on three goals: diagnosing 90 percent of people who are HIV infected, getting 90 percent of people diagnosed on antiretroviral treatments and achieving viral suppression with 90 percent of people being treated.
“Epidemics are like forest fires,” Schafer said. “They need to be brought under control before they can be extinguished. That is what 90-90-90 is about, building the fire breaks that will allow the end of AIDS to occur.”
Schafer estimates that about 70 percent of those infected with HIV in Malawi have been diagnosed. One of the biggest challenges the alliance faces in getting to 90 percent is convincing men to be tested.
Reaching men
The alliance operates seven general health clinics daily from different sites every day. Eighty-four percent of Malawi’s population live in remote, rural villages.
“They are far more than just HIV clinics and that is by design because of this issue of stigma,” Schafer said.
The people who attend the clinics have the security of coming and waiting in line with people who are there for all kinds of maladies. Schafer said the clinics typically attract 150 to 225 people at a time.
“Maybe a dozen of them will be men; the rest will be women and children,” Schafer said. “We’ve come to understand that health clinics are viewed as female spaces where women gather.
“The reason for that,” he said, “is that women primarily come to the clinic to bring their children. While they are there, they get their health needs met. The men are left out of that equation.”
To address this issue, the alliance has started reserving some days for men-only health clinics.
“And we’ve introduced a program where we’re going literally door to door through villages asking families to be tested in their homes,” Schafer said. “To our surprise, they are very, very open to it.”
Schafer said the Malawians seem to like the idea of being tested in the privacy of their homes, and the fact every home is visited is also important.
“There is no stigma if everybody gets tested,” he said.
