PRESERVING HUMAN RIGHTS IN THE ERA OF “TEST AND TREAT” FOR HIV PREVENTION

Freedom Riders Joseph Randall, James Farmer, Sidney Shanken, and John Harvard clasp hands before they join a protest to test segregated facilities in Tennessee. Photograph by Bettman. Printed with permission of Corbis.

The promising and biomedically grounded “test and treat” HIV prevention strategy has empowered a growing movement to desocialize the field of HIV prevention.^1,2 Mayer and Venkatesh provide a rigorous and balanced evaluation of this prevention approach,³ which would involve universal, voluntary HIV screening and initiation of antiretroviral treatment for all persons infected with HIV. If empirically feasible, the “test and treat” strategy would vastly increase access to life-saving medications and would likely prevent HIV transmission on a wide scale. But scale-up of this biomedical intervention should not divert resources from other effective prevention efforts, particularly social and structural prevention strategies, harm reduction strategies, and community-strengthening initiatives. Confronting the global HIV/AIDS pandemic has laid bare the health and social disparities that disproportionately impact the most marginalized segments of society. While we remain hopeful about the “test and treat” approach, the potential of this strategy should not undermine the social and structural response to an epidemic driven by inequity.^3–6

Over the past three decades, social and structural prevention interventions have made significant inroads in addressing the political, economic, and social realities underlying HIV transmission. Empowerment strategies that promote agency, livelihood, and well-being actively engage the most vulnerable populations and address injustice and human suffering beyond the context of HIV/AIDS.^7–10 The danger of desocializing HIV prevention lies in losing this comprehensive human rights response.

Injection drug users, men who have sex with men, and individuals who engage in commercial sex work remain criminalized and condemned around the world. Rendering individuals who inject drugs less infectious by placing them on antiretroviral therapy is itself worthwhile, but addressing human rights violations such as undue detention, police harassment, and denial of access to addiction treatment and creating social and financial capital for rehabilitation are no less important. Similarly, using the “test and treat” strategy alone to reduce heterosexual transmission leaves unchallenged harmful gender disparities that limit women's capacity to negotiate equitable roles in their partnerships and in society. In turn, inability to prevent other sexually transmitted infections, unintended pregnancies, and intimate partner violence can lead to significantly gendered morbidity. Treating these vulnerabilities as interconnected is ultimately critical to both HIV prevention and promotion of human rights, and unless the “test and treat” strategy is integrated with a more comprehensive response, it will fall short of meeting the needs of the most vulnerable populations.

HIV prevention's strength lies in its interdisciplinary nature; those working in research and outreach can engage a wide array of approaches—biomedical, behavioral, social, and structural—and harness their collective power. This capacity allows for a comprehensive human rights–oriented response to the HIV/AIDS epidemic that simultaneously seeks to preserve human life and human dignity. The strategies defining this new era of HIV prevention must preserve a human rights orientation and respond to the injustices that medicine and technology alone cannot resolve.