A U.N. Declaration on Ending AIDS Should Have Been Easy. It Wasn’t.

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On Tuesday, the United Nations is expected to adopt new targets for ending AIDS as a public health threat by 2030, seemingly a goal most countries could easily have agreed to. But consensus has been elusive.

In early negotiations over the agreement, called a political declaration, the United States and the European Union fought to ban policies and laws that stigmatize, or even criminalize, high-risk groups — and drastically scaled back moves to relax patent protections for H.I.V. drugs.

The U.N. declaration sets priorities for the global AIDS response and guides policies at a national level. It also gives global health organizations and civil society organizations leverage to pressure governments to honor their commitments.

After several days of heavy edits by delegates from some countries and deft negotiations by others, member countries are expected to accept a final version of the declaration on Tuesday morning. Included in the final draft is an important new goal of having most nations reform discriminatory laws, so that less than 10 percent of the world’s countries would have measures that unfairly target people at risk of, or living with, H.I.V.

“Those laws are driving people most affected by H.I.V. away from H.I.V. prevention and treatment,” said Matthew Kavanagh, director of the Global Health Policy and Politics Initiative at Georgetown University. “This could be a critical tool in getting the world back on track to ending AIDS.”

On Monday, Dr. Kavanagh and his colleagues published new work showing that countries that criminalize same-sex relationships, drug use and sex work have had much less success in turning back H.I.V.

But the declaration does not move the needle on patent protections. The United States was among those nations whose delegates significantly watered down — or moved to cut — language to relax patents to allow for greater access to affordable H.I.V. drugs in low- and middle-income countries, a stance at direct odds with the Biden administration’s support of patent waivers for Covid vaccines.

“The mixed messaging from the administration, given recent support for Covid-19 vaccine patent waivers, is confusing and disappointing,” said Annette Gaudino, director of policy strategy at Treatment Action Group, an advocacy organization in New York. “This would be far from the first time the U.S. has put pharmaceutical companies’ profits over people and public health.”

The U.N. brings together heads of state, health ministers and nongovernmental organizations to set priorities for tackling the H.I.V. pandemic every five years. At a similar meeting in 2016, member countries agreed to aim for fewer than 500,000 new H.I.V. infections annually, fewer than 500,000 AIDS-related deaths and eliminating H.I.V.-related discrimination by 2020.

The world did not meet those targets: About 1.5 million people became infected with H.I.V. in 2020, and about 690,000 died.

Ending AIDS by 2030 was an aspirational target adopted in 2015 by the U.N., part of a broader agenda regarding sustainable development. But without more progressive policies and laws, the goal is not achievable, Dr. Kavanagh said.

“To end AIDS by 2030, governments must commit to take a people-centered, rights-based approach to H.I.V., to work on policy and law reform, to engage and support communities, and to end inequalities,” Winnie Byanyima, executive director of U.N.AIDS, said in an emailed statement.

The initial draft of the declaration, dated April 28, included a commitment to end “punitive laws, policies and practices, stigma and discrimination based on H.I.V. status, sexual orientation and gender identity.”

Delegates from some countries, including China, Russia and Iran, tried to delete allusions to sexual or gender identity, or to sex education for girls. They succeeded only partially: The current text calls for prevention approaches tailored to high-risk groups, including sex workers, men who have sex with men, drug users and transgender people.

The declaration, in its current form, also urges countries to “empower women and girls to take charge of their sexual and reproductive health and reproductive rights,” a section that Saudi Arabia, Russia and the Holy See tried to scrub from the text.

Representatives from Belarus, China and Russia also deleted a section that asked member countries to recognize citizens’ autonomy on matters related to sexuality; their substituted text encouraged “responsible sexual behavior, including abstinence and fidelity.” The final document reverted to the original text.

Even if the declaration is adopted on Tuesday, these countries may disassociate themselves with specific sections that contradict their cultural or religious norms.

Including the language about high-risk groups is critical to success, some experts said. Gay men and other men who have sex with men, people who inject drugs, and female sex workers have a nearly 30-fold higher risk of H.I.V., compared with the general population.

If those groups cannot access the preventive therapies, clean needles, condoms or education they need, “we are going to erode the possibility of actually ending AIDS by 2030,” said Eric Sawyer, an advocate and long-term survivor with H.I.V.

An early draft of the declaration also contained a lengthy section on relaxing patent protections. Under current global rules, only the 50 least developed countries are allowed to eliminate patents on pharmaceutical products in order to distribute them to citizens.

The draft called for “an indefinite moratorium on international intellectual property provisions for medicines, diagnostics and other health technologies.” Representatives of the United States and Switzerland deleted that section. A representative of the European Union said, “This is not the place to discuss these general issues.”

The United States also added language to the scaled-back version to recognize the “importance of the intellectual property rights regime in contributing to a more effective AIDS response.”

Activists said taking a stance against patent protections was entirely consistent for the European Union, which also opposed a waiver for patents on Covid vaccines. Vaccine manufacturers have argued that patent protections are essential for driving innovation.

But citing the urgent need for vaccines, officials in the Biden administration have said that they would back a patent waiver that allow companies to make cheaper versions of the vaccines for the rest of the world.

Given that development, “it would be really inconsistent for the U.S.” to oppose relaxing patent protections for H.I.V. drugs, said Brook Baker, senior policy analyst for Health Global Access Project, an advocacy organization.

“Why in the world would the U.S. be talking out of two sides of its mouth on what seems to be nearly an identical issue?”