This article is written by Mariah Wilberg, Statewide HIV Strategy and Services Coordinator, Minnesota Department of Human Services. This article was selected by the National Association of County and City Health Officials as a winner in Apolitical's 2020 American Public Servant Writing Competition.

Innovative. Early adopters. Nimble. Bureaucracy.

You may be thinking that one of these doesn’t belong. Public institutions aren’t exactly known for being ahead of the curve. The stereotype is that public servants are resistant to change, lagging behind as we cling to archaic systems, processes, and ways of thinking.

I’m writing to share a story of hope. Public institutions can embrace paradigm shifts. Public servants can be changemakers. And you don’t need to be in a position of authority to do it. What does this look like in practice?

Stigma vs science

To give you an example, I want to highlight how Minnesota has emerged as a leader in fighting HIV stigma.

Combination antiretroviral therapy has transformed HIV from a death sentence into a chronic and manageable condition. Daily therapy renders the amount of HIV circulating through the body, or viral load, to undetectable levels. This keeps the immune system healthy, and we now know that it also prevents further transmission. Undetectable = Untransmittable — or U=U — is an international campaign celebrating the fact that a person living with HIV who acheives and maintains an undetectable or suppressed viral load cannot transmit HIV through sex, even in the absence of condoms or other HIV prevention methods.

For decades, people living with HIV have been treated as viral vectors, a view reinforced by media, public policy, and public health messaging

This life-changing truth has been verified by four large studies (HPTN 052, PARTNER, Opposites Attract, and PARTNER 2 , confirmed by leading HIV researchers worldwide and is being shared by nearly 1,000 organisations in 101 countries. The Centres for Disease Control and Prevention affirm the science, agreeing that HIV treatment is 100 percent effective at preventing sexual HIV transmission with optimal use.

Despite this robust consensus, many public institutions and officials are either indifferent or actively suppressing this message.

For decades, people living with HIV have been treated as viral vectors, a view reinforced by media, public policy, and public health messaging. HIV is the only disease that is routinely criminalised, with many losing their freedom for engaging in consensual behavior that cannot and did not transmit HIV. The notion that people living with HIV are dangerous is deeply ingrained in our culture, institutions, and psyches, so this new science is hard for many to accept.

In 2017, Minnesota became the third U.S. state to join the U=U campaign, following New York and Michigan. This was a tangible way to demonstrate our dedication to ensuring that all people living with HIV in our state have access to accurate and meaningful information about their social, sexual, and reproductive health.

Endorsing the U=U campaign was not a decision made lightly or quickly.

When I started in my previous position at the Minnesota Department of Health in 2016, getting our state government to join the U=U movement was high on my agenda. As a person living with HIV, I vividly remember the day I learned that I could be intimate without putting my partner at risk. I cried as years of shame, stigma, and fear dissolved. It was the moment that I truly accepted my HIV status.

I wanted all people living with HIV in Minnesota to feel the same freedom, hope, and relief. I understood the significance of U=U – as a powerful antidote to stigma, a motivation to engage in HIV care, and a potential way to decrease new HIV diagnoses.

Bringing about change within a bureaucracy is daunting. Please continue to strive

Adopting a new approach takes patience, time, and negotiation. It required generating support and buy-in from all levels of the agency – program, section, division, and executive leadership. U=U is a nuanced message. Remaining undetectable and untransmittable requires daily medication adherence and routine monitoring from a health care provider. We had to agree on a plain language way to describe the science that also clearly conveyed the complexity of this prevention method.

We also had to consider how promoting U=U would fit in with other organisational goals, such as preventing sexually transmitted infections (STI).

Our field will always be plagued by these tensions. We must navigate these contradictions to achieve progress on goals that may conflict. One cannot supersede the other. Rather than being prescriptive, we chose to provide all evidence-based information about STI and HIV prevention and trust people to make decisions that are right for them.

After ten months of careful listening and thoughtful discussions, the Minnesota Department of Health issued a news release supporting U=U.

Uncharted territory

Being an early adopter brings exciting opportunities. While the science supporting U=U is clear, there is still much work to do to operationalise the concept and integrate it into programming and interventions.

Minnesota forged ahead with a U=U campaign viewed by millions of people. A colleague and I traveled to different teams at the health department to understand how U=U fit in with existing programming, messaging, and policies. We made the necessary changes to accommodate the new science and provided training to community partners to ensure that people in our state receive consistent messaging.

We’ve since been praised as a leader in U=U implementation by national HIV capacity building organisations, and I’ve had the opportunity to present at several national conferences and provide peer-to-peer technical assistance to other states. Championing U=U allowed me to develop and demonstrate leadership skills, and I’ve since transitioned to a new position with the Minnesota Department of Human Services leading our statewide plan to end HIV. We continue to move forward with U=U education statewide.

So, what does this mean for public servants?

Bringing about change within a bureaucracy is daunting. Please continue to strive. Do not shy away from uncharted territory. Lean in with compassion, dedication, and unwavering commitment. Embracing change will benefit you and your organisation — and most importantly — improve the lives of the people you serve. If you’re in public health, start today by joining 20 U.S. state and 30 county and city health departments and endorse the U=U campaign. — Mariah Wilberg

(Picture credit: Unsplash)

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