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UNAIDS Winnie Byanyima discusses how communities stand ready to play their part in response to HIV. » Foreword
THE GLOBAL FUND Getting local: understanding the specific needs of the local population will step up our fight against HIV. » p4
WORLD HEALTH ORGANISATION Substantial testing gaps for HIV remain. What can we do to continue improving prevention and treatment? » p5
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Communities are making all the difference in the HIV response Communities have always played a huge part in the response to HIV. People coming together, organising themselves, telling truth to power, and demanding their right to health. For people most vulnerable to HIV, it is no exaggeration to say that communities often make the difference between life and death.
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or young women and girls, for marginalised, vulnerable groups of people such as gay men and other men who have sex with men, transgender people, s e x worker s, p e ople who u s e drugs, prisoners and migrants, the pathway to health is not always as clear-cut as it should be. S t ig m a a nd d i sc r i m i n at ion, repressive laws, ignorance and even hate, can all prevent vulnerable people from accessing life-saving prevention, treatment and care. Communities are fighting for HIV services
This is where communities often step in. Communities of people living with HIV, of marginalised and vulnerable groups, of women and of young people, lead and sustain the delivery of peer-to-peer HIV services. They also defend human rights and advocate for access to essential services. They fight every day to keep people at the centre of decisionmaking and implementation and help to make sure that no one is left behind. Women and girls are the backbone of care support in their families and communities, providing unpaid and often undervalued work in caring
Communities must have the space and power to voice their demands and write their own solutions. for children, the sick, the elderly and the disabled. They often underpin fragile social support systems. The involvement and leadership of women is vital in the response to HIV and we must support them to leverage their potential. Community-based services often support fragile public health systems by filling critical gaps; they are led by, or connect, women and other marginalised populations; they provide services that complement clinic-based care and they extend the reach of healthcare to groups that would otherwise fall through the gaps.
and write their own solutions. In 2016, world leaders signed the United Nations Political Declaration on Ending AIDS, which recognised the essential role that communities play in advocacy, participation in
WINNIE BYANYIMA Executive Director UNAIDS the coordination of AIDS responses and service delivery. Moreover, they recognised that community responses to HIV must be scaled up and committed to at least 30% of services being community-led by 2030. Most countries are nowhere near reaching that commitment and where investment in communities is most lacking, there is often weaker progress against HIV and other health challenges.
Communities stand ready to play their part in building healthier and more resilient societies, but they need our support. On World AIDS Day, let’s celebrate communities, recognise the essential role they play in the response to HIV, and commit to meeting the promises made to them. Read more at globalcause.co.uk
Reduced funding is a barrier to HIV At a time when reduced funding is putting the sustainability of HIV services in jeopardy, community activism remains critical. Indeed, a greater mobilisation of communities is urgently required and barriers that prevent them delivering services and seeking funds must be dismantled. Communities must have the space and power to voice their demands
7 October, 2019 - Zanzibar, Tanzania - Soud Khamis Soud, a volunteer at ZAPHA+ and a young person living with HIV
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Stepping up the HIV fight - reaching all those left behind DR ADE FAKOYA Senior Disease Coordinator HIV, The Global Fund to Fight AIDS, Tuberculosis and Malaria
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espite considerable advancements, we must address the areas where we are making less progress in the battle to control HIV as a public health threat. These include young women and adolescent girls in east and southern Africa, key populations including men who have sex with men, sex workers and transgender persons, and high-risk men and boys in HIV prevalent settings.
Doing well, but with big gaps in the HIV response With over 20 million people on lifesaving, anti-retroviral therapy, we have made incredible progress in the fight against one of the world’s biggest health threats: HIV. However, by the time you have finished reading this article, there will be ten new HIV infections in young women and girls aged 15-24. By the end of the week, this number will have soared to 6,400. Despite the success of programmes such as the President’s Emergency Plan for AIDS Relief (PEPFAR) DREAMS programme, or the Global Fund’s HER) HIV epidemiological response, there is still a long way to go. We are not on track to meet our ambitious – but achievable – global goals of reducing the number of new infections to 500,000 by 2020. Currently, they stand at 1.7 million. Nor are we on track to reduce the number of people who die of HIV to 500,000 per year; we’re currently at 1.2 million. Three areas particularly need attention: the inexorable persistence of new infections in adolescent girls and young women (AGYW), the high prevalence of HIV in key populations (over 50% of all new infections worldwide were in key populations and their partners in 2018) and the late access to services for many heterosexual men in East and Southern Africa. Getting local: better data = better programmes
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What do we need to do differently? Firstly, we need to have much more specific, locally-generated/locallyowned data to drive high quality programming. Understanding the specific needs of the local population, who they are, who is getting infected and the coverage of services, is vital to mounting an effective response. Local community and local facility data should drive programmes. We call this ‘geographical targeting’. An easy mantra to remember this is ‘population, location and saturation’ – then using this data to understand on whom you need to focus.
Mandisa Dukashe and her family live in Eastern Cape, South Africa. Mandisa is a trained nurse and works in the response to HIV to ensure quality control in health-care settings. She is living with HIV and encourages people to get tested for HIV. Her husband and two daughters are all HIV-negative.
Progress, challenges and opportunities in HIV prevention and testing Access to HIV testing services (HTS) and treatment has improved.
DR RACHEL BAGGALEY Coordinator, HIV Testing, prevention and populations Department of HIV and Global Hepatitis Programme, World Health Organization
People-centred care – “Involve us, we’ll tell you what we need” Providing biomedical interventions a lone w il l not end HI V. Good programmes require a whole range of layered services and being bold in tack ling underly ing gender inequalities. These inequalities include vulnerability to HIV infection, gender-based violence, educational and economic disadvantage and a lack of involvement in programme development and delivery. There are now many good examples of community involvement and participation, which are improving the quality and reach of services. Two critical areas for success are the meaningful involvement of AGYW themselves, in the design and monitoring of services, and the tailoring of services according to the varying needs of those accessing treatment and prevention services.
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n 2005, an estimated 10% of people with HIV in Africa were aware of their status. Globally, 12% of people who wanted to test for HIV, were able to do so. Now, in 2019, an estimated 81% of people with HIV in Africa, and 79% of people with HIV globally, are aware of their status. Yet substa nt ia l test i ng gaps remain, and many people at the highest HIV risk remain unreached. New approaches are needed to reach people with undiagnosed HIV earlier At the Independent Communications Authority of South Africa (ICASA), W HO is lau nch i ng updated, consolidated g uidance on HI V
testing services (HTS) that will s upp or t t he development a nd scale-up of evidence-based H T S ap p r o a c h e s i n d i f fe r e nt settings. This includes an updated recommendation on HIV self-testing (HIVST). WHO recommends HIVST as a discreet and convenient way to test, with the potential to reach people who need H TS who would not otherwise test. Important programmes d ist r ibut i ng HI VST have been i mplemented i n si x A f r ic a n countries, with more than 4.3 million HI VST k its distributed. HI VST has reached men, young people, first-time testers and people from key populations. The approaches used have prov ided invaluable
lessons on service delivery and community involvement. This experience has also catalysed HIVST policy development; HIVST is starting to contribute to bridging the testing gap. Prevention efforts are equally as important A similar effort to increase the coverage of prevention services is needed. In high-burden countries in East and Southern Africa (ESA) t h e vo l u nt a r y m e d i c a l m a l e circumcision (VMMC) programme is reducing new infections. Nearly 23 million VMMCs were performed in ESA by 2018. The challenge is to build on successful approaches, to reach and engage men and to also MEDIAPLANET
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National HIVST policy and implementation 2018, by region 40% (77/194) reporting countries have HIVST policies, of these only 49% (38) are implementing
# Reporting % Implementing
18
11 7 3
10
8 4 2
6
5
4
3 1 1
1
2 2 2
Asia and Pacific
Caribbean
East and Southern Africa
Eastern Europe and Central Asia
8% N=40
0% N=16
48% N=21
19% N=16 19
11 9
9
7 5
5 1 1 1
provide broader health benefits. We know that young women in ESA have significantly higher HIV risk than young men. Innovative programmes are reaching them too. In South Africa, for example, a national programme is to provide information and services for women addressing gender-based violence and sexual reproductive health issues, including HIV. Key populations and partners account for over half of 1.7 million new HIV infections per year In the criminal justice system, prevalence of HIV and hepatitis C are much higher. Sex workers bear a disproportionate burden o f H I V g l o b a l l y, l i n k e d t o criminalisation and violence, and only a few countries address these structural barriers. A recent global study indicates
HIV prevalence for men who have sex with men is 17.9% compared to 5% in the general male population. Continuing to improve prevention and treatment As people from key populations continue to face higher HIV risk, and constitute an increasing proportion of new infections, prevention needs to be prioritised. Choices include PrEP, alongside condoms, harm reduction, STI management and addressing structural barriers. While HIV treatment coverage is increasing overall, key populations still remain less likely to access HIV testing, prevention and treatment; if HIV incidence among those at highest risk is not reduced, epidemic control will not be possible. Progress in the HIV response is the result of remarkable advances in testing and treatment, effective
1
2
7
6 4
3
3
1
Latin America
Middle East and North Africa
West and Central Africa
Western and Central Europe and North America
6% N=17
5% N=21
4% N=25
46% N=41
HIVST policy and implementation
HIVST policy and pilots
HIVST policy only, no pilots or implementation
No HIVST policy
No HIVST policy but policy under development Source: GAM WHO, UNAIDS, UNICEF 15 July 2019
HIV self-testing policy uptake
Strengthen the focus on services for criminalised and marginalised populations who have the greatest needs. a pooled HIV prevalence of 19% among transgender women – who face multiple barriers to accessing HIV services. Estimated HIV prevalence in men who have sex with men is much greater than in adult men in general populations — six times higher in the Middle East (3%) and 25 times higher in the Caribbean (25%). In sub-Saharan Africa the estimated MEDIAPLANET
prevention options, and continuing innovation. The challenge is to ma i nta i n t he moment u m a nd strengthen the focus on services for criminalised and marginalised popu lat ion s who have t he greatest needs.
In 2019, 77 countries have national policies that support HIVST and 38 are implementing HIVST programmes Policies are under development in 47 countries and 33 countries are piloting GLOBALCAUSE.CO.UK
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Only communities can make Universal Health Coverage possible MIKE PODMORE Director, STOPAIDS
Swipe right: Oz explains dating and living with HIV
Almost 220 million people globally use online dating services. In a world where more and more people meet partners virtually, Without Universal Health Coverage (UHC), there how and when do you disclose your HIV status? International AIDS can be no end to AIDS by 2030, but without learning Society Member, 25-year old Oz, shares his experience of living with from the HIV response there will be no UHC for all. HIV and navigating online dating.
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his year has invigorated focus and commitments to achieve Universal Health Coverage (UHC). Many single disease sectors, such as HIV, are exploring the opportunities and potential risks of embracing its promise. On one hand, it is true that we will never reach the end of AIDS by 2030 without meaningfully integrating HIV services and working towards the common goal of UHC. On the other, progress towards ending AIDS will be lost, and UHC will never be successful, if the lessons of the HIV response are not mainstreamed. Lessons for the UHC movement to adopt Key components of successes in the HIV response include: political leadership at the national and global level, to drive ambitious com m it ments a nd f u nd ing; prov i s ion of s er v ic e s b eyond treatment to include prevention, care and support and social enablers; data-collection and target-setting focused on ensuring services reach the most marginalised first; and, of course, the critical role of civil
discrimination and eliminating regressive laws. One inspiring example of this i s t he c ol l ab or at ion b e t we en t h e V i e t n a m e s e G o ve r n m e nt and sex-worker-led networks to provide effective HIV prevention programmes and increase testing a nd t reat ment ser v ices for sex workers.
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A seat, and a vote, at the table
Displaying your HIV status on your profile
C i v i l s o c i e t y a n d , c r u c i a l l y, com mu n it ies a f fe c te d by H I V must be meaningfully included in national and global healthg o ve r n a n c e m e c h a n i s m s fo r planning and decision-making. This means having both a seat and a vote. It enables us to be watchdogs at all levels to ensure that programmes and funding are directed to where they are most needed. One example of this is where civ il societ y and communities on mu lt i latera l hea lt h boa rd s have raised the alarm about the negative impact of donors pulling their funding from middle-income countries. This led to a greater focus on sustainability and, where n e c e s s a r y, m o r e r e s p o n s i b l e
i ke my m i l len n ia l peers, I mostly meet people through dating apps. One common feature of the apps I use is the option to display your HIV status, or the last time you had an STI test. In some, you can also specify that your viral load is undetectable or you are on PrEP.
While living in Germany, I saw many people’s profiles displaying their status, which encouraged me to do the same. One night, a while after I moved back to Turkey, I saw someone whose status said ‘on PrEP’. I was using a new app and remembered my profile was empty, so I added ‘positive and undetectable’. I didn’t think much of it, because I was open with everyone about my HIV status. However, I realised that – unlike i n G er ma ny – no one’s stat u s actually said ‘positive’. Those who displayed their HIV
Seeing those highly stigmatising signs again and again can ruin your self-esteem; but it shouldn’t mean you can’t meet or date people online. positive status were extremely rare and were usually empty profiles. The stigma of a ‘positive’ status After this, some people I was talking to stopped responding. Others messaged me, thinking I had made a mistake and prompted me to correct my status. This was happening for days. It started getting too much and all my conversations ended up discussing HIV, which I was doing enough of in my daily life, so I ultimately removed it. I guess I can say that dating apps started feeling a bit more toxic after I was diagnosed. Going into an app where people commonly use hashtags like #ddf (drug and disease free) and #clean (meaning HIV negative), sometimes followed by
‘u b 2’ (meaning you should be HIV negative too), not only angers me but is upsetting. Seeing those highly stigmatising signs again and again can ruin your self-esteem; but it shouldn’t mean you can’t meet or date people online. Disclosing your HIV status online is a very personal decision. There is no right time or way to do it and you don’t have to disclose at all. If you want to disclose your status, do it when it feels right, and when you feel comfortable, or things can get awkward. And yes, this comes from experience!
OĞUZHAN (OZ) NUH International AIDS Society Member, 25-year-old student from Turkey
The theme of World AIDS day 2019 is: ‘Communities make the difference’. society and affected communities. It is the latter that is embodied in the theme of World AIDS Day 2019; ‘Communities make the difference.’ There is no health response where this has been better demonstrated. Reaching the most marginalised Civil society and communities affected by HI V play a central role in delivering and monitoring services at local level. They are key in mobilising people to access these services, and advocate for removing ba r r iers to acces s, i mprov i ng quality, driving down costs, holding decision-makers to account, fighting
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transition so that communities are not abandoned. Placing civil society and affected communities at the centre of the national and global UHC movement will be a prerequisite to its success. We hope to work hand in hand with communities, donors and all stakeholders to make this a reality.
Read more at globalcause.co.uk
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Understanding sexual pleasure is vital to eradicate AIDS by 2030 Sexual health and sexual rights have long been considered key to overall health and wellbeing. However, policy and advocacy in the areas of HIV, AIDS and other STIs have often been neglected any consideration of sexual pleasure.
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n order to achieve the aim of ending HIV by 2030, a holistic approach t hat considers sexual health, rights and pleasure simultaneously is paramount. With this in mind, the Global Advisory Board (GAB) for Sexual Health and Wellbeing , an independent expert group convened by Durex to advocate for a positive and inclusive approach to sexuality, focuses on the ‘triangle’ of sexual health, rights and pleasure. Vithika Yadav, Chairperson of the GAB, explains: “We realised that, while we had the World Health Organization’s working definition of ‘sexual health’ and ‘sexual rights’, we did not have a definition of ‘sexual pleasure’. We then created the first international working definition of sexual pleasure, linking it with
sexual health and sexual rights to complete the missing side of the ‘triangle.’” A three-pronged approach to sexual health and wellbeing GAB’s ‘triangle approach’ allows orga n isat ion s i nvolved i n t he promotion of health and wellbeing to spin the triangle in any direction, choosing any of the three ‘sides’ as a focus or entry p oi nt , d e p e nd i n g on their priorities, but maintaining a constant connection between the three. For pleasure to be
healthy, we need to consider: selfdetermination, consent, privacy, safety, confidence and the ability to communicate/negotiate with partner(s). We also need sexual rights to ensure that sexual pleasure is a positive experience for those involved and not obtained by violating the rights of others.
VITHIKA YADAV Chairperson of the Global Advisory Board for Sexual Health and Wellbeing, Head of Love Matters India / RNW Media
A toolkit to empower healthcare professionals Consideration of all three sides is vital to ensure anyone who walks into a sexual health clinic is able to access services comfortably, without fear of judgement. In order to educate sexual health providers and allow them to deliver high-quality services incorporating rights and pleasure for all, GAB created a training toolkit based on the ‘triangle approach’, entitled ‘Sexual Pleasure: The Forgotten Link in Sexual and Reproductive Health and Rights’. Training has been conducted in India, UK, Lebanon, South Africa, the Netherlands, USA and Russia. The board is also transforming the toolkit into a digital training course to scale
up its global implementation. GAB is encouraging everyone to start incorporating sexual pleasure into the discussion, alongside sexual health and rights. Only then, they say, can we win the fight against HIV, AIDS and STIs once and for all. WRITTEN BY: MEREDITH JONES-RUSSELL
Supported by
HIV/AIDS in Eastern Europe and Central Asia ALEX KALOMPARIS VP Public Affairs, Australia, Canada and Europe, Gilead Sciences
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hi le t here has been great global progress in accelerating towards the UNAIDS 90–90–90 targets, with many European countries exceeding this target, this is not a consistent picture.
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Eastern Europe and Central Asia (EECA) is one of the few regions in the world where the annual rate of HIV infections continues to rise.1 Deaths from AIDSrelated illnesses have increased 300% in the last 20 years within the region,1 and more than 400 people become infected with HIV every day.1 To add res s t he challenges in EECA and ensure no one is left behind in the global effort to end the HIV/AIDS epidemic, the Elton John A IDS Fou ndat ion and Gilead Sciences are col laborat ing on a groundbreaking initiative called RADIAN. “There are more than one million
ANNE ASLETT Chief Executive Officer, Elton John AIDS Foundation
There are more than one million people living with HIV in Eastern Europe and Central Asia who need access to appropriate care. people living with HIV in EECA who need access to appropriate care. Both the Elton John AIDS Foundation and Gilead have previously worked together in the region and there is still an urgent need to drastically expand our efforts,” said Anne Aslett, Chief Executive Officer, Elton John AIDS Foundation, “The RADIAN partnership leverages an understanding of the EECA community from previous initiatives and will drive forward the shared ambition to end the HIV epidemic.” The RADIAN initiative (radianhiv. org) is comprised of two key elements, the RADIAN “Model Cities” fund
and the RADIAN “Unmet Need” fund. By adapting a dual-track programme, RADIAN can direct resources to communities in need that are immediately ready to scale interventions through targeted funding, while simultaneously building capacity in others. “Our goal w ith the R A DI A N programme is to provide the support for a targeted HIV response that has been historically lacking in this region,” said Anne Aslett. “RADIAN aims to contribute measurable changes in HIV incidence, screening and linkage to care, to meaningfully address new HIV infections and deaths
from AIDS-related illnesses in the region. Over the next five years, the learnings from RADIAN will be used as a blueprint towards helping change the trajectory of HIV in EECA.” AUTHORED BY: ALEX KALOMPARIS Source: 1. UNAIDS (2019). UNAIDS Data 2019. Available at: https://www.unaids.org/en/resources/ documents/2019/2019-UNAIDS-data [Accessed October 2019].
Supported by
JOB BAG: IHQ-HIV-2019-11-0016 DATE OF PREPARATION: NOVEMBER 2019
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