UNAIDS Outlook 2010

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UNAIDS Outlook 2010

  1. 1. OUTLOOK UNAIDS OutlOOk RepORt | 2010 The A To Z of universAl Access Where does The money for AIDS go? ThaT was Then. This is now! in my Words: The LAST hiv prevenTion, wOrD from 4 people, 4 sTories michel sidibÉ A DAY IN THE LIFE prudence mAbele shAres her sTory pAge 18
  2. 2. The Harsh Divide AIDS Treatment in Africa © Gideon Mendel, 2003
  3. 3. Thobani Ncapayi, from Khayelitsha, Cape Town, is HIV-positive and receiving treatment. “Now I feel like everybody else. I am not thinking all the time about HIV. I do not bury my dreams”, he says.
  4. 4. CONTENTS UNAIDS OutlOOk RepORt | 2010 IN wOrDS What We are thinking | 05 38 epidemic OVerVieW | 07 Get the latest statistics globally and regionally. anatOmy Of a Bad LaW | 12 A light-hearted look at the serious issue of how bad laws can hamper HIV treatment and prevention efforts. Being the change | 16 What is the future of AIDS? Tackling issues surrounding young people, sexuality and how the behaviours of adults and 28 young people are changing. treatment caSe StUdy: the gLOBaL fUnd | 22 ideaS LaB | 28 Innovations in the AIDS response. Putting ideas to work. See what is happening around the world in HIV prevention, treatment and care efforts. 08 IN PICTUrES the harSh diVide | 01 AIDS treatment in Africa UnaidS’ nine priOrity areaS | 14 Inspired by the UNAIDS Outcome Framework, Outlook puts in pictures nine priority areas. chiLdren BOrn Of hOpe | 30 A woman in Viet Nam shares her family photo album as she gets ready to deliver her second child. 31 14 29 2 | Outlook Report | www.unaids.org
  5. 5. FEATUrES 08 THAT wAS THEN. THIS IS NOw! How HIV prevention responses and modes of transmission studies are changing the way we look at HIV prevention. The case is made for using new data on modes of trans- mission, how HIV moves from person to person, as a key component when designing HIV prevention programmes. 18 COVEr STOrY: A DAY IN THE LIFE Prudence Mabele shares her story. Living with HIV for 19 years, she is the founder and executive director of the Positive Women’s Network, which she created in 1996. The organization provides support and information to women living with HIV in South Africa. Learn how this dynamic woman is making a difference in the AIDS response. 24 wHErE DOES THE MONEY FOr AIDS GO? See how funding flows in the AIDS response. Domestic spending and donor dollars—we connect the dots between resources, data and what is happening on the ground. 34 IN4 MY wOrDS HIV prevention is making a 4 people, stories on how difference in their lives. 38 THEthe 2006ZUnited Nations Political Declaration: A TO OF UNIVErSAL ACCESS Inspired by a reminder of the key issues involved in the movement towards universal access to HIV prevention, treatment, care and support. 40 THE LASTofwOrD year as Executive Director, Coming to the end his first Outlook gives Michel Sidibé the last word. UNAIDS/09.37E / JC1796E, ISBN 978 92 9173 832 8 © Joint United Nations Programme on HIV/AIDS (UNAIDS) 2009. All rights reserved The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. UNAIDS does not warrant that the information published in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. www.unaids.org | Outlook Report | 3
  6. 6. > “PeoPle living wiTh hiv should noT be discriminaTed againsT, including Through resTricTions on Their abiliTy To Travel beTween counTries. ThaT They are should fill us all wiTh shame. …i call on all governmenTs To review Their legal frameworks To ensure comPliance wiTh The human righTs PrinciPles on which a sound aids resPonse is based. This is noT solely a medical or scienTific challenge. iT is a moral challenge, Too. leT us find The wisdom and courage for bold acTion on all These fronTs. ThaT is The only way To address This challenge in all iTs comPlexiTy and breadTh.” uniTed naTions secreTary-general ban ki-moon > The uniTed sTaTes recenTly joined a growing number of counTries in removing hiv-relaTed Travel resTricTions. unaids esTimaTes ThaT nearly 60 counTries imPose some form of Travel resTricTions on PeoPle living wiTh hiv. The inTernaTional guidelines on hiv/aids and human righTs sTaTe ThaT any resTricTion on liberTy of movemenT or choice of residence based on susPecTed or real hiv sTaTus alone, including hiv screening of inTernaTional Travellers, is discriminaTory. > 4 | Outlook Report | www.unaids.org
  7. 7. What We Are Thinking TOwArDS UNIVErSAL ACCESS South Africa, home to the largest number of people living with HIV, will launch on World AIDS Day 2009 a major mobilization campaign towards achieving Here are some key statistics for the its universal access goals. President Zuma has committed the government to year 2008: achieving 80% coverage for antiretroviral therapy and to cutting new HIV infections by half. This reinvigorated commitment has the potential to reshape the face of the epidemic. Many other countries are also reviewing their national responses to AIDS, fine-tuning their strategies for scaling up access to HIV NEw INFECTIONS PEr DAY prevention, treatment, care and support. (Read excerpts of President Zuma’s children 1200 w speech on page 11.) young people 2500 w EACH SMALL STEP COUNTS Adults 3700 w Human rights and dignity for the voiceless have gained the upper hand in many places. The Supreme Court of Indonesia has ruled that drug users need treatment, NEw HIV INFECTIONS not jail. The Delhi High Court in India restored dignity to men who have sex with men by reading down a 150-year-old law that criminalized consensual adult sexual children 430,000 w behaviour. El Salvador promulgated a ministerial decree banning discrimination young people 910,000 w based on sexual orientation. The United States of America has removed restrictions Adults 1,360,000 w on people living with HIV entering the country. And sex workers in Kolkata, India, are running more than a dozen non-formal education centres and two boarding homes for children of sex workers to continue their education. PEOPLE LIVING wITH HIV children 2,100,000 v EACH bOLD IDEA COUNTS UNAIDS believes that the virtual elimination of mother-to-child transmission of young people 12,500,000 v HIV can be achieved by 2015. In Botswana, Namibia and Swaziland, more than Adults 18,800,000 v 90% of all HIV-infected pregnant women already receive antiretroviral prophylaxis for preventing their babies from being born with the virus. Universal access targets for antiretroviral therapy are being met in many countries, including Zambia. The AIDS-rELATED DEATHS integration of tuberculosis and HIV services in South Africa has helped to save the children 280,000 w lives of many people and has reduced the tuberculosis burden. Adults 1,700,000 v The demand for AIDS treatment should become an opportunity for Africa to reform its pharmaceutical practices. A single African drug agency has the potential rESOUrCES AVAILAbLE (US$) to guarantee quality medicines, integrate the African market for drugs and invite private sector investment in the continent. And it can be a model for wider multilateral odA 2.1 billion v development that will contribute to an AIDS+MDG movement in Africa. bilateral odA 5.7 billion v The Thailand vaccine trial has shown that a vaccine against HIV will be available one domestic 7.2 billion v day. When that day comes, it must be financed as a public good, accessible by all. philanthropic 0.7 billion v AIDS IS COMING OUT OF ISOLATION For all its uniqueness, AIDS cannot be left in a silo. Recent evidence shows that HIV may have a significant impact on maternal mortality. Research models estimate that about 50 000 maternal deaths were associated with HIV in 2008. The two programmes, maternal child health and HIV, must work in synergy to achieve their common goal—saving mothers and babies. We must link our progress in AIDS to the other Millennium Development Goals and pursue a bold strategy that will take us to 2015 and beyond. In This Issue In this first issue UNAIDS Outlook Report explores new ideas and ways to use the data collected in the AIDS Epidemic Update companion report. It’s clear that the HIV epidemic the world faces today is not the same as when it was at its peak in 1996. The number of people living with HIV has continued to grow, albeit less rapidly. The way we respond today needs to keep pace with and overtake the epidemic if we are to see a real change in people’s lives, aspirations and futures. www.unaids.org | Outlook Report | 5
  8. 8. DID YOU KNOW? Facts from the 2009 AIDS Epidemic Update V, AIDS, treAtment, preVentIon, cAre, Support, people lIVIng wItH HIV, HumAn rIgHtS, genDer, SexuAlIty, teStIng AnD counSellIng, ScIence, eSeArcH, SexuAl HeAltH, reproDuctIVe HeAltH, StIgmA, DIScrImInAtIon, orpHAnS, cHIlDren, mobIle populAtIonS, eDucAtIon, refugeeS, Sex orkerS, clIentS of Sex workerS, Home bASeD cAre, pAllIAtIVe cAre, pSycHoSocIAl Support, nutrItIon, fooD SecurIty, conDomS, eDucAtIon, accine, social change, universal precautions, blood safety, coinfection, tb/hiv, travel restrictions ВИЧ, СПИД, леЧенИе, ПрофИлактИка, хоД И ПоДДержка люДей, жИВущИх С ВИЧ, ПраВа ЧелоВека, генДер, СекСуальная орИентацИя, конСультИроВанИе И теСтИроВанИе, науЧные ССлеДоВанИя, СекСуальное зДороВье, реПроДуктИВное зДороВье, СтИгма, ДИСкрИмИнацИя, СИроты, ДетИ, мобИльные груППы наСеленИя, бразоВанИе, беженцы, работнИкИ СекС-бИзнеСа, клИенты работнИкоВ СекС-бИзнеСа, ухоД на Дому, ПаллИатИВный ухоД, ПСИхоСоцИальная оДДержка, ПИтанИе, ПроДоВольСтВенная безоПаСноСть, ПрезерВатИВы, образоВанИе, ВакцИна, СоцИальне ИзмененИя, унИВерСальные еры ПреДоСторожноСтИ, безоПаСноСть кроВИ, ко-ИнфекцИИ, тб / ВИЧ, огранИЧенИя на ПоезДкИ vih, sida, tratamiento, prevención, atención, poyo, personas que viven con el vih, derechos humanos, género, sexualidad, asesoramiento y pruebas del vih, ciencia, investigación, alud sexual, salud reproductiva, estigma, discriminación, huérfanos, niños, poblaciones móviles, educación, refugiados, profesionales el sexo y sus clientes, atención domiciliaria, cuidados paliativos, apoyo psicosocial, nutrición, seguridad alimentaria, preservativos, acunas, cambio social, precauciones universales, seguridad de la sangre, coinfección, tuberculosis/vih, restricciones de viaje vih, sida, rAItement, préVentIon, SoInS, SoutIen, perSonneS VIVAnt AVec le VIH, DroItS De l’Homme, SexoSpécIfIcIté, SexuAlIté, DépIStAge et conSeIl, cIence, recHercHe, SAnté Sexuelle, SAnté généSIque, StIgmAtISAtIon, DIScrImInAtIon, orpHelInS, enfAntS, populAtIonS mobIleS, éDucAtIon, éfugIéS, profeSSIonnel(le)S Du Sexe, clIentS DeS profeSSIonnel(le)S Du Sexe, SoInS à DomIcIle, SoInS pAllIAtIfS, SoutIen pSycHoSocIAl, utrItIon, SécurIté AlImentAIre, préSerVAtIfS, éDucAtIon, VAccIn, cHAngement SocIAl, précAutIonS unIVerSelleS, SécurIté trAnSfuSIonnelle, o-infection tuberculose / vih, restrictions aux voyages hiv, aids, treatment, prevention, care, support, people living with hiv, human rights, enDer, SexuAlIty, teStIng AnD counSellIng, ScIence, reSeArcH, SexuAl HeAltH, reproDuctIVe HeAltH, StIgmA, DIScrImInAtIon, orpHAnS, HIlDren, mobIle populAtIonS, eDucAtIon, refugeeS, Sex workerS, clIentS of Sex workerS, Home bASeD cAre, pAllIAtIVe cAre, pSycHoSocIAl upport, nutrItIon, fooD SecurIty, conDomS, eDucAtIon, VAccIne, SocIAl cHAnge, unIVerSAl precAutIonS, blooD SAfety, coInfectIon, tb/HIV, ravel restrictions ВИЧ, СПИД, леЧенИе, ПрофИлактИка, ухоД И ПоДДержка люДей, жИВущИх С ВИЧ, ПраВа ЧелоВека, генДер, СекСуальная рИентацИя, конСультИроВанИе И теСтИроВанИе, науЧные ИССлеДоВанИя, СекСуальное зДороВье, реПроДуктИВное зДороВье, СтИгма, ИСкрИмИнацИя, СИроты, ДетИ, мобИльные груППы наСеленИя, образоВанИе, беженцы, работнИкИ СекС-бИзнеСа, клИенты работнИкоВ СекС- ИзнеСа, ухоД на Дому, ПаллИатИВный ухоД, ПСИхоСоцИальная ПоДДержка, ПИтанИе, ПроДоВольСтВенная безоПаСноСть, ПрезерВатИВы, бразоВанИе, ВакцИна, СоцИальне ИзмененИя, унИВерСальные меры ПреДоСторожноСтИ, безоПаСноСть кроВИ, ко-ИнфекцИИ, тб / ВИЧ, гранИЧенИя на ПоезДкИ vih, sida, tratamiento, prevención, atención, apoyo, personas que viven con el vih, derechos humanos, género, exualidad, asesoramiento y pruebas del vih, ciencia, investigación, salud sexual, salud reproductiva, estigma, discriminación, huérfanos, ños, poblaciones móviles, educación, refugiados, profesionales del sexo y sus clientes, atención domiciliaria, cuidados paliativos, poyo psicosocial, nutrición, seguridad alimentaria, preservativos, vacunas, cambio social, precauciones universales, seguridad de la angre, coinfección, tuberculosis/vih, restricciones de viaje vih, sida, traitement, prévention, soins, soutien, personnes vivant avec le vih, roItS De l’Homme, SexoSpécIfIcIté, SexuAlIté, DépIStAge et conSeIl, ScIence, recHercHe, SAnté Sexuelle, SAnté généSIque, StIgmAtISAtIon, ScrImInAtIon, orpHelInS, enfAntS, populAtIonS mobIleS, éDucAtIon, réfugIéS, profeSSIonnel(le)S Du Sexe, clIentS DeS profeSSIonnel(le) Du Sexe, SoInS à DomIcIle, SoInS pAllIAtIfS, SoutIen pSycHoSocIAl, nutrItIon, SécurIté AlImentAIre, préSerVAtIfS, éDucAtIon, VAccIn, hangement social, précautions universelles, sécurité transfusionnelle, co-infection tuberculose / vih, restrictions aux voyages  CAMbODIA  PAPUA NEw GUINEA  USA The age difference between spouses Between 2007 and 2008, the number In the United States, the rate of new in Cambodia correlates positively of people over the age of 15 who HIV infections among men who with a woman’s increased risk of received HIV testing and counsel- have sex with men has steadily in- HIV infection. ing in Papua New Guinea went up creased since the early 1990s, rising approximately fourfold. by more than 50% in 1996–2009.  KENYA In 2007, HIV prevalence among un-  EGYPT i NETHErLANDS circumcised men in Kenya was more In Egypt, 6.2% of reported AIDS The Netherlands reported no new than three times higher than among cases are due to receipt of blood HIV infections due to mother-to- men who were circumcised. products, while 12% come from child transmission in 2007. renal dialysis.  rUSSIA  CHINA In the Russian Federation studies  CHILE In China, estimated HIV prevalence indicate that more than 30% of sex A five-clinic survey of female sex among injecting drug users ranges workers have injected drugs. workers in Santiago, Chile, detected from 6.7% to 13.4%. no HIV infections. Sex workers reported always using condoms with clients; however, consistent condom use with steady partners was rare. 6 | Outlook Report | www.unaids.org
  9. 9. Epi dEmic [ ] The following are excerpts from the 2009 AIDS Epidemic Update, which reports on the latest developments in the global AIDS epidemic. With OvEr maps and regional summaries, the 2009 edition provides the most recent estimates of the epidemic’s scope and human toll and explores new trends in the epidemic’s evolution. viEw The number of people living with HIV world- sub-Saharan Africa is generating consider- CArIbbEAN wide continued to grow in 2008, reaching able public health gains. Yet sub-Saharan The Caribbean has been more heavily an estimated 33.4 million (31.1 million–35.8 Africa’s epidemic continues to outpace the affected by HIV than any region outside million). The continuing rise in the popula- response. Preserving the long-term viability sub-Saharan Africa, with the second highest tion of people living with HIV reflects the of treatment programmes and mitigating level of adult HIV prevalence. AIDS-related combined effects of continued high rates of the epidemic’s impact in the region requires illnesses were the fourth leading cause of new HIV infections and the beneficial impact immediate steps to elevate the priority given death among Caribbean women in 2004 of antiretroviral therapy. Globally, the spread to HIV prevention and to match prevention and the fifth leading cause of death among of HIV appears to have peaked in 1996, strategies with actual needs. Caribbean men. Heterosexual transmission, when 3.5 million (3.2 million–3.8 million) often tied to sex work, is the primary source new HIV infections occurred. In 2008, the ASIA of HIV transmission, although emerging estimated number of new HIV infections was Asia is home to 60% of the world’s popula- evidence indicates that substantial transmis- 2.7 million (2.4 million–3.0 million). tion and is second only to sub-Saharan Africa sion is also occurring among men who have The epidemic appears to have stabilized in in terms of the number of people living with sex with men. most regions, although prevalence continues HIV. Asia’s epidemic has long been concen- to increase in Eastern Europe and Central trated in specific populations, namely inject- LATIN AMErICA Asia, due to a high rate of new HIV infec- ing drug users, sex workers and their clients, With a regional HIV prevalence of 0.6%, tions. Sub-Saharan Africa remains the most and men who have sex with men. However, Latin America is primarily home to low-level heavily affected region, accounting for 71% of the epidemic in many parts of Asia is steadily and concentrated epidemics. Men who have all new HIV infections in 2008. The resur- expanding into lower-risk populations sex with men account for the largest share of gence of the epidemic among men who have through transmission to the sexual partners infections in Latin America, although there sex with men in high-income countries is in- of those most at risk. In China, where the is a notable burden of infection among inject- creasingly well-documented. Differences are epidemic was previously driven by transmis- ing drug users, sex workers and the clients apparent in all regions, with some national sion during injecting drug use, heterosexual of sex workers. But only a small fraction epidemics continuing to expand even as the transmission has become the predominant of HIV prevention spending in the region overall regional HIV incidence stabilizes. mode of HIV transmission. supports prevention programmes specifi- AIDS-related deaths appear to have peaked cally focused on these populations. The HIV burden appears to be growing among women in 2004. The estimated number of AIDS- EASTErN EUrOPE AND in Central America. related deaths in 2008 is 2 million CENTrAL ASIA (1.7 million–2.4 million). Eastern Europe and Central Asia is the only NOrTH AMErICA AND An estimated 430 000 new HIV infections region where HIV prevalence clearly remains wESTErN AND CENTrAL EUrOPE (240 000–610 000) occurred among children on the rise. Injecting drug use remains the Progress in reducing the number of new HIV under the age of 15 in 2008. Most of these primary route of transmission in the region. infections has stalled in North America and new infections are believed to stem from In many countries, drug users frequently Western and Central Europe. Between 2000 transmission in utero, during delivery or engage in sex work, magnifying the risk of and 2007, the rate of newly reported cases of post-partum as a result of breastfeeding. transmission. With increasing transmission HIV infection in Europe nearly doubled. In among the sexual partners of drug users, 2008, the Centers for Disease Control and SUb-SAHArAN AFrICA many countries in the region are experienc- Prevention (USA) estimated that annual HIV The epidemic continues to have an enor- ing a transition from an epidemic that is incidence has remained relatively stable in mous impact on households, communities, heavily concentrated among drug users to the USA since the early 1990s, although the businesses, public services and national one that is increasingly characterized by annual number of new HIV infections in economies in the region. However, the significant sexual transmission. 2006 was approximately 40% greater than rapid scaling-up of antiretroviral therapy in previously estimated. www.unaids.org | Outlook Report | 7
  10. 10. THAT wAS THEN. THIS IS NOw! tion programmes be focused? And what should HIV programming consist of? NEw DATA FrOM THE 2009 AIDS epIDemIc Experience from various countries upDAte SHOwS US THAT wE HAVE TO bECOME clearly indicates that HIV prevention programmes work when we do the SMArTEr AbOUT HIV PrEVENTION IF wE wANT following: • Better understand populations at TO MAKE A rEAL DIFFErENCE. higher risk; • Address contextual factors; • Saturate high-burden areas as W ith an estimated 2.7 million prevention programmes on the evidence a priority; new HIV infections worldwide they find. This model is also proving • Increase investments for HIV prevention and sustain them and five new people becoming helpful in detecting dissonance between over time. infected for every two put on antiretro- where the infections are occurring, for viral treatment, it’s becoming increas- developing strategies to stop new infec- bETTEr UNDErSTANDING OF ingly clear that major programmes that tions and for resource allocation. POPULATIONS AT HIGHEr rISK worked in preventing new infections at The national AIDS authorities of In some countries with generalized the beginning of the epidemic may not Kenya, Lesotho, Swaziland, Uganda and and hyperendemic epidemics, HIV has have the same effect now. Zambia have just done this; their find- spread to the general population. Even in As the HIV epidemic is evolving, so ings were recently published in a series such situations, a better understanding must the response. One way countries entitled HIV prevention response and of the risk dynamics is necessary for the are adapting is by using data to follow main modes of transmission. formulation of prevention messages that the source of new infections, or ‘modes This has helped to answer key ques- make a difference. of transmission’, and then basing HIV tions, such as where should HIV preven- Take, for example, a small country like Lesotho, where there are nearly 60 Chart 1. Incidence by modes of transmission new infections each day. Adult HIV prevalence in Lesotho is more than 23%, 76,315 91,546 118,279 11,381 74,263 and both men and women start having 100 loW risk heTerosexuAl sex at an early age. From a simple read- pArTners ing of these data one might think that 80 cAsuAl heTerosexuAl sex HIV prevention programmes must try men hAving sex WiTh men to reach all men and women in Lesotho. 60 injecTing drug users However, researchers found that those pArTners of clienTs of with a single partner accounted for more femAle sex Workers percenT neW infecTions 40 clienTs of femAle than one third of all new infections, sex Workers while nearly two thirds occurred due to 20 oTher multiple partner behaviours. Addition- ally, the 2004 demographic and health 0 surveys study showed that a third of kenyA ugAndA moZAmbique sWAZilAnd ZAmbiA all couples in the country include one Source: results from know your epidemic project in southern and east Africa. partner living with HIV. However, few Reports available at http://www.unaidsrstesa.org/hiv-prevention-modes-of-transmission. behaviour and social change com- 8 | Outlook Report | www.unaids.org
  11. 11. & Now munications programmes were tar- geted explicitly towards adults, married couples and people in long-term steady THAT WAS THIS IS Then relationships. A similar conclusion was also drawn by researchers in Swaziland. In fact, Swaziland felt that it had to redefine its definition of ‘populations at higher risk’ and customize them to their own epidemic pattern. For example, they THEN NOw identified mobile populations as a group IN AFRICA, MULTIPLE PARTNERS MULTIPLE AND CONCURRENT PARTNERS needing attention, as men and women who were away from home for longer SUGAR DADDIES MORE EVIDENCE OF YOUNG MEN WITH periods and slept more nights away IN AFRICA. OLDER MEN HAVING SEx YOUNG WOMEN, AND OLDER WOMEN from home have higher HIV preva- WITH YOUNG WOMEN AND YOUNGER MEN lence. Other groups identified for HIV prevention programmes were people TREATMENT 4 MILLION PEOPLE ON TREATMENT in longer-term steady relationships and TOO ExPENSIVE TO AROUND THE WORLD, INCLUDING BECOME WIDESPREAD A GREATER UNDERSTANDING OF married couples who have multiple and PAEDIATRIC FORMULATIONS concurrent partners, HIV-discordant couples and concordant positive couples THE ASIA EPIDEMIC WILL A REGIONAL UNDERSTANDING OF and people living with HIV. BECOME AS GENERALIZED THE EPIDEMIC—CONCENTRATED IN In Kenya most new infections occur AS IN AFRICA POPULATIONS AT HIGHER RISK AND THEIR SExUAL PARTNERS in people who engage in casual sex with multiple partners and among their mo- IN ASIA, CONCENTRATED AMONG CANNOT IGNORE LONG-TERM nogamous partners. However, the study POPULATIONS AT HIGHER RISK—MEN SExUAL PARTNERS OF RISK highlighted the continued need to reach WHO HAVE SEx WITH MEN, INjECTING GROUPS sex workers, men who have sex with DRUG USERS AND SEx WORKERS AND THEIR CLIENTS men, prisoners and injecting drug users, who together account for nearly 31% of IN LATIN AMERICA, FOCUS MAINLY ON INCREASING ATTENTION ON MEN all new infections. Similar conclusions INjECTING DRUG USE, SEx WORKERS AND WHO HAVE SEx WITH MEN—GROUP AT were also drawn in Mozambique, where THEIR CLIENTS HIGHER RISK about 27% of new infections occurred IN MIDDLE EAST AND RISK GROUPS BECOMING VISIBLE: among sex workers, men who have sex NORTH AFRICA, AMONG MEN WHO HAVE SEx with men and injecting drug users. NO RISK GROUPS WITH MEN, INjECTING DRUG On the other hand, the epidemic in USERS, STREET CHILDREN AND Asia is fuelled by unprotected paid sex, HIGHER-RISK MEN the sharing of contaminated injecting IN WESTERN EUROPE AND NORTH INCREASING INCIDENCE AMONG MEN equipment by injecting drug users and AMERICA, HIV AMONG MEN WHO HAVE WHO HAVE SEx WITH MEN AND AMONG unprotected sex among men who have SEx WITH MEN AND INjECTING DRUG RACIAL AND ETHNIC MINORITIES sex with men. Men who buy sex con- USERS IS ON THE DECLINE stitute the largest infected population group—and most of them are either married or will get married. This puts sexual entitlements, cultural expecta- world. A recent UNICEF study in Swa- a significant number of women, often tions of men and women and income ziland showed that one in four women perceived as ‘low-risk’ because they only inequality. Men and women continue faced sexual violence as a child and two have sex with their husbands or long- to have long-term multiple concurrent out of three 18–24-year-old women had term partners, at risk of HIV infection. sexual partnerships in which sexual acts experienced sexual violence. The study The numbers can be staggering, as Asian are often unprotected. also showed that boyfriends and hus- countries have huge populations. In Lesotho, age-disparate relation- bands were the most frequent abusers. TIP: LOOK DEEPEr AT YOUr EPIDEMIC—MAKE SUrE ships are common and contribute to the Prevention experts in all these coun- THAT PrEVENTION MESSAGING IS NOT DILUTED bY very high HIV prevalence in females. tries concluded that current HIV pre- LAbELLING ALL AT EqUAL rISK Or LOw rISK. This practice is not properly addressed vention strategies that focus primarily on by policies to change the social norms individual behaviour rather than on the ADDrESS CONTExTUAL FACTOrS that are currently permissive towards social norms that make risky behaviour Studies show that despite the evidence of such relationships. Similar findings were acceptable are not adequate to effectively the risk factors of the epidemic, there are also seen in Kenya, Mozambique, Swazi- reduce HIV transmission. few programmes that address the social land and Zambia. TIP: THINK SOCIAL CHANGE. and structural factors adequately in HIV Violence against women and girls is prevention programmes. another issue that needs to be addressed SATUrATE HIGH-bUrDEN ArEAS The modes of transmission study in as part of HIV prevention programmes. AS A PrIOrITY Swaziland showed that its HIV epidemic A multicountry study conducted by the HIV prevalence figures must be is maintained by underlying cultural and World Health Organization found that read in conjunction with national socioeconomic factors, such as power between 1% and 21% of women reported demographics. A UNAIDS study that differentials in intimate relationships, sexual abuse before age 15 across the looked at the extent of HIV in urban www.unaids.org | Outlook Report | 9
  12. 12. areas found that 29% of the total HIV TIP: INVESTMENTS IN HIV PrEVENTION HAVE TO cant HIV transmission occurred among epidemic in the eastern and southern SIGNIFICANTLY INCrEASE IF A SErIOUS ATTEMPT married couples has paved the way for Africa region was concentrated in 15 AT STEMMING NEw INFECTIONS IS TO bE MADE. a campaign to promote HIV testing and major cities. Together, this is nearly 15% counselling among couples. The Uganda of the global epidemic. But there are few wHAT NExT? rESHAPING HIV National AIDS Commission used the dedicated urban-focused programmes in PrEVENTION PrOGrAMMES findings to inform the development of Africa. Many countries are beginning to use prevention policy guidelines and the This was also confirmed in the findings from modes of transmission Ministry of Health agreed to focus on modes of transmission study in Lesotho, studies to look ahead and plan better. The addressing couples as part of its preven- which found that even though adult National AIDS Commission of Lesotho tion activities in health settings. HIV prevalence is above 15% in all has used the data from the review to Responding to an evaluation of the districts, 59% of people living with revise its national strategic plan. The plan impact of these studies, a respondent HIV reside in the three western most was recosted and a set of scenarios was from Uganda said “There now appears populous districts. This means precious developed to help prioritize and make to be consensus that there is a problem resources could go further and achieve cost-effective investments. The data also of new HIV infections among married more if HIV prevention programmes helped to inform the development of a and cohabiting [couples] and something were scaled up in the three most heavily number of sector-specific policies and has to be done to address this. Before affected districts. a behaviour change communication the modes of transmission analysis there TIP: FOCUS ON THE GEOGrAPHICAL strategy. was a sense of denial, especially from the ArEAS wHErE MOST NEw INFECTIONS ArE In Uganda, the results of a similar faith-based organizations…” LIKELY TO OCCUr. study were widely disseminated, includ- In Kenya, the modes of transmission ing through the mass media. This helped studies influenced the decision to develop INCrEASE rESOUrCE ALLOCATION to increase understanding of the risk a new national strategic plan. “The fact FOr HIV PrEVENTION faced by different population groups. that policy-makers decided to overhaul the Another way of looking at why preven- The Uganda study’s finding that signifi- current national strategy was a strong sign tion programmes are failing is to look deeper into the investments being made. Chart 2. Role of major cities in national HIV epidemics The trend is worrying. Spending on HIV in eastern and southern Africa prevention programmes is low in most 100 parts of the world and is falling in many 85 instances. And what is available is not 80 reaching those most in need. In Uganda, only one third of the 60.3 60 resources invested in the AIDS response 40.3 went towards prevention, while more 36.7 percenT neW infecTions 40 36.7 than half went towards care and treat- 31.8 26.6 28.8 30.1 30.9 ment. In Swaziland, the HIV prevention 19.8 budget was only 17% of the total funding 20 12.4 14 14.6 14.9 15.2 16.4 16.4 available, while in Lesotho it was a mere 0 0 10%. 0 mAdAgAscAr ugAndA TAnZAniA mAlAWi lesoTho nAmibiA moZAmbique sWAZilAnd rWAndA kenyA ZimbAbWe ZAmbiA boTsWAnA eriTreA AngolA souTh AfricA eThiopiA mAuriTius comonos seychelles In Kenya and Lesotho, HIV preven- tion spending has fallen in recent years. Since 2005 the amount of total funding 1 1 1 2 4 5 1 3 1 8 2 3 5 1 1 4 8 2 0 0 available at the national level for preven- number of ciTies counTed tion activities in Kenya has fallen to less than 25% of the total AIDS funding. Source: Van Renterghem, UNAIDS 2009. We have to eliminate mother-to- child transmission of HIV. Rightfully, Chart 3. Percentage of spending on programmes directed at major investments from within the HIV populations at higher risk of HIV, as a percentage of total prevention prevention budget go towards prevent- spending, by type of epidemic ing babies from being born with HIV. 8.00 progrAms for sex Workers And Their clienTs In Kenya, approximately half of the 7.00 progrAms for men hAving sex WiTh men prevention resources go towards coun- hArm reducTion progrAms for injecTing drug users selling and testing and the prevention of 6.00 mother-to-child transmission of HIV. 5.00 In many countries, funding aimed at 4.00 groups at higher risk, such as sex work- ers and their clients, men who have sex 3.00 with men and injecting drug users, are 2.00 negligible or non-existent in proportion 1.00 percenT to their contribution to new infections. Most of the prevention funding goes 0.00 l c g towards raising awareness, with less for supporting contextual factors. Source: Izazola J et al, Journal of AIDS 2009. 10 | Outlook Report | www.unaids.org
  13. 13. of how seriously they took the findings.” The government has also committed I substantial resources, including from n a landmark speech to the National Coun- domestic sources, to help the National AIDS Commission better coordinate cil of Provinces in October 2009, President the AIDS response and to scale up the jacob Zuma presented his vision to stop the prevention response. “The study also AIDS epidemic in South Africa. In his speech, brought greater attention to resource the President called for an end to denialism and allocation and distribution and an ef- launched a major movement to cut new HIV in- fections by half and to reach at least 80% access Many countries are to antiretroviral therapy by 2011. beginning to use Below are some excerpts from President Zuma’s speech: findings from modes of Indeed, if we do not respond with urgency and re- transmission studies solve, we may well find our vision of a thriving nation slipping from our grasp. to look ahead …It is necessary to go into the hospitals, clinics and hospices of and plan better. our country to see the effects of HIV and AIDS on those who should be in the prime of their lives. It is necessary to go into fective national debate on this is taking people’s homes to see how families struggle with the triple burden place and has influenced decisions to of poverty, disease and stigma. Let me emphasize that although be made that made the costing of the we have a comprehensive strategy to tackle HIV and AIDS that national response a key issue”. has been acknowledged internationally, and though we have the HIV prevention needs strong largest antiretroviral programme in the world, we are not yet win- leadership. A leadership that is bold ning this battle. We must come to terms with this reality as South enough to question the status quo and Africans. the continuing practice of harmful social norms and practices. Leadership …If we are to stop the progress of this disease through our that is able to galvanize communities society, we will need to pursue extraordinary measures. We will to take collective responsibility for HIV need to mobilize all South Africans to take responsibility for their prevention and to sustain these efforts health and well-being and that of their partners, their families over time with adequate investments. and their communities. Thailand learnt it the hard way. With visionary leadership and imple- …There should be no shame; no discrimination; no recrimina- mentation of evidence-informed public tions. We must break the stigma surrounding AIDS. health strategies in the 1990s, Thailand …Let World AIDS Day, on the 1st of December 2009, mark the managed to arrest an epidemic that beginning of a massive mobilization campaign that reaches all threatened to spiral out of control. When investment and focus for HIV South Africans, and that spurs them into action to safeguard their prevention wavered in the wake of the health and the health of the nation. The important factor is that Asian economic crisis, the epidemic our people must be armed with information. Knowledge will help bounced back. us to confront denialism and the stigma attached to the epidem- TIP: HIV PrEVENTION IS FOr LIFE. THErE ic...we must not lose sight of the key targets that we set ourselves ArE NO SHOrT CUTS. in our national strategic plan. These include the reduction of the Uganda is showing similar patterns. rate of new infections by 50%, and the extension of the antiretro- Thanks to early leadership efforts, HIV viral programme to 80% of those who need it, both by 2011. Pre- prevalence declined from a peak of vention remains a critical part of our strategy. We need a massive 18% in 1992 to 6.1% in 2002, but today change in behaviour and attitude especially amongst the youth. there are signs that this decline may We must all work together to achieve this goal. have ended. HIV prevalence has stabi- lized between 6.1% and 6.5% in some ...The renewed energy in the fight against AIDS and in mobiliz- antenatal clinic sites and is rising in ing towards World AIDS Day must start now, by all sectors of our others. This has been accompanied by society. Working together, we cannot fail. Whatever challenges we a deterioration in behavioural indica- face, we will overcome. Whatever setbacks we endure, tors, especially an increase in multiple we will prevail. Because by working together we can and concurrent partnerships. will build a thriving nation. But countries can learn from Thai- land, which reinvested and prioritized The full speech can be accessed online at: http://www.thepresidency.gov.za. its HIV prevention efforts and has suc- ceeded in reducing HIV incidence in recent years.• www.unaids.org | Outlook Report | 11
  14. 14. Anatomy of Note to readers: the comments are the reactions of the Executive Secretary upon receiving this advice from the legal ministry. She is sharing her thoughts a Bad Law and frustrations with her colleagues. Her reactions reflect some of the legal obstacles that impede access to universal access to HIV prevention, treatment, care and support. What additional changes would you make? the world Somewhere in We need to better define annoyance and do more work with law Memo enforcement officials. The law is abused to harass sex workers and men ority who have sex with men. AIDS Auth , National w and Just ice Executive Secretary inistry of La To: , Lega l Affairs, M t Secretary From: Permanen Outlook CC: Readers of 2009 ecember 1, Date: D S bill Re: DRAFT AID e ware of th inistry is a While the Law M contra vention of AIDS bill. ons are in ilution of the draft the provisi our view, d ge receipt number of s vices. In like to a cknowled concern ed that a ety fro m variou and ord er in the d We would emic, it is ct our soci intain law AIDS epid ant to prote ent agencies to ma gra vity of the laws are import enforce m T ws. These e ability of existing la hamper th pr ws would of these la example: or country. F y , or is guilt Se es any act when he/she do or ann oyance to rea of nuisance mon injury, danger arily Penal Co de : “A perso n is guilty s any com ust necess any Nuisance sion cause y property in the vi cinity, or m oever to b 4—Public r omis se. Wh Section 23 such act o r occup rights to u sion, and ho dwell o y persons who had exp of an illegal omis people in general w nce to an r both .” use or to the or annoya or a fine, o xample, the public, obstruction, danger risonment, uals. For e ry , b le with imp s by individ to a large extent. cause inju nce shall be punisha of public p lace rbed This causes nu isa the misuse en of disrepute is cu ion against m espe es protect omen and person ag ainst sion provid rks and spaces by w dge of any This provi ublic pa rnal knowle ale person to have of p has ca the misuse n who (a) ermits a m and is liable to “Any perso al; or (c) p ral Offences: e of an anim commits an offence d in sectio n Public 0—Unnatu l knowledg er of nature, ces specifie Section 42 ature; (b) has carna e ord f the offen fn gainst th it any o Section the order o dge of him or her a ts to comm n years.” ho attemp ca rnal knowle r life. Any person w nme nt for seve rarely use d, is reveal h ent fo to impriso on, though eps to that the imprisonm a felony and is liable his provisi take st lues. T Says who? Look at our 420 comm its societal va a, we must HIV stat gainst our paedophili mose xuality is a rming in crease in disclosu literature and history... As you are aware, ho en the ala terrent. Giv , rather than modify it. ch situation t moral de ith whom su ny importan of this law e person w fa the six w an e enfo rcement prostitu tion, and th o hundred metres o increase th Sex work carries on ce of tw situation. rson who in a distan n: “Any pe ich are with 5— Prostitutio rem ises…wh Section 34 carried out, in any p We are pu is prostitution Since when is ‘looking gay’ in public a misuse of public space? Men who have sex with men and paedophilia are not the same. There are other laws to address Why are we trying to regulate exploitation of children, which is adult sexual behaviour? a crime.. 12 | Outlook Report | www.unaids.org
  15. 15. We need substitution therapy drugs on essential medicines list, not banned substances list. Don’t mix trafficking and sex work. Trafficking is a crime and has a specific definition. I would rather have a place of p ublic rigorous implementation of public place religious worship, months.) of any kind …may be education al institutio n, host community-led prevention punishable with impriso el, hospital, nursin and treatment services We are bo nment for g home or und by inte a term wh su women an rnational co ich may ext ch other d girls. Th nventions end to 3 X It is alread e eradicatio and huma y recogniz n of prostitu n rig of this law ed tion is an im hts considerations will reduce that sex workers are portant po litica to stop tra ffickin prostitution so and greatly urces of HIV infectio l objective of the go g of advance th n. Hence th ve e goals of e rigorous rnment. your minis application Narcotics try. Act of 198 Section24 5 And their ‘source’ substance —Consum po ption of na rcotic subst of infection? Look at the neighboring drug or an ssessed or consum ances: “W here the n notification y psychotr in the Offic opic subst ed is coca ance as m ine, morph arco ine, diacety tic drug or psychotr country. They decriminalized a fine or w ith both.” ial Gazette ay be spe , with impri cified sonment fo in this behalf by the l-morphine or any oth opic er narcotic sex work and now HIV Section 34 r a term w G hich may e overnment, by xtend to o infections are down. —Punishm ne year or any narco ent for illeg with tic drug or al possess contraven psychotro ion in a sm tion of any pic substa all quantity possesses provision o nce or con for person f this Act, sum al in been inten a small quantity any or any rule ption of such drug o use, consumption o drug or psy ded for his personal co narcotic d rug or psy or order m ade or perm r substance : “Whoeve f There are other ways for chotropic it r, in chotropic substance nsumption and not fo substance issued there under, reducing demand for sex work , be punis , which is hable by fiv r sale or distribution proved to The above two article s were incl e years in prison.” , or consu mes any n have or drug use. Let us not use fear prey to ad arcotic diction. uded to sp ecifically st op young of criminal penalties. It is ection 35— Detention people fro m taking d rugs and fa driving them underground. ason to be of drug use lling lieve to ha rs and ped y narcotic ve committ dlers: “De dru ed an offe tain and se be unlawfu g or psychotropic su nce punish able u arch any p erson who l, arrest him bstance in pression "p and any o his possess nder Chapter III, an m he has ublic place ther perso ion and su d, e by, or acc " includes n in his co mpany. Fo ch possess if such person has essible to, any r the purpo ion appears to him the public.” public conveyance ses , hotel, sho provision is p, or other of this section, the place inten ecially tho of great im se who are portance to help law ded for Listen to the Supreme Court selling dru gs. enforceme nt agencie s catch an of Indonesia—: drug users need d punish o ffenders, treatment, not jail sentences c Health A ct 2007 n 14—Dis closure of his/her HIV HIV status: status to h “Any perso n who has x e period d is oes not exc /her spouse or reg been teste d positive atus. The testing cen eed six (6 ) fu ular sexua tres shall p ll weeks, starting fro l partner a s soon as for HIV is bound to Our outreach workers will be ure of the possible p n. The test HIV test re sults and h rovide all th elp the co e necessa m the date ry psychoso he/she wa s notified o rovided at risk of arrest any time. How ing weeks, pro centre shall be req uple cial suppo fh rt to facilita is/her come we do not see major drug vided all e uired to m to accept and adap te the .” fforts are m ake the dis t to the rea ade to ena ble the pa closure in the event lity of the of the exp traffickers getting put away? rtners to h iration of ave full un uzzled by derstandin your reque g of the st to amen d this law and all pro visions me ntioned. Most people take steps to protect their loved ones. It’s mostly women who are tested What is needed is an environment where people can first. This will lead to more take the test, not fear the test. Partner notification stigma and discrimination of must be voluntary. women. www.unaids.org | Outlook Report | 13
  16. 16. UNAIDS’ NINE PrIOrITY ArEAS: wE CAN rEDUCE SExUAL TrANSMISSION OF HIV wE CAN PrEVENT MOTHErS FrOM DYING AND bAbIES FrOM bECOMING INFECTED wITH HIV wE CAN ENSUrE THAT PEOPLE LIVING wITH HIV rECEIVE TrEATMENT wE CAN PrEVENT PEOPLE LIVING wITH HIV FrOM DYING OF TUbErCULOSIS wE CAN PrOTECT DrUG USErS FrOM bECOMING INFECTED wITH HIV wE CAN rEMOVE PUNITIVE LAwS, POLICIES, PrACTICES, STIGMA AND DISCrIMINATION THAT bLOCK EFFECTIVE rESPONSES TO AIDS wE CAN STOP VIOLENCE AGAINST wOMEN AND GIrLS wE CAN EMPOwEr YOUNG PEOPLE TO PrOTECT THEMSELVES FrOM HIV wE CAN ENHANCE SOCIAL PrOTECTION FOr PEOPLE AFFECTED bY HIV

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