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

The Harsh Divide
AIDS Treatment in Africa
© Gideon Mendel, 2003

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.

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

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

>
“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

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

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

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

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

& 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

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

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

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

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

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

Young People
Being the Change | The next generation
A change is happening
among young people
across the world,
especially in parts
of sub-Saharan
Africa. Young people
are waiting longer
to become sexually
active, they have fewer
multiple partners and
there’s an increased
use of condoms among
those with multiple
partners. As a result,
HIV prevalence
among young people
is dropping in many
countries.
Changing with the times The risk of young people acquiring HIV
Let us imagine Precious1, a young woman depends on their gender, age and the region
in Mbabane, Swaziland. She has heard a lot they come from. Therefore decisions about
about HIV. In her school. At church. And prevention programmes for young people, as
in hushed tones at funerals. She knows she with other populations, should be informed
has to protect herself, but fears she will let by evidence.
herself get carried away when she is with her Unfortunately, in countries with
boyfriend, Prince. Prince says he is faithful generalized and hyperendemic epidemics,
to her and gives her lots of gifts. Her risk HIV prevention programmes for young
of acquiring HIV infection is far different people are not rigorous enough to address
from that of Kathleen, who is of the same age the root causes of increasing risk and
and has a boyfriend and lives in a suburb of vulnerability of our imaginary young people,
Dublin, Ireland. Precious, Prince and Damien.
Iqbal, a young man in Dhaka, On the other hand, in countries with low
Bangladesh, who goes to school has a much or concentrated epidemics, HIV prevention
reduced risk of acquiring HIV infection than programmes are aimed at all young people,
Damien, his peer in Port Moresby, Papua taking up resources that would have been
New Guinea. And in Kathmandu, Nepal, better served if focused on young people like
Siddharth, a young injecting drug user, has a Siddharth and Eduardo.
much higher risk than Gautam, a boy of his A provincial AIDS programme man-
own age who does not use drugs. Sixteen- ager in a low-prevalence country once
year-old Eduardo in São Paulo, Brazil, is remarked to a visiting donor delegation
recognizing that he is gay and is beginning that was pushing for focus on populations
a conversation with his parents about it. at higher risk “they may be your targeted
Each of them faces life in a different way. population, but young people are our
Their risks are different. Their vulnerabilities precious population.”
are different. A typical programme reaching a young
Why is it then that most HIV prevention person costs US$ 9 per year. The choices we
programmes for young people treat each one have to make are about finding cost-effective
of them as the same? ways of reaching young people and choosing
16 | Outlook Report | www.unaids.org

appropriate programmatic elements that take all sexual activity as transactional or age- Fatiha Serour, Director, Commonwealth
into account a better appreciation of their disparate. Sexual activity begins relatively Youth Programme (CYP). “On the other
risk of HIV infection. early for girls and boys in many countries hand, programmes reaching adults at higher
with generalized HIV epidemics. A study in risk often fail to grasp these special needs of
when Being female Swaziland reports that protective traditional adolescents and young people.”
is a risk faCtor values have disappeared due to peer pressure Take the story of Srey Mon. She worked
In several parts of the world the and modernization. On the other hand, long hours of hard work for low pay in
risk of becoming infected by HIV is sexual norms in many cultures promote the a small cafe in Phnom Penh, Cambodia.
disproportionate for girls and young women. practice of multiple
HIV prevalence among young women is partnerships. New HIV infections among young
Some harmful
higher than among men in many Caribbean
sexual behaviours are
people are dropping in many countries,
and Oceanic countries. Teenage girls in
Kenya are three times more likely to be not just tolerated but notably in sub-Saharan Africa.
infected with HIV than boys of their age. promoted. A popular
This worsens as they approach adulthood, Sesotho saying goes “men are pumpkins. But her employer was very tough with her.
with nearly five and a half times more women They will spread to other yards.” Various Frustrated, she moved to another town and
than men of the same age infected. studies have shown that engaging men and began selling sex. She did not have access to
The real issue is not being female. The boys, who often perpetuate negative sexual HIV prevention services as she worked
higher risk continues because of the failure norms, is essential for sustainable social alone. Eventually she got infected with HIV
globally to address the root causes of their change. and died of an AIDS-related disease at the
vulnerability, engaging on issues such as But are HIV prevention programmes age of 24.
intergenerational sex, transactional sex, addressing these factors? Sadly not. A review javier goes to high school in La Paz,
concurrent sexual partnerships and violence. of HIV prevention programmes in sub- Bolivia. In the eyes of the law, he is not yet
Saharan Africa shows that few programmes an adult. In his classroom, they talk of HIV.
directly address the issues of concurrency, However, his classmates and parents do not
Countering the Cougar anD multiple partners or age-disparate sex. Most know that he is gay. As a result, he is unable
sugar DaDDy faCtor focus on creating awareness. to seek HIV prevention services, and is afraid
A high rate of intergenerational sexual of stigma.
partnerships is seen in many countries where risky Business Srey Mon and javier are not alone. There
young women and men want or need money The story in countries with low or are thousands more like them who are not
and goods and older men and women have concentrated epidemics is similar, with HIV being reached early enough to protect them
the resources to meet these needs and desires. prevention programmes for young people from HIV. However, policy-makers are taking
A qualitative study on multiple rarely addressing the root causes of HIV risk notice in many countries and are adjusting
concurrent partnerships in Lesotho showed and vulnerability. their programmes to better suit young people
that, among other things, money and a desire However, a greater travesty is that the at higher risk.
programmes are
Young people now account for 40%
reaching the wrong we Can empower young people to
set of young people. proteCt themselves from hiv
of all new infections, down from 45% According to the To do this we have to be smart in our ap-
Asia Commission on
in previous years. AIDS, roughly 95%
proaches. In generalized and hyperdendemic
epidemics, programmes for young people
of HIV infections must promote comprehensive services that
for material goods were viewed as the central among young people in Asia are among include knowledge about HIV, sexuality
factors in all age-discrepant relationships. adolescents at higher risk. Yet more than education and discussion on harmful sexual
One of the participants said, “As schoolgirls, 90% of resources for young people as a group norms and practices. In other scenarios,
we like the guys who have cars and these days are spent on low-risk youth, who account programmes must focus on young people at
you will find that it is the older guys who for less than 5% of infections. In Eastern higher risk as a priority, instead of homog-
have cars. The older guys, these ones who are Europe and Central Asia, a large number enizing programmes for all young people.
more like adults, those are the ones that you of new HIV infections occur among young Yes, all young people are precious, but
will feel like they have really charmed you.” people. A third of the street youth in Saint
•
let’s provide them with programmes that are
In South Africa in 2008 more than a quarter Petersburg, Russian Federation, were found meaningful to their life contexts.
of all young women had sexual partners five to be infected with HIV.
or more years older than themselves. There is an urgent need to change 1
The names in this article are fictitious, but the
Sometimes young people are seeking direction to reach the adolescents and young stories are real.
basic necessities, such as food and clothes. people at higher risk,
Other times they are acutely aware of what such as injecting drug
they don’t have compared with their peers. users, young men who
As intergenerational sex is a societal issue have sex with men, and
it cannot be tackled by mere provision of young women who sell
information about abstinence, being faithful sex and their young male
or safer sex. What are needed are social clients. They are largely
sanctions against the adults who practise it. invisible and unreached
And parents need to support their children by prevention services.
when they stand up against this practice. And their reproductive
Having multiple and concurrent partners and sexual health needs
is also reported among young people in “are seldom addressed
many countries. The factors promoting by traditional youth
concurrency among young people are many outreach programmes
and full of complexities. run in schools and youth
It would be too simplistic to characterize network groups,” said
www.unaids.org | Outlook Report | 17

A Day in the Life
Prudence
Mabele
Thirty-eight-year-old Prudence Mabele of South Africa has been living with HIV for
19 years. She is the founder and executive director of the Positive Women’s Network
(PWN), a nongovernmental organization she created in 1996 that provides support and
information to women living with HIV in South Africa. The organization’s work spans
from the promotion of gender equality and equity, to education on sexual and repro-
ductive health, to women’s rights.
6:00 A.M. wAKE-UP spend the whole day at the office. educate positive women and give them
I get up early because I like to take Some days I attend meetings and the means to empower themselves,
my time. I watch Morning Live (a give presentations. Last week I was take control over their own lives, and
South African news and current af- interviewed by the host of a popular support other women living with HIV.
fairs programme) to stay up to date South African national radio channel. Through PWN, we provide emotional
with what’s going on in my country, I spoke a bit about myself, living with support and education, and we em-
get inspiration and ideas, and learn HIV, and PWN. After my interview, power women to be agents of change
about the issues that can influence the host was inundated with phone in their own communities.
my day-to-day work. A few weeks ago calls from listeners asking all sorts of
there was a discussion about female questions about HIV. This made me 5:45 ExCErCISE
genital mutilation that prompted me realize that there are many people who Exercising is important for me, both
to include this topic in our activities need information about HIV but don’t physically and mentally. I try to work-
and discussions with PWN workers. know where to go or are afraid to ask out for an hour when I can at the gym
Morning Live can sometimes make or someone in-person. that’s near work.
break my day!
12:00 LUNCH 7:00 DINNEr
7:45 brEAKFAST I usually take lunch down at one of the After settling in following a long
I love the feeling of making my own cafes near the office. There are lots of day’s work, I have dinner with friends,
breakfast in the morning, usually a places offering freshly cooked food like sometimes my sister stops by, and then
bowl of freshly cooked oatmeal and homemade curries and sandwiches. I take my medicines at 8:00. I like to
a cup of tea. After breakfast I take my eat healthy food, and I often have fish,
treatment. I take it twice a day: at 8 1:00 OUTrEACH vegetables and rice. I love samp with
a.m. and 8 p.m. I work often outside of the office to beans, a staple South African meal. I
go out to the communities with the watch a bit of television and then work
8:30 DrIVE outreach coordinators and speak to for an hour or so. Yes, I’m a worka-
I drive to work in my own car, and women about HIV prevention, gender- holic!
that usually takes 25 minutes—Johan- based violence, women’s rights and
nesburg’s crazy traffic allowing. health issues. 11:00 rEST
In bed: recharging my batteries for
9:00 wOrK 3:00 EDUCATE another day.
I start my work by answering e-mails When I am out in the community,
and making phone calls. I don’t always the reasons why I do what I do are
so clear. I decided to create PWN to
18 | Outlook Report | www.unaids.org

One of the greatest satisfactions
I get from my work is to see a
woman taking steps toward
knowing herself more, accepting
her HIV status, learning about
staying healthy, and ultimately
becoming a leader and an agent
of change.
— Prudence Mabele
www.unaids.org | Outlook Report | 19


What’s in her bag
 UMbrELLA  brEAST CANCEr LEAFLET
Always good to have in case of rain. My friend recently died of breast cancer. I have taken the
issue to heart and am including breast cancer awareness
 KEYCHAIN education in PWN’s activities.
Supporting Rainbow Nation New South Africa and local
craftspeople who design and create ribbons for PWN and  PASSPOrT
other organizations. Don’t leave home without it, because you never know
where you might need to go.
 SUNGLASSES
Blocking out the hot South African sun—and looking  bUSINESS CArD
good too! Who I am and what I do.
 rEADING GLASSES  INTErNET KEY
For the fine print. I am workaholic, and this vital little tool lets me work
on the go wherever I am.
 CONDOMS
Male and female condoms: safer sex and HIV prevention  CELL PHONE
awareness are instrumental to PWN’s outreach and part So I can stay in touch.
of a combination prevention strategy.
 MP3 PLAYEr
 wrITING INSTrUMENTS Favourite album at the moment is Miriam Makeba’s
Pens and highlighter in a nifty pouch. Mama Africa.
 wEEKDAY PILL bOx  CAr KEYS
Holds treatment regime taken twice daily. Getting me from here to there.
20 | Outlook Report | www.unaids.org

4
{
1
first black woman in South africa to disclose her hiV
things
status—diagnosed in 1990 and went public in 1992.
She did it because she was tired of the silence and stig-
ma surrounding hiV, and she wanted to set a precedent and
encourage other hiV-positive women to do the same, to
you need
discuss their status with their loved ones, not to be ashamed
and to seek treatment and lead fulfilling lives.
to know 2
She loves jazz, especially South african and american.
hugh masekela, Jonas gwangwa, Jimmy dludlu and
gloria Bosman—the list is endless.
about 3
She defines her style as “afrocentric”, with lots of
ethnic jewellery. her grandmother designed her own
clothes and she instilled in her her love of fashion. She
prudence
supports South african designers such as david tlale, J.J.
Schoeman and Bongiwe Walaza.
4
next year she plans on starting her mBa to start her
own business and further her work around helping
people in communities and rural areas.
www.unaids.org | Outlook Report | 21

Resources needed for getting results
TrEATMENT CASE STUDY: THE GLObAL FUND
all others 51%
gloBal funD 49%
FINANCING FOr ANTIrETrOVIrAL
THErAPY
UNAIDS works closely with several funding partners, including the United States President’s
Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis
and Malaria.
For example, UNAIDS provides technical assistance to countries seeking Global Fund grants
to help to reach their universal access goals. With this help, countries are getting results and are
making the case for a fully-funded Global Fund.
The Global Fund has increased access to antiretroviral therapy. At the end of 2008, four million
people were estimated to be receiving treatment in low- and middle-income countries—half of
these treatments were financed by the Global Fund. This was confirmed when WHO, UNAIDS
and UNICEF reported in September 2009 that an additional one million people began
antiretroviral therapy globally in 2008.
22 | Outlook Report | www.unaids.org

PErCENTAGE ON ANTIrETrOVIrAL THErAPY SUPPOrTED bY GLObAL FUND PrOGrAMMES
west anD Central afriCa 39%
southern afriCa 39%
east afriCa 75%
south asia 61%
north afriCa & miDDle east 67%
latin ameriCa & the CariBBean 22%
eastern europe anD Central asia 71%
east asia & the paCifiC 74%
31% increAse in lAsT yeAr
NUMbEr OF PEOPLE ON ANTIrETrOVIrAL THErAPY SUPPOrTED bY GLObAL FUND
PrOGrAMMES
mid-2008 1.75 million
mid-2009 2.3 million
globAl fund TArgeT end 2009 2.4 million
The Global Fund was responsible for about 600 000 people
commencing treatment in 2008 and by the end of 2008 was
financing around half of the four million people estimated to be on
antiretroviral therapy in low- and middle-income countries.
www.unaids.org | Outlook Report | 23

where does
The money
for aids go?
CONTINUED INTErNATIONAL made today are based on future needs. INVESTING IN THE AIDS rESPONSE
INVESTMENTS FOr AIDS NEEDED Many developed countries are beginning In 2008, investments for AIDS reached
International assistance to the to emerge from the economic crisis and a record high of US$ 15.6 billion. This
global AIDS response has helped it is increasingly important to meet the represented a 39% increase from 2007.
countries to scale up access to HIV investment of US$ 25 billion required Out of this, around US$ 8.2 billion came
prevention, treatment, care and support to reach the 2010 country targets for in the form of international assistance.
programmes in most parts of the world. universal access. The share of international assistance
This international assistance has been “The economic crisis should not is around 55% of the global resources
instrumental in catalysing and sustaining become an excuse to stop investing available.
the AIDS response in many countries. in the AIDS response” said Michel The biggest contribution was made
The funding cycle patterns of Sidibé, Executive Director of UNAIDS. by the Government of the United States
donors to some extent insulated HIV “We cannot afford to let the economic of America, whose contribution of
investments in 2009. However, it is crisis paralyse us. Not when the AIDS US$ 3.5 billion accounted for 61% of
critical that investment decisions being response is showing results.” bilateral official development assistance
24 | Outlook Report | www.unaids.org

Map 1. Bilateral OdA flows for AIdS control, 2008 (US$)
sourCe
reCipient
2 Billion
22 million
sourCe
3.5 Billion
reCipient sourCe
32 million 21 million
reCipient
21 million
reCipient
36 million
reCipient reCipient
153 million 1.98 Billion
sourCe
88 million
UNAIDS analysis based on data from the Kaiser Family Foundation and OECD/DAC CRS.
in 2008. Some of the other larger donors THE MAjOrITY OF INTErNATIONAL Mozambique (US$ 368 million),
included the United Kingdom, France, ASSISTANCE FOr AIDS wAS DIrECTED Zambia (US$ 361 million) and Ethiopia
the Netherlands and Germany, which TOwArDS COUNTrIES IN (US$ 357 million).
together contributed US$ 2.5 billion. SUb-SAHArAN AFrICA The amount of official development
Even though their total contribution Out of the ten top recipients of assistance received per capita was higher
may be small as a percentage of the total, international assistance for AIDS, nine in Guyana (US$ 70 per capita), Namibia
countries such as Ireland, Luxembourg, were in sub-Saharan Africa. Together, (US$ 52 per capita), and Botswana
the Netherlands, Norway and Sweden they accounted for nearly 57% of (US$ 34 per capita).
disbursed between US$ 280 and US$ all investments from the major donors On the other hand, South Africa,
582 per US$ 1 million of GDP, far higher in 2008. which ranked first in terms of the
than many richer countries. In terms of absolute value, the top absolute value of official development
five recipients were South Africa (US$ assistance received, was the recipient of
Philanthropic organizations too 729 million), Nigeria (US$ 432 million), US$ 15 per capita, while Nigeria, which
have contributed consistently to the
AIDS response. Their contributions International assistance to HIV-related programmes by source
and bilateral disbursements, 2008
have increased consistently over the
past decade, totalling more than US$ inTernATionAl AssisTAnce To hiv And Aids in 2008 bilATerAl disbursemenTs To uniteD states (61%)
600 million in 2008, representing 7% hiv-relATed progrAmmes in 2008 uniteD kingDom (16%)
of total resources available in 2008. 6 netherlanDs (8%)
An estimated 85% came from USA- germany (5%)
5
based organizations and the rest from norway (2%)
European not-for-profit organizations. 4
sweDen (2%)
About a half of all philanthropic irelanD (2%)
contributions came from the Bill & 3 founDations (7%)
australia (2%)
Melinda Gates Foundation. The majority eC (1%)
franCe (1%)
of the resources went towards supporting 2
un (6%)
CanaDa (1%)
research, while other resources went on gfatm (17%)
Belgium (0.5%)
us $ Billion
HIV prevention and treatment. But the 1
Bilateral (69%)
Denmark (0.4%)
forecast for 2010 is not good, especially japan (0.4%)
for smaller organizations, whose 2008 others (0.9%)
revenues have dipped in the wake of the
Source: UNAIDS analysis, 2009, based on data from OECD/DAC, Funders Concerned About Aids (FCAA) and, for the
financial crisis. philanthropic sector, European HIV/AIDS Funders Group (EFG).
www.unaids.org | Outlook Report | 25

2008 international disbursements An estimated 55% of the resources therapy in resource-poor settings.
available in 2007 were channelled to Providing nutrition and food security
COUNTrY bILATErALS MULTILATErAL TOTAL*
government-led initiatives. Civil society are critical components of care and
uniTed sTATes 87.5% 12.5% 3,953.5
uniTed kingdom 91.2 8.8 976.3 organizations, on the other hand, support for many people living with
frAnce 12.4 87.6 538.7 received only about 17%, while 6% went HIV, particularly in sub-Saharan Africa.
neTherlAnds 86.1 13.9 500.8 to multilateral organizations and 2% to The World Food Programme
germAny 60.139.9 477.7 public–private partnerships. implements AIDS programmes in over
sWeden 50.9 49.1 171.5
50 countries, addressing treatment, care
norWAy 64.6 35.4 159.8
cAnAdA 42.7 57.3 137.6 THE rOLE OF MULTILATErAL and support, and impact mitigation
jApAn 15.5 84.5 135.8 OrGANIZATIONS IN AID DELIVErY for people affected by the epidemic. In
iTAly 7.0 93.0 123.6 Most multilateral organizations Lesotho, for example, nearly one third of
irelAnd 79.8 20.2 112.5 traditionally disburse resources received people on antiretroviral therapy, along
AusTrAliA 78.1 21.9 109.2
from governments, foundations with their family members, receive
spAin 18.681.4 102.4
denmArk 46.0 54.0 48.2 and individual donations from the nutritional support from the food body.
belgium 72.6 27.4 35.4 general public. Many countries favour “HIV has robbed families of bread-
luxembourg 38.5 61.5 15.2 channelling a major proportion of their winners and added financial burden
AusTriA 29.1 70.9 7.5 resources through these channels. to poor households” says Bhim Udas,
sWiTZerlAnd 36.8 63.2 6.5
For example, Austria, Finland, Country Director of the World Food
greece 86.4 13.6 6.1
finlAnd 55.0 45.0 5.3 France, Italy, japan, Portugal and Programme in Lesotho. “The
neW ZeAlAnd 61.8 38.2 5.1 Switzerland disbursed more than 80% pervasive food insecurity in Lesotho
porTugAl 1.7 98.3 2.0 of their international assistance to makes it difficult for people on
*US dollars in millions. multilateral organizations. The major antiretroviral therapy to meet their
Source: OECD/DAC, Measuring Aid to HIV/AIDS
Control. April 2009. multilateral organizations receiving nutritional requirements”.
these investments are the Global Fund
ranked second in terms of absolute to Fight AIDS, Tuberculosis and Malaria INCrEASING AID EFFECTIVENESS—
value, received only US$ 2.9 per capita. and UNITAID. In 2007, contributions DOING MOrE wITH LESS
Domestic investments for AIDS disbursed to the Global Fund exceeded Most of the international assistance
have increased over the past decade, US$ 1 billion for the first time, reaching to AIDS is channelled through bilateral
but most countries still depend on US$ 1.72 billion in 2008. However, channels, from one government to
international assistance to finance multilateral organizations only represent another. An estimated 69% of funding
their programmes. In countries such as 25% of all international investments came as bilateral assistance from
Ghana, Haiti, Indonesia, Mozambique for AIDS. countries that are members of the
and Rwanda, more than 70% of AIDS- However, most importantly, more Development Assistance Committee of
related expenditures in 2006 came from than 70 countries receive more than 75% the Organisation for Economic Co-
international sources. of the international assistance for AIDS operation and Development. Another
If international funding were to be from multilateral organizations. Another 23% was disbursed through multilateral
reduced and not matched by an increase 30 countries receive between 50% and agencies. Private funding from the
in domestic funding, it is likely that the 75% in a similar way. The Global Fund philanthropic sector accounted for 7% of
AIDS response in over 100 countries has disbursed around US$ 1.03 billion to the international assistance.
would be in jeopardy. 136 low- and middle-income countries. This increase in resources and
The public sector is the major UNITAID has provided US$ 265 million a corresponding increase in the
recipient of international assistance. for the AIDS response, generated out number of actors at the country
of a special airline ticket tax levied by level often overwhelms national
Allocation of official around 20 countries in 2007. efforts to coordinate an inclusive and
development assistance for HIV By mid-2009, nearly 2.3 million multisectoral response based on national
to implementing bodies, 2007 people living with HIV were receiving priorities. The result is vertical and
antiretroviral therapy from programmes piecemeal actions against AIDS that are
3,000
multilateral oDa Bilateral oDa
supported by the Global Fund. often duplicative and rarely sustainable.
UNITAID support is currently providing This poses significant challenges to the
2,500
treatment for more than 170 000
children, with a goal of reaching nearly Source of international
2,000
400 000 children by the end of 2010. assistance to countries
1,500 Thanks to UNITAID and its partners,
11 paediatric formulations are now Countries reCeiving more
1,000 available in developing countries, and than 75% of hiv aiD from
multilateral organizations
the price of quality AIDS medicines for
500 children has fallen by 60% since 2006. 46
Countries reCeiving Between
The UN system’s assistance to the 50% anD 75% of hiv aiD from
0 AIDS response is largely in the area 68 multilateral organizations
puBliC
seCtor
ngo’s & Civil to Be multilateral other puBliC-private
soCiety DefineD organizations partnerships of technical support. However, it also 27
866.2
1936.0
117.6
733.0
151.7
143.7
151.7
143.7
164.0
55.5
1.7
98.3
provides support to implementation. For Countries reCeiving less
than 50% of hiv aiD from
example, the World Food Programme multilateral organizations
Source: UNAIDS analysis based on OECD/DAC CRS
was one of the first agencies to provide UNAIDS analysis based on OECD/DAC CRS online
online database (last visited 25 May 2009). food to expand access to antiretroviral database (last visited 25 May 2009).
26 | Outlook Report | www.unaids.org

recipient country, which often has to accountability mechanisms for each At the same time as domestic
juggle with the requirements of partner. The 2009 national strategic plan
investments increase in developed and
multiple donors. forms the basis for overall mobilization
emerging economies, as well as middle-
“Our ability to keep up with this of resources from donors. income countries, it is important that
is going to be especially challenging systems are in place to ensure that civil
in this economic downturn. We’d be IMPLICATIONS FOr THE FUTUrE society organizations continue to receive
foolish not to open up a strategy to The economic crisis in 2009 has affected funding for their activities.
try and bring in other bilateral and the AIDS response in many ways. Many governments are reluctant to
multilateral resources. We need to be Although it is unclear whether a lack fund civil society organizations or invest
smarter about how we think as funders. of resources or faulty planning was in programmes reaching marginalized
We can’t just go in with parallel systems
responsible, many countries experienced populations. International organizations
of intervention. It is probably the biggest
funding cuts for treatment and are often their only source of funding.
issue on my plate, thinking about how prevention services. “It is widely accepted that civil
to deal with that expanding need, and To a large extent a rapid response society is an important actor in the
how to continue the medical, clinical mechanism set in place by UNAIDS, sphere of HIV prevention. But funding
and ethical commitment we’ve made its Cosponsors and partners helped to from international organizations
to the patients already on drugs. We’re avert stock-outs and shortages; however, to civil society for HIV prevention
looking for efficiencies by moving to a the scaling up of programmes has been among injectors is coming to an
more country-based delivery system. We interrupted in many countries. As we end soon. Given the lack of the
also need an aggressive new dialog with look ahead to 2010, it is important to government’s support for harm
our global partners, who have resources ensure that the more than 4 million reduction programmes for injecting
that can converge on this” said Eric on treatment continue to receive their drug users, we are extremely worried
Goosby, Global AIDS Coordinator and medicines without interruption. about how to keep our programmes
Ambassador-at-Large, in an interview to The global landscape is changing. running,” says Pavel Aksenov, Executive
the Science Insider Magazine. The G8 has given way to the G20. This Director of the Russian Harm Reduction
In this context it is important is an opportunity for many emerging Network.
that countries have a framework to economies to redefine their role in the Fully funding multilateral agencies,
including the Global Fund, is critical in
2010. These channels represent a key
PrINCIPLES FOr THE COOrDINATION OF NATIONAL AIDS rESPONSES. lifeline to HIV prevention and treatment
programmes in over 137 countries
THrEE ONES PrINCIPLES AIM TO ACHIEVE THE MOST EFFECTIVE AND around the world. The nearly 50:50 split
EFFICIENT USE OF rESOUrCES, AND TO ENSUrE rAPID ACTION AND between domestic and international
rESULTS-bASED MANAGEMENT: investments in the AIDS response will be
put under strain in 2010.
ONE AGrEED AIDS ACTION FrAMEwOrK THAT PrOVIDES THE bASIS Although there are signs of economic
recovery in many of the main donor
FOr COOrDINATING THE wOrK OF ALL PArTNErS. countries, they are not uniform. Will this
ONE
change the pattern of investments? Who
NATIONAL AIDS COOrDINATING AUTHOrITY, wITH A brOAD-bASED will bridge the gap? These questions are
MULTISECTOrAL MANDATE. not easy to answer, but we must look at
options. The 0.7% target on international
ONE AGrEED COUNTrY-LEVEL MONITOrING AND EVALUATION SYSTEM. aid and the Abuja target of 15% for
health must not be buried, even in these
tough economic times.
optimally utilize the resources towards global response to AIDS. More than 16% Universal access targets can be
one common goal. The ‘Three Ones’ of all international assistance available reached if governments commit 0.5%
principles of UNAIDS have served as for AIDS went to G20 members. The of their GDP to international aid and
a good model in many countries to lion’s share was taken by three countries: maintain the current proportion of
increase aid effectiveness. Take, for South Africa, India and China. investments for AIDS. It is important
example, Malawi. The country has The Global Fund investments that the landmark commitment by the
developed a strategic management in China and India total more than USA to provide US$ 48 billion between
framework, revised in 2009, which US$ 461 million, representing 6% of 2009 and 2013 is fully met. As the largest
provides a common understanding of the investments for AIDS in 2008. single donor, any cut in its share is likely
the expected results, outputs, impacts, Increasing domestic expenditures on to have a direct impact on the lives of
performance measurement and AIDS in these countries will significantly millions.
reporting mechanisms to be followed free resources for other countries. The considerations for the many
by all key stakeholders involved in the Brazil is a good example. The majority economic stimulus package and bail-
AIDS response in Malawi. A number of the resources for its AIDS response out plans approved by governments
of donors have for many years pooled are funded domestically. While South hold true for AIDS, health and
their funds in support of Malawi’s Africa, India and China are ranked 1, 7 development—helping people. The AIDS
national AIDS strategy and have signed and 12, respectively, in top aid recipients response needs a stimulus package now,
a memorandum of understanding for the AIDS response, Brazil stands at as this can push forward the gains and in
that outlines the responsibilities and number 56. time make them irreversible. •
www.unaids.org | Outlook Report | 27

NEwS innovATions in The Aids response
Ideas Lab
MALAWI
ENSUrING TrEATMENT EqUITY
UNITED STATES
SYrINGE ExCHANGE
Malawi has a policy for equity in HIV incidence among injecting drug
access to antiretroviral therapy users in the United States has
that includes monitoring the age, declined to under one person
sex and socioeconomic status of for every 100 people in a year
people undergoing HIV testing and thanks to harm reduction. The
INDIA
accessing HIV treatment services. Congress passed a bill that
In its free treatment first-come, first- lifted a 20-year ban on federal
served programme, equity analysis funding for needle exchange,
helps identify inequities that are which may encourage more
unnecessary, avoidable and unfair. equitable service coverage
SEx wOrKErS jOIN FLOOD rELIEF ACTIVITIES Programmes have been changed across the country, reduce
Ashodaya Samithi, an association of and integrated to reduce the costs of the stigma faced by drug
sex workers in Mysore, India, made transport, food and missed work. users and facilitate a move
a donation to the Government of towards integration of
Karnataka of 50 000 rupees, which services for drug
their organization had collected in
support of flood relief efforts. Such
efforts contribute to breaking down
users into the regular
health system. SOUTH AFRICA
SMS FOr HIV TESTING AND COUNSELLING
the stigma faced by sex workers. The
Project Masiluleke uses mobile
Chief Minister expressed how deeply
CHINA
technology to encourage South
touched he was by the charitable
Africans to get tested for HIV. It
donation, saying that a donation of
sends one million “Please call me”
this size meant more to him than a
text messages each day throughout
donation 10 000 times larger from
South Africa. This encourages
wealthy sources.
people to get tested and treated
PrOGrESS ON TrEATMENT for HIV. The SMS messages are
Opioid substitution therapy, the written in local languages and are
UNITED STATES INTERNATIONAL most cost-effective treatment avail-
able for heroin dependence, is now
available in 66 countries and ter-
used to direct users to the National
AIDS Helpline. Once people call,
the hotline representatives provide
AIDSSPACE.OrG
PEEr-TO-PEEr SOCIAL NETwOrKS rEACH OUT ritories, including low- and middle- information on HIV testing services
A new online social network brings
People living with HIV in seven US income countries such as China, and locations. Knowing one’s
people, ideas and information into
cities referred peers from their social, Indonesia and Iran. Prison access HIV status is critical in a
one place. AIDSspace is an online
sexual or drug-using networks for to opioid substitution treatment country where nearly 20%
community for connecting people,
HIV testing and appropriate medical has increased from five countries in of the population is living
sharing knowledge and accessing
care and prevention services in an 1996 to 29 in 2008—a good start, with HIV, but fewer than
services for the 33.4 million people
efficient high-yield strategy. This but much remains to be done to 3% know their status. The
living with HIV and the millions
peer-driven approach meant that key improve coverage worldwide both in initial results of the project
who are part of the AIDS response.
populations at higher risk of HIV prisons and in the community. indicated a tripling of
Through AIDSspace you can: meet
exposure, often difficult to reach with calls to the hotline during
and connect with others to learn
other more conventional strategies, the first three weeks. The
from their work, exchange ideas
accessed HIV counselling, testing project’s sponsors include
and discover new networks; post
and referral services in much higher Nokia and South Africa’s
and share key policies, case
numbers and with significantly high- National AIDS Helpline.
studies, best practices, multimedia
er undiagnosed HIV infection levels
materials, conference posters,
than through any other strategy.
reports and other essential resources;
find and post jobs. Sign up today at
www.aidsspace.org.
28 | Outlook Report | www.unaids.org

UGANDA
rEDUCING MOrTALITY bY COMbINING
INTERNATIONAL PrOPHYLAxIS AND ANTIrETrOVIrAL THErAPY
TrEATMENT
In a prospective cohort study in
ANTITrETrOVIrAL TrEATMENT
FOr HIV PrEVENTION Uganda, a combination of antiret-
BRAZIL
rAINFOrEST CONDOMS
A new paradigm puts treatment and
prevention in the same continuum.
Antiretroviral medicines are already
roviral drugs and co-trimoxazole
reduced mortality by 95% compared
with no intervention. These results
preventing transmission of HIV to were achieved even though no
A condom factory in xapuri, Brazil,
babies and now new approaches are routine clinic visits were scheduled
is helping to prevent the spread of
being trialled to include their use as after initial enrolment, and home
HIV and at the same time may also
a potential pre-exposure prophylaxis visits were provided by trained lay
be helping to save the rainforest. This
ZAMBIA
and as a topical microbicide. providers. Provision of
unique factory uses natural latex
antiretroviral therapy
collected by local rubber tappers and
to adults has also
aims to supply the Brazilian govern-
been associated with
ment with 100 million condoms a
NEw TrEATMENT COMbINATIONS FOr CHILDrEN the added benefit of
year. The factory is a joint venture
In Zambia, antiretroviral therapy lowering mortality
between the local state of Acre, the
and once-daily co-trimoxazole rates in HIV-negative
Ministry of the Environment, and the
prophylaxis reduced mortality among children in the family
Ministry of Health.
HIV-infected children by sixfold. and a reduction in the
This yielded results comparable with rate of orphanhood.
ROMANIA
high-income settings. However,
even with these impressive medical
outcomes, mortality within the first
SOUTH AFRICA
months of therapy remains high for
MONITOrING ArV STOCK-OUTS HIV-infected children in sub-Saha-
In wake of the economic crisis, ran Africa.
22 associations of people living with DIAGNOSING HIV AMONG INFANTS
HIV in Romania joined together to AND YOUNG CHILDrEN
form a federation that has established Use of simplified assays on dried
UNITED STATES
an alert system to warn of potential blood spots now offers a feasible,
stock-outs. Whenever a shortage of cost-effective means of diagnosing
drugs occurs, members inform each INjECTAbLE ANTIrETrOVIrAL DrUGS? HIV in infants and young children.
other and the Ministry of Health. Researchers are studying nanosus- Early diagnosis and early antiretro-
This enables policy-makers to take pensions of antiretroviral drugs to see viral therapy were found to reduce
quick action. The federation has if they would be suitable as long-act- infant mortality by 76% and to slow
extended the partnership to associa- ing formulations that could maintain HIV-related disease progression by
tions of patients living with other good drug blood levels without pills, 75% in two medical
chronic diseases, which monitor the just as injectable contraceptives can centres in South
FA S T FA C T
situation for a wide range of condi- do—a hope for the future! Africa.
MORE THAN
tions.
29%
OF PREGNANT WOMEN
ACCESSING PUBLIC
HEALTH SERVICES
TESTED POSITIVE IN
SOUTH AFRICA
www.unaids.org | Outlook Report | 29

Children born of hope
in Viet Nam *
Hand in hand with her five-year-old son at 7 Ngan still remembers the shock of her HIV-
a.m., Ngan hurries out of her small home in positive result at a routine antenatal check-up
Thanh Xuan, the area in Hanoi where she lives. during her first pregnancy five years ago. The
She is on her way to do some early morning following months, when she dealt with her
grocery shopping before taking her son to his own emotions and fears, were tough. At the
kindergarten, just like the many other mothers same time, Ngan faced discrimination from
you can see when a new day starts in the city. the community and even her own family. The
anxiety of transmitting the virus to her baby was
But Ngan’s story is different: she is HIV-positive with her day and night.
and is now 22 weeks into her second pregnancy.
Thanks to the early discovery of Ngan’s HIV
*UNAIDS is committed to supporting countries to virtually status, she received antiretroviral therapy during
eliminate mother-to-child transmission by 2015. the first quarter of her pregnancy. Huy, Ngan’s
son, was born a healthy boy free of HIV in
October 2004.
30 | Outlook Report | www.unaids.org

Ngan is expecting her second baby. She visits the
Tay Ho Day Care Centre for an antenatal check
to make sure that everything is okay with the
baby she carries. Her doctor tells her that
she is in good health and that the baby is now
450 grams.
HIV-positive women in Viet Nam’s provinces
who want to become mothers are still concerned
about where to get comprehensive care for both
mother and child before, during and after
delivery. Better equipped obstetric facilities with
staff knowledgeable on HIV and prevention of
mother-to-child-transmission are much needed
at the provincial level.
Ngan considers herself lucky—the virus was not
transmitted to her son from her, because she had
access to prevention of mother-to-child services.
Without these services, the chances of passing
HIV to the baby are 30–40%. With the provision
of comprehensive prevention services, the
transmission rate can be reduced to less than 2%.
www.unaids.org | Outlook Report | 31

32 | Outlook Report | www.unaids.org

PrEVENTING MOTHEr-TO-CHILD
TrANSMISSION TIMELINE
As the sun sets over Hanoi, Ngan has already
1994
picked up Huy from the kindergarten, and they AZT found to reduce mother-to-child
make their way home on the bustling streets of transmission.
the city.
Helping each other out after a long day,
Ngan and her husband Quang cook together
in their small house in the Thanh Xuan district
of Hanoi.
Father and son play together after dinner, but 1998
the evening is not ending yet for husband and Inter-Agency Task Team on PMTCT initiated to
provide leadership and guidance to countries.
wife. Ngan is an active member of the White
Dove Club, a self-help group of people living 1999
Single dose of nevirapine found to be effective
with HIV covering the southern district of for PMTCT.
Thanh Xuan. Every night Ngan visits locations
2000
frequented by injecting drug users in the area. United Nations Millennium Declaration com-
mits Member States to eight time-bound
The White Dove Club team collects used targets, including MDG 6 to combat HIV.
syringes and needles and distributes clean ones 2001
to the people who inject drugs. Her husband Declaration of Commitment is signed by 189
Member States at the first UN General Assem-
Quang, a former drug user, drives Ngan
bly Special Session on HIV/AIDS. Target is set
around while their son stays at home with his to reduce by 50% the proportion of infants
grandparents. infected with HIV by 2010.
2002
Ngan and Quang have regained the acceptance UNAIDS, in collaboration with its Cosponsors,
of their neighbours because people appreciate develop core indicators to measure progress
against the goals set in the Declaration of
that they lead a healthy life. Ngan’s parents-in- Commitment.
law, whose other two sons died from drug use,
are proud of their eldest son for the support and
care he shows his family.
2006
Political Declaration on HIV/AIDS, renewal of
commitments made in 2001 as well as MDGs.
WHO releases guidelines that discourage use
of single-dose nevirapine and that promote
more efficacious antiretroviral prophylaxis for
PMTCT.
Guidance on the global scale-up of PMTCT of
HIV released.
2007
An estimated 34% of HIV-positive pregnant
women received antiretroviral drugs to prevent
HIV transmission.
2008
An estimated 45% of HIV-positive pregnant
women received antiretroviral drugs to prevent
HIV transmission.
2009
UNAIDS Executive Director calls for virtual
elimination of mother-to-child transmission
by 2015.
www.unaids.org | Outlook Report | 33

What does HIV prevention
mean to you?
What HIV prevention measures do
you use or have you used in the past?
How has HIV prevention
changed your life?
In My Words: Four people from different parts of the
world reflect on what HIV prevention means to them.
Alexei Voronin* to live again, to stop doing drugs, to study. I
wanted to start again from scratch.
and say that I didn’t use any prevention
measures and got into big trouble. They ask
I think today about how unconcerned I “what kind of trouble?” I don’t reveal my HIV
Twenty-seven-year-old Alexei Voronin lives in was about HIV prevention and I can’t believe status, but I tell them about serious health
the small town of Volkhov in the suburbs of it myself. I feel bad about all those years that I problems that can’t be cured.
Saint Petersburg, Russian Federation. Alexei lost. Now I work as an outreach worker for a For a long time I didn’t believe I could
is HIV-positive and a former injecting drug harm reduction programme at Humanitarian have a proper family life
FA S T FA C T
user. He’s been married for two years. His wife Action. My job is to motivate drug users to after all that I had been AN ESTIMATED
3.7
doesn’t have HIV. visit our bus, where they can exchange used through. When I met Elena
syringes for sterile ones. They can also see a I felt that she was the girl of
I started doing drugs when I was a teenager. psychologist and have a blood test. my life, but I was scared to MILLION PEOPLE IN
EASTERN EUROPE
At that time the only important thing was I always try to motivate those guys death to tell her about my AND CENTRAL ASIA
CURRENTLy INjECT
getting money and finding drugs. I didn’t from the streets to have a look at something HIV status. But she accepted DRUGS.
think of any prevention measures to protect different from their everyday routine. I ask it and we got married two
myself from HIV when I was sharing a them about their sex life and whether they years ago. The last thing
syringe with my HIV-positive elder brother. use condoms to prevent HIV and sexually I would like to do is to infect my wife with
In 2006, after feeling very ill, my mother transmitted infections. When they say HIV so we don’t have unprotected sex. We also
,
took me to a special hospital for infectious that they don’t have money for condoms I don’t talk of having children yet, but that will
diseases. There I met a psychologist from offer immediately a pack of condoms and be a huge challenge for both of us.
the organization Humanitarian Action, explain what a condom can save them from. * The names in this article are fictitious, but the
who changed my life. I felt that I would like Sometimes I share my experience with them stories are real.
34 | Outlook Report | www.unaids.org

When they say that
they don’t have money
for condoms I offer
immediately a pack
of condoms and explain
what a condom can
save them from.
Ms Minh I knew I had to use
condoms and not
share needles to protect
Born in 1977 in Hanoi, Ms Minh was a sex myself from HIV.
worker and drug user between 1998 and 2005.
She is now a peer educator on harm reduction for
sex workers. She is married for the second time to
an ex-injecting drug user and is without children.
In 1996 I was working as a waitress to earn
enough money for myself and my husband,
Jovanna Baby
who was in jail at that time. At some point, It continued in that way until 2005, when
I started using drugs, and as I needed more I was determined to stop using drugs and
and more money, I decided to start selling sex. became a peer educator, thanks to the help of
For a long time I was totally unaware my family. I think sex workers today are much Jovanna Baby is a 46-year-old Brazilian and
of HIV and did not believe there was such a luckier than us before thanks to the strong the founder of the Brazilian Transvestites
virus, and neither did my sex worker friends. HIV response in Viet Nam. In the role of a and Transsexual Association. She is currently
No one informed us about it. We all thought peer educator, I give advice to the sex workers living in Piaui, bringing her knowledge
it was something made up to threaten us so living in my area on how to prevent sexually on HIV and human rights to remote
that we would give up drugs and sex work. transmitted infections and HIV Every three
. zones in the Northeast Region of Brazil.
Most of my friends and I had unprotected months our self-help group organizes HIV
sex with our customers and shared needles testing for the sex workers in this area at our I have been a transvestite since I was 13 years
when using drugs. I was ignorant about meeting venue so that they don’t worry about old. I was born in Bahia, but in 1980, at the
HIV until I was admitted to a rehabilitation facing stigma and discrimination in public age of 14, I moved to Rio de Janeiro. I had to
centre in 2003, where Hanh, my best sex health-care settings. leave, run away from my
worker friend, had already been admitted When my friend Hanh and I reflect parents’ home in order FA S T FA C T
two months earlier. about our past, we both agree that if we to be able to live my HIV PREVALENCE
EXCEEDS
10%
Hanh told me in tears that she tested had known that unprotected sex and drug own gender identity and
positive for HIV and had to stay in a separate use were so devastating we would not have sexuality.
house. I was struck by that fact and started dared to put ourselves in such a big risk in I worked as a sex IN 12 OF 14 COUNTRIES
IN LATIN AMERICA
attending training courses on HIV at the the first place. worker for 20 years and AMONGST MEN WHO
HAVE SEX WITH MEN
centre, knowing how lucky I was not to I have always been very
have had contracted HIV yet. After leaving In the role of peer educator, careful with my health
the centre I went back to sex work. I knew I and personal hygiene. The use of condoms
had to use condoms and not share needles I give advice to the sex has always been a constant practice in
to protect myself from HIV But the fact was
. workers living in my area my sexual relations, either professional or
that I could not always use condoms at work. sentimental. My safe sexual behaviour has
When you feel in need of drugs you only care on how to prevent sexually helped me a great deal. I always use condoms,
about how to get money, and if a customer transmitted infections always. I love my life.
didn’t want to use a condom I would easily Prevention is like a ‘watch dog’ this is my
,
give in to that. and HIV. motto. I take care of myself and I only have
www.unaids.org | Outlook Report | 35

artwork by curlygirldesign.com

INFO INDEx
2015
Deadline set to achieve the
Millennium Development Goals
33.4
Millions of adults and children who
are living with HIV worldwide
safe sex, only! It has been one of the greatest
contributions to my self-esteem. Being able to
affirm that I am an HIV-negative person, even
having worked most of my life in the sex trade,
Chengetai
Ndlovu
4
Millions of people in low- and
middle-income countries who were
receiving antiretroviral therapy at
is a reward for me. the close of 2008
Prevention is important for us Changetai is a 28-year-old young woman
71 %
transvestites in order to enable us to have a from Zimbabwe. She’s been married for five
more dignified life. We know that prejudice is years and is a mother of two children, aged 5
very strong in Brazil, and it is even worse when and 9. She came to South Africa six years ago
it comes to people living with HIV especially if
,
and works as an accountant for a small South
you are a transvestite. of all new HIV infections occurred
That is why I decided to help my African accountancy firm.
in sub-Saharan Africa in 2008
fellow sex workers and other transvestites by
25
I must have been 16 years old when I first
$
orientating them on the use of condoms as
heard about HIV prevention. It was still
a continuous practice they should adopt in
not publicly embraced because sex was not
their lives. This sort of behaviour helped them
openly discussed in public. There were a
to stay in good health as well as get higher
few calls to young people to act responsibly. Billions (US$) required for the
earnings at a time when AIDS was scarily
When we were visited by members of the global AIDS response in low- and
growing and those sex workers who protected
government blood transfusion services, who middle-income countries to achieve
themselves from infection were far preferred
were requesting us to donate blood, they universal access, based on country-
by potential clients. It was due to those
informed us about sexually transmitted defined targets for 2010
spontaneous attitudes towards my colleagues
infections and HIV and asked us to abstain
that I decided to organize a transvestite and
transsexual movement in Rio de Janeiro. We
then founded a national association and a lot
has been achieved, with more to come.
Prevention brought me a great deal of
knowledge, not only on HIV but also on my
from sex.
I am aware that HIV is predominantly
spread through sex. I have lost friends and
relatives because of HIV and I still wonder if
,
we will be able to convince each one of us
to control our sexual activities and practise
430
Number in thousands of new HIV
infections occurring among children
rights as a human being. It made me aware of under the age of 15 in 2008
safe sex.
my inviolable rights as a citizen.
60
For me, the first prevention measure is to
never indulge in something that I know is a
risk to my health. I love myself and I want to
see many more years to come. The fear of HIV
%
scares me enough to keep me safe and I do
not take the warnings for granted. The many Number of female sex workers who
lives that are affected by the epidemic are do not consistently use condoms
enough testimony to make me realize about with their clients in China
the seriousness of the disease.
The case for prevention becomes
Source is the UNAIDS Epidemic Update
decisive in light of the absence of a cure for and UNAIDS paper entitled What countries
AIDS. In my assessment, HIV prevention need—investments needed for 2010 targets.
remains the single most important
•
intervention any society can easily
implement with guaranteed success.
www.unaids.org | Outlook Report | 37

A to Z of universal access
UNIVErSAL ACCESS is a gloBal Commitment to sCale up aCCess to hiv treatment, prevention, Care anD support.
estaBlisheD in the 2006 un politiCal DeClaration, the movement is leD By Countries worlDwiDe with support
from unaiDs anD other Development partners, inCluDing Civil soCiety.
A NTIRETROVIRAL E VIDENCE-INFORMED INTENSIFYING
COMBINATION PREVENTION
THERAPY HIV prevention actions must be evidence-
More than 4 million people in low- and informed, based on what is known There is no single magic bullet for HIV
middle-income countries were receiving and proven to be effective. Prevention prevention. Countries and communities need
antiretroviral therapy at the close of 2008, programmes must be differentiated to use a mix of behavioural, biomedical and
representing a 36% increase in one year and and locally adapted to the relevant structural HIV prevention actions to suit
a tenfold increase over five years. However, at epidemiological, economic, social and their actual epidemic and the needs of those
least 5 million people cultural contexts in which they are at higher risk. Combination HIV prevention
living with HIV still implemented. means providing services and programmes
do not have access for individuals, such as promoting the
F
to life-prolonging knowledge and skills necessary to undertake
safe behaviours. Combination HIV
treatment and care. INANCING prevention needs investment in structural
The roll-out of Based on the country-defined targets for
antiretroviral therapy interventions, including legal reforms to
2010, it is estimated that an investment of
will also significantly outlaw discrimination against people living
US$ 25.1 billion will be required for the glob-
reduce the burden of with HIV and the enforcement of laws that
al AIDS response in low- and middle-income
tuberculosis in high-prevalence countries. prohibit sexual and gender-based violence.
countries to achieve universal access. The
B EHAVIOUR AND
impact of the global financial crisis threatens
to roll-back the hard-won progress made in
the global response to AIDS. However, it also
j OINT UN PROGRAMME
Contributing to achieving global
SOCIAL CHANGE represents an opportunity for countries and commitments to universal access to
Transmission of HIV is international organizations to pursue much comprehensive programmes for HIV
mediated directly by needed reforms, to refocus on results. prevention, treatment, care
human behaviour, so and support is the number
changing the behaviours
of individuals and
communities that enable
G IPA
GIPA, or the ‘greater involvement of people
one priority for the joint
UN Programme on HIV/
AIDS (UNAIDS). To
HIV transmission is the living with HIV/AIDS’, is a principle that that end, UNAIDS brings
ultimate goal required for aims to realize the rights and responsibilities together the efforts and
HIV prevention. of people living with HIV, including their resources of the UNAIDS
right to participation in decision-making Secretariat and ten UN
C ONDOMS
processes that affect their lives. People living
with HIV are active partners in the universal
system organizations.
Consistent male and female condom
use significantly reduces the risk of HIV
access movement and are promoting the con-
cept of ‘positive health, dignity and preven-
transmission. Condoms are a key component tion’ in a number of ways, including taking
K NOW YOUR
EPIDEMIC & RESPONSE
of combination prevention strategies that the leadership in creating stronger links and
Knowing your epidemic and response
individuals can choose to reduce their risks of increasing collaboration between the health
enables countries to ‘match and prioritize
sexual exposure to HIV. sector and civil society organizations already
your response’ by identifying, selecting and
providing HIV prevention, treatment and
D
funding those HIV prevention measures that
care services.
are most appropriate and effective for the
ISCRIMINATORY LAWS
H
country in relation to its specific epidemic
Discriminatory laws fuel social judgement scenario(s) and settings.
and further alienate those already most IV TESTING AND
marginalized in society, including sex
workers, people who inject drugs, men
who have sex with men and people living
COUNSELLING
Efforts should be made to encourage people
to know their HIV status through access
L EADERSHIP
Leadership is the catalyst for change in a
with HIV. Reforming laws that are based on to confidential counselling and testing. community no matter its size: the global
deeply-rooted discriminatory social attitudes In all types of HIV testing the principles stage, the village gathering or national
will result in legislation that is a powerful and of confidentiality and consent should be government. Without strong commitment,
positive tool in the response to AIDS. maintained and counselling should be and action that follows words, universal
provided. Such efforts are not only necessary access cannot be achieved.
to improve the health of individuals, they are
also necessary to achieve universal access to
prevention, treatment, care and support and
to mount effective responses against HIV.
38 | Outlook Report | www.unaids.org

M OTHERS AND BABIES
UNAIDS calls for the virtual elimination
Q UALITY CARE AND
SUPPORT SERVICES
W OMEN AND GIRLS
Women and girls account for half of all
of mother-to-child HIV transmission by Quality care and support services for people people living with HIV. In sub-Saharan Af-
2015. An estimated 370 000 children are living with or affected by HIV help to reduce rica, women account for approximately 60%
born with HIV in sub-Saharan Africa every the negative social and economic impacts of estimated HIV infec-
year and only 45% of HIV-positive pregnant of the disease and bring hope to whole tions. Ensuring women’s
women are receiving antiretroviral therapy communities. However, most people around empowerment and gender
prophylaxis in low- and middle-income the world do not yet have access to such equality, including revers-
countries. Evidence shows that timely services. Reaching out to these people is a ing the underlying socio-
administration of antiretroviral drugs to global priority. economic factors contrib-
HIV-positive pregnant uting to women and girls’
R
women significantly HIV risk, are critical for
reduces the risk of IGHTS the success of the AIDS
HIV transmission to It has long been recognized that the response response and achievement of the MDGs.
their babies. In many to HIV must be both evidence-informed and
x
developed countries rights-based. Effective HIV responses are
mother-to-child
transmission of HIV
those that empower individuals and groups DR-TB
to claim their human rights, including the Tuberculosis, including extensively drug-
has been virtually right to education, information, liberty, resistant tuberculosis (xDR-TB) and
eliminated. privacy, and health. Responses should multidrug-resistant tuberculosis (MDR-TB),
N
also be founded on the principles of non- remains one of the leading causes of death
discrimination and equality. among people living with HIV, despite being
ATIONAL HIV RESPONSES preventable and curable. To appropriately
S
Effective national HIV responses adopt the
respond to both epidemics and avoid more
‘Three Ones’ principles: one agreed AIDS
action framework that provides the basis for
TRENGTHENING widespread drug resistance, care and preven-
coordinating the work of all partners; one
HEALTH SYSTEMS tion for both diseases should be priority
Strengthened health systems and human concerns of all tuberculosis and
national AIDS coordinating authority, with
resources are crucial to achieving the goal of HIV programmes.
a broad-based multisectoral mandate; and
universal access to HIV
one agreed country-level monitoring and
prevention, treatment, care
evaluation system. Their full implementation
and support. AIDS is part of
helps to achieve the most effective and
the global health agenda,
efficient use of resources and to scale up
just as the global health
universal access services.
agenda is part of the AIDS
O
response: neither can work
in isolation.
RPHANS
More than 15 million children under the age
of 18 have lost one or both parents to AIDS.
Vulnerable to poverty, they may be in need
T ECHNICAL SUPPORT
Technical support has helped to remove ob- Y OUNG PEOPLE
of support packages that could include food, stacles to achieving universal access in many In 2008, 40% of new HIV infections were
education or family or community support. countries. It contributes to greater efficiency, among young people aged 15 to 24. Over 95%
of all new HIV infections in the Asia region
P
effectiveness and the impact of national AIDS
responses and it builds in-country capacities occur among young populations at higher
OPULATIONS AT and systems for sustainable responses to AIDS. risk. However, over 90% of resources for
HIGHER RISK young people as a group are spent on low-risk
Risk is defined as the probability or
likelihood that a person may become
infected with HIV. Certain behaviours create,
U NIVERSAL ACCESS
Universal access is a global commitment to
youth, who represent less than 5% of infec-
tions. Comprehensive evidence-informed
responses are required to address the specific
increase and perpetuate risk. Examples scale up access to HIV treatment, prevention, needs of young people at higher risk. The
include unprotected sex with a partner care and support. The movement, enshrined engagement of this group in developing the
whose HIV status is unknown, multiple in the 2006 UN Political Declaration, is policies, programmes and processes that di-
sexual partnerships involving unprotected led by countries worldwide with support rectly affect and benefit them is a prerequisite.
sex and injecting drug use with
Z
from UNAIDS, development partners and
contaminated needles and civil society.
syringes. The populations at EROING IN ON
higher risk vary from country
to country. But most commonly
these populations include
V ACCINES
A ready-to-use vaccine is many years away.
SExUAL VIOLENCE
Sexual violence increases women and girls’
vulnerability to HIV. Women and girls who
sex workers, injecting drug Results from the Thai Phase III vaccine trail survive sexual violence need access to com-
users and men who have sex show a modest 31% efficacy in preventing prehensive health and counselling services
with men. new HIV infections. This result has instilled and, where necessary, services for HIV pre-
new hope for scientists in the HIV vaccine vention, treatment, care and support.
research field. In the absence of a vaccine,
HIV prevention efforts must be sustained
and scaled up.
www.unaids.org | Outlook Report | 39

the last WORd
M
ichel Sidibé became the Executive
Director of UNAIDS in january
2009. A native of Mali, he leads
the United Nations efforts in
supporting countries in the global
AIDS response.
You are just about to complete your first
year as Executive Director of UNAIDS.
How does it feel?
If possible, I am even more humbled
and honoured now than when I was
appointed. Every day I am seeing real
change and the perseverance of the hu-
man spirit in difficult times. And this has
renewed my commitment to push my-
self, the organization, and the world for
even more results. I also want to thank
the excellent UNAIDS team, which has
taught me and inspired me.
What issues have you encountered ?
Let me touch on just a few. The priority
areas developed for the Outcome Frame-
work are a direct manifestation of what I
have seen this year. Universal access has
What can each of us do for What is your favourite piece of music?
remained the top priority for UNAIDS.
World AIDS Day? Last Tango in Paris by Gato Barbieri, The
The global economic crisis has been a The theme of this year is Universal Access Cat by the jimmy Smith Quartet and
big issue. I have seen how it is affecting and Human Rights. For me, that means the album In the Heart of the Moon by
families, businesses communities and doing everything we can to support Toumani Diabaté and Ali Farka Toure.
countries across the world. I am glad countries to reach their universal access
What is your happiest memory?
to see that countries have continued to goals for HIV prevention, treatment, care
Helping to deliver my first daughter.
invest in strengthening safety nets and and support—all the while protecting and
protecting the poor. promoting human rights. What is your favourite film?
The Magnificent Seven, with Steve
On my first country visit, which was On World AIDS Day we can remember
McQueen.
to South Africa, I saw that TB, despite the brothers and sisters we have lost and
being curable, remains one of the most renew our courage and commitment What motivates you?
common causes of death among people to get results. And I want to say that The faces of children in need.
living with HIV. We have seen bad laws everyone can join AIDSspace.org, to find
What human quality do you most
repealed and seen how punitive laws ways to get involved every day, not just on
admire?
continue to discriminate. World AIDS Day.
Tolerance.
I’ve called for the virtual elimination of
We would like to finish with a few What do you most value in your friends?
vertical transmission. I believe we can
lighter questions… Loyalty and honesty.
reach the year 2015 with virtually no
more babies born with HIV. I am also Where did you live as a child? If you could be granted one wish in life,
excited about the future of HIV preven- In the most populous neighbourhood of what would you ask for?
tion research. I believe we have seen a Bamako, Mali. Peace and love for the world.
new injection of hope.
How do you relax? What do you want to be when you
Other thoughts are high on my list, Cooking for family and friends. grow up?
including issues such as violence against Television host, to help foster public
What is your favourite food?
women, HIV prevention, treatment, debate.
Feijoada (Brazilian black beans).
social protection, the need for a new
Where is your favourite place?
African drug agency, young people and Who is your hero in history?
Timbuktu at sunset.
people at higher risk, such as men who Kwame Nkrumah, ex-president of Ghana,
have sex with men, injecting drug users who first spoke of his vision for a What is your motto?
and sex workers. unified Africa. just do it!
40 | Outlook Report | www.unaids.org

AidS
Male circuMcision is
now recognized as
care Part of a coMbination
HiV PreVention
strategY.
Only 45% of HIV-positive pregnant
women receive treatment to
prevent the transmission of the virus
to their children.
67%
Hiv OF ALL HIV-POSITIVE
PEOPLE LIVE IN
SUb-SAHArAN AFrICA.
PartnersHiP
www.unaids.org | Outlook Report | 41

PHOTO CrEDITS
Cover:
UNAIDS/M. Hamman
The Harsh Divide:
Gideon Mendel, 2003
Page 2:
UNAIDS/Justin Mott
Page 3:
UNAIDS/Justin Mott
Page 14
UNAIDS/P.Virot
UNAIDS/P.Virot
UNAIDS/O.O’Hanlon
UNAIDS/J.Wainwright
UNAIDS/S.Drakborg
UNAIDS/P.Virot
UNAIDS/S.Drakborg
Page 16:
UNAIDS
Page17:
UNAIDS/P.Virot
Page 19:
UNAIDS/M. Hamman
Page 21:
UNAIDS/M.Hamman
Page 24:
Scott Wallace/The World Bank
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UNAIDS/Justin Mott
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UNAIDS/S.Drakborg
UNAIDS/G.Pirozzi
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UNAIDS/P.Virot
UNAIDS/J.Wainwright
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UNAIDS/ N.Lieber