20120718 togetherwewillendaids.UNAIDS


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20120718 togetherwewillendaids.UNAIDS

  2. 2. Copyright © 2012Joint United Nations Programme on HIV/AIDS (UNAIDS)All rights reservedThe designations employed and the presentation of the material in this publication do not imply the expression of any opinionwhatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of its authorities, orconcerning the delimitation of its frontiers or boundaries. UNAIDS does not warrant that the information published in thispublication is complete and correct and shall not be liable for any damages incurred as a result of its use.WHO Library Cataloguing-in-Publication DataTogether we will end AIDS.“UNAIDS / JC2296E”.1.HIV infections – prevention and control. 2.HIV infections – drug therapy. 3.Acquired immunodeficiency syndrome – preventionand control. 4.Anti-HIV agents. 5.Antiretroviral therapy, Highly active. 6.National health programs. 7.International cooperation.I.UNAIDS.ISBN 978-92-9173-974-5 (offset) (NLM classification: WC 503.6)ISBN 978-92-9173-978-3 (digital)All photos reproduced with the permission of the contributors, except pages 4, 14-15, 99: ©Keystone/AP; page 93: ©Katherine Hudak.
  3. 3. foreword 2MOBILIZING AFRICAN LEADERSHIP 4GETTING TO ZERO 6RESULTS, RESULTS ... MORE NEEDED 16science into action 44TRANSFORMING SOCIETIES 56getting value for money 80INVESTING SUSTAINABLY 102BY THE NUMBERS 120notes and references 124
  4. 4. 2 | UNAIDS Together we will end AIDS
  5. 5. ForewordThe global community has made great progress in Last year, United Nations Member States set clearresponding to the AIDS epidemic. More people than targets for significantly reducing HIV infection andever are receiving treatment, care and support. The AIDS deaths, and for scaling up treatment by 2015.prevention revolution is delivering dramatic results The goals in their Political Declaration on HIV andwhile science is offering new hope. AIDS can be met with the right commitment to, and investment in, the AIDS response.A decade of antiretroviral treatment has transformedHIV from a death sentence to a manageable chronic People living with HIV enjoy full and productivedisease. There is a real opportunity to eliminate lives, raising families, supporting others andnew infections among children within the next becoming leaders in their own right. This successthree years, and our goal to ensure that 15 million comes in large part thanks to the contributionspeople receive antiretroviral therapy by 2015 can be of rights advocates, health workers, young peopleachieved. and communities united in their efforts to end the epidemic. The AIDS response has proven theYet every day, thousands more people are newly power of partnerships among the private sector, theinfected with HIV. Many are in groups at higher international community and political leaders.risk. They deserve special support and access toprevention services, such as condoms and measures Now is the time to take even more bold action,to reduce harm. Others lack the information and inspired by true global solidarity to achieve anresources they need and deserve to avoid infection. AIDS-free world. I hope all those reading this reportFar too many do not have the power to negotiate will use the information it provides to spur progresssafer sex. towards this goal. Together, we can realize our vision of zero new HIV infections, zero discrimination andStigma against people living with HIV and those at zero AIDS-related deaths.higher risk of infection persists. This is a humanrights violation that also hampers our ability toaddress AIDS. Stigma, discrimination, punitive laws,gender inequality and violence continue to inflamethe epidemic and thwart our strongest efforts to ‘getto zero’. Ban Ki-moon Secretary-General of the United Nations UNAIDS Together we will end AIDS | 3
  6. 6. 4 | UNAIDS Together we will end AIDS
  7. 7. Mobilizing African leadershipto help end AIDSDramatic progress made in access to HIV treatment As the Chairperson of the African Union, I amin Africa during the past decade has transformed the promoting shared responsibility and truly Africanlives of numerous families, strengthening the social ownership for the AIDS response. I am workingfabric and increasing economic productivity. We can closely with all African leaders to develop astate that we have renewed hope, but there is no room roadmap for shared responsibility with concretefor complacency. milestones for funding, for access to medicines that must imperatively be produced locally in Africa,The United Nations 2011 Political Declaration on for enhanced regulatory harmonization and forHIV and AIDS called for shared responsibility improved governance. The roadmap will outline theand global solidarity. Africa is committed to roles and responsibilities of governments, regionaldemonstrating its leadership to sustain progress and economic communities, African institutions, peopleto making the vision of an AIDS-free generation living with and affected by HIV and our developmenta reality. To this end, AIDS Watch Africa is being partners. It will bring me pride to share this plan atrelaunched as a unique platform for advocacy, the United Nations General Assembly in New Yorkmobilization and the accountability of the heads of later this year – an African contribution to achievingstate and government who are already members of the goal of eliminating mother-to-child transmissionAIDS Watch Africa as well as inviting new countries of the virus and stopping the spread of HIV in theto join and take ownership of this initiative. The entire world.AIDS response can also benefit from being integratedwith efforts to address tuberculosis, malaria andother diseases that will benefit from Africa-sourced,sustainable solutions. Yayi Boni President of Benin and Chairperson of the African Union UNAIDS Together we will end AIDS | 5
  8. 8. getting to zero
  9. 9. 8 | UNAIDS Together we will end AIDS
  10. 10. Shaping the future we wantIt has been two years since the XVIII International treatment by 2015, as set out by the 2011 PoliticalAIDS Conference in Vienna. At that time, the global Declaration on HIV and AIDS and unanimouslycommunity had begun to cautiously celebrate the adopted by United Nations Member States.fragile progress in preventing and treating HIV. New infections among children have declinedNevertheless, the world was clearly at a defining dramatically for the second year in a row. Of themoment, and forward movement was not guaranteed. estimated 1.5 million pregnant women living with HIV in low- and middle-income countries inSoon after that Conference, UNAIDS began to 2011, 57% received effective antiretroviral drugsarticulate a new vision for the future of AIDS: one to prevent transmission of HIV to their children –that swept aside the pale aspirations of incremental up from 48% in 2010. With the momentumgains and dared the world to imagine what the end of being generated by the Global Plan towards theAIDS should look like – and challenged everyone to elimination of new HIV infections among childrenreach for it, fearlessly and without compromise. by 2015 and keeping their mothers alive, the international community has set a strong courseIt was a bold vision – some even called it a dream – to achieve an AIDS-free generation.but the world deserves no less than a future of zeronew HIV infections, zero discrimination and zero During the past year, many countries – especiallyAIDS-related deaths. the burgeoning economies of Africa – have seized the opportunity to demonstrate their ownership ofToday, progress towards this vision is accelerating their national AIDS response and share responsibilitydramatically in several areas. Many prominent for the global response. They are transcending theleaders are now speaking openly about the beginning outdated donor–recipient paradigm and using theof the end of AIDS, getting to zero and the start of an AIDS response to create a new and more sustainableAIDS-free generation. agenda for global health and development.The world is investing in this vision, and the This agenda of shared responsibility is taking firminvestment is paying off. hold. We are seeing the evidence as countries step up to increase domestic investment in HIV, sharing theIn 2011, more than 8 million people living with HIV burden and the accountability for results. Sharing thein low- and middle-income countries were receiving burden, however, is more than investment – it meansantiretroviral therapy, up from 6.6 million people collectively tackling the political, institutional andin 2010 – for an increase of more than 20%. This structural barriers that impede progress. It meansputs the international community on track to reach ensuring that resources are going where they canthe goal of 15 million people with HIV receiving have the greatest impact. UNAIDS Together we will end AIDS | 9
  11. 11. Importantly, it also means reinforcing inclusive The United States has also been directly affectedcountry leadership. This is global solidarity in action. by the epidemic. There are more than 1.2 million Americans living with HIV who must also benefitLow- and middle-income countries are steadily from the global response. Over the last 20 years, theincreasing their domestic investment in AIDS, annual number of new infections in the United Stateseven during this difficult economic time. Total has not decreased, while the epidemic has becomedomestic HIV resources in low- and middle-income particularly concentrated in selected communities.countries reached an estimated US$ 8.6 billion To reverse the HIV epidemic, both globally and[US$ 7.3 billion–US$ 10.0 billion] in 2011 - the domestically, the leadership of the United Stateshighest ever. Many African countries, including remains of critical importance.Ghana, Kenya, Nigeria and South Africa, haveincreased their domestic spending on AIDS in Just as the international community has a sharedrecent years. After the Global Fund to Fight AIDS, responsibility to reach the target of US$ 22 billion toTuberculosis and Malaria changed its eligibility US$ 24 billion for the global AIDS response by 2015,criteria, China pledged to fill the resource gap with its it also shares responsibility to pursue sustainable andown money. This year, the Government of India plans equitable solutions for health and development.to contribute at least 90% of the funding for Phase IVof its National AIDS Control Programme. Although sub-Saharan Africa accounts for 23.5 million of the 34 million people living with HIVDuring this difficult economic period, the leading globally, it imports more than 80% of its antiretroviralcontribution of the United States of America to the drugs. Global solidarity can help to strengthenglobal AIDS response remains strong. Through the regional and national capacity for the production ofindividual compassion and collective commitment quality-assured medicines and foster harmonizationof the American people, the United States has saved of policies regulating medicines across countriesmillions of lives around the world over many years. and regions – thereby breaking down trade barriersIn 2003, when only about 100 000 people in sub- and encouraging the emergence of local centres ofSaharan Africa had access to treatment and the goal excellence for producing medicines.of extending HIV treatment to people in low- andmiddle-income countries seemed beyond reach, the When Africa ensures greater ownership andUnited States launched the United States President’s sustainability of its AIDS response, the benefits willEmergency Plan for AIDS Relief (PEPFAR). Last year, also strengthen the growth of new industries andwith the support of PEPFAR and other international expand knowledge-based economies.funding sources – including through the GlobalFund and domestic programmes – nearly 6.2 million In these ways, the AIDS response can catalysepeople were receiving HIV treatment in Africa. In broader health and development gains – such as2011, the United States continued to provide 48% leveraging partnerships for innovative financing andof all international assistance for the global HIV enhancing pharmaceutical security for other healthresponse. emergencies.10 | UNAIDS Together we will end AIDS
  12. 12. As we drive to reach the targets of the United Nations second-line regimens if2011 Political Declaration on HIV and AIDS and to resistance develops? Infoster the agenda for shared responsibility and global high-income countries, Innovation will be asolidarity, we must keep our eyes on the future. We where people have beenmust write the next – and final – chapter in the story receiving treatment for major deciding factorof AIDS. decades, the high cost of in the future of the HIV HIV medication – up to responseThis is what UNAIDS is calling the AIDS-Plus US$ 6000 per month – is aAgenda – shaping the future we want. sobering reality.What we want is a future in which innovation is We must avoid developing drug resistance byprized, protected and promoted. A future in which designing smarter combination therapy. Low- andsocial justice and human rights are not just desired middle-income countries could set the standard forbut demanded. A future in which science is pressed treatment programmes worldwide through rationallyinto action to serve people. designed and simplified treatment options that can stave off large-scale resistance and escalating costs.We want a future that embraces the ‘Treatment-Plus’ approach – expanding the use of antiretroviral Innovation will be a major deciding factor in the futuredrugs to prevent and treat HIV infection to include of the HIV response. Innovation is more than makingserodiscordant couples, pregnant women living with new medicines and making them easier to use.HIV, people with higher CD4 counts and, perhapsultimately, all people diagnosed with HIV. We must also innovate service delivery, we must innovate prevention – in particular, we must notCertainly, the major challenge we face is to make falter in our quest for a vaccine – and we mustpaying for treatment sustainable over the long term. innovate how we invest resources.Regardless of how successful we are in getting life-saving drugs to people, we still face the inevitably Sustainable, long-term funding for the AIDSrising costs of drug resistance and the need to response can be ensured by demonstrating toprovide chronic care for people living with HIV over countries, donors and stakeholders that this is atheir lifetimes. smart investment. UNAIDS’ new investment tool for countries demonstrates how improving theIt does not matter how many people can access efficiency of investment and the effectiveness of HIVtreatment if we cannot keep them alive and receiving programming will deliver far greater returns.treatment. If fully implemented, this approach can reverse theWe must start planning now how to manage the cost rising trends in the resources required for AIDSof treatment beyond 2015. How will we fund costly within this decade. UNAIDS Together we will end AIDS | 11
  13. 13. Innovation also extends to social justice. HIV thrives We must support them in living with dignity andamid inequality and disparity and in the absence of purpose.opportunity. A climate that supports human rights,dignity and gender equality can help to prevent Getting to zero discrimination requires us to dopeople from becoming infected with HIV and dying more than protect people who are vulnerable to HIVfrom AIDS-related causes. Such a climate reduces – we must empower them. This is why civil societyignorance about what fuels the epidemic and remains the lifeblood of the AIDS response. Peopleempowers individuals and communities to address living with HIV, women and girls, young people andtheir risks and related needs. Allowing stigma, communities at increased risk of HIV infection have adiscrimination, criminalization, gender inequity unique role in developing and monitoring the globaland violence against women and girls to continue is compact to end AIDS. They are essential stakeholderstantamount to deciding to perpetuate HIV. in ensuring that investment frameworks respond to their needs and in identifying where investment gapsWe also need to innovate AIDS activism – to revive may exist.the spirit of the early days of the response, whenpeople living with HIV and affected by AIDS rose As we gather at the XIX International AIDSup to defy ignorance and inertia and the time when Conference in Washington, DC, some key issues needcollaboration – not competition – brought scientists to be debated that are at the core of the AIDS-Plustogether and into direct contact with the affected Agenda. Let us start the conversation now – together.communities. Finally, I ask you to keep optimism in your heart. IfA vigorous civil society is central to holding we cannot envision a world without AIDS, then wepartners and countries to account for honouring will always be dealing with its consequences. Gettingthe commitments they make. People living with to zero is our only option.HIV, people at higher risk of HIV infection, womenand young people must therefore be present at the No other number is good enough for us, for ourtables where decisions are made. We must listen to families and partners, for our children and for theirthem, learn from them and respect their leadership. children. Michel Sidibé Executive Director, UNAIDS12 | UNAIDS Together we will end AIDS
  14. 14. Let us start theconversationnow – together. UNAIDS Together we will end AIDS | 13
  15. 15. “The United States “We can end this now supports anti-retroviral pandemic. We can treatment for beat this disease. We nearly 4 million people worldwide. can win this fight. We But we’ve got to just have to keep at do more. We’re achieving these it, steady, persistent results not by – today, tomorrow, acting alone, but every day until by partnering with developing we get to zero.” countries. This is a global fight, and it’s one that America must“I was so proud continue to lead.”to announcethat myadministrationwas endingthe ban thatprohibitedpeople withHIV fromenteringAmerica.” US President Barack Obama, World AIDS Day speech 2011. http://goo.gl/0gDNg 14 | UNAIDS Together we will end AIDS
  16. 16. “Few could haveimagined thatwe’d be talkingabout the realpossibility ofan AIDS-freegeneration.” infections may be “The rate of new going down elsewhere, but it’s not going down here in America ... There are communities in this country being devastated, still, by this disease.“ “To the global community – we ask you to join us. Countries that have committed to the Global Fund need to give the money that they promised. Countries that haven’t made a pledge… need to do so. That includes countries that in the past might have been recipients, but now are in a position to step up as major donors.“ UNAIDS Together we will end AIDS | 15
  17. 17. 16 | UNAIDS Together we will end AIDS
  18. 18. RESULTS, RESULTS ...MORE NEEDED UNAIDS Together we will end AIDS | 17
  19. 19. Strong results for some targets,not enough for othersThe 2011 Political Declaration on If this momentum is maintained in the coming years, the world will be close to reachingHIV and AIDS set ambitious targets the target of having 15 million people onto achieve by 2015. The world is antiretroviral therapy by 2015 as set out in theclose to being on track to reach the 2011 Political Declaration on HIV and AIDS (1). Progress is especially impressive in sub-Saharantargets of having 15 million people Africa, where nearly 6.2 million people wereliving with HIV on treatment and receiving antiretroviral therapy in 2011, up fromeliminating new HIV infections just 100 000 in 2003.among children by 2015, but more The expansion of HIV treatment has resulted inaction is needed to halve sexual HIV fewer people dying of AIDS-related causes. Astransmission and transmission of treatment expands, other challenges emerge. Early treatment is a key challenge, and highHIV among people who inject drugs. standards of service quality must be maintained to ensure people remain on treatment, limit15 million can be receiving treatment by 2015 side effects and prevent drug resistanceMore people than ever are receiving from emerging. More needs to be done toantiretroviral therapy, as treatment coverage achieve equitable access to treatment for keycontinues to expand. Just over 8 million populations at higher risk of HIV infection.people in low- and middle-income countries New efforts are needed to ensure that allwere receiving treatment in 2011, with countries have affordable and reliable accesscoverage reaching 54% [range 50–60%].1 This to the highest-quality antiretroviral drugs. Freshis 1.4 million more people than in 2010 and solutions are required for the funding, licensingsignificantly higher than the 400 000 people and logistical challenges that accompany thereceiving treatment in 2003. global roll-out of HIV treatment.As of 21 June 2012, 185 countries reported as part of the Global AIDS Response Progress Reporting system. All estimates of epidemiology, treatment, efforts toeliminate new infections among children (data collection and analysis jointly done with UNICEF, UNAIDS and WHO), domestic spending on HIV and data from theNational Commitments and Policy Instrument for 2011 are preliminary. The data for some of the countries had not been fully validated at the time of going to press.18 | UNAIDS Together we will end AIDS
  20. 20. An estimated 1.4 million more people were Declining death rates The world is nearly onreceiving antiretroviral therapy in low- and meant that there were track to having 15 millionmiddle-income countries in 2011 than in 2010, more people living withsimilar to the progress made between 2009 HIV in 2011 than ever people living with HIV onand 2010 (2). The most dramatic progress has before: 34.2 million antiretroviral treatmentbeen in sub-Saharan Africa, where treatment [31.8 million–35.9 by 2015coverage increased by 19% between 2010 and million]. Globally,2011. In addition, at least 745 000 people were women comprised halfreceiving antiretroviral therapy in high-income (49% [46–51%]) of the adults living with HIV incountries. 2011, a proportion that has varied little in the past 15 years. The burden of HIV on women,More lives are being saved. Antiretroviral however, is considerably greater in sub-Saharantherapy has added 14 million life-years in Africa, where 6 in 10 adults living with HIV inlow- and middle-income countries globally 2011 were women.since 1995, with more than 9 million of thesein sub-Saharan Africa. The estimated number Treatment access is expanding especiallyof cumulative life-years added in sub-Saharan rapidly where the need is greatest. In sub-Africa more than quadrupled between 2008 Saharan Africa, more than half (56% [53–60%])and 2011. the people needing treatment were getting it People receiving antiretroviral therapy versus the 2015 target and the number of AIDS-related deaths, low- and middle-income countries, 2003–2011 18 3People receiving antiretroviral therapy (millions) AIDS-related deaths (millions) 0 0 2003 2011 2015 AIDS-related deaths Estimated range of AIDS-related deaths People receiving antiretroviral therapy 2015 Target UNAIDS Together we will end AIDS | 19
  21. 21. in 2011, and 22% more people were getting 2006. The rest of adults on treatment were stilltreatment in 2011 than a year earlier: 6.2 million receiving a stavudine-based combination, butversus 5.1 million. Coverage of antiretroviral almost all the countries reporting these datatreatment was highest in Latin America (70% have officially decided to shift away from such[61–82%]) and the Caribbean (67% [60–73%]), regimens (2).which boast some of the longest-runningantiretroviral treatment programmes in the Equitable access – room for improvementworld. Treatment coverage remains low in other Achieving equitable access to treatment forlow- and middle-income regions. key populations at higher risk remains an unmet challenge of the global HIV response.Along with expanded treatment access, a shift Treatment coverage is low in Asia (44% [36–is under way towards drug regimens associated 49%]), Eastern Europe and Central Asia (23%with fewer side effects. Stavudine (or d4T), [20–27%]) and North Africa and the Middle Easta comparatively inexpensive drug that has (13% [10–18%]). The HIV epidemics in theseplayed an important role in the early scaling regions are mostly concentrated among keyup of treatment in most countries in sub- populations at higher risk of HIV infection (suchSaharan Africa but has debilitating side effects, as people who inject drugs, sex workers andis steadily being phased out. About 58% of their clients and men who have sex with men),adults in low- and middle-income countries who often face special difficulties in accessingwere receiving either zidovudine- or tenofovir- treatment and care services. In the eightbased first-line regimens in 2010 versus 33% in countries in Eastern Europe and Central AsiaCumulative life-years gained from antiretroviral drugs, 1996–2011 25 Global High-income countries Cumulative life-years gained (millions) Low- and middle-income countries 0 1996 201120 | UNAIDS Together we will end AIDS
  22. 22. Treatment 2.0 In 2010, UNAIDS and WHO launched Treatment 2.0, a programmatic approach to make antiretroviral therapy more accessible, affordable, simple and efficient. It aims to achieve and sustain universal access and maximize the preventive benefits of treatment. Treatment 2.0 has five interrelated priority areas: optimizing drug regimens, simplifying diagnostics, reducing costs, adapting service delivery and mobilizing communities. Optimizing treatment regimens means promoting safer and more effective antiretroviral regimens – preferably as fixed-dose combinations with minimal toxicity, a high barrier to drug resistance and minimal interactions with other drugs, while harmonizing drug regimens for children and adults (including pregnant women and people with TB and hepatitis coinfection). This addresses the key needs of individuals and programmes from a public health perspective. Treatment does not simply mean delivering drugs; it also requires easy-to-use diagnostic and monitoring tools to test people’s HIV status and assess the people already receiving treatment. New point- of-care laboratory technologies are emerging, but accessibility and affordability are major concerns. UNAIDS and UNDP have launched policy briefs on intellectual property rights, aiming to create a legislative environment that fully uses the Trade-Related Aspects of Intellectual Property Rights (TRIPS) Agreement flexibilities. These enable countries to improve their local pharmaceutical capacity and/or to better facilitate the import of generic drugs from existing suppliers, enhancing competition and reducing prices. The policy briefs also advise against creating new ‘TRIPs-plus’ provisions in pharmaceutical patenting that go beyond TRIPS. Alternative affordable and sustainable mechanisms to foster pharmaceutical innovation should be pursued. Ongoing negotiations based on the Global Strategy and Plan of Action on Intellectual Property, Innovation and Public Health and a recent report from the WHO Consultative Expert Working Group are seeking to establish innovative funding mechanisms for health research and development. Treatment 2.0 requires the full involvement of people living with HIV and affected communities in planning, implementing and evaluating quality-assured, rights-based HIV care and treatment programmes. In partnership with civil society organizations, such as Médecins Sans Frontières, UNAIDS is gathering evidence that more strongly involving community-based organizations in treatment adherence support and treatment monitoring can improve service delivery and treatment outcomes and reduce the burden on health systems. UNAIDS Together we will end AIDS | 21
  23. 23. for which data are available (Armenia, Belarus, for treatment, but many do not. In a review ofGeorgia, Kazakhstan, Kyrgyzstan, Russian studies in sub-Saharan Africa (4), 31–77% ofFederation, Tajikistan and Ukraine), people people living with HIV stayed in care until theywho inject drugs who are also living with HIV initiated antiretroviral therapy. Many peopleare less than half as likely to be receiving HIV living with HIV (including in high-incometreatment as people living with HIV who do not countries), regardless of whether they are awareinject drugs.2 Laws and policies that discriminate of their HIV status), commence treatment onlyagainst these populations and lack of services after they begin experiencing AIDS-relatedto meet their needs are important barriers to illnesses. This is a major reason why lateincreasing access to treatment. initiation is still associated with high rates of mortality during the first months following theCoverage of HIV treatment for children also initiation of HIV treatment (5–9).needs to improve, since it is much lower thanfor adults. There are practical ways around these barriers. In South Africa, for example, people whoBetter links to care received their CD4 test result at the same timeRealizing the full potential of antiretroviral therapy as they were diagnosed with HIV infection wererequires a series of further advances, starting with twice as likely to start treatment within threemore effective approaches to HIV testing. months as those who had to wait an extra week to get the same results (10).Many people living with HIV do not knowthey are infected, which is one reason why an Drug resistanceestimated 7 million [6.4 million–7.3 million] As more people start antiretroviral therapy,people in low- and middle-income countries concerns are growing about the possiblewho are eligible for HIV treatment are not increase in HIV drug resistance. HIV mutatesaccessing it. New approaches to HIV testing rapidly, and since treatment is intended to beneed to be explored to ensure that people are lifelong, more drug-resistant strains of the virusaware of their HIV status and people infected seem likely to emerge.with HIV can access care and HIV treatment. Low to moderate levels of transmitted drugIntegrating HIV testing into routine health resistance have been observed, but the needservices has helped to increase the uptake of for vigilance remains. The rate of acquisition oftesting but not sufficiently. Too often, people HIV drug resistance in people on HIV treatmentwho take HIV tests do not return to learn the has remained relatively stable and low, thanksresults. Rapid tests and community-based to the use of effective HIV regimens. However,approaches to testing may help to increase the transmission of HIV drug resistanceaccessibility and uptake. among people recently infected with HIV increased from about 1% in 2005 to about 3%People who test HIV-positive need to enrol in 2010. Among people initiating treatmentand remain in care until they become eligible in low- and middle-income countries, about22 | UNAIDS Together we will end AIDS
  24. 24. Eligibility for antiretroviral therapy versus coverage, low- and middle-income countries,by region, 2011 23% Eastern Europe and Central Asia 13% Middle East and North Africa 67% Caribbean 44% Asia 76% Oceania 70% Latin America 56% Sub-Saharan AfricaThe area of the larger circle represents the number of people eligible for antiretroviral therapy. The shaded circle and percentage represent coverage in 2011.5% had drug resistance in recent surveys, to detect and minimize events associatedwith resistance increasing somewhat with the with the development of resistance, suchscale-up of treatment programme coverage as poor adherence, stock-outs, prescription(12). WHO has developed a global strategy for of inappropriate regimens and errors inpreventing and assessing HIV drug resistance dispensing. The second pillar is surveillance ofin collaboration with the WHO HIVResNet. resistance among people newly infected withMore than 60 countries had implemented one HIV and among people receiving antiretroviralor more elements of the strategy by mid-2011 therapy. Both are essential to avoid the(13). The strategy has two components. The development of resistance and to designfirst is monitoring programme performance, effective first- and second-line regimens. UNAIDS Together we will end AIDS | 23
  25. 25. HIV and tuberculosis coinfection 2011. Almost half these deaths occurred inHIV-related tuberculosis (TB) remains a serious southern Africa. In Latin America, wide accesschallenge. In 2010, 8.8 million people acquired to antiretroviral therapy has helped reduce theactive TB worldwide, of which 1.1 million were annual number of people dying from AIDS-living with HIV. TB remains the leading cause of related causes to 57 000 [35 000–86 000] indeath among people living with HIV. More than 2011, down from 63 000 [35 000–105 000] 1080% of the people living with HIV and TB are years earlier. In the Caribbean, an estimatedin sub-Saharan Africa; in some countries in this 10 000 [8000–12 000] people died from AIDS-region, up to 82% of people with TB are also related causes in 2011, about half as many as inliving with HIV (14). Action to tackle HIV and TB 2001. The annual number of people dying fromjointly is increasing, but it needs to accelerate AIDS-related causes in Oceania fell to 1300further. [1000–1800] in 2011, down from about 2300 [1700–3000] during 2006.Reducing mortality figures will requireincreasing TB cure rates from 70% to 85%, In Western and Central Europe and Northdetecting at least 80% of TB cases among America, the extensive availability ofpeople living with HIV and ensuring that at least antiretroviral therapy, especially in the countries30% of people with HIV who do not have active with the largest epidemics, has significantlyTB receive isoniazid preventive therapy, an reduced AIDS-related mortality. The combinedinexpensive and highly effective regimen (2). number of people dying from AIDS-related causes in these regions has varied little duringAIDS-related mortality decreasing the past decade and totalled an estimatedIncreasing access to antiretroviral therapy has 29 000 [26 000–36 000] in 2011.resulted in significantly fewer people dying ofAIDS-related causes. The number of people Although the numbers of AIDS-related deathsdying annually from AIDS-related causes are declining globally and in most regions, thisworldwide decreased from a peak of 2.3 million trend is not universal. The number of people[2.1 million–2.5 million] in 2005 to an estimated dying from AIDS-related causes has remained1.7 million [1.6 million–2.0 million] in 2011. The stable in Asia, where the number of peopleimpact of HIV treatment is most evident in sub- dying from AIDS-related causes in 2011 totalledSaharan Africa, where an estimated 550 000 an estimated 330 000 [260 000–420 000], the(or 31%) fewer people died from AIDS-related largest number of deaths outside of sub-Saharancauses in 2011 than in 2005, when the number Africa. In Eastern Europe and Central Asia,of AIDS-related deaths peaked. AIDS-related deaths continue to rise. In 2011, an estimated 90 000 [74 000–110 000] people diedIn sub-Saharan Africa, increased access to HIV of AIDS-related causes, six times more than thetreatment has reduced the number of people estimated 15 000 [11 000–26 000] in 2001. AIDS-dying from AIDS-related causes from an annual related deaths in the Middle East and Northpeak of 1.8 million [1.6 million–1.9 million] in Africa increased from 14 000 [8600–28 000] in2005 to 1.2 million [1.1 million–1.3 million] in 2001 to 25 000 [17 000–35 000] in 2011.24 | UNAIDS Together we will end AIDS
  26. 26. José GomesTemporãoExecutive Director, South American Institute ofGovernance in HealthIMPLEMENTING TRIPS FLEXIBILITIES WILL HELPEND AIDSThe right of access to health is a principle of Brazil’snational health system. Sustaining this public healthpolicy is a major challenge.As Brazil’s Minister of Health during President Lula’ssecond term, I made every effort to keep up thiscommitment, understanding that all people living withHIV need timely, continuous access to treatment. In2007, after protracted negotiations with the patentholder, the Government of Brazil issued a compulsorylicense for efavirenz, used by one third of Brazilianpeople with advanced HIV disease at the time. This wasnot an easy decision for the government, but it was theright decision to protect the public interest. It gave usaccess to generic versions and reduced our costs byabout US$ 95 million over five years, thus guaranteeingthe sustainability of our treatment programme.By using the flexibilities provided by TRIPS and the2001 Doha Declaration on TRIPS and Public Health,we were able to use resources more efficiently andintroduce new third-line drugs to ensure options forpeople living with HIV to enjoy longer and better lives.As President Lula stated at the time, the governmentmust use all measures to protect the right to healthof all citizens. It worked for Brazil, and it could make adifference to help end AIDS in other countries as well. UNAIDS Together we will end AIDS | 25
  27. 27. Progress has been made ineliminating new HIV infectionsamong children and keepingmothers aliveOne year ago, the Global Plan towards Progress has been made towards reaching the targets of the Global Plan. The number ofthe elimination of new HIV infections children acquiring HIV infection continues toamong children by 2015 and keeping decline as services to protect them and theirtheir mothers alive (15) was launched mothers against HIV expand.at the United Nations General About 330 000 [280 000–380 000] children wereAssembly High Level Meeting on newly infected with HIV in 2011, almost half theAIDS. This plan, launched by UNAIDS number in 2003, when the number of childrenand the United States Office of the acquiring HIV infection peaked at 570 000 [520 000–650 000] (2), and 24% lower than theGlobal AIDS Coordinator, includes number of children newly infected in 2009 (thetwo ambitious targets for 2015: reduce baseline year for the Global Plan). Among thethe number of children newly infected 21 Global Plan priority countries in sub-Saharan Africa, the number of children newly infectedwith HIV by 90%; and reduce the decreased from 360 000 [320 000–420 000] innumber of pregnancy-related deaths 2009 to 270 000 [230 000–320 000] in 2011, a 25%among women living with HIV decrease. With accelerated efforts, the number ofby 50%. Although the Global Plan children acquiring HIV infection can probably be reduced by 90% by 2015 from the baseline yearinvolves all countries, 22 countries of 2009. The estimated number of women living(including 21 in sub-Saharan Africa) with HIV dying from pregnancy-related causes hashave been given priority, since they declined worldwide by 20% since 2005.account for nearly 90% of pregnant Focusing on childrenwomen living with HIV.3 The pace of the improvements is impressive.26 | UNAIDS Together we will end AIDS
  28. 28. Decline in new HIV infections among children,2009–2011The Global Plan towards the elimination of new HIV infectionsamong children by 2015 and keeping their mothers aliveidentified 22 priority countries. Many of them need urgent actionto achieve the Global Plan target. Greater progress is possible.Rapid decline Moderate decline Slow or no declineWill reach the target if the Can reach the target if the In danger of not reaching the2009–2011 decline of more than decline in 2009–2011 of target, with a decline in 2009–30% continues through 2015. 20–30% is accelerated. 2011 of less than 20%.31% Ethiopia 22% Botswana 0% Angola31% Ghana 30% Burundi 4% Chad43% Kenya 24% Cameroon – Democratic Republic of60% Namibia 20% Côte d’Ivoire the Congo49% South Africa 21% Lesotho 5% Mozambique39% Swaziland 26% Malawi 2% Nigeria55% Zambia 24% Uganda 19% United Republic of45% Zimbabwe Tanzania – IndiaNote: The baseline year for the Global Plan is 2009. Some countries had already made important progress in reducing the number of new HIV infections among children in the years before 2009, notablyBotswana which by 2009 already had 92% coverage of antiretroviral regimens among pregnant women and a transmission rate of 5% (see table pp122–123). In countries with high coverage, furtherdeclines are much harder to achieve. UNAIDS Together we will end AIDS | 27
  29. 29. New HIV infections among children (0–14 years old), 2001–2011 and the target for 2015 700Number of children newly infected with HIV (thousands) 0 2001 2011 2015 The cumulative number of new HIV infections Focusing on mothers averted among children more than doubled In low- and middle-income countries, an between 2009 and 2011 in low- and middle- estimated 1.5 million [1.3 million–1.6 million] income countries, as services to eliminate new women living with HIV were pregnant in 2011. HIV infections among children expanded (1). Reaching the target of halving the number of Almost 600 000 new HIV infections among mothers dying among these women requires children have been averted since 1995 because that all the estimated 620 000 [600 000– of antiretroviral prophylaxis being provided 700 000] pregnant women living with HIV who to pregnant women living with HIV and their are eligible for treatment receive it. This is infants. Most of the children who averted especially crucial in sub-Saharan Africa, where infections live in sub-Saharan Africa, where the AIDS is the leading cause of mothers dying (16). number of children who acquired HIV infection in 2011 (300 000 [250 000–350 000]) was 26% Globally, the number of women dying from lower than in 2009. AIDS-related causes during pregnancy or within 42 days after pregnancy ends (referred to as Drastically reducing the numbers of children pregnancy-related deaths) was estimated to newly infected with HIV will depend especially be 37 000 (18 000–76 000) in 2010, down from on progress being made in the priority an estimated 46 000 (23 000–93 000) deaths in countries identified in the Global Plan. 2005. Among the 22 high-priority countries, the 28 | UNAIDS Together we will end AIDS
  30. 30. number of pregnancy-related deaths among Preventing reproductive-age women frommothers living with HIV decreased from 41 500 acquiring HIV infection(21 000–84 000) in 2005 to 33 000 (16 000–68 000) In several countries with high levels of HIVin 2010 (17). prevalence, steep drops in the number of adults acquiring HIV infection since 2001 haveIf HIV infection in children is to be eliminated helped to reduce the number of pregnantand mothers kept alive, a comprehensive women living with HIV and, in turn, reducedpackage of interventions must be implemented. the number of children newly infected. FurtherThis package involves a series of steps that reducing the number of people acquiring HIVstarts with preventing women from becoming infection in the general population will help toinfected with HIV. Expanding community reduce the number of children infected evenengagement in creating demand and more. Recent recommendations by WHO toexpanding community support services linked provide HIV testing and counselling to couplesto health facilities at the primary level of care and to offer antiretroviral therapy for HIVare essential for successfully delivering the prevention in serodiscordant couples couldpackage. reduce the number of people newly infectedCoverage with antiretroviral regimens among pregnant women living with HIV, low-and middle-income countries, 2005-2011 70 Percentage 0 2005 2011 Pregnant women living with HIV receiving antiretroviral medicine for preventing mother-to-child transmission (%)* Pregnant women living with HIV receiving the most effective antiretroviral regimens for preventing mother-to-child transmission (%)**Coverage in 2010 and onwards cannot be compared with previous years as it does not include single-dose nevirapine, which WHO no longer recommends. UNAIDS Together we will end AIDS | 29
  31. 31. further. When couples are counselled and Reducing the unmet need for family planning tested for HIV infection together they can make will improve the prospects of mothers surviving. informed decisions about HIV prevention and Globally, an estimated 20% of pregnancy- reproductive health, including contraception related deaths could be prevented if unmet and conception. need for contraception were to be eliminated (19). If a woman becomes infected with HIV during pregnancy or when breastfeeding, the A recent study (20) suggested that using probability of transmission to the child is higher hormonal contraception potentially increases than among women who are already living a woman’s chances of becoming infected with with HIV (18). It is therefore vital that pregnant HIV. After reviewing existing evidence, a group women and women who are breastfeeding take of experts convened by WHO determined extra precautions to avoid HIV infection. that there is not enough evidence to suggest that women at higher risk of HIV infection Reducing the number should stop using hormonal contraception butNew HIV infections of reproductive-age highlighted the importance of using condoms among children women acquiring HIV for preventing HIV infection among womencan be dramatically infection will also have using hormonal contraceptives. reduced by 2015 long-range benefits to maternal health and Reducing transmission of HIV from mothers reduce the number of living with HIV to their babies all women dying from pregnancy-related causes, The third intervention is to counsel and test especially in countries with a high prevalence of pregnant women for HIV, and if they are HIV infection. living with HIV, to provide the services and medication necessary to ensure their health Avoiding unintended pregnancies and reduce the risk of transmission to the child. Preventing unintended pregnancies is the In 2011, 57% of the estimated 1.5 million [1.3 second intervention that is critical for reducing million–1.6 million] pregnant women living the number of children acquiring HIV infection. with HIV in low- and middle-income countries In 17 of the 22 priority countries, more than received effective antiretroviral drugs to avoid 20% of married women report wanting to limit transmission to the child. This is considerably or space their next birth but lack access to short of the Global Plan’s coverage target of contraception. A recent analysis of 6 of the 22 90% by 2015. priority countries found that 13–21% of women living with HIV who knew their HIV status had Among the 22 priority countries, Botswana, an unmet need for family planning. Family South Africa and Swaziland have achieved planning services need to be made available 90% coverage for preventing mother-to-child to both women living with HIV and women transmission with dual- and triple-therapy who are HIV-negative. regimens. Ghana, Namibia, Zambia and 30 | UNAIDS Together we will end AIDS
  32. 32. Zimbabwe appear to be on track to achieving Two options are currently recommended.this. Programmes that use option A need to distinguish whether or not pregnant womenIn the other priority countries, however, require antiretroviral therapy for their ownless than 75% of the estimated number of health (CD4 count less than 350 cells per mm3)pregnant women living with HIV received before starting antiretroviral medicine. Womenantiretroviral therapy during pregnancy in 2011 who do not need antiretroviral therapy for(2). Elsewhere, coverage was especially low their own health should receive antiretroviralin western and central Africa (27% [23–30%]), medicine through 7 days after delivery, andNorth Africa and the Middle East (6% [4–9%]) their babies receive antiretroviral medicineand Asia (19% [14–25%]), where single-dose through the end of the breastfeeding period.nevirapine is still in wide use (2). The additional step of CD4 testing before starting treatment is important for programmesCounselling and testing pregnant women and that use option A. Not only will option A notproviding them with the necessary medication protect the health of the women with lowerand services are only part of the intervention. CD4 counts but it is also less effective thanThe most effective antiretroviral regimens option B in stopping transmission from mother(excluding single-dose nevirapine, which is no to child when mothers are at advanced stageslonger recommended for pregnant women of HIV disease. Programmes that use optionliving with HIV except for emergency use B can immediately start the regimen of threeamong pregnant women who first present antiretroviral drugs, which will be administeredto the health facility during labour) must until one week after breastfeeding has ended,be provided to the mother and the child while their infants receive a short course ofto prevent the children from acquiring HIV 4–6 weeks of antiretroviral medicine. Someinfection. Antiretroviral prophylaxis must be countries are considering switching protocolscontinued throughout breastfeeding. Among from option A to option B or to option B+,the 21 priority countries in sub-Saharan Africa, in which pregnant women start lifelongcoverage of prophylaxis during pregnancy antiretroviral therapy immediately. Optionand delivery is estimated at 61%, but the B+ would bring further advantages, since itestimated coverage drops to 29% during probably improves women’s health and ensuresbreastfeeding. Several of the priority countries that women and babies are protected from dayhave documented low rates of HIV transmission one of future pregnancies, further reducingat six weeks of age because of increased access the chances of HIV transmission. In particular,to high-quality services to prevent infants from in countries with high fertility, this may have aacquiring HIV infection. However, the infection considerable effect on the number of childrenrates among children up to 18 months (and acquiring HIV infection. The increased resourcessometimes older) are still high because of needed for continued treatment may betransmission during breastfeeding. offset by simplified procedures, improved UNAIDS Together we will end AIDS | 31
  33. 33. health outcomes for mothers and children and started to increase, the regimens were notadditional benefits, such as preventing HIV strong enough to reduce the transmission ratetransmission in discordant couples and reducing substantially. Since 2010, when more effectivethe risk of developing resistant HIV strains as a prophylaxis regimens were introduced, theconsequence of treatment interruptions among transmission rate has declined.women with multiple pregnancies (21). Lower rates of HIV transmission from mothersHigh coverage and the most effective regimens to children confirm the increasing successwill allow countries to reach the low mother-to- of countries’ efforts to provide effectivechild transmission rates targeted by the Global prophylaxis throughout pregnancy, delivery andPlan of 5% in breastfeeding populations and breastfeeding. Between 2010 and 2011, much2% in non-breastfeeding populations. Between of the progress in reducing the transmission2000 and 2005, despite widespread knowledge rate resulted from moving towards moreof how to reduce mother-to-child transmission, effective regimens, whereas the number ofthe transmission rate remained flat.4 Initially, the women reached with any prophylactic regimencoverage of vertical transmission interventions increased slowly.was too low to have any effect; once coveragePercentage of eligible mother-child pairs receiving effective prophylaxis to preventnew HIV infections among children, low- and middle-income countries, 2011 61% 29% During pregnancy and delivery During breastfeeding32 | UNAIDS Together we will end AIDS
  34. 34. LUCY GHATINational Empowerment Network of People Livingwith HIV/AIDS in Kenyaending new HIV infections among childrenand keeping THEIR mothers alive will helpend AIDSAs a mother living with HIV, I would do everything inmy capacity to stop passing the virus to my baby andI know that other women sharing my status would dothe same. I believe we can end new HIV infectionsamong children and keep their mothers alive: we havethe scientific knowledge and tools to make this a realityand proof that it can be done. But in Kenya, one ofevery five children born to a woman living with HIV stillgets infected with HIV.Results from many locations show that providingantiretroviral therapy to pregnant women living withHIV will prevent the transmission of HIV to infants.But science will only work when programmes are welldesigned and address the unique challenges facingwomen. Only 60% of pregnant women living with HIVin Africa received the medicine needed to prevent theirchildren from becoming infected with HIV in 2011.Many programmes still focus on health facilities,even though half the relevant women do not accessthese facilities. This calls for better programmedesign, necessary investment and the meaningful andsustainable involvement of communities at all levels ofthe response. We need women and men to becomeagents of change, to build knowledge and demandand to advocate for resources, stronger communitysystems and the scaling up of services. UNAIDS Together we will end AIDS | 33
  35. 35. Challenges remain. One of five children born year, and about 50% of children infectedto women living with HIV was infected with HIV during breastfeeding die within nine years ofduring pregnancy or through breastfeeding infection (22). The use of dried blood spotsin 2011. More effective regimens and higher has increased access to early infant diagnosis.coverage can reduce this rate to less than 5%. However, too many regimens for children are being used, complicating service provision, andProviding treatment, care and support to efforts to simplify must continue to be made.mothers living with HIV and their families As programmes to eliminate new HIV infectionsAs a result of the slow progress earlier in the among children in antenatal care settings at thedecade, about 3.4 million [3.1 million– primary level of care continue to expand, more3.9 million] children younger than 15 years were attention must be paid to ensure that childrenliving with HIV globally in 2011, 91% of them in are diagnosed and treated in these settings.sub-Saharan Africa. An estimated 230 000[200 000–270 000] children died from AIDS- There is still a major gap between children andrelated illnesses in the same year. adults in coverage of antiretroviral therapy. Globally, about 562 000 children receivedThe fourth intervention is to provide support, antiretroviral therapy in 2011 (up from 456 000care and treatment to mothers living with HIV in 2010), but coverage was only 28% [25–32%]:and to their families. Children who become higher than the 22% [20–25%] in 2010 butinfected when their mother is pregnant or while much lower than the 57% [53–60%] coveragebreastfeeding require early HIV diagnosis and of antiretroviral therapy among adults. Eventimely treatment. Providing appropriate HIV though antiretroviral therapy services stilltreatment and care for mothers and children, reach only a small fraction of eligible children,including screening and managing TB, improves substantially fewer children are dying fromoverall survival prospects for children. Failing AIDS-related causes: 230 000 [200 000–270 000]that, disease progression and death is usually in 2011 versus 320 000 [290 000–370 000] inrapid: almost 50% of the children infected 2005.during pregnancy or delivery die within one34 | UNAIDS Together we will end AIDS
  36. 36. In 2011, an estimated 620 000 [600 000– treatment allows mothers to live longer and700 000] pregnant women were eligible for more healthy lives.antiretroviral therapy for their own health, butonly 190 000 pregnant women living with HIV Improving the retention of women and childrenwith a CD4 count less than or equal to 350 in programmes for preventing mother-to-cells per ml received it. Fewer than half (45%) child transmission and in antiretroviral therapyof pregnant women known to be living with is critical to reducing vertical transmissionHIV in low- and middle-income countries were and keeping mothers and babies living witheven assessed for their eligibility to receive HIV alive and healthy. Enhancing communityantiretroviral therapy in 20105 (2). support and using mobile health technologies, such as text messaging for appointment andProviding timely antiretroviral therapy to adherence reminders, as well as reducing themothers living with HIV greatly reduces the number of steps in the cascade of care areindirect maternal mortality among them. In crucial to optimizing results.addition to reducing pregnancy-related deaths, UNAIDS Together we will end AIDS | 35
  37. 37. Fewer adolescents and adultsacquiring HIV infection but notdeclining rapidly enoughThe number of adolescents and adults of adults acquiring HIV infection in 2011 in that region fell by more than 35% to 1.5 million(adults means people 15 years and [1.3 million–1.6 million] from the estimated 2.2older in the remainder of this section) million [2.1 million–2.4 million] at the height ofnewly infected with HIV continues the epidemic in 1997.to decline globally as prevention HIV services are not yet reaching all keyefforts gain momentum. Nevertheless, populations at higher risk of infection, suchthe rate of decline is not sufficient as sex workers, people who inject drugs andto reach the goals of reducing the men who have sex with men. The number of people newly infected is therefore not decliningnumber of people acquiring HIV sufficiently in areas where the epidemic isinfection by 50% by 2015. The concentrated among key populations at higherestimated number of adults acquiring risk. This is particularly evident in Eastern Europe, Central Asia, the Middle East andHIV infection in 2011 was 2.2 million North Africa. After slowing in the early 2000s,[2.0 million–2.4 million], 500 000 the number of people newly infected in Easternfewer than in 2001. This declining Europe and Central Asia has been rising againtrend stems from a combination of since 2008. The annual number of people newly infected has also risen in the Middle East andfactors, including the natural course North Africa for the past decade.of HIV epidemics, behaviouralchanges and increasing access to Fewer new infections in several regionsantiretroviral therapy. Fewer people acquired HIV infection in sub- Saharan Africa in 2011 than in any year since 1997. An estimated 1.5 million [1.3 million–1.6Most of the adults newly infected are still million] adults were newly infected with HIVliving in sub-Saharan Africa,6 but the number in 2011, about 22% fewer than in 2001 andacquiring HIV infection is declining. The number 3% fewer than in 2010. Modifications in risky36 | UNAIDS Together we will end AIDS
  38. 38. New HIV infections among adults, 2001–2011 and the target for 2015Number of adults newly infected with HIV (millions) 4 0 2001 2011 2015behaviour, including a reduced number of the larger epidemics, with seven countriessexual partners, increased condom use and accounting for more than 90% of people livingdelayed sexual debut provided the momentum with HIV: China, India, Indonesia, Malaysia,for this downward trend, as did increasing Myanmar, Thailand and Viet Nam (2). Althoughcoverage of biomedical interventions, such as India has done particularly well, halving themale circumcision and antiretroviral therapy. number of adults newly infected between 2000 and 2009 (30), some smaller countries in Asia,The vast majority of adults newly infected such as Afghanistan and the Philippines, arewith HIV in sub-Saharan Africa acquire the experiencing increases in the number of peoplevirus during unprotected sexual intercourse, acquiring HIV infection (2).including paid sex and sex between men(23,24). Especially in countries with high Injecting drug use, unprotected sex betweenprevalence, many of the people acquiring HIV men and unprotected paid sex fuel theinfection have multiple and concurrent partners. epidemics in this region. The prevalence ofAnother important share of the people newly HIV among these key populations at higherinfected are HIV-discordant couples (25–29). risk is high in many Asian countries. Overall, an estimated 16% of the people who injectThe rate of HIV transmission is also slowing in drugs in Asia are living with HIV (31), but theAsia. An estimated 360 000 [240 000– prevalence of HIV infection is much higher in480 000] adults were newly infected with HIV some places. Between 8% and 32% of men whoin the region in 2011, considerably fewer than have sex with men are living with HIV in cities inthe 440 000 [290 000–510 000] estimated for China (32), India (33), Indonesia (34), Myanmar2001. This reflects slowing HIV incidence in (35) and Thailand (36). UNAIDS Together we will end AIDS | 37
  39. 39. The annual number of adults newly infected New HIV infections among adults, with HIV in Oceania has declined in recent 2001–2011, in regions with years, including in Papua New Guinea, which declining and stable incidence has the largest HIV epidemic in this region (37). In 2011, an estimated 2600 [1900–3500] adults acquired HIV infection, 17% fewer than in 2001. 2.5 Most of the people who acquire HIV infection in this region get the virus by sexual transmission (38). In the Caribbean, the estimated 12 000 [8700– 14 000] adults newly infected with HIV in 2011 were 38% fewer than in 2001. Although most countries in the region have acknowledged that heterosexual transmission is a main route of HIV infection, with People (millions) More action is needed high prevalence among female sex workers (25), to halve sexual HIV few have acknowledged transmission and unprotected sex transmission among between men as a factor in theirpeople who inject drugs epidemics. Yet studies by 2015 have found the HIV prevalence among men who have sex with men ranging from more than 5% in cities in the Dominican Republic (39) to 8% in the Bahamas, 19% in Guyana and 33% in Jamaica (40). 0 2001 2011 Stable incidence elsewhere The HIV epidemics in Latin America have Estimated ranges and mid-points for: stabilized at comparatively low levels. However, Sub-Saharan Africa nearly 100 000 people acquire HIV infection Asia annually in this region. In most countries in this region, HIV is spreading mainly in and around Latin America networks of men who have sex with men. Caribbean Studies have found an HIV prevalence of at Oceania least 10% among men who have sex with men 38 | UNAIDS Together we will end AIDS
  40. 40. in 9 of 14 countries in the region, with infection New HIV infections among adults,levels as high as 19% in some cities (41–43). 2001–2011, in regions withInjecting drug use is another significant route of rising incidenceHIV transmission in this region, especially in thesouthern cone of South America and in Mexico. 350The incidence of HIV infection has changedlittle since 2004 in North America and Westernand Central Europe overall, but there aretroubling developments in some of the smallerepidemics in central Europe.7 An estimated88 000 [54 000–156 000] adults were newlyinfected with HIV in 2011, compared with79 000 [65 000–97 000] in 2001. Unprotected People (thousands)sex between men is still the main driver of HIVtransmission in this region (44), with injectingdrug use and unprotected paid sex relativelyminor factors. The epidemics among men whohave sex with men appear to be resurgent inNorth America and much of Western Europe(45).Increasing incidence in two regionsThere is no sign yet that the epidemics inEastern Europe and Central Asia are slowing 0down. An estimated 160 000 [110 000– 2001 2011220 000] adults were newly infected with HIV Estimated ranges and mid-points for:in 2011, 22% more than in 2005. In the RussianFederation, the number of people reported Eastern Europe and Central Asianewly diagnosed increased from 39 207 in Middle East and North Africa2005 to 62 581 in 2010 (2). Since 2005, newlyreported HIV cases have also been increasingin the smaller epidemics in Central Asia(Kyrgyzstan, Tajikistan and Uzbekistan) (44).The use of contaminated injecting equipmentremains the main route of transmission in thisregion. The HIV incidence among peoplewho inject drugs in St Petersburg, Russian UNAIDS Together we will end AIDS | 39
  41. 41. Federation, for example, was 8.1 per 100 circumcision programmes has been slow.person-years in 2009, almost twice the rate five This intervention has the potential betweenyears earlier (46). Studies in other cities have 2011 and 2025 to prevent 22% of the peoplefound an HIV prevalence of 32–64% among who would otherwise acquire HIV infectionpeople who inject drugs (47–49). An estimated from acquiring it in 14 countries of Eastern35% of women living with HIV in this region and Southern Africa if 80% of men agedprobably acquired HIV through injecting drug 15–49 years are circumcised by 2015 and thatuse, and an additional 50% were probably coverage is maintained. Achieving this level ofinfected by partners who inject drugs (50). coverage requires that almost 21 million men be circumcised. By the end of 2011, over 1.3The available evidence in the Middle East and million men had been circumcised, representingNorth Africa8 points to ongoing increases in just over 6% of the target.the number of people acquiring HIV infection.In 2011, an estimated 36 000 [26 000–56 000] Some groups in society face exceedinglyadults acquired HIV infection, 29% more than high risks of acquiring and transmitting HIV.in 2001. Unprotected sex (including between People who sell sex, for example, have amen) and sharing contaminated drug-injecting disproportionately large burden of HIV. A recentequipment are the primary drivers of HIV meta-analysis of surveys in 50 countries (41)infection in this region (51). found an average prevalence of HIV infection among female sex workers of 12%. HIV data forKey programmes lag behind male sex workers are scarce, but studies haveAchieving prevention goals requires found HIV prevalence of 14% in Campinas,systematically implementing a comprehensive Brazil (52), 5% in Shenzhen, China (53) and 16%package of basic services, including greater in Moscow, Russian Federation (54). Studiesefforts in reaching key populations at higher risk suggest that the HIV prevalence among menof HIV infection. who have sex with men in low- and middle- income countries could be 19 times higherThe global response to HIV appears likely to than among the general population (55), andfail to meet internationally agreed targets for about one third of all the people acquiringHIV prevention. Epidemiological data suggest HIV infection outside sub-Saharan Africa werethat this failure primarily stems from a failure infected in relation to injecting drug use (56).to adequately implement and scale up someof the basic programmes that aim to reduce HIV transmission is concentrated among keyHIV transmission among adults. These include: populations at higher risk in many countries,voluntary medical male circumcision, where and yet the availability and uptake ofappropriate; behavioural change programmes; services for these key populations is woefullycondom promotion; and programmes for key inadequate. There are proven, effectivepopulations at higher risk of HIV infection. methods to prevent HIV from being transmittedImplementing voluntary medical male by sharing contaminated drug-injecting40 | UNAIDS Together we will end AIDS
  42. 42. Olga BelyaevaHead of the Board of the Association of SubstitutionTreatment Advocates of Ukrainestopping new HIV infections amonginjecting drug users will help end AIDSThe HIV epidemic is still growing in eastern Europeand central Asia. The main driver of this epidemic isthe sharing of contaminated drug-injecting equipment.We can end HIV transmission among people who injectdrugs. We know how to do that.The success of well-designed and well-run harmreduction programmes in reducing HIV transmission isindisputable. I know this from personal experience. Theintroduction of harm reduction has changed the qualityof my life and that of others who use drugs in Ukraine.The benefits of needle and syringe programmes andopioid substitution therapy are obvious. There isincreasing policy support for substitution therapy in theregion, but coverage is still too low. Programmes mustbe adapted for women and girls who inject drugs; theyremain in the shadows.Current drug policies exacerbate stigma anddiscrimination against people who use drugs, and theylimit access to comprehensive HIV services. ‘Nothingfor us without us’ – the principle that people who usedrugs should have a central role in decisions affectingthem – is becoming a reality in our region, but a greatdeal still remains to be done.We know harm reduction works. If we can make it workfor more people, we can end the HIV epidemic in myregion. UNAIDS Together we will end AIDS | 41
  43. 43. 8 millionreceived treatment More than 8 million people living with HIV received antiretroviral therapy in low- and middle-income countries in 2011.
  44. 44. equipment (57,58), for example, but many Although efforts to provide treatment forcountries still shun them (59). people living with HIV and to prevent HIV being transmitted from mothers to theirPreliminary data from 95 countries reporting in children appear to be nearly on track to achieve2011 suggest that less than 20% of countries global targets, other basic HIV services arefor which data were available had HIV-testing being neglected. Basic programme activities,coverage of sex workers of 80% or greater. including services that adequately address theAbout 15% reported HIV testing of people who prevention needs of key populations at higherinject drugs of 80% or greater. The poorest risk and programmes that aim to change sexualavailability and uptake of testing services was behaviour and increase voluntary medicalreported for men who have sex with men, with male circumcision need to be implemented toless than 10% of countries reporting 80% or accelerate progress towards agreed preventiongreater coverage. targets. UNAIDS Together we will end AIDS | 43
  45. 45. science intoaction
  46. 46. Turning science into programmes There have been many breakthroughs affected countries. This encouraging trend towards fewer people becoming infected can in scientific research and product be maintained through continued AIDS-focused development in recent years. social transformation and intensive tailored Combined with the results of efforts that target risk. The momentum of an expanding epidemic is difficult to reverse, but existing programmes, there is a clear a shrinking epidemic is much easier to manage, opportunity to apply this knowledge albeit with sustained effort. to help end AIDS. Second, mass access to antiretroviral therapy, The global epidemic has slowed since the including in the most resource-constrained 1990s, with the help of collective efforts and environments, has already reduced HIV-related significant investment in prevention, treatment, illness and deaths and is poised to drive the care and support. AIDS will not end of its number of people newly infected further own accord in the foreseeable future, but it downwards, as those living with HIV become is possible to see a route that can lead us to less infectious. Widespread concern that access ending the epidemic. Efforts and investment to antiretroviral therapy would distort priorities will need to rise to meet this challenge. and harm health systems in countries struggling to provide even the most basic health services There are four clear reasons why we can see has proven unfounded. On the contrary, a solution, and all of them are underpinned concerted efforts on HIV have more often lifted by political commitments. First, widespread the capacities of health systems, especially in changes in behaviour and other concerted, relation to procurement and related systems multifaceted actions have significantly reduced and facilities, with benefits felt across all health the number of people conditions. acquiring HIV infection.We can see the route to This reduction has Third, the goal of eliminating HIV transmission ending AIDS been most dramatic from mothers to their children has become a in the most severely litmus test of equity and the health of women 46 | UNAIDS Together we will end AIDS