Epidemiology

A new website that enables people to identify national laws and policies related to the AIDS response has been launched by UNAIDS.

Covering areas as diverse as a country’s ability to diagnose HIV among young babies, the existence of laws that discriminate against transgender people and whether people are prosecuted for carrying condoms, the Laws and Policies Analytics website aims to give a full overview of a country’s laws and policies related to the HIV response. It also allows to view policy data jointly with other data on the HIV epidemic and response.

“We must better understand legal and policy environments to drive effective responses to the HIV epidemic. This new tool will provide access to data on national laws and policies and allow for joint analysis with data on the epidemic and response, so that we can drive more deeply-informed decision-making,” said Shannon Hader, UNAIDS Deputy Executive Director, Programme.

Under the 2016 United Nations Political Declaration on HIV and AIDS, countries committed to accelerate efforts to significantly increase the availability of high-quality data on HIV. The information used on the new website was reported since 2017 and most recently in 2019 through the National Commitments and Policy Instrument (NCPI), a part of the Global AIDS Monitoring mechanism through which countries report their progress against the commitments they made in the 2016 Political Declaration.

Data were provided by national authorities, civil society organizations and other nongovernmental partners engaged in the AIDS response. Data on HIV-related laws and policies compiled from other external official documents complement the nationally supplied data. UNAIDS carries out a thorough validation of all policy data included to ensure their accuracy. Data will be updated annually.

The website hosts data from over 140 countries. Users can search by country or region through an interactive map or can select a specific topic.

Through making policy data widely available, UNAIDS seeks to promote transparency and an increased use of policy data in analyses of the HIV epidemic and the response to HIV in countries worldwide.

The Laws and Policies Analytics website can be accessed at lawsandpolicies.unaids.org.

Impressive advances in some countries, troubling failures in others as available resources for HIV fall by nearly US$ 1 billion

ESHOWE/GENEVA, 16 July 2019—The pace of progress in reducing new HIV infections, increasing access to treatment and ending AIDS-related deaths is slowing down according to a new report released today by UNAIDS. UNAIDS’ Global AIDS Update, Communities at the centre, shows a mixed picture, with some countries making impressive gains while others are experiencing rises in new HIV infections and AIDS-related deaths.

“We urgently need increased political leadership to end AIDS,” said Gunilla Carlsson, UNAIDS Executive Director, a.i., “This starts with investing adequately and smartly and by looking at what’s making some countries so successful. Ending AIDS is possible if we focus on people, not diseases, create road maps for the people and locations being left behind, and take a human rights-based approach to reach people most affected by HIV.”

The report shows that key populations and their sexual partners now account for more than half (54%) of new HIV infections globally. In 2018, key populations—including people who inject drugs, gay men and other men who have sex with men, transgender people, sex workers and prisoners—accounted for around 95% of new HIV infections in eastern Europe and central Asia and in the Middle East and North Africa.

However, the report also shows that less than 50% of key populations were reached with combination HIV prevention services in more than half of the countries that reported. This highlights that key populations are still being marginalized and being left behind in the response to HIV.

Globally, around 1.7 million people became newly infected with HIV in 2018, a 16% decline since 2010, driven mostly by steady progress across most of eastern and southern Africa. South Africa, for example, has made huge advances and has successfully reduced new HIV infections by more than 40% and AIDS-related deaths by around 40% since 2010.

However, there is still a long way to go in eastern and southern Africa, the region most affected by HIV, and there have been worrying increases in new HIV infections in eastern Europe and central Asia (29%), in the Middle East and North Africa (10%) and in Latin America (7%).

The report was launched at a community event in Eshowe, South Africa, by Ms Carlsson and David Mabuza, the Deputy President of South Africa. It contains case studies and testimonies identifying community programmes that can quicken the pace of the response to HIV.

“South Africa has a rich history of communities being at the centre of the AIDS response, so it is fitting that we launch the 2019 UNAIDS Global AIDS Update in this country, in Eshowe, in KwaZulu-Natal, where a community-based service delivery model, with HIV at its centre, is showing results,” said Deputy President Mabuza.

Financing

Disconcertingly, the report shows that the gap between resource needs and resource availability is widening. For the first time, the global resources available for the AIDS response declined significantly, by nearly US$ 1 billion, as donors disbursed less and domestic investments did not grow fast enough to compensate for inflation. In 2018, US$ 19 billion (in constant 2016 dollars) was available for the AIDS response, US$ 7.2 billion short of the estimated US$ 26.2 billion needed by 2020.

To continue progress towards ending AIDS, UNAIDS urges all partners to step up action and invest in the response, including by fully funding the Global Fund to Fight AIDS, Tuberculosis and Malaria with at least US$ 14 billion at its replenishment in October and through increasing bilateral and domestic funding for HIV.

Treatment and the 90–90–90 targets

Progress is continuing towards the 90–90–90 targets. Some 79% of people living with HIV knew their HIV status in 2018, 78% who knew their HIV status were accessing treatment and 86% of people living with HIV who were accessing treatment were virally suppressed, keeping them alive and well and preventing transmission of the virus.

Communities at the centre shows however that progress towards the 90–90–90 targets varies greatly by region and by country. In eastern Europe and central Asia for example, 72% of people living with HIV knew their HIV status in 2018, but just 53% of the people who knew their HIV status had access to treatment.

“I’ve been on treatment for 16 years, am virally suppressed and doing well,” said Sthandwa Buthelezi, founder of Shine, an organization in Eshowe that addresses stigma and discrimination in the community. “But stigma and discrimination are still widespread, particularly in health care settings. As an activist, I encourage everyone, including community leaders, to talk openly about HIV so that people can live positively and shine.”

AIDS-related deaths

AIDS-related deaths continue to decline as access to treatment continues to expand and more progress is made in improving the delivery of HIV/tuberculosis services. Since 2010, AIDS-related deaths have fallen by 33%, to 770 000 in 2018.

Progress varies across regions. Global declines in AIDS-related deaths have largely been driven by progress in eastern and southern Africa. In eastern Europe and central Asia however, AIDS-related deaths have risen by 5% and in the Middle East and North Africa by 9% since 2010.

Children

Around 82% of pregnant women living with HIV now have access to antiretroviral medicines, an increase of more than 90% since 2010. This has resulted in a 41% reduction in new HIV infections among children, with remarkable reductions achieved in Botswana (85%), Rwanda (83%), Malawi (76%), Namibia (71%), Zimbabwe (69%) and Uganda (65%) since 2010. Yet there were nearly 160 000 new HIV infections among children globally, far away from the global target of reducing new HIV infections among children to fewer than 40 000 by 2018.

More needs to be done to expand access to treatment for children. The estimated 940 000 children (aged 0–14 years) living with HIV globally on antiretroviral therapy in 2018 is almost double the number on treatment in 2010. However, it is far short of the 2018 target of 1.6 million.

Women and adolescent girls

Although large disparities still exist between young women and young men, with young women 60% more likely to become infected with HIV than young men of the same age, there has been success in reducing new HIV infections among young women. Globally, new HIV infections among young women (aged 15–24 years) were reduced by 25% between 2010 and 2018, compared to a 10% reduction among older women (aged 25 years and older). But it remains unacceptable that every week 6200 adolescent girls and young women become infected with HIV. Sexual and reproductive health and rights programmes for young women need to be expanded and scaled up in order to reach more high-incidence locations and maximize impact.

HIV prevention

Communities at the centre shows that the full range of options available to prevent new HIV infections are not being used for optimal impact. For example, pre-exposure prophylaxis (PrEP), medicine to prevent HIV, was only being used by an estimated 300 000 people in 2018, 130 000 of whom were in the United States of America. In Kenya, one of the first countries in sub-Saharan Africa to roll out PrEP as a national programme in the public sector, around 30 000 people accessed the preventative medicines in 2018.

The report shows that although harm reduction is a clear solution for people who inject drugs, change has been slow. People who inject drugs accounted for 41% of new HIV infections in eastern Europe and central Asia and 27% of new HIV infections in the Middle East and North Africa, both regions that are lacking adequate harm reduction programmes.

Men remain hard to reach. Viral suppression among men living with HIV aged 25–34 years is very low, less than 40% in some high-burden countries with recent surveys, which is contributing to slow progress in stopping new HIV infections among their partners.

Stigma and discrimination

Gains have been made against HIV-related stigma and discrimination in many countries but discriminatory attitudes towards people living with HIV remain extremely high. There is an urgency to tackle the underlying structural drivers of inequalities and barriers to HIV prevention and treatment, especially with regard to harmful social norms and laws, stigma and discrimination and gender-based violence.

Criminal laws, aggressive law enforcement, harassment and violence continue to push key populations to the margins of society and deny them access to basic health and social services. Discriminatory attitudes towards people living with HIV remain extremely high in far too many countries. Across 26 countries, more than half of respondents expressed discriminatory attitudes towards people living with HIV.

Communities

The report highlights how communities are central to ending AIDS. Across all sectors of the AIDS response, community empowerment and ownership has resulted in a greater uptake of HIV prevention and treatment services, a reduction in stigma and discrimination and the protection of human rights. However, insufficient funding for community-led responses and negative policy environments impede these successes reaching full scale and generating maximum impact.

In KwaZulu-Natal in South Africa, one in four adults (aged 15–59 years) were living with HIV in 2016. To advance the response, Médecins Sans Frontières managed a community-based approach to HIV testing that links people to treatment and supports them to remain in care. By 2018, the 90–90–90 targets were achieved in Eshowe town, rural Eshowe and Mbongolwane, well ahead of the 2020 deadline.

Another study in South Africa and Zambia enrolled hundreds of Community HIV Care Providers (CHIPS) over five years to visit homes, provide information about HIV and offer HIV testing and linkage to care. The study found that areas with CHIPS communities had around 20% fewer new HIV infections each year and the proportion of people living with HIV who knew their HIV status, were on antiretroviral therapy and were virally suppressed increased from 54% to more than 70%.

UNAIDS urges countries to live up to the commitment made in the 2016 United Nations Political Declaration on Ending AIDS for community-led service delivery to be expanded to cover at least 30% of all service delivery by 2030. Adequate investments must be made in building the capacity of civil society organizations to deliver non-discriminatory, human rights-based, people-centred HIV prevention and treatment services in the communities most affected by HIV.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

South Africa is making strong progress in scaling up HIV testing and increasing viral suppression in patients receiving antiretroviral therapy (ART), but is not yet reaching its targets for treatment coverage and HIV prevention, according to an updated Thembisa model released at the 9th South Africa AIDS Conference in June.

The results of the annual updated Thembisa model (version 4.2) was released by researchers at the Centre for Infectious Diseases Epidemiology and Research, University of Cape Town. Work on the Tembisa HIV estimates is  funded by UNAIDS through a grant from the United States Centres for Disease Control (CDC), and used data from multiple sources including recent surveys by the Human Sciences Research Council and the Medical Research Council of South Africa.

South Africa is committed to reaching the UNAIDS 90–90–90 Fast-Track targets by 2020. The aim of this strategy is to ensure that 90% of people living with HIV are tested and know their status, that 90% of people living with HIV are receiving treatment, and 90% of people on treatment have a suppressed viral load. The latest Thembisa estimates indicate that South Africa reached 90–68–88 by mid-2018. This means that total viral load suppression among all people living with HIV was 55%, which is 18 percentage points below the target of 73%.

The Thembisa model also estimates that men had a lower uptake of HIV testing and treatment compared to women. As a result, in 2018, 47% of HIV-positive men were virally suppressed compared to 58% of HIV-positive women. This was also reflected in annual AIDS-related deaths which halved from 2010 to 2018, but with men increasingly over-represented.

Women accounted for 62% of new HIV infections in adults from 2017 to 2018. The lead developer of the Thembisa model, Leigh Johnson, said two factors were hampering progress on reducing HIV incidence: low ART coverage and the need to improve linkage and retention in care, and evidence of reduced condom use. He noted that adolescent girls and young women (15–24 years) account for 31% of all sexually-acquired HIV and require special attention.

The Thembisa results highlighted concern about slow progress in reducing HIV incidence. The model estimates that in the last year there were more than 240 000 new HIV infections in South Africa, which was a reduction of less than 40% from 2010. The UNAIDS target is to reduce annual new infections by 75% between 2010 and 2020. To achieve this, South Africa would need to reduce new infections to fewer than 100 000 by mid-2020, which poses a significant challenge.

The Thembisa results show that  that KwaZulu-Natal, the province with the most severe HIV epidemic, succeeded in reducing its annual new HIV infections by 49% from 2010 to 2018. Thembisa also estimates that annual new infections among children declined 55% from 29 000 in 2010 to 13 000 in 2018.

More detailed results and model details are available on the Thembisa website: https://thembisa.org/downloads

Dan Namarika, the Principal Secretary for Health in Malawi, graduated from the College of Medicine in 1999 as one of the first students to follow their entire medical training in Malawi. His long career as a medical doctor, which included four years as personal physician to the late President Bingu wa Mutharika, was prompted by a desire to act against AIDS.

“The reason I chose medicine was because of AIDS. I couldn’t believe there was an illness like this with no cure. I remember the first case in my neighbourhood. It was a lady who succumbed to AIDS after a chronic illness. I have had family members that have died. My long history has been impacted on by AIDS,” he says.

Since the peak of the HIV epidemic to which Mr Namarike refers, when there were 110 000 new infections (in 1993 and 1994) and 65 000 deaths because of AIDS-related illnesses (in 2004 and 2005), Malawi has made good progress in its HIV response.

This progress can be attributed to the introduction of innovations such as the test and start strategy in 2016, which offers immediate HIV treatment for all people living with HIV and Option B+ in 2011, a prevention of mother-to-child transmission of HIV strategy that ensures that all pregnant women living with HIV have lifelong access to HIV treatment. 

As a result, new HIV infections in Malawi have dropped by 40%, from 64 000 in 2010 to 39 000 in 2017, and AIDS-related deaths by half, from 34 000 in 2010 to 17 000 in 2017. Life expectancy continues to rise, from a mere 46 years in 2004 to 64 in 2018, and projections are that it will rise to 74 by 2030.

In 2017, 92% of pregnant women living with HIV in Malawi accessed services to prevent mother-to-child transmission of HIV. This lowered the number of new HIV infections among children (0–14 years) to an all-time low of 4900 in 2017.

Mr Namarika attributes these successes in large part to the multisectoral HIV response and high-level political commitment and leadership. “Besides policies being made at the highest levels of government, we also have ministries other than health involved, such as the treasury, gender, education and local government; we have civil society, the faith-based sector, cultural leaders and technical assistance from development partners, such as UNAIDS,” he says.

He also praises programmatic innovations, such as task shifting from doctors to nurses and community health-care workers, which has helped to reach more people with HIV testing and treatment services.

The 2015–2020 National Strategic Plan for HIV and AIDS has the 90–90–90 targets at its heart, with ending AIDS by 2030 in Malawi as the end goal. Malawi has made good progress in the number of people living with HIV who know their status (90%) and the number of people living with HIV who are on HIV treatment (71%). More work is needed to increase the number of people living with HIV who have suppressed viral loads (61%), which puts Malawi at risk of not meeting the targets in the next 500 days.

The major obstacle to Malawi’s progress in meeting the targets, according to Mr Namarika, is people being left behind because of socioeconomic and structural disparities driven by power relationships, such as poverty, unemployment and gender inequality. He also believes that a location–population approach is needed to address vulnerabilities exacerbated by migration and natural disasters, such as the drought–flood cycle experienced by people located in the south-east of the country.

Another challenge in the national AIDS response is high new HIV infections among adolescent girls and young women between the ages of 15 and 24 years, who accounted for 9500 new infections in 2017—more than double that of their male counterparts (4000).

“Most young people cannot make ends meet. This puts girls most at risk—their rights can be easily trampled on by older men. Also, health-seeking behaviour among young men needs to be improved,” says Mr Namarika.

However, Mr Namarika believes that the biggest obstacle to progress in the AIDS response is complacency.

“When I was a young medical doctor on some days we would have 19 deaths just in the paediatric ward alone. Not in the whole hospital, just in that one ward. Now, the young doctors don’t see that anymore, so they don’t believe that HIV is real,” he says.

He believes that it is critical to continue to engage with communities on AIDS with the same urgency that there was in the early 2000s, so that the significant gains that the country has made are not lost.

“If the cost of AIDS is not regarded as one of the biggest historical disasters we have experienced in the 54 years of our independence, then we have lost our history,” he insists.

The way forward primarily is to continue financing the AIDS response and to put more emphasis on HIV prevention. This will require a growing domestic investment, as well as convincing development partners to put more external sources of funding into HIV prevention, he says.

Malawi has become the latest country to launch a health situation room, a software platform designed to help the government make informed decisions about policies and programmes related to health, including HIV.

The innovative tool bolsters national information systems through real-time visualization of information from multiple data sets. It will enable leaders and programme managers to improve health programmes to achieve the 90–90–90 targets, whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads by 2020.

Malawi is making good progress in its response to HIV. In 2017, 90% of people living with HIV in the country knew their status, 71% of people living with HIV had access to treatment and 61% of people living with HIV had a suppressed viral load. Around 1 million people are living with HIV in Malawi, with new HIV infections in 2017 down by 40% since 2010. However, HIV infections among young women and adolescent girls aged 15–24 years remain high and account for more than one in four new infections per year.

In his speech at the launch of the health situation room in the capital, Lilongwe, the President of Malawi, Arthur Peter Mutharika, said the tool was an important step forward.

“The health situation room is a demonstration of my government’s commitment towards accountability and transparency,” said Mr Mutharika. “My desire is that the health situation room will show us where to focus to improve even further in our quest for a healthier Malawi.”

The Executive Director of UNAIDS, Michel Sidibé, said the launch would strengthen the country’s health sector.

“The health situation room is an important innovation as it shares real-time data to improve the understanding of the country’s HIV epidemic and other health challenges,” said Mr Sidibé at the launch. “It will guide Malawi’s response and help officials to close the gaps, ensuring that no one is left behind as the country gets on track to end the AIDS epidemic by 2030.”

“The fact that something is hard to evaluate doesn’t make it impossible,” said Anna Downie, who leads on strategic information at Frontline AIDS. Reflecting on the challenge of evaluating advocacy, coalition-building, generating new partnerships and increasing the capacity of communities, she added, “To be successful, it is essential to allow space for innovation, to hear from communities about what is important to them and involve them from the outset so that you are looking for the same results and the evaluation is truly useful.”

Ms Downie was one of a number of experts who gathered in UNAIDS headquarters on 29 March in Geneva, Switzerland, for UNAIDS’ first consultation on evaluation. With the aim of informing the new UNAIDS evaluation policy, to be presented to the UNAIDS Programme Coordinating Board (PCB) meeting in June, the participants shared lessons they have learned while working on evaluation.

“Generating evaluations that are independent, credible and useful is the foundation of our work” said Susanne Frueh, the Chair of the United Nations Evaluation Group and Chair of the consultation.

The central role of countries in supporting a strong and independent evaluation function at UNAIDS was highlighted. The need for dedicated funding for evaluation, for the evaluation function to be independent and for transparency in the appointment of the head of the evaluation function were highlighted. The credibility and expertise of the staff of the office of evaluation, the establishment of an independent advisory committee and the need to protect the office from becoming politicized were also noted.

Michel Sidibé, UNAIDS Executive Director, highlighted the importance of the evaluation function. “We will not be able to transform or sustain our gains in the AIDS response if we don’t have clear learning from what we are doing. We will not be able to quicken the pace of action and help countries to scale up if we are not able to share our work and lessons learned,” he said.

The participants agreed that it is essential not only to ensure a strong gender and equity element in evaluations but also to measure what works and identify results in the areas of gender and human rights, which are cornerstones of the AIDS response. Triangulating data on human rights with civil society is a good way of ensuring that the evaluation provides a full picture. The importance of assessing the support provided by UNAIDS when major donors transition from countries was also highlighted.

In the medium to long term, the participants highlighted the need to build the capacity of young evaluators and to consider working with the growing number of evaluation companies from the global South.

The UNAIDS policy on evaluation is to receive a final round of comments from stakeholders soon. It will then undergo a peer review by the United Nations Evaluation Group before being presented to the UNAIDS PCB for endorsement. 

Thirty minutes before the workshop had even started, the meeting room was full. A murmur of voices echoed around the room as the participants took a last look at the data that would be used in the next round of HIV estimate modelling. It was important to get this right—the results of the workshop would eventually influence the allocation of billions of United States dollars-worth of investments in the AIDS response.

More than 100 people from 11 countries in eastern and southern Africa, supported by nine organizations, had come together in Johannesburg, South Africa, to analyse the trends and burden of the HIV epidemic in their countries. The UNAIDS workshop was one of 11 held worldwide between 28 January and 30 March 2019 during which 140 country teams—including epidemiologists, HIV programme managers and monitoring and evaluation experts—learned about the latest updates to the software used to estimate the number of people living with HIV, new HIV infections and AIDS-related deaths.

Over the course of the workshops, the teams produced new estimates on the HIV epidemics in their countries from 1970 to 2018, refining estimates made in past years. Country programmes and donor responses are based on the latest and most accurate data. Such data are used to set targets, identify hotspots, revise national programmes and decide the course of the AIDS response.

Before they arrive at the workshop, the country teams collect programme and surveillance data from their health information systems. At the workshop, those data are entered into Spectrum—a sophisticated UNAIDS-supported computer software package used to compile and analyse data on the HIV epidemic—to produce country HIV estimates.

Those countries that have good facility-level data use that information, together with data on road networks, population densities and other variables, to calculate the number of people living with HIV by district—information that is crucially important for a location–population approach to the AIDS response. Those district estimates are further broken down into different age groups and by sex.

Countries that receive funds from the United States of America import their estimates into a spreadsheet known as the Data Pack, which is used in the process to determine the level of financial support a country will receive.

One country whose AIDS response is supported by the United States is Lesotho. Assigned to support the country team members during the Johannesburg meeting was John Stover, the lead developer of Spectrum, who has an exceptional ability to explain complex concepts and find rigorous solutions even where few data exist.

The Lesotho country team members were eager to develop a comprehensive plan as part of Lesotho’s bid for additional funding, but they were concerned about the new estimates of child HIV infections, which were higher than their previous estimates. Mr Stover worked with the team over the course of the week to walk them through each of the assumptions made in the models, explaining how the model matched the data available from the country and the recent Lesotho Population-Based HIV Impact Assessment (LEPHIA) results and what caused the change in the estimates. A new tool has been included in Spectrum that shows where the new child infections came from and how to strengthen the prevention of mother-to-child HIV transmission programme to reduce the number of new child HIV infections in the future. When they left the workshop, the team had the capacity to explain the new estimates to policy-makers in Lesotho and beyond and to propose how to lower those new HIV infections in the future.

Additional workshops that trained more than 500 people on the Spectrum software have been held around the world, including in: Bangkok, Thailand; Panama City, Panama; Marrakesh, Morocco; Dakar, Senegal; Stockholm, Sweden; and Port of Spain, Trinidad and Tobago. The workshops were supported by facilitators from 14 organizations.

The estimates produced in the workshops will be reviewed by staff at UNAIDS over the coming month for quality assurance, before being signed off by ministers of health and published by UNAIDS at aidsinfo.unaids.org and in a UNAIDS report in mid-2019.