UNAIDS and the Global Health Workforce Alliance are launching an Agenda for Zero Discrimination in Health Care. The agenda supports a vision for a world where everyone, everywhere, enjoys health services without discrimination and where the health workforce is empowered to provide discrimination-free services to all.

Many people around the world face barriers to accessing quality health-care services and realizing the highest attainable standard of health. The multiple reasons for this vary across countries and communities. Even where health-care services are available and of good quality, people often experience or fear stigma and discrimination, which prevent them from accessing the health services they need and are entitled to receive.

A new report by Asia Catalyst produced in collaboration with eight community-based organizations in Cambodia, China, Myanmar and Viet Nam has documented discriminatory practices in health-care settings specifically against people living with HIV. Findings include experiences of involuntary HIV testing, involuntary disclosure of status, segregation, arbitrary additional expenses imposed due to HIV status and medical advice against pregnancy and for sterilization on the sole basis of HIV status.

The agenda offers a space for collaboration between countries, the World Health Organization, UNAIDS, other United Nations and intergovernmental organizations, professional health-care associations, civil society, academics and others to take coordinated action for achieving zero discrimination in health care.

The agenda will prioritize coherent joint actions in three critical areas:

• Political support: by increasing political commitment through mobilization of all key constituencies, to secure prioritization of this agenda at all levels.
• Implementation: by fostering scale-up of implementation of effective actions to achieve discrimination-free health care.
• Accountability: by promoting monitoring and evaluation frameworks and mechanisms to build evidence, monitor progress and ensure accountability.

The action plan outlines seven priorities; these include: building and sharing evidence and best practices; standard-setting; ensuring meaningful engagement of the people most affected by discrimination in the development, implementation and monitoring of policies and programmes; and strengthening the leadership of professional health-care associations.

A virtual community of practice has been created to mobilize more partners around the shared vision and action plan, to join contact ghwa@who.int. 

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Transgender people often face violence, unemployment and poverty, owing to ignorance and prejudice. Such stigma and discrimination places transgender women at a higher risk of HIV infection.

All people are equal and no one should be discriminated for any reason. “In our country it will take a lot to make this affirmation a reality,” the Peru’s Ombudsman Eduardo Vega Luna said in response to the situation. However, he called for “more awareness campaigns that encourage citizens to look at the future with hope and without violence and discrimination.”

One such activity was recently organized by United Nations organizations in Peru, including UNAIDS, UNDP, OHCHR and United Nations Information Centre, and civil society organizations, like PROMSEX, IESSDEH, Center for Interdisciplinary Studies in Sexuality, AIDS and Society of the Cayetano Heredia University, transgender people, the Magnum Foundation and the European Union. An exhibition, “Yo tengo derechos”, meaning “I have rights”, presented photographs taken by Danielle Villasana, an award-winning photojournalist whose work focuses on gender, identity, health and social politics. A recent graduate of the University of Texas, Austin, she has worked with transgender communities since 2012.

The photographs in the exhibition—part of the United Nations Free and Equal campaign, which advocates for lesbian, gay, bisexual and transgender equality—showed transgender people with their colleagues and family members in their daily lives as students, artists, professionals and activists. In their testimonies for the exhibition, transgender people spoke about happiness, love and how they cope with daily struggles.

María del Carmen Sacasa, United Nations Resident Coordinator in Peru, said, “For us, the main human rights theme is non-discrimination. It’s not a minor issue, particularly when it comes to transgender people, who are rejected in many fields.”

The exhibition reminded people of one of the main human rights principles: discrimination is unacceptable. 

Isah Mohammed Takuma is married and has a one-year-old daughter. At 32, he is a university graduate and currently serves as the National Coordinator of the Association of Positive Youths Living with HIV/AIDS in Nigeria.

He says he draws daily inspiration from his personal experience to support HIV prevention efforts in Nigeria. “I was 19 when I first had sex. I thought one time was not enough to get infected with HIV,” he said.

Even when he started to fall sick, he simply could not believe that HIV was the cause of his health troubles. He was 23 when he tested HIV-positive and his life changed forever.

“It was a nightmare and I had to go through hurdles to recover. My CD4 count was low; my viral load was high. I was like a walking corpse,” Mr Takuma recalled.

Antiretroviral treatment soon put him back in good health. He returned to university and completed his studies much later than planned, but he was happy to be alive and healthy again.

At university, he started a support group for young people living with HIV. He told his story to peers as a way to prevent new HIV infections. “Many other people in my class got to know their HIV status because of my efforts, and I am really proud about that,” Mr Takuma said.

The Nigerian Government reports that more than 6.7 million people were tested for HIV in 2014 and that it continues its efforts to expand treatment, with coverage at 22% in 2014. The global treatment target set for 2020 is that 90% of people living with HIV are on life-saving antiretroviral therapy.

Despite the challenges that people living with HIV face in the country, Mr Takuma said the fact that he and his wife have an HIV-free child “tells the story of what Nigeria’s HIV response has done in the lives of many young people like me.”

Nigeria has the second largest HIV epidemic in the world. In 2014, 3.4 million people were living with HIV in the country, of which 380 000 were children below the age of 14. HIV prevalence among young women between the ages of 15 and 24 was 1.3% in 2014, almost twice as high as it was for their male counterparts.

Like Mr Takuma, Faith, 16, is passionate about advocating for HIV prevention among young people.

The soft-spoken and cheerful student was born with HIV but only got to know her status at the age of 10. However, she started on antiretroviral treatment when she fell ill two years ago.

She is now healthy and advocates for treatment for all. “I have even been on radio to speak about HIV,” she said. “We want adolescents and youth to understand that it is possible to have a normal life without any stress.”

“We also want to take part in international engagements to share our stories and be an inspiration to other girls and young people,” she said.

Faith views her involvement with the Association of Positive Youths Living with HIV in Nigeria as vital to ensuring that women and girls enjoy healthy and productive lives.

She aspires to graduate as a nurse to help save lives in Nigeria.

UNAIDS and the One Million Community Health Workers (1mCHW) initiative have announced a major strategic partnership to support the achievement of the 90–90–90 treatment target and to lay the foundation for sustainable health and development.

The new partnership emerged at a high-level meeting of eight African health ministers and other stakeholders in Addis Ababa, Ethiopia, held on 1 February, which focused on the 90–90–90 treatment target and human resources for health. The participants of the meeting called for the world to leverage the aim of achieving the 90–90–90 treatment target to strengthen human resources for health.

In his opening address, Marc Angel, UNAIDS champion for the 90-90-90 treatment target, told participants that increased human resources for health would be essential.     

“Achieving the 90-90-90 target requires health workers, specific expertise and laboratories equipped with the necessary materials,” said Mr Angel.

Jeffrey Sachs, director of the Earth Institute at New York’s Columbia University and founder of the 1mCHW initiative, emphasized his commitment to the 90–90–90 treatment target. As the United Nations Secretary-General’s Special Adviser on the Sustainable Development Goals (SDGs), Mr Sachs pledged to place 90–90–90 at the centre of advocacy for the SDGs.

“The 90–90–90 effort of UNAIDS is historic: a rigorous, scientific and bold approach to end the AIDS epidemic,” Mr Sachs said. “The end of AIDS is within reach, and community health workers will play a pivotal role in empowering communities to end deaths from AIDS and to break the transmission of the virus. The 1 Million Community Health Worker campaign is honoured to join UNAIDS in its path-breaking programme.”

Cosponsored by UNAIDS, the African Union and Ethiopia’s Ministry of Health, the meeting revealed both strong support for the 90–90–90 treatment target and agreement that it offers a unique opportunity to recruit and mobilize hundreds of thousands of community health workers.

“Ethiopia will spare no efforts to reach the 90–90–90 treatment target,” said Kesetebirhan Admasu, Ethiopia’s Minister of Health. “We are determined to relegate AIDS to the books of history.”

To reach the 90–90–90 treatment target, the number of people accessing antiretroviral therapy will need roughly to double over the next five years. While HIV programmes have pioneered innovative strategies to enhance the efficiency of service delivery, it is clear that reaching the target will require expanding the number of health workers available to deliver HIV services.

However, many African countries, as well as countries in other regions, have an acute shortage of health workers. Although Africa accounts for 25% of the global health burden, the region is home to only 3% of all health workers.

To ease health worker shortages, the meeting focused on the importance of training and employing trained, provisioned, supervised and remunerated community health workers to expand access to HIV services. “We must reinforce the interface between communities and the service provider,” said UNAIDS Executive Director Michel Sidibé. “We need to use communities and civil society organizations to reach people who are difficult to reach.”

The 1mCHW campaign unites more than 150 organizations worldwide in a major global effort to recruit and deploy trained, equipped, supervised and remunerated community health workers, with particular attention to especially underserved rural communities.

Countries such as Ethiopia, Ghana and Malawi have already taken major steps to train and deploy community health workers to deliver community-based health services. Ethiopia, for example, has trained tens of thousands of health extension workers, who have substantially increased access to good-quality health services. Creation of the community health worker programme in Ethiopia has been associated with a 19-year increase in life expectancy over two decades. Ghana is in the process of deploying 20 000 community health workers in a national scale-up effort. 

Other countries are moving to emulate these successful national efforts to expand human resources for health. Lesotho, for example, is embarking on a national effort to create a cadre of health extension workers, with mentoring provided by Ethiopia and Malawi.

Much of the discussion during the one-day meeting focused on how the push to achieve the 90–90–90 treatment target can help drive a sustainable expansion of human resources for health. The global effort to achieve the 90–90–90 treatment target will involve the delivery of simplified, decentralized care to millions of healthy people living with HIV. Self-care, including through such innovations as peer-driven adherence clubs and community distribution of antiretroviral therapy, will play a vital role in the delivery of HIV chronic care management.

Community health workers will be essential for providing these simplified, decentralized services. The Fast-Track approach calls for a sharp increase in financing for community service delivery and an increase in the proportion of HIV services that are delivered through community channels from 5% currently to 30%.

The same community-centred models that will be critical for ending the AIDS epidemic as a public health threat also have a potentially key role to play in addressing the other health targets in the SDGs. Community health workers mobilized through the push to achieve the 90–90–90 treatment target can also help in the delivery of other important health services. Similarly, the chronic care models generated by HIV treatment scale-up are applicable to the management of the growing burden of noncommunicable diseases, such as hypertension and diabetes.

Although the road map for action is clear on 90–90–90 and the health workforce, financing remains a potential obstacle, as investments will be needed for training, supervision and compensation for community workers. There was agreement among health ministers and other participants that mobilizing the necessary investments for expanding the health workforce will require both increased domestic outlays and further increases in international assistance. Mr Sachs called for the creation of a fund for strengthening health systems.

“Here in Africa, we must commit our own domestic resources for health,” said Olawale Maiyegun, Director of Social Affairs for the African Union Commission. “We must live up to our commitments in the Abuja Declaration to dedicate at least 15% of our domestic budget to health.”

“Health is not a cost,” Mr Sidibé said. “Health is not expenditure. Health is an investment. If we scale up, we can bring the epidemic to an end. Yet if we don’t come up with the resources we need, AIDS will rebound, and all our investments in the last 30 years will be lost.”

In planning the meeting, the cosponsors worked with the World Health Organization, the African Society for Laboratory Medicine, the International Association of Providers of AIDS Care, the International Federation of Red Cross and Red Crescent Societies, the Office of the United States Global AIDS Coordinator, Columbia University, the Sustainable Development Solutions Network, the One Million Community Health Workers campaign and the Government of Luxembourg.

The Middle East and North Africa region is facing political and humanitarian crises that have destabilized the region and have had an impact on social and economic development in the most affected countries. However, despite setbacks in certain areas, health continues to be a priority. Algeria stands out as one of the countries in the region with the most advanced health responses, particularly to the AIDS epidemic.

During a visit to Algeria from 12 to 14 January, UNAIDS Executive Director Michel Sidibé commended governments in the region for recently adopting the Algiers Declaration, an important tool for ending the AIDS epidemic in the Middle East and North Africa. One of the key components of the declaration calls for scaling up HIV testing and treatment services in the Middle East and North Africa, especially among vulnerable populations, mainly injecting drug users, men who have sex with men and sex workers. Currently, testing and treatment coverage are low in the region.

Speaking at the Institute of Diplomacy and International Relations, Mr Sidibé said, “If in the next five years 90% of people living with HIV know their status, the region will certainly manage to enable 90% of people who know their HIV-positive status to access life-saving treatment by 2020.” In his keynote speech, Mr Sidibé also recognized Algeria’s role in accelerating the AIDS response in the country and championing the Algiers Declaration in the region.

Algeria has recently introduced HIV testing at all health-care facilities and has adopted a law criminalizing all forms of violence against women. In addition, the country has significantly increased antiretroviral therapy coverage, mostly relying on domestic funds.

During his mission, Mr Sidibé visited the Institut Pasteur in Algeria and the National Laboratory for the Control of Pharmaceutical Products, part of the Algiers Centre of Excellence for Research on Health and HIV/AIDS.

“The Institut Pasteur is a centre with a continental potential for research, diagnostics, training and medicine production,” said Mr Sidibé. He added that it is time for Africa to produce its medicines and develop its technological and scientific infrastructure.

During the visit, Mr Sidibé met with the Minister of Health, Abdelmalek Boudiaf, and spoke about the strong and productive partnership between the Government of Algeria and UNAIDS. Mr Sidibé congratulated Algeria for its people-centred approach to health and its commitment to ending the AIDS epidemic. “Universal access to health care is in the Algerian constitution,” Mr Boudiaf said.

Israel is an indigenous community leader living in Veracruz, Panama City. He was diagnosed with HIV 7 years ago, when he was 24. At that time, Israel had no knowledge of HIV. “I thought I would die soon after and I wouldn't see my children grow up,” he said.

Israel looked for support and started to get involved with local civil society organizations advocating for improved sexual and reproductive health for young people and promoting the human rights of key populations. He became an active member of Genesis+ Panama, bringing to the organization the voice of indigenous people.

“Indigenous youth continue to encounter significant barriers in accessing comprehensive sexuality education and services in our language and according to our own practices and model of well-being,” Israel said. “This is a missed opportunity, since our communities can contribute to the HIV response and the development of our society.”

HIV among indigenous populations is an emerging public health concern, as data show that indigenous people are particularly vulnerable to HIV. The government reports that indigenous people have little knowledge of how HIV is transmitted, negative attitudes towards people living with HIV and low HIV testing rates. Reporting on indigenous people’s rights, the Economic Commission for Latin America and the Caribbean found that more indigenous girls initiate sexual activity before the age of 15 than their non-indigenous peers. The rate of teenage pregnancies is more than twice as high for indigenous girls. Another matter of concern is that violence against women, which has links to HIV infection, is prevalent among indigenous populations in Panama. 

Israel works hard to change the situation in his community. He organizes meetings with indigenous young people and teenagers, either at a home or the beach, to discuss health and other important topics. “I want to give my children and other young people access to information and tools to prevent HIV,” he said.

Israel also coordinates a football team of young indigenous women. Each weekend the team participates in local leagues. Before the games start, Israel and the other coaches provide the players with training related to HIV prevention. He said, “There are many young people at risk in my community and I feel that by leveraging the power of football we are creating opportunities to improve their well-being and strengthen social capital.”

Israel also dedicates his time to raising awareness about respect and solidarity towards key populations and people living with HIV. “In indigenous communities, myths still persist around HIV,” he said. “The fear of being excluded or rejected prevents people from taking an HIV test or going to health facilities.”

Reflecting on what he has learned since his diagnosis, Israel said, “HIV has not limited me. It opened my eyes to social justice and motivated me to become the person I am today.”

Japan hosted the Fifth Replenishment Preparatory Meeting of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) on 16 and 17 December, which laid the groundwork for a pledging conference in mid-2016 at which donors will finalize the Global Fund’s next three-year funding cycle.

The participants included Japan’s Foreign Minister, Fumio Kishida, health ministers from several countries, Margaret Chan, the Director-General of the World Health Organization, Bill Gates, co-chair of the Bill & Melinda Gates Foundation, and Luiz Loures, Deputy Executive Director of UNAIDS.   

”We have an unprecedented opportunity in the next five years to break the AIDS epidemic,” said Mr Loures. “If we scale up care, treatment and prevention services and create an environment where people have full access to them we will be on course to end the AIDS epidemic by 2030.”

On the eve of the meeting, Japan also organized a conference on universal health coverage in order to evaluate the financial systems and funding required by countries to promote access to affordable health care and medicine. Universal health coverage is key to ending the epidemics of HIV, tuberculosis and malaria, which are fuelled by poverty, stigma and discrimination.

Japan has been one of the leading investors in the AIDS response, supporting programmes focused on key populations across Asia and investing in projects such as the Kenya HIV Situation Room, which is using cutting-edge technology to provide high-quality data about that country’s epidemic.

While he was in Japan, Mr Loures also visited PLACE Tokyo, which provides community-based services related to HIV and sexual health, including consultation services for people living with HIV.

“The role of communities remains as critical as ever in addressing the realities, needs and challenges of people living with HIV in Japan,” said Mr Loures. “I congratulate PLACE Tokyo for the work they are doing to support people living with HIV, their partners and family members.”

The Deputy Executive Director of UNAIDS, Luiz Loures, joined a high-level panel in the opening plenary of the 46th Union World Conference on Lung Health to discuss the global challenges faced in ending the linked epidemics of HIV and tuberculosis (TB) as part of the Sustainable Development Goals.

The five-day conference is being held in Cape Town, South Africa, from 2 to 6 December 2015. South Africa has the highest rate of HIV-related TB in the world, with more than 60% of people living with TB in South Africa also living with HIV.  

Mr Loures stressed the need to engage and support the people and communities most affected by TB and HIV. “A people-centred, rights-based approach is essential to address HIV and TB,” said Mr Loures. “The power of change only comes when it is nurtured in the people themselves, through empowerment, outreach and inclusion.”

Constance Manwa, a survivor of multidrug resistant TB, community activist and mother living with HIV said, “Getting the community involved helps a lot. I was a patient but also gave lectures to the other patients in the community. It is important to get the message out to get tested early. People listen more to a person who has the same experience.”

Communities help in tailoring prevention and treatment services to meet the needs of people living with TB and can reach the people who are being left behind. They can also help in providing support for people living with HIV and TB to stay in care and on treatment.

Progress has been made. Since 1990, TB deaths have declined by almost 50%. However, TB is still the leading cause of death in South Africa and a leading cause of death globally. In 2014, more than one million people around the world died of TB. 

“We must stop talking about problems and start talking about solutions,” said Mark Dybul, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. ‘We need new drugs, we need new diagnostics, we can definitely eliminate tuberculosis.”

If the Fast-Track approach to end the AIDS epidemic is to be successful, the rights, roles and responsibilities of men in the AIDS response need to be placed firmly on the global agenda.

It has long been noted that the Fast-Track Strategy cannot be achieved without action on gender equality and human rights. The vulnerability of young women and girls has been an important focus of many programmes and has been debated many times, but more recognition is needed that harmful norms also drive the epidemic among men. Health systems are falling short of addressing the needs of men, which is having a negative impact on the health of both men and women.

“Men play a critical role. When we engage men for their own health and to change harmful gender norms, we improve both men’s and women’s health. This is an essential element of the UNAIDS Fast-Track approach to ending the AIDS epidemic,” said Michel Sidibé, UNAIDS Executive Director.

Reaching men with HIV-related prevention, treatment, care and support services is vital. Men and adolescent boys make up nearly 49% of the global population of 34.3 million adults living with HIV and account for 52% of all new adult HIV infections. Around 60% of the 1.2 million people who died of AIDS-related illness in 2014 were male.

According to UNAIDS, there is a lack of services for men who are at higher risk of HIV infection. Diversity among men, including age, risk behaviour and sexual orientation, needs to be taken into account when planning programmes.

Women under the age of 25 are often vulnerable to HIV, and gender inequality and the structures of society often prevent them from accessing the HIV information and services that can protect them. Men, on the other hand, are affected later in life and are more empowered to access services, but, for many reasons, they don’t.

Men’s access to HIV services is important for their own health but it is also an important way to reduce vulnerability among women. Engaging men in health services for their own health can also provide an entry point for programmes that can also transform harmful gender norms.

UNAIDS calls for more work to be done to explore exactly how harmful gender norms and notions of masculinity may increase men’s vulnerability. For example, stereotypes of male “strength” and invincibility can lead to men not using condoms and avoiding health services, such as HIV testing. It has been shown by research in 12 low- and middle-income countries that men with less equitable attitudes to women are less likely to be tested for HIV.

In addition, studies have reported that men are more likely not to seek out—and stick to—antiretroviral therapy.

UNAIDS contends that health professionals themselves often assume that men do not need, or are not willing to use, HIV-related services. There is a need for such preconceptions to change, with the development of comprehensive policies and programmes that promote men’s access to programmes and address their specific needs. This means changing the perceptions of men in the response to HIV, as they are often referred to as “transmitters” or “vectors”, stereotypes that blame them for infection, stigmatize them and isolate them further from accessing services.

There is a call for a global shift in the discussion on HIV and gender—that it should become more inclusive of men and encourage their greater positive engagement in all aspects of the AIDS response and in advancing gender equality. Sexual and reproductive health is not the responsibility of women alone. Focused, integrated sexual and reproductive health services must be made available to men and adolescent boys. Although much more research needs to be done, there is already a body of data that lays the groundwork for developing and implementing more comprehensive policies and programmes.

To reflect the seriousness of this issue and the need to chart the way forward, a global high-level meeting on men, adolescent boys and AIDS is being held in Geneva on 10 and 11 December. It is co-convened by UNAIDS, Sonke Gender Justice and the International Planned Parenthood Federation. The main objectives are, broadly, to build consensus on what the evidence is saying about men and adolescent boys in the HIV response and what role they have to play in ending the AIDS epidemic.