The recent scale-up of the number of people living with HIV accessing antiretroviral therapy can be linked to the increased availability of generic antiretroviral medicines. Given that people living with HIV will need life-long access to such medicines, there is a need to scale up the research and development, production and distribution of generic antiretroviral medicines that are both effective and affordable.

A new journal supplement explores the production of antiretroviral medicines in resource-limited countries and their delivery to people living with HIV and how production and delivery can be made more effective and efficient. The publication also explores the lessons for the production and delivery of a broader set of drugs in low- and middle-income countries. Consisting of a compilation of 13 articles, Ensuring access to generic antiretroviral drugs in low- and middle-income countries is the result of a collaboration between UNAIDS and the journal Antiviral Therapy.

The task of ensuring that medicines and other health technologies are reliably and sustainably manufactured and are available to people in resource-limited countries is complex. According to the articles, the global community needs to focus on three key pillars that will help to ensure access to medicines: political vision and commitment; partnerships; and sharing of knowledge and technologies.

“The political commitment and partnerships exist and we have the tools and science to advance this agenda,” said UNAIDS Executive Director Michel Sidibé. “To meet this challenge, all partners must come together to cultivate a strong vision, backed up by an actionable plan, political leadership and sufficient and sustainable resources,” he added.

The authors of the supplement recognize that manufacturing and distributing medicines occurs within regulated free-market economic systems and that there is a need to deal with increasingly multifaceted patent issues, which affect price but ensure quality.

The authors conclude that as life expectancy grows, as countries develop and as the health needs of populations worldwide increase, the global community needs to ensure access to medicines for all. The AIDS response has often been at the forefront of the development agenda, and again must lead the way.

A delegation of the UNAIDS Programme Coordinating Board (PCB) conducted a field visit to Indonesia from 22 to 24 October to see how the country has implemented an integrated and decentralized response to AIDS that has accelerated the strategic use of HIV treatment, increased testing and counselling and strengthened HIV prevention services for key populations.

Indonesia demonstrates how a multisectoral approach to HIV, combined with consistent leadership at all levels, is helping the country to stabilize the epidemic, accelerate treatment and provide innovative and comprehensive HIV services. The country’s AIDS response is guided by an investment strategy, developed with support from UNAIDS, which focuses resources and efforts where they are most needed.

“Indonesia’s response shows that cross-sectoral engagement and leadership—including impressive and vibrant civil society involvement—is critical for turning strategies into action,” said UNAIDS Deputy Executive Director Jan Beagle, who was leading the visit. “As we look towards ending the AIDS epidemic by 2030, continued commitment at all levels will be key to effective impact—for AIDS and the broader health and development agenda.” 

According to national estimates, 638 000 people are living with HIV across Indonesia, and latest national data show that new infections are stabilizing, although there are increases among men who have sex with men. Indonesia’s epidemic is largely concentrated among key populations, including sex workers and their clients, men who have sex with men, people who inject drugs and transgender people. While national HIV prevalence is low, a higher burden of HIV is found among key populations and in certain geographic areas, such as urban settings and in the Papua provinces.

The delegation, which included members from Australia, Brazil, El Salvador, Iran (Islamic Republic of), Luxembourg, Ukraine and Zimbabwe, as well as the PCB NGO delegation and UNAIDS Cosponsors, met with a range of national partners, including senior government representatives at the national, provincial and city levels, the National AIDS Commission, development partners, civil society organizations and the United Nations Country Team. The delegation also visited several sites to see examples of scaling up access to HIV testing and treatment and ways of addressing stigma and discrimination.

During a meeting with the PCB delegation, the Acting Governor of Jakarta, Basuki Tjahaja Purnama, highlighted the city government’s response to HIV in the capital. The Acting Governor underscored the significant investments that the local government has made to HIV programmes, including increasing access to HIV treatment, and expressed his commitment to prioritize health, education, employment and housing for people living with HIV, ensuring that no one is left behind.

Over the past years, Indonesia has increased its domestic financing to 42% of its total spending on AIDS. Throughout the visit, political commitment to further increase domestic funding was emphasized at all levels. However, government officials also stressed that international financing remains critical to scaling up the response, in particular for accelerating access to HIV treatment.

Community-friendly services key to a sustainable response

At a gathering of civil society groups, including networks of people living with and most affected by HIV, the delegation was presented with an overview of how youth organizations are mobilizing young Indonesians, as part of the ACT 2015 initiative, to ensure that HIV and sexual and reproductive health and rights remain a priority for the country’s new government and in the next development era.

Site visits to a number of public and private HIV service-providing institutions in Jakarta and Denpasar showcased how community-friendly and community-led services are improving uptake of services and reducing stigma and discrimination. Examples included the country’s main HIV treatment referral hospital in Jakarta, which runs programmes to sensitize staff on the specific needs of key populations at higher risk, and the Yayasan Kertipraja Foundation and the Bali Medika Clinic in Denpasar, where a number of programmes are led by key populations and provide easy-to-access services after work hours and on Saturdays. As well as increasing demand among key populations, such programmes have also led to early uptake of HIV treatment. The National AIDS Commission, with support from UNAIDS, is looking at how to further replicate and scale up such models across the country.

Civil society, public and private organizations and UNAIDS are leveraging advances in mobile technology to empower communities. Together they have produced a new mobile application called iMonitor+, which enables users to access HIV prevention and treatment services and provide feedback on the quality of such services.

The Deputy Governor of Bangkok, Pusadee Tamthai, the UNAIDS Executive Director, Michel Sidibé, the Public Campaign Officer of the Indonesian AIDS Coalition, Ayu Oktariani, and the Director of Service Workers in Group Foundation (SWING), Surang Janyam, launched iMonitor+ on 27 October in Bangkok, Thailand.

“This is a data revolution: real-time, mobile health information systems. iMonitor+ is not just a gadget, but a tool for social transformation. It will empower people to demand services and foster public accountability,” said Mr Sidibé.

iMonitor+ uses global positioning satellite technology to locate a user, who can then receive information on where to access condoms, HIV testing, counselling and treatment and other key services. If there are stock-outs of antiretroviral medicine and other HIV commodities, the user can send alerts to a central dashboard and be directed in real time to other services nearby.  Users can also report any experience of stigma or violation of their rights in HIV service and other delivery settings to the dashboard. Public health authorities and community partners are working together to resolve as quickly as possible issues raised by the alerts.

“iMonitor+ has great potential as an important early warning tool, which can notify public health authorities of gaps in key services,” said the Deputy Governor of Bangkok. “By working with civil society to develop iMonitor+ we have opened up an important channel for dialogue and strengthened key partnerships for social transformation.” 

Since early June more than 100 volunteers from five community networks in Thailand, Indonesia, India and the Philippines have been pilot testing iMonitor+ to provide feedback and adapt the application to each network’s specific needs. In Thailand, the Bangkok Metropolitan Administration has partnered with SWING to test and fine-tune the application.

“iMonitor+ is an effective platform with which to work with public health authorities,” said the Director of SWING. “It is providing us with an opportunity to directly influence the way the services are delivered to communities.”

The Indonesian AIDS Coalition has been running a trial with iMonitor+ in four cities, including Jakarta. Ayu Oktariani said, “We are finding that health authorities are taking the real-time alerts we register with iMonitor+ seriously and that they move much more rapidly than before to close service delivery gaps.”

The feedback from communities and service providers will ensure continuous innovation and adaptability of the app. This participatory monitoring tool is not only an important community tool for quality assurance and responsiveness of HIV services, but can give people the power to monitor services in many areas aside from public health and serve as an instrument for improved public accountability.

Thailand remains committed to working with other partners to end the AIDS epidemic in the region. Speaking to UNAIDS Executive Director Michel Sidibé on 27 October in Bangkok, Thailand, Prime Minister Prayut Chan-o-cha emphasized that Thailand will maintain its efforts in the HIV response and will share its experience with neighbouring countries and the world. He also stressed that Thailand’s commitment to the three zeroes—zero new HIV-infections, zero discrimination and zero AIDS-related deaths—is absolutely unwavering.

Through its innovative Ending AIDS by 2030 strategy, on 1 October the country became the first in Asia to offer life-saving treatment to everyone living with HIV. Documented and undocumented migrants can access a similar package of services. The Prime Minister said that globalization and migrant labour is a reality and there is a need to ensure that no one is left behind.

Mr Sidibé congratulated the Prime Minister for Thailand’s innovation and remarkable progress in placing people at the centre of the AIDS response. “Thailand showed that with commitment and vision it is possible to reach the three zeroes,” said Mr Sidibé. “We see Thailand as a strong transformative force for social justice in the AIDS response.”

Mr Sidibé is on a two-day trip to the country, during which he is meeting government leaders and key civil society organizations.

In 2013, Thailand estimates that almost 460 000 people were living with HIV, which is a 33% reduction since 2000. There were 8256 new HIV infections in 2013, which was a reduction of 71% from 2000, and nearly 21 000 people died of AIDS-related causes, which was a decrease of 62% since 2000. 

Myanmar’s Minister for Health, Than Aung, confirmed during a meeting with the United Nations Secretary-General’s Special Envoy for AIDS in Asia and the Pacific, J.V.R. Prasada Rao, that domestic funding for HIV treatment will be increased by US$ 5 million. Mr Rao completed a five-day visit to Myanmar on 17 October, in which he focused on supporting the country’s efforts to rapidly and effectively scale up its AIDS programme.

There were 190 000 people living with HIV and 6700 new HIV infections in Myanmar in 2013. More than 65 000 people were receiving HIV treatment in 2013 and the Ministry of Health estimates the new funding will enable 40 000 additional people living with HIV to access antiretroviral medicine and will increase the national HIV treatment target coverage to 85%. The Minister of Health has asked his staff to work with UNAIDS to determine the cost of reaching 100% coverage.

Mr Rao welcomed Myanmar’s commitment to the HIV response and said, “The government is showing remarkable leadership in its national AIDS response and I ask the country’s leaders to extend strong support to the goal of ending AIDS by 2030. This goal must be a part of the sustainable development goals on health, which countries will adopt in 2015.”

The Minister of Health also pledged an additional US$ 1 million to further scale up opioid substitution therapy for 10 000 people by the end of 2016. Studies show that harm reduction programmes such as needle–syringe exchange programmes and opioid substitution therapy are effective in reducing the spread of HIV.

In Myanmar, key populations, including people who inject drugs, sex workers, men who have sex with men and transgender people, are at higher risk of HIV infection. Mr Rao urged the government to amend policies that violate the human rights of key populations and praised the country’s draft intellectual property law, which will help protect access to affordable medicines.

During his mission Mr Rao met other top officials, including the Attorney General, Tun Shin, the Deputy Minister for Home Affairs, Kyaw Kyaw Htun, and the Deputy Minister of Foreign Affairs, Thant Kyaw. He also met with Aung San Suu Kyi, Chairperson of the National League for Democracy and Member of Parliament, who expressed her support for efforts to reform laws and policies.  

Mr Rao also met civil society representatives from key populations while participating in a panel discussion on the sustainable development goals and HIV. 

A new report on Tuberculosis (TB) released on 22 October by the World Health Organization shows that 9 million people developed TB in 2013, and 1.5 million died, including 360 000 people who were living with HIV.

The Global Tuberculosis Report 2014 highlights that while the number of TB deaths among people living with HIV has been falling for almost a decade—from 540 000 in 2004 to 360 000 in 2013—early case detection, antiretroviral treatment, preventive therapy and other key activities need to be further scaled-up.

According to WHO, one of the keys to reducing the number of deaths from HIV-associated TB is early case detection through the provision of HIV testing to all TB patients and routine TB screening among people attending HIV care. In 2013, 48% of TB patients had a recorded HIV test result and only half of those estimated to be co-infected with HIV-related TB were identified. Since 2012, WHO has recommended antiretroviral therapy (ART) for all TB patients testing positive for HIV within the first 8 weeks of initiation of TB treatment (and within 2 weeks of TB treatment for TB patients with profound immunosuppression). From 2012 to 2013, HIV treatment coverage among recorded TB patients rose encouragingly from 60% to 70% but this still represents less than a third of those estimated to be living with both TB and HIV.

Uptake of isoniazid preventive therapy (IPT)—which prevents people living with HIV from developing active TB—is rising slowly, the report finds. However, while the provision of IPT is increasing in Africa, only 21% of countries globally and 14 out of the 41 high burden TB/HIV countries reported provision of IPT to HIV positive people in 2013.

The implementation of collaborative TB/HIV activities has not evolved evenly across countries. The report stresses that further scale up of collaborative TB/HIV activities could be facilitated by joint TB and HIV programming, which would help to overcome constraints, promote synergies and achieve efficiency gains, especially between TB and HIV programmes.

WHO recommendations on the activities needed to prevent TB in HIV-positive people and to reduce the impact of HIV co-infection among HIV-positive TB patients have been available since 2004. These include establishing and strengthening coordination mechanisms for delivering integrated TB and HIV services; HIV testing for all patients with presumptive and diagnosed TB, providing antiretroviral therapy and co-trimoxazole preventive therapy to all HIV-positive TB patients, providing HIV prevention services for TB patients, intensifying TB case-finding among people living with HIV, offering IPT to people living with HIV who do not have active TB, and preventing the transmission of TB infection in health care and congregate settings.

The report concludes that despite encouraging progress, reaching the global target of halving deaths from HIV-associated TB is at risk, if countries don’t intensify the collaborative HIV/TB activities.

Anywur Mayan took her first HIV test two years ago. A health worker came to her house in rural Jonglei State and briefly explained that he was checking her for a virus. He pricked her finger and drew some blood. A few minutes later he told her the test had come back negative and left.

She did not really learn what HIV is or how it is spread until early June this year, after she had moved hundreds of miles from her Jonglei home to escape fighting there. Her new settlement Nimule—a border town near South Sudan’s border with Uganda—is safer, but has much higher HIV prevalence.

Behind there, there is nothing,” said Anywur, pointing in the direction of Jonglei. “Our houses, our belongings, they were all destroyed.

Fighting broke out in the South Sudanese capital, Juba, in mid-December and spread rapidly across nearly half the country. The United Nations Office for the Coordination of Humanitarian Affairs estimates that tens of thousands of people have been killed and more than 1.7 million have fled from their homes since December 2013—about 1.3 million displaced internally and 448 000 seeking refuge in neighbouring countries.

Raising awareness

Anywur, with her husband and infant son, set out in January for Nimule, where the HIV prevalence—estimated at 4.4%, according to the 2012 Antenatal Clinics Surveillance Report—is well above the national average of 2.6%.

In Anywur’s new home in Nimule a collection of local organizations has taken on the task of raising awareness about HIV. Anywur said she only found out what HIV is when a team of community educators gave a detailed presentation about the virus with the aid of information, education and communication materials created by the South Sudan AIDS Commission (SSAC) and UNAIDS.

Where we came from, this kind of education, it is not there,” she said.

But local activists and health workers said they still have thousands more people they need to reach and not enough resources to do it. At the same time, the new arrivals add a layer of complexity to the work they were already doing in the community.

HIV services

The highway connecting Juba to Uganda and the rest of eastern Africa cuts through Nimule, which hosts the country’s most active border crossing. Overloaded trucks rumble through the town at all hours, carrying fruits and vegetables, mattresses and anything else that can be sold in Juba’s markets.

Like many border towns, Nimule has its share of sex workers and their clients, especially long-distance truck drivers. The 2013 South Sudan Global AIDS Response Progress Report estimates that 62.5% of all new adult HIV infections in the country last year arose from sex work, the majority being clients of female sex workers.

Before the fighting broke out, Patrick Zema, Nimule Hospital’s HIV testing and counselling supervisor, said they were making significant progress in increasing awareness about the virus, reducing stigma and linking people to services. The hospital currently has 1 300 clients enrolled in antiretroviral therapy.

But now they are starting from the beginning with the displaced communities. “They come and they fear to test their blood,” said Pascalina Idreangwa Enerko, the chairperson of the local Cece Support Group of People Living with HIV, who attributes this behaviour to a combination of a lack of knowledge about the virus and stigma that comes with an HIV-positive diagnosis. “Thanks to the health education provided, they come out. It is important that they know their status.

Since April, Cece has teamed up with two community-based organizations—Humans Must Access Essentials (HUMAES) and Caritas Torit—to do near-daily mobile awareness-raising campaigns within the far-flung displaced community.

The community mobilizers begin with an hour-long presentation on HIV awareness and prevention. Then they encourage people to visit different stations, including one for paediatric consultations, a free drug dispensary and an HIV testing centre.

Reena’e Awuor Ondiek, Caritas Torit’s HIV counsellor, said her table was not popular when they first started in February, but she has noticed a change in people’s attitudes as she has made repeated visits to the same communities.

The programme has also helped address one of the other major challenges created by the crisis. “The conflict moved people from one place to another and interrupted follow up,” said Habib Daffalla Awongo, SSAC’s director general for programme coordination. “Some patients have been lost within host populations.” During their community visits, a Caritas team has already located people who stopped treatment as they fled the fighting and restarted them on antiretroviral therapy.

The team is still facing challenges, the most critical being a shortage of money. They are unable to hire the vehicles they need to reach thousands of displaced people who are camping outside of Nimule and who have almost no access to HIV services.

But Ondiek said there is no shortage of people like Anywur who need their services in the communities they can reach.

Among the cattle, helicopters and bands, the 88th Agricultural and Commercial Show of Zambia lived up to its 2014 theme: “Breaking new ground”—with a lively HIV prevention exhibit.

The trade show served as the stage for UNAIDS and its partners to reach young people with information and services aimed at preventing sexually transmitted infections and HIV.

Each day, more than 80 000 young people attended the trade show, which was held in Lusaka from 30 July to 4 August 2014.  

The UNAIDS office in Zambia brought together popular bands and service providers so that young people could get information on sexual reproductive health and services in an adolescent friendly way. 

Bands from Lusaka and provinces across the country drew large crowds with fun and energetic performances. Musicians playing at the Band Stand, the most popular arena among youth, delivered prevention messages. They also promoted individual responsibility for protecting themselves and their partners.

“The success of our joint initiative highlights that when young people can act immediately on the messages they hear and access services, they are more than willing to do so,” said Helen Frary, UNAIDS Country Director for Zambia. “Providing these services in an environment they identify with can go a long way in stopping stigma.”

Voluntary counselling and testing services and male and female condoms were readily available near the stage. Led by the United Nations Population Fund, the Condomize! Campaign drew attention to the fact that a low rate of condom use is one of the reasons behind HIV infections in Zambia. More than 120 000 condoms were distributed free of charge with UNAIDS support.

“It is refreshing to see young people taking condoms without fear or diffidence,” said Clementine Mumba of the Condomize! campaign.  

More than 1096 people got counselling and testing through the Society for Family Health and the Community for HIV/AIDS Mobilization Program. The number of people who received counselling and testing exceeded expectations, with providers running out of test kits midway through the last day of the event.

The United Nations Children’s Fund called on adolescents and young people present at the event to join its Zambia U-Report SMS platform and interact with counsellors via text messages on issues related to sexual health and HIV. New members topped 2200. 

Now a 19-year-old university student in South Africa, Noxolo Myeketsi started receiving a social welfare grant in 2005. Part of a state-run programme to assist poor households, the cash transfers allowed her to stay in school and her grandmother to buy food and pay their bills.

The grant changed Noxolo’s life for the better. Other girls turned to having sex, often with older men, in exchange for basic needs, and potentially exposed themselves to sexually transmitted infections and HIV.

“I believe that without the grant assistance, I would not have been able to make healthy decisions in my life. Maybe I would have ended up being a sugar daddy’s girl, like others from my area, or ended up contracting HIV,” Noxolo said.

Social protection schemes, including financial incentives, can make a difference in a number of ways. The World Bank reports that, globally, there is strong evidence that cash transfers improve the education, health and lifelong income of beneficiaries. 

“Cash transfer programmes work for HIV prevention and a host of other human development outcomes as well, and they are scalable,” said David Wilson, Director of the World Bank’s Global HIV/AIDS Program.

Studies conducted in South Africa show that small cash grants provided to poor households allow teenage girls to make safer sexual choices and can significantly reduce the number of new HIV infections. When psychosocial care and support are added to the cash, the results for girls are even better.

At the UNAIDS Programme Coordinating Board (PCB) meeting held in Geneva in July a thematic session was organized on addressing the social economic drivers of HIV through social protection, at which Noxolo spoke about the positive impact grants can have.

Following up on the PCB meeting, UNAIDS and the World Bank pledged to assist governments in the process of scaling up social protection programmes, including cash transfers, for HIV prevention in eastern and southern Africa, covering Botswana, Kenya, Lesotho, Malawi, South Africa, Swaziland, United Republic of Tanzania and Zambia.

“It is befitting that South Africa is the centre of the initiative because the country accounts for 23% of sub-Saharan Africa’s new HIV infections, 18% of the global HIV burden and has one of the world largest social protection programmes,” said Benjamin Ali, UNAIDS Country Director for South Africa.

Countries and partners will be urged to collaborate in a comprehensive review of social protection systems. Proposals to make such systems HIV sensitive include modifying age bands and other inclusion criteria to ensure that the groups most affected and at risk of HIV infection are covered, providing some cash directly to girls and young women and linking cash incentives to their adherence to HIV prevention and treatment programmes.

UNAIDS Executive Director Michel Sidibé recently visited a centre in Moroni that primarily provides antenatal care for pregnant women and prevention of mother-to-child transmission of HIV. It is run by the Association comorienne pour le bien-être familial (ASCOBEF), a nongovernmental organization.

At the centre, women have access to health services early in pregnancy and are offered an HIV test so that, if they need it, they can get treatment for themselves and appropriate postnatal care for their infants. The work ASCOBEF does at the centre highlights the critical role that civil society plays in supporting the Government of the Comoros in its response to HIV.

During his visit, Mr Sidibé had the opportunity to meet with members of civil society whose organizations conduct HIV counselling and testing, awareness-raising and community mobilization. They discussed their activities and the challenges they face in providing comprehensive care for people living with HIV, including the limited support they get from other sectors.

“We must not tolerate the shrinking of a democratic space of nongovernmental actors. The role of civil society is essential,” said Mr Sidibé.

Mr Sidibé reiterated the important role of civil society in advocating a human rights approach, especially in the context of the post-2015 development agenda and the rights and gender action that is needed to ensure that no one is left behind.