At the 2014 International AIDS Conference in Melbourne, Australia, one of the questions being asked is: “Where should the world focus its attention in the AIDS response?” 

In the recent Gap report, UNAIDS highlighted the importance of location and population. The report shows that 15 countries account for more than 75% of the 2.1 million new HIV infections that occurred in 2013. The countries—Brazil, Cameroon, China, India, Indonesia, Kenya, Mozambique, Nigeria, Russian Federation, South Africa, Uganda, United Republic of Tanzania, United States of America, Zambia and Zimbabwe—can all make a positive impact by scaling up HIV services where they are most needed to reduce new HIV infections.

This was one of the issues highlighted by the UNAIDS Executive Director, Michel Sidibé, when he met with Nafsiah Mboi, the Minister of Health of Indonesia—which is working to increase access to HIV testing and early treatment—at the conference.

“I know that Indonesia can quickly change the trajectory,” said Mr Sidibé. “The government is committed and has the capacity to accelerate scale-up and I expect we will see the results soon.”

Countries often face multiple epidemics and hence there is an increased urgency to focus at the city and district level in order to effectively reach the people currently being left behind.

“Countries with the highest burden have to do the heavy lifting to end the AIDS epidemic and provide services to all affected people—location by location, population by population,” said Mr Sidibé.

Populations at higher risk of HIV infection are often difficult to reach. India has sustained investments in key populations for more than a decade and expanded outreach in more than a thousand locations within the country. In the Russian Federation, despite clear scientific evidence of the impact of harm reduction services, very few people who inject drugs have access to opioid substitution therapy and needle–syringe programmes.

Brazil, which has been a pioneer in the AIDS response, has recently seen HIV infections rise among young gay men and other men who have sex with men. Health authorities and civil society groups in Brazil are exploring innovative new ways to get life-saving information and treatment to a new generation of young men who may not know they are at higher risk of becoming infected.

In Mozambique, new data analysis shows that the districts with the highest density of people living with HIV are located along transport corridors and in important seaports in the central and southern regions of the country, and the country is now beginning to expand access to HIV services in these areas.

In Nigeria, a similar analysis led to a focus on 13 states, including the Federal Capital Territory, which includes Abuja, for intensifying scale-up. South Africa, the country with the largest number of people living with HIV, has made significant gains in stopping the AIDS epidemic. A national HIV testing campaign, combined with intense civil society engagement, led to more than 2.5 million people having access to antiretroviral therapy.

“This is why the exchange of ideas is so important,” said Mr Sidibé. “When we can share data and best practices, we can close the programmatic gaps.”

The 20th International AIDS Conference opened in Melbourne, Australia, on 20 July 2014 with a moving and powerful range of statements from leading figures in the response to HIV. The ceremony was dedicated to the memory of the victims lost in the international tragedy—several of whom were on their way to participate in AIDS 2014.

Nobel laureate and President of the International AIDS Society Professor Françoise Barré-Sinoussi paid tribute to the friends and colleagues who died. “We dedicate AIDS 2014 to them, we will remember their legacy and keep them in our hearts,” she said.  

Michel Sidibé, Executive Director of UNAIDS, gave an inspiring address calling for an end to the AIDS epidemic by 2030 and stressed the need for a new “catch-up” plan to leave no one behind. “Now, more than ever, we must concentrate our limited resources on where most infections occur and on where most people die,” he said. “The world needs a new “catch-up” plan for the 15 countries that account for 75% of new HIV infections.”

UNAIDS Goodwill Ambassador and Master of Ceremony James Chau guided the speakers through the special memorial opening session. He extended a warm welcome to Ayu Oktariani, a young woman living with HIV from Indonesia, who spoke passionately about the challenges she faces in her daily life, “Living with HIV is not easy,” she said. “It's not only about HIV; it's about people’s judgement of my sexual behaviour.” She talked about discriminatory attitudes of health-care workers and the lack of information on sexual and reproductive health. “Many of us have HIV because we did not have the means or information to protect ourselves,” she added.

Co-chair of AIDS 2014 Professor Sharon Lewin told the participants how important the conference was to Australia and the world. A sentiment echoed by the Premier of the State of Victoria, Denis Napthine, “This conference is about stepping up the pace, making a difference and making the world a better place,” he said.

Aboriginal Elder Joy Wandin Murphy extended a warm welcome to Australia to all the participants. She talked about the country’s past struggles and stressed the importance of tolerance and acceptance. “If we understand each other we can live in harmony, and, if we do, we can eliminate stigma and discrimination so we can all live together.”   

The Jonathan Mann memorial lecture was given by Justice Michael Kirby, who strongly emphasized the importance of equality and justice for all. He talked about the impact of punitive laws and the devastating impact they can have on people living with and affected by HIV. He stressed that, “Law and policy must be made part of the solution and not part of the problem for AIDS.”

The United Nations Secretary-General Ban-Ki moon and the Prime Minister of Australia Anthony Abbott delivered video messages expressing their sorrow for all who died on flight MH17 and encouraged participants to take the opportunity provided by the conference to advance the response and reach the end of the AIDS epidemic.

Deputy Prime Minister of Australia Warren Truss stated that Australia will pursue an ambitious commitment to ending AIDS as part of the post-2015 agenda. The event was closed by a concert from Dan Sultan.

The 20th International AIDS Conference will run from 20 to 25 July in Melbourne, Australia. The delegates will review and present the latest scientific findings as well as the social and structural innovations and challenges in the AIDS response.

AIDS 2014 opened overshadowed by an international tragedy. During a ceremonial inauguration to welcome the conference participants to the city, the organizers expressed deep sadness for the loss of the many delegates travelling on flight MH17. 

Speakers at the event stressed the importance of honouring the legacy of the researchers and AIDS advocates who died by increasing efforts and commitments to pursue their cause. “It is a difficult moment. We lost friends, activists and people who are the voice of the voiceless,” said UNAIDS Executive Director Michel Sidibé.

The Premier of Victoria, Denis Napthine, said, “This is a massive loss to our community, who worked together across the world to tackle HIV.”

Mr Sidibé participated together with the Lord Mayor of Melbourne, Robert Doyle, and the co-chair of the AIDS 2014 conference, Sharon Lewin, in the lighting of the AIDS 2014 sign event. Messages from international leaders, including President Barack Obama, the Lord Mayor of Melbourne, and the Mayors of Milan, Osaka, Tianjin and Thessaloniki, were projected onto the façade of the Arts Centre Melbourne’s Hamer Hall. Mr Sidibé’s message read “Ending AIDS is the only dream we should all have.”

The 20th International AIDS conference will take place from 20 to 25 July in the Australian city of Melbourne under the theme “Stepping up the pace”.

AIDS 2014

Delegates from all over the world will participate in a series of sessions, panels and community-led discussions to take stock of the progress made, analyse the latest scientific advances and mobilize governments and communities to chart the way forward to end the AIDS epidemic.

This year’s theme recognizes the many advances made in the past few years in the areas of vaccine research, the growing number of people receiving antiretroviral therapy and the falling number of new HIV infections. However, “Stepping up the pace” also stresses the need to keep HIV as a priority in the global agenda and that more investments, collaborative research and political commitment are needed to ensure that no one is left behind.

UNAIDS Executive Director Michel Sidibé will be among the high-level speakers participating in the conference, together with President Bill Clinton and artist and activist Bob Geldof. UNAIDS will be participating in a number of events before and during the conference, including the preconference sessions on youth, men who have sex with men, and interfaith communities, as well as other sessions on HIV treatment, adolescents, prevention of mother-to-child transmission and human rights, among others.

People living with HIV who have access to social protection programmes enjoy a range of benefits, such as being more likely to retain their jobs and keep their children in school, but too many of the most vulnerable are out of reach of these programmes, says a new report by the International Labour Organization (ILO).  

Access to and effects of social protection on workers living with HIV and their households draws its conclusions from research conducted in four countries, Guatemala, Indonesia, Rwanda and Ukraine, that are currently developing or scaling up their social security systems.

Across the countries a variety of social protection schemes are used to support the most vulnerable and to avoid increased vulnerability. These include establishing poverty alleviation and reduction programmes, prioritizing the poor in economic development strategies, providing access to social security systems, greater labour opportunities for women, and providing health insurance and pensions and social assistance for low-income individuals and families.  

The report notes that social protection programmes can reduce the disadvantages, inequalities and structural barriers that make people more vulnerable to HIV. It reveals that, in the studied countries, between 63% and 95% of people living with HIV who had access to social protection were able to keep their jobs or some form of productive activity, 49–99% said that their children remained in school and 72–86% were able to access life-saving antiretroviral treatment.

It notes that the social protection systems of the four governments are much more readily accessed by those under the umbrella of the public and formal sectors. People living with HIV are often in the informal economy and therefore much more likely to miss out. This may be a particular issue for women and key populations at higher risk.

There is a tendency to address HIV by concentrating on enabling access to HIV treatment. The study stresses that in order to be effective, a social protection safety net that works for HIV-positive people must be multilayered, addressing wider social and economic vulnerabilities, and not just about making free antiretroviral medicines available.

“Access to antiretroviral treatment keeps people living with HIV alive. But too often, the lack of broader social protection benefits keeps women and men, and their households, vulnerable and poor,” said Alice Ouedraogo, Chief of ILO’s HIV/AIDS and the World of Work Branch, which produced the report.

The study examines a number of challenges to accessing services, such as a lack of awareness that the programmes actually exist or that the process involved in getting services is too complicated or cumbersome.

There is also the issue of out-of-pocket expenses, including transport costs to get to health centres and money to pay for treatment of opportunistic infections. ILO argues that a combination of income, livelihood and employment support is needed, in addition to health services, to further increase the impact of social protection.

“As we prepare for the post-2015 development agenda, it is important to invest in policies and programmes that leave no one behind, including people living with HIV and key populations,” Ms Ouedraogo concluded.

Aditya Wardhana, Executive Director of the Indonesia AIDS Coalition, welcomed the new research and the light it shines on a key area that has so far received relatively little attention. He said, “ILO’s research has opened a discourse on the urgent need for a sensitive social protection scheme towards people living with HIV and AIDS-affected communities, who have been long neglected by the existing social protection system.”

There must be a stronger focus on the health needs and human rights of all people who use drugs, especially people who inject drugs and are living with HIV, according to World drug report 2014, launched on 26 June—International Day against Drug Abuse and Illicit Trafficking—by UNODC Executive Director Yury Fedotov.

For many of the world’s drug users there is a worrying lack of evidence-informed programmes focusing on prevention, treatment, social rehabilitation and integration. “There remain serious gaps in service provision. In recent years, only one in six drug users globally has had access to or received drug dependence treatment services each year,” Mr Fedotov said.

Injecting drug use and the associated increased vulnerability to HIV remains a critical issue and is worsening in some regions, such as parts of Europe. Using joint estimates for the first time from UNODC, UNAIDS, the World Bank and the World Health Organization, the report states that of the 12.7 million people who inject drugs globally, around 1.7 million are living with HIV (13%).

The situation is said to be particularly serious in two regions, south-west Asia and eastern Europe, where HIV prevalence among people who inject drugs is 28.8% and 23%, respectively. The report cites statistics showing that for the 49 countries for which data are available, HIV prevalence among injecting drug users is more than 22 times higher than in the general population, and at least 50 times higher for 11 countries.

The World drug report 2014 emphasizes the need to implement harm reduction services, the most important of which for avoiding HIV infection are needle and syringe programmes, opioid substitution therapy, voluntary counselling and testing, and antiretroviral therapy. Where these programmes are available, such as countries in western and central Europe, there has been a decline in both HIV incidence and in the number of AIDS-related deaths caused by unsafe injecting drug use.

As Mr Fedotov maintains in the preface to the report, “We have seen that countries that have adequately invested in harm reduction services have lowered remarkably HIV transmission among people who inject drugs.”

As well as examining injecting drug use and HIV, the report explores a number of other central issues in a world where drug use prevalence is reported as now stable. These include: the effects of a surge in opium production in Afghanistan; the decreasing global cocaine supply; the mixed picture of cannabis use dropping globally but increasing in North America; and the more than doubling in seizures of methamphetamine between 2010 and 2012.

Private Albert Joseph Lustiko of the South Sudan Army calls himself an ambassador for HIV testing. When he finishes his morning work as a cleaner at the Juba base he sticks around to talk to other soldiers about HIV and to encourage them to take advantage of the HIV testing and counselling (HTC) services at the nearby military hospital.

“Some of the soldiers know they are sick but they refuse to go for HIV testing, even though they have symptoms,” said Mr Lustiko. He blames their hesitance on poor understanding of the virus and low awareness of the available treatment, but also on the stigma that comes with living with HIV.

Lustiko undertook an HIV test in 2009 after hearing radio campaigns about the importance of HTC. After learning his HIV-positive status, he asked his two wives to go to the hospital with him to get tested. His first wife thought the diagnosis meant he was “the living dead”, and he spent two days explaining to her that with antiretroviral treatment (ART) his diagnosis was not a death sentence. Eventually, she agreed to get tested. Both wives tested negative for HIV and, since his diagnosis, have maintained their status, and each of them have had children born free of HIV.

“I’m now sending a message to everybody,” Lustiko said. “Whether you are a woman or a man, whether you are HIV-positive or HIV-negative, tell your spouse so that all of you can go to the hospital. If one of you is HIV-positive, you have to go to the hospital and follow the regulations. Get advice from there, and you can live longer with your wife. You can have children with your wife.”

However, lack of knowledge about HIV extends beyond Mr Lustiko’s family and the army base. Health officials say there is generally low knowledge about HIV across South Sudan. Only 45% of women between 15 and 49 years old had even heard about the virus, according to an analysis of the country’s epidemic released earlier this year by the government and UNAIDS.

Since its independence in July 2011, South Sudan has been making efforts to overcome the HIV epidemic. However, critical challenges, including stigma, low awareness and knowledge of HIV status, and shortage of community outreach and quality health-care services, continue to hamper the national response to HIV. A household health survey in 2010 revealed that only 23% of the men who participated in the survey had taken an HIV test, and less than half of those had received their results.

According to Moses Mutebi, the World Health Organization’s HIV programme manager for South Sudan, it is critical to spread the message across the country about the importance of knowing one’s status, especially among people at higher risk of contracting HIV.

“The vast majority of people don’t know their HIV status,” said Dr Mutebi. “That’s why we can’t identify who is living with HIV. But whoever has been identified as living with HIV, they have been linked to care and treatment.”

South Sudan is now integrating provider-initiated HTC in health centres to allow patients to avoid the stigma that comes with visiting stand-alone HTC sites and get tested for HIV. “While patients are meeting the surgeon, the dermatologist or the physician, doctors can provide information on HIV and the need to test,” said Emmanuel Lino, Deputy Director at the Ministry of Health in charge of HIV services. “It’s like we are normalizing HIV voluntary counselling and testing.”

Dr Lino noted that his ministry is running training at health centres across the country for doctors, nurses and “even the gatekeepers,” so they have a working knowledge of the virus and where people can go for HIV testing and treatment.

Getting more people on HIV treatment, however, is bound to reveal other gaps in the country’s health system, such as that there are only 22 facilities providing ART across the entire country. South Sudan is also short of the laboratory space required to diagnose patients and the equipment needed to monitor the virus.

Even Mr Lustiko, who is generally satisfied with the services he has received, pointed out that his ART site has run out of medicine more than once, leaving him to go without for several months. An unplanned interruption in ART is extremely dangerous, since it can allow the virus to rebound or cause the patient to develop resistance to the treatment.

The ministry has plans in place to address these problems, including better integration of ART services into existing primary health-care centres and building 100 new centres in the coming years. Dr Lino said there is a standing commitment from the government to address the needs as they arise. But first, he said, people must be made more aware of the virus.

The number of the world’s refugees, asylum seekers and internally displaced people has risen dramatically, topping 50 million for the first time since the Second World War, says a report released by UNHCR, the United Nations refugee agency.  

According to UNHCR global trends 2013, published to coincide with World Refugee Day, marked annually on 20 June, 51.2 million people have been forcibly displaced, up 6 million from 2012.

The war in the Syrian Arab Republic is given as the main reason for this increase, as a growing number of individuals and families join 2.5 million Syrian refugees and 6.5 million internally displaced people. Conflicts in South Sudan and Central African Republic are also highlighted as the cause of widespread forced movement.

The plight of internally displaced people, a record 33.3 million, is highlighted as a special concern by UNHCR. It is hard to reach the many that remain in conflict zones and they lack the international protection received by refugees. Given this situation, the report describes 2013 as one of the most challenging years in UNHCR’s history.

United Nations High Commissioner for Refugees António Guterres said, “We are seeing here the immense costs of not ending wars, of failing to resolve or prevent conflict. Peace is today dangerously in deficit. Humanitarians can help as a palliative, but political solutions are vitally needed. Without this, the alarming levels of conflict and the mass suffering that is reflected in these figures will continue.” 

People who are forcibly displaced often become more vulnerable socially, economically and in terms of their health. For example, contracting HIV may be more likely if they engage in transactional sex to meet their basic needs. In addition, access to health and education services can be very limited and the use of rape as a weapon of war also heightens vulnerability.

The global trends report contends that UNHCR remains committed to safeguarding the rights and well-being of those forced to flee their homes and continues to work to find long-term solutions, such as voluntary return, local integration or resettlement in a third country. According to Mr Guterres, the countries of the world also have to redouble efforts to both end conflict and support people in need.

“The international community has to overcome its differences and find solutions to the conflicts of today in the Central African Republic, South Sudan, Syrian Arab Republic and elsewhere. Non-traditional donors need to step up alongside traditional donors. As many people are forcibly displaced today as the entire populations of medium-to-large countries, such as Colombia or Spain, South Africa or Republic of Korea,” he added.

UNAIDS Executive Director Michel Sidibé commended Tunisia for its leadership role in the AIDS response in the Middle East and North Africa region during his meeting with President Moncef Marzouki on 20 June in Tunis, Tunisia. Mr Sidibé also congratulated the country for its selection to host the 18th International Conference on HIV/AIDS and STI’s in Africa (ICASA) in 2015.

President Marzouki placed Tunisia among the pioneer countries to ratify the Arab Convention on HIV Prevention and Protection of the Rights of People Living with HIV—adopted in March 2012 by the Arab Parliament—and promised to push for AIDS to remain on the post-2015 development agenda. At the end of the meeting, President Marzouki signed the Protect the Goal ball, pledging his commitment to raise global awareness of HIV.

During his three-day visit to the country, Mr Sidibe also met with representatives of civil society and affected communities, the Vice-President of the National Constituent Assembly, Mehersia Labadi, the Minister of Health, Mohamed Salah Ben Ammar, the Minister of Finance, Hakim Ben Hamouda, and Donald Kaberuka, President of the African Development Bank.

In discussions with community leaders, Mr Sidibé stressed the important role of civil society in advocating for a rights-based approach in the AIDS response and the need for governments to engage them more in the political dialogue. He also emphasized the urgent need for legislative reform and a public health approach towards people who use drugs, to avoid criminalization and ensure access to HIV services.

Mr Sidibé also reiterated the importance of domestic funding to ensure a sustainable response to the epidemic, while stressing the need to establish a concrete investment plan that focuses resources where they are most needed.

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Significant progress has been made in the Asia and the Pacific region towards reaching the targets of the 2011 United Nations Political Declaration on HIV and AIDS, and the region can aspire to ending the AIDS epidemic by 2030. This was one of the main conclusions of the two-day consultation held on 12 and 13 June in Bangkok, Thailand, to discuss the challenges and opportunities for accelerating the scale-up of HIV prevention and treatment programmes in the region post-2015.

With less than 500 days to go to reach the targets of the 2011 Political Declaration, the meeting reinforced the need for concerted action to reach the 2015 targets as well to set ambitious new targets for 2020 and 2030. In a bid to leave no one behind and realize zero new HIV infections, zero discrimination and zero AIDS-related deaths, it was agreed by participants that scaling up HIV testing, focusing on key populations at higher risk, innovation in service delivery and increased funding are key to ending the AIDS epidemic by 2030.

The regional consultation brought together more than 50 participants, including representatives of the Governments of China, Fiji, India, Indonesia, Myanmar, Thailand and Viet Nam, regional communities of people living with HIV, men who have sex with men, sex workers, transgender people and people who use drugs, UNAIDS Cosponsors and development partners.

Following the regional consultation, country dialogs will be organized with key stakeholders to agree on a set of national HIV prevention and treatment targets.

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