Cover of the UNFPA report: HIV prevention gains momentum: Successes in female condom programming.
Credit cover photo: Jack Hollingsworth/Blend

Ensuring that high quality condoms are widely available, either free or at an affordable price, is fundamental to a pragmatic and effective AIDS response. In a recently published report, the United Nations Population Fund (UNFPA) focuses on the increasing use of female condoms and highlights how millions of women around the world are now using this method to protect themselves against HIV.

HIV prevention that women can control

Titled HIV prevention gains momentum: Successes in female condom programming, the report looks at the issue through the prism of national case studies. These pinpoint how a variety of partners have come together, pooling ideas, expertise and resources, to empower women to access female condoms. This is crucial as HIV is the leading cause of death among women of reproductive age worldwide, and in sub-Saharan Africa 60 percent of all people living with HIV are female.  

“Girls and women remain vulnerable to HIV and we have to summon the courage and political will to empower and protect them,” said Dr Babatunde Osotimehin, UNFPA’s Executive Director, quoted in the report’s foreword. “We have to invest in practical tools that women can use to protect themselves, such as the female condom,” he added.

Concerted efforts appear to have an impact: the report states that access to female condoms has increased dramatically over the last few years, with 50 million used in 2009. Today condoms are available in more than 90 countries through public health programmes. However, availability and price remain issues as the female condom can cost as much as one US dollar per unit and, despite considerable progress made, in 2009 only one female condom was available for every 36 women worldwide.

Stories highlighted in Successes in female condom programming range from coffee ceremonies in Ethiopia where married women help each other break taboos surrounding condoms, to networks of hairdressers and small businesspeople in Guyana, Malawi and Zimbabwe encouraging their clients to use them.

Innovative distribution outlets

For example, Langton Ziromba owns a small barbershop in Zimbabwe’s capital, Harare, and in addition to giving haircuts and shaves he also promotes and sells female condoms to his male customers. Mr Ziromba is one of around 70 barbers and 2000 hairdressers in the country trained by Population Services International (PSI), a UNFPA partner. Such activity, the report outlines, has contributed towards the growth in sales of female condoms through social marketing and public sector programmes from one million in 2005 to more than five million in 2009.

Other countries, such as Myanmar, have focused on key populations like sex workers and men who have sex with men. In 2006 UNFPA entered into an agreement with the Myanmar government and PSI to provide 700,000 female condoms to these groups over a three year period. According to the report, progress was “remarkable” and in the first year of the initiative use of female condoms among sex workers nearly doubled from 20 percent in 2004 to 36 percent in 2006.

Building national capacity for programming

The publication also draws attention to the push to increase the capacity of national governments and their partners to implement comprehensive condom programming, of which female condoms are an integral part, with a view to outside assistance eventually being phased out.  

Since 2002 UNFPA has been the lead agency for the UN Inter-Agency Task Team on Comprehensive Condom Programming and plays a key role in discussions on funding, technical assistance and regional and global support. It also works with governments and partners to stimulate demand and facilitate the design and implementation of culturally appropriate condom programming so that individuals around the world are empowered to protect themselves against HIV.

More than 600 people around the world have downloaded the UNAIDS AIDSinfo application for the Apple iPad since its launch in June, 2011. The ‘app’ provides immediate access to key country by country HIV data and can help policymakers, researchers and educators to better understand why and how HIV infection is spread and where treatment, care and support programmes are needed.

Research indicates that people are increasingly turning to this new mobile device to find information; there are currently tens of millions iPad users. “UNAIDS is committed to making information and strategic policy advice about the AIDS epidemic widely available,” said Dr Bernhard Schwartländer, Director, Evidence, Strategy and Results Department. “We will continue to be innovative in the tools and channels we use to reach decision-makers and advocates with timely and accurate information.”

The AIDSinfo iPad app presents factsheets on 192 countries, comprising data, trends and charts on HIV epidemiology. Some of the functions include sharing key information via email, posting charts to Facebook and an RSS news feed. Although the application was optimized for the Apple iPad, with touch-based controls, a visible link is provided to the AIDSinfo database online, which contains additional data and powerful tools to enable more comprehensive investigations of the HIV epidemic.

UNAIDS is continuing to monitor usage of the app, review user feedback and evaluate options for further development including platform-agnostic access based on HTML5 and expansion of the AIDSinfo database via mobile and other interfaces.

The AIDSinfo iPad app is free from the Apple iTunes store, and AIDSinfo is available via the internet. For more information visit the UNAIDS website.

The UK charity National AIDS Trust (NAT) launched a report on 4 August 2011, entitled Estimating the likelihood of recent HIV infection – implications for criminal prosecution, which explores the validity and meaning of the Recent Infection Testing Algorithm HIV tests, or RITA tests, within the context of criminal prosecutions of HIV transmission. 

The report, primarily aimed at professionals working in the criminal justice system and HIV specialists who may be called on as expert witnesses in criminal HIV transmission cases, calls for caution about the potential use of RITA results to determine timing of HIV infection. 

About RITA and its potential use in criminal law context

RITA tests estimate the likelihood that a person found to be HIV-positive has been infected recently, usually within the previous six months. To date, the United Kingdom is the only country reported to routinely return RITA results to newly diagnosed patients.

As criminal law in the UK allows for the prosecution of people for transmitting HIV to another person, the report underlines the importance that RITA tests and their limitations be fully understood and not misused in criminal proceedings. The report underlines that while there have been no reported instances of use of RITA results in courts to attempt to prove timing of HIV transmission and consequently the identity of the person who transmitted HIV, this may happen in the near future.

No test can conclusively state when an individual acquired HIV

“No scientific test is able to conclusively state when an individual acquired HIV,” said Dr Cate Hankins, Chief Scientific Adviser to UNAIDS. “It is important to be cautious, follow clear protocol, and understand the limitations of RITA results when delivering them to patients or using them within a criminal law context.”

According to the report, proving HIV transmission in the context of criminal law cases requires the use of a combination of scientific evidence, medical records and testimony to establish the facts, timing and direction of HIV transmission. 

“Scientific advances such as RITA testing are extremely welcome when estimating the recency of HIV infection on a population level, especially as late diagnosis is a huge issue,” said Ms Deborah Jack, Chief Executive of National AIDS Trust. “However, it is crucial that the limitations of RITA tests are fully understood and are not used out of context, for example during criminal proceedings.”

As RITA tests are designed to work at the population level (based on averages) rather than at the individual level, taking into account significant rates of false RITA test results in individuals, the report draws the conclusion that RITA tests are not reliable as evidence of recent HIV infection for individuals in the context of criminal proceedings.

Better understanding of HIV science in the context of criminal law

The NAT report comes weeks ahead of an expert meeting on the scientific, medical, legal and human rights aspects of the criminalization of HIV transmission and exposure organized by UNAIDS in Geneva from 31 August to 2 September 2011.

The meeting will bring together leading scientists and medical experts on HIV together with legal and human rights experts. Participants will examine relevant scientific and legal evidence and concepts relating, among others, to harm, risk, intent and proof, and their conceptualization/application in the context of criminalization of HIV exposure and transmission.

The meeting is part of UNAIDS’ work towards halving the number of countries with punitive laws and practices around HIV transmission, sex work, drug use, or homosexuality that block effective AIDS responses by 2015.

Rene Mauricio Valdes, UN Resident Coordinator in Guatemala, at the inaugural event of the "HIV Testing Campaign" for UN staff members.
Credit: UNAIDS Guatemala

An estimated 100 000 people took part in the Ministry of Health and Social Welfare of Guatemala’s National HIV Testing Week Campaign, now in its second year. In order to fulfill the right to health for all citizens, the Ministry, through the National AIDS Program, has established 295 HIV testing sites at national hospitals and health centers around the country.

Twenty-seven years after the first reported case of HIV in Guatemala, access to testing remains limited. According to data from the National Epidemiology Center two out of three people living with HIV were unaware of their status. Early detection of HIV infection is crucial as it enables timely access to treatment and, with it, a better quality of life for people living with HIV.  

Under the slogan "No matter who you are, get tested for HIV," an estimated 100 000 people took an HIV test the last week of July. Supported by Red Cross Guatemala, civil society organizations, and universities, the initiative promoted inclusiveness and an environment free of stigma and discrimination.

To meet the country's commitment to universal access to prevention, treatment, care and support to HIV, the Government institutionalized the annual National HIV Testing Week to offer all citizens – including key populations at higher risk – access to HIV tests over a one week period.

"This is an opportunity to stop HIV in Guatemala and get closer to UNAIDS’ vision of zero new infections, zero AIDS deaths and zero stigma and discrimination,” said Enrique Zelaya, UNAIDS Country Coordinator for Guatemala and Mexico.

Innovative proposal in the UN

The UN system in Guatemala also took part in the weeklong campaign. Under the guidance of the UN system-wide workplace programme on HIV, UN Cares, with both human and material resources from the Red Cross and the Guatemala National AIDS Program, HIV testing was made available at different offices of the UN System in Guatemala.

"It is a privilege, an opportunity and a right to have this national initiative and to take it closer to our workplaces," said the UN Resident Coordinator in Guatemala, Rene Mauricio Valdes.

The HIV epidemic in Guatemala

An estimated 65 701 people are living with HIV in Guatemala. Each year, there are an estimated 7 557 new infections, the equivalent of 21 people newly infected each day. The country’s epidemic is concentrated among key populations at higher risk, such as transgender people, people with tuberculosis, men who have sex with men, female sex workers, youth at risk, and prisoners.

L to R: Cyril Dubois, Global Fund’s chief of Division, west and central Africa, Minister of Health and Prevention of Senegal, Mr Modou Diagne Fada, UNAIDS Regional Director for West and Central Africa, Dr Meskerem Grunitzky-Bekele.

UNAIDS and the Global Fund have convened a meeting in Dakar, Senegal, to respond to the increasing need for risk management and accountability related to HIV funding. The event brought together more than 300 participants from countries in West and Central Africa who discussed financial, procurement and supply management risks as well as questions around accountability and governance.

The main objective was to provide organizations which are implementing HIV programmes with a better understanding of risk management to be able to secure funding from the Global Fund.

The meeting was opened by the Senegalese Minister of Health and Prevention, Modou Diagne Fada who announced that the Government of Senegal will gradually increase the proportion of its national budget which is spent on health to 15% by 2015.

Speaking at the plenary, UNAIDS Regional Director for West and Central Africa, Meskerem Grunitzky-Bekele, highlighted that “sound risk management is key for the AIDS response and crucial to optimizing resources for HIV.”

Participants identified several risk factors such as weak institutional architecture of the national AIDS response; limited availability of qualified personnel and poor financial and accounting management standards. Another risk factor identified relates to investment choices and the need to identify where to invest for a maximum effect and return was highlighted.

“A good understanding of accountability and the importance of proactive and transparent risk management during grant implementation constitute the two essential pillars of sound management that will prevent disruptions from happening,” said Cyril Dubois, Global Fund’s chief of Division, West and Central Africa. “These steps are complementary in order to ensure that the financing provided by donors is used most effectively. Such an approach creates an environment that will ensure that the grants provided to countries fully benefit the populations affected by the diseases,” he added.

Corrective actions were defined together with an action plan to put in place mechanisms and systems for preventive risk management and strengthen accountability at country level. According to the participants, the key elements to overcoming the situation are building countries leadership; providing comprehensive technical support in key areas such financial management, and creating spaces to access capacity development initiatives tailored to countries needs.

UNAIDS provided technical support for risk management through different phases of grants implementation. Over the past year, Guinea, Togo, Niger, Chad, and Central African Republic have received support in adequate budget definition and follow up, financial review and management, or evaluation of risk management-related technical assistance.

Credit: UNAIDS/P.Virot

In the past decade, increased commitment and funding has enabled countries to boost their HIV responses. However, many of the gains remain fragile as countries face challenges to take charge of their own AIDS responses.

Following the High Level Meeting on AIDS where world leaders agreed on bold targets, UNAIDS convened a workshop in Dar es Salaam, Tanzania to strengthen investments in capacity development of six sub-Saharan African countries—Benin, Ethiopia, Ghana, Malawi, Nigeria and Swaziland.

The focus of the workshop was on increasing country ownership in their AIDS response. The workshop also encouraged countries to share experiences and indentify bottlenecks. According to participants, some of the key challenges include limitations in programme implementation, poor governance systems, lack of leadership and human resources and uneven financial and management capacities

“The area of capacity development is a learning area for Ethiopia. Through this workshop we have learnt from the obstacles and challenges faced by countries and how to avoid those pitfalls,” said Alemu Arno Ararso, Director of the Multi-sectoral Response Coordination at the Federal HIV/AIDS Prevention and Control Office (FHAPCO), Ethiopia. “We know that investing in capacity development will help our country achieve its AIDS objectives and expected results,” Mr Ararso added.

The six countries have received grants from the EC to develop and implement technical support plans, addressing issues such as governance systems, leadership development, human resources and financial management capacities.

Ghana, Nigeria and Swaziland have integrated their technical support and capacity development plans into their national AIDS strategic frameworks and are starting implementation. Ghana plans to utilize the EC grant to bring together development partners to discuss the creation of a pooled fund for the provision of technical support. In addition, Ghana is working with academia to establish training programmes in health systems strengthening and monitoring and evaluation, with a view to building long-term and sustainable country capacities.

At the end of the workshop participants emphasized the importance of national partners with organizations such as universities. Special mention was given to the fact that, despite countries’ efforts to scale-up in-country capacities, migration of skilled professionals has reduced the impact.

“As efforts evolve from an emergency to a more sustained response, country capacities now need to be developed in a range of core areas,” said UNAIDS Team Leader in the Aid Effectiveness and Country Capacities Division, Angela Trenton Mbonde. “Country ownership and capacity development should play a more central role in moving forward the AIDS response,” she added.

The country inputs and experiences shared throughout the workshop will inform the revision of the UNAIDS Capacity Development Guidance Note intended to promote a common understanding of capacity development in the context of technical support planning and national HIV programmes.

Young leaders and government policy-makers discussing commitments made regarding young people and the AIDS response. UN HQ, New York. 26 July 2011.
Credit: UNFPA

A new report highlights that global commitments will be achieved only if the unique needs of young women and men are acknowledged and their human rights fulfilled, respected, and protected.

The Global Inter-Agency Task Team on HIV and Young People launched the synthesis report entitled Securing the Future Today containing strategic information about HIV and young people. The report was launched at an event organized by UNAIDS on the sidelines of the United Nations High-level Meeting on Youth which took place in New York from 25-26 July under the theme “Youth: Dialogue and mutual understanding”.

The side event, convened in collaboration with UNFPA, ILO, Global Youth Coalition on HV/AIDS, Population Council and Catholic Relief Services, brought together young leaders and government policy-makers to discuss commitments made regarding young people and the AIDS response. Participants looked for solutions to reach a shared vision of “Zero new HIV infections, Zero discrimination and Zero AIDS-related deaths” among young people.

In order to reduce new HIV infections among young people, achieve the broader equity goals set out in the MDGs and begin to reverse the epidemic, HIV prevention and treatment efforts must be tailored to the specific needs of young people.

Recent epidemiology data from UNAIDS indicates that young people are leading the HIV prevention revolution by taking action to protect themselves from HIV. Young people’s sexual behaviors are changing and HIV prevalence among young people is dropping in 15 of the 21 countries most affected by HIV. However, in 2009, young people accounted for 41% of all new HIV infections among adults with 3 000 young people becoming newly infected with HIV each day. Also in 2009, 4.9 million young women and men were living with HIV worldwide.

The report highlights that young people are a key resource to reverse the global AIDS epidemic and lead the response in decades to come. But it stresses that the legal and policy barriers that prevent young people from accessing HIV services must be addressed, and young people should be engaged more effectively in the response.

In that sense, the side-event provided a platform for young people to have a direct dialogue with national Governments in order to encourage the scale up of HIV prevention and treatment services for young people as well as the active involvement and leadership of young people, including those living with HIV, in the AIDS response at all levels.

According to the new report, to effectively advance the response among young people, there is a need to increase investments. However, it also cautions that simply directing more resources will not increase HIV testing and uptake of services among young people. Instead, empowering young people and particularly young women to exercise their rights to sexual and reproductive health, improve programmes for young people and repeal national laws and policies that restrict access to HIV services for young people is required to protect future generations from HIV.

On the periphery of the IAS 2011 conference taking place in Rome from 17-20 July 2011, UNAIDS in collaboration with the Global Coalition on Women and AIDS (GCWA), ATHENA, Salamander Trust, WECARe+ and Network Persone Seropositive convened a town hall dialogue to discuss how the HIV response facilitates the achievement of sexual and reproductive health and rights for all women, including women living with HIV, at every stage of their lives. 

For women living with HIV stigma and discrimination and gender-based violence acutely affect their access to comprehensive services and human rights. Within health services, they often face a lack of choice with regard to family planning; disapproval from service providers with regard to meeting sexuality and fertility desires; and violation of their sexual and reproductive rights in the form of coerced or forced abortion or sterilization. Participants agreed that advancing the health and rights of women in all their diversity is fundamental to the success of the HIV response, just as the HIV response is a critical avenue for achieving sexual and reproductive health and rights for women.

The event was also used as a platform to launch a report Community Innovation: Achieving sexual and reproductive health and rights for women and girls through the HIV response. Compiled by UNAIDS and the ATHENA Network, it presents case studies pioneering community undertakings to advance women’s sexual and reproductive health and rights through the HIV response and vice-versa, from different community perspectives. This report recognizes that women face unique challenges to access and fulfil their sexual and reproductive health and rights, including gender-based violence, and therefore have less access to HIV prevention, care and support services.

“Women and girls at every level and throughout different stages of their lives must be supported to demand quality services that meet their needs and those of their community,” said UNAIDS Deputy Executive Director, Programme, Dr Paul De Lay.

Learning from these community case studies is an opportunity to enhance the AIDS response, in light of the Millennium Development Goals and the 2011 Political Declaration on HIV/AIDS. The case studies indicate that for responses to be effective they must include the empowerment and inclusion of women in all their diversity, dedicate attention to sexual and reproductive health, including improvements in maternal and child health, and address the socio-cultural practices underlying gender inequality.

UNAIDS Getting to zero: strategy 2011-2015 also places gender equality and human rights as one of three core pillars. This report is part of that commitment to ensuring that women and girls’ rights are met through the HIV response and it was undertaken in the context of the UNAIDS Agenda for accelerated country action for women, girls, gender equality and HIV. 

“UNAIDS continues to be a strong advocate for women’s health and rights, as well as to strongly stand against stigma and discrimination amongst all marginalized groups. We will continue to do so until we have achieved the vision of zero discrimination,” said Dr De Lay.

UNAIDS Executive Director Michel Sidibé delivering his keynote speech at the opening session of the IAS 2011.

“We are at a scientific watershed in the global AIDS response,” said IAS 2011 International Chair and International AIDS Society President Elly Katabira. “We have witnessed two years of significant biomedical advances, the likes of which we have not seen since the antiretroviral breakthroughs of the mid 1990s. The excitement around these advances in research—whether they are the CAPRISA 004 vaginal gel, the HPTN 052 study on treatment as prevention or the encouraging signs on PrEP and vaccines—is very much driving the debates and discussions that we are going to see in Rome over the next few days.”

It is against this backdrop that the 6^th IAS Conference on HIV Pathogenesis, Treatment and Prevention (IAS 2011) opened in Rome on 17 July. More than 5000 AIDS researchers, scientists, clinicians, community leaders and policy experts have gathered to examine the latest developments in HIV-related research and to explore how scientific advances can inform the global response to AIDS. 

The IAS Conference will also focus on finding ways to translate research into practice, particularly in low- and middle-income countries. In his opening session keynote speech, UNAIDS Executive Director Michel Sidibé described the current gaps in access to HIV treatment within and between countries and key populations as “an affront to humanity,” but also reminded the audience that these gaps “can and must be closed by innovations in developing, pricing and delivering treatments and commodities for HIV, TB, malaria, reproductive health and other health issues”. “We have to remember that history will judge us not by our scientific breakthroughs, but how we apply them,” added Mr Sidibé.

Echoing this call at the opening session, IAS 2011 Local Co-Chair and Research Director at the Istituto Superiore di Sanità Stefano Vella insisted on the need to evenly share the recent advances in biomedical research between the global North and South. “We need to ensure that the advances we are making in research such as the now proven concept of antiretroviral treatment as a means of HIV prevention is translated into action for people in developing countries.”

Mr Vella also used the occasion to call on the Italian government to re-commit to the Global Fund to Fight AIDS, Tuberculosis and Malaria. “Advances in science need to be matched by advances in resourcing. I call on the Italian government to recommit itself as a donor nation to the Global Fund to Fight AIDS, Tuberculosis and Malaria,” said Mr Vella.

IAS 2011 will reveal promising new data across all four scientific tracks – particularly in the areas of HIV treatment as prevention, HIV cure efforts, new drugs and new antiretroviral combinations, and the scale up of effective prevention and treatment interventions in resource-limited settings.

Credit: UNAIDS

The Medicines Patent Pool has begun negotiations with Boehringer-Ingelheim and Bristol-Myers Squibb for patents on HIV medicines essential to treating people living with HIV in the developing world. The announcement was made today during the IAS 2011 conference. The Pool was already in negotiation with five other patent holders and concluded its first licensing agreement with a leading pharmaceutical company, Gilead Sciences, a week ago.

UNAIDS Executive Director Michel Sidibé welcomed the news because “sharing innovation and patents will drive down the price of medicines and bring antiretroviral treatment to millions more people.”

“It is morally wrong that nine million are waiting for treatment and that 5 000 people are dying every day of AIDS-related illnesses,” Mr Sidibé added.

“Of all pharmaceutical companies with HIV medicines patents, only three are currently not in negotiation with the Pool. We call on Johnson & Johnson, Merck, and Abbott to follow the lead of their colleagues and enter into negotiations with us,” said Ellen ‘t Hoen, Executive Director of the Medicines Patent Pool.

The Medicines Patent Pool and Gilead Sciences agreement is for five products for the treatment of HIV and Hepatitis B: the medicines tenofovir, emtricitabine, cobicistat, and elvitegravir, and a combination of these medicines in a single pill known as the “Quad.”

Public health licensing of products in clinical development is rare and is an important advance in a field where many potentially valuable medicines are still in the developmental phase. This licence will allow for generic versions of new products to enter the market shortly after the products are available in rich countries. 

"UNITAID has worked for four years to develop the Medicines Patent Pool concept. Today we are proud to see that it is becoming a tangible reality," said Philippe Douste-Blazy, chair of the UNITAID Executive Board. "I salute these important steps by Gilead and other pharmaceutical companies and urge other pharmaceutical companies to place their patents at the service of global public health."

The Medicines Patent Pool was established by UNITAID in July 2010 to work towards bringing down the prices of HIV drugs and encouraging the development of new formulations, such as medicines for children, through voluntary licensing of critical intellectual property.