Participants at the discussion “Getting to Zero” – Achieving zero new HIV infections for injecting drug users hosted by the Permanent Representative of the United Kingdom to the United Nations in Vienna, Ambassador Simon Smith on 21 March 2011.

Globally, there are an estimated three million people who inject drugs also living with HIV—with nearly 13 million more at risk of HIV infection. While access to HIV prevention services, including harm-reduction programmes has increased, in 2009 the median coverage of HIV prevention services was 32%.

High-level experts gathered for a round table on “Getting to Zero” – Achieving zero new HIV infections for injecting drug users, in Vienna Austria on 21 March 2011. The event took place on the opening day of the fifty-fourth session of the Commission on Narcotic Drugs (CND) which runs in the city until 25 March 2011. It was convened by UNAIDS and hosted by the Permanent Representative of the United Kingdom to the United Nations in Vienna, Ambassador Simon Smith.

Dr Paul De Lay, Deputy Executive Director, Programme at UNAIDS presented the joint programme’s 2011-2015 strategy, Getting to zero. One of the medium-term goals of the strategy is to prevent all new HIV infections among people who use drugs by 2015. He outlined an approach to delivering results that is both “effective and cost efficient.”

UNAIDS calls for comprehensive, evidence-informed and human-rights-based programmes to be accessible to all people who inject drugs. These include opioid substitution programmes, sterile needle and syringe access and better alignment of law enforcement and public health approaches. To illustrate how this approach can be cost effective, Dr De Lay cited the example of Ukraine where needle and syringe programmes are estimated to cost less than $100 per HIV infection averted. Another programme element required is increasing uptake of antiretroviral therapy for people who use drugs and are living with HIV.

A DFID/World Bank Impact Assessment in Viet Nam that explores the impact of harm reduction efforts was presented by DFID representative Mr Will Niblett. The assessment showed clearly that programmes which were implemented at sufficient scale—for example, distributing at least 200 needles and syringes per drug user per year—had a major impact on reducing HIV incidence. The assessed impact was found not only in relation to the drug-using population which was the direct beneficiary of programmes, but also to incidence rates in the whole population as onward transmission is reduced.

Participants debated the challenges to stopping HIV infections among injecting drug users. Solutions were explored including creating enabling environments, funding community responses and scaling up to ensure optimum coverage and quality programming.

Representatives from both government and civil society and from all regions concluded that concerted efforts to reach the Strategy's goal need to foster more active community responses, address barriers to scale up, and involve both the justice and policing sectors as key partners. Mr Christian Kroll, UNODC Global Coordinator for HIV/AIDS joined Dr De Lay in giving the closing remarks.

Commission on Narcotic Drugs

The Economic and Social Council established the Commission on Narcotic Drugs (CND) in 1946 as the central policy-making body of the United Nations in drug-related matters. CND enables Member States to analyse the global drug situation, provide follow-up to the General Assembly and to take measures at the global level within its scope of action. It also monitors the implementation of the three international drug control conventions and is empowered to consider all matters pertaining to the aim of the conventions, including the scheduling of substances to be brought under international control.

A version of this story also appears at www.who.int.

Credit: WHO

To mark World TB Day, the World Health Organization (WHO), the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Stop TB Partnership are calling on world leaders to step up their commitment and contributions to meet the goal of diagnosing and treating one million people with multidrug-resistant tuberculosis (MDR-TB) between 2011 and 2015.

WHO has released a report, Towards universal access to diagnosis and treatment of MDR-TB and XDR-TB by 2015, which presents progress in the MDR-TB response in the countries with the highest burden of drug-resistant TB. "Many countries have made progress, but despite the recent scale-up in efforts, the world needs to do much more to get care to all MDR-TB patients who need it," says Dr Margaret Chan, WHO Director-General. "We cannot allow MDR-TB to spread unchecked."

The risk of leaving multidrug-resistant tuberculosis untreated

Leaving MDR-TB untreated increases the risk of spread of drug resistant strains of TB. WHO estimates there will be more than 2 million new cases of MDR-TB between 2011 and 2015.

Treatment programmes

Programmes financed by the Global Fund and that follow WHO treatment standards are expected to diagnose and treat about 200 000 people for MDR-TB by 2015, a fourfold increase from those 50 000 patients who are currently undergoing treatment.

It is anticipated that the Global Fund will provide 84% of all international investments in TB in 2011. However, both domestic and international resources need to be scaled up to cope with MDR-TB if progress in the response to TB is to be maintained.  

“MDR-TB is a threat to all countries as it is difficult and expensive to treat. Unless we make an extraordinary effort to tackle this problem our ability to finance and secure continued progress against TB in general will be threatened” says Professor Michel Kazatchkine, Executive Director of the Global Fund.

Time to step up commitments

According to Dr Jorge Sampaio, the UN Secretary-General's Special Envoy to Stop TB, "It is time for countries with rapidly growing economies and a heavy burden of MDR-TB to step up their commitment and financing for their own MDR-TB programmes. Several have the capacity to show new leadership on south-south cooperation and aid to neighbouring countries that are also affected."

Since 2009, the 23 countries most heavily affected by TB drug resistance have nearly doubled their budgets for MDR-TB. According to the Global Fund, from 2002 to 2010, they have financed TB programmes around the world that have provided treatment to 7.7 million people and saved the lives of 4.1 million.

"The Global Fund's success can be measured in the number of lives that have been saved through care provided by the TB programmes it finances," says Dr Lucica Ditiu, Executive Secretary of the Stop TB Partnership. "Every TB patient should have access to proper care...To reach a million people with effective care for MDR-TB over the next five years, we will need to work closely with all partners, especially with affected communities."

MDR-TB is a form of TB that fails to respond to standard first-line drugs. In 2009, WHO reported that 9.4 million people became ill with TB and 1.7 million died, including 380 000 people with HIV-associated TB. There were some 440 000 cases of MDR-TB and 150 000 deaths in 2008, the latest year for which estimates are available.

Minister-President and Minister for Economy, Foreign Policy, Agriculture and Rural Policy Kris Peeters (left) and UNAIDS Executive Director Michel Sidibé (right) signing the renewed cooperation agreement. Geneva, 22 March 2011. Credit: UNAIDS

UNAIDS and Flanders renewed their multi-year agreement of cooperation on 22 March 2011 during an official visit from a Flemish delegation to the UNAIDS headquarters in Geneva.

“Today’s agreement emphasizes the strong and reliable engagement and commitment of Flanders in the global AIDS response, especially during this time of financial constraints,” said UNAIDS Executive Director Michel Sidibé.

The Flemish delegation was headed by the Minister-President and Minister for Economy, Foreign Policy, Agriculture and Rural Policy, Mr Kris Peeters, the Minister for Finance, Budget, Work, Town and Country Planning and Sport, Mr Philippe Muyters and the Permanent Representative of Belgium in Geneva, H.E. Ambassador François Roux.

The new agreement for the period of 2011-2014 will focus on strengthening HIV prevention efforts mainly in southern Africa countries. The agreement also reflects Flanders’ decision to move away from funding individual projects to a broader programmatic approach.

During the visit, UNAIDS Executive Director shared the UNAIDS’ strategy for 2011-2015. Mr Sidibé also highlighted the importance of the forthcoming UN General Assembly High Level Meeting on AIDS to renew commitments towards the global AIDS response.

UNAIDS Executive Director Michel Sidibé and the Archbishop of Canterbury commit to closer collaboration in preventing and reducing the impact of sexual violence and HIV.
Credit: Clive Mear / Tearfund.

The findings from recent research on the role of the church in responding to sexual violence have been presented at an event in London organised jointly by Tearfund, Christian AID and the Anglican Communion.

The report, Silent No More, which was commissioned by the Christian relief and development agency Tearfund, is a self-critical look at the way in which churches have responded to sexual violence in three African countries that have been or are still facing conflict.

The findings of the report show that too often churches have remained silent and failed to care and stand up for people on the margins of society––particularly people affected by sexual violence. It unveiled that although sexual violence is endemic to many countries the scale and impact largely remain hidden. It also criticised the church for deepening the impact of sexual violence through silence and reinforcing stigma and discrimination.

“It is of the first importance that churches and all communities of faith continue to hold before the world’s eyes the absolute priority for justice and dignity for all,” said the Archbishop of Canterbury, Dr Rowan Williams. “We need to equip people to become agents of change and agents of hope. I hope this is the beginning of the church being what it ought to be and should be.”

UN statistics show that in some countries as many as one in three women are beaten, coerced into sex or otherwise abused in their lifetimes. This renders women particularly vulnerable to the risk of HIV infection by denying them the means to protect themselves against HIV.

Speaking at the conference, UNAIDS Executive Director, Michel Sidibé said, “Women and girls are most affected by sexual violence and are most vulnerable to HIV. UNAIDS will work closely with faith-based organizations to ensure the dignity and protection of women and girls.”

Key recommendations from the report call for the church to realise its potential in preventing and reducing the impact of sexual violence. The recommendations outline the importance of challenging the prevalence of sexual violence and ask churches to demonstrate compassion and care for people affected by sexual violence. They also urge aid agencies, governments and donors to recognize the potential of the church and to work together against sexual violence.

UNAIDS has called zero tolerance for gender-based violence. In 2009 UNAIDS launched an Agenda for Women and Girls and HIV which is currently being rolled out across the globe. The Agenda outlines the need to accelerate country-level action to transform the way in which gender inequality and the rights of women and girls are addressed through the AIDS response.

Anastasia Solovieva, head of “Unity Fidelity Advocacy" (left) and Maria Godlevskaya, member of the network and head of the charity foundation Candle (right) during the official presentation of the Russian network of women living with HIV. Saint Petersburg, 5 March 2011.

“Women need help to overcome fear and to defend their rights,” says Anastasia Solovieva, head of the first Russian network of women living with HIV, called “Unity Fidelity Advocacy".

The network, launched on the eve of the International Women's Day in Saint Petersburg is supported by UNAIDS. It unites women and organizations supporting them from various parts of Russia to improve the quality of life of women affected by HIV. Through integrated HIV services, the network advocates for wider access to HIV treatment, care and support and the protection of human rights. 

In the past decade the spread of HIV has shifted in Russia. HIV transmission has moved from injecting drug use to include heterosexual transmission. And there has been a rise in the number of women living with HIV.

Natalya Ladnaya, chief officer of the Russian Federal AIDS Centre, points out that 65% of women who became infected in 2010 were infected through sexual contact. Many women have been infected by their husbands, and first learned of their HIV-positive status during pregnancy.

According to Ms Ladnaya, lack of HIV prevention programmes among women and very low levels of awareness about the virus and how to prevention transmission are some of the reasons behind this situation. “Women often do not insist on using a condom,” added  Maria Godlevskaya, member of the new network and head of the charity foundation Candle.

In Russia, as many as 95% of pregnant women living with HIV receive antiretroviral therapy to prevent HIV transmission to their babies. However the country still faces many challenges in the wider area of sexual and reproductive health. Many women at higher risk of HIV infection do not have access to services for the prevention of mother-to-child HIV transmission (PMTCT).

According to reports from civil society organizations in different regions of Russia, stigma in society and even among healthcare workers discourages pregnant women living with HIV to approach healthcare facilities. Additionally, sex workers and women who inject drugs are even less likely to be able to access PMTCT services for fear of discrimination.

"It is especially difficult in the remote regions of Russia,” said Ms Solovieva. “We need to work together to adapt the health system to the needs of women affected by the epidemic.”

Sri Lanka captain Kumar Sangakkara (second from left) joins the youth drama group during their play on the impact of stigma and discrimination for those living with HIV.

Sri Lankan cricket captain Kumar Sangakkara took time off the pitch during the Cricket World Cup tournament to speak to hundreds of young people about the importance of being informed and responsible about HIV. The event was part of the International Cricket Council (ICC), UNAIDS and UNICEF’s Think Wise campaign for the ICC Cricket World Cup 2011.

“You need to educate yourself and become more aware of the world around you and HIV. Be unafraid and unashamed to speak openly about these subjects with your friends, family and your teachers in school,” said Mr Sangakkara, during the event which was held at his old school, Trinity College, in the city of Kandy.

As part of the event, a youth drama group staged a play to demonstrate the impact of stigma and discrimination for people living with HIV. The drama reinforced the need for more education and life skills to prevent the spread of HIV, particularly among adolescents.

"To use theatre and cricket together was a great idea. No one expected Kumar to be a part of the play and when he came on with us, people really listened. Everything we were saying was reinforced by his presence and in his own words," said Kapila Rasnayaka, one of the young people involved in the drama group.

Kumar Sangakkara, along with other leading international cricketers including Graeme Smith (South Africa) and Virender Sehwag (India), is a ‘Champion’ spokesperson for the joint Think Wise partnership. In Kandy he was joined by Sri Lanka team mates Ajantha Mendis and Upul Tharanga who also showed their support for HIV prevention efforts in the country.

“If we are going to ‘get to zero’ on HIV, we need the active engagement of young people—the leaders of tomorrow’s response—now,” said UNAIDS Country Coordinator for Sri Lanka, David Bridger. “Sangakkara’s involvement in the campaign has helped push the boundaries, inciting discussion and a buzz around HIV that we will build on with the hope that young people will take the HIV response into their hands,” he said.

More than 7 000 people worldwide are newly infected with HIV each day—one out of three is a young person between 15 and 24 years-old. The Think Wise campaign encourages young people to be informed, take appropriate action to prevent HIV infection and stand together against the stigma and discrimination often facing people living with HIV.

The reduction in multiple sexual partnerships major significant cause of the decline in HIV prevalence in Zimbabwe.

HIV prevalence in Zimbabwe has declined remarkably in recent years, dropping from 26% to 14% between 1997 and 2009. In a recent edition of the journal PLoS Medicine, researchers explored the reasons for this decline and examined what lessons can be learned and replicated.

Sponsored by UNFPA, UNAIDS and the Zimbabwean Ministry of Health and Child Welfare, the study pinpointed several key factors in Zimbabwe’s success. These include changes in sexual behaviour, personal experiences related to the high AIDS mortality in the country and correct information about HIV transmission. 

“The behaviour changes associated with the HIV decline appear to be largely the result of people increasingly talking about HIV and its link to risky sexual behaviour,” said Clemens Benedikt, HIV prevention manager in the UNFPA office in Zimbabwe and one of the authors of the report.

The most significant cause of the decline was seen to be the reduction in multiple sexual partnerships, with a 30% fall in men reporting extra-marital relationships. This can be partly attributed to the success of HIV prevention programmes, both mass media and those based on inter-personal communication through the church, work-place, friends and family. Such programmes stressed the protective effect of having fewer partners and promoted condom use during casual sex. 

According to the study, there have been a number of significant shifts in sexual norms. For example, in previous years, men gathering in beer halls and bottle stores tended to be surrounded by women, some of whom were sex workers. Now, it is more typical for such places to be men only.

The entrenched economic crisis has also played a role. Men reported having less money to spend on sustaining multiple partnerships as well as using the services of sex workers. However, this is noted as a secondary factor given that the most severe effects of the financial crisis were felt after 2002 when most of the decline in HIV incidence had already happened.

Another apparent spur in behaviour change was high AIDS mortality. AIDS-related deaths increased significantly during the mid- to late-nineties and stabilized after 2000. Many women and men in the authors’ focus groups reported that knowing people who had died as a result of AIDS was a large motivating factor to modify their own sexual behaviour.  According to the study, the policy of home-based care for people living with HIV adopted in Zimbabwe may have also contributed to this phenomenon as people were brought face-to-face with the reality of AIDS in their own homes.

“Zimbabwe provides a clear example of the profoundly positive results that behaviour change can bring about in an effective AIDS response,” said Bruce Campbell, co-author of the report and currently UNFPA Representative in Viet Nam. “People can and do look at their individual and collective circumstances and make informed decisions about how to protect themselves and others, especially in an environment where information and education interventions highlight the link between sexual risk behaviour and HIV.”

The authors also argue that Zimbabwe's experience highlights the importance of prevention in an effective and sustained response to HIV, despite the growing availability of antiretroviral drugs. According to UNAIDS, globally there are still two new HIV infections for every one person starting treatment and prevention efforts make up only around 20% of AIDS-related spending in low- and middle-income countries.

Similar to the Zimbabwean example, HIV prevention success has been achieved in a number of countries in sub-Saharan Africa. According to the latest UNAIDS report on the global epidemic, some 22 countries have reduced the rate of new infections by more than 25% between 2001 and 2009. These include several other countries with the region’s highest prevalence, including South Africa and Zambia. And in many cases, it is young people who are leading the ‘prevention revolution ‘and changing their behaviour by deciding to delay sex, having fewer partners and using condoms.

More than 90 delegates participated in the Latin America consultation to review progress made towards achieving universal access to HIV prevention, treatment, care and support. Mexico City, 2-3 March 2011.

The Secretary of Health of Mexico, Dr José A. Córdova, called on countries in Latin America to continue efforts to counter stigma, discrimination and homophobia in the region.

Dr Córdova was one of seven Ministers and Vice Ministers of Health among more than 90 delegates contributing to the review of progress made towards achieving universal access in the AIDS response. The consultation, held in Mexico City from 2-3 March 2011, made regional recommendations and developed a roadmap on how to achieve universal access to HIV prevention, treatment, care and support by 2015.

“We need to strengthen the human rights approach in our response to AIDS and establish mechanisms to ensure that both public and private services are free of stigma and discrimination or homophobia,” said Dr Córdova.

Persistent homophobia, gender-based violence, persecution and even killings of most-at-risk populations such as men who have sex with men (MSM) and transgender people were identified as some of the main obstacles to ensuring access to HIV-related services in the region. Strengthening health systems that do not discriminate people living with HIV and key populations at higher risk of infection was seen by participants as a priority to achieve universal access. Improving access to legal services for human rights violations, discrimination and gender-based violence was also highlighted.

The AIDS epidemic in the region has remained stable for the last 10 years with an HIV prevalence of 0.5%. Antiretroviral therapy coverage is at 51%, which represents the highest in the world. However, young people, sex workers, MSM, and transgender people still have limited access to sexual and reproductive health programmes that provide information, skills, services and commodities to prevent HIV infection.

“We can only improve HIV prevention for the transgender community in Latin America through the respect for their identity in the health services,” said Marcela Romero from REDTRANSLAC, Argentina.

Participants identified a need to strategically position HIV within broader political agendas—including education, justice, equality, labour, and social development. This, it was felt, would secure political commitment and financial sustainability. According to the participants, investment from different sectors would have a multiplier effect that will contribute not only to achieve universal access goals but support the achievement of the broader Millennium Development Goals.

The need to strengthen relations between governments, civil society organizations and networks of people living with HIV throughout the region was another recommendation from the meeting. It was also proposed to jointly purchase antiretroviral drugs for the region rather than as individual countries to achieve economies of scale and to increase HIV treatment coverage. Additional strategies included enhancing production of locally produced antiretroviral drugs.

“Working together we can ensure a unified regional response to the epidemic and set the path towards sustainability in Latin America,” said UNAIDS Regional Director Dr César Núñez.

UNAIDS Deputy Executive Director Paul De Lay speaking at the briefing organised by amfAR entitled "Accelerating an HIV Prevention Revolution: A Roadmap".
Credit: amfAR

As part of amfAR’s emerging issues series, a briefing was held on Capitol Hill, in Washington, D.C. on 9 March entitled "Accelerating an HIV Prevention Revolution: A Roadmap". Speaking at the briefing, UNAIDS Deputy Executive Director Paul De Lay stressed the need to scale up combination HIV prevention worldwide.

“Bringing one or two interventions to scale will not suffice to curb the spread of HIV. Rather, we must urgently work to bring multiple prevention strategies to scale simultaneously,” said Dr De Lay. “Like combination antiretroviral therapy, complementary HIV prevention strategies work synergistically when they are combined in a strategic way,” he added.

The briefing highlighted emerging scientific advances in HIV prevention research, innovative community models, opportunities for scaling up prevention programmes, and domestic and global policy implications.

Other panelists at the briefing included Willard Cates, Family Health International, who gave an overview of HIV prevention technologies; Robert Remien, Columbia University, who spoke on behaviour change prevention strategies; and Carl Dieffenbach, Division of AIDS at the National Institutes of Health, who discussed innovative community models for HIV prevention.

Since its inception in 1985, amfAR has invested nearly $325 million into AIDS research and has awarded grants to more than 2 000 research teams worldwide.

Read more on the amfAR event

High profile women wearing the Same Sky bracelets.
Credit: Same Sky

“Our project offers a hand up, not a hand out,” says Francine Le Frak, founder of Same Sky, a “trade-not-aid” initiative that markets high-end artisan bracelets produced by women’s cooperatives in Rwanda for the North American market.

Ms Le Frak, a film producer from the USA and now social entrepreneur, started Same Sky while trying to make a film about the genocide in Rwanda. Although the film project never materialized, she felt there were other skill sets she could lend to make a difference in the lives of the women she met in the country.

“I wanted to help the women who were still truly devastated by the genocide 15 years later,” Le Frak says. “I decided to work with women living with HIV. I found that they were forgotten, and [they] just couldn’t seem to get back into the swing of life.”

Today, an estimated 88 000 women living are with HIV in the country. Many women report having faced sexual violence in their lifetime.

Same Sky works with a local organization in Rwanda called Gahaya Links Handicraft Center, based in the capital Kigali. Gahaya Links was founded by two sisters: Joy Ndunguste and Janet Nkubana, and their company was incorporated in 2004 as the first handicrafts export company. 

Based on the principle of women’s economic empowerment through fair trade, Gahaya Links supports women’s cooperatives as a way to give women a source of sustainable income.

Francine LeFrak with Same Sky artisans and Joy Ndungetse, Founder of Gahaya Links Handicraft Center in Kigali, Rwanda. Credit: Same Sky

“We help women acquire skills that they can use to make an income, and Francine has given them access to a market to sell their products,” says Joy Ndungetse, co-founder of Gahaya Links. “You can now see the joy of living on their faces.”

“I’m a good marketer,” says Le Frak. “We want to give the women the opportunity to sell their products. You can train all day but if you don’t give them the opportunity of employment, what are you accomplishing?” Le Frak asks.