This story has also been published at www.who.int/hiv

Photo credit: WHO

A brightly coloured van known as the ‘Tutu Tester’ has become a familiar sight in Cape Town, South Africa, as part of an accelerating drive to persuade people to know their HIV status. More than 10 000 people have been tested and counselled since May 2008 when the mobile clinic from the Desmond Tutu HIV Foundation took to the road.

It is one of many initiatives in sub-Saharan Africa designed to dispel the stigma and fear long associated with AIDS through imaginative campaigns ranging from sex worker advice at truck stops to peer counselling in mining areas to national testing weeks spearheaded by celebrities. The campaigns are part of wider national and international efforts to expand the number of people receiving testing and counselling—which is often referred to as ‘the gateway to HIV prevention, treatment and care’ because it is a precondition for timely access to all three, including antiretroviral therapy which cuts mortality rates.

Ninety percent of low- and middle-income countries last year reported that they have national HIV testing and counselling polices, up from 70% in 2007, according to the 2009 Towards universal access progress report, published by WHO, UNICEF and UNAIDS. Countries hardest hit by the pandemic—Botswana, Kenya, Lesotho, Malawi, Namibia, Rwanda, South Africa, Swaziland, Tanzania and Uganda—are testing and counselling pregnant mothers as the basis for prevention of mother-to-child transmission (PMTCT) to cut the number of infants born with HIV, and to help HIV-negative pregnant women stay negative.

There is encouraging evidence that more countries are adhering to WHO-UNAIDS guidance on provider-initiated testing and counselling in health facilities. This recommends HIV testing and counselling as part of the standard care to all persons with symptoms or medical conditions that could indicate HIV infection, to infants born to HIV-positive women, and in generalized epidemics to all persons attending health facilities. The guidelines are key to facilitating early diagnosis in countries which are struggling with a dual HIV-TB epidemic.

The number of health centres providing HIV testing and counselling is on the increase. In 15 reporting nations in East, South and South-East Asia, the number of such facilities rose from 13 000 to 15 000 between 2007 and 2008; in reporting Latin American and Caribbean countries it doubled, while sub-Saharan Africa boasted a 50% increase.
Some countries have made more progress than others. Ethiopia increased its number of facilities from 1005 to 1469 and reported that 4.5 million people received testing and counselling in 2008, up from 1.9 million in 2007. At the other end of the scale, less than 10% of health centres in Nigeria and the Democratic Republic of Congo had testing and counselling facilities.

Cameroon adopted provider-initiated testing and counselling in 2007. This was part of the government commitment to increase the number of people on treatment, up from 600 in 2001 to 60 000 in November 2008, according to WHO’s National Programme Officer for HIV/AIDS in Cameroon, Etienne Kembou. Although much remains to be done to train health professionals to implement the government model at local level, Kembou says about 85% of pregnant women at health facilities agree to be tested, as do growing numbers of men. “AIDS is not stigmatised like it was in the 1990s and many people who are HIV-positive are open about it,” Kembou says, adding that the annual national testing week and peer education projects aimed at 15–25 year-olds have helped enormously.

Uganda and Kenya have expanded coverage through home-based testing and counselling, whereby trained counsellors go from door to door. The advantage is that couples can be counselled together in a familiar environment without the stigma of going into a government facility. As a result, there are fewer disclosure problems which may arise with the male or female partner testing separately. It means that undiagnosed children with the virus can access HIV services and that high-risk areas such as the Kibera slum near Nairobi can be targeted.

In nations like Botswana and Swaziland, the government drive to scale up male circumcision for HIV prevention has led to an upsurge in testing and counselling among males, an often underserved group, as a precondition for the surgical intervention. WHO’s country representative in Botswana, Eugene Nyarko, says intensified prevention campaigns targeting youth are bearing fruit. “Across the board there is an increase in testing because young people know they can benefit from interventions if they know their status.”

In South Africa, which has the highest number of people in the world living with HIV, a national population-based survey in 2008 by the Human Sciences Research Council showed that 50% of respondents over 15 years of age said they had received an HIV test, compared to 20% in 2002. Between 2005 and 2008, the percentage of women and men who reported having an HIV test in the past 12 months more than doubled.

Civil society groups in South Africa, like the Treatment Action Campaign, have mounted high profile ‘Get Tested’ campaigns. There are many local initiatives backed by foreign donor funding and the government, and the message is getting through.

Sweetness Mzoli, runs an organisation called Kwakhanya (‘Light’) which helps care for 300 beneficiaries in Khayelitsha, a poor suburb of Cape Town with high HIV prevalence. She tours minibus taxi ranks trying to persuade men to be tested and counselled and notes there is far less resistance than even a year ago. “It’s coming right. There’s a lot of men out there who want to talk about their status and who want to know their status,” she comments.

The ‘Tutu Tester’ is also a regular visitor to Khayelitsha’s taxi ranks, as well as to shopping malls and other crowded areas. The testing and counselling process is efficient, thorough and friendly. Clients can avoid lengthy queues at public health facilities, while knowing they will receive high quality, confidential service.

“When you make it quick and efficient, people are willing to undergo testing,” says project coordinator Nienke van Schaik. The mobile clinic now offers a package, including testing for hypertension and diabetes “to make it less scary,” she says. “We literally just pitch up. People see us and run off and fetch their partners and family members. People are willing to test.”

This story has also been published at www.who.int/hiv

Credit: WHO/James Oatway 2009

Despair is giving way to cautious optimism even in the most HIV-affected African nations as antiretroviral drugs become more widely available to stop HIV-positive women from infecting their unborn child or infant, thus edging closer to United Nations targets for an HIV-free generation of children.

The prevention of mother-to-child transmission (PMTCT) is one of the most powerful tools in HIV prevention and has huge potential to improve both maternal and child health. Yet despite recent progress much work remains.
 
In 2008, 45% of pregnant women in low- and middle-income countries received antiretrovirals to prevent HIV transmission to their child, up from 35% in 2007 and 10% in 2004, according to the 2009 Towards universal access progress report, published by WHO, UNICEF and UNAIDS. In Eastern and Southern African nations, which have the highest rates of infection, coverage jumped to 58% in 2008 from 46% in 2007, thanks to increased national commitment and focused international support. 

One important reason is that HIV testing and counselling among pregnant women is increasing with the expansion of provider-initiated approaches in health-care settings. In 2008, 21% of pregnant women giving birth in low- and middle-income countries received an HIV test, up from 15% in 2007. In sub-Saharan Africa, the corresponding percentage rose from 17% to 28%, with particularly high rates of increase in countries in Eastern and Southern Africa. This was partly due to an increase in antenatal facilities providing PMTCT services and attracting high first-visit turnouts by pregnant women.

Globally, AIDS is the leading cause of mortality among women of reproductive age. In 2008, an estimated 1.4 million pregnant women living with HIV gave birth, 91% of them in sub-Saharan Africa, according to the report. One third of children living with the virus die before the age of one year and almost half by the second year. 

In 2008, 70 low- and middle-income countries had established a national scale-up plan with population-based targets to prevent mother-to-child transmission of HIV, up from 34 countries in 2005. 54 countries had plans to scale up paediatric HIV services in 2008, compared to 19 countries in 2005. An estimated 32% of the infants born to HIV-infected mothers in 2008 were reached with antiretrovirals, more than five times as many as in 2004.

 UN recommendations on PMTCT are based on a four-pronged approach: primary prevention of HIV infection among women of childbearing age; preventing unintended pregnancies among women living with HIV; preventing HIV transmission from women living with HIV to their infants, and providing appropriate treatment, care and support to mothers living with HIV and their children and families.

The UN General Assembly has set a target for 80% of pregnant women and their children to have access to essential prevention, treatment and care by 2010 to reduce the proportion of infants with HIV by 50%. This would entail at least 500 000 additional pregnant women accessing PMTCT services in order to meet this target. Given that PMTCT represents the interface between HIV and maternal and child health services, this would have a positive impact on the health of women and children in general. Achieving the target remains a formidable challenge, but more and more countries are making strides in the right direction.

Botswana, long regarded as sub-Saharan Africa’s flagship in prevention, treatment and care, has easily surpassed the target, with an estimated 95% of HIV-positive pregnant women and their newborns receiving testing, counselling and antiretrovirals. PMTCT has long been one of the pillars of national prevention programmes, according to WHO country representative Eugene Nyarko. “Government commitment and responsibility has been key,” he says.

 Huge progress has been made in Swaziland, which has the world’s highest HIV prevalence. More than 90% of pregnant women in public health facilities now receive counselling and testing, and most of those testing positive are given antiretrovirals, according to Derek von Wissel, director of Swaziland’s National Emergency Response Committee on HIV/AIDS. “The availability of treatment is a huge positive element. People are not as fearful of testing since they know that HIV is no longer a death sentence and that there are remedies.” Swaziland has cut its mother-to-child HIV transmission rate from a peak of more than 30% to around 20%, and the goal is to reduce it to 5% by 2014, says von Wissel. “In Botswana, the paediatric programme is slowing down because fewer and fewer infants are being infected with HIV. We will hopefully go in that direction as well,’’ he says.

Equally significantly, more countries are following WHO recommendations to use a combination of two or three antiretroviral drugs to prevent vertical transmission from mother to child. In 2007, 49% of women receiving antiretrovirals were given a single-dose regimen of nevirapine. By 2008, this had fallen to about 31%, with more women receiving the more efficacious combination of several antiretrovirals.
 A survey of babies tested for HIV during routine immunization in South Africa’s KwaZulu-Natal province showed the six-week vertical HIV transmission rate was 7% in 2008/2009 compared to 20.8% in 2004/2005. The dramatic reduction was largely due to an increase in testing, counselling and treatment and the switch to a combination of more than one antiretroviral drug.

 “These data demonstrate that effective antiretroviral interventions can be delivered at scale and transmission rates can be dramatically reduced,” according to the Towards universal access progress report. “From where we were five years ago, there has been a tremendous increase in coverage,” comments Hoosen Coovadia, one of the South Africa’s top professors of paediatrics and PMTCT scientists. But he says capacity constraints at local level remain a challenge, and that health authorities should do more to use PMTCT as a catalyst to widen reproductive health services and involve male partners.

Progress in general in Western and Central Africa was held back by low coverage levels in Nigeria and the Democratic Republic of Congo which bear the heaviest HIV burden in the region. Nigeria alone accounts for 30% of the global gap in the UN’s target of reaching 80% of women by 2010.

In North Africa and the Middle East, less than 1% of pregnant women living with HIV received an antiretroviral regimen to stop HIV transmission to their child. In East, South and South-East Asia the figure was 25%. Coverage in Latin America increased from 47% in 2007 to 54% in 2008, and in the Caribbean from 29% to 52%. In Europe and Central Asia, coverage jumped from 74% in 2007 to 94% in 2008.

Even in countries with strong PMTCT programmes, there is no room for complacency. Thailand, for instance, has cut mother-to-child transmission rates to less than 5%, according to Siripon Kanshana, Deputy Permanent Secretary in the Ministry of Public Health. But she says there is a need for further capacity building and more training of medical personnel—nurses in particular—in testing and counselling and in monitoring side effects of antiretrovirals and potential drug resistance. “The Ministry of Health has the commitment. But the government still needs advocacy from UN agencies to help strengthen our health care systems to cope.”

UNAIDS Executive Director presents the new WHO/UNAIDS/UNICEF report at the UN in Geneva, 30 September 2009. Credit: WHO/Christopher Black

Geneva / Paris -- More than 4 million people in low- and middle-income countries were receiving antiretroviral therapy (ART) at the close of 2008, representing a 36% increase in one year and a ten-fold increase over five years, according to a new report released today by the World Health Organization (WHO), the United Nations Children's Fund (UNICEF) and the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector highlights other gains, including expanded HIV testing and counselling and improved access to services to prevent HIV transmission from mother to child.

"This report shows tremendous progress in the global HIV/AIDS response," said WHO Director-General Margaret Chan. "But we need to do more. At least 5 million people living with HIV still do not have access to life-prolonging treatment and care. Prevention services fail to reach many in need. Governments and international partners must accelerate their efforts to achieve universal access to treatment."

Treatment and Care

Access to antiretroviral therapy continues to expand at a rapid rate. Of the estimated 9.5 million people in need of treatment in 2008 in low- and middle-income countries, 42% had access, up from 33% in 2007. The greatest progress was seen in sub-Saharan Africa, where two-thirds of all HIV infections occur.

Prices of the most commonly used antiretroviral drugs have declined significantly in recent years, contributing to wider availability of treatment. The cost of most first-line regimens decreased by 10-40% between 2006 and 2008. However, second-line regimens continue to be expensive.

Despite recent progress, access to treatment services is falling far short of need and the global economic crisis has raised concerns about their sustainability. Many patients are being diagnosed at a late stage of disease progression resulting in delayed initiation of ART and high rates of mortality in the first year of treatment.

Testing and Counselling

Recent data indicate increasing availability of HIV testing and counselling services. In 66 reporting countries, the number of health facilities providing such services increased by about 35% between 2007 and 2008.

Testing and counselling services are also being used by an increasing number of people. In 39 countries, the total reported number of HIV tests performed more than doubled between 2007 and 2008.

Ninety-three percent of all countries that reported data across all regions provided free HIV testing through public sector health facilities in 2008.

Nevertheless, the majority of those living with HIV remain unaware of their HIV status. Low awareness of personal risk of HIV infection and fear of stigma and discrimination account, in part, for low uptake of testing services.

Women and Children

In 2008, access to HIV services for women and children improved. Approximately 45% of HIV-positive pregnant women received antiretroviral drugs to prevent HIV transmission to their children, up from 35% in 2007. Some 21% of pregnant women in low- and middle-income countries received an HIV test, up from 15% in 2007.

More children are benefiting from paediatric antiretroviral therapy programmes: the number of children under 15 years of age who received ART rose from approximately 198 000 in 2007 to 275 700 in 2008, reaching 38% of those in need.

Globally, AIDS remains the leading cause of mortality among women of reproductive age.

"Although there is increasing emphasis on women and children in the global HIV/AIDS response, the disease continues to have a devastating impact on their health, livelihood and survival," said Ann M. Veneman, UNICEF Executive Director.

Most-At-Risk Populations

In 2008, more data became available on access to HIV services for populations at high risk of HIV infection, including sex workers, men who have sex with men and injecting drug users.

While HIV interventions are expanding in some settings, population groups at high risk of HIV infection continue to face technical, legal and sociocultural barriers in accessing health care services.

"All indications point to the number of people needing treatment rising dramatically over the next few years," said Michel Sidibé, Executive Director of UNAIDS. "Ensuring equitable access will be one of our primary concerns and UNAIDS will continue to act as a voice for the voiceless, ensuring that marginalized groups and people most vulnerable to HIV infection have access to the services that are so vital to their wellbeing and to that of their families and communities."

With arts and culture being pillars of the Jeux de la Francophonie, the Y-PEER network performed a dance and song written by its members about AIDS. Beirut, 28 September 2009. Credit: UNAIDS/Nabil

The UNFPA-supported Y-PEER initiative is a groundbreaking youth programme that raises HIV prevention awareness through street art, music and dance. UNAIDS Executive Director Michel Sidibé had the opportunity this week to attend a dance performance by the Youth Peer Education Network during the Jeux de la Francophonie.

With arts and culture being one of the two pillars of the Jeux de la Francophonie, the Y-PEER network performed a dance and song written specifically by its members for these games. The lyrics include HIV prevention messages in Arabic, French and English, with the dancers forming a large red ribbon of red fabric at the end of the routine.

“UNAIDS and our Cosponsors are committed to including young people’s leadership as an integral part of national responses including empowering young people to prevent sexual and other transmission of HIV infection among their peers,” said Mr Sidibé.

“This evening’s performance was inspiring, putting these goals into action with young people creatively participating in the AIDS response in their own terms,” said Mr Sidibé after the show. “Culture and creative expression are powerful tools for mobilizing people of all ages and I applaud the Y-PEER.”

UNAIDS Executive Director Michel Sidibé writes a message at the UNAIDS booth at Y-PEER event, Beirut, 28 September 2009. Credit: UNAIDS/Nabil

Y-PEER is a groundbreaking and comprehensive youth-to-youth initiative pioneered by UNFPA. The international network includes over 7000 young peer educators in Europe, Central Asia, Latin America, North Africa and the Middle East. The network has adopted an approach of “edutainment”—combining education and entertainment— to communicating HIV facts. Young people work together to raise awareness on sexual and reproductive health including the facts about sexually transmitted infection and HIV prevention.

The Lebanese Y-PEER network was launched in 2008 with the support of UNFPA and through 35 peer educators, the network has reached 1000 young people all over country in just three months.

With 7,400 new HIV infections daily worldwide and young people aged 15-24 accounting for 45% of these. 

The Jeux de la Francophonie brings together sport and culture to foster dialogue and understanding among French speaking nations. It will run in Beirut until 6 October, bringing together 70 countries from all over the world.

The Director General in the Ministry of Public Health, Lebanon, Dr Walid Ammar (right) met UNAIDS Executive Director Michel Sidibé. Beirut, 28 September 2009. Credit: UNAIDS/Nabil

UNAIDS Executive Director Michel Sidibé concluded an official visit to Lebanon on 29 September. Mr Sidibé recognized and supported the country’s achievements in the HIV response and efforts to target key populations at risk of HIV. He also welcomed the Government of Lebanon’s strong commitment to introduce oral substitution therapy into the country’s public health system.

Mr Sidibé met with the Director General in the Ministry of Public Health, Lebanon, Dr Walid Ammar, and commended the government’s initiative to scale up its harm reduction programme. He stressed the need to expand prevention and treatment efforts among key populations affected with HIV in order to achieve universal access goals.

Mr Sidibé also met with the Executive Secretary of the Economic and Social Commission for Western Asia, Mr Bader Al-Dafa, to discuss approaches to prevent escalation of the HIV epidemic in the countries of the Middle East and North Africa, focusing on gender, socio-economic, marginalization and other factors which increase vulnerability.

Mr Sidibé emphasized the priority of keeping HIV prevalence low in the region, “for low prevalence to continue, I encourage more openness in communicating about AIDS issues. Let us all work together without judgment or discrimination for people living with or at risk of HIV,” said Mr Sidibé.

Mr Sidibé met with civil society groups while in Lebanon. Credit: UNAIDS/Nabil

Recognizing the pivotal role of civil society in the HIV effort, he also met with representatives from non-governmental organizations (NGOs) in the country. These included Helem Association, the first organization working with men who have sex with men (MSM) in the region as well as Soins Infirmiers et Developpement Communautaire (SIDC) which has implemented outreach and HIV prevention for MSM. He also met with Vivre Positif, which works towards ending discrimination and stigmatization towards people living with HIV.

Lebanon’s national AIDS programme has recently introduced 19 voluntary counselling and treatment centres that target key populations and are managed through NGOs. The country also recently launched a centre for antiretroviral distribution along with the provision of psycho-social support for people living with HIV.

According to UNAIDS 2007 estimates, Lebanon is a low HIV prevalence country with a total of 2900 people living with HIV. High mobility and migration levels are important drivers of the epidemic, with 45% of notified HIV cases up to 2004 being linked to travel abroad. Lebanon is among the few countries in the region that has accounted for specific strategies to target each of the key population groups.

Mr Sidibé's visit to Lebanon also included his participation in the Jeux de la Francophonie, of which UNAIDS is an official partner this year.

Jeux de la Francophonie opened in Beirut. Credit: UNAIDS/Nabil

The Jeux de la Francophonie (the Francophone Games) have been opened in Beirut by His Excellency Michel Suleiman, the President of Lebanon. The Jeux de la Francophonie is an event where sport and culture combine to foster dialogue and understanding among French speaking nations. The games are organized by a national organizing committee and the l’Organisation Internationale de la Francophonie (OIF).

“Through partnership change can happen,” said Mr Michel Sidibé, Executive Director of UNAIDS. “I am delighted that this year for the first time, UNAIDS is an official partner to the Jeux de la Francophonie. The OIF has shown leadership and a strong commitment to placing AIDS on the games’ agenda.”

Abdou Diouf, Secretary-General of La Francophonie addresses the opening ceremony
Credit: UNAIDS/Nabil

Observing the opening ceremony, Mr Sidibé noted the ability of the event to unify people all over the world. “The games, with their unique approach of merging sport and culture, have created a space for the open and respectful dialogue needed to challenge the taboos often surrounding issues pertaining to AIDS,” said Mr Sidibé.

Empowering young people to protect themselves from HIV is one of UNAIDS nine priority areas in the Outcome Framework 2009-2011.

In the Jeux de la Francophonie young athletes and artists of the French-speaking world are given an opportunity to meet through sporting and cultural events. The games have an ambition to foster dialogue and understanding among participants as well as spectators. It also aims to encourage young athletes and artist to contributing to international solidarity and gender equality, as well develop artistic exchanges between francophone countries.

"La Francophonie contre le sida - Francophone countries against AIDS"

Across the city of Beirut UNAIDS Goodwill Ambassadors Michael Ballack and Emmanuel Adebayor feature on 100 billboards with the powerful message “La Francophonie contre le sida” (Francophone countries against AIDS).
Credit: UNAIDS

In a joint campaign, across the city of Beirut UNAIDS Goodwill Ambassadors Michael Ballack and Emmanuel Adebayor feature on 100 billboards with the powerful message “La Francophonie contre le sida” (Francophone countries against AIDS). The UNAIDS logo along with other partners to the Games, is displayed by the organizing committee within the Chamoun stadium, visible to an expected 200, 000 spectators and 50 million people following the games via broadcasting. 

Through the partnership, UNAIDS aims to raise awareness on AIDS issues and to help inform young people how to protect themselves against HIV infection.

With 7,400 new HIV infections daily worldwide and young people aged 15-24 accounting for 45% of these, empowering young people and raising awareness of the epidemic is seen as a key to bring about change.

Running from the 27 September to 6 October, the Jeux de la Francophonie brings together 70 countries from all over the world.

UNAIDS and cosponsors UNICEF, UNFPA and WHO have joined the Centers for Disease Control and Prevention, UNIFEM and private sector supporters through the Clinton Global Initiative to address the injustices and health impact of sexual violence against girls. The initiative, launched in New York by the partners, will focus on countries where sexual violence is a key initiation point for the spread of HIV and other infectious diseases.

Partners of the initiative will come together to conduct research in seven countries using the methodology piloted in Swaziland in 2007 by UNICEF and the Centers for Disease Control and Prevention (CDC).

In collaboration with World Health Organization, UNICEF and CDC will use the survey results to develop a technical package of policy and social interventions, tailored individually for the countries in southern Africa, Asia and the Pacific regions.

 “While it is generally known that sexual violence against girls is a global problem, very limited data exist on the extent of this problem in the developing world. Obtaining valid data is a key step toward mobilizing policy and other positive interventions,” said Dr. Rodney Hammond, Director of the Division of Violence Prevention in CDC’s Injury Center.

“Sexual violence against children is a gross violation of their rights, a moral and ethical outrage and an assault on the world’s conscience,” said Ann M. Veneman, Executive Director of UNICEF. “Sexual abuse can lead to lost childhoods, abandoned education, physical and emotional problems, the spread of HIV, and an often irrevocable loss of dignity and self-esteem.”

“Sexual violence against girls increases their vulnerability to HIV infection and must be stopped,” said Michel Sidibé, UNAIDS, Executive Director. “AIDS responses must include programmes to stop sexual violence as an integral part of HIV prevention and treatment programmes.” 

2007 Swaziland survey

In 2007 CDC, UNICEF and several local institutions partnered to implement a national survey on violence against girls and young women in Swaziland. Swaziland has the highest prevalence of HIV among adults globally. The survey showed that approximately one-third of girls had a history of sexual violence.

This survey led to a series of policy and legislative interventions in the country, including establishment of the nation’s first Sexual Offenses Unit for children, and a push for legislation against domestic violence and sexual offences.

According to WHO, in 2002 approximately 150 million girls experienced some form of sexual violence. Research demonstrates that violence occurring early in life affects neurological and cognitive functioning, and triggers multiple negative impacts, including sexual disease transmission, drug and alcohol abuse and psychological distress.

Stopping violence against women and girls

The Centers for Disease Control and Prevention (CDC) and UNICEF are the lead organizations in new this initiative, with partners including the CDC Foundation, the Nduna Foundation, Grupo ABC, WHO, UNAIDS, UNFPA and UNIFEM.

Stopping violence against women and girls is one of the nine priority areas of UNAIDS as described in the UNAIDS Outcome Framework (2009-2011). UNAIDS with its cosponsors will leverage the AIDS response as an opportunity to reduce sexual violence and support the initiative partners’ efforts to develop comprehensive responses to sexual violence and HIV prevention and treatment within and beyond the health sector. UNAIDS will provide funding to support this issue.

Clinton Global Initiative

The Clinton Global Initiative (CGI) has served as the central convening body for bringing together the lead organizations and key partners. CGI venues served as the critical link for engaging new partners and it has also served as the key forum for the steering committee overseeing this effort, and as a mobilizing force for raising public awareness and leadership commitment.

UNAIDS Executive Director Michel Sidibé has been in New York this week for a series of events and meetings.   

Geneva, 24 September 2009 – The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) are optimistic about the results, announced today, of the largest ever HIV vaccine clinical trial held to date.

The study results, representing a significant scientific advance, are the first demonstration that a vaccine can prevent HIV infection in a general adult population and are of great importance.

The two UN agencies congratulate both the principal investigators, sponsors and the trial volunteers who have made this encouraging result possible.

The RV144 HIV vaccine study results, revealing a 31.2% vaccine efficacy in preventing HIV infections are characterized as modestly protective. However, these results have instilled new hope in the HIV vaccine research field and promise that a safe and highly effective HIV vaccine may become available  for  populations throughout the world who are most in need of such a vaccine. No vaccine safety issues were observed in the trial.

Much more work, though, has to be done by the principal investigators and a large group of international collaborators to analyse the trial data, understand the protective mechanism, determine the duration of protection, and map next steps. Licensure at this point in time may not be possible solely on the basis of this study's results, and it remains to be seen if the two specific vaccine components in this particular regimen would be applicable to other parts of the world with diverse host genetic backgrounds and different HIV subtypes driving different regional sub-epidemics. Once an HIV vaccine does become available, it will need to be universally accessible by all persons at risk.

In addition, early HIV vaccines with modest levels of efficacy would most likely have to be used as complementary tools in combination with strategies to promote changes in behavioural and social norms, promotion of correct and consistent condom use, access to safe injection equipment, as well as male circumcision.

The Phase III trial, involving 16 395 adult male and female volunteers in Thailand, was a test- of-concept of a novel HIV vaccine regimen with two different candidate vaccines developed by Sanofi-Pasteur and the non-profit organization Global Solutions for Infectious Diseases. The trial was performed by the Thai Ministry of Public Health, sponsored by the United States Army Surgeon General and received funding from the United States National Institute for Allergy and Infectious Diseases and the United States Army Medical Research and Materiel Command, Department of Defense. 

WHO and UNAIDS began supportive work for this trial 18 years ago, in 1991, when Thailand was recommended as one of the WHO-sponsored countries in preparation for HIV vaccine trials and the development of the National AIDS Vaccine Plan. In particular, WHO and UNAIDS through their HIV Vaccine Advisory Committee (VAC) provided continuous technical guidance and advice for review, approval and implementation of the RV144 trial protocol. In 2006, VAC performed an external evaluation of the trial examining various ethical and community-related issues: this evaluation showed that the trial was being conducted at the highest scientific and ethical standards and with active community participation.

Moreover, WHO and UNAIDS, in collaboration with partners, such as the Global HIV Vaccine Enterprise have jointly developed numerous policy documents relating to access to care and treatment for trial participants, design and purpose of test of concept HIV vaccine trials as well as scientific parameters.

WHO and UNAIDS will work with the global HIV stakeholder community to further understand and resolve a range of questions related to the potential introduction of an HIV vaccine of moderate protective efficacy. This includes additional, in-depth trials in different populations with diverse host and virus genetic backgrounds.

Until a highly effective HIV vaccine becomes available UNAIDS and WHO underline the importance of effective and proven HIV prevention methods for all people. A comprehensive HIV prevention package includes, but is not limited to, behavioural interventions to reduce sexual risk practices, including correct and consistent male and female condom use, early and effective treatment for sexually transmitted infections, male circumcision in high HIV prevalence settings, harm reduction for injecting drug users, post-exposure prophylaxis with antiretroviral drugs, and interventions to prevent HIV transmission in health care settings. 

The Unite for Children, Unite against AIDS campaign has produced a short video on the importance of social protection for children

As leaders convene at the G20 summit in Pittsburgh, the Unite for Children, Unite against AIDS campaign, spearheaded by UNICEF and also supported by UNAIDS among other partners, is encouraging a discussion on the role of social protection for children and families affected by AIDS, families like Margaret Nyambura’s.

Ms Nyambura is nearly 70 and she doing her best to care for her five grandchildren in a small house outside Kenya’s capital Nairobi. Ranging in age from five to 14 years old, the children have lost their parents to AIDS-related illness. Making ends meet is a daily battle for Margaret, who does not have a job. Her family is close to destitution and can barely cover expenses for food, shelter and education. She is faced with competing priorities and few resources to deal with them.

Maureen Sakala lives in Lusaka, Zambia, with her mother, siblings and twelve orphaned children, including those of a brother who died of AIDS-related illness. Such families can benefit from increased social protection. Credit: UNICEF/NYHQ2009-0309/Nesbitt

Such a situation is common among impoverished families living in countries hard hit by AIDS. The epidemic can compound poverty when HIV-related needs are pitted against everyday needs, such as food, and long- term investments like education. It can pressure children into becoming breadwinners and caregivers before their time.

Evidence suggests that the current global financial crisis is exacerbating an already precarious situation for these families, who take on approximately 90% of the cost of caring for infected and affected children. There are a growing number of ‘Margarets’. The World Bank has already highlighted a decline in economic growth in the poorest nations  and predicts a drop in the remittances workers send home to their families this year.

UNICEF contends that the economic crisis makes the needs of the millions of children affected by HIV worldwide even more urgent. As Dr Rachel Yates, Senior Adviser on Children and HIV at UNICEF maintains, “the economic crisis has come on top of the existing food and AIDS crises that have already stretched families to the breaking point.” The situation also threatens to undermine children’s fundamental rights to health, survival and a decent standard of living.

As reported in a recent statement from UNICEF and a number of partners, social protection utilizes an array of actions to tackle vulnerability and exclusion. This form of protection enables countries to provide a range of options for safeguarding their most impoverished families against the impact of big, adverse events like a global recession or chronic illness. When it is tailored to the needs of children, this approach is known as ‘child-sensitive social protection’.

As described by Yates, "child-sensitive social protection including cash transfers and family support services has shown to be an effective way of protecting families and children in times of greatest need, including children worst affected by the AIDS epidemic."

Social transfers such as cash payments, pensions, and food stamps can put resources directly into the hands of those who need them most, and are one key component of social protection. For example, Britain’s Department for International Development has been working with UNICEF and the Kenyan government to arrange cash payments for Margaret and her grandchildren, and others like them.

But, as the joint statement also notes, poor and AIDS-affected families require help beyond social transfers alone, and a raft of diverse interventions, ranging from improved social services to supportive policies and laws, and from tackling stigma and discrimination to ensuring that children have the birth certificates they need to go to school, should also be available.

There is an increasing political consensus that strong social protection systems are required to buffer families and communities against the predations of poverty, lack of opportunity and vulnerability to the effects of AIDS. In April 2009, the G20 backed this approach. African Union leaders have also given their support. 

The Unite for Children, Unite against AIDS campaign is calling on leaders at the Pittsburg summit to build on its earlier commitment to social protection -- and to make children a key part of it. It is hoped that world leaders come together to help children and their families and carers in developing countries cope with both the global economic crisis and the AIDS epidemic.

For Chris Desmond of the Harvard School of Public Health and a leading member of the Joint Learning Initiative for Children and AIDS (JLICA), of which UNICEF and UNAIDS are partners, social protection in hard economic times is not a luxury but a necessity:

“There’s always a benefit to social protection.  [It] is in many ways an investment in the future of a country… We need those resources, we need those human resources.  We shouldn’t see social protection in a negative sense, where we’re providing some sort of charitable relief to people.  We’re protecting the assets of our society – human resources are the fundamental assets of our society.”

The partnership agreement was signed by Australian Foreign Minister Stephen Smith and UNAIDS Executive Director, Michel Sidibé, on the eve of the opening of the UN General Assembly in New York, 21 September 2009. Credit: UNAIDS/Brad Hamilton

As a sign of consistent and growing partnership on the AIDS response, UNAIDS signed a multi-annual agreement with the Government of Australia on Monday 21 September 2009.

The agreement includes shared goals and objectives for the cooperation between UNAIDS and Australia in the Asia-Pacific region and includes funding of AUD 25.5 million (approximately USD 22 million) over three years. A commitment for increasing funds to UNAIDS by 16.8 per cent from 2010 is also provided for in the agreement.

The agreement was signed by Australian Foreign Minister Stephen Smith and UNAIDS Executive Director, Michel Sidibé, on the eve of the opening of the UN General Assembly in New York.

“The agreement represents the growing cooperation we have with the Australian Government. We are grateful for Australia’s long-term commitment to HIV and its leadership on AIDS in the Asia-Pacific region,” Mr Sidibé stated during the meeting which took place in New York. “Predictable funding and continuous engagement are of particular importance to the AIDS response in these difficult financial times to ensure that previous gains on AIDS are not reversed.”

The agreement includes shared goals and objectives for the cooperation between UNAIDS and Australia in the Asia Pacific region and includes funding of AUD 25.5 million (approximately USD 22 million) over three years. Credit: UNAIDS/Brad Hamilton

According to Stephen Smith the partnership with UNAIDS is of great value to the Australian Government who is particularly concerned about countries heavily affected by HIV in the Asia Pacific region. Australia’s Foreign Minister also looked forward to his country’s continued and growing collaboration with UNAIDS in supporting national AIDS responses, for example in Papua New Guinea.

The Australian Government’s overseas aid programme AusAID launched a new international HIV strategy earlier this year. “Intensifying the response: Halting the spread of HIV”  was released in April setting priorities that will guide Australia’s international development assistance to tackle the epidemic in the Asia-Pacific region. These priorities include increased and better targeted HIV prevention activities, particularly in high-risk groups; the integration of HIV prevention, treatment and care services into primary healthcare facilities; improved capacity to fund and deliver services; and a review and improvement in laws and policies to ensure people know their HIV status, receive treatment, and can access condoms and clean needles.