(from left) Nicolas Sarkozy President of France; Carla Bruni-Sarkozy, First Lady of France and Global fund Ambassador for the Protection of Mothers and Children against HIV/AIDS; Executive Director of the Global Fund, Michel Kazatchkine; Michel Sidibé, Executive Director of UNAIDS. Credit: UNAIDS/B. Hamilton 

Carla Bruni-Sarkozy echoed UNAIDS call to virtually eliminate mother-to-child HIV transmission by 2015 while addressing the UN Secretary General Ban Ki-moon and leaders at a side event to the opening of the United Nations General Assembly in New York. The President of Burkina Faso Mr Blaise Compaoré and the Prime Minister of Ethiopia Mr Meles Zenawi co-chaired the event.

“Around the world only a third of women living with HIV receive the necessary treatment to prevent the transmission. Isn’t it an immense injustice, that thousands of children still are born with HIV, when treatment exists, when no baby needs to be born with HIV?” asked the First Lady of France and the Global Fund’s Ambassador for the protection of mothers and children against AIDS. Ms Bruni-Sarkozy called on global leaders to double the number of HIV-positive pregnant women who receive effective antiretroviral treatment within 18 months.

UN Secretary-General Ban Ki-moon called for a more ambitious approach: “We have effective drugs. There is no reason why any mother should die of AIDS. There is no cause for any child to be born with HIV,” he said. “If we work hard enough we can virtually eliminate mother-to-child transmission.”

(Front row of panel from left): Christina Rodriguez, community member; Carla Bruni-Sarkozy, First Lady of France and the Global Fund’s Ambassador for the protection of mothers and children against AIDS, UN Secretary-General Ban Ki-moon
Credit: UNAIDS/B. Hamilton

Community member Christina Rodriguez, 17 years-old, from New York called for access to services for young people, and shared a moving personal testimony from Keren Gonzalez, 13 years-old, from Honduras, who could not attend the meeting. Morolake Odetoyinbo from Nigeria highlighted the importance of provinding treatment, care and support for mothers living with HIV so that they can stay alive and take care of their children, and called for urgent leadership to deliver on this life-saving commitment.

Other leaders participated in the event including President Sarkozy of France, President Abdoulaye Wade of Senegal, Prime Minister Balkenende of the Netherlands, as well as First Ladies of several countries.

Countries will work with the Global Fund, UNAIDS and UNICEF support to ensure rapid scale-up of programmes to prevent transmission of HIV from mothers to children. The Global Fund will support the switch from single-dose Nevirapine to more effective dual and triple therapy regimens in the next 18 months. More emphasis and funds will be applied to comprehensive programmes addressing reproductive health and the strengthening of maternal and child health services.

Executive Director Michel Sidibé UNAIDS has made the prevention of mothers from dying and babies from becoming infected with HIV a priority and it is one of the nine priority areas in the UNAIDS Outcome Framework 2009-2011.

A report published today by the AIDS, Security and Conflict Initiative (ASCI) provides new evidence and outlines recommendation for actions on the links between security, conflict, peacebuilding and HIV.

The report entitled HIV/AIDS, Security and Conflict: New Realities, New Responses is the result of a three year research programme lead by the ASCI. It brings together and summarizes findings from 29 studies using a variety of different qualitative and quantitative research approaches; the programme engaged research partners in 17 different countries. The studies cover four thematic areas: HIV and fragile states, uniformed services, humanitarian crisis and post-conflict transitions, and cross-cutting issues such as gender, data collection and measurement – as such the report provides key evidence for policy-making.

New approaches needed

Demonstrating the impact HIV has on security, the ASCI report outlines how security crises and security institutions can influence HIV incidence. Importantly, the study indicates that with good policy and appropriate programmes, challenges can be overcome. It recommends 10 ways in which efforts towards peacekeeping, peacebuilding and humanitarian response can integrate HIV issues. These include:  

• Greater attention to the links between violence against women, forced sex, and reaching out to people who control sex workers and sex trafficking.
• Address the gap in HIV services which can appear in the time between relief and development programmes. This can be addressed if HIV prevention, care, treatment and support are integrated into disarmament and demobilization efforts.
• Create awareness on how criminalization of injecting drug use, sex work and men who have sex with men alienate populations at higher risk making them harder to reach with HIV prevention and other health services.
• Explore the possible advantages of a “Command Centered Approach” by placing responsibility for AIDS policy at the highest level of command within the military to allow for armies to achieve both the highest level of effectiveness and best practices in HIV prevention, treatment and care.

Aligning efforts to prevent HIV

Commenting on the new report, Mr Michel Sidibé, UNAIDS Executive Director, said: “these findings underscore the importance of aligning efforts to prevent sexual violence, and HIV prevention – these connections have yet to be well established within the global context of HIV prevention, treatment, care and support.” The UNAIDS Outcome Framework 2009-2011 includes as two of its nine priority areas stopping violence against women and girls as well as removing punitive laws, practices, stigma and discrimination that block an effective response to AIDS. 

AIDS, Security and Conflict Initiative (ASCI)

ASCI is a joint global research initiative between the Social Science Research Council (New York) and Clingendael Institute for International Relations (the Hague), with the aim of  informing policy and programming through strengthening the evidence base and addressing critical gaps in knowledge on AIDS and security.

President of Swaziland AIDS Support Organization (SASO) Mr. Vusi Matgerula addressing the event on behalf of the people living with HIV movement in Swaziland. Credit: UNAIDS/G.Williams

Strengthening efforts towards a stigma-free work environment for United Nations staff living with HIV and their families, UN Plus has launched a new Friends of UN Plus initiative in Swaziland. Keeping up the momentum to break down barriers and silence around HIV in southern Africa, this will be followed by the launch of a similar initiative in Mozambique on September 23.

Friends of UN Plus is a novel initiative by UN Plus, an advocacy and support group comprising staff members who are living with HIV. UN Plus membership in the southern African region has doubled in the last year but many staff members living with HIV still feel fearful of disclosing their status. Although UN Plus has a non-disclosure policy, the reluctance to disclose HIV status reflects high stigma levels in society. The Friends initiative, therefore, is meant to provide a supportive environment to those who have reservations about being openly associated with UN Plus. It aims to be a forum through which the needs of HIV-positive staff and those caring for HIV-positive friends and family can be articulated and addressed.

Dr. Jama Gulaid, UNICEF Representative and UN HIV/AIDS Theme Group chair for Swaziland addressing the launch of Friends of UN+ in Mbabane, Swaziland on 17 September 2009. Credit: UNAIDS/G.Williams

''Today was a bold and decisive step we took for us to launch this initiative.  I am so glad that staff will now have a platform to share safely and a space for outreach.  It does not hurt to help and to reach out.  We can all do something to make life better for those in our families, offices and communities living with HIV," said an HIV positive staff member of the UN in Swaziland.

The country launches are designed to highlight workplace rights and continue the ongoing dialogue on human rights, treatment needs and challenges of people living with HIV. Through training, meetings, treatment literacy sessions and related activities the initiative aims to educate staff members about UN Plus’ contribution towards reduction of stigma and discrimination, promotion of social acceptance and increase of social, legal and leadership commitment for HIV at the UN system workplace.

Group photo of participants at the launch of Friends of UN Plus in Mbabane, Swaziland on 17 September 2009. Credit: UNAIDS/G.Williams

The Swaziland launch included a panel discussion where representatives of people living with HIV answered questions from the local press on issues of equality and rights. Two members of the local media joined the panel to share their experiences of how they cover stories of people living with HIV in a meaningful way.

Friends of UN Plus will operate in tandem with UN Cares, the UN HIV in the workplace programme, the UN Wellness Program and other workplace initiatives and agency-specific programmes that exist at country levels.

UNAIDS Executive Director Michel Sidibé and Prof. Jeffrey Sachs, Director of the Earth Institute, signing the agreement. 21st September, New York.
Credit: UNAIDS/B.Hamilton

UNAIDS and the Millennium Villages Project signed an agreement in New York to strengthen efforts to eliminate mother-to-child transmission of HIV in Africa. The aim of the partnership is to help local governments create “Mother to child transmission-free zones” in 14 ‘Millennium Villages’ across ten African countries.

The Millennium Villages Project, a partnership between The Earth Institute at Columbia University, Millennium Promise, and UNDP, seeks to end poverty by working in rural areas throughout Africa. The new initiative will use the existing infrastructure, human capacity and technical resources in the villages, to help rapidly expand family- and community-centered heath services with focus on stopping new HIV infections among children.

UNAIDS Executive Director Michel Sidibé and Prof. Jeffrey Sachs, Director of the Earth Institute, signed the agreement in the presence of business and African leaders. The ceremony was held under the auspices of President Yoweri Museveni of Uganda and President Abdoulaye Wade of Senegal.

“I salute this partnership to help protect mothers and their children from HIV. This initiative will mobilize resources and generate political will to save young lives, leading to a generation of African children born free of HIV,” said President Wade.

(L to R): President Abdoulaye Wade of Senegal, UNAIDS Executive Director Michel Sidibé, Prof. Jeffrey Sachs, Director of the Earth Institute and President Yoweri Museveni of Uganda.
Credit: UNAIDS/B.Hamilton

Also speaking at the ceremony were Dr Lydia Mungherera, a Ugandan HIV prevention activist representing the organizations HIV+ and TASO. The Executive Director of UNICEF, Ms Ann M. Veneman, the Minister of State of Mali, Mr. Abou Sow; the South African Minister of Health Dr. Aaron Motsoaledi; and Ambassador Eric Goosby, MD, the United States Global AIDS Coordinator participated in a panel discussion at the event.

Each day 1,200 children under the age of 15 are infected with HIV; 90% of these infections occur in sub-Saharan Africa. According to Mr. Sidibe, “In all of Western Europe there were fewer than 100 mother-to-child transmissions (MTCT) in 2007, whereas in sub-Saharan Africa, there were more than 370,000.”

The top priorities outlined in the memorandum include measures to ensure that women of child bearing age avoid getting infected, those that are infected avoid unwanted pregnancy; increase access to antenatal care services; HIV testing and counselling to expectant mothers; and expanded access to HIV prevention and treatment services for children.

The agreement will bring together the Millennium Village Project’s multi-sectoral and science-based development and primary healthcare strategy with UNAIDS’ expertise in community and family-centred prevention strategies in order to create ‘MTCT-free zones’, whose progress will be monitored by both entities.

Executive Director of UNICEF, Ms Ann M. Veneman, South African Minister of Health, Dr. Aaron Motsoaledi, and UNAIDS Executive Director Michel Sidibé.
Credit: UNAIDS/B.Hamilton

“We hope that the creation of ‘MTCT-free zones’ in the Millennium Villages will serve as a model that can be used throughout Africa whereby communities are engaged, men and young people are active partners, and children are born free from HIV,” Mr Sidibé said.
In 2007, there were 2 million children under 15 years living with HIV, up from 1.6 million in 2001 and less than 15% in need of treatment were getting it. In sub-Saharan Africa, only a third of pregnant HIV-positive women received the antiretroviral treatment (ART) to prevent transmitting the infection to their infants, compared with nearly 100% in Western Europe.

Operating in 14 sites in 10 sub-Saharan African countries, the Millennium Villages project has been working with local governments to introduce a model primary health system which will cover approximately 500,000 people.

The Villages work on a model primary health system and include education, nutrition and economic development. The primary health systems include; free services at the point of care; trained professional community health workers; a network of adequately staffed primary clinics; access to a mobile communication network and emergency transport services to facilitate referrals; and a local referral hospital to support second-tier care. The system houses a monitoring and evaluation platform that can readily assess the adequacy, uptake and impact of HIV testing and counselling and family centered HIV prevention services.

UNAIDS Executive Director Michel Sidibé met with Metro TeenAIDS (MTA), a community health organization in Washington, DC dedicated to supporting young people to overcome the impact of AIDS. Credit: UNAIDS/Jati Lindsay

UNAIDS Executive Director Michel Sidibé met yesterday with Metro TeenAIDS (MTA), a community health organization in Washington, DC dedicated to supporting young people to overcome the impact of AIDS.

Currently, 1% of young people ages 13-24 in Washington, DC are confirmed to be living with HIV.

Metro TeenAIDS is the leading youth organization in the Washington DC-metro area focusing all its efforts on the prevention, education, treatment and the unique needs of young people around HIV. Its mission is to prevent the spread of HIV, promote responsible decision making and improve the quality of life for young people living with or affected by HIV. Metro TeenAIDS also provides HIV counseling and testing services to young people. In the last three months alone, over six hundred youth have been tested at MTA.

During his visit, Mr Sidibé met with Mr. Adam Tenner, Executive Director of Metro TeenAIDS, Metro TeenAIDS staff, as well as some of its youth staff who work as peer-educators. Metro TeenAIDS staff gave Michel Sidibé a tour of the facilities, including its youth center Freestyle which is currently being renovated, and took part in a lively roundtable discussion on HIV prevention with youth.

Together, they discussed MTA’s innovative programming, varying from youth leadership and advocacy, text messaging, internet outreach, and other new media social marketing campaigns. One member of the staff, Carmel Pryor, discussed REALtalk DC, a social marketing campaign that has been extremely successful in the District and includes a texting service for free testing information and HIV education.

Some youth and staff had recently traveled to South Africa on a work trip and discussed their experiences. “South Africa looks a lot different from DC, but it’s really, really the same in terms of the scope of the issues and how it affects community” said Nicole Styles, Outreach Coordinator.

During his visit, Mr Sidibé met with Mr Adam Tenner, Executive Director of Metro TeenAIDS, as well as peer-educators working in the program and with youth benefiting from their services. Credit: UNAIDS/Jati Lindsay

With Washington DC having the highest HIV prevalence of any city in the US, at a striking ten times the national average, Mr Sidibé underlined the importance of the work undertaken by Metro TeenAIDS to expand access to youth-friendly health services. “Young people are our window of opportunity. What do we do to accompany them to stay HIV free?” asked Mr. Sidibe.

“The HIV epidemic in the U.S. is part of the global AIDS response” said Mr Sidibé highlighting the fact that young people aged 15-24 account for 45% of new infections worldwide. One of the key priority areas in the UNAIDS outcome framework is empowering young people, and Mr. Sidibé reaffirmed UNAIDS’ commitment to genuine participation of youth in expanding international response to HIV.

Established in 1988, the Metro TeenAIDS has provided education programs and prevention resources to over 200 000 young people, affected family members as well as youth workers in Washington, Maryland and Virginia.

(L to R): Krista Lauer, AIDS Project Los Angeles, Dr Cheikh E. Traoré, Sexual Diversity, UNDP Senior Advisor, Tudor Kovacs, Population Services International, Romania, Ambassador Eric Goosby, U.S. Global AIDS Coordinator and UNAIDS Executive Director Michel Sidibé.
Photo credit: UNAIDS/Jati Lindsay

As part of his official visit to Washington, D.C., UNAIDS Executive Director Michel Sidibé participated in the Forum on HIV, Human Rights and Men Who Have Sex with Men on 16 September 2009. The event was organized by UNAIDS in collaboration with the HIV Policy Working Group on Men Who Have Sex with Men and Other Sexual Minorities, and in cooperation with the Honorable Howard Berman (D-CA) and the Honorable Barbara Lee (D-CA).

The Forum was held to raise attention to the human rights issues that affect men who have sex with men (MSM) and other sexual minorities, as well as the policy and structural barriers that prevent MSM and other sexual minorities from accessing HIV services, including prevention, treatment, care and support.

“We are here because it remains an undeniable fact in all regions of the world—including here in the US—that men who have sex with men lack universal access to HIV services,” said Michel Sidibé.

The meeting also facilitated a conversation on how US policy makers and AIDS organizations could support PEPFAR countries in national AIDS responses that are relevant to men who have sex with men.

“If we are to see a renewed emphasis on human rights in the proposed Global Health Initiative and if we are to see commitment to MSM programming in PEPFAR II—we need to see unwavering leadership,” said Sidibé.

UNAIDS Executive Director Michel Sidibé shared the platform with Ambassador Eric Goosby, U.S. Global AIDS Coordinator. Other speakers included Jaevion Nelson, Jamaica Youth Advocacy Network, Dr Cheikh E. Traoré, Sexual Diversity, UNDP Senior Advisor, Tudor Kovacs, Population Services International, Romania and Krista Lauer, AIDS Project Los Angeles. Evelyn Tomaszewski of the National Association of Social Workers moderated the forum.

Ambassador Eric Goosby, U.S. Global AIDS Coordinator and UNAIDS Executive Director Michel Sidibé during the UNAIDS Forum on HIV, Human Rights and Men Who Have Sex with Men. Washington, September 16, 2009.
Photo credit: UNAIDS/Jati Lindsay

According to UNAIDS, unprotected sex between men accounts for between 5% and 10% of global HIV infections, although the proportion of cases attributed to this mode of transmission varies considerably among countries. It is the predominant mode of HIV transmission in much of the developed world.

Evidence-based research demonstrates that providing HIV services to men who have sex with men helps to reduce the rate of HIV infection among this at-risk group. In many communities taboo and stigma towards men who have sex with men forces them to conceal their sexual practices which in turn may put their female partners at risk of HIV infection. Additionally, criminalizing men who have sex with men excludes them, or encourages them to exclude themselves, from accessing HIV related services out of fear.

In the coming months, UNAIDS and its partners will host a series of events on three high risk, marginalized populations: men who have sex with men, people who inject drugs, and sex workers. These meetings will build understanding of the importance of addressing the human rights needs of marginalized populations within the global AIDS response. The events will address policy and programmatic issues to increase awareness among AIDS policy and advocacy organizations to better address the needs of marginalized populations. The MSM event was the first of this series. UNAIDS will host the next Policy Forum on Sex Workers on 15 October 2009.

Lawrence Makeleni, UN+ plus member in south Africa speaking at the UN+ launch in Pretoria.
Credit: UNAIDS/G.Williams

UN Plus, the advocacy group of United Nations staff members living with HIV, is launching three country groups in Southern Africa – Pretoria, Johannesburg and Lesotho - after an increase in membership of UN Plus in the region. UN Plus members are undertaking a road trip across southern Africa where they will later launch the ‘Friends of UN Plus’ initiative in Swaziland and Mozambique.

UN Plus was established in March 2005 and has full support from the UN Secretary–General Mr Ban Ki-Moon who has met with the group on several occasions. UN Plus brings together HIV positive staff working in the UN system from across regions and agencies. Its membership in the southern African region has doubled in the last year; this region now accounts for 42% of its 158 members. The road trip, which began on 14 September and culminates in Johannesburg on 25 September, celebrates this achievement. It includes visits to South Africa, Swaziland, Lesotho and Mozambique.

Participating in the road trip are UN Plus Coordinator Bhatupe Mhango and UN Plus co-founder Manuel da Quinta. They are accompanied by Dan Maina, the UN Cares Regional Coordinator for Eastern and Southern Africa; Simphiwe Mabhele of the UN SA Wellness programme (International Labour Organizatin) and Lawrence Makeleni, a UN Plus member from South Africa.

Although membership has increased, UN Plus has observed that many UN staff are not open about their HIV status due to high stigma levels, among other factors, associated with HIV. The group, therefore, plans to launch a ‘Friends of UN Plus’ initiative in Swaziland and Mozambique this month as a forum through which the needs of UN staff members living with HIV and those caring for HIV-positive friends and family can be articulated and addressed.

UNICEF representative in South Africa during the launch of UN+ in Pretoria
Credit: UNAIDS/G.Williams

Lawrence Makeleni welcomed the initiative, saying, “There is a strong need to provide hope and mobilise support to UN staff who are living with HIV and not open about their status. Being the only staff living openly with HIV [in South Africa] I believe that advocacy and working together in an efficient and organised way will provide others the ability to be more open about HIV.”

The South Africa and Lesotho chapters of UN Plus follow similar launches in Malawi and Kenya. In 2007, its members had agreed to start UN Plus groups at country level if at least two or more members were active and at least one had openly disclosed their HIV status, although UN Plus does not force its members to declare their status outside the group. In accordance with this principle, there are at least three active members of UN Plus in South Africa and Lesotho.

Dr. Catherine Sozi, UCC south Africa pins the UN plus badge on the lapel of UNODC Representative in South Africa and Resident coordinator a.i. Mr. Jonhatan Lucas marking the official launch of UN+ in South Africa.
Credit: UNAIDS/G.Williams

With this launch, UN Plus aims to initiate dialogue on the rights of people living with HIV and highlight the work of the UN in providing such a platform. It also expects to get a more formal recognition of its activities and membership and ensure that UN staff members in the region are more sensitised and committed to providing an enabling environment with zero tolerance for stigma and discrimination against people living with HIV. UN Plus currently represents 28 agencies and 41 countries. The group offers an opportunity for members to share their experiences of positive living and survival skills, treatment, care and support, stigma and discrimination and other issues regarding HIV. It also monitors how well their specific work environments respond to the UN Personnel Policy on HIV and AIDS.

There are an estimated 5.7 million people living with HIV in South Africa. In Lesotho that number is close to 270,000, or 23.2% of its population.

A version of this story was first published at www.unodc.org

AIDS activist Loon Gangte raises awareness of HIV and Hepatitis C co-infection

Loon Gangte is President of the Delhi Network of Positive People (DNP+) and a strong advocate of HIV and Hepatitis C (HCV) prevention. In an interview with the Regional South Asia office of the United Nations Office on Drugs and Crime (UNODC), he explains why HIV and HCV co-infection, especially among injecting drug users, is an issue needing urgent intervention. He begins with his views on stigma and discrimination.

UNODC: Injecting drug users (IDUs) living with HIV face stigma and discrimination. Why do you think it is important to be open about one's status, as you are?

LG: HIV-positive injecting drug users face a double stigma. They are marginalized and discriminated against on the basis of their drug use as well as their HIV status. In many cases it therefore becomes very difficult for HIV-positive IDUs to be comfortable with themselves. I had been leading a life with drug use for 15 years when I discovered my HIV status in 1998. I could not gather the courage to inform my family for four years because I was concerned about how they would react.

It was difficult to break the news but with the help of the young pastor at the church in Churachandpur, I was able to do so. They were shocked but not surprised.

I think it is very important to be open about one's status because it allows you to seek the right kind of medical treatment at the earliest opportunity. Secondly, it encourages others to be open about their own status and seek help. If you don't disclose your status, eventually the one who suffers is you. It is like wearing a tight shoe that hurts constantly but no one is aware of your painful situation. Imagine today if people are not open about their status, there would be no prevention and treatment programmes.

UNODC: Have you personally faced any stigma and discrimination? What is the DNP+ doing to address this problem?

LG: The people I’ve lived and worked with in New Delhi for the past 12 years have been supportive despite knowing my status. However, a couple of years ago, I was patiently standing in a long queue to collect HIV medication in a hospital in New Delhi. It was more than an hour before I finally inched my way to the tiny window and pushed the prescription paper through. During those days, if you were living with HIV, it was stamped prominently 'HIV- Positive', much like a bold seal. Seeing this, the nurse ordered me to the end of the queue again. While I stood back in line, I couldn’t work out why I was being discriminated against. Much later I realized that my HIV-positive status compelled her to single me out and treat me differently. I did not understand this right away since for me being HIV-positive did not mean that my rights have to be taken away. I am like any other person; if you cut my skin it will bleed, I have aspirations, the organs in my body function very much like any other man's. The presence of a tiny virus cannot make anyone take away my fundamental rights.

The Delhi Network of Positive People has been working on treatment advocacy and towards reducing the stigma and discrimination faced by people living with HIV. Whenever any instance of discrimination is faced by members, DNP+, with help from the Lawyers Collective, intervenes and addresses the issue immediately, whether it is at the workplace, hospital, school or in the family. As part of their work they have Positive Speakers who highlight incidents of stigma and discrimination at various conferences as well as in workshops, school meetings, trainings and discussions. This helps bring attention to the issues faced by HIV-positive people. To address self stigma, DNP+ has started a self help group to provide those living with HIV with safe spaces to meet, interact and share experiences. Over a period of time members of the support groups become active members of DNP+ and champion the rights of those who are HIV-positive.

UNODC: You are also living with Hepatitis C infection. Describe your experiences in accessing treatment for HCV.

LG: Having both HIV and Hepatitis C is referred to as co-infection. I was diagnosed with this co- infection two years ago. I have been lucky that I have got funding through the International Treatment Preparedness Coalition for periodic Hep C testing. I am not on treatment currently. Hep C infection spreads rapidly among injecting drug users due to its high infectivity (about 10 times higher than HIV, and—unlike HIV—it can be transmitted by sharing not only needles and syringes, but also other injecting equipment such as water, cotton, etc). Because HCV and HIV have similar routes of transmission (particularly through needle sharing), co-infection is common among injecting drug users. Co-infection causes further complications, accelerates HCV progression and makes HIV treatment more difficult.

At the same time, HCV often presents no symptoms, and the vast majority of IDUs are not aware of their status as this group is not being reached by services and remains outside of the health care system. Thus, for universal access to be fully realized, treatment for HIV and HCV co–infection must be provided.

UNODC: Why is advocating for HCV treatment in India so important?

LG: One study estimates that 92% of injecting drug users is infected with Hepatitis C in India . Rates of HCV and HIV co-infection are high, especially in the north east of the country. The state of Manipur is worst affected . Currently there is no official, national or state-wide surveillance for Hep C in India. I have personally noticed that many of those infected with HIV are also infected with HCV. Despite considerable prevalence, HCV diagnosis, treatment and care are largely inaccessible here.

The biggest challenge is to raise awareness about HCV and HIV co-infection among drug users and health professionals. The test for Hep C is costly and ranges from US $1200 - US $2100 in India. Testing for HCV can be included as part of the anonymous testing for HIV being provided through Integrated Counselling and Testing Centres.

The medications used in HCV treatment, pegylated interferon and ribaviron, are expensive. A six month course costs between US$ 4 000—5 000; the lifetime income of some Indians. Unlike HIV, where first line Antiretroviral Therapy (ART) is provided free, there is no government support or subsidy for HCV treatment. Ironically, in Manipur where HCV and HIV co-infection is high, patients are dying of liver complications, despite treatment with and adherence to ART.

The WHO, UNAIDS and UNODC target setting guidelines for countries now include treatment for Hepatitis B and C as part of the comprehensive package of services for drug users. As always, prevention is key in arresting transmission. The national and public health systems need to be supported to prevent blood-borne transmission and provide HCV treatment, regardless of cost and if possible free of cost: many infected with Hepatitis C cannot afford the cost of testing and treatment. Prices of drugs for HCV have to be drastically reduced.

UNODC works in India on HIV prevention, care and treatment for injecting drug users and prison population. UNODC works with Government counterparts, non governmental organizations, networks of people who use drugs, and people living with HIV and advocates for delivering comprehensive packages of services.

The Center for Strategic and International Studies (CSIS) Global Health Policy Center invited the UNAIDS Executive Director Michel Sidibé to share his vision for the future direction of UNAIDS, including prospects for accelerated global action in support of universal access to HIV services.

In his first public address in Washington D.C. since assuming his position as head of UNAIDS, Mr Sidibé recognized the efforts made by the United States in responding to AIDS, from the gay rights movement of the early days of the epidemic to the PEPFAR programme and the leadership of the Obama administration, and in particular the new comprehensive global health strategy. However, he stressed that “Despite these heroic efforts, HIV continues to outstrip our response.”

“Change is possible,” he stated “but only if we are ready to address the underlying drivers of the epidemic.” Mr Sidibé emphasized the need to take the AIDS response out of isolation and link it to the Millennium Development Goals (MDG). “The AIDS plus MDG agenda provides an opportunity to unite the creativity, determination and momentum of the AIDS movement with movements for other MDGs,” he said. “Surely this will accelerate progress on AIDS as well as other MDG targets—reaping bidirectional benefits and multiplier effects,” he added.

UNAIDS Executive Director Michel Sidibé addressed CSIS, 14 September 2009. Credit: CSIS/Daniel J. Porter

During his presentation, Mr Sidibé took the opportunity to outline UNAIDS strategy for the AIDS response. Mr Sidibé underscored that the “value proposition” of UNAIDS—advocating, brokering and convening—is now more urgent than it has ever been.

As part of his official visit to the country’s capital, Mr Sidibé will meet with representatives of the United States Senate, Congress and Administration as well as with the country’s Global AIDS Ambassador Mr Eric Goosby.

Later in the week, Mr Sidibé will participate in the Forum on HIV, Human Rights and Men Who Have Sex with Men. This event will raise attention to the human rights issues that affect men who have sex with men (MSM) and other sexual minorities. It will also look at the policy and structural barriers that prevent MSM and other sexual minorities from accessing HIV services, including prevention, treatment, care and support.

Vincent was one of the 3,316 DART participants and is also one of the main characters of The DART Story, a newly launched documentary film. Credit: Medical Research Council

Having 12 children and a very old mother to support, Vincent, middle-aged Ugandan single father living with HIV, knows that his death would spell disaster for the whole family. “If I had died, where would these people go?” said VincentN perched on a stool with his legs outstretched

Fortunately, Vincent has survived. He said it is DART that has saved his life. DART, the Development of Antiretroviral therapy in Africa, is the largest HIV treatment trial ever carried out on the world’s second most-populous continent.

The DART trial has recently reached a remarkable finding in HIV treatment: that taking HIV treatment does not have to be accompanied by regular laboratory tests, at least for the first two years.

James Hakim, professor of the University of Zimbabwe Medical School and co-principal investigator of DART, said the health economists in the DART team who have analyzed the trial data have concluded that a third more people could be successfully treated for HIV in Africa if expensive lab tests weren’t used routinely. “The challenge now is for policy-makers to widen availability of ART,” said the professor.

Before, it was believed that a person on HIV treatment should have regular tests, including CD 4 cell counts, a measure of how well the body’s immune system, which is damaged by HIV, is working.

The DART results show that 87% of people receiving HIV treatment without routine blood test monitoring were still alive and well after five years, only 3 percentage points less than in the group that had routine blood test monitoring. This finding suggests that many more people living with HIV in Africa could receive treatment for the same amount of money that is currently spent on routine lab tests used to monitor the effects of antiretroviral therapy.

It could also lead to antiretroviral therapy being delivered safely and effectively by trained and supervised health workers in remote communities where routine laboratory tests are not available due to high costs or poor resources.

Professor Peter Mugyenyi of the Joint Clinical Research Centre in Uganda, also a DART co-principal investigator, agreed that governments now have evidence that expensive blood tests aren’t needed routinely for HIV treatment to be successful and safe. “It also means that treatment could be delivered locally as long as health care workers have the right training, support and supervision,” said Peter, “This could make a huge difference to people who live in remote areas that are many days walk from the nearest hospital or laboratory.”

According to UNAIDS estimates HIV treatment only reached a third of the 9.7 million people in need at the end of 2007. In Africa alone, around 4 million people urgently need antiretroviral therapy but the resources are limited.

The DART Story

Aiming at finding a safe, simple and more economical way of carrying out HIV treatment, the DART trial began six years ago when treatment for people living with HIV was just starting to become more widely available in Uganda and Zimbabwe.

Vincent was one of the 3,316 DART participants that had severe or advanced HIV infection while not having previously had any antiretroviral therapy. He is also one of the main characters of The DART Story, a newly launched documentary film narrated by Annie Katuregye. The narrator herself, whose husband died of AIDS-related illnesses seventeen years ago at the age of 34, joined the DART trial in Uganda in 2003.

Annie Katuregye joined the DART trial in Uganda in 2003 and is the narrator of the film The DART Story. Credit: Medical Research Council

Like all the other DART participants, Annie and Vincent
randomly allocated to one of two groups. People in the first group received antiretroviral therapy and their doctor was given the results of blood tests done every three months to check for drug side-effects and measure their CD4 cell count. People in the second group had the same antiretroviral treatment and the same blood tests done, but their doctors did not see CD4 count results and only saw the results of safety tests if they were seriously abnormal. People in both groups received free medical care and free diagnostic tests for episodes of illness throughout the trial.

Besides the only 3-percentage-point difference in survival, 78% of the people who survived in the first group had developed no new AIDS-related illnesses, compared with 72% in the second group. No difference in the occurrence of side effects caused by antiretroviral treatment was found between the two groups.

Moreover, irrespective of group, the survival rate in the DART trial is amongst the best reported from any trial, antiretroviral therapy programme or study in Africa. Historical comparisons, based on data from follow-up of similar patients in Uganda who did not have access to antiretroviral treatment make it clear that few of the DART participants would have been alive after five years without treatment.

Sponsored and funded by the UK Medical Research Council, the DART trial was collaboratively carried out by scientists and health care workers from Africa and the United Kingdom. With an original purpose of finding out whether the lab-based strategies used to deliver antiretroviral therapy to people with HIV infection in resource rich countries were essential in Africa, DART has hit its target.