By Rodrigo Pascal, UNAIDS Partnerships Officer

Allan Dunaway, Founder and President of Honduras National Association of people living with HIV.

It is indeed sad news to hear of the passing of Allan Dunaway who died in San Pedro de Sula, Honduras on 25 January 2009 at the age of 39.

Allan was one of the earliest AIDS activists in Latin America and he dedicated 18 years to supporting people living with HIV struggle for the right to treatment access in his country.

Allan and his beloved wife Rosa González were the first couple in Honduras to publicly declare that they were living with HIV. They were co-founders of Fundacion Llaves, which provides care and support for people living with HIV and Allan was the founding member and President for two consecutive periods of the Honduras National Association of people living with HIV. He was also the Chair of San Pedro de Sula National AIDS Forum.

The words of his wife Rosa resonate with my memories of Allan as being by nature a quiet person but who was determined to highlight important issues on behalf of others: “Allan never doubted that he had to give a face to AIDS; and he made it clear from the beginning days of his activism that he had a responsibility to speak for those who had no voice.” Allan was tireless in his efforts to make a difference. He reached out to local organizations and community groups building capacity and empowering them to organize events, marches and workshops. He also conducted workshops on managing funds and administration. He believed in the power of collaboration and worked hard to ensure that different organizations were informed of each other's activities and so strengthen the overall impact of their projects.

Allan was an assiduous advocate of human rights and worked closely with the National Commissioner for Human Rights to end discrimination against people living with HIV.

One of the proudest moments for Allan was to hear his 13-year-old daughter Keren deliver a breathtaking speech on behalf of young people living with HIV to thousands of delegates from around the globe at the opening of 2008 International AIDS Conference.

Allan also attended the High Level Meeting in New York in June 2008 when he and Rosa and a group of women living with HIV met with the UN Deputy Secretary-General.

Speaking of the loss, Richard Stern of Agua Buena Human Rights Association said: “Allan was a hero in a political struggle for human rights, but most of all he was a devoted husband and father. He will be sorely missed by all of us who worked with him for so many years.”

This is indeed a sad loss for Rosa and Keren. As a family, the Dunaways have been passionate advocates for universal access to care, support and treatment for those living with HIV, particularly in Latin America. I have no doubt Rosa and Keren by continuing their advocacy will keep Allan’s memory alive.

By Eric Sawyer, cofounder of ACT UP, Housing Works, Inc., & Health GAP, Inc.

Martin Delaney.

Last week we lost one of the true heroes in the response to AIDS. Martin Delaney, the founder and longtime Executive Director of the HIV advocacy/education organization Project Inform, died of liver cancer at his home near San Francisco on January 23, 2009. Marty Delaney was 63.

The world is truly a poorer place after the loss of Martin Delaney. Marty was on the front lines of the community’s response to AIDS from the very beginning of the epidemic. Marty was smart, sweet and quick to move to the side of social justice in any issue he confronted. His vision, energy and un-ending commitment contributed to the development of some of the first effective treatments for HIV opportunistic infections.

In 1985 Martin Delaney founded Project Inform, a national HIV treatment information, public policy and advocacy organization based in San Francisco. Marty created Project Inform because people living with HIV and their loved ones needed access to information to help save their lives; because people who were not infected needed information to stay that way; and because people who cared needed help organizing advocacy campaigns to push the government to find a sense of urgency and a new approach to finding treatments for HIV/AIDS.

Through his work at Project Inform Marty was one of the founders of the community-based HIV research movement and helped to ensure that HIV treatment education becoming widely available to patients, medical providers and anyone who cared worldwide.

He led in the movement to accelerate Food and Drug Administration approval of promising drugs and was a key player in the development of today’s widely used Accelerated Approval regulations and Parallel Track system for providing access to experimental drugs to seriously ill people prior to formal FDA approval.

Mr Delaney was a member of the National Institute of Allergy and Infectious Diseases (NIAID) AIDS Research Advisory Committee from 1991 to 1995, served on NIAID’s National Advisory Allergy and Infectious Disease Council from 1995 to 1998. On January 19 2009, Mr. Delaney received the NIAID Director’s Special Recognition Award for “extraordinary contributions to framing the HIV research agenda.”

In recent years, among many other activities, Mr Delaney led the Fair Pricing Coalition to improve access to HIV treatment, and advocated for an aggressive research agenda to find a cure for AIDS.

Of Marty’s passing, our mutual good friend Larry Kramer (ACT UP and GMHC Founder) said: “He was a great, great, great person. Every single treatment for AIDS is out there because of activists like Marty and Project Inform. I shall miss him very much. He was a dear friend and fellow fighter. He was a phenomenal leader, a brilliant strategist, and an indefatigable caretaker of us all.

For further information about Martin Delaney or Project Inform, please contact Ryan Clary at 415-558-8669 or rclary@projectinform.org.

There is no doubt in the minds of health experts and activists that the official figures hugely underestimate the numbers of MSM living with HIV and newly acquiring HIV infection in Ukraine and elsewhere in the Region. Credit: UNAIDS/S.Dragborg

Judging by the official statistics, cases of HIV infection amongst men who have sex with men (MSM) in Ukraine, as in much of Eastern Europe and Central Asia, are so rare as to seem scant cause for concern.

“No statistics means no problem,” says Zoryan Kis of the All-Ukrainian Network of PLHIV (People Living with HIV). “The fact that the official numbers are very low is a danger for our work because we know that the epidemic exists but it is hidden.”

But there is no doubt in the minds of health experts and activists that the official figures hugely underestimate the numbers of MSM living with HIV and newly acquiring HIV infection in Ukraine and elsewhere in the Region.

In the 20 years since the first case of HIV infection was detected in Ukraine, only 158 MSM have been officially registered as living with HIV in a country with a total population of some 46 million people.

According to the 2007 UNGASS country report Ukraine has the most severe HIV epidemic in Europe, with just over 1.6 percent of the adult population estimated to be living with HIV. In 2007, 17,687 people were reported as newly infected with HIV, up 10 percent from 2006. Among them, the official number of new cases amongst MSM was just 48.

Together with the high degree of stigma attached to MSM in Ukraine, something the country shares with other countries in Eastern Europe and central Asia, this understating of the problem has contributed to authorities’ reluctance to back campaigns of prevention among MSM, activists say.

Beyond the official statistics, there is considerable data on MSM which paints a different picture. Various organisations, including UNAIDS, WHO and the International HIV/AIDS Alliance in Ukraine estimated that in 2006 there were between 177,000 and 430,000 MSM in the Ukraine, of whom between 3 and 15 percent of live with HIV, which is several hundred times the figure reflected in the official studies.

Stigma and discrimination

Official HIV figures in Ukraine, as elsewhere in the region, are based on the results of voluntary HIV testing during which people should normally be asked why they have sought a test.

But in countries where MSM face widespread discrimination and where there is a high degree of stigma attached to male to male sex, there is understandable reluctance on the part of MSM to give the true reason.

“Most of MSM are not open. They would not go and say: ‘I have had sex with men’. They would say ‘I have had risky behaviour, I have been injecting drugs or even I have visited the dentist and I am worried,” says Kis.

And often officials do not press for answers. “I have been tested four or five times, but I have never been asked for my sexual orientation,” Kis adds.

According to the European Centre for the Epidemiological Monitoring of HIV/AIDS, only 1,828 cases of HIV infection in MSM have been officially reported between 2002 and 2006 years in the 15 former Soviet countries making up the World Health Organisation’s Eastern European health region.

Turkmenistan and Tajikistan, report none, while Azerbaijan has only 10 and Belarus 29. The highest number is reported by Russia; but its 1,245 cases over the 5 years compares with more than 38,000 in Britain and 11,000 in Germany in the same period, countries with smaller overall populations.

Prevention services for MSM have improved in the last few years, but they remain significantly inadequate to impact and sustain behavioural change and thus reduce HIV transmission among this group of men in Ukraine.
Credit: UNAIDS/P.Carrera

Ambitious goals

In 2006, Ukraine set ambitious national goals for scaling up towards universal access to HIV prevention, treatment, care and support for groups at high risk of HIV. However, HIV prevention activities in the Ukraine, as in most of the rest of the region, are carried out by NGOs with financial backing from international donors, mainly the Global Fund for AIDS, Malaria and Tuberculosis.

For example, a two-year project called “Men Who have Sex with Men: HIV/STI Prevention and Support” was implemented in Kiev by the AIDS Foundation East-West, the Gay Alliance NGO and Noah’s Ark-Red Cross Sweden, with financial support from the Elton John AIDS Foundation amongst others.

The International HIV/AIDS Alliance in Ukraine, which is co-holder of the Global Fund grants, is currently undertaking 14 projects aimed at HIV prevention among MSM. They include outreach services, provision of information and education around HIV and sexually transmitted infections (STIs), behavioural change communication, promotion of safer sex, condom and lubricants distribution, counselling and rapid-testing for HIV, testing and treatment of STI, self-help groups and anti-stigma trainings.

“The scale and scope of prevention services for MSM has improved in the last few years, but they remain significantly inadequate to impact and sustain behavioural change and thus reduce HIV transmission among this group of men in Ukraine,” says Dr. Ani Shakarishvili, UNAIDS Country Coordinator in Ukraine.

The situation is similar elsewhere in Eastern Europe and Central Asia. For example, there are no state-funded HIV prevention programmes for MSM in Russia.

“Governments everywhere are reluctant to spend money on sex workers, on drug users, but MSM comes at the top of the reluctance list. It is probably the last programmes that the governments will start,” says Roman Gailevich, UNAIDS Regional Programme adviser.

The new programme marks an encouraging change of stance by the government.
Credit: UNAIDS/S.Dragborg

For the first time

Under pressure from international donors and an increasingly vocal and better organised local MSM community, the Ukrainian Government recently agreed to include and set targets for HIV prevention and treatment for MSM as a priority in its National AIDS Programme for 2009-2013.

“This change stems from comprehensive surveys in the community which show the real role of MSM in the HIV epidemic in Ukraine,” says Anna Dovbakh, head of team: policy & programme development at the International HIV/AIDS Alliance in Ukraine.

“Since 2005, activists of the LGBT (Lesbian, Gay, Bisexual and Trans-sexual) community have become more active and professional in their HIV advocacy and response,” she adds.

Activists and health experts say that the new programme, which is currently before the Parliament, marks an encouraging change of stance by the government.

But the jury is out on what real difference it will make, not least because the money for HIV prevention will continue to come from the Global Fund and other donors.

“The lack of Governmental commitment to provide resources, support and services for MSM and to address the existing legal, financial and administrative barriers to service access for MSM indicates that the Government of Ukraine is still not fully prepared to address the HIV epidemic in MSM,” says Shakarishvili.

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(from left) UNAIDS Executive Director Michel Sidibé and UN Secretary-General Ban Ki-moon, 22 January 2009.
Credit: UN

Michel Sidibé was sworn in as new Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) by Secretary-General Ban Ki-moon at UN Headquarters in New York yesterday. Mr Sidibé took up his post as head of UNAIDS and Under Secretary-General of the United Nations on 1 January.

After taking the oath of office, Mr Sidibé had the opportunity to share his vision for a re-energized global AIDS response with Mr Ban. Accelerating the work on universal access to HIV treatment, prevention, care and support is Mr Sidibé’s top priority for UNAIDS.

Secretary-General Ban Ki-moon stressed his readiness to support Mr. Sidibé, saying: "I want to assure you of my full support in your new role as Executive Director of UNAIDS. I have no doubt your decades of experience with UNICEF and UNAIDS, including in the field, will be an asset to the fight against HIV."

"I am deeply committed to the fight against HIV on a personal level. I have—and will continue—to speak publicly about the importance of making universal access to preventive treatment, care and support a reality by 2010," said Mr Ban.

Mr Sidibé took the oath of office from Secretary-General Ban Ki-moon, 22 January 2009. Credit: UN

The Secretary-General also encouraged Mr. Sidibé "to seek bold measures" to ensure that people, irrespective of their life choices, get access to services. "We must therefore continue efforts to eliminate stigma and discrimination against people living with HIV and uphold their rights—including their right to travel."

Credit: UN

Thanking the Secretary-General for his exceptional commitment to AIDS, Mr Sidibé asked for his continued leadership in addressing critical challenges and barriers, especially those in achieving universal access and pledged to fulfil the mandate given to him by the Secretary-General.

Sidibe described UNAIDS as an organization with a soul. "UNAIDS is committed to solid teamwork with the Cosponsoring agencies and other partners in order to connect the United Nations with people," said Mr Sidibé.

China announced in 2008 plans for an extensive programme to tackle sharply rising rates of HIV amongst men who have sex with men (MSM)
Credit: UNAIDS

China announced in 2008 plans for an extensive programme to tackle sharply rising rates of HIV amongst men who have sex with men (MSM), in the latest sign that the country may be starting to face up to a crisis which long seemed taboo.

Announcing the MSM campaign, the ministry of health said that risky sexual behaviour was the biggest single factor behind the spread of HIV in mainland China, excluding Hong Kong, and that men who had sex with men were now the group most likely to become infected with the virus. In China there are around 700,000 people living with HIV, and 11.1 percent of these are MSM.

“In the past between 1 and 3 percent of MSM on the mainland had HIV; Now it is anywhere from 2.5 to 6.5 percent”, Hao Yang, deputy chief of the ministry’s disease prevention and control bureau, was quoted as saying by the China Daily.

The campaign involved targeted prevention measures for the estimated 5-10 million- Chinese MSM, including stronger promotion of condom use, expanded coverage and quality of HIV prevention activities, increased access to voluntary HIV counselling and testing services, and improved access to treatment for sexually transmitted infections.

As a starting point for its new large-scale campaign to reduce HIV among MSM, China is aiming for some 21,000 MSM to be HIV-tested in order to be able to establish a clearer statistical baseline for the infection rate. This is the largest such study undertaken anywhere in the world and the first of its kind in Asia.

Its prevention effort will involve MSM community based organizations (CBOs) and civil society at all levels. Community-based organisations are carrying out AIDS awareness campaigns, VCT referrals, peer education, safer sex promotion and condom distribution; hot-lines are being run and internet chat rooms and websites used.

UNAIDS, the joint United Nations programme on HIV/AIDS, sees the empowering of MSM and other marginalized groups to protect themselves from HIV as one of the main elements of the global AIDS response.

"The Chinese government has made addressing HIV prevention among MSM a priority and that is something which UNAIDS welcomes," said Bernhard Schwartlander, UNAIDS Country Coordinator in China.

In most Asian countries MSM remains an uncomfortable subject: in many of them, sex between men is illegal and reports of harassment are frequent.
Credit: UNAIDS

But despite progress in China, a number of shortcomings remain, with stigma and discrimination still all too prevalent amongst the general population and even within the MSM community itself.

It is estimated that by late 2007, only 8 percent of MSM had been reached by comprehensive HIV prevention interventions. Furthermore, more than half of China's MSM have more than one sexual partner but only between 10 and 20 percent of them use condoms, according to health ministry estimates.

“It is critical that the government and the many MSM working groups find ways to improve their ability to work together in open and nondiscriminatory partnerships", said Schwartlander.

Largely ignored

Developments in China come amidst indications that governments elsewhere in the Asia-Pacific region are also becoming more willing to acknowledge an epidemic that many had previously largely ignored.

In most Asian countries MSM remains an uncomfortable subject: in many of them, sex between men is illegal and reports of harassment are frequent. As a result, there has been little in the way of specific support for programmes for MSM.

“A lot of attention is being drummed up, but a lot more needs to happen,” said Paul Causey, a Bangkok-based consultant working with the Asia Pacific Coalition on Male Sexual Health (APCOM) and the United Nations on MSM-related issues.

Most Asian men who have sex with other men are not open about their sexual behaviour. Social taboos and discrimination mean that many opt to disguise their sexual preferences; for many others, their sexual practices with other men may only be a small part of social roles they play or their sexual lives. Given that many men who have sex with men also have sex with women, high HIV rates among MSM can also translate into substantial numbers of women at risk of exposure to HIV.

The combination of high numbers of partners with high-risk behaviour such as unprotected anal intercourse has been a key factor behind the accelerating HIV infection rate in many Asian cities.

It said that hardly any Asian country is devoting significant resources to MSM, despite the fact that prevention costs a lot less than treatment. According to the commission, $1 invested in effective prevention can save up to $8 in treatment expenditure for expanding epidemic countries.

Most Asian men who have sex with other men are not open about their sexual behaviour. Social taboos and discrimination mean that many opt to disguise their sexual preferences.
Credit: UNAIDS

Engaging community groups

The tipping point in awakening to the dimension of the MSM crisis was the convening of a special conference in New Delhi in September 2006 entitled “Risks and Responsibilities: Male Sexual Health and HIV in Asia and Pacific”.

The conference was truly tripartite, bringing together governments, donors and 380 members of community groups. As important as the event itself was the run-up, with 16 countries holding UNAIDS-sponsored preparatory meetings. In some cases, including that of China, it was virtually the first time that government officials and representatives from the wider MSM community groups met to assess the situation and discuss solutions.

One of the other lasting achievements of that conference was the decision to launch APCOM, which brings together civil society groups, government sector representatives, donors, technical experts and the United Nations to push for an effective response to the rising HIV incidence amongst MSM.

Its efforts complement those of a United Nations technical working group on MSM and HIV/AIDS in China launched in mid-2006. The group is led by the United Nations Development Programme (UNDP).

“The technical working group is working with government, MSM community groups and donors to improve co-ordination and communication, build government capacities to involve civil society organisations (CSOs) in policy-making and public service delivery, and develop the institutional and professional capacities of CSOs,” said Edmund Settle, HIV manager for UNDP in China.

photo credit:

According to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) 2009 Annual Report, PEPFAR has exceeded its five-year goals for treatment of two million and care of ten million people.

PEPFAR has supported life-saving HIV treatment for more than 2.1 million men, women and children worldwide. It also supported care for more than 10.1 million people affected by HIV, including more than 4 million orphans and vulnerable children.

On 12 January Secretary of State Condoleezza Rice delivered opening remarks for the release of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) 2009 Annual Report to Congress. The report outlines the dramatic successes PEPFAR has had in the AIDS response and highlights the programmes’ achievements through its partnerships with host nations around the world.

In 2003, United States President George W. Bush launched the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to tackle the global HIV epidemic. It was the largest commitment by any nation to combat a single disease in history. Through PEPFAR, the U.S. Government has provided $18.8 billion in HIV funding, and the U.S. Congress has authorized up to $48 billion for AIDS, tuberculosis and malaria over the next 5 years.

In the financial year 2008, PEPFAR provided $1.6 billion in support of HIV treatment programmes, in the programme’s focus countries and approximately $712 million to support prevention activities.

U.S. Global AIDS Coordinator, Ambassador Mark Dybul, highlighted the strengthening of health systems as another success of the President’s Emergency Plan. “The data that are available suggest that this intervention in HIV/AIDS is actually building the health care for other areas and having a spillover effect.”

Aside from the individual pain homophobic attitudes inflict, the continuing stigma attached to same-sex relations is complicating hugely the task of slowing the spread of HIV. Credit: L. Tanabe, National STD/AIDS Programme, Brazil

Every two or three days a person is killed in Brazil in violence connected with his or her sexuality, according to Brazil’s oldest gay rights association, Grupo Gay da Bahia (GGB). In Mexico, the reported figure is nearly two a week.

Most of the victims are men who have sex with other men (MSM) -  whether they are gays or bisexuals -  or transgender people.

But if Brazil and Mexico top the table of violence against men who have sex with men in Latin America, this may be because rights groups there monitor the situation more closely than elsewhere in Latin America. Much violence simply goes unreported elsewhere, gay activist organizations say.

“Brazil and Mexico are the only countries which have a register, which keep track of the murders. That does not mean necessarily that there is more violence there,” says Arturo Díaz Betancourt of the Mexican National Council for the Prevention of Discrimination.

It is notable that when the United Nations Special Rapporteur on Extra-Judicial Killings made an official mission to Guatemala in 2006 his attention was drawn to a series of murders of gay and transgender people, and his subsequent report to the Human Rights Council stated “There has been impunity for murders motivated by hatred towards persons identifying as gay, lesbian, transgender, and transsexual. Credible information suggests that there were at least 35 such murders between 1996 and 2006. Given the lack of official statistics and the likely reticence if not ignorance of victims’ family members, there is reason to believe that the actual numbers are significantly higher.”

Many Latin American countries boast socially advanced legislation when it comes to defending sexual freedom and orientation. With law reform in Nicaragua and Panama over the past 12 months, there are now no states in Latin America which criminalize homosexual relations, for example.

Yet perhaps influenced by a lingering “machismo”, prejudice and discrimination continue to flourish, whatever the laws say. Latin America is widely regarded as having a long way to go to successfully counter homophobia, or “fear or hatred of homosexuals.”

“There is a real contrast between reality and theory. This is the developing region of the world with the highest number of laws against discrimination based on sexual orientation,” says Dr. Ruben Mayorga, UNAIDS Country Coordinator for Argentina, Chile, Paraguay and Uruguay.

Aside from the individual pain homophobic attitudes inflict, the continuing stigma attached to same-sex relations is complicating hugely the task of slowing the spread of HIV in a region where sex between men is a leading mode of HIV transmission, health experts say.

Stigma and homophobia increase the isolation of gays, bisexuals and transgender people making them more reluctant to come forward, be identified and get advice.

“Homophobia represents a threat to public heath in Latin America,” the Pan American Health Organization affirmed in a report. “This form of stigma and discrimination based on sexual orientation does not just affect the mental and physical health of the homosexual community, but contributes to the spread of the HIV epidemic.”

UNAIDS has long campaigned against discrimination whether against those infected by the HIV virus or against a person for his or her sexual orientation.

Main source of new HIV infections

Stigma and homophobia increase the isolation of gays, bisexuals and transgender people making them more reluctant to come forward, be identified and get advice. Credit: L. Tanabe, National STD/AIDS Programme, Brazil

The urgency in Latin America is underlined by official reports on the state of the HIV epidemic in Colombia, Ecuador, Bolivia and Peru where sex between men is acknowledged as being the main source of new HIV infections. HIV prevalence is far higher than in the general population with rates of between 10% and 20% in many Latin America’s main cities.

In its 2008 report to the UN General Assembly (UNGASS) on the state of the HIV epidemic, Brazil stated that MSM are 11 times more likely to be HIV positive than the population as a whole.

In parts of Central America, where there is major political and social resistance to recognising the rights of gays, lesbians and transgender people, HIV incidence rates amongst MSM are particularly high.

And the impacts of these high rates of HIV extend beyond men who have sex with men themselves. In Peru, for example, most women who get infected by the virus get it from men who have had sex with other men, according to a Health Ministry study, thus prevention among MSM is crucial for effective prevention of HIV transmission to women.

Prevention fails to keep pace

Spending on HIV prevention amongst MSM in Latin America is well below what is called for by the extent of the epidemic within that group. On average, less than 10% of the money spent on prevention goes into campaigns aimed specifically at MSM, according to UNAIDS.

In Bolivia, it was estimated in 2005 that fewer than 3% of MSM had access to prevention services, compared with 30% coverage for sex workers.

“All these years, prevention has not been carried out where it needs to be, which is where the epidemic lies,” said Díaz. “They have not worked with gays, with trans (gender people), on the contrary there is rejection and deep discrimination,” he said, referring to the situation across the region.

The explanation lies in a mix of political, cultural and even religious factors, rights activists and health officials say.

“Politically, MSM is not something to make a lot of noise about. In most countries and by many institutions it is not sees as a political gain,” says Mayorga.

Religious groups, whether Roman Catholic or evangelical, which regard sexual relations between people of the same sex as “sinful” have often strenuously opposed attempts to pay special attention to MSM.

“Governments are highly influenced by religious sectors that mobilise against policies that benefit gays, bisexuals or trans,” says Orlando Montoya, who works in Ecuador with ASICAL, an organization promoting the health of gays, other MSM and lesbians in Latin America.

However, it is hard to generalize. Some churches have been at the forefront of outreach to men who have sex with men and many local religious organizations in Latin America have responded to HIV with tolerance and compassion, including among the most marginalized populations.

Internationally overlooked

But it is not just a question of country governments not paying due attention to MSM. Latin America has not attracted the level of international investment in stemming HIV epidemics that has been seen in other parts of the world -- in Asia and in Africa.

To some extent, the region has been victim of the three “nots” when it comes to receiving international financing for its HIV efforts, Mayorga says. It is ‘not’ very populated, it is ‘not’ very poor and it is ‘not’ a very big epidemic.

Rules covering assistance by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the principal international financing arm against the diseases, have worked against the region because they have tended to exclude middle and upper middle income countries, such as Argentina and Chile.

However, the Fund has recently agreed to study proposals for assistance for programmes in better-off countries facing concentrated epidemics with HIV prevalence rates of over 5 % in groups at risk, such as MSM, drug users, transgendered people or sex workers.

Renewing the focus

In the face of the persistent evidence of neglect, there are some positive signs in the region that MSM epidemics will be responded to with more adequate measures and policies.

In the past four or five years, Brazil and Mexico, and to a more limited extent Argentina and Colombia, have run campaigns against homophobia. These countries, together with others, have also sought to incorporate special MSM action into programmes to contain the spread of HIV.

The official programme “Brazil without Homophobia” was launched in 2004, with the aim of improving the service given to gays, other MSM and transgender people within state health institutions. It will also scale up coverage and the response to the HIV epidemic within these groups.

Peru has launched a national plan giving priority to prevention programmes for what are defined as “most-affected” groups – which include MSM, sex workers and prisoners. With financing from the Global Fund, the plan aims to extend prevention coverage to at least 25% of MSM and 50 percent of sex workers.

Similarly, Bolivia has drawn up a national plan to cut HIV infection rates by half by 2015, which includes campaigns to strengthen rights of MSM and transgender people and to combat discrimination and stigma.

Despite these promising developments, Latin America is still a long way from getting its MSM epidemics under control and homophobia and stigma remain significant stumbling blocks to achieving it.

Know your epidemic, understand the politics

For every two people accessing HIV treatment, another five are newly infected with the virus. Given the gap, there is broad agreement among scientific, government and civil society communities on the need to intensify HIV prevention efforts.

UNAIDS promotes HIV prevention responses that are tailored to local contexts and are evidence-informed through epidemiological analysis, behavioural data and an understanding of social and gender norms.

According to an editorial published last year in the Journal of the Royal Society of Medicine, “knowing your epidemic” is in itself not enough to act upon it. The December 2008 article, co-authored by Michel Sidibé, UNAIDS, Kent Buse, UNAIDS and Clare Dickinson, HLSP Institute, argued that the failure to appreciate the political dimensions of HIV can frustrate efforts to promote and implement evidence-informed policy.

The authors advocate that analysis identifying the political obstacles and opportunities to evidence-informed policy should constitute a core feature of every national HIV response.

An analysis of 28 peer-reviewed articles reporting on empirical studies of policy change in low and middle income countries was published by the HLSP Institute in October 2008. The findings aimed to help advocates and policy-makers take more strategic decisions about future policies and their implementation.

Viet Nam’s rapid economic development and growth over the last decade has resulted in increased levels of mobility both within the country and across its borders.

Viet Nam’s rapid economic development and growth over the last decade has resulted in increased levels of mobility both within the country and across its borders. Large infrastructure and development projects coupled with industrial growth have encouraged young people and workers from all over the country to move to major cities and provinces.

However, in areas of rapid economic development and increasing internal migration, factors such as separation from family and communities and harsh working conditions contribute to an increased vulnerability of migrants and mobile populations to HIV and other sexually transmitted infections as they engage in unsafe behaviours such as unprotected sex and injecting drug use.

Additionally, as HIV prevention and health care services are not specifically targeted towards migrants and mobile populations these groups tend to have poorer access to such services. This is especially true for migrants and mobile people who are often not registered as residents in the area where they work.

The migrant population includes female sex workers, migrant workers on construction sites, industrial and exporting zones and workers at river ports and bus stations.

Since its designation as an Industrial and Processing Zone in 2002, Can Tho province, in the south western region of the country, has stood out as a magnet destination for migrant workers as it is the largest city in the Mekong River Delta. The number of HIV cases in Can Tho has also increased at least ten fold, from 73 in 1997 to 733 in 2006.

In 2004, the Canada South East Asia Regional HIV/AIDS Programme initiated a project with the Can Tho Department of Labour, Invalids and Social Affairs and the Can Tho Trade Union to undertake HIV prevention activities with migrants working as casual labourers, truck drivers and sex workers. The project established the Far Away From Home Club, which aims to provide a supportive and empowering environment for sex workers and other migrant workers in Can Tho City.

It is estimated that there are 1100–1600 female sex workers in Can Tho province, of whom 400–500 are street-based sex workers; the same authorities place the number of people who inject drugs between 2200–2500.

Peer education

The Club empowers members of mobile populations such as sex workers and internal migrants by providing life-skills training focusing on HIV and other sexually transmitted infections, on AIDS, public speaking skills, gender and sexuality, stigma and discrimination.

A core team of 10 peer educators (five sex workers and five migrant workers) have supported over 60 Far Away From Home Club members; they have received and shared information and skills that reduce their likelihood of exposure to HIV. These members return to their social networks and informally share their knowledge with their peers.

One of the main achievements of the project has been to ensure the confidentiality of all of those who seek help and support from the group. The assurance of complete anonymity and confidentiality has encouraged more sex workers and migrant workers to access health services through the referral of the Club members and peer educators. In particular, referrals were made to a variety of clinics that provide confidential and accessible services for mobile populations, including treatment of sexually transmitted infections voluntary counselling and testing, and general health check-ups.

The club touches the lives of hundreds of migrants and mobile people every month through their engagement of the private sector in workplace interventions or its outreach activities at hotspots for direct and indirect sex workers.

Involving migrants and mobile populations and empowering them to advocate for access to HIV services for their peers has been crucial to the success of the programme. Furthermore, its ethical soundness, relevance and effectiveness have made the project a successful component of the HIV prevention strategies and a reference work targeting migrants and mobile populations.

2008 has been a year of progress, challenge, debate, and change. In this year end review, UNAIDS provides a snapshot of key issues, events, and initiatives that shaped the global AIDS response in the past 12 months.

HIV prevention and treatment efforts lagging behind
	Significant challenges in the AIDS response remain: for every two people put on treatment, five others are newly infected. The total number of people living with HIV has increased to 33 million. Nearly 6 million people are in need of treatment today. Access to pediatric treatment for children is lagging behind, and men who have sex with men, people who inject drugs and sex workers are often ignored by HIV prevention and treatment programmes. WHO/UNAIDS/UNICEF 2008 Universal Access report (pdf, 35 Kb) UNICEF Third Stocktaking Report on Children and AIDS Investing in HIV prevention technologies

Is there a single magic bullet for HIV prevention?
	HIV prevention strategies and programmes have been at the centre of many debates. Various experts have approached it from different angles: the role of multiple sexual partners and concurrent relationships, HIV treatment as prevention, male circumcision, the role of condoms, and delaying sexual debut have been subjects of discussion. UNAIDS has argued that the word “only” doesn’t work for AIDS—whether it is for treatment only, HIV prevention only, condoms only, abstinence only or male circumcision only. In reality all are needed—a truly comprehensive approach. For UNAIDS, the three pillars of a comprehensive and effective AIDS response, as we move towards universal access, are HIV prevention, treatment, and care and support. UNAIDS advocates that countries implement HIV prevention programmes that will be truly effective in reducing new HIV infections. This requires a strategic combination of interventions that address populations that are at risk or vulnerable for HIV transmission and that utilize behavioral and social change methods that are appropriate and informed by the latest evidence. The Lancet special series on prevention UNAIDS’ response to Science article “Reassessing HIV prevention” (pdf, 32 Kb)

Mr Michel Sidibé appointed new UNAIDS Executive Director.
	Michel Sidibe, the current Deputy Executive Director of Programmes for UNAIDS, was appointed the new Executive Director of UNAIDS on World AIDS Day. He assumes his new position in January 2009. Read press release