Tatiana Semikop’s story begins in 1994 when she was working as a criminal police officer in Odesa. That was the year Tatiana met an 11-year-old boy living with HIV who did not know who or where to turn to for help and support. At the time Tatiana knew very little about AIDS but wanted to help the boy, so she set out to learn more and to find out how he could get support. However, the more Tatiana looked, the more she realized there was little available.

“I was shocked,” said Tatiana. “I couldn’t believe that no-one in the oblast or even the city could give me the information I was looking for, no-one seemed to know anything, it was as if the disease didn’t exist,” she added.

Finding out more

During her efforts to find out more about AIDS, Tatiana heard about a workshop being organized by UNAIDS to provide on HIV prevention for law enforcement groups. Through this workshop she gained vital knowledge on the complex issues related to AIDS in Ukraine and the different kinds of interventions needed in the country to help stem the spread of the disease.

Ukraine is facing the most severe AIDS epidemic in Europe. At the end of 2005, nearly 400,000 people were living with HIV in Ukraine and adult HIV prevalence was estimated at over 1.4%. Ukraine’s epidemic is primarily concentrated among people considered to be most ‘at-risk’—and 60% of the people living with HIV inject drugs.

“Using non-sterile injecting equipment is the major driver of the AIDS epidemic in Ukraine,” said Anna Shakarishvili, UNAIDS Country Coordinator in Ukraine. “More than 45% of new HIV infections reported in the first half of 2006 were in people who inject drugs. But sexual transmission of the infection from drug users is also rapidly increasing and the number of children born to HIV positive mothers continues to rise,” she added.

Unprecedented approach

Through her police work, Tatiana encountered injecting drug users on a regular basis and to her it made sense to start focusing her HIV prevention work here. With her help, Ukraine’s first projects to reduce harm from injecting drug use were initiated and implemented.

A unique feature of the programmes was the cooperation with the law enforcement groups and an agreement by Odesa’s Mayor to say these activities could take place—a groundbreaking move for the country at that time.

“We couldn’t believe that we had really dared to take such an unprecedented and unique approach to tackling the epidemic,” said one of the seven members of the small team who started the pilot project. “This had never been done before in Ukraine,” she added.

From these modest beginnings, today there are programmes focusing on injecting drug users and HIV across Ukraine which have become commonly recognized and respected HIV prevention tools.

Twelve years later

Twelve years since first encountering the issue of AIDS, Tatiana Semikop has moved up to the ranks of police lieutenant-colonel, is an author of a scientific dissertation on the psychological characteristics of police work relating to AIDS, and is the Chairwoman of one of the most efficient non-governmental HIV-service organizations in Ukraine – Vera, Nadezhda, Lubov (“Faith, Hope and Love”). In March this year Tatiana Semikop received her second ‘Woman of the Year’ award from law enforcement groups in Odesa for her continued commitment and dedication to the AIDS response.

Inspired by their mother’s example, Tatiana’s children have followed in her footsteps. Her 16-year old daughter Nina, gives lectures on AIDS at her secondary school, participates in various projects and writes articles on AIDS for a city newspaper. Her 24 year-old son Evgeny has already become a coordinator of one of the HIV-service projects in Odesa.

Vera, Nadezhda, Lubov

Tatiana’s organization Vera, Nadezhda, Lubov provides a variety of services across Odesa and neighbouring districts –-including a special mobile voluntary counselling and testing outlet that tests female sex workers for HIV and sexually transmitted infections at the site of their work; and helps women who have suffered domestic violence.

The organization has more than 100 members and provides information services and training on AIDS and other related issues at educational institutions around the city and in the rural areas. Vera, Nadezhda, Lubov also publishes a newspaper for people who inject drugs, sex workers and people living with HIV.

Tatiana is particularly proud of the creation of a community centre for people living with HIV and people most at risk of HIV infection. “We organise nature trips, holidays and we have special visiting photo exhibitions, a self help group and a social club,” she said.

Working on AIDS issues has become a source of inspiration for Tatiana and her colleagues. Many of the organization’s employees have personal experiences of drug addiction and came to know about the organization when seeking support. Now, having received training and professional experience, they have become indispensable employees, committed to helping others going through similar life situations.

“The explanation for our success is very simple,” said Tatiana. “We believe in what we are doing, and we see the fruit of our efforts every day.”

Links:

Read more on Ukraine
Read more on the European AIDS Conference: Responsibility and Partnership – Together against HIV/AIDS 

Photo credit:UNAIDS/ICC

Amidst celebrations at the opening of the ICC Cricket World Cup in the Caribbean on Sunday 11 March, players and spectators around the world were asked to reflect on the lives of children and young people living with and affected by HIV in the region.

The message came as part of joint efforts between the International Cricket Council (ICC), UNAIDS, UNICEF and the Caribbean Broadcast Media Partnership on HIV/AIDS (CMBP) to draw attention to the issues facing children and young people affected by HIV and to highlight the need to step-up action on AIDS in the region.

The Cricket World Cup is the highlight of the cricketing year. More than two billion television viewers are expected to tune in over the next seven weeks to watch 16 teams battle it out for a place in the World Cup final, to be held in Barbados on 28 April.

AIDS-awareness activities

Through a number of activities to be held over the next seven weeks, the public, especially young people aged 15-24, will get information on stigma and discrimination around HIV and on how to protect themselves against the virus. The partnership is part of the ICC’s commitment to promoting the ‘Spirit of Cricket’ and its positive impact on society and its commitment to support the Unite for Children, Unite against AIDS campaign launched in 2005 by UNICEF, UNAIDS and other partners.

“The spirit of cricket is a special part of our game and is a concept that stretches beyond the boundaries of the outfield,” said ICC President Percy Sonn. “We hope the range of activities delivered at the ICC Cricket World Cup 2007 will make a difference to raising awareness and reducing stigma around HIV in the Caribbean and across the ever-growing cricket world,” he added.

A series of video messages supporting the Unite for Children. Unite against AIDS campaign by 28 of the world’s top cricketers, including Australian captain Ricky Ponting and Indian captain Rahul Dravid, will be broadcast on TV and at the matches.

Photo credit:UNAIDS/ICC

Players and officials from each team will wear the red and blue campaign ribbon during their first games and during the final. Players will also visit programmes in the Caribbean supporting children and young people affected by HIV.

As part of the events around the World Cup, the Caribbean Broadcast Media Partnership on HIV/AIDS – a coalition of over 50 broadcasters in 23 Caribbean countries and territories – is also launching the region’s first media-led, multi-platform campaign on HIV/AIDS, known as LIVE UP! The campaign aims to inspire the people of the Caribbean, especially young people, to consider what they can do to stem the spread of HIV.

"The exceptional reach of broadcast media in the Caribbean gives us a unique opportunity to educate audiences about how to avoid HIV, and how to combat the stigma and discrimination that surround the disease," noted CBMP Steering Committee Chair Allyson Leacock. "By doing what we do best, communicating with our neighbours, members of the CBMP are helping our audience to remain healthy and well-informed, while we all work together to reduce the impact of HIV in our region."

Sport – a force for change

Cricket is popular in many of the countries that are most impacted by AIDS, including India and South Africa. Together, these two countries are home to around 11 million of the 40 million people living with HIV worldwide.

In the Caribbean, UNAIDS estimated that 250,000 people – 15,000 of whom were children under the age of 15 – were living with HIV in 2006.

“Young people today have never known a world without AIDS. Sports stars – such as top cricket players – can act as role models for today’s young generation and reach out to them on AIDS issues,” said UNAIDS Executive Director Dr. Peter Piot. “Sport is a force for change that can break down barriers, build self-esteem and teach life skills and social behaviour. By highlighting AIDS issues, the ICC Cricket World Cup and its cricketing stars are showing exactly the kind of exceptional response needed for the exceptional challenge of AIDS.”

Representatives of 27 European Union and neighbouring countries met in Bremen, Germany to discuss ways of strengthening political leadership in the response to AIDS. Over 600 people attended the conference which was organised by the German Federal Government as part of its 2007 European Union Presidency. UNAIDS Executive Director Dr Peter Piot spoke on the opening day about the epidemic in the region and actions necessary to curb the epidemic. The second day of the Conference included workshops covering many key aspects of the AIDS response in the region including presentations on human rights, migration, stigma, gender and issues concerning sex work, injecting drug use and men who have sex with men.

UNAIDS Executive Director, Dr.Peter Piot talks to Ms. Angela Merkel, Chancellor of the Federal Republic of Germany at the 2007 European AIDS Conference in Bremen, Germany, 12-13 March 2007.

Ms. Angela Merkel, Chancellor of the Federal Republic of Germany during her speech at the 2007 European AIDS Conference in Bremen, Germany, 12-13 March 2007.

UNAIDS Executive Director, Dr. Peter Piot during his speech at the 2007 European AIDS Conference in Bremen, Germany, 12-13 March 2007

Ms. Ulla Schmitt, Germany's Federal Minister of Health at the closing press conference of the European AIDS Conference in Bremen, Germany. 12-13 March 2007

UNAIDS Executive Director, Dr. Peter Piot visiting the UNAIDS stand with Her Highness Begum Aga Khan and Germany's Federal Minister of Health, Ms. Ulla Schmitt at the 2007 European AIDS Conference in Bremen, Germany. 12-13 March 2007.

UNAIDS Executive Director, Dr. Peter Piot met with the Ukranian Minister of Health, Mr. Yuyi Poliachenko at the 2007 European AIDS Conference in Bremen, Germany. 12-13 March 2007

Mr. Kevin De Cock, Director of the department of HIV/AIDS at the World Health Organisation at a workshop on the role of the European Union and the European States in the world-wide fight against AIDS, during the 2007 European AIDS Conference. 12-13 March 2007

Ms. Sophia Kistling, Director of the International Labour Organisation's programme on AIDS at a workshop on the role of the European Union and the European States in the world-wide fight against AIDS, during the 2007 European AIDS Conference. 12-13 March 2007

Ms. Nina Ferencic, UNICEF's Regional Advisor for AIDS in Central and Eastern Europe at a workshop on cross-border cooperation in Europe during the 2007 European AIDS Conference in Bremen, Germany. 12-13 March 2007

Ms. Dorothee Eckertz, World Bank Operations officer, speaking on lessons learned in harm reduction in the wider european neighbourhood at a workshop on human rights during the 2007 European AIDS Conference.

All photo credit: N.Wolff

UNAIDS Executive Director Dr. Peter Piot with Ms. Angela Merkel,
Chancellor of the Federal Republic of Germany

The northern city of Bremen is the setting chosen by the German Federal Government to host the conference of the German Presidency of the Council of the European Union: “Responsibility and Partnership – Together Against HIV/AIDS”.

Germany has convened the conference as part of efforts to fulfil its pledge of making AIDS its top health priority during Germany’s European Union Presidency in 2007. The German Government has recently reaffirmed this commitment by announcing 400 Million Euros in 2007 for its action plan on AIDS.

The conference, taking place from 12-13 March, is expected to attract over 600 people from around Europe including ministers and representatives from 27 European and neighbouring countries. German Federal Chancellor, Dr Angela Merkel will give the keynote address and UNAIDS Executive Director Dr Peter Piot will speak on the opening day about the epidemic in the region and actions necessary to curb the epidemic.

The conference comes as a follow-up to the 2004 meetings in Dublin and Vilnius where groundbreaking declarations to step up political action on AIDS were signed by participating European ministers.

The second day of the Conference will comprise of workshops covering many key aspects of the AIDS response in the region including presentations on human rights, migration, stigma, gender and issues concerning sex work, injecting drug use and men who have sex with men.

UNAIDS Executive Director Dr. Peter Piot with Germany's
Federal Minister of Health, Ms. Ulla Schmitt

At the close of the conference the attending ministers of health are expected to sign a declaration reaffirming the commitments made in Dublin and Vilnius in a bid to increasing political leadership on AIDS on national, regional and international levels.

UNAIDS is currently coordinating a review of the 2004 meetings which the German Ministry of health is supporting financially, having recently announced 400,000 Euros for initiation of the project.

“ Germany is a valued partner of UNAIDS,” said Bertil Lindblad, UNAIDS Regional Director for Europe. “This is an important year for Germany as holders of both the EU and G8 Presidencies and its commitment to making AIDS its top health priority is not only a commendable decision but a truly necessary one.”

During a visit to Bangkok, Thailand, UNAIDS Executive Director Dr Peter Piot met with the Prime Minister of Thailand and celebrated the International Women’s Day with the Executive Secretary of United Nations Economic and Social Commission for Asia and the Pacific and with Ms. Joana Merlin-Scholtes, the United Nations Resident Coordinator and UNDP Resident Representative in Thailand.

Dr Piot also released a statement stressing the importance of addressing gender inequality and the feminization of the AIDS epidemics. “Women, inside and outside the home, must have the economic, social and political power to stand up for their rights and protect themselves and their families from violence and disease.” He also stated that “to stop the feminization of the epidemic, as well as the epidemic itself, we have to initiate legal but also social, cultural and economic changes to challenge some of the most pervasive social patterns and gender norms that continue to fuel the AIDS epidemic.”

UNAIDS Executive Director, Dr.Peter Piot during his meeting with General Surayud Chulanont, Prime Minister of Thailand at the Government House (Thai koo Fah building). 8 March 2007

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UNAIDS Executive Director, Dr. Peter Piot talks to Ms. Joana Merlin-Scholtes, UN Resident Coordinator Thailand at the United Nations Conference Centre, Bangkok, Thailand during the International Women's Day, 8 March 2007

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From L to R: Ms. Joana Merlin-Scholtes, UN Resident Coordinator and UNDP Resident Representative in Thailand, Dr. Peter Piot, Executive Director UNAIDS and Mr. Kim Hak-Su, UN Under Secretary General and Executive Secretary UNESCAP during the International Women's Day 2007 held at the United Nations Conference Centre, Bangkok, Thailand. 8 March 2007.

Mr. Kim Hak-Su, UN Under Secretary General and Executive Secretary UNESCAP during his opening statement for the International Women's Day 2007, at the United Nations Conference Centre, Bangkok, Thailand. 8 March 2007

UNAIDS Executive Director, Dr. Peter Piot during his intervention for the International Women's Day 2007, at the United Nations Conference Centre, Bangkok, Thailand. 8 March 2007

Ms. Thelma Kay, Director of the Division of Emerging Social Issues, UNESCAP during the International Women's Day 2007 event held at the United Nations Conference Centre, Bangkok, Thailand on 8 March 2007

Ms. Jean D'Cunha, Regional Programme Director of UNIFEM (East and Southeast Asia) during the ceremony held at the United Nations Conference Centre, Bangkok, Thailand for the International Women's Day 2007. 8 March 2007.

All photo credit at United Nations Conference Centre: Daniel Tshin

Links:
Read UNAIDS Executive Director's statement - Addressing gender and AIDS: a compulsory requirement

Purnima is a renowned social scientist and an expert in gender issues in international health, especially in AIDS. Purnima worked for over 12 years as an Associate Professor at the Tata Institute of Social Sciences, Mumbai, India before she joined the Global Programme on AIDS at the World Health Organization in Geneva in 1994. At UNAIDS, she pioneered work on gender and AIDS and managed the Executive Office until 1999. After working for the Population Council in New York in 1999 and the Global Fund to fight AIDS, Tuberculosis and Malaria, Purnima returned to UNAIDS in 2004 as Director of Policy, Evidence and Partnerships. She has co-authored and edited four books including one of the first books on social and cultural aspects of AIDS in India and is a founder-editor of the journal, Culture, Health and Sexuality. On International Women’s Day, Purnima reminds us how women are more vulnerable to HIV and how violence against women increases their vulnerability.

Dear Purnima, today is International Women’s day. Can you tell us how and why women are particularly affected by the AIDS epidemic?

Women represent almost half of people living with HIV. According to the latest data available, 17.7 million adult women are now living with HIV. This is more than ever before and the trends suggest that this number is on the rise. Everyday, 7000 women become infected with HIV. The expression “feminization of the epidemic” does not nearly catch the enormity of the situation…Nearly 25 years into the epidemic, gender inequality remains one of the major drivers of HIV. Yet current AIDS responses do not, on the whole, tackle the social, cultural and economic factors that make women more vulnerable to HIV, and that unduly burden them with the epidemic’s consequences. Women and girls have less access to education and HIV information, tend not to enjoy equality in marriage and sexual relations, and remain the primary caretakers of family and community members suffering from AIDS-related illnesses. When infected with HIV, women are more likely to be deprived of treatment and more likely to face discrimination . To be more effective, AIDS responses must address the factors that continue to put women at risk.

What would be in your opinion, the top priority intervention to reduce women’s risk to HIV?

'No one solution is obviously enough but if I had to choose one, I'd say education is critical. Sending all girls to school and making sure that they complete high school must become a collective top priority. With each additional year of education, girls acquire vital life skills and higher income-earning potential. Girls who complete secondary education know more about HIV – both how to prevent infection and what to do if they think they are infected. They tend to have fewer sexual partners over a lifetime and are more likely to use condoms. And by providing women with more economic options and independence, education gives them vital knowledge, skills, and opportunities. This means they can make informed choices about delaying marriage and childbearing, having healthier babies and avoiding risky behaviour – as well as knowing more about their rights.

The theme of this year’s International Women’s Day is Ending Impunity for Violence Against Women can you tell us more about the issue?

Violence against women continues to be a common, yet widely ignored phenomenon that robs women worldwide of their health, well-being and lives. In many places, violence against women and HIV risk are intertwined.

The most prevalent forms of violence against women are perpetrated by their intimate partners. A staggering 40–60% of women surveyed in Bangladesh, Ethiopia, Peru, Samoa, Thailand and United Republic of Tanzania said they had been physically and/or sexually abused by their partners. Laws for protecting women from such abuse are either lacking, too weak or too poorly enforced to make much of a difference. Social norms in many countries condone domestic violence as a private, even normal matter—leaving millions of women without hope of legal recourse. But there is nothing natural or inevitable about violence against women. Attitudes can and must be changed.

How does violence against women increase risk of HIV infection?

Violence against women is often associated with a heightened risk of HIV infection. Studies in South Africa and Tanzania show that women who have been subjected to violence are up to three times more likely to be HIV-infected than women who have not experienced violence.

Violence—even the fear of violence—also prevents many women and girls from learning or disclosing their HIV status, or accessing essential AIDS services. In Cambodia, the fear of domestic violence appears to be one of the reasons why unexpectedly low numbers of women have been using HIV counselling and testing services at some antenatal clinics. At a clinic in Zambia, some 60% of women eligible for free antiretroviral treatment opted out of treatment, partly because they feared violence and abandonment if they were to disclose their HIV status to their partners. Fear of violence also prevents women from demanding protection or negotiating safer sex.

What is happening to help reduce violence against women?

Promising initiatives are under way to help reduce violence against women. Some, like Stepping Stones, now active in almost 30 countries, and Men as Partners in South Africa, use community-based workshops to challenge gender stereotypes and reshape power relations. Others, such as the Gender Violence Recovery Center in Kenya and the Cambodian Women’s Crisis Center, provide shelters, medical services and counselling, including HIV services or referrals, to women who have experienced domestic violence and sexual abuse. Such efforts must be expanded, supported and incorporated into national AIDS strategies. Governments the world over have committed to eliminate violence against women. It’s time to do more.

What are immediate measures that would help reduce violence against women and reduce their risk to HIV?

Governments must enact and enforce laws that prevent violence against women. In parallel, they must also develop strategies and approaches to ensure that those who uphold the law—civil servants, police, judiciary, healthcare workers, social services etc.—implement it in fact, and to support the victims of violence. We must also develop and fund community-based programmes to help change social norms that condone violence against women and perpetuate its acceptability. This includes educating women, men, boys and community leaders about the rights of women, and the need to change menacing norms of masculinity.

We must also work to expand women’s access to support services and economic resources so that they can escape and recover from abusive and life threatening relationships.

It’s important that national AIDS plans integrate strategies to reduce violence against women, and link violence prevention efforts with mainstream HIV prevention and treatment services.

Links:

View feature documentary "Women are 2… Finding Solutions"

Experts from across the world are gathering this week in Montreux in Switzerland to review the results of recent trials establishing that male circumcision reduces by almost 60% the risk of men to acquire HIV during vaginal sex. These results announced in December 2006 and detailed in recent publications in The Lancet sparked interest and debate in the world of HIV. Is male circumcision as significant an advance as some of its proponents have claimed?

Dr Kim Dickson, from the HIV Department of the World Health Organization is a recognized and respected figure in the field of reproductive health and HIV. She currently coordinates the joint WHO/UNAIDS working group on male circumcision and HIV prevention as well as the Inter-agency Task Team on male circumcision and HIV prevention. She has kindly agreed to tell us more about the meeting and its expected outcomes.

Unaids.org: Dr Dickson, you coordinate the joint WHO/UNAIDS working group on male circumcision and HIV prevention. Can you tell us why WHO and UNAIDS are convening this meeting on male circumcision?

KD: When the US National Institutes of Health decided, in December 2006, to stop the two trials they were funding in Kenya and Uganda on male circumcision and HIV, it became clear that we needed to assess male circumcision as a potential public health intervention in the response to AIDS. The trials, as detailed in the results recently published in The Lancet, confirmed many previous observational studies which suggested that male circumcision significantly reduced the risk of men in acquiring HIV during vaginal sex.

It was important that the World Health Organization and the Joint United Nations Program on HIV/AIDS review the research results and consider what they mean for HIV prevention policy and programming in countries. It was decided to convene a meeting to bring around the table as many stakeholders as possible to look at and discuss many of the issues that male circumcision can raise, and, if possible, give guidance and recommendations for Member States and other stakeholders.

Unaids.org: How many participants are joining in this meeting and what do they represent?

KD: We invited the trials' investigators to present their methodology and their results. We also invited other scientists, from different disciplines such as social science, human rights and communications to ask the investigators questions which were not necessarily in the scope of their trials. We also have 16 representatives from Member States, and 11 from the civil society, including women’s health advocates and a representative from the Global Network of People Living with HIV, to present their own reading of the results and also to raise the issues that they face in their countries and in the context of their activities.

We paid special attention to invite people representing different positions. Last, but not least, we also have eight funding agencies and six implementing partners joining in the discussions. Overall, we are expecting almost 80 participants in Montreux. No need to say that we expect intense discussions that will touch upon many difficult issues.

Unaids.org: What do you expect as the outcomes of this meeting?

KD: The first and immediate outcome resides in the debate that is going to take place this week. This is the first time ever that such a wide range of stakeholders exchange views and discusses the consequences of male circumcision as an additional prevention method in the response to AIDS. At this stage, we cannot pre-empt the outcome. Maybe we will conclude the meeting with more questions than we began with- though I am hoping that at least some questions will be answered and that we will be able to make some recommendations.

The meeting will also identify what we need to do next in order to move forward. In any case, there will be a meeting report which we will make public shortly after the meeting.

Finally, I want to emphasize again and again that our objective is to examine male circumcision as an additional prevention method which should always be part of a comprehensive package which includes, among other elements, the correct and consistent use of male and female condoms, the delay in sexual debut and the reduction of sexual partners. The meeting will discuss how we can strengthen our communications so as not to undermine other prevention methods if we are to scale up male circumcision services.

If the United Nations moves forward with guidance to countries on male circumcision as a public health intervention for HIV prevention, it will be promoted as an ‘additional’ intervention to current HIV prevention packages; not as an alternative. People must understand that male circumcision does not provide complete prevention and they should be encouraged to use more than one of the prevention choices available to them.

UNAIDS has released Practical Guidelines for Intensifying HIV Prevention:Towards Universal Access to assist policy makers and planners in countries to strengthen their national HIV prevention response.

The development of the Guidelines recognises that universal access is not only about sustaining and increasing access to antiretroviral treatment for those in need, but also to ensure that all people, particularly those most vulnerable to HIV, are able to prevent HIV infection so as to bring about a decrease in the number of new HIV infections — estimated at 4.3 (3.6–6.6) million in 2006.

The Guidelines call on National AIDS Authorities – in the Spirit of the Three Ones Principles - to provide leadership in coordinating and strengthening their national HIV prevention efforts. To strengthen national efforts countries are being encouraged to ‘know your epidemic’ by identifying the behaviours and social conditions that are most associated with HIV transmission, that undermine the ability of those most vulnerable to HIV infection to access and use HIV information and services. Knowing your epidemic provides the basis for countries to ‘know your response’, by recognizing the organizations and communities that are, or could be, contributing to the response, and by critically assessing the extent to which the existing response is meeting the needs of those most vulnerable to HIV infection.

Photo credit:UNAIDS/G.Pirozzi

Dr Peter Piot, Executive Director of UNAIDS, said that, “We encourage countries to know their epidemic because we have learned over the last twenty-five years that the epidemic keeps evolving. It is important for countries to take stock of where, among whom and why new HIV infections are occurring. Understanding this enables countries to review, plan, match and prioritise their national responses to meet these needs”.

UNAIDS  categorizes HIV epidemics scenarios as low level, concentrated or generalized. For planning purposes the Guidelines propose an additional scenario—the hyperendemic scenario. The hyperendemic scenariorefers to those areas, such as the high prevalence countries of southern Africa, where HIV is circulating in the general population through sexual networking – especially heterosexual multiple concurrent partner relations with low and inconsistent condom use -- and prevalence exceeds 15% in the adult population. Within countries and regions different scenarios may exist and the epidemic may evolve from one scenario to another depending on the response, the underlying dynamics and drivers of the epidemic.

To help countries prioritise their response, the Guidelines provide a synthesis of essential and proven prevention measures that countries can use to “tailor your prevention plans” in relation to the epidemic scenarios and to meet the needs of the populations with highest rates and highest risks of HIV.

Photo credit:UNAIDS/L.Gubb

Matching and prioritizing national response requires that countries set ambitious, realistic and measurable prevention targets in relation to their epidemic. This includes setting goals, and defining outcomes, outputs and processes for HIV prevention services to be delivered to the people and places where they are most needed. The Guidelines stress the need to constantly use strategic information, such as behavioural surveys, to measure and track whether they are achieving their objectives.

Dr Purnima Mane, Director, Policy, Evidence and Partnerships says that, “The fundamental intention underlying these guidelines is for countries to engage their leaders and communities to know their epidemics and to match the prevention response to meet their priority needs. Ensuring adequate coverage of most at risk and most vulnerable populations is essential to achieving Millennium Development Goal 6; and so too is urgent action to combat the drivers of the epidemic such as HIV related stigma, human rights violations, and gender inequality”.

The UNAIDS Practical Guidelines for Intensifying HIV Prevention: Towards Universal Access have been developed in consultation with the UNAIDS cosponsors, international collaborating partners, government, civil society leaders and other experts. They build on Intensifying HIV Prevention: UNAIDS Policy Position Paper and the UNAIDS Action Plan on Intensifying HIV Prevention.

In the final part of a special series on the issue of male circumcision and its links to the reduction of HIV acquisition, www.unaids.org discusses expected upcoming action and developments from the United Nations on male circumcision through a special interview with UNAIDS Chief Scientist, Dr Catherine Hankins

From 6-8 March 2007, public health experts from the World Health Organization, UNAIDS and other partner organizations will gather in Montreux, Switzerland, to discuss the topical and often thorny issue of male circumcision and its links to HIV prevention, and to define future United Nations guidance to countries on the policy and programming implications of recent research findings.

As the consultation approaches, UNAIDS’ Chief Scientific Adviser, Dr Catherine Hankins gives a preview of the different issues that may be raised, and an insight into considerations for potential outcomes and action for the United Nations.

Unaids.org: Dr Hankins, you’ve been involved in the issue of male circumcision and its impact on HIV for many years—how do the current findings corroborate scientists’ claims that there is a link between circumcision and reduced HIV infections?

CH: For many years, researchers and scientists have noted that parts of Sub-Saharan Africa where circumcision is common, such as countries in West Africa, have much lower levels of HIV infection, while those in southern Africa, where circumcision is rare, have the highest. Before the availability of data from these three randomised controlled trials, multiple observational studies indicated that male circumcision carried with it a reduced risk of HIV infection. The latest findings from the three trials indicate that male circumcision provides a protective benefit against HIV infection of 50% to 60%

A further trial, led by researchers at Johns Hopkins University, to assess the impact of male circumcision on the risk of HIV transmission to female partners is currently under way in Uganda, with results expected in 2008.

Unaids.org: What is the United Nations doing about this latest evidence that male circumcision reduces risk of HIV acquisition?

CH: Although these results demonstrate that male circumcision reduces the risk of men becoming infected with HIV, the United Nations agencies involved in this work absolutely underline that it does not provide complete protection against HIV infection- we need to make sure that men and women understand that circumcised men can still become infected with the virus and if HIV-positive, can infect their sexual partners.

Next week, WHO, the UNAIDS Secretariat and their partners will review the trial findings in detail at a consultation which will define specific recommendations for expanding and/or promoting male circumcision. These recommendations will need to take into account a number of key issues including the cultural and human rights considerations associated with promoting male circumcision; the risk of complications from the procedure performed in various settings; the potential of male circumcision to undermine or to work in synergy with existing protective behaviours and prevention strategies that reduce the risk of HIV infection; and the financial and human resource implications of male circumcision in different service delivery settings.

In order to support countries or institutions that decide to scale up male circumcision services, with our partners we are developing technical guidance on ethical, rights-based, clinical and programmatic approaches to male circumcision. We are also developing guidance on training, standard setting and certification procedures.

Unaids.org: What are some of the key concerns about increasing male circumcision practice that will be discussed at the consultation?

CH: A number of thorny issues arise related to promoting male circumcision as a public health intervention for HIV prevention. Adult male circumcision has a higher risk of adverse effects than infant male circumcision, and should be undertaken by trained health workers in safe, adequately equipped and sanitary conditions with appropriate pre and post-surgical counselling and follow-up. There is a real need to ensure that male circumcision interventions for health benefits are differentiated from female genital mutilation which the UN opposes and is considered to have no health benefits and potentially severe consequences for women and girls.

We also have to take into account the cultural issues- within cultures and faith traditions in which male circumcision is not considered acceptable, promoting it may or may not prove challenging. Without question, we absolutely have to ensure that men and women are aware that male circumcision is not a ‘magic bullet’- it doesn’t provide total protection and it doesn’t mean people can stop taking the safe sex precautions they were already using, such as use of male or female condoms, delaying sexual debut, avoiding penetrative sex and decreasing the number of sexual partners. We must continue to promote combination prevention and ensure that male circumcision is perceived as an additional benefit but one that should be in combination with other strategies to prevent sexual transmission of HIV. We don’t want increased risk behaviour to offset the benefits.

If the United Nations moves forward with guidance to countries on male circumcision as a public health intervention for HIV prevention, it will be promoted as an ‘additional’ intervention to current HIV prevention packages; not an alternative.

Effective communication on male circumcision will be critical and will be an opportunity to reinforce messages on the need for a comprehensive approach to prevention that encourages people to use more than one of the prevention choices available to them.

Unaids.org: Would male circumcision be part of the HIV prevention response for all settings?

Countries with high HIV prevalence and low male circumcision levels may be among the first to consider the potential for male circumcision to play a role in their HIV prevention programming. Other countries may decide to provide male circumcision services to particular populations who could benefit from the additional protection that male circumcision can afford.

The UN and its partners are fully aware that male circumcision may raise cultural and religious issues – it should never be imposed and, if it is promoted, must be done in a culturally acceptable manner in settings where it is not traditionally practised.

CH: Like all types of surgery, circumcision is not without risk. Circumcision by unqualified individuals under unsanitary conditions with poorly maintained or sub-optional equipment can lead to serious, immediate and long-term complications, or even death. Where health professionals have been trained and equipped to perform safe male circumcisions, however, the rate of post-operative complications is less than 5% and the large majority of these resolve with simple, appropriate post-operative care.

Anecdotal accounts of serious complications, including penile amputation and death after male circumcision in traditional settings have been reported. It is difficult to give overall figures for adverse events in all settings, in part because well-documented studies of complication rates in low-and-middle income countries are rare.

Unaids.org: Is there a need to improve male circumcision practices?

CH: Absolutely. Action is required now to improve circumcision practices in many regions, and to ensure that health-care providers and the public have up-to-date information on the health risks and benefits of male circumcision. Many boys and men wishing to be circumcised do not have access to safe circumcision services nor to post-circumcision care if they do suffer from complications. Regardless of the HIV prevention benefits, it is now increasingly important to make existing practices safer. Where circumcision is legal, authorities need to ensure that practitioners are properly trained and licensed to do this procedure. Monitoring should also be done to ensure that procedures are performed safely and that untrained practitioners do not continue to perform unsafe circumcisions.

Unaids.org: Does male circumcision raise human rights issues?

CH: Yes, as is the case with all medical and health procedures. In line with internationally accepted ethical and human rights principles, UNAIDS and WHO are of the view that no surgical intervention should be performed on anyone if it results in adverse outcomes in terms of health or the integrity of the body, and where there is no expectation of health benefit. Nor should any surgical intervention be performed on anyone without informed consent, or the consent of the parents or guardians when a child is not capable of providing consent.

As male circumcision involves surgery and removal of a part of the body, it should only be performed under these conditions: a) participants are fully informed of the possible risks and benefits of the procedure; b) participants give their fully informed consent; and c) the procedure can be performed under fully hygienic conditions by adequately trained and well equipped practitioners with appropriate post-operative follow-up.

Unaids.org: What effect on the HIV epidemic might we expect if male circumcision were commonly practised where it currently is not?

An international group of experts have carried out a mathematical modelling exercise on the impact on HIV incidence of a programme of universal male circumcision in sub-Saharan Africa, assuming the programme worked as it had in Orange Farm, South Africa and that all men would be circumcised within 10 years. The model predicts that 5.7 million infections and 3 million deaths would be prevented over 20 years among both men and women. There are many unknowns within this model but it does predict that male circumcision would provide a significant, potential benefit, similar to a partially effective vaccine. Importantly though, the model also shows that male circumcision alone cannot eliminate the HIV epidemic in sub-Saharan Africa.

Unaids.org: Could male circumcision eliminate the risk of HIV infection?

CH: No. Male circumcision alone certainly does not prevent men from becoming infected with HIV. Nor does it prevent women from being infected with HIV by men who have been circumcised. Circumcision needs to be seen as one of the range of methods to reduce the risk of HIV—including avoidance of penetrative sex, delaying sexual debut, reduction in the number of sexual partners, and correct and consistent male or female condom use. Male circumcision reduces the risk of HIV infection during vaginal intercourse, but is unknown whether it would have an effect on other routes of sexual HIV transmission: the receptive partner in anal intercourse may not have a reduced risk due to the circumcision status of his or her partner and, if male, will not have a reduced risk due to his own circumcision status. It is also not known whether male circumcision reduces the risk of HIV infection for the insertive partner during anal intercourse. Male circumcision has no effect in the case of HIV transmission through injecting drug use.

Unaids.org: Given all these considerations, is it likely the UN will recommending that adult men become circumcised as a way to protect themselves from HIV?

CH: This is what will be discussed at the consultation, and the partners expect to release information about the discussions and possible next steps at the end of the week’s meeting.

In any and all cases for future direction and action, the UN and its partners will certainly underline that male circumcision does not provide complete protection from HIV. It should therefore never replace other known effective preventive methods, such as delay in onset of sexual activity, abstinence from penetrative sex, correct and consistent use of condoms, and reductions in the number of sexual partners.

It’s very important that we stress that circumcised men, if HIV positive, can still infect their sexual partners if they do not use condoms during penetrative sexual intercourse.

“He is clapping from wherever he is,” Maria Lucia Araujo said emotionally of what her son, Cazuza’s reaction would be to the children’s home “Viva Cazuza” which was founded in his name.

Cazuza, one of Brazil's best-known solo artists, died in 1990 of an AIDS-related illness in Rio de Janeiro at the age of 32. Today, 65 children living with HIV are being supported by Sociedade Viva Cazuza, a non-profit organization dedicated to helping children living with HIV which is funded by royalties from his songs.

In February 1989, Cazuza became the first Brazilian celebrity to announce publicly that he was HIV positive. In the October after his death, Maria Lucia Araujo founded the home for children living with HIV.

Lucia Araujo didn’t know anything about HIV or AIDS when she learnt of her son’s diagnosis. “When he first told me that he was HIV positive I assumed that he would recover within the year,” she said. Her son’s death transformed her life. Married to a wealthy husband she had no need to work, but she had to do something. “I would have gone mad,” she said. “I couldn’t have slept if I hadn’t done anything.”

So she opened the home, the first of its kind in Rio. Since its opening, the organization has helped 67 children. As the availability of antiretroviral drugs has improved so has the children’s health. “The children go to local schools and have an active life just like any of the other children in the area,” said Lucia Araujo.

UNAIDS estimates that globally there are around 2.3 million children under 15 years old infected with HIV and according to a recent report by UNICEF, some 15.2 million children under the age of 18 have lost one or both parents to AIDS.

“There is a real need to support children living with HIV in Brazil,” said Dr. Laurent Zessler, UNAIDS Country Coordinator in Brazil. “We must make sure these children are not discriminated against. Children living with HIV are able to stay in school and live full and active lives, HIV shouldn’t be allowed to take away their childhoods,” he added. 

“Since my son died the nature of the virus has changed a great deal; it is no longer a gay man’s disease, now more and more women are affected. They often have no idea that they are HIV positive and pass it to their children without knowing,” Maria Lucia said.

Children come to the house through many different avenues. One of the 24 children currently living in the house is 15-year-old Danielle who arrived 10 years ago with her sister after her mother died and her father was unable to cope. During her stay she has built up a good relationship with her father and hopes to live with him again someday.

Paraguayan Jose was found at the age of three abandoned and very sick in a hospital on the Paraguayan border. Now, nine-year-old Jose wants to be a film director.

The organisation also supports young adults who have left the home. Once a week, the home’s clinic is open for HIV positive adults to collect their antiretroviral drugs. As with all Brazilians who are HIV positive, antiretroviral treatment is provided free of charge by the government.

Besides material support, Sociedade Viva Cazuza also operates a Web site where people can ask experts about AIDS issues. The experts receive around 12,000 questions a month. Maria Lucia is shocked by the questions still being asked 20 years after AIDS first arrived in Brazil. “The most common questions are still – how do I contract the disease? How can I protect myself from contracting the disease?” she said. “It is not like Cancer where the experts still are not sure what causes it or how to prevent it – to prevent AIDS it’s simple – use a condom.”

Maria Lucia has become a prominent spokesperson on AIDS appearing regularly on television. She believes her son’s heritage is not only ‘his beautiful songs’ but also the home, by being open about HIV and appearing in public as the illness progressed. “He did a lot to educate people and help reduce discrimination against people living with HIV,” she said.