During the West and Central Africa Summit on HIV in Dakar, several international partners and ministers gathered to discuss the pressing situation around health financing in the region, exacerbated by the economic crisis due to COVID-19. When it comes to funding HIV responses, WCA is facing a perfect storm: resources available for HIV in the region in 2020 were approximately three quarters of the amount needed. In addition, total HIV resources in the region declined by 11% in the last decade. While PEPFAR and the Global Fund have increased their commitments to the region, domestic resources have slowed down since 2018 and dropped dramatically in 2020.

COVID-19 epidemic did not help. Most African governments have responded to the economic shock by increasing government spending last year however, but with revenues hit by the slow-down, the pandemic will leave many countries with large deficits and unmanageable debts.

Winnie Byanyima, UNAIDS Executive Director, stressed the importance of focusing on these challenges by also re-thinking and reforming overall health systems. She urged countries, as did many other panellists, to use dwindling funds more efficiently, and to ensure additional resources be dedicated to health. “Healthy people means healthy economies,” she said.  She also called for more space to be given urgently to community-led services.

“We need to properly fund community infrastructure and response to be strongly integrated with formal health systems. This is critical as we think about preparing and coping with future pandemics,” Ms Byanyima said.

PEPFAR Deputy Coordinator for Multi-Sector Relations Mamadi Yilla wholeheartedly agreed. "COVID-19 acted like a catalyst and everyone recognized civil society’s role in getting services to the people,” she said. Mentioning that PEPFAR has invested billions in Africa since 2003, she said that the partnerships have to be re-invented and urged governments to work hand in hand with civil society as well as deploy funds in a targeted fashion.

“We have to challenge ourselves to make each dollar count,” said Global Fund Executive Director Peter Sands, "COVID-19 has indeed highlighted the obvious: investing in health makes sense.” He added, “It is important to have finance and economic ministers as part of the answer because health ministers will not be able to solve this on their own.”

Recognizing the need for increased domestic spending on health, the Senegalese Minister of Economy, Planning and Cooperation, Amadou Hott, noted that the current economic slump limits countries' ability to invest more of their resources in the sector. He, like Ms Byanyima, said additional resources must be drawn from debt cancellation, additional international financing mechanisms such as augmenting international liquidity (Special Drawing Rights (SDRS) from the IMF), and fight tax evasion to help increase domestic tax collection.

The Sierra Leone Health Minister, Austin Demby, said that earmarking disease specific resources does not build sustainable health systems, citing an example of a recent measles outbreak in his country. He had to immediately deploy funds to contain it. “We have to create broader platforms to be more flexible,” he said. “Make sure some of the systems around community engagement, and services used every day for HIV, tuberculosis, and malaria can be used for other diseases.”

In addition, financing shouldn’t be tied to specific implementing partners. Both Ministers stressed that to transform health systems, they needed to be given more leeway to implement models that can be self-sustaining on domestic resources, which was not currently the case.

Finally, climate change must be taken into account as it impacts the planet and inevitably people’s wellbeing. The West and Central Africa region, hit hard by desertification and drought, will only feel more pressure on already overwrought health systems.

“Linking funding for climate change and health is crucial because one will inevitably impact the other and increase vulnerabilities to pandemics and diseases,” Mr Hott said in his closing remarks.

The goal of zero discrimination still eludes the Central African Republic. HIV-related stigma is pervasive in the lives of people living with HIV in the country. According to the 2018 People Living with HIV Stigma Index, discrimination affects almost all of the people living with HIV surveyed (more than 87%). And more than 45% of people living with HIV have experienced some form of stigma because of their HIV status. Stigma affects women (49%) more than men (37%).

“But the fight against HIV remains a public health priority for the government, which was the first country to join the Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination, in December 2019,” said Marguerite Ramadan, the Minister of Gender Promotion, Women’s Protection, Family and Children, Central African Republic.

Since its engagement in the Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination, the Central African Republic has implemented several key activities.

A memorandum of understanding was signed between the Ministry of National Defence and Reconstruction, the Ministry of Health and Population, the AIDS Control Council (CNLS) and UNAIDS to implement programmes aimed at eliminating gender-based violence and accelerating HIV prevention, treatment and care within the defence and security forces. A national charter of patients’ rights has been launched and is being disseminated progressively in health centres. A series of key human rights activities have been included in the Global Fund to Fight AIDS, Tuberculosis and Malaria’s grant for 2021–2023.

A Zero Discrimination Platform, composed of some 30 partners representing ministries, CNLS, United Nations agencies, technical and financial partners, civil society, human rights organizations and other organizations was launched in 2020 and is supporting these efforts, including through identifying synergies.

During the COVID-19 pandemic, initiatives have slowed down, so in order to relaunch the momentum of the Zero Discrimination Platform and agree on collective priorities for the end of 2021 and 2022, a validation workshop and launch of a joint workplan took place in Bangui, Central African Republic, on 28 October under the chairmanship of the Minister of Gender Promotion, Women’s Protection, Family and Children.

Priorities include the adoption of a revised law on HIV, the revision of training programmes for health professionals to include ethics and human rights, the signing of a memorandum of understanding between organizations of lawyers and networks of people living with HIV and key populations to provide free legal services and training on knowing your rights, the development of radio and television spots on discrimination issues and high-level advocacy for better integration of HIV issues in humanitarian interventions.

“The denial of health services to people living with HIV remains unfortunately common in the country, and the prevalence and effects of discrimination are often particularly severe for members of key populations, who face multiple and overlapping forms of discrimination,” said Marie Engel, Director, a.i., of the UNAIDS Country Office for the Central African Republic.

In the lead up to the West and Central Africa Summit on HIV/AIDS taking place in Dakar from 31 October to 2 November 2021, UNAIDS asked its country directors across the region five questions about the AIDS response in their country. Here are the replies of Ms. Sirra NDOW, UNAIDS country director in the Gambia

Similar to other western African countries, the Gambia has a low but highly concentrated HIV epidemic, affecting heavily key populations such as men who have sex with men and female sex workers. While impressive progress towards reducing new adult and paediatric infections have been observed in recent years, COVID-19 has caused a lot of complications. Repurposing HIV medical equipment and health personnel to address the fast-rising epidemic was necessary to limit COVID-19 related deaths. It also came with a cost—reducing the capacity to deliver HIV prevention and treatment services.

Lessons must be learned from the dual HIV/COVID-19 epidemics. Effort must be invested in better prevention services, especially tailored to key populations. Health personnel must be better trained and better supported to manage their workload and prevent bottlenecks. The approach of task shifting/sharing must continue and be further complemented by the strengthening of community health workers and decentralization of services. Finally, no progress will be truly radical unless stigma, discrimination and violence against people living with HIV and other marginalized groups are eradicated.  

1.  What are the main areas of progress in your country’s response to the HIV epidemic in the last five years?

The HIV epidemic in The Gambia mirrors those prevailing in other West African countries: the epidemic is overall low—less than 2% of the general population—but highly concentrated among key populations. The most recent Integrated Biological Behavioural Surveillance Study (IBBS.2018) estimates that prevalence is over 35% among men who have sex with men (MSM) and over 10% among female sex workers (IBBS 2018).

In 2018, the Gambia started implementing WHO’s recommendation to provide all people living with HIV with lifelong antiretroviral therapy (ART) regardless of clinical status or CD4 cell count. Between 2015 and 2020, impressive progress happened as new infections were cut by half and new infections among children were reduced by 75% (National AIDS Strategic Plan,2020-2025). All pregnant women attending antenatal clinics are routinely offered HIV tests, and all pregnant women living with HIV are eligible for ART (Option B+). Until the COVID-19 epidemic started, ART uptake had increased significantly. The country also adopted task shifting for HIV/AIDS and malaria—typically enabling nurses to dispense ART and capacitating community health workers to deliver a range of HIV services.

2. What are the main challenges that still need to be addressed?

Despite increased outreach activities, the testing coverage remains very low with less than 40% of the estimated PLHIV knowing their status. Inadequate investment in HIV prevention programmes and lack of access to prevention services, especially among key population groups, continue to impede progress in the national HIV response. HIV prevalence has increased more than three-fold among MSM from less than 10% in 2011 to over 35% in 2018 (IBBS, 2018) and no program have been designed to accelerate the uptake of pre-exposure prophylaxis as a prevention strategy among MSM.

HIV-related human rights and gender situation in the Gambia has not improved in the past five years. Key populations suffer multiple burden of frequent human rights violations, systematic disenfranchisement, stigma, and discrimination. The existence of punitive laws perpetuates barriers to accessing HIV services for key populations and further contributes to their social and economic marginalization. There remains lots to be done on promoting human rights literacy, putting in place mechanisms to monitor and report human rights violations, and advocate for policy reform and sensitization of lawmakers on human rights and gender-related issues.

Inadequately trained human resources for health coupled with frequent transfers of experienced and trained staff continue to threaten the national response. Decentralizing services, engaging community health services sites should be prioritized to further expand prevention, treatment, and care services. Finally, tracking patients at ART centres is a challenge due to inadequate cross-border programmes. There is need to strengthen cross-border initiatives to enhance follow-ups, defaulter tracing and referral of patients on treatment.

3. How has COVID-19 affected the HIV response in your country?

In the Gambia, there was no public health facility adequately equipped to treat COVID-19 cases and patients were treated at the Medical Research Council. There was no public health laboratory for COVID-19 testing, so health professionals repurposed PCR machines, which were originally intended for HIV testing, to test for COVID-19. HIV laboratory staff were also requested to provide COVID-19 services in addition to routine HIV and TB services While such urgent actions were required by the emerging pandemic, it led to a severe disruption in HIV diagnosis and the delivery of HIV and TB treatment services.

Social unrest caused by the COVID-19 pandemic also impeded access to regular healthcare, including for people living with HIV (PLHIV) and resulted in disruptions of ART availability. Rapidly, a multi-month dispensation of ARVs was initiated to try to maintain continued availability of treatment for all stable PLHIVs. During this period, a sharp decline in the number of PLHIV on ART was observed as well as a decline in HIV testing services in the general population.

4. Who are the unsung leaders of the AIDS response in your country?

We commend the admirable work delivered by community health workers in the Gambia, and the outstanding solidarity displayed by the community of people living with HIV.

5. If you could ask your Head of State to change one thing to strengthen the HIV response, what would it be?

To be a champion for the AIDS responses and to commit to mobilize adequate resources for the response.

In the lead up to the West and Central Africa Summit on HIV/AIDS taking place in Dakar from 31 October to 2 November 2021, UNAIDS asked its country directors across the region five questions about the AIDS response in their country. Here are the replies of Dr. Erasmus Morah, UNAIDS country director in Nigeria

The National response in Nigeria is growing more ambitious and efficient—better information and high-level political commitment have led to increased antiretroviral therapy coverage. Communities, networks of people living with HIV and key populations are given more space to be actors in the response. The private sector is stepping up to play its part in funding the response.

Despite such effort, Nigeria is failing children living with HIV and vertical transmission is on the rise. Violent arrests are still routinely carried out against key populations. And user fees continue to impede access to HIV care and hinder adherence to treatment. Resilience in times of the COVID-19 epidemics gives hope that more effort will be invested to address these systemic barriers to truly turn the tide on HIV and end AIDS.

1.  What are the main areas of progress in your country’s response to the HIV epidemic in the last five years?

First, the availability of data has expanded to enable the country to truly know its epidemic and its response. Several surveys took place since 2017 which provided precious support to national decision-makers to prioritize, track program performance and mobilize resources to end the epidemic.

In 2017, the Nigerian President committed to treating 50,000 Nigerians annually and has since honored his commitment. HIV treatment coverage has leapt from 55% in 2016 to over 85% in 2020. Currently, we estimated that 90% of people living with HIV (PLHIV) know their status, 86% of them receive antiretroviral therapy (ART), and among those, 72% have a suppressed viral load—meaning they have no risk of transmitting it.

To put communities at the centre of the response, the network of persons living with HIV and key populations are engaged in community-led monitoring to assess the quality of services they are receiving and to use data to influence policy and lead to programmatic changes.

To reduce Nigeria’s over reliance on international resources, the Nigeria Business Coalition Against AIDS has worked with the National Agency for the Control of AIDS (NACA) and UNAIDS to set up a trust fund of 150 million US dollars for HIV to be launched on World AIDS Day 2021. A sustainability plan is also being developed for HIV, tuberculosis and malaria.

2. What are the main challenges that still need to be addressed?

Unfortunately, children are still being left behind, and their treatment coverage remains much lower compared with adults. Only 45% of children living with HIV know their status, 45% of them receive antiretroviral therapy (ART), and among those, 31% have a suppressed viral load.  It is sad to note that prevention of mother-to-child-transmission has been less effective over the past five years. 

We continue to deplore the frequent arrest of key populations. Criminalization of the behaviour of key populations, violence and widespread stigma and discrimination continues to feed their avoidance of health care centers.

Finally, some health facilities are still demanding user fees from patient—despite evidence from western and central Africa showing that user charges undermine uptake of antiretroviral therapy, hinders the retention of people in care and reduce the quality of care. Studies specifically carried out in Nigeria have also shown that user fees undermine adherence to HIV treatment (Global AIDS report, 2020).

3. How has COVID-19 affected the HIV response in your country?

Despite the initial negative impact of lockdowns, the contingency measures put in place has ensured that Nigeria was able to successfully put about 300,000 people on treatment by the end of 2020. Through the one UN Basket Fund, about 10,000 households of PLHIV in needs were provided with cash transfers, personal protective equipment, and hygiene products to help prevent and mitigate the impact of COVID-19.

To ensure service continuity, the National AIDS and STI Control Program (NASCP) issued a policy directive from the Minister of Health for multi-month dispensing of ART, meaning that all clinically stable patients were provided with 3 months of treatment at once. NASCP set up a situation room to track HIV commodity stocks. Furthermore, NASCP regularly updated the UNAIDS HIV service disruption portal with programmatic data to monitor HIV service delivery during the COVID-19 pandemic. PLHIV networks provided home delivery ART services for their peers who could not access health services.

4.  Who are the unsung leaders of the AIDS response in your country?

First, we need to recognize the outstanding work delivered by communities of key populations and networks of Persons Living with HIV in Nigeria. They truly are unsung heroes of the AIDS response. We also need to laud the support and commitment of international partners such as PEPFAR and the Global Fund.

5. If you could ask your Head of State to change one thing to strengthen the HIV response, what would it be?

I would call on Nigeria to take forward its commitments by investing its fair share in the AIDS response and by increasing domestic financing.

To counter the low level of people living with HIV in Central African Republic (CAR) on treatment, the country has been testing new treatment approaches.

One is distributing up to 6 months of medicine, known as multi-month dispensing. The other is community ARV dispensation. CAR’s 2021-2025 National HIV Strategic Plan, identified these differentiated approaches at the community and hospital level and has been trying it out.

In the capital, Bangui, four pilots opened and 15 sites will progressively offer MMD (multi-month dispensing), health check-ups and community outreach thanks to funding from the Global Fund. This follows on the success of community-based treatment groups (CAGs) introduced by the Ministry of Public Health and Population and the National AIDS Control Council (CNLS) in 2015, with the support of the NGO Médecins Sans Frontières.

Certain community members deliver antiretroviral treatment to people living with HIV, especially in rural or conflict-stricken areas. Results showed that treatment intake was much more regular and people living with HIV had a rate of 75% viral suppression.

In addition, with UNAIDS support under a Luxembourg grant, the country has set up a steering committee to oversee the scale up of differentiated services, developed and validated national guidelines on the provision of differentiated services and two guides on multi month dispensing and the possibility of getting refills in a non-hospital setting.

At the end of October, clinicians, lab technicians, health care providers, community health care workers from the four pilot health centers participated in a workshop to go over the new approaches and guidelines. The CNLS and the country’s Division of Communicable Disease Control (DLMT) were confident adapting to the HIV epidemic in this way was a right step to keep patients on treatment. Currently, less than half of the people living with HIV take life-saving medicine (88,000-100,000 people live with HIV in CAR.)

Dr Marie-Charlotte Banthas from the DLMT said that "differentiated treatment models have demonstrated consistent improvement in patient engagement and retention of care, while freeing up time for the care of people with advanced disease.” She then added, ”It's a model of care for people living with HIV and staff working in the HIV field, a model of life."

These approaches came at the right time considering the lockdowns due to COVID-19, remarked UNAIDS CAR Country Director a.i. Marie Engel.

"With the long projected trajectory of the Covid pandemic, there is an even greater need to adapt the system to reduce service disruptions and not have recent gains in the HIV response stymied,” she said.

Developing countries have been hit with an endless tide of inadequate gestures and broken promises from rich countries and pharmaceutical companies, who are failing to deliver billions of doses they promised while blocking the real solutions to vaccine inequality, according to a new report published today by the People’s Vaccine Alliance.

The report, “A Dose of Reality,” found that of the 1.8 billion COVID vaccine donations promised by rich nations only 261 million doses – 14 per cent – have been delivered to date, while western pharmaceutical companies have delivered only 12 per cent of the doses they allocated to COVAX, the initiative designed to help low- and middle-income countries get fair access to COVID vaccines.

At the same time, the EU and other rich nations have refused to support the proposal of over 100 nations to waive patents on vaccines and COVID related technologies while leading pharmaceutical companies have failed to openly share their technology with the World Health Organisation to enable developing countries to make their own vaccines and save lives.

Winnie Byanyima, Executive Director of UNAIDS, said: “Rich nations and corporations are shamefully failing to deliver on their promises whilst blocking the actual solution; ensuring developing nations have the ability to make their own vaccines.

“It is painfully clear that the developing world cannot rely on the largesse and charity of rich nations and pharmaceutical companies, and hundreds of thousands of people are dying from COVID-19 as a result. This is beyond appalling.”

The UK Government, which has been actively blocking calls from countries like South Africa and India to be allowed to make their own vaccines, has only delivered 9.6 million – less than 10 per cent - of the 100 million doses it promised to poorer nations. Meanwhile it has itself taken half a million doses from COVAX, despite extreme vaccine shortages in developing countries and having already secured more than enough doses for British people from direct deals with the pharmaceutical companies. Canada has taken over 970,000 doses from COVAX, while delivering only 3.2 million – or 8 per cent – of the 40 million doses it promised. Germany, another country blocking the waiver, has delivered 12 per cent of the 100 million doses it promised and France has delivered just 9 per cent of the 120 million it promised. The US has delivered the most doses - nearly 177 million doses – however this is just 16 per cent of the 1.1 billion promised.

The Alliance said that while COVAX failed to acknowledge that relying on pharmaceutical companies may not deliver doses, the companies have undermined the initiative, first by not allocating it enough doses and second by delivering far less than they agreed. Of the 994 million doses allocated to COVAX by Johnson & Johnson, Moderna, Oxford/AstraZeneca, and Pfizer/BioNTech, only 120 million -12 per cent- have actually been delivered, which is fifteen times less than the 1.8 billion doses delivered to rich countries from these companies. Both Johnson & Johnson and Moderna are yet to deliver a single dose they promised to the initiative.

Oxfam’s Robbie Silverman said: “The failure of rich country donations and the failure of COVAX have the same root cause – we have given over control of vaccine supply to a small number of pharmaceutical companies, who are prioritising their own profits.

“These companies can’t produce enough to vaccinate the world, they are artificially constraining the supply, and they will always put their rich customers at the front of the line.

“The only way to end the pandemic is to share the technology, and know-how with other qualified manufacturers so that everyone, everywhere can have access to these lifesaving vaccines.”

During the UN General Assembly in September, President Biden rallied support for the goal to vaccinate 70 per cent of people in every country by September of 2022. While this target is rightly ambitious, the People’s Vaccine Alliance says it should be achieved much more quickly, and there is still no plan to achieve it.

The WHO stated that it must be a global priority to get doses to developing countries by the end of this year, but the Alliance says rich countries are not listening and working to a timetable of delivering an inadequate supply of doses by some time in 2022, which is likely to lead to countless unnecessary deaths.

Maaza Seyoum, of the African Alliance and People’s Vaccine Alliance Africa, said: “Across the world health workers are dying and children are losing parents and grandparents. With ninety-nine per cent of people in low-income countries still not vaccinated, we have had enough of these too little too late gestures.

“Governments must stop allowing pharmaceutical companies to play god while raking in astronomical profits and start delivering actual action that will save lives.”

To deflect growing pressure to share their vaccine technology free of intellectual property restrictions leading western pharmaceutical corporations have consistently over-exaggerated their projected production volumes, claiming there will soon be enough for everyone while delivering the overwhelming majority of their stock to rich nations. Collectively, the four companies claimed they would manufacture an estimated 7.5 billion vaccines in 2021, yet with less than three months until the end of the year, they have only delivered half of these. Forecasts suggest the companies will produce 6.2 billion vaccines by the end of the year, a shortfall on their projections of more than 1.3 billion doses.

With a week to go before leaders meet for the G20 summit in Rome, The People’s Vaccine Alliance - which has 77 members including ActionAid, the African Alliance, Global Justice Now, Oxfam and UNAIDS – is calling on them to stop breaking their promises to vaccinate the world and to:

• Suspend intellectual property rights for COVID vaccines, tests, treatments, and other medical tools by agreeing to the proposed waiver of the TRIPS Agreement at the World Trade Organisation.
• Demand, and use all their legal and policy tools to require pharmaceutical companies to share COVID-19 data, know-how, and technology with the WHO’s COVID-19 Technology Access Pool and South Africa mRNA Technology Transfer Hub.
• Invest in decentralised manufacturing hubs in developing countries to move from a world of vaccine monopolies and scarcity to one of vaccine sufficiency and fairness in which developing countries have direct control over production capacity to meet their needs.
• Immediately redistribute existing vaccines equitably across all nations to achieve the WHO target of vaccinating 40 per cent of people in all countries by the end of 2021 and 70 per cent of people in all countries by mid-2022.

“I am 18 years old, and I am already thinking about getting married. In our area, girls get married early. I’m afraid that with my positive HIV status I won't be able to find a boyfriend, which means I won’t have a family,” said Sayora Akmatova (not her real name), a participant of a training on sexuality education for adolescents living with HIV, held in Osh, Kyrgyzstan.

More than 60 young people living with HIV and their parents from different regions of Kyrgyzstan recently participated in a series of trainings for adolescents and young people living with HIV on sexuality education, reproductive health and prevention of violence conducted by Araket Plus and the Reproductive Health Alliance Kyrgyzstan.

“Adolescents and young people living with HIV are exposed to various types of violence, so there is a need to integrate HIV prevention and treatment programmes with programmes on sexuality education, reproductive health and gender equality. Through such courses we wanted to ensure that teenagers living with HIV received a comprehensive training package, including leadership skills, how to identify and address violence and how to overcome self-stigma,” said Meerim Sarybaeva, the UNAIDS Country Director for Kyrgyzstan.

During the parallel training for parents of adolescents living with HIV, issues such as psychological challenges and personal boundaries, the importance of interpersonal communication and the need to communicate difficult and sensitive topics with children, such as contraception, condom use and sexually transmitted infections, were discussed.

Uluk Batyrgaliev, a sexual and reproductive health trainer at the Reproductive Health Alliance Kyrgyzstan worked with a group of parents and talked about how the fears of parents of children living with HIV are most often associated with their future.

“I was surprised to hear those parents of HIV-positive children agree in advance between themselves to marry their children to each other, so not to infect the “clean”,” said Mr Batyrgaliev. “The word “clean” is used by the parents to describe people who are HIV-negative. This is incredibly self-stigmatizing.” 

Galina Chirkina, the Executive Director of the Reproductive Health Alliance Kyrgyzstan, emphasized that the relationship between sexual and reproductive health problems and HIV is evident to professionals but is not always apparent to others or adolescents living with HIV.

“We teach young people living with HIV to have a common understanding of how they can have a successful sexual life, and how they can plan their future and family. Realizing the right to reproductive health and the future starts with sexual education.”

The education system in Kyrgyzstan doesn’t include sexuality education courses for young people in schools. However, as optional courses, teachers can choose healthy lifestyle courses that include special sexuality education lessons for high school students. A healthy lifestyle curriculum was developed in 2014 with United Nations system support in Kyrgyzstan and was recommended for all schools in the country.

The trainings were organized within the regional cooperation programme on infectious diseases, implemented by the UNAIDS Country Office for Kyrgyzstan and funded by the Government of the Russian Federation.

COVID-19 has underscored the crucial need for pandemic responses to include social protection measures that reach and benefit marginalized populations.

As the pandemic swept across western and central Africa in early 2020, the region was already grappling with socioeconomic distress and humanitarian crises. Social restrictions imposed to contain the pandemic exacerbated those challenges. Impoverished and vulnerable populations, including people living with HIV and key populations, were hit hard.  

Surveys conducted between June and August 2020 in 17 countries in the region on the situation and needs of people living with HIV—with support from UNAIDS, in partnership with the Network of African People Living with HIV West Africa—revealed that up to 80% of people living with HIV were experiencing livelihood losses, and more than 50% of them needed financial and/or food assistance.  

These findings convinced UNAIDS and the World Food Programme (WFP) to launch a pilot project on unrestricted cash transfers in July 2020 to help people living with HIV and key populations cope with the socioeconomic impact of HIV and COVID-19 in four priority countries: Burkina Faso, Cameroon, Côte d’Ivoire and Niger. The initiative was designed to capitalize on WFP’s existing arrangements with service providers and on UNAIDS’ community engagement and relationships with civil society networks in the four priority countries.

Cash transfers are increasingly recognized as an effective form of social protection, with positive social and economic effects. They provide income support and help households avoid selling off assets or removing children from school, and they have multiplier effects on local economies. They constituted approximately 40% of global social safety net expenditures in 2018, but less than 20% in western and central Africa.

As the pandemic spread across western and central Africa, only a few countries (Côte d’Ivoire and Senegal among them) allocated additional support for vulnerable households in the form of cash transfers or social grants.

The immediate objective of the pilot was to reach about 5000 households with one-off, unconditional cash transfers, which ranged from US$ 88 per beneficiary (in Côte d’Ivoire) to US$ 136 (in Cameroon).

“I am so grateful for this support. I used it to pay the fees for my sewing course and to buy a sewing machine to start my own business. I also helped my mother who lost her job due to the pandemic,” said a young woman living with HIV in Cameroon.

Civil society organizations and financial service providers were engaged during the planning of the pilot. Eligibility for the transfers was decided based on a variety of vulnerability criteria, and beneficiaries were identified with the support of community-led organizations. Additional steps involved sensitizing beneficiaries, distributing the cash transfers, troubleshooting and monitoring the process. Specific attention was made to ensure confidentiality and to mitigate any potential stigma for beneficiaries.

Across the four countries, almost 4000 beneficiaries were reached, and it is estimated that a further 19 000 household members also benefited from the cash transfers, most of which went towards food, health care, education and housing expenses, or for income-generating activities. Country experiences varied in terms of the depth of their collaboration with community partners and the extent to which government actors were involved.  

The experience of the pilot demonstrated that delivering rapid cash transfers to marginalized people living with HIV and key populations in very difficult circumstances is possible, and that it provides valuable emergency support.   

Critical lessons learned include the need for inclusive and flexible approaches, working in ways that are clear and transparent to community partners and systematically involving community partners throughout the process. Defining clear and unbiased eligibility criteria, applying them consistently and sensitizing beneficiaries and communities are also vital.

Capacity-building and other support (including funding) for community partners is another critical element. Community-level organizations, trusted counsellors and peer educators were essential for establishing trust, identifying and reaching the intended beneficiaries, minimizing stigma and assessing the impact of the cash transfers. Engaging with government structures from the beginning helps to create the potential for long-lasting improvements.  

One-off cash transfers of this kind can help households withstand short-term shocks, but they do not do away with the need to fully integrate vulnerable and marginalized populations into crisis responses and comprehensive social protection systems. It is imperative that countries across Africa expand inclusive, multipurpose social protection that is accessible and sustainable. Enhancing the people-centredness of cash transfers and slotting them in with other forms of social provisioning and support that are not necessarily cash-based—such as free or subsidized primary health care, education, water and energy—is part of this process.

Following this pilot experience on the use of cash transfers to support the most vulnerable people living with HIV and key populations, UNAIDS and the Civil Society Institute for Health have further strengthened their collaboration on advancing HIV-sensitive and inclusive social protection in western and central Africa. Recently they organized, with the support of LUXDEV funding and in collaboration with several UNAIDS Cosponsors, a capacity-building workshop to mobilize and build the capacity of civil society and communities and to promote dialogue and collaboration among civil society organizations, partners and governments to advance inclusive, HIV-sensitive social protection in the region.

Building on the recommendations of the workshop, a number of follow-up activities were agreed to enhance the role and positioning of communities in advancing HIV-sensitive social protection within their countries and the region. 

“The cash transfer initiative in Niger came at the right time. The cash transfers were used by the beneficiaries to stockpile food and pay rent, but most importantly to allow the children to continue their schooling. This initiative demonstrated the value and importance of working together with the communities and our Cosponsors to achieve a common goal,” said El Hadj Fah, the UNAIDS Country Director for Niger.

The Bangkok Metropolitan Administration (BMA) in Thailand has been awarded the inaugural Circle of Excellence Award at the Fast-Track cities 2021 conference, held recently in Lisbon, Portugal. The Circle of Excellence Award showcases outstanding work in fast-tracking the HIV response and advancing innovative programming to end the AIDS epidemic in cities by 2030.

“To receive the Circle of Excellence Award for Bangkok is a great honour. It demonstrates not only the past achievements but, moreover, the future commitment to accelerate the HIV response and towards ending AIDS in Bangkok. We are proud that innovations have produced remarkable results, particularly same-day antiretroviral therapy and key population-led health services, such as specialized and holistic services for transgender people and the scale-up of pre-exposure prophylaxis (PrEP) programmes. These innovations are not only applied in Bangkok but have become models for the region,” said Parnrudee Manomaipiboon, the Director-General of the Department of Health, BMA, during the award ceremony.

Organized by the International Association of Providers of AIDS Care, in collaboration with UNAIDS, the Fast-Track Cities Institute and other partners, the Fast-Track cities conference highlighted successes achieved across the Fast-Track cities network, addressed cross-cutting challenges faced by local stakeholders and shared best practices in accelerating urban HIV, tuberculosis and hepatitis B and C responses.

“Bangkok has put in place a 14-year strategic plan for ending AIDS from 2017 to 2030, which is under the leadership of the Bangkok Fast-Track Committee,” said Pavinee Rungthonkij, the Deputy Director-General, Health Department, BMA. “During COVID-19, BMA and partners have introduced innovations such as multimonth antiretroviral therapy, an express delivery of antiretroviral therapy service, sexually transmitted infection self-sampling and PrEP,” she added. Among other achievements, Bangkok has expanded its PrEP services to 16 municipal public health centres and eight city hospitals and implemented citywide awareness campaigns. PrEP in the City was the first citywide PrEP campaign focusing on transgender people in Asia.

“Significant progress has been made in the HIV response since Bangkok joined the Paris Declaration to end the AIDS epidemic in cities in 2014. It shows that mutual commitments and a strengthened partnership between stakeholders at all levels are key to an effective HIV response. Bangkok will continue to leverage support, scale up innovations and Fast-Track solutions to achieve the 2025 targets and end AIDS by 2030,” said Patchara Benjarattanaporn, the UNAIDS Country Director for Thailand.

Fast-Track cities in South-East Asia have been stepping up efforts during the COVID-19 pandemic to ensure that HIV treatment and prevention services remain unaffected by the pandemic and to protect the gains made in the HIV response. The dynamic city-based infrastructures that have been built up around the HIV response are being leveraged to implement innovative programmes to safeguard people living with HIV and other vulnerable populations and contain the spread of COVID-19.

Jakarta, Indonesia, provides a clear example of how cities are accelerating their HIV responses, enabling continued progress while taking into account the effects of the COVID-19 pandemic. Since the first COVID-19 outbreak, Central Jakarta, with more than 10 000 people living with HIV on antiretroviral therapy, ensured treatment continuity with the implementation of multimonth antiretroviral therapy dispensing and community-led home-based delivery. In collaboration with partners, the Provincial Health Office of Jakarta developed the Jak-Anter service, which connects people living with HIV with health facilities across the metropolitan area, allowing for direct client-organized antiretroviral therapy delivery, benefiting nearly 30% of people living with HIV in the area.

This best practice was shared at an event, ASEAN Cities Getting to Zero: Protecting Fast-Track Cities’ Gains during the COVID-19 Pandemic, which brought together five cities from the Association of Southeast Asian Nations (ASEAN) on the margins of the Fast-Track cities 2021 hybrid conference in Lisbon, Portugal, on 21 October.

“Cities play a critical role in delivering on the United Nations Political Declaration on AIDS. As we make our collective steps towards the next phase of achieving the three zeroes, we must work in partnership to address the variety and complexity of HIV epidemics. Evidence-informed national regulations will ensure effective collaboration between national and subnational governments,” said Budi Gunadi Sadikin, the Minister of Health of Indonesia.

The event allowed ASEAN cities to share innovative practices in implementing HIV programmes amid the COVID-19 pandemic.

“ASEAN is committed to fast-tracking the HIV response to end AIDS by 2030. We must continue to work hand in hand and to ensure equitable access to HIV services and solutions, break down barriers and improve resource mobilization for efficient and sustainable HIV responses,” said Dato Lim Jock Hoi, the Secretary-General of ASEAN.

A recurring theme during the session was how quickly ASEAN cities utilized virtual platforms to scale up access to HIV services, especially during lockdowns. In the Philippines, Pasig City delivered quality services to key populations by increasing investments in HIV programmes and treatment facilities and the use of virtual platforms. Like Jakarta, Pasig City partnered with community-based organizations to deliver antiretroviral therapy, condoms and lubricants by establishing a service delivery network with service providers and health facilities to provide core packages of health-care services during the COVID-19 pandemic.

Can Tho, a city in Viet Nam, piloted a project to deliver self-test kits to key populations, in particular gay men and other men who have sex with men and people who use drugs, through virtual platforms. In collaboration with the World Health Organization and civil society partners, Can Tho quickly responded to COVID-19 by training community outreach workers to conduct community-based HIV rapid testing and by scaling up HIV self-testing.

Bangkok’s innovations included same-day delivery of antiretroviral therapy and the scale-up of key population-led health services. Bangkok, a regional leader in pre-exposure prophylaxis (PrEP) and a provider of specialized and holistic services for transgender people, expanded its PrEP services to 16 municipal public health centres and eight city hospitals during the COVID-19 pandemic.

Young people were noted as being at the forefront of the HIV response in ASEAN cities. In an effort to reduce the number of new HIV infections among young people in Langkawi, Malaysia, the Kedah State Health Department established the GLITZ project. The programme focuses on young people, including young key populations, through various outreach activities, mentor–mentee programmes and school and university visits to educate young people on HIV prevention. 

As the Fast-Track cities network continues to grow in the ASEAN region, the complexity of HIV in urban areas is better understood. The network offers a way for cities to share best practices and experiences at a time of increasing urbanization and globalization.

“It has been 10 years since the ASEAN Cities Getting to Zero project was initiated. Since then, the project has successfully expanded to 76 cities in the region. As we see more participating cities and significant signs of progress in the HIV response, I encourage avenues for South–South collaboration. Together, in partnership, we can end AIDS as a global health threat by 2030,” said Taoufik Bakkali, the Director, a.i., of the UNAIDS Regional Support Team for Asia and the Pacific.