Nearly 40 years into the HIV response, improved access to HIV treatment means the 26 million people living with HIV globally who are on HIV treatment can live long and healthy lives. But what does health care for an ageing population of people living with HIV look like?

Having lived with HIV for more than 30 years, this is a question 66-year-old Stephen Watiti from Uganda has been considering. 

“My needs are going to be changing … and in the future most of the people living with HIV will be 50 years and above,” said the celebrated medical doctor, who is based at Mildmay Uganda Hospital, in Kampala.  

In the eastern and southern Africa region, approximately 3.6 million of the 20.7 million people living with HIV are over the age of 50 years.

The new UNAIDS World AIDS Day report, Prevailing against pandemics by putting people at the centre, calls for a differentiated HIV response that is more intensive and more effective at ensuring that we reach those who until now have been left behind. This includes expanding treatment access equitably by providing people-centred, age-sensitive and integrated health services. 

People living with HIV should be supported to lead long and healthy lives and people over 50 years of age should have equal access to social protection, employment and social integration.

Mr Watiti said little attention has been given to this phenomenon. “We have worked a lot in paediatric HIV. In geriatric HIV, there is no person who is trained in preparation for that,” he said. 

Back in 1999, a period void of HIV treatment and substantial HIV knowledge and training among people in eastern and southern Africa, Mr Watiti experienced multiple AIDS-related illnesses. He had a “frightening” near-death experience where his CD4 count plummeted. His ailing body had to battle tuberculosis, cryptococcal meningitis and Kaposi’s sarcoma—all at the same time. 

Mr Watiti started HIV treatment in 2000. However, due to the affordability and accessibility of the antiretroviral medicines in his regimen at that time, his adherence was poor, and he fell sick due to treatment failure.

In 2003, with a new antiretroviral regimen, and the unwavering support of a counsellor from the AIDS Support Organization in Uganda, Mr Watiti realized he was “no longer dying.”

During this period, he realized the need for him to educate and inspire his patients living with HIV. And so he returned to work.

Mr Watiti has come a long way. Despite living with uncertainty as part of an older generation living with HIV, Mr Watiti intends to live a full life, practising medicine well into his seventies.

“I’ll have to keep swallowing this medicine unless there’s a cure by then,” he said.

However, Mr Watiti wants to know what can be done to ensure that people living with HIV who are on treatment have a good quality life, including access to mental health services.

This is a question he raised during a conversation with UNAIDS Executive Director Winnie Byanyima at the launch of the UNAIDS World AIDS Day report.

Ms Byanyima agreed. “Considering that someone is going to live off a tablet for the rest of their lives and sometimes that person is living in poverty or hiding their secret because of stigma, this is a huge challenge of the mental and emotional well-being of a person,” she said. “People living with HIV need a wider comprehensive package of services, including mental health. The AIDS response cannot be narrowed just to the tablet.”

Mr Watiti was a beacon of hope for people who were living with HIV at a time when surviving AIDS was a grim prospect and is an example of resilience for people living with HIV today. 

Mr Watiti says as he counsels his patients to overcome HIV stigma and about the importance of diligently taking their medication, it was as if he was talking to himself: “To tell you the truth, if there’s one person I've helped the most, it is me.”

Like HIV, the COVID-19 pandemic thrives on inequalities and inequities. In addition to its impact on people’s health, the COVID-19 pandemic has resulted in significant increases in gender-based violence around the globe, including in the Middle East and North Africa.

Some countries in the region lack essential services for survivors of violence, especially in, for example, rural areas, conflict zones or humanitarian settings. Where services do exist, they do not always reach marginalized women and girls, and in many cases have been reduced or de-prioritized during the pandemic. Gender-based violence in the Middle East and North Africa is also sometimes not prioritized by the police and justice systems and many countries do not criminalize domestic violence, marital rape and other forms of gender-based violence that are particularly relevant in the region, such as female genital mutilation.

The United Nations Issue-Based Coalition on Gender, Justice and Equality is taking a twin-track approach to gender-based violence in the region, combining a programmatic response that prevents gender-based violence and supports survivors with the launch of a region-wide awareness campaign. The campaign uses the regional goodwill ambassadors of the coalition United Nations agencies to shed light on the risks that women and girls face as a result of the health crisis and to raise people’s awareness on how to counter gender-based violence and support survivors.

“Any form of violence against women and girls is a direct violation of human rights. I want to assure every violated woman and girl through this campaign that we are all with you,” said Yousra, UNAIDS Goodwill Ambassador for the Middle East and North Africa.

The joint campaign is an illustration of the strength of collaboration among United Nations agencies and what partnerships can do in building and empowering the global appeals and calls to action of the United Nations Secretary-General and the Spotlight Initiative, a global, partnership between the European Union and the United Nations to eliminate all forms of violence against women. The campaign leverages the ability of regional celebrities to reach local communities to raise awareness on the compounding impact of COVID-19 on gender-based violence and the vulnerabilities of marginalized and vulnerable groups.

“The response to COVID-19 in this region, and globally, has shown us that when we act in solidarity, in true partnerships and with a sense of shared responsibility, we can win against the intertwining health threats of COVID-19, HIV and the shadow pandemic of gender-based violence,” said Rangayian Gurumurthy, Director, a.i., of the UNAIDS Regional Support Team for the Middle East and North Africa.

“During COVID-19, most of us are confined in our homes with our partners. This has increased relationship problems, as well as social and economic problems. Many are subjected to violence from our close family or our intimate partner. That is why our nongovernment organization dedicated a hotline for psychological support,” said a woman living with HIV in the Islamic Republic of Iran.

On World Children’s Day, UNAIDS is joining with partners to call for accelerated access to better tools to prevent, diagnose and treat HIV in children and tuberculosis (TB) in children living with HIV with a joint statement announcing the launch of the Rome Action Plan 2020.

Children living with HIV are disproportionately being left behind by the HIV response. Treatment coverage among children globally is extremely low. In 2019, only 53% of the estimated 1.8 million children living with HIV were found and on treatment. That means that 850 000 children living with HIV are not on life-saving HIV treatment. More than half of those missing children are in just five countries—the Democratic Republic of the Congo, Kenya, Mozambique, Nigeria and South Africa—and two thirds of those children are aged 5–14 years. Furthermore, we are not doing enough to prevent new infections, with 150 000 new HIV infections among children aged under 15 years in 2019. Therefore, specific programmes and activities must be rapidly deployed to reach those children and allow them to benefit from the extraordinary expansion of paediatric innovations.

The reasons for this are manyfold. Mothers are not tested for HIV during pregnancy and breastfeeding and therefore cannot receive HIV treatment that will keep them healthy and prevent their child becoming HIV infected. Children are not tested for HIV at or shortly after birth so cannot benefit from early HIV treatment with better outcomes. The most commonly available HIV treatments for HIV are not child-friendly, often tasting bitter and cannot be dissolved or sprinkled on food for infants and young children who cannot swallow tablets.

Children and especially children living with HIV are particularly vulnerable to TB, which is the commonest cause of death among people living with HIV. TB among children living with HIV is difficult to diagnose and the treatment is complicated and unpleasant to take, especially in combination with HIV treatment.

“The Rome Action Plan has driven new diagnostics and more effective, affordable and palatable treatments for children living with HIV. We have a moral obligation to now ensure those tools actually reach the children who need them most,” said Shannon Hader, UNAIDS Deputy Executive Director, Programme. “We need action—to reach those children countries need to focus in on their data, understand where and how the children who are missed are likely to be reached and eliminate any artificial barriers—from policy to implementation—that get in the way. And as for innovation—better diagnostics and treatments for both HIV and TB among children—we’re not done yet. We will continue to advocate and partner for more and better.”

Since 2016, as part of the UNAIDS and United States President’s Emergency Plan For AIDS Relief faith initiative, the Vatican has been bringing together key partners in a series of high-level dialogues to find better ways to prevent, diagnose and treat HIV in children, and this year included a focus on TB among children living with HIV for the first time. On 5 and 6 November, the Vatican’s Cardinal Turkson convened the virtual Rome Five meeting. This innovative dialogue brought together leaders from the private and public sectors, governments, regulatory authorities, faith-based and community-based organizations and other implementing partners to find solutions to reduce the burden of HIV and TB among children.

The meeting resulted in a new Rome Action Plan 2020, a series of ambitious commitments made by participating organizations aimed at overcoming the bottlenecks to HIV and TB services for children. Among the many commitments made by the partner organizations, UNAIDS has committed to supporting governments to collect and report on the burden of HIV and TB among children so that national responses can be targeted to where they are most needed. UNAIDS will set and report on ambitious age-specific global targets for the prevention, testing and successful treatment of HIV in children and TB in children living with HIV. UNAIDS will continue to advocate at the highest political level for increased investment and committed actions at the country level so that the world can get on track to ending AIDS and TB among children living with HIV.

Irina Kutsenko, a deputy of the Odesa City Council in Ukraine responsible for social issues, is an active advocate of community rights who campaigned for medical and social services for HIV to be brought closer to the most disadvantaged. She is the first and so far the only government official nominated by civil society for the #inYourPower award. The award, which is given by civil society to leaders, government officials and eastern European and central Asian politicians, is given to people who have contributed to improving the financial sustainability and effectiveness of HIV programmes for key populations and to removing legal barriers to HIV services and protecting human rights.

However, the route to the award was not straightforward. “As a deputy, I closed the opioid substitution therapy site in my district. I collected signatures from people against the gay movement in our city,” she said. But after completing a course run by the International Academy of Harm Reduction, she began to research the topic in more detail. “I started reading about the issue on the Internet, listening to interviews of people, listening to life stories, until I understood that I was wrong!”

Ms Kutsenko started to cooperate with community organizations to make Odesa a safer city for key populations.

“When representatives of community organizations came to me with a harm reduction project in the city, I already understood what they were talking about. At that moment, I realized that nongovernmental organizations today know more than officials. At the beginning, I was only listening,” she said.

The first task for Ms Kutsenko and the community organizations was to find a common language and common platform. “We needed everyone: doctors, the authorities and public organizations to unite and work towards one common goal,” she said. “It didn't work out when everyone was separate.”

But, as Gennadiy Trukhanov, the Mayor of Odesa, said, it was not easy for the city. The city authorities, in addition to responding to local everyday problems also need to address global challenges, in particular helping health-care workers to fight the COVID-19 pandemic. “Mayors are assessed by the state of the city: roads, public spaces, etc. We can have clean cities, but with the spread of infectious diseases around the world, the time may come when there will be no one to walk along these roads,” he said.

Over the past few years, Odesa has been implementing steps within the framework of the Paris Declaration to end the AIDS epidemic in cities and was the first city in Ukraine to commit to the Zero TB Cities initiative. The city has initiated outpatient treatment of tuberculosis, instead of in hospital, and has begun widescale testing programmes for HIV, increasing the detection rate of HIV and ensuring that people who test positive access treatment.

“Of course, there are still many problems, but, step by step, we are changing the situation in the city,” said Ms Kutsenko.

Ms Kutsenko’s story can be viewed on YouTube.

The World Health Organization (WHO), in coordination with UNAIDS, has updated its HIV Testing Services dashboard with new data for 2020, ahead of this year’s World AIDS Day.

The interactive dashboard gives users a wide range of information on HIV testing from countries worldwide on, for example, HIV prevalence, the number of people testing positive for HIV and the number of people testing for HIV for the first time or repeating a test. Data are given in charts and tables and are differentiated by age, sex and other characteristics.

“It is critical to have differentiated HIV testing data at this stage in the epidemic,” said Cheryl Johnson, WHO Technical Officer. “Having such data will help programmes to implement the World Health Organization’s guidelines so that they may reach the remaining people living with HIV who do not know their status. We look forward to working with countries on how they can use their data to guide efficient and effective HIV testing services.”

Countries need to have a range of testing approaches to reach people living with HIV who do not know their status and others at risk of acquiring HIV. The dashboard will help countries to develop the best mix of testing services—such as self-testing, index testing and various forms of community and facility-based testing services—suitable for their settings. Countries can also monitor the progress of the number of people who newly learn their HIV status.

“We are using data to intensify our efforts to reach the remaining people living with HIV who don’t know their status and to facilitate linkage to care by prioritizing and differentiating testing so we can reach underserved geographies and populations in Uganda. The dashboard is a useful tool to help guide decision-making and our national strategy moving forward,” said Geoffrey Taasi, Programme Officer, HIV Testing Services, Ministry of Health, Uganda.

The information on the dashboard is a mixture of WHO and UNAIDS data, national programme data, modelled estimates and population survey data—it also includes the implementation status of testing services and national policies. The data used were selected in consultation with representatives of ministries of health, research partners, local and international implementing partners and donors.

In addition to the website, the dashboard can be accessed through the WHO HTS Info app using a smartphone or tablet.

“Expansion of relevant HIV testing approaches is critical for Viet Nam to achieve the 90–90–90 targets. With support from the World Health Organization and other partners, we have successfully piloted community-based HIV testing, including lay provider testing and self-testing. We are now working to scale up these approaches nationwide,” said Nguyen Hoang Long, Director-General of the Viet Nam Authority of HIV/AIDS Control, Ministry of Health, Viet Nam.

Côte d’Ivoire has launched its Harnessing the Power of Partnerships faith-based initiative.

As one of several focus countries for an initiative of the United States President’s Emergency Plan For AIDS Relief (PEPFAR) and UNAIDS, which was launched in June 2020 to leverage global and country leadership by faith-based organizations in the HIV response, Côte d’Ivoire will work with faith-based organizations in the country to align their activities to faith action plans in support of the national HIV response. Experience shows that such an alignment results in a better coordinated and sustained participation of the faith sector in national responses to HIV.

Faith-based organizations have always played an important role in the response to HIV through their strong links with communities and their broad network of hospitals, clinics and other health facilities. However, to unleash the full potential of those organizations, there is still a need to reinforce their capacities to adopt new policies and innovations, to improve their collaboration and coordination with partners in the HIV response and to further address HIV-related stigma and discrimination within faith communities.

“This initiative will build on the global and national leadership of faith-based organizations in the response to HIV, with a particular focus on areas where faith-based organizations have a real and sustainable impact,” said Samba Mamadou, Director-General of the Côte d’Ivoire Ministry of Health and Public Hygiene.

Through the partnership, PEPFAR’s implementing partners in the country will work with faith-based organizations to develop messages of hope to reduce HIV-related stigma and discrimination and increase demand for HIV services. Key issues to be addressed will include treatment cessation through “faith healing” and the need for strengthened HIV literacy.

The next steps of the initiative include convening a meeting with all the relevant stakeholders to develop a faith action plan in support of the national HIV strategic plan for 2021–2025.

“The initiative is designed as a consortium of longstanding faith-based organizations and partners working together to build and combine their strengths, promote evidence-informed policy and practice and strengthen advocacy efforts,” said Brigitte Quenum, UNAIDS Country Director for Côte d’Ivoire.

The initiative, which is under the leadership of the Ministry of Health and Public Hygiene and the National AIDS Control Program, and is supported by UNAIDS, was launched in mid-October at an event attended by more than 50 partners that was hosted by UNAIDS and streamed online. 

"The faith-baith institutions welcome this interfaith initiative to strengthen the contribution of our institutions and leaders in a more synergistic way,” said Pastor Yapi, Deputy Vice-President of the Alliance des Religieux pour la Santé Intégrale et la Promotion de la Personne Humaine.

A new television series for young people in the Kyrgyz language, School Elections, was launched online last week. During six 15–20-minute episodes, a girl, Ayana, who is living with HIV, tells her story of bullying, friendship and the fight for human dignity. The producers of the series hope that Ayana’s example will give hope to young people who face similar challenges.

“We have a simple idea to promote: you may differ from others in your health, appearance or level of wealth. But regardless of this, we all deserve respect, friendship, love and happiness. This series is about kindness and acceptance of others as they are,” said Azim Azimov, Head of Production at the Media Kitchen production studio and the main screenwriter of the series.

Starting on 6 November, new episodes will be aired weekly on YouTube and will also be broadcast on television, Instagram and the teens.kg youth project website. Additionally, each series has one to three interactive episodes—the leading actors invite the viewers to look at the problems raised in the series through the viewers’ eyes, experience each situation for themselves and make their own decisions.

According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), more than 30% of students around the world experience various forms of bullying at the hands of their classmates. Students who are perceived as “different” are often subjected to bullying for reasons of appearance, health status, including HIV status, sexual orientation and gender identity, social status or the economic situation of the family.

“This series tells people about the complex issue in simple and understandable language, to show how strong-willed and honest young people can overcome ignorance, indifference, cruelty and injustice, inspire others and change life for the better,” said Tigran Yepoyan, UNESCO Regional Adviser on HIV, Education and Health.

“This series is a powerful new instrument for reducing stigma in our society, it not only shows the difficulties of living with HIV, discrimination and bullying but also motivates our adolescents not to be afraid to fight for dignity and justice and move forward towards their dreams,” said Meerim Sarybaeva, UNAIDS Country Director for Kyrgyzstan.

The official soundtrack of the series, which was supported by the UNESCO Institute for Information Technologies in Education and UNAIDS, was performed by the singer Ayim Ayilchieva.

Haiti’s first safe house for transgender people opened last week. Kay Trans Ayiti launched with the snip of a red ribbon and cheers from a circle of activists and residents. The group took turns taking pictures between bobbing pink and blue balloons tied to the veranda.

The triumphant moment came during a tough time. Asked how transgender people have fared in Haiti during COVID-19, home founder Yaisah Val was emphatic. “When the rest of the population has a cold, the trans community has pneumonia. Just imagine that with the hunger, poverty and meagre resources in Haiti, we are always on the outside,” she says.

In many ways, Ms Val is not as shut out as the people she serves. Haiti’s first publicly open transgender woman introduces herself as a mother of two and a wife. She has a degree in education and clinical psychology. She was a teacher and school counsellor before becoming a full-time community mobilizer, activist and gender identity spokesperson. During what she calls her stealth years, she was easily accepted as a woman.

Born in the United States of America to Haitian parents, she has had the benefit of a stable home, supportive teachers and a wildly loving grandmother.

“If you are going to be a sissy you will be the best sissy there is because you are mine,” her granny told her when she was a boy named Junior.

This is an anomaly. According to the United Caribbean Trans Network, transgender people in the region are far less likely to be supported by family, complete their secondary education and be employed. They are more likely to be homeless, to sell sex to survive and to face extreme violence. All this sharply increases the community’s HIV risk. A recent study found that transgender women in Haiti had an HIV prevalence of 27.6%—14 times higher than the general population.

But notwithstanding her “privileged” life, Ms Val’s 47-year journey has been fraught.

From when she was two or three years old she knew she was a girl. The gender policing from relatives was immediate and incessant: “Straighten up that boy. You can’t let him grow up like that.” At seven she was admitted to Washington Children’s Hospital with self-inflicted wounds to her genitals. Puberty was, “hell … a lot of confusion and self-hate.”

About 20 years ago she became herself during the Haitian Carnival. She braided her hair, slipped into a dress and boarded a loud, colourful tap-tap bus with her friends. One man flirted. He called her pretty and opened doors. She felt like Cinderella.

“That boy eventually found out and beat me within an inch of my life,” Ms Val remembers. “Whether you are upper class or middle class or on the streets, as long as you are trans it does not matter. Once you disclose, all respect is gone … you are just this thing. That one word disarms you of all humanity in people’s eyes.”

Transitioning offered a sort of freedom, “I was living and being seen as who I am, who I had always been.” But the fear of being assaulted or excluded made her identity a stressful secret. Old boyfriends did not know she was transgender until she came out years later. She only disclosed to the man who would become her husband after they had lived together for a year and were on the brink of getting married.

“I don’t recommend people do that,” Ms Val says again and again, referring to transgender people hiding their gender identity from romantic partners. “It can be violent. It can be dangerous.”

In her case it worked out. Her partner decided that she was the same person he knew and loved. Three years ago, the story repeated when she disclosed to her children.

“I was just surprised,” her son, Cedrick said. “I was shocked in a good way. They’d slowly started educating me over the years, so I understood what it meant. Ever since then the whole mother/son bond went to a new level for both of us. It filled in all those gaps. Now everything made sense, like her childhood stories.”

Coming out to those closest to her has opened the floodgates to activism. In 2016, Ms Val became the first person in Haiti’s history to publicly identify as a transgender person. She has been a key partner for UNAIDS Haiti and the island’s lesbian, gay, bisexual, transgender and intersex (LGBTI) people organizations. Last year she participated in a national dialogue on LGBTI rights. Together with her husband she started taking in homeless transgender people. That paved the way for Kay Trans Ayiti, which now houses 10 transgender people. Fundraising is under way for a programme of psychosocial support, hormonal replacement legal advice and job training. One of their employment initiatives is a food cart. Some of their residents are living with HIV. They are supported to remain adherent to their antiretroviral treatment.

Ms Val knows first-hand how terrifying it is to access sexual and reproductive health care as a transgender woman. She recalls the experience of going to a gynaecologist in Haiti to get a check-up related to her vaginoplasty. The doctor did not understand what “transgender” meant. That visit ended with the gynaecologist calling other doctors to gawk.

“I was a YouTube channel, a Google page … anything but a human being. I was upset. I was crying. This is why transgender people do not access health care! We have a lot of transmen with gynaecological issues who make herbal treatments rather than go to the doctor,” Ms Val says.

Her group, Community Action for the Integration of Vulnerable Women in Haiti (Action Communautaire pour l’integration des Femmes Vulnerable en Haiti, or ACIFVH), is working with two HIV clinics to sensitize health-care providers. Combatting the ignorance and conservatism is a tall task. Even after educational sessions some doctors and nurses have tried pushing their religious views on the trainers.  

“I was lucky not to be hindered by transphobia and discrimination,” Ms Val reflects. “Imagine if I did not have a supportive grandmother, an education and opportunities. I would not have been the person you see now.

“If you throw a seed on concrete it is not going to thrive. Being trans is not the problem. It is the reaction people have to it:  throwing them on the streets, not letting them work, not taking them into schools. We need to have a place in society. It is hard. It will take a while. But someone has to start.”

Ukraine has announced that it is now funding 80% of its national HIV response’s HIV prevention, care and support programmes.

Under its 20–50–80 transition plan, which began in 2018, the government committed to increasing its share of the funding of HIV prevention, care and support programmes, which previously were fully funded by international donors, over three years. In the first year of the transition plan, the state was to finance 20% of those programmes, with the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) providing 80%. In the second year, the ratio was to reach 50/50 and in the third year 80% of funding was to be provided by the state, with 20% from by the Global Fund. This level of funding, which comes from both national and local budgets and is for prevention, care and support programmes within the national HIV and tuberculosis (TB) response and for the procurement of HIV/TB-related services from community organizations, has now been achieved.

The transition plan was proposed by a group of public and community organizations led by 100% Life, formerly called the All-Ukrainian Network of People Living with HIV. Dmytro Sherembey, the Head of the Board of 100% Life, said that most of the funding of the country’s HIV response used to come from donors, primarily the Global Fund. The 20–50–80 formula provided a simple algorithm tied to an agreed timeframe and obliged the government to increase domestic funding, since under the plan donor financing would be stopped if the government failed to meet its obligations.

“It was not an easy decision. It would have been easier to just sign a grant with the Global Fund. But we understood that if the government did not increase its funding, about half a million people who use the services would be left with nothing,” said Mr Sherembey. Also, since the government is unable to provide a wide spectrum of HIV prevention, care and support services on its own, community organizations have stepped in. However, there was a worry that reduced funding for community organizations would result in their being unable to provide such services, resulting in hundreds of thousands of people being deprived of care.

A Strategic Group for the Implementation of the Transition Plan, which included the Public Health Centre of Ukraine’s Ministry of Health, 100% Life, UNAIDS, the ICF Alliance for Public Health, Renaissance and Deloitte, developed new mechanisms through which local community organizations could cooperate with local authorities. The Sumy and Poltava regions of Ukraine were the first to start financing HIV and TB programmes from domestic funding. In 2018, the equivalent of more than US$ 650 000 was allocated to the programmes from Ukraine’s state budget.

“The transition plan provides an opportunity to continuously strengthen links between government and nongovernmental organizations in the provision of quality services to people living with HIV and tuberculosis. Nongovernmental organizations are moving away from their former role of volunteer activists and are starting to carry out professional social work and are accountable for its results. And the state, in turn, purchases their services through the public procurement system,” said Igor Kuzin, the Acting Director of the Centre for Public Health of the Ministry of Health of Ukraine.

With the support of Ukraine’s Ministry of Finance, the implementation of the transition plan progressed. In 2019, about US$ 4 million was allocated, equal to 50% of funding, which reached 25 regions in Ukraine. In 2020, the cost to the government of treatment and other services is expected to be about US$ 12.5 million, which is 80% of funding for such programmes.

“Together with the Public Health Centre of Ukraine’s Ministry of Health, and international and civil society partners, we will carefully monitor and analyse the results of this new model of HIV service delivery in order to ensure its sustainability, effectiveness and consistency,” said Raman Hailevich, the UNAIDS Country Director for Ukraine.

A woman living with HIV is at the Centre for HIV Research and Education Services (CHARES) in Kingston, Jamaica. She normally gets a three-month allotment of her antiretroviral medicines. But not this time. The doctor warns her that, since April, state pharmacies have only been dispensing a one-month supply.

About a 20-minute drive away at the Comprehensive Health Clinic, a client waits for his name to be called. He doesn’t use one of the wooden benches allocated for sexual health patients. Instead, he finds a nearby seat and listens intently.

HIV service providers in Jamaica have been challenged this year with responding both to new challenges caused by COVID-19 and long-standing service delivery stumbling blocks. The UNAIDS Country Director, Manoela Manova, wanted to get a better understanding of the issues on the ground, so she visited both treatment sites to speak with everyone, from adherence counsellors to doctors.

The University Hospital of the West Indies’ CHARES has been a best practice model for HIV treatment in Jamaica. For the island as a whole, 79% of those on treatment were virally suppressed last year. At CHARES, however, an impressive nine in every 10 clients are virally suppressed and therefore keep healthy and are unable to transmit the virus.

But even for this accomplished programme, COVID-19 has presented significant challenges.

Laboratory support has been diverted toward COVID-19 and there has been a backlog in receiving viral load testing results.

CHARES had been used to writing three-month prescriptions for stable clients, but since COVID-19, state-run pharmacies have been dispensing only a one-month supply. This is part of the government’s strategy to avoid stock-outs given the supply chain challenges at this time, but it means that those on treatment need to go out to get their medicines more often. CHARES has begun home deliveries, particularly for older people, who are more reluctant to venture out given the novel coronavirus risk. 

COVID-19 containment measures have increased the need for mental health support. Income loss, school closures and curfews have placed an added strain on thousands of Jamaican households, including many people living with HIV. But when clients are referred to psychiatric support in the main hospital they rarely go for fear of experiencing discrimination. Further, since the hospital in which CHARES is located is a designated COVID-19 treatment site, some clients have opted to stay away.

“We need closer monitoring and evaluation to address the challenges around patient management at this time,” said CHARES Programme Director Racquel Brown. “Optimally we would like to hire someone with responsibility for analysing patient data to make more strategic decisions around care and treatment.”  

The Comprehensive Health Centre serves a number of people living with HIV alongside those infected with other sexually transmitted infections. Here, too, multimonth dispensing has not been possible during COVID-19. Patients’ need for nutrition support has been high during this period. Some have had their antiretroviral medicines but no food with which to take them.  

But other challenges came before COVID-19. Two out of five clients are lost to follow-up. Patients have given service providers wrong addresses. And the clinic’s viral suppression rate stands at 70%, below the national average. Some come off their treatment against their doctor’s advice.

Ms Manova said many of the challenges at both clinics are linked to self-stigma and discrimination, which is the main issue facing Jamaica’s HIV response. For the country as a whole, just 43% of all people living with HIV were on treatment in 2019 despite the island’s relatively high testing coverage.

“Before and during COVID-19, our results are undermined by shame, fear and prejudice,” she noted. “For an effective public health response, we have to be deliberate and consistent about building trust with communities and combatting all forms of stigma and discrimination that block people from accessing care.”

“It was inspiring and sobering to spend time with these health-care providers,” Ms Manova said. “Jamaica has correctly treated community health-care employees as essential workers. Staff including community facilitators, social workers, adherence counsellors and case managers are just as needed as doctors and nurses. Their work is critical at this time to address the individual needs and emotions that could affect treatment outcomes.”