To defend her access to life-saving opioid substitution therapy, Marzhan Zhunusova overcame her fear of flying and, for the first time, took a flight to Astana, the capital of Kazakhstan. She was visiting the city to take part in a country-wide mobilization of people accessing the country’s harm reduction pilot programme, with people from all over Kazakhstan publicly showing the importance of opioid substitution therapy.

After injecting drugs for more than 25 years, Ms Zhunusova had lost hope for a better life. “When I first heard about opioid substitution therapy, I thought that it may be the way out and that it could help me. Drugs, my HIV-positive status, I thought my life was over. I’m 45 years old and only now thanks to methadone have I started to live life fully.”

The campaigners marched in Astana on 27 June and were joined by activists from other groups, including people living with HIV and gay men and other men who have sex with men.

The people who mobilized for the event share similar backgrounds. Their use of drugs may have deprived them of their health and their dreams. Some do not have jobs or have served time in prison. Many are isolated from society and the majority are living with HIV.

Ibrahim Dolgiev tried drugs for the first time in the 1970s, when he was 22 years old. “After many years of trying to stop using drugs, for the past year I’ve been in the opioid substitution therapy programme. It has been a salvation for me. My life has changed dramatically for the better, and for the first time in many years I can get through the day without heroin,” he said.

The people taking part in the mobilization came together to express their hope that the opioid substitution therapy programme will remain and that it will be further expanded.

In partnership with international and national partners, UNAIDS provided the Government of Kazakhstan with evidence-informed arguments on the effectiveness of opioid substitution therapy in controlling the HIV epidemic among people who use drugs.

“Access to opioid substitution therapy is one of the main factors enhancing adherence to antiretroviral therapy among people who use drugs,” said Alexander Goliusov, the UNAIDS Country Coordinator in Kazakhstan.  

“Over the past three years, people who use drugs in the opioid substitution therapy pilot project in Pavlodar demonstrated 100% adherence to antiretroviral therapy,” said Zhannat Musaevich Tentekpayev, Chief Doctor of the Pavlodar AIDS Centre.

Unfortunately, however, the future of the programme in Kazakhstan remains uncertain, and no one has been enrolled in the programme since December 2017.

At the end of June 2018, a government commission announced that the pilot programme would continue, but that it would not be expanded to other regions of the country. An investigation into the cost-effectiveness of the programme is under way and the results will be presented by November. The Kazakhstan Union of People Living with HIV has appealed to the President of Kazakhstan not to close down the programme, noting that support for effective national responses to HIV is critical to making progress towards the 90–90–90 targets.

"While the law enforcement agencies are deciding whether the opioid substitution therapy programme is appropriate or not, the number of people accessing the programme remains very limited. The programme has to be not only maintained, it must exit its pilot status and be available and accessible everywhere in Kazakhstan for people who inject drugs,” said Oksana Ibrahimova, the coordinator of the Kazakhstan Union of People Living with HIV.

Today, there are 13 opioid substitution therapy centres in Kazakhstan, in nine of the 16 regions of the country. Since the beginning of the programme in 2008, more than 1000 people have been enrolled. Currently, 322 people are enrolled in the programme, the majority of whom have stopped using drugs, become employed and are enjoying a family life.

On 28 September, Central Sulawesi, Indonesia, was struck by a powerful earthquake and a subsequent tsunami. Thousands of people are known to have died and tens of thousands of people have been displaced. In the event of a major humanitarian disaster, the basic needs of people are always difficult to fulfil—this is especially true for people living with HIV in Central Sulawesi.

The hospitals in the town of Palu are heavily damaged but remain operational. There are still stocks of antiretroviral therapy in those hospitals, but there are concerns about how long those stocks will last. Before the disaster, according to government data, there were an estimated 1913 people living with HIV in Central Sulawesi, with 334 people, including three children, on antiretroviral therapy.

People in the region have been rallying as champions for people living with HIV. Yuli works for the Indonesia AIDS Coalition, a civil society organization monitoring support for antiretroviral therapy, in Makassar in South Sulawesi, Indonesia. On 2 October, while on her way to Donggala, a region affected by the earthquake, to check on her family, she heard from her employer about severe disruptions in the supply of antiretroviral medicines in Palu.

Yuli and her colleagues headed to Palu to provide help, contacting hospitals and other service providers to gather the remaining stocks of antiretroviral medicines to distribute to those in need. Her mission quickly became a commitment to support the HIV response in Palu, including helping in contact tracing and providing social support for people living with HIV in the region.

“The reason I’m still here more than two weeks after the disaster is because it is impossible to see the conditions and not lend a helping hand,” Yuli said, explaining that, in addition to antiretroviral medicine, people in Central Sulawesi need support for their basic needs and psychosocial support.

By 16 October, 92 out of the 344 people previously on antiretroviral therapy had accessed a one-month supply of antiretroviral medicines, either from Yuli and her team or directly from clinics.

“My main concern is that I want to make sure that even though the disaster happened, people living with HIV still get access to antiretroviral therapy and not stop their treatment,” Yuli said.  

UNAIDS and partners in the region have joined together as the National Core Team for HIV Response in Humanitarian Settings. The team is actively working to support the HIV response in the affected areas, trying to find out the status of the people living with HIV yet to be found and ensuring the distribution of antiretroviral medicines to those who need them. A command post for HIV has been established in Palu, with a team monitoring the availability of antiretroviral medicines in the affected region.  

“HIV is often overlooked in emergency situations. We must work hard to ensure that people living with HIV are not forgotten in times of need. We applaud the quick initiative and commitment of Yuli and her fellow outreach workers and will continue to provide them with support,” said Krittayawan Tina Boonto, UNAIDS Country Director for Indonesia.

The UNAIDS office in Indonesia has mobilized resources to fund six field visits by peer supporters for people living with HIV to Palu to provide immediate assistance. UNAIDS will also conduct a full needs assessment for HIV, tuberculosis and malaria in Central Sulawesi to develop funding requests for medium- and long-term assistance and will establish contingency plans for use in the event of future disasters in Indonesia.

UNAIDS has revised its internal adoption and paternity leave policy and introduced new rules on surrogacy leave, marking an important step in ensuring a more inclusive working environment.

The revised policy includes the extension of adoption leave from eight to 16–18 weeks, depending on the number of children being adopted, the extension of paternity leave from four to 16 weeks and the introduction of 16 weeks of leave for a single birth by surrogacy and 18 weeks for multiple births by surrogacy.

The new policy is the result of concerted advocacy efforts by the UNAIDS Secretariat Staff Association (USSA), in collaboration with UNAIDS management, and is one of the commitments made in the recently launched UNAIDS Gender Action Plan 2018–2023.

“The revised policy will allow fathers to spend more time with their families at a critical stage in life,” said a staff member who will soon become a father. “Men can and have to play an important role in childcare and actively challenge gender norms that pass most responsibility for childcare onto women,” he said.

Adopting a more equitable policy framework that supports caregiving by both men and women can help in overturning perceptions that women of childbearing age are potentially too expensive or an absentee risk when compared with similarly qualified men.

“The UNAIDS Secretariat Staff Association welcomes this important milestone in our internal policy framework, which will not only bring direct benefits to staff who will become parents, but to all staff, as it challenges pervasive gender norms,” said Pauliina Nykanen-Rettaroli, USSA Chair.

The introduction of specific leave for births by surrogacy reflects UNAIDS’ commitment to diversity. “It doesn´t make a difference if you become a parent by natural birth, adoption or surrogacy; you still become a parent and should be entitled to the same benefits,” said a staff member. “This policy reflects the organization’s commitment to be as inclusive as possible and walk the talk of what it advocates for, which is dignity and respect for all,” she added.

“In our new Gender Action Plan, we committed to adopting a single parental leave policy and I am proud that UNAIDS has now delivered on this. All parents should be supported to spend time with their children. By supporting this, UNAIDS is contributing to shifting the burden of care and advancing gender equality,” said Gunilla Carlsson, UNAIDS Deputy Executive Director, Management and Governance.

People who inject drugs often have one or more associated health issues. Drug use and mental health issues often coexist and drug use can increase the risk of contracting infections. Among people who inject drugs, for example, the risk of acquiring to HIV is 22 times greater than for people in the general population. People who use drugs are also widely stigmatized and marginalized, putting them out of reach of health and social services.

In line with Germany’s efforts to take a people-centred, human rights-based approach to health, the non-profit organization Fixpunkt has begun offering a safe haven for people who inject drugs. Fixpunkt provides a wide range of services, including support for people who are on opioid substitution therapy, counselling for mental health and social problems, basic health services, sterile injecting equipment and supervised drug consumption rooms and professional assistance in the event of overdose.

Controversial life-savers

For people who inject drugs, supervised drug consumption sites are a lifeline. They are also a critical entry point into the wider health and social support system. Currently, supervised drug consumption sites are available in six of the 15 federal states in Germany. The state of Baden-Württemberg, for example, has just decided to create the legal provisions to allow the facilities and the first supervised consumption room is about to be opened in the city of Karlsruhe.

However, in the nine other federal states legal barriers currently prevent the provision of these potentially life-saving services. “More political and financial support is needed to fulfil the real potential of safe injection sites. For people who use drugs, living on the streets, these are life-saving facilities. They often do not have access to medical, health and other social services. In these facilities they can establish contact and trust and find help to change their situation,” said Astrid Leicht, Director of Fixpunkt.

The Deputy Executive Director, a.i., of UNAIDS visited one of Fixpunkt’s mobile sites on 15 October to see the impact of the services they provide. “This is an important step forwards for Germany. By taking a people-centred approach and ensuring that people who inject drugs have access to harm reduction and other health services, such as safe injection sites, Berlin will be able to stop new HIV infections among people who inject drugs and reduce the harms related to injecting drug use. More projects like Fixpunkt are need to ensure that no one is left behind.” The biggest challenge, he learned, is that there are not enough facilities or resources to provide optimal opening hours or accompanying outreach work within the neighbourhoods and communities.

Sylvia Urban, board member of Aktionsbündnis gegen AIDS and of Deutsche AIDS-Hilfe, said, “The decisions in Baden-Württemberg and Karlsruhe are ground-breaking. We hope that the remaining states and many cities will follow. These facilities save lives and prevent HIV infections. From a public health and HIV prevention perspective, there is no good reason not to provide supervised drug consumption rooms.”

High demand in southern Germany and Bremen

Supervised drug-consumption rooms are desperately needed in, for example, Mannheim, the city with the highest number of drug-related deaths in proportion to inhabitants, as well as in Stuttgart, Munich, Nuremberg, Augsburg and Bremen, which have high numbers of preventable drug-related deaths.

Worrying situation in eastern Europe

UNAIDS and the World Health Organization recognize that supervised drug consumption facilities are a particularly important intervention. Yet, in eastern Europe there are very few facilities of this kind and in some countries, including the Russian Federation, there are virtually no harm reduction services provided at all amid a context of rising new HIV infections.

“Supervised drug-consumption facilities and harm reduction programmes are crucial components of HIV and hepatitis prevention. The tools and interventions to end the epidemics are all available, but many governments prevent their implementation,” said Sylvia Urban, from Deutsche AIDS Hilfe. “Only with services to minimize the negative health impacts of drug use can the HIV epidemic be stopped. In order to achieve this, legal and other barriers, including stigma, need to be removed.”

World Mental Health Day is observed on 10 October each year. This year, UNAIDS is highlighting that governments need to do more to integrate mental health and HIV services.

People living with HIV are at a greatly increased risk of developing mental health conditions, often suffering from depression and anxiety as they adjust to their diagnosis and adapt to living with a chronic infectious disease.

People living with mental health problems can also be at higher risk of HIV. The risks are exacerbated by low access to information and knowledge of HIV, including how to prevent it, injecting drug use, sexual contact with people who inject drugs, sexual abuse, unprotected sex between men and low use of condoms.

“HIV affects the most vulnerable and marginalized in society, who are also disproportionally affected by mental health issues,” said Michel Sidibé, Executive Director of UNAIDS. “By integrating HIV and mental health services we will be able to reach more people with the specialist care and life-saving support they urgently need.”

Currently, very few health services are addressing the HIV-related needs of people living with mental health issues or the mental health issues of people living with HIV. This situation needs to change. Studies conducted over five continents have estimated that HIV prevalence among people living with severe mental disorders could be between 1.5% in Asia and up to 19% in Africa.

People living with HIV can experience mental health issues that can affect quality of life and stop them seeking health care, adhering to treatment and continuing in care. Studies across 38 countries show that 15% of adults and 25% of adolescents living with HIV reported depression or feeling overwhelmed, which could be a barrier to adherence to antiretroviral therapy.

In addition, treatment itself can cause a wide range of side-effects on the central nervous system, including depression, nervousness, euphoria, hallucinations and psychosis. Studies in Africa found a 24% prevalence of depression among people living with HIV.

Identifying mental health issues among people living with HIV is critical; however, far too often those go undiagnosed and untreated. There are many reasons for this, all of which need to be addressed. People may not want to reveal their psychological state to health-care workers for fear of stigma and discrimination and health-care workers may not have the skills or training to detect psychological symptoms or may fail to take the necessary action for further assessment, management and referral if symptoms are detected.

Mental health services should ensure access to voluntary and confidential HIV testing and counselling for people who may be at increased risk of HIV. Primary health-care providers must be trained to recognize and treat common mental health and substance-use disorders and refer people to expert care.

Prevention, testing, treatment and care services must meet the complex medical, psychological and social needs of people affected by HIV and mental health issues, which can be best managed through integrated programmes. Integrated approaches need to be across sectors and involve social, legal, health-care and educational services and engage community-based organizations.

Integrating mental health and HIV programming prevents new HIV infections and improves the health and well-being of people living with and affected by HIV.

The Parliamentary Network to Fight AIDS, Tuberculosis and Malaria reaffirmed its commitment to increase funding to end the three diseases at its annual meeting in Lomé, Togo, held on 4 and 5 October. The network committed to urge the heads of state and government of the Francophonie to advocate for increased funding during the sixth replenishment conference of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which will be held in Lyon, France, in October 2019.

“UNAIDS recognizes the important initiatives of French-speaking parliamentarians at both the national and international levels, as well as the advocacy and efforts of the Parliamentary Network to Fight AIDS, Tuberculosis and Malaria,” said Christian Mouala, UNAIDS Country Director for Togo.

The network, which is affiliated to the Parliamentary Assembly of the Organisation internationale de la Francophonie, also agreed that it will focus on the reform of punitive laws that perpetuate HIV- and tuberculosis-related stigma and discrimination.

“The responses to AIDS, tuberculosis and malaria require the commitment of all: national ministries of health, researchers, funders and, of course, parliamentarians. Only by pooling our efforts and with the strength of our parliaments and our members can we hope to, one day, overcome these epidemics,” said Didier Berberat, President of the Network to Fight AIDS, Tuberculosis and Malaria and Councillor for States, Switzerland.

UNAIDS has a cooperation agreement with the Parliamentary Assembly of the Organisation internationale de la Francophonie, which is due to be renegotiated this year.

First announced during the 2003 State of the Union Address by the then President, George W. Bush, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) is celebrating its 15th anniversary in 2018. Over the past 15 years, PEPFAR has dramatically changed the landscape of the global response to HIV, and bipartisan support across successive administrations since its launch has continued to ensure that PEPFAR expands it work towards controlling the AIDS epidemic.

Launched with an initial budget of US$ 15 billion over its first five years, PEPFAR has gone on to commit US$ 70 billion to the AIDS response. The funding has had remarkable results: in 2017, PEPFAR was supporting 13.3 million of the 21.7 million people living with HIV on treatment, including 1 million children, and in May 2018 announced that more than 14 million were on treatment.

PEPFAR has funded major HIV prevention programmes. The preventative effect of voluntary medical male circumcision on HIV transmission has been ramped up by funding more than 15.2 million circumcisions since 2003. Prevention of mother-to-child transmission of HIV services have ensured that 2.2 million babies have been born HIV-free, while 85.5 million people have accessed HIV testing services, allowing the people taking the tests to start on treatment or access HIV prevention services to stay HIV-free.

PEPFAR’s work with children orphaned or otherwise made vulnerable by HIV resulted in more than 6.4 million children being supported by PEPFAR in 2017, while the PEPFAR DREAMS programme saw new HIV infections among adolescent girls and young women drop by 25–40% in those locations in which the programme was implemented.

On 27 September PEPFAR published its 2018 progress report, showing the progress made one year into its 2017–2020 strategy. PEPFAR supports the AIDS response in 53 countries—of those, 13 are already on track to control their HIV epidemics by 2020, while many more could still do so through scaling up resources and policies to ensure access to HIV prevention and treatment services.

“The contributions of PEPFAR have transformed the lives of people living with or affected by HIV around the world,” said Michel Sidibé, Executive Director of UNAIDS. “We are very proud of our longstanding partnership and look forward to continuing to work closely together to deliver results for men, women and children, particularly the most marginalized.”

Faith-based organizations have long played a critical role in the response to tuberculosis (TB). Many faith-based health service providers have implemented effective TB/HIV responses modelled on decades of work on TB. Today, faith-based organizations are delivering effective, high-quality TB/HIV services that complement national public health programmes in the countries most affected by TB and HIV.

Successful TB/HIV responses address both the biomedical and the social determinants that underpin these illnesses, such as poverty, inequality, situations of conflict and crisis, compromised human rights and criminalization. Children and adolescents are particularly vulnerable to infection and the impact of TB/HIV on their families. Because they have positions of trust at the heart of communities, faith-based organizations can provide services and support that extend beyond the reach of many public sector health systems.

To provide an opportunity to strengthen relationships and forge new partnerships, on 27 September the World Council of Churches–Ecumenical Advocacy Alliance, in collaboration with UNAIDS, the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the United Nations Interagency Task Force on Religion and Development, hosted an interfaith prayer breakfast on the sidelines of the 73rd Session of the United Nations General Assembly in New York, United States of America. Keynote speakers and table discussions focused on the outcomes of the United Nations High-Level Meeting on Tuberculosis, which took place on 26 September, and examined how the longstanding experience of faith-based organizations in responding to TB/HIV can support the new declarations agreed by Member States during the historic high-level meeting.

The participants included faith leaders and health service providers from different religious traditions. Survivors of multidrug-resistant TB brought a powerful sense of urgency and reality to the discussion. The participants renewed their call to national governments to not only maintain, but increase, support in order to end AIDS and TB as public health threats by 2030.

Quotes

Cervical cancer—an illness that can be prevented by vaccination against the human papillomavirus (HPV) and that is curable if detected and treated early—is developed by more than 500 000 women each year, half of whom die of the disease. If cervical cancer prevention, screening and treatment efforts are not urgently scaled up, it is projected that this number could double by 2035.

Cervical cancer is an AIDS-defining illness, since women living with HIV who become infected with HPV are more likely to develop pre-invasive lesions that can, if left untreated, quickly progress to invasive cancer—women living with HIV are four to five times more likely to develop invasive cervical cancer. HPV infection has been found to significantly increase the risk of HIV transmission for both men and women.

Thanks to HIV treatment, many more women living with HIV are living long and healthy lives, but it is imperative that women living with HIV do not succumb to other illnesses, including cervical cancer. “It makes no sense to save a woman’s life from AIDS, only to let her die from treatable or preventable cancer,” President George W. Bush, whose George W. Bush Institute is leading efforts to end AIDS and cervical cancer, said in October 2015.

Nine out of 10 women who die from cervical cancer live in low- and middle-income countries. Given that the burden of HIV is primarily felt in low- and middle-income countries, and particularly by adolescent girls and young women, responding to both cervical cancer and HIV together in those countries is vital. Unfortunately, however, most low- and middle-income countries with a high prevalence of HIV have limited programmes for cervical cancer prevention and control.

There is a growing awareness of the need to maximize synergies between the AIDS response and efforts to prevent, diagnose and treat cervical cancer through HPV vaccination, education, screening and treatment. Likewise, existing HIV programmes can play a strategic role in expanding cervical cancer prevention services.

Reducing deaths from cervical cancer requires a wide-ranging approach that includes the following:

• Health education, including age-appropriate comprehensive sexuality education.
• HPV vaccination for adolescent girls.
• Screening all women at risk of developing cervical cancer. Screening programmes should include HIV counselling, testing and treatment, as well as other sexual and reproductive health services and treatment of precancerous cervical lesions and invasive and advanced cervical cancer.
• Ensuring access to palliative care, when needed.

“All women living with HIV need access to information on HPV and should be offered cervical cancer screening and treatment if necessary,” said Michel Sidibé, Executive Director of UNAIDS.

In May 2018, the United States President’s Emergency Plan for AIDS Relief, the George W. Bush Institute and UNAIDS launched a joint effort through a US$ 30 million partnership to accelerate efforts in eight sub-Saharan African countries to ensure that women and girls living with HIV are a priority in national cervical cancer prevention and control programmes.

“Thanks to the generosity of the American people, the United States President’s Emergency Plan for AIDS Relief has saved the lives of millions of HIV-positive women around the world,” said Deborah Birx, United States Global AIDS Coordinator and Special Representative for Global Health Diplomacy, at the launch of the partnership in May 2018. “We must ensure these same women—mothers, daughters, aunts and grandmothers—who are living with HIV and thriving do not succumb to cervical cancer.”

As part of the United Nations Secretary-General’s strategy to prevent and respond to sexual exploitation and abuse, global leaders have come together to issue a statement reaffirming their personal commitment to eliminate sexual exploitation and abuse across the United Nations system.

In the statement, the leaders recognize the unique responsibility of the United Nations to set the standard for preventing, responding to and eradicating sexual exploitation and abuse within the United Nations system, address its impact effectively and humanely and safeguard and empower survivors.

The leaders are 48 heads of state or government from the Secretary-General’s Circle of Leadership and 22 United Nations entities, including UNAIDS. UNAIDS is firmly committed to zero tolerance for sexual exploitation and abuse anywhere and recently hosted a high-level event with the African Union during the 73rd session of the United Nations General Assembly to tackle sexual and gender-based violence in humanitarian crises.

In the statement, the leaders recognize the shared responsibility of the United Nations and its Member States to protect survivors and whistle-blowers and take appropriate action against perpetrators. They also express their commitment to working together to implement the United Nations Secretary-General’s strategy, which outlines four main areas of action: putting victims first; ending impunity; engaging civil society and external partners; and improving strategic communications for education and transparency.

Click here to read the full statement.