An Avert spotlight on the HIV response – we reflect on the most important take-homes from the UNAIDS 2019 Global Report.
Earlier this month, UNAIDS launched their annual global report on the state of the HIV epidemic. The publication, Communities at the Centre, highlights civil society’s important role in galvanising the HIV response from the start of the HIV epidemic, while acknowledging waning progress towards global targets.
Reflecting on the key messages in the report, there is much to be proud of. But as 2020 nears, it’s clear that without further action and resources, we will miss key global targets for eliminating HIV as a public health threat by 2030.
As HIV treatment scales up, deaths are declining
Record-breaking numbers of people are now accessing antiretroviral treatment and becoming virally suppressed, resulting in a 33% decline in the number of people dying from an AIDS-related illness compared to 2010. Furthermore, four out of five people living with HIV are now aware of their status. But as of 2018 only 23.3 million people living with HIV had been reached with lifesaving treatment, so extra efforts are needed to reach 30 million by 2030.
Reductions in new HIV infections are stalling
As 2020 approaches, UNAIDS notes that reductions in the number of people newly infected with HIV are declining. Progress is too slow to reach the goal of only 500,000 people newly infected with HIV by 2020, a reduction of 75% from 2010. The annual number of new infections (all ages) fell from 2.1 million in 2010 to 1.7 million in 2018, a 16% reduction that leaves the world far off the 2020 target.
Children have been failed
The Start Free, Stay Free, AIDS Free initiative aimed to reach 1.6 million children living with HIV with treatment while reducing annual infections to less than 40,000 by 2018. Yet data included in this report reveals 160,000 children aged 0–14 years became newly infected with HIV in 2018 and only 940,000 were accessing treatment.
Despite these ambitious targets being missed, new infections have fallen significantly from 240,000 children in 2010, thanks in part to the fact that 82% of pregnant women living with HIV are accessing medicines for prevention of mother-to-child transmission (PMTCT).
Combination prevention targets continue to lag behind
In 2018, 4 million men took up voluntary male medical circumcision (VMMC), but an additional 16 million men need to be reached to achieve the 25 million target by 2020. In 12 priority countries in 2018, 84% of circumcisions were among adolescent boys and young men aged 10-24.
What’s more, condom distribution, promotion and use have stalled in many countries. In 27 sub-Saharan African countries, condom use at last high-risk sex among men was just 58.6%, while targets call for 90% condom use.
Access to pre-exposure prophylaxis (PrEP) is increasing, with 300,000 people taking it at least once in 2018, the biggest number of whom were in the USA (130,000). There is still much to understand about how to market and increase demand for this intervention, particularly among young women and key affected populations in sub-Saharan Africa. In 2018, Kenya reached 30,000 people with PrEP.
Only a handful of countries offer sufficient numbers of harm reduction services to adequately reach populations of people who inject drugs and their networks. Only three high-income countries – Austria, Luxembourg and Norway – reported UN-recommended levels of coverage for these programmes, and these countries account for less than 1% of the global population of people who inject drugs.
Digital programmes have promise
The report acknowledged the promise of online interventions in reaching young people and key affected populations with outreach services, including sex workers, men who have sex with men, transgender people and people who use drugs. These populations face barriers relating to consent, stigma, discrimination and violence, which drive them away from traditional services. Social media platforms and other digital interventions can help navigate, offering opportunities for people to connect and congregate online, sharing information and experiences to support better health.
Punitive laws, discrimination and lack of reporting overburden key populations
Key populations continue to be unfairly burdened by HIV. This group and their sexual partners accounted for over half (54%) of new HIV infections globally in 2018. Gay men accounted for 17% of all new HIV infections, followed by people who inject drugs (12%) and sex workers (6%). Less than half were reached with any combination prevention service.
Regionally, these discrepancies are even more pronounced. In Eastern Europe and Central Asia, people who inject drugs accounted for 41% of new HIV infections; 27% of infections in the Middle East and North Africa and 13% of new infections in Asia and the Pacific.
Gay men accounted for more than half of new HIV infections in North America and Western Europe, 40% of new infections in Latin America and 30% of infections in Asia and the Pacific.
Eastern & southern Africa excels, but elsewhere progress stalls
Across eastern and southern Africa, where 54% of people living with HIV reside, HIV incidence and AIDS-related deaths fell by 28% and 44% (respectively) between 2010 and 2018. Although young women (aged 15–24 years) continue to account for 26% of new HIV infections, there are signs of progress in this group thanks to work across this region. Globally, new HIV infections were reduced by 25% between 2010 and 2018 among girls aged 15-24.
In contrast, AIDS-related deaths have risen in eastern Europe and central Asia and the Middle East and North Africa over the eight year period, by 5% and 9% respectively. The annual number of HIV infections has increased in three regions: eastern Europe and central Asia (29% increase), Middle East and North Africa (10% increase) and Latin America (7% increase).
A widening resource gap
For the first time, resources available for the AIDS response have declined. In 2018 US$19 billion was made available compared to US$19.6 billion in 2017.
Where resources have been mobilised and funds raised, massive gains have been made in key areas of the HIV response. For example, in East and Southern Africa, expenditures per person living with HIV reached the region’s 2020 resource needs estimates, which has enabled many of the countries to close gaps in targets for HIV incidence and reductions of AIDS-related deaths. Conversely, in West and Central Africa, just 48% of the resource needs have been mobilised, limiting gains here.
UNAIDS interim Executive Director Gunilla Carlsson said in her forward in the report, “We have the knowledge and tools we need to end AIDS. We cannot change the virus, but we can change inequalities, power imbalances, marginalization, taboos, and stigma and discrimination. We can change behaviours and societies. The change we need requires strong collective efforts by both governments and communities.”
“Success is being achieved where policies and programmes focus on people, not diseases—policies and programmes that are designed with communities and that respond to the ways that people live their lives. With access to knowledge, rights and power, communities are empowered to drive change, to reduce the impact of HIV and to accelerate better health for all.”