GENEVA, 26 August 2020—UNAIDS is calling on countries to adopt urgent measures to reinforce social protection programmes to shield the most vulnerable people from the health impact and socio-economic fall-out of the COVID-19 pandemic.

People living with HIV and tuberculosis (TB) are being significantly impacted by COVID-19. Modelling has estimated the potential catastrophic impacts of the COVID-19 pandemic with increases of up to 10%, 20% and 36% projected deaths for HIV, TB and malaria patients, respectively, over the next five years.

Among the most vulnerable are women and girls, gay men and other men who have sex with men, sex workers, people who use drugs and transgender people. Many of them are excluded from existing social protection programmes.

“Countries must ensure that everyone is able to receive essential services including health care and they must invest adequately in social protection programmes to keep people safe and to shield them from the consequences of losing their livelihoods,” said Winnie Byanyima, Executive Director of UNAIDS.

The socio-economic fall-out of the COVID-19 pandemic will have the greatest impact on some of the most disadvantaged people in societies around the world. For example, COVID-19 threatens to double the number of people facing acute food insecurity to more than 265 million by the end of the year. Most of these people will be in countries already badly afflicted by conflict, economic or climate crises. Refugees are among the groups facing the greatest dangers.

Hundreds of millions of people around the world are also in line to lose their jobs in the formal and informal sectors of the economy. Around 150 million full time jobs were lost in the first quarter of the year and millions more people are set to lose their livelihoods in the months ahead.

“Today, only 29% of the world’s population has access to adequate social protection coverage,” said Guy Ryder, Director General of the International Labour Organization.” Governments must act to ensure the sustainability of livelihoods, businesses and jobs and the protection of workers’ health, rights and incomes during and after COVID-19.”

Women are particularly vulnerable to the economic crisis being disproportionately employed in the informal sectors of the economy and therefore most likely to lose their incomes. They are also often employed on the frontline of the response to COVID-19, making up 70% of the workforce in the health and social care sectors, as well as carrying out the bulk of unpaid domestic duties in the home, childcare and other caring functions.

An increase in gender-based violence during lockdown also makes it imperative for governments to invest in social protection programmes designed specifically for the protection of women and girls.

A generation of young people are also at risk from the socio-economic crash caused by the pandemic. The vulnerability of children and young people is being further amplified by school closures which have affected more than 90% of the world’s student population, interrupting their education and their access to crucial social services, such as school meals.

“Children and young people are suffering disproportionately from the socio-economic impact of the COVID-19 crisis,” said Henrietta H. Fore, Executive Director of UNICEF. “Before the outbreak, two out of three children had no or inadequate social protection fund. Countries need to live up to their commitment for social protection for everyone who needs it.”

The call for action for governments to invest adequately in social protection programmes is endorsed by UNAIDS, the United Nations Children’s Fund (UNICEF) and the International Labour Organization (ILO) and supported by the World Food Programme (WFP), the Office of the  United Nations High Commissioner for Refugees (UNHCR), the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), the United Nations Office on Drugs and Crime (UNODC), the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the World Bank.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

As the Global Fund to fight AIDS, Tuberculosis and Malaria—one of the main donors for the HIV response in the last 20 years in Eastern Europe and Central Asia (EECA)—is moving away from funding the HIV response in EECA, the region is looking for ways to invest their available domestic resources in a much more cost-effective way.

“There are purely epidemiologic and economic arguments behind this transition,” said Dumitru Laticevschi, Regional Manager Eastern Europe and Central Asia Team, The Global Fund. “The economies here are considerably better for the same level of disease burden than the average in the world, that’s why it is expected that the region increasingly takes care of the epidemic by itself.”

The key challenge for the Global Fund, UNAIDS and other partners is to strengthen national responses and “to squeeze the problem to a size that is manageable for the governments to take over,” added Mr Laticevschi.

A series of HIV allocative efficiency studies conducted in 2014 in the region with support from the World Bank, UNAIDS Secretariat and some cosponsors, the Global Fund, USAID/PEPFAR and other partners, recommended countries to prioritize investment in the most cost-effective interventions to maximize health outcomes, including updating HIV testing and treatment protocols, reducing treatment costs, and optimizing service delivery. The studies were based on the Optima HIV mathematical modelling approach which has been applied in over 60 countries globally to help support HIV-related investment choices.

Recently, a new wave of the allocative studies was concluded in 11 countries of the region (Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Romania, Tajikistan, Ukraine, and Uzbekistan). Individual reports with a set of recommendations for each country, as well as a regional report with aggregated results from the eleven-country analysis are available here.

“We provided the technical support for these analyses,” said Sherrie Kelly, Team Lead HIV, TB, and Malaria Applications, Burnet Institute who supported the 2014 and 2019 studies in EECA. “We have the models in place and work with the national teams. The countries are the owners of the projects, data, and results. We are just the mathematical modelers.”

The modeling is informed by demographic, epidemiological, behavioural and other data, as well as expenditure estimates provided by national teams and available in the literature. The epidemic model is overlaid with a programmatic costing component and a resource optimization algorithm. Results are intensively discussed and validated by national teams and key stakeholders from respective countries. The UNAIDS Secretariat facilitated the entire process to ensure the capacity of national partners to facilitate optimized health spending was strengthened.

“We hope that the recommendations from the study will help our national partners to adjust National Strategic Plans and to focus on the most efficient, cost-saving interventions with maximum health outcomes and will not only save money, but will save people’s lives,” said Alexander Goliusov, UNAIDS Regional Director in EECA a.i..

NEW YORK/GENEVA, 22 July 2020—Launching today, the COVID-19 Law Lab initiative gathers and shares legal documents from over 190 countries across the world to help states establish and implement strong legal frameworks to manage the pandemic. The goal is to ensure that laws protect the health and wellbeing of individuals and communities and that they adhere to international human rights standards.

The new Lab (at covidlawlab.org) is a joint project of United Nations Development Programme (UNDP), the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the O’Neill Institute for National and Global Health Law at Georgetown University.

Well-designed laws can help build strong health systems; evaluate and approve safe and effective drugs and vaccines; and enforce actions to create healthier and safer public spaces and workplaces. Critically, they are key to effective implementation of the WHO International Health Regulations: surveillance; infection prevention and control; management of travel and trade; and implementation of measures to maintain essential health services.

“Laws and policies that are grounded in science, evidence and human rights can enable people to access health services, protect themselves from COVID-19 and live free from stigma, discrimination and violence,” says Achim Steiner, UNDP Administrator. “The COVID-19 Law Lab is an important tool for sharing good practices on laws and policies.”

The COVID-19 pandemic has seen a vast increase in urgent legislative action to control and reduce the pandemic.

"Strong legal frameworks are critical for national COVID-19 responses," said Dr. Tedros Adhanom Ghebreyesus, WHO Director-General. “Laws that impact health often fall outside the health sector. As health is global, legal frameworks should be aligned with international commitments to respond to current and emerging public health risks. A strong foundation of law for health is more important now than ever before.”

However, laws that are poorly designed, implemented, or enforced can harm marginalized populations, entrench stigma and discrimination, and hinder efforts to end the pandemic.

“Harmful laws can exacerbate stigma and discrimination, infringe on people's rights and undermine public health responses," according to Winnie Byanyima, Executive Director of UNAIDS. "To ensure responses to the pandemic are effective, humane and sustainable, governments must use the law as a tool to uphold the human rights and dignity of people affected by COVID-19.”

The COVID-19 Law Lab is a database of laws that countries have implemented in response to the pandemic. It includes state of emergency declarations, quarantine measures, disease surveillance, legal measures relating to mask-wearing, social distancing, and access to medication and vaccines. The database will continue to grow as more countries and themes are added.

It will also feature research on different legal frameworks for COVID-19. These analyses will focus on the human rights impacts of public health laws and help countries identify best practices to guide their immediate responses to COVID-19 and socioeconomic recovery efforts once the pandemic is under control. It builds off the work of the UHC Legal Solutions Network, which was established to help countries achieve universal health coverage through the implementation of rights-based legal frameworks.

"We need to track and evaluate how laws and policies are being used during the Pandemic to understand what works," said Dr. Matthew M. Kavanagh, faculty in Georgetown University's Department of International Health. Katie Gottschalk, Executive Director of the O'Neill Institute for National and Global Health Law at Georgetown University Law Center added, "We must learn lessons from the early stage of pandemic policies to implement the most effective laws going forward – the COVID-19 Law Lab allows us to do just that."

UNDP

The United Nations Development Programme is the leading United Nations organization fighting to end the injustice of poverty, inequality, and climate change. Working with our broad network of experts and partners in 170 countries, we help nations to build integrated, lasting solutions for people and planet. Learn more at undp.org or follow @UNDP.

WHO

The World Health Organization provides global leadership in public health within the United Nations system. Founded in 1948, WHO works with 194 Member States, across six regions and from more than 150 offices, to promote health, keep the world safe and serve the vulnerable. Our goal for 2019-2023 is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and wellbeing. For updates on COVID-19 and public health advice to protect yourself from coronavirus, visit www.who.int and follow WHO on Twitter, Facebook, Instagram, LinkedIn, TikTok, Pinterest, Snapchat, YouTube

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

O’Neill Institute for National and Global Health Law and Georgetown University

The O’Neill Institute, housed at Georgetown University, was established to create innovative solutions to the most pressing national and international health concerns, with the essential vision that the law has been, and will remain, a fundamental tool for solving critical health problems. The Georgetown University Department of International Health is home to scholarship in public health, economics, political science, and medicine. Georgetown’s Global Health Initiative serves as a university-wide platform for developing concrete solutions to the health challenges facing families and communities throughout the world. Read more at oneillinstitute.org and connect with us on Twitter and Facebook.

UHC Legal Solutions Network

The COVID-19 Law lab is a product of the UHC Legal Solutions Network is a collaboration between the World Health Organization (WHO), the United Nations Development Programme (UNDP), the Joint United Nations Programme on HIV and AIDS (UNAIDS), the Inter-Parliamentary Union (IPU), and the O'Neill Institute for National and Global Health Law at Georgetown University. The initiative aims to support countries to achieve universal health coverage by working with policymakers, civil society groups and other stakeholders to craft laws ensure that all people and communities have the right to access the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

The United Nations system in Nigeria joined the fight against COVID-19 shortly after the first case was detected in the country in late February 2020.

UNAIDS’ lessons learned and expertise in facilitating, linking and bringing stakeholders together have been instrumental in guiding the United Nations multi-agency response, led by the Resident Coordinator, Edward Kallon. And by proactively mobilizing its political capital and goodwill in the country, UNAIDS has helped to bring resources and better lines of communication, coordination and accountability to the national COVID-19 response.

In mid-March, the Presidential Task Force was established to develop a COVID-19 response plan for how organizations should work together. Appointed as the only development member of the task force, the Representative, a.i., of the World Health Organization (WHO), Fiona Braka, provides the overall United Nations technical leadership to the government. Lessons learned from the HIV response fed into the development of the “four ones” guiding principles for the national response to the COVID-19 pandemic—one national COVID-19 multisectoral pandemic response plan, one COVID-19 national coordinating authority, one COVID-19 monitoring and evaluation system and one COVID-19 financing and investment platform.

“The “four ones” principles will simplify and clarify roles, responsibilities and relationships, including within the government,” said the Minister of Health of Nigeria, Osagie Ehanire.

Another lesson learned from the HIV response was the importance of ensuring that marginalized and vulnerable people are given consideration at every step of the development of a response to a pandemic. The potential impact of COVID-19 on people living with HIV, key populations and the poor also had to be at the centre of decision-making.

“UNAIDS regularly coordinated with the networks since the beginning of the COVID-19 outbreak, providing technical guidance and ensuring synergy with the efforts of the government,” said Abdulkadir Ibrahim, the National Coordinator of the Network of People Living with HIV/AIDS in Nigeria.

Working with the United Nations Development Programme, UNAIDS liaised with the wider United Nations system and the government and facilitated the handover of US$ 2 million worth of emergency medical commodities to the government, ensuring that the supplies and equipment were prioritized for use in public health facilities and by health-care workers.

The One UN COVID-19 Basket Fund was launched on 6 April. Part of one of the “four ones”, the one COVID-19 financing and investment platform, the Basket Fund channels the contributions of donors to the COVID-19 response. UNAIDS played a critical role in its establishment, working with the United Nations Resident Coordinator and the United Nations Development Programme to ensure that the financing platform put people and communities at the centre. UNAIDS, UN Women, WHO and the United Nations Population Fund helped to mobilize US$ 6.5 million for civil society and community engagement, social protection for vulnerable households, community-led surveillance and monitoring of COVID-19 and HIV and the documentation of community best practices.

In announcing a €50 million contribution to the Basket Fund, the Head of the European Union delegation to Nigeria, Ketil Karlsen, said, “The COVID-19 Basket Fund gives us the opportunity to cooperate and act rapidly in the deployment of assistance that can help to enhance health-care services and cushion the most vulnerable.” 

Perhaps the most important contribution by UNAIDS to the COVID-19 response in the country, however, has been advocating to harness the vast HIV infrastructure in the country for the fight against COVID-19.

“We must leverage HIV assets on the ground, including not just laboratory facilities but community health workers and volunteers. To fight COVID-19 effectively we will have no choice but to engage communities to own the response,” said Erasmus Morah, the UNAIDS Country Director for Nigeria.

In a joint effort, the United States Government, the National Agency for the Control of AIDS, the United Nations Children’s Fund, WHO, UNAIDS and the Presidential Task Force mapped and initiated the engagement of approximately 100 000 community health-care workers and volunteers to undertake risk communication, social mobilization, contact tracing and home care.

COVID-19 is far from over in the country, with cases steadily rising, and United Nations staff have not been spared. However, as Mr Kallon, said, “The United Nations must stay open for business and deliver for the people while ensuring that staff members and their dependents are provided with the necessary environment for their protection against COVID-19.” Following this, a COVID-19 isolation and treatment centre as an extension of the United Nations clinic was established for staff as frontline workers, together with their dependent family members. 

Moving forwards with the COVID-19 response, in addition to the continued support for the Presidential Task Force, the United Nations Country Team, including UNAIDS, is gearing up to support Nigeria to address the major gaps in subnational preparedness. Key issues such as the loss of livelihoods, heightened vulnerabilities and food insecurity, the increased risk of gender-based violence and limited access to essential health services will also be addressed in the coming months.

Statement of the Joint UN Programme on HIV/AIDS (UNAIDS) Interagency Working Group on Key Populations on the need to ensure access to quality, safe, and non-discriminatory services for HIV key populations and migrants in the context of the COVID-19 pandemic

The rapid spread of COVID-19 continues to impact billions of lives around the world. Unprecedented human and financial resources are needed to address this pandemic. UN entities, NGOs, communities of people living with HIV, sex workers, gay men and other men who have sex with men, people who use drugs, transgender people, and people in prisons and their sexual partners, as well as civil society all have a role to play in fighting COVID-19, saving lives, and tackling far-reaching social and economic consequences. Critical moments like this remind us more than ever that inequality can be a matter of life and death and that everyone is born free and equal in dignity and rights, including to the highest attainable standards of health.

Lessons learned from the global HIV response should inform COVID-19 responses: HIV has taught us that it is a shared responsibility and we need to empower communities and involve them in the response; we should never compromise on human rights; we need to remove all forms of stigma and discrimination; and we need to support vulnerable and marginalized groups.

UNAIDS estimates that 62 % of the new HIV infections are among key populations and their sexual partners. Key populations experience particular forms of exclusion, criminalisation, inequality and discrimination that render them particularly vulnerable to HIV and again now to COVID-19. People in prisons and closed settings, where physical distancing is not always an option, are extremely vulnerable to COVID-19. People in prisons also have a higher prevalence of HIV and TB which poses a higher risk of complication if infected with SARS-COV 2, as do migrants, who also face greater HIV vulnerability. LGBT people are reporting an elevated risk of domestic and family violence, increased social isolation and difficulties in accessing crucial HIV treatment and gender-affirming health services. Leaving key populations behind at this critical moment could have a grave impact on health and human lives. It could reverse the gains in the global HIV response as well. 

We call on all Governments and partners to join us in,

Making quality, non-discriminatory HIV prevention, treatment, care and support services, and health services in general, available for key populations and migrants in the context of the COVID-19 pandemic.

These services must be based on respect, protection and fulfilment of human rights, regardless of existing punitive laws, policies and practices. They must be free from stigma and discrimination, based on evidence and science, and compliant with the most recent international guidance. Services must be equitable, based on informed consent, confidential and safe - for communities, as well as healthcare workers.

Rapidly adapting service provision to take into account the new realities of the COVID-19 pandemic.

Examples of adapted services are safe access to home HIV testing and remote counselling. Where possible, 3 to 6 months’ supply of ARVs, TB and viral hepatitis treatment should be supplied to ensure continuity of treatment, reduce transmission of HIV and co-infections, as well as the risk of COVID-19. People who use drugs should have access to harm reduction, including, where applicable and as advised by medical professionals, access to multiple opioid substitution doses to reduce OST site visits and COVID-19 exposure risk. Alternatives to imprisonment, where allowed, for non-violent offences could save lives, particularly for crimes not recognised under international law. Measures of early release should be taken for specific categories of people who are at particular risk of being affected by COVID-19, such as the elderly and individuals affected by chronic diseases or other health conditions, as well as pregnant women, women with dependent children, prisoners approaching the end of their sentence and those who have been sentenced for minor crimes in prisons, in-line with national policies and without compromising public health and safety. Emergency social protection measures for key populations are needed since they are often excluded from social services, including, but not limited to, housing and health insurance, and are often in precarious work situations. Service provision must continue to take into consideration intersectionality, gender and age diversity. It must be properly resourced with people, funding and materials. In order to be effective and efficient, these services must include key populations, their communities and organizations in their design and implementation.

Ensuring COVID-19 responses do not lead to the proliferation of punitive laws and measures to enforce restrictions or to criminalise transmission and exposure.

The gravely detrimental effect of such punitive measures on already marginalized or criminalized people has been well-documented in the HIV response, including by the Global Commission on HIV and the Law.

We won't stop COVID-19 if some people can’t afford or access testing or treatment. We must ensure that responses to COVID-19, or any other pandemic or health emergency, do not leave key populations, migrants and other vulnerable groups behind. As the Interagency Working Group on Key Populations we stand ready to work with all partners to ensure safe and rights-based access of key populations to quality HIV and COVID-19 services.

The Interagency Working Group on Key Populations is established under the UNAIDS Division of Labour and is co-convened by the United Nations Development Programme (UNDP), the UN Population Fund (UNFPA), and the United Nations Office on Drugs and Crime (UNODC) in partnership with the Global Network for and by People Living with HIV (GNP+), the International Network of people who Use Drugs (INPUD), MPact Global Action for Gay Men’s Health and Rights (MPact), Global Network of Sex Work Projects(NSWP), IRGT, and the UNAIDS Secretariat.

Shakhnoz Amirova (not her real name) lives in Tashkent, Uzbekistan. She has been taking antiretroviral therapy regularly since 2017, when she discovered that she was living with HIV. She continued the treatment while pregnant with her child, so she did not have to worry about her baby’s health, which was born HIV-free. But the COVID-19 pandemic has changed everything, and the lockdown restrictions severely limited access to medical services.

The immediate anxiety about the possible disruption to her HIV treatment and that of her husband, who is also living with HIV, was allayed by the health-care facility that she attends, the Republican AIDS Center, dispensing a two-month supply of antiretroviral therapy for everyone who needs it.

However, Ms Amirova was pregnant again and worried about the impact that COVID-19 may have on her and her unborn child, since information on how COVID-19 may affect people living with HIV was scarce. She was even unsure whether the coronavirus outbreak would stop her being able to have her baby at the maternity hospital.

“Women living with HIV feel especially vulnerable during pregnancy and childbirth, as fear of virus transmission, stigma and discrimination are added to the fears for the well-being of their baby. Of course, the situation with coronavirus is an additional stress factor. At such a difficult moment, women really need help and support, and we are trying to provide this help to them,” said Evgenia Korotkova, a representative of Ishonch va Khaet, an organization that helps people living with HIV.

The Positive Maternity programme run by Ishonch va Khaet helps women living with HIV who are pregnant or have recently given birth with social support, delivering antiretroviral therapy and baby food and providing medical care. During the COVID-19 outbreak, Ishonch va Khaet and similar organizations are working doubly hard so that people who need help get it as quickly as possible.

Yuldashev Kahramon Haldarovich, the Director of the Republican AIDS Center, noted the special role of nongovernmental organizations during a pandemic. “Community involvement in HIV prevention and support for people living with the virus are very important, especially at such tense moments, when the efforts of all health professionals and doctors are concentrated on fighting another pandemic. We cannot leave people who need HIV services behind; they also need help, and they need it today. The work of volunteers from social organizations is priceless.”

Since keeping patients and medical personnel in maternity hospitals safe from COVID-19 is such a priority, UNAIDS and the United Nations Population Fund have made a donation of a range of personal protective equipment, including masks and gloves, and disinfectant to 21 maternity hospitals in Uzbekistan.

“Protecting medical personnel in maternity hospitals from infection is as important as protecting pregnant women. The country is currently on the way to eliminating mother-to-child transmission of HIV. Preventive measures against COVID-19 are important for supporting the progress made,” said Charos Maksudova, the representative of UNAIDS in Uzbekistan.

Ms Amirova safely gave birth in the maternity hospital, happy that both her and her baby avoided becoming infected by the new coronavirus and that her baby was born HIV-free. “But fear for my children, especially for a newborn, does not leave me for a minute,” said Ms Amirova.

Now back at home, she is receiving help from peer counsellors from the Positive Maternity programme.

GENEVA, 7 July 2020—The latest report on the progress towards the Start Free, Stay Free, AIDS Free targets shows that despite great progress made since the early days of the epidemic, the HIV response for children has fallen behind. Year after year, the bold target of eliminating new HIV infections among children is being missed and children are dying needlessly from AIDS-related illnesses—deaths that could be prevented with simple and cheap treatments if the children were diagnosed and treated in time.

“To see so many tools available, so many new HIV infections among children that have been prevented, so many children living with HIV doing well, but to see others missed and still left behind is a tragedy,” said Winnie Byanyima, Executive Director of UNAIDS. “We cannot accept that tens of thousands of children still become infected with HIV and die from AIDS-related illnesses every year.”

The Start Free, Stay Free, AIDS Free framework has three simple concepts. First, babies have a right to enter the world free from HIV. Second, through HIV prevention, children, adolescents and young women have a right to stay free from the virus. Third, children and adolescents who do acquire HIV have the right to be diagnosed, treated and cared for, so that they can remain AIDS-free.

The world’s countries have agreed to a range of HIV prevention and treatment targets. So that children start out their lives HIV-free, one of those targets was to reduce new child (aged 0–14 years) HIV infections to less than 40 000 by 2018 and 20 000 by 2020. However, newly published estimates show that 150 000 children were newly infected with HIV in 2019—a 52% reduction since 2010, but still four times the 2018 target.

By ensuring that pregnant women living with HIV are diagnosed, started on and retained on antiretroviral medicines during pregnancy, delivery and breastfeeding, the chance that they will pass on the virus is less than 1%. Globally, 85% of pregnant women living with HIV received those medicines in 2019. But despite this high coverage, children are still becoming infected due to unequal access to treatment services (primarily in western and central Africa), women falling out of care and pregnant and breastfeeding women becoming newly infected with HIV.

“As a global community, we have made remarkable progress toward controlling the HIV pandemic, yet we are still missing far too many children, adolescents and young women,” said Angeli Achrekar, Principal Deputy United States Global AIDS Coordinator, United States President’s Emergency Plan for AIDS Relief. “We must all redouble our efforts to urgently reach these critical populations—and PEPFAR remains deeply committed to doing its part.”

The stay-free component set a target of reducing new HIV infections among adolescent girls and young women to less than 100 000 by 2020. Adolescent girls and young women have long been disproportionately affected by HIV—among the Start Free, Stay Free, AIDS Free focus countries, adolescent girls and young women make up 10% of the total population but represent 25% of new HIV infections and are at an almost twofold higher risk of HIV infection compared with their male peers. However, new HIV infections among young women have been falling. In South Africa, where combination prevention programmes for adolescent girls and young women are in place, new HIV infections among this age group have dropped by 35%. And in Eswatini, new HIV infections among young women aged 15–24 years have dropped by 54%.

“For too long, the response to HIV has overlooked children, adolescent girls and young women,” said Henrietta Fore, the Executive Director of the United Nations Children’s Fund. “But there is hope. The recent momentum in reducing new infections among adolescent girls and young women in countries like Eswatini and South Africa show us what is possible when governments and communities, led by girls themselves, join forces. We must not let COVID-19 and its economic headwinds slow us down. We must remain bold and ambitious in our joint efforts to ensure that the next generation of children remain free of HIV and AIDS.”

So that children and adolescents stay AIDS-free, countries called for ambitious but achievable targets for HIV treatment for children—to provide 1.4 million children living with HIV with antiretroviral therapy by 2020. In 2019, however, only 950 000 (53%) of the 1.8 million children living with HIV were receiving HIV treatment—much lower than the 67% of adults on treatment.  It is clear that to save lives, the missing 840 000 children not on treatment —an estimated two thirds of whom are estimated to be between 5 and 14 years—must be diagnosed and treated as a matter of urgency.

“The lack of optimal HIV medicines with suitable paediatric formulations has been a longstanding barrier to improving health outcomes for children living with HIV, contributing towards low treatment coverage,” said Tedros Adhanom Ghebreyesus, the Director-General of the World Health Organization. “Access to services for vulnerable groups must be expanded through stronger community engagement, improved service delivery and tackling stigma and discrimination.”

Despite the failures, the positive news is that we do know how the world could have met the Start Free, Stay Free, AIDS Free targets. And with enough commitment, we can still overcome the main obstacles to the targets and reverse the failures.

“The past decade has been marked by innovation and progress in the field of paediatric HIV, but the dramatic miss on targets for children in this latest report is simply unacceptable. We must urgently renew our commitment to fighting for an AIDS-free generation, but today, as a global community, we are failing the most vulnerable among us: children and youth,” said Chip Lyons, President and Chief Executive Officer, Elizabeth Glaser Pediatric AIDS Foundation.

“We can do better. We must do better,” added Ms Byanyima. “We know how to save lives and stop new HIV infections among children. I demand that we spare no effort. Anything less is shameful.” 

UNAIDS and the United States President’s Emergency Plan for AIDS Relief launched the Start Free, Stay Free, AIDS Free framework in 2016 to build on the achievements of the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive, which ended in 2015.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

Thousands of households have been helped in Abidjan, Côte d’Ivoire, through a joint initiative to reach vulnerable households with money for nutrition and food security and basic health kits during the COVID-19 pandemic. 

Restrictions on movement imposed to stop the spread of the new coronavirus in Côte d’Ivoire have had a significant impact on the ability of people to earn a living, resulting in an increasing danger of hunger. For people living with HIV, malnutrition and food insecurity reduce HIV treatment adherence, impacting their health and increasing HIV transmission, since stopping treatment can increase a person’s viral load, which increases the chance of passing the virus on. Food insecurity can also increase HIV risk behaviours, potentially putting people at increased risk of acquiring HIV.

The partnership between the World Food Programme, UNAIDS and the Magic System Foundation—a nongovernmental organization that works in the fields of education, health, the environment and culture—allows for a cash transfer of 51 000 central African CFA francs (around US$ 89) per household to cover food needs for two months, distributes hygiene kits and protective equipment to limit the transmission of COVID-19 and gives advice on nutrition.

“The cash transfer allowed me to buy my medicine for three months and to stock up on rice for my family. It gave me the strength to live and smile again,” said one of the recipients.

The priority focus of the campaign are female-headed households and households with pregnant and breastfeeding women, young children, the elderly, people with disabilities and people living with HIV.

“UNAIDS and the Ivorian Network of People Living with HIV are working with various partners—mayors, nongovernmental organizations, the Red Cross, mosques, churches, community leaders, neighbourhood leaders and traditional chiefs—to facilitate access to especially vulnerable people living with HIV,” said Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire.

“The health crisis has forced some households to adopt irreversible food strategies, such as selling assets or borrowing money to meet their food needs. Cash-based food aid helps build the resilience of vulnerable households and preserve their livelihoods. The cash transfer provides the opportunity to have a diversified and balanced diet for good health, while leaving recipients with a choice,” said Adeyinka Badejo, the World Food Programme Representative in Côte d’Ivoire.

A further round of assistance for vulnerable households, especially households containing members of key populations or people living with HIV, will take place soon. The second round will draw on a rapid assessment of the needs of people living with HIV during the COVID-19 pandemic, which was carried out by the network of people living with HIV with the support of UNAIDS, and on the lessons learned from the first round of assistance.

In 2019, the ECHO trial reminded the world of the very high HIV incidence among women in parts of southern Africa. Those high levels of HIV, and of sexually transmitted infections, were found among women accessing routine contraceptive services.

A new joint report by the World Health Organization (WHO) and UNAIDS sets out the steps needed to improve and integrate HIV prevention and contraceptive services in order to reduce new HIV infections among women.

“We need to reflect on the diverse needs of women, including adolescent girls, women with lower levels of education and key populations, who have often been neglected in contraceptive and broader sexual and reproductive health and rights programming. The new approach means more contraceptive choices, additional HIV prevention choices and complementary community activities beyond facilities,” said Paula Munderi, Coordinator of the Global HIV Prevention Coalition at UNAIDS. 

The report clearly states that women at the highest risk of HIV and sexually transmitted infections in southern Africa and women from key populations should be the focus for the most urgent action.

Different approaches in places with different levels of HIV risk are suggested. For example, where there is a high incidence of HIV and sexually transmitted infections, HIV prevention choices, including male and female condoms, and prevention counselling need to be essential elements of contraceptive services and actively promoted. In settings with extremely high HIV incidence in southern Africa, the rapid introduction of pre-exposure prophylaxis (PrEP) within contraceptive services should be considered.

“Sexual and reproductive health and rights and HIV integration have been promoted for more than a decade, yet progress remains limited. Supporting women living with HIV to access contraception in HIV treatment clinics and providing HIV services in contraception services is a critical priority requiring committed funding for concrete action,” said Rachel Baggaley, Unit Head, Testing, Prevention and Populations, Global HIV, Hepatitis and STI programmes at WHO.

In order to understand what women need and want, the report suggests that women be at the centre of decision-making. “HIV prevention and contraceptive choices for women and girls are still not widely available. We need to ensure that the agency and choice of girls and women are promoted by making available a wide range of HIV prevention commodities, ranging from PrEP and microbicides to user-friendly condoms. Women and girls thrive when they are given an opportunity to choose,” said Nyasha Sithole, an advocate for the rights of girls and women from Zimbabwe.

Although people living with HIV who are on antiretroviral therapy and are virally suppressed cannot transmit HIV to their sexual partners, millions of women accessing contraception continue to have unprotected sex with men who do not know their HIV status. As the PopART trial showed, high HIV incidence among young women is also the result of men not accessing treatment. The report proposes concrete steps to strengthen partner prevention, testing and treatment services, including HIV self-tests for men combined with community outreach and gender-transformative prevention approaches.

“Effective integration requires multilayered prevention that can—and should—encompass both sexual and reproductive health and HIV services, including multipurpose prevention technologies. Siloed care, stock-outs and too little input from women themselves are among the long-standing barriers to women’s health care, and COVID-19 exacerbates these difficulties,” said Mitchell Warren, Executive Director of AVAC.

With the physical distancing necessary as a result of the COVID-19 pandemic reducing contact with health services, it will be essential that interactions with health-care providers be optimized through integrating services. “Prevention of HIV and sexually transmitted infections should be the standard of care for contraception information and services provided to women at a high risk of acquiring HIV,” said James Kiarie, Unit Lead, Contraception and Fertility Care, Department of Sexual and Reproductive Health, WHO.

The COVID-19 pandemic has affected everyone, including key populations at higher risk of HIV. And the gains made against other infectious diseases, including HIV, are at risk of being reversed as a result of disruptions caused by COVID-19. This is the background to a new report published by FHI 360, in collaboration with UNAIDS and the World Health Organization (WHO), which gives advice on how to minimize the impacts of COVID-19 on key populations.

“With a focus on key populations, this guidance complements ongoing efforts to sustain access to HIV prevention services and commodities, sexual health and family planning services, prevention of gender-based violence and HIV counselling, testing and treatment during the COVID-19 pandemic,” said Paula Munderi, Coordinator of the Global HIV Prevention Coalition at UNAIDS. “Preserving essential HIV services for key populations and promoting the safety and well-being of staff and community members during the COVID-19 pandemic is vital to maintaining the hard-fought gains of the AIDS response.”

With practical guidance on how to support the continuation of HIV services for people living with HIV and key populations, the report is aimed at helping the implementers of programmes to carry on their work.

“Key populations are particularly vulnerable to HIV service interruptions and additional harm during the COVID-19 pandemic. We urgently require rights-based solutions that maintain or increase key populations’ access to HIV services while minimizing potential exposure to COVID-19 and promoting individuals’ safety. These must support physical distancing and decongestion of health facilities, but in ways that respond to the current realities of key populations,” said Rose Wilcher, from FHI 360.

The report gives practical suggestions in three main areas.

The first is on protecting providers and community members from COVID-19. HIV services can only continue to be provided during the COVID-19 pandemic if steps are taken to prevent coronavirus infection among programme staff, providers and beneficiaries. Links to COVID-19-related screening and care, and services to support the mental well-being of providers and beneficiaries, can also be given as part of HIV services.

The second area is supporting safe and sustained access to HIV services and commodities. HIV programmes can integrate physical distancing measures, offer virtual consultations and give multimonth dispensing of HIV medicines. Physical peer outreach should be continued where possible.

Monitoring service continuity and improving outcomes is the third area covered by the report. Since there are likely to be service disruptions, HIV programmes will need to adjust their monitoring and evaluation systems in order to allow for regular assessments of continued HIV service delivery and of the impact of COVID-19 on HIV programmes and their beneficiaries. This may require setting up strategic information systems that use physical distancing measures such as virtual data collection and reporting tools.

“The COVID-19 pandemic shouldn’t be used as an excuse to slow momentum in the global response to HIV among key populations. Instead, the pandemic is a time to draw lessons from our work to end AIDS. It is also an opportunity to provide relief to health systems overstretched by COVID-19 by fully funding community-based organizations led by gay and bisexual men, people who use drugs, sex workers and transgender people to ensure improved access to HIV services for key populations,” said George Ayala, Executive Officer of MPact.

“It remains critical to ensure access to HIV prevention, testing and treatment services during COVID-19 and sustain access to life-saving services. This document provides practical guidance and know-how on maintaining essential health services for key populations in these challenging times,” said Annette Verster, the technical lead on key populations at the WHO Department of HIV, Hepatitis and STIs.

The report was developed by FHI 360 as part of the Meeting Targets and Maintaining Epidemic Control (EpiC) project, which is supported by USAID and the United States President’s Emergency Plan for AIDS Relief. UNAIDS, WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria and partners gave inputs and advice.