The Minister of Health of Brazil, Alexandre Padilha met with UNAIDS Deputy Executive Director, Luiz Loures on the country’s new HIV strategy in Brasilia on October 31.

Later this year, Brazil is planning to launch a new approach to the HIV response. While the strategy’s plan to provide life-saving antiretroviral therapy (ART) to everyone has received widespread attention, Minister Padilha provided more details on two other innovative aspects of the programme.

The new strategy will focus HIV programmes on geographic regions where HIV prevalence is much higher than the rest of the country. It also plans to expand ART coverage by task shifting HIV treatment services from special clinics to primary health care clinics.

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The President of the North, Central America, and Caribbean Association Football (CONCACAF), Jeffrey Webb, will be the recipient of the 2013 UNAIDS “Protect the Goal” Special Award for the Diaspora. The announcement was made during the opening of the 2013 CONCACAF Sports Summit taking place in the Cayman Island.

The “Protect the Goal” Award ceremony will take place on 15 January 2014 in Dakar, Senegal during the fourth Pan-African Youth Leadership Summit. Mr Webb will be honored for his exceptional work in using sport to advocate for social development.

The “Protect the Goal” campaign aims to raise awareness of HIV and mobilize young people to commit to HIV prevention. The special award highlights the value of football as a tool for social change. It emphasizes the importance of social responsibility and features individuals and organizations that play an important role in promoting social good and advocacy for HIV awareness and prevention through sport.

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100 000 more Brazilians living with HIV expected to benefit from proposed new prevention as treatment protocol

Some 100 000 more people living with HIV in Brazil are set to receive life-saving antiretroviral therapy (ART) under a major new initiative that will offer early treatment to all HIV-positive adults. It is estimated that between 430 000 and 520 000 people are living with HIV in Brazil — just over 300 000 of which are currently accessing treatment.

The initiative will not only enable more people living with HIV to stay alive and well, it is also part of the government’s efforts to harness the preventative impact of antiretroviral therapy to stop new HIV infections. Antiretroviral therapy is a powerful HIV prevention option as studies have shown that it can reduce the risk of transmitting the virus to a sexual partner by up to 96%.

According to Minister of Health Alexandre Padilha, the proposal put forward in Clinical protocol and therapeutic guidelines for managing HIV infection in adults cements Brazil’s leadership in the global AIDS response. “We are resuming a leading role in the response to the AIDS epidemic in the world. Currently, only two countries — the United States and France — recommend the use of early treatment,” he maintained. Fábio Mesquita, Director of the Department of STDs, AIDS and Viral Hepatitis, added, “Brazil will be the first developing country to adopt the policy of treatment as prevention.”

Key populations at the heart of new protocol

It is hoped that the new initiative will help to stem the advance of the virus, particularly among people most affected by HIV such as young men who have sex with men, sex workers, the transgender community and injecting drug users. For example, for men who have sex with men the estimated HIV prevalence is over 10%, more than 20 times higher than in the general population.

Reaching all people with life-saving services is high on Mr Padilha’s agenda. “We need to use all the available measures to reduce transmission, and the new protocol’s proposals should create a positive impact on the reduction of transmission of the HIV virus in these populations,” he said.

The Clinical Protocol document also sets out ways in which to clearly define and simplify treatment regimens, while strengthening adherence and the long-term effectiveness of antiretrovirals. There are plans to introduce a combined fixed dose, a 3-in-1 medication, as the preferred first-line regimen. This treatment is scheduled to be available in 2014.

"Brazil is once again showing bold leadership in the response to AIDS — and is doing so in an open and inclusive manner, through public consultation,” said UNAIDS Country Coordinator Georgiana Braga-Orillard. “The initiative will improve the lives of people living with HIV and reduce deaths due to AIDS across the country.”

The report is now under public consultation until 5 November and will be finalized before the end of the year. 

A complete text of the proposed new protocol is available at: www.saude.gov.br/consultapublica

The Municipality of Salvador in the State of Bahia today signed a Memorandum of Understanding (MoU) with the Joint United Nations Programme on HIV/AIDS (UNAIDS) in which both organizations agreed to work jointly to raise awareness of HIV and mobilize the worlds of sport and culture to promote UNAIDS Protect the Goal campaign.

The main objective of the MoU is to establish a technical development cooperation framework in support of UNAIDS vision of “Getting to Zero” in the State of Bahia and carry out advocacy activities in support of UNAIDS “Protect the Goal” campaign, a brand new initiative that highlights the power of protection and fosters HIV prevention and treatment particularly among young people in advance of the 2014 FIFA World Cup in Brazil.

Globally, an estimated 4.6 million young people (15-24 years of age) are living with HIV. About 2 300 young people are infected with HIV each day. Many young people living with HIV, who are eligible for treatment lack access or do not know their HIV status. In Latin America, the situation among youth is of particular concern given that less than 30 per cent of those aged 15-24 years correctly identify how to prevent sexual transmission of HIV, and condom use in this age group remains low, while only 30 per cent of women aged 20 to 24 report using condoms during last sexual activity.

In Brazil, HIV and AIDS estimates for 2011 were as follows: New infections (all ages): 18,000 [11,000 - 26,000]; Number of people living with HIV: 490,000 [430,000 - 570,000]; Percentage of people living with HIV (aged 15 - 24); Adults aged 15 to 49 prevalence rate: 0.30% [0.30% - 0.40%]; Adults aged 15 and up living with HIV: 470,000 [410,000 - 550,000]; Women aged 15 and up living with HIV: 200,000 [170,000 - 230,000]; Deaths due to AIDS: 15,000 [12,000 - 20,000]; and Orphans due to AIDS aged 0 to 17: 78,000 [48,000 - 110,000].

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The South American Football Confederation (CONMEBOL) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) today signed a Memorandum of Understanding (MoU) in order to combine efforts to promote UNAIDS' Protect the Goal campaign and raise awareness about HIV/AIDS, particularly among the youth. The signing ceremony took place on the occasion of the special session of South America's soccer governing body in the presence of CONMEBOL President Eugenio Figueredo and Dr Djibril Diallo, on behalf of UNAIDS Executive Director Michel Sidibé.

The main objectives of the MoU are to carry out joint advocacy and communication activities in competitions organized by CONMEBOL —one of the Fédération Internationale de Football Association's (FIFA) six continental confederations— in support of the "Protect the Goal" campaign, a brand new initiative within the framework of UNAIDS' sport for global advocacy that was launched at the 2013 Orange Africa Cup of Nations in South Africa.

Globally, an estimated 4.6 million young people (15-24 years of age) are living with HIV. About 2300 young people are infected with HIV each day.

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Female sex workers receiving HIV prevention information in Myanmar. Credit: UNAIDS/Seng Mai

The response to HIV, tuberculosis and malaria in three pilot countries has been dramatically enhanced with multimillion dollar grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria. El Salvador, Myanmar and Zimbabwe will receive US$ 622 million from the recently created Global Fund’s new funding model.

The new model maximizes available resources and ensures that investments are strategically focused on programmes which have been proven to achieve the greatest possible impact.

Representing a shift in the Global Fund’s business model, it features new central elements such as a multi-partner country dialogue; followed by a focused concept note that summarizes the national context. The request for funding—an iterative application process— now includes increased engagement of technical partners such as UNAIDS.

Following the most recent Global Fund Board meeting in Sri Lanka (18-19 June) which approved the grants for the three early applicant nations, the Board’s chair Simon Bland said, “Countries have been able to act quickly to get this new funding model started, and that’s great news.” Mr Bland stressed that, “These first grants show how, by working with partners, we can reach more people facing these diseases.”

Technical guidance, partnerships and inclusion

Myanmar will receive more than US$ 315 million over the next four years, US$ 160 million of which is for the country’s AIDS response. A particular focus will be meeting an urgent need for antiretroviral treatment coverage with the goal of achieving universal access to HIV treatment by 2016, up from 43% in 2012. HIV services will also be expanded to reach more areas of the country and HIV prevention activities including harm reduction and methadone programming are to be increased.

UNAIDS and its Cosponsors collaborated in the Myanmar’s successful application through technical guidance and assistance. UNAIDS supported the Myanmar Technical Strategy Group on AIDS chaired by the government to facilitate a consultative process which identified programme priorities, with input from technical partners, key populations and programme implementers.

“As members of the Technical Strategy Group and the concept note drafting team, UNAIDS supported us through a transparent and inclusive consultation process,” said Soe Moe Kyaw, member of the Myanmar Positive Group. “Network members representing key populations of people who inject drugs, sex workers and men who have sex with men participated in meetings at which priorities and programmatic gaps were identified. They were also consulted directly to ensure that their priority needs were fully understood and incorporated in order to reflect and complete the country concept note,” added Mr Kyaw.

The grant to El Salvador, worth US$ 26.9 million, will improve access to HIV-related services and deliver treatment among key populations such as men who have sex with men, transgender people and sex workers. By 2016, it aims to reach more than 90% service coverage for these groups. UNAIDS helped national partners with the collection of evidence and epidemiological data and worked with civil society to support the country dialogue, which included key populations.

“The new funding approach allowed the country to identify gaps in the HIV response and to strengthen efforts to reach key populations, which have been engaged since the beginning of the process and will be key partners in the implementation of the grant,” said Dr Ana Isabel Nieto, Director of the National AIDS Programme. “We recognize the invaluable help which UNAIDS provided, especially in terms of collecting, analyzing and documenting strategic information to support the funding proposal.”

Zimbabwe will use its US$ 311 grant to further strengthen impressive gains in challenging HIV. The funding is intended to increase the total number of people on antiretroviral therapy from 565 000 to just over 893 000 by 2016. UNAIDS and partners played a key role in the application process.

"UNAIDS co-led a highly participatory country dialogue involving communities and key populations and provided critical support in the development of the concept note,” said Dr Henry Madzorera, Minister of Health and Child Welfare.

Each of the early applicant grants include investments in improving data systems so that countries can really know their epidemic and in better monitoring and evaluation of programmes designed to reach most affected populations. The new funding model will be fully implemented in 2014 and six other countries are currently going through the application process.

Participants at the consultation held in Brasilia, Brazil this week. Credit: UNAIDS

The critical issues that middle-income countries face in ensuring they have access to affordable and high-quality HIV medicines were explored during a consultation held in Brazil’s capital Brasilia this week. 

Responding to a situation where global debates around access to medicines tend to focus on lower-income countries, delegates from Brazil, China, Ecuador, India, Indonesia, South Africa and more than 20 middle-income nations from all continents, together with representatives from civil society and international organizations discussed their specific needs, perspectives and concerns. It was recognized that this is especially crucial given that by 2020 the vast majority of people with HIV will be living in such countries.

Many middle-income nations are now paying a high price for AIDS medicines, particularly those used for second- and third-line treatment. In fact, even the WHO-recommended first- line treatment, the one pill a day 3-drug fixed dose combination, is out of the reach of some countries, including Brazil, China and the Russian Federation.

This has profound implications for treatment optimization and long-term affordability and sustainability—identified as the central challenges at the meeting. Middle-income countries, often seen as lucrative markets, may not benefit from international initiatives on access to drugs. Most foot the bill themselves either through government funding or out of pocket expenditure and there is uncertainty as to whether the growing numbers of people on treatment will continue to get the life-saving medicines they need for as long as they need them.

“We must look at specific policy options and mechanisms available to middle-income countries to tackle barriers and ensure universal access to treatment,” said Ed Vela from UNITAID, which co-hosted the June 10 to12 event with UNAIDS, WHO/Pan American Health Organization and the Brazilian government.

There was much analysis and information sharing about the markets and prices of HIV medicines and their regulatory status in different middle-income nations. Individual country experiences and approaches were presented, taking into account the often wide disparities between those at different stages of economic growth.

Jarbas Barbosa da Silva Junior, Vice–Minister and Secretary for Health Surveillance of Brazil noted that his country was taking bold steps to rise to the challenge of inequalities present in a large middle-income country such as Brazil. “This meeting is an essential step to strengthen the cooperation mechanism between middle-income countries (MIC) and will help us reach universal and sustainable access to treatment”.

The meeting was hosted by UNITAID, UNAIDS, WHO/Pan American Health Organization and the Brazilian government. Credit: UNAIDS

The key question of public health-focussed management of intellectual property rights was scrutinised in some detail. Supported by UNITAID, the Medicines Patent Pool—where holders voluntarily share their patents on HIV medication—allows generic drugs to be made at a reduced cost. However, the meeting heard that this facility is largely extended to sub-Saharan Africa and that most middle-income countries outside this region are excluded. Participants looked at ways in which policy levers and incentive mechanisms could be implemented to enable more countries to benefit from such voluntary mechanisms. 

After three days of discussion, sharing information, ideas and strategies, delegates were keen to ensure that the consultation was not an end in itself but the start of a process. The need to continue to improve implementation of the policy options put forward for increased access to medicines for MICs was agreed. The outcome document from the meeting outlines key next steps in the areas of pricing, intellectual property, research and development, and regulation, by fostering information sharing and south to south collaboration on these areas

According to Mariangela Simao, UNAIDS Director of Gender, Human Rights and Community Mobilization, “The meeting was a valuable step forward bringing together middle-income countries from around the world with different challenges in achieving long term access and sustainability of antiretroviral therapy.”

The Organization of American States (OAS)—the world’s oldest regional mechanism comprising 35 independent states of the Americas—has adopted a bold new Resolution on the Promotion and Protection of Human Rights of People Vulnerable to or Living With or Affected by HIV.

Meeting at its 43^rd General Assembly, delegates approved the Resolution which puts human rights, gender equality and social justice at the heart of the region’s HIV response. The new agreement emphasizes the importance of the greater involvement and participation of the most affected populations in the response to the epidemic.

In spite of progress addressing HIV in the region—treatment coverage is high, and new HIV infections have begun to decline in parts of the Caribbean—the Resolution recognizes the still significant challenges that remain to ensure equitable access to HIV services, particularly among most at risk groups as well as women and girls.

Opening the Assembly, Secretary General of the OAS, Jose Miguel Insulza noted the frequent ‘disregard’ of the rights of minorities but highlighted the critical opportunity the OAS provides "for frank, open policy dialogue on these issues in the Hemisphere".

Deeply rooted stigma and discrimination is still all too pervasive among community and religious leaders, service providers and state agents. This impedes access to services, employment, and in some cases, leads to social exclusion for people most vulnerable to HIV, including sex workers, men who have sex with men, transgender people, drug users and indigenous populations. The Resolution calls for specific measures to promote gender equality and address the needs of women, adolescents and girls, noting the strong inter-relation between gender-based violence as both a cause and consequence of HIV.

As discussions continue globally around the sustainability of the AIDS response, the Resolution flags the ‘exorbitant’ cost of antiretroviral treatment in some countries and the challenge of securing generic alternatives. Furthermore, despite increases in domestic funding for the AIDS response, the Resolution notes that resources are still not being sufficiently invested in programmes that support and sustain education, behavior change and other HIV prevention strategies.

The Resolution looks at ways to strengthen collaboration with international bodies such as the Inter-American Commission on Women and the Inter-American Commission on Human Rights to advocate for greater protective laws and policies. These include the exchange of experiences and best practices, the organization of joint activities, and the coordination of efforts and capacities to attain the greatest possible impact.

OAS Member States called upon UNAIDS and the Pan American Health Organization (PAHO) to join efforts in the implementation of the Resolution as well as to provide countries with support to eliminate new HIV infections among children, to ensure access to affordable treatment, to end stigma and discrimination and to promote gender equality.

"This Resolution comes at an opportune time, when global discussions on development and health are shifting, but also demonstrates that new opportunities are emerging to maintain the momentum to reach UNAIDS vision of zero discrimination, zero new HIV infections, and zero AIDS-related deaths," said UNAIDS Executive Director Michel Sidibé.

Mr Sidibé met with Secretary General Insulza in Washington DC, prior to the OAS General Assembly where he remarked that "The OAS has been a leader in driving forth discussions around affordable medicines, and is breaking new ground in terms of addressing stigma and discrimination, and recognizing the intersection between gender-based violence and HIV".

The Confederation of North, Central America and Caribbean Association Football (CONCACAF) and UNAIDS signed a Memorandum of Understanding on 19 April in Panama City, Panama and agreed to engage football in the AIDS response, particularly among young people.

The agreement was signed on the sidelines of the 2013 CONCACAF Under-17 Championship in the presence of CONCACAF President Jeffrey Webb and Senior Adviser Dr Djibril Diallo, who represented UNAIDS Executive Director Michel Sidibé. It was signed in the presence of FIFA President Sepp Blatter, FIFA Secretary General Jerome Valcke and Confederation of African Football (CAF) Secretary General Hishram ElAmrani.

The two organizations agreed to carry out joint advocacy and communication activities in competitions organized by CONCACAF in support of the UNAIDS “Protect the Goal” campaign. This initiative was launched in January at the 2013 Orange Africa Cup of Nations in South Africa and is part of UNAIDS’ sport for global advocacy programme. The campaign promotes HIV prevention and treatment, in advance of the 2014 FIFA World Cup in Brazil.

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Honduras has adopted a reform of the Penal Code that will ensure legal protection against discrimination based on sexual orientation and gender identity.

Honduras is moving a step closer to the UNAIDS vision of ‘zero discrimination’. Its Congress has recently adopted a reform of the Penal Code that will ensure legal protection against discrimination based on sexual orientation and gender identity.

"This has been a historic step for Lesbian, Gay, Bisexual, Transexual and Intersex (LGBTI) populations that have suffered from widespread violence and impunity in Honduras,” said Donny Reyes, Coordinator at Arcoiris, a civil society organization advocating for greater LGBTI rights. “Finally our right to freedom and to live in peace has been formally recognized,” he added.

Between 2009 and 2012, more than 90 homophobia-related killings were reported in the country, according to the Human Rights Observatory of Lesbian Cattrachas Network. These incidents, which are among the highest in the region, are attributed to the high levels of homophobia and transphobia that exists in Honduran society.

The high number of violent deaths and human rights violations against LGTBI people prompted Ana Pineda, the Minister of Justice and Human Rights to promote the reform of the Penal Code.

The amended code establishes as an offence with aggravating circumstances the “discrimination with hatred or contempt on the basis of sex, gender, religion, national origin, belonging to indigenous and Afrodescendant groups, sexual orientation or gender identity”.  This offence may be punishable by up to 3–5 years imprisonment and a monetary fine. The penalty increases if it is a violent crime.

Dialogue between the government, civil society and UNAIDS led to the creation of special units within the General Attorney’s Office to strengthen the investigation of allegations of violence on the basis of sexual diversity. Each unit comprises a qualified legal advisor, an analyst and three investigators. The Units are currently investigating 17 cases of killings on the basis of sexual orientation and/or gender identity.

“Strengthening investigation, establishing a legal framework which sanctions discrimination and making sure that judges will apply the new provisions are both crucial steps to prevent and reduce violence against members of the LGTBI community,” said Ms Pineda.

Reducing vulnerability to HIV

The amended Penal Code is expected to improve access to HIV-related services, education and employment for LGTBI people. The discrimination, exclusion and violence against LGTBI people have exacerbated their vulnerability to HIV infection by discouraging them from accessing health services out of fear.

In Honduras the HIV epidemic seriously affects men who have sex with men (MSM), where the prevalence of HIV has reached 9.9% compared to the 0.6% among the general population.

A recent report in The Lancet highlights that transgender people have at least 50 times the odds of men and women in the general population of becoming infected with HIV—due to biological as well as structural risks for HIV infection such as social exclusion, economic marginalization, and unmet health-care needs.

"This ruling will provide LGTBI people with greater access to HIV related services" said Nicole Massoud, UNAIDS Country Coordinator for Honduras and Nicaragua. “UNAIDS congratulates the State of Honduras for its commitment to promote and defend human rights. The challenge now is to ensure that all professionals are informed and trained on these new provisions to help ensure we reach zero stigma and discrimination.”