Social norms

The recent regional launch of the global AIDS report 2020, Prevailing against pandemics by putting people at the centre, in eastern Europe and central Asia provided a platform for the proposal of a joint revision of social and legal enablers in the region to achieve the proposed 2025 targets. UNAIDS Cosponsors, governments and civil society partners presented their views on the issue and the joint action to be taken. 

Based on the regional data, the 90–90–90 treatment cascade in the region is far off the targets, having reached only 70–44–41. Lev Zohrabyan, the UNAIDS Strategic Information Adviser for Eastern Europe and Central Asia, noted that one of the reasons for this is late diagnosis: in 2019, 53% of all new HIV cases in the region were registered in the later stages. In his opinion, it shows that testing strategies need revision and require enabling societal conditions.

Societal and service enablers have been given prominence in the proposed 2025 targets; in particular, it is outlined in the 10–10–10 targets that:

• Less than 10% of countries have punitive legal and policy environments that deny access to justice.
• Less than 10% of people living with HIV and key populations experience stigma and discrimination.
• Less than 10% of women, girls, people living with HIV and key populations experience gender inequality and violence.

Achieving these goals includes having enabling laws, policies and public education campaigns that dispel the stigma and discrimination that still surrounds HIV, empower women and girls to claim their sexual and reproductive health and rights and end the marginalization of people at higher risk of HIV infection.

“Interventions in these areas create conditions for people to be more active in HIV testing, seek help and start antiretroviral therapy immediately upon diagnosis, adhere to a treatment regimen or proactively seek HIV prevention services, including pre-exposure prophylaxis,” said Mr Zohrabyan.   

Rosemary Kumwenda, the Regional HIV/Health Team Leader at the United Nations Development Programme Istanbul Regional Hub, presented an analysis of the legislation in the eastern Europe and central Asia region on the criminalization of HIV and key populations, noting that the situation in the region remains unfavourable for an effective HIV response. The criminal codes have changed in many countries, but discriminatory laws are changing very slowly. Although many countries revisited their legislation regarding HIV exposure, HIV transmission is criminalized in virtually every country in the region. The Russian Federation and Belarus remain “leaders” in the criminalization of HIV and key populations. Criminal penalties for sex between adult men remain in Uzbekistan and Turkmenistan. The biggest challenge for the region, where more than 48% of new HIV cases are among people who inject drugs, is the criminalization of drug use and possession.

In the presentation An Inventory of Existing Tools for Creating a Favourable Social and Legal Environment in the Eastern Europe and Central Asia Region, given by Tatiana Deshko, the Director of the Department of International Programs, ICF Alliance for Public Health, Ukraine, the ReACT mechanism, which comprehensively works for the rights of key populations, was presented. ReACT (Rights, Evidence, Actions) is the programme’s principle for monitoring violations of rights and is being implemented in 37 cities in seven countries of the region with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Cases of rights violation are registered in a mobile application and then lawyers work with specific cases at the individual level or at the system level of revising legislation. Last year, about 2000 cases were registered. The analysis shows that law enforcement agencies are the primary violators of the rights of key populations in almost all countries, using threats, intimidation, illegal detention and abuse of authority. The health-care system, with denials of medical services, discrimination based on HIV status or disclosure of HIV status, is ranked after law enforcement. “Strategic analysis of cases based on the ReACT-collected data allows not only help for specific people to protect their rights but also formulating recommendations for revising legislation in countries,” said Ms Deshko.

As part of the discussion of the second 10, Alexandra Volgina, the Manager of the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination, Global Network of People Living with HIV, spoke about the People Living with HIV Stigma Index 2.0 study and the role of the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination.

Four countries of the region, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Ukraine, have entered the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination. “If we compile the ReACT system, the Stigma Index and other instruments you’ll get a clear picture of what exactly needs to be done to make a difference. We need to address this issue jointly, all partners together. If we change the situation in the area of ​​stigma and discrimination, we will be able to stop the epidemic,” said Ms Volgina.

An example of such an integrated approach, from data to policies and action, was shared by Evghenii A. Golosceapov, a member of the Equality Council in the Republic of Moldova, the first state institution in the post-Soviet countries dealing with discrimination against various groups.

As part of the Equality Council’s work, studies on the People Living with HIV Stigma Index were carried out, where, through public opinion polls and in-depth interviews, categories of people who are marginalized by society were determined. People living with HIV ranked the second among those categories, after lesbian, gay, bisexual, transgender and intersex people. The Equality Council also uses data from the People Living with HIV Stigma Index, the ReACT registration system and research on the legal environment on HIV.

On this comprehensive basis, more than 70 recommendations on practical steps in the field of legislative changes were developed. These data were used to develop a new national HIV programme and a country proposal to the Global Fund. In addition, the Equality Council considers specific cases of discrimination and complaints (e.g. dismissal due to HIV status) and supports civil society organizations in defending the rights in court. In recent years, the restriction on artificial insemination for people living with HIV has been lifted in the Republic of Moldova, as well as the ban on adoption and guardianship.

All the data collected shape the Roadmap for the Elimination of Discrimination, a government programme in which people living with HIV play a critical role. In the Republic of Moldova, the ScorCard system has also been launched, which allows real-time tracking of the implementation of recommendations and progress towards the adopted targets in reducing stigma and discrimination.

Regional gender gaps in the context of the HIV response were presented by Enkhtsetseg Miyegombo, a Programme Specialist at the UN Women Europe and Central Asia Regional Office.

According to her, the COVID-19 pandemic has largely erased progress in this area and exacerbated existing inequalities: lockdowns disproportionately affected the workload of women who do unpaid domestic work, reduced women’s economic opportunities due to job losses, limited their mobility and increased documented violence against women. These new circumstances were superimposed on existing problems—a lack of awareness about HIV, barriers to discussing safer sex with a partner, revival of patriarchal stereotypes, religious restrictions—as a result of which, women find themselves under growing pressure. Ms Miyegombo highlighted that investment in gender equality programmes is critical to the effectiveness of the regional HIV response.

A study conducted by the Eurasian Women’s Network on AIDS helped to identify the key characteristics of violence and the specifics of organizing assistance to victims of violence in 12 countries of the eastern Europe and central Asia region. The results of the study supplemented the available international data on violence and equipped national civil society organizations with real facts for political advocacy. Elena Rastokina, a specialist in advocacy and community mobilization from the Almaty Model of HIV Epidemic Control project in Kazakhstan, presented successful practices of community-based monitoring in the eastern Europe and central Asia region, concluding that this approach is important as it allows communities to know their rights and barriers and to have systematic data to advocate for systematic change.

Alexander Goliusov, the Director, a.i., of the UNAIDS Regional Support Team for Eastern Europe and Central Asia, stressed that the new 10–10–10 targets are addressing the inequalities that are fuelling the spread of HIV, COVID-19 and other pandemics. “Testing and treatment remain our priorities; however, now our fast track to them lies in combatting inequalities,” he said.

The recording of the launch in Russian and English, along with all presentations and materials, can be found here.

At the end of January 2021, the Kyrgyzstan Constitutional Court decided to exclude HIV from the list of diseases that prevent people from adopting children or becoming guardians or foster parents. The barrier to parenting for people living with HIV in the country had been in effect for many years.

The change—brought about by a joint effort of activists, lawyers and human rights defenders, but primarily by people who personally suffered from discrimination and fought for their rights—is a victory against stigma and discrimination against people living with HIV in Kyrgyzstan.

Baktygul Israilova, pictured above and who leads the Country Network of Women Living with HIV, is one of those who were affected. Several years ago, she wanted to adopt a child. “At that time, I did not fully understand the depth of the problem. I thought that if I prepared all the necessary documents, submitted them to the right department, they would consider me and make a positive decision,” Ms Israilova said. “I am a mother of two wonderful girls, I have a job, a stable job, so at that time it seemed that everything should be on my side.”

When she found out that she could not adopt a child because of her HIV status, she was shocked. “I’m used to the fact that people living with HIV are constantly discriminated against, but why can’t they become parents and give their love and care to a child from an orphanage?” she said.

At that time, Ms Israilova was starting on her path in HIV activism. “Until that time I was always afraid of something, at first my HIV status. I was worried for my girls, I was worried that I would not find a job, I was afraid that people would not understand me, I was worried that I would not achieve anything in my life. But then I became tired of being afraid. It was a turning point in my life. It was then that I openly declared my HIV status and became the first woman in the country openly living with HIV.”

According to the Kyrgyzstan National Statistical Committee, in 2019 there were more than 2000 children and adolescents under the age of 18 years who were left without parental care, of which 592 were orphans.

In 2018, Ms Israilova met Svetlana Izambayeva, pictured above, an activist from the Russian Federation who is living with HIV and who became one of the first women in the Russian Federation to declare her HIV status openly. Ms Izambayeva had extensive and successful experience in the struggle for the right to adopt in her home country and helped and advised the women in Kyrgyzstan in their battle.

A similar case was being considered by the Kyrgyzstan courts in which the Kyrgyz lawyer Ainura Osmonalieva and lawyers from the Adilet legal clinic were trying to help a woman living with HIV to get custody of her nephew after the death of his mother.

The activists joined forces and resources and studied the entire existing legal framework, international obligations, ratified conventions and the United Nations Political Declaration on Ending AIDS, which the country had committed to implement. The process lasted for two years. Activists from other countries, particularly from the Eurasian Women’s Network on AIDS, helped to collect evidence. The activists highlighted examples of changes in legislation in three eastern European countries—the Republic of Moldova, the Russian Federation and Ukraine. The UNAIDS Country Office in Kyrgyzstan supported the advocacy efforts of the Country Network of Women Living with HIV at all stages and provided technical support to strengthen its organizational and advocacy capacity.

Ms Israilova said that when she had to speak and defend her position before the Constitutional Court judges, she was ready for any developments. “Even if we were given a negative decision, we would not have given up, but tried again and again to achieve a result where every person living with HIV can adopt or become a guardian of a child.”

“When we received a positive decision, I came home and told my girls about what we had achieved. They have long dreamed of a brother and even came up with a name for him. My girls are my light, which illuminates my path. I have managed to achieve a lot in life thanks to the fact that I have them. Now I must prepare all the necessary documents to give happiness to another child,” said Ms Israilova.

Photos: November 2019. Credit: UNAIDS

In 2016, Member States agreed a set of targets at the United Nations High-Level Meeting on Ending AIDS to be met to put the world on course to end the AIDS epidemic by 2030. One of those targets was to strengthen national social and child protection systems to ensure that, by 2020, 75% of people living with, at risk of or affected by HIV benefit from HIV-sensitive social protection. The target is human rights-based. It feeds into and benefits from promoting, protecting and fulfilling all human rights and the dignity of all people living with, at risk of or affected by HIV.

Evidence of how social protection programmes meet the needs of people who are poor and excluded and benefit people living with, at risk of or affected by HIV is increasing. The question is not whether the AIDS response should increase attention to social protection, but how best to leverage resources and partnerships of movements working on ending poverty and inequality to work effectively towards ending AIDS.

Of 127 countries reporting in the UNAIDS National Composite Policy Index in 2017, 109 (86%) stated that they had an approved social protection strategy, policy or framework in 2016, and 99 of those countries (78%) were implementing those programmes. A total of 85 countries stated that their strategies were HIV-sensitive to at least some extent. More than half (47) of the 87 countries with a coordinating mechanism for their social protection strategy have included their national AIDS programme in that structure. However, only 12 countries reported that their social protection strategies were fully HIV-sensitive.

To step up efforts to get social protection on the Fast-Track, UNAIDS recently held a conference at which the participants heard about how to strengthen national social and child protection systems. The conference focused on three objectives: strengthening the links with social and other movements for ending poverty and inequality; intensifying action on social protection; and reinvigorating programming for HIV, food security and nutrition.

“Stronger linkages are required across health, education and community systems to reduce the vulnerability of people living with, at risk of and affected by HIV through social protection services,” said Tim Martineau, UNAIDS Deputy Executive Director, Programme, a.i.

The event also saw the launch of a new UNAIDS report, Social protection: a Fast-Track commitment to end AIDS. The report provides guidance on how to scale up what works in the context of different HIV epidemics and for different populations. It also provides guidance to governments, people living with or affected by HIV, policy-makers and other stakeholders on how to intensify the integration of HIV with social protection and other programmes for ending poverty and inequality towards ending AIDS.

“We must remember that without improving the material and emotional well-being of people, we cannot end the AIDS epidemic,” said Denys Dmytriiev, from the All Ukrainian Network of People Living with HIV.

The International Conference on Fast-Tracking Social Protection to End AIDS was held in Geneva, Switzerland, on 25 and 26 April.

“Age of consent: my body, my rights”, “Rights have no age” and “#Sex happens” were some of the creative advocacy messages that young people came up with during the pilot training on an age of consent advocacy manual that took place in Harare, Zimbabwe.

As part of the All In partnership to end adolescent AIDS, UNAIDS and the PACT, a global coalition of 25 youth-led and youth-serving organizations and networks working on HIV, developed a comprehensive advocacy manual on age of consent policies that relate to the sexual and reproductive health and rights of youth and adolescents. The manual seeks to provide youth advocates with the skills and information they need to respond to legal barriers, specifically age of consent laws and policies related to sex, HIV and sexual and reproductive health services.

As stated in the UNAIDS Prevention gap report, “In many settings, parental and other third-party consent requirements for access to HIV and sexual and reproductive health services remain an important barrier to their uptake. Adolescents often are reluctant to seek services that require the consent of a parent or guardian. Similarly, laws that restrict people’s access to health services—for example, by requiring third-party authorization for accessing sexual and reproductive health services or by criminalizing certain consensual sexual behaviours—exclude people from the health information and services they need”.

The piloting of the manual in Zimbabwe was facilitated by Youth Engage, a youth-led advocacy organization that brought together 25 youth advocates from diverse backgrounds.

Young people, with support from the National AIDS Council of Zimbabwe, are now mobilizing and preparing for a dialogue with parliamentarians to discuss the age of consent laws on marriage, sex and HIV testing in Zimbabwe and young people’s access to sexual and reproductive health services.

The manual will soon be piloted in India and will become a key resource for advocates to challenge legal and policy barriers that pose obstacles for young people’s access to HIV and sexual and reproductive health services all over the world.

In collaboration with UNAIDS and other partners, the United Nations Development Programme (UNDP) and IRTG, a Global Network of Trans Women and HIV, have released a new publication today entitled Implementing comprehensive HIV and STI programmes with transgender people: practical guidance for collaborative interventions. The publication presents concrete steps that public health officials, health workers and nongovernmental organizations can adopt to implement HIV and sexually transmitted infection (STI) programmes with transgender people.

Topics covered in the publication include community empowerment and human rights, addressing violence, stigma and discrimination, and delivering transgender-competent services, especially for HIV and STI prevention, diagnosis, treatment and care. The publication also covers community-led outreach, safe spaces and the use of information and communications technology in service delivery. It describes how to manage programmes and build the capacity of organizations led by transgender people and shows how services can be designed and implemented to be acceptable and accessible to transgender women. Wherever possible, it gives particular attention to programmes run by transgender organizations.

The publication was developed in collaboration with transgender people and advocates, service providers, researchers, government officials and representatives of nongovernmental organizations from all over the world. UNDP and IRTG coordinated its production, with the support of the United Nations Population Fund, the University of California, San Francisco, Center of Excellence for Transgender Health, the Johns Hopkins Bloomberg School of Public Health, the World Health Organization, the United States Agency for International Development, the United States President’s Emergency Plan for AIDS Relief and UNAIDS.

The document is based on recommendations included in the Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations, published in 2014 by the World Health Organization.

Transgender women continue to be heavily affected by HIV, being 49 times more likely to become infected with HIV than non-transgender adults.