The drop-in centre of the Uganda Harm Reduction Network (UHRN) looks lonely from the deserted suburban pavement. It is a non-descript house, hidden behind an imposing solid pink steel gate, in an equally non-descript neighbourhood.

It looks like so many other drop-in centres in eastern Africa that serve key populations—anonymous and low-key. Necessary characteristics, perhaps, in a region that mostly criminalizes people who use drugs, gay men and other men who have sex with men, sex workers and transgender people.

Once through the gate, visitors are greeted with a hive of activity that belies the quiet exterior. Clients and staff are buzzing around, setting up chairs under the makeshift gazebo in the verdant garden. In a few minutes, a group of people who use drugs will take part in a harm reduction workshop run by one of the centre’s staff. There is also a consulting room at the front of the drop-in centre; and at the back, is the office of Wamala Twaibu.

Mr Twaibu is the founder and chairperson of the Eastern Africa Harm Reduction Network and UHRN. A self-styled “former drug user with roots in Uganda and the pioneer of the harm reduction movement in eastern Africa,” Mr Twaibu has a kind face and a penetrating gaze that tells a story of adversity, resilience and triumph.

In the consulting room, 25-year-old Kemigisa Sandriano, a heroin user and sex worker, is taking an HIV test conducted by the centre’s resident doctor, Mukiibi Grace Nickolas. The night before, Ms Sandriano was assaulted by a client after he took off the condom during sex. She protested, telling him to leave. Her swollen, bloodshot right eye attests to what happened after that. She is smiley and talkative, seemingly unbothered by yet another instance of violence at the hands of a client. She is happy that in his battle to get his money back, she won.

Ms Sandriano was introduced to heroin by her ex-husband, who she says “ruined” her life. Nevertheless, she is upbeat about her recovery.

“I have the hope that I can stop. I even went to rehab for three months. When I saw my days of rehab coming to an end, I saw no plan and I started again,” she says.

“I am ready to go to rehab again,” she continues. “But when I come out, I don’t want to be idle. When they take us out of rehab, we need a job. They can say to us, “Work in a supermarket, work in this shop, so you can stabilize.””

Employment aside, Mr Twaibu says medically assisted treatment for people with opioid dependence is critical for rehabilitation. And, since, December 2020, with advocacy from UHRN and financial support from the United States President’s Emergency Plan for AIDS Relief and the Centers for Disease Control and Prevention, the first medically assisted treatment services in Uganda have been available at the Butabika National Mental Referral Hospital in Kampala.

UHRN screens and provides initial preparation for eligible clients and refers and links them to the hospital and provides them with ongoing psychosocial support services. In December 2020, there were 81 people who use drugs enrolled in medically assisted treatment.

Besides medically assisted treatment, through its drop-in centre UHRN offers a comprehensive package of health services, including behaviour change communication, a needle–syringe programme, psychosocial support, overdose management, HIV testing and counselling and sexually transmitted infection screening.

The COVID-19 pandemic posed a major challenge to UHRN’s clients, who even under normal circumstances face high levels of stigma and discrimination, police abuse and harassment, alienation and limited access to health and social services.

Sex workers, transgender men and women, people who use drugs and gay men lost livelihoods and faced even more violence and detention under the guise of lockdown measures. Movement was severely limited as motor vehicles required a special permit to operate.

UHRN rose to the challenge. A team of 25 peer educators used bicycles, funded by Frontline AIDS, and motorcycles to reach their clients where they were, providing antiretroviral medicine refills and condoms to clients who could not reach health facilities.

The organization rolled out virtual counselling services on risk reduction and addiction management through phone calls and WhatsApp. As part of personal protective equipment procurement, UNAIDS, through the National Forum of People Living with HIV/AIDS Networks in Uganda, provided soap and bleach to prevent COVID-19 infection among the drop-in centre’s dedicated staff, who worked right through the pandemic.

Despite the constraints of the pandemic, UHRN’s needle–syringe programme reached 287 clients in 2020, providing more than 15 000 clean needles and syringes, tourniquets, cotton balls, swabs, water ampoules, condoms, lubricant and safe-injecting information notes.

“I’m proud that harm reduction issues are taking a centre stage in Uganda,” says Mr Twaibu. “Community-led means ownership. Usually when the community is at the centre, accountability and community needs are prioritized,” he says.

The Union for HIV Prevention and Harm Reduction is a nongovernmental organization located in Balti, in the Republic of Moldova. It provides integrated services to people who use drugs and other affected populations throughout the north of the country.

Each year, more than 3000 people benefit from its services, which including mobile testing for HIV, sexually transmitted infections and hepatitis, harm reduction services, including a needle–syringe programme, the distribution of condoms and psychological and social support. The organization’s outreach and medical workers work closely with state clinics and hospital departments that offer opioid substitution therapy to people who use drugs.

However, the organization has faced a long-time logistical problem with regard to the collection of used needles and syringes generated by the harm reduction programme. Medical waste disposal in the Republic of Moldova, especially in the north of the country, is problematic. Ala Iatco, the nongovernmental organization’s head, explained that destruction of used equipment was only possible by contracting medical institutions to do the work and that the union had to send boxes with contaminated waste to Chisinau, the capital of the country.

“For the approximately 20 years of the harm reduction programme in the country, this problem was always present and solved through burning needles and syringes or other non-environmentally-friendly ways. We had to find a solution to increase the effectiveness of the comprehensive package of services and enhance the safety and security of personnel and volunteers while operating the needle–syringe programme,” said Svetlana Plamadela, UNAIDS Country Manager for the Republic of Moldova.

The UNAIDS Country Office for the Republic of Moldova, together with the United Nations Office on Drugs and Crime and the union, came together and suggested a solution. In July 2017, specialized modern medical waste management equipment was procured from the Russian Federation and installed within a Union for HIV Prevention and Harm Reduction facility. The total cost of US$ 23 000 was funded with resources from the One UN Joint Action to Strengthen Human Rights in the Transnistrian Region of the Republic of Moldova project, financed with the support of the Swedish Embassy and co-funded by the Center for Health Policies and Studies (PAS Center), which is a Principal Recipient of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“The availability of the one-stop disposal system provided by the needle smelters and syringe cutters significantly reduces the risk of accidental exposure and contamination with bloodborne diseases by the volunteers and medical personnel,” added Ms Plamadela.

So far, three organizations—the Union for HIV Prevention and Harm Reduction, Young Women Cernoleuca and Adolescent!—have benefited from the needle–syringe destruction equipment. Partner organizations usually make monthly shipments of needles and syringes for destruction, which are collected by field workers in eco-boxes.

According to Ms Iatco, the equipment is easy to use and maintain. “The machine transforms the contaminated syringes and needles into biologically safe waste. We save almost 50% of the cost of destruction. And, most importantly, we face much fewer risks as we avoid transportation, storage and transfer of hazardous material. For our organization, located in a remote area where no such equipment is available in medical institutions, it’s a cost-effective and less risky solution,” she said.

The needle–syringe programme in the Republic of Moldova started in 1999. Its main goal is to prevent the transmission of HIV and other infections among people who inject drugs by avoiding the sharing of injecting equipment and ensuring enhanced access to health-care services and psychosocial support. The programme also aims to curb the sexual transmission of HIV among people who inject drugs and their sexual partners by promoting the use of condoms and raising awareness about the link between drug use and risky sexual behaviours.

UNAIDS is saddened by the death from AIDS-related causes of Patrick O’Connell. Mr O’Connell, who lived with HIV for nearly four decades, was the founding director of Visual AIDS.

Visual AIDS was founded in 1988 by arts professionals as a response to the effects of AIDS on the arts community and as a way of organizing artists, arts institutions and arts audiences towards direct action on HIV. The organization also assists artists living with HIV. Perhaps its most high-profile achievement, however, was designing the red ribbon worn by millions of people around the world every World AIDS Day, 1 December.

In 1991, Visual AIDS artists came together to design a visual symbol to demonstrate compassion for people living with HIV and their caregivers. Inspired by the yellow ribbons honouring American soldiers serving in the Gulf War, the artists chose to create a red ribbon to symbolize support and solidarity for people living with HIV and to remember those who had died from AIDS-related illnesses. The colour red was chosen for its, “connection to blood and the idea of passion—not only anger, but love, like a valentine,” the project founders said. The project became known as the Red Ribbon Project.

Mr O’Connell was instrumental in helping to organize the cutting, folding and distribution of thousands of ribbons around his home city, New York. He was part of the campaign to send letters and red ribbons to all the attendees of the 1991 Tony Awards in the United States of America, where actor Jeremy Irons stepped out on national television with a red ribbon pinned prominently on his lapel.

UNAIDS remembers Mr O’Connell for his vital advocacy work. The red ribbon, which today is a symbol of solidarity and support for people living with HIV not only in the United States but internationally, would not have existed without him.

Civil society activism and competition from manufacturers of generic drugs drove down the prices of antiretroviral medicines from about US$ 14 000 per person per year for first-line regimens in high-income countries in 1990 to about US$ 1200 per year in low- and middle-income countries in 2003. By 2018, the price per person per year in sub-Saharan Africa was under US$ 100 for most fixed-dose combinations that include tenofovir. The prices of other fixed-dose combinations also have continued to decline over the past few years.

UNAIDS estimates that the market value for generic antiretroviral medicines within low- and middle-income countries was about US$ 1.8 billion in 2018. Approximately 80% of generic antiretroviral medicines procured by low- and middle-income countries are currently manufactured in one country: India.

While there remains significant scope for further price reductions in countries where generic antiretroviral medicines are not yet easily accessible, disruptions caused by the COVID-19 pandemic could have the opposite effect. Lockdowns, disruptions to production, border restrictions and transport disruption threaten to affect the supply of materials and the manufacture and distribution of HIV medicines, with tighter supply factors possibly leading to pressure on market prices.

100% Life, formerly known as the All-Ukrainian Network of People Living with HIV, the largest organization for people living with HIV in eastern Europe and central Asia, is marking its 20th anniversary on 5 May. Those 20 years have seen it work on the most challenging issues of the HIV response in Ukraine, on health-care reform and overcoming stigma and discrimination and barriers to accessing health services.

The organization works to provide 100% access to treatment to 100% of Ukrainian people living with HIV. It strives to improve the quality of life for people living with HIV and promotes the rights and freedoms of people living with HIV, tuberculosis and hepatitis C, including the right to self-determination and the right to make decisions that directly influence their lives.

Beginning with seven members in 2001, today it has grown to 474 members and 15 000 associate members. The first office was opened in Kyiv and now the organization unites 24 regional offices across the country.

In 2004, the organization, together with partners, prevented interruptions of antiretroviral therapy for 137 patients. At the end of 2019, 100% Life was purchasing HIV medicine for 113 000 people.

“Over the years of work, we have purchased 7 230 000 packs of antiretroviral therapy,” said Dmitry Sherembey, head of the 100% Life Coordinating Council. Think about these figures! Behind each of them is a saved life. We are grateful to all our partners who believed in us and continue to believe.”

In 2016, the first 100% Life medical centre was opened in Kyiv. Five years later, three more centres have been opened in Ukraine, in Poltava, Rivne and Chernihiv. These centres are the first clinics created by patients for patients, where services are provided free from stigma and discrimination.

“I have great respect for the struggle that the organization has waged against stigma and discrimination against people living with HIV and other vulnerable people. It is thanks to 100% Life that the first opioid substitution therapy programmes for people who use drugs in Ukraine started, sex workers began to speak openly about their rights and people living with HIV had hope for a normal life, medical care and help from the state,” said Raman Hailevich, the UNAIDS Country Director for Ukraine.

In 2016, the organization received the United States President’s Emergency Plan for AIDS Relief (PEPFAR) award for the best partnership among the 40 countries in which PEPFAR operates.

The same year, there was a breakthrough in state funding of the HIV response, which was increased by 2.3 times. The success of the 20/50/80 transition plan is partly because of the efforts of 100% Life, which worked with the government and advocated for increases in the HIV budget, access to treatment and the optimization of health-care systems.

The struggle of 100% Life won’t stop. New problems come along that need to be addressed.

“We are now facing a new challenge—the COVID-19 pandemic,” added Mr Sherembey. “Our experience gained over the years of interaction with government agencies, partners and donors allows us to contribute to the common cause of the struggle. With the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria and USAID, almost a million pieces of personal protective equipment have been purchased for Ukrainian doctors and social workers, 200 000 tests for COVID-19 have been bought, equipment for oxygen stations at hospitals has been procured, information campaigns on vaccination against COVID-19 have been conducted, and much more is being done.”

Winnie Byanyima, the UNAIDS Executive Director, recently visited the Hakahana Clinic in Katutura, Windhoek, Namibia, where she saw the Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe (DREAMS) project in action, a project funded by the United States of America. The clinic is a government health facility and a DREAMS participating clinic that has provided health services to 10–24-year-old adolescent girls and young women since September 2020.

Together with the United States Ambassador, Lisa Johnson, and the Executive Director of the Namibian Ministry of Health and Social Services, Ben Nangombe, Ms Byanyima met with DREAMS girls and community care workers at the facility.

“I am very impressed by the confidence and optimism the young women express as a result of the support they receive through the DREAMS programme,” said Ms Johnson.

The DREAMS project seeks to reduce new HIV infections among adolescent girls and young women in Namibia and other countries in sub-Saharan Africa. In 2019, there were 1400 new HIV infections among adolescent girls and young women aged 15–24 years in Namibia—more than double the number of HIV infections among their male peers. It is therefore critical that the HIV response continues to gain momentum.

DREAMS uses a core package of evidence-informed, multisectoral interventions that are proven to reduce new HIV infections among adolescent girls and young women. This includes empowering them with social protection, safe spaces, education and economic skills and with access to family planning and sexual and reproductive health services.

“The knowledge I learnt from DREAMS has taught me about making the right decision. I feel empowered,” said Johanna Shinana, a DREAMS Ambassador.

DREAMS is implemented in five districts in three regions of Namibia and the Hakahana Clinic provides eight safe spaces for young women mostly between the ages of 19 and 24 years.

Ms Byanyima, together with Sheila Roseau, the Country Representative of the United Nations Population Fund (UNFPA), Aina Heita, the United Nations Educational, Scientific and Cultural Organization National Programme Officer for HIV/AIDS, and Thomas Ukola, the Deputy Director at the Directorate of Special Programmes within the Ministry of Health and Social Services, also visited the Namibia Planned Parenthood Association (NAPPA) clinic, which is also in Katutura.

NAPPA is a welfare organization established in 1996 to complement the Ministry of Health and Social Services to provide sexual and reproductive health services and information to young people aged 15‒24 years and lesbian, gay, bisexual, transgender and intersex people from the marginalized and underserved area around Katutura.

“I encourage young people to take advantage of the services that are offered for them and encourage others to take up these services,” said Ms Byanyima while she was at the NAPPA clinic.

Ms Byanyima was introduced to the Condomise Campaign at the clinic. The campaign, supported by UNFPA, is led by young people and provides young people with key messages on sexual and reproductive health and rights, HIV and skills on how to use condoms correctly.  

Klaivert Muandingi, the President of the African Youth and Adolescents Network in Namibia, called on young people to be free in accessing condoms and other commodities. “Condomize, do not compromise. Love smart and play safe,” he said.

The Gboklè/Nawa/San Pedro region is the second largest economic hub in Côte d’Ivoire and one of the regions most affected by the HIV epidemic. The region attracts many workers because of its important economic and industrial activities, mainly related to the port and agriculture, as well as sex workers and other members of key populations.

A joint United Nations Development Programme (UNDP)/UNAIDS mission to the region from 16 to 20 April learned about the realities of the HIV response in the region in the context of COVID-19 and assessed how the response takes into account the needs of the most vulnerable.

The mission first paid a courtesy call on the region’s administrative and health authorities, and then quickly focused on the sites where services are offered to people living with HIV and key populations. In the health-care facilities visited, whether at the Regional Hospital of San Pedro, above, or at the health centre of APROSAM (Association pour la Promotion de la Santé de la Femme, de la Mère et de l’Enfant) nongovernmental organization, the mission team saw the commitment and determination of the health-care teams and the administrations of the facilities. “We have set up a quality assurance team within the hospital to guarantee services centred on the needs of each patient,” said Alexandre Kissiedou, the Director of the Regional Hospital of San Pedro.

The visit to APROSAM was one of the most captivating moments of the mission. During the visit, the mission team had in-depth discussions with representatives of a dozen associations, who had come to APROSAM’s headquarters to meet the mission delegation. Useful discussions took place with representatives of associations of people living with HIV and associations representing key populations, as well as with representatives of nongovernmental organizations working with young people.

“It is the first time that civil society is honoured with the visit of the country representatives of two United Nations agencies,” said Odette Koffi, the Executive Director of APROSAM, an association involved in the response to HIV, tuberculosis and malaria in the region. She also noted that civil society is truly committed to the HIV response but lacks the means to meet the needs of all.

“Income-generating activities are no longer working as they used to. Today we can’t even feed ourselves properly and we can’t take antiretroviral medicines on an empty stomach,” said Maya Rose Nean, the head of the local CERBAS association for women living with HIV, when describing how COVID-19 had impacted women living with HIV in the country.

Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire, speaking on behalf of the delegation, underlined the vital work of nongovernmental organizations in the HIV response and praised the commitment of civil society organizations, people living with HIV and key populations. She said that a dialogue between UNDP and UNAIDS will address some of the pressing needs discussed with civil society. A donation of 400 food and hygiene kits was made by UNDP and UNAIDS to vulnerable people living with HIV and key populations.

The last day of the mission focused on human rights, with a visit to the Elan d’Amour reception centre, above, which offers temporary accommodation to people living with HIV and people who are victims of stigma, discrimination and gender-based violence, including people who come from remote areas for care and/or to collect their antiretroviral therapy. The delegation then visited a legal clinic supported by UNDP. These visits allowed the delegation to get a good understanding of the realities of human rights in the region, but also to understand their implications for specific HIV-related vulnerabilities. As a result of these two visits, the two agencies agreed to consider a joint project to better address HIV and human rights issues in the region.

For both teams, this mission was a success. The various needs identified will be the subject of concerted action either between UNDP and UNAIDS or by working with other Cosponsors that can provide relevant solutions.

Brigitte Quenum, the UNAIDS Country Director for Côte d’Ivoire, above left, met with the Prefect of the San Pedro department. 

Viral hepatitis infection is a major global public health problem causing approximately 1.4 million deaths per year—more than the annual number of AIDS-related deaths. Ninety-six per cent of these deaths are from cirrhosis and hepatocellular carcinoma due to hepatitis B and C viruses, which are transmitted via blood and body fluids.

People living with HIV and hepatitis B or hepatitis C coinfection have a more rapid progression to cirrhosis. Liver disease has emerged as an important cause of death among people living with HIV coinfected with either hepatitis B or hepatitis C.

Hepatitis C coinfection with HIV is reported across all key populations at higher risk of HIV, especially among people who inject drugs. This is due to the ease with which both viruses are spread through the sharing of non-sterile drug preparation and injecting equipment.

Representatives of all stakeholders in the AIDS response came together virtually on 23 April for the interactive multistakeholder hearing ahead of June’s United Nations High-Level Meeting on AIDS.

Those taking part included people living with, at risk of and affected by HIV, representatives of Member States, parliamentarians, and representatives of local governments, civil society organizations, philanthropic foundations, academia, medical associations, the private sector, and broader communities. The objective of the meeting was to support Member States with the preparations for the high-level meeting through an interactive dialogue with communities, civil society and other key stakeholders.

In his opening remarks, the President of the General Assembly, Volkan Bozkir, applauded activists for their work in reducing the impact of the HIV epidemic.

“Your participation here today is not taken for granted. I understand that many of you began advocating and organizing after experiencing loss, suffering, discrimination, and marginalization. I commend you for sharing your lived experience in order to create a better world for all. Your resilience is unmatched.”

In her address to the meeting, the Executive Director of UNAIDS, Winnie Byanyima, said that it was the loud and persistent voice of people living with HIV and the communities most affected by the epidemic that had accelerated progress against the virus. Ms. Byanyima also underlined that the HIV response was closely linked to social justice issues.

“The struggle to end AIDS is inextricably linked with the struggle to end human rights violations, including discrimination and violence against women and girls and the marginalization and criminalization of people living with HIV and of key populations—sex workers, people who use drugs, gay, bisexual and other men who have sex with men, and transgender people.”

Faith Ebere Onuh is a young woman who was born with HIV and a member of the Association of Positive Youth Living with HIV and AIDS in Nigeria (APYIN). When she was 14 years old Ms Ebere Onuh started educating other young people living with HIV about the importance of adhering to their HIV medication. She has become a mentor and a voice for the voiceless, speaking up for young people in Nigeria.

“As a young person, I have learned in my time living with HIV and working with my community that to reach the target of ending AIDS by 2030, we must work together, as a global community. While as various individual member states we may be making progress, globally we are still off track, and some regions like mine, West and Central Africa, continue to lag behind.”

Neville Gertze, Permanent Representative of Namibia to the United Nations and co-facilitator for the preparations for the 2021 High-Level Meeting on AIDS, said lessons learned in responding to HIV and COVID-19 could be leveraged to improve health systems.

“By taking on board lessons learned through HIV, fighting COVID-19 can aid in reimagining systems of health to accelerate the health-related commitments of the 2030 Agenda for Sustainable Development. At the same time the HIV experience helps to inform COVID-19 responses, the unfolding response to the COVID-19 pandemic will undoubtedly yield lessons that can benefit both the HIV response as well as broader efforts to strengthen health systems.” 

There were four panels during the day to consider the following areas of the HIV response.

1. Equitable and equal access to HIV prevention, treatment and services.

2. Structural and social barriers to achieving HIV outcomes (zero new HIV infections, zero discrimination and zero AIDS-related deaths).

3. How to fully resource and sustain efficient HIV responses and integrate them into systems for health, development, social protection, humanitarian settings and pandemic responses.

4. Bringing it together: building synergies and addressing critical gaps.

A summary report of the interactive multistakeholder hearing will be available on the  President of the General Assembly website prior to the United Nations High-Level Meeting on AIDS, which takes place from 8 to 10 June 2021.

There have been successes in the commitment to end vertical transmission of HIV (from mother to child). For example, in eastern and southern Africa, 95% of pregnant women living with HIV received antiretroviral therapy to prevent vertical transmission of HIV in 2019.

Such successes have not been universally seen, however. In western and central Africa, the picture is not so positive—coverage of services for the prevention of vertical transmission in the region is among the lowest in the world. In 2019, only 58% of pregnant women living with HIV in the region received antiretroviral therapy to prevent vertical transmission.