Only one third of gay men and other men who have sex with men know their HIV status in the Lao People’s Democratic Republic, partly because stigma and discrimination remains a barrier for accessing HIV testing in public hospitals and clinics. Complicated protocols, uneven and at times judgemental treatment by health providers and non-confidentiality of testing results further impact on HIV testing.

“Many of our friends are scared of getting an HIV test because they think the testing steps are challenging and often unfriendly,” said Phoulikhan Siphabouddy, a community-based supporter of LaoPHA, a Lao nongovernmental organization.

To address this, USAID supported the government and LaoPHA to pilot oral fluid screening in three provinces.

Most people assume that testing involves taking a blood sample. But oral fluid testing detects antibodies for HIV, not the virus itself. A test swab is gently wiped along a person’s upper and lower gums once, then the swab is placed inside a test tube containing a reagent. The result is known within 20 minutes.

Members of the community, so-called peer educators, train volunteers for the oral fluid screening. The screening is fast, easy and can be done anywhere.

Around 82% of people reached agreed to have an HIV test through oral fluid screening, compared to only 17% of referrals to clinics, according to the Ministry of Health.

“The new approach dramatically exceeded Laos’ HIV testing targets by more than 200%,” said Bounpheng Philavong, Director of the Lao Centre for HIV/AIDS and STI.

He, along with LaoPHA, are convinced that community-led services provide an enabling environment for key populations to access HIV services in a non-discriminatory manner. Linkages to care and support for people living with HIV has also improved for people who test positive, with the same community volunteers providing support for referral to trusted clinics.

Indigenous health worker Jijuké Hukanaru Karajá works as a nurse in the Indigenous Health District of Araguaia, named after one of Brazil’s major rivers located in the eastern Amazon basin. She has been working with indigenous peoples for many years and criss-crosses between Brazil’s cities and indigenous villages to provide crucial health services. Ms Karajá feels very proud to be a part of the Brazilian indigenous public health system, having followed in her father’s footsteps.

“I’ve worked in town and in my indigenous village with my own people, and it’s extremely gratifying to help them in this way,” she said.

Ms Karajá believes that being indigenous eases communication and cultural differences. HIV and syphilis prevalence remains low among indigenous peoples in Brazil, but she fears that growing interaction with nearby cities will change that.

Established in 2010, the indigenous health services deliver services to every indigenous community, regardless of their remoteness. An 800-strong team of doctors, nurses, health-care technicians, psychologists, advisers and indigenous health workers work tirelessly, covering huge distances. They carry out tests for HIV, syphilis and other sexually transmitted infections. According to Ms Karajá, indigenous communities welcome them.

“Testing always follows a series of talks and workshops in villages about prevention of HIV and other sexually transmitted infections, and so the whole process flows naturally,” she said. If anyone tests positive for HIV, immediate counselling is available. Importantly, in the scope of this unique system, all HIV response efforts incorporate cultural beliefs.

Over a decade ago, a groundbreaking project pioneered by Adele Benzaken, at the time a researcher at Fundação Alfredo da Matta in Manaus, received funding from the Bill & Melinda Gates Foundation to test more than 46 000 indigenous peoples within their own communities. Activities focused notably in Amazonas and Roraima, remote forested states that are home to more than half of the indigenous peoples in Brazil. Stopping gender-based violence and keeping children from being born with congenital syphilis and HIV were among their priorities.

“Before the project, this indigenous population had very little access to any kind of diagnosis, treatment and prevention,” remembers Ms Benzaken, who today runs the national STI, AIDS and Viral Hepatitis Department of the Ministry of Health in Brazil. “They were vulnerable and didn’t have access to programmes.”

In 2012, rapid testing became a public policy for Brazil’s indigenous and general population. In five years, rapid HIV test distribution to the 34 operating indigenous health districts almost tripled to 152 000 in 2017; syphilis rapid test distribution more than doubled to more than 65 000 in the same year.

By boat, road and foot, health workers travel across the vast territories to test, raise awareness and discuss preventive methods, such as condoms.

Brazil is home to almost 900 000 indigenous peoples, with indigenous lands representing more than 12% of the country. Altogether, the country has 305 ethnicities speaking 274 different languages. The largest ethic group among them are the Tikuna.

Vinicios Ancelmo Lizardo—or Pureenco, in his original Avaí indigenous name—works as a health worker mainly in the Amazon region. “To help my people, I have to help them understand what health really means to them,” he said. Before explaining HIV prevention to a group of Tikuna in their own language, he speaks to them about love, sex and freedom, and he makes them laugh by teaching them—with the help of a lifelike dildo—how a male condom should be used.

Mr Lizardo admits that breaking cultural barriers and building bridges between science and tradition is challenging. But he knows that as most indigenous communities can no longer stay isolated, they cannot be left behind.

Ireland has pledged €400 000 to UNAIDS for a project to provide HIV services for the most vulnerable populations in the United Republic of Tanzania, with the first tranche, €200 000, already received.  

“Through our development programmes, Ireland supports the most marginalised in society to access key services so that they can live with dignity. Ireland is pleased to collaborate with UNAIDS to improve the plight of populations that are in most need of timely HIV services,” said the Irish Ambassador to the United Republic of Tanzania, Paul Sherlock.

UNAIDS will work in close collaboration with the Ministry of Health, the Benjamin Mkapa Foundation and civil society organizations to address issues that hinder the most vulnerable populations from accessing HIV prevention, treatment and care in a timely manner. Support that UNAIDS will provide includes convening stakeholders, providing technical leadership and strategic guidance and ensuring participation and representation.

Stigma and discrimination, inequality and violence against women and girls and criminal and punitive laws that affect vulnerable populations remain among the major barriers to an effective response to HIV in the country.

The 18-month project will help its beneficiaries with legal literary skills, raise awareness on the right to health and address HIV-related stigma and discrimination.

Ireland is a long-standing partner of UNAIDS, providing US$ 2.56 million in core funding to UNAIDS in 2018.

“UNAIDS and Ireland share a goal of ensuring that the AIDS response leaves no one behind. The funding from Ireland offers us a timely opportunity to give the most vulnerable populations in the United Republic of Tanzania a chance to live in dignity and good health,” said Leopold Zekeng, UNAIDS Country Director, United Republic of Tanzania.

While Botswana has made excellent progress in achieving the UNAIDS 90–90–90 treatment targets, evidence shows it has experienced a 4% increase in new HIV infections from 2010 to 2017, from 13 000 to 14 000. This is against the backdrop of a massive 30% decrease in new HIV infections across the eastern and southern African region.

Adolescent girls and young women are particularly at risk of HIV infection, as well as unintended pregnancy and sexual and gender-based violence. In 2017 there were 1 500 new HIV infections among adolescent girls between the ages of 10 and 19 years, compared to fewer than 500 new infections among adolescent boys the same age.

As a result, Neo Masisi, the First Lady of Botswana, uses her voice to advocate for better health outcomes for adolescent girls and young women. In an effort to drive high-impact, age-appropriate and gender-sensitive interventions, she holds dialogues with adolescent girls and young women about their experiences.

On 9 December 2018, she hosted a post-World AIDS Day event attended by 100 adolescent girls and young women, to bring to light to issues they face on a daily basis—unintended pregnancy, gender-based violence, access to sexual and reproductive health rights and how these intersect with HIV. “I am concerned about how young people have not known a life without HIV and hence they are more vulnerable to social ills,” said Mrs Masisi.

During the dialogue, Richard Matlhare, a representative from the National AIDS Coordinating Agency, emphasised that “the five-year Botswana National Strategic Framework on HIV/AIDS provides a paradigm shift, which is a sector-specific strategy explicitly focusing on adolescent girls and young women and their male partners.”

Participants at the dialogue also previewed the Pan-African movie Faces, directed by Joseph Adesunloye and starring South African actress, Terry Pheto, who plays the character of Aisha, a woman who has to deal with HIV infection and gender-based violence.

Ms Pheto, who attended the dialogue, spoke about her role as an actress and influencer and how she aims “not simply to entertain, but also educate, adolescent girls and young women and men on HIV and gender-based violence.” She added that projects such as these are “very close to my home and heart.”

Key populations—gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs, prisoners and other incarcerated people and migrants—and their sexual partners account for 40% of new HIV infections in western and central Africa.

However, key populations still have insufficient access to HIV prevention, treatment and care services. Fragile health systems, stigma and discrimination, sexual and gender-based violence and lack of supportive policies are some of the barriers that key populations face.

While high-quality programmes for key populations do exist in western and central Africa, there are limited opportunities to learn from each other and to strengthen South–South capacity. Monitoring of commitments made by all stakeholders, including governments, is also an issue. Three regional meetings took place in November to address those shortcomings.

The West Africa Health Organisation (WAHO), the United Nations Development Programme and ENDA Santé, a civil society organization, in collaboration with UNAIDS, met in Dakar, Senegal. The meeting brought together representatives of national AIDS commissions or programmes from 14 Economic Community of West African States (ECOWAS) countries and members of the Africa key populations expert group to chart the process for the development of a regional strategy on HIV/tuberculosis and sexual and reproductive health and rights for key populations, scheduled to be finalized in early 2020.

In 2015, under the leadership of WAHO, and in collaboration with UNAIDS and USAID, ministers of health, heads of national AIDS commissions, public prosecutors and inspectors general of police of ECOWAS Member States signed the Dakar Declaration on Factoring Key Populations in the Response to HIV and AIDS in ECOWAS Member States. The declaration aims to better take into account key populations in the response to HIV in the ECOWAS region in core areas, including strengthening of strategic information, health systems and community services and addressing stigma and discrimination.

In November, WAHO, UNAIDS and USAID commissioned a review of the progress made against the declaration and organized a regional progress review workshop attended by country representatives of 13 countries. The declaration has created a significant momentum, coupled with a number of achievements, innovations and good practices at the country level.

Ending AIDS in West Africa, a five-year cooperative agreement funded by USAID and led by FHI 360 and its core partners, Johns Hopkins University and ENDA Santé, facilitated the fourth key population regional meeting in western Africa, in partnership with the Government of Togo and partners.

The meeting was a key opportunity to bring together members of key populations, government officials, donors, academics and representatives of implementing partners and United Nations agencies to share lessons learned and promising practices from implementation, relevant and novel research and programmatic data, and to build networks and platforms for technical exchange. Country delegates also formulated country action plans to improve the quality, efficiency and scale of HIV-related programmes for key populations.

“The more the response to HIV is multisectoral, multidisciplinary and inclusive, the more impactful results we will have,” said Vincent Palokinam Pitche, Coordinator of the Permanent Secretary of the National AIDS Commission in Togo.

“There is a need to support the collection and analysis of strategic information to guide efforts to facilitate access by key populations to prevention, care and treatment services, to intensify services that are evidence-informed and rights-based and to invest in programmes for an enabling legal and social environment,” said Christian Mouala, UNAIDS Country Director for Togo.

Despite the existence of human rights obligations and policy commitments, HIV-related stigma and discrimination continues to be widespread around the world and in all sectors of society.

Following a call from civil society in 2017 to accelerate and scale up action to address stigma and discrimination, UNAIDS, UN Women, the United Nations Development Programme and the Global Network of People Living with HIV (GNP+) agreed to co-convene the Global Partnership to Eliminate All Forms of HIV-Related Stigma and Discrimination.

The global partnership was launched on 10 December on the 70th anniversary of the adoption of the Universal Declaration of Human Rights, during an event in Geneva, Switzerland. The panel of people speaking at the event included Phanpob Plangprayoon, the Deputy Permanent Representative of Thailand to the United Nations Office and other International Organizations in Geneva, Dan Namarika, the Secretary for Health of Malawi, Raquel Duarte, the Deputy Minister of Health of Portugal, and Simran Shaikh, a community representative to the UNAIDS Programme Coordinating Board (PCB).

The panellists presented programmes that have proved to be effective in reducing HIV-related stigma and discrimination in the areas in which the global partnership will focus—health care, schools, the workplace, the family, justice systems and emergency and humanitarian settings.

“This partnership aims to translate Member States’ commitments into well-resourced programmes that are proved to work and that can result in the enjoyment of HIV-related rights for all,” said Michel Sidibé, Executive Director of UNAIDS.

“The Global Network of People Living with HIV is pleased to be a co-convenor of this critical and ground-breaking global partnership that seeks to transform our communities’ best strategies for addressing and measuring HIV-related stigma and discrimination into actionable and accountable global targets and goals,” said Javier Hourcade Bellocq, GNP+ Board Chair.

People living with HIV, adolescents, young people and key populations experience discrimination, including discrimination based on their gender and gender identity, race, ethnicity, age, drug use, sexual orientation and migration status. These added layers of stigma and discrimination increase their vulnerability to HIV and undermine their rights, including the right to health, work and education.

At the end of the event, the UNAIDS PCB nongovernmental organization delegation called on Cosponsors, Member States, civil society, key populations, communities and partners to join the global partnership and lead and support concrete country actions and investments to end HIV-related stigma and discrimination.

On World AIDS Day, South Africa launched a multidisease national wellness campaign to accelerate screening and testing for HIV, tuberculosis, sexually transmitted infections and noncommunicable diseases, including hypertension and diabetes. The campaign, known as Cheka Impilo, is a direct response to the call by the President of South Africa, Cyril Ramaphosa, during his first State of the Nation address in February 2018 to initiate an additional 2 million people on HIV treatment by 2020, find 88 000 missing tuberculosis cases annually and screen 7 million people for noncommunicable diseases in the first year.

South Africa has made considerable progress in its AIDS response in the past decade and reported that there were more than 4.5 million people on life-saving antiretroviral therapy by the end of June 2018—20% of all people on treatment worldwide. UNAIDS estimates show that as a result the number of AIDS-related deaths in South Africa has dropped significantly, from 200 000 in 2010 to 110 000 in 2017. However, there were 270 000 new HIV infections in 2017, including approximately 77 000 among adolescent girls and young women aged 15–24 years.

The then Acting President, Deputy President David Mabuza, who is also Chairperson of the South African National AIDS Council (SANAC), urged his fellow countrymen to end gender-based violence and get tested for HIV and seek treatment if HIV-positive. “We will not walk alone. We have always had partners like UNAIDS, the Global Fund and PEPFAR walking with us, side by side, shoulders to the grindstone. We know what unity and struggle is. We are not giving in and we are not turning back,” Mr Mabuza said.

Michel Sidibé, UNAIDS Executive Director, attended the commemoration of the 30th anniversary of World AIDS Day in South Africa to show his support for the launch of the campaign. “Oppression and power imbalances must be reversed. Women and girls must be empowered and harmful masculinities must be consigned to the history books. Our girls and young women deserve a chance to live in a world with dignity and respect and free from violence and HIV,” said Mr Sidibé.

Aaron Motsoaledi, Minister of Health of South Africa, thanked Mr Sidibé for inspiring South Africa almost a decade ago to turn its AIDS response into a success story, characterized by a journey from despair to hope, and from denial to acceptance and to ownership.

Steve Letsike, Deputy Chairperson of SANAC and Chairperson of the SANAC Civil Society Forum, said, “Enough is enough. Patriarchy, sexism, misogyny, homophobia, transphobia and stigma and discrimination must end. We can do better for our people because they matter.”

The First Lady of Chad, Hinda Déby Itno, has been appointed as the UNAIDS Special Ambassador for the Prevention of HIV and the Protection and Health of Adolescents by the Executive Director of UNAIDS, Michel Sidibé.

During the appointment ceremony, which took place on 21 November at the Presidential Palace in N’Djamena, Chad, Mr Sidibé highlighted the many initiatives that the First Lady had put in place as a member of the Organisation of African First Ladies against HIV/AIDS. He urged her to continue her leadership in the response to HIV in areas as diverse as the elimination of mother-to-child transmission of HIV, gender equality and access to sexual and reproductive health services. He also noted that the personal involvement of the First Lady had helped in the passing of a law promoting sexual and reproductive health issues and the outlawing of female genital mutilation.

“Every child deserves a life without HIV,” said Ms Itno.

During his two-day visit to Chad, Mr Sidibé also met with the President of Chad, Idriss Déby Itno, during which they spoke about health and HIV, the challenges of the response to HIV in the country and the role of African youth in the AIDS response.

Mr Sidibé also met with civil society in Chad, who he congratulated for the campaign to reduce of cost of HIV treatment in the country. Mr Sidibé said that civil society has a role to play in ensuring that the resources invested in the responses against malaria, tuberculosis and HIV are used efficiently, considering the shortage of such resources.

Pre-exposure prophylaxis (PrEP) is highly effective at preventing HIV infection when it is taken correctly—once a day during times when the likelihood of becoming infected with HIV is very high, or, for gay men and other men who have sex with men, before and after sexual activity, so-called event-driven PrEP.

Several western cities that offer PrEP have seen a drop in the number of diagnoses of HIV among gay men and other men who have sex with men, but overall PrEP access and uptake in Europe is not yet sufficient to affect the course of the HIV epidemic.

How to improve the delivery of PrEP was the subject of a two-day meeting in Stockholm, Sweden, held on 15 and 16 November entitled Pre-Exposure Prophylaxis in the EU/EEA: PrEP Service Delivery and Monitoring: Minimum Standards and Key Principles. Representatives of 22 European countries joined together with PrEP users and community HIV advocates to seek ways to strengthen the provision and monitoring of PrEP.

Gay men and other men who have sex with men are the most affected by HIV in Europe. PrEP users in Europe are almost all gay men and other men who have sex with men, but the vast majority do not have formal access to PrEP. Consequently, among those taking PrEP, many access it online and take it with no medical support and monitoring.  

PrEP is pre-exposure prophylaxis—the use of antiretroviral medicines to prevent HIV among people who are HIV-negative. 

The meeting heard how the offer of PrEP in friendly and accessible settings can attract people to HIV testing and for diagnosis and treatment of other sexually transmitted infections. Taking PrEP provision out of highly specialized centres, in consultation with communities of potential PrEP users, provides a gateway to broader health care. Innovative online approaches to improve PrEP self-management and sexually transmitted infection diagnosis and treatment were presented.

Maturing European PrEP programmes are leading on ways to achieve the equitable and rapid scale-up of PrEP that is needed for there to be an impact on the HIV epidemic. Decentralization of PrEP provision and integration with broader health services often has to be achieved without an increase in funding. Service providers are therefore looking for guidance on minimum safe standards for PrEP provision.

PrEP users and PrEP providers agreed that the patterns of PrEP use are evolving, with no clear distinction between daily and event-driven PrEP. Factors such as the ability to afford the next PrEP refill, and improved identification of times when there will be a high chance of acquiring HIV, are increasingly determining how PrEP is being taken. Incorrect PrEP taking can result in people becoming infected with HIV or lead to the development of resistance to the PrEP medicines. Therefore, the meeting participants called for guidelines on how to effectively stop and start PrEP and the HIV testing regimens to follow for this type of non-daily PrEP use to be safe.

Three actions were identified during the meeting. A consultation paper will be developed on essential and desirable components and principles of a decentralized PrEP programme, including safe non-daily use. A technical review of standardized monitoring will be drafted by the World Health Organization and the European Centre for Disease Prevention and Control. And all meeting attendees are being asked to give what details they can on pricing of PrEP medicines to governments and consumers, which will be shared between European HIV programmes in order to strengthen price negotiations.

UNAIDS is working with countries to ensure that the commitment in the 2016 United Nations Political Declaration on Ending AIDS to reach 3 million people with PrEP by 2020 is met.