The League of Cities of the Philippines (LCP) pledged to fast-track the AIDS response in the cities, by signing a partnership agreement with UNAIDS to reduce the number of new HIV infections in the country. The signing event took place on the fringe of the LCP’s 30th anniversary celebrations on 27 July 2018. More than 145 mayors and local representatives from cities attended the event, which included a gala dinner.

UNAIDS’ newly released report, Miles to go: closing gaps, breaking barriers, righting injustices, shows that the annual new infections have more than doubled in the Philippines in the past seven years to an estimated 12,000 in 2017. With a 174% increase since 2010, the Philippines is the country with the fastest growing HIV epidemic in the Asia and the Pacific region. New infections have now overtaken Thailand, Viet Nam and Myanmar, placing Philippines number 5 in terms of new infections in 2018 in the region. Cities and urban areas are particularly affected. Health authorities say that 70 cities, including the 17 cities in metro Manila, accounted for 80% of reported HIV cases in the country.

“The AIDS epidemic in the country is an issue that needs urgent action among local governments, especially since key populations at risk of infections reside mostly in the cities,” said Laarni L. Cayetano, National Chair of the League of Cities of the Philippines.

Most agreed that there is a need to scale-up services tailored to key populations that go beyond female sex workers.   More than 90% of new HIV infections are occurring among men who have sex with men (MSM) and transgender people (TG). Condom use among men who have sex with men and transgender people hovers at 50% and 37% respectively and HIV testing is low. Only 16% of MSM knew their HIV status in 2015.

Local governments in the Philippines have earmarked resources and started more innovative HIV prevention services. For example, Quezon City has opened three Sundown clinics (Klinikas) that provide rapid HIV testing and counseling in a non-stigmatizing environment for gay men, men who have sex with men and transgender people. The city has also increased its HIV funding nine times since 2012 and has been urging other provinces to follow suit.

“Philippines has a small window of opportunity to act fast and stop a major HIV epidemic from taking hold,” said Eamonn Murphy, UNAIDS Regional Director for the Asia and the Pacific. He added, “This commitment is achievable if cities where the epidemic is having a big impact take the lead.” He also reaffirmed UNAIDS commitment to work in close partnerships with national and local authorities to support their efforts to bring HIV infections under control and provide technical expertise in how best to invest funds and reach people.

For the National President of the League of Cities of the Philippines, Edgardo D. Pamintuan, time is of the essence.  “I strongly believe that if we effectively implement HIV response strategies in our localities though our partnership with UNAIDS, our efforts at the city level can make a significant impact in reaching the country’s targets,” he said.

A global coalition of more than 80 youth organizations working on HIV (the PACT), and Youth Voices Count (YVC) launched a poll to get a sense of what young people know about sexual reproductive health.

More than half of the 270,000 young people aged 10-24 from 21 countries who responded to the U-Report poll (54% of boys and young men, and 58% of girls and young women) sought HIV and other services at a health centre or clinic in the previous three months.  About 36% of young people aged 10-24 who did not seek services reported feeling uncomfortable visiting a health centre or clinic, and more than 28% of young people (both sexes) said they felt scared to seek services.

The poll with support from UNAIDS, UNICEF and UNFPA was complemented by an in-depth survey and interviews led by YVC, which showed that approximately 15% of those who accessed any sexual health services in the past 6 months experienced refusal or mistreatment because of their age, sexual orientation, gender identity or HIV status. And of those who felt mistreated because of their age, 55% identified as gay, bisexual, and 25% identified themselves as living with HIV. Further, 32% of young gay, bisexual men and other young men who have sex with men, and 50% of young transgender people, felt that they had been discriminated against because of their gender identity or sexual orientation. Finally,16% of young people who identified themselves as living with HIV said they had been mistreated because of their HIV status.

Although healthcare settings should be safe spaces for those receiving care, this is not the case. Policies and attitudes remain barriers to youth-friendly HIV and sexual and reproductive health services. Indeed, 37% of respondents who reported having visited a clinic were not willing to recommend doing so to their peers.

This year’s theme for International Youth Day is Safe Spaces for Youth, highlighting the need of young people for safe spaces to come together, hang out, and participate in decision making processes as well as freely express themselves. This includes in healthcare settings, which should be places of safety and refuge, free from stigma, maltreatment, and violence.

Every day, approximately 1600 young people are infected with HIV, while one young person dies of AIDS-related illnesses every 10 minutes. Young women aged 15-24 are particularly affected. In sub-Saharan Africa, young women are twice as likely to be infected with HIV as their male counterparts. And young key populations (including gay men and other men who have sex with men, bisexual people, transgender people, young sex workers and young people who inject drugs) are at a high risk of HIV around the world due to rights violations, discrimination, exclusion, criminalization and violence. Of the young people living with HIV globally, most do not know their status.

Download more slides like this from 2018 Global AIDS Update Miles to Go 

Some 18 months after the launch of the catch-up plan, the National AIDS Council (CNLS), the Ministry of Health and UNAIDS co-organized a workshop in Bangui, to take stock of the progress and the challenges to accelerate access to treatment for people living with HIV in the Central African Republic. The workshop also served as an opportunity to renew political commitment to the HIV response and to call for urgent action on prevention.

The Prime Minister of the Central African Republic, Simplice Mathieu Sarandji, opened the meeting with 80 stakeholders present, including members of government, civil society organisations, people living with HIV, members of key populations, as well as local governments, traditional and religious leaders.

Key areas of progress since the launch of the catch-up plan in January 2017 included the development of new policies to implement test and treat, and the increase in the number of people on HIV treatment from 25,000 in 2016 to 34,000 in June 2018. Community treatment groups have been delivering HIV treatment to people in remote and insecure regions such as the eastern town of Zemio. In addition, a community treatment observatory is helping monitor access to and quality of HIV care in Bangui.

However, there are miles to go. Less than 35% of people living with HIV in Central African Republic access treatment — this is among the lowest in sub-Saharan Africa. Challenges include an inadequate monitoring and evaluation system, a lack of effective supervision of facilities providing HIV services, limited community engagement to implement HIV testing and treatment, as well as limited financial commitments to reach treatment targets. Most agreed on the need to improve coordination.

As a result, participants identified priorities for the next six months to reach treatment targets for 2019. All stressed that communities, people living with HIV and key populations must be involved every step of the way. In addition, participants stressed the urgent need for increased domestic and donor funding.

A steering committee and technical working groups prepared the two-day workshop based on available data and on-the ground site visits. The groups included representatives from the Ministry of Health, CNLS, community organisations, people living with HIV, international NGOs such as Medécins Sans Frontières and the French Red Cross as well as UNICEF, UNFPA, WHO and UNAIDS.

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Thailand is starting to roll out pre-exposure prophylaxis (PrEP) for HIV prevention among key higher-risk groups in high burden provinces, scaling up PrEP pilot projects within the national health system. The announcement was made at the satellite session “Breaking barriers and building bridges toward sustainability of the AIDS response in South-East Asia” during the International AIDS Conference in Amsterdam, Netherlands.

At the session, Dr Panumard Yarnwaidsakul, Deputy Director-General of the Department of Disease Control, Ministry of Public Health, said that the country is moving from trials and demonstration projects to policy and practice. PrEP now is a core part of the combination prevention package in the national HIV response in the country. Mr Yarnwaidsakul added that Thailand is also in process of including PrEP provision as part of the benefits package under the country’s universal health coverage.

As with many countries in Asia and the Pacific, Thailand's epidemic is focused among gay men and other men who have sex with men, transgender people and people who use drugs. The representatives of the Thai government acknowledged that PrEP is cost-effective and is an innovative approach for people at substantial risk of HIV infection.

Randomized trials have demonstrated that PrEP can decrease HIV incidence among at-risk populations, including men who have sex with men and sero-discordant couples. It has been shown that offering PrEP can encourage more people at higher risk to attend HIV clinics, undergo HIV testing and access either PrEP or treatment depending on the test result.

In Thailand, the discussion about offering PrEP at scale started in 2010.

The satellite session learned from "The Princess PrEP", a successful key population-led PrEP initiative under the support of Her Royal Highness Princess Soamsawali and PEPFAR/ USAID LINKAGES Thailand project.This effort served as local evidence to support the development of PrEP roll-out, where key population-led health services are a critical component.

As a next step, the Ministry of Public Health aims to train health care workers and key population peer providers to deliver PrEP.

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Sitting on center stage, clutching a microphone, Chinmay Modi along with a dozen young people answered questions about HIV during an all-youth panel session at the Amsterdam 2018 AIDS conference.

The 25-year-old born with HIV described his struggle accessing services. "In India, sex is a big taboo. A 16-year-old cannot buy condoms for example and parents need to give consent to be tested for HIV." He said educating children and parents is key. His greatest desire involves pushing for specific youth-focused services.

Dany Stolbunov from Ukraine echoed that sentiment, saying "Nothing for us, without us." He said that in his region stigma and discrimination kept people from even accessing services. He bemoaned the fact that young people in Ukraine have limited information and are not seen as a priority.  

HIV FACTS

In 2017, there were approximately 250 000 new HIV infections and 38 000 AIDS-related deaths among adolescents and 1.8 million adolescents living with HIV globally.

Adolescent girls in sub-Saharan Africa are disproportionately affected by new HIV infections, making up 56% of new HIV infections among adolescents globally.

HIV is a leading cause of death among adolescents (10-19 years).

"We are ready to fight for our rights," he added, explaining that young people have a voice and want to use it.

Bruna Martinez strongly believes that broad sexual education discussing gender, health issues and pleasure would not only limit stigma, it would also make teenagers fear HIV less.

"HIV should not be in a vacuum," she said. "We are a generation that can discuss sex and that's a great thing; so give us the tools that tip things in our favor."

All agreed that teenagers and young people have the most at stake in ending the HIV epidemic. Their demand is clear: go beyond scholarships by empowering us.

Melodi Tamarzians, the Dutch youth ambassador for sexual and reproductive health and rights, said, "Do not tick the youth box by giving us a token position." In her view, to enable young people, adults need to invest in them and give them advisory roles.

AIDS 2018 prided itself on giving a greater space to young people in Amsterdam. Youth and junior investigators made up more than one-third of the submissions presented at the conference, according to the conference organizer, the International AIDS Society (IAS.) In addition, young people got the most scholarships than at any other conference. And the Global Village (a free admission space by the conference area) featured the largest space conceived of and run by young people. It included a snack area, a mini-indoor football field, a safe-space theater area and youth-led activities, and booths such as a radio recording area, a youth against AIDS t-shirt stand and even an exhibit about the vagina.

Ms Martinez volunteered and then worked with the Amsterdam Youth Force that mobilized and organized other young people to make the youth space their own. "At this conference, we showed everybody that we could deliver," she said.

She hopes that this meaningful youth presence will carry over. "It's important that we are not being catered to but rather that we are recognized," she said, her AIDS 2018 lanyard laden with pins and stickers. She sees her recent stint with the Youth Force as a way to change things. "There are still so many young people getting infected with HIV and dying. It means we are failing and the system is not working," Ms Martinez said. In her view, HIV policy has to also come from the ground upwards. She emphasized peer-to-peer education and valuing local knowledge. Standing in front of a huge 'Let's face HIV together' she said, "We speak the language of the young people and we know what we are living, so acknowledge us fully."

Worldwide every year, 12 million girls under the age of 18 years are married—that's equivalent to 23 girls every minute. Married too soon. Their personal growth, health and fundamental rights and freedoms denied. Gender inequalities and gender-based violence force thousands of girls into marriage and motherhood. Girls with no education are three times as likely to marry by the age of 18 years as those with a secondary or higher education. And girls who marry before they are 15 years old are 50% more likely to face physical or sexual violence from a partner.

Child marriage often means that girls find it difficult to negotiate safer sex with their husbands, who are commonly older and more sexually experienced, making the girls especially vulnerable to HIV and other sexually transmitted infections.

UNAIDS’ latest report, Miles to go, highlights the reality that adolescent girls and young women aged 15–24 years, particularly those from sub-Saharan Africa, are being left behind. Every week, more than 6600 adolescent girls and young women become newly infected with HIV, with sub-Saharan African women and girls bearing the brunt, accounting for one in four HIV infections in 2017 despite being just 10% of the population.

Girls Not Brides, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Ministry of Foreign Affairs of the Netherlands and UNAIDS hosted a panel discussion on the issue of child marriage at the International AIDS Conference in Amsterdam, Netherlands, bringing together panellists from across regions, sectors and generations. Monica Geingos, the First Lady of Namibia, was a special guest speaker.

When girls and women are empowered with rights and given equitable access to education, enabled to participate fully in the labour force and equitably represented in government and decision-making bodies, the benefits far outreach improving the lives of the individual woman. Their families, communities and countries thrive. Yet, more than 150 million girls will become child brides by 2030.

The panellists highlighted the need to tackle the underlining determinants behind both HIV and child marriage. They emphasized the need for a comprehensive multisectoral and resourced approach. Gender inequality and harmful social norms have to be challenged. The solutions, they said, include keeping girls in school, providing health services that serve young people’s needs and mobilizing families and communities, including men and boys.

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Antiretroviral stock-outs are a serious public health problem in the Latin America region and represent an important risk to the sustainability of the HIV response, according to participants at AIDS2018.

On July 26, a session titled Sustainability of the response to HIV in Latin America; factors that impact access to drugs and health supplies addressed and analyzed the magnitude, the structural causes and the impact of stock-outs on the sustainability of the HIV response in Latin America. Participants discussed strategies to pave the way forward and highlighted best practices on joint purchases of antiretroviral (ARV) treatment like the PAHO/OMS strategic fund, which has helped prevent stock-outs.

In Latin America, one of the most important achievements in the HIV response has been the recognition that accessing HIV treatment is part of the right to health in the public health system, resulting in an increased number of people receiving antiretroviral treatment in recent years. However, a major challenge to fulfill the right to health is to guarantee uninterrupted supplies of ARV drugs and other essential health commodities.

According to the Pan American Health Organization (PAHO), in 2012 45% of the countries reported at least one stock-out episode; the figure had been 54% in 2010. Although some improvements are seen from 2010 to 2012, the region is still experiencing a high frequency of stock-outs.

Shortages of ARVs and other essential supplies result in changes and interruptions in patient treatment, threaten the lives of people with HIV and hamper the reduction of new HIV infections and AIDS-related deaths.

Participants at the session stressed the need for greater health system strengthening and joint procurement processes, including the incorporation of TRIPS flexibilities to reduce ARV costs, aligned with policies for simplified treatment regimens. According to participants, all these factors are essential to prevent and respond to stock-outs of ARVs and medical supplies.

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Maria Godlevskaya, a courageous community activist living with HIV from the Eastern Europe and Central Asia region, was the only Russian language speaker at the opening of the 22nd International AIDS Conference, AIDS2018. 

"We all deserve high-quality treatment, regardless of sexual orientation, beliefs and religious preferences. We all deserve a quality life with HIV and without it. For many people, stigma and discrimination remain the main barriers to access support to preserve their health and the health of their loved ones." said Maria Godlevskaya in her opening remarks at AIDS2018. "I believe in the community. As an indestructible link in the chain of resistance, I have defended, defend and will defend the rights of people living with HIV to have full quality of life and a high standard of living. I encourage everyone to support our campaign "Chase the virus, not people!" #chasethevirusnotpeople

Maria has been living with HIV for over 18 years. She openly speaks about her HIV status on television and openly shares her personal story with journalists. Maria leads a team of peer counselors and runs a video blog at E.V.A. - the first Russian network to support women affected by HIV. She shares her personal experience and disseminates the latest HIV news and information with people affected by the epidemic across Russia every day.

"Some people call me and others reach out to me via social media. I try to respond to every request. I think my life has changed dramatically and now I have found my purpose in life. It is priceless to be able to communicate with people around the world.”

Maria was diagnosed with HIV when she was 16 years old. "When you are 16, there is no panic. You are not frightened by horror stories about AIDS and not bound by social rules, so it was not hard for me to accept my HIV diagnosis. I was more worried about my mother. My diagnosis was like litmus paper - people who were afraid of HIV abandoned me, but the most trusted ones have remained forever.”

Maria has been working for different HIV organizations for many years, starting with providing counselling for people who were using drugs and living with HIV. "At that time there were no well developed communities to support people who use drugs. We helped those in remission to start treatment and stay adherent to treatment."

A few years ago, Maria became pregnant and gave a birth to a healthy baby. "When I met the father of my child, I immediately told him about my "peculiarity” and left him to choose to stay with me. And he gave me a beautiful answer: ‘Every person has something special’ he said.  So we stayed together, and he remained HIV negative.”

I stayed on HIV treatment throughout and after my pregnancy, and I was lucky to have a great relationship with my doctor. My pregnancy and birth is now an example for other women living with HIV. Today I get lots of questions from young Russian women about pregnancy, health care, obstetrical care for women with HIV, so I can share with them my positive experience.”

Maria’s organization, E.V.A. implements many projects in Saint Petersburg and across Russia, focused on providing HIV services for women and their families: support groups for women living with HIV and their families; trainings to increase medical literacy among people living with HIV, and help for women to communicate and negotiate with their doctors and care givers.

"Our trainings help women to adhere to treatment, minimize side effects, and manage undesirable consequences. We empower women to enhance their physical condition as they get used to taking ART long-term. We also support peer consellors so they can provide other women with moral and psychological support.”

Maria considers the main challenge of the growing HIV epidemic among women in Russia is that women have received little sexual education, lack a culture of safe and equal sexual relations and experience irregular monitoring of their HIV status. Many women simply do not identify themselves with any key population, and consider that having one regular sexual partner will safeguard their health. 

"Now we are seeing so many new HIV infections among women over the age of 50 - which brings new challenges as how to support these women. When a woman in her thirties learns her HIV positive status, she may understand how she acquired it. But women in their fifties or sixties are often shocked to learn they have HIV and they often think that their lives are over. In such cases, peer counsellors are so important because they can answer practical questions from their own personal experience.”

“I have a clear set of goals: I know why I'm doing what I do, and I have the energy and strength. I try to set real goals and don’t try to save the whole world – I’m just supporting those who really need help.”

As the dark monsoon clouds give way for the sun, yellowish crimson rays fall on Ambika’s face. She squints and continues to intently inspect the lush green lettuce she is growing in her backyard. The 17-year-old is living with HIV and lost both her parents to AIDS. With a glint in her eyes and a perpetual smile, she casually mentions that she likes to run in the mornings. Later, her coach proudly reveals that she is a 10-kilometre runner and is preparing to participate in the next Durban Marathon. Her friends Ashwini and Bhawani, aged 18 and 16 years, both living with HIV and 10 km runners themselves, proudly mention that, “Ambika won the Bangalore Ultra run. It was 12.5 km!”

These young women are a part of an initiative called Champion in Me that uses sport to respond to stigma and discrimination against adolescents living with HIV. Based in Bangalore, the programme uses running as a medium to empower them and strengthen their belief in themselves. Today, almost 200 children living with HIV are part of the programme, and it continues to expand. They live as a family together in the premises of Snehagram, an organization located in Tamil Nadu. Aimed at meeting the needs of adolescents living with HIV, the programme provides long- and short-term opportunities for academic learning and vocational skill development.

Manik and Babu, both 18 years old, are part of Champion in Me. They have participated in more than 20 runs, including at events such as the International Children’s Games in the Netherlands, the IDBI Marathon in New Delhi and the Boston Marathon. Their journey, challenges and experiences have been documented in Running Positive, a film screened at the International AIDS Conference, being held in in Amsterdam, Netherlands, from 23 to 27 July.

Manik said, “This film will motivate you to question the conventional image of an HIV-positive individual in India and the treatment meted out to them.” Babu explains that the film sheds light on how sports can be used to mainstream a segment of society that is vulnerable and discriminated against. 

Their elated coach, Elvis Joseph, said, “I have champions who are running not just for themselves, but for all their friends who are living with HIV.”

“These young people living with HIV have inspired all of us. They have now documented their lives in this touching movie,” said Bilali Camara, UNAIDS Country Director for India.

Estimating how many people living with HIV are on treatment is vital to keeping track of the success or otherwise of the global AIDS response. HIV treatment not only keeps people alive, but, through reducing the viral load of a person, greatly reduces the chance that a person living with HIV will transmit the virus to someone else.

UNAIDS published its latest estimates of the number of people living with HIV accessing antiretroviral therapy in its new report, Miles to go. An estimated 21.7 million [19.1–22.6 million] people of the 36.9 million [31.1–43.9 million] people living with HIV at the end of 2017 were on HIV treatment.

A total of 143 countries submitted the data that UNAIDS used to compile the estimate, representing 91% of all people estimated to be on treatment worldwide. Those 143 countries supply actual counts of people on treatment, not estimates, although estimates are used for those few countries that do not supply counts. Countries report their numbers of people on treatment—both adults and children, disaggregated by sex—through the Global AIDS Monitoring tool every six months. Similar data are included in the Spectrum epidemiological estimation software.

UNAIDS provides technical assistance and training to public health officials and clinical officers—the people who compile the numbers in the countries—to ensure that their reports on treatment coverage are accurate. In addition, every year, in partnership with the United Nations Children’s Fund, the World Health Organization and other partners that support the delivery of HIV treatment services, UNAIDS reviews and validates the treatment numbers reported through both the Global AIDS Monitoring tool and Spectrum.

When UNAIDS’ estimates of treatment coverage in countries are compared with estimates of treatment coverage made in Population-Based HIV Impact Assessments (PHIA) and other surveys, similar levels of treatment coverage are seen (see the attached graph).

In 2017, UNAIDS carried out a triangulation of data as a way to confirm or deny the results of its annual data collection. That analysis sought to answer a simple question: are enough antiretroviral medicines produced and bought to treat the number of people reported to be on antiretroviral therapy?

At the end of 2016, 19.4 million people globally were on antiretroviral therapy, with an estimated 14.1 million people accessing treatment in generic-accessible low- and middle-income countries.

A study of the exports and domestic procurement of antiretroviral medicines in 2016 from India showed 11.4 million person-years of treatment. When the generic antiretroviral medicines produced in other countries were included, an estimate of 14.2 million–16.2 million person-years on treatment was made—sufficient to treat the 14.1 million people in generic-accessible low- and middle-income countries.

In 2018, UNAIDS partnered with the World Health Organization, the Global Fund to Fight AIDS, Tuberculosis and Malaria and selected technical partners and ministries of health in 28 countries, most of which are in sub-Saharan Africa, to conduct data quality reviews of reported treatment numbers and, where over- or undercounting is found, to correct current and historical reports of treatment numbers. Previous data quality reviews since 2016 have been used to adjust estimates, for example by taking into account people who transfer from one clinic to another, but are reported by both clinics, or people who have died, left care or emigrated but are not identified and removed from treatment registries.

More details on the methods for calculating the number of people on treatment can be found in the annex on the methods in Miles to go, while details of how the triangulation was undertaken can be found in a publication published on an earlier triangulation exercise.