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UNAIDS Outlook 2010
1. OUTLOOK
UNAIDS OutlOOk RepORt | 2010
The A To Z of
universAl
Access
Where does
The money for
AIDS go?
ThaT was Then.
This is now!
in my Words: The LAST
hiv prevenTion, wOrD from
4 people, 4 sTories michel sidibÉ
A DAY
IN THE LIFE
prudence mAbele shAres her sTory
pAge 18
3. Thobani Ncapayi, from Khayelitsha, Cape Town,
is HIV-positive and receiving treatment. “Now I
feel like everybody else. I am not thinking all the
time about HIV. I do not bury my dreams”,
he says.
4. CONTENTS UNAIDS OutlOOk RepORt | 2010
IN wOrDS
What We are thinking | 05
38
epidemic OVerVieW | 07
Get the latest statistics globally and regionally.
anatOmy Of a Bad LaW | 12
A light-hearted look at the serious issue of how bad laws
can hamper HIV treatment and prevention efforts.
Being the change | 16
What is the future of AIDS? Tackling issues surrounding
young people, sexuality and how the behaviours of adults and
28 young people are changing.
treatment caSe StUdy: the gLOBaL fUnd | 22
ideaS LaB | 28
Innovations in the AIDS response. Putting ideas to work.
See what is happening around the world in HIV prevention,
treatment and care efforts.
08
IN PICTUrES
the harSh diVide | 01
AIDS treatment in Africa
UnaidS’ nine priOrity areaS | 14
Inspired by the UNAIDS Outcome Framework, Outlook
puts in pictures nine priority areas.
chiLdren BOrn Of hOpe | 30
A woman in Viet Nam shares her family photo album
as she gets ready to deliver her second child.
31 14
29
2 | Outlook Report | www.unaids.org
6. >
“PeoPle living wiTh hiv should noT be discriminaTed
againsT, including Through resTricTions on Their
abiliTy To Travel beTween counTries. ThaT They are
should fill us all wiTh shame.
…i call on all governmenTs To review Their legal
frameworks To ensure comPliance wiTh The human
righTs PrinciPles on which a sound aids resPonse
is based. This is noT solely a medical or scienTific
challenge. iT is a moral challenge, Too. leT us find
The wisdom and courage for bold acTion on all
These fronTs. ThaT is The only way To address This
challenge in all iTs comPlexiTy and breadTh.”
uniTed naTions secreTary-general ban ki-moon
>
The uniTed sTaTes recenTly joined a growing number
of counTries in removing hiv-relaTed Travel
resTricTions.
unaids esTimaTes ThaT nearly 60 counTries imPose
some form of Travel resTricTions on PeoPle living
wiTh hiv. The inTernaTional guidelines on hiv/aids
and human righTs sTaTe ThaT any resTricTion on
liberTy of movemenT or choice of residence based
on susPecTed or real hiv sTaTus alone, including
hiv screening of inTernaTional Travellers, is
discriminaTory.
>
4 | Outlook Report | www.unaids.org
7. What We Are Thinking
TOwArDS UNIVErSAL ACCESS
South Africa, home to the largest number of people living with HIV, will launch
on World AIDS Day 2009 a major mobilization campaign towards achieving Here are some key statistics for the
its universal access goals. President Zuma has committed the government to year 2008:
achieving 80% coverage for antiretroviral therapy and to cutting new HIV
infections by half. This reinvigorated commitment has the potential to reshape
the face of the epidemic. Many other countries are also reviewing their national
responses to AIDS, fine-tuning their strategies for scaling up access to HIV NEw INFECTIONS PEr DAY
prevention, treatment, care and support. (Read excerpts of President Zuma’s children 1200 w
speech on page 11.)
young people 2500 w
EACH SMALL STEP COUNTS Adults 3700 w
Human rights and dignity for the voiceless have gained the upper hand in many
places. The Supreme Court of Indonesia has ruled that drug users need treatment, NEw HIV INFECTIONS
not jail. The Delhi High Court in India restored dignity to men who have sex with
men by reading down a 150-year-old law that criminalized consensual adult sexual children 430,000 w
behaviour. El Salvador promulgated a ministerial decree banning discrimination young people 910,000 w
based on sexual orientation. The United States of America has removed restrictions Adults 1,360,000 w
on people living with HIV entering the country. And sex workers in Kolkata, India,
are running more than a dozen non-formal education centres and two boarding
homes for children of sex workers to continue their education. PEOPLE LIVING wITH HIV
children 2,100,000 v
EACH bOLD IDEA COUNTS
UNAIDS believes that the virtual elimination of mother-to-child transmission of
young people 12,500,000 v
HIV can be achieved by 2015. In Botswana, Namibia and Swaziland, more than Adults 18,800,000 v
90% of all HIV-infected pregnant women already receive antiretroviral prophylaxis
for preventing their babies from being born with the virus. Universal access targets
for antiretroviral therapy are being met in many countries, including Zambia. The
AIDS-rELATED DEATHS
integration of tuberculosis and HIV services in South Africa has helped to save the children 280,000 w
lives of many people and has reduced the tuberculosis burden. Adults 1,700,000 v
The demand for AIDS treatment should become an opportunity for Africa to
reform its pharmaceutical practices. A single African drug agency has the potential rESOUrCES AVAILAbLE (US$)
to guarantee quality medicines, integrate the African market for drugs and invite
private sector investment in the continent. And it can be a model for wider multilateral odA 2.1 billion v
development that will contribute to an AIDS+MDG movement in Africa. bilateral odA 5.7 billion v
The Thailand vaccine trial has shown that a vaccine against HIV will be available one domestic 7.2 billion v
day. When that day comes, it must be financed as a public good, accessible by all. philanthropic 0.7 billion v
AIDS IS COMING OUT OF ISOLATION
For all its uniqueness, AIDS cannot be left in a silo. Recent evidence shows that
HIV may have a significant impact on maternal mortality. Research models
estimate that about 50 000 maternal deaths were associated with HIV in 2008. The
two programmes, maternal child health and HIV, must work in synergy to achieve
their common goal—saving mothers and babies. We must link our progress in
AIDS to the other Millennium Development Goals and pursue a bold strategy that
will take us to 2015 and beyond.
In This Issue
In this first issue UNAIDS Outlook Report explores new ideas and ways to use the
data collected in the AIDS Epidemic Update companion report.
It’s clear that the HIV epidemic the world faces today is not the same as when
it was at its peak in 1996. The number of people living with HIV has continued to
grow, albeit less rapidly. The way we respond today needs to keep pace with and
overtake the epidemic if we are to see a real change in people’s lives, aspirations
and futures.
www.unaids.org | Outlook Report | 5
8. DID YOU KNOW?
Facts from the 2009 AIDS Epidemic Update
V, AIDS, treAtment, preVentIon, cAre, Support, people lIVIng wItH HIV, HumAn rIgHtS, genDer, SexuAlIty, teStIng AnD counSellIng, ScIence,
eSeArcH, SexuAl HeAltH, reproDuctIVe HeAltH, StIgmA, DIScrImInAtIon, orpHAnS, cHIlDren, mobIle populAtIonS, eDucAtIon, refugeeS, Sex
orkerS, clIentS of Sex workerS, Home bASeD cAre, pAllIAtIVe cAre, pSycHoSocIAl Support, nutrItIon, fooD SecurIty, conDomS, eDucAtIon,
accine, social change, universal precautions, blood safety, coinfection, tb/hiv, travel restrictions ВИЧ, СПИД, леЧенИе, ПрофИлактИка,
хоД И ПоДДержка люДей, жИВущИх С ВИЧ, ПраВа ЧелоВека, генДер, СекСуальная орИентацИя, конСультИроВанИе И теСтИроВанИе, науЧные
ССлеДоВанИя, СекСуальное зДороВье, реПроДуктИВное зДороВье, СтИгма, ДИСкрИмИнацИя, СИроты, ДетИ, мобИльные груППы наСеленИя,
бразоВанИе, беженцы, работнИкИ СекС-бИзнеСа, клИенты работнИкоВ СекС-бИзнеСа, ухоД на Дому, ПаллИатИВный ухоД, ПСИхоСоцИальная
оДДержка, ПИтанИе, ПроДоВольСтВенная безоПаСноСть, ПрезерВатИВы, образоВанИе, ВакцИна, СоцИальне ИзмененИя, унИВерСальные
еры ПреДоСторожноСтИ, безоПаСноСть кроВИ, ко-ИнфекцИИ, тб / ВИЧ, огранИЧенИя на ПоезДкИ vih, sida, tratamiento, prevención, atención,
poyo, personas que viven con el vih, derechos humanos, género, sexualidad, asesoramiento y pruebas del vih, ciencia, investigación,
alud sexual, salud reproductiva, estigma, discriminación, huérfanos, niños, poblaciones móviles, educación, refugiados, profesionales
el sexo y sus clientes, atención domiciliaria, cuidados paliativos, apoyo psicosocial, nutrición, seguridad alimentaria, preservativos,
acunas, cambio social, precauciones universales, seguridad de la sangre, coinfección, tuberculosis/vih, restricciones de viaje vih, sida,
rAItement, préVentIon, SoInS, SoutIen, perSonneS VIVAnt AVec le VIH, DroItS De l’Homme, SexoSpécIfIcIté, SexuAlIté, DépIStAge et conSeIl,
cIence, recHercHe, SAnté Sexuelle, SAnté généSIque, StIgmAtISAtIon, DIScrImInAtIon, orpHelInS, enfAntS, populAtIonS mobIleS, éDucAtIon,
éfugIéS, profeSSIonnel(le)S Du Sexe, clIentS DeS profeSSIonnel(le)S Du Sexe, SoInS à DomIcIle, SoInS pAllIAtIfS, SoutIen pSycHoSocIAl,
utrItIon, SécurIté AlImentAIre, préSerVAtIfS, éDucAtIon, VAccIn, cHAngement SocIAl, précAutIonS unIVerSelleS, SécurIté trAnSfuSIonnelle,
o-infection tuberculose / vih, restrictions aux voyages hiv, aids, treatment, prevention, care, support, people living with hiv, human rights,
enDer, SexuAlIty, teStIng AnD counSellIng, ScIence, reSeArcH, SexuAl HeAltH, reproDuctIVe HeAltH, StIgmA, DIScrImInAtIon, orpHAnS,
HIlDren, mobIle populAtIonS, eDucAtIon, refugeeS, Sex workerS, clIentS of Sex workerS, Home bASeD cAre, pAllIAtIVe cAre, pSycHoSocIAl
upport, nutrItIon, fooD SecurIty, conDomS, eDucAtIon, VAccIne, SocIAl cHAnge, unIVerSAl precAutIonS, blooD SAfety, coInfectIon, tb/HIV,
ravel restrictions ВИЧ, СПИД, леЧенИе, ПрофИлактИка, ухоД И ПоДДержка люДей, жИВущИх С ВИЧ, ПраВа ЧелоВека, генДер, СекСуальная
рИентацИя, конСультИроВанИе И теСтИроВанИе, науЧные ИССлеДоВанИя, СекСуальное зДороВье, реПроДуктИВное зДороВье, СтИгма,
ИСкрИмИнацИя, СИроты, ДетИ, мобИльные груППы наСеленИя, образоВанИе, беженцы, работнИкИ СекС-бИзнеСа, клИенты работнИкоВ СекС-
ИзнеСа, ухоД на Дому, ПаллИатИВный ухоД, ПСИхоСоцИальная ПоДДержка, ПИтанИе, ПроДоВольСтВенная безоПаСноСть, ПрезерВатИВы,
бразоВанИе, ВакцИна, СоцИальне ИзмененИя, унИВерСальные меры ПреДоСторожноСтИ, безоПаСноСть кроВИ, ко-ИнфекцИИ, тб / ВИЧ,
гранИЧенИя на ПоезДкИ vih, sida, tratamiento, prevención, atención, apoyo, personas que viven con el vih, derechos humanos, género,
exualidad, asesoramiento y pruebas del vih, ciencia, investigación, salud sexual, salud reproductiva, estigma, discriminación, huérfanos,
ños, poblaciones móviles, educación, refugiados, profesionales del sexo y sus clientes, atención domiciliaria, cuidados paliativos,
poyo psicosocial, nutrición, seguridad alimentaria, preservativos, vacunas, cambio social, precauciones universales, seguridad de la
angre, coinfección, tuberculosis/vih, restricciones de viaje vih, sida, traitement, prévention, soins, soutien, personnes vivant avec le vih,
roItS De l’Homme, SexoSpécIfIcIté, SexuAlIté, DépIStAge et conSeIl, ScIence, recHercHe, SAnté Sexuelle, SAnté généSIque, StIgmAtISAtIon,
ScrImInAtIon, orpHelInS, enfAntS, populAtIonS mobIleS, éDucAtIon, réfugIéS, profeSSIonnel(le)S Du Sexe, clIentS DeS profeSSIonnel(le)
Du Sexe, SoInS à DomIcIle, SoInS pAllIAtIfS, SoutIen pSycHoSocIAl, nutrItIon, SécurIté AlImentAIre, préSerVAtIfS, éDucAtIon, VAccIn,
hangement social, précautions universelles, sécurité transfusionnelle, co-infection tuberculose / vih, restrictions aux voyages
CAMbODIA PAPUA NEw GUINEA USA
The age difference between spouses Between 2007 and 2008, the number In the United States, the rate of new
in Cambodia correlates positively of people over the age of 15 who HIV infections among men who
with a woman’s increased risk of received HIV testing and counsel- have sex with men has steadily in-
HIV infection. ing in Papua New Guinea went up creased since the early 1990s, rising
approximately fourfold. by more than 50% in 1996–2009.
KENYA
In 2007, HIV prevalence among un- EGYPT i NETHErLANDS
circumcised men in Kenya was more In Egypt, 6.2% of reported AIDS The Netherlands reported no new
than three times higher than among cases are due to receipt of blood HIV infections due to mother-to-
men who were circumcised. products, while 12% come from child transmission in 2007.
renal dialysis.
rUSSIA CHINA
In the Russian Federation studies CHILE In China, estimated HIV prevalence
indicate that more than 30% of sex A five-clinic survey of female sex among injecting drug users ranges
workers have injected drugs. workers in Santiago, Chile, detected from 6.7% to 13.4%.
no HIV infections. Sex workers
reported always using condoms with
clients; however, consistent condom
use with steady partners was rare.
6 | Outlook Report | www.unaids.org
9. Epi
dEmic
[ ]
The following are excerpts from the 2009 AIDS
Epidemic Update, which reports on the latest
developments in the global AIDS epidemic. With
OvEr
maps and regional summaries, the 2009 edition
provides the most recent estimates of the epidemic’s
scope and human toll and explores new trends in
the epidemic’s evolution.
viEw
The number of people living with HIV world- sub-Saharan Africa is generating consider- CArIbbEAN
wide continued to grow in 2008, reaching able public health gains. Yet sub-Saharan The Caribbean has been more heavily
an estimated 33.4 million (31.1 million–35.8 Africa’s epidemic continues to outpace the affected by HIV than any region outside
million). The continuing rise in the popula- response. Preserving the long-term viability sub-Saharan Africa, with the second highest
tion of people living with HIV reflects the of treatment programmes and mitigating level of adult HIV prevalence. AIDS-related
combined effects of continued high rates of the epidemic’s impact in the region requires illnesses were the fourth leading cause of
new HIV infections and the beneficial impact immediate steps to elevate the priority given death among Caribbean women in 2004
of antiretroviral therapy. Globally, the spread to HIV prevention and to match prevention and the fifth leading cause of death among
of HIV appears to have peaked in 1996, strategies with actual needs. Caribbean men. Heterosexual transmission,
when 3.5 million (3.2 million–3.8 million) often tied to sex work, is the primary source
new HIV infections occurred. In 2008, the ASIA of HIV transmission, although emerging
estimated number of new HIV infections was Asia is home to 60% of the world’s popula- evidence indicates that substantial transmis-
2.7 million (2.4 million–3.0 million). tion and is second only to sub-Saharan Africa sion is also occurring among men who have
The epidemic appears to have stabilized in in terms of the number of people living with sex with men.
most regions, although prevalence continues HIV. Asia’s epidemic has long been concen-
to increase in Eastern Europe and Central trated in specific populations, namely inject- LATIN AMErICA
Asia, due to a high rate of new HIV infec- ing drug users, sex workers and their clients, With a regional HIV prevalence of 0.6%,
tions. Sub-Saharan Africa remains the most and men who have sex with men. However, Latin America is primarily home to low-level
heavily affected region, accounting for 71% of the epidemic in many parts of Asia is steadily and concentrated epidemics. Men who have
all new HIV infections in 2008. The resur- expanding into lower-risk populations sex with men account for the largest share of
gence of the epidemic among men who have through transmission to the sexual partners infections in Latin America, although there
sex with men in high-income countries is in- of those most at risk. In China, where the is a notable burden of infection among inject-
creasingly well-documented. Differences are epidemic was previously driven by transmis- ing drug users, sex workers and the clients
apparent in all regions, with some national sion during injecting drug use, heterosexual of sex workers. But only a small fraction
epidemics continuing to expand even as the transmission has become the predominant of HIV prevention spending in the region
overall regional HIV incidence stabilizes. mode of HIV transmission. supports prevention programmes specifi-
AIDS-related deaths appear to have peaked cally focused on these populations. The HIV
burden appears to be growing among women
in 2004. The estimated number of AIDS- EASTErN EUrOPE AND in Central America.
related deaths in 2008 is 2 million CENTrAL ASIA
(1.7 million–2.4 million). Eastern Europe and Central Asia is the only NOrTH AMErICA AND
An estimated 430 000 new HIV infections region where HIV prevalence clearly remains wESTErN AND CENTrAL EUrOPE
(240 000–610 000) occurred among children on the rise. Injecting drug use remains the Progress in reducing the number of new HIV
under the age of 15 in 2008. Most of these primary route of transmission in the region. infections has stalled in North America and
new infections are believed to stem from In many countries, drug users frequently Western and Central Europe. Between 2000
transmission in utero, during delivery or engage in sex work, magnifying the risk of and 2007, the rate of newly reported cases of
post-partum as a result of breastfeeding. transmission. With increasing transmission HIV infection in Europe nearly doubled. In
among the sexual partners of drug users, 2008, the Centers for Disease Control and
SUb-SAHArAN AFrICA many countries in the region are experienc- Prevention (USA) estimated that annual HIV
The epidemic continues to have an enor- ing a transition from an epidemic that is incidence has remained relatively stable in
mous impact on households, communities, heavily concentrated among drug users to the USA since the early 1990s, although the
businesses, public services and national one that is increasingly characterized by annual number of new HIV infections in
economies in the region. However, the significant sexual transmission. 2006 was approximately 40% greater than
rapid scaling-up of antiretroviral therapy in previously estimated.
www.unaids.org | Outlook Report | 7
10. THAT wAS THEN.
THIS IS NOw!
tion programmes be focused? And what
should HIV programming consist of?
NEw DATA FrOM THE 2009 AIDS epIDemIc Experience from various countries
upDAte SHOwS US THAT wE HAVE TO bECOME
clearly indicates that HIV prevention
programmes work when we do the
SMArTEr AbOUT HIV PrEVENTION IF wE wANT following:
• Better understand populations at
TO MAKE A rEAL DIFFErENCE. higher risk;
• Address contextual factors;
• Saturate high-burden areas as
W
ith an estimated 2.7 million prevention programmes on the evidence a priority;
new HIV infections worldwide they find. This model is also proving • Increase investments for HIV
prevention and sustain them
and five new people becoming helpful in detecting dissonance between
over time.
infected for every two put on antiretro- where the infections are occurring, for
viral treatment, it’s becoming increas- developing strategies to stop new infec-
bETTEr UNDErSTANDING OF
ingly clear that major programmes that tions and for resource allocation.
POPULATIONS AT HIGHEr rISK
worked in preventing new infections at The national AIDS authorities of
In some countries with generalized
the beginning of the epidemic may not Kenya, Lesotho, Swaziland, Uganda and
and hyperendemic epidemics, HIV has
have the same effect now. Zambia have just done this; their find-
spread to the general population. Even in
As the HIV epidemic is evolving, so ings were recently published in a series
such situations, a better understanding
must the response. One way countries entitled HIV prevention response and
of the risk dynamics is necessary for the
are adapting is by using data to follow main modes of transmission.
formulation of prevention messages that
the source of new infections, or ‘modes This has helped to answer key ques-
make a difference.
of transmission’, and then basing HIV tions, such as where should HIV preven-
Take, for example, a small country
like Lesotho, where there are nearly 60
Chart 1. Incidence by modes of transmission new infections each day. Adult HIV
prevalence in Lesotho is more than 23%,
76,315 91,546 118,279 11,381 74,263 and both men and women start having
100 loW risk heTerosexuAl sex at an early age. From a simple read-
pArTners ing of these data one might think that
80 cAsuAl heTerosexuAl sex HIV prevention programmes must try
men hAving sex WiTh men to reach all men and women in Lesotho.
60 injecTing drug users However, researchers found that those
pArTners of clienTs of with a single partner accounted for more
femAle sex Workers
percenT neW infecTions
40
clienTs of femAle
than one third of all new infections,
sex Workers while nearly two thirds occurred due to
20 oTher multiple partner behaviours. Addition-
ally, the 2004 demographic and health
0 surveys study showed that a third of
kenyA ugAndA moZAmbique sWAZilAnd ZAmbiA
all couples in the country include one
Source: results from know your epidemic project in southern and east Africa. partner living with HIV. However, few
Reports available at http://www.unaidsrstesa.org/hiv-prevention-modes-of-transmission. behaviour and social change com-
8 | Outlook Report | www.unaids.org
11. & Now
munications programmes were tar-
geted explicitly towards adults, married
couples and people in long-term steady
THAT WAS THIS IS
Then
relationships. A similar conclusion was
also drawn by researchers in Swaziland.
In fact, Swaziland felt that it had to
redefine its definition of ‘populations at
higher risk’ and customize them to their
own epidemic pattern. For example, they THEN NOw
identified mobile populations as a group IN AFRICA, MULTIPLE PARTNERS MULTIPLE AND CONCURRENT PARTNERS
needing attention, as men and women
who were away from home for longer
SUGAR DADDIES MORE EVIDENCE OF YOUNG MEN WITH
periods and slept more nights away
IN AFRICA. OLDER MEN HAVING SEx YOUNG WOMEN, AND OLDER WOMEN
from home have higher HIV preva- WITH YOUNG WOMEN AND YOUNGER MEN
lence. Other groups identified for HIV
prevention programmes were people TREATMENT 4 MILLION PEOPLE ON TREATMENT
in longer-term steady relationships and TOO ExPENSIVE TO AROUND THE WORLD, INCLUDING
BECOME WIDESPREAD A GREATER UNDERSTANDING OF
married couples who have multiple and
PAEDIATRIC FORMULATIONS
concurrent partners, HIV-discordant
couples and concordant positive couples THE ASIA EPIDEMIC WILL A REGIONAL UNDERSTANDING OF
and people living with HIV. BECOME AS GENERALIZED THE EPIDEMIC—CONCENTRATED IN
In Kenya most new infections occur AS IN AFRICA POPULATIONS AT HIGHER RISK AND
THEIR SExUAL PARTNERS
in people who engage in casual sex with
multiple partners and among their mo- IN ASIA, CONCENTRATED AMONG CANNOT IGNORE LONG-TERM
nogamous partners. However, the study POPULATIONS AT HIGHER RISK—MEN SExUAL PARTNERS OF RISK
highlighted the continued need to reach WHO HAVE SEx WITH MEN, INjECTING GROUPS
sex workers, men who have sex with DRUG USERS AND SEx WORKERS AND
THEIR CLIENTS
men, prisoners and injecting drug users,
who together account for nearly 31% of IN LATIN AMERICA, FOCUS MAINLY ON INCREASING ATTENTION ON MEN
all new infections. Similar conclusions INjECTING DRUG USE, SEx WORKERS AND WHO HAVE SEx WITH MEN—GROUP AT
were also drawn in Mozambique, where THEIR CLIENTS HIGHER RISK
about 27% of new infections occurred
IN MIDDLE EAST AND RISK GROUPS BECOMING VISIBLE:
among sex workers, men who have sex
NORTH AFRICA, AMONG MEN WHO HAVE SEx
with men and injecting drug users. NO RISK GROUPS WITH MEN, INjECTING DRUG
On the other hand, the epidemic in USERS, STREET CHILDREN AND
Asia is fuelled by unprotected paid sex, HIGHER-RISK MEN
the sharing of contaminated injecting
IN WESTERN EUROPE AND NORTH INCREASING INCIDENCE AMONG MEN
equipment by injecting drug users and
AMERICA, HIV AMONG MEN WHO HAVE WHO HAVE SEx WITH MEN AND AMONG
unprotected sex among men who have SEx WITH MEN AND INjECTING DRUG RACIAL AND ETHNIC MINORITIES
sex with men. Men who buy sex con- USERS IS ON THE DECLINE
stitute the largest infected population
group—and most of them are either
married or will get married. This puts sexual entitlements, cultural expecta- world. A recent UNICEF study in Swa-
a significant number of women, often tions of men and women and income ziland showed that one in four women
perceived as ‘low-risk’ because they only inequality. Men and women continue faced sexual violence as a child and two
have sex with their husbands or long- to have long-term multiple concurrent out of three 18–24-year-old women had
term partners, at risk of HIV infection. sexual partnerships in which sexual acts experienced sexual violence. The study
The numbers can be staggering, as Asian are often unprotected. also showed that boyfriends and hus-
countries have huge populations. In Lesotho, age-disparate relation- bands were the most frequent abusers.
TIP: LOOK DEEPEr AT YOUr EPIDEMIC—MAKE SUrE ships are common and contribute to the Prevention experts in all these coun-
THAT PrEVENTION MESSAGING IS NOT DILUTED bY very high HIV prevalence in females. tries concluded that current HIV pre-
LAbELLING ALL AT EqUAL rISK Or LOw rISK. This practice is not properly addressed vention strategies that focus primarily on
by policies to change the social norms individual behaviour rather than on the
ADDrESS CONTExTUAL FACTOrS that are currently permissive towards social norms that make risky behaviour
Studies show that despite the evidence of such relationships. Similar findings were acceptable are not adequate to effectively
the risk factors of the epidemic, there are also seen in Kenya, Mozambique, Swazi- reduce HIV transmission.
few programmes that address the social land and Zambia. TIP: THINK SOCIAL CHANGE.
and structural factors adequately in HIV Violence against women and girls is
prevention programmes. another issue that needs to be addressed SATUrATE HIGH-bUrDEN ArEAS
The modes of transmission study in as part of HIV prevention programmes. AS A PrIOrITY
Swaziland showed that its HIV epidemic A multicountry study conducted by the HIV prevalence figures must be
is maintained by underlying cultural and World Health Organization found that read in conjunction with national
socioeconomic factors, such as power between 1% and 21% of women reported demographics. A UNAIDS study that
differentials in intimate relationships, sexual abuse before age 15 across the looked at the extent of HIV in urban
www.unaids.org | Outlook Report | 9
12. areas found that 29% of the total HIV TIP: INVESTMENTS IN HIV PrEVENTION HAVE TO cant HIV transmission occurred among
epidemic in the eastern and southern SIGNIFICANTLY INCrEASE IF A SErIOUS ATTEMPT married couples has paved the way for
Africa region was concentrated in 15 AT STEMMING NEw INFECTIONS IS TO bE MADE. a campaign to promote HIV testing and
major cities. Together, this is nearly 15% counselling among couples. The Uganda
of the global epidemic. But there are few wHAT NExT? rESHAPING HIV National AIDS Commission used the
dedicated urban-focused programmes in PrEVENTION PrOGrAMMES findings to inform the development of
Africa. Many countries are beginning to use prevention policy guidelines and the
This was also confirmed in the findings from modes of transmission Ministry of Health agreed to focus on
modes of transmission study in Lesotho, studies to look ahead and plan better. The addressing couples as part of its preven-
which found that even though adult National AIDS Commission of Lesotho tion activities in health settings.
HIV prevalence is above 15% in all has used the data from the review to Responding to an evaluation of the
districts, 59% of people living with revise its national strategic plan. The plan impact of these studies, a respondent
HIV reside in the three western most was recosted and a set of scenarios was from Uganda said “There now appears
populous districts. This means precious developed to help prioritize and make to be consensus that there is a problem
resources could go further and achieve cost-effective investments. The data also of new HIV infections among married
more if HIV prevention programmes helped to inform the development of a and cohabiting [couples] and something
were scaled up in the three most heavily number of sector-specific policies and has to be done to address this. Before
affected districts. a behaviour change communication the modes of transmission analysis there
TIP: FOCUS ON THE GEOGrAPHICAL strategy. was a sense of denial, especially from the
ArEAS wHErE MOST NEw INFECTIONS ArE In Uganda, the results of a similar faith-based organizations…”
LIKELY TO OCCUr. study were widely disseminated, includ- In Kenya, the modes of transmission
ing through the mass media. This helped studies influenced the decision to develop
INCrEASE rESOUrCE ALLOCATION to increase understanding of the risk a new national strategic plan. “The fact
FOr HIV PrEVENTION faced by different population groups. that policy-makers decided to overhaul the
Another way of looking at why preven- The Uganda study’s finding that signifi- current national strategy was a strong sign
tion programmes are failing is to look
deeper into the investments being made. Chart 2. Role of major cities in national HIV epidemics
The trend is worrying. Spending on HIV in eastern and southern Africa
prevention programmes is low in most 100
parts of the world and is falling in many
85
instances. And what is available is not
80
reaching those most in need.
In Uganda, only one third of the 60.3
60
resources invested in the AIDS response 40.3
went towards prevention, while more 36.7
percenT neW infecTions
40 36.7
than half went towards care and treat- 31.8
26.6 28.8 30.1 30.9
ment. In Swaziland, the HIV prevention 19.8
budget was only 17% of the total funding 20
12.4 14 14.6 14.9 15.2 16.4 16.4
available, while in Lesotho it was a mere 0 0
10%. 0
mAdAgAscAr
ugAndA
TAnZAniA
mAlAWi
lesoTho
nAmibiA
moZAmbique
sWAZilAnd
rWAndA
kenyA
ZimbAbWe
ZAmbiA
boTsWAnA
eriTreA
AngolA
souTh AfricA
eThiopiA
mAuriTius
comonos
seychelles
In Kenya and Lesotho, HIV preven-
tion spending has fallen in recent years.
Since 2005 the amount of total funding 1 1 1 2 4 5 1 3 1 8 2 3 5 1 1 4 8 2 0 0
available at the national level for preven- number of ciTies counTed
tion activities in Kenya has fallen to less
than 25% of the total AIDS funding. Source: Van Renterghem, UNAIDS 2009.
We have to eliminate mother-to-
child transmission of HIV. Rightfully, Chart 3. Percentage of spending on programmes directed at
major investments from within the HIV populations at higher risk of HIV, as a percentage of total prevention
prevention budget go towards prevent- spending, by type of epidemic
ing babies from being born with HIV. 8.00 progrAms for sex Workers And Their clienTs
In Kenya, approximately half of the
7.00 progrAms for men hAving sex WiTh men
prevention resources go towards coun-
hArm reducTion progrAms for injecTing drug users
selling and testing and the prevention of 6.00
mother-to-child transmission of HIV. 5.00
In many countries, funding aimed at
4.00
groups at higher risk, such as sex work-
ers and their clients, men who have sex 3.00
with men and injecting drug users, are 2.00
negligible or non-existent in proportion
1.00
percenT
to their contribution to new infections.
Most of the prevention funding goes 0.00
l c g
towards raising awareness, with less for
supporting contextual factors. Source: Izazola J et al, Journal of AIDS 2009.
10 | Outlook Report | www.unaids.org
13. of how seriously they took the findings.”
The government has also committed
I
substantial resources, including from
n a landmark speech to the National Coun-
domestic sources, to help the National
AIDS Commission better coordinate cil of Provinces in October 2009, President
the AIDS response and to scale up the jacob Zuma presented his vision to stop the
prevention response. “The study also AIDS epidemic in South Africa. In his speech,
brought greater attention to resource the President called for an end to denialism and
allocation and distribution and an ef- launched a major movement to cut new HIV in-
fections by half and to reach at least 80% access
Many countries are to antiretroviral therapy by 2011.
beginning to use Below are some excerpts from President Zuma’s speech:
findings from modes of Indeed, if we do not respond with urgency and re-
transmission studies solve, we may well find our vision of a thriving nation
slipping from our grasp.
to look ahead …It is necessary to go into the hospitals, clinics and hospices of
and plan better. our country to see the effects of HIV and AIDS on those who
should be in the prime of their lives. It is necessary to go into
fective national debate on this is taking people’s homes to see how families struggle with the triple burden
place and has influenced decisions to of poverty, disease and stigma. Let me emphasize that although
be made that made the costing of the we have a comprehensive strategy to tackle HIV and AIDS that
national response a key issue”. has been acknowledged internationally, and though we have the
HIV prevention needs strong largest antiretroviral programme in the world, we are not yet win-
leadership. A leadership that is bold ning this battle. We must come to terms with this reality as South
enough to question the status quo and Africans.
the continuing practice of harmful
social norms and practices. Leadership …If we are to stop the progress of this disease through our
that is able to galvanize communities society, we will need to pursue extraordinary measures. We will
to take collective responsibility for HIV need to mobilize all South Africans to take responsibility for their
prevention and to sustain these efforts health and well-being and that of their partners, their families
over time with adequate investments. and their communities.
Thailand learnt it the hard way.
With visionary leadership and imple- …There should be no shame; no discrimination; no recrimina-
mentation of evidence-informed public tions. We must break the stigma surrounding AIDS.
health strategies in the 1990s, Thailand …Let World AIDS Day, on the 1st of December 2009, mark the
managed to arrest an epidemic that
beginning of a massive mobilization campaign that reaches all
threatened to spiral out of control.
When investment and focus for HIV
South Africans, and that spurs them into action to safeguard their
prevention wavered in the wake of the health and the health of the nation. The important factor is that
Asian economic crisis, the epidemic our people must be armed with information. Knowledge will help
bounced back. us to confront denialism and the stigma attached to the epidem-
TIP: HIV PrEVENTION IS FOr LIFE. THErE ic...we must not lose sight of the key targets that we set ourselves
ArE NO SHOrT CUTS. in our national strategic plan. These include the reduction of the
Uganda is showing similar patterns. rate of new infections by 50%, and the extension of the antiretro-
Thanks to early leadership efforts, HIV viral programme to 80% of those who need it, both by 2011. Pre-
prevalence declined from a peak of vention remains a critical part of our strategy. We need a massive
18% in 1992 to 6.1% in 2002, but today change in behaviour and attitude especially amongst the youth.
there are signs that this decline may We must all work together to achieve this goal.
have ended. HIV prevalence has stabi-
lized between 6.1% and 6.5% in some ...The renewed energy in the fight against AIDS and in mobiliz-
antenatal clinic sites and is rising in ing towards World AIDS Day must start now, by all sectors of our
others. This has been accompanied by society. Working together, we cannot fail. Whatever challenges we
a deterioration in behavioural indica- face, we will overcome. Whatever setbacks we endure,
tors, especially an increase in multiple we will prevail. Because by working together we can and
concurrent partnerships. will build a thriving nation.
But countries can learn from Thai-
land, which reinvested and prioritized The full speech can be accessed online at: http://www.thepresidency.gov.za.
its HIV prevention efforts and has suc-
ceeded in reducing HIV incidence in
recent years.•
www.unaids.org | Outlook Report | 11
14. Anatomy of Note to readers: the comments are the reactions of the Executive Secretary
upon receiving this advice from the legal ministry. She is sharing her thoughts
a Bad Law
and frustrations with her colleagues. Her reactions reflect some of the legal
obstacles that impede access to universal access to HIV prevention, treatment,
care and support. What additional changes would you make?
the world
Somewhere in
We need to better define annoyance
and do more work with law
Memo
enforcement officials. The law is
abused to harass sex workers and men
ority
who have sex with men.
AIDS Auth
, National w and Just
ice
Executive Secretary inistry of La
To: , Lega l Affairs, M
t Secretary
From: Permanen
Outlook
CC: Readers of
2009
ecember 1,
Date: D
S bill
Re: DRAFT AID
e
ware of th
inistry is a
While the Law M contra vention of
AIDS bill. ons are in ilution
of the draft the provisi our view, d
ge receipt number of s vices. In
like to a cknowled concern ed that a ety fro m variou and ord er in the d
We would emic, it is ct our soci intain law
AIDS epid ant to prote ent agencies to ma
gra vity of the laws are import enforce m T
ws. These e ability of
existing la hamper th pr
ws would
of these la example:
or
country. F y
, or is guilt Se
es any act
when he/she do or ann oyance to rea
of nuisance mon injury, danger arily
Penal Co
de
: “A perso
n is guilty s any com ust necess any
Nuisance sion cause y property in the vi cinity, or m oever to b
4—Public r omis se. Wh
Section 23 such act o r occup rights to u
sion, and ho dwell o y persons who had exp
of an illegal omis people in general w nce to an r both .” use
or to the or annoya or a fine, o xample,
the public, obstruction, danger risonment, uals. For e
ry , b le with imp s by individ to a large extent.
cause inju nce shall be punisha of public p
lace
rbed This
causes nu
isa the misuse en of disrepute is cu
ion against m espe
es protect omen and person ag
ainst
sion provid rks and spaces by w dge of any
This provi ublic pa rnal knowle ale person to have
of p has ca
the misuse n who (a) ermits a m and is liable to
“Any perso al; or (c) p
ral Offences: e of an anim commits an offence d in sectio
n Public
0—Unnatu l knowledg er of nature, ces specifie
Section 42 ature; (b) has carna e ord f the offen
fn gainst th it any o Section
the order o dge of him or her a ts to comm n years.”
ho attemp
ca rnal knowle r life. Any person w nme nt for seve rarely use
d, is reveal h
ent fo to impriso on, though eps to that the
imprisonm a felony and is liable his provisi take st
lues. T
Says who? Look at our 420 comm
its societal va a, we must HIV stat
gainst our paedophili
mose xuality is a rming in crease in disclosu
literature and history... As you are
aware, ho en the ala
terrent. Giv , rather than modify
it. ch situation
t moral de ith whom su ny
importan of this law e person w fa the six w
an
e enfo rcement prostitu tion, and th o hundred metres o
increase th
Sex work carries on ce of tw situation.
rson who in a distan
n: “Any pe ich are with
5— Prostitutio rem ises…wh
Section 34 carried out, in any p We are pu
is
prostitution
Since when is ‘looking gay’ in
public a misuse of public space?
Men who have sex with men and
paedophilia are not the same.
There are other laws to address Why are we trying to regulate
exploitation of children, which is adult sexual behaviour?
a crime..
12 | Outlook Report | www.unaids.org
15. We need substitution therapy
drugs on essential medicines list,
not banned substances list. Don’t mix trafficking and sex
work. Trafficking is a crime
and has a specific definition.
I would rather have a
place of p
ublic rigorous implementation of
public place religious worship,
months.)
of any kind
…may be
education
al institutio
n, host
community-led prevention
punishable
with impriso el, hospital, nursin and treatment services
We are bo nment for g home or
und by inte a term wh su
women an rnational co ich may ext ch other
d girls. Th nventions end to 3
X
It is alread e eradicatio and huma
y recogniz n of prostitu n rig
of this law ed tion is an im hts considerations
will reduce that sex workers are portant po
litica
to stop tra
ffickin
prostitution so
and greatly urces of HIV infectio l objective of the go g of
advance th n. Hence th ve
e goals of e rigorous rnment.
your minis application
Narcotics try.
Act of 198
Section24
5 And their ‘source’
substance
—Consum
po
ption of na
rcotic subst
of infection? Look at the neighboring
drug or an ssessed or consum ances: “W
here the n
notification
y psychotr
in the Offic
opic subst
ed is coca
ance as m
ine, morph arco
ine, diacety tic drug or psychotr
country. They decriminalized
a fine or w
ith both.”
ial Gazette ay be spe
, with impri cified
sonment fo in this behalf by the
l-morphine
or any oth
opic
er narcotic
sex work and now HIV
Section 34
r a term w G
hich may e overnment, by
xtend to o
infections are down.
—Punishm ne year or
any narco ent for illeg with
tic drug or al possess
contraven psychotro ion in a sm
tion of any pic substa all quantity
possesses provision o nce or con for person
f this Act, sum al
in
been inten a small quantity any or any rule ption of such drug o use, consumption o
drug or psy
ded for his
personal co
narcotic d
rug or psy
or order m
ade or perm
r substance
: “Whoeve
f There are other ways for
chotropic it r, in
chotropic
substance
nsumption
and not fo substance issued there under, reducing demand for sex work
, be punis , which is
hable by fiv r sale or distribution proved to
The above
two article
s were incl
e years in
prison.”
, or consu
mes any n
have or drug use. Let us not use fear
prey to ad arcotic
diction. uded to sp
ecifically st
op young
of criminal penalties. It is
ection 35—
Detention
people fro
m taking d
rugs and fa
driving them underground.
ason to be of drug use lling
lieve to ha rs and ped
y narcotic ve committ dlers: “De
dru ed an offe tain and se
be unlawfu g or psychotropic su nce punish
able u
arch any p
erson who
l, arrest him bstance in
pression "p and any o his possess nder Chapter III, an m he has
ublic place ther perso ion and su d,
e by, or acc " includes n in his co
mpany. Fo ch possess if such person has
essible to, any r the purpo ion appears to him
the public.” public conveyance ses
, hotel, sho
provision is p, or other of this section, the
place inten
ecially tho of great im
se who are portance to help law
ded for Listen to the Supreme Court
selling dru
gs.
enforceme
nt agencie
s catch an
of Indonesia—: drug users need
d punish o
ffenders, treatment, not jail sentences
c Health A
ct 2007
n 14—Dis
closure of
his/her HIV HIV status:
status to h “Any perso
n who has
x
e period d is
oes not exc /her spouse or reg been teste
d positive
atus. The
testing cen
eed six (6
) fu
ular sexua
tres shall p ll weeks, starting fro
l partner a
s soon as
for HIV is
bound to Our outreach workers will be
ure of the possible p
n. The test
HIV test re
sults and h
rovide all th
elp the co
e necessa
m the date
ry psychoso
he/she wa
s notified o
rovided at risk of arrest any time. How
ing
weeks, pro centre shall be req uple cial suppo fh
rt to facilita is/her come we do not see major drug
vided all e uired to m to accept and adap te the
.” fforts are m ake the dis t to the rea
ade to ena
ble the pa
closure in
the event
lity of the
of the exp
traffickers getting put away?
rtners to h iration of
ave full un
uzzled by derstandin
your reque g of the
st to amen
d this law
and all pro
visions me
ntioned.
Most people take steps to protect their loved ones. It’s mostly women who are tested
What is needed is an environment where people can first. This will lead to more
take the test, not fear the test. Partner notification stigma and discrimination of
must be voluntary. women.
www.unaids.org | Outlook Report | 13
16.
17. UNAIDS’ NINE PrIOrITY ArEAS:
wE CAN rEDUCE SExUAL TrANSMISSION OF HIV
wE CAN PrEVENT MOTHErS FrOM DYING AND bAbIES FrOM
bECOMING INFECTED wITH HIV
wE CAN ENSUrE THAT PEOPLE LIVING wITH HIV rECEIVE TrEATMENT
wE CAN PrEVENT PEOPLE LIVING wITH HIV FrOM DYING OF
TUbErCULOSIS
wE CAN PrOTECT DrUG USErS FrOM bECOMING INFECTED wITH HIV
wE CAN rEMOVE PUNITIVE LAwS, POLICIES, PrACTICES, STIGMA AND
DISCrIMINATION THAT bLOCK EFFECTIVE rESPONSES TO AIDS
wE CAN STOP VIOLENCE AGAINST wOMEN AND GIrLS
wE CAN EMPOwEr YOUNG PEOPLE TO PrOTECT THEMSELVES
FrOM HIV
wE CAN ENHANCE SOCIAL PrOTECTION FOr PEOPLE AFFECTED bY HIV
