tag:theconversation.com,2011:/au/topics/unaids-24848/articlesUNAIDS – The Conversation2022-12-01T21:03:51Ztag:theconversation.com,2011:article/1955422022-12-01T21:03:51Z2022-12-01T21:03:51ZOn World AIDS Day, Canada must lead the way in combating HIV-AIDS<figure><img src="https://images.theconversation.com/files/498368/original/file-20221201-12-91tm7n.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C3888%2C2566&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Provinces like British Columbia have reduced infection rates thanks to successful treatment and prevention measures. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Dec. 1 marks <a href="https://www.worldaidsday.org/">World AIDS Day</a>. As researchers focused on fighting the HIV-AIDS epidemic, we are increasingly concerned all the progress made in the fight against the virus is at risk. </p>
<p>In 1996, the first remarkable breakthrough against the HIV-AIDS epidemic came with the novel combination of drugs that became known as <a href="https://www.ncbi.nlm.nih.gov/books/NBK554533/">Highly Active Antiretroviral Therapy (HAART)</a>.</p>
<p>For the first time, HAART was able to stop viral replication and render the virus undetectable in blood and bodily fluids, and consequently promote immune reconstitution. This in turn would prevent an HIV infection from developing into AIDS, significantly reducing premature deaths.</p>
<h2>Treatment as prevention</h2>
<p>The next major breakthrough came in the early 2000s. Through close monitoring of the epidemic in British Columbia, our research documented that HIV infected individuals who have consistent viral suppression with HAART are virtually unable to transmit the infection. This led us to recommend initiating HAART immediately following HIV diagnosis to accelerate overall HIV/AIDS control. </p>
<p>We called the strategy <a href="https://bccfe.ca/tasp/about">Treatment as Prevention</a> (TasP) to illustrate the fact that HAART simultaneously stops progression to AIDS, premature death and HIV transmission.</p>
<p>TasP was enthusiastically embraced by the Joint United Nations (UN) Programme on HIV/AIDS (UNAIDS), in 2010. However, it soon became apparent that the TasP strategy was too ill defined, and this open the door for it to be inconsistently deployed between regions.</p>
<p>In 2014, <a href="http://www.unaids.org/sites/default/files/media_asset/JC2670_UNAIDS_Treatment_Targets_en.pdf">UNAIDS unveiled two sequential TasP-inspired targets</a> to quantify the proportion of people living with HIV who need to be diagnosed, the proportion of diagnosed people who need to be on HAART, and the proportion of people on HAART who need to be <a href="https://www.hiv.gov/hiv-basics/staying-in-hiv-care/hiv-treatment/viral-suppression">virologically suppressed</a> by 2020 and 2025. Viral suppression is defined by having less than 200 copies of HIV per milliliter of blood.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&rect=0%2C300%2C3085%2C1958&q=45&auto=format&w=1000&fit=clip"><img alt="A white flag with the words World Aids day and a red ribbon flies in front of the peace tower." src="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&rect=0%2C300%2C3085%2C1958&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=440&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=440&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=440&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=553&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=553&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498367/original/file-20221201-26-iq7whf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=553&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Canada has made breakthroughs in the fight against HIV-AIDS, but more must be done to make access to treatment more equitable.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>These targets were specifically designed so that by 2030 the world would see a 90 per cent decrease in AIDS mortality and new HIV infections, and meet the goal of ending the HIV-AIDS pandemic. In 2015, the UN <a href="https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/june/20210608_hlm-opens">formally endorsed</a> the <a href="https://doi.org/10.7448%2FIAS.19.1.20917">90-90-90 by 2020</a> target. It endorsed our subsequent <a href="https://bccfe.ca/blog/united-nations-adopts-ambitious-95-95-95-95-target">95-95-95 by 2025</a> target in 2021. </p>
<p>However, a lack of leadership and resources have hampered progress towards the UN targets around the world. This has been exacerbated by the COVID-19 pandemic, which disrupted some medical services, decreased HIV testing, interrupted the provision of HAART and diverted funding. </p>
<h2>Differing success rates across Canada</h2>
<p>In 2020, the Public Health Agency of Canada (PHAC) released a much-awaited <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/hiv-canada-surveillance-report-december-31-2020.html">epidemiological HIV/AIDS update</a>. The update came ahead of the <a href="https://aids2022.org/2022/04/29/the-international-aids-conference-returns-to-montreal/">International AIDS Conference</a> held in Montréal in July 2022. </p>
<p>Unfortunately, the results were rather concerning. HIV cases in Canada have remained flat since the 1990s, but there is a marked contrast between British Columbia and the rest of the country. While B.C. saw a steady decline in cases between 1996 and 2020, the rest of Canada saw no further reduction in cases over the same period. </p>
<p>HIV cases peaked throughout Canada in the early 80s. But a decrease in high-risk sexual practices led to a substantial reduction in cases. After that, the course of the epidemics diverged. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="HIV incidence across Canada and B.C. from 1980-2020" src="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=263&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=263&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=263&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=330&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=330&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498393/original/file-20221201-20-syova6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=330&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">HIV cases from 1980 until 2020 in Canada and British Columbia.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<p>The reason for this discrepancy can be explained by the success of TasP in B.C., where the strategy originated. The graph below compares progress toward the UN’s 2020 target across Canada’s provinces and territories.</p>
<p>B.C., Nova Scotia, Newfoundland and Labrador and the three territories are the only Canadian jurisdictions that surpassed all three components of the <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html#s10">benchmark target</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A chart showing Canadian provinces' progress towards the UNAIDS 90-90-90 targets" src="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498340/original/file-20221130-24-rlmqen.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Estimated percentage of people living with HIV diagnosed, on treatment and virally suppressed by selected regions in Canada at the end of 2020.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<p>A failure to optimally implement TasP nationally has led to markedly different <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html">HIV rates</a> across the country. In 2020, the national HIV incidence rate was 4.8 per 100,000 people. B.C., which had the highest domestic incidence rate at the peak of the epidemic in the 1980s, was well below the national average, at 2.5 per 100,000 population. The province is now at the low end of the national spectrum, together with the territories and Atlantic provinces at 2.1 and 2.2 per 100,000 population, respectively. </p>
<p>Alberta and Ontario were within the range of the national average at 4.2 and 4.1 per 100,000 population. At the other end, Saskatchewan, Manitoba and Québec were above the national average at 23.0, 7.7 and 5.8 per 100,000 population, respectively. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Map of Canadian provinces & territories showing HIV incidence rates in 2020." src="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=497&fit=crop&dpr=1 600w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=497&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=497&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=625&fit=crop&dpr=1 754w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=625&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/498341/original/file-20221130-22-542xnm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=625&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">HIV rates in Canada by province and territory in 2020.</span>
<span class="attribution"><span class="source">(Public Health Agency of Canada 2020 National HIV Estimates Report)</span></span>
</figcaption>
</figure>
<h2>What Canada needs to do</h2>
<p>Clearly, Canada has the tools and the means to end the epidemic. The question remains, are we up to the task? The key requirements are well known: </p>
<ol>
<li>Normalize HIV testing to ensure everybody knows their HIV status.</li>
<li>Remove barriers to <a href="https://www.ohtn.on.ca/out-of-pocket-costs-associated-with-hiv-in-publicly-funded-high-income-health-care-settings/">accessing health services</a>. </li>
<li>Expand support for affected populations, with particular emphasis on harder-to-reach and most affected populations (men who have sex with men, people dealing with substance use, sex workers, inmates, immigrants and First Nations Peoples).</li>
<li>Make free harm reduction services widely available (condoms, lubricants, injection and smoking paraphernalia, supervised injection and smoking consumption sites and safer drug supply programs).</li>
<li><a href="https://doi.org/10.9778/cmajo.20180058">Free HAART</a> for all HIV-positive people.</li>
<li>Free <a href="https://www.cdc.gov/hiv/risk/prep/index.html">pre-exposure prophylaxis (PrEP)</a> to all people at heightened HIV risk.</li>
<li>Free relevant laboratory monitoring for all those on HAART or PrEP. </li>
</ol>
<p>In addition, we must demand full transparency and accountability from our health-care system. That starts with PHAC annually reporting progress towards the UN 95-95-95 by 2025 target, HIV prevalence and AIDS-related mortality. </p>
<p>Finally, the federal government should sponsor a yearly independent summit of all relevant stakeholders to promote accountability and transparency, compare regional progress and share lessons learned in the process. </p>
<p>As a leader in treatment and prevention, Canada has a global responsibility to optimally implement a strategy to effectively combat HIV-AIDS. That will require a major commitment from the provinces given that health care is a provincial responsibility. </p>
<p>Canada knows how to end the HIV-AIDS epidemic. It is high time to get it done.</p><img src="https://counter.theconversation.com/content/195542/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julio Montaner has received support, paid to his institution, from the BC Ministry of Health, Health Canada, the Public Health Agency of Canada, Genome BC, Vancouver Coastal Health and the VGH Foundation. Institutional grants have been provided by Gilead, Merck and ViiV Healthcare.</span></em></p><p class="fine-print"><em><span>Viviane Dias Lima receives funding from the Canadian Institutes of Health Research (PJT-148595; PJT-156147), and the Canadian Foundation for AIDS Research (CANFAR Innovation Grant – 30-101). </span></em></p>Dec. 1 marks World AIDS Day. Canada has the tools and means to end the epidemic. The question remains, are we up to the task?Julio Montaner, Killam Professor, Department of Medicine, University of British ColumbiaViviane Dias Lima, Scientist, Senior Methodologist & Associate Professor, Department of Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1689092021-09-29T10:40:27Z2021-09-29T10:40:27ZHead of UNAIDS unpacks the knock-on effects of COVID-19. And what needs to be done<figure><img src="https://images.theconversation.com/files/423801/original/file-20210929-28-j14zmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">UNAIDS Executive Director Winnie Byanyima.</span> <span class="attribution"><span class="source">Fabrice Coffrini/AFP via Getty Images</span></span></figcaption></figure><p><em>The COVID-19 pandemic has deepened global inequities. The world’s poor have borne the brunt of national lockdowns and will struggle to recover and poorer countries have been unable to rollout comprehensive vaccination campaigns because of a grossly unequal distribution of vaccines. On top of this COVID-19 has also derailed progress against diseases that affect poor people. Imraan Valodia sat down for a conversation with Winnie Byanyima, the Executive Director of UNAIDS.</em> </p>
<hr>
<p><strong>Imraan Valodia:</strong> What impact has COVID-19 had on the fight against HIV in countries, particularly those in the global South, carrying the biggest burden of the disease and with significantly weaker healthcare systems?</p>
<p><strong>Winnie Byanyima:</strong> Firstly, we must recognise the successes of the AIDS response. We have achieved what many once said was impossible. Of the <a href="https://www.unaids.org/en/resources/fact-sheet">38 million</a> people living with HIV, 27.5 million are accessing lifesaving antiretroviral therapy. We have cut the rate of new HIV infections by more than half and averted 16.6 million deaths.</p>
<p>But let us be clear: fighting a pandemic with <a href="https://theconversation.com/why-ending-hiv-still-rests-on-a-working-cure-as-well-as-prevention-113592">no cure and no vaccine</a> is hard.</p>
<p>Hundreds of thousands are still dying of AIDS and 1.5 million people were newly infected last year. AIDS remains a crisis and COVID-19 is making it worse.</p>
<p>Even before COVID-19, we were <a href="https://www.unaids.org/en/resources/909090">off track</a> in meeting the global AIDS targets and the COVID-19 pandemic has pushed us back even further. COVID-19 related restrictions have hurt the most vulnerable, including marginalised and stigmatised communities and has disrupted access to HIV services.</p>
<p>Since COVID-19 hit, the Global Fund to Fight AIDS, TB and Malaria <a href="https://www.theglobalfund.org/en/news/2021-09-08-global-fund-results-report-reveals-covid-19-devastating-impact-on-hiv-tb-and-malaria-programs/">estimate</a> that the number of mothers receiving prevention of mother to child transmission services dropped by 4.5%, people reached with HIV prevention programmes declined by 11%, HIV testing declined by 22% and medical male circumcision to prevent HIV dropped by 27%.</p>
<p>In very high prevalence settings in Africa, it is estimated that the effects of COVID-19 could contribute to a 10% increase in HIV deaths over five years. </p>
<p>Amid unprecedented global disruptions, we must act urgently to prevent a resurgent global AIDS pandemic and to quickly recover our progress toward ending AIDS. To get fully back on track on HIV we absolutely have to get on top of COVID-19.</p>
<p><strong>Imraan Valodia:</strong> COVID-19, like HIV, has deepened inequalities in society and disproportionately affected women while widening the long-existing gender pay gap. How do we begin to address this gender economic and inequality pandemic?</p>
<p><strong>Winnie Byanyima:</strong> Both COVID-19 and HIV are feeding off inequalities: women whose rights are not respected; women who do not have economic security or access to the most basic health or education services. These are the people that pay the heaviest price of our inaction on inequality. They pay the price in insecurity, in poverty, in sickness, and too often in death.</p>
<p>Five in six African adolescents newly acquiring HIV are <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30404-8/fulltext">girls</a>. The reason is power. Research <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2021/april/20210406_keeping-girls-in-school-reduces-new-hiv-infections">shows</a> that completion of secondary education reduces a girl’s risk of acquiring HIV by up to half, and by even more if this is complemented by a package of rights and services. Yet as countries struggle with the current fiscal challenges, education and girls’ empowerment are among sectors that are suffering the biggest budget cuts.</p>
<p>Governments also have a responsibility to shift the <a href="https://theconversation.com/unpaid-care-work-still-falls-on-women-seven-steps-that-could-shift-the-balance-163908">burden of care</a> away from women’s invisible unpaid labour. Affirmative action is essential to counteract the legacy of discrimination against women.</p>
<p>Economic interventions are needed to overturn the gross imbalance of wealth. But ending the age of inequality requires the strengthening of emancipatory social and cultural forces to overturn the gross imbalance of power in all its interconnecting forms.</p>
<p><strong>Imraan Valodia:</strong> You say that extreme inequality is not inevitable – it’s a policy choice – explain what you mean by this? What roles can individuals, communities, and nations play to end it?</p>
<p><strong>Winnie Byanyima:</strong> There is a pandemic of inequality – between men and women, between the South and the North; between dominant and marginalised communities, between the elite and the majority – which hold back our enormous potential.</p>
<p>Inequalities are perpetuated by laws, by informal rules (social norms), by national social and economic policies and resource allocation, and by global policies and finance. And key to determining all those outcomes are inequalities of voice and power.</p>
<p>In the face of the colliding crises, it has become clear that we need bold new approaches to how we survive and thrive. Action is needed at all levels – not to build a perfect world but to enable a resilient one.</p>
<p>The answers are being articulated by activists and organisers, particularly young people from the most marginalised communities. They are showing how to build societies able to overcome any crisis and to unleash the potential of all. They have done so because the people most impacted are those who understand it best.</p>
<p>As a UN leader, I have experienced the power of the pressure of communities, women’s groups and grassroots movements, pushing us; at times that pushing is uncomfortable for us; but my message to you is: </p>
<blockquote>
<p>Keep pushing!</p>
</blockquote>
<p><strong>Imraan Valodia:</strong> What lessons can we learn for the management of future pandemics from the triangle of science, government and communities that was in place in dealing with HIV?</p>
<p><strong>Winnie Byanyima:</strong> We have learned a lot about how to fight pandemics. This year marks <a href="https://theconversation.com/africa/search?q=AIDS+40+years">40 years</a> that we have been fighting AIDS and our successes and failures have taught us that we cannot successfully conquer a pandemic without working together to end inequalities, promote people-centred approaches, engage communities, and respect human rights.</p>
<p>This is one of the most challenging moments in the history of HIV and global health. We need greater urgency in our response to pandemics, global solidarity behind a data-driven global plans to end AIDS and to end COVID-19, and partnerships to prepare to respond to the next threat.</p>
<p>We need to draw from the collective experience, brilliance and value set of the AIDS response. If we apply the hard-earned lessons of AIDS up front, we will increase our odds of winning.</p>
<p><em>This article is part of a media partnership between the Southern Centre for Inequality Studies’s and The Conversation Africa for its 2021 annual Inequality Lecture, which was presented on Thursday, 30 September. You can watch the full lecture <a href="https://www.facebook.com/conversationAfrica/videos/660007621560449?_rdc=1&_rdr">here</a>.</em></p><img src="https://counter.theconversation.com/content/168909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Imraan Valodia receives funding from a number of local and international organizations that support research.</span></em></p>Greater urgency is needed in the response to pandemics, to end AIDS and to end COVID-19.Imraan Valodia, Dean of the Faculty of Commerce, Law and Management, and Head of the Southern Centre for Inequality Studies, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1284752020-01-12T08:50:03Z2020-01-12T08:50:03ZNew estimates show 14.8 million children globally are HIV-exposed but uninfected<figure><img src="https://images.theconversation.com/files/306349/original/file-20191211-95173-ewrpv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In many countries with a high HIV prevalence, at least <a href="http://aidsinfo.unaids.org/">95%</a> of children born to mothers living with HIV remain HIV-uninfected. This is due to the success of wide-scale provision of antiretroviral therapy to mothers with HIV to prevent transmission to their children during pregnancy, labour or breastfeeding.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/south-africa-steps-up-its-game-to-end-mother-to-child-transmission-of-hiv-128439">South Africa steps up its game to end mother-to-child transmission of HIV</a>
</strong>
</em>
</p>
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<p>Children born to mothers with HIV are known as HIV-exposed. While many children who are HIV-exposed and also HIV-uninfected are growing and developing well, some <a href="https://www.ncbi.nlm.nih.gov/pubmed/30773459">face</a> greater <a href="https://www.ncbi.nlm.nih.gov/pubmed/31515160">risks</a>. </p>
<p>They are more likely to be hospitalised with severe <a href="https://www.ncbi.nlm.nih.gov/pubmed/28081048">infections</a> when they are infants. They are also at higher risk of dying before their <a href="https://www.ncbi.nlm.nih.gov/pubmed/27456985">second birthday</a>. And the risks are even higher when babies who are HIV-exposed and uninfected are born early, with low weight at birth, or to mothers with severe HIV disease. </p>
<p>This is why it’s important to know as much as possible about this population of children, how many there are and where they are in the world. </p>
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Read more:
<a href="https://theconversation.com/babies-born-to-mums-with-hiv-face-higher-risks-even-though-theyre-hiv-negative-100509">Babies born to mums with HIV face higher risks even though they're HIV negative</a>
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<p>Every year the <a href="http://aidsinfo.unaids.org">United Nations</a> provides key estimates related to the HIV epidemic. These usually include the number of people living with HIV, the number of new infections and the number of people receiving treatment. In 2018 for the first time, estimates for children aged 0-14 years who were HIV-exposed and uninfected were included. </p>
<p>We <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30448-6/fulltext">used</a> the most recent UNAIDS estimates, published in July 2019, to calculate the share of each country in the global total of children who are HIV-exposed and uninfected. These estimates allow us to report on changes in the size of this population and trends over time, between 2000 and 2018. And we calculated the percentage of children who are HIV-exposed uninfected in countries with the highest HIV burden.</p>
<h2>What we found</h2>
<p>We found that in 2018 there were 14.8 million children who were HIV-exposed and uninfected around the world. This population has more than doubled from 6.7 million in 2000. </p>
<p>Ninety percent of all these children are from sub-Saharan Africa. Strikingly, half of all children who are HIV-exposed and uninfected come from just five countries – South Africa, Uganda, Mozambique, Tanzania and Nigeria. </p>
<p>South Africa alone accounts for 3.5 million or 24% of all children who are HIV-exposed and uninfected. </p>
<p>Equally alarming is that in four southern African countries more than 20%, or at least one in every five children, is HIV-exposed and uninfected – Eswatini (32%), Botswana (27%), South Africa (22%) and Lesotho (21%).</p>
<h2>What next</h2>
<p>The substantial global population of children who are HIV-exposed and HIV-uninfected needs a coordinated strategy to reduce HIV exposure in children and to ensure their optimal health and wellbeing. Informed by these estimates, we propose a coordinated global strategy for improving their health outcomes. </p>
<p>This strategy requires collaboration from governments and their partners, including multilateral organisations, researchers and funders. It must be built on a strong foundation of dialogue with families and communities affected by HIV, who have seldom been consulted on the wellbeing of their children when they are HIV-uninfected. </p>
<p>Our proposed strategy has three pillars: </p>
<ul>
<li><p>First, to reduce the number of adolescent girls and women newly infected with HIV and to reduce unintended pregnancies in adolescent girls and women living with HIV. The number of children who are HIV-exposed is determined by the number of pregnant women living with HIV, which has remained unchanged at <a href="http://aidsinfo.unaids.org">1.3 million</a> globally every year since 2000. </p></li>
<li><p>Second, to keep mothers with HIV on lifelong antiretroviral therapy to ensure they stay well and don’t transmit HIV during pregnancy and breastfeeding. Countries with a high burden of HIV also need systems to continually evaluate the safety of this therapy.</p></li>
<li><p>Third, to ensure that research covers the geographical regions that are most affected. Exposure to HIV and to antiretroviral drugs during pregnancy has been well researched in high-income countries. But their HIV prevalence is low and other factors very different from the low- and middle-income countries where most of the children exposed to HIV are found. For instance, child mortality, preterm birth, infectious diseases and malnutrition occur far more often in low- and middle-income countries.</p></li>
</ul>
<p>There are large numbers of children who are HIV-exposed and HIV-uninfected in southern Africa – and they are not surviving and thriving as well as children born to women without HIV. There is an urgent need in this region to find solutions enabling all children to reach their developmental potential and contribute fully to their communities.</p><img src="https://counter.theconversation.com/content/128475/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Slogrove receives funding from research funding agencies on a competitive funding basis including the US National Institutes of Health and the International AIDS Society.</span></em></p><p class="fine-print"><em><span>Kathleen M. Powis receives research funding on a competitive basis from the US National Institutes of Health and the International AIDS Society.</span></em></p>In Eswatini, Botswana, South Africa and Lesotho more than 1 in 5 children are HIV-exposed but uninfected. A coordinated strategy is needed to ensure all children reach their developmental potential.Amy Slogrove, Senior lecturer in Paediatrics and Child Health, Stellenbosch UniversityKathleen M. Powis, Assistant Professor, Harvard UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1132212019-03-15T11:56:59Z2019-03-15T11:56:59ZNew UN guidelines to mainstream human rights in the global drugs debate<p>It’s 110 years since international cooperation on drug control began. In February 1909 the <a href="https://www.unodc.org/unodc/en/frontpage/this-day-in-history-the-shanghai-opium-commission-1909.html">International Opium Commission in Shanghai</a> saw governments from around the world come together to address what was dubbed “the opium question”, by proposing a global plan to suppress illicit opium use and markets. The meeting kicked off a century-long project of ever increasing international collaboration to eradicate illicit drug use and markets, culminating in the <a href="https://www.unodc.org/unodc/treaties/">three United Nations drug treaties</a> adopted in 1961, 1971 and 1988.</p>
<p>Since the 1970s, and the start of the “<a href="https://www.history.com/topics/crime/the-war-on-drugs">war on drugs</a>”, these efforts have been marked by the increasing use of laws focused on punishment, policing, prisons and even the military as core tools of drug enforcement. Alongside this there has also been an escalation of human rights violations linked to drug control.</p>
<p>While ignored for many decades, the human rights consequences of drug enforcement are an increasing concern within UN bodies. In some cases, this is the result of years of <a href="https://www.hri.global/contents/561">patient campaigning</a> by civil society organisations and <a href="https://www.hr-dp.org/contents/1532">affected communities</a>. In others, it has been triggered by gross human rights violations linked to drugs, such as <a href="https://www.rappler.com/newsbreak/investigative/tondo-vigilante-gang-war-on-drugs-series-conclusion">state killings</a>, the <a href="https://www.hri.global/files/2019/02/22/HRI_DeathPenaltyReport_2019.pdf">death penalty for drug offenders</a> and HIV epidemics <a href="http://www.unaids.org/sites/default/files/media_asset/JC2954_UNAIDS_drugs_report_2019_en.pdf">driven by unsafe injecting drug use</a>.</p>
<p>While this attention is welcome, it has <a href="https://www.cambridge.org/core/books/drug-control-and-human-rights-in-international-law/F741DAD5332289EE22DB1718D8B89F5B">rarely resulted</a> in systematic or operational change within UN mechanisms to ensure the protection of human rights. But this is now beginning to change.</p>
<h2>Joint commitment</h2>
<p>In early March, the Chief Executives Board of the United Nations, representing 31 UN agencies – including the World Health Organisation, UNICEF, the High Commissioner for Human Rights and the UN Office on Drugs and Crime – adopted a common <a href="https://www.unsceb.org/CEBPublicFiles/CEB-2018-2-SoD.pdf">position on drug policy</a>. Among the actions agreed is was a commitment to “support the development and implementation of policies that put people, health and human rights at the centre … and to promote a rebalancing of drug policies and interventions towards public health approaches”. </p>
<p>This agreement creates potential for significant policy evolution on drugs within the UN as a whole. However, the vast majority of human rights violations driven by drug control – <a href="https://www.hri.global/files/2019/02/22/HRI_DeathPenaltyReport_2019.pdf">executions</a>, <a href="https://www.project-syndicate.org/commentary/bangladesh-deadly-war-on-drugs-by-naomi-burke-shyne-2018-10?barrier=accesspaylog">killings</a>, <a href="https://www.timeslive.co.za/amp/sunday-times/lifestyle/2016-03-27-killing-the-economic-lifeblood-of-the-eastern-capes-weed-producing-people/">involuntary crop eradication</a>, <a href="https://www.reuters.com/article/us-drugs-thailand-prisons/soaring-prison-population-prompts-thailand-to-re-think-lost-drug-war-idUSKCN0ZX01J">mass incarceration</a>, <a href="http://newjimcrow.com/">racist policing</a>, <a href="https://www.opensocietyfoundations.org/publications/expecting-better-improving-health-and-rights-pregnant-women-who-use-drugs">gender-based violence</a>, <a href="https://www.dejusticia.org/en/publication/palliative-care-and-their-status-in-latin-america/">denial of life saving health programmes</a>, to name a few – are not the result of UN inaction. They are driven by national laws and policies that member state governments implement to, in their view, fulfil UN drug treaties obligations.</p>
<p>Over the past decade, some countries have begun to review and reform these harmful rules, promoting societal well-being and reducing the harms of illicit drug economies. Judicial reviews of the criminalisation of possession for personal use have taken place in <a href="http://sjconsulta.csjn.gov.ar/sjconsulta/%20documentos/verUnicoDocumento.html?idAnalisis=671140">Argentina</a> and <a href="http://www.saflii.org.za/za/cases/ZACC/2018/30.pdf">South Africa</a>, for example. There have been <a href="https://www.release.org.uk/sites/default/files/pdf/publications/A%20Quiet%20Revolution%20-%20Decriminalisation%20Across%20the%20Globe.pdf">national referendums on promoting health in drug policy</a> in Italy and Switzerland, and <a href="https://www.newsweek.com/where-weed-legal-around-world-you-can-now-officially-smoke-pot-canada-1173623">legislative reviews of cannabis laws</a> in Uruguay, Canada and some US states.</p>
<p>Despite this progress, far too many countries remain entrenched in the war on drugs approach, and human rights violations are still taking place as a result. Member states’ divergent approach has resulted in increasingly fragmented political discourse in UN forums too. Human rights discussions are divisive, and commitments to promote them largely rhetorical or lost in diplomatic translation. </p>
<h2>From questions to solutions</h2>
<p>The stagnation of these political debates has often obscured progressive developments on <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=2ahUKEwiH5ayAyIHhAhXMcJoKHTIIAuMQFjABegQICBAC&url=https%3A%2F%2Fwww.ohchr.org%2Fen%2Fhrbodies%2Fhrc%2Fregularsessions%2Fsession30%2Fdocuments%2Fa_hrc_30_65_e.docx&usg=AOvVaw3Yv1gkE3TcC4g761wyXMjO">human rights</a> and <a href="https://www.unodc.org/documents/justice-and-prison-reform/UNODC_Human_rights_position_paper_2012.pdf">drug control</a> elsewhere in the UN. What has been missing to bridge this gap is a shared tool to clarify global human rights conversations and guide national reform. Which is just what we, as part of a team of international experts, have now published with United Nations Development Program, World Health Organisation and UNAIDS as the <a href="https://www.humanrights-drugpolicy.org/">International Guidelines on Human Rights and Drug Policy</a>.</p>
<p>Based on established international legal standards, these guidelines cover 27 principles that span the drug market from cultivation to consumption. It is also a catalogue that reflects the expansive human experience of drug control, from cancer patients travelling days to receive morphine, to the struggles of indigenous peoples to protect their sacred relationship with psychoactive plants, to the people who are criminalised for using drugs and denied essential harm reduction services.</p>
<p>The guidelines do not create new laws, but centralise existing human rights standards in the context of drug control. They provide concrete guidance on what states can and should do to promote the safety, security, well-being and rights of their communities. Following their launch, sub-regional and national dialogues with key government, civil society and academic stakeholders are being planned to localise and demonstrate the practical power of these standards.</p>
<p>The century-old international drug control monolith was not erected overnight. Nor will it be reformed or dismantled overnight. That process will take time and determination, and commitment to prioritising evidence, health and rights in national and international lawmaking. The guidelines are one milestone in that journey towards reform, one that we hope helps shift the focus of global drug policy away from “the opium question” to “the rights solution”.</p><img src="https://counter.theconversation.com/content/113221/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Rick Lines is co-founder and Chair of the International Centre on Human Rights and Drug Policy, which is one of partners on the project described in this article.</span></em></p><p class="fine-print"><em><span>Julie Hannah is the Director of the International Centre on Human Rights and Drug Policy at the University of Essex (HRDP) and receives funding from the Global Partnership on Drug Policies and Development, implemented by GIZ on behalf of the German Federal Ministry for Economic Cooperation and Development; the Swiss Federal Department of Foreign Affairs; and the United Nations Development Programme to develop and/or implement the International Guidelines on Human Rights and Drug Policy. The Guidelines are published by the HRDP, United Nations Development Program, World Health Organization and UNAIDS.</span></em></p>The UN’s new rights focus has the potential to overhaul the punitive nature of the war on drugs.Rick Lines, Associate Professor of Crimininology and Human Rights, Swansea UniversityJulie Hannah, Director, International Centre on Human Rights and Drug Policy, University of EssexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1044322018-10-22T14:17:13Z2018-10-22T14:17:13ZHow innovation can help end the AIDS epidemic by 2030<figure><img src="https://images.theconversation.com/files/241212/original/file-20181018-67188-12rs5mq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The WHO recommends HIV viral load testing to monitor people on ARVs. </span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A United Nations <a href="http://www.unaids.org/en/resources/909090">initiative</a> backed by global experts has set its sights on an ambitious programme to bring an end to the AIDS epidemic by 2030. </p>
<p>The 90-90-90 strategy aims to do this by reaching three targets: 90% of all people with HIV must know their status, 90% of those diagnosed with HIV must receive antiretroviral therapy, and 90% of people receiving antiretroviral therapy must be virally suppressed. When a person is <a href="http://www.who.int/hiv/mediacentre/news/viral-supression-hiv-transmission/en/">virally suppressed</a> it means the virus in their blood is undetectable. The last goal is informed by <a href="https://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(17)30183-2/fulltext#%20">evidence</a> that people with a suppressed viral load are less likely to transmit HIV to others.</p>
<p>But a couple of steps still need to be taken before these goals can be met. The first is large scale community based HIV testing that aims to get people tested on an annual basis at the very least. The second is linking testing to care. This is critical because it addresses the gap between a person being diagnosed with HIV to when they start antiretroviral therapy. </p>
<p>The third step is the close monitoring of people taking antiretroviral medication. The World Health Organisation (WHO) recommends <a href="http://apps.who.int/iris/bitstream/handle/10665/255702/9789241512633-eng.pdf?sequence=1">viral load testing</a> as the primary method of monitoring people on antiretroviral therapy. Viral load is the measure of the amount of HIV in a person’s blood and is used as a measure of how well a person is responding to HIV treatment. The lower the viral load the better the health outcomes. </p>
<p>WHO guidelines advise that all patients on antiretroviral therapy receive a viral load test at six months and 12 months, and annually thereafter if the patient is stable. But very few patients receive that level of care. </p>
<p>The main barrier is the time it takes to get test results back from laboratories that are often situated great distances from clinics. One way round the problem is to enable viral load testing to take place at primary health care level – what’s known as point-of-care viral load testing. This would be a game changer. Results would be known immediately and health workers could intervene swiftly by evaluating antiretroviral treatments in real time. This would, in turn, improve treatment outcomes. </p>
<p>But achieving this requires innovation. A new approach is being piloted. The idea is to test if point-of-care viral load monitoring is in reach.</p>
<h2>Testing</h2>
<p>Monitoring the viral loads of people on antiretroviral therapy is an essential part of HIV management. Viral load testing helps doctors determine if a person is taking their medication as prescribed. It also helps to determine if patients are on the correct combination of antiretroviral drugs.</p>
<p>It’s a key part of the arsenal against HIV because research shows that people who are virally suppressed are less likely to pass on the virus to someone else. That makes it a key factor in breaking the cycle of transmission.</p>
<p>The most efficient way of doing this is through point-of-care testing sites. These are based within the community so that patients don’t have to travel long distances to get tests done as well as to receive treatment. This new model is being piloted with the aim of providing convenient access to care for patients.</p>
<p>Currently nearly all viral load testing is conducted in centralised and <a href="http://www.nhls.ac.za/?page=hiv_pcr&id=61">designated laboratories</a>. This means that there can be lags in getting results back to the field. Patients can wait for weeks. </p>
<p>Laboratory based viral load testing is also expensive. Point-of-care testing is also cheaper than lab-based viral loads: health care workers could do the test rather than highly paid technicians. </p>
<p>Small steps have been made in the direction of enabling viral load monitoring to be done at point of care.</p>
<p>But additional equipment is also needed. Pilots evaluating point-of-care viral load testing are ongoing. A pilot is being run using a portable testing machine – the m-PIMA HIV1/2 – that fits on a desk top and can provide an accurate reading of viral load in under 70 minutes. </p>
<p>The machine is being tested to establish whether it meets WHO standards. Once it is given the stamp of approval by the WHO, ministries of health can start the implementation at all sites. </p>
<h2>Closing the gap</h2>
<p>All countries still struggling to bring the HIV pandemic under control are focused on achieving the 90-90-90 goals. </p>
<p>South Africa, which still has the <a href="http://www.unaids.org/en/regionscountries/countries/southafrica">biggest HIV epidemic in the world</a>, with 7.9 million people living with <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">HIV</a>, is no exception, and is making significant progress.</p>
<p>It is edging closer to the target of having 90% of people with HIV <a href="http://www.hsrc.ac.za/uploads/pageContent/9234/SABSSMV_Impact_Assessment_Summary_ZA_ADS_cleared_PDFA4.pdf">knowing their status</a>. And it’s made significant progress on the second target that 90% of people with HIV should be on treatment. </p>
<p>But it has some way to go on the third. While the country is on track to meet the goal that 90% of people on treatment be virally suppressed, it’s advances on this front haven’t been uniform. Some regions of the country still lag behind others. Being able to roll out point of care testing would go a long way in helping close these gaps.</p><img src="https://counter.theconversation.com/content/104432/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Glenda Gray is the deputy chairperson of the Orange Babies Charity in South Africa, director of HCRISA, president and CEO of the South African Medical Research Council and a board member at the NRF. She is writing this article in her personal capacity.</span></em></p>Introducing viral load testing at health facilities can help South Africa reach the United Nations target to end AIDS.Glenda Gray, Research Professor, Perinatal HIV Research Unit and President, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/905462018-01-30T15:10:35Z2018-01-30T15:10:35ZZimbabwe’s LGBT community: why civil rights and health issues go hand in hand<figure><img src="https://images.theconversation.com/files/203016/original/file-20180123-182955-1bjal0b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Zimbabwe's LGBT community has long struggled to gain recognition, protection and support.</span> <span class="attribution"><span class="source">Reuters/Juda Ngwenya</span></span></figcaption></figure><p>Zimbabwe’s recently deposed president Robert Mugabe made no secret of his loathing for gay men and lesbians. He once famously <a href="http://www.tandfonline.com/doi/full/10.1080/00918361003712087?scroll=top&needAccess=true">described them</a> as “worse than pigs and dogs”. In 2015, he stood before the UN General Assembly and <a href="https://www.youtube.com/watch?v=pxH_Rp9VIj8">declared</a> “we [Zimbabweans] are not gays”.</p>
<p>After nearly four decades, Mugabe’s reign is over. Lesbian, gay, bisexual and transgender (LGBT) groups are among those <a href="https://www.gaystarnews.com/article/lgbti-groups-celebrate-end-mugabes-reign-zimbabwe/#gs.=OeWv9A">celebrating his departure</a>. </p>
<p>But his ouster is unlikely to change the lives of LGBT Zimbabweans, for two main and interlinked reasons. The first is that this group of people remains marginalised and excluded from health policies, particularly around testing and treatment of HIV. The second is that Zimbabwe’s law frames LGBT people as criminals or “would-be” criminals – a constant threat to “normal” (that is, heterosexual) people’s health.</p>
<p>My ongoing <a href="https://www.researchgate.net/profile/Candice_Chikura_Mtwazi">research</a> suggests that work is needed to change the perception of LGBT people as both victims and carriers of HIV. Addressing the country’s laws is an important starting point. This is because there are two bits of legislation that directly affect the LGBT community: the first is that it’s illegal to be gay in Zimbabwe. The second is that it’s <a href="https://www.unodc.org/res/cld/document/zwe/2006/criminal_law_codification_and_reform_act_html/criminal_law_codification_and_reform_act.pdf">a criminal offence</a> to knowingly expose anyone to HIV.</p>
<p>The result is that people infected with HIV don’t get the treatment they need. This in turn means that HIV infections aren’t brought under control. And the public perception that people in the LGBT community are carriers of HIV is reaffirmed.</p>
<h2>Denial and exclusion</h2>
<p>Research <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435254/pdf/bmjgh-2016-000168.pdf">has shown</a> that LGBT people are simply not acknowledged as legitimate sub-groups according to the state and in the country’s HIV strategies or health policies.</p>
<p>For example, UNAIDS and the World Health Organisation <a href="http://apps.who.int/iris/bitstream/10665/246200/5/9789241511124-annexes-eng.pdf">include</a> “men who have sex with men, sex workers, transgender people” among those groups which are vulnerable to HIV infection. But LGBT groups do not feature at all in Zimbabwe’s official definition of “at risk” populations. Without this kind of policy recognition, they lack official support and protection.</p>
<p>On top of this LGBTI people often refrain from discussing their sexuality with health workers or <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435254/pdf/bmjgh-2016-000168.pdf">hide</a> certain aspects of their sexual practices. Others may <a href="https://www.outrightinternational.org/sites/default/files/559-1.pdf">stay away</a> from clinics and hospitals to avoid stigma and discrimination. </p>
<p>All of this creates porous areas through which HIV can spread. That in turn confirms the dominant narrative of LGBT people being “vectors” of the disease. </p>
<p>Zimbabwe has an estimated population of 14.2 million people; about 1.55 million of them were <a href="https://www.pepfar.gov/documents/organization/257623.pdf">living with HIV</a> in 2014. The highest prevalence (16.7%) was among people aged between 15 and 49. The country can only respond effectively to the pandemic if the state allows health policies to recognise and support all sexualities. The current policies are conditional and selective, and that doesn’t really help anyone.</p>
<h2>Is change possible?</h2>
<p>Zimbabwe’s new president Emmerson Mnangagwa was asked during a recent interview at the World Economic Forum in Davos whether his country might change its stance on sexual minorities.</p>
<p>He replied that the law would continue to prevail, <a href="https://edition.cnn.com/2018/01/24/africa/zimbabwe-president-emmerson-mnangagwa-davos-intl/index.html">saying</a>:</p>
<blockquote>
<p>In our Constitution it is banned – and it is my duty to obey my constitution.</p>
</blockquote>
<p>He then went on to say that “those people who want it [decriminalisation] are the people who should canvass for it.”</p>
<p>This sort of tacit acknowledgement of LGBT people as a group that could advocate for their rights and inclusion offers a glimmer of hope. After all, Mnangagwa’s predecessor offered no space at all for sexual minorities to argue their case. Perhaps change may yet come to Zimbabwe’s LGBT community – and to the country’s laws.</p><img src="https://counter.theconversation.com/content/90546/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Candice C. Chikura does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Zimbabwe’s new president, Emmerson Mnagagwga has offered a glimmer of hope to LGBT people in the country.Candice C. Chikura, Project Manager | Doctoral Scholar | Associate Lecturer in Law, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/893982018-01-17T12:52:36Z2018-01-17T12:52:36ZWe found ways to shorten the turnaround time for diagnosing babies with HIV<figure><img src="https://images.theconversation.com/files/199973/original/file-20171219-4951-1xdq84l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exploring ways to improve the turnaround times for HIV tests on babies.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>They say timing is everything. And in sub-Saharan Africa, where roughly a third of untreated HIV infected babies die before they reach the <a href="https://www.ncbi.nlm.nih.gov/pubmed/15464184">age of one</a>, a timely diagnosis is everything.</p>
<p>According to the latest <a href="http://www.unaids.org/sites/default/files/media_asset/AIDS-by-the-numbers-2016_en.pdf">UNAIDS data</a>, 150 000 children are infected with HIV in sub-Saharan Africa, annually. Due to the high number of children dying, diagnosing babies with HIV as early as possible is critical.</p>
<p>Public health officials have been grappling with this for many years. How can they reduce the time it takes to get newborns’ blood samples to the diagnostic lab and the test results back? This matters because it determines how soon babies can start medical treatment. The average turnaround time in sub-Saharan Africa often range <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-9-59">from one to three months</a>.</p>
<p>In general, shorter turnaround times can be achieved by improving the clinic-to-lab supply chain. This can happen through increasing the number of vehicles equipped to transport samples, hiring enough drivers, training enough medical personnel, buying the right type of diagnostic equipment, and improving communication systems.</p>
<p>African countries like <a href="https://www.ridersintl.org/malawi.html">Malawi</a> and <a href="http://www.who.int/reproductivehealth/publications/mhealth/infant_diagnosis_hiv_nigeria/en/">Nigeria</a> have done this, with impressive results.</p>
<p>But as we show in our new <a href="https://pubsonline.informs.org/doi/abs/10.1287/opre.2017.1646">study</a> improving the day-to-day operations of clinic-to-lab supply chains is simply not enough. Sometimes the opportunities lie in the structure of the supply chain itself.</p>
<p>We came to this conclusion after evaluating the early infant diagnosis network in Mozambique. It’s one of many sub-Saharan African nations struggling to improve its turnaround time for HIV testing. </p>
<p>We examined tens of thousands of cases in Mozambique right down to the original time stamps on samples and the return dates of test results. Then we developed a tool to streamline this supply chain system. We found that some simple changes could improve the turnaround time and increase the number of infants starting treatment. </p>
<h2>An inefficient system</h2>
<p>One of the biggest barriers to faster test turnaround times in Mozambique has to do with the network structure of laboratories and clinics. There are about 400 clinics in the country. These are assigned to laboratories based on governmental administrative districts. But these boundaries are drawn for political reasons instead of public health reasons. </p>
<p>As a result one administrative district may be densely populated while another is sparsely populated. And this means that the workload at the various diagnostic laboratories differs according to the size of their surrounding populations.</p>
<p>If too many clinics send their samples to the same lab, they become congested and results are delayed. But if too few clinics send their samples to a given lab, the technicians have to wait longer to gather enough samples to justify conducting tests. This is because it costs just as much to test 100 samples as it does one sample – and the materials are expensive. </p>
<h2>Changing the system</h2>
<p>For <a href="https://pubsonline.informs.org/doi/abs/10.1287/opre.2017.1646">our study</a> we developed two models which captured the operational, medical, and behavioural factors affecting an early infant diagnosis network’s effectiveness. </p>
<p>In the first model we re-assigned clinics to labs to maximize the number of infants who start treatment, by minimizing the turnaround time of results.</p>
<p>It showed us two important things. Firstly, a relatively minor modification reassigning some clinics to different labs could decrease the average sample turnaround time by 11% compared with the current system. </p>
<p>Secondly, this increased the number of infected infants starting treatment by about 4%.</p>
<p>But we took our modelling one step further. In our second model we wanted to determine if relocating the existing diagnostic machinery between labs could have an even larger public health impact. </p>
<p>What we found was that consolidating all diagnostic capacity in one centralised lab is optimal. Based on our study we predict that consolidation could decrease the average turnaround times by an estimated 22% and increase the number of infected babies initiating treatment by 7%.</p>
<p>This result has implications, as consolidating <a href="http://www.who.int/phi/publications/Increasing_Access_to_Diagnostics_Through_Technology_Transfer.pdf">diagnostic laboratories</a> has been a much-debated issue in the field of public health in sub-Saharan Africa. </p>
<h2>The bigger picture</h2>
<p>Improving turnaround times between the diagnostic lab and the clinic and speeding up the initiation date for HIV positive babies to start treatment boils down to using operations management to improve global health. </p>
<p>By shaving precious days, weeks and even months off diagnostic turnaround times, infants infected with HIV are able to get treatment quicker.</p>
<p>Whether it’s reassigning clinics among the existing labs, or optimally reallocating the diagnostic capacity to a centralised lab, improvements need to be made because timing truly is everything.</p><img src="https://counter.theconversation.com/content/89398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jónas Oddur Jónasson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Diagnosing babies with HIV as early as possible is critical to ensuring that they get onto treatment.Jónas Oddur Jónasson, Assistant Professor of Operations Management at the MIT Sloan School of Management, MIT Sloan School of ManagementLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/705552017-01-30T07:50:31Z2017-01-30T07:50:31ZAffordable, universal health care can help end AIDS — just ask Canada<p>Recently, in a Canadian hospital in British Columbia, the province where I live and work, an older man who was suffering from fatigue and post-operative issues was given an HIV test. He wasn’t a member of a high-risk group, but testing for HIV is now standard in many hospitals here.</p>
<p>The man was found to be HIV-positive. His wife, who had experienced fatigue and bruising, was also diagnosed with the disease. The couple was able to immediately access HIV treatment, leading to rapid health improvement, such as better immune function, even though they’d lived undiagnosed for several years. </p>
<p>This is standard practice in BC, where testing for HIV <a href="http://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/hiv-testing-guidelines-bc.pdf">is recommended</a> for everyone aged 18 to 70. And if people discover they are HIV-positive, doctors can connect them to a program providing immediate, universal access to <a href="http://www.cfenet.ubc.ca/drug-treatment-program">antiretroviral treatment</a>, the most cutting-edge medication currently available.</p>
<h2>Universal treatment saves lives</h2>
<p>This process contrasts sharply that of neighbouring United States.</p>
<p>There, the US Centres for Disease Control and Prevention (CDC) recommends universal HIV testing, but the Republican-controlled congress is seeking to <a href="http://obamacarefacts.com/questions/what-will-happen-if-obamacare-is-repealed/">roll back the Affordable Care Act</a>, which includes a provision that prohibits insurers from refusing treatment for “pre-existing conditions” (<a href="https://www.aids.gov/federal-resources/policies/health-care-reform/">including HIV</a>). </p>
<p>Variations in state-level eligibility criteria for Medicaid and restrictions on the uses of federal funds also continue to pose hurdles to HIV testing and treatment, particularly for marginalised populations. </p>
<p>In the US, about one in eight people living with HIV are <a href="https://www.cdc.gov/hiv/statistics/overview/ataglance.html">unaware of their status</a>. Among Blacks and Latinos, an estimated one in five are <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1697789">unaware of their infection</a>. African Americans are also least likely to get <a href="https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-supplemental-report-vol-21-4.pdf">HIV care once diagnosed</a> and one and a half times more likely to die from the disease than white Americans.</p>
<p>In the American south, where HIV is on the rise, many cases go undiagnosed. An estimated one in six HIV-positive people in Alabama <a href="http://www.adph.org/aids/assets/2014_HIVSurveillance_AnnualUpdate_FINAL_reEditedVersion.pdf">don’t know they have the disease</a>. In Louisiana, nearly a quarter of people <a href="https://www.washingtonpost.com/postlive/the-south-is-the-epicenter-of-new-hiv-infections-in-the-united-states/2012/07/20/gJQA70Z6xW_story.html">have already progressed to AIDS</a> by the time they test positive for HIV. </p>
<p>Even if Americans are diagnosed, treatment, which can cost from US$23,835 to US$42,714 a year, may well be <a href="https://www.ncbi.nlm.nih.gov/pubmed/25710311">out of their financial reach</a>. According to the CDC, in 2013 only 50% of Americans diagnosed with HIV had received treatment in the past year. </p>
<p>The threatened repeal of the Affordable Care Act under the <a href="http://www.reuters.com/article/us-usa-obamacare-hiv-analysis-idUSKBN14P228">new Republican administration</a> could worsen health outcomes for people with HIV.</p>
<h2>The UN’s ‘90-90-90’ goal</h2>
<p>America’s diagnosis and treatment statistics already fall well short of the United Nations’ <a href="http://www.unaids.org/en/resources/documents/2014/90-90-90">“90-90-90” target</a>. To have an AIDS-free generation by 2030, UNAIDS has declared that 90% of those living with HIV should be diagnosed; 90% of those diagnosed should be on treatment; and 90% of those on treatment should show a suppressed viral load.</p>
<p>The 90-90-90 target is based on the concept of “treatment as prevention” (<a href="http://cfenet.ubc.ca/tasp">TasP</a>), which was first introduced to the world in 2006 by the director of British Columbia’s Centre for Excellence in HIV/AIDS (BC-CfE), Dr. Julio Montaner.</p>
<p>Years of scientific evidence has conclusively shown that providing treatment to all people living with HIV – no matter what their economic situation or <a href="https://www.ncbi.nlm.nih.gov/pubmed/10102000">stage of the disease</a> – improves <a href="http://www.cfenet.ubc.ca/news/releases/study-life-expectancy-people-living-with-hiv-canada-now-reaches-65-years-age">health and longevity</a>, stops the disease from <a href="http://www.cfenet.ubc.ca/news/releases/study-finds-aids-incidence-and-related-deaths-drastically-decreasing-bc-with-access">evolving into AIDS</a> and reduces the likelihood of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4158850/">HIV transmission</a>.</p>
<p>With consistent and sustained treatment, people living with HIV achieve a viral load that is undetectable by standard blood tests, at which point their chances of spreading HIV becomes negligible. A study released <a href="http://www.aidsmap.com/No-one-with-an-undetectable-viral-load-gay-or-heterosexual-transmits-HIV-in-first-two-years-of-PARTNER-study/page/2832748">in 2014</a> followed 800 couples in which one partner was HIV-positive with a viral load below <a href="http://jamanetwork.com/journals/jama/fullarticle/2533066">200 copies per mL</a> and found that after two years, none of the partners had been infected.</p>
<h2>Cost-effective care</h2>
<p>Expanding access to earlier treatment through TasP not only save lives, it also saves money. </p>
<p>At the BC-CfE, where I am a lead health economist, we’ve researched how to best allocate resources to improve population health. Our work has demonstrated that although treatment for one person is expensive in the short term, in the long term it is a cost-effective pathway to curbing the HIV epidemic. </p>
<p>The estimated lifetime health-care cost for individuals infected at age 35 is US$343,222 (60% for antiretroviral medications). For HIV-negative individuals in HIV high-risk groups, the lifetime health-care cost estimate is US$101,652.
Therefore, each HIV infection avoided <a href="https://www.ncbi.nlm.nih.gov/pubmed/25710311">saves US$241,570</a>.</p>
<p>In British Columbia, where TasP was implemented with support <a href="http://www.theglobeandmail.com/news/british-columbia/bc-the-lone-province-to-adopt-hiv-treatment-as-prevention-strategy/article14920379/">from the provincial government</a>, there has been a consistent decline in new HIV cases and a nearly <a href="http://www.thelancet.com/journals/lanhiv/article/PIIS2352-3018(15)00017-X/abstract">90% decrease in HIV-related morbidity and mortality</a>. </p>
<p>Our research has determined that this expanded HIV testing and treatment could save BC up to C$66.5 million in public spending over <a href="http://www.cfenet.ubc.ca/news/releases/expanding-access-haart-saves-millions-health-care-and-productivity-costs">25 years</a> by averting new infections, delaying or avoiding costly hospital stays and enabling people living with HIV to stay in the workplace.</p>
<h2>Treatment going global</h2>
<p>Such a regime could pave the way to a more sustainable health-care system, which is an important incentive in countries with rising health-care costs. </p>
<p>Today, with a US$2.5 million grant from the US National Institute of Drug Abuse (NIDA), the BC-CfE is providing economic modelling and investigating the optimal combination of interventions to fight HIV epidemics in New York, Los Angeles, Baltimore, Miami, Atlanta and Seattle.</p>
<p>The BC-CfE is also consulting with China’s Centre for Disease Control. Though China has <a href="https://www.avert.org/professionals/hiv-around-world/asia-pacific/china">generally low HIV rates</a>, certain regions have higher prevalence of the disease, and challenges remain in reaching the population groups most affected by HIV. The BC-CfE has shown that streamlining the testing process in a largely rural province of China could be a cost-effective way of more quickly connecting people to treatment. </p>
<p>China was the first country to adopt TasP as a strategy to combat HIV and AIDS, <a href="http://www.cfenet.ubc.ca/news/forecast/memorandum-understanding-cements-relationship-between-china-and-bc">in 2013</a>. In 2016, it announced that treatment through antiretroviral therapy should be available to <a href="http://www.cfenet.ubc.ca/news/in-the-news/china-offers-free-treatment-all-diagnosed-with-hiv">all people diagnosed with HIV</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/154484/original/image-20170126-30385-1bebkgd.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The BC Centre for Excellence in HIV/AIDS signing an agreement to support China’s efforts to address HIV, in Beijing.</span>
<span class="attribution"><span class="source">BC Centre for Excellence in HIV/AIDS</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Since 2013 Panama, Brazil, Spain, France and Sierra Leone have joined China in adopting TasP, as have the US cities of San Francisco and Washington, DC. </p>
<p>There are challenges, of course. Social determinants of health, such as homelessness, unemployment and mental health issues, still pose barriers to care. BC connects especially vulnerable and hard-to-reach populations <a href="http://www.cfenet.ubc.ca/stop-hiv-aids/about">to treatment</a> with dedicated efforts by outreach workers, social workers and nurses. </p>
<p>Addressing their needs for housing, proper nutrition or counselling first can enable a routine of <a href="http://www.cfenet.ubc.ca/blog/addressing-social-determinants-health-expand-access-testing-and-treatment">consistent HIV care</a>. But such targeted outreach is harder to coordinate in rural areas and in developing nations. </p>
<p>Still, interventions such as TasP that meet key populations where they are, rather than require behavioural change or financial hardship to obtain treatment, are one proven path to expanding access to <a href="http://www.unaids.org/en/resources/presscentre/featurestories/2016/november/20161121_keypops">HIV testing, care and treatment</a>.</p>
<p>It is possible to end AIDS. All that is required is the political will to do so.</p><img src="https://counter.theconversation.com/content/70555/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bohdan Nosy is a research scientist for the The British Columbia Centre for Excellence in HIV/AIDS (BC-CfE), which has received funding from the National Institutes of Health (NIH) for research work conducted in the United States and China. Research reported in this article was supported by the National Institute on Drug Abuse of the NIH under award numbers CTN-0056 and R01 DA041747. Dr. Bohdan Nosyk is also a Michael Smith Foundation for Health Research Scholar and holds the St. Paul’s Hospital CANFAR Chair in HIV/AIDS Research (a partnership with the St. Paul’s Hospital Foundation and the Faculty of Health Sciences at Simon Fraser University).
The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
</span></em></p>Thanks to universal testing and easy access to treatment, the Canadian province of British Columbia has seen a major decease in HIV-related mortality.Bohdan Nosyk, Associate Professor and Endowed Chair, Economics of HIV/AIDS at the Faculty of Health Sciences, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/621362016-07-12T16:16:26Z2016-07-12T16:16:26ZHIV, AIDS and 90-90-90: what is it and why does it matter?<figure><img src="https://images.theconversation.com/files/130271/original/image-20160712-9264-y3w75c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Ajay Verma/Reuters </span></span></figcaption></figure><p><em>Twenty years ago when someone acquired HIV, they would, on average, not live more than 12 years. Today, a young person who becomes infected in the developed world can expect to have a near-normal lifespan with access to lifelong, uninterrupted HIV treatment. Globally, the HIV/AIDS community has worked hard to realise the Sustainable Development Goal of ending the AIDS epidemic by 2030. One crucial part of this plan is bringing HIV treatment to all who need it. Professor
Glenda Gray, President of the South African Medical Research Council, explains the importance of 90-90-90 and why there is so much talk around it.</em></p>
<p><strong>What is 90-90-90?</strong></p>
<p>A concept introduced by the United Nation’s programme on HIV/AIDS in 2013, <a href="http://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_en.pdf">90-90-90</a> is a set of goals. The idea is that by 2020, 90% of people who are HIV infected will be diagnosed, 90% of people who are diagnosed will be on antiretroviral treatment and 90% of those who receive antiretrovirals will be virally suppressed. <a href="https://www.verywell.com/viral-suppression-3132658">Viral suppression</a> is when a person’s viral load – or the amount of virus in an HIV-positive person’s blood – is reduced to an undetectable level.</p>
<p>The strategy is an attempt to get the HIV epidemic under control and is based on the principal of universal testing and treating. What is central to “test and treat” approaches is that if one can identify people early on in their infection, and start treatment so they become virally suppressed, the onward transmission of HIV will be prevented and this will impact on HIV incidence at a population level.</p>
<p>There are an estimated <a href="http://www.unaids.org/en/resources/fact-sheet">36.7 million HIV-positive</a> people across the globe. In line with this, the goals would mean that 33.2 million of these people would be diagnosed, 29.5 million would be on antiretrovirals and 26.9 million would have viral suppression.</p>
<p>According to some of the <a href="http://www.unaids.org/en/resources/fact-sheet">latest figures</a>, there are only 19.8 million people – or 53% – who have been tested. About 13.4 million people remain undiagnosed. There are 17 million people on antiretrovirals while a substantial 12.9 million have not been initiated on antiretrovirals and remain untreated. Of those on antiretroviral treatment, only 11.6 million have viral suppression, which means that almost a third of HIV-infected individuals on treatment are not virally suppressed. This not only impacts on the development of antiretroviral drug resistance and future treatment options; it also has implications for the onward transmission of HIV.</p>
<p><strong>How realistic is this plan?</strong></p>
<p>This is a strategy to try and control the HIV epidemic and get towards an HIV-free world. The concept of universal test and treat is an aspirational concept, but it is an incredibly difficult plan to implement at scale, particularly in resource-poor settings that are heavily burdened with HIV.</p>
<p>This plan entails that the health service identify HIV in people who are not symptomatic, and who are not seeking care. It entails taking HIV testing out of the clinics and into the community, and requires new and innovative ways to get people tested for HIV infection. In order to make this plan realisable the health system has to endeavour to make HIV testing easily available even in the most remote areas of the world.</p>
<p>The second component of this plan entails ensuring that HIV-infected individuals are triaged into care, and they need to start antiretroviral treatment as close to diagnosis as possible. People who are asymptomatic and well may not feel ready to start taking treatment for life, which means that there needs to be adequate counselling and support, and the health benefits of early initiation of care need to be adequately explained.</p>
<p>Antiretroviral drugs need to be available in all places at all times. Once treatment is initiated, the aim is to keep people on treatment and adherent so that they can be virally suppressed and incapable of transmitting the virus to sexual partners, and to have maximal health benefits from early initiation of treatment. It also requires countries to have at least three lines of drug therapy. Currently only five countries in sub-Saharan Africa have three lines of treatment for people to transition onto once they have drug resistance or experience toxicities.</p>
<p>Most countries are unable to realise these ambitious programmes. There are several reasons for this:</p>
<p>First, they require resources for extraordinary access to HIV testing. Second, they need resources to procure drugs and prevent stock-outs. And, lastly, they need resources to keep people on treatment for life. No country either rich or poor can boast this kind of access or resources.</p>
<p>Although resource-rich countries that have less of a burden of disease are more likely to get and retain people on treatment, in heavily burdened countries there are difficult choices to make as a government, as programmes such as this require extraordinary resources.</p>
<p>It entails a robust health system, innovation to improve HIV testing access, and antiretroviral supplies that will be uninterrupted and support all three lines in case of drug resistance. It will entail not only a robust health system but a cadre of health-care workers who are trained and able to deliver a good service.</p>
<p>It also requires financial investment and a country that sees the investment case and is willing to put its own money and not that of donors into the programme.</p>
<p><strong>Which countries have made remarkable progress towards 90:90:90?</strong></p>
<p>In Africa, Botswana is close to reaching the 90-90-90 target for testing, treatment and viral suppression. Botswana was the first country on the African continent to provide free antiretroviral treatment to people with HIV, starting in 2002. Furthermore it has achieved its level of coverage when providing treatment to people with CD4 cell counts below 350 cells/mm³, even before moving to providing treatment for everyone diagnosed with HIV infection.</p>
<p>Previous international reviews of treatment cascade performance have shown that northern European countries and Australia have made the greatest progress towards reaching the 90-90-90 target.</p>
<p>Switzerland, Australia, the UK, Denmark and the Netherlands were well on their way to achieving this target. In each case, easily attainable improvements in the rate of diagnosis or treatment initiation should allow these countries to reach the goal.</p>
<p><strong>Which countries are struggling to reach the 90:90:90 goals?</strong></p>
<p>Many countries are struggling to reach these targets because of hard-to-reach populations. Testing and treatment has enormous challenges irrespective of the country you live in.</p>
<p>Many of those who receive HIV treatment are those who are the easiest to reach. This means that the road to universal access for all populations still poses major challenges.</p>
<p>There are substantial coverage gaps in many regions. To use Africa as an example: in 2013, treatment coverage on the continent ranged from <a href="http://www.unaidsrstesa.org/wp-content/uploads/2015/06/unaids_profile_Regional.pdf">41% in eastern and southern Africa</a> to 11% in the <a href="http://onusidalac.org/1/images/botones/UNAIDS_Treatment_target_V5.pdf">Middle East and North Africa</a>.</p>
<p>At least 30 countries in the world account for <a href="http://www.unaids.org/sites/default/files/media_asset/201506_JC2743_Understanding_FastTrack_en.pdf">89% of all new HIV infections</a>. At least 18 of these countries are in Africa, including Côte d’Ivoire, the Democratic Republic of the Congo, Mozambique, Nigeria and South Africa. But the list also includes other low- and middle-income countries like Brazil, China and India, and high-income countries like the US.</p><img src="https://counter.theconversation.com/content/62136/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Glenda Gray does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The 90-90-90 strategy is an attempt to get the HIV epidemic under control by adopting a ‘test and treat’ approach. This is part of the plan to eliminate AIDS by 2030.Glenda Gray, Research Professor, Perinatal HIV Research Unit and President, South African Medical Research CouncilLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/608322016-06-10T11:05:25Z2016-06-10T11:05:25ZWe will never stop AIDS as long as sexism and homophobia go unchallenged<p>The HIV/AIDS pandemic has destroyed or damaged the lives of many tens if not hundreds of millions of people across the world. The World Health Organisation reports that <a href="http://www.who.int/gho/hiv/en/">in 2014</a> 39.9m people worldwide were living with HIV or AIDS, and that 1.2m died from AIDS-related illnesses – and the disesase continues to disproportionately affect the most vulnerable people and societies. </p>
<p>Now a new attempt has been made to rally the world behind a strategy. The <a href="http://www.unaids.org/en/aboutunaids/unitednationsdeclarationsandgoals/2016highlevelmeetingonaids">2016 High-Level Meeting on Ending AIDS</a>, held at the UN General Assembly, focused on the importance of accelerating the response to HIV with a view to ending the pandemic by 2030, and reached a <a href="http://www.unaids.org/en/resources/documents/2016/2016-political-declaration-HIV-AIDS">political declaration</a> that sets targets to “[end the epidemic as a public health threat by 2030](](http://www.un.org/apps/news/story.asp?NewsID=54172)”.</p>
<p>But ambitious as it is, the declaration fails to address one of the most crucial factors driving the pandemic: discrimination along the lines of racism, sexism, homophobia, and transphobia, as well as religious fanaticism and denials of societal problems such as gender-based violence. </p>
<p>The meeting and the declaration made it clear that many states still prioritise their own political objectives over the need for education, awareness-raising, and the ending of discrimination. A great many countries simply refuse to acknowledge that the discrimination and intolerance they still incubate are major factors in the disease’s spread. </p>
<p>They refuse to champion education and awareness-raising about the disease, particularly within marginalised and vulnerable groups. Instead, they persist with policies, practices and beliefs that create precisely the social conditions in which the virus can spread faster.</p>
<p>This is a major obstacle in the fight to limit and stop the advance of the disease. As the international advocacy organisation <a href="http://www.aidsfreeworld.org/">AIDS-Free World</a> has long argued, “<a href="http://www.aidsfreeworld.org/About-Us/History.aspx">when discrimination ends, so will AIDS</a>”.</p>
<p>As the academic Susana T Fried <a href="https://www.opendemocracy.net/ending-HIV-ideology-vs-evidence-at-UN">explained</a>, there are three main reasons this persists: a refusal to name the communities most affected globally by HIV and AIDS, namely men who have sex with men, transgender women, drug users and sex workers; efforts to dismiss or downplay the clear evidence that gender-based violence plays a significant role in the spread of HIV; and efforts to block the declaration from stressing the need for comprehensive sex education.</p>
<h2>Standing in the way</h2>
<p>Anyone who follows events at the UN will not be surprised to learn that the countries at the forefront of undermining this latest effort are countries where homophobia, transphobia, gender-based violence, gender-discrimination, religious fanaticism, and intolerance of minority religions and beliefs are encouraged or tacitly approved by state laws and practices. </p>
<p><a href="http://www.bbc.co.uk/news/world-25927595">More than 70</a> UN member states criminalise the acts or identities of sexual and gender minorities. If the declaration from the 2016 meeting named the communities that these states marginalise and abuse, it would effectively force them to acknowledge that those groups exist and are vulnerable rather than criminal. And that in turn could actually require states to provide these people with health and other services.</p>
<p>But as so often happens when it comes to human rights at the global level, there’s a dangerous paradox here. Even if language acknowledging vulnerable people could be forced into the declaration, it wouldn’t necessarily protect these people from their own governments.</p>
<p>People trying to access HIV/AIDS services grudgingly provided by inhospitable states (if they did indeed provide them) would effectively be “outed” to the authorities. And identifying such groups as “vulnerable” could well be used to further stigmatise, belittle or oppress their members. </p>
<p>More dispiriting still, these matters have received too little attention at the General Assembly, and the motivations of the states trying to block them have gone largely unchallenged.</p>
<p>Many countries where gender discrimination remains entrenched within law and culture haven’t even accepted that gender-based violence is a problem, let alone moved to address it. Those states have blocked any effort to acknowledge the clear evidence of the link between gender-based violence and the spread of HIV. They have no incentive to acknowledge that this abuse leads to the disproportionate spread of HIV amongst victims (almost always women and girls). </p>
<p>Equally, countries marked by religious fanaticism and intolerance of minorities are generally unlikely to support comprehensive sex education. In many such countries, sexual, reproductive and bodily autonomy directly contradict laws, practices and norms once again, particularly when it comes to women and girls. </p>
<h2>One way forward</h2>
<p>If these obstacles cannot be cleared, the world stands little chance of finally halting the spread of HIV, preventing AIDS-related deaths, and ending the abusive practices that have allowed and enabled the global pandemic to continue.</p>
<p>Still, simply criticising those countries for bringing their national political agendas to the table makes little sense. After all, as the legendary diplomat Sergio Vieira de Mello <a href="https://books.google.co.uk/books?id=K9IeQkuhepIC&pg=PA83&lpg=PA83&dq=fish+criticising+one+another+for+being+wet&source=bl&ots=L3AuCwqnlz&sig=QIxrkC32zlIHFRFTrDCERUAX348&hl=en&sa=X&ved=0ahUKEwjQxPzRpJvNAhWrCcAKHSdpC10Q6AEIHjAA#v=onepage&q=fish%20criticising%20one%20another%20for%20being%20wet&f=false">pointed out</a>, UN members criticising other countries for being political is akin to fish criticising each other for being wet. But it’s equally senseless to expect multilateral negotiations between states who have vested and politicised interests in watering down the text of a declaration until it’s no longer fit for purpose.</p>
<p>This global health crisis requires the sort of response seen during any other time of grave public emergency: expert-led norms, policies and practices imposed upon all states across the world irrespective of whether they contradict national attitudes and agendas on gender, sex, religion or the restriction of the rights of minorities. </p>
<p>That is not statement of colonial intent. It is an already established norm. We already aim to enforce global laws on many other global threats to human life; we should do the same to combat this disease.</p><img src="https://counter.theconversation.com/content/60832/count.gif" alt="The Conversation" width="1" height="1" />
<h4 class="border">Disclosure</h4><p class="fine-print"><em><span>Rosa Freedman receives funding from the British Academy, the ESRC and the Society of Legal Scholars.</span></em></p>Enough tiptoeing around: without ending state discrimination, we have little hope of stopping HIV and AIDS.Rosa Freedman, Senior Lecturer (Law), University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/543932016-02-17T04:29:07Z2016-02-17T04:29:07ZAIDS: how far the world has come and how far it needs to go to get to zero<figure><img src="https://images.theconversation.com/files/111626/original/image-20160216-19232-18o0se6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man lights candles as part of a World AIDS Day event in Jakarta.</span> <span class="attribution"><span class="source">Dadang/Tri</span></span></figcaption></figure><p><em>Foundation essay: Our foundation essays are longer than usual and take a wider look at key issues affecting society.</em></p>
<p>There is no story in global health as transformative, awe-inspiring, and yet as tragic as the AIDS pandemic. The disease was unknown only a generation ago — a medical curiosity among young gay men in New York and San Francisco in June 1981. </p>
<p>Within a few short years, AIDS could be found on every continent, enveloping the world to become one of the most devastating pandemics in human history. It has caused untold human suffering, social disintegration, and economic destruction.</p>
<p>In the early days of the pandemic, public health officials relied on prevention strategies devised for other sexually transmitted diseases. This includes testing, counselling, education, condoms and partner notification. </p>
<p>Newly diagnosed people had an average survival period of six to eight months. And their weakened immune systems made them vulnerable to rare cancers, pneumonias, chronic fatigue and horrific wasting until death ensued. </p>
<h2>The early years of fear, pain and despair</h2>
<p>The socio-political response was, at best, denial, ignorance, and silence. Ronald Reagan, US President at the time, did not utter the word “AIDS” in public until 1986. At worst, it was social marginalisation, discrimination, and punishment. People were blamed for their own suffering and criminalised for their behaviour. The fear, pain, and despair faced by people living with AIDS and their loved ones cannot be overstated.</p>
<p>But by 2010, <a href="http://www.unaids.org/">UNAIDS</a> announced a goal that was once unimaginable: <a href="http://www.unaids.org/sites/default/files/sub_landing/files/JC2034_UNAIDS_Strategy_en.pdf">getting to zero</a>. Zero new infections, zero AIDS-related deaths and zero discrimination. </p>
<p>The 2012 International AIDS Conference was held in the US for the first time in 22 years because the US restricted entry of persons living with HIV between 1990 and 2011. At the conference, then Secretary of State Hillary Clinton called for an AIDS-free generation. To be sure, these high hopes provoked a skeptical response, with experts saying the goal was unrealistic and open-ended. What exactly is the definition of “zero” or “AIDS-free,” and which generation are we talking about? </p>
<p>But stepping back from perennial debates about aspiration tempered by realism, it is impossible not to marvel at the technological advances that enabled global health leaders to say the unthinkable: that we may one day see the end of the scourge of AIDS.</p>
<h2>Powerful technological interventions</h2>
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<p>The technological advances that made all this possible include, first and foremost, <a href="http://www.who.int/hiv/topics/treatment/en/">antiretroviral</a> treatments. A newly diagnosed 25-year-old today can expect to live another 50 years on treatment. But it also includes combination prevention, which extends well beyond traditional methods of testing, counselling, condoms and education. These do remain vital. </p>
<p>Research has shown remarkable reductions in HIV transmission from <a href="http://www.who.int/hiv/topics/malecircumcision/en/">male circumcision</a>, pre-exposure <a href="https://www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/pre-exposure-prophylaxis/">prophylaxis</a> (PrEP), and antiretroviral therapy. </p>
<p>At the 2011 International AIDS Conference, scientists announced a jaw-dropping 95% plus reduction in sexual transmission among heterosexual couples adhering to antiretroviral treatment.</p>
<p>What if it were possible to reach every person at risk, or already infected, with these powerful interventions? What if the next discovery could empower women to protect themselves, such as with a vaginal <a href="http://www.who.int/hiv/topics/microbicides/microbicides/en/">microbicide</a>, which is on the horizon? Given the political will, isn’t it imaginable that the international community could “get to zero”?</p>
<p>How did all these technological advances come about, and why did this particular disease forge a pathway toward unprecedented scientific discoveries? Very sadly, science has not been able to match these technological advances for most global health challenges. Not mental illness, cancer, or tuberculosis. </p>
<p>It has been said that these are all highly complex, multi-factorial diseases, while AIDS is not. But this is far from the truth.</p>
<h2>Social mobilisation like never before</h2>
<p>AIDS is one of the most complicated and stubbornly persistent diseases the world has ever known. Yet the sociopolitical dimension of AIDS has galvanised perhaps the greatest social mobilisation around a health crisis that the world has seen. </p>
<p>From the AIDS Coalition to Unleash Power <a href="http://www.actupny.org/documents/capsule-home.html">(ACT UP)</a> and Lambda Legal <a href="http://www.lambdalegal.org/">Defense</a> in the US to the Treatment Action <a href="http://www.tac.org.za/">Campaign</a> in South Africa, courageous individuals and organisations have literally transformed the politics of AIDS, turning neglect and derision into empowerment and social action.</p>
<p>This vast social mobilisation was targeted not only at fighting the social dimensions of this disease with poignant calls for dignity, nondiscrimination, and justice. It was perhaps principally about access to medicines. </p>
<p>AIDS campaigns had crisp clarity, appealing to a basic sense of social justice: the rich have access to life sustaining medicines while the poor do not. This message resonated in developed countries where the poor often were denied access to antiretroviral medication. But it also resonated in developing countries where most people could not afford a life-saving pill that the majority of those in the developed world could access.</p>
<p>The access-to-medicines campaigns brought AIDS advocates to pursue solutions beyond the health sector. Activists directly attacked the prevailing trade liberalisation paradigm, which protects intellectual property, and asserted the higher priority of the right to health.</p>
<p>In South Africa the TAC <a href="http://www.tac.org.za/documents/MTCTCourtCase/ConCourtJudgmentOrderingMTCTP-5July2002.pdf">successfully challenged</a> the government’s restrictions on access to perinatal treatment before the Constitutional Court. At the international level, the AIDS movement energised the World Health Organisation to take access to medicines seriously. This prompted campaigns such as the World Health Organisation’s <a href="http://www.who.int/3by5/en/">3 by 5</a> initiative. It forced the World Trade Organisation to change course, introducing Doha Declaration <a href="https://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm">flexibilities</a> to soften a harsh intellectual property regime.</p>
<h2>A global effort</h2>
<p>This social mobilisation also unleashed unprecedented resources in global health — new funding for biomedical research, vaccines, and treatment. Moreover, social mobilisation around AIDS literally transformed global health governance. It fundamentally altered the foreign assistance of the most powerful countries. For example PEPFAR in the United States, and <a href="http://www.unitaid.eu/en/">UNITAID</a>, formed by Brazil, Chile, France, Norway, and the United Kingdom. </p>
<p>For the first time, the major powers began to frame an infectious disease as a national security threat, addressed at the highest political levels at the G8. Social mobilisation drove the United Nations’ response, prompting the first high-level summit ever held on a health issue to be devoted to AIDS.</p>
<p>A novel public-private-partnership emerged, outside the UN/WHO structure, to generate and pool resources — the Global Fund to Fight AIDS, Tuberculosis and Malaria.</p>
<p>Although the international community has rallied to fight AIDS, fierce debates have raged within the movement. Initially, advocates worried that traditional public health strategies such as testing and reporting would undermine privacy or foster discrimination. At the same time, policy makers debated which interventions — and in what combination — were most effective. And then there was the divisive issue of cost-effectiveness. Could governments afford expensive interventions such as lifetime treatment with antiretrovirals? </p>
<p>If not, how could the benefits be fairly allocated among the large population of persons at risk or living with HIV? And should the same level of resources devoted to AIDS be made equally available for other pressing health conditions, such as child/maternal health, injuries, or non-communicable diseases? </p>
<p>These battles ensued within both domestic health sectors and foreign health assistance budget debates. They remain topics of lively debate.</p>
<p><em>*This is the first of three articles drawn from the book <a href="http://www.hup.harvard.edu/catalog.php?isbn=9780674728844.">Global Health Law</a>, released by Professor Lawrence Gostin.</em></p><img src="https://counter.theconversation.com/content/54393/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lawrence O. Gostin does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Globally, the health community is moving to a point where there could be zero new HIV infections or deaths. But it has been a long road.Lawrence O. Gostin, Professor of Global Health and Director, O'Neill Institute, Georgetown UniversityLicensed as Creative Commons – attribution, no derivatives.