In areas with high HIV prevalence and low rates of male circumcision, voluntary medical male circumcision (VMMC) can greatly contribute to HIV prevention. Despite this, there was a steep drop in the number of VMMCs performed in the 15 priority countries in 2020, due mainly to service disruptions caused by the COVID-19 pandemic: approximately 2.8 million procedures were performed in 2020, compared with 4.1 million in 2019.

Several countries suspended their programmes when the pandemic took hold, including South Africa. Despite this, programmes in some countries proved resilient enough to recover quickly and expand during the rest of 2020—notably in Rwanda and Zambia, where programme coverage grew by about 15%. In these countries, adjustments for the safe continuation of VMMC services during COVID-19 included changes in promotion and demand generation, client transportation, service delivery at a health facility or in the community and post-procedure follow-up appointments.

A total of about 18 million VMMCs were performed in 2016–2020, far shy of the 2020 target of 25 million. As well as COVID-19, an additional setback in 2015 and 2016 was the detection of tetanus cases in Uganda, which led to activities being scaled back in that country.

HIV service disparities by race have been documented in several parts of the developed world.

In the United States of America, black people account for a disproportionately large percentage of new HIV infections in the country: 41% in 2019, although they represent only about 13% of the national population. This is in part due to lower coverage of HIV prevention services. Just 8% of black Americans and 14% of Hispanics/Latinos who were eligible for pre-exposure prophylaxis were prescribed it, compared to 63% of whites.

Studies also report significant racial disparities in HIV treatment outcomes, with delayed initiation of treatment and care, lower adherence to antiretroviral therapy, increased stigma and discrimination, mistrust of or lack of access to health-care providers and inadequate access to health insurance among the contributing factors. Many of these gaps are among black and Latino gay men and other men who have sex with men, who must contend with both racial inequalities and homophobia.

Data from South Africa highlight the challenge faced by many treatment programmes when it comes to successfully retaining people in HIV care.

The HIV treatment programme in South Africa reaches more people living with HIV than any other in the world, with more than 5 million adults (aged 15 years and older) receiving antiretroviral therapy in 2020. Among the 2.5 million adults living with HIV in South Africa who are not on treatment, a steadily increasing percentage are people who had started treatment but are no longer receiving it.

Efforts to support people on treatment to maintain treatment and achieve durable viral suppression are critical to improving health outcomes, maximizing the preventive benefits of treatment and preventing the emergence of drug-resistant strains of HIV. The World Health Organization recently updated its HIV treatment guidelines with a new recommendation to trace people who have disengaged from care and provide support for re-engagement.

The neighbouring Baltic states of Estonia and Latvia offer starkly contrasting examples of how different public health approaches affect HIV epidemics among people who inject drugs. In the early 2000s, the two countries had among the highest rates of HIV diagnosis in Europe. As was the case for many European countries at that time, the sharing of non-sterile injecting equipment among drug users was fuelling their HIV epidemics.

The two epidemics began to diverge in the mid-2000s. According to the HERMETIC study, new HIV infections in Estonia declined by 61% countrywide and by 97% among men who inject drugs between 2007 and 2016.

Latvia’s HIV epidemic followed a different trajectory. The HERMETIC study highlights that, between 2007 and 2016, new HIV infections increased by 72% overall. By 2016, overall HIV incidence in Latvia was almost double that in Estonia (35 cases per 100 000 people versus 19 cases per 100 000).

Both epidemics centred largely on the sharing of injecting equipment by people who inject drugs, and probably on unprotected sex between people who inject drugs and their sexual partners. The HERMETIC study concludes that the main difference between the two epidemics lay in the availability of harm reduction services.

Needle–syringe programmes had been operating in Latvia since 1997, but on a very limited scale. As late as 2016, Latvia was distributing about 93 needle–syringes per drug user per year; neighbouring Estonia was distributing 230 per user per year. Both countries expanded access to opioid substitution therapy, which is proven to reduce drug injecting and HIV transmission, and improved HIV testing and antiretroviral therapy services for people who inject drugs. Although access to opioid substitution therapy remained limited in both countries, it was higher in Estonia than in Latvia.

The HERMETIC study’s results indicate that by 2016, about half the people who inject drugs in Estonia were taking HIV tests in a 12-month period—and three quarters of those who tested HIV-positive were on antiretroviral therapy. In Latvia, meanwhile, about 10% of people who inject drugs took an HIV test in any given year between 2007 and 2016, and only 27% of those living with HIV were on antiretroviral therapy. Slow adoption of international HIV treatment guidelines contributed to the low treatment coverage in Latvia.

Underinvestment in the HIV responses of low- and middle-income countries was a major reason why the global targets for 2020 were missed. Financial resource availability during the past five years was consistently below the resources needed, and in 2020 it was 29% less than the US$ 26 billion target for that year (in constant 2016 US dollars).

In western and central Africa, large resource shortfalls and continued reliance on out-of-pocket expenditures (such as user fees for health services) are associated with more modest declines in the incidence of HIV infection and the rate of AIDS-related mortality compared to eastern and southern Africa, where a combination of domestic and international investments has fuelled the rapid expansion of HIV prevention, testing and treatment in areas with a high burden of HIV, resulting in strong and steady reductions in the rate of HIV infections and AIDS-related mortality.

The cost of antiretroviral medicines has a major effect on resource needs for HIV responses. Currently, the average prices for first- and second-line antiretroviral therapy are broadly similar in low- and lower-middle-income countries, but are substantially higher in upper-middle-income countries.  

For example, countries in eastern Europe and central Asia and in Latin America tend to pay considerably higher prices for antiretroviral medicines compared with countries in other regions. Further price reductions for antiretroviral medicines and other key HIV commodities can be achieved through the strategic use of flexibilities under the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and by rearranging procurement and supply management systems to take advantage of economies of scale. If these and other cost savings are made, a 17% increase in resources for HIV testing and treatment can result in a 35% increase in the number of people receiving treatment by 2025—enough to reach the 95–95–95 testing and treatment targets.

Current inequalities in HIV testing and treatment for children living with HIV and trends in historical coverage of services to prevent vertical (mother-to-child) transmission of HIV are driving year-on-year trends in AIDS-related mortality.

Reductions in AIDS-related deaths among children and adolescents are steepest among children aged 0 to 9 years (a 60% decline since 2010), reflecting both improvement in efforts to prevent new vertical infections and efforts to diagnose and treat children in the months following childbirth and during breastfeeding.

However, among adolescents (aged 10–19 years), progress is slower, with AIDS-related deaths declining just 37% over the same period.

The single biggest paediatric treatment challenge is to rapidly find children living with HIV who were missed at birth or during breastfeeding and link them to care. Scale-up of rights-based index, family and household testing and self-testing, and integrating HIV screening with other child health services, can help close this gap.