The Republic of Moldova has launched an online platform, ScorecardHIV, to measure progress in the country's HIV response.

The new tool includes indicators and data on epidemiology, funding and procurement, programmes, human rights and community-led services. It will allow governmental institutions, health programme managers, HIV service organizations, communities and other stakeholders to track the progress and assess the effectiveness of HIV programmes in the country. A data filtering system allows the customization of indicators in accordance with the user’s interests and needs.

“The ministry will take the lead and provide political support to make sure further implementation of the tool is as effective, systematic and sustainable as possible,” said Denis Chernelya, the Secretary of State at the Ministry of Health, Labour and Social Protection. “It will be an extremely useful tool for internal monitoring as well as for understanding the main factors that contribute or impede the achievement of the set targets.”

The scorecard aims to ensure open, transparent and collective state and community-led monitoring of the HIV response. It will contribute to real-time data analysis and a rapid evidence-informed HIV response. The platform was developed by the UNAIDS Country Office for the Republic of Moldova together with the Positive Initiative nongovernmental organization and other local civil society organizations under the auspices of the Ministry of Health, Labour and Social Protection and the National Programme for the Prevention and Control of HIV/AIDS and Sexually Transmitted Infections.

The indicator map of the scorecard, which was discussed and agreed upon by all stakeholders, is sourced from the national HIV programme, ministries and government agencies and civil society organizations and is updated regularly, depending on the selected indicator—once a month, quarterly or half yearly. The platform allows data to be aggregated from different applications and sources and visualizes progress and failures in HIV programme implementation almost in real time. A task force consisting of several community organizations will update the scorecard and periodically review it.

The scorecard demonstrates how real-time data, technology and innovation can be of service for evidence-informed decisions and can strengthen cooperation between the government and communities.

“If we need to make decisions today, then we need the most recent data today. All our efforts were aimed at digitizing all possible processes, creating an infrastructure and finding IT solutions where everything can be accumulated, and then creating an analytics tool that will show us the main indicators,” said Ruslan Poverga, the Director of the Positive Initiative.

“We welcome such an important development in the Republic of Moldova,” said Alexander Goliusov, Director, a.i., of the UNAIDS Regional Support Team for Eastern Europe and Central Asia.  “The scorecard was developed in line with the core principles of the new global AIDS strategy, including significant and measurable participation of civil society, a national response based on the available scientific evidence and technical knowledge, and respect for human rights and gender equality. I believe that the ability to track progress in real time, identify priority areas for rapid measures and political will and buy-in by the county’s national authorities will enable the Republic of Moldova to significantly accelerate progress towards the goal of ending AIDS by 2030.”

The gaps in HIV responses and resulting HIV infections and AIDS-related deaths lie upon faultlines of inequality.

Data from 46 countries in sub-Saharan Africa show a positive relationship between HIV prevalence and income disparity. After controlling for education, gender inequality and income per capita, a one-point increase in a country’s 20:20 ratio—which compares how much richer the top 20% of a given population is to the bottom 20% of that population—corresponds to a two-point increase in HIV prevalence.

HIV prevalence and income inequality, sub-Saharan African countries, 2019

The recent regional launch of the global AIDS report 2020, Prevailing against pandemics by putting people at the centre, in eastern Europe and central Asia provided a platform for the proposal of a joint revision of social and legal enablers in the region to achieve the proposed 2025 targets. UNAIDS Cosponsors, governments and civil society partners presented their views on the issue and the joint action to be taken. 

Based on the regional data, the 90–90–90 treatment cascade in the region is far off the targets, having reached only 70–44–41. Lev Zohrabyan, the UNAIDS Strategic Information Adviser for Eastern Europe and Central Asia, noted that one of the reasons for this is late diagnosis: in 2019, 53% of all new HIV cases in the region were registered in the later stages. In his opinion, it shows that testing strategies need revision and require enabling societal conditions.

Societal and service enablers have been given prominence in the proposed 2025 targets; in particular, it is outlined in the 10–10–10 targets that:

• Less than 10% of countries have punitive legal and policy environments that deny access to justice.
• Less than 10% of people living with HIV and key populations experience stigma and discrimination.
• Less than 10% of women, girls, people living with HIV and key populations experience gender inequality and violence.

Achieving these goals includes having enabling laws, policies and public education campaigns that dispel the stigma and discrimination that still surrounds HIV, empower women and girls to claim their sexual and reproductive health and rights and end the marginalization of people at higher risk of HIV infection.

“Interventions in these areas create conditions for people to be more active in HIV testing, seek help and start antiretroviral therapy immediately upon diagnosis, adhere to a treatment regimen or proactively seek HIV prevention services, including pre-exposure prophylaxis,” said Mr Zohrabyan.   

Rosemary Kumwenda, the Regional HIV/Health Team Leader at the United Nations Development Programme Istanbul Regional Hub, presented an analysis of the legislation in the eastern Europe and central Asia region on the criminalization of HIV and key populations, noting that the situation in the region remains unfavourable for an effective HIV response. The criminal codes have changed in many countries, but discriminatory laws are changing very slowly. Although many countries revisited their legislation regarding HIV exposure, HIV transmission is criminalized in virtually every country in the region. The Russian Federation and Belarus remain “leaders” in the criminalization of HIV and key populations. Criminal penalties for sex between adult men remain in Uzbekistan and Turkmenistan. The biggest challenge for the region, where more than 48% of new HIV cases are among people who inject drugs, is the criminalization of drug use and possession.

In the presentation An Inventory of Existing Tools for Creating a Favourable Social and Legal Environment in the Eastern Europe and Central Asia Region, given by Tatiana Deshko, the Director of the Department of International Programs, ICF Alliance for Public Health, Ukraine, the ReACT mechanism, which comprehensively works for the rights of key populations, was presented. ReACT (Rights, Evidence, Actions) is the programme’s principle for monitoring violations of rights and is being implemented in 37 cities in seven countries of the region with the support of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Cases of rights violation are registered in a mobile application and then lawyers work with specific cases at the individual level or at the system level of revising legislation. Last year, about 2000 cases were registered. The analysis shows that law enforcement agencies are the primary violators of the rights of key populations in almost all countries, using threats, intimidation, illegal detention and abuse of authority. The health-care system, with denials of medical services, discrimination based on HIV status or disclosure of HIV status, is ranked after law enforcement. “Strategic analysis of cases based on the ReACT-collected data allows not only help for specific people to protect their rights but also formulating recommendations for revising legislation in countries,” said Ms Deshko.

As part of the discussion of the second 10, Alexandra Volgina, the Manager of the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination, Global Network of People Living with HIV, spoke about the People Living with HIV Stigma Index 2.0 study and the role of the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination.

Four countries of the region, Kazakhstan, Kyrgyzstan, the Republic of Moldova and Ukraine, have entered the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination. “If we compile the ReACT system, the Stigma Index and other instruments you’ll get a clear picture of what exactly needs to be done to make a difference. We need to address this issue jointly, all partners together. If we change the situation in the area of ​​stigma and discrimination, we will be able to stop the epidemic,” said Ms Volgina.

An example of such an integrated approach, from data to policies and action, was shared by Evghenii A. Golosceapov, a member of the Equality Council in the Republic of Moldova, the first state institution in the post-Soviet countries dealing with discrimination against various groups.

As part of the Equality Council’s work, studies on the People Living with HIV Stigma Index were carried out, where, through public opinion polls and in-depth interviews, categories of people who are marginalized by society were determined. People living with HIV ranked the second among those categories, after lesbian, gay, bisexual, transgender and intersex people. The Equality Council also uses data from the People Living with HIV Stigma Index, the ReACT registration system and research on the legal environment on HIV.

On this comprehensive basis, more than 70 recommendations on practical steps in the field of legislative changes were developed. These data were used to develop a new national HIV programme and a country proposal to the Global Fund. In addition, the Equality Council considers specific cases of discrimination and complaints (e.g. dismissal due to HIV status) and supports civil society organizations in defending the rights in court. In recent years, the restriction on artificial insemination for people living with HIV has been lifted in the Republic of Moldova, as well as the ban on adoption and guardianship.

All the data collected shape the Roadmap for the Elimination of Discrimination, a government programme in which people living with HIV play a critical role. In the Republic of Moldova, the ScorCard system has also been launched, which allows real-time tracking of the implementation of recommendations and progress towards the adopted targets in reducing stigma and discrimination.

Regional gender gaps in the context of the HIV response were presented by Enkhtsetseg Miyegombo, a Programme Specialist at the UN Women Europe and Central Asia Regional Office.

According to her, the COVID-19 pandemic has largely erased progress in this area and exacerbated existing inequalities: lockdowns disproportionately affected the workload of women who do unpaid domestic work, reduced women’s economic opportunities due to job losses, limited their mobility and increased documented violence against women. These new circumstances were superimposed on existing problems—a lack of awareness about HIV, barriers to discussing safer sex with a partner, revival of patriarchal stereotypes, religious restrictions—as a result of which, women find themselves under growing pressure. Ms Miyegombo highlighted that investment in gender equality programmes is critical to the effectiveness of the regional HIV response.

A study conducted by the Eurasian Women’s Network on AIDS helped to identify the key characteristics of violence and the specifics of organizing assistance to victims of violence in 12 countries of the eastern Europe and central Asia region. The results of the study supplemented the available international data on violence and equipped national civil society organizations with real facts for political advocacy. Elena Rastokina, a specialist in advocacy and community mobilization from the Almaty Model of HIV Epidemic Control project in Kazakhstan, presented successful practices of community-based monitoring in the eastern Europe and central Asia region, concluding that this approach is important as it allows communities to know their rights and barriers and to have systematic data to advocate for systematic change.

Alexander Goliusov, the Director, a.i., of the UNAIDS Regional Support Team for Eastern Europe and Central Asia, stressed that the new 10–10–10 targets are addressing the inequalities that are fuelling the spread of HIV, COVID-19 and other pandemics. “Testing and treatment remain our priorities; however, now our fast track to them lies in combatting inequalities,” he said.

The recording of the launch in Russian and English, along with all presentations and materials, can be found here.

Violence impacts the lives of women and girls, people living with HIV and key populations in myriad negative ways. National authorities and civil society representatives in dozens of countries reported to UNAIDS in 2019 that various provisions and services were in place to protect the health, safety and security of survivors of domestic and sexual violence. However, the degree to which policies and legislation are implemented and enforced—including their coverage and quality—varies widely.

Prevention efforts are also lagging significantly, as evidenced by the high levels of intimate partner violence reported in surveys conducted around the world. Surveys conducted in 46 countries between 2014 and 2018 show that 19.7% of ever-married or partnered women and adolescent girls (aged 15 to 49 years) experienced physical and/or sexual violence by an intimate partner in the past 12 months.

Countries with service delivery points providing appropriate medical and psychological care and support for women and men who have experienced sexual violence, countries with available data, 2019

Countries with provisions related to domestic violence, countries with available data, 2019

The presidential and legislative elections in the Central African Republic on 27 December 2020 were meant to mark the consolidation of democracy and bolster economic and social recovery in a country tormented by decades of conflict and humanitarian challenges. However, the electoral process has given way to a serious political and military crisis, with the resurgence of armed conflict and a blockade of the main trade and supply routes to the landlocked country by rebel groups.

It is in this context of crisis, and in the aftermath of bloody clashes between armed groups and government forces on the outskirts of the capital, Bangui, that the UNAIDS country office in the Central African Republic hosted a workshop to produce HIV estimates for the country from 18 to 22 January. This important annual exercise is conducted by UNAIDS with national authorities in all regions of the world to provide countries and HIV stakeholders with essential data on the pandemic and the response.

Marie Charlotte Banthas, the Director of Disease Control at the Ministry of Health, oversees HIV and tuberculosis treatment programmes in the Central African Republic. Over the past three years, her services have been at the forefront of efforts to accelerate access to antiretroviral therapy from some 25 000 people on treatment in 2016 to more than 48 000 in June 2020. A former head of monitoring and evaluation at the Ministry of Health, she considers the HIV estimates workshop a priority, despite the deteriorated security situation. “There is no effective response to HIV without data. We need to hold this workshop to provide the country with reliable data to better guide our efforts and improve the care of our patients,” she said. 

Civil society also considers HIV estimates as a crucial endeavour. Bertille Zemangui is the President of the National Network of Free Girls, a sex workers’ organization representing key populations. To attend the HIV workshop, Ms Zemangui had to travel long distances each day through sensitive areas. The increased cost of public transport due to the crisis was not enough to discourage Ms Zemangui and other workshop participants. “The current situation is difficult. Everything has become expensive: transportation, food. But we have to be there to make our voice heard because it is sex workers and other key populations that are most affected by HIV in the Central African Republic,” she said. According to data from a 2019 survey, HIV prevalence among sex workers is 15% and 6.5% among gay men and other men who have sex with men, compared to 3.5% among all adults in the country. 

For security reasons, the estimates workshop was moved to the UNAIDS office and participation was reduced to national and international experts and members of civil society. “This workshop provided us with a clearer idea of the magnitude and trajectory of the epidemic for 2021. These are essential to measuring our progress towards achieving the 95–95–95 goals,” said Marcel Massanga, the Deputy National Coordinator of the National AIDS Control Council. The workshop also served to identify approaches to improve the quality and completeness of HIV data in the Central African Republic. Thus, the participants agreed on the need to integrate HIV data into the District Health Information System 2 (DHIS2) platform with a view to strengthening the health system. 

There are concerns that the volatile security situation could jeopardize the Central African Republic’s efforts to accelerate its HIV response. In 2020, the country launched an ambitious National HIV Strategic Plan 2021–2025, which aims to eliminate discrimination, halve new HIV infections and ensure that 95% of people living with HIV access antiretroviral therapy by 2025. “It will not be possible to achieve these ambitious goals without peace and stability. Already we have information that in several areas people living with HIV have fled into the bush and are without treatment. We must quickly implement contingency plans to respond to these emergencies,” said Patrick Eba, the UNAIDS Country Director for the Central African Republic.

Among 151 reporting countries, 92 continue to criminalize HIV exposure, transmission and nondisclosure—all grave violations of the rights of people living with HIV that also frustrate efforts to control HIV epidemics. These laws reinforce stigma and discrimination against people living with HIV and those more vulnerable to HIV infection, they disregard up-to-date knowledge on the science of HIV-related risks and harms, and they have adverse impacts on public health.

The most recent data from population-based surveys show that while discriminatory attitudes towards people living with HIV are declining consistently in some regions, they are rebounding in others. In eastern and southern Africa, for instance, discriminatory attitudes have been reduced to historically low levels in some countries. Elsewhere, however, disconcertingly large proportions of adults continue to hold discriminatory attitudes towards people living with HIV. In 25 of 36 countries with recent data on a composite indicator that includes two types of discriminatory attitudes, more than 50% of people aged 15 to 49 years reported having discriminatory attitudes towards people living with HIV.

Data reported to UNAIDS by countries have been used to project the potential impact of the COVID-19 pandemic on the global HIV response over the next five years. Several scenarios with different durations of service disruptions of between three months and two years were modelled.

The disruptions included: (a) a rate of increase in HIV treatment half the pre-COVID-19 rate; (b) no voluntary medical male circumcision; (c) 20% complete disruption of services to prevent vertical transmission; and (d) no pre-exposure prophylaxis scale-up.  An important assumption across all the scenarios was that the current research pipeline would generate one or more safe and effective COVID-19 vaccines, and that the world will succeed in rolling out vaccines globally.

Results from the model showed that COVID-19-related disruptions may result in 123 000 to 293 000 additional HIV infections and 69 000 to 148 000 additional AIDS-related deaths globally. More positively, however, these projections show that the COVID-19 pandemic’s effects on the HIV response would be relatively short-lived. Using these projections, UNAIDS and its partners have concluded that the COVID-19 pandemic should not be a reason for delaying the 2030 deadline for ending AIDS as a public health threat.