Towering over a throng of young people, Christine Kafando peppers the crowd with questions.

“Do you feel pressure from other boys and girls?” “Do you feel abandoned because of poverty?” “Do you have all the information you need regarding your health and HIV? If not, ask me, ask your partners, ask! Okay!”

The 40 boys and girls nod and shrug. They have come for a workshop run by the Association Espoir pour Demain (AED) in Bobo-Dioulasso, Burkina Faso, which aims to create a space for young people to learn about sexual health and to train some to become peer educators.

“After having seen a number of young students come to us pregnant, we felt a need to start these workshops,” Ms Kafando, the founder of AED, said.

Issa Diarra said the workshop enabled a dialogue. “In our society, we really don’t talk that much about sex and, I would add, health issues, but here we really had the chance to discuss all that,” he said. Another attendee of the workshop, Roland Sanou, agreed, “Sex today remains taboo for young people, but I don’t want it to stay that way.”

Many of them say times have changed and that the way they think is different from the way their parents thought. “Currently, we young people are aware and we know what we want and we know that being sick can keep us from realizing our dreams, so that’s why we are rallying,” said Baba Coulibaly.

At the beginning, AED helped women living with HIV to access treatment. It then grew to help mothers and their babies born with HIV. Fifteen years later, many of those children are now teenagers and still drop by. Reflecting on her two decades as an HIV advocate, Ms Kafando said, “For so many years, women have been the face of HIV, but it’s key to include men and boys to raise their awareness.”

Jacinta Kienou, a nurse who has been at the association since it was founded, said that there were two big challenges: a number of young people living with HIV no longer take their treatment regularly and many young people are unsure about how to deal with relationships.

“Because they live with HIV, and they are young, lots of problems bubble up concerning affection and acceptance by others with regard to their HIV status,” she said. “Often relationships end because of someone’s HIV status. We council them and their parents at that time,” she added.

In Burkina Faso, young people make up more than 60% of the population and data show that many of them do not know their HIV status. UNAIDS Strategic Information Officer André Kaboré describes two gaps concerning young people. “Despite high-quality treatment being readily available, there are children out there who don’t know they’re living with HIV. Worse, many of those who do know that they are living with HIV aren’t accessing treatment,” he said.

In the country, 94 000 people are living with HIV, 9400 of whom are children under the age of 15 years. While 65% of adults living with HIV are on life-saving antiretroviral therapy, only 28% of children living with HIV whose status is known, about 3500, are on treatment. Ms Kafando calls them the forgotten generation. “They fell through the cracks because until now they had never been sick or needed attention and thus were never tested for HIV,” she said.

The head of the National AIDS Council for Bobo-Dioulasso and the surrounding region, Suzanne Sidibé, said, “We lost sight of children born with HIV. Our aim, with the help of the Association Espoir pour Demain, is to fan out to families through health mediators.”

Hoho Kambiré, who is living with HIV, has four children, two of whom are living with HIV. As an AED health mediator, she speaks about the benefits of knowing one’s status to all who will listen. She visits families, accompanies women to clinics and provides support.

“It is necessary to test all the children to know who is sick and who is not sick and follow up to keep them healthy,” she said. AED has now more than 50 health mediators, mostly women like Ms Kambiré, who originally came to the association seeking health services herself. 

The United Nations Children’s Fund (UNICEF) and UNAIDS both support AED financially. Mireille Cissé, a UNICEF HIV specialist, said that the United Nations in Burkina Faso had identified the top priorities for the AIDS response in the country, including working with civil society.

“We agreed that a community link needed to be established, because they are our entry into families,” she said. UNICEF formalized the health mediators’ contribution by providing a stipend for their work and works hand in hand with the regional office of the Ministry of Health.

“A real victory for us was to have the health mediators integrated into the health teams of the districts,” Ms Cissé said. “That buy-in really facilitated the role of the health mediators and has raised their profile.”

UNAIDS has reinforced the capacity of the health mediators to widen their scope of work, which ranges from psychosocial counselling to training on treatment adherence. “To maintain our progress in the HIV response and end AIDS depends a lot on civil society like the Association Espoir pour Demain,” Job Sagbohan, UNAIDS Country Director, said. “We really hope for maximum impact.”

While the incidence of HIV infection globally for all ages declined by 22% between 2011 and 2017, HIV infections among people who inject drugs appear to be rising. HIV incidence—the number of new HIV infections among a susceptible population during a certain time—among people who inject drugs rose from an estimated 1.2% in 2011 to 1.4% in 2017.

There is compelling and comprehensive evidence that harm reduction—including opioid substitution therapy and needle–syringe programmes—prevents HIV infections among people who inject drugs. However, criminalization of drug use and possession for personal use and the widespread stigma, discrimination and violence faced by people who use drugs hampers access to health and harm reduction services.

In its new report, Health, rights and drugs: harm reduction, decriminalization and zero discrimination for people who use drugs, UNAIDS has outlined a set of recommendations for countries to adopt for a public health and human rights response to drug use.

Mandisa Dukashe was nervous before she took an HIV test in 2002. As a nursing student in South Africa, where more than 4 million people were living with HIV at the time, she knew it was possible that she would test positive for the virus. “I was very stressed,” she says. “I kept postponing the test.”

Ms Dukashe had learned about HIV during her university studies, so the staff at the clinic assumed that she was well informed and didn’t need pretest counselling. “They told me I am a nursing student and should know what it entails.”

The test result was positive. Ms Dukashe joined 510 000 other South Africans who became newly infected with HIV in 2002—20% of all new infections worldwide.

When Ms Dukashe was diagnosed with HIV, South Africa had only recently started to roll out treatment and it was five years before she got access to it. It was harder to come by then, with limited medicine formulations that were only prescribed for people falling ill with an AIDS-related illness.

In 2002, South Africa had more than 4 million people living with HIV but fewer than 15 000 people receiving treatment through public facilities. That year the country also recorded more than 190 000 AIDS-related deaths.

The picture today is much improved.

Ms Dukashe and her family featured on the cover of the 2018 UNAIDS World AIDS Day report, Knowledge is power, as living proof that sustained HIV treatment can suppress a person’s viral load and prevent the transmission of HIV to a partner and children. “This can be done by anyone,” she says.

In 2017, there were more than 4.3 million people on HIV treatment and 110 000 AIDS-related deaths in South Africa. Yet there are still miles to go to end the AIDS epidemic by 2030. South Africa continues to rapidly scale up HIV treatment and is determined to reduce annual AIDS-related deaths to 80 000 or fewer by 2020.

Ms Dukashe says it didn’t take long to reconcile herself to her HIV-positive status. She was determined to embrace her status, look after herself and spread the word. She wanted to warn other young people to avoid HIV infection, take a test and seek support if they tested HIV-positive. “After the counselling, I felt so bold and confident and I was ready within a week to go out and tell the world with an intention of raising awareness, in particular among young women and adolescent girls.”

But things were not always easy for her. Ms Dukashe was married when she was diagnosed. “Some people say that HIV can bring you closer, but that wasn’t to be.” They eventually divorced and it took time before Ms Dukashe found love again. “At first, I didn’t want to reveal my HIV status because I knew that it could be an issue, so I focused on my nursing studies. Eventually I fell in love with a guy and I feared he would reject me, but I had to tell him—I cannot live a lie. It took me three months to disclose my status, but to my surprise his response was much better than I hoped. He remains HIV-negative and he is the best husband and father of my children that I could ever ask for. When you have got that kind of support you can live healthily and even forget about HIV.”

Despite the love and support of her husband and family, the weight of living with HIV came flooding back to Ms Dukashe when she and her husband started planning to have children. “When the time came for us to talk about preventing HIV transmission to our children, we needed to think carefully, plan and consult medical experts. That brought it all back for me and I got depressed for a while.”

But help was available, she says. “I got counselling and worked through those feelings and it was all worth it. I now have two wonderful children who were born without HIV. It was my responsibility and also my husband’s responsibility. We got great support and advice.

“Being able to give birth to HIV-negative children was a blessing because I believe if I did not test, my kids could have been born with HIV.”

Ending new HIV infections among children is a high priority for South Africa, with a target of virtual elimination by 2020. Yet despite many years of concentrated effort, 13 000 children acquired HIV from their mothers in 2017.  “It pains me that I could not breast-feed my babies,” says Ms Dukashe. “Because I wanted so hard to prevent them from getting HIV I fed them with formula milk, which made me sad.”

Thanks to improved treatment options, women living with HIV are now encouraged to take HIV treatment for their own health and to avoid their children becoming infected during pregnancy, birth or breastfeeding. All breastfeeding women in South Africa living with HIV and on HIV treatment are encouraged to exclusively breastfeed until their baby is at least six months old.

Ms Dukashe is now working as a project manager for point-of-care HIV testing and quality assurance. She is also a motivational speaker, creating demand for HIV testing and treatment, including among women of child-bearing age and their partners.

“I want to encourage everybody in our situation: there is life after HIV, there is love. People should not think twice about going for an HIV test. It was the best decision I ever made, since I learned what to do to keep myself healthy and prevent transmission to my spouse and children. Thinking twice is not going to change the result.”

“As a healthcare professional, it is important for me to show that I am living positively with HIV and managing it successfully. My experience should encourage others to protect themselves and get tested regularly. If you test positive for HIV, start treatment and get counselling and support so you can keep yourself healthy and protect others. HIV is, unfortunately, a reality for millions of people, but treatment works and we are stronger than HIV.”

Finally, Ms Dukashe has a message for young women: “HIV is invisible. Always use a condom and be wary of older men. Age-disparate relationships are a risk. If you rely on an older partner and try to please them, you won’t be able to insist on using a condom,” she said. “I speak from experience, as someone who faced the same pressures.”

The PK5 neighbourhood of Bangui, Central African Republic, is home to much of the city’s Muslim community. Once a bustling commercial area and the centre of Bangui’s nightlife, PK5 has become a no-go zone for many.

Like much of the country, the PK5 area and its population were greatly affected by the violence that engulfed the country in 2012 and 2013. The non-Muslim inhabitants of PK5 left; rival armed groups continue to exert control. Across the country, the consequences of the violence have led to a huge displacement of people and a humanitarian crisis. At the end of 2018, it was estimated that 2.9 million people—more than half of the country’s population—were in need of humanitarian assistance and protection.

However, the people of PK5 remain resilient. Recognizing the need for a greater awareness of HIV in the community, Muslim youth leaders and the Catholic University Center, with the support of UNAIDS, organized an HIV testing and awareness-raising campaign from 23 January to 13 February at the Henri Dunant Health Centre in PK5.

The campaign was the first of its kind to take place in PK5 since the 2012–2013 violence. In the two weeks of the campaign, 1500 people accessed voluntary HIV testing and counselling services. People who tested positive for HIV were referred for treatment.

The campaign was opened by Pierre Somse, the Minister of Health, during an event attended by religious leaders, women and young people. Mr Somse took an HIV test and stressed the importance of all people knowing their HIV status. Knowledge of HIV status in the country remains low, with only 53% of people living with HIV knowing their HIV status.

“The government is committed to intensifying its efforts to deliver health and social services to all Central Africans. PK5 is not forgotten and its population will not be left behind in our efforts to increase access to HIV testing, treatment, care and support,” said Mr Somse.

Pamela Ganabrodji, Head of Information and Counselling at the Henri Dunant Health Centre, added, “We are very proud of what we have achieved through this HIV campaign, but challenges remain. We call on the government and international partners to continue supporting the HIV and sexual and reproductive health activities of the Henri Dunant Health Centre, which are critical in a community where cultural and social taboos represent a key barrier.”

On the last day of the campaign, a community dialogue was held to discuss the HIV and sexual and reproductive health challenges faced by the people of PK5. The needs are urgent and range from basic health and social services to a lack of economic opportunities. Low access to modern contraceptives, incomplete knowledge about HIV and poverty contribute to making young people and women vulnerable to HIV.

“With this campaign, we, the young people of PK5, are showing that we are not helpless and that we are part of the solution for HIV and other social issues,” said Aroufay Abdel Aziz, President of the Muslim Youth of the Central African Republic.

A second phase of the HIV testing and sensitization campaign will continue until the end of March and will include focused HIV prevention messages with sensitization by peer educators and focus group discussions on HIV and sexual and reproductive health issues.

“UNAIDS will continue to engage the government and other United Nations agencies and partners to reinforce the involvement of young people in the HIV response,” said Patrick Eba, UNAIDS Country Director for the Central African Republic.

The United Kingdom of Great Britain and Northern Ireland has announced that it will end the transmission of HIV in the country within 10 years—an announcement that was warmly welcomed by UNAIDS.

In 2016, all United Nations Member States pledged to end AIDS by 2030 in the United Nations Political Declaration on Ending AIDS. This recommitment from the United Kingdom is welcome news that the country remains determined to achieve that goal. 

The United Kingdom has dramatically stepped up its efforts to respond to HIV in recent years, resulting in a 28% decline in new HIV cases in the past two years alone. However, the government says it can do more.

The Secretary of State for Health and Social Care, Matt Hancock, launched the campaign, which is backed by an additional £600 000 from the Public Health England HIV Prevention Innovation Fund, at the AIDSfree Cities Global Forum in London on 30 January. The £600 000 will be used to support 14 volunteer organizations that are spearheading new approaches to HIV prevention and will focus on engaging at-risk or underserved communities.

Also at the event, the Secretary of State for International Development, Penny Mordaunt, made a bold declaration about the country’s commitment to ending AIDS globally. “While the world has made great strides in tackling HIV and AIDS, we need to step up our efforts,” she said. “We passionately believe we can create an AIDS-free future for the whole world. That’s the scale of our ambition.”

The United Kingdom Government has played a leading role in the global response to HIV since the start of the epidemic. It has invested £1.2 billion in the Global Fund to Fight AIDS, Tuberculosis and Malaria and is expanding access to antiretroviral therapy though UK Aid, a five-year, £150 million, programme set up to change the lives of more than 3 million of the world’s poorest people.

“This announcement is a further example of how committed the United Kingdom really is to ending AIDS. Not only in the United Kingdom, but around the world,” said Tim Martineau, Deputy Executive Director of UNAIDS, Programme, a.i. “UNAIDS has worked closely with the United Kingdom since 1996 and we look forward to continuing that partnership to ensure that every penny invested brings us one step closer to ending AIDS.”

The event in London was part of the AIDSfree Appeal, a campaign led by the Elton John AIDS Foundation and the London Evening Standard and Independent newspapers. The money raised from public donations through the appeal will be used to support Elton John AIDS Foundation projects in six key cities around the world—Atlanta, United States of America, Delhi, India, Kyiv, Ukraine, London, Maputo, Mozambique, and Nairobi, Kenya. Through UK Aid Match, the United Kingdom Government has pledged to double public donations up to £2 million, to be spent on projects in Maputo and Nairobi.

The AIDSfree Cities Global Forum welcomed leaders from the six cities, who spoke about their hopes for the future. The event was a prelude to the Fast-Track Cities Global Conference, taking place in London in September 2019, at which representatives of more than 275 Fast-Track cities will convene as the first global gathering of cities accelerating their work to end AIDS as a public health threat.

The Fast-Track cities initiative was launched by UNAIDS in 2014 in partnership with the City of Paris, the International Association of Providers of AIDS Care and UN-Habitat to provide support to cities to Fast-Track their HIV responses and end their AIDS epidemics by 2030.

London signed up to the Fast-Track cities initiative in 2018. New HIV infections in the city have fallen by more than 40% in recent years and London has surpassed the 90–90–90 targets—whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads—having already reached 95–98–97, a remarkable achievement.

“We are eager to take the lessons learned at the forum to a wider gathering of Fast-Track cities later this year in London that will take the measure of progress made and challenges still to be addressed,” said José M. Zuniga, President and Chief Executive Officer of the International Association of Providers of AIDS Care.

Only one third of gay men and other men who have sex with men know their HIV status in the Lao People’s Democratic Republic, partly because stigma and discrimination remains a barrier for accessing HIV testing in public hospitals and clinics. Complicated protocols, uneven and at times judgemental treatment by health providers and non-confidentiality of testing results further impact on HIV testing.

“Many of our friends are scared of getting an HIV test because they think the testing steps are challenging and often unfriendly,” said Phoulikhan Siphabouddy, a community-based supporter of LaoPHA, a Lao nongovernmental organization.

To address this, USAID supported the government and LaoPHA to pilot oral fluid screening in three provinces.

Most people assume that testing involves taking a blood sample. But oral fluid testing detects antibodies for HIV, not the virus itself. A test swab is gently wiped along a person’s upper and lower gums once, then the swab is placed inside a test tube containing a reagent. The result is known within 20 minutes.

Members of the community, so-called peer educators, train volunteers for the oral fluid screening. The screening is fast, easy and can be done anywhere.

Around 82% of people reached agreed to have an HIV test through oral fluid screening, compared to only 17% of referrals to clinics, according to the Ministry of Health.

“The new approach dramatically exceeded Laos’ HIV testing targets by more than 200%,” said Bounpheng Philavong, Director of the Lao Centre for HIV/AIDS and STI.

He, along with LaoPHA, are convinced that community-led services provide an enabling environment for key populations to access HIV services in a non-discriminatory manner. Linkages to care and support for people living with HIV has also improved for people who test positive, with the same community volunteers providing support for referral to trusted clinics.

Ireland has pledged €400 000 to UNAIDS for a project to provide HIV services for the most vulnerable populations in the United Republic of Tanzania, with the first tranche, €200 000, already received.  

“Through our development programmes, Ireland supports the most marginalised in society to access key services so that they can live with dignity. Ireland is pleased to collaborate with UNAIDS to improve the plight of populations that are in most need of timely HIV services,” said the Irish Ambassador to the United Republic of Tanzania, Paul Sherlock.

UNAIDS will work in close collaboration with the Ministry of Health, the Benjamin Mkapa Foundation and civil society organizations to address issues that hinder the most vulnerable populations from accessing HIV prevention, treatment and care in a timely manner. Support that UNAIDS will provide includes convening stakeholders, providing technical leadership and strategic guidance and ensuring participation and representation.

Stigma and discrimination, inequality and violence against women and girls and criminal and punitive laws that affect vulnerable populations remain among the major barriers to an effective response to HIV in the country.

The 18-month project will help its beneficiaries with legal literary skills, raise awareness on the right to health and address HIV-related stigma and discrimination.

Ireland is a long-standing partner of UNAIDS, providing US$ 2.56 million in core funding to UNAIDS in 2018.

“UNAIDS and Ireland share a goal of ensuring that the AIDS response leaves no one behind. The funding from Ireland offers us a timely opportunity to give the most vulnerable populations in the United Republic of Tanzania a chance to live in dignity and good health,” said Leopold Zekeng, UNAIDS Country Director, United Republic of Tanzania.

Key populations—gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs, prisoners and other incarcerated people and migrants—and their sexual partners account for 40% of new HIV infections in western and central Africa.

However, key populations still have insufficient access to HIV prevention, treatment and care services. Fragile health systems, stigma and discrimination, sexual and gender-based violence and lack of supportive policies are some of the barriers that key populations face.

While high-quality programmes for key populations do exist in western and central Africa, there are limited opportunities to learn from each other and to strengthen South–South capacity. Monitoring of commitments made by all stakeholders, including governments, is also an issue. Three regional meetings took place in November to address those shortcomings.

The West Africa Health Organisation (WAHO), the United Nations Development Programme and ENDA Santé, a civil society organization, in collaboration with UNAIDS, met in Dakar, Senegal. The meeting brought together representatives of national AIDS commissions or programmes from 14 Economic Community of West African States (ECOWAS) countries and members of the Africa key populations expert group to chart the process for the development of a regional strategy on HIV/tuberculosis and sexual and reproductive health and rights for key populations, scheduled to be finalized in early 2020.

In 2015, under the leadership of WAHO, and in collaboration with UNAIDS and USAID, ministers of health, heads of national AIDS commissions, public prosecutors and inspectors general of police of ECOWAS Member States signed the Dakar Declaration on Factoring Key Populations in the Response to HIV and AIDS in ECOWAS Member States. The declaration aims to better take into account key populations in the response to HIV in the ECOWAS region in core areas, including strengthening of strategic information, health systems and community services and addressing stigma and discrimination.

In November, WAHO, UNAIDS and USAID commissioned a review of the progress made against the declaration and organized a regional progress review workshop attended by country representatives of 13 countries. The declaration has created a significant momentum, coupled with a number of achievements, innovations and good practices at the country level.

Ending AIDS in West Africa, a five-year cooperative agreement funded by USAID and led by FHI 360 and its core partners, Johns Hopkins University and ENDA Santé, facilitated the fourth key population regional meeting in western Africa, in partnership with the Government of Togo and partners.

The meeting was a key opportunity to bring together members of key populations, government officials, donors, academics and representatives of implementing partners and United Nations agencies to share lessons learned and promising practices from implementation, relevant and novel research and programmatic data, and to build networks and platforms for technical exchange. Country delegates also formulated country action plans to improve the quality, efficiency and scale of HIV-related programmes for key populations.

“The more the response to HIV is multisectoral, multidisciplinary and inclusive, the more impactful results we will have,” said Vincent Palokinam Pitche, Coordinator of the Permanent Secretary of the National AIDS Commission in Togo.

“There is a need to support the collection and analysis of strategic information to guide efforts to facilitate access by key populations to prevention, care and treatment services, to intensify services that are evidence-informed and rights-based and to invest in programmes for an enabling legal and social environment,” said Christian Mouala, UNAIDS Country Director for Togo.