The Sanpatong Hospital in North Thailand has reinvented and refined its HIV programme for more than three decades. It began attending to people living with HIV in 1989, and in 1996 started offering antiretroviral treatment.

“We have patients who have been with us for 30 years,” says Dr Tawit Kaewprasert, Deputy Director of Provincial Public Health Office and Director of Sanpatong Hospital.

In the last five years the hospital has not had a single case of mother-to-child HIV transmission. An impressive 96% of people on treatment who received viral load tests there this year were virally suppressed, with 98% of those patients being undetectable. Management speaks about the 92% retention rate for clients who were on treatment in 2022 in terms of how those results can be improved.

“We have not achieved that target just yet,” Dr Manusin Kongka says, referring to the proportion of people who stayed on antiretroviral therapy. “But we can reach the target and even achieve beyond 95%.”

The team even aims to achieve 100% viral suppression among people who have been on treatment for at least five years. The current 96% result isn’t considered to be good enough.

This ambitious goal-setting flows from the National HIV Policy and Thailand’s commitment to end AIDS by 2030 through a well-articulated strategy to reach, recruit, test, treat and retain people in care, while also working to prevent new infections.

 Of course the strategy relies heavily on Sanpatong and institutions like it. This 130-bed facility boasts a central lab that serves surrounding hospitals in Chiang Mai, Lamphun and Mae Hong Son with HIV diagnosis, CD4, viral load monitoring and some opportunistic infections testing.

Their approach includes the adoption of HIV response best practices including PrEP, index testing and same-day treatment initiation.

“Patients can start treatment before they even get their CD4 result,” Dr Kongka explained.

All staff have received anti-stigma training as well as orientation around the U=U, undetectable = untransmittable, initiative. The facility uses a differentiated approach for antiretroviral treatment delivery. Depending on their health status, some clients can collect multiple month dispensing at district health promoting hospitals while others can receive their medicine by mail.  

But a major key to Sanpatong’s success is the linkages it has made with groups of community-led organizations to drive case detection, linkage to care, psychosocial support and the monitoring of services. The Hospital works with Mplus, CAREMAT and FHI360 on prevention, testing and retention in care. Organizations of people living with HIV run support groups. The Community Led Monitoring team even helps primary care nurses to contact patients who have been lost to follow up and conduct home visits. The people living with HIV network collaborated with key community-based organizations in Chiang Mai to conduct community-led monitoring to improve the quality of HIV services at the Sanpatong hospital.

“Our collaboration with community organizations increases awareness about HIV, improves quality of care and access to care, decreases the waiting in community clinics and increases continuity of care for HIV patients,” said Ms Sineenuch Suwansre, HIV Coordinator.

This close collaboration with communities is enhanced by the Thailand Government’s move to integrate HIV services into the Universal Health Coverage scheme. Now certified organizations and lay HIV service providers can access domestic financial support within the national health infrastructure.

“Universal Health Coverage is a mechanism for the sustainable financing of HIV prevention as well as sustainable financial support to key population- and community-led health services. The Thai government’s move to fund Community-led Health Services as an element of the mainstream public health system is a win for people living with HIV, for HIV prevention and for sustainability,” said UNAIDS Thailand Country Director, Patchara Benjarattanaporn. 

DAR ES SALAAM / GENEVA, 29 November 2022—Analysis by the UN ahead of World AIDS Day reveals that inequalities are obstructing the end of AIDS. On current trends the world will not meet agreed global targets on AIDS. But the new UNAIDS report, Dangerous Inequalities, shows that urgent action to tackle inequalities can get the AIDS response on track.

UNAIDS set out earlier this year that the AIDS response is in danger—with rising new infections and continuing deaths in many parts of the world. Now, a new report from UNAIDS shows that inequalities are the underlying reason why. It shows how world leaders can tackle those inequalities, and calls on them to be courageous to follow what the evidence reveals.

Dangerous Inequalities unpacks the impact on the AIDS response of gender inequalities, of inequalities faced by key populations, and of inequalities between children and adults. It sets out how worsening financial constraints are making it more difficult to address those inequalities.

The report shows how gender inequalities and harmful gender norms are holding back the end of the AIDS pandemic.

“The world will not be able to defeat AIDS while reinforcing patriarchy,” said UNAIDS Executive Director Winnie Byanyima. “We need to address the intersecting inequalities women face. In areas of high HIV burden, women subjected to intimate partner violence face up to a 50% higher chance of acquiring HIV. Across 33 countries from 2015-2021 only 41% of married women aged 15-24 could make their own decisions on sexual health. The only effective route map to ending AIDS, achieving the sustainable development goals and ensuring health, rights and shared prosperity, is a feminist route map. Women’s rights organizations and movements are already on the frontlines doing this bold work. Leaders need to support them and learn from them.”

The effects of gender inequalities on women’s HIV risks are especially pronounced in sub- Saharan Africa, where women accounted for 63% of new HIV infections in 2021.

Adolescent girls and young women (aged 15 to 24 years) are three times more likely to acquire HIV than adolescent boys and young men of the same age group in sub-Saharan Africa. The driving factor is power. One study showed that enabling girls to stay in school until they complete secondary education reduces their vulnerability to HIV infection by up to 50%. When this is reinforced with a package of empowerment support, girls’ risks are reduced even further. Leaders need to ensure all girls are in school, are protected from violence which is often normalized including through underage marriages, and have economic pathways that guarantee them a hopeful future.

By interrupting the power dynamics, policies can reduce girls’ vulnerability to HIV.

Harmful masculinities are discouraging men from seeking care. While 80% of women living with HIV were accessing treatment in 2021, only 70% of men were on treatment. Increasing gender- transformative programming in many parts of the world is key to halting the pandemic. Advancing gender equality will benefit everyone.

The report shows that the AIDS response is being held back by inequalities in access to treatment between adults and children. While over three quarters of adults living with HIV are on antiretroviral therapy, just over half of children living with HIV are on the lifesaving medicine. This has had deadly consequences. In 2021, children accounted for only 4% of all people living with HIV but 15% of all AIDS-related deaths. Closing the treatment gap for children will save lives.

Discrimination against, stigmatization and criminalization of key populations are costing lives and preventing the world from achieving agreed AIDS targets.

New analysis shows no significant decline in new infections among gay men and other men who have sex with men in both the western and central Africa and eastern and southern Africa regions. Facing an infectious virus, failure to make progress on key populations undermines the entire AIDS response and helps explain slowing progress.

Around the world, over 68 countries still criminalize same sex sexual relations. Another analysis highlighted in the report found that gay men and other men who have sex with men who live in African countries with the most repressive laws are more than three times less likely to know their HIV status than their counterparts living in countries with the least repressive laws, where progress as far more rapid. Sex workers who live in countries where sex work is criminalized have a 7 times greater chance to be living with HIV than in countries where sex work is legal or partially legalized.

The report shows progress against inequalities is possible and highlights areas where the AIDS response has made remarkable progress. For example, while surveys among key populations often highlight lower service coverage among key populations, three counties in Kenya have achieved higher HIV treatment coverage among female sex workers than among the general population of women (aged 15-49 years). This has been helped by strong HIV programming over many years, including community-led services.

“We know what to do to end inequalities,” said Ms Byanyima. “Ensure that all of our girls are in school, safe and strong. Tackle gender based violence. Support women’s organisations. Promote healthy masculinities—to take the place of the harmful behaviours which exacerbate risks for everyone. Ensure services for children living with HIV reach them and meet their needs, closing the treatment gap so that we end AIDS in children for good. Decriminalize people in same-sex relationships, sex workers, and people who use drugs, and invest in community-led services that enable their inclusion — this will help break down barriers to services and care for millions of people.”

The new report shows donor funding is helping catalyse increased domestic funding: increases in external HIV funding for countries from PEPFAR and the Global Fund during 2018-2021 were correlated with increases in domestic funding from a majority of national governments. New investments to address HIV-related inequalities are urgently needed. At a moment when international solidarity and a surge of funding is most needed, too many high-income countries are cutting back aid for global health. In 2021, funding available for HIV programmes in low- and middle-income countries was US$ 8 billion short. Increasing donor support is vital to getting the AIDS response back on track.

Budgets need to prioritize the health and well-being of all people, especially vulnerable populations that are most affected by HIV-related inequalities. Fiscal space for health investments in low- and middle-income countries needs to be expanded, including through substantial debt cancellation and through progressive taxation. Ending AIDS is far less expensive than not ending AIDS.

In 2021, 650 000 people were lost to AIDS and 1.5 million people newly acquired HIV.

“What world leaders need to do is crystal clear,” said Ms Byanyima. “In one word: Equalize. Equalize access to rights, equalize access to services, equalize access to the best science and medicine. Equalizing will not only help the marginalised. It will help everyone.”

WATCH REPORT LAUNCH

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.

On 25 November 2021, the city of Kryvyi Rih, the fourth largest city in Ukraine, signed the Paris Declaration to end the AIDS epidemic in cities. The city is an important economic and industrial centre, a major transport hub and the birthplace of the Ukrainian President, Volodymyr Zelensky.

A group created by the city administration to develop and implement the Paris Declaration determined the main areas of work, which included the expansion of HIV prevention services for key populations through community organizations and the scale-up of HIV testing through family doctors, among others.

Physicians across the city were trained in HIV, while Gennady Kruglenko, the chief doctor at the Kryvyi Rih municipal AIDS centre, visited Odesa and Dnipro to learn about their experience with implementing the Paris Declaration.

“We were seriously preparing to start this work,” said Mr Kruglenko. “But the war slowed down our plans. Our region borders the areas of active military operations, but our centre continues providing full-scale HIV services, and we are not going to stop. And we have not abandoned the main goal of the Paris Declaration: ending the AIDS epidemic.”

The Kryvyi Rih AIDS centre has been operating since 1994, and today there are about 10 000 people living with HIV accessing HIV treatment from it. People can get HIV treatment from five different sites, which makes it much easier for people living in different parts of Kryvyi Rih. Kryvyi Rih is the longest city in Europe, the length of which exceeds 120 km.

The AIDS centre continues to work as a reference laboratory for several regional centres. Its modern equipment allows the performance of all necessary tests, including diagnosis confirmation, CD4 counts, viral load and others, to be performed. People living with HIV with complex cases, for example opportunistic infections, that require the attention of experienced doctors are referred to the centre.

Marina Baidachenko, an infectious diseases doctor at the AIDS centre, says that the centre currently also provides services to people who have fled the war. “There are people who move within the country, who apply for services through a network of our social workers. The system in Ukraine is such that no matter where the patient is, he or she can receive treatment through the general system,” she said.

Each doctor providing specialized HIV care in Ukraine has access to the medical records of patients in a general electronic registry, with strict confidentiality measures in place. This ensures that the records of people living with HIV who move from one region to another can be accessed in the new region, thereby allowing the maximum number of displaced patients to remain on antiretroviral therapy, despite the war.

According to Ms Baidachenko, the war is felt every minute. “Air raids are very frequent, missiles are flying,” she said. The employees of the AIDS centre must go to the first floor or basement, which have been adapted as bomb shelters, every time the air raid siren sounds.

“To issue antiretroviral therapy to a person, you need to open his or her electronic card in the computer, create an electronic prescription through the registry and send it to the warehouse where the medicines are issued. When there are 200–300 patients in the centre, it’s hard to tell them to wait until the alarm is over,” said Ms Baidachenko.

With the help of a UNAIDS emergency grant, the centre equipped additional workplaces with laptop computers, office equipment and Wi-Fi. Now prescriptions take only minutes and doctors can move to a safe place when the siren sounds and take their computers and continue to serve people.

Close cooperation with community organizations, such as the Public Health Charity Foundation of Krivyi Rih, has become even more important during the war.

“Each of our doctors has about 2000 people on antiretroviral therapy. Now with the war, there are only two doctors left. They have to give a prescription, check the tests, explain the medical aspects—they simply don’t have time for other important issues, such as psychological support,” said Mr Kruglenko.

According to Alexander Lee, the Project Manager of the Public Health Charity Foundation, the war has changed the format and scope of the organization’s work. “Many of our clients were left alone with their problems and fears because family members left Ukraine. The response required increased mobility of the organization’s employees for consultations and assistance to clients in remote areas of the city,” he said.

Social workers are also helping to connect medical facilities with people who use drugs, gay men and other men who have sex with men and members of other communities, who have become even more vulnerable.

“Therefore, in the chain of services, everyone does a small, but very “big”, thing,” Mr Kruglenko added.

Raman Khailevich, the UNAIDS Country Director for Ukraine, emphasized that UNAIDS supports the city’s efforts to continue providing all HIV services in close cooperation with civil society organizations. “Such interaction in peacetime was one of the most important components of the successful AIDS response in Kryvyi Rih, and in wartime it is the only way not to lose what has been achieved but also to continue moving towards the goal of ending AIDS, saving every life,” he said.

A new publication by UNAIDS and the World Health Organization (WHO) emphasizes the importance of integrating HIV and mental health services and other interventions, including linkages to social protection services, for people living with HIV and other vulnerable populations.

Mental health conditions increase the risk of HIV infection, and people living with HIV have an increased risk of mental health conditions, which are associated with lower retention in HIV care, increased risk behaviours and lower engagement with HIV prevention.

Furthermore, despite an increasing body of evidence showing that effective methods of prevention, screening and diagnosis of, and treatments for, common mental health conditions, including depression and anxiety, exist and can be implemented in low- and middle-income countries, services for mental health, neurological and substance use conditions are often not integrated into packages of essential services and care, including for HIV.

“We know that integration of screening, diagnosis, treatment and care for mental health conditions and psychosocial support with HIV services does not need to be expensive,” said Eamonn Murphy, UNAIDS Deputy Executive Director, a.i., Programme. “The integrated approaches that are people-centred and local context-specific ensure better HIV and overall health outcomes, well-being and quality of life.”

The publication is primarily intended for national and local policy-makers, global, regional, country and local programme implementers, organizations working in and providers of health, HIV, mental health and other relevant services, civil society and community-based and community-led organizations and advocates.

Although focus is on the integration of mental health with HIV services and other interventions, the considerations in the publication may be relevant to other services, including for HIV comorbidities such as tuberculosis, viral hepatitis and sexually transmitted infections.

“Our publication successfully brings together tools, best practices, case studies and guidelines that can help countries and facilitate the integration of interventions and services to address the interlinked public health challenges of mental health and HIV, all while improving access to care for persons who are the most vulnerable, such as adolescents and key populations,” said Meg Doherty, Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO.

“With this joint UNAIDS/WHO publication, we hope we can collectively support countries, service providers and other practitioners, policy-makers, programme implementers and communities in their efforts to address HIV, mental health, neurological and substance use conditions for affected individuals in an integrated and impactful way,”  said Devora Kestel, Director, Mental Health and Substance Use, WHO.

Integration of mental health and psychosocial support with HIV services and interventions, including those led by communities, is one of the key priority actions included in the Global AIDS Strategy 2021–2026: End Inequalities, End AIDS and the 2021 United Nations Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030. Both documents call for addressing the interlinked issues of HIV and mental health through integrated services by investing in robust, resilient, equitable and publicly funded systems for health and social protection, by reversing health and social inequalities and by ending stigma and discrimination.

The new publication stresses that the AIDS epidemic cannot end without addressing the mental health of people living with, at risk of or affected by HIV, ensuring equitable access to HIV services for people with mental health issues and conditions and achieving universal health coverage.

“Young people here don’t regularly access HIV services. I really want to invite my friends to get tested, but they are all so afraid. They don’t have enough information or support from their families and are scared about finding out their status,” said Andika Bayu Aji, a young person from West Papua, Indonesia.

The HIV epidemic among young people in Asia and the Pacific has largely been overlooked, even though about a quarter of new HIV infections in the region are among people aged 15–24 years. The vast majority of young people affected by HIV in the region are members of vulnerable populations—people living with HIV, gay men and other men who have sex with men, transgender people, sex workers and people who inject drugs.

Like many countries in the region, Indonesia’s HIV infections among young people, which make up almost half of new infections, are attributed to stigma and discrimination, poor educational awareness of HIV, lack of youth-friendly services and social taboos.

“Young people far too often experience stigma and discrimination in health-care settings. Health-care workers are first-line responders. If the services are bad, young people won’t use them and they will tell other young people not to use them. We are limited by which clinics we can access because many, if not most, are not youth-friendly,” said Sepi Maulana Ardiansyah, who is known as Davi and is the National Coordinator for Inti Muda, the national network of young key populations in Indonesia.

A recent study conducted by Inti Muda and the University of Padjajaran found that the willingness of young people to access services in provinces like West Papua was very low, mainly due to the lack of youth-friendly services and the poor understanding of key population issues by health-care workers. Young people often face difficulty accessing services because of the remoteness of clinics and hospitals and encounter barriers such as the age of consent for testing.

Stigma and discrimination, and especially discrimination from health-care providers, discourages many young key populations from accessing HIV services. Concerns about privacy and confidentiality are some of the main challenges. Additional obstacles include that the opening hours of public clinics are often ill-suited to people’s daily routines, and the assumptions and attitudes of health-care workers can be judgemental, especially on issues around sexual orientation, gender identity and mental health.

Between 14 and 18 March, Inti Muda, with technical support from Youth LEAD and UNAIDS, organized a sensitization training of health-care workers in two cities, Sentani and Jayapura, in the West Papua region. More than 50 health-care workers participated. A few days before the training, Inti Muda organized a festival for more than 80 young people, joining in an effort to engage young people in the HIV response and generate demand for access to HIV services.

“Prior to this training, I didn’t know about the different needs of key populations, which hinders our ability to reach them. We learned about important techniques for reaching young people, such as providing youth-friendly counselling, digital interventions and encouraging them to get tested,” said Kristanti, from the District Health Office of Jayapura.

“I learned that the needs of young people are diverse. The training will allow us to improve our services to become youth-friendly, which is now our main priority,” added Hilda Rumboy, a midwife in charge of the HIV Services Department at the Waibhu Primary Health Centre.

The training and festival were supported by the Australian Department of Foreign Affairs and Trade (DFAT). The recent investment of AU$ 9.65 million set aside by the Australian Government from the sixth replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), including DFAT funding of AU$ 2 million previously committed to UNAIDS, is aimed at reducing the annual number of new HIV infections among key populations in Cambodia, Indonesia, Papua New Guinea and the Philippines.

“Ensuring young people and vulnerable groups have access to accurate, digestible information about how to prevent HIV, and that testing facilities are cheap and accessible, is crucial to ending the AIDS epidemic. We are proud to work with local communities and UNAIDS to increase availability of information on HIV, improve the reach and quality of medical services and encourage young people and vulnerable groups to get tested,” said Simon Ernst, Acting Minister Counsellor for Governance and Human Development at the Australian Embassy in Indonesia.

The training is based on the manual developed by Youth LEAD in 2021, which was financially supported by the Global Fund’s Sustainability of HIV Services for Key Populations in Asia Programme and the UNAIDS Regional Support Team for Asia and the Pacific. Under the DFAT grant for the next two years, Youth LEAD will expand the training to two more countries, Cambodia and the Philippines, supporting networks led by young people in the respective countries to roll out the training.

“Young people still encounter many challenges that prevent them from accessing the life-saving health care they need. The UNAIDS Country Office for Indonesia is working closely with the UNAIDS regional support team and DFAT to ensure that networks led by young people have the capacity and leadership capabilities to take control of the HIV response and to have direct involvement in creating safe spaces where young people can access HIV services free from stigma and discrimination,” said Krittayawan Boonto, the UNAIDS Country Director for Indonesia.

Around 10 million people living with HIV are still not on antiretroviral therapy

GENEVA, 7 February 2022—Newly published research from the Netherlands has revealed the existence of a more transmissible and damaging variant of HIV. People living with the newly revealed HIV subtype experience double the rate of immune system decline (CD4 count), have higher HIV viral loads (amount of virus in the blood) and are vulnerable to developing AIDS two to three times faster after diagnosis than if they were living with other strains of the virus. The study, led by researchers from the University of Oxford’s Big Data Institute, was the first to discover this highly virulent variant of the subtype-B of HIV. The study also revealed that the variant has been circulating in the Netherlands for years and remains receptive to HIV treatment.

The HIV pandemic continues to take a life every minute and scientists have long worried about the evolution of new, more transmissible, variants of HIV. This newly identified variant does not represent a major public health threat but underscores the urgency of speeding up efforts to halt the HIV pandemic.

“Ten million people living with HIV worldwide are not yet on treatment, fuelling the continued spread of the virus and potential for further variants,” said Eamonn Murphy, UNAIDS Deputy Executive Director, Programme, a.i. “We urgently need to deploy cutting-edge medical innovations in ways that reach the communities most in need. Whether it’s HIV treatment or COVID-19 vaccines, inequalities in access are perpetuating pandemics in ways that harm us all.”

HIV remains the deadliest pandemic of our time—an estimated 79 million people have become infected with the virus, for which there is still no vaccine and no cure. Some 36 million people have died from AIDS-related illnesses since the start of the pandemic and 1.5 million people were newly infected with HIV in 2020. Of the 38 million people living with HIV today, 28 million are on life-saving antiretroviral therapy, keeping them alive and well and preventing transmission of the virus.

UNAIDS

The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners towards ending the AIDS epidemic by 2030 as part of the Sustainable Development Goals. Learn more at unaids.org and connect with us on Facebook, Twitter, Instagram and YouTube.