People living with HIV are at a higher risk of severe COVID-19 illness and death, yet the vast majority are denied access to COVID-19 vaccines. Key populations and their sexual partners account for 65% of new HIV infections but are largely left out of both HIV and COVID-19 responses—800 000 children living with HIV are not on the treatment they need to keep them alive

GENEVA, 14 July 2021—The UNAIDS Global AIDS Update 2021, launched today, highlights evidence that people living with HIV are more vulnerable to COVID-19, but that widening inequalities are preventing them from accessing COVID-19 vaccines and HIV services.

Studies from England and South Africa have found that the risk of dying from COVID-19 among people living with HIV was double that of the general population. In sub-Saharan Africa, which is home to two thirds (67%) of people living with HIV, less than 3% had received at least one dose of a COVID-19 vaccine by July 2021. At the same time, HIV prevention and treatment services are eluding key populations, as well as children and adolescents.

COVID-19 vaccines could save millions of lives in the developing world but are being kept out of reach as rich countries and corporations hold on tightly to the monopoly of production and delivery of supplies for profit. This is having a severe impact around the world as health systems in developing countries become overwhelmed, such as in Uganda, where football stadiums are being turned into makeshift hospitals.

“Rich countries in Europe are preparing to enjoy the summer as their populations have easy access to COVID-19 vaccines, while the global South is in crisis,” said Winnie Byanyima, Executive Director of UNAIDS. “We have failed to learn the lessons of HIV, when millions were denied life-saving medicines and died because of inequalities in access. This is totally unacceptable.”

The new UNAIDS report shows how COVID-19 lockdowns and other restrictions have badly disrupted HIV testing—in many countries this has led to steep drops in HIV diagnoses, referrals to care services and HIV treatment initiations. In KwaZulu-Natal, South Africa, for example, there was a 48% drop in HIV testing after the first national lockdown was imposed in April 2020. There were also fewer new HIV diagnoses and a marked drop in treatment initiation. This occurred as 28 000 HIV community health-care workers were shifted from HIV testing to COVID-19 symptom screening.

The report, Confronting inequalities, shows that in 2020 the 1.5 million new HIV infections were predominantly among key populations and their sexual partners. People who inject drugs, transgender women, sex workers and gay men and other men who have sex with men, and the sexual partners of these key populations, accounted for 65% of HIV infections globally in 2020. Key populations accounted for 93% of new HIV infections outside of sub-Saharan Africa, and 35% within sub-Saharan Africa. However, they remain marginalized and largely out of reach of HIV services in most countries.

The report shows that many of the 19 countries that achieved the 90–90–90 targets by 2020 have been leaders in differentiated service delivery, where facility-based services are complimented by community-led services. Most have also included key populations as central to their responses. In Estonia, for example, the expansion of comprehensive harm reduction services was followed by a 61% countrywide reduction in HIV infections and a 97% reduction in new HIV infections among people who inject drugs.

HIV testing and treatment has been scaled up massively over the past 20 years. Some 27.4 million of the 37.7 million people living with HIV were on treatment in 2020. However, gaps in service provision are much larger for children than for adults. In 2020, around 800 000 children aged 0–14 years who were living with HIV were not on HIV treatment. Treatment coverage was 74% for adults but just 54% for children in 2020. Many children were not tested for HIV at birth and remain unaware of their HIV status, making finding them and bringing them into care a major challenge.

Confronting inequalities also shows that women and girls in sub-Saharan Africa continue to be at a higher risk of HIV infection, with gender inequality and gender-based violence at the centre of that risk. Gender inequalities and gender-based violence rob women and girls of their fundamental human rights, including the right to education, health and economic opportunities. This increases their risk of HIV infection and blocks access to services. In sub-Saharan Africa, adolescent girls and young women account for 25% of all new HIV infections despite representing just 10% of the population.

Poverty and lack of schooling are also formidable barriers to health and HIV services. The report shows how family planning services for women and voluntary medical male circumcision for men and boys are much less likely to be accessed by people living in poverty. In 2020, the number of voluntary medical male circumcisions dropped by more than 30% in 15 priority countries in eastern and southern Africa.

Poverty is also a driver of migration, which has been shown to severely impact access to HIV services and puts lives in danger as migrants flee conflict and poverty in the hope of safety and economic security.

“Billionaires are sailing their yachts in the same Mediterranean waters that migrants are drowning in,” said Winnie Byanyima. “How can we stand by and let this be the “new normal”. We must confront these horrific inequalities and put the emphasis back on respect for basic, fundamental human rights.”

Inequalities are not naturally occurring. They are the result of policy and programmatic actions that divide rather than include. For example, key populations are marginalized and criminalized for their gender identities and expression, sexual orientation and livelihoods. New analysis included in the report shows a positive correlation between better HIV outcomes and the adoption of laws that advance non-discrimination. A study from sub-Saharan Africa found that HIV prevalence among sex workers was 39% in countries that criminalized sex work, compared to 12% in countries where sex work was partially legalized.

“We are 40 years into the fight against HIV. Both the successes and the failures have taught us that we cannot prepare for or defeat a pandemic unless we tear down inequalities, promote people-centred, rights-based approaches and work together with communities to reach everyone in need,” said Ms Byanyima.

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.

UNAIDS urges world leaders to adopt a bold political declaration on HIV at the United Nations General Assembly High-Level Meeting on AIDS, being held in New York and online next week, and to commit to achieving a new set of targets for 2025 to end AIDS by 2030

NEW YORK/GENEVA, 3 June 2021—Four decades after the first cases of AIDS were reported, new data from UNAIDS show that dozens of countries achieved or exceed the 2020 targets set by the United Nations General Assembly in 2016—evidence that the targets were not just aspirational but achievable.

The report shows that countries with progressive laws and policies and strong and inclusive health systems have had the best outcomes against HIV. In those countries, people living with and affected by HIV are more likely to have access to effective HIV services, including HIV testing, pre-exposure prophylaxis (medicine to prevent HIV), harm reduction, multimonth supplies of HIV treatment and consistent, quality follow-up and care.

“High-performing countries have provided paths for others to follow,” said Winnie Byanyima, the Executive Director of UNAIDS. “Their adequate funding, genuine community engagement, rights-based and multisectoral approaches and the use of scientific evidence to guide focused strategies have reversed their epidemics and saved lives. These elements are invaluable for pandemic preparedness and responses against HIV, COVID-19 and many other diseases.”  

Globally, the report shows that the number of people on treatment has more than tripled since 2010. In 2020, 27.4 million of the 37.6 million people living with HIV were on treatment, up from just 7.8 million in 2010. The roll-out of affordable, quality treatment is estimated to have averted 16.2 million deaths since 2001.

Deaths have fallen in large part due to the roll-out of antiretroviral therapy. AIDS-related deaths have fallen by 43% since 2010, to 690 000 in 2020. Progress in reducing new HIV infections has also been made, but has been markedly slower—a 30% reduction since 2010, with 1.5 million people newly infected with the virus in 2020 compared to 2.1 million in 2010.

The report underscores that countries with punitive laws and that do not take a rights-based approach to health punish, ignore, stigmatize and leave key populations—which make up 62% of new HIV infections worldwide—on the margins and out of reach of HIV services. For example, almost 70 countries worldwide criminalize same-sex sexual relationships. Gay men and other men who have sex with men, sex workers, transgender people, people in prison and people who inject drugs are left with little or no access to health or social services, allowing HIV to spread among the most vulnerable in society.

Young women in sub-Saharan Africa also continue to be left behind. Six out of seven new HIV infections among adolescents aged 15–19 years in the region are among girls. AIDS-related illnesses remain the leading cause of death among women aged 15–49 years in sub-Saharan Africa.

COVID-19 has shown the fragility of the health and development gains made over the past decades and has exposed glaring inequalities. To get the world on track to end AIDS by 2030, the global AIDS community and UNAIDS have used an inequalities lens to develop an ambitious and achievable strategy with new targets to reach by 2025. Ending inequalities requires HIV responses that can reach the populations currently being left behind.

If reached, the targets will bring HIV services to 95% of the people who need them, reduce annual HIV infections to fewer than 370 000 and AIDS-related deaths to fewer than 250 000 by 2025. This will require an investment of US$ 29 billion a year by 2025. Each additional US$ 1 of investment in implementing the global AIDS strategy will bring a return of more than US$ 7 in health benefits.

UNAIDS urges the United Nations General Assembly to commit to the targets in a new political declaration on HIV at the fifth United Nations General Assembly High-Level Meeting on AIDS, taking place from 8 to 10 June 2021.

“The world cannot afford to underinvest in pandemic preparedness and responses,” said Ms Byanyima. “I strongly urge the United Nations General Assembly to seize the moment and commit to taking the actions needed to end AIDS.”

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.

Disruption to HIV services as high as 75% has been reported in some countries—to prevent increased AIDS-related deaths, HIV services must continue during the COVID-19 pandemic

GENEVA, 13 April 2021—UNAIDS and the World Health Organization (WHO) have supported mathematical modelling to establish the benefits of continuing HIV services compared to the potential harm of additional COVID-19 transmission. The analysis shows that maintaining HIV services would avert between 19 and 146 AIDS-related deaths per 10 000 people over a 50-year time horizon, while the additional COVID-19-related deaths from exposures related to HIV services would be 0.002 to 0.15 per 10 000 people. The analysis demonstrates that the benefits of continuing to provide HIV services during the COVID-19 pandemic far outweigh the risk of additional COVID-19-related deaths.

“The world should make investments now that don’t leave it with such stark trade-offs in the future,” said Peter Ghys, Director, Strategic Information and Evaluation, UNAIDS. “We need to build robust future systems for health that recognize community-led contributions as part and parcel of a resilient system, not as an afterthought.”

The analysis looked at disruptions to four key HIV services: voluntary medical male circumcision, HIV diagnostic testing, viral load testing and programmes to prevent mother-to-child transmission of HIV. It compared COVID-19 deaths in 2020 and 2021 among health workers and clients due to keeping HIV services open with averted AIDS-related deaths occurring now and over the next 50 years due to maintenance of services. The models were applied to countries with a range of HIV and COVID-19 epidemics.

The COVID-19 pandemic has caused widespread disruption to health services, with restrictions in population movements and health services suspended or limited in many countries. The analysis shows that the potential harm of additional COVID-19 transmission occurring in HIV health services needs to be carefully balanced against the benefits of those services, which, the analysis shows, include fewer AIDS-related deaths. These results may seem intuitive, but it is important to realize that some services have been closed to protect people living with HIV from exposure to COVID-19 and its potential lethal outcomes. However, the risk of not keeping those essential HIV services open entails a greater overall risk of death related to lack of prevention of HIV, access to diagnosis and eventual treatment—these trade-offs are unacceptable.

While there is some additional short-term risk of COVID-19 transmission associated with providing HIV services, the risk of additional COVID-19 deaths is at least 100 times less than the AIDS-related deaths averted by continuing those services. Additional effort to encourage health-care seeking for HIV services during the ongoing COVID-19 pandemic may be needed.

“Ministries of health take into account many factors in deciding when and how to offer essential health services during the COVID-19 pandemic,” said Meg Doherty, Director of WHO’s Global HIV, Hepatitis and Sexually Transmitted Infections Programmes. “This work shows that taking the longer view, the benefits of continuing key HIV services are far larger than the risks of additional COVID-19 transmission; innovative and safe delivery of services must continue as the pandemic is brought under control.”

The full analysis can be found on medrxiv at: https://doi.org/10.1101/2021.03.01.21252663

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.

Early diagnosis of infants who have acquired HIV vertically (from their mother) is vital. Swift testing of infants exposed to HIV and an immediate start of antiretroviral therapy upon diagnosis can ensure the survival of children who have acquired HIV. Without early diagnosis and treatment, about half of infants with HIV die by the age of two years, but many HIV-exposed infants in low- and middle-income countries are not accessing early infant diagnosis.

In the Caribbean, coverage of virological testing for early infant diagnosis varies from 21% in Jamaica to 99% in Cuba.

Stakeholders of the Caribbean HIV response have launched the In Your Hands HIV self-testing campaign, which advocates for self-testing policies to be developed and implemented as part of a comprehensive strategy to ensure that HIV diagnosis does not decline during the COVID-19 pandemic.

Even before COVID-19, the Caribbean was not on track to achieve the 90% testing target due at the end of 2020. In 2019, 77% of all people living with HIV in the Caribbean knew their HIV status. A survey conducted by the Pan Caribbean Partnership against HIV and AIDS (PANCAP) and the Pan American Health Organization (PAHO) showed that during 2020 facility- and community-based HIV testing services were reduced in 69% of countries due to COVID-19.

“This decline means that people with undiagnosed HIV are not getting life-saving antiretroviral treatment and, of course, continue to be unaware of their HIV status, with the risk of potentially exposing others,” said Sandra Jones, PAHO’s Technical Advisor for HIV/STI, TB & Viral Hepatitis in the Caribbean.

“The COVID-19 pandemic has presented the opportunity for us to explore new and innovative approaches that are result-oriented,” Rosmond Adams, the PANCAP Director, said.

According to James Guwani, the Director of the UNAIDS Caribbean Sub-Regional Office, it is particularly important to increase testing uptake among men, who are more likely to be diagnosed late. In 2019, 85% of Caribbean women living with HIV were aware of their HIV status, compared to just 72% of men. There is also a need to increase testing coverage among members of key populations, who have reduced access to HIV services due to stigma and discrimination. 

The World Health Organization recommends that HIV self-testing be offered as an additional approach to facility- and community-based services. Evidence shows that self-testing is safe and accurate and increases testing uptake among people who may not test otherwise.

Through the campaign, partners are advocating for national policies to include a communication package with information to link testers to HIV prevention and treatment services, as well as minimum standards for the procurement and distribution of HIV self-testing kits in the private and public sectors.

“We strongly believe that HIV self-testing can help close the gap on the first 90. It can be targeted to individuals not being reached by existing HIV testing services, particularly those populations with low testing coverage and at high risk of HIV. It’s not a replacement for all testing services, but it should be included in the toolbox,” said Victoria Nibarger, the Caribbean Regional Programme Coordinator for the United States President’s Emergency Plan for AIDS Relief (PEPFAR).

Under a Global Fund to Fight AIDS, Tuberculosis and Malaria project for the region, work is under way to conduct a verification and feasibility assessment for the introduction of HIV self-testing across countries. Already Guyana has announced plans to roll out HIV self-testing this year, while several countries have either made a commitment to develop policies or are now in the process of doing so. 

UNAIDS is helping to coordinate the campaign in the Caribbean, with a focus on supporting a knowledge management strategy that ensures all stakeholders have the information, messages and tools they need to successfully lobby at the national level. A key priority is ensuring civil society engagement and addressing community concerns about how self-testing policies will be implemented.   

While representatives of communities of people living with HIV and key populations endorsed the call for HIV self-testing, they have advised that increased investments are needed in post-test counselling and adherence counselling for the entire HIV response.

Deneen Moore, a Caribbean representative of the International Community of Positive Women, said, “We need to improve peer navigation so that when people test positive they have someone there to help them. We also need more social contracting so that civil society organizations can help reach people who test positive. There is definitely a need for us to be involved in the process.”

The advocacy initiative is jointly endorsed by UNAIDS, PAHO, PANCAP, PEPFAR and the Caribbean Med Labs Foundation.

UCOP+, the Congolese Union of Organizations of People Living with HIV, through funding and technical support from UNAIDS, set up the Observatory project, designed to collect and analyse data to guide action to improve the quality of HIV services.

“The Observatory, which looks at access to and the quality of HIV and HIV/tuberculosis services, is a community-based initiative. Its main objective is to help the government and civil society define and implement national policies in accordance with international norms and standards,” said Natalie Marini, Human Rights and Gender Adviser at the UNAIDS Country Office for the Democratic Republic of the Congo.

The Observatory was set up following repeated stock-outs of HIV and tuberculosis medicine, requests for payment for services that are supposed to be free, the persistence of stigma and discrimination and human rights violations and the long distances that people have to travel to access health care. Three areas are monitored monthly—the availability of services, the quality of care, including the availability of medicine, and accessibility of care.

The initiative shows the importance of collaboration between civil society, health services and donors in the HIV response and has led to an improvement in HIV/tuberculosis services in health facilities. “The Observatory is an indispensable tool that gives us the first clues about supply,” said Aimé Mboyo, director for the National AIDS Control Programme. “It helps us enormously.” The data from the Observatory complements the data of the National Health Information System (SNIS).

Since its launch in 2013, the Observatory has contributed to reducing the cost of access to health care in some health facilities and has anticipated stock-outs and helped to reduce their frequency. The Observatory has also reduced self-stigma by valuing the people who use the services and putting them at the heart of the system. “Before, I didn’t have anything to say about the care offered to me,” said Joséphine Ntumba (not her real name), who is living with HIV. “Now I can give my opinion and make a difference.”

The concept of a “community observatory” has been shown to be a success and is now integrated in the concept note for the Democratic Republic of the Congo of the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, there is still a long way to go—only three out of 23 provincial health departments are covered. 

The Central African Republic has made significant progress in its response to HIV over the past four years. New HIV infections continue to decline and the number of people on antiretroviral therapy has increased from less than 25 000 in 2016 to more than 47 000 in 2019.

Despite this progress, the Central African Republic remains far from the 90–90–90 targets. Less than half of the 100 000 people living with HIV in the country have access to treatment and the government estimates that less than 20% of people on treatment have an undetectable viral load. For those who are on treatment, the quality of care is insufficient. Recent studies reveal a very high rate of immunological and therapeutic failure among people living with HIV on treatment.

Various factors contribute to this situation, including hospital-based management, the unavailability of biological monitoring in rural areas, the lack of human and material resources in health facilities and laboratories and the absence of community-based approaches that promote treatment adherence and information. In addition to these system-related factors, since December 2020 the country has faced a resurgence of a political and security crisis, which makes access to treatment difficult.

There is a need to simplify and adapt the cascade of HIV-related services to take into account the preferences and expectations of different groups of people living with HIV while reducing unnecessary burdens on the health system. People-centred care is now the goal of the Central African Republic.

The Central African Republic aims to diversify, accelerate and generalize differentiated services. The Catalytic Initiative promoted by UNAIDS with the financial support of Luxembourg is helping the country to achieve this ambition. A first decisive step has been taken with the organization of a round-table discussion, entitled Catalytic Initiative on Differentiated HIV and Tuberculosis Services. The meeting brought together the Ministry of Health, the Comité National de Lutte contre le SIDA, civil society, people living with HIV, tuberculosis stakeholders, key populations, youth organizations, the United Nations, Médecins Sans Frontières and the French Red Cross.

The participants reviewed the existing pilot programmes of differentiated services in the country and the obstacles related to their implementation. They stressed the urgent need to expand differentiated services, particularly in the current context of the increasing insecurity and humanitarian challenges that make it difficult for people to access HIV and tuberculosis services.

“It is in the current context of the security crisis that the differentiated services approach is most valuable in the Central African Republic,” said Patrick Eba, UNAIDS Country Director for the Central African Republic.

The participants agreed on the activities to be implemented and validated the project implementation schedule to improve the quality of care and biological monitoring of people living with HIV and tuberculosis patients by stimulating the implementation of differentiated services.

“I welcome this opportunity offered by UNAIDS to remove bottlenecks to improve the overall management of HIV,” said Marie-Charlotte Banthas Bata, the Director of Communicable Disease Control at the Ministry of Health and Population, Central African Republic, pictured above, centre.

“Community organizations must be at the centre of the implementation of differentiated approaches,” said Bienvenu Gazalima, the President of the National Network of Associations of People Living with HIV in the Central African Republic 

The next key steps will be the documentation of existing differentiated approaches in the country and the development of a national guidance document for scaling them up.