Homeless people have difficulty accessing health-care services at the best of times, but the COVID-19 pandemic has curtailed access even more. Stigma and discrimination and the conditions they live in make homeless people particularly vulnerable not only to COVID-19 but also tuberculosis, HIV, hepatitis and other diseases.

“Before the COVID-19 pandemic there were about 11 shelters in Minsk where people could get clean clothes, wash themselves, have food and stay for a night. Now only three of them remain open,” said Karina Radchenko, a volunteer from Street Medicine, the country's first volunteer network to treat the homeless. “We know that some of them are living with HIV, but because they don’t have proper identification and residence registration they can’t get free treatment. This is why we need to keep providing support to the homeless, especially now.”

Launched by Street Medicine, UNAIDS, the Positive Movement—a Minsk-based nongovernmental organization that provides HIV services—and the Ministry of Health of Belarus, a new initiative is providing HIV testing and support to the homeless during the COVID-19 pandemic.

Working on the streets, the volunteers distribute condoms, hygiene packs and over-the-counter medicines and provide HIV testing and counselling together with first aid, such as wound treatment and bandage application. The first phase of the initiative will see at least 200 homeless people in Minsk and beyond being tested for HIV and will collect information on their HIV prevention needs and the barriers they face in accessing HIV treatment and other health services.

“Homeless people very often don’t have identification, and this complicates a formal recognition of their HIV status and their access to HIV treatment,” said Vera Ilyenkova, the UNAIDS Country Manager for Belarus. “One of the goals of this initiative is to help people who test positive for HIV to get connected to health facilities so they can get treatment and proper documents from the authorities.”

A new film about HIV in the Russian Federation by YouTuber and journalist Yuri Dud is stirring people’s interest about the epidemic in the country.

Since its release on 11 February, the video has been viewed by more than 14 million people, and the number of online searches about HIV and HIV testing has skyrocketed. According to Google Trends, the number of searches on where to buy an HIV test has increased by 4000% since the launch of the video—the highest level of interest in HIV and HIV testing in the past five years.

In the film, published on his YouTube channel, Mr Dud talks to people living with HIV, activists, experts and journalists. Through his interviews, the film voices some of the taboos surrounding HIV in Russian society, including condom use, and looks into the drug use epidemic in the country, the services available for people who use drugs and the lack of sex education, among other things.

It is clear in the film that younger people still lack basic information about HIV—things like the difference between HIV and AIDS, the effectiveness of treatment or even how the virus is transmitted are still mysteries for many in the country. “You can touch people living with HIV, exchange clothes, swim in the same pool, drink from the same mug, cuddle, kiss. It's stupid to be squeamish about people living with HIV. It is much better to be squeamish about unprotected sex and drugs. These are still the two main modes of HIV transmission,” said Mr Dud.

The popularity of the film has prompted government officials to take a closer look at the HIV epidemic and response.

“Yuri Dud’s film about HIV is undoubtedly useful. It provides a lot of important information and motivates people to get tested for HIV,” said Oleg Salagai, Deputy Health Minister, in his Telegram channel. Mr Salagai emphasized how the film draws attention to the issue of the stigma endured by people living with HIV. “HIV is not a death sentence anymore. It is very important that people living with HIV have access to HIV treatment to live a healthy and fulfilling life,” he wrote.

Mr Salagai was not the only government official reacting to the video.

Alexei Kudrin, the Head of the Accounts Chamber of the Russian Federation, promised to carry out a review of the effectiveness of HIV prevention and care programmes in the country. “This year, the Accounts Chamber will analyse the effectiveness of government resources allocated to people living with HIV in the Russian Federation,” he said.

And the first Deputy Head of the State Duma Health Committee, Fedot Tumusov, invited members of parliament to watch the film and discuss to the HIV situation in the Russian Federation. He is also planning a round-table meeting in the State Duma to explore ways to improve access to HIV prevention and treatment.

“The public response to Mr Dud’s film is incredible. However, even such a successful action is not enough. We need consistent and long-term activities to raise HIV awareness coupled with programmatic actions to ensure access to HIV testing and treatment for all,” said Alexander Goliusov, Director, a.i., of the UNAIDS Regional Support Team for Eastern Europe and Central Asia.

Eastern Europe and central Asia, of which the Russian Federation is a part, has the fastest growing HIV epidemic in the world. Most new HIV infections in the Russian Federation are among key populations, including people who inject drugs, despite the well-documented power of harm reduction programmes, where available, to reduce new HIV infections—insufficient access to sterile injecting equipment and the unavailability of opioid substitution therapy are stymying efforts in the country to prevent HIV infections among people who inject drugs.

It is vital that people living with HIV know their HIV status. If people know they are HIV-positive, they can access treatment to keep themselves heathy. And when their treatment has reduced their viral load to an undetectable level, they can’t pass on the virus to their sexual partners. However, there are often large disparities in knowledge of HIV status, both geographically and by subpopulation.

In eastern and southern Africa, for example, young people and men living with HIV are much less likely to be aware of their status: while 90% of women living with HIV aged 25 years and above knew their status in 2018 (thanks in large part to the success of efforts to prevent mother-to-child transmission of HIV), that was the case among only 80% of men of the same age, 66% of young women (aged 15–24 years) and 50% of young men (aged 15–24 years). In western and central Africa, the gaps are even larger.

Stepping into the Remera Health Centre in Kigali, the Desert AIDS Project (DAP) delegation visited one of the 552 integrated health centres in Rwanda. The clinic offers everything from primary care to clinical care for all ages, as well as HIV services.

The head of the centre, Emile Musabyimana, led the group around the facility, which includes a laboratory where HIV, viral load and tuberculosis testing are carried out. He is particularly proud that Remera has adopted the test and treat approach, which means that anyone who tests positive for HIV is immediately offered treatment.

The Remera Health Centre serves about 3000 people living with HIV, of which 2400 are virally suppressed. The clinic monitors patients on a monthly basis until their viral loads drop to undetectable levels.

Established by a group of volunteers in 1984, the DAP provides HIV prevention, treatment and care services to people living with and affected by HIV across the Palm Springs, California, area. It has expanded its primary care facility to include a dental clinic and affordable housing.

The delegation, in Kigali for the International Conference on AIDS and STIs in Africa (ICASA), discussed some of the challenges the Remera centre faces. Mr Musabyimana explained that too few young people come to the clinic.

“We need to address the issues of why they don’t come and get tested,” he said. “And when they do know their HIV-positive status, they don’t always stay on treatment.”

As a result, the centre organized an informal chat with young people living with HIV with the delegation.

“A lot of these kids were born with HIV and a lot of them are stigmatized and so they’re fighting it and fighting through it,” said Patrick Jordan, DAP Vice-Chair. He added, “To see them in their valiant efforts and how strong they are is inspiring.”

David Brinkman, DAP Chief Executive Officer, couldn’t agree more. He applauded the health centre’s work as well as Rwanda’s low HIV prevalence rate compared to neighbouring countries in the region.

“We really have to acknowledge what Rwanda is doing,” he said. “People on the ground have all the knowledge they need, it’s now about resources so that when we combine knowledge and resources, we will end the epidemic by 2030.”

Over the past year, a partnership between DAP and UNAIDS has been growing, with the idea of joining forces to support grass-roots and community-led HIV efforts worldwide.

The United Republic of Tanzania has approved a change to the law that lowers the age of consent for HIV testing from 18 years to 15 years. The amendment to legislation also makes self-testing for HIV legal, also from the age of 15 years.

“These amendments will significantly accelerate our intention to meet the 90–90–90 goals, which aim at ending the AIDS epidemic by 2030,” said Ummy Mwalimu, Minister of Health, Community Development, Gender, Elderly and Children. The ministry was instrumental in tabling the amendments to the legislation.

The 90–90–90 targets are ambitious treatment targets to help end the AIDS epidemic. They aim to ensure that, by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people who know their HIV status will be on antiretroviral therapy and 90% of all people on antiretroviral therapy will be virally suppressed.

The changes to the law will contribute to improved access to HIV testing for adults aged 15 years and over.

At the end of 2018, the progress on the 90–90–90 targets in the United Republic of Tanzania was 78–92–87. In 2018, there were 72 000 new HIV infections in the country. While this is a 13% reduction from 2010, it is below the 28% reduction across eastern and southern Africa. 

“I congratulate the Government of the United Republic of Tanzania on its leadership and high-level political commitment to the AIDS response. UNAIDS will continue to work hand-in-hand with all our partners to ensure that access to HIV testing and treatment continues to expand,” said Leo Zekeng, UNAIDS Country Director in the United Republic of Tanzania.

Game-changing approaches, such as medicine to prevent HIV (PrEP), integration of contraceptive services with HIV testing, viral load suppression (U = U), harm reduction, and comprehensive sexuality education, give people the power to protect themselves from HIV and, for people living with HIV, the power to thrive

NAIROBI/GENEVA, 26 November 2019—A new report by UNAIDS, Power to the people, released ahead of World AIDS Day, shows that where people and communities living with and affected by HIV are engaged in decision-making and HIV service delivery, new infections decline and more people living with HIV gain access to treatment. When people have the power to choose, to know, to thrive, to demand and to work together, lives are saved, injustices are prevented and dignity is restored.

“When people and communities have power and agency, change happens,” said Winnie Byanyima, Executive Director of UNAIDS. “The solidarity of women, young people, gay men and other men who have sex with men, sex workers, people who use drugs and transgender people has transformed the AIDS epidemic—empowering them will end the epidemic.”

The report was launched in Kenya on 26 November by the Executive Director of UNAIDS, the Cabinet Secretary of Health of Kenya and community representatives. It shows that significant progress has been made, particularly in expanding access to treatment. As of mid-2019, an estimated 24.5 million of the 37.9 million people living with HIV were accessing treatment. As treatment roll-out continues, fewer people are dying of AIDS-related illnesses.

“The partnership between government and civil society, together with the meaningful involvement of communities, has allowed us to significantly reduce new HIV infections and AIDS-related deaths,” said Sicily Kariuki, Cabinet Secretary for Health in Kenya. “Communities are the very centre of the AIDS response and are critical to ending AIDS.”

Progress in reducing HIV infections, however, is mixed and 1.7 million people were newly infected with the virus in 2018. New HIV infections declined by 28% from 2010 to 2018 in eastern and southern Africa, the region most affected by HIV. In a promising sign, the incidence rate of HIV among adolescent girls and young women aged between 15 and 24 years in the region declined from 0.8% in 2010 to 0.5% in 2018, a 42% decline. However, young women and girls still bear the brunt of new HIV infections—four out of five new HIV infections among adolescents in sub-Saharan Africa are among girls.

Outside of eastern and southern Africa, new HIV infections have declined by only 4% since 2010. Of increasing concern is the rise of new HIV infections in some regions. The annual number of new HIV infections rose by 29% in eastern Europe and central Asia, by 10% in the Middle East and North Africa and by 7% in Latin America.

“In many parts of the world, significant progress has been made in reducing new HIV infections, reducing AIDS-related deaths and reducing discrimination, especially in eastern and southern Africa, but gender inequality and denial of human rights are leaving many people behind,” said Ms Byanyima. “Social injustices, inequality, denial of citizenship rights and stigma and discrimination are holding back progress against HIV and the Sustainable Development Goals.”

Power together

The report shows that when people and communities have power and agency, change happens. Communities have put rights-based, people-centred principles at the heart of HIV programmes, ensuring that AIDS responses tackle the inequalities and injustices that fuel the epidemic.

Women and girls are the backbone of care support in their families and communities, providing unpaid and often undervalued work in caring for children, the sick, the elderly and the disabled and underpinning fragile social support systems. This must change. The involvement and leadership of communities of women is vital in the response to HIV.

“As a community leader, I am able to relate to people and understand their background better than someone from the outside. I have been living openly with HIV for 25 years, so people come to me with their issues, such as HIV-related stigma, disclosure and adherence. I have never stepped back from this role as I am part of this community,” said Josephine Wanjiru, an HIV community activist Kiandutu, Thika, Kenya.

The power to choose

Women and girls are demanding integrated contraception and HIV and sexually transmitted infection testing, prevention and care options. Almost 40% of adult women and 60% of adolescent girls (aged 15–19 years) in sub-Saharan Africa have unmet needs for modern contraception.

In several countries in sub-Saharan Africa, young women’s uptake of medicine to prevent HIV—pre-exposure prophylaxis (PrEP)—has been shown to be high in projects that integrate PrEP into youth-friendly health services and family planning clinics and when provision of PrEP is separated from treatment services.

Eleven million voluntary medical male circumcisions to prevent HIV have been performed since 2016, 4 million in 2018 alone in the 15 priority countries.

The power to know

The power to know allows people to keep themselves free from HIV or, if living with the virus, keep healthy. However, people are finding out their HIV status too late, sometimes years after they became infected, leading to a delay in starting treatment and facilitating HIV transmission. In Mozambique, for example, the average time for diagnosis after infection for men was four years.

Adherence to effective treatment suppresses the virus to undetectable levels, keeping people healthy and preventing transmission of the virus. Knowing this allows people living with HIV the opportunity to lead normal lives, confident that they are protecting their loved ones, and confronting stigma and discrimination.

HIV self-testing is now helping more people to find out their HIV status in privacy, breaking the barriers of stigma and discrimination and facilitating linkage to treatment.

Knowledge of HIV among young people is alarmingly low in many regions. In countries with recently available survey data, just 23% of young women (aged 15–24 years) and 29% of young men (aged 15–24 years) have comprehensive and correct knowledge of HIV. Studies show that comprehensive sexuality education does not lead to increased sexual activity, sexual risk-taking or higher infection rates for HIV or other sexually transmitted infections.

The power to thrive

The power to thrive is ensuring that people have the right to health, education, work and a standard of living adequate for health and well-being.

New HIV infections among children have declined by 41% since 2010 and nearly 82% of pregnant women living with HIV are on antiretroviral therapy. However, thousands of children are falling between the cracks. Half of all children born with HIV who are not diagnosed early will die before their second birthday, but, globally, only 59% of HIV-exposed children were tested before two months of age.

In 2018, 160 000 children (aged 0–14 years) became newly infected with HIV, and 100 000 children died from an AIDS-related illness. They died either because they weren’t diagnosed, or because of a lack of treatment—a shocking indictment of how children are being left behind.

Gender inequalities, patriarchal norms and practices, violence, discrimination, other rights violations and limited access to sexual and reproductive health services exacerbate the risk of HIV infection among adolescent girls and young women, particularly in sub-Saharan Africa. Each week, an estimated 6000 young women (aged 15–24 years) are infected with HIV.  

In Eswatini, a recent study showed that adolescent girls and young women who experienced gender-based violence were 1.6 times more likely to acquire HIV than those who did not. The same study also showed that the economic empowerment of women and girls helped in reducing new HIV infections among women by more than 25% and increased the probability of young women and girls going back to school and finishing their education.

Key populations are being left behind

Key populations and their partners account for at least 75% of new HIV infections outside of sub-Saharan Africa and are less likely to be on treatment than others. More than one third of key populations do not know their HIV status. Community-led support among gay men and other men who have sex with men is effective in increasing the uptake of PrEP, promoting safer sex, increasing HIV testing rates and supporting treatment adherence.

Transgender people are subjected to discrimination in every sphere of life, including education and employment—only 10% work in the formal economy. But community activism has led to long overdue attention to the rights and realities of transgender people.

Community empowerment activities among sex workers have been shown to increase the odds of condom use with clients by three times and reduce the odds of HIV infection by more than 30%.

The power to demand

The power to demand gives communities and individuals the power to participate in the decisions that affect them. There have been reports of crackdowns, restrictions and even attacks on groups and campaigns supporting key populations. Some governments refuse to recognize, support or engage community organizations in their national responses to HIV and are subsequently missing out on their enormous potential to reach the people most affected by HIV.

People and communities will end AIDS

The work of community-led organizations is unique and powerful and can have a substantial impact on how the world fairs towards ending AIDS. UNAIDS urges all countries to fully support and enable their community-led organizations, ensure they have a seat at all decision-making tables concerning the health and well-being of their community members and remove any barriers to their active engagement in the response to HIV. Only by fully funding and fully supporting the work of community organizations will the end of AIDS become a reality.

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.