In part one of this two-part series, I discuss the good news in UNAIDS’ Global Report, released in advance of World AIDS Day on December 1.
We’ve made unprecedented strides in past decade–and just in the past few years–to end the HIV/AIDS epidemic. We’re well on our way. Many barriers remain, however, and I’d like to explore these last hurdles as we near the “post-2015″ world, the deadline for the Millennium Development Goals and a number of HIV-related targets. The UNAIDS Global Report (which discusses results from 2011) has many glowing points to make, but it does not shy away from where we still need to go. “AIDS,” the organization writes, “is not over.”
Despite great declines in the number of new infections and AIDS-related deaths, there are still 34 million people living with HIV worldwide–70 percent of whom are in sub-Saharan Africa. Antiretroviral therapy (ART) and other interventions have turned HIV into a chronic illness rather than a death sentence, but prevention and treatment efforts cost money. Let’s get that out of the way first: Even though many low- and middle-income countries are spending more within their own borders on HIV programs, UNAIDS still anticipates a funding gap of U.S. $5-7 billion, or 30 percent, annually. Many national programs rely on support from higher-income countries’ development aid programs particularly for treatment, and the international funding climate, as always, is tenuous. UNAIDS calls on more targeted spending by identifying where the needs are greatest, which will vary from country to country.
Although behavior change programs are in many ways successful, there are still gaps in many young peoples’ basic knowledge of HIV in countries with generalized epidemics. Furthermore, condom availability and use–a issue of both supply and demand, as UNAIDS notes–must expand further. The UNFPA estimated that in 2011, only nine condoms were available to each man between the ages of 15 and 49 in sub-Saharan Africa. UNAIDS cited one study that estimated that in 2010, there was a gap of 11 billion condoms between what countries procured and what populations needed. Furthermore, UNAIDS notes that there has been “limited progress” in scaling voluntary male circumcision programs, an effective and low-cost HIV prevention strategy.
As new infections are declining globally, they are actually increasing in some countries in the Middle East and North Africa and potentially in Central Asia and Eastern Europe as well. As UNAIDS outlines, funding and programs lag for the highest-risk populations–which are often marginalized, if not criminalized–and these gaps are perpetuating and even driving up epidemics around the world. UNAIDS points out that a criminalized status and high levels of stigma due to HIV status and/or other issues makes it difficult, if not impossible, to access HIV services. Without laws in place to stop discrimination, cultural shifts to end stigma, and risk and harm reduction strategies, we will struggle to end the HIV epidemic.
In my last post, I pointed out that many countries are starting to fund risk reduction programs for female sex workers. The vast majority of funding for prevention and support for sex workers is from international donors–around 90 percent. Outreach to clients is lagging as well, which does little to reduce the demand for unprotected sex. In Swaziland, which has the highest HIV prevalence rate in the world, 70 percent of sex workers are living with HIV. No, that is not a typo. Globally, female sex workers are 13.5 times more likely to have HIV than other women. In an article published this week, the New York Times details how mobile technology is actually fueling the epidemic among sex workers in India.
Almost always, the prevalence rate among men who have sex with men (MSM) is greater than the general public. For example, in Chile, the national rate is around 1 percent, while it is 20 percent for MSM. UNAIDS notes that some evidence suggests that the global prevalence rate among MSM may have actually grown between 2010 and 2012. Apart from the need for more consistent condom use (and behavior change programs and increased availability of condoms), the issue of stigma, discrimination, and criminalization are all very acute. In countries with high rates of homophobia or laws prohibiting homosexuality, such as in the Middle East and North Africa, MSM are much less likely to seek testing, counseling, and treatment or be reached by prevention efforts. Transgendered people are even more marginalized and even less supported by domestic and international efforts–UNAIDS calls this group “largely invisible in the AIDS response.”
UNAIDS writes that the failure to reach injecting drug users is “driving the expansion of the epidemic in many countries.” In 11 countries, HIV prevalence among people who inject drugs is 50-fold higher than the rate among the general population. UNAIDS calls for “evidence-informed responses,” such as clean needle distribution. These programs have been proven effective, but the political and funding will is not there to support programs for this mostly criminalized and marginalized group.
Gender inequality also remains a huge barrier to greater success against HIV. As long as there is gender inequality and gender-based violence and abuse, as long as women are unable to insist on condom use or are afraid to get tested or disclose their status due to societal stigma or fear of abuse, we will not be able to end the epidemic.
This side of epidemic is gloomy–and it should be. The people who are largely left out of the successes in the fight against AIDS point to the ugly parts of our societies, to the discrimination and inequality that is perpetuating and in some cases exacerbating the HIV epidemic. Without turning the focus of efforts to prevent and treat HIV/AIDS to marginalized and vulnerable groups, and without tackling the root causes of that discrimination and marginalization, a successful path to 2015 will be difficult. There are a number of other steps to take–more condoms, more money, cheaper antiretroviral drugs, stronger health systems–but the time is now to step up and support the highest-risk groups and to work towards cultural acceptance and, more importantly, legislation that protects these groups from discrimination and stigma, from sex workers, to homosexuals, to drug users, to women overall. The 2011 results that UNAIDS has provided make that clear. Without a saner, more pragmatic, human-rights-based approach to HIV, we’ll fall short. And we’ve come much too far to backslide.
In the header photo, Bayalpata Hospital in Nepal commemorates World AIDS Day, courtesy of Nyaya Health, via Flickr, CC BY 2.0.