On July 18, 2018, UNAIDS released a report titled "Miles to go—closing gaps, breaking barriers, righting injustices1" as a part of global AIDS update report 2018.  The report is a stark wake-up call for countries as it indicates that the global AIDS response is at a precarious point - partial success in saving lives and stopping new HIV infections is giving way to complacency. At the halfway point to the 2020 targets, the pace of progress is not matching the global ambition - for example the progress in Asia and the Pacific Region is encouraging while West and Central Africa lagging behind, as described below:

Progress in Asia and the Pacific Region

Asia and the Pacific Region have made strong inroads with their HIV response. Sustained and focused efforts to reach key populations led to significant reduction in HIV infections in Cambodia, India, Myanmar, Thailand and Vietnam between 2010 and 2017. However, epidemics are expanding in Pakistan and Philippines. on a brighter note, new HIV infections and AIDS-related deaths have significantly dropped in India during the period 2010-2017.

The vast majority of new HIV infections in Asia and the Pacific are associated with current or former members of key populations and their partners. Unprotected sex between men especially young men, is an increasingly important factor in many of the regions' HIV epidemics; epidemics among gay men and other men who have sex with men are expanding in several countries. Key populations must remain at the core of HIV prevention. HIV risk among young people within key populations is of particular concern; since 2010, new HIV infections among young people (aged 15–24 years) increased by 170% in Philippines and 29% in Pakistan.

In case of Combination HIV Prevention there has been an encouraging increase in the number of countries offering pre-exposure prophylaxis (PrEP), albeit mainly through pilot projects and at demonstration sites. By March 2018, PrEP was available on a limited basis to gay men and other men who have sex with men in China, India, Malaysia, New Zealand, Philippines, Thailand and Vietnam.

West and Central Africa lagging behind

Only 26% of children and 41% of adults living with HIV had access to treatment in western and central Africa in 2017, compared to 59% of children and 66% of adults with HIV in eastern and southern Africa. Since 2010, AIDS-related deaths have fallen by a mere 24% in western and central Africa, compared to a considerable 42% decline in eastern and southern Africa.

Nigeria has more than half (51%) of the HIV burden in the region and there has been little progress in reducing new HIV infections in recent years. New HIV infections declined by only 5% (9000) in seven years (from 179 000 to 170 000) and only one in three people living with HIV is on treatment (33%), although HIV treatment coverage has increased 24% from just two years ago.

The report further highlights the following observations:

1. HIV prevention crisis

Global new HIV infections have declined by just 18% in the past seven years, from 2.2 million in 2010 to 1.8 million in 2017. Although this is nearly half the number of new infections compared to the peak in 1996 (3.4 million), the decline is not quick enough to reach the target of fewer than 500 000 by 2020.

The reduction in new HIV infections has been strongest in the region most affected by HIV - eastern and southern Africa - where new HIV infections have been reduced by 30% since 2010. However, new HIV infections are rising in around 50 countries. In Eastern Europe and Central Asia the annual number of new HIV infections has doubled, and new HIV infections have increased by more than a quarter in the Middle East and North Africa over the past 20 years.

2. Treatment scale-up should not be taken for granted

Due to the impact of antiretroviral therapy roll-out, the number of AIDS-related deaths is the lowest in this century (940 000), having dropped below 1 million for the first time in 2016. Yet, the current pace of decline is not fast enough to reach the 2020 target of fewer than 500 000 AIDS-related deaths.

In just one year, an additional 2.3 million people are newly accessing treatment. This is the largest annual increase to date, bringing the total number of people on treatment to 21.7 million. Almost 60% of the 36.9 million people living with HIV were on treatment in 2017, an important achievement, but to reach the 30 million target there needs to be an annual increase of 2.8 million people, and there are indications that the rate of scale-up is slowing down.

3. Key populations account for almost half of all new HIV infections worldwide

The report also shows that key populations are not being considered enough in HIV programming. Key populations and their sexual partners account for 47% of new HIV infections worldwide and 97% of new HIV infections in Eastern Europe and Central Asia, where one third of new HIV infections are among people who inject drugs.

Half of all sex workers in Eswatini, Lesotho, Malawi, South Africa and Zimbabwe are living with HIV. The risk of acquiring HIV is 13 times higher for female sex workers, 27 times higher among men who have sex with men, 23 times higher among people who inject drugs and 12 times higher for transgender women.

4. Stigma and discrimination persist

Discrimination by health-care workers, law enforcement, teachers, employers, parents, religious leaders and community members is preventing young people, people living with HIV and key populations from accessing HIV prevention, treatment and other sexual and reproductive health services.

Across 19 countries, one in five persons living with HIV responding to surveys reported being denied health care and one in five persons living with HIV avoided visiting a health facility for fear of stigma or discrimination related to their HIV status. In five of 13 countries with available data, more than 40% of people said they think that children living with HIV should not attend school with children who are HIV-negative.

However, successive surveys in Cambodia, India, Thailand and Vietnam indicate that attitudes towards people living with HIV have improved. The Avahan programme in Karnataka and other states in India remains a sterling example of the impact of combining condom programming with community empowerment and structural improvements that tackle stigma, violence and unsafe working environments.

5. New agenda needed to stop violence against women

In 2017, around 58% of all new HIV infections among adults over 15 years old were women and 6600 young women between the ages of 15 and 24 years became infected with HIV every week. Increased vulnerability to HIV has been linked to violence. More than one in three women worldwide have experienced physical or sexual violence, often at the hands of their intimate partners.

Criminalization also exposes sex workers to violence from clients and other sexual partners. Studies from India and the United Kingdom of Great Britain and Northern Ireland found that sex workers who had been arrested or imprisoned were more likely to be assaulted by clients than peers who had avoided arrest.

The report also included an example of Indian state of Karnataka, where advocacy work with senior police officials, sensitization workshops and the inclusion of HIV and human rights topics in pre-service curricula led to significant decrease in the arrest of female sex workers, especially during police raids. Before the interventions, half (50%) of the 4110 surveyed female sex workers said they had been arrested or detained at some point during police raids; that proportion shrank to 20% after the interventions.

A recent analysis of data from 27 European countries underscores the public health benefits of decriminalizing sex work. It found that countries that have decriminalized at least some aspects of sex work have fewer sex workers living with HIV than countries that criminalize all aspects of sex work. Predictive models based on data from Canada, India and Kenya indicate that the decriminalization of sex work could avert 33–46% of HIV infections over the course of a decade.

Note – The report shows that though there has been progress in the 90–90–90 target toward diagnosis-treatment access-suppressed viral load, only six countries - Botswana, Cambodia, Denmark, Eswatini, Namibia and the Netherlands have reached the 90–90–90 target and seven more countries are on track. However, much faster paced progress is required to achieve the global target. The largest gap is in the first 90 as observed in western and central Africa, where only 48% of people living with HIV know their status.

Footnote

1. http://www.unaids.org/sites/default/files/media_asset/miles-to-go_en.pdf

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