General Assembly Distr.: General
28 March 2011

Implementation of the Declaration of Commitment on

HIV/AIDS and the Political Declaration on HIV/AIDS

Mobilizing for impact: five recommendations

The present report contains the following five recommendations for all stakeholders:

(a) Champion a prevention revolution that harnesses the energy of young people and the potential of new modes of communication that are transforming the world, rescinds punitive laws that block effective responses and ensures that people are empowered to protect themselves, their partners and their families from HIV;

(b) Forge a revitalized framework for global solidarity to achieve universal access to HIV prevention, treatment, care and support by 2015;

(c) Break the upward trajectory of costs and deliver more effective, efficient and sustainable programmes;

(d) Ensure that our responses to HIV promote the health, human rights, security and dignity of women and girls;

(e) Commit to forging robust mutual accountability mechanisms

Introduction

1. In 2001, the number of people living with HIV was increasing, therapies revolutionizing the HIV response in high-income countries were virtually unavailable in the most severely affected countries and total resources

spent on HIV activities in low- and middle-income countries amounted to only about 10 per cent of spending in 2009. The epidemic was reversing decades of development progress in sub-Saharan Africa, threatening stability and security, and exacerbating global inequity in health.

2. The 2001 special session resulted in a visionary Declaration that included time-bound targets in the response. The special session gave rise to a major global health financing institution, namely the Global Fund to Fight AIDS, Tuberculosis and Malaria. Pledging additional steps to strengthen the response, Member States embraced a complementary set of commitments in the 2006 Political Declaration on HIV/AIDS, including the pledge to achieve universal access to HIV prevention, treatment, care and support.

5. The year 2011 is a historic marker in the global response; it allows the international community to review the progress of the last decade and marks 30 years into the epidemic.

6. This report assesses progress and gaps in the response, based on data submitted by 182 countries and on national and regional reviews on universal access to HIV prevention, treatment, care and support.1 Key findings include the
following:

HIV prevention. The number of people newly infected with HIV declined by 19 per cent in the decade before December 2009, with at least 33 countries experiencing a decline in HIV incidence of at least 25 per cent and 10 high prevalence countries achieving the global goal of reducing HIV prevalence among young people by at least 25 per cent.

Antiretroviral therapy. As at December 2010, more than six million people were estimated to be receiving antiretroviral therapy in low- and middle income countries. Yet the majority of people in need still lack access.

Towards an HIV-free generation. Global coverage for antiretroviral prophylaxis to prevent the vertical transmission of HIV has exceeded 50 per cent..

Human rights. About three in 10 countries worldwide still lack laws prohibiting HIV-related discrimination.

Financing the response. Funding for HIV programmes has dramatically increased, helping drive an overall surge in global health financing (see figure I). Nonetheless, in 2009, international HIV assistance declined for the first

time, mirroring reductions in other forms of development aid.

II. Thirty years of AIDS: reviewing the past, looking towards the future

Sub-Saharan Africa remains the most severely affected region, accounting for 68 per cent of all people living with HIV, 69 per cent of new infections and 72 per cent of AIDS deaths. The epidemic, however, has not spared other regions; more than 10.8 million people are living with HIV outside sub-Saharan Africa. It continues to deepen poverty, increase hunger, slow progress on maternal and child health and exacerbate other infectious diseases.

8. The epidemic particularly affects women and girls. In 2009, women represented a slight majority (about 51 per cent of all people living with HIV and about 60 per cent of all people living with HIV in sub-Saharan Africa).

The 2001 and 2006 Declarations: a framework for unprecedented progress

11. The 2001 Declaration of Commitment on HIV/AIDS helped to galvanize global resolve to reverse the epidemic. Outcome indicators were established to monitor implementation of the targets adopted in 2001, with countries submitting biennial progress reports to the Joint United Nations Programme on HIV/AIDS (UNAIDS). Civil society and people living with HIV have played an especially critical role in tracking progress in implementing the 2001 and 2006 Declarations, evaluating national policy responses and contributing to country-specific reviews.

12. More than 110 countries established clear, time-bound national targets for service coverage. Although most countries are unlikely to have met their targets for 2010, advances over the last decade definitively demonstrate that universal access is both feasible and essential for long-term success.

III. Towards a world with zero new HIV infections, zero discrimination and zero AIDS-related deaths

In 2010, UNAIDS articulated a new vision for the response, that of a world with zero new HIV infections, zero discrimination and zero AIDS-related deaths. This new vision is intentionally ambitious, reflecting the high aspirations of a people centered global movement.

A. Zero new infections

Although global HIV incidence is now declining, many countries have failed to satisfy prevention commitments. As a result, the epidemic continues to outpace the response, with two people newly infected for every individual who started antiretroviral therapy in 2009.

Progress in preventing vertical transmission

17 As at December 2009, 15 countries had achieved the target set in the 2001 Declaration of at least 80 per cent coverage of antiretroviral prophylaxis among pregnant women living with HIV, and an additional seven countries in sub-Saharan Africa reported coverage between 50 per cent and 80 per cent. Countries in Eastern Europe and Central Africa have achieved especially high coverage. As a result of scaled-up prevention services, the number of

children newly infected declined by 24 per cent globally from 2004 to 2009.

18. Eliminating vertical transmission requires far greater, and more rapid, advances to increase coverage and administer more effective regimens. Enhanced efforts are required to integrate HIV testing into antenatal services, since only 26 per cent of pregnant women in low- and middle-income countries were tested in 2009. Services to prevent mother-to-child transmission need to be more closely linked to sexual and reproductive health care. In 2009, 30 per cent of recipients of prevention services in antenatal settings received a suboptimal single-dose antiretroviral regimen, highlighting the importance of improving access to more efficacious combination regimens.

Encouraging trends among young people

19. Young people are leading the global prevention revolution. Among countries in which adult HIV prevalence exceeded 2 per cent, eight reported statistically significant declines in the percentage of girls who had sex before age 15, with seven countries reporting significant declines in early sexual debut among boys (see figure IV). Young people also show favourable trends in condom use (in 6 countries for young women and in 5 countries for young men) and number of sex partners (in 7 countries for young women and in 10 countries for young men). Although

HIV-related knowledge among young people has increased, only 34 per cent of young people demonstrated accurate and comprehensive knowledge of HIV in 2009, well below the 95 per cent target identified in the 2001 Declaration of Commitment. Concerted action can address such knowledge deficits, as numerous countries — including Belarus, Chile and Eritrea — have demonstrated the feasibility of achieving rates of HIV-related knowledge exceeding 70 per cent among young people.

20. The 2001 Declaration called for expanded access to essential commodities, including male and female condoms. Although universal condom access has not been achieved, a clear trend towards increased availability and use during higher risk sex is apparent.

Inadequate attention to the prevention needs of key populations at higher risk

21. prevention needs of key populations are at higher risk of exposure. However, as at 2009, only 26 per cent of countries had established prevention targets for sex workers, 30 per cent for people who used drugs and 18 per cent for men who had sex with men. Most countries do not report data on these key populations.

22. According to data from 27 countries, only 32 per cent of people who injected drugs accessed HIV prevention services in 2009. In most countries surveyed in 2010, neither needle or syringe programmes nor long-acting opioid agonist therapy was available to reduce HIV transmission associated with drug use.

Making combination prevention a reality

23. countries are basing prevention strategies not on an understanding of the total number of people living with HIV (HIV prevalence), but rather on an improved understanding of the people newly infected with HIV (HIV incidence). As a result, a number of countries have taken steps to revise their prevention approaches to address emerging challenges and focus limited resources where they will have the greatest impact.

24. emergence of important new prevention tools, such as adult male circumcision, which reduces the risk of

female-to-male sexual transmission by about 60 per cent. During the past two years, more than 200,000 men were circumcised in these 13 priority countries, including more than 90,000 in the Nyanza Province of

Kenya alone.

25. Behavioural and biomedical approaches need to be supplemented with efforts that address the underlying social determinants of risk and vulnerability. In 2010, two studies in sub-Saharan Africa supported by the World Bank found that cash payments, contingent on adherence to recommended behaviour (such as staying in school or avoiding unprotected sex), reduced young people’s risk of becoming infected with HIV or another sexually transmitted infection.

Emergence of critical new biomedical strategies for HIV prevention

26. During the past year, additional biomedical strategies have emerged to reduce the likelihood that any single sexual act will result in HIV transmission. In 2010, clinical trial results demonstrated that a vaginal microbicide could reduce a woman’s risk of becoming infected during sexual intercourse. Additional trials are under way to confirm these results and to evaluate other microbicide candidates. If confirmed, these findings will help close a critical gap in the prevention toolkit: an effective prevention method that women may initiate on their own.

27. Also in 2010, a multi-country study found that a daily tablet containing the antiretroviral drugs tenofovir and emtricitabine reduced the risk of infection among men who had sex with men by 44 per cent. As in the case of microbicides, other trials are being conducted to confirm these results, including trials involving heterosexual cohort studies.

28. Each of these biomedical prevention advances involves unique and complex challenges. Additional studies are required to optimize acceptability, enhance adherence to prescribed protocols, monitor the risk of viral resistance in case of seroconversion and determine optimal service delivery models. National decision makers should expedite the integration of validated new tools into prevention programmes, where indicated, to increase the viability and sustainability of combination prevention efforts.

29. The search also continues for a preventive vaccine. Researchers have identified multiple antibodies that appear to neutralize HIV, providing important new avenues for vaccine development.

Integrating prevention and treatment

30. As the 2006 Political Declaration on HIV/AIDS emphasized, prevention, treatment, care and support are mutually reinforcing and must be closely linked. Emerging evidence of the important prevention benefits of antiretroviral therapy, which lowers viral load and thereby reduces the infectiousness of people living with HIV, merely underscores the need to link prevention and treatment efforts.

31. Separate planning approaches, however, are often undertaken for prevention and treatment. Little integration occurs at the level of service delivery. Referral systems for people who test HIV-positive are frequently fragmented and unmonitored. Prevention interventions have not been fully integrated in many clinical sites and about half of pregnant women testing HIV-positive in 2009 were not assessed for their eligibility to receive antiretroviral therapy. To strengthen links between prevention and treatment and to empower people living with HIV in prevention efforts, civil society partners joined with UNAIDS to call for implementation of a strategy known as “positive health, dignity and prevention”. This strategy integrates prevention efforts into a holistic approach that takes account of the treatment needs and human rights of people living with HIV.

B. Zero discrimination

32. Thirty years after the epidemic was initially recognized, human rights violations continue to prevent open and compassionate discussion of the HIV challenge, deter individuals from seeking needed services, and increase individual vulnerability. An international survey of people living with HIV in 2010 found that more than one third had experienced loss of employment, denial of health care, social or vocational exclusion and/or involuntary disclosure. Globally, Governments cite stigma as the single greatest impediment to accelerated progress in the response. Social attitudes need to be transformed, and resources must be allocated to anti-stigma strategies and other initiatives to promote and protect human rights.

Inadequate protection against discrimination

33. The 2001 Declaration called on all Member States to have in place strong, enforceable measures to eliminate discrimination against people living with HIV or vulnerable groups. Although the number of countries reporting anti-discrimination laws in place increased from 56 per cent in 2006 to 71 per cent in 2010 (see figure V), it is disturbing that nearly 3 in 10 countries still lack such laws or regulations.

34. When anti-discrimination provisions are in place, they are often not effectively enforced. Globally, fewer than 60 per cent of countries report having a mechanism to record, document and address cases of HIV-related discrimination. In many countries, people living with HIV are at high risk of losing their homes, employment, property and inheritance due to inadequate protection.

35. In 2010, the vast majority of countries (91 per cent) addressed stigma and discrimination in their national HIV strategies, and 90 per cent of countries reported anti-stigma activities. However, most countries have no budget for anti-stigma activities.

Discrimination against key populations at higher risk

38. Seventy-nine countries and territories criminalize same-sex sexual relations between consenting adults, and more than 100 countries criminalize aspects of sex work. In settings throughout the world, fear and social disapproval increase the vulnerability of mobile populations, prisoners, adolescents who practice high-risk behaviour and people in humanitarian settings. Such discrimination deepens social marginalization, increases the risk of harassment or violence and inhibits communities from mobilizing to address the epidemic.

39. Discriminatory policies also reduce access to essential prevention and treatment services. Among 106 countries, non-governmental sources in 62 per cent of countries reported that laws, regulations or policies were in place diminishing access to services for key populations at higher risk (see figure VI).

40. Strong leadership helps overcome the legacy of discrimination. Recent years have witnessed the expansion of prevention programmes for men who have sex with men in China, the scaling up of community-centred services targeted for sex workers in India and the decision by a growing number of countries to remove restrictions on harm reduction programmes for people who use drugs.

C. Zero AIDS-related deaths

41. Despite recent progress, nearly two in three people who are eligible for therapy still lack access. Transforming the response requires delivering lifepreserving therapies to the people who need them, as well as new treatment, care and support approaches that are more sustainable.

Coverage is increasing but still inadequate

42. Recent gains in access to treatment are unprecedented (see figure VII). By the end of 2009, eight low- or middle-income countries were providing antiretroviral therapy to at least 80 per cent of the people eligible for treatment. Striking gains have been made in Eastern and Southern Africa.

43. About 10 million people who could benefit from treatment were not receiving it in 2009.

The quest for equitable access to treatment

44. Globally, treatment coverage is notably lower for children (28 per cent) than for adults (37 per cent). Historically, children’s poorer access to treatment stemmed from the shortage of antiretroviral formulations for children, difficulties in diagnosing HIV among infants and the higher cost of drugs for children. An array of cost-effective antiretroviral formulations for children are now available, and improved technology permits rapid HIV diagnosis.

45. Marginalized populations also struggle to obtain equitable access to treatment, in part as a result of the hostility of many health-care workers. Among 21 countries reporting data on antiretroviral treatment utilization among people who injected drugs, 14 countries reached fewer than 5 per cent of such individuals.

Timely diagnosis and continuity of care

46. Although HIV testing has increased in recent years, fewer than 40 per cent of people living with HIV were aware that they were infected in 2009. Adolescents have special difficulty in accessing testing services, and globally, only 6 per cent of babies born to women living with HIV are tested. In numerous countries, testing rates have sharply risen following implementation of provider-initiated testing and counseling, intensive national campaigns and mobile testing initiatives.

47. Maintaining health-care continuity is essential to favourable medical outcomes for people living with HIV.

48. Several factors impede treatment uptake and contribute to dropout. These include inadequate or non-existent transport to distant clinical sites, insufficient support services, side effects associated with suboptimal treatment regimens, out-ofpocket expenses for non-drug components of treatment services, opportunity costs (such as lost income) associated with clinic attendance and inadequate human resources for health.

Management of tuberculosis and other co-occurring conditions

IV. Cross-cutting issues

Gender equality and the empowerment of women and girls

55. Revolutionizing HIV prevention requires concrete progress towards gender equality. This priority is especially imperative in sub-Saharan Africa, where 76 percent of all women living with HIV reside and where 13 women become infected for every 10 men.

56. This imbalance reflects not only the heightened physiological vulnerability of girls and young women, but also a high prevalence of intergenerational partnerships, lack of woman-initiated prevention methods and broader social and legal inequality that impedes the ability of young women to reduce their sexual risk. Women’s odds

of living with HIV are inversely correlated with educational attainment, a fact that highlights the role of universal education initiatives in reducing HIV-related vulnerability. Women also bear a disproportionate share of the HIV-related caregiving burden and are often more likely to be the victims of discrimination.

57. Despite the epidemic’s enormous toll on women and girls, fewer than half of countries provide a specific budget for HIV-related programmes for women and girls. The prevalence of gender-based violence is as high as 50 per cent in some countries, with one of four women in sub-Saharan Africa reporting that their first

sexual experience was coerced. Few programmes are in place to engage men and boys in efforts to eliminate gender-based violence and inculcate healthier gender norms. Zero tolerance of gender-based violence must be a shared goal.

Robust and sustained financing for the response

58. Only a collective sense of shared responsibility and accountability will ensure that the response has sufficient resources in future years. In 2009, low- and middle income countries accounted for 52 per cent of HIV expenditure. However, many low-income countries remain almost wholly dependent on external support.

59. Many countries, including some with severe and growing epidemics, have not given the response the priority it deserves. Middle-income countries, in particular, should cover their own HIV-related costs, with the possible exception of a few hyperendemic countries that will need continued assistance. Low-income countries will remain largely dependent on international AIDS assistance in future years, highlighting the need for more effective use of resources, streamlined donor reporting requirements, alignment with national strategies and institutions and more

predictable funding. However, even low-income countries have an important role to play in funding and taking ownership of their response. Long-term financing for the response highlights the urgent need for sustained support to the Global Fund.

60. As efforts are made to mobilize new resources for the response, intensified attention must focus on maximizing the efficient use of available resources. The Treatment 2.0 approach, a new treatment platform launched by UNAIDS in 2010 (see figure IX), aims to optimize the long-term benefits of HIV treatment while implementing measures to increase efficiency.

 

61. Lowering the costs of HIV commodities is critical. The number of countries that allow for flexibilities in intellectual property rules has declined in recent years, and a growing array of bilateral and regional trade agreements are undermining the ability of countries to maximize these flexibilities to promote access to essential medicines.

Building sustainable capacity

62. Both the 2001 and 2006 Declarations recognize the importance of strengthening systems. The challenges the epidemic poses to fragile health systems are especially evident in sub-Saharan Africa, home to more than two of three people living with HIV, but to only 3 per cent of the world’s health-care providers. The number of health facilities administering antiretroviral therapy rose by 36 per cent from 2008 to 2009. Studies indicate that HIV programmes are conferring broad benefits on health systems, refurbishing clinics, strengthening commodity procurement and supply management and building national capacity for monitoring and evaluation.

64. many communities lack the capacity to optimize their contributions to national responses. Donors should provide the resources and technical support that communities need, including adequate compensation for work performed, and national Governments must ensure that communities are full partners in developing, implementing and monitoring AIDS strategies. Increased support is also needed to strengthen national social protection systems to improve efforts to mitigate the impact of the epidemic.

General Assembly Distr.: General

28 March 2011

Implementation of the Declaration of Commitment on

HIV/AIDS and the Political Declaration on HIV/AIDS

Mobilizing for impact: five recommendations

The present report contains the following five recommendations for all stakeholders:

(a) Champion a prevention revolution that harnesses the energy of young people and the potential of new modes of communication that are transforming the world, rescinds punitive laws that block effective responses and ensures that people are empowered to protect themselves, their partners and their families from HIV;

(b) Forge a revitalized framework for global solidarity to achieve universal access to HIV prevention, treatment, care and support by 2015;

(c) Break the upward trajectory of costs and deliver more effective, efficient and sustainable programmes;

(d) Ensure that our responses to HIV promote the health, human rights, security and dignity of women and girls;

(e) Commit to forging robust mutual accountability mechanisms

Introduction

1. In 2001, the number of people living with HIV was increasing, therapies revolutionizing the HIV response in high-income countries were virtually unavailable in the most severely affected countries and total resources

spent on HIV activities in low- and middle-income countries amounted to only about 10 per cent of spending in 2009. The epidemic was reversing decades of development progress in sub-Saharan Africa, threatening stability and security, and exacerbating global inequity in health.

2. The 2001 special session resulted in a visionary Declaration that included time-bound targets in the response. The special session gave rise to a major global health financing institution, namely the Global Fund to Fight AIDS, Tuberculosis and Malaria. Pledging additional steps to strengthen the response, Member States embraced a complementary set of commitments in the 2006 Political Declaration on HIV/AIDS, including the pledge to achieve universal access to HIV prevention, treatment, care and support.

5. The year 2011 is a historic marker in the global response; it allows the international community to review the progress of the last decade and marks 30 years into the epidemic.

6. This report assesses progress and gaps in the response, based on data submitted by 182 countries and on national and regional reviews on universal access to HIV prevention, treatment, care and support.1 Key findings include the

following:

HIV prevention. The number of people newly infected with HIV declined by 19 per cent in the decade before December 2009, with at least 33 countries experiencing a decline in HIV incidence of at least 25 per cent and 10 high prevalence countries achieving the global goal of reducing HIV prevalence among young people by at least 25 per cent.

Antiretroviral therapy. As at December 2010, more than six million people were estimated to be receiving antiretroviral therapy in low- and middle income countries. Yet the majority of people in need still lack access.

Towards an HIV-free generation. Global coverage for antiretroviral prophylaxis to prevent the vertical transmission of HIV has exceeded 50 per cent..

Human rights. About three in 10 countries worldwide still lack laws prohibiting HIV-related discrimination.

Financing the response. Funding for HIV programmes has dramatically increased, helping drive an overall surge in global health financing (see figure I). Nonetheless, in 2009, international HIV assistance declined for the first

time, mirroring reductions in other forms of development aid.

II. Thirty years of AIDS: reviewing the past, looking towards

the future

Sub-Saharan Africa remains the most severely affected region, accounting for 68 per cent of all people living with HIV, 69 per cent of new infections and 72 per cent of AIDS deaths. The epidemic, however, has not spared other regions; more than 10.8 million people are living with HIV outside sub-Saharan Africa. It continues to deepen poverty, increase hunger, slow progress on maternal and child health and exacerbate other infectious diseases.

8. The epidemic particularly affects women and girls. In 2009, women represented a slight majority (about 51 per cent of all people living with HIV and about 60 per cent of all people living with HIV in sub-Saharan Africa).

The 2001 and 2006 Declarations: a framework for unprecedented progress

11. The 2001 Declaration of Commitment on HIV/AIDS helped to galvanize global resolve to reverse the epidemic. Outcome indicators were established to monitor implementation of the targets adopted in 2001, with countries submitting biennial progress reports to the Joint United Nations Programme on HIV/AIDS (UNAIDS). Civil society and people living with HIV have played an especially critical role in tracking progress in implementing the 2001 and 2006 Declarations, evaluating national policy responses and contributing to country-specific reviews.

12. More than 110 countries established clear, time-bound national targets for service coverage. Although most countries are unlikely to have met their targets for 2010, advances over the last decade definitively demonstrate that universal access is both feasible and essential for long-term success.

III. Towards a world with zero new HIV infections, zero

discrimination and zero AIDS-related deaths

In 2010, UNAIDS articulated a new vision for the response, that of a world with zero new HIV infections, zero discrimination and zero AIDS-related deaths. This new vision is intentionally ambitious, reflecting the high aspirations of a people centered global movement.

A. Zero new infections

Although global HIV incidence is now declining, many countries have failed to satisfy prevention commitments. As a result, the epidemic continues to outpace the response, with two people newly infected for every individual who started antiretroviral therapy in 2009.

Progress in preventing vertical transmission

17 As at December 2009, 15 countries had achieved the target set in the 2001 Declaration of at least 80 per cent coverage of antiretroviral prophylaxis among pregnant women living with HIV, and an additional seven countries in sub-Saharan Africa reported coverage between 50 per cent and 80 per cent. Countries in Eastern Europe and Central Africa have achieved especially high coverage. As a result of scaled-up prevention services, the number of

children newly infected declined by 24 per cent globally from 2004 to 2009.

18. Eliminating vertical transmission requires far greater, and more rapid, advances to increase coverage and administer more effective regimens. Enhanced efforts are required to integrate HIV testing into antenatal services, since only 26 per cent of pregnant women in low- and middle-income countries were tested in 2009. Services to prevent mother-to-child transmission need to be more closely linked to sexual and reproductive health care. In 2009, 30 per cent of recipients of prevention services in antenatal settings received a suboptimal single-dose antiretroviral regimen, highlighting the importance of improving access to more efficacious combination regimens.

Encouraging trends among young people

19. Young people are leading the global prevention revolution. Among countries in which adult HIV prevalence exceeded 2 per cent, eight reported statistically significant declines in the percentage of girls who had sex before age 15, with seven countries reporting significant declines in early sexual debut among boys (see figure IV). Young people also show favourable trends in condom use (in 6 countries for young women and in 5 countries for young men) and number of sex partners (in 7 countries for young women and in 10 countries for young men). Although

HIV-related knowledge among young people has increased, only 34 per cent of young people demonstrated accurate and comprehensive knowledge of HIV in 2009, well below the 95 per cent target identified in the 2001 Declaration of Commitment. Concerted action can address such knowledge deficits, as numerous countries — including Belarus, Chile and Eritrea — have demonstrated the feasibility of achieving rates of HIV-related knowledge exceeding 70 per cent among young people.

20. The 2001 Declaration called for expanded access to essential commodities, including male and female condoms. Although universal condom access has not been achieved, a clear trend towards increased availability and use during higher risk sex is apparent.

Inadequate attention to the prevention needs of key populations at higher risk

21. prevention needs of key populations are at higher risk of exposure. However, as at 2009, only 26 per cent of countries had established prevention targets for sex workers, 30 per cent for people who used drugs and 18 per cent for men who had sex with men. Most countries do not report data on these key populations.

22. According to data from 27 countries, only 32 per cent of people who injected drugs accessed HIV prevention services in 2009. In most countries surveyed in 2010, neither needle or syringe programmes nor long-acting opioid agonist therapy was available to reduce HIV transmission associated with drug use.

Making combination prevention a reality

23. countries are basing prevention strategies not on an understanding of the total number of people living with HIV (HIV prevalence), but rather on an improved understanding of the people newly infected with HIV (HIV incidence). As a result, a number of countries have taken steps to revise their prevention approaches to address emerging challenges and focus limited resources where they will have the greatest impact.

24. emergence of important new prevention tools, such as adult male circumcision, which reduces the risk of

female-to-male sexual transmission by about 60 per cent. During the past two years, more than 200,000 men were circumcised in these 13 priority countries, including more than 90,000 in the Nyanza Province of

Kenya alone.

25. Behavioural and biomedical approaches need to be supplemented with efforts that address the underlying social determinants of risk and vulnerability. In 2010, two studies in sub-Saharan Africa supported by the World Bank found that cash payments, contingent on adherence to recommended behaviour (such as staying in school or avoiding unprotected sex), reduced young people’s risk of becoming infected with HIV or another sexually transmitted infection.

Emergence of critical new biomedical strategies for HIV prevention

26. During the past year, additional biomedical strategies have emerged to reduce the likelihood that any single sexual act will result in HIV transmission. In 2010, clinical trial results demonstrated that a vaginal microbicide could reduce a woman’s risk of becoming infected during sexual intercourse. Additional trials are under way to confirm these results and to evaluate other microbicide candidates. If confirmed, these findings will help close a critical gap in the prevention toolkit: an effective prevention method that women may initiate on their own.

27. Also in 2010, a multi-country study found that a daily tablet containing the antiretroviral drugs tenofovir and emtricitabine reduced the risk of infection among men who had sex with men by 44 per cent. As in the case of microbicides, other trials are being conducted to confirm these results, including trials involving heterosexual cohort studies.

28. Each of these biomedical prevention advances involves unique and complex challenges. Additional studies are required to optimize acceptability, enhance adherence to prescribed protocols, monitor the risk of viral resistance in case of seroconversion and determine optimal service delivery models. National decision makers should expedite the integration of validated new tools into prevention programmes, where indicated, to increase the viability and sustainability of combination prevention efforts.

29. The search also continues for a preventive vaccine. Researchers have identified multiple antibodies that appear to neutralize HIV, providing important new avenues for vaccine development.

Integrating prevention and treatment

30. As the 2006 Political Declaration on HIV/AIDS emphasized, prevention, treatment, care and support are mutually reinforcing and must be closely linked. Emerging evidence of the important prevention benefits of antiretroviral therapy, which lowers viral load and thereby reduces the infectiousness of people living with HIV, merely underscores the need to link prevention and treatment efforts.

31. Separate planning approaches, however, are often undertaken for prevention and treatment. Little integration occurs at the level of service delivery. Referral systems for people who test HIV-positive are frequently fragmented and unmonitored. Prevention interventions have not been fully integrated in many clinical sites and about half of pregnant women testing HIV-positive in 2009 were not assessed for their eligibility to receive antiretroviral therapy. To strengthen links between prevention and treatment and to empower people living with HIV in prevention efforts, civil society partners joined with UNAIDS to call for implementation of a strategy known as “positive health, dignity and prevention”. This strategy integrates prevention efforts into a holistic approach that takes account

of the treatment needs and human rights of people living with HIV.

B. Zero discrimination

32. Thirty years after the epidemic was initially recognized, human rights violations continue to prevent open and compassionate discussion of the HIV challenge, deter individuals from seeking needed services, and increase individual vulnerability. An international survey of people living with HIV in 2010 found that more than one third had experienced loss of employment, denial of health care, social or vocational exclusion and/or involuntary disclosure. Globally, Governments cite stigma as the single greatest impediment to accelerated progress in the response. Social attitudes need to be transformed, and resources must be allocated to anti-stigma strategies and other initiatives to promote and protect human rights.

Inadequate protection against discrimination

33. The 2001 Declaration called on all Member States to have in place strong, enforceable measures to eliminate discrimination against people living with HIV or vulnerable groups. Although the number of countries reporting anti-discrimination laws in place increased from 56 per cent in 2006 to 71 per cent in 2010 (see figure V), it is disturbing that nearly 3 in 10 countries still lack such laws or regulations.

34. When anti-discrimination provisions are in place, they are often not effectively enforced. Globally, fewer than 60 per cent of countries report having a mechanism to record, document and address cases of HIV-related discrimination. In many countries, people living with HIV are at high risk of losing their homes, employment, property and inheritance due to inadequate protection.

35. In 2010, the vast majority of countries (91 per cent) addressed stigma and discrimination in their national HIV strategies, and 90 per cent of countries reported anti-stigma activities. However, most countries have no budget for anti-stigma activities.

Discrimination against key populations at higher risk

38. Seventy-nine countries and territories criminalize same-sex sexual relations between consenting adults, and more than 100 countries criminalize aspects of sex work. In settings throughout the world, fear and social disapproval increase the vulnerability of mobile populations, prisoners, adolescents who practice high-risk behaviour and people in humanitarian settings. Such discrimination deepens social marginalization, increases the risk of harassment or violence and inhibits communities from mobilizing to address the epidemic.

39. Discriminatory policies also reduce access to essential prevention and treatment services. Among 106 countries, non-governmental sources in 62 per cent of countries reported that laws, regulations or policies were in place diminishing access to services for key populations at higher risk (see figure VI).

40. Strong leadership helps overcome the legacy of discrimination. Recent years have witnessed the expansion of prevention programmes for men who have sex with men in China, the scaling up of community-centred services targeted for sex workers in India and the decision by a growing number of countries to remove restrictions on harm reduction programmes for people who use drugs.

C. Zero AIDS-related deaths

41. Despite recent progress, nearly two in three people who are eligible for therapy still lack access. Transforming the response requires delivering lifepreserving therapies to the people who need them, as well as new treatment, care

and support approaches that are more sustainable.

Coverage is increasing but still inadequate

42. Recent gains in access to treatment are unprecedented (see figure VII). By the end of 2009, eight low- or middle-income countries were providing antiretroviral therapy to at least 80 per cent of the people eligible for treatment. Striking gains have been made in Eastern and Southern Africa.

43. About 10 million people who could benefit from treatment were not receiving it in

2009.

The quest for equitable access to treatment

44. Globally, treatment coverage is notably lower for children (28 per cent) than for adults (37 per cent). Historically, children’s poorer access to treatment stemmed from the shortage of antiretroviral formulations for children, difficulties in diagnosing HIV among infants and the higher cost of drugs for children. An array of cost-effective antiretroviral formulations for children are now available, and improved technology permits rapid HIV diagnosis.

45. Marginalized populations also struggle to obtain equitable access to treatment, in part as a result of the hostility of many health-care workers. Among 21 countries reporting data on antiretroviral treatment utilization among people who injected drugs, 14 countries reached fewer than 5 per cent of such individuals.

Timely diagnosis and continuity of care

46. Although HIV testing has increased in recent years, fewer than 40 per cent of people living with HIV were aware that they were infected in 2009. Adolescents have special difficulty in accessing testing services, and globally, only 6 per cent of babies born to women living with HIV are tested. In numerous countries, testing rates have sharply risen following implementation of provider-initiated testing and counseling, intensive national campaigns and mobile testing initiatives.

47. Maintaining health-care continuity is essential to favourable medical outcomes for people living with HIV.

48. Several factors impede treatment uptake and contribute to dropout. These include inadequate or non-existent transport to distant clinical sites, insufficient support services, side effects associated with suboptimal treatment regimens, out-ofpocket expenses for non-drug components of treatment services, opportunity costs (such as lost income) associated with clinic attendance and inadequate human resources for health.

Management of tuberculosis and other co-occurring conditions

IV. Cross-cutting issues

Gender equality and the empowerment of women and girls

55. Revolutionizing HIV prevention requires concrete progress towards gender equality. This priority is especially imperative in sub-Saharan Africa, where 76 percent of all women living with HIV reside and where 13 women become infected for every 10 men.

56. This imbalance reflects not only the heightened physiological vulnerability of girls and young women, but also a high prevalence of intergenerational partnerships, lack of woman-initiated prevention methods and broader social and legal inequality that impedes the ability of young women to reduce their sexual risk. Women’s odds

of living with HIV are inversely correlated with educational attainment, a fact that highlights the role of universal education initiatives in reducing HIV-related vulnerability. Women also bear a disproportionate share of the HIV-related caregiving burden and are often more likely to be the victims of discrimination.

57. Despite the epidemic’s enormous toll on women and girls, fewer than half of countries provide a specific budget for HIV-related programmes for women and girls. The prevalence of gender-based violence is as high as 50 per cent in some countries, with one of four women in sub-Saharan Africa reporting that their first

sexual experience was coerced. Few programmes are in place to engage men and boys in efforts to eliminate gender-based violence and inculcate healthier gender norms. Zero tolerance of gender-based violence must be a shared goal.

Robust and sustained financing for the response

58. Only a collective sense of shared responsibility and accountability will ensure that the response has sufficient resources in future years. In 2009, low- and middle income countries accounted for 52 per cent of HIV expenditure. However, many low-income countries remain almost wholly dependent on external support.

59. Many countries, including some with severe and growing epidemics, have not given the response the priority it deserves. Middle-income countries, in particular, should cover their own HIV-related costs, with the possible exception of a few hyperendemic countries that will need continued assistance. Low-income countries will remain largely dependent on international AIDS assistance in future years, highlighting the need for more effective use of resources, streamlined donor reporting requirements, alignment with national strategies and institutions and more

predictable funding. However, even low-income countries have an important role to play in funding and taking ownership of their response. Long-term financing for the response highlights the urgent need for sustained support to the Global Fund.

60. As efforts are made to mobilize new resources for the response, intensified attention must focus on maximizing the efficient use of available resources. The Treatment 2.0 approach, a new treatment platform launched by UNAIDS in 2010 (see figure IX), aims to optimize the long-term benefits of HIV treatment while implementing measures to increase efficiency.

 

61. Lowering the costs of HIV commodities is critical. The number of countries that allow for flexibilities in intellectual property rules has declined in recent years, and a growing array of bilateral and regional trade agreements are undermining the ability of countries to maximize these flexibilities to promote access to essential

medicines.

Building sustainable capacity

62. Both the 2001 and 2006 Declarations recognize the importance of strengthening systems. The challenges the epidemic poses to fragile health systems are especially evident in sub-Saharan Africa, home to more than two of three people living with HIV, but to only 3 per cent of the world’s health-care providers. The number of health facilities administering antiretroviral therapy rose by 36 per cent from 2008 to 2009. Studies indicate that HIV programmes are conferring broad benefits on health systems, refurbishing clinics, strengthening commodity procurement and supply management and building national capacity for monitoring and evaluation.

64. many communities lack the capacity to optimize their contributions to national responses. Donors should provide the resources and technical support that communities need, including adequate compensation for work performed, and national Governments must ensure that communities are full partners in developing, implementing and monitoring AIDS strategies. Increased support is also needed to strengthen national social protection systems to improve efforts to mitigate the impact of the epidemic.