UNAIDS is issuing countries with a stark wake-up call. In a new report, UNAIDS warns that the global response to HIV is at a precarious point. At the halfway point to the 2020 targets, the report, Miles to go—closing gaps, breaking barriers, righting injustices, warns that the pace of progress is not matching global ambition. It calls for immediate action to put the world on course to reach critical 2020 targets.
“We are sounding the alarm,” said Michel Sidibé, executive director of UNAIDS. “Entire regions are falling behind, the huge gains we made for children are not being sustained, women are still most affected, resources are still not matching political commitments and key populations continue to be ignored. All these elements are halting progress and urgently need to be addressed head-on.”
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.
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 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 were 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.
West and central Africa lagging behind
Just 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 in eastern and southern Africa. Since 2010, AIDS-related deaths have fallen by 24% in western and central Africa, compared to a 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 from just 24% two years ago.
Progress for children has slowed
The report shows that the gains made for children are not being sustained. New HIV infections among children have declined by only 8% in the past two years, only half (52%) of all children living with HIV are getting treatment and 110 000 children died of AIDS-related illnesses in 2017. Although 80% of pregnant women living with HIV had access to antiretroviral medicines to prevent transmission of HIV to their child in 2017, an unacceptable 180 000 children acquired HIV during birth or breastfeeding—far away from the target of fewer than 40 000 by the end of 2018.
“One child becoming infected with HIV or one child dying of AIDS is one too many,” said Mr Sidibé. “Ending the AIDS epidemic is not a foregone conclusion and the world needs to heed this wake-up call and kick-start an acceleration plan to reach the targets.”
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.
“The right to health for all is non-negotiable,” said Sidibé. “Sex workers, gay men and other men who have sex with men, prisoners, migrants, refugees and transgender people are more affected by HIV but are still being left out from HIV programs. More investments are needed in reaching these key populations.”
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.
“Communities are echoing UNAIDS’ call,” said Vincent Pelletier, positive leader and executive director of Coalition PLUS. “We need universal access to adapted prevention services, and protection from discrimination. We call upon world leaders to match commitments with funding, in both donor and implementing countries.”
Stigma and discrimination persists
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 people living with HIV responding to surveys reported being denied health care and one in five people 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 be able to attend school with children who are HIV-negative.
New agenda needed to stop violence against women
In 2017, around 58% of all new HIV infections among adults more than 15 years old were among 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.
“Inequality, a lack of empowerment and violence against women are human rights violations and are continuing to fuel new HIV infections,” said Sidibé. “We must not let up in our efforts to address and root out harassment, abuse and violence, whether at home, in the community or in the workplace.”
90–90–90 can and must be achieved
There has been progress towards the 90–90–90 targets. Three quarters (75%) of all people living with HIV now know their HIV status; of the people who know their status, 79% were accessing treatment in 2017, and of the people accessing treatment, 81% had suppressed viral loads.
Six countries, Botswana, Cambodia, Denmark, Eswatini, Namibia and the Netherlands, have already reached the 90–90–90 targets and seven more countries are on track. The largest gap is in the first 90; in western and central Africa, for example, only 48% of people living with HIV know their status.
A big year for the response to tuberculosis
There have been gains in treating and diagnosing HIV among people with tuberculosis (TB)—around nine out of 10 people with TB who are diagnosed with HIV are on treatment. However, TB is still the biggest killer of people living with HIV and three out of five people starting HIV treatment are not screened, tested or treated for TB. The United Nations High-Level Meeting on Tuberculosis in September 2018 is an opportunity to bolster momentum around reaching the TB/HIV targets.
The cost of inaction
Around US$ 20.6 billion was available for the AIDS response in 2017—a rise of 8% since 2016 and 80% of the 2020 target set by the United Nations General Assembly. However, there were no significant new commitments and as a result the one-year rise in resources is unlikely to continue. Achieving the 2020 targets will only be possible if investments from both donor and domestic sources increase.
From townships in southern Africa to remote villages in the Amazon to mega-cities in Asia, the dozens of innovations contained within the pages of the report show that collaboration between health systems and individual communities can successfully reduce stigma and discrimination and deliver services to the vast majority of the people who need them the most.
These approaches continue to drive the solutions needed to achieve the 2020 targets. When combination HIV prevention—including condoms and voluntary medical male circumcision—is pursued at scale, population-level declines in new HIV infections are achieved. Oral pre-exposure prophylaxis (PrEP) is having an impact, particularly among key populations. Offering HIV testing and counseling to family members and the sexual partners of people diagnosed with HIV has significantly improved testing access.
Eastern and southern Africa has seen significant domestic and international investments coupled with strong political commitment and community engagement and is showing significant progress in achieving the 2020 targets.
“For every challenge there is a solution,” said Sidibé. “It is the responsibility of political leaders, national governments and the international community to make sufficient financial investments and establish the legal and policy environments needed to bring the work of innovators to the global scale. Doing so will create the momentum needed to reach the targets by 2020.”
‘Life for a poz is an ongoing struggle. Face it.’ – @pozzieblue
Contributing writer @pozzieblue tested HIV-positive in July 2013, while working as a nurse in the Middle East. He now writes how life has been after he was detained and then deported.
This is part of “More than a Number”, which Outrage Magazine launched on March 1, 2013 to give a human face to those infected and affected by the Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS) in the Philippines, what it considers as “an attempt to tell the stories of those whose lives have been touched by HIV and AIDS”.
More information about (or – for that matter – to be included in) “More than a Number”, email firstname.lastname@example.org, or call (+63) 9287854244 and (+63) 9157972229.
BACKGROUND: While working as a nurse in Abu Dhabi, United Arab Emirates, @pozzieblue tested HIV-positive in July 2013. He was placed in an isolated facility in the middle of a desert, and then deported to the Philippines. Months after trying to get his life back together, he shared his story to Outrage Magazine in November 2013. This is a new contributed article from him, sharing how life has changed for him after he tested HIV-positive; and the lessons he hopes others like him learns from life.
After being detained and deported, life was not easy. I felt I’ve went back to zero. I grieved a lot, and sometimes I thought I’ve reached the acceptance phase but the anger and sadness fluctuates every now and then. There was even a time that I went to RITM from my hometown by myself, and I was still struggling from my pneumonia and ARV allergic reaction. I needed to go back to my hub so I could refill my new ARV. I was on MRT train when I felt I was fainting so I’ve decided to sat on the floor to gain my strength and to avoid falling. It felt so terrible and lonely because as a nurse who used to take care different people, nobody cared to approach and ask me if I’m okay.
This is the reason why I realized that I need to focus on one of the most important aspect of my life, my health. Later on, I discovered twitter. I am grateful because this social media became a great support system to me because the of the fellow poz who have their account there. They have been very encouraging to my PLHIV journey, so I’m truly thankful to them. In fact, I have found some of my true best friends.They were there in supporting me in different ways, specially to my mental health.
When my health became stable, I started working from different fields. I hopped from the BPO industry, teaching International students and doing online jobs. I was upset because it was hard to start a clean slate. Maybe because deep in my heart, I hold this faith that there is still another world waiting for me, but this virus in my blood inhibits me, as well as the trauma I’ve had. Then I promised myself that my life will not end this way and just like the long-time drama anthology says “Ikaw ang bida ng buhay mo.”
I tried enriching my neurons by finishing my Master’s Degree and improving my English skill. I was spending my earnings in different classes and dealing my thesis. During that time, I was also rekindling my relationship to God. There was a time that I felt He left me, but I realized that during those lowest lows of my life, he was there all through out, but I couldn’t see him because I was blinded with frustration, anger and regrets.
After going through with my Master and passing my English test. I’ve received an information from another PLHIV that he knows a nurse who was accepted to work in UK to practice his profession, despite being a poz. That simple online conversation ignited a hope in my heart. Hence, I started applying for an overseas job again. I can still remember how much worry it caused me whenever I needed to disclose my HIV status to my prospective employers but I’m grateful that they don’t mind it.
To make the story short, I’m now in UK and I just passed my final exam to become a Registered Nurse here few weeks ago. It wasn’t an easy journey, but with perseverance, good health and divine intervention; I was able to fulfill this dream. I remember what Pope Francis said, “When you lose the capacity to dream, you lose the capacity to love, and the energy to love is lost.” This is my new mantra now.
To all my fellow PLHIV out there: life may seem to be a continuous struggle but continue learning and enriching yourself. Ask for help if you think you need one. Pain and sorrow is subjective. I may not know what you are going through but I sincerely wish everyone well.
PrEP is safe and effective for widespread use, research shows
Worldwide, there are only 300,000 people estimated to be taking PrEP. This is far too small a number to prevent 1.8 million new HIV infections.
New research shows that pre-exposure prophylaxis (PrEP) could be given to millions of people worldwide with no increased risk of safety issues during treatment.
PrEP is a combination of two drugs that people can take before sex to prevent HIV infection. Existing evidence shows that people who take tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) as PrEP have a 90% lower chance of being infected with HIV than people not taking it.
However, widespread use of TDF/FTC can be justified only if its preventative benefits outweigh potential risks of safety issues. These new results, presented today, show that PrEP is safe to use.
The researchers undertook a meta-analysis of 13 randomized trials with 15,678 participants. People at risk of HIV infection were given either TDF/FTC as PrEP or no treatment (the control, or placebo). There was no significant difference in risk of high grade or serious adverse events comparing PrEP with control. The risk of serious adverse events was almost the same for both groups: 9.4% for those on PrEP and 10.1% for those on placebo. There was also no significant difference in risk of renal or bone adverse outcomes. The risk of bone fractures was 3.7% on PrEP versus 3.3% on no treatment. The risk of significant renal dysfunction was 0.1% on PrEP and 0.1% for no treatment.
“In 2016, there were 1.8 million new HIV infections worldwide and the same number again in 2017,” International AIDS Society President Anton Pozniak said. “Across a range of studies, men who have sex with men have one in 30 chance of contracting HIV in a year. Other particularly vulnerable populations’, such as people who inject drugs or sex workers, have a one in 50 chance of being infected with HIV.
“Worldwide, there are only 300,000 people estimated to be taking PrEP. This is far too small a number to prevent 1.8 million new HIV infections. Clearly, to have a significant effect on the HIV epidemic, we need to scale up PrEP to reach tens of millions of people worldwide.”
Other PrEP modalities, such as long-acting injectable drugs and antibodies, are being tested in order to offer more choices of how PrEP could be taken.
“Globally, there is a new HIV infection every 18 seconds,” study co-author Dr Andrew Hill, from Liverpool University, said. “Every person newly infected will then need to be treated for life, and could transmit HIV to others. We need radical changes in our prevention strategy to cut new HIV infections down to zero.”
The most widely used PrEP, a combination of TDF and FTC, costs only £40 per year to make. A generic TDF/FTC course is available in the UK for £300 per year and £50 in sub-Saharan Africa. With recent legal rulings, low-cost, generic PrEP is becoming more available. This provides an opportunity, with the decreasing costs making it increasingly feasible to provide PrEP to millions of people at risk of HIV worldwide.
“The World Health Organization updated its official guidelines in 2015 to include the use of PrEP as a prevention method,” Dr. Pozniak commented. “The data is clear and it’s time to globally implement this recommendation.”
These results are supported by another recent analysis, which showed no difference in adverse events between TDF/FTC and a combination of tenofovir alafenamide (TAF) and FTC when taken for treatment with an additional antiviral drug.
Roadmap for speedy development of HIV vaccine announced
As scientific discoveries lead to promising new approaches to HIV vaccine development, and with several large-scale vaccine efficacy studies underway, a new strategy takes a fresh look at the major challenges confronting the HIV vaccine paradigm.
The Global HIV Vaccine Enterprise, hosted by the International AIDS Society (IAS), launched a five-year strategy to accelerate the development of an effective vaccine to prevent HIV infection. The new Global HIV Vaccine Enterprise Strategic Plan (2018-2023) was unveiled at the opening of HIV Research for Prevention (HIVR4P 2018), the world’s only scientific conference dedicated exclusively to biomedical HIV prevention, in Madrid, Spain.
“This strategy presents an opportunity to address some of the most significant challenges in HIV vaccine development today,” IAS President Anton Pozniak said.
The new strategy evaluates current opportunities, challenges and obstacles in HIV vaccine research and development and recommends a series of steps to:
- Propel the vaccine pipeline by strengthening strategies to align, amplify and accelerate development of candidate vaccines
- Prepare for success by tackling priorities essential to clarifying the roadmap for future access to a vaccine
- Expand resources and engagement by enlisting a diverse community of partners to support and contribute to the field.
The new strategic plan was developed through an IAS-led consultation involving HIV vaccine research and funding stakeholders, the Enterprise Strategic Advisory Group and the IAS Governing Council. The plan advances the ongoing partnership between the IAS, the world’s largest association of HIV professionals, and the Global HIV Vaccine Enterprise, which promotes coordination, collaboration and resource mobilization to accelerate HIV vaccine development.
“While the HIV vaccine landscape offers greater scientific promise than ever before, the field also faces real challenges in terms of aligning scientific priorities, developing the smartest and most effective research studies, maintaining funding and engaging and maximizing the contributions of all global stakeholders in the search for a vaccine,” Pozniak added.
“The new strategy builds on more than a decade of work by the Global HIV Vaccine Enterprise to identify critical gaps in systems and knowledge, promote collaboration and address one of the greatest scientific challenges of our time.”
As scientific discoveries lead to promising new approaches to HIV vaccine development, and with several large-scale vaccine efficacy studies underway, the new strategy takes a fresh look at the major challenges confronting the HIV vaccine paradigm. Among these are:
- The increasing complexity of conducting vaccine efficacy trials as more biomedical HIV prevention options become available
- The need to address critical gaps in scientific knowledge about immune responses to HIV
- Stagnant funding and the need to increase government and industry commitment and investment to meet emerging vaccine research opportunities
- Uncertainty about regulatory and access pathways for a successful vaccine.
To address these challenges and others, the IAS/Enterprise plan proposes a series of near-term activities to address critical, of-the-moment challenges, along with longer-term goals and guideposts to measure achievements and guide adjustments in the strategy as the field evolves. The plan’s activities will be sequenced strategically and guided by annual implementation plans – with detailed activities, timelines and deliverables.
“This plan captures the promise and challenges of a unique and exciting moment in HIV vaccine development and offers a roadmap for action to bring us closer to the end of this epidemic,” President of the South African Research Council Glenda Grey said.
“With the support, expertise and convening power of IAS, this new strategic plan will build on the Enterprise’s longstanding role as a both a neutral convener and facilitator of collaboration in the HIV vaccine field and propel realizing our shared vision to develop a safe, effective and globally available HIV vaccine.”
Trans youth lack access to trans-affirming care, which may put them at risk for HIV
One-quarter of youth were less inclined to discuss GSM (gender and sexual minority) identity and sexual health with their primary care providers due to concern that their provider would disclose this information to parents.
Many trans youth lack access to trans affirming care, which may put them at risk for HIV. This is according to a study that explored trans youth’s perceptions regarding encounters with primary care providers (PCPs) related to gender and sexual minority (GSM) identity and sexual health.
In “Perceived Barriers to HIV Prevention Services for Transgender Youth”, which appeared in LGBT Health, C.B. Fisher, A.L. Fried, M. Desmond, K. Macapagal and B. Mustanski engaged youth aged 14-21 (N = 228; 45% trans masculine, 41% trans feminine, 14% gender nonbinary) and asked them to complete a survey on GSM identity disclosure and acceptance, gender-affirming services, sexual health attitudes and behaviors, and interactions with PCPs involving GSM identity and concerns about stigma and confidentiality.
A factor analysis yielded three scales: GSM Stigma, Confidentiality Concerns, and GSM-Sexual Health Information. Items from the GSM Stigma scale showed that nearly half of respondents had not disclosed their GSM identity to their PCP due to concern about an unaccepting PCP. One-quarter of youth were less inclined to discuss GSM identity and sexual health with their PCP due to concern that their provider would disclose this information to parents; these concerns were greater among adolescents <18 and those not out to parents about their gender identity. Only 25% felt their PCP was helpful about GSM-specific sexual health issues. Youth who were out to parents about their gender identity and had received gender-affirming hormone therapy were more likely to report receiving GSM-specific sexual health information.
For the researchers, “trans youth may not discuss their GSM identity or sexual health with PCPs because they anticipate GSM stigma and fear being ‘outed’ to parents.” And so “PCPs should receive transgender-inclusive training to adequately address youths’ sexual health needs and privacy concerns.”
159 reported HIV-related deaths in August as number of new infections remain high
There were 1,047 new HIV positive Filipinos reported to the HIV/AIDS & ART Registry of the Philippines in August 2018, higher than the 859 HIV cases reported in July.
There were 1,047 new HIV positive Filipinos reported to the HIV/AIDS & ART Registry of the Philippines (HARP) in August 2018, bringing the January-August 2018 figure to 7,579; and the total HIV cases overall (from January 1984 to August 2018) to 58,181. The August figure is higher than the 859 HIV cases reported in July.
Worryingly, the DOH reported that for August, there were 159 HIV-related deaths; in July, there were only 30. The figure may even be higher because of under- or non-reporting.
Majority of those newly diagnosed to have HIV in the Philippines are still male – e.g.998 (95%) of the newly diagnosed in August were male. The median age was 28 years old (age range: 15 – 61 years old). More than half of the cases (51%, 537) were 25-34 years old and 30% (309) were 15-24 years old at the time of testing.
Sexual contact remains the main mode of transmission (98%, 1,022). Among this, 87% were males who have sex with males (MSM). Other modes of transmission were needle sharing among injecting drug users (2%, 17). There were eight cases that had no data on mode of transmission.
Only 30,667 PLHIVs are on ART as of August 2018. Most (97%) were males.
Incidentally, the Department of Health (DOH) continues to receive flak for its inaction and misaction when dealing with HIV in the Philippines. In September, for instance, and even if DOH laments proposed budget cuts, it allocated supposedly scarce funds to hold a beauty pageant. To appease critics, it eventually held a rushed Metro Manila-centric “dialogue” with select people living with HIV (PLHIV), although what transpired in the gathering was not publicly shared.
Some gay and bi men see PrEP as a ‘social problem’
Some see PrEP as a “social problem” since its users were seen as promiscuous, irresponsible, immoral and naïve. They also believe that uptake of PrEP is undermining use of condoms and that PrEP users are responsible for ongoing epidemics of STIs among gay and bi men.
Everyone isn’t on the same page on PrEP.
Gay and bisexual men hold different attitudes towards men who use pre-exposure prophylaxis (PrEP), according to ‘It’s just an excuse to slut around’: gay and bisexual mens’ construction of HIV pre-exposure prophylaxis (PrEP) as a social problem‘, a research done by M. Pawson, et al. and published in Sociology of Health & Illness.
The use of emtricitabine/tenofovir (Truvada) as PrEP was approved in the US in 2012; eventually also rolled out in other countries (including extremely limited and elitist distribution in the Philippines). Studies have shown that, with good adherence, PrEP can reduce the risk of HIV infection by almost 100%.
However, PrEP uptake has faced significant barriers, including knowledge, access and affordability.
Also, the integration of PrEP within existing HIV prevention efforts based on behavior change – especially consistent condom use – has encountered challenges, particularly when linked with the stigma associated with sexual promiscuity and “bareback” sex (unprotected anal intercourse with non-primary partners).
For this research, a series of focus group discussions were conducted in New York City. Thirty-two gay and bi men (with an average age of 35 years) were invited to share their views about PrEP, in late 2015 and early 2016. Most (n = 28) self-identified as gay and 11 were HIV positive.
Overall, the men had a good awareness of PrEP, with many reported seeing advertisements, discussion of PrEP on social media or said they had heard of PrEP from friends.
But not all the participants discussed PrEP accurately, with various misconceptions existing – e.g. that it’s a lifetime commitment, and that if one stopped taking PrEP and subsequently became infected with HIV the virus would be resistant to antiretrovirals because of previous exposure to medication.
Some of the men also see PrEP as a “social problem” since its users were seen as promiscuous, irresponsible, immoral and naïve. These same individuals believed that uptake of PrEP was undermining use of condoms and that PrEP users were responsible for ongoing epidemics of STIs among gay and bi men.
The researchers noted that “by framing PrEP use as enabling gay and bisexual men to violate subcultural norms of sexual etiquette espoused in previous HIV prevention efforts, claims makers were able to present PrEP users as social problem villains,. Countering claims makers’ framing PrEP as a social problem, some men constructed PrEP as a helpful prevention tool in the fight against the HIV epidemic within gay and bisexual communities. Much of their discourse was couched within a harm reduction model in which PrEP medication is framed as significantly reducing the harm associated with engaging in risky sexual behavior.”
Those who participated also had notions of “deserving” and “undeserving” PrEP users – e.g. men in relationships with an HIV-positive partner fell into the “deserving” category.
“By studying the construction of PrEP as a social problem, we were able to highlight how gay and bi men define what they consider appropriate ways to prevent the spread of HIV. Public health organizations that design and disseminate HIV prevention messaging should strive to construct more inclusive definitions of sexual health practices in ways that seek to combat the stigma currently associated with those who make use of other preventions methods besides condoms,” the researchers ended.
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