UNAIDS OUTLOOK | 2014 The Cities Report
13 SPECIAL SECTION STATE OF CITIES 21 WHAT IS THE URBAN ADVANTAGE? 32 PHOTOGRAPHY BY RICHARD SILVER 58 PARIS GOING BEYOND CITY LIMITS 66 FUTURE LEADERS TODAY 80 THE LAST WORD WITH TERESIA NJOKI OTIENO END THE AIDS EPIDEMIC IN CITIES BY 2030. COMMIT TO ACHIEVE THE 90-90-90 HIV TREATMENT TARGETS BY 2020. COMMIT TO PROVIDE SUSTAINED ACCESS TO HIV TESTING, TREATMENT, AND PREVENTION SERVICES. END STIGMA AND DISCRIMINATION. PUT PEOPLE AT THE CENTRE. RESPECT HUMAN RIGHTS AND LEAVE NO ONE BEHIND. ACT LOCALLY AND IN PARTNERSHIP WITH COMMUNITIES TO GALVANIZE GLOBAL SUPPORT FOR HEALTHY AND RESILIENT SOCIETIES. ADDRESS THE CAUSES OF RISK, VULNERABILITY AND TRANSMISSION. USE ALL MEANS INCLUDING MUNICIPAL ORDINANCES AND OTHER TOOLS TO ADDRESS SOCIAL ISSUES THAT MAKE PEOPLE VULNERABLE TO HIV, AND OTHER DISEASES. WORK CLOSELY WITH COMMUNITIES TO BUILD AND FOSTER TOLERANCE. USE THE AIDS RESPONSE FOR POSITIVE SOCIAL TRANSFORMATION. LEVERAGE INNOVATIVE SOCIAL TRANSFORMATION TO BUILD SOCIETIES THAT ARE EQUITABLE, INCLUSIVE, RESPONSIVE, RESILIENT AND SUSTAINABLE. INTEGRATE HEALTH AND SOCIAL PROGRAMMES TO IMPROVE THE DELIVERY OF SERVICES. BUILD AND ACCELERATE THE AIDS RESPONSE. DEVELOP AND PROMOTE INNOVATIVE AND ACCESSIBLE PROGRAMMES. ENCOURAGE AND FOSTER COMMUNITY LEADERSHIP AND ENGAGEMENT TO BUILD DEMAND AND TO DELIVER SERVICES RESPONSIVE TO LOCAL NEEDS. MOBILIZE RESOURCES FOR INTEGRATED PUBLIC HEALTH AND DEVELOPMENT. INVEST IN THE AIDS RESPONSE. ADAPT CITY PLANS AND RESOURCES FOR A FAST-TRACKED RESPONSE. DEVELOP INNOVATIVE FUNDING AND MOBILIZE ADDITIONAL RESOURCES AND STRATEGIES. UNITE LEADERS FROM AROUND THE WORLD. MEASURE RESULTS AND ADJUST PROGRAMMES TO BE FASTER, SMARTER AND MORE EFFECTIVE. SHARE EXPERIENCES, KNOWLEDGE AND DATA ABOUT WHAT WORKS AND WHAT CAN BE IMPROVED. REPORT ON PROGRESS. END THE AIDS EPIDEMIC IN CITIES BY 2030. 2 The Cities Report END THE AIDS EPIDEMIC IN CITIES BY 2030. COMMIT TO ACHIEVE THE 90-90-90 HIV TREATMENT TARGETS BY 2020. COMMIT TO PROVIDE SUSTAINED ACCESS TO HIV TESTING, TREATMENT, AND PREVENTION SERVICES. END STIGMA AND DISCRIMINATION. PUT PEOPLE AT THE CENTRE. RESPECT HUMAN RIGHTS AND LEAVE NO ONE BEHIND. ACT LOCALLY AND IN PARTNERSHIP WITH COMMUNITIES TO GALVANIZE GLOBAL SUPPORT FOR HEALTHY AND RESILIENT SOCIETIES. ADDRESS THE CAUSES OF RISK, VULNERABILITY AND TRANSMISSION. USE ALL MEANS INCLUDING MUNICIPAL ORDINANCES AND OTHER TOOLS TO ADDRESS SOCIAL ISSUES THAT MAKE PEOPLE VULNERABLE TO HIV, AND OTHER DISEASES. WORK CLOSELY WITH COMMUNITIES TO BUILD AND FOSTER TOLERANCE. USE THE AIDS RESPONSE FOR POSITIVE SOCIAL TRANSFORMATION. LEVERAGE INNOVATIVE SOCIAL TRANSFORMATION TO BUILD SOCIETIES THAT ARE EQUITABLE, INCLUSIVE, RESPONSIVE, RESILIENT AND SUSTAINABLE. INTEGRATE HEALTH AND SOCIAL PROGRAMMES TO IMPROVE THE DELIVERY OF SERVICES. BUILD AND ACCELERATE THE AIDS RESPONSE. DEVELOP AND PROMOTE INNOVATIVE AND ACCESSIBLE PROGRAMMES. ENCOURAGE AND FOSTER COMMUNITY LEADERSHIP AND ENGAGEMENT TO BUILD DEMAND AND TO DELIVER SERVICES RESPONSIVE TO LOCAL NEEDS. MOBILIZE RESOURCES FOR INTEGRATED PUBLIC HEALTH AND DEVELOPMENT. INVEST IN THE AIDS RESPONSE. ADAPT CITY PLANS AND RESOURCES FOR A FAST-TRACKED RESPONSE. DEVELOP INNOVATIVE FUNDING AND MOBILIZE ADDITIONAL RESOURCES AND STRATEGIES. UNITE LEADERS FROM AROUND THE WORLD. MEASURE RESULTS AND ADJUST PROGRAMMES TO BE FASTER, SMARTER AND MORE EFFECTIVE. SHARE EXPERIENCES, KNOWLEDGE AND DATA ABOUT WHAT WORKS AND WHAT CAN BE IMPROVED. REPORT ON PROGRESS. END THE AIDS EPIDEMIC IN CITIES BY 2030. The Cities Report 1 The Cities Report Contents UNAIDS OUTLOOK | 2014
05 24 42 ON THE WEB INNOVATORS ROCKING THE WORLD CITY PROFILES New map it feature The who’s who 12 cities in 24 pages
08 32 66 DID YOU KNOW? RICHARD SILVER YOUNG LEADERS TO WATCH Snapshots from around the world A photographer’s perspective Agents of change
34 70 13 BUILDING FOUNDATIONS ART POSTERS SPECIAL SECTION Transforming cities Power on paper State of cities 38 72 14 CULTURAL ICONS ACTION PACKED CITIES WHY CITIES? What popped when Shaking up the status quo So many people, so little time
80 21 THE LAST WORD URBAN ADVANTAGE Teresia Njoki Otieno Cities are key to ending the AIDS epidemic TRANSFORMING cities THE FINE PRINT
Copyright © 2014. Joint United Nations Programme on HIV/AIDS (UNAIDS).
ISBN 978-92-9253-066-2 INTERACTIVE MAP JC2687
All rights reserved. Publications produced by UNAIDS can be obtained from the UNAIDS Information Production Unit. Mapping it out On the go or at your desk— Reproduction of graphs, charts, highlights from the UNAIDS maps and partial text is granted ON THE OUTLOOK Cities report are for educational, not-for-profit and now available through a new commercial purposes as long as proper credit is granted to UNAIDS: interactive map and journal. UNAIDS + year. Reproduction WEB Go online to discover what permission or translation-related cities are doing around the requests—whether for sale or for unaids.org world in the AIDS response: non-commercial distribution—should www.unaids.org/citiesreport be addressed to the Information Production Unit by e-mail at: [email protected].
UNAIDS.org The designations employed and Go to the unaids.org the presentation of the material in website to download the this publication do not imply the expression of any opinion whatsoever full report and check out on the part of UNAIDS concerning the related resources. legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. @UNAIDS Get news from UNAIDS UNAIDS does not warrant that through our social media the information published in this channels. Like us on Face- publication is complete and correct book (facebook.com/unaids) and shall not be liable for any damages and follow us on Twitter incurred as a result of its use. (twitter.com/unaids). The Joint United Nations Programme on HIV/AIDS (UNAIDS) leads and inspires the world to achieve its shared vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. UNAIDS unites the efforts of 11 UN organizations—UNHCR, UNICEF, WFP, UNDP, UNFPA, UNODC, UN Women, ILO, UNESCO, WHO and the World Bank—and works closely with global and national partners to maximize results for the AIDS response. Learn more at unaids.org and connect with us on Facebook and Twitter.
The Cities Report 5 Foreword Placing cities on a Fast-Track to end the AIDS epidemic
he future of human health and A Fast-Track AIDS response means development is being shaped that by 2020, 90% of people living with “We stand by cities and urban areas. More HIV will know their HIV status, 90% shoulder to shoulder T than six of every 10 people of people living with HIV who know will live in urban centres by 2050. The their status receive HIV treatment with community and actions of city leaders will therefore have and 90% of people on HIV treatment city leaders” a profound impact on public health, have a suppressed viral load. These are especially in low- and middle-income the 90-90-90 targets. The Fast-Track countries, where more than 95% of Targets for 2020 also call for reducing urban growth is expected. new adult HIV infections to fewer than 500 000 people worldwide and Cities are engines of transformation. eliminating HIV-related stigma and They are home to the largest and most discrimination. Combined, these targets dynamic economies and they are provide a fragile, five-year window to set energized by young, mobile and diverse the world on track to ending the AIDS populations with talent, creativity and epidemic by 2030. innovation. This is why, on World AIDS Day Urban areas are also home to millions 2014, mayors from around the world of people who have fallen through the are gathering to launch the Paris cracks of social, political and economic Declaration on Fast-Track Cities and life. People who lack access to education, pledging to achieve the 90-90-90 targets health services and prevention measures by 2020. The mayors are declaring their face significantly higher health risks. leadership and their cities’ commitment Under these social conditions, many to accelerating the scale-up of HIV diseases, including HIV, spread more prevention and treatment and achieving quickly. Additionally, poor sanitation zero discrimination. and crowding foster the spread of tuberculosis, which is the leading cause Cities will only reach the Fast-Track of death among people living with HIV. Targets by leaving no one behind: ensuring that marginalized and Cities need to address their significant stigmatized people can access sexuality disparities in access to basic education, HIV testing and prevention services, social justice and economic options such as condoms and effective opportunities. Using a Fast-Track AIDS HIV treatment. They must also scale up response, cities can improve social tuberculosis care. A Fast-Tracked AIDS equality for people affected by HIV approach requires cities to work with and those living with the disease, while vulnerable people and populations at also addressing related public health particular risk, including sex workers, challenges in new and innovative ways people who inject drugs, transgender to prevent disease. people and men who have sex with
6 The Cities Report men. Cities must also be safe and free evidence about what works. They have Track Cities initiative. Cities can of violence, especially against young opportunities to scale-up the most ease the unnecessary suffering and women and girls. effective programmes and to reach large disproportionate human and financial numbers of people living in relatively costs and consequences of ill health The Joint United Nations Programme compact areas in a holistic manner. and death due to HIV. Together, we can on HIV/AIDS (UNAIDS), the United achieve a new era of cities as nurturing Nations Human Settlements Programme A scaled-up, Fast-Tracked AIDS centres of equity and access to health (UN-Habitat) and the International response will inspire cutting-edge and prosperity. Association of Providers of AIDS Care services and pave the way for cities (IAPAC) will fully support the Fast- to address other public health Track Cities initiative. The initiative is challenges, including sexual and Anne Hidalgo aimed at engaging mayors and other reproductive health, maternal and Mayor of Paris urban leaders and generating support child health, gender-based violence, France from many sources, including affected improved tuberculosis care and other communities and key populations, as communicable and noncommunicable Michel Sidibé well as development and multilateral diseases. Cities can also encourage new Executive Director partners. Mayors and city governments types of public-private partnerships and will lead the Fast-Track Cities civil society involvement in the delivery UNAIDS initiative—individually and jointly—in of health and other services. This partnership with communities, civil approach can transform institutions and Joan Clos society, public health officials, clinicians, societies at large and unlock powerful Executive Director law enforcement agencies and others. opportunities to tackle barriers that UN-Habitat deprive many people of the full benefits We are optimistic that cities will succeed of city life. José M. Zuniga in this bold endeavour, because we President/CEO have already seen cities successfully Ending the AIDS epidemic in urban International Association of adopt accelerated AIDS responses. San areas will need more than increased Providers of AIDS Care Francisco is actively engaging multiple funds and resources. It requires the partners in a strategy to end its AIDS commitment of leaders who can inspire epidemic. Cities such as Bangkok, New and harness the compassion and York, Paris and Vancouver have also generosity of citizens to bring about significantly reduced HIV transmission lasting change. It also requires energized by improving access to HIV services, communities that can accelerate including widely available voluntary and sharpen the focus of local AIDS HIV testing, earlier initiation of HIV responses and share knowledge about treatment and unfettered access to best practices. combination HIV prevention. We stand shoulder to shoulder with Ending the AIDS epidemic globally community and city leaders as they requires cities to be fully engaged. Cities commit to achieve the 90-90-90 work at scale and they generate plentiful targets by 2020 through the Fast-
The Cities Report 7 A snapshot of what cities are doing around DID YOU KNOW? the world in the AIDS response.
1 Atlanta 2 Badung 3 eThekwini 4 Copenhagen 5 Francistown (Durban) and Gaborone Atlanta, United States of People living with HIV in Copenhagen, Denmark, is America, is using early HIV Badung, Indonesia, holding eThekwini (Durban), South engaging with sex workers In 1999, Francistown and detection and new an identity card can Africa, is committed to where they live and work to Gaborone, Botswana, reporting strategies to access free HIV treatment eliminating new HIV infections better offer HIV counselling piloted their first mother-to- reduce HIV infections. and health care, thanks among children. Mother-to- and testing. child programme. Today, to local government child transmission rates in the 96% of pregnant women health insurance. city are now less than 1%. living with HIV are accessing antiretroviral medicines.
6 Hamburg 7 Kiev 8 Kigali 9 Manila 0 Mumbai
Hamburg, Germany, Kiev, Ukraine, is the home Orange Day in Kigali, Health officials in Manila, Mumbai, India, has is working with migrants base of the All-Ukrainian Rwanda, raises capital of the Philippines, expanded its diagnosis and to improve HIV Network of People Living awareness and promotes are working with the police treatment of drug-resistant outreach services. with HIV with more than action to prevent gender- and entertainment venues tuberculosis, resulting in an 400 employees across based violence. to distribute condoms and 8-fold increase in patients the country providing to promote HIV testing for accessing treatment for HIV services to 40 000 transgender people and men drug-resistant tuberculosis in people each year. who have sex with men. 2013, compared to 2011.
! New York @ Curitiba # San Pedro Sula $ Saint Petersburg % Windhoek
Started in 1981, Gay Men’s Curitiba was the first city in The local government of Saint Petersburg in the New HIV infections were Health Crisis in New York, Brazil to implement rapid San Pedro Sula in Honduras Russian Federation hosts mapped against the United States of America, HIV tests and to use mobile finances an educational and the Silver Rose—a network availability of key HIV-related was the world’s first HIV clinics to reach populations cultural programme for supporting sex workers to services in Windhoek, service organization. at risk for HIV. HIV prevention among access HIV services. Namibia, resulting in the young people. expansion of services to informal settlements.
8 The Cities Report SPECIAL SECTION state of cities OUTLOOK EXPLORES why Fast-Tracking cities will help reach the 2020 targets and end the AIDS epidemic by 2030
The Cities Report 9 SPECIAL SECTION
Countries with a high proportion of Cities are home to large proportions people living with HIV in one city of people living with HIV
Lima Peru Kingston Monrovia Jamaica Liberia
Abidjan Buenos Aires Côte d’Ivoire Argentina
Pointe-Noire Congo
Asmara Eritrea
Lisbon Freetown Portugal Sierra Leone
Santiago Chile
People living with HIV 10 000 (PLHIV) in the country People living with HIV (PLHIV) in the city
Liberia: Eritrea: Jamaica: Peru: Côte d’Ivoire: 80% of PLHIV 73% of PLHIV 64% of PLHIV 45% of PLHIV 43% of PLHIV live in Monrovia live in Asmara live in Kingston live in Lima live in Abidjan
Argentina: Sierra Leone: Portugal: Congo: Chile: 43% of PLHIV 43% of PLHIV 43% of PLHIV 39% of PLHIV 37% of PLHIV live in Buenos Aires live in Freetown live in Lisboa (Lisbon) live in Pointe-Noire live in Santiago
10 The Cities Report SPECIAL SECTION
Quick facts about cities and HIV 01 By 2030, an estimated 60% of the global population will live in cities—twice as much as in 1950. 02 Between now and 2030, the number of people living in cities is expected to grow from 3.6 billion to 5 billion. 03 90% of the world’s urban population growth between now and 2030 is predicted to be in low- and middle-income countries, mostly in Africa and Asia. 04 Cities and urban areas bear a major part of the global HIV burden—in sub-Saharan Africa, nearly half (45%) of people living with HIV reside in urban areas. In many countries outside of sub-Saharan Africa, such as Brazil, Jamaica, and the Russian Federation, cities are home to more than half of all people living with HIV nationally. 05 More than 60% of urban residents in Africa live in slums; in Asia, at least a third of urban residents do so. Cities will struggle to control their AIDS epidemics as long as these populations are marginalized from the benefits of city life.
The Cities Report 11 Moscow Paris Rio de Janeiro
New York City Miami London
Sydney Venice Shanghai
Landmark icons by Albéric d'Hardivilliers and Léopoldine Solovici, Le Duo. Represented by Morgane Le François. SPECIAL SECTION
why cities AROUND 52% OF THE WORLD’S POPULATION live in urban areas—so much potential!
The Cities Report 13 14 The Cities Report WHY CITIES
Why cities
Each year brings new evidence of progress being made in the global AIDS response. Clear goals and sustained commitment, as well as community mobilization and scientific innovations, have brought the world to the point where it is no longer a matter of whether we can end the AIDS epidemic, but when.
Why Fast-Track cities? cities themselves, with an ever-greater proportion of humanity living and nding the AIDS epidemic by working in them. 2030 is feasible if the world’s major cities act immediately Cities are vibrant hubs of economic E and decisively to Fast-Track growth, learning and innovation, their AIDS responses by 2020. creativity and community dynamism, which make them ideal platforms for Cities need to reach Fast-Track developing better, fairer societies. But treatment targets of 90-90-90 cities are also marked by inequity which by 2020: can stand in the way of development. ▶ 90% of people living with HIV knowing their HIV status; ▶ 90% of those diagnosed with HIV receiving antiretroviral therapy; and ▶ 90% of people on antiretroviral FAST-TRACK CITIES therapy achieving undetectable levels ENDING THE AIDS EPIDEMIC BY 2030 of HIV (viral suppression).
Leaders recognize that where access to HIV testing, treatment, and prevention Targets has been optimized and taken to scale, By 2020 By 2030 including in many cities around the world, AIDS-related deaths and new 90-90-90 95-95-95 HIV infections have been dramatically Treatment Treatment reduced. Reaching these targets would avert nearly 28 million new HIV infections and more than 20 million 500 000 200 000 AIDS-related deaths by 2030. New infections New infections among adults among adults Two of the most dramatic events of the past few decades have converged in ZERO ZERO cities. One is the astonishing growth of Discrimination Discrimination
The Cities Report 15 SPECIAL SECTION
Fig. 1 Urban and rural population trends in developing and developed countries, 1950–2050
10 10
8 8
6 6
4 4 Global population (billion) Global population (billion) 2 2
0 0 1950 1970 1990 2011 2030 2050 1950 1970 1990 2010 2030 2050
Year Year
Urban - Developing countries Rural - Developing countries Urban - Developed countries Rural - Developed countries
16 The Cities Report SPECIAL SECTION
Fig. 2 World map of 200 cities with the greatest estimated number of people living with HIV, 2013
people’s health and well-being, especially those living in impoverished and poorly serviced parts of cities. In 2012, almost 30% of urban populations in low- and middle-income countries, and more than 60% in sub-Saharan Africa, lived in slum areas. UN projections show that one in three new city dwellers may soon be living in a slum. These trends are spurring support for including a goal on “inclusive, safe and sustainable cities and human settlements” in the post- 2015 sustainable development goals.
Cities’ burdens of HIV In all regions of the world, cities and urban areas bear a large share of the The second event is the global The amazing growth of cities global HIV burden. Importantly, this is AIDS epidemic. In all regions, large The world is urbanizing at a rapid pace. the case in many of the 30 Fast-Track proportions of people living with HIV Around 52% of the world’s population countries, which UNAIDS has identified reside in urban areas, and sometimes in live in urban areas—that proportion is as priorities for accelerating the global quite specific parts of cities and towns. expected to reach 60% by 2030. A few AIDS response because they account for Ending the epidemic requires ensuring generations ago, in 1900, that figure was 89% of all new infections. that resources, services and support for around 10%. preventing and treating HIV reach those The extent to which HIV affects cities populations and locations. Cities offer Nearly all (about 90%) of the world’s is apparent when one focuses on the unique opportunities for doing this. urban population growth between now 200 cities with the biggest burdens Fast-Tracking HIV responses in cities— and 2030 is expected to be in developing of HIV. Together, those cities are without neglecting efforts in rural and countries, mostly in Africa and Asia estimated to account for more than one other areas—will therefore be crucial for (Fig. 1). Some of the fastest growing quarter (26%) of the 35 million [33.2 ending the AIDS epidemic. cities are in Asia, and also in Africa, the million–37.2 million] people living region hardest hit by HIV. with HIV globally (Fig. 2 and Fig. 3). For example, in Brazil, about 15 cities The pace, scale and character of account for nearly 60% of the national urbanization have a decisive effect on total of people living with HIV. In
The Cities Report 17 SPECIAL SECTION
the United States of America, 21 cities Effective action in cities flawless, this approach succeeded (among the top 200) account for 40% of is essential if the world is in reducing new HIV infections the national total of people living with significantly in a few years. Using the HIV. It is estimated that more than half of to end the AIDS epidemic opportunities available today, such the people living with HIV in the Russian by 2030 Fast-Tracking approaches can have a Federation are living in 15 cities. In Viet In countries with large AIDS dramatic effect, even in countries with Nam, about one third (31%) of people epidemics, the numbers of people large epidemics. This requires detailed living with HIV reside in only two cities, living with HIV are so high that strategic information that can guide while in Pakistan, a single city, Karachi, effective actions in cities are likely to targeted prevention programmes and is home to over 30% of people living with influence national outcomes. Even enable maximum coverage of HIV HIV. where the epidemic is smaller, cities testing and treatment services. tend to be home to large numbers of The importance of city AIDS epidemics people belonging to key populations. Tackling inequity in cities is also evident in sub-Saharan Africa. Evidence from all regions of the world Cities boast many attractions, but Based on data from 25 countries shows that key populations are at the benefits of city living are seldom that have conducted nationally- higher risk of HIV infection but receive distributed equitably. Income representative household-based limited attention in HIV programmes. inequality is often worse in cities population surveys, HIV prevalence This is particularly the case for sex and towns than in rural areas, health among people aged 15–49 years in the workers and their clients, people who disparities in cities can be severe. region is, on average, twice as high in inject drugs and men who have sex with The effects are visible especially in urban areas as in rural areas (and in men. Ensuring that these populations urban slums and informal settlements. Ethiopia, HIV prevalence in urban receive HIV prevention, treatment Globally, an estimated 1 billion people areas was nearly seven-fold higher in and care services in a protective live in overcrowded and poorly 2011) (Fig. 4). In several countries in environment can greatly contribute to serviced slums; the vast majority of this region, including those with major ending national AIDS epidemics. AIDS epidemics, urban areas account them in developing countries. It is estimated that more than 30% of city for the majority of people living with Thailand famously used its “urban residents in less-developed countries HIV, and the urban share of HIV advantage” in the 1990s when it live in slum areas; in sub-Saharan infections appears to be increasing in successfully focused its HIV strategy Africa, that proportion exceeds 60%. many of them. on increasing condom use among sex workers and their clients in Bangkok and other major cities. Although not
18 The Cities Report SPECIAL SECTION
These communities often struggle to Fig. 3 compete for essential services. Many of Proportion of all people living with HIV who live in the 200 cities with the them lack secure land tenure, and urban biggest HIV burdens, by region growth plans, infrastructure schemes, pricing policies and administrative 64% procedures often neglect their needs and entitlements. Lack of shelter, safe water, acceptable sanitation, nutrition, 54% 54% and basic education and health care are endemic problems, along with high unemployment, crime and physical insecurity, and environmental hazards. These conditions leave people vulnerable to ill health and disease, and block access to treatment and 39% 38% care. For example, food insecurity and 37% overcrowded and poor-quality housing 33% 32% are known to be associated with 31% tuberculosis. 29%
Such disparities also play out in some 26% 24% AIDS epidemics. In Kenya and South 23% Africa, for example, the risk of acquiring 21% 20% HIV appears to be higher in urban 20% 18% slums than in other parts of cities or in rural areas. Nationally, HIV prevalence in South Africa in urban formal 12% settlements is half (10%) that in urban 7% slums (20%). In Nairobi, Kenya, 12% of slum dwellers were found to be living 4% with HIV, compared to 5% of residents 2% in the rest of the city. Eastern Latin North Western East and Asia and Middle East Europe America America and southern Pacific and North HIV infection and health services are and central and the and central Africa Africa Asia Caribbean Western Africa not always evenly distributed in cities. Europe Although most new HIV infections in the Namibian capital, Windhoek, occur in its informal settlements, there Fig. 4 are few health services in the populous Ratio of urban versus rural HIV prevalence among people aged 15-49 years neighbourhoods. Informal settlements for selected countries in Durban, South Africa, were found to have the lowest coverage of HIV 7.0 testing among infants, the highest rates 6.0 of mother-to-child HIV transmission and the lowest rate of enrolment on HIV 5.0 treatment compared with other areas. 4.0
Preventing and controlling HIV in 3.0 such circumstances therefore requires 2.0 approaches that tackle the underlying social inequities. Even within health ratio Urban/rural prevalence 1.0 systems, measures can significantly 0.0 improve access to health services for 2007 2006 2009 2011 2011 2008 2009 2010 2003 2012 2010 2012 2008 2011 2009 all people in need. But the efforts have 2010 2010 2007 2012 2010
greater force when they link with Niger Kenya Congo Ghana Gabon Liberia Malawi Guinea Zambia Uganda Burundi Rwanda Lesotho Senegal Ethiopia Principe actions across other developmental and Sao Tome Swaziland Cameroon Zimbabwe of the Congo 2008 Mozambique Sierra Leone 2008 Côte d’Ivoire 2011 sectors, when they are rights-based, Burkina Faso 2010 United Republic of United Republic of Tanzania (the) 2011 Tanzania and when they involve the active Democratic Republic participation of affected communities. Social inclusion is the first step in the important process of transformation.
The Cities Report 19 SPECIAL SECTION
HIV risks in city life Migration into cities is sometimes also City life can involve numerous risks, associated with elevated risk of acquiring Three decades later, that movement has some of which also boost the chances of HIV. In Khutsong (Carletonville), a turned the tables on the AIDS epidemic. acquiring HIV. Cities are hubs for many mining town in South Africa, female There were almost 40% fewer new HIV of the HIV epidemics that are driven migrants are 1.6 times more likely to infections globally in 2013 compared by injecting drug use and paid sex. be HIV-positive than non-migrants. with 2001. In more than three dozen The anonymity cities offer also enables In India, HIV infection among people countries, new infections have declined people to express their sexuality more who migrated from rural to urban areas by more than half. Around 13.6 million freely. Despite their vulnerability to is about three times the national level people living with HIV are receiving HIV, key populations in cities often lack (1.0% versus 0.3%). In many African and life-saving HIV treatment, which has access to HIV prevention and treatment Asian countries, migration in and out of averted more than 7.6 million deaths services. cities can be an important factor linking since 1995. different networks of HIV transmission. In Thailand overall, an average 7% Cities’ AIDS responses vary greatly in of men who have sex with men are Cities also need to scale up tuberculosis their reach and effectiveness. Some estimated to be living with HIV, but in testing and care. Tuberculosis is one of have succeeded in reversing their Bangkok, the figure is closer to 25%. the leading causes of death for people AIDS epidemics (for example, Chennai Similarly, in Nigeria, the HIV infection living with HIV and effective tuberculosis and Sydney) and some have drastically level among men who have sex with treatment is an essential component of cut new HIV infections (for example, men is 17%; in the Federal Capital the AIDS response. In cities that have New York). But their efforts—and Territory it is more than twice as high long had effective municipal tuberculosis achievements—are not yet the norm. (38%), while a study in 24 Mexican programmes, HIV services can easily be HIV infections are increasing again cities among men who have sex with integrated with tuberculosis services. among certain key populations in a few cities that seemed to have their epidemics under control. This is a reminder that sustained and adaptive efforts are needed to stay a step ahead of the epidemic.
Particularly in low- and middle-income countries, HIV testing and prevention efforts typically only reach about one fifth to one quarter of city dwellers who are most at risk of acquiring HIV. In many cities, only between one third and one half of people living with HIV are accessing antiretroviral therapy. These gaps affect key populations especially. Most cities need to substantially increase their current levels of programme coverage, particularly working with sex workers, men who have sex with men and people who inject drugs. ■ men found that about 17% of them Cities have been were HIV-positive. HIV prevalence leading the way among people who inject drugs in cities Cities have been at the forefront of is also many times higher than in the the AIDS response since the epidemic general population at 9% [2–19%] in 20 began. From Bangkok to San Francisco, cities in the United States, for example, Kampala to Zurich, Johannesburg to São and between 25% and 56% in five Paulo, courageous community activists Indonesian cities. and health workers, and far-sighted public officials, created programmes It takes special efforts to enable key that inspired a global movement to end populations to protect themselves and the AIDS epidemic. They have led the their partners against HIV. But when way with rights-based approaches that stigma and harassment are avoided, and have reduced HIV infections among health and other services fit the realities some of the populations worst affected and needs of these populations, HIV by the epidemic. infections decrease.
20 The Cities Report SPECIAL SECTION urban advantage AROUND THE WORLD The role of cities in ending the AIDS epidemic
The Cities Report 21 URBAN ADVANTAGE
and other health professionals tend to prefer working in cities rather than in Why cities have such remote areas. Many cities host academic and research institutions, including a big role in ending teaching hospitals, some of which have proved to be invaluable partners with public health authorities. Transportation the AIDS epidemic options are greater, making it easier for residents to access services. It is easier Cities around the world have been harnessing to reach people with information and these kinds of urban advantages to save lives outreach services.
and improve people's well-being. Cities around the world have been harnessing these kinds of urban advantages to save lives and improve people’s well-being. In the early days of the AIDS epidemic, San Francisco focused its efforts on bathhouses and other venues frequented by men who have sex men, and managed to bring its epidemic under control. HIV transmission in and beyond the sex trade was held in check in Dakar, Senegal, by offering sex workers screening and testing for sexually transmitted Throughout history, cities have infections. The HIV services that la attracted newcomers with the Clinique Confiance has been providing to promise of freedom, opportunity sex workers and their clients in Abidjan, and a better life. They provide jobs, Côte d’Ivoire, continue to be hailed as they offer refuge to those fleeing good practices in the AIDS response. conflict or natural disasters, and they excel as spaces of learning, creativity The political and social culture is often and innovation. more tolerant in cities than across countries as a whole. This grants ll this makes cities powerful cities the flexibility for pioneering engines of economic growth programmes that fit people’s lives and and development. The top 300 needs, rather than bowing to prejudice cities in the world are home to or populism. The more compact nature about 19% of the global population, yet of municipal governments also makes it A easier for city officials to build support generate nearly half of the global gross domestic product. for effective public policies across various departments. Vancouver, several Many of the advantages that generate European cities (including Frankfurt, such economic power also foster Lisbon and Zurich) and several cities other benefits. When large numbers of in Australia, including Sydney, have people live and work in close proximity, opted for public health rather than a transaction costs are lower and public purely punitive approach to injecting spending on infrastructure and services drug use by providing safe, supervised becomes more economically viable. injecting spaces where counselling and Cities also favour the networking of other support are available. In some talent, knowledge and resources. of these cities, HIV infections among people who inject drugs decreased Jobs are more numerous, social significantly once effective harm services are more plentiful, better reduction programmes were introduced. resourced and easier to access, and The public health-focused approach also health systems are stronger in cities proved to be less expensive than jailing than in the countryside. As a result, people for using drugs. incomes are higher, literacy rates and education levels (especially for women) City life also favours the social and are higher, and life expectancy is longer political activism and mobilization for city dwellers compared with their that drive health and developmental counterparts in rural areas. Doctors breakthroughs. Much of the impetus
22 The Cities Report SPECIAL SECTION
for the early response to HIV in cities in rural informal settlements (28% such as New York City and Paris, or compared to 35%). Stigma, resource the campaign that led to South Africa’s constraints and other barriers continue rollout of free antiretroviral therapy, to impede HIV testing and treatment came from city-based organizations efforts in many cities. and activists, such as the Treatment Action Campaign. In Indonesia, a If the urban advantages are seized, an coalition of civil society organizations effective city response will go further recently used opportunities to than saving lives. A ramped-up AIDS participate in city policy-making to response fuels new, cutting-edge Much of the impetus spearhead a process that is expanding service delivery platforms that can for the early response health insurance coverage for pave the way for cities to address other to AIDS in cities impoverished residents in the cities public health challenges—including of Semarang and Pekalongan (East tuberculosis, sexual and reproductive such as New York Java). Approaches that embrace the health issues, maternal and child City and Paris, or the participation of citizens and employ health, gender-based violence and non- campaign that led to the knowledge and experience of communicable diseases. It can unlock affected communities point the way powerful opportunities to tackle the South Africa's rollout forward for cities. social and health barriers that deprive of free antiretroviral too many people of the benefits of city therapy, came from These kinds of advantages position life. It breaks through political and cities ideally to adapt, strengthen and institutional gridlock so other things city-based expand their own responses in ways can get done. It builds new, innovative organizations and that can take the global AIDS response public-private partnerships based on activists. to a new level, but at the moment, evidence and results. ■ not enough cities are capitalizing on these advantages. For example, despite Thailand’s progress toward scaling up antiretroviral therapy, less than 40% of people living with HIV in Bangkok receive treatment compared to 56% nationally. A population-based survey in South Africa shows that ART coverage in urban localities is less than
The Cities Report 23 SPECIAL SECTION
meet the innovators VIBRANT HUBS OF CREATIVITY AND LEARNING Cities have nurtured and challenged some of the most innovative people in the AIDS response
24 The Cities Report SPECIAL SECTION
Vuyiseka Dubula power to account. We have I am very proud to be alive demonstrated this through and enjoy the small things the Treatment Literacy in life, such as being able to Cape Town, Programme as a vehicle run the Comrades Marathon, South Africa to empower people with further my education and be knowledge and organizing in a role model to my siblings to communities to create a force show that HIV is not a death Former Secretary-General for change. sentence. I love being able to of the Treatment Action be a mother to my two kids Campaign (TAC) between Personally, this experience and grow with them. 2007 and 2014, South African provided a space for me to National AIDS Council participate in real politics What are your most People Living with HIV Sector from below. For instance, to hopeful moments Leader and Programmes fight for my sexual health about today? Director for Sonke Gender and reproductive rights as Movements like TAC still Justice a young woman—to have bring hope to many people healthy children and live that the struggle is not What inspired you to a normal, productive life only about pills, but also get involved in the with uninterrupted access to about improving the health AIDS response? ARVs. Access to treatment system to deliver quality, My involvement in the AIDS is not a means to an end in affordable and safe HIV movement was inspired by itself. Instead, adherence is services for all. The current my struggle for access to the main goal for any person Minister of Health, Dr Aaron treatment after I received my in order to enjoy the full Motsoaledi, is a symbol of own HIV-positive results in benefits treatment has to hope and one wishes we 2001. I was told, “You have an offer. The change begins could clone his dedication illness but go home and wait with me. My viral load has and passion to other critical for your death” because of the been undetectable since areas of service delivery, such unavailability of treatment. August 2004. My two as education. It was not available—not children and my husband because it did not exist but remain HIV-negative. I am hopeful that we are not because it was too expensive very far from finding a cure for poor people like me to What are you most and a vaccine for HIV. afford. This motivated me to proud of? I am hopeful that my get involved in the movement I am very honoured to be daughter and my son will for both personal survival counted among comrades stand a better chance to and to support the political from TAC, Equal Education, escape HIV infection if struggle—to make sure that Social Justice Coalition we also address social and we do not perish silently as and Sonke Gender Justice, gender inequalities. people living with HIV in whose lives are dedicated to South Africa. The struggle for social justice. Without these However, without financial affordable medicines is not organizations and many commitments both over. There is still more more, South Africa would domestically and globally to room for everyone to add not be the same. I am proud sustain the HIV response we their voice to get more to have contributed to the will fall short in achieving affordable third-line post-liberation politics of our goals. We all owe it antiretrovirals (ARVs) and our country and I am still to ourselves and future tuberculosis drugs. committed to see no more generations to see this new HIV infections, deaths, struggle to the finish line. What have you tried discrimination, gender to change? inequality and gender- Together, as a collective based violence in the world, of people living with HIV beginning with South Africa. under the umbrella of the We are the generation that Treatment Action Campaign cannot afford to sit and wait. (TAC) we have managed We need to get out there and to demonstrate the power be part of change. of ordinary people to hold
The Cities Report 25 SPECIAL SECTION
devastated by the outlook, drugs, and then we would zero AIDS deaths and but compassion and courage start HIV therapy. Now zero stigma through a also characterized those we know the virus is doing coordinated strategy. early days. I saw first-hand harm and destruction even the power of community earlier. And the harm of Today, though, viral advocacy and the importance the virus outweighs the suppression is somewhere of physician participation. So toxicity of the medicines. around 50%. It is double how could I not get involved Last year, we launched a the national average, but it’s in AIDS? There were so citywide programme to get not good enough. Getting many unresolved questions, HIV patients on ART the people tested, linked to care and such an urgency to same day they are diagnosed. and virally suppressed will answer them. This is a game-changer—for rely on integrating diagnosis, the health of people living treatment on demand, and What have you tried with HIV and to prevent the outreach services such as to change? transmission of the virus. housing, substance abuse My current work at the global counselling, and mental level in research stems from What are you most health counselling under one my experience in the AIDS hopeful about today? umbrella of care. ward —a constant struggle to It is such an exciting time. Diane Havlir understand the disease, how The response has been Charles King to treat it and how to develop completely reenergized by San Francisco, strategies that [keep] our the recent breakthroughs United States patients alive and healthy. in prevention research and New York, Over the last 25 years, I understanding the impact United States have conducted numerous of early treatment. While Chief of the HIV/AIDS studies on antiretroviral there is still no cure for Division and Positive Health therapy, drug resistance AIDS, and the rate of new President of Housing Programme at San Francisco and the beneficial effect of HIV infections in the United Works, Inc. General Hospital, Professor starting antiretroviral therapy States has remained relatively What inspired you to of Medicine at the University early in persons with HIV stable, San Francisco is get involved in the of California, San Francisco, and tuberculosis. redoubling its response. We AIDS response? and Founder of the San established a multisector Francisco Getting to Zero We know that by finding San Francisco Getting to I am an ordained Baptist Consortium people early and keeping Zero consortium aspiring to minister and served as them healthy, we stop the be the first city to reach zero the associate pastor of a What inspired you to cascade of getting sick, new HIV transmissions, congregation at Immanuel get involved in the dropping out of work and AIDS response? ending up in the hospital— I chose to do my residency and even transmitting the in internal medicine at the virus to a partner. The worst- University of California, case scenario is ending up in San Francisco, because the intensive care unit, which of the AIDS epidemic. I still happens in San Francisco started my career at the in this day and age. Inpatient Medical Service at San Francisco General What are you most Hospital, which was home proud of? to the first AIDS ward in the In 2010, here in San United States. Our service Francisco, we were the first was filled with young men, clinic in the world to offer suffering with every possible treatment to everyone, manifestation of AIDS. In regardless of CD4 cell count. the early 1980s, the average This then became adopted life expectancy of patients as our public health policy. admitted there was 18 Before, we had waited for months—it was where people peoples’ CD4 count to fall went to die. The patients to a certain level in order and their partners were to avoid toxicities of the
26 The Cities Report SPECIAL SECTION
Baptist Church in New social drivers of the social issues in order to Haven, Connecticut, epidemic, particularly transform our city for the United States of America, discrimination and social and betterment of the lives of in the early 1980s. Over economic marginalization. our residents. The National the course of three years, No matter how they manifest, Capital District Council and I helped to bury some two these drivers are the same I have been working with dozen parishioners or their drivers of inequality and United Nations Women family members who died most health disparities. (UN Women) to implement of AIDS—yet the subject of the Safe Cities programme AIDS was never discussed What are you most in the marketplaces of Port at the funeral or even with proud of? Moresby to ensure that the family. That changed I am most proud of having women can safely earn their for me at the bedside of our had to opportunity to give living. I have seen the power minister of music, who was voice to some of the most of the AIDS response to dying of AIDS. I offered marginalized people living address fundamental social to pray for him during with HIV over the course issues—like gender a hospital visit, and he of the last 30 years. Beyond Powes Parkop inequality and vulnerability. informed me that it would that, I am incredibly proud I believe that with strong not do any good as God was that we have proven, at least Port Moresby, leadership and the right punishing him because he in North America, the vital Papua New Guinea interventions, the dynamism was a homosexual. At that role of housing for both of the city and the AIDS moment, AIDS forced me treatment and prevention response can be embraced to out of the closet as a gay of HIV. As well, I am proud Governor build a healthier and more man. When I left his hospital that we have been able to resilient community. room, I went straight to the demonstrate that homeless What inspired you to office of the pastor to tell him people, including people who get involved in the What have you tried that I was going to come out use drugs, are as capable as AIDS response? to change? as a gay man and start doing anyone of adherence to ART As Governor of Port I have worked hard to clean something about AIDS. He and of contributing to society Moresby, among my top up the city in order to bring gave me the pulpit to preach if given the opportunity. priorities has been addressing about a sense of pride in the a sermon on AIDS and I would like to see these issues of safety, security and local people, and to ensure about four months later I learnings expanded to the cleanliness in the city. My that they can live and earn came out to the congregation. rest of the world. vision is to transform the a living without the risk I have been an AIDS activist city in order to improve the of violence and abuse. A ever since. What are you most quality of life and instill pride central aspect of my vision hopeful about today? in all our residents. Rapid for the city relies on building What have you tried This summer (2014), in urbanization has brought social inclusion at the local to change? response to mobilization many challenges to Port level—including people I found my role in the by Housing Works and Moresby. The expansion living with and at higher response to AIDS serving other community-based of informal settlements, risk of HIV. I participated homeless people who are organizations, New York high unemployment rates, in the International AIDS living with the virus. My first State’s Governor, Andrew alienated youth and alcohol Conference in Melbourne, advocacy was to establish the Cuomo, made a public abuse have heightened safety Australia, in July 2014, right to housing for people commitment to end AIDS and security issues and which reinforced my beliefs with AIDS who were still as an epidemic in our state by stretched the capacity of our of the clear need for cities using drugs and to prove 2020. I have been asked city’s services. to act where our national the efficacy of housing as to co-chair the taskforce that counterparts may be unable. a threshold for all other is developing the blueprint For women in Port Moresby I urged AIDS stakeholders to services. Our second effort for achieving this. I am violence and abuse has communicate to city leaders was to prove that formerly hopeful that if the Governor become a constant and on the clear political benefits homeless people with AIDS adopts this blueprint, New ever-present threat and this of investing in a strong AIDS could develop job skills and York will be the first is not acceptable. These response as well as other enter the workforce even political jurisdiction to vulnerabilities not only put health and social issues. before the availability of end the epidemic and thus women at higher risk of antiretroviral therapy (ART). provide a model for other contracting HIV but also City leaders must be Since then, our advocacy political jurisdictions around enhance and sustain social reminded that this is in has broadened to address the globe. inequalities for the whole everyone’s interest. I was very all of the many city. We must address these inspired by what I heard at
The Cities Report 27 SPECIAL SECTION
the AIDS Conference and today I am committed to reforming Port Moresby legislation that prevents people from accessing relevant, rights-based HIV services—particularly sex workers. Given the deterioration of our health services over the past three decades it is also of critical importance that I work with private and public stakeholders to improve the health system in the city. health facility. An opt-out attempted to commit suicide HIV testing programme for several times. Then I had a What are you most pregnant women attending chance to learn more about proud of? PMGH is a significant part of HIV and understood why I am proud of the buai scaling up testing in the city. people stigmatized those (betelnut) ban, which has with HIV. It was because brought about an incredible What are you most they did not have adequate change in the cleanliness of hopeful about today? understanding about HIV the city. The chewing of buai Since the International AIDS and thought that those not only made the city very Conference I have consulted infected with HIV were dirty, due to the rubbish from with the UN country team bad people. That was my the husks and the spitting of as well as the National AIDS motivation to get involved in red muck everywhere, but Council Secretariat on the HIV response—to help also has many health issues improving, simplifying and people understand more like increased risk of mouth scaling up counselling and about HIV. cancers, the deterioration of treatment services in the city teeth and the spreading of as well as improving the city’s After I came out as a person tuberculosis through spit. regulation of sex work. I am with HIV, many people This ban is the first step confident that together we contacted me seeking my necessary to bringing about can work to ensure that those support since they could social change in the city. Our who need it most are able to not share [their status] residents must take pride in access testing and treatment with anyone due to the our city and its appearance in Port Moresby. fear of stigma. Helping in order for them to others overcome their actively participate in social Pham Thi Hue fears and hopelessness is transformation and really motivational. What the improvement of our inspires me the most is the health system. Hai Phong, Viet Nam acceptance and respect I have gained from my I am proud of the work family and community. that we have been doing Founder of Red Flamboyant My son is also very proud of with UN Women on the Safe Cooperative Hai Phong, what I have been doing for Cities initiative author and mother the community. because the safety of our women and children is of What inspired you to What have you tried critical importance. get involved in the to change? AIDS response? I have been working hard to I am proud of the When I first found out that I change the way society sees transformations taking place was HIV-positive, my family us. I show people how I live at Port Moresby General and I experienced such and contribute to society Hospital (PMGH), both the stigma and discrimination to change people’s attitudes city and country’s largest from my community that I about HIV.
28 The Cities Report SPECIAL SECTION
Over the past 12 years, rightful role in the response. I have had many opportunities to meet with leaders in local Jean-Luc Romero and central government. In every meeting, I have tried to express the life, challenges and Paris, France hopes of people living with HIV, in hopes that government policies best meet the needs of President, Elus Locaux Contre our community. le Sida (ELCS)
What are you most What inspired you to proud of? get involved in the AIDS response? I am proud of the many trips I have made to all 63 I have lived with HIV for provinces in Viet Nam to over 25 years, and I wanted help and inspire other people to transform my individual who are living with HIV struggle into a collective so that they can become struggle. That is why I stronger and more confident. created Elus Locaux Contre le Sida (ELCS) in 1995, and I am proud of myself. I have publicly disclosed my HIV proven that a person with status. The association now HIV still can live and work has over 16 000 members like anyone else. I am proud in France. For me, the fight of family, my husband and against AIDS is a promise—a my son. We have worked promise renewed every day. very hard to help each other And a promise is made to be stay healthy and fight HIV. held! We now have a very happy Why are cities important? family, where my son always feels loved. Cities are key to any response already killed [almost] 40 to overcome challenges: around HIV. I have advocate million people, among financial investment, What are you most for the response from whom our friends and loved of course, but equally hopeful about today? cities for nearly 20 years as ones. The outlook on HIV importantly the social space The way society treats people president of ELCS! Cities can by policy that too often where the rights of all people living with HIV has changed, organize extremely effective gets stuck in an ideological are respected. On this last even though stigma and outreach and together can position, far from the point, work is needed. discrimination still exist. influence international realities faced by civil society. So my three words for People living with HIV now plans. Take the International The view that one can give to today are: hope, vigilance have access to treatment and Association of Francophone a person with HIV, a view in and commitment! I hope we still have access Mayors and Metropolis, which, although infrequently, to this life-saving therapy for example. These two one finds benevolence but when donors leave Viet organizations bring together much more prejudice and Nam. The Government of cities, and have both taken fear. I try to change this Viet Nam does show strong strong positions for the outlook, simply because it is commitment to the global removal of obstacles affecting a matter of life or death. goal of ending AIDS in 2030. freedom of movement and However, many challenges settlement of people with What are you most still remain and we, as people HIV worldwide. hopeful about today? living with HIV, need to The fact that the end of AIDS What have you tried continue our fight for is no longer a utopian dream, to change? ending stigma and but an attainable reality! We discrimination, to ensure The outlook on a disease now have the means to do so access to treatment and other that one never considers as long as there is sustained HIV services and for our for oneself but, which has political commitment
The Cities Report 29 SPECIAL SECTION
Mamadou Sawadogo response to AIDS. Thus, awareness on HIV in the with the creation of a local country, resulting in a strong association of people living political commitment from Ouagadougou, with HIV in Burkina Faso the highest authorities. Burkina Faso (Responsabilité Espoir Vie Solidarité, REVS +), What have you done that we were better organized you are most proud of? Chairman, National Network to act on the ground; to The fact I dared, with my of People Living with HIV save future generations wife who is HIV-negative, through actions in the to take action on an issue What inspired you community, and in particular that nobody wanted to to get involved in in schools and among engage openly before 1997. AIDS response? serodiscordant couples. To have played a role in I tested positive in November supporting leadership 1996 during my training as What have you tried development among people a nurse. Far from resigning to change? living with HIV in all myself, my instinct of self- Through our work in the provinces of the country. care and helping others took association REVS + we To have been able to affect over. Faced by prejudice helped change perceptions policy change and alignment against HIV and AIDS towards HIV and AIDS and in the decentralization of and thinking that I was towards people living with antiretroviral therapy going to die sooner than I HIV. With the introduction since 2003. thought, I got involved with of the national network laboratories to donate my of people living with HIV What are you most serum to science in order (REGIPIV-BF), we were hopeful about today? to save other lives. During able to organize support If we continue to build this time, two films—the for people living with HIV bridges, using new testimony of Philly Lutaaya, across different provinces of information technology a prominent Ugandan the country—giving them and communication musician, and the film confidence on the care they platforms, solidarity between “Philadelphia”, strengthened received and empowering individuals, communities my commitment, but also them to manage their own and continents can continue shifted my strategy towards health. We supported and to grow. Because through improving my community's motivated families to take solidarity there is hope. knowledge on HIV. responsibility for members of their family with HIV My actions in the field of who needed care. Since 2003 community awareness and we have facilitated access to my exchanges with medical antiretroviral therapy and experts have fostered striking care for country provinces. partnerships with other In a few words, since 1998 activists involved in the we changed the collective
30 The Cities Report SPECIAL SECTION
1989 to start an organization What are you most for, and run by, people who hopeful about today? inject drugs. Some good things are happening in areas that mean But what made HIV a lot to me. The abject failure prevention almost impossible of drug prohibition is now was the policy of global drug increasingly acknowledged prohibition. So in 1987 I though most countries started supporting drug law continue to define drugs reform publicly, knowing as primarily a criminal that this would be the longest justice problem. The pace and most difficult battle. Our of change is very slow. Drug hard work paid off. Australia law reform has started in was among the first countries quite a few countries. But to ensure that a needle HIV infections have been syringe programme was increasing in many countries Alex Wodak started in the geographical area, and among the very adopted and implemented for some years, including population, I was responsible nationally. By 1988, needle my own country. It is good and syringe programmes Sydney, Australia for! Doing nothing was to see hepatitis C incidence never an option. We had to were available in all six decreasing among people find and implement effective states and two territories. who inject drugs in many Emeritus Consultant, prevention measures quickly. Now in 2014, 42 million countries. It is also good Alcohol and Drug Service, St Providing sterile needles needles and syringes are to see harm reduction and Vincent's Hospital; President, and syringes was obviously distributed annually. medical male circumcision Australian Drug Law Reform the key. increasingly accepted as core Foundation; and Co-founder What are you most HIV prevention methods. I and former President of What did you try proud of? am also delighted that there the International Harm to change? Why should I be proud of is greater acceptance of the Reduction Association I looked with admiration doing what I was paid to need for evidence-based and and envy at the explosive, do—protecting the health rights-based approaches. ■ What inspired you to dynamic, purposeful, of vulnerable people and get involved in the disciplined response to HIV the entire community? I am AIDS response? by men who have sex with ashamed that it took me From 1982 for the next 30 men. I knew that getting so long to finally have the years I was the Director of people who inject drugs to courage of civil disobedience the Alcohol and Drug Service respond as a community was to distribute sterile needles at a major teaching hospital a critical part of the battle. and syringes. I am proud to in Sydney, Australia. My job I began by trying to get all have worked with wonderful included looking after people the stakeholders working on people to help prevent a who used drugs. A study this problem. Several of us terrible epidemic. Few people published in the early 1980s started advocating for needle can ever do much worthwhile showed that a large number and syringe programmes, but on their own. I was only able of men who had sex with these were politically blocked to contribute to the control men had contracted HIV in at the time. I realized that of HIV in Australia and other one year in an area close to an act of civil disobedience countries by working with my hospital. I realized that was unavoidable if an HIV others. One thing that I am this could be the start of a epidemic among and from proud of is that a friend had generalized epidemic and people who inject drugs was to cancel a research project that people who injected to be prevented. A group of on HIV in small children drugs were the critical us started providing sterile because there weren’t enough bridge population. I was injecting equipment in children with HIV to study. terrified of the prospect of November of 1986. I also a generalized epidemic. If worked hard to expand and it ever happened, it would liberalize the methadone have very serious health, treatment programme. I social and economic costs to worked on community the nation—and would have development—helping in
The Cities Report 31 RICHARD SILVER New York-based photographer Richard Silver collaborated with UNAIDS to share his visually stunning photographs of cities. Noted for his tilt-shift style of showing city life in miniaturization and for showing iconic building through time-slicing—his work offers viewers a different perspective on cities.
32 The Cities Report Q&A
1 4 What made you focus You’ve been all over the on cities? world. Are there some things that are the same in As a photographer, c ities offer cities everywhere? so many opportunities and I love to watch a city wake for me, as an architectural up. In the early morning, the lover, cities are my favourite people out are the people who destinations in the world. actually open the city. The Skyscrapers and people—the garbage men, business owners hustle and bustle—cities just cleaning up the storefronts, excite me like no other places lots of delivery people— on earth. newspapers being dropped give us glimpses of the past as well as what the future 2 off, food being delivered and of course some people just holds for us. You have a very distinctive getting home from the night style. What made you 7 before. The quietness that the interested in “tilt-shift”? early morning offers always What challenges do you Back in 2006 I was surfing the see cities facing? feels to me like the city is web looking for something to mine and mine alone before Too many people, too much inspire me photographically. everyone else gets to come in. traffic and pollution. In many I happened to stumble of my recent trips I have been upon Olivo Barbieri’s tilt- 5 stuck in the most annoying shift photos of Rome. He Can you share with us a traffic jams. The need for is an Italian photographer city story? better public transportation, specializing in this style. I I was in Mumbai, India in fewer cars in the cities and a figured out how to achieve the 2013 and I was taking my need for cleaner air are things same effect using Photoshop time-sliced photos of the that need to be addressed and not the conventional Gateway to India. When I do sooner rather than later. tilt-shift lens. I have been tilt- my time-sliced photos, I stand Cities are bursting at their shifting every place I travel to in the same place for about an seams— all at the expense since then. hour and a half just clicking of health and in my opinion happiness. 3 away during sunset. I become a sort of a fixture. Sometimes, You live in the heart of one 8 of the most vibrant cities a few people might ask me what I am doing but in What made you interested in the world—how does in working on this cities Mumbai everyone asked me. New York influence you? initiative? People were telling me stories Almost everything in this Being asked to collaborate Richard Silver Photos: of how they would bring city can be photographed on this project is a highlight p.14, New York their families here to watch p.16, London and done differently by each in my photographic career. the sunset or get together to p.18, Shanghai photographer. I concentrate When I think of UNAIDS catch up on things. There was p.22, Paris my energies mostly towards and the art world, Keith p.23, New York such curiosity, friendliness the architectural aspects of Haring is what comes to my p.32-33, Rio de Janeiro and openness—it made me New York. Over the past few mind immediately as I am a p.36-37, Tokyo feel so special. years I figured out a new huge fan of his work. I take style of photographing called 6 pride in being able to say “time-sliced”. I photograph that my photography will be What is the best thing iconic buildings at sundown associated with an artist such about cities? and slice the photos together as Keith Haring. If my work Cities offer diversity. You to make one single image. I can help in the fight against can go to almost any major use approximately 30 different AIDS, then I am all in for city in the world and you images taken over a course that fight. of 1.5 hours to complete the will find the mix of old image. Only a city such as and new architecture, all New York could give me the different kinds of people inspiration needed to seek out in all age groups, rich and my personal style. poor working together along with vast varieties of transportation. Cities also
The Cities Report 33 SPECIAL SECTION
building foundations TRANSFORMING CITIES starts with lessons learned
34 The Cities Report BUILDING FOUNDATIONS
track their HIV epidemics, map where interventions are lacking, and plot How AIDS responses the provision of quality services and medicines to the people who need them. can help change cities They have been able to solicit and make productive use of technical support. And they have carefully monitored and for the better assessed their efforts, and adjusted or Making the most of cities’ advantages requires discarded elements that did not work. tackling some of the challenges they face, including poverty and overcrowding, insecurity, and the No such thing as impossible: some lessons breakdown or lack of basic services. The many from the HIV response for benefits that cities offer are also not distributed transforming cities equitably, sometimes to distressing degrees. Go to the roots of the challenge. Inclusiveness and equity do not yet define many AIDS responses show that the most effective and cost-efficient way to of the world’s cities. safeguard people’s health is to enable them to protect themselves against infection and ill health. This approach works best when factors like social and economic inequity and marginalization are also addressed. ities that have been successful in reversing their AIDS Make resources reach further. epidemics have used With creative methods, it is possible approaches that empower to provide vital, ostensibly challenging Cand respect the rights of affected services—such as HIV treatment—on communities, tackle discrimination, a massive scale in all kinds of settings address violence and exclusion, without overwhelming systems. strengthen accountability, and put Providing HIV treatment services at equity centre stage. They local health facilities and delegating have found the courage to change certain tasks to nurses and community regulations or enact by-laws to facilitate health workers rebooted the global HIV evidence-informed public health treatment effort. programmes. Cities have realized that the most effective actions prioritize Tap the power of participation. the rights and needs of residents, Inclusive and participatory HIV irrespective of their legal status or programmes tend to be the most entitlements. They also recognized that successful, especially in reaching the efforts had to fit with the realities marginalized populations. When of people’s lives, which led them to try programmes genuinely involve affected innovative ways to support and harness communities, they become more robust community participation. Sometimes and acceptable. They are more likely simple alternatives, such as changing to fit people’s actual circumstances and clinics’ opening hours, have led to needs, accountability is stronger, and the dramatic improvements. results tend to improve.
Successful programmes have drawn on Diversify funding. the knowledge, energy and networks Negotiating predictable flows of funding of affected communities and other and drawing them from a range of stakeholders, rather than operating in sources provides the fiscal security that a top-down fashion. They have linked multi-year strategies require and makes and collaborated with nongovernmental it easier to take the creative risks that and community organizations, and can lead to new breakthroughs. with academic institutions. This has enabled them to tap the problem- solving creativity that is intrinsic to life in dynamic and growing cities, and to experiment with new methods to
The Cities Report 35 Successful programmes have drawn on the knowledge, energy and networks of affected communities and other stakeholders, rather than operating in a top-down fashion. 1 Million people accessing antiretroviral therapy globally in 2003 13.6 million people accessing antiretroviral therapy globally in June 2014
Collect and use health and HIV prevention, treatment, accurate information. care and support services. Cities can use Accurate and up-to-date understandings protective by-laws and regulations, and of where HIV infections are occurring engage with communities to advance in cities, who needs and is able to rights-based responses to HIV. access essential services, and where shortages or overstocks of medicines, Link services for greater impact. commodities or staff are occurring Linking or integrating essential services are the cornerstones of successful can make it easier, less time-consuming AIDS responses. and more attractive for people to use them. When linked, tuberculosis and Keep people’s rights HIV services show good results. centre-stage. Linking HIV with harm reduction A human rights-based approach is services for treating drug dependence essential for AIDS responses, for both is proving highly effective, as is the principled and pragmatic reasons. integration of HIV services with Coercive or discriminatory approaches primary health care and with sexual violate fundamental human rights and reproductive health services. norms, and they drive people away from
36 The Cities Report Make essential services easier Use basic technologies creatively. and more affordable to use. The expansion of HIV treatment has HIV programmes prove that it meant finding ways to avoid sudden is possible to make high-quality stock-outs of HIV test kits and medicines and services widely available, medicines. Procurement, distribution affordable and easy to use, even in and stock management systems have trying circumstances. This is being been overhauled to quickly react done by transforming health financing to changing conditions. A special systems, streamlining procurement and application enables patients and health supply management systems without workers to use their mobile phones compromising on quality, negotiating to alert health officials to actual or price cuts with corporations, and potential shortages of HIV medicines. developing simpler drug treatments Mobile phone reminders are also being and monitoring methods. As a result, used to support adherence to treatment. the number of people receiving Not only does this improve HIV antiretroviral therapy globally soared treatment, it creates new channels of within a decade from less than 1 million accountability between citizens and the in 2003 to almost 13 million in 2013. state that bring quick gains to all sides. ■
The Cities Report 37 Cultural Icons AIDS in popular culture—works that changed the response forever
1 |
1 | The Keiskamma Altarpiece being thrown out by unseen lovers from a 3 | The AIDS Memorial Quilt South Africa hotel, while children turn this detritus of United States Created by a group of 130 women in the AIDS prevention work into toy balloons. Photo: The AIDS Names Project Eastern Cape province of South Africa, the It is a commentary about changing culture In June of 1987, a small group of strangers Keiskamma Altarpiece is a message of hope and sexual habits in Kinshasa. Mr Samba, gathered in a San Francisco storefront to for people living with HIV. The Altarpiece a leading contemporary African painter, document the lives they feared history would is composed of images of members of stated, “My art is part and parcel of my neglect. Their goal was to create a memorial the Hamburg community in the Eastern environment. It draws its inspiration from for loved ones who had died of AIDS, and Cape province of South Africa. Part of the the people, it is concerned with the people, to help people understand the devastating grandeur of the artwork is its scale, as well as and it is meant for them.” impact of the disease. The NAMES Project the ingenuity of its stitchery and beadwork. AIDS Memorial Quilt was created and in The Keiskamma Altarpiece was brought 1987 the Quilt was displayed for the first time to international attention by the curatorial on the National Mall in Washington DC. team of MAKE ART/STOP AIDS at the XVI Over the years the Quilt has grown to 1.3 International AIDS Conference in Toronto, million square feet and said to be the largest Canada, August 2006. piece of community folk art in the world.
2 | Les Capotes Utilisées Today the Quilt is a powerful visual Democratic Republic of the Congo reminder of the AIDS pandemic. More than Cheri Samba’s paintings reveal his perception 48,000 individual 3-by-6-foot memorial of the social, political, economic and cultural panels—most commemorating the life of realities of his country. Condoms were 2 | someone who has died of AIDS—have introduced on a massive scale in Kinshasa been sewn together by friends, lovers and in the late 1980s. The painting, Les Capotes family members. Utilisées (1990) shows several condoms
38 The Cities Report 8 |
3 | 8 |
4 | And the Band Played On: the theme of Mother Teresa, a mother and by many of Brazil’s megacities. The film also Politics, People and the AIDS Epidemic child are shown together—symbolizing the depicts the experience of AIDS in prison, Written by San Francisco Chronicle hope that exists in the response to AIDS. and the unique journalist Randy Shilts, And the Band Played meeting place of the On chronicles the discovery and spread of 6 | Philadelphia Doctor’s infirmary as HIV. An international bestseller, a nominee United States a means to explore a for the National Book Critics Circle Award, Philadelphia, an American drama, was one panorama of human and made into a critically acclaimed movie, of the first mainstream Hollywood films histories, compassion the book went beyond the headlines to to acknowledge HIV, homosexuality and and injustice. The investigate the social and scientific aspects homophobia. The film follows Beckett, a film was directed by of the disease. young lawyer at a high- Hector Babenco and Openly gay, Mr profile law firm. He is gay written by Babenco, Shilts refused to and has HIV. When his Fernando Bonassi, accept HIV as law firm discovers the Victor Navas and what was then news, he is fired. Beckett Dráuzio Varella. labeled a ‘gay wants to sue, but has disease’, and trouble finding a lawyer 8 | Street Art through his work to take his case. What Since the 1980s, street art has become a he demonstrated follows is a powerful tale popular medium for artists to communicate the effects of the of Beckett's legal, medical directly with the public at large, outside the inequities and and emotional journey. confines of the formal art world. There exists stigma against The film was shot in Philadelphia, United a strong current of activism and subversion people living with States, an early centre for AIDS activism, and in urban street art, which can act as a HIV. Mr Shilts was tested for HIV while employed approximately 50 people living powerful platform for political expression and he was writing the book; he died of with HIV as extras in the film. Philadelphia provocation for public discussion and self- complications from AIDS was written by Ron Nyswaner, directed by reflection. The origins of the modern street in 1994. Jonathan Demme and starred Tom Hanks art movement can be traced back to New and Denzel Washington.The film is credited York City’s graffiti boom of the 1980s, led by 5 | Mother Theresa with changing the national dialogue around artists such as Keith Haring and Jean-Michel India HIV by helping to foster more honest and Basquiat; the same era in which many young One of India’s best known artists, Maqbool accurate public awareness of the epidemic. artists battled the emerging HIV epidemic. Fida Husain Alongside Keith Haring (who died of AIDS in was born in 7 | Carandiru 1990), David Wojnarowicz (who died of AIDS 1915. Known Brazil in 1992) was among the pioneers to utilize for his emphatic The film Carandiru is inspired street art to combat conservative attitudes understanding by the real-life experience towards the epidemic and express his own of the human of Dr Drauzio Varella, a despair and rage as a young man dying of condition, Mr doctor supervising an AIDS- AIDS. In recent years, urban artists around Husain did not awareness programme in one the world have increasingly embraced the shy away from of Latin America’s largest medium of street art in the form of murals, controversy— and most notorious prisons. performances and installations, particularly in from oil on canvas Built to house 3000 inmates, times of political and social turmoil. to documentaries Caradiru had more than 7000. and performance Violence, abuse and injecting art installations. In drug use ensued. The film one of a series of puts a human face on the paintings around violence and lawlessness faced
The Cities Report 39 CITIES ARE leading the way city profiles 12 CITIES IN 24 PAGES Bangkok | Dakar | eThekwini (Durban) | Kingston | Melbourne | Mumbai Nairobi | New York | Paris | Quezon City | San Francisco | São Paulo
The Cities Report 41 CITY | BANGKOK
Bangkok
Bangkok
Strong partnerships are at the heart of the city’s achievements in the AIDS response.
Bangkok’s innovative response to its AIDS epidemic is multisectoral, Strong, flexible partnerships integrating information and health services for people most at risk while tackling stigma at its roots. are at the heart of the city’s HIV achievements. OVERVIEW OF THE HIV EPIDEMIC Longstanding collaborations with academic and research pproximately one quarter of new HIV infections in Thailand occur in Bangkok. As is common in the Asian region men who have sex with men, sex workers institutions have been and people who inject drugs are most affected. The city’s epidemic grew rapidly crucial, providing a strong A in the 1980s, as large numbers of sex workers and their male clients acquired information and evidence HIV. The 100% condom programme implemented throughout Thailand in the base for projects. 1990s, hailed as one of the most successful programmes of its time, had a significant impact on the epidemic in Bangkok. Continued rigorous efforts of the Bangkok Metropolitan Administration, the Ministry of Public Health and NGOs in the city have brought down the number of new HIV infections to fewer than 1900 per year and rates continue to decrease.
42 The Cities Report CITY | BANGKOK Bangkok
that uses social media to encourage men who have THE AIDS RESPONSE DID YOU KNOW? sex with men to take HIV tests and access other HIV Famous for its vibrant entertainment, shopping Bangkok’s AIDS strategy aims prevention and treatment and other tourist attractions, to end the city’s epidemic services. Set up two years Bangkok is one of the most by 2030. The Bangkok ago, GAYBKK already has populous cities in south-east Metropolitan Administration more than 20 000 members. Asia. Known as the city of (BMA) manages the strategy, Civil society partners have GOVERNOR happiness, Bangkok extends in close partnership with designed internet cafes as OF BANGKOK over an area of 1500 square the Ministry of Public safe spaces that offer friendly kilometres and boasts the Health, the private sector, entry points for HIV services. longest name of any city in civil society and community “As the Governor of Bangkok, the world, Krung Thep organizations, academia and I have the responsibility for Maha Nakhon. Bangkok is international organizations. the well-being of the people among the first cities in the
of Bangkok. I am concerned world to offer transgender In addition to tracking the that HIV continues to public toilets. epidemic’s evolution and impact adversely on the city’s providing a range of HIV economy, society, public prevention services, the health and human resources, strategy includes efforts and I am committed to to monitor stigma and ending the AIDS epidemic WHY THIS CITY discrimination. A sexuality by 2030. I am confident that IS MAKING A education programme for city through the dedication and DIFFERENCE schools helps students learn collaboration of all sectors about sexual diversity, gender of society, with innovation issues and HIV. Bangkok’s and optimization of action, health facilities, the BMA’s As one of the key locations of Thailand’s HIV epidemic, our target to end AIDS can hospitals and community be achieved, thus helping health centres are being Bangkok’s response is crucial to reaching the Bangkok to be a healthier transformed into one-stop city and a desirable place to shops that offer HIV services national goal of ending AIDS by 2030. Strong, live that offers quality of life such as counselling and and happiness for its citizens. testing as part of the standard flexible partnerships are at the heart of the city’s HIV We hope that with strong health screening package. partnership and dedicated Bangkok, in line with the rest achievements. Longstanding collaborations with academic effort by all sectors, we shall of Thailand, has introduced be able to end AIDS by universal health care for Thai and research institutions have been crucial, providing 2030. We are confident that residents and its substantial together, we can.” migrant population. a strong information and evidence base for projects. Increasingly, services for Mom Rajawongse key affected populations are By “knowing its epidemic”, Bangkok has been able to Sukhumbhand Paripatra, being integrated into regular Governor services. BMA’s community focus its resources more mobile clinics provide after- effectively to reach most hours outreach services. Civil affected populations. Progress society entities including: has been impressive: new Thai Red Cross, SWING, HIV infections have fallen by Rainbow Sky and PSI, further 69% since 2000. Almost 90% complement these efforts of women living with HIV with community-based in Bangkok were accessing information and services. services for preventing There is a special focus on mother-to-child transmission reaching men who have sex of HIV in 2013. with men with an effective HIV response. The BMA has set up a GAYBKK club
The Cities Report 43 CITY | DAKAR
Dakar
Dakar
The city is accelerating progress towards achieving the Abuja+12 commitments.
With a national response based on bold commitments and investments, Dakar, In 2013, 18% of all pregnant Senegal, is keeping HIV prevalence low and leaving no one behind. women in the country were OVERVIEW OF THE HIV EPIDEMIC screened in Dakar. Of all the pregnant women living with akar, the capital of Senegal, is located on a peninsula that covers less than HIV nationwide, 15% were 1% landmass of the country but is home to 23.2% of its population. Dakar is an industrial city and characterized by a large migrant population with 5739 diagnosed in the city. D inhabitants per square kilometre, compared with the average country density of 65 inhabitants.
Although the city’s HIV prevalence is lower than the national average, 44% of those on antiretroviral therapy in Senegal receive their treatment in Dakar. The HIV burden is higher among the city’s key populations. Overall HIV prevalence in Dakar has been low and continues to decline from 0.6% in 2005 down to 0.4% in 2010-2011. New HIV infections in Senegal have declined by about 60% between 2001 and 2013.
44 The Cities Report CITY | DAKAR Dakar
sector remains limited and stigma at treatment centres DID YOU KNOW? WHY THIS CITY persists. We hope that by IS MAKING A 2015 the incidence of HIV Dakar has the best-equipped DIFFERENCE will decrease by 50% and network of health facilities its impact on individuals, in Senegal. However, more families and communities will needs to be done with Dakar has all the country’s be reduced. We also hope that respect to social support referral care facilities. Of the vision of the 2014–2017 for impoverished and THE AIDS RESPONSE the 25 hospitals in the national strategic plan will vulnerable populations. country, just under half end the AIDS epidemic are located in Dakar. The by 2030 with the Dakar The 2011–2015 national city administration is the Mayor’s Office central in its strategy aims to reduce the principal source of funding implementation.” rate of new HIV infections by for these facilities and 50% and providing treatment covers almost all of the Khalifa Ababacar Sall, Mayor for 80% of people living with administrative costs. HIV. The key programmes include: the prevention of All public health facilities in mother-to-child transmission Dakar offer HIV counselling of HIV; treatment, care and and testing services at all support for people living levels, including counselling with HIV; surveillance of centres for adolescents that HIV infection; safe blood render services for young transfusions; and HIV testing people and pregnant women. and counselling. HIV services are decentralized to district levels across all regions in the country.
In addition to integrating prevention of sexual HIV transmission in educational programmes, Dakar has put a focus on the prevention of new infections among MAYOR OF DAKAR children. One quarter of all pregnant women living with HIV in Senegal receive HIV “Among our key treatment and care in Dakar. achievements, communication for behavior change and participatory approaches to prevention interventions, have been focused on and integrated into education programmes. The implementation of the prevention of sexual transmission programme has contributed to a significant reduction in new infections. But workplace and targeted programmes for mobile populations have not adequately reached the required scale. Participation of the private
The Cities Report 45 CITY | ETHEKWINI (DURBAN)
eThekwini (Durban)
eThekwini (Durban)
The city is focusing on changing sexual behaviour as means for reducing HIV incidence.
Changing sexual behaviour is seen as one of the most effective ways to reduce new eThekwini aims to reduce HIV infections in the busy South African port city. new HIV infections to less OVERVIEW OF THE HIV EPIDEMIC than 1% and to reduce AIDS-related morbidity national survey in 2012, among pregnant women who went for antenatal care and mortality by 2016. services, estimated HIV prevalence in eThekwini at 39%, the third highest in South Africa. In the same year, the national population-based survey showed A that adults living in informal settlements were more likely to be HIV-positive than people living in formal areas. The survey also estimated that, of the adults who had sex in the preceding 12 months, 15% had multiple sexual partners. The city is also characterized by a high tuberculosis burden with a 70% tuberculosis/HIV co-infection rate. HIV prevalence among men who have sex with men in eThekwini is particularly high at 48%.
46 The Cities Report CITY | ETHEKWINI (DURBAN) eThekwini (Durban)
encourages the exchange of information, experience DID YOU KNOW? and best practices on urban development and city eThekwini is the second management to enhance most populous city in South good governance. eThekwini’s Africa after the Greater mayor signed the Alliance Johannesburg metropolitan of Mayors' Initiative for area and the largest city in Community Action on KwaZulu-Natal. Some 50% THE AIDS RESPONSE AIDS at the Local Level MAYOR OF ETHEKWINI of the city area is used for (AMICALL), reflecting the subsistence farming and only importance of locally led, 2% for urban settlement. The eThekwini is working to multisectoral action that “Providing access to city’s population of about ensure that HIV treatment complements supportive antiretroviral therapy for 3.44 million is predominantly and services are accessible national policies. women living with HIV young, with 66% under the in the areas with the highest has significantly reduced age of 35. HIV burden. The city is mother-to-child transmission, committed to eliminate which currently stands at less After Johannesburg, new HIV infections among WHY THIS CITY than 1%. This means virtual eThekwini is the second children and do more to reach IS MAKING A elimination is a reality for most important key populations including sex DIFFERENCE our city. Progress has been manufacturing hub in workers, taxi drivers, truckers dramatic in scaling up access South Africa, and its and men who have sex with to antiretroviral treatment.” harbour is Africa’s busiest men. Services are provided eThekwini has made strong port. Manufacturing, via fixed and mobile clinics. advances in several aspects James Nxumalo, tourism, finance and of its HIV and tuberculosis Mayor, eThekwini transport are the four The city is also focused on response. Condom largest economic sectors. young people in schools and distribution doubled between universities. HIV prevention 2012 and 2014. At the end of Well-established circular initiatives such as First things March 2014, 271 000 people migration patterns have First and Graduate Alive, were receiving antiretroviral contributed to population offer voluntary medical therapy (ART) which is growth. The largest source male circumcision, condom 32% of all ART provided in of migrants to eThekwini is distribution, family planning KwaZulu-Natal province. from outside the country, with and HIV treatment. Condom 15% of these migrants living distribution is an integral part According to the eThekwini in informal settlements. The of the city’s HIV prevention District Health Barometer, proportion of the population strategy; in 2013, 18 million tuberculosis incidence living in informal settlements is male condoms and 3.2 decreased from 1155 per estimated at 33%. million female condoms 100 000 in 2012 to 1032 in were distributed. 2013. However, it was still the fourth highest in the country. As in the rest of the province, The tuberculosis treatment the city runs Operation success rate (all tuberculosis) Sukuma Sakhe programme, increased annually from which means ‘stand up and 63.1% in 2009 to 78.3% in build’. This programme 2012. This is lower than the tackles a range of problems, national target of 85%. Of including: food security; the tuberculosis patients who disease and infection, most started tuberculosis treatment notably HIV and tuberculosis; in 2013, HIV status was disempowerment of women known in 83%. Some 56% of and youth; poverty; violence the HIV-positive tuberculosis against women and girls; patients were recorded to be teenage pregnancy; substance accessing ART. abuse; crime; and motor vehicle accidents. eThekwini is part of the South African Cities Network (SACN) that
The Cities Report 47 CITY | KINGSTON
Kingston
Kingston
The city’s public campaigns are helping to prevent new HIV infections.
Challenges remain but the city is determined to engage, inform and empower Kingston has 10 out of 21 its citizens to reduce new HIV infections. treatment sites in Jamaica OVERVIEW OF THE HIV EPIDEMIC and plays an essential role in treating and caring for people ingston has come a long way since the first AIDS-related death was recorded in living with HIV. 1982. One third of the country’s 30 265 people living with HIV were diagnosed in the Kingston metropolitan area, although only 7500 are estimated to reside in K the capital. In Kingston, the majority of people newly diagnosed with HIV have an HIV-related illness or disease, indicating late diagnosis.
According to Ministry of Health estimates, in 2013 HIV prevalence among the homeless and people who inject drugs was at 4% and among prison inmates was at 9%. Data for female sex workers and men who have sex with men is incomplete but it is estimated to stand at 4% and 32% respectively.
The government’s financial contribution is increasing but the response effort remains under-resourced and highly dependent on funding from external sources.
48 The Cities Report CITY | KINGSTON Kingston
WHY THIS CITY DID YOU KNOW? IS MAKING A Jamaica’s dancehall culture, DIFFERENCE sports, drama and faith- based activities have been used to support radio, TV The national HIV programme and print campaigns to utilizes an evidence-based disseminate key messages approach. Consequently, THE AIDS RESPONSE MAYOR OF KINGSTON on HIV and increase condom there is greater investment of usage. Campaigns—such as resources in the city and other ‘Smart Women Always Buy, Since 2005, when a national parishes with the highest “Key challenges include the Carry and Use Condoms’ HIV policy was developed, HIV burden. Additionally, relative low rate of economic and ‘Hold On, Hold Off’ foster Kingston has provided HIV programmes are growth, high unemployment local and national discussions political leadership to address primarily coordinated levels, early sexual debut about HIV. gender equality and human from Kingston, where the of young girls and stigma, rights, charting the course for support of nongovernmental including self-stigma. In an enabling environment and organizations and some communities, a macho greater involvement of people international partners is culture reinforces negative living with HIV. strongest. Kingston has 10 behaviour choices. Jamaicans out of 21 treatment sites in are also uncomfortable Investment in the HIV Jamaica and plays an essential speaking openly about sex response is aligned with the role in treating and caring for and sexual health. Our geographic burden of the people with HIV. The city has youth are not sufficiently epidemic. However this has hosted multiple discussions informed and empowered not necessarily focused on on human rights, including to articulate their position, the most affected population parliamentary hearings on negotiate for self-protection groups. This is changing as the Sexual Offences Act, or to provide peer education. more data has been gathered. and provided leadership in The more young adults and the Caribbean region for a adolescents are involved, our The Justice for All dialogue on HIV and human public campaigns will lead Programme, led by the rights with conservative to a reduction in [incidence] Sexual Health Agency, faith-based communities. of HIV for generations to aims to address stigma, come. Educated citizens discrimination and legal are enabled to make more reform through consultations rational decisions about the and engagement with importance of protecting parliamentarians, faith-based themselves and their partners. organizations and young I am hopeful we will soon people. A unit working for see a society that will not the greater involvement of perceive HIV as a reason to people living with HIV is discriminate, but a reason to also aiming to reduce embrace and give care. stigma and discrimination We are working assiduously in the workplace. in partnership for a society that is empowered, educated and healthy. The change is on the horizon.”
Angela Brown Burke, Mayor and Senator Councillor
The Cities Report 49 CITY | MELBOURNE
Melbourne
Melbourne
2 | 3 |
The city is a pioneer in harm reduction in the AIDS response
Progressive strategies that include needle and syringe programmes and opioid substitution therapy have led to one of the world’s lowest HIV transmission rates The impact has been clear: among people who inject drugs.
globally, Australia has one of OVERVIEW OF THE HIV EPIDEMIC the lowest transmission rates of HIV among people who f the 307 HIV case notifications in the 12 months prior to July 2014 in the state inject drugs. of Victoria, 75% were men who have sex with men and 2.6% were injecting drug users. More than half of the estimated people living with HIV in Victoria O live in the inner city of the state capital, Melbourne.
50 The Cities Report CITY | MELBOURNE Melbourne
who have sex with men. The centre works closely with DID YOU KNOW? communities, researchers and community-based Melbourne’s scientists have organizations to design been pivotal in developing appropriate programmes, some of the world’s most provide services and innovative biotechnology, community education. In including flu treatment Victoria, 50% of all HIV cases and the bionic ear. Most THE AIDS RESPONSE are diagnosed through these MAYOR OF recently, Melbourne hosted focused services. MELBOURNE the 20th International AIDS Conference, AIDS 2014, Australia's health care system Melbourne is at the forefront bringing together more is funded and administered of treatment as prevention, “The city of Melbourne than 16 000 delegates from by several levels of with the Victorian pre- prides itself on being diverse around the world. government (national, state/ exposure prophylaxis and inclusive in all ways. territory and local) and is demonstration project On behalf of people living supported by private health researching the use of daily with HIV and those at risk insurance arrangements. antiretroviral medication by of acquiring HIV, it is Australia’s national public HIV-negative people at high everyone's responsibility health insurance scheme, risk of infection. to reduce HIV-related Medicare, is funded and stigma and discrimination administered by the and to be a leader in the Australian Government with elimination of HIV.” States. The Australian and WHY THIS CITY Robert Doyle, Lord Mayor state/territory governments IS MAKING A of Melbourne fund and deliver a range DIFFERENCE of other health services including population health programmes, community Australia has been a global health services, health and leader in harm-reduction medical research, Aboriginal strategies, particularly in and Torres Strait Islander the way it has established health services, mental health and expanded needle services, health workforce and exchange and safe disposal health infrastructure. programmes. Melbourne and Sydney have been at the Strategic HIV policy is forefront of these pioneering determined by government efforts, negotiating ways agencies in close consultation around national laws to with community, research open safe injecting rooms. and clinical stakeholders. The impact has been clear: The Victorian AIDS Council globally, Australia has one of is the primary organization the lowest transmission rates responsible for implementing of HIV among people who the national AIDS strategy inject drugs. These strategies in Melbourne and the wider have also led to low rates of state territory. prison-related transmission.
The Melbourne Sexual Health Centre offers sexual and reproductive health services, provides testing, HIV treatment and education. It also offers focused services via a gay-friendly clinic that operates specifically for men
The Cities Report 51 CITY | MUMBAI
Mumbai
Mumbai
The city sees public-private partnerships as key to expanding HIV programmes.
Nongovernmental organizations are leading the city’s response to HIV with innovative The Maharashtra State solutions to the problems of a rapidly changing sex work environment in an environment of stigma and taboo. Commission for Women, a statutory body constituted to OVERVIEW OF THE HIV EPIDEMIC improve the status and dignity of women, now has a reams of a better life bring people from all over India to Mumbai. With more than 18 million inhabitants, Mumbai is the most populous city in India. It policy dedicated to support has one of the highest levels of HIV prevalence in the country. Mumbai has female sex workers and D witnessed a decline in HIV infections among key populations, though rates for transgender people these groups remain substantially higher than the national averages. The biggest change in HIV prevalence was among female sex workers in a period of 8 years— from 54% in 2003 to less than 10% in 2011.
52 The Cities Report CITY | MUMBAI Mumbai
WHY THIS CITY DID YOU KNOW? IS MAKING A The constant struggle for DIFFERENCE living space is one of the biggest social challenges facing Mumbai. However, Actions by health and social from this adversity a strong rights advocates, community housing rights movement THE AIDS RESPONSE stakeholders and people living MAYOR OF MUMBAI has emerged. Various social with HIV have been key to protection programmes overturning legal barriers are available to people Partnership between the and stigma associated with “Health care is a fundamental living with HIV, including public and private sector is HIV. The Maharashtra State necessity: not only for pension programmes, travel one of the key features of Commission for Women, a preventing disease and concessions and free medical the city’s HIV programme. statutory body constituted minimizing its effect, but aid for low-income families. The Mumbai District AIDS to improve the status and most importantly as a central Nutritional and educational Control Society reaches out dignity of women, now has a step to improve a person’s support is also provided in to people at greatest risk, policy dedicated to support well-being and contribution collaboration with community- providing prevention of female sex workers and to society. We are committed based and nongovernmental mother-to-child transgender people. Medical to further improve organizations. transmission services, insurance, biometric smart comprehensive health care workplace programmes cards, women’s collectives and secure universal coverage and services for HIV and and wellness clinics for sex and access to HIV prevention, tuberculosis co-infections. workers are some of the treatment and care services. With policy-makers civil society innovations Our focus is on the vulnerable committed to evidence- supporting Mumbai’s key and socially marginalized, based planning, hospitals, populations at highest risk. including women, children pharmacies, and health and young people.” and maternity clinics are Evidence indicates these providing services for HIV efforts are delivering positive Snehal Ambekar, Mayor prevention, treatment, care results, demonstrated by the and support. decline in HIV prevalence in women attending antenatal care clinics. Seroprevalence trends show that while more women are being tested, the number of positive cases has decreased.
The Cities Report 53 CITY | NAIROBI
Nairobi
Nairobi
Focusing on location and population, the city is able to reach people most affected by the AIDS epidemic.
A diverse range of community partnerships are helping the sprawling metropolis Steep declines in AIDS- meet its complex HIV challenges. related deaths, especially OVERVIEW OF THE HIV EPIDEMIC among women, indicate the programme is making airobi City has the highest burden of HIV in Kenya, with about 180 000 headway in addressing some residents living with HIV. In 2013, Nairobi county had more than 3000 new HIV infections. HIV prevalence in the capital is higher than the national HIV-related gender inequities. N average, with about 8.4% of adult women in the city living with HIV and 5.3% of adult men. HIV infection levels are highest in the city’s slum areas, with women most affected. Girls and young women aged 15–24 years living in the poorest areas are nearly four times more likely to acquire HIV compared with their peers in other parts of the city. Key populations also have a high risk of HIV infection. Nationally, almost one in five men who have sex with men and people who inject drugs are living with HIV, as are almost 30% of female sex workers.
54 The Cities Report CITY | NAIROBI Nairobi
The changing character of Nairobi and its mobile THE AIDS RESPONSE DID YOU KNOW? population provide a complex setting for the Nairobi is an expanding city urban HIV epidemic. that is seen by many as Nairobi has taken important A successful response the economic and cultural steps to control its epidemic. requires close cooperation centre of East Africa. With The city is mapping the areas among stakeholders across a population of 4 million, where HIV infections are traditional city administrative Nairobi generates about 60% reported and at the same boundaries and a strong of Kenya’s total economic time developing estimates on GOVERNOR understanding of a changing OF NAIROBI output. At the same time, the the sizes of key populations. HIV epidemic and city is divided by conspicuous This data is helping to make dynamic environment. inequalities. Nairobi has two it possible to focus HIV “We are proud of the progress of Africa’s three largest slum efforts and bring HIV services we have made in Nairobi areas, Kibera and Mathare, closer to the most affected but we are also aware of the where only a minority of communities. Nairobi is also long way ahead—in getting residents have access to safe part of a major voluntary WHY THIS CITY everyone to know their HIV drinking water and sanitation. medical male circumcision IS MAKING A status, and link people who Nairobi’s population is campaign. The wider Nairobi DIFFERENCE are HIV-positive to the care strikingly diverse. It includes county has expanded access and treatment they need, internal and international to HIV treatment to 92% and for people who test migrants, as well as refugees of adults compared with Nairobi has developed HIV-negative to come back from neighbouring countries. the 79% national coverage, strong capacity to undertake again and be empowered Nairobi is increasingly while treatment for children research and provide HIV to lead a healthy life. We sprawling towards nearby is relatively high (74%) services by building high- are committed to learn towns and villages, effectively compared to 42% national level collaboration between from what has worked, in forming a city-region that average coverage. Projects international and local reaching people, but also encompasses smaller to empower women institutions. There has been in ensuring people’s rights, neighbours, such as the economically and provide a special focus in the Kenyan especially those living with urban areas of Thika, Athi cash transfers for orphans capital on strengthening HIV HIV, women and young girls River, Machakos and Kiambu. and other at-risk children programme leadership and management. Quality and and those most vulnerable. aim to reduce people’s As a city, we respond to the vulnerability to HIV. sustainable HIV services have been linked with HIV epidemic to support our citizens, but we also use A diverse range of programmes for preventing and treating tuberculosis, and the response to HIV to drive community partnerships change on gender inequality, complement government with reproductive health and family planning. Although human rights, and economic efforts: the Oxfam/Concern growth. Kenya has achieved Worldwide Nairobi Urban health-care services are limited in the slum areas, significant milestones since Social Protection Programme the first cases of HIV were supports food and livelihood residents have benefited from the scale-up of HIV diagnosed. We have witnessed security in slums by providing our response saving many cash transfers and skills treatment. Steep declines of AIDS-related deaths among lives, from as high as 700 training to more than 5 000 people dying daily due to households; the Mathare women can be seen as an indicator that the programme AIDS-related complications, Youth Sports Association to fewer than 150 AIDS- links sport with HIV is addressing HIV-related gender inequities. Evidence- related deaths today. The through its Football for Hope AIDS response has delivered programme; and young based programmes, combined with the capacity and strengthened health representatives from services to the residents. Nairobi’s 10 slums meet to deliver HIV services to key population groups, make Today, we know that a lot monthly as part of the Nairobi more can be achieved if we Slum Leaders Assembly to Nairobi’s AIDS response a strong one. provide political leadership discuss issues of concern and and commitment to to formulate community- technical solutions.” based responses. Evans Kidero, Governor, Nairobi City County
The Cities Report 55 CITY | NEW YORK
New York
New York
The city has committed to “Bend the Curve” and move to end the AIDS epidemic in New York State by 2020.
Since 1981 New York City has been at the centre of the United States HIV epidemic. In 2014, Governor Andrew New York has also been a leader in the AIDS response. Cuomo announced a OVERVIEW OF THE HIV EPIDEMIC three-point plan called “Bending the Curve”, which t is estimated that nearly 3000 residents of New York City will newly acquire HIV aims to bring HIV rates in in 2014, which is significantly lower than the 14 000 new HIV infections the city faced in 1993. In 2012 an estimated 114 926 people were living with HIV in New New York State and City below I York with more than half accessing antiretroviral therapy. From the efforts of epidemic levels by 2020. stakeholders as diverse as activists, health care professionals, human rights groups, city and state officials, New York has created the nation’s most far-reaching and comprehensive safety net for people with HIV and become a model for responding to the epidemic.
56 The Cities Report CITY | NEW YORK New York
In 2014, Governor Andrew Cuomo announced a three- DID YOU KNOW? point plan called “Bending the Curve”, which aims to In the United States, New bring HIV rates in New York York has the highest number State and City below of people living with HIV and epidemic levels by 2020. of people at significant risk The goal is to reduce of acquiring HIV. The city is the number of new HIV well-equipped to address THE AIDS RESPONSE infections each year to 750 MAYOR OF NEW YORK the epidemic because (from the currently estimated of its large network of 3000 per year) by 2020. The committed professionals, New York remains a leader in three-point plan includes: "This [AIDS] crisis continues talented providers and the AIDS response. The early promoting HIV testing; and we have more to do…I'm organized advocates. Also mobilization of the lesbian, linking and retaining people very proud to work with with established community gay, bisexual and transgender living with HIV in care; and Governor Cuomo to provide planning processes, there communities and allies, facilitating access to pre- some measure of security to is an extensive social safety mobilized an unprecedented exposure prophylaxis (PrEP). people struggling with the net that specifically aims to response. It included debilitating effects of HIV- reduce structural barriers and support groups, community- AIDS. We are committed to provide care and treatment based care and support lifting up the most vulnerable for people living with HIV. programmes, risk assessments WHY THIS CITY among us. This is the mark of for HIV transmission and IS MAKING A a compassionate city.” guidelines for safer sex, DIFFERENCE and the first treatments for Bill de Blasio, opportunistic infections. The Mayor of New York city was also a pioneer in the While challenges remain, development and availability New York’s HIV response of antiretroviral therapy, is effective. Multiple from community-based trials factors contribute to HIV to buyers’ clubs to import transmission in a large, medication and treatments diverse city and disparities from other countries. in access to information, to testing and access to Activist coalitions developed healthcare persist. Prevention a sense of urgency in of HIV transmission is the city and government difficult and stigma related to officials, and pharmaceutical HIV and at risk behaviors manufacturers were forced and lifestyles further to respond to the needs complicate New York’s HIV of people living with and response. Scaling-up HIV at risk for HIV. Advocates services to provide 100% also mobilized support access to treatment, care for funding, innovations and support, as well as in research, and approval effectively addressing the processes to deliver early social drivers of the epidemic, access to experimental will be a substantial and treatments. New Yorkers complicated undertaking. fought for the protection of the human rights of people living with HIV, and pushed for anti-discrimination laws to prevent evictions, employment harassment, and personal attacks.
The Cities Report 57 CITY | PARIS
Paris
Paris
The city’s HIV response has not been limited to city limits.
Paris has been at the forefront of the response to HIV since the beginning of the epidemic, through the work of service organizations, activists, political leaders More than 50 000 people and scientists.
receive medical care and OVERVIEW OF THE HIV EPIDEMIC 500 000 people benefit from action focused aris is the French city most affected by HIV. The prevalence of people living on HIV prevention, with HIV in the capital is much higher than the national average, according to awareness and testing. the latest statistics from the Institut de Veille Sanitaire. In recent years (2009- P 2013), approximately 1200 Parisians annually have been diagnosed with HIV, that figure has remained stable with no significant increases. Among people living with HIV in Paris, 78% are aged 25 to 49 years, 9% are under 25 years and 13% are 50 years or older. Women represent one-third of all people living with HIV in Paris and almost all contracted HIV through heterosexual sex. Most males (65%) who contracted HIV in Paris are men who have sex with men.
58 The Cities Report CITY | PARIS Paris
WHY THIS CITY DID YOU KNOW? IS MAKING A Paris relies on a highly DIFFERENCE developed network of associations that work with populations at higher risk The response of Paris to the and are based in areas close AIDS epidemic is not limited to people most affected THE AIDS RESPONSE to the city but includes MAYOR OF PARIS by HIV. The dedicated support for projects in associations are a source for countries with high rates of innovation for more efficient Paris operates information HIV prevalence. Since 2001, "The economic crisis responses to HIV. The centres for the testing more than 22 million Euros worsens the vulnerability networks operate across the and diagnosis of sexually have been allocated to and insecurity of people health-care spectrum, from transmitted infections. These French associations, affected by HIV and causes HIV prevention to patient centres make it possible for civil societies and non- difficulties in access to care. monitoring, including testing everyone to know their HIV governmental organizations The City of Paris wants to and initial treatment, in and hepatitis serostatus. for HIV work. More than make every effort to fight coordination with the City The City of Paris plans to 50 000 people receive against social inequalities of Paris and hospital develop sexual health centres medical care and 500 000 in health. At the global services. This work is a offering holistic care, from people benefit from action level, elected officials can be key leverage point for health promotion to patient focused on HIV prevention, key players in the response successfully achieving the monitoring. The new centres awareness and testing. to HIV, towards further ambitious goal to end the will also provide information stabilizing the epidemic and AIDS epidemic in Paris. services, testing and initial ultimately eradicating the treatment, in particular for disease permanently. Paris key populations. Studies in has made ambitious political the city have confirmed the commitments endorsed by need for more effective HIV the Paris Declaration on prevention programmes for AIDS. So long as the response men who have sex with men. to HIV needs to continue, we have no right to let our political will falter!”
Anne Hidalgo, Mayor of Paris
The Cities Report 59 CITY | QUEZON CITY
Quezon City
Quezon City
2 | 3 |
The city is focusing on local investment and innovation for a successful AIDS response.
After-hours health clinics and a peer education drive have led to an impressive increase The 2011 Quezon City in the uptake of HIV services. Investment Plan for AIDS lays OVERVIEW OF THE HIV EPIDEMIC out a five-year plan, which aims to reach 80–90% of key uezon City, with a population of 2.76 million, accounts for a significant populations with prevention proportion of the HIV epidemic in the Philippines, with a total population of about 95 million. Since 2007 there has been an upwards trend of HIV coverage annually by 2015. infections among men who have sex with men. HIV prevalence in this group Q increased from under 1% to nearly 7%.
60 The Cities Report CITY | QUEZON CITY Quezon City
terms. Of the people tested by peer educators in the DID YOU KNOW? field, fewer than 50% go back to the facilities for Under the leadership of its treatment; to counter this, mayor Herbert Bautista, the satellite treatment hubs are Quezon City government has being established. worked with local landowners and the private sector to undertake an ambitious THE AIDS RESPONSE MAYOR OF housing programme. The
WHY THIS CITY QUEZON CITY government purchased land IS MAKING A and managed the building of Quezon City has taken strong DIFFERENCE affordable, decent housing for and bold action to understand “Quezon City is unrelenting informal settlers and poorer and respond to its epidemic. in its effort to pursue and residents. In the third stage of Advocacy linked to strategic In response to the evidence sustain its programme of the programme, more than information has led to presented in the Integrated zero new infections, zero 1000 housing units have increasing local investment, HIV Behavioural and discrimination and zero been built. with city administrators Serological Surveillance AIDS-related deaths. Our leading and funding the HIV (IHBSS), Quezon City is governance mantra is to In recognition of its response. The 2011 Quezon taking intensive action to respond and invest in achievements in the response City Investment Plan for scale up its HIV response programmes to address this to HIV, the Quezon City AIDS aims to reach 80–90% for key populations. A health issue rather than government received the of key populations with local investment planning turn a blind eye to this stark Philippines’ Galing Pook HIV prevention coverage was undertaken with reality. We remain committed award for outstanding annually by 2015. stakeholders, including to providing preventive local governance in 2014 international partners. intervention, treatment, for its socialized housing The Sundown Clinic is care and counselling to programmes and the perhaps the city’s most The response is being ensure our patients receive pioneering sundown clinic. innovative programme. In rolled-out and it is already a better quality of life.” response to a significant showing an increase in the increase in HIV infections uptake of services. More than Herbert M Bautista, among men who have double the number of men Mayor of Quezon City sex with men, the city who have sex with men are established a community being reached. clinic that operates from the afternoon until late at night to enable people to attend after work. The clinic, Kilinka Bernardo, is a comprehensive sexual health-care clinic that provides testing, counselling and treatment for HIV and sexually transmitted infections.
To localize its peer education programme, the city has hired 20 educators who work at night providing outreach, counselling and testing. Access to HIV related information is now offered online, enabling people to access information in private and on their own
The Cities Report 61 CITY | SAN FRANCISCO
San Francisco
San Francisco
The city is on track to end its AIDS epidemic by 2030.
During the 1980s HIV took a particularly heavy toll on San Francisco. But the city has come back even stronger by investing in HIV treatment, research, education and The city was a pioneer of the community support.
test-and-treat strategy and has OVERVIEW OF THE HIV EPIDEMIC set up a programme to help people access treatment on the n the early 1980s San Francisco was at the centre of the HIV epidemic in the day of diagnosis. United States. HIV affected its large gay community, with studies suggesting that up to 51% of gay men were living with HIV. At that time, life expectancy I of people admitted to the hospital with AIDS-related illness was measured in months. There were few treatment options and family, friends and clinicians often watched helplessly as young men and women died from pneumonia, encephalitis and other AIDS-related illnesses. As of 2010, more than 19 000 had died from AIDS-related causes and thousands more are living with HIV.
62 The Cities Report CITY | SAN FRANCISCO San Francisco
THE AIDS RESPONSE DID YOU KNOW?
“We are in a new era in the HIV epidemic. We are moving San Francisco today is towards the end of the AIDS almost unrecognizable to epidemic,” said Diane Havlir, people who lived through MD, Professor of Medicine at the HIV epidemic during the University of California and the 1980s and early 1990s. MAYOR OF chief of HIV at San Francisco Through an aggressive home- WHY THIS CITY SAN FRANCISCO General Hospital. “We’re grown response, citizens IS MAKING A talking about San Francisco developed what is known as DIFFERENCE reducing new HIV infections the ‘San Francisco model’, a “Building upon the by 90% in 2020.” comprehensive grass-roots Through these efforts, San tremendous leadership of response, where a variety Francisco halved the number [US House of Representatives of HIV services were often of new infections between Minority Leader] Nancy found under one roof. When 2004 and 2011, and now Pelosi in Congress on the antiretroviral therapy became reports about 350 new cases reauthorization of the available, San Francisco per year. The city hopes Ryan White Care Act, San embraced it as a life-saving to trim that number by a Francisco will continue to intervention. Clinicians, further 25% this year. It has sustain investments in HIV researchers, public health set its sights on becoming and AIDS care and treatment. officials and the community the first city to end AIDS in Despite continued historic led efforts to improve HIV which diagnosis, treatment budget challenges, we remain treatment and prevention in and outreach services, such committed to funding critical the city and beyond. They as housing, substance abuse care services for those living worked together to establish counselling and mental health with HIV in San Francisco.” a continuum of care, from counselling, are integrated diagnosis to successful under one umbrella of care. Edwin M Lee, treatment for the estimated 16 Mayor of San Francisco 000 people living with HIV in 2013, many of whom are aged 50 years and older. Through the many testing centres and clinics set up throughout the city by the government, HIV is consistently detected in its earlier stages. This makes it more treatable, keeps people healthier and significantly reduces transmission. The city was a pioneer of the `test- and-treat’ strategy and has set up a programme to help people access treatment on the day of HIV diagnosis.
The Cities Report 63 CITY | SÃO PAULO
São Paulo
São Paulo
3 |
Working in partnerships the city aims to ensure stigma-free access to healthcare.
Latin America's largest city responds to HIV with innovative collaborations São Paulo boasts one of the at national, state and municipal levels. first clinics for transgender OVERVIEW OF THE HIV EPIDEMIC people in Brazil, providing holistic and stigma-free ao São Paulo, the centre of the HIV epidemic in Brazil, had the first case in health care. the country identified in 1980. From 1980 to 2013 there were 89 270 HIV cases reported, almost 20% of all cases in the country. S In São Paulo, the rate of HIV diagnosis declined to 24.1 cases per 100 000 inhabitants in 2012 from 35.5 per 100 000 in 2000. The number of AIDS-related deaths also declined, from 1379 deaths in 2000 to 796 in 2012. As is the case throughout Brazil, key populations are the most affected by the epidemic. HIV prevalence among men who have sex with men was estimated at 15% in 2012.
64 The Cities Report CITY | SÃO PAULO São Paulo
DID YOU KNOW? WHY THIS CITY IS MAKING A With almost 12 million DIFFERENCE inhabitants, São Paulo is the largest city in the Americas and the world’s 12th most São Paulo boasts one of the populous city. As such, it first clinics for transgender shares common problems THE AIDS RESPONSE people in Brazil, providing MAYOR OF SÃO PAULO with other cities in Brazil holistic and stigma-free and elsewhere, including health care. The clinic widespread use of crack Brazil’s first local AIDS supports the use of hormones “We have expanded free cocaine. São Paulo is dealing programme was launched and offers psychosocial and access to condoms and with the problem using a in São Paulo in 1984. Since legal help, and referrals for trained over a thousand revolutionary strategy for the then, several actions have surgical procedures funded health workers to use HIV country. The harm reduction been taken in response to by the public health system. rapid diagnostic tests. We programme De Braços the epidemic, leading to a The clinic has more than 1500 offer free antiretroviral Abertos (Open Arms) offers reduction in new cases of enrolled clients. treatment to all people job opportunities within the AIDS as well as in AIDS- living with HIV and municipality to regular drug related mortality. These Since 2011, São Paulo have established strong users. Together with the successes are the result of adopted a strategy to increase partnerships with civil society prospect of work, there is a the combined efforts of the HIV testing uptake by gay to increase services for key package of benefits, national, state and local and transgender persons populations. But to advance including support for housing governments in strong and men who have sex with the AIDS response we must and food, and help to partnership with civil men via a mobile unit placed also reduce access barriers— access health care. society organizations, at cruising sites in the city stigma and discrimination particularly from within centre. The Quero Fazer have created major obstacles the gay community. programme (I want to do it), to health services. Pioneers conducted in partnership in Brazil, we created the with a local nongovernmental “Open Arms” Programme organization, tested more —a human rights-centred than 4500 people. Among programme that provides them, 233 new HIV cases jobs, opportunities, housing were diagnosed, with almost and health care, including half of those the result of first- HIV prevention and time testing. treatment, to people who use crack-cocaine and live on the Recently, the AIDS streets of the city.” programme started providing free condoms. By the end Fernando Haddad, of 2014, it expects to place Mayor of São Paulo condoms at every bus stop. In the first three days after the pilot was launched, 15 000 condoms were taken by people passing by.
The Cities Report 65 TOMORROW TODAY YOUNG LEADERS TO WATCH
of Public Health’s Office of HIV/ seek to create opportunities AIDS, and on Next Step’s Youth of empowerment in all fields. Task Force. Upholding our human rights means ensuring that young I recently held community girls must not face stigma, dialogues as part of the ACT! discrimination, violence or 2015 initiative to advance submission. We must also be SRHR and HIV in the post-2015 able to exercise our sexual agenda. Now I am working with and reproductive health rights, various grassroots, national including accessing HIV services. and international organizations to promote ACT! 2015 at the In Algeria, we are building a country level. spirit of solidarity and leadership with youth and civil society to ensure we are part of every single 01 policy and strategy on HIV and sexual and reproductive health. Lorraine Anyango We defend our needs under United States the post-2015 agenda through Public Policy Fellow at AIDS a process of dialogue with United in Washington DC, government and stakeholders North American Youth Representative to the UNAIDS Youth Advisory Forum
Over the last six years, I have worked on a number of domestic and global programmes that are improving the lives of, and opportunities for, young people 02 around the world. Through a number of roles, I have directly Fatima Zahra Benyahia supported and advocated Algeria for young people living with Executive Director, AIDS HIV, to ensure their needs are Algérie NGO met and that their voices are I joined the fight against AIDS included in decision-making 03 six years ago with the hope of processes. As a Peer Mentor helping develop a national and at Next Step, I helped design Sara Vida Coumans regional youth movement that and deliver HIV education and Netherlands aims to break the social and sexual and reproductive health Advocacy Officer at dance4life cultural barriers and taboos that programmes for youth in five surround HIV–particularly in the While sexuality is something to counties across Massachusetts. Middle East and North Africa. be celebrated, young people’s I advocate for young people living Since then, this has been my sexuality is often approached with HIV as a representative of ambition, awake and asleep. with fear. The idea that young the Massachusetts Integrated people have sexual and Prevention Planning Committee, I belong to a movement of reproductive rights is (still) not the Statewide Advisory Board for young women who defeat something that is internationally the Massachusetts Department drivers of vulnerability daily, and acknowledged.
66 The Cities Report TOMORROW TODAY
ÒToday, I advocate for integrated HIV and sexual and reproductive health services that meet the needs of young key populations in my community.Ó
This sparked my motivation to in my community. I am a strong policies in each of our countries join the [youth] movement when opponent to the HIV Prevention that benefit and improve the HIV I was 16-years-old. I began in and Control Act, which response across Latin America. my community, but continued criminalizes HIV transmission at the international level where I in Uganda, and recently led the Right now we are focused on advocate for the rights of young organization of the first Youth negotiating with our government people. While doing this work, I Pre-Conference, which was held on implementing policies to always keep in mind that policies before the National Paediatric protect and promote the sexual should reflect the diversity of AIDS Conferences in Uganda. and reproductive health and young people. rights of women, youth and the lesbian, gay, bisexual, At dance4life we provide peer- transgendermand and intersexed led comprehensive sexuality (LGBTI) population. With the right education in 20 countries, and policies and programmes, we aim to build the leadership 04 hope to empower people to lead and advocacy skills of young healthy sexual lives. people, so that they can make a Musah Lumumba difference at the local, regional, Busia, a border town shared national and international levels. between Uganda and Kenya Lead on HIV treatment at Y+ Over the years, I have noticed a When I was 16, I was forced to gap between what policy-makers undergo an HIV test because my say in international negotiations brother had died of an AIDS- and the realities young people related illness. I tested positive. face in their countries. At My once rising popularity 05 dance4life we want to bridge suddenly declined due to the this gap, by supporting young widespread HIV-related stigma Jaime Luna people’s meaningful participation and discrimination within my Panama in policy-making processes to school environment. Member of Genesis+ Panama, the ensure that policies better reflect HIV-Positive Youth Network of their needs and realities. To cope up with the situation, Panama (Y+Pty) I founded a straight talk club in For five years I have lived with 06 2004. As “prezo” or president I HIV and for more than three was able to regain the respect Lebohang Masango years I have been working to of my peers and become a Johannesburg leader once again. I was a peer support people living with HIV, ZAZI ambassador, City of mobilizer and educator facing the especially young people and Johannesburg realities of growing up with HIV. key populations. I am part of a new generation, developing Ambassador for Zazi (‘Know your Witnessing the HIV epidemic brand new ideas and prioritizing strength’), a campaign aimed at first hand, and the inability of so prevention, strengthening young women and girls in South many of my peers to access the global HIV response and Africa. HIV treatment and services, representing the best of Latin inspired me to study clinical American positive youth. I came to Zazi from an medicine after high school. understanding of feminist Today, I advocate for integrated We are training new leaders to politics—that young women HIV and sexual and reproductive use evidence, inform government aren’t safe in our country, with health services that meet the officials and participate in an epidemic of gender-based needs of young key populations decision-making to create violence, and that we need to empower ourselves in whatever way we can. Zazi has helped me
The Cities Report 67 TOMORROW TODAY YOUNG LEADERS TO WATCH
to understand that, as young I have been lucky to have access women, in intimate relationships to comprehensive sex education we need to assert ourselves, since I was 14-years-old. This put our health first and not allow has helped me to become the anyone else to determine our leader I am today but furthermore health status. it showed me how important it is for a young person to be able to Young people in Johannesburg make informed decisions about need ‘cool’ role models to his/her sexuality. I have had the normalize the use of condoms opportunity to work with so and communicate messages many young passionate activists, about HIV that speak to them and they share one goal: to as young people. I travel to gain the skills and knowledge university campuses with Zonke, necessary to have a dignified, a female musician and a female self-determined, healthy and 08 house DJ, DJ Zinhle, who are meaningful life. also Zazi ambassadors. There Jaevion Nelson we give young people messages One of my biggest priorities is Jamaica on HIV and family planning to gain better access for young Programme and Advocacy through entertainment. The people in terms of decision- Manager, J-FLAG message that I want to leave making and the design of young women with is, “Your sexual and reproductive health In 2007, I began volunteering life is yours.” and rights (SRHR) policies and with the Jamaica Youth programmes. I am proud that Advocacy Network (JYAN). It as a result of the joint efforts of was an excellent opportunity for different organizations, Bulgaria me to not only advocate for the is on the way to have a law that sexual and reproductive health supports universal access to rights (SRHR) of young people, 07 comprehensive sex education for especially those who are most all young people. vulnerable, but to understand, Peter Mladenov appreciate and accept my
Bulgaria Half of the world’s population own sexuality. International Coordinator is under the age of 25. Young of Y-PEER people must be able to fully I later headed JYAN’s SRHR participate in the design of the and HIV portfolio where I next [Sustainable Development designed and implemented a Goals] agenda. I am often guided sex education project for by what a fellow youth activist schools where the Health Family once told me, “We should not Life and Education Curriculum forget the future is in our hands was not being implemented, and and we are the ones who have an online youth resource project the power to design the way we for LGBT. want it to be!” Since 2010, I have been working at J-FLAG—the foremost organization in Jamaica advocating for the rights of LGBT people. With J-FLAG I designed the “Fight the Hate” project which
68 The Cities Report TOMORROW TODAY
ÒWe can all be agents of change to ensure young women with HIV live with dignity, free from stigma and discrimination.Ó
successfully launched a bold general public with messages on LGBT, sex workers, people who video campaign as well as a living positively with HIV. inject drugs, young people, 10-module sensitization training people living with disabilities and programme for public health My personal experience and people living with HIV to identify workers in collaboration with struggles can be an inspiration their priorities and ensure that Jamaica’s Ministry of Health and to other young women living they are addressed through National Family Planning Board. with HIV in Indonesia. We can the Global Fund’s New Together we seek to ensure all be agents of change to Funding Model. access to quality healthcare, free ensure young women with HIV from stigma and discrimination, live with dignity, free from stigma My team is currently working for all Jamaicans. and discrimination. on an exciting project called "Light on Live" which aims to provide temporary shelter for young LGBT who face rejection or have recently been imprisoned because of their 10 sexual orientation. We hope to offer young people a safe Serge Douomong Yotta space as well as impress upon Cameroon the government the need to Executive Director of Affirmative open a national debate on Action Cameroon, Member of the homosexuality in Cameroon and UNAIDS Youth Advisory Forum demonstrate the harmful impact of homophobic laws on the 09 sexual health of young people. Ayu Oktariani Indonesia Public campaigner, Indonesia AIDS Coalition and Youth LEAD Focal Point for young women living with HIV
I am a 27-year-old mother living with HIV from Jakarta, Indonesia. I have dedicated more than I work for the Indonesia AIDS five years to working on human Coalition (IAC), a national NGO. rights, including lesbian, gay, IAC focuses on advocacy issues bisexual and transgender (LGBT) and promotes transparency, and youth issues in the AIDS accountability and civil response. I am committed to participation in the national AIDS supporting the Global Fund’s response. Given that 75 million implementation of rights-based people in the country use the programmes throughout the Internet on a daily basis, I have world. With the help of several embraced the opportunity to be partners, I recently organized a a public and online campaigner series of national consultations for the IAC, in hopes of reaching with key populations, including both key populations and the
The Cities Report 69 POWER ON PAPER ART POSTERS
Words and images in posters can change the way people think about HIV, challenge attitudes towards people living with and affected by HIV and mobilize the world to action.
ig, small, provocative or simple—HIV advocacy posters continue to play a critical role in the response to HIV. Posters inform and reach people in a way that Btraditional messages cannot. Renowned artists such as Keith Haring used poster and street art to make their messages known.
New generations are learning about HIV and messages are still needed to explain how HIV is transmitted, prevention options, how to stop stigma and how to manage HIV treatment. More complex messages are also needed to challenge misperceptions and myths about HIV. Posters can help translate complex messages and speak on sensitive issues on sex and sexuality, drug use, illness, family relationships and economic disparities.
While posters today are more likely to show up on a virtual wall than on a street corner—the goal is the same: to grab attention, provide information and inspire action.
70 The Cities Report POWER ON PAPER
The Cities Report 71 action-packed cities AROUND THE WORLD cities are working to end the AIDS epidemic in creative and innovative ways
72 The Cities Report LIGHTS, CAMERA, ACTION!
Looking forward Buenos Aires, and policy changes across City leaders recognize the Argentina a number of sectors. Such actions include: need to continue to strive for change across many sectors ■ Extension of same-sex of society in order to achieve Buenos Aires building marriage rights and a more inclusive real equality for LGBT benefits to foreigners, the society by embracing populations in all areas of life registration of children sexual diversity including health, education, born by surrogate work, social services and mothers to same-sex political participation. Introducing Buenos Aires parents and the legal The main challenges Argentina is among the most recognition of the identity ahead are to achieve a legally progressive countries of transgender children. more inclusive and non- in the world in terms of ■ Activities led by the stereotypical representation protecting and promoting Sub-Secretariat of Human of lesbians, gays, bisexual equality and the human Rights and civil society and transgender people in rights of lesbian, gay, bisexual organizations that promote the media and to increase and transgender (LGBT) a culture of diversity acceptance of sexual diversity populations. In its capital, and non-discrimination, in the family environment Buenos Aires, law prohibits including Buenos Aires and in schools. discrimination on the basis of Diversity Days. sexual orientation. ■ Legislative reform to The city in action eliminate discrimination While the legal framework in the context of blood in Buenos Aires provides donations and to accept an enabling environment— donations from stigma, prejudice and LGBT individuals. discrimination against ■ The creation of legal and LGBT populations persist. psychological support In hopes of creating a more services, provided by inclusive urban society, the the Minister of Social City of Buenos Aires has Development of the City. undertaken a range of actions to move from legal equality ■ Offering LGBT-specific for the LGBT population HIV counselling and towards the realization of testing services. equality in everyday life. • Ensuring integration of These progressive steps are transgender men and closely aligned with the women into the city’s Plan for LGBT Citizens, a public workforce. set of recommended public policies for LGBT citizenship ■ Supporting various cultural developed by the Argentine activities, such as the Federation of Lesbians, Gays, musical Diversa Sinfonia. Bisexuals and Transgender. Impact With the objective of These actions, among others, eliminating stigma and have helped “normalize” discrimination experienced sexual diversity in the hearts by LGBT populations and and minds of porteños enabling equal access to (inhabitants of Buenos Aires) opportunity and resources, and have helped reduce the city has implemented a discrimination towards host of programmes, services LGBT people in everyday life.
The Cities Report 73 LIGHTS, CAMERA, ACTION!
leadership, mobilize city- with men increased to 57% Chengdu, China specific resources, and focus in 2010—an increase of 15% on where the epidemic is over the previous year, while localized. a remarkable 89% of all Chengdu mobilizing people who tested positive community resources “By working to build a began antiretroviral therapy. to reach men who have sex with men strong, multi-sectoral The recent implementation response in Chengdu, with of couples counselling and meaningful community testing for male couples Introducing Chengdu participation, we can scale has also served to create Home to more than 14 million up coverage of prevention, a safe environment for people, the city of Chengdu treatment and care services results disclosure, facilitate is the economic, cultural among MSM and halt the cooperation for behavioral and educational centre of spread of HIV in our city,” risk reduction, and southwestern China. While said Mr Yang Xiaoguang, encourage planning for HIV prevalence is low among Director of Chengdu Health treatment and care. the general population, the Bureau. To effectively reach growing epidemic among men this traditionally stigmatized Looking forward who have sex with men has population, the strategy The city of Chengdu garnered increased political has embraced a novel continues to adapt its attention and resources. In the partnership between the local response in the face of city of Chengdu, more than government, health service ongoing and emerging 10% of the population of men providers and community- challenges to ensure that who have sex with men is based organizations interventions remain living with HIV. which has enabled various effective and relevant to the innovations, such as: various populations they seek to address. The heavy The city in action ■ The roll-out of venue-based burden of the epidemic on Chengdu was one of the programmes such as at bars young people is of particular cities participating in a and bathhouses. multi-city initiative, which concern—six out of ten laid the groundwork for ■ The use of online social people living with HIV the founding of the Urban networking tools to build are under 30-years-old. Health and Justice Initiative. awareness and reach Accelerating the roll out The six cities include people at risk. of the city’s strategic plan will require implementing Bangkok, Thailand; Chengdu, ■ Ensuring community-based youth-friendly and youth- China; Ho Chi Minh City, services are available when relevant interventions, Viet Nam; Yangon, people do test positive as well as enhancing the Myanmar; Manila, and take medication, financial, technical and Philippines; and Jakarta, including psychosocial human resource capacity of Indonesia. and adherence support. civil society and grassroots The strategy has also taken organizations that are central Following a meeting the progressive step of to the response. that brought these six providing treatment to cities together, in 2011 people as soon as they test the government of positive, regardless of CD4 Chengdu developed a city count. AIDS strategy aimed at dramatically reducing new Impact HIV infections and AIDS- Data shows that in just one related deaths among men year, between 2009 and who have sex with men. 2010, consistent condom use increased from 8 to 40%. The strategy seeks to usher Access to HIV treatment in sustained political among men who have sex
74 The Cities Report new molecular tuberculosis Looking forward Harare, Zimbabwe diagnostic test that reduces Harare City continues to the time it takes to diagnose improve the facilities used tuberculosis cases from to diagnose tuberculosis, Harare decentralizing weeks down to hours. especially among people with new diagnostics for “The project afforded HIV, and is engaging new tuberculosis tuberculosis patients donors such as the Global convenience, patients didn’t Fund to support the highly need to wait for two weeks to successful project. The model Introducing Harare be started on treatment,” said that Harare has provided One of the biggest challenges Dr Clemence Duri, Director is now being considered in in responding to tuberculosis of Harare City Tuberculosis other cities in Zimbabwe to is early detection. Many Programme. “Instead people improve decentralization and people with tuberculosis are were getting results within 24 access to tuberculosis and either not detected or detected hours.” HIV services. too late, leading to increased mortality and continued The programme greatly transmission of the disease improved access, accuracy to others. In Zimbabwe, only and time to treatment for four out of every ten people people with tuberculosis who get sick with tuberculosis through eight different are diagnosed and started laboratories around the city. on treatment. An estimated Together, these clinics saw 70% of tuberculosis patients thousands of outpatients a also have HIV, requiring day. an integrated response. The capital, Harare, holds Impact only 10% of the country’s Time to treatment initiation population, yet 20% of was reduced from two to all tuberculosis patients in three weeks to 24 hours, Zimbabwe are diagnosed and thereby cutting transmission treated in the city. in the community. After implementing the new The city in action molecular test, there was a The City of Harare Health 40% increase in the number Department wanted to of people with confirmed improve tuberculosis tuberculosis. These people detection and treatment by would have been missed in decentralizing tuberculosis prior years and many would testing and care services. have died while waiting for a All testing for tuberculosis diagnosis. The benefit of the was previously done in one intervention was even more centralized laboratory and acutely felt among people treatment was initiated at just living with HIV, as the new two hospitals. With support molecular test can double the from Tuberculosis REACH, number of tuberculosis/HIV which provides grant funding co-infected people identified, for innovative projects compared to conventional to improve tuberculosis methods. detection and treatment, the initiative was able to establish numerous microscopy laboratories. The city was also able to introduce a
The Cities Report 75 LIGHTS, CAMERA, ACTION!
Kigali, Rwanda actions,” said Ndayisaba sex workers, for instance, Fidèle, the mayor of Kigali. the city sponsored the “We are all concerned by engagement of several CBOs Kigali focusing efforts the epidemic and are all in regional events such as on key populations invited to take actions to the International Conference in a single city-wide prevent new HIV infections, on AIDS and Sexually strategy reduce AIDS-related deaths Transmitted Infections in and address stigma and Africa (ICASA) 2013 in Introducing Kigali discrimination.” South Africa and the global Kigali has long been the meeting of municipalities economic, cultural and The HIV plan is focused held in Rabat, Morocco transport hub of Rwanda. It is on both the populations during the United Cities and also home to one-third of the and geographic locations Local Governments Forum country’s people living with most affected by the epidemic of 2013. HIV. City officials consider the with multisectoral solutions. Looking forward response to HIV among the The city also looked at how top priorities. The prevalence issues affect access to services Kigali recognizes that of HIV in the City of Kigali is such as: urban poverty, the capacity of CBOs to 7.3%, more than three times informal settlements, work meaningfully and effectively the average in rural areas in the informal sector, participate in the governance (2.3%). The epidemic burden mobility and migration, and of the response is greatly among key populations is norms and institutionalized limited—particularly among particularly high—recent practices that reinforce those organizations that evidence indicates HIV discrimination on the represent key populations. prevalence is as high as 56% basis of gender, class, age Inadequate financial and among the city's sex workers. and ethnicity. human resources keep these organizations from Impact The city in action being able to make direct A 2010/2011 review of The city is at the forefront of contribution to the city’s HIV the city’s HIV response the national response to HIV, response. This limitation is found that while there and has achieved universal considered a major challenge was considerable political access to HIV treatment with to developing a stronger and commitment and leadership more than 80% of people more inclusive response — in coordinating the HIV living with HIV accessing and one that city leaders are response across the various antiretroviral therapy in committed to overcoming. districts of the city, there mid-2014. Under the city’s was an urgent need for new Strategic Plan for HIV, stronger coordination of city officials, community- efforts. The review called for based organizations (CBOs) a single, common plan that and their partners in the clearly outlined the short response have demonstrated and medium-term goals of even greater commitment the city’s response. Kigali to ensuring evidence guides city officials took action and the development of results- launched the Strategic Plan oriented programmes. for HIV and AIDS Response in the City of Kigali, 2013- To reach those key 2016. populations that continue to be left behind, the city “As leaders it is important of Kigali is ramping up that we learn from evidence. investments and partnerships We need to know the nature with CBOs. In order to of the epidemic that we strengthen civil society face and therefore work on capacity to implement translating evidence into programmes to reach female
76 The Cities Report Rabat, Morocco but also of preoccupations adapt its response to current and new challenges, and emerging challenges to particularly to guarantee ensure that interventions Rabat mobilizing for their access to treatment remain effective and migrants’ access to and care,” said El Houssaine relevant to migrants. health services and Louardi, Minister of Health Proponents are hopeful that HIV programmes of Morocco. the regularisation of the administrative situation of Introducing Rabat In this context, the Ministry many migrants will continue Located on the Atlantic Ocean of Health with support to ease and encourage access at the mouth of the river from UNAIDS launched to HIV services in Rabat. Bouregreg, Rabat is both the a community health capital of Morocco and of the programme focused on Rabat-Salé-Zemmour-Zaer improving migrants’ access Region. With a population of to care. A study shed light on approximately one million, living conditions and specific it forms the second largest health challenges. A mapping city in the country after of HIV programmes was Casablanca. Due to Morocco’s also undertaken. The central geographic position, data provided strategic the country has become a information to inform the popular transit location, development of an integrated while its economic and social action plan focused stability has also encouraged a on strengthening HIV growing number of migrants. prevention activities and care for migrants. The city in action Impact Over the past several years, a number of non- With the support of the governmental organizations Ministry of Health, the (NGOs) have begun to ability of NGOs to provide implement programmes to relevant, accessible health promote HIV prevention services to migrants in Rabat among migrants and to has markedly improved. A increase access to health full package of services is services and to promote now available to migrants. human rights. Moreover, migrants in irregular administrative Following the guidance situations benefit from of His Majesty the King free services covered by Mohammed VI, in national health programmes. September 2013, Morocco In 2013, 10 500 migrants started implementation of benefited from outreach HIV a new immigration policy, prevention programmes. including the promotion of Antiretroviral treatment and migrants’ access to social care for migrants living with benefits including health HIV are provided by the Ibn services and equal rights Sina Hospital. that are afforded to Looking forward Moroccan nationals. As part of the new integrated “Morocco has become a national strategy on sustainable homeland for immigration developed by migrants, economic and the government, the city cultural enrichment sources of Rabat will continue to
The Cities Report 77 LIGHTS, CAMERA, ACTION!
Vancouver, Canada people can safely inject drugs net-societal benefit of more and connect to health care than CAD $6 million. services—from primary care Vancouver prioritizing to treat disease and infection, Looking forward public health to addiction counselling and Despite supportive scientific over punishment treatment and housing and evidence and strong local community support. support, Insite continues to Introducing Vancouver face intense scrutiny and Impact controversy. In 2010, the The Canadian city of To date, more than 30 site faced closure by the Vancouver is often voted peer-reviewed studies have federal government although among the world’s best places been published describing Canada’s Supreme Court to live. However, deep in the the programme’s impacts. ruled in 2011 that it remain city’s downtown area, one These publications indicate open. In their ruling, the neighbourhood struggled that Insite provides a range Supreme Court noted "the for decades with the influx of benefits to its clients and experiment has proven of illegal drugs—which had the greater community. A successful. While Insite effectively made the area recently released report remains open, resistance an epicentre for heroin use. summarizing 15 years of from the federal government Estimates of HIV prevalence data on the drug situation has limited the expansion of among people who inject in Vancouver provides clear the pilot project. Proponents drugs in Vancouver range evidence that harm reduction in cities such as Toronto from 17-30%. programmes have helped and Ottawa remain hopeful, reduce illicit drug use and The city in action however, that policy change improve public health. Fewer will one day enable the Determined to curb its people are injecting drugs; establishment of more safe concentrated but growing more are accessing addiction injection sites as a powerful HIV epidemic, and in treatment and HIV and component of a strong city response to community hepatitis C transmission HIV prevention strategy. demands, city officials in related to injecting drug use Vancouver opted for health- has plummeted. In 1996, focused policies over the almost 40% of drug users in federal law enforcement Vancouver reported sharing approach. Major pressure needles; by 2011, needle derived from the scientific sharing had dropped to and medical community in 1.7% while the proportion Vancouver, with significant of people who injecting support mobilized by leading drugs accessing methadone international HIV specialist treatment rose from 12% in Dr Julio Montaner of the 1996 to 54.5% in 2008. British Columbia Centre for Excellence in HIV/AIDS. A large and growing body In 2003, Vancouver’s health of scientific evidence authority successfully applied demonstrates that harm to the federal government reduction programmes, for a legal operating such as needle exchanges, exemption to pilot North are effective in reducing the America’s first medically harm associated with illicit supervised injection facility drug use. One cost-benefit (SIF), called ‘Insite’. Legal analysis published in the exemption was granted International Journal of Drug on the condition that the Policy in 2010 determined programme be subjected to that the site prevents 35 cases rigorous scientific evaluation. of HIV and about 3 deaths Today, Insite provides a safe, per year, indicating a yearly health-focused centre where
78 The Cities Report Cities in their situation. City officials keeping public drug use to were able to overcome Western Europe tolerable levels. controversies between prohibitionist Looking forward Five cities across and harm reduction The lessons learned Western Europe ideologies in favour of a through the experience of reducing open balance between providing these five cities resonate drug scenes opioid maintenance across a range of contested treatment combined with and controversial urban outreach social work and The issue challenges. For years, effective policing. ongoing political and “Open drug scenes” are ideological conflicts gatherings of people who A common feature across prevented these cities consume and deal illegal all five cities is that harm from being able to pursue drugs publicly. Five cities reduction has been adopted effective measures until across Western Europe— as a central strategy. There political compromise could Amsterdam, Frankfurt, were differences in how this be wrought. The cities are Lisbon, Vienna and Zurich— strategy was implemented actively pursuing sustainable have explored a variety of but the common features solutions, recognizing that measures to reduce open were a free-of-charge, low there will be no “quick fixes” drug scenes in a constructive threshold public health to the issue of public and sustainable way. These service, often at city service drug gatherings. cities have demonstrated that level. Critically, experiences combining prevention, harm in low-threshold methadone, reduction and treatment needle exchange and heroin- services with law enforcement assisted therapy have yielded and ensuring close evidence of both crime collaboration between police, reduction and significant health care and social services HIV prevention. can bring about real change. All five cities have also Cities in action developed specific strategies In the past, city officials to contact and attract in Amsterdam, Frankfurt, “hard to reach” users, Lisbon, Vienna and Zurich through outreach services had confronted growing in cooperation with police public drug scenes with officers. A shared element an oftentimes conflicted has been the provision of approach between liberal easily available contact and and conservative policies. In crisis centres that offer a Zurich, for example, political range of social services, controversies and shifting often incorporating needle decisions obstructed effective dispensing, and in some action for several years cities, user rooms. despite a growing epidemic of public injecting drug use. Impact In the last several years, A recent study reviewing across all five cities, there the experience of these have been no noticeable five cities found that only open drug scenes. The when the cities developed combination of a harm a comprehensive policy reduction strategy and that integrated treatment systematic prevention of and helping measures with public nuisance appears control measures were they to have been effective in able to successfully alleviate
The Cities Report 79 Teresia Njoki Otieno Eastern Africa Representative, International Steering the last word Committee of The International Community of Women Living with HIV (ICW)
How has the AIDS response in your city changed your life? Access to information, treatment and care has really improved and the integration of services is making life easier for me and for other women. As a woman living with HIV, it is important for me to have an opportunity to influence policies and programmes that affect me and others like me. It is also important for me to have services provided to communities. Our world is changing so quickly, with new ways of communicating, new medicines, new expectations of young people. Life is greatly improving for many people, but there are also many people and populations who remain unable to access HIVservices and a better life. How have you changed the response? ing on the young generation as we focus What is your We have succeeded where people came on ending AIDS. We need to empower happiest memory? and support vulnerable populations, and together, bound in their fierce belief Giving birth to healthy children we need to tap into the experience and of their own value and dignity, and —despite my HIV status. courageously confronted forces in our expertise of women living with HIV. societies that arise from misunderstand- Who is your hero? What can each of us do ing, stigma, greed and indifference. for World AIDS Day and Women leaders who, living with HIV, That is the source of power in the AIDS every day? have endured stigma, shame and response—the hearts and souls of peo- degrading inhuman treatment because Each of us has an unmatched ability to ple living with and affected by HIV. We of their HIV status. Women who stood form meaningful engagement and part- have struggled and continue to struggle by other women to encourage, support, nerships with people living with HIV, to to overcome stigma and discrimination, educate, fight for and mentor them for a understand our own epidemic and to be rejection by our families, fear in our better tomorrow. communities and unjust criminalization able to provide the right kind of services by our state. I joined other women to on the very city corners where they are What motivates you? needed. We need to be flexible and fast call for a human rights framework in I desire an end to the AIDS epidemic; to moving with regard to policy change responding to HIV and gender inequal- see all children born free from the virus; and service delivery, while maintaining ities, and for respect for sexual and to see women empowered in making a steadfast commitment to the human reproductive health and rights. informed decisions and bridging the gap rights of all people and populations. for the less privileged in society. What is the most important Where did you grow up? thing we can do for What’s next? I grew up in Nairobi. I see change for our communities? What I have learned from the AIDS the better every day. And it is up to me, Neither social nor legal barriers should response is that, as citizens and inhabi- you—all of us—to continue to push for keep anyone from embracing their own tants of cities in the 21st century, we all more just policies and laws; for better power to define the outcome of their face basic social responsibilities to treat programmes and services for and with community—that is everyone’s right. women living with HIV with the respect the people who need them most; for Conversely, as members of our com- and dignity they deserve, to uphold social norms that are accommodating; munities (local communities, countries community rights and community obli- and respect for diversity and women’s and increasingly as global citizens) we gations and most importantly to ensure human rights. must also participate in planning our the next generation does not have to do common future—that is our obligation. this all over again. We must become change agents, focus-
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