Miles to Go—Closing Gaps, Breaking Barriers, Righting Injustices
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GLOBAL AIDS UPDATE 2018 MILES TO GO CLOSING GAPS BREAKING BARRIERS RIGHTING INJUSTICES MILES TO GO CLOSING GAPS BREAKING BARRIERS RIGHTING INJUSTICES Contents Foreword 6 1. Introduction and summary 8 PART I. Progress towards Fast-Track commitments 23 2. State of the epidemic 24 3. Combination HIV prevention 38 4. 90–90–90 66 5. Eliminating mother-to-child HIV transmission 88 6. AIDS out of isolation 98 7. Investment 110 PART II. Barriers to ending AIDS 119 8. Stigma and discrimination 120 9. Violence 132 10. Marginalization 142 11. Laws and policies 156 12. Poverty and inequality 170 PART III. Regions in focus 189 13. Eastern and southern Africa 190 14. Western and central Africa 198 15. Asia and the Pacific 206 16. Latin America 216 17. Caribbean 224 18. Middle East and North Africa 232 19. Eastern Europe and central Asia 240 20. Western and central Europe and North America 248 Annex on methods 255 “AIDS is our number one enemy. This enemy can be defeated. Four principles—love, support, acceptance and care for those affected—can make us winners.” Nelson Mandela 1918–2013 UNAIDS dedicates this report to the memory of Madiba, whose courage and compassion continues to inspire us 100 years after his birth. Foreword The global AIDS response is at a precarious point—partial success in saving lives and stopping new HIV infections is giving way to complacency. At the halfway point to the 2020 targets, the pace of progress is not matching the global ambition. This report is a wake-up call—action now can still put us back on course to reach the 2020 targets. The number of AIDS-related deaths is the lowest this century, with fewer than 1 million people dying each year from AIDS-related illnesses, thanks to sustained access to antiretroviral therapy. Three out of four people living with HIV now know their status—the first step to getting treatment. And now a record 21.7 million people are on treatment—a net increase of 2.3 million people since the end of 2016. The scale-up of access to treatment should not be taken for granted, though. In the next three years an additional 2.8 million people must be added each year, but there are no new commitments to increase resources, there is an acute shortage of health-care workers and there is continuing stigma and discrimination. There is a prevention crisis. The success in saving lives has not been matched with equal success in reducing new HIV infections. New HIV infections are not falling fast enough. HIV prevention services are not being provided on an adequate scale and with sufficient intensity and are not reaching the people who need them the most. Acceptance of condoms, voluntary medical male circumcision, pre- exposure prophylaxis, cash transfers must be increased rapidly and not be secondary prevention tools. And I await the day when there is a functional cure and a vaccine against HIV. Children are being left behind. The good news is that 1.4 million new HIV infections have been averted since 2010, but I am distressed by the fact that, in 2017, 180 000 children became infected with HIV, far from the 2018 target of eliminating new HIV infections among children. While the overall HIV treatment level is high, there is a huge injustice being committed against our children—only half of under-15s living with HIV were being treated last year. 6 Stigma and discrimination still has terrible consequences. The very people who are meant to be protecting, supporting and healing people living with HIV often discriminate against the people who should be in their care, denying access to critical HIV services, resulting in more HIV infections and more deaths. It is the responsibility of the state to protect everyone. Human rights are universal—no one is excluded, not sex workers, gay men and other men who have sex with men, people who inject drugs, transgender people, prisoners or migrants. Bad laws that criminalize HIV transmission, sex work, personal drug use and sexual orientation or hinder access to services must go, and go now. Women and girls continue to be disproportionately affected. It is outrageous that one in three women worldwide has experienced physical or sexual violence. We must not let up in our efforts to address and root out harassment, abuse and violence, whether at home, in the community or in the workplace. UNAIDS stands firm in its commitment to act against harassment, abuse and violence, wherever they occur. The upcoming United Nations High-Level Meeting on Tuberculosis is a huge opportunity to bring AIDS out of isolation and push for the integration of HIV and tuberculosis services. There have been major gains in treating and diagnosing HIV among people with tuberculosis, but still, decades into the HIV epidemic, three in five people starting HIV treatment are not screened, tested or treated for tuberculosis, the biggest killer of people living with HIV. Equally important is integration of HIV services with sexual and reproductive health services and developing strong links with services for noncommunicable diseases. Our goal must be to save lives holistically, not disease by disease, issue by issue, in isolation. There is a funding crisis. I am heartened by the fact that resources for AIDS increased in 2017, but there is still a 20% shortfall between what is needed and what is available. And we cannot afford any cuts in international assistance to the AIDS response. A 20% cut in international funding will be catastrophic for the 44 countries that rely on international assistance for at least 75% of their national AIDS responses. A fully funded AIDS response is non-negotiable, as is funding for universal health coverage. AIDS is not over, but it can be. At the halfway point to the 2020 targets, we must recommit ourselves to achieve them. The successes in HIV treatment show what can be done when we put our minds to it. People living with HIV are leading longer, healthier lives. But we still have miles to go. We have promises to keep. Michel Sidibé UNAIDS Executive Director 7 1. Introduction and summary STOPPING BY WOODS ON A Time is running out SNOWY EVENING By Robert Frost Stopping by woods on a snowy evening, the iconic poem by Robert Frost, describes a solemn pause and moment of reflection in the middle of a long winter journey. The Whose woods these are I think I know. traveller gazes upon the silent, snow-covered forest with His house is in the village though; reverence, and he appears satisfied with his progress. The He will not see me stopping here traveller’s horse, however, is agitated. The dark and cold are real and growing threats. Satisfaction must not devolve To watch his woods fill up with snow. into complacency. There are miles to go before the end of My little horse must think it queer the journey. To stop without a farmhouse near The scene is an apt metaphor for the global AIDS response Between the woods and frozen lake in 2018. The darkest evening of the year. In 2016, the United Nations General Assembly agreed He gives his harness bells a shake to embark on an ambitious journey—to front-load To ask if there is some mistake. investment, remove structural barriers and embark on a The only other sound’s the sweep Fast-Track expansion of critical HIV services to reach the Of easy wind and downy flake. vast majority in need by 2020. If successful, HIV infections and deaths from AIDS-related illness should decline by The woods are lovely, dark and deep, 75%, creating the momentum necessary to end the AIDS But I have promises to keep, epidemic as a public health threat by 2030. And miles to go before I sleep, And miles to go before I sleep. This progress report has been issued at the midpoint of the Fast-Track phase of the global AIDS response. The latest data from countries show that the Fast-Track approach is a winning strategy: the communities, cities and countries that have achieved high levels of coverage of evidence-informed combination prevention, testing and treatment services are making steady progress towards the 2020 targets and milestones. But such energy and determination are not widespread. Entire regions are falling far behind. And in all countries— whether they are high-income, middle-income or low- income—a common pattern has emerged: gains on HIV, 8 health and development have overlooked the people steadily moving towards the Fast-Track milestones (Figure in greatest need. Society’s most vulnerable—children, 1.1). Further efficiency gains could see these milestones met adolescent girls and young women, indigenous peoples, in the region most affected by HIV. migrants, the poor and uneducated, and key populations at highest risk of HIV infection—are being left behind. Globally, steady scale-up of antiretroviral therapy continues: an estimated 21.7 million [19.1–22.6 million] people were As we reflect on our progress, some satisfaction is accessing treatment at the end of 2017, five and a half times warranted. But on balance, the world is slipping off track. more than just a decade ago. Progress towards the 90–90– The promises made to society’s most vulnerable individuals 90 targets is also steady. Three quarters of people living are not being kept. There are miles to go in the journey to with HIV globally—an estimated 75% [55–92%]—knew their end the AIDS epidemic. Time is running out. HIV status at the end of 2017. Among those who knew their HIV status, 79% [59– >95%] were accessing antiretroviral SOME PROGRESS TO BE PROUD OF therapy, and 81% [61– >95%] of people accessing treatment had suppressed viral loads.