Get on the

Fast-Track
The life-cycle
approach to HIV
Finding solutions for everyone
at every stage of life

0–
14
50+ 15–
24

25– Key
populations

49
UNAIDS | 2016
2
contents

1 Foreword 3

2 Introduction 6

3 Children (0–14) 12

4 Young people (15–24) 28

5 Key populations throughout the life cycle 50

6 Adulthood (25–49) 72

7 Ageing (50+) 90

8 Conclusion 101

9 AIDS by the numbers 105

10 Annex on methods 133

2
foreword

The scope of HIV prevention and treatment options has never been wider than it is today.
The world now has the scientific knowledge and experience to reach people with HIV
options tailored to their lives in the communities in which they live.

This life-cycle approach to HIV ensures that we find the best solutions for people throughout
their lifetime.

And it begins with giving children a healthy start in life free from HIV. The progress made
in reducing mother-to-child transmission of HIV is one of the remarkable success stories in
global health. Antiretroviral medicines have averted 1.6 million new HIV infections among
children since 2000. Even so, intensified efforts are needed to virtually eliminate transmis-
sion from mother to child.

Adolescence is a turbulent time, and a particularly dangerous time for young women living
in sub-Saharan Africa. As they transition to adulthood, their risk of becoming infected with
HIV increases dramatically. When women and girls are empowered, they have the means to
protect themselves from becoming infected with HIV and to access HIV services.

No one should be left behind through the life-cycle approach. Key populations, such as sex
workers, people who inject drugs and men who have sex with men, prisoners and migrants,
need access to the HIV treatment and prevention options that best meet their needs.

In this report, UNAIDS is announcing that 18.2 million people now have access to HIV
treatment. The Fast-Track response is working. Increasing treatment coverage is reducing
AIDS-related deaths among adults and children. But the life-cycle approach has to include
more than just treatment. Tuberculosis (TB) remains among the commonest causes of
illness and death among people living with HIV of all ages, causing about one third of AIDS-
related deaths in 2015. These deaths could and should have been prevented.

TB, like cervical cancer, hepatitis C and other major causes of illness and death among
people living with HIV, is not always detected in HIV services. It is vital that we collaborate
closely with other health programmes to prevent unnecessary deaths.

The impact of better treatment coverage means that a growing number of people will be
living with HIV into old age, while there has also been an increase in new HIV infections
among older people. The consequences of long-term antiretroviral therapy, combined with
the diseases of ageing, will be new territory for many HIV programmes.

Drug resistance is a major threat to the AIDS response, not just for antiretroviral medicines
but also for the antibiotic and antituberculous medicines that people living with HIV
frequently need to remain healthy. More people than ever before are in need of second- and
third-line medicines for HIV and TB. The human burden of drug resistance is already unac-
ceptable; the financial costs will soon be unsustainable. We need to make sure the medicines
we have today are put to best use, and accelerate and expand the search for new treatments,
diagnostics, vaccines and an HIV cure.

3
 As we build on science and innovation we will need fresh thinking to get us over the
remaining obstacles. The cliché is true—what got us here, won’t get us there. We face
persistent inequalities, the threat of fewer resources and a growing conspiracy of compla-
cency.

Coming from Africa, I am proud that low- and middle-income countries are responsible for
more than half of the HIV resources available. Coupled with a successful replenishment of
the Global Fund to Fight AIDS, Tuberculosis and Malaria and a resilient bi-partisan United
States President’s Emergency Plan for AIDS Relief, our push for shared responsibility and
global solidarity is working.

However, resources will continue to be scarce and the need to show a return on investment
will be stronger than ever before. And with no reduction in the global number of new HIV
infections among adults in the past five years, and rising numbers of new infections in some
regions of the world, we need to realize that if there is a resurgence in new HIV infections
now, the epidemic will become impossible to control.

On this World AIDS Day, I call on world leaders, partners, activists, communities and
people living with HIV to get on the Fast-Track to end this epidemic.

AIDS is not over, but it can be.

Michel Sidibé
UNAIDS Executive Director

4
5
 introduction

The human life cycle is an individual journey of change. During infancy, childhood, adulthood
and advanced age, we are faced with different sets of risks and opportunities. As we age, our
roles change within families and communities.

The dynamics of the life cycle have been adopted by the business world to guide the develop-
ment and improvement of products and services, and to explain the growth and decline of
The life cycle can be
used as a lens to better enterprises. The life cycle can also be used as a lens to better understand the complex dynamics
understand the complex of the HIV epidemic and the response. Innovations in data collection reveal how the risks of
dynamics of the HIV infection, the challenges of accessing services and the solutions to these challenges change at
epidemic and the different stages of life.
response.
The infection risks faced by the unborn child of a mother living with HIV are minimized when
readily available diagnostics and antiretroviral medicines are used in a timely manner. Expectant
mothers need good-quality antenatal care that routinely offers HIV testing. Pregnant women
found to be living with HIV require immediate antiretroviral therapy, and support to adhere
to their treatment throughout pregnancy, breastfeeding and the rest of their lives. Newborn
children and their mothers require linked postnatal care that includes early virological testing
for the babies and paediatric treatment to the few who acquire HIV.

As children go through adolescence, new challenges emerge. HIV risks among young people are
higher when they come of age within challenging environments, with insufficient access to food,
education and housing, and high rates of violence. Perceptions of low infection risk, insufficient
condom use and low rates of HIV testing persist among young people. The transition from
childhood to adulthood is also a dangerous time for adolescents living with HIV. Treatment
adherence is low and treatment failure is high among adolescents living with HIV. A three-
fold increase in children living with HIV growing to adolescence within the past 10 years has
magnified this challenge within the treatment programmes of dozens of countries.

During adolescence, HIV risk is considerably higher among girls, especially in high-prevalence
settings such as eastern and southern Africa. Social protection measures and keeping adoles-
cents in school reduce HIV risks. Schools are also the most convenient vehicle for comprehen-
sive sexuality education, which provides adolescents and young people with the knowledge
and skills necessary to make conscious, healthy and respectful choices about relationships and
sexuality. The HIV-related effects of these measures are linked closely to the empowerment of
adolescent girls and young women that comes with an education and economic independence.

As life progresses into adulthood, the proportion of people newly infected with HIV globally
who are men grows steadily, from 35% of people aged 15–19 years to 63% of people aged 40–44
years.1 Even in eastern and southern Africa, where predominantly male key populations account
for a much smaller proportion of new infections than the global average, 54% of new HIV infec-
tions among people aged 30–34 years in 2015 were men.

6
 Proportion of new HIV infections by sex, global and eastern and southern
Africa, 2015
100

80
Percentage (%)

60

40

20

0
9

9
–1

–2

–2

–3

–3

–4

–4

–1

–2

–2

–3

–3

–4

–4
15

20

25

30

35

40

45

15

20

25

30

35

40

45
Age (years) Age (years)
Men Women global eastern and southern Africa

Source: UNAIDS 2016 estimates.

New phylogenetic data from South Africa reveal a vicious cycle of HIV infection among older
and younger people that may be at play in many high-prevalence settings: young women are
acquiring HIV from adult men—as these young women grow older, they tend to transmit HIV
to adult men, and the cycle repeats. Data from other studies suggest that gender inequalities and
harmful masculinities underpin this cycle. Lower access to education, lower levels of economic
independence and intimate partner violence erode the ability of young women to negotiate safer
sex and retain control of their bodies. Men, meanwhile, tend to be ignored by health policies
and HIV strategies, they seek services infrequently, and they tend to be diagnosed with HIV and
initiate treatment very late—often with deadly consequences.
Efforts to reduce new HIV
infections among adults
have stalled, threatening
future progress towards Leveraging the life-cycle approach
the end of AIDS.
to kickstart HIV prevention
The insights revealed by the life-cycle approach must be leveraged to address one of the
greatest challenges facing the global AIDS response: stalled progress on HIV prevention
among adults. New infections among young women aged 15–24 years have declined by
only 6% between 2010 and 2015, while the rate of new HIV infections among 25–49-
year-old men and women is essentially flat. Meanwhile, new infections appear to be rising
among people who inject drugs and men who have sex with men.

UNAIDS warned in July 2016 that this prevention gap is a threat to future progress towards
the end of AIDS. The Prevention gap report2 shows how some countries have achieved decline
in new HIV infections among adults of 50% or more over the last 10 years, while many others
have not made measurable progress or experienced worrying increases in new HIV infections.

1
All data in the text of the report without endnote references are from UNAIDS 2016 estimates or 2016 Global AIDS Response Progress Reporting.
National estimates and programme data submitted by countries to UNAIDS are available on the AIDSinfo website (aidsinfo.unaids.org).

7
 Measures to close this gap are readily available. A combination of HIV risk awareness,
economic empowerment and oral pre-exposure prophylaxis (PrEP) is a potentially
powerful HIV prevention method for young women living in within extremely
challenging economic and social circumstances. Social protection measures such as cash
transfers and free education have been shown to dramatically reduce economically driven
sex among 12–18-year-old girls. Assisted partner notification and self-test kits have been
shown increase access to HIV testing among men. Cities and countries that have put in
place truly comprehensive HIV programmes tailored to the needs of key populations have
successfully reduced new HIV infections among sex workers, people who inject drugs and
men who have sex with men. These evidence-informed, high-impact approaches must
be consistently applied across the life cycle, using a location–population approach that
prioritizes the geographical areas and populations in greatest need.

Building on a strong global foundation

Redoubled efforts to close the prevention gap can be built on a foundation of unparalleled
global advocacy and financial commitment. Strategic global partnerships have already
put the elimination of mother-to-child transmission within sight. Twenty-one countries
in Africa have worked with UNAIDS and the United States President’s Emergency Plan
for AIDS Relief (PEPFAR) to reduce new infections among children aged 0–14 years by
51% since 2010. Further efforts focused on children, adolescent girls and young women
Antiretroviral therapy is
now accessed by 18.2 are being guided by a new framework: Start Free Stay Free AIDS Free. Governments and
million [16.1 million–18.8 civil society are also working with the United Nations system within the High-Level Task
million] people living with Force on Women, Girls, Gender Equality and HIV in Eastern and Southern Africa to raise
HIV, and AIDS-related greater awareness of the disproportionate HIV risks faced by adolescent girls and young
deaths have plummeted
women. The 90–90–90 targets,3 launched by UNAIDS at the 2014 International AIDS
by 45% since 2005.
Conference, has rallied global efforts on HIV testing and treatment, and improved focus
on the viral suppression required to realize the full preventative effect of treatment.

Antiretroviral therapy is now accessed by 18.2 million [16.1 million–19.0 million] people
living with HIV. Consistently strong scale-up of treatment has seen AIDS-related deaths
plummet by 45%, from a peak of 2 million [1.7 million–2.3 million] in 2005 to 1.1 million
[940 000–1.3 million] in 2015. More and more adults living with HIV are over the age of
50 years. Age-related diseases such as cardiovascular disease are more common among
people living with HIV, and antiretroviral drug resistance poses a significant threat to
people who have been living with HIV for many years. Mounting cases of drug-resistant tuber-
culosis (TB) are threatening to slow steady reductions in deaths among people living with HIV
caused by TB disease. Women living with HIV remain at heightened risk of developing cervical
cancer due to insufficient coverage of human papillomavirus immunization programmes in

2
http://www.unaids.org/en/resources/documents/2016/prevention-gap

3
By 2020, 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment, and 90%
of people on treatment have suppressed viral loads.

8
 low- and middle-income countries, and an estimated 10 million people who inject drugs have
hepatitis C infection. Achieving the 2020 target of fewer than 500 000 AIDS-related deaths
annually will require taking AIDS out of isolation through people-centred systems for universal
health coverage, including treatment for TB, cervical cancer and hepatitis B and C.

Low- and middle-income countries

investing in the end of AIDS
Ten years ago, the acceleration of the AIDS response was largely dependent on bilateral
and multilateral donors. At the United Nations General Assembly in 2011, UNAIDS
called for shared responsibility, broader ownership and wider accountability to meet the
investment needs of the response in a sustainable manner (1). Low- and middle-income
countries have answered this challenge. In the past five years, domestic investment in
the AIDS responses of these countries has increased by 46%, reaching US$ 10.8 billion in
2015. Total annual investment in these countries reached US$ 19.0 billion, including the
Low- and middle-income
contributions of PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and
countries have answered
UNAIDS’ call for shared other bilateral and multilateral donors.
responsibility. In the
past five years, domestic
investment in the AIDS
responses of these
countries has increased by Investments in the AIDS responses of low- and middle-income countries,
46%, reaching US$ 10.8
by source of funding, 2000–2015
billion in 2015.
25

20

15
US$ (billion)

10

0
00

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15
20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

Domestic (public and private) Other bilateral governments Other multilaterals and foundations
United States (bilateral) Global Fund to Fight AIDS, Tuberculosis and Malaria

Source: UNAIDS estimates, June 2016 - UNAIDS-Kaiser Family Foundation. Financing the response to AIDS in low- and middle-income countries till
2015 - OECD CRS last accessed June 2016.

9
 A sizable investment gap remains, however. Reaching the Fast-Track Targets agreed by
the United Nations General Assembly will require an additional US$ 7 billion annually
by 2020. Reaching and sustaining this level of investment until 2030, and focusing these
resources on delivering the most effective HIV services to the people in greatest need
across the life cycle, will result in millions of additional lives saved and tens of millions of
additional HIV infections averted.4

Additional HIV infections averted through a Fast-Track response, compared to 2015

levels of coverage, 2016–2030
2.0
1.8
1.6
1.4
Number (millions)

1.2
1.0
0.8
0.6
0.4
0.2
0.0
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Eastern and southern Africa Asia and the Pacific Latin America and the Caribbean
Western and central Africa Eastern Europe and central Asia North Africa and the Middle East

Source: Lamontagne E, Over M, Stover J et al. The economic returns of ending the AIDS epidemic by 2030. 2016, in press.

Additional AIDS-related deaths averted through a Fast-Track response, compared to

2015 levels of coverage, 2016–2030
0.9

0.8

0.7
Number (millions)

0.6

0.5

0.4

0.3

0.2

0.1

0.0.
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Eastern and southern Africa Asia and the Pacific Latin America and the Caribbean
Western and central Africa Eastern Europe and central Asia North Africa and the Middle East

Source: Lamontagne E, Over M, Stover J et al. The economic returns of ending the AIDS epidemic by 2030. 2016, in press.

4
Compared with 2015 levels of coverage.

10
Validation of UNAIDS treatment data
UNAIDS/WHO estimates of the number of people who were accessing antiretroviral therapy at the end of
June 2016 were based on new treatment data submitted by 124 countries and estimates for 50 countries
using data previously reported to UNAIDS/WHO or other published data. Together these 174 countries
include 98% of the world’s population. Validation activities for the number of people on antiretroviral therapy
have included comparisons with a number of independent data sources, including WHO, PEPFAR, the Global
Fund, antiretroviral drug procurement and patient tracking data from selected countries, Indian generic
manufacturer transaction data, selected countries’ data quality assessments and national population-based
surveys that included measurement of antiretroviral medicines in the blood samples of survey participants.

The analysis of generic manufacturers' export data suggested that a quantity of antiretroviral drugs to treat
13.7 million–15.7 million people was procured in 2015, compared to the reported 13.9 million people on
antiretroviral therapy in generic-accessible low- and middle-income countries. Additional triangulation
for high-burden countries validated the numbers of people on treatment for the majority of countries
where alternative data sources were available. In some countries, the quality of the data available at health
facilities and reported to the national health information system, although improving over time, was of
concern. Because of the uncertainty in data quality in some countries, the estimated numbers of people
on antiretroviral therapy presented in this report are accompanied by ranges representing this uncertainty.
UNAIDS, WHO and other partners continue to support countries to improve the accuracy of the numbers of
peopl\e reported to be on treatment.

A detailed description of UNAIDS methods for estimating mid-2016 antiretroviral therapy numbers is
included in an annex to this report.

References

1. Panel 1: shared responsibility—a new global compact for HIV. New York: United
Nations General Assembly; 2011 (http://www.unaids.org/en/media/unaids/contentas-
sets/documents/document/2011/06/20110601_HLM_Pannel1.pdf).

11
 Finding solutions for everyone
at every stage of life

12
0–
14
 children (0–14)

Progress and gaps

In June 2011 UNAIDS and the United States President’s Emergency Plan for AIDS
Relief (PEPFAR) launched the Global Plan towards the elimination of new HIV
infections among children by 2015 and keeping their mothers alive (Global Plan)
along with 22 countries that at the time accounted for 90% of the global number of
pregnant women living with HIV.

The Global Plan galvanized global and national political will and action. Global
coverage of services to prevent mother-to-child transmission of HIV increased
The number of children
aged 0–14 years on dramatically, from 50% [44-56%] in 2010 to 77% [69-86%] in 2015. As a result, the
antiretroviral therapy number of new HIV infections among children aged 0–14 years has declined by 51%
globally has doubled since 2010. In addition, the number of children aged 0–14 years on antiretroviral
over the past five years, therapy globally has doubled over the past five years, from nearly 452 000 children in
reducing AIDS-related
2010 to 910 000 [801 000–947 000] children by mid-2016, pushing down the number
deaths among children
by 44%. of AIDS-related deaths among children by 44%.

New HIV infections among children (aged 0–14 years) and percentage of pregnant
women living with HIV receiving antiretroviral medicine (either prophylaxis or
lifelong therapy) to prevent mother-to-child transmission, global, 2005–2015

Percentage (%) of pregnant women living with HIV accessing PMTCT services
500 000 100
Number of new HIV infections among children (aged 0–14 years)

400 000 90

80
350 000

70
300 000

60
250 000
50
200 000
40

150 000
30

100 000
20

50 000 10

0 0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

New HIV infections PMTCT coverage Global targets of new HIV infections Global PMTCT target

Source: UNAIDS 2016 estimates.

Note: In 2010, single-dose nevirapine was no longer included in ARV coverage as an effective regimen for the prevention of mother-to-child
transmission.

14
 Children (aged 0–14 years) living with HIV on antiretroviral therapy and
number of AIDS-related deaths among children, global, 2005–July 2016

1 800 000 350 000

Number of AIDS-related deaths among children (aged 0–14 years)

1 600 000

Number of children living with HIV (aged 0–14 years)

300 000

1 400 000
250 000
1 200 000

on antiretroviral therapy
200 000
1 000 000

800 000 150 000

600 000
100 000

400 000

50 000
200 000

0 0
6
01
05

06

08

14

15

18
09

13

19
07

12

20
m 6
10

11

17
-2
1
20

20

20

20

20

20
20

20

id

20
20

20

20
20
20

20

20

Children living with HIV on antiretroviral treatment AIDS-related deaths among children

Global child antiretroviral treatment target

Source: 2016 Global AIDS Response Progress Reporting; UNAIDS 2016 estimates.

Efforts to move forward are being guided by a new global framework: Start Free Stay Free
AIDS Free (1). Co-chaired by UNAIDS and PEPFAR, the framework aims to end AIDS in
children, adolescents and young people by 2020 by building on key lessons learned from
the Global Plan: the critical role of country ownership; putting women, especially women
living with HIV, at the centre of policy discourse; strong monitoring and evaluation;
and good coordination and strong technical assistance. The Start Free and AIDS Free
components are focused on achieving the 2018 targets for children agreed by the United
Nations General Assembly:
>> Reduce the number of children newly infected annually to less than 40 000 by 2018.

>> Reach and sustain 95% of pregnant women living with HIV with lifelong HIV
treatment by 2018.

>> Provide 1.6 million children aged 0–14 years and 1.2 million adolescents aged 15–19
years living with HIV with lifelong antiretroviral therapy by 2018 [Reach 95% of all
children living with HIV].

15
 The world is nearly on track to reach the targets to reduce mother-to-child transmission;
however, the current rate of scale-up of paediatric treatment appears insufficient. Closing
the gap will require a tremendous additional effort to diagnose infants living with HIV and
enrol them in treatment as soon as possible.

Country status
Progress towards the elimination of new HIV infections among children has been
made across all regions, and in particular in eastern and southern Africa, which
achieved a 66% reduction in vertical transmission between 2010 and 2015 (2).
However, coverage of services varies greatly among countries within regions. Of
great concern are nine countries with large numbers of pregnant women living with
HIV unable to access antiretroviral medicines, and particularly Nigeria, which alone
accounted for more than a quarter of new HIV infections among children in 2015.

Distribution of new HIV infections among children (aged 0–14 years), global, 2015

Remaining
Nigeria
countries

India

Zambia

Malawi Kenya

Zimbabwe Mozambique

Indonesia United Republic of Tanzania

South Africa

Source: UNAIDS 2016 estimates.

16
Progress toward the elimination of HIV infections among children (aged 0–14 years), by
country, 2015

Decline in new HIV infections Percentage of pregnant women

among children (aged 0-14 years), living with HIV receiving
low- and middle-income countries, antiretroviral medicines (either
2010-2015 prophylaxis or lifelong therapy)
to prevent mother-to-child
transmission, low- and middle-
income countries, 2015

Asia and the Pacific

Afghanistan
Australia
Bangladesh
India
Indonesia
Malaysia
Mongolia
Myanmar
Nepal
Pakistan
Papua New Guinea
Philippines
Sri Lanka
Thailand
Viet Nam

Eastern Europe and central Asia

Azerbaijan
Belarus
Georgia
Kazakhstan
Kyrgyzstan
Republic of Moldova
Tajikistan
Ukraine
Uzbekistan

Latin America and the Caribbean

Argentina
Bahamas
Belize
Bolivia (Plurinational State of)
Brazil
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico

17
 Nicaragua
Panama
Paraguay
Peru
Suriname
Trinidad and Tobago
Uruguay
Venezuela (Bolivarian Republic of)

Eastern and southern Africa

Angola
Botswana
Eritrea
Kenya
Lesotho
Madagascar
Malawi
Mozambique
Namibia
Rwanda
South Africa
South Sudan
Swaziland
Uganda
United Republic of Tanzania
Zambia
Zimbabwe

Middle East and North Africa

Algeria
Djibouti
Egypt
Iran (Islamic Republic of)
Morocco
Somalia
Sudan
Yemen

Western and central Africa

Benin
Burkina Faso
Burundi
Cameroon
Cabo Verde
Central African Republic
Chad
Côte d’Ivoire
Democratic Republic of the Congo
Equatorial Guinea
Gabon
Gambia
Ghana
Guinea
Liberia
Mali
Mauritania
Niger

18
 Senegal
Sierra Leone
Togo

Western and central Europe

and North America
Greece
Italy
Latvia
Spain

Legend

Measures not available Measures not available

≤19% ≤32%
20-49% 33-65%
50-79% 66-94%
≥80% ≥95%

For countries not shown, both measures are not available or under review.

Key challenges
HIV testing among pregnant women

Routinely offering HIV tests to pregnant women during their first antenatal visit
and retesting them in the third trimester and during breastfeeding is the gold
standard in high-incidence settings (3). In some countries, however, inadequate
health-care infrastructure, poor linkages between HIV and maternal and child
health services, and lack of awareness of the importance of routinely offering HIV
testing prevent many women living with HIV from being reached.
Countries with low HIV testing coverage among pregnant women have many
challenges in common, such as a lack of test kits due to poor procurement and
supply chain systems. In addition, traditional beliefs, cultural practices, stigma and
discrimination, lack of confidentiality within health-care settings and transportation
challenges hinder access and contribute to underutilization of services. In the United
Republic of Tanzania, for example, a study found that concerns about confidentiality
of testing and test results, quality of HIV counselling and testing services, and
practical considerations such as accessibility and availability of ancillary services all
had an impact on the uptake of HIV testing services for pregnant women (4).

Mother-to-child transmission during breastfeeding

Many country programmes have emphasized the importance of providing

antiretroviral medicines during pregnancy and delivery but some do not take
sufficient steps to ensure that new mothers living with HIV are supported to adhere

19
 to their treatment in the months after giving birth. HIV-negative new mothers at
high-risk of HIV are also insufficiently tested while they are breastfeeding. As a
result, infants are exposed unknowingly to HIV during breastfeeding, with half
of all mother-to-child HIV transmissions occurring during this period. Many
women living with HIV are not aware that they need to remain on treatment while
breastfeeding their infants, and opportunities to reinforce the adherence messages
and resupply women with medication are fewer once the baby is born, as women
reduce their contact with the health system. Even when the baby is immunized, it
may not be the mother who makes the visit to the clinic, relying instead on an older
sibling or a grandparent while the mother works. Side-effects from antiretroviral
therapy and personal perception of wellness can also lead mothers to stop taking
their medication (5). Insufficient adherence support to breastfeeding women living
with HIV has seen postnatal HIV transmissions from mother to child remain higher
than 5% in eight of the 21 high-priority countries.

Six-week and final mother-to-child transmission rates, by country, 2015

Angola 11.1 20.6

Chad 10.9 19.4
Ghana 7.9 17.7
Côte d’ Ivoire 5.7 16.1
Democratic Republic
7.6 15.2
of the Congo
Cameroon 5.2 12.6
Lesotho 6.2 11.0
Malawi 4.3 8.7
Kenya 4.8 8.3
United Republic
3.6 7.6
of Tanzania
Zimbabwe 4.0 7.2
Burundi 3.2 6.7
Mozambique 3.0 6.2
Zambia 2.8 5.8
Namibia 1.9 4.1
Swaziland 1.7 3.3
Uganda 1.3 2.9
Botswana 2.1 2.6
South Africa 1.4 2.0

0 5 10 15 20 25
Mother-to-child transmission rate (%)

Six-week transmission rate Final transmission rate

Source: UNAIDS 2016 estimates.

20
 Low levels of paediatric diagnosis and slow initiation of treatment

Although AIDS-related deaths among children have reduced dramatically in recent years,
the vast majority of deaths still occur during the first five years of life.

Early HIV diagnosis and early antiretroviral therapy greatly reduce infant mortality
and HIV progression (6). Without antiretroviral therapy, 50% of children living with
HIV die before their second birthday (7). Tuberculosis (TB) is a common killer. In
2015, about 40 000 children living with HIV died from TB (8). Coverage of early
infant diagnosis remains low, however: only 4 of 21 priority countries—Lesotho, South
Africa, Swaziland and Zimbabwe—provided HIV testing to more than half the infants
exposed to HIV within their first eight weeks (9).

Coverage of early infant

diagnosis remains low: AIDS-related deaths among children by age group, global, 2000–2015
only 4 of 21 priority
countries provided HIV
testing to more than half 300 000
the infants exposed to
HIV within their first 8
250 000
weeks.

200 000
Number

150 000

100 000

50 000

-
00

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15
20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

20

0–4 years 5–9 years 10–14 years

Source: UNAIDS 2016 estimates.

21
 Even when infants are tested early, ineffective transport and poor communication
systems may result in prolonged turnaround times between blood sample collection
at clinics and the return of results. For example, a study in Zambia found that the
turnaround time from sample collection to return of results to the caregiver was 92
days (10). This leads to higher proportions of exposed infants being lost to follow-up
(11), initiating treatment very late or dying before they can start treatment. Others do
not have access to appropriate paediatric formulations.

TB disease occurring among pregnant women living with HIV is associated with
higher maternal and infant mortality (12,13). Maternal TB is also independently
associated with a 2.5-times increased risk of HIV transmission to exposed infants,
(14). All pregnant women, new mothers living with HIV should be screened for TB
symptoms, and children living with HIV should be fully investigated if they have signs
or symptoms suggestive of TB.

Percentage of infants born to women living with HIV receiving a virological test
within the first two months of life, by country, 2015

100
>95
93

81
80

60
54
Percentage (%)

47
44 45
42
40
33 33
31
30 30

20
20 17

2 3
0
Burundi

Chad

Nigeria

Democratic Republic
of the Congo
Malawi

Cameroon

Ghana

Ethiopia

Côte d’Ivoire

Uganda

United Republic
of Tanzania
Kenya

Botswana

Mozambique

Zimbabwe

Swaziland

Lesotho

South Africa

Source: 2016 Global AIDS Response Progress Reporting.

22
 A comprehensive approach
The Global Plan and the Start Free Stay Free AIDS Free framework have been built
on the four-pronged prevention of mother-to-child transmission of HIV framework
developed by the United Nations and implementing partners in the early 2000s.

Four prongs to eliminate mother-to-child transmission of HIV and improve

maternal health

Prong 1
Women of
Primary prevention of
reproductive age
HIV among women of
childbearing age

Prong 4 Women living with HIV

Provision of appropriate Prong 2
treatment, care and Prevention of
support to women, unintended
children living with HIV pregnancies among
Pregnant women living
and their families women living with HIV
with HIV

Prong 3
Prevention of HIV from a
Children living with HIV woman living with HIV to
her infant

Prong 1: primary prevention of HIV among women of childbearing age, including

treatment provision for serodiscordant couples and services for prevention, diagnosis and
treatment of sexually transmitted infections. Because childbearing age is defined in women
as age 15–49 years, this prong includes a significant proportion of adolescents. A key
component of Prong 1 is periodic HIV testing of women of childbearing age, including
Women at substantial during pregnancy and breastfeeding (15).
risk of infection should
continue taking PrEP
Prong 2: prevention of unintended pregnancies among women living with HIV through
when they become family planning not only reduces the number of HIV-exposed pregnancies but also reaps
pregnant and during the maternal and child health benefits associated with child spacing (16).
breastfeeding.
Prong 3: prevention of transmission of HIV infection from pregnant women living with
HIV to their children is best achieved when antiretroviral therapy is initiated by pregnant
women immediately following diagnosis and maintained during breastfeeding.

Prong 4: provision of appropriate care, treatment and support for women living with
HIV, and their children and families: World Health Organization (WHO) guidelines
recommend immediate lifelong antiretroviral therapy for all adults and children living
with HIV, regardless of viral load, CD4 count or WHO clinical stage.

23
 Closing the gaps
Pre-exposure prophylaxis for pregnant and breastfeeding women

Oral pre-exposure prophylaxis (PrEP) is being increasingly considered as an additional

HIV prevention option for pregnant and breastfeeding women in settings with continuing
high HIV incidence during this period of life (17). WHO recommends that women taking
PrEP should continue taking PrEP when they become pregnant and during breastfeeding
if they remain at substantial risk of infection. Investigators have examined the impact of the
antiretroviral medications tenofovir and emtricitabine on fetal development. An extensive analysis
commissioned by WHO confirmed that PrEP should be an option for pregnant and breastfeeding
women in high-prevalence settings in sub-Saharan Africa, and it recommended that mothers and
infants should be monitored for potential adverse effects (18). Globally, pregnant and breastfeeding
women within serodiscordant couples—where the male partner is living with HIV—should
consider PrEP in addition to antiretroviral therapy for the male partner until viral suppression
is achieved. Preventing HIV infection during pregnancy and breastfeeding has important
implications for transmission to the child because women who seroconvert during pregnancy or
breastfeeding are 18% and 27% likely to transmit the virus to their unborn child, respectively.

Simpler and cheaper diagnostic tools

The most commonly available virological HIV tests for infants require complex laboratory
instruments and highly specialized personnel, making it difficult for caregivers in rural areas
to provide consistent and timely results. Portable point-of-care systems have been developed
in response to this challenge. There are currently three assays on the market that can be run
from battery packs or main electricity and are rugged enough for use in mobile laboratories.
Because they are small and portable, and because they can be operated by trained
non-laboratory personnel, point-of-care technologies are likely to increase access to early
infant diagnosis and reduce loss to follow-up (19). An evaluation of the first commercially
available point-of-care and near-patient testing, conducted in multiple African countries,
suggests that these tests are as accurate as laboratory assays (20).

Early infant diagnosis is becoming more affordable. The Diagnostics Access Initiative1 jointly
negotiated in 2015 a 35% price reduction for diagnostic kits produced by Roche Diagnostics (21).

Testing infants at birth

Not all infant cases of HIV—especially when transmission from mother to child occurs
during childbirth—are detectable at birth. WHO recommends testing infants born to women

1
A partnership including UNAIDS, the World Health Organization (WHO), the Clinton Health Access Initiative (CHAI),
the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis
and Malaria, the US Centers for Disease Control and Prevention (CDC), the African Society for Laboratory Medicine,
USAID, UNITAID and UNICEF.

24
 living with HIV at six weeks of age, as this ensures a more accurate test result. Some mothers,
however, do not bring their babies back for testing at six weeks, and other babies living with
HIV may die within the first six weeks. In South Africa, paediatric HIV-related deaths peak
relatively early (22). In an effort to ensure that more infants living with HIV are diagnosed
and initiate treatment, the South African National Department of Health launched guidelines
in 2015 that called for all HIV-exposed infants to be tested at birth and at 10 weeks (23).
South Africa’s experience with at-birth testing is being watched carefully to see whether key
challenges can be overcome, such as mothers not bringing their babies back for the 10-week
test after their babies test negative for HIV at birth.

Linking mother–infant pairs

Point-of-care diagnostics cannot enhance paediatric outcomes unless there are parallel efforts to
improve clinical service delivery. In some areas of Uganda in 2013, less than 3% of infants born
to women living with HIV were retained in care after one month. With support from PEPFAR,
the Ministry of Health worked with 22 health facilities to improve retention of mothers living
with HIV and their babies. Mothers were interviewed to better understand their challenges.
The survey showed that 80% of retention problems were caused by forgotten appointments,
scheduling conflicts, lack of transport, privacy concerns and fear of disclosure to their partners.
The information was used to improve the quality of care, and community representatives such
Sending the results of
as peer mothers were engaged to locate mothers and their babies who were lost to follow-up. By
infants’ virological tests February 2014, 10 months after baseline, the 22 health facilities had all achieved strong gains,
by SMS has quickened retaining more than 60% of mother–baby pairs (24).
the delivery of test
results by an average of Many national health registries are still not properly formatted to facilitate longitudinal follow-up
17 days. of HIV-exposed infants or mother–baby pairs. Several countries are moving to paper-based or
electronic longitudinal registers that capture data on HIV-exposed infants and mother–baby
pairs and prompt paediatricians to determine the final HIV status of the infant at the end of
breastfeeding. Electronic health records allow for joint tracking of the mother and her infant
using one tool, and enable babies to be tested and treated even when they are brought to the
clinic for follow-up by someone else other than the mother.

Malawi is piloting the use of the short message service (SMS) widely available on mobile phones
to send reminders to mothers who miss postnatal appointments (25). SMS is also being used
in Kenya, South Africa, Mozambique, Zimbabwe, Rwanda and Zambia to send the results of
infants’ virological tests from centralized laboratories to printers in community-level health
facilities. A systematic review comparing paper-based systems and SMS systems showed that
SMS printers quickened the delivery of test results by an average of 17 days (26). In Kenya,
the HIV Infant Tracking System (HITSystem), which sends computer alerts to early infant
diagnosis and laboratory staff, and text messaging alerts to mothers, increased the proportion
of HIV-exposed infants retained in care nine months after birth; decreased turnaround times
between sample collection, laboratory results and notification of mothers; and increased the
proportion of infants living with HIV who initiate antiretroviral therapy (27).

25
 References

1. Start Free Stay Free AIDS Free. Geneva: Joint United Nations Programme on HIV/
AIDS and United States President’s Emergency Plan for AIDS Relief (https://free.unaids.
org/).

2. Prevention gap report. Geneva: Joint United Nations Programme on HIV/AIDS; 2016.

3. Consolidated guidelines on HIV testing services. Geneva: World Health Organization;

2015.

4. Njau B, Ostermann J, Brown D, Mühlbacher A, Reddy E, Thielman N. HIV testing

preferences in Tanzania: a qualitative exploration of the importance of confidentiality,
accessibility, and quality of service. BMC Public Health. 2014;14:838.

5. Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, et al. Why did I stop?
Barriers and facilitators to uptake and adherence to ART in Option B+ HIV care in
Lilongwe, Malawi. PLoS One 2016;11:e0149527.

6. Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA, et al. Early
antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med
2008;359:2233–2244.

7. Newell, Marie Louise, et al., ‘Mortality of Infected and Uninfected Infants Born to
HIV-Infected Mothers in Africa: A pooled analysis’, The Lancet, vol. 364, no. 9441, 2
October 2004, pp. 1236–1243.

8. Global tuberculosis report 2016. Geneva: World Health Organization, 2016.

9. On the Fast-Track to an AIDS-free generation. Geneva: Joint United Nations

Programme on HIV/AIDS; 2016.

10. Sutcliffe CG, van Dijk JH, Hamangaba F, Mayani F, Moss WJ. Turnaround time for early
infant diagnosis in rural Zambia: a chart review. PLos One. 2014;9:e87028.

11. Essajee S, Vojnov L, Penazzato M, Jani I, Siberry GK, Fiscus SA, Markby J. Reducing
mortality in HIV-infected infants and achieving the 90–90–90 target through innovative
diagnostic approaches. J Int AIDS Soc. 2015;18(Suppl. 6):20 299.

12. Gupta A, Nayak U, Ram M, et al. Postpartum tuberculosis incidence and mortality
among HIV-infected women and their infants in Pune, India, 2002–2005. Clin Infect
Dis 2007; 45:241–9. 4.

13. Pillay T, Khan M, Moodley J, Adhikari M, Coovadia H. Perinatal tuberculosis and

HIV-1: Considerations for resource-limited settings. Lancet Infect Dis 2004; 4:155–65.

14. Gupta A, Bhosale R, Kinikar A, et al. Maternal Tuberculosis: A Risk Factor for Mother-
to-Child Transmission of Human Immunodeficiency Virus. The Journal of Infectious
Diseases. 2011;203(3):358-362. doi:10.1093/jinfdis/jiq064.11

15. Dinh T-H, Delaney KP, Goga A, Jackson D, Lombard C, Woldesenbet S, et al. Impact of
maternal HIV seroconversion during pregnancy on early mother to child transmission

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 of HIV (MTCT) measured at 4–8 weeks postpartum in South Africa 2011–2012: a
national population-based evaluation. PLOS One. 2015;10:e0125525.

16. A focus on women: a key strategy to preventing HIV among children. Geneva: Joint
United Nations Programme on HIV/AIDS; 2014 (http://www.unaids.org/sites/default/
files/media_asset/JC2538_preventingHIVamongchildren_en_2.pdf).

17. Mofenson LM. Tenofovir pre-exposure prophylaxis for pregnant and breastfeeding
women at risk of HIV Infection: the time is now. PloS Med. 2016;13:e1002133.

18. Mofenson LM, Baggaley RC, Mameletzis I. Tenofovir Disoproxil Fumarate Safety for
Women and their Infants during Pregnancy and Breastfeeding: Systematic Review.
AIDS. 2016 Nov 7. [Epub ahead of print] PubMed PMID: 27831952.

19. Accelerate access to innovative point of care (POC) HIV diagnostics: CD4, EID and
VL. New York: United Nations Children’s Fund (http://www.unicef.org/innovation/
innovation_82102.html).

20. HIV/AIDS diagnostics technology landscape, 5th edition. Geneva: UNITAID; 2015
(http://www.unitaid.eu/images/marketdynamics/publications/UNITAID_HIV_
Nov_2015_Dx_Landscape.PDF).

21. Breakthrough global agreement sharply lowers price of early infant diagnosis
of HIV. Press release. Vancouver and Geneva: Joint United Nations Programme
on HIV/AIDS; 19 July 2015 (http://www.unaids.org/en/resources/presscentre/
pressreleaseandstatementarchive/2015/july/20150719_EID_pressrelease).

22. Lilian RR, Kalk E, Bhowan K, Berrie L, Carmona S, Technau K, Sherman G. Early
diagnosis of in utero and intrapartum HIV infection in infants prior to 6 weeks of age. J
Clin Microbiol. 2012;50:2373–2377.

23. National consolidated guidelines for the prevention of mother-to-child transmission

of HIV (PMTCT) and the management of HIV in children, adolescents and adults.
Pretoria: National Department of Health, Republic of South Africa; 2015.

24. Improving retention of mother–baby pairs: tested changes and guidance from Uganda.
Kampala: Ministry of Health; 2014 (https://www.usaidassist.org/sites/assist/files/phfs_
retention_of_mother-baby_pairs_change_package_usltr_oct2014.pdf).

25. Mwapassa V, Pro G, Chinkhumba J, Mukaka M, Kobayashi E, Stuart A, et al. Mother–

infant pair clinic and SMS messaging as innovative strategies for improving access to
and retention in eMTCT care and Option B+ in Malawi: a cluster randomized control
trial (the PRIME Study). J Acquir Immune Defic Syndr. 2014;67(Suppl. 2):S120–S124.

26. Essajee S, Vojnov L, Penazzato M, Jani I, Siberry GK, Fiscus SA, Markby J. Reducing
mortality in HIV-infected infants and achieving the 90–90–90 target through innovative
diagnosis approaches. J Int AIDS Soc. 2015;18(Suppl. 6):20 299.

27. Finocchario-Kessler S, Gautney BJ, Khamadi S, Okoth V, Goggin K, Spinler JK, et al. If
you text them, they will come: using the HIV infant tracking system to improve early
infant diagnosis quality and retention in Kenya. AIDS. 2014;28(Suppl. 3):S313–S321.

27
Finding solutions for everyone
at every stage of life
15–
24
 young people (15–24)

Progress and gaps

The 2030 Agenda for Sustainable Development aims to improve opportunities for
young people through greater access to good-quality education, health care and
employment opportunities, and through the achievement of gender equality and the
empowerment of all women and girls. The empowerment of young people is a key
component of an effective AIDS response. Of particular importance are adolescent
girls and young women in the countries hardest hit by the AIDS epidemic. In 2015
nearly 7500 young women aged 15–24 years acquired HIV every week, the vast
majority in southern Africa. Women’s and girls’ heightened vulnerability to HIV
goes far beyond physiology: it is intricately linked to entrenched gender inequalities,
harmful gender norms, and structures of patriarchy that limit women and girls from
reaching their full potential and leave them vulnerable to HIV.

Efforts to prevent HIV

The High-Level Task Force on Women, Girls, Gender Equality and HIV in Eastern
infections in young and Southern Africa, which brings together senior government and civil society
people are off track. representatives from nine countries and the regional directors of UNAIDS, the
Hitting the 2020 United Nations Children’s Fund (UNICEF), the United Nations Population Fund
target will require a (UNFPA) and UN Women, has demanded greater attention be paid to the underlying
74% reduction in new
causes of this vulnerability, including laws and cultural norms that block access to
infections among young
women between 2015 sexual and reproductive health services and facilitate violence against women. The
and 2020. Task Force’s efforts have been reinforced by the Fast-Track commitments made by
the United Nations General Assembly in 2016. The Political Declaration for Ending
AIDS includes a pledge to eliminate gender inequalities and end all forms of violence
and discrimination against women and girls, as well as a set of bold targets:

>> Reduce the number of new HIV infections among adolescent girls and young
women to below 100 000 per year.

>> Ensure that 90% of young people have the skills, knowledge and capacity to
protect themselves from HIV.

>> Ensure 90% of young people in need have access to sexual and reproductive
health services and combination HIV prevention options by 2020.

Efforts to prevent HIV infections in adolescent girls and young women are off track.
Between 2010 and 2015, new infections among females aged 15–24 years declined by 6%,
from 420 000 [360 000–480 000] to 390 000 [330 000–460 000]. Hitting the target of 100 000
new infections among young women will require a 74% reduction between 2015 and 2020.

30
 New HIV infections among young women (aged 15–24 years), global, 2005–2015
600 000

500 000

400 000
Number

300 000

200 000

100 000

0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

New HIV infections Global target

Source: UNAIDS 2016 estimates.

Country status
Reaching Fast-Track Targets for young people will require intensified and united
efforts. Population-based surveys suggest that less than 30% of young people aged
13–18 years in eastern and southern Africa attend secondary school, while in western
and central Africa approximately a third of young women aged 15–24 years report
having the final say in their own health care (1). Nearly a quarter of women aged
15–49 years in sub-Saharan Africa had an unmet need for family planning in 2015
(2). Less than half of young women aged 15–24 years in Comoros, Nigeria, and
Zambia reported using a condom the last time they had sexual intercourse with a
non-marital, non-cohabitating partner. Powerful new tools for HIV prevention such
as pre-exposure prophylaxis (PrEP) remain underutilized.

Percentage of young women (aged 15–24 years) reporting use of a condom at

last sexual intercourse with a non-regular partner in the 12 months prior to the
survey, eight countries in sub-Saharan Africa, 2012–2015

100
90
80
70
Percentage (%)

60
50
40
30
20
10
0
Lesotho Namibia Kenya Rwanda South Nigeria Zambia Comoros
Africa*

Source: Population-based surveys, 2012–2015.

*Data for South Africa refers to condom use at last sex among young women aged 15-24 who reported being sexually active.

31
 Demand for family planning satisfied by modern methods among young women
(aged 15-24 years), by country, 2010-2015

300

90

80

70
Percentage (%)

60

50

40

30

20

30

0
ia

da

ia

ia

da

os
an ic
aw
ny

bi
bw

oo

qu
th
ib

op

er
nz bl

or
an

an
m

Ca a
al
so

Ke
am

ig
Ta pu

bi
er
i
ba

m
hi
Rw

Ug
Za

N
Le

am
m
Et

of Re

Co
N

m
Zi

oz
d
ite

M
Source: Demographic and Health Surveys, 2010-2015. Un

Food insecurity, dropping Key challenges

out of school and
exposure to violence Structural barriers
have been linked to
increases in HIV-related The HIV risks faced by adolescents are higher when they come of age within challenging
risk behaviour among environments. An analysis of more than 3500 adolescents aged 10–17 years in South Africa
young women.
found that insufficient access to food and education, living in informal housing and exposure
to community violence, mediated by psychosocial issues, predicted increased onset of HIV risk
behaviour a year later (3). Demographic and Health Surveys conducted in sub-Saharan Africa
suggest that early sexual debut is most common among the least educated girls aged 15–19 years
(4). Adolescent girls who drop out of school are more likely to marry before the age of 18 years
(5), and child brides are often unable to negotiate safer sex, leaving them vulnerable to sexually
transmitted infections, including HIV (6).

Intimate partner violence

Multiple studies have shown that exposure to violence during childhood and adolescence
increases HIV-related risk behaviour among adolescent girls and young women (7). In
some regions, women who are exposed to intimate partner violence are 50% more likely
to acquire HIV than women who are not exposed (8). Studies have linked intimate partner
violence and even the fear of violence to women’s reluctance or inability to negotiate
condoms or to use contraceptives. Among women living with HIV, violence and trauma
can lead to lower adherence to treatment, lower CD4 counts and higher viral loads (7).

32
 Low levels of risk perception and knowledge of HIV status

National AIDS programmes have historically struggled to persuade people at higher risk of HIV
to periodically test for HIV. This has been especially the case among older adolescents and young
people, who often underestimate their risk of infection (9,10). Among people who tested positive
for HIV within Demographic and Health Surveys conducted in 19 low- and middle-income
countries (mostly in sub-Saharan Africa) between 2011 and 2015, only 50% of people aged 15–19
years had ever been tested for HIV and received the results, suggesting the other 50% were unaware
of their HIV-positive status. This compared with 76% of people aged 20–24 years living with HIV
and 78% of people aged 25–29 years living with HIV (11).
Low risk perception has also been linked to poor adherence among young heterosexual
women participating in oral PrEP pilots in sub-Saharan Africa (12). These pilots have
produced mixed results, with efficacy linked to whether women adhere to daily doses of
antiretroviral medication (13).

Percentage of people living with HIV (aged 15–59 years) who have ever been
tested for HIV and received the results, by age group, 19 low– and middle-
income countries, 2011–2015

100

90

80

70

60
Percentage (%)

50

40

30

20

10

0
15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59
Age (years)

Source: Demographic and Health Surveys, 2011–2015.

33
 There is a staggering Transmission dynamics between older men and younger women
gender imbalance in new
HIV infections among Data from seven longitudinal studies in six locations within eastern and southern Africa over five
young people, especially years (2010–2014) reveal a staggering gender imbalance in new HIV infections among young
in eastern and southern people within this region. In the eastern African cohorts, 74% of new infections among people
Africa. In some cohorts aged 15–19 years were in women; in southern Africa, young women accounted for 91% of new
within southern Africa,
infections among people aged 15–19 years (14). These studies and many others inform UNAIDS
young women accounted
estimates that show adolescent girls and young women aged 15–24 years accounted for 19% of new
for 91% of new infections
among people aged HIV infections globally in 2015 and 23% of new HIV infections in sub-Saharan Africa. Boys and
15–19 years. young men in the same age group accounted for 11% of new infections in sub-Saharan Africa.

Distribution of new HIV infections among men and women by five-year age
groups, nine locations in eastern and southern Africa, 2010–2014.

25

20

15
Percentage (%)

10

0
9

4
9

4
9

9
4

4
9
9
4

4
9
4

9
–2

–3
–1

–4

–5
–3

–4
–5

–3
–2
–3
–2

–4

–5

–2
–1
–4

–5
25

30
15

40

50
35

45
50

30
25
35
20

45

55

20
15
40

55

Age (years) Age (years)

eastern African countries southern African countries

Men Women

Source: Network for Analysis of Longitudinal Population-based HIV/AIDS Data on Africa (ALPHA), 2016.

34
Increasing attention has been paid to the role that age-disparate relationships
may play in this gender imbalance. Studies conducted in a variety of settings have
suggested that larger age differences among partners are associated with lower
condom use and higher rates of sexually transmitted infections among adolescent
girls and young women (15–18). Data from the third National HIV Communication
Survey of South Africa conducted in 2012 suggest that women aged 16–24 years
in age-disparate partnerships were more likely to report unprotected sex, and that
sexual transmission risks were amplified among young women in urban areas (19).
Another study, however, found that partner age disparity did not predict HIV
acquisition among young women in KwaZulu-Natal, South Africa (20).

New results from a phylogenetic study in KwaZulu-Natal shed further light on how
age-disparate sexual relationships appear to be an important element within high-
prevalence epidemics. The Centre for the AIDS Programme of Research in South
Africa (CAPRISA) analysed the blood of nearly 10 000 randomly sampled people
within two districts of the province between 2014 and 2015. Adult HIV prevalence
in these districts is 36% and is as high as 66% among women in their thirties (21).
The difference in HIV prevalence among men and women is greatest in the young
age groups, reinforcing that women in this community on average acquire HIV at a
younger age than men. The researchers mapped the genetic sequences of the viruses
in the HIV-positive blood samples and used this information to map the sexual
partnerships among the people living with HIV within the study:

>> A total of 90 clusters of probable male–female transmission were identified, and

within those clusters were 123 women and 103 men.

>> Among the women aged under 25 years, their sexual partners were on average 8.7
years older, with 62% of these men aged 25–40 years.

>> Among the women aged 25–40 years, their sexual partners were on average just 1
year older.

>> Among the men aged 25–40 years linked to a woman aged under 25 years, 39%
were linked simultaneously to a woman aged 25–40 years.
The most probable direction of transmission among these individuals was inferred
by the levels of HIV prevalence within this community—HIV transmission is most
likely to occur from high to low prevalence. Together, these data suggest that many
men aged 25–40 years living with HIV may have acquired HIV from a woman
aged 25–40 years, and that most of the younger women aged under 25 years living
with HIV may have acquired HIV from a man aged 25–40 years. Over time, as
the younger women grow older, this cycle is expected to continue (22). Greater
understanding of the sexual networks driving HIV transmission could help in the
design of programmes to reduce HIV infection in adolescent girls and young women.

35
 Cycle of HIV transmission, results from a phylogenetic study, KwaZulu-Natal, South Africa, 2016

Most HIV transmission Most HIV transmission

is likely from higher is likely from higher
prevalence (men 25-40 prevalence (women
years old) to lower
prevalence) women Men 25-40 years old) to lower
prevalence (men 25-40
under 25 years old)
(25-40 years old) years old)

HIV prevalence: 40%

Among men linked to young women
(<25), 39% were simultaneously
linked to a 25-40-year-old woman

Young Women Women

(under 25 years old) (25-40 years old)
HIV prevalence: 22% HIV prevalence: 60%

TIME
As women age, the cycle
repeats

Source: Centre for the AIDS Programme of Research in South Africa, 2016.

36
 Children living with HIV entering adolescence and adulthood

The scale-up of paediatric antiretroviral treatment has more than halved the
number of AIDS-related deaths among children. Hundreds of thousands of infants
born with HIV but enjoying a healthy childhood are one of the great triumphs of the
AIDS response over the past decade, but this comes with new challenges.
More and more children living with HIV are entering adolescence and adulthood.
An analysis of UNAIDS epidemiological data from 25 countries shows that the total
number of people aged 15–19 years living with HIV in these countries grew from
an estimated 800 000 in 2005 to 940 000 in 2015. Although new HIV infections
among young people living with HIV have gradually declined over the past 10 years,
the number of adolescents and young people who acquired their infection through
mother-to-child transmission increased nearly three-fold, from an estimated 96 000
to 380 000, reaching 40% of all people aged 15–19 years living with HIV in these
countries.

Number of young people living with HIV (aged 15–19 years) by mode of HIV
acquisition, 25 countries,* 1970–2015

1 200 000

1 100 000

1 000 000

900 000

800 000

700 000
Number

600 000

500 000

400 000

300 000

200 000

100 000

0
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

Sexual and unsafe injection transmission Mother-to-child transmission

* The 25 countries included in the analysis are Botswana, Brazil, Cameroon, Côte d’Ivoire, Democratic Republic of the
Congo, Ethiopia, Haiti, India, Indonesia, Iran (Islamic Republic of), Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria,
Rwanda, South Africa, Swaziland, Thailand, Uganda, Ukraine, United Republic of Tanzania, Zambia and Zimbabwe.
Source: UNAIDS special analysis, 2016; for more details, see annex on methodology.

37
 This transition is magnifying a challenge faced by HIV treatment programmes:
adolescents living with HIV have high rates of poor medication adherence and
treatment failure (23). The reasons behind this trend appear to be the manifold
social, familial and psychological changes that occur during adolescence, combined
with a transition from caregiver-mediated adherence within paediatric treatment to
the autonomous adherence expected of adolescent patients (24).

Cervical cancer

Women living with HIV are at four to five times greater risk of developing cervical
cancer (25). This risk is linked to the human papillomavirus (HPV), a common
infection among sexually active men and women that is difficult for women with
Women living with HIV compromised immune systems (such as women living with HIV) to clear. Among
are at 4–5 times greater women living with HIV, HPV prevalence rates can reach levels as high as 80% in
risk of developing Zambia and 90–100% in Uganda (26,27). Minimizing deaths from cervical cancer
cervical cancer. requires a comprehensive approach. Because HPV infection is common at younger
ages, a key strategy is early vaccination of adolescent girls, before sexual exposure
(28). HPV immunization programmes to date have been predominantly in high-
income countries. Of the estimated 118 million women aimed to be reached by HPV
immunization programmes conducted from June 2006 to October 2014, only 1%
were from low-income or lower-middle-income countries (29).

Synergies between the HIV response and efforts to prevent, diagnose and treat
cervical cancer through HPV vaccination, education, screening and treatment
must be maximized (30).The Cervical Cancer Prevention Program in Zambia has
demonstrated that linking cervical cancer screening and HIV services is a cost-
effective way of improving cervical cancer screening and treatment. This programme,
which integrated a national cervical cancer prevention programme into an existing
HIV programme, led to an expansion of cervical cancer screening to more than 100
000 women (28% of whom were living with HIV) over a period of five years (31).

38
 A comprehensive approach
Reducing new HIV infections among adolescent girls and young women to below 100 000
per year by 2020 requires comprehensive approaches tailored to local contexts. UNAIDS
has developed an options menu from which countries and districts can choose a mix of
structural and programmatic actions, based on country data and local contexts (32).

Detailed strategy mix for HIV prevention among young women–a menu
of options

MENU DIMENSIONS OF HIV PREVENTION

IMPACT
OPTIONS CHANGE OUTCOMES
CORE PREVENTION PROGRAMMES

Condoms

Social and
behavioural change
communication Fewer partners/
programmes more partner
choice
School-based (less risk partners)
prevention
(in context of
comprehensive Support choices of
sexuality education) women who have
agency
Safer sex
Pre-exposure negotiation
prophylaxis (PrEP) (condom use) Reduced
Behavioural HIV incidence
HIV testing services,
antiretroviral therapy, factors
voluntary medical
male circumcision
communicatiottns Consistent use
for men Reduce of antiretroviral
susceptibility medicines
and transmissibility for prevention
Community (antiretroviral
mobilization Synergistic
therapy, PrEP, effects on
post-exposure education,
Multimedia and prophylaxis)
Biological GBV, gender
POLICY AND STRUCTURAL ACTIONS

new media
factors norms,
SRHR
Cash transfers/
incentives
Enhance agency
Social policies
among adolescent
Keep girl and laws that
girls and young
in school protect and
women
promote human
Policy and rights
legal change
Structural
factors
Integration with More men go for
gender-based HIV/health
violence prevention services
and sexual and (HIV testing
reproductive health services/
rights antiretroviral
therapy and
voluntary medical
Enhanced male circumcision)
leadership

39
 Core prevention programmes

Social and behaviour change communication programmes entail a

combination of different activities, ranging from individual counselling to small-
group, community and media activities.

School-based HIV prevention: school presents an opportunity to reach a

substantial proportion of adolescent girls at low cost in order to address key HIV
prevention issues that affect them. School-based HIV prevention consists mostly
of interpersonal communication approaches, but it should also involve condom
distribution, which is still unavailable in school-based programmes in most high-
prevalence settings. Comprehensive sexuality education incorporates other sexual
and reproductive health issues, including early pregnancy, improving understanding
of puberty, and building confidence in communication and relationships among
learners.

Condoms: when used consistently and correctly, condoms are highly effective in
preventing the sexual transmission of HIV. Condom availability and accessibility need
to be rolled out in combination with promoting and enhancing women’s ability to
negotiate condom use.

PrEP is the use of antiretroviral medicines by HIV-negative people to avoid HIV

infection. The World Health Organization (WHO) recommends the use of oral PrEP
by all population groups at substantial risk of HIV infection (HIV incidence of about
3 per 100 person-years or higher). Oral PrEP is highly effective when the medication
is taken regularly; research on other forms of PrEP is ongoing.

HIV testing services can be a critical entry point for prevention communication.
HIV testing services should reinforce key communication messages to increase sexual
risk perception in the specific epidemic context.

Immediate offer of antiretroviral therapy for all people diagnosed with HIV is
critical to realizing population-level prevention effects of antiretroviral therapy for
adolescent girls and young women.

Voluntary medical male circumcision is a cost-effective, one-time intervention

that provides lifelong partial protection against female-to-male HIV transmission, and
contributes to lowering community-level HIV prevalence, thereby protecting women.

Policy change and structural programmes

Community mobilization is a process that helps communities identify, respond

to and address their needs. Community mobilization and participation has made
substantial contributions to HIV prevention, including among adolescent girls
and young women. In practice, community mobilization approaches are often

40
implemented through the same channels and organizations as, and complement,
social and behavioural change communication programmes. The active, informed and
voluntary participation of young people in decision-making processes, including the
design, implementation and monitoring of programmes which affect their health, is
vital to strengthening the effectiveness of the response.

Multimedia and new media: mass media components (including radio and
television programmes) are often part of social and behaviour change communication
programmes. A range of approaches have been applied for HIV prevention, including
call-in programmes, talk shows, soap operas with HIV prevention messages, and
advertising for condoms and HIV testing services. New media and multimedia
approaches are particularly relevant for adolescent girls and young women due to the
increased availability of smartphones.

Cash transfers and social grants: several recent studies show promising effects
of cash transfers and other economic incentives for preventing HIV among girls and
young women (33). Cash transfers are more likely to have an effect on reducing HIV
if they can increase schooling or meet survival needs and thereby prevent adolescent
girls from engaging in transactional and age-disparate relationships.

Keeping girls in school: increased school attendance can reduce the risk of
adolescent girls acquiring HIV, in three different ways. First, being in school
reduces early marriage and risky sexual partnerships (34, 35). Second, in advanced
HIV epidemics, higher educational attainment is itself associated with reduced
HIV prevalence later in life and with safer behaviours (36). Third, keeping girls in
school ensures that greater numbers of adolescent girls can access HIV prevention
information in the context of comprehensive sexuality education or school-based
campaigns.

Other policy and legal changes: provision of youth-friendly services in health

facilities, removal of legal barriers to adolescents’ use of HIV and sexual and reproductive
health services, ending child marriage, and passing and enforcing legislation against
gender-based violence are determinant factors of a conducive and enabling environment
to ensure all young people, adolescent boys and adolescent girls have access to HIV and
other sexual and reproductive health services. In addition, some countries have policies
related to parental, age, spousal and other third-party consent requirements that hamper
young people's access HIV testing and counseling, and other sexual and reproductive
health services. Stronger political advocacy is required in many countries to increase the
pace of policy and legislative change.

Integration: although HIV remains the single largest health concern for adolescent
girls and young women in high-prevalence settings, they also face a range of other
health issues, including gender-based violence and sexual, reproductive and maternal
health needs. Synergies in programme delivery, increases in service utilization, and
improvement in health outcomes can be achieved through integration of these services.

41
 Leadership and role models: leadership involvement in development programmes
is commonly applied as a strategy to build ownership and improve community
understanding, thus opening the way towards sustainability. In high-prevalence
locations, leaders can serve as role models for how society engages and interacts with
young women.

Closing the gaps

Bringing comprehensive approaches to scale

Combining a range of evidence-informed health services and structural changes is critical

to reducing HIV infections and improving treatment outcomes among adolescents and
young people. The DREAMS partnership1 is investing US$ 385 million to put in place
comprehensive approaches for adolescent girls and young women within dozens of
communities in 10 sub-Saharan African countries.2 Reaching the Fast-Track Targets will
require rapid expansion of this comprehensive approach. In Swaziland, a grant from the
Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is helping to bring
this approach to scale. Together, the DREAMS partnership, the Global Fund and PEPFAR
are covering 43 of the country’s 55 administrative subdivisions.

Programmes for adolescent girls and young women (aged 15–24 years)
in Swaziland, 2016

DREAMS*
The Global Fund to Fight
AIDS, Tuberculosis and
Malaria (Global Fund)
DREAMS and
the Global Fund
PEPFAR Country
Operational Plan
PEPFAR Country Operational
Plan and the Global Fund

*DREAMS is supported by the United States President’s Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates
Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences, and ViiV Healthcare.
Source: Swaziland Central Statistics Office 2016; PEPFAR Swaziland 2016.

1
Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe Women. The partnership is supported by the United States President’s Emer-
gency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation, Girl Effect, Johnson & Johnson, Gilead Sciences and ViiV Healthcare.
2
Kenya, Lesotho, Malawi, Mozambique, South Africa, Swaziland, Uganda, United Republic of Tanzania, Zambia and Zimbabwe. Together, these
countries accounted for an estimated 55% of new HIV infections among adolescent girls and young women in 2015.

42
 In South Africa, a three-year national HIV prevention campaign for adolescent girls
and young women, entitled SheConquers, was launched in 2016. SheConquers is
built around a five-point strategy that aims to decrease new HIV infections, teenage
pregnancies and gender-based violence among young women and adolescent girls,
to increase and retain young women and adolescent girls in school, and to increase
economic opportunities for young people, particularly young women (37).
A key component of these programmes is comprehensive sexuality education
within schools, which provides young people with the knowledge and skills to make
conscious, healthy and respectful choices about relationships and sexuality. There is
strong evidence that comprehensive sexuality education improves HIV knowledge
and self-efficacy related to refusing sex or condom use, and contributes to delayed
sexual debut and increased condom use, thus reducing sexually transmitted infections,
HIV transmission and unintended pregnancy (38).

The Eastern and Southern African Ministerial Commitment on Comprehensive

Sexuality Education and Sexual and Reproductive Health Services for Adolescents and
Young People was endorsed in December 2013 by ministers of education and health
from 20 countries in eastern and southern Africa. Progress made during two years of
implementation (2014–2015) showed that targeted interventions, sound strategies,
adequate resources and political will can stimulate reductions in HIV infections, early
and unintended pregnancies, gender-based violence and child marriage (39).
Comprehensive sexuality education is increasingly provided to adolescents and young
A combination of HIV people in high-prevalence settings. Among 21 countries in sub-Saharan Africa with
risk awareness, economic
available data, 12 include comprehensive sexuality education in at least 40% of their
empowerment and oral
PrEP is a potentially
secondary schools (39); most, however, do not include critical components on human
powerful HIV prevention rights and gender. Comprehensive sexuality education programmes with an explicit
method for young women focus on gender rights and gender power dynamics are five times more effective than
living within extremely those that do not, particularly in reducing unwanted pregnancies and incidence of
challenging economic and HIV and other sexually transmitted infections (40).
social circumstances.

Female-controlled prevention methods

As communities and cultures work towards an enabling environment, young women

at high risk of HIV infection require discreet and practical prevention options, such as
oral PrEP. Participants in a pilot conducted by CAPRISA illustrate that a combination
of HIV risk awareness, economic empowerment and oral PrEP can be a powerful HIV
prevention method within extremely challenging economic and social circumstances.
For example, a 22-year-old single mother from the Umlazi township in KwaZulu-
Natal, South Africa described how she maintains several sexual relationships with
men who support her financially. Some of these partners refuse to wear condoms.
Oral PrEP helps address her substantial HIV risks as she works to build a sustainable
livelihood as a pig farmer (22).

43
 The adherence challenges of oral PrEP are being addressed through experimental rings
that continuously release the antiretroviral drug dapivirine within the vagina. The most
recent results of phase III clinical trials show that that these vaginal rings reduced HIV
infections by at least 56% when used consistently, and reduced HIV risk by 75% or more
among a subgroup of participants who appeared to use the ring the most (41).

Voluntary medical male circumcision

Few policies and programmes currently focus on improving the health-seeking

More than 11 million behaviour of young men. As a result, such behaviour is generally poor (42).
adolescent boys and men Voluntary medical male circumcision, which provides men with lifelong partial
have been voluntarily
protection against HIV infection, is a potentially important entry point for providing
circumcised in 14 priority
men and boys with broader, more appropriate health packages. More than 11
countries within eastern
and southern Africa since million adolescent boys and men have been voluntarily circumcised in 14 priority
2008. countries within eastern and southern Africa since 2008, a success story that has
prompted WHO and UNAIDS to launch a new, more holistic framework for action:
VMMC2021. VMMC2021 has two main targets: by 2021, 90% of males aged 10–29
years will have been circumcised in high-priority settings in sub-Saharan Africa; and
90% of males aged 10–29 years will have accessed age-specific health services tailored
to their needs.

Social protection reduces HIV risk and improves treatment adherence

Social protection programmes are increasingly recognized as facilitators of improved

HIV prevention and treatment outcomes. Cash transfers and other financial incentives
have been used successfully to incentivize safer sexual practices in Lesotho and the United
Republic of Tanzania (43,44). In South Africa, augmenting financial support with social
support from parents and teachers, free education and care and support services increased
HIV-prevention benefits among adolescents and young people over cash alone (45).
Past-year incidence of economically driven sex was 10.5% among girls aged 12–18 years
participating in a study between 2009 and 2012 who did not receive any social protection
measures. Among those who received cash transfers alone, 5.7% engaged in economically
driven sex; and when cash, free education and parental monitoring were combined, only
2.1% engaged in economically driven sex (45).

Combining social protection provisions also increases the effectiveness of antiretroviral

therapy. A study of 1059 adolescents aged 10–19 years living with HIV in South Africa
showed that three social protection provisions—nutritional support of two meals a day,
attending an HIV support group, and ensuring high parental/caregiver supervision—were
associated with improved treatment adherence (24). Fifty-four per cent of adolescents
receiving no social protection provisions reported non-adherence to antiretroviral therapy
within the past week. Among adolescents who received cash transfers and provisions of
food, attended a support group and benefited from high parental supervision, only 18%
reported non-adherence (24).

44
 Past-week adolescent antiretroviral therapy non-adherence, by access to various
social protection measures, South Africa, 2016

80

70

60
Percentage (%)

50

40

30

20

10

0
No social Support Food Monitoring Food Support Food Food
protection group security security and group and security and security,
support monitoring monitoring support
group group and
monitoring

Source: L. D. Cluver, E. Toska, F. M. Orkin, F. Meinck, R. Hodes, A. R. Yakubovich & L. Sherr (2016) Achieving equity in
HIV-treatment outcomes: can social protection improve adolescent ART-adherence in South Africa?, AIDS Care, 28:sup2,
73-82, DOI: 10.1080/09540121.2016.1179008.

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49
Finding solutions for everyone
at every stage of life
Key
populations
throughout
the life cycle
 key populations throughout the life cycle

Progress and gaps

Communities of people who inject drugs, sex workers, transgender people and men who
have sex with men are among the hardest hit by the AIDS epidemic. HIV prevalence
within these groups is 5–49 times higher than in the general population, and an
estimated 36% of all new infections in 2014 were among key populations and their
sexual partners (1).

Reaching key populations with comprehensive HIV prevention services is critical to

achieving the global target to reduce new HIV infections to fewer than 500 000 by
2020. However, few countries and cities have mounted comprehensive responses for
key populations. Stigma, discrimination and criminalization are day-to-day barriers
to services in too many countries. HIV infection trends among key populations reflect
this. The available data are sparse and difficult to aggregate but suggest that new HIV
infections among people who inject drugs globally climbed from an estimated
114 000 in 2011 to 152 000 in 2015; new infections among sex workers remained
virtually unchanged at 125 000 a year over the same period. For men who have sex
with men, new infections rose by about 12% from 2011 to an estimated 235 000 new
infections in 2015. The few available data on transgender people suggest a stable rate in
new infections over the same time period.

Trends in new HIV infections among key populations, global, 2011–2015

250 000

200 000

150 000
Number

100 000

50 000

0
2011 2012 2013 2014 2015

Sex workers People who inject drugs Gay man and other men Transgender people*
who have sex with men

* Data on transgender people are from the Asia-Pacific and Latin America and Caribbean regions only.

Source: UNAIDS special analysis, 2016.

52
 Country status

Criminalization of any aspect of sex work, by country, 2016

Selling and buying sexual services criminalized

Selling sexual services criminalized

Buying sexual services criminalized

Partial criminalization

Other punitive regulation

Not subject to punitive regulation /not criminalized

Issue determined /differs at subnational level

Data not available

Source: Sexual Rights Initiative. 2016. National sexual rights law and policy database. (http://sexualrightsdatabase.org/page/welcome, accessed 13 November, 2016).

53
 Criminalization of same-sex sexual relations, by country

Death penalty

Imprisonment 15 years to life

Imprisonment up to 14 years

Relationship between males is illegal, no penalty specified

Promotion ("propaganda") laws limiting freedom of expression

Laws penalizing same-sex sexual acts decriminalized, or never existed

Data not available

Source: International Lesbian, Gay, Bisexual, Trans and Intersex Association, State Sponsored Homophobia 2016: A world survey of sexual orientation laws:
criminalisation, protection and recognition (Geneva; May 2016).

54
 Key challenges
Young people within key populations

Young people within key populations face particular HIV risks, often due to lower
knowledge of risks or lower ability to mitigate those risks compared with their older,
more experienced counterparts. A study of female sex workers in three main urban
areas of Mozambique (Maputo, Beira and Nampula) found that young women who
sell sex (aged 15–17 years) were less likely to access available testing and treatment
services (2).

In Kumasi, one of the largest cities in Ghana, sex workers aged 18–20 years expressed
accurate knowledge of HIV and intentions to consistently use condoms with clients;
however, factors such as higher payments, drug and alcohol use, fear of violence and
police harassment interrupted these intentions (3).

Available epidemiological data suggest that young men who have sex with men have
Young people within greater HIV risk than both heterosexual young people and older men who have sex
key populations face with men (4). Social and structural factors play an important role in the frequency
particular HIV risks, often
of unprotected anal sex with partners living with HIV among young men who have
due to lower knowledge
of risks or lower ability sex with men. Young men who have sex with men are often more vulnerable to the
to mitigate those risks effects of homophobia (manifested in discrimination, bullying, harassment, family
compared with their disapproval, social isolation and violence), criminalization and self-stigmatization
older, more experienced (4). These can have serious repercussions for their physical and mental health; their
counterparts.
ability to access HIV testing, counselling and treatment; their emotional and social
development; and their ability to access education, vocational training and viable
work opportunities (4). Use of drugs or alcohol and selling sex contribute to HIV risk
and represent overlapping vulnerabilities that some young men who have sex with
men share with other young key populations.

Young people who inject drugs are more likely than older people to lack knowledge
about safer injecting practices and HIV prevention, and to be unaware of risks to
their health (4). The few data available on young people who inject drugs suggest
their HIV risk is extremely high. A 2011 study found that more than a quarter of
young people who injected heroin in Dar es Salaam, United Republic of Tanzania,
were living with HIV (5); and a 2010 survey of street youth across multiple cities in
Ukraine found that a third of people aged 15–17 years who injected drugs were living
with HIV (6).

Insufficient domestic financing for key populations and lack of social

contracting

As international aid levels stagnate and donor priorities evolve, greater domestic
investments in HIV are being made. Within this global trend, however, key
populations have been woefully left behind in many countries. Between 2010 and

55
 2014, among 85 countries that reported spending on services for men who have sex
with men, only nine countries were funding more than half of their HIV response,
only eight countries put in more than 10% of the total, and more than two thirds of
reporting countries relied on international sources for almost 100% of their spending
on these services.1 On average, domestic funding accounted for only 12% of spending
on prevention programmes for men who have sex with men. The percentage of
total prevention spending that comes from domestic sources is similarly low for
sex workers (20%) and people who inject drugs (25%) (1). Even when programme
financing is picked up by national governments, community-based organizations
previously funded from international sources may be dropped from programmes,
despite overwhelming evidence that their engagement is critical to the success of
these programmes. Peer-supported education, condom distribution and referral to
health services tend to be neglected in favour of clinical approaches that emphasize
HIV case finding and treatment. The establishment of social contracting mechanisms
for services provided by such organizations is critical to the sustainability and
effectiveness of efforts to deliver HIV services to key populations.

Human rights barriers to accessing services

30% of countries report The highest attainable standard of health, including access to affordable, timely
having laws, regulations health-care services, is a basic human right for all, including key populations (8). The
or policies that are HIV response can effectively tackle the public health threat posed by the epidemic
barriers to effective HIV only if punitive legal environments, stigma, discrimination and other human rights
prevention, treatment,
barriers that routinely block key populations from health services are addressed.
care and support for men
These barriers exist in multiple settings, including health, education, employment,
who have sex with men,
people who inject drugs, community, law enforcement and justice.
sex workers and trans-
Thirty per cent of countries report having laws, regulations or policies that are
gender people.
barriers to effective HIV prevention, treatment, care and support for men who
have sex with men, people who inject drugs, sex workers and transgender people
(9–14). Criminalization of sex work, drug use and same-sex acts, and other punitive
practices, policies and laws prevent systematic programming. HIV and other
health services are often unavailable in prison, and a history of imprisonment can
compound marginalization and exclusion.

Same-sex sexual relations are criminalized in 73 countries—approximately one third

of the world same-sex sexual relations (15). Men who have sex with men living within
these legal environments are deterred from seeking HIV-related services. In other
countries, notably the Russian Federation and Lithuania, the ill-defined concept of
“promoting homosexuality” has been criminalized; laws related to this have been
used to attack lesbian, gay, bisexual, transgender and intersex rights rights groups and

1
More than 50%: Colombia, Dominica, Chile, Cuba, Sri Lanka, Malaysia, Mexico, Algeria, Mauritius. more than 10%: Costa Rica, Guatemala,
Pakistan, Kazakhstan, Mauritius, Suriname, Thailand, Congo (7).

56
have had a serious impact on the ability to provide community-based HIV prevention
services (15). Similarly, transgender people typically face a lack of legal recognition
of their gender and are not explicitly included in anti-discrimination laws (16), and
there are laws in 55 countries that criminalize transgender people or are used to
prosecute them (13).

When it is illegal to possess small quantities of drugs for personal use, people who
inject drugs are more likely to engage in high-risk practices such as sharing needles.
The fear of being arrested by police prevents people who inject drugs to access
harm reduction and other HIV and health services. Alongside HIV, people who use
drugs are extremely vulnerable to hepatitis C and tuberculosis. An estimated 10
million people who inject drugs have hepatitis C infection (18). Other punitive laws,
policies and practices include discrimination against people with a history of drug
use, mandatory registration of people who use drugs, and denial of harm-reduction
measures (19). Drug-related offences carry the death penalty in 31 countries, and the
death penalty is actively enforced in 7 of these (12). Women who use drugs, especially
those who inject drugs, face higher levels of stigma, discrimination and vulnerability
to harm than their male counterparts. In some countries they have been forced to
undergo sterilization or abortions, separated from their children and denied public
housing and other benefits (19).

The criminalization of sex work puts sex workers at risk of violence from law
enforcement officers and clients because they have no recourse to the law. Selling
and/or buying sex is partially or fully criminalized in at least 39 countries (11). In
many more countries some aspect of sex work is criminalized, and in other countries
general criminal law is applied to criminalize sex work (for example, laws against
loitering and vagrancy). When possession of condoms is used by the police as
evidence of sex work, this greatly increases the risk of HIV among this key population
(1). Even where sex work is not criminalized, sex workers are rarely protected under
the law (21).

Criminalization of key populations contributes to incarceration in prisons and other

closed settings where HIV and tuberculosis risks are compounded by overcrowding
and limited access to HIV and other health services. As a result, people in prisons
are at high risk of HIV infection, HIV-related comorbidities and AIDS-related
deaths. Injecting drug use is much more common in prisons than among the general
population. Paradoxically, the provision of harm reduction services in prisons is
extremely rare (19). The prevalence of hepatitis C virus ranges from 3.1% to 38%
among prisoners and has been linked to sharing injecting equipment, tattooing
and unprotected sexual intercourse (22). A high prevalence of HIV, overcrowding,
poor ventilation, drug use and previous unhealthy lifestyles have been identified as
contributors to the spread of tuberculosis within prisons (23). A systematic review
found that improving tuberculosis control in prisons would significantly reduce a
country’s overall tuberculosis disease burden (24).

57
 Comprehensive approaches

Detailed strategy mix for HIV prevention among transgender people

DIMENSIONS OF HIV PREVENTION

IMPACT
CHANGE OUTCOMES

Trans competent
health services
(incl transitional Reduce host Consistent use
management care, susceptibility of condoms and
sexual and lubricants
reproductive
health, sexually
transmitted
infections and
coinfections/ Biological
morbidities TB, factors
Hep and mental
CORE PREVENTION PROGRAMMES

health) Increased access

to tailored HIV Reduced HIV
prevention incidence
Condoms and services
lubricant
programming Decrease source of
HIV Infection
Pre-exposure pro-
phylaxis, post-ex-
posure prophylaxis
and harm reduction Increased
interventions for adherence to
substance use and Behavioural care, treatment
safe injections factors and viral
suppression Reduced HIV
morbidity and
Social and mortality
behavioural
change
communication
programmes Increase safer
sexual behaviours,
uptake of services Social policies
HIV testing and and laws that
and adherence
counseling and protect and
antiretroviral promote human Human rights
therapy rights of lesbian,
gay, bisexual,
transgender and
intersex people
POLICY AND STRUCTURAL ACTIONS

Community Structural
empowerment factors are respected.
Discrimination
Reduced and transphobia
Policy and legal prevalence of decreased
change: violence,
addressing laws Effective anti discrimination,
and rights discrimination stigma and risk
legislation and for HIV
Stigma and recognition under
discrimination the law
reduction and
prevention of
violence

Individual and
community/
peer-led/outreach
services

58
 Detailed strategy mix for HIV prevention among people who inject drugs

DIMENSIONS OF HIV PREVENTION

IMPACT
CHANGE OUTCOMES

Consistent use
Needle and syringe
Availability of of sterile needles
programmes
a services and syringes

Condom
programmes
and information,
education and
Biomedical Consistent
communication
factors condom use
for people who
inject drugs
CORE PREVENTION PROGRAMMES

and their sexual Reduced HIV

partners incidence
Reduction in
the number of
Opioid substitution Risk perception and injections among
therapy and other adoption of safer people on opioid
evidence-informed behaviours substitution
drug dependence therapy
treatments

HIV testing and

antiretroviral Behavioural
therapy factors Reduced
morbidity and
mortality
Prevention,
diagnosis and
treatment for
viral hepatitis,
tuberculosis and
sexually transmitted
infections

Opioid overdose
management
with naloxone,
including community
distribution

Empowerment Enabling
of community environment and
and civil society empowerment for Increased
organizations service uptake adherence to
POLICY AND STRUCTURAL ACTIONS

treatment, viral
suppression and
reduced onward Reduction in
Legal support and Structural human rights
transmission
access to justice factors violations and
drug-related
crime
Reduction in
Harm reduction stigma,
services in prisons discrimination

Actions to reduce
stigma and
discrimination

Alternatives to
criminalization,
incarceration,
penalization
of drug use or
possession for
personal use.

59
 Detailed strategy mix for HIV prevention among sex workers

DIMENSIONS OF HIV PREVENTION IMPACT

CHANGE OUTCOMES

Targeted
interventions to Consistent use
Availability of of condoms with
reduce violence
a services clients and regular
against sex
workers partners
CORE PREVENTION PROGRAMMES

Targeted condom
programmes
and focused Biomedical
information, factors Acces to PreP
education and
communication for
sex workers

Reduced HIV
incidence

HIV testing and Reduction

antiretroviral Increased agency
and adoption in violence
treatment and against sex
prevention of of safer
behaviours workers
mother-to-child
transmission

Violence
systematically
Pre-exposure
reported by
prophylaxis (PrEP)
sex workers and Reduced
increased follow-up morbidity and
mortality

Access to
legal support and
justice Behavioural
POLICY AND STRUCTURAL ACTIONS

factors

Increased
adherence linked
Support and to treatment, viral
empower suppression
sex worker-led Reduction in
community and human rights
civil society Improved risk
violations,
organizations environment
including violence

Reduction in
stigma,
discrimination (in
Actions to reduce the health sector)
stigma and
discrimination,
including legal Structural
reform and factors
decriminalization
of sex work

60
 Detailed strategy mix for HIV prevention among gay men and other men who
have sex with men

DIMENSIONS OF HIV PREVENTION IMPACT

CHANGE OUTCOMES

HIV testing services Increased

and antiretroviral adherence to
Reduce
therapy treatment, viral
transmissibility
suppression and
reduced onward
transmission
CORE PREVENTION PROGRAMMES

Pre-exposure Biomedical
prophylaxis (PrEP) factors Increased number
of people on and
protected by
PrEP Reduced HIV
incidence

Condoms and
lubricant Increase access
Consistent use
programming of condoms and
lubricants

Behavioural
Social and
factors Reduction of
behavioural
change AIDS-related
communication mortality
programmes
Increase safer
sexual behaviours,
uptake of services
Individual and and adherence
community/ Reduced number
peer-led/ sex of sexual partners
venue-based
outreach services Reduced stigma,
Structural
discrimination
factors
and violence

Improved risk
New information environment
and communication Decriminalization
technologies (ICT) of same sex
POLICY AND STRUCTURAL ACTIONS

behaviours and
empowerment

Protective laws,
regulationsand
policies in the
context of HIV

Address stigma,
discrimination,
including in the
health sector, and
prevent violence

Community
empowerment

61
 Core prevention programmes

Condom programmes targeted at key populations: when used correctly and

consistently, condoms are highly effective in preventing sexual transmission of HIV.
Condom programmes must be tailored to effectively target each key population.

Pre-exposure prophylaxis (PrEP) is the latest addition to efforts to expand combination

prevention options for people at high risk of HIV infection. PrEP empowers individuals with
limited personal prevention options to discreetly take control of their own HIV risk. In some
countries there appears to be high demand among men who have sex with men.

HIV testing can be a critical entry point because the counselling and testing process
presents an opportunity for behaviour change communication and opens the pathway to
treatment and care for people living with HIV.

HIV treatment not only is life-saving for the recipient but also helps protect the sexual
partners of people from key populations from being infected. Combination programmes
for key populations should include, where appropriate, access to pre- and post-exposure
prophylaxis. Female sex workers and women who inject drugs also need access to services
for prevention of mother-to-child transmission of HIV.

Information, education, communication: empowering members of key populations

with the information they need to protect themselves is a key component of HIV prevention.
This is typically best done through peer-to-peer networks and encompasses not only health
but also legal issues and involvement in policy advocacy. Social media offers innovative ways
to reach out to and engage with groups who are otherwise hard to reach.

Harm reduction: needle–syringe programmes, opiate substitution therapy and

overdose prevention using naloxone are strong evidence-based services for people who
inject drugs, including those in prisons and other closed settings. Other key populations
also benefit from harm-reduction programmes for alcohol, drugs and other substance use.

Non-HIV health services such as prevention, screening and treatment for tuberculosis,
hepatitis B and C, and sexually transmitted infections are valuable public health
interventions in their own right, and can reinforce efforts to attract members of key
populations to take up HIV prevention and testing services.

Trans-competent health services and peer-led outreach are essential to overcome

the unique barriers preventing transgender people from accessing vital HIV prevention
and treatment services. Widespread stigma, discrimination and denial of gender identity
in mainstream health services deter transgender people from seeking services there.
Peer-led outreach has been proven highly effective, but education and behaviour change
communication with mainstream health-care workers are also very important.

Policy change and structural programmes

Empowerment of key population communities and the civil society organizations that
represent their interests has enabled HIV policy-making to be informed and shaped by the
people it aims to help.

62
 Rights literacy, legal services, access to justice, and monitoring and
reviewing discriminatory and other punitive laws: criminalization of sex
work, drug use and sexual orientation, and denial of gender identity are structural
barriers to the HIV response. Rather, laws should protect key populations, and key
population communities need to be well-informed about what rights they do have
and empowered to exercise them.

Stigma, discrimination and violence reduction: violence and other human

rights violations are a fact of daily life for many key populations, and stigma impedes
their ability to seek HIV and other services. Programmes addressing discrimination
in health care and building human rights competencies of law enforcement workers
are important interventions to reduce structural barriers that keep key populations
away from services. Reducing violence, tackling discrimination wherever it is found,
and overcoming the crippling effects of stigma are all key HIV interventions.

Closing the gaps

Comprehensive approaches produce results

Truly comprehensive There is strong evidence that comprehensive programmes can reduce HIV incidence
programmes can reduce among key populations. Programmes that incorporate access to a range of medical
HIV incidence among key care services, including PrEP, integrated HIV and sexually transmitted infection
populations. However, services, and rapid initiation of treatment for people diagnosed with HIV are
few countries and cities
reducing HIV infections among men who have sex with men in the American cities
have put them in place.
of San Francisco, Boston and Seattle (25). In Boston, where men who have sex with
men account for 64% of people living with HIV, new HIV infections among men
declined by 31% between 2005 and 2013 (26). In Seattle, where more than two thirds
of residents diagnosed with HIV are men who have sex with men, the percentage of
men who have sex with men accessing HIV testing services who tested positive for
HIV declined from 2.8% to 1.8% between 2007 and 2014 (27).

A comprehensive package of services for people who inject drugs, featuring harm
reduction and an enabling legal environment, can produce dramatic results. In Portugal,
depenalization of the purchase, possession and consumption of small amounts of narcotic
drugs, and expansion of the availability of harm-reduction services, coincided with a 95%
decrease in the number of people who inject drugs diagnosed with HIV over 10 years (19).

Street children, particularly those who use drugs, are among the people most
vulnerable to HIV and the hardest to reach. A multisectoral response in Saint
Petersburg, Russian Federation, including social support and HIV prevention
measures such as violence prevention, significantly reduced HIV infections among
street children; HIV prevalence decreased by 73% between 2006 and 2012 (28).

63
 South Africa steps up for sex workers

HIV prevalence among female sex workers in Johannesburg, South Africa is 71.8% (29).
The South African Government tackled this challenge through a comprehensive HIV
programme focused on sex workers that has inspired a national action plan specifically
targeting sex workers’ needs.

The Red Umbrella programme of the National AIDS Council of South Africa,
implemented from October 2013 to March 2016, combined biobehavioural, social
and structural interventions. The nationwide programme enlisted peer motivators
to assist in the distribution of condoms and lubricant, information on sexually
transmitted infections and HIV prevention, paralegal services and health service
referrals. Community empowerment services that aim to reduce violence, stigma and
discrimination included sensitization training and a helpline for sex workers. Red
Umbrella exceeded its targets, reaching 34 638 sex workers with HIV testing services
(129% of the target) (30). Attitudes of health-care workers and law enforcement officers
improved over the course of the programme, and the programme also fostered high
levels of social cohesion and mutual support among sex workers.

As the programme drew to a close, the South African National Sex Worker HIV Plan
2016–2019 was launched. The Plan acknowledges that South Africa’s drive to reduce

Rapid scale-up of HIV testing and counselling services for sex workers:
the experience of the Red Umbrella Programme in South Africa, 2013–2016

140

120

100
Percentage (%)

80

60

40

20

0
Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter Quarter
1 2 3 4 5 6 7 8 9 10

Actual
Target

Source: Networking HIV & AIDS Community of Southern Africa (NACOSA), 2016.

64
new HIV infections can succeed only if sex workers are no longer marginalized and
stigmatized. It calls for a standard minimum package of services to be implemented by
government and nongovernment providers. Sex workers will also be eligible for PrEP and
universal test-and-treat services. There are three tiers of service delivery: dedicated clinics
in areas with a high density of sex workers; mobile services delivered at sex work hotspots
with support from outreach teams; and 1000 peer educators. Together they aim to provide
services to approximately 70 000 sex workers (29).

Zimbabwe is also in the process of developing a strategic action plan to guide the services
for sex workers. As part of the United States President’s Emergency Plan for AIDS Relief
(PEPFAR) DREAMS initiative, nongovernmental organizations are supporting young
women who sell sex in six districts to access services through the Sisters with a Voice
programme. The programme includes community mobilization specifically tailored to
young sex workers’ needs, and referral to a range of services, such as educational grants,
cash transfers, social protection and PrEP (31).

Transgender HIV prevention innovations from Peru and India

Among key populations at higher risk of infection, transgender women have until
recently been either ignored or subsumed within the response for men who have sex
with men. Their HIV risk profile, needs and specific challenges are quite distinct,
however, and can be addressed only with actions tailored specifically for them.

Until recently, Peru’s national HIV programme did not recognize the country’s 23 000
transgender women, although they have the highest HIV prevalence in the country.
In the capital, Lima, HIV prevalence among transgender women is 30%, in contrast to
0.23% among the general population (32). Biological and behavioural risks (receptive
anal sex, transactional sex, high number of sexual partners, low condom use) and
structural factors, such as a gender identity that is not legally recognized, drive high
HIV incidence among transgender women. It is common for government security
forces to perpetrate violence against transgender women, and the lack of protective laws
exacerbates transgender women’s social and structural exclusion (32, 33).

In December 2014 the Ministry of Health in Peru committed to improve programming

for transgender women. Policy dialogue between key stakeholders included the
Ministry of Health, academia, civil society, transgender organizations and international
agencies. The result was the Targeted Strategy Plan of STIs/HIV/AIDS Prevention
and Comprehensive Care for Transwomen (34). The plan stresses the importance
of structural interventions and the engagement of community organizations and
places particular emphasis on three key elements of strong planning for hard-to-
reach populations: availability of relevant data, capacity-building for advocacy among
transgender women, and active participatory policy dialogue.

In India, community engagement and strengthening are key elements of the Pehchan
programme. With a grant from the Global Fund to Fight AIDS, Tuberculosis and

65
 Malaria, the programme provided HIV, health, legal and social services to transgender
communities across 18 Indian states through a rights-based empowerment approach
(35). A study quantifying the impact of the programme found that access to condoms
increased by 12.5%. Condom use during last anal sex increased 18.1% with regular male
partners and increased 8.1% with casual male partners. There was a 20.1% increase in
access to HIV outreach education and testing and counselling, and even bigger increases
in access to emergency crisis response (19.7%), legal support (26.8%) and mental health
services (33.0%).

Taking full advantage of PrEP

PrEP has been shown to greatly reduce the risk of HIV infection among key populations.
A study of men who have sex with men in the United Kingdom of Great Britain and
Northern Ireland found PrEP reduced HIV incidence by 86% (36). Low adherence
PrEP greatly reduces
HIV risk among key erodes effectiveness, however. A demonstration project among adolescent men aged
populations, but it is not 15–17 years who have sex with men found that adherence dropped off considerably after
a “magic bullet”; PrEP study visits changed from monthly to quarterly, suggesting that young people on PrEP
must be used alongside would benefit from more intensive support compared with their older participants (37).
programmes such as
condom distribution, The study emphasizes that PrEP should not be taken as a “magic bullet”; PrEP must be
treatment for sexually used alongside other programmes, including condom distribution, education, treatment
transmitted infections for sexually transmitted infections, and programmes aimed at removing structural
and the removal of struc-
barriers such as punitive laws, stigma, discrimination and police abuse. For sex workers,
tural barriers.
there are fears that PrEPcould be seen by their clients as an alternative to condoms (38).
PrEP also requires regular HIV testing as it cannot be taken safely by people living with
HIV; this is a challenge in settings where HIV testing is not easily and freely available to
key populations, or where stigma and discrimination in health-care settings keep people
away from testing services. PrEP also increases the medicalization of HIV prevention,
which places extra demands on both the health system and the individual.

Bringing the data together: the Key Populations Atlas

Knowing which programmes can drive the end of AIDS is only one step. The next
step is to know exactly where those interventions should be deployed. The UNAIDS
Key Populations Atlas is the largest single visualization tool dedicated to displaying
HIV-relevant data describing the epidemic and response among five key populations:
men who have sex with men, sex workers, people who inject drugs, transgender people
and people in prison (18).

The Atlas brings together epidemiological, behavioural, structural and programmatic

data about the HIV epidemic and response at subnational levels. It is the first effort
to aggregate these data in a way that can be used by both public health professionals
and community advocates. The distribution of data, the assessment of quality of the

66
Geospatial data visualization in the UNAIDS Key Populations Atlas

The UNAIDS Key

data, and the ability to layer structural determinants (e.g. resources, laws, stigma and
Populations Atlas is the discrimination) with epidemiological data provide policy-makers with a holistic picture
largest single visualiza- of a country’s key populations. The Atlas shows were data are available, shows where
tion tool dedicated to gaps exists, and reveals crucial details not reflected in national-level data. For example,
displaying HIV-relevant in Ethiopia the reported national prevalence of HIV among sex workers is 24%, but
data describing the
subnational data from seven sites show wide variation, from 13% to 32%. Such data are
epidemic and response
among five key popula- especially useful when local programme planners do not have access to geographical
tions. information system tools. In addition, community advocates can use the tool to call for
equity in service access.

In the near future the Atlas will incorporate subnational data from programmes outside
global AIDS monitoring reporting for a large number of localities, and the legal database
will be expanded.

67
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Boston, MA: Executive Office of Health and Human Services; 2015 (http://www.
mass.gov/eohhs/docs/dph/aids/2015-profiles/city-boston.pdf).

27. HIV/AIDS 2015 epidemiology report: Washington State—Seattle & King County,
84th edition. Seattle, WA: Public Health—Seattle & King County and Infectious
Disease Assessment Unit, Washington State Department of Health; 2015 (http://
www.kingcounty.gov/healthservices/health/communicable/hiv/epi/~/media/health/
publichealth/documents/hiv/2015EpiReport.ashx).

69
 28. Kornilova MS, Batluk JV, Yorick RV, Baughman AL, Hillis SD, Vitek CR. Decline
in HIV seroprevalence in street youth 2006–2012, St. Petersburg, Russia: moving
toward an AIDS-free generation. Int J STD AIDS. 2016 [Epub ahead of print].

29. South African National Sex Worker HIV Plan 2016–2019. Pretoria: South African
National AIDS Council; 2016.

30. Stacey M, Shackleton S, Rangasami J, Konstant T. From brothels to parliament:

lessons learnt from scaling up a rights-based sex worker HIV programme. Cape
Town: NACOSA; 2016.

31. F Cowen, Centre for Sexual Health and HIV/AIDS Research, personal
communication, 1 November 2016.

32. Salazar X, Núnez-Curto A, Villayzán J, Castillo R, Benites C, Caballero P, Cáceres

CF. How Peru introduced a plan for comprehensive HIV prevention and care for
transwomen. J Int AIDS Soc. 2016;19 (Suppl. 2):20 790.

33. Silva-Santisteban A, Raymond HF, Salazar X, Villayzan J, Leon S, McFarland W, et

al. Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru:
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Behav. 2012;16:87 281.

34. Maiorana A, Kegeles S, Salazar X, Konda K, Silva-Santisteban A, Cáceres C.

Community involvement: “Proyecto Orgullo”—an HIV prevention, empowerment
and community mobilisation intervention for gay men and transgender women in
Callao/Lima, Peru. Glob Public Health. 2016;11:1076–1092.

35. Shaikh S, Mburu G, Arumugam V, Mattipalli N, Aher A, Mehta S, Robertson J.

Empowering communities and strengthening systems to improve transgender
health: outcomes from the Pehchan programme in India. J Int AIDS Soc. 2016;19
(Suppl. 2):20 809.

36. McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al.
Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD):
effectiveness results from the pilot phase of a pragmatic open-label randomised
trial. Lancet. 2016;387:53–60.

37. Hosek S, Rudy B, Landovitz R, Kapogiannis B, Siberry G, Rutledge B, et al. An

HIV pre-exposure prophylaxis (PrEP) demonstration project and safety study for
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Pathogenesis, Treatment and Prevention, Vancouver, Canada, 19–22 July 2015.

38. Examining the implications of PrEP as HIV prevention for sex workers. Brighton:
Institute of Development Studies; 2016.

70
71
Finding solutions for everyone
at every stage of life
25–
49
 adulthood (25–49)

Progress and gaps

Across the life cycle, the absolute risk of HIV infection often peaks in adulthood
(ages 25–49), especially among men. This can be seen in the 2010–2014 data of
longitudinal studies conducted in eastern and southern Africa. Among all cohorts,
the risk of HIV infection peaked after age 25 years, and 50% of new infections
among men were in men aged 30–49 years (1).

Efforts to reduce new

New HIV infections among men and women (aged 25–49 years), global,
infections among 2005–2015
adults have struggled.
The annual number of 800 000
new infections among
700 000
adults aged 25–49 years
globally has remained 600 000
essentially flat.
500 000

400 000

300 000

200 000

100 000

0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Women aged 25-49 years

Men aged 25-49 years

Source: UNAIDS 2016 estimates.

Efforts to reduce new infections among adults have struggled in recent years. After a
decade of steady decreases, the annual number of new infections among both men and
women aged 25–49 years globally has remained essentially flat. This lack of progress
reflects the failure of many countries to put in place comprehensive HIV prevention
programmes that provide a range of service options and address well-recognized
structural barriers.

Despite these struggles, game-changing evidence of the strong preventive effect of

antiretroviral therapy published in 2011 helped stimulate ambitions to end AIDS as a
public health threat by 2030. Since then, the 90–90–90 targets, launched by UNAIDS
at the 2014 International AIDS Conference, have focused global efforts on a set of
measurable targets to be achieved by 2020: 90% of people living with HIV know their

74
 HIV status, 90% of people who know their HIV-positive status are accessing treatment,
and 90% of people on treatment have suppressed viral loads.

Considerable progress has been achieved against the second of the three “90s”. The
number of people living with HIV (all ages) accessing antiretroviral therapy continued
to increase during the first half of 2016, reaching 18.2 million [16.1 million–19.0
million] globally, and the rate of scale-up appears on track to achieve the target of 30
million people by 2020. Efforts to remain on this trajectory are threatened, however, by

People living with HIV on antiretroviral therapy, all ages, global,

2010–July 2016
35

30
Number (millions)

25

20
Treatment scale-up
appears on track. 15
However, efforts to hit
the 2020 target are 10

threatened by insufficient
5
knowledge of HIV status
among people living with 0
HIV.
05

06

07

08

09

10

11

12

13

14

16

17

18

19

20
20 6
1
01
20

20

20

20

20

20

20

20

20

20

m 20

20

20

20

20
-2
id

People living with HIV on antiretroviral therapy (all ages)

Global target

Source: Global AIDS Response Progress Reporting, 2016; UNAIDS 2016 estimates.

considerable challenges that stand in the way of achieving the first and third “90s”. At
the end of 2015, only 60% [56–65%] of people living with HIV knew their HIV status. In
addition, far too few people living with HIV have achieved viral suppression—only 38%
[35–41%] at the end of 2015, roughly half of the 73% required to achieve the third “90”
and realize the prevention dividend of treatment.

Country status
Progress towards the 90–90–90 targets is uneven across regions and countries. Country
data on the first “90” are sparse in most regions. Headway on the second “90”, which
translates to 81% of people living with HIV on antiretroviral therapy, is strongest
in western and central Europe, eastern and southern Africa, Latin America and the

75
 Caribbean. Very few of the countries in these regions with available data appear on track to
achieve the third “90”, however, which translates to 73% of people living with HIV virally
suppressed.

Of particular concern is western and central Africa, where available data suggest that few
countries are on track to achieve the first two “90s”, and none appears on track to achieve the
third “90”. Poor treatment coverage in the region is driving high levels of mortality—30%
of the world’s AIDS-related deaths in 2015 occurred in the region, which is home to 18% of
people living with HIV globally.

Progress toward the 90–90–90 targets, all ages, by country, 2015

Coverage of
Knowledge of status Viral suppression
antiretroviral therapy
among people living among people living
among people living
with HIV (%) with HIV (%)
with HIV (%)

Asia and the Pacific

Afghanistan
Australia
Bangladesh
Cambodia
India
Indonesia
Malaysia
Mongolia
Myanmar
Nepal
Pakistan
Papua New Guinea
Philippines
Sri Lanka
Thailand
Viet Nam
Eastern Europe and central Asia
Armenia
Azerbaijan
Belarus
Georgia
Kazakhstan
Kyrgyzstan
Republic of Moldova
Tajikistan
Ukraine
Uzbekistan

Latin America and the Caribbean

Argentina
Bahamas
Barbados
Belize
Bolivia (Plurinational State of)
Brazil
Chile
Colombia
Costa Rica
Cuba

76
 Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Nicaragua
Panama
Paraguay
Peru
Suriname
Trinidad and Tobago
Uruguay
Venezuela (Bolivarian Republic of)

Eastern and southern Africa

Angola
Botswana
Eritrea
Kenya
Lesotho
Madagascar
Malawi
Mauritius
Mozambique
Namibia
Rwanda
South Africa
South Sudan
Swaziland
Uganda
United Republic of Tanzania
Zambia
Zimbabwe

Middle East and North Africa

Algeria
Djibouti
Egypt
Iran (Islamic Republic of)
Lebanon
Morocco
Somalia
Sudan
Tunisia
Yemen

Western and central Africa

Benin
Burkina Faso
Burundi
Cabo Verde
Cameroon
Central African Republic

77
 Chad
Côte d’Ivoire
Democratic Republic of the Congo
Equatorial Guinea
Gabon
Gambia
Ghana
Guinea
Liberia
Mali
Mauritania
Niger
Senegal
Sierra Leone
Togo

Western and central Europe

and North America
Greece
Latvia
Spain

Legend 90% and higher 81% and higher 73% and higher
45–89% 41–80% 37–72%
44% or lower 40% or lower 36% or lower
Measures not available Measures not available Measures not available

For countries not shown, measures are not available or under review.

Source: 2016 Global AIDS Response Progress Reporting; UNAIDS 2016 estimates.

Key challenges
HIV programmes failing to engage men

Men generally enjoy more opportunities, privileges and power than women. Health
outcomes among boys and men in most parts of the world, however, are substantially
worse than among girls and women (2). Much of this gender disparity appears due to
behaviours associated with masculinity and male norms of risk-taking and adventure—
including excessive alcohol use—and greater reluctance to seek medical care when they
are ill (2, 3). By contrast, women tend to increase their use of health services during their
reproductive years (4), when HIV risk is highest.

The same value systems and norms of masculinity that discourage men and boys from
accessing health services have been shown to be powerful barriers to HIV services in
a diversity of settings (5, 6). Several studies conducted in eastern and southern Africa
suggest that notions of masculinity increase the risk of HIV infection and also inhibit men
from getting tested for HIV (2). Voluntary medical male circumcision programmes are
important entrypoints for addressing these issues.

78
 Late diagnosis and treatment initiation, especially among men

The quicker a person living with HIV is diagnosed and initiates treatment, the quicker
his or her viral load can be reduced to levels that nearly eliminate the risk of onward
Late diagnosis and transmission of the virus. By contrast, late diagnosis and treatment initiation have serious
treatment initiation implications for both HIV prevention and treatment outcomes and are a particular
among men have serious challenge among adult men. A gender gap in awareness of HIV status can be seen
implications for both HIV in population-based surveys. In 21 countries where HIV tests were included within
prevention and treatment
Demographic and Health Surveys conducted between 2011 and 2015, 59% of men living
outcomes.
with HIV aged 15–49 years reported they had previously been tested for HIV and received
the results, compared with 72% of women in the same age range. In 12 countries of
western and central Africa, just 37% of men living with HIV and 52% of women living
with HIV reported they had previously been tested and received the results.

Percentage of people living with HIV (aged 15–49 years) who have ever been
tested for HIV and received the results, men and women, 21 countries, 2011–2015

100

90

80

70
Percentage (%)

60

50

40

30

20

10

0
Eastern and Western and central All* (n=21)
southern Africa (n=7) Africa (n=12)

Men living with HIV (aged 15–49 years) Women living with HIV (aged 15–49 years)

Source: Demographic and Health Surveys, 2011–2015.

*Includes Dominican Republic and Haiti.

Men living with HIV are also less likely than women living with HIV to access
treatment, according to an analysis of patient records from more than 765 000 adults
on antiretroviral therapy in 12 low- and middle-income countries between 2002
and 2013 (7). In seven of these countries, the gender-related disparities appeared to
increase over time.

79
 Longitudinal surveys conducted in three communities across eastern Africa reveal additional
insights. In the years before antiretroviral therapy was available in these communities, the
percentages of men and women living with HIV who died within 10 years of infection were
essentially the same (48%) (1).

After treatment became fully available, however, the percentage of men living with HIV who
were alive and on treatment up to 10 years after infection was considerably lower, and deaths
among men were much higher, compared with women. Among people living with HIV aged
under 30 years, 51% of women were on treatment compared with 35% of men; among people
living with HIV over age 30 years, 19% of women had died within 10 years of infection,
compared with 34% of men (1).

Comparison of men and women 10 years after HIV infection, before and after the
availability of antiretroviral therapy, three locations in southern Africa

214 172 317 136 270 260 458 330

100
15 19
22
29
80 40 34
Percentage (%)

65 34 31
70
60
43 27

40
71
60 51 51
20 39
30 35 35

0
<30 30+ <30 30+ <30 30+ <30 30+
Men Women Men Women
Antiretroviral therapy not available Antiretroviral therapy fully available

Alive, started antiretroviral therapy Alive, never had antiretroviral therapy Died

Source: Network for Analysis of Longitudinal Population-based HIV/AIDS data on Africa (ALPHA), 2016.

Across seven years (2006–2012), men living with HIV within these cohorts had longer gaps
between infection and diagnosis and between infection and initiation of treatment, compared
with women. As a result, men living with HIV were more likely than women to die before
starting antiretroviral therapy. Death rates among adults who initiated treatment were also
higher among men compared with women (8).

The implications for HIV prevention can be seen within the HIV transmission cycle revealed
by the CAPRISA phylogenetic study in KwaZulu-Natal, South Africa. Among the men living
with HIV in the phylogenetically linked clusters, only 26% were aware of their HIV status,
only 5% were on treatment, and the median viral load was extremely high (9).

80
 Poor adherence, drug resistance and treatment failure

HIV drug resistance is an increasing concern for both individual patients and national
treatment programmes. People living with HIV must carefully adhere to antiretroviral
medications to reduce viral load to undetectable levels, protect their immune system and
reduce the possibility of drug-resistant strains of HIV developing within their bodies. Even
when a medication is the difference between life and death, the difficulty of regularly taking
sometimes complicated daily doses is apparent in the data: a 2011 meta-analysis of 84 studies
on adherence conducted in 20 countries found that an average of 62% of patients reported
adhering to at least 90% of their prescribed doses (10).

When drug-resistant strains of HIV are transmitted to other people, larger percentages of
people come under threat of treatment failure, requiring greater amounts of costly second-
and third-line antiretroviral regimens. As antiretroviral therapy continues to expand and
the average duration of treatment increases, both the absolute number and the relative
proportion of people needing second-line therapy grows (11). In a cohort study of nearly
300 000 people in 16 countries of sub-Saharan Africa, about 1.6 in every 100 people on
People living with antiretroviral therapy switched to second-line regiments each year, and overall 7.9% of
HIV accounted for 1.2 patients were on second-line treatments after 5 years (12). A recent modelling of future
million of all new
treatment needs for sub-Saharan Africa found that achieving rapid scale-up of treatment
tuberculosis cases in
would require up to 3 million people in the region to be on second-line therapy in 2020 (12%
2015, 11% of the global
total. of patients) and up to 4.6 million on second-line therapy in 2030 (18% of patients) (13).

Tuberculosis and people living with HIV

Tuberculosis (TB) risk increases immediately after HIV infection, and TB disease is often
the first illness that causes people living with HIV to seek healthcare. Routine offer of HIV
testing is recommended for all people with TB symptoms and for all people diagnosed
with TB disease, and those who test positive for HIV should immediately initiate
antiretroviral therapy.

Globally, there has been impressive progress. In 2015, 55% of the 6.1 million new TB cases
notified to national TB programmes had documented HIV test results, an 18-fold increase
since 2004 (14). In the African region, where the burden of HIV-associated TB is highest,
81% of TB patients had a documented HIV test result (14). Antiretroviral therapy among
TB patients known to be living with HIV was 78% globally, and above 90% in India, Kenya,
Malawi, Mozambique, Namibia and Swaziland (14).

Despite this progress, people living with HIV accounted for 1.2 million of all new
tuberculosis cases in 2015, 11% of the global total, and 400 000 deaths among people living
with HIV resulted from TB disease (14). Mounting cases of drug-resistant TB—an estimated
580 000 additional people required treatment for multi-drug-resistant TB in 2015 (14)—is a
particular challenge. People living with HIV who need treatment for drug-resistant TB are
exposed to an increased risk of drug interactions and side-effects from the potentially toxic
combination of antiretroviral medicines with second- and third-line anti-TB medicines.

81
 A comprehensive approach

Detailed strategy mix for HIV prevention among adolescent boys and adult men in
high-prevalence settings—a menu of options

MENU OPTIONS DIMENSIONS OF HIV PREVENTION IMPACT

CHANGE OUTCOMES

Sexual behaviors
Behavioural change Fewer partners/
communication, incresed safer sex
including sexuality (condom use)
education
CORE PREVENTION PROGRAMMES

in schools
Behavioral factors Reduced HIV
incidence

Condoms and
lubricants

Voluntary medical Demand and

male circuncision uptake of health Inceased
services prevalence of
male circumcision

HIV testing
services and early
antiretroviral Reduced
therapy (service mortality
modalities reaching
men) Biological factors

Incrased
Community treatment, viral
suppression
POLICY AND STRUCTURAL ACTIONS

mobilization
Susceptibility and and onwards
transmissibility transmission

Laws and policies,

e.g. addressing
alcohol, spousal
separation Reduced HIV
incidence
Structural in women,
factors improved gender
Enhanced equality
leadreship and
male role models Reduced
gender-based
violence
Health-seeking
Programmes that and gender-based
address harmful violence
gender norms and
maculinities

82
Core prevention programmes

Behavioural change communication on HIV should include messaging that equips

men and boys with the knowledge, skills, attitudes and values that will enable them to
abandon harmful gender norms and develop a positive view of their sexuality in the
context of their emotional and social development.

Condoms and lubricant: when used consistently and correctly, condoms are highly
effective in preventing the sexual transmission of HIV.

Voluntary medical male circumcision is a cost-effective, one-time intervention that

provides lifelong partial protection against female-to-male HIV transmission.

HIV testing services and immediate antiretroviral therapy: HIV testing

is a critical entry point for both HIV prevention and treatment initiation. Realizing
the population-level prevention effects of antiretroviral therapy will require particular
modalities that address the typically late diagnosis and treatment initiation among men.

Policy change and structural programmes

Community mobilization is a process that helps communities identify, respond to and

address their needs. Community mobilization and participation have made substantial
contributions to HIV prevention. In practice, community mobilization approaches are
often implemented through the same channels and organizations as, and complement,
social and behavioural change communication programmes.

Policy and legal changes: supportive policies include those that increase equality
in sexual relations, particularly in decision-making around sex; promote responsible
male behaviour; enforce measures to end violence against women; emphasize men’s
participation in HIV testing, reproductive and child health, and family health; and
support men as caregivers (15).

Enhanced leadership and male role models: leadership involvement in

development programmes is commonly applied as a strategy to build ownership and
improve community understanding, thus opening the way towards sustainability. For HIV
prevention in high-prevalence locations, leaders can serve as role models for how men
engage and interact with women.

Programmes that address harmful gender norms and masculinities: gender-

transformative interventions can increase protective sexual behaviours, prevent
partner violence, modify inequitable attitudes, and reduce transmission of HIV and
other sexually transmitted infections (16).

83
 Closing the gaps
Expanding HIV testing options

Reaching the first “90” (90% of all people living with HIV aware of their HIV status by
2020) requires expansion of HIV testing options. Self-testing kits are both discreet and
convenient for people who may be reluctant to take a test at a health facility or who live
in places where health facilities are inaccessible. Self-testing options have been proven
to be both feasible and acceptable in settings ranging from rural areas of Zimbabwe (17)
to large cities in China (18). In Kenya, where population-based surveys have suggested
Assisted partner that the willingness to use self-test kits is high, researchers gave self-test kits to pregnant
notification and self-test women during their first antenatal clinic visit and asked the women to give the kits and
kits have been shown instruction materials to their male partners. Control groups were given invitation letters
increase access to HIV
requesting men come to the antenatal clinic for a standard HIV test. Eighty-three per
testing among men.
cent of men who received the self-test kit reported using it, and about half reported
taking an HIV confirmatory test at a health facility, compared with 28% and 37% of
men in the two control groups (19). The study demonstrated that self-test kits can be
used to increase access to HIV testing among men and help reduce mother-to-child
transmission of HIV.

Assisted partner notification, whereby health-care providers contact the sexual partners
of people diagnosed with HIV and offer counselling and testing, is also showing positive
results in low-income settings. In a study in Cameroon, health advisors successfully
notified 1347 partners of more than 1400 people living with HIV, of whom 900 were
tested, 451 were found to be living with HIV and 386 were enrolled in HIV medical
care (20). A similar pilot conducted at a clinic in Maputo, Mozambique, identified large
numbers of undiagnosed people living with HIV (21). Both studies found that assisted
partner notification was acceptable to the participants; the Maputo study found that it
posed a low risk of adverse events, such as violent reactions by the sexual partners who
are notified. In Kenya, electronic patient intake forms and geospatial technology have
been used to augment assisted partner services (22).

Simplifying treatment regimens

Greater treatment adherence rates can be achieved through the adoption of simpler
regimens (23,24). Once-daily single-pill regimens can up to double strong treatment
adherence rates compared with multi-tablet regimens, improve therapeutic outcomes
and achieve health-care cost efficiencies (25). On the cutting edge of efforts to further
simplify antiretroviral therapy for patients is the development of injectable medicines that
are administered monthly or every two months. Initial results from a trial of four- and
eight-week injections of two antiretroviral drugs, cabotegravir and rilpivirine, have showed
promising results, and four-week injections are expected to progress to phase III trials

84
 (26). Patients involved in the trial expressed a preference for injectable antiviral medicines
compared with daily pills, despite some side-effects such as temporary soreness at the
injection site. As well as greater convenience and easier adherence for monthly doses, some
patients reported that injections helped them manage HIV-related stigma because monthly
injections were more discreet and reduced the risk of unintended disclosure of their
HIV-positive status (27).

Expanding viral load monitoring

Up to 70% of switches
Compared with CD4 tests that are more commonly available in low- and middle-
to second-line treatment income countries, viral load tests are more likely to detect treatment failure early,
may have been providing an opportunity to undergo enhanced adherence support, or, if adherence
unnecessary. Viral load problems are ruled out, to ensure prompt and correct switching to second- and
tests are more likely to third-line treatment regimens. Lower AIDS-related mortality rates in South Africa,
detect treatment failure
compared with Malawi and Zambia, have been attributed to South Africa’s scale-up of
early, providing an
opportunity to undergo viral load testing (28).
enhanced adherence
Many countries have been slow to make the change to viral load testing due to the costs
support before switching.
involved; but in the longer term, the expansion of viral load testing should yield cost
savings and better treatment outcomes. A study conducted in six African countries found
that almost half of patients who changed to a second-line regimen on the basis of only
clinical or CD4 monitoring were switched unnecessarily (29). Another multi-country
study conducted by Médecins Sans Frontières found that only 30% of people suspected of
treatment failure had an elevated viral load, meaning that 70% might have been switched
to second-line treatment unnecessarily if viral load was not used to confirm treatment
failure (30). Avoiding these unnecessary switches means keeping people on more
affordable first-line regimens and paying greater attention to other issues, such as poor
adherence, that may be affecting a particular patient’s health.

The costs of viral load tests are expected to decrease as volume increases, and the
ongoing development of point-of-care viral load testing platforms offers the prospect
of simpler, more cost-effective and patient-friendly approaches in the future (31).
Point-of-care testing allows faster return of test results, enabling clinicians to identify
and address adherence challenges and treatment failure more quickly.

The benefits of viral load testing can be maximized when it is rolled out alongside
other evidence-informed strategies for improving treatment adherence, such as peer
support groups. A recent study found that measuring viral load at 3 months after
treatment initiation, combined with an adherence intervention, reduced the risk
of virological failure by 22%, compared with monitoring viral load 6 months after
starting therapy (32). In Mozambique, self-formed community antiretroviral therapy
groups are associated with high rates of linkage to care and superior coverage for viral
load testing (33).

85
 TB prevention and intensified TB case finding

TB prevention, early diagnosis of TB and early initiation of TB and HIV treatments

for people living with HIV are all essential to ending AIDS and TB by 2030. Key
prevention interventions include TB preventive therapy and preventing person-to-
person spread of TB through infection control activities. In 2015, more than 900 000
people living with HIV were started on TB preventive treatment, a large increase
from the negligible levels in 2005 (14). South Africa accounted for the largest share
(45%) of this total, followed by Malawi, Mozambique and Kenya (14). Serious gaps
remain: of the 30 countries with the highest burden of HIV-related TB, 21 did not
report any provision of preventive treatment in 2015.

Because TB is often difficult to diagnose in people living with HIV, extra effort—
known as intensified TB case finding—is needed. Screening for TB symptoms should
be conducted among people living with HIV at every opportunity. When people
living with HIV have TB symptoms, screening should be followed up with an accurate
TB test. The World Health Organization recommends the use of Xpert MTB/Rif to
diagnose TB among people living with HIV (14). The majority of countries with high
burdens of HIV-related TB endorse this recommendation. However, access to Xpert
MTB/Rif testing remains limited for many people living with HIV. Joint investment
by both national TB and HIV programmes is needed to scale up the use of Xpert
MTB/Rif, which has the added benefit of rapid detection of Rifampicin resistance.

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in South Africa. J Acquir Immune Defic Syndr. 2012;60:428–437.

12. Haas AD, Keiser O, Balestre E, Brown S, Bissagnene E, Chimbetete C, et al.

Monitoring and switching of first-line antiretroviral therapy in sub-Saharan Africa:
collaborative analysis of adult treatment cohorts. Lancet HIV. 2015;2:e271–e278.

13. Estill J, Ford N, Salazar-Vizcaya L, Haas AD, Blaser N, Habiyambere V, Keiser O. The
need for second-line antiretroviral therapy in adults in sub-Saharan Africa up to 2030:
a mathematical modelling study. Lancet HIV. 2016;3:e132–e139.

14. Global tuberculosis report 2016. Geneva: World Health Organization, 2016.

15. Betron M, Barker G, Contreras JM, Peacock D. Men, masculinities and HIV/
AIDS: strategies for action. International Center for Research on Women, Instituto
Promundo, MenEngage Alliance and Sonke Gender Justice Network; 2014.

16. Dworkin SL, Treves-Kagan S, Lippman SA. Gender-transformative interventions to

reduce HIV risks and violence with heterosexually-active men: a review of the global
evidence. AIDS Behav. 2013;17:2845–2863.

17. Mavedzenge SN, Sibanda E, Mavengere Y, Dirawo J, Hatzold K, Mugurungi O, et al.

Acceptability, feasibility, and preference for HIV self-testing in Zimbabwe. Presented
at the 21st International AIDS Conference, Durban, South Africa, July 2016.

18. Han L, Bien CH, Wei C, Muessig KE, Yang M, Liu F, et al. HIV self-testing among
online MSM in China: Implications for expanding HIV testing among key
populations. J Acquir Immune Defic Syndr. 2014;67:216–221.

19. Gichangi A. Provision of oral HIV self-test kits triples uptake of HIV testing among
male partners of antenatal care clients: results of a randomized trial in Kenya.
Presented at the 21st International AIDS Conference, Durban, South Africa, July
2016.

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 20. Henley C, Forgwei G, Welty T, Golden M, Adimora A, Shields R, et al. Scale-up and
case-finding effectiveness of an HIV partner services program in Cameroon: an
innovative HIV prevention intervention for developing countries. Sex Transm Dis.
2013;40:909–914.

21. Myers RS, Feldacker C, Cesár F, Paredes Z, Augusto G, Muluana C, et al. Acceptability
and effectiveness of assisted human immunodeficiency virus partner services in
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2016;43:690–695.

22. Cherutich P, Golden M, Betz B, Wamuti B, Ng’ang’a A, Maingi P, et al. Surveillance

of HIV assisted partner services using routine health information systems in Kenya.
BMC Med Inform Decis Mak. 2016;16:97.

23. Huhn GD, Tebas P, Gallant J, Wilkin T, Cheng A, Yan M, et al. A randomized, open-
label trial to evaluate switching to elvitegravir/cobicistat/emtricitabine/tenofovir
alafenamide plus darunavir in treatment-experienced HIV-1 infected adults. J Acquir
Immune Defic Syndr. 2016 Oct 6. [Epub ahead of print.]

24. Raffi F, Yazdanpanah Y, Fagnani F, Laurendeau C, Lafuma A, Gourmelen J.

Persistence and adherence to single-tablet regimens in HIV treatment: a cohort study
from the French National Healthcare Insurance Database. J Antimicrob Chemother.
2015;70:2121–2128.

25. Truong WR, Schafer JJ, Short WR. Once-daily, single-tablet regimens for the
treatment of HIV-1 Infection. P&T. 2015;40:44–55.

26. Margolis D, Brinson CC, Smith GH, de Vente J, Hagins DP, Eron JJ, et al. Cabotegravir
+ rilpivirine as long-acting maintenance therapy: LATTE-2 week 48 results. Abstract
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Africa, July 2016.

27. Kerrigan D, Mantsios A, Margolis D, Murray M. Experiences with long-acting

injectable ART: a qualitative study among people living with HIV participating in a
phase II study of cabotegravir + rilpivirine (LATTE-2) in the United States and Spain.
Abstract THAB020421st presented at the International AIDS Conference, Durban,
South Africa, July 2016.

28. Keiser O, Chi BH, Gsponer T, Boulle A, Orrell C, Phiri S, et al. Outcomes of
antiretroviral treatment in programmes with and without routine viral load
monitoring in southern Africa. AIDS. 2011;25:1761–1769.

29. Sigaloff KCE, Hamers RL, Wallis CL, Kityo C, Siwale M, Ive P, et al. Unnecessary
antiretroviral treatment switches and accumulation of HIV resistance mutations:
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2011;58:23–31.

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31. HIV/AIDS diagnostics technology landscape. Geneva: UNITAID; 2015.

32. Kerschberger B, Boulle AM, Kranzer K, Hilderbrand K, Schomaker M, Coetzee D,

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33. Simons E, Ellman T, Guiliani R, Bimansha C, Mkwamba A, Lázaro CDTPM.

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Mozambique. Presented at the 21st International AIDS Conference, Durban, South
Africa, July

89
 Finding solutions for everyone
at every stage of life

90
50+

91
 ageing (50+)

Progress and gaps

Far from being the death sentence that HIV once was, when treatment is available
HIV has become a manageable chronic disease. Many people who acquired HIV in
their thirties and forties are now living into their sixties and beyond (1). Added to
this, people who acquire HIV in middle age account for a significant proportion of
new infections (2). The result is that there are more people than ever aged 50 years
and over who are living with HIV.

Globally, 17% of adults (people aged 15 years and over) living with HIV are aged
50 years and over. Sustained high coverage of antiretroviral therapy in high-income
countries has seen the percentage of adults living with HIV aged 50 years and over
climb to 31%, up from 25% in 2010. In low- and middle-income countries, where
treatment coverage is lower, people aged 50 years and over account for 15% of adults
living with HIV, up from 12% in 2010.

If global treatment targets are reached, the number of people aged 50 years and
over living with HIV in low- and middle-income countries is expected to soar from
an estimated 4.7 million [4.4 million–5.1 million] to 6.9 million [5.8 million–8.5
million] people in 2020—a 47% increase.

Number of people living with HIV (aged 50 years and over), high-income countries
and low- and middle-income countries, 2000–2015 and projected to 2020

6
Number (million)

0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020

People living with HIV (aged 50 years People living with HIV (aged 50 years and
and over) in high-income countries over) in low- and middle-income countries

Source: UNAIDS 2016 estimates.

Notes: Projections 2016–2020 are based on an assumption that scale up of antiretroviral treatment will reach 81% coverage
of all people living with HIV by 2020. Country income classifications are from 2015.

92
 Despite their higher mortality rates, men account for a higher proportion of older adults
living with HIV. In 2015 there were an estimated 3.3 million [3.0 million–3.5 million] men
and 2.5 million [2.3 million–2.7 million] women aged 50 years and over living with HIV.
This is due in part to higher rates of HIV infection among older men compared with older
women. An estimated 120 000 [110 000–140 000] people aged 50 years and over acquired
HIV in 2015 globally, of whom 58% were men.

Sub-Saharan Africa accounted for 67% of new HIV infections among people aged 50 years
and over in 2015. Longitudinal survey data show that men and women aged 50 years and
older accounted for 11% of new HIV infections in three locations in eastern Africa and
5% of new HIV infections in six locations in southern Africa (3). Studies show that people
aged 50 years and over are less likely to have been tested for HIV and are less likely than
their younger counterparts to have talked to their partners about HIV (4).

Key challenges
Many people who
The long-term complications of antiretroviral medications, lifestyle and age-related
acquired HIV in their
diseases create substantial health challenges for older people living with HIV (5). Ensuring
thirties and forties are
now living into their they get the holistic treatment and care they need is critical to maintaining their health and
sixties and beyond well-being.
thanks to the scale up of
antiretroviral therapy.
If global treatment
targets are reached, the Lifelong HIV treatment brings its own complications
number of people aged As people living with HIV get older, they are more susceptible to the adverse effects
50 years and over living of antiretroviral therapy and must increasingly manage long-term side-effects. They
with HIV in low- and
are also more likely to take antiretroviral medication in combination with other
middle-income countries
is expected to increase
medications. While adherence to HIV treatment among older people appears better
by 47%. than that among younger people, dealing with multiple medical conditions poses an
increased risk of non-adherence to HIV treatment and complications with medication
interactions, threatening the efficacy of antiretroviral therapy overall (2,6). Antiretroviral
drug resistance poses a significant threat to people who have been living with HIV for
a significant number of years, and to the health systems that support them. Both the
development of resistance within an individual and the spread of drug-resistant strains
within the population may reduce the effectiveness of treatment and undermine efforts to
reduce AIDS-related deaths (7).

Older people living with HIV face particular health concerns

As people living with HIV grow older, they are at increased risk of developing
age-associated noncommunicable diseases, which may worsen HIV disease progression
(8, 9). Ageing alone results in increased susceptibility to secondary infections and a
delayed immune response, and this may be accelerated in people living with HIV (10). In
addition, research from high-income countries shows that people living with HIV may

93
 have up to five times the risk of chronic disease, notably cardiovascular disease, geriatric
syndromes and co-morbidity—even among people who have consistently sustained viral
suppression (11, 12).

Moreover, high rates of smoking among people living with HIV (as high as 60% in one
large-scale study of people living with HIV in the United States of America and Europe)
also have a significant impact on health. Indeed, people living with HIV and receiving
treatment may lose more life-years through smoking than through HIV, and mortality
associated with smoking increases markedly with age (13).

People living with Depression is common in people living with HIV, with prevalence rates up to three times
HIV may have up to higher than in the general population (14). In a large study of people aged 50 years and
five times the risk of over living with HIV, 39% showed symptoms of major depression (15). HIV-associated
chronic disease, notably
stigma, increased loneliness, reduced levels of energy and decreased cognitive functioning
cardiovascular disease,
geriatric syndromes and have all been linked to depression among people living with HIV (16), and this is
comorbidity. particularly so for older adults (15).

Women and key populations face even more difficulties

Women living with HIV face specific health challenges as they grow older. They appear to
lose ovarian function earlier in life than women without HIV infection, and they are also at
increased risk of developing chronic age-related disease such as cardiovascular disease and
impaired cognitive function (17, 18). Menopause aggravates the ageing process in women,
and postmenopausal women are at greater risk of complications than men since the loss of
sex hormones contributes to impaired immune function and overall age-related deterioration
(18). Clinicians require more information on how menopause interacts with HIV infection so
they can provide appropriate care to women living with HIV during the menopausal transition
(17). Studies also show that older women living with HIV are profoundly affected by self-
stigma (19).

Just like younger people living with HIV, their older counterparts are characterized by
great diversity, and there is no typical older person living with HIV (20). They are men
and women, heterosexual and homosexual, some are transgender, some sell sex, some
buy sex, some use drugs, and some are in prison or other closed settings. As such, they
have different needs and different challenges. Ageing adults within key populations face
significant social, psychological and physical challenges associated with the ageing process
(15). The mental and physical health of lesbian, gay, bisexual and transgender people is
poorer than that of their heterosexual counterparts, with associated consequences for
higher rates of disease susceptibility later in life, including cardiovascular disease and
obesity (21). As transgender people age, they report higher rates of disability, general
poor health, depression, anxiety, loneliness and suicidal ideation. Many transgender
elders enter their later years with severe health concerns and yet without the social and
community supports necessary to address them (22).

94
Critical risks, services and strategic information for people living with HIV
aged 50 and over

Age-appropriate Other health Strategic

Risks
HIV services care services information

• Cardiovascular • Antiretroviral • Dietary • Research on

diseases therapy counselling and ageing with HIV
• Frailty • HIV prevention support • Improved
• Depression and harm • Nutrition epidemiological
• Smoking reduction assessment data on HIV in
• Gender- • Smoking cessation people aged over
responsive sexual • Exercise 50 years
health care promotion • Improved
• Blood-pressure understanding
monitoring of HIV incidence
• Cholesterol among people
management aged over
• Mental health care 50 years
• Palliative care

Closing the gaps

Leverage the wisdom and knowledge of older people living with HIV

Although ageing brings its own unique challenges, it also brings experience and wisdom
that can be leveraged for both individual and wider community health and well-being. In
a 2011 study among older people living with HIV, the strength and resilience required to
live with HIV were identified as common positive traits that emerged from self-acceptance,
the will to live, optimism, independence and self-management strategies (23). Engaging
with older adults living with HIV, sharing practical coping from peers, and enabling young
people to benefit from the wisdom and knowledge of older people living with HIV all have
immense potential benefits. Involving older people living with HIV in research, advocacy
and programme development also contributes to innovation.

Several countries have included older people within national strategies and policies on HIV,
or incorporated HIV into national ageing plans and policies. These approaches need to be
adopted more widely. HIV issues among older Americans have been highlighted in the Office
of National AIDS Policy within the White House Domestic Policy Council. In addition, the
National Institutes for Health have initiated a research programme that includes collecting
evidence on mechanisms and triggers of functional decline, intervention research and
societal infrastructure, mental health and substance abuse issues (24). HIV prevention is also
on the agenda of the United States’ association of retired people, AARP (25).

In Ethiopia older people are identified as an important group, both as beneficiaries

and contributors, within the Strategic Framework for the National Response to HIV/
AIDS (4). Similarly, in Thailand, the 10th National AIDS Plan (2007–2011) included
older people as a specific target group for interventions. HIV was addressed in the 2003
Policy for the Elderly in Cambodia, in the United Republic of Tanzania’s 2003 National

95
 Ageing Policy, and in the South Africa Older Persons Policy of 2006. In Kenya, the
National Policy on Older Persons and Ageing of 2009 refers to HIV, and people aged
50–64 years are included in the Kenya National AIDS Strategic Plan. Some national
surveys are now including HIV infection data for people aged 50 years and over,
including the AIDS Indicator Surveys in Botswana, Kenya and Mozambique, and the
population-based HIV impact assessments supported by the United States President’s
Emergency Plan for AIDS Relief (PEPFAR) being conducted in several countries of
eastern and southern Africa (26).

Adapt health care to the needs of older people living with HIV

Given that people aged 50 years and over living with HIV are at increased risk of
The wisdom and
knowledge of older developing a wide range of noncommunicable diseases, their health management needs
adults living with HIV are complex; however, health-care systems in regions that are home to most people living
have immense potential with HIV were designed to primarily address acute, not chronic, care (11). To provide
benefits. Involving older cost-effective, efficient and comprehensive chronic care, greater integration of HIV
people living with HIV in
services using a life-cycle-of-care approach is needed, including integration with services
research, advocacy and
for noncommunicable diseases, sexually transmitted infections, broader sexual and
programme development
contributes to innovation. reproductive health, substance use disorders, mental health, hepatitis, tuberculosis, blood
safety, geriatric care and gender-based violence (20). This will require training HIV-related
health-care providers on geriatric care, and training geriatric providers on HIV-related
care. The relatively well-developed HIV delivery systems in many low- and middle-
income countries offer some unique and important opportunities for the integration of
noncommunicable disease services (27).

References

1. Life expectancy of individuals on combination antiretroviral therapy in high-income

countries: a collaborative analysis of 14 cohort studies. The Antiretroviral Therapy
Cohort Collaboration. Lancet. 2008;372:293–299.

2. Balderson BH, Grothaus L, Harrison RG, McCoy K, Mahoney C, Catz S. Chronic

illness burden and quality of life in an aging HIV population. AIDS Care.
2013;25:451–458.

3. Network for Analysis of Longitudinal Population-based HIV/AIDS data on Africa

(ALPHA). Special analysis for UNAIDS. 2016.

4. HIV and ageing background note. UNAIDS/PCB (49)/16.25. Joint United Nations
Programme on HIV/AIDS Programme Coordinating Board thirty-ninth meeting.

5. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing
HIV infection: recommendations for a public health approach, second edition.
Geneva: World Health Organization; 2016.

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6. Silverberg MJ, Leyden W, Horberg MA, DeLorenze GN, Klein D, Quesenberry CP.
Older age and the response to and tolerability of antiretroviral therapy. Arch Intern
Med. 2007;167:684–691.

7. Boyd M, Emery S, Cooper DA. Antiretroviral roll-out: the problem of second-line

therapy. Lancet. 2009;374:185–186.

8. Schouten J, Wit FW, Stolte IG, Kootstra NA, van der Valk M, Geerlings SE, et al.
Cross-sectional comparison of the prevalence of age-associated comorbidities and
their risk factors between HIV-infected and uninfected individuals: the AGEhIV
cohort study. Clin Infect Dis. 2014;59:1787–1797.

9. Kirk JB, Bidwell Goetz M. Human immunodeficiency virus in an aging population: a

complication of success. J Am Geriatr Soc. 2009;57:2129–2138.

10. Somarriba G, Neri D, Schaefer N, Miller TL. The effect of aging, nutrition, and
exercise during HIV Infection. HIV/AIDS. 2010;2:191–201.

11. Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease.
Lancet. 2013;382:1525–1533.

12. Guaraldi G, Zona S, Brothers TD, Carli F, Stentarelli C, Dolci G, et al. Aging with HIV
vs. HIV seroconversion at older age: a diverse population with distinct comorbidity
profiles. PloS One 2015;10:e0118531.

13. Helleberg M, May MT, Ingle SM, Dabis F, Reiss P, Fätkenheuer G, et al. Smoking and
life expectancy among HIV infected individuals on antiretroviral therapy in Europe
and North America. AIDS. 2015;29:221–229.

14. Kessler RC, Gruber M, Hettema JM, Hwang I, Sampson N, Yonkers KA. Comorbid
major depression and generalized anxiety disorders in the National Comorbidity
Survey follow-up. Psychol Med. 2008;38:365–374.

15. Grov C, Golub SA, Parsons JT, Brennan M, Karpiak SE. Loneliness and HIV-related
stigma explain depression among older HIV-positive adults. AIDS Care. 2010;22:630–
639.

16. Rabkin JG. HIV and depression: 2008 review and update. Curr HIV/AIDS Rep.
2008;5:163–171.

17. Santoro N, Fan M, Maslow B, Schoenbaum E. Women and HIV infection: the
makings of a midlife crisis. Maturitas. 2009;64:160–164.

18. Alcaide ML, Parmigiani A, Pallikkuth S, Roach M, Freguja R, Della Negra M, et al.
Immune activation in HIV-infected aging women on antiretrovirals: implications for
age-associated comorbidities—a cross-sectional pilot study. PloS One. 2013;8:e63804.

19. Psaros C, Barinas J, Robbins GK, Bedoya CA, Safren SA, Park ER. Intimacy and
sexual decision making: exploring the perspective of HIV positive women over 50.
AIDS Patient Care and STDs. 2012;26:755–760.

20. World report on ageing and health. Geneva: World Health Organization; 2015.

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 21. Henderson, Neil, and Kathryn Almack. 2016. “Lesbian, Gay, Bisexual, Transgender
Ageing and Care: A Literature Study.” Social Work 52 (2): 267–79. doi:10.15270/52-2-
504.

22. Transgender aging. New York: Services & Advocacy for GLBT Elders (SAGE) (http://
www.sageusa.org/issues/transgender.cfm).

23. Emlet CA, Tozay S, Raveis VH. “I’m not going to die from the AIDS”: resilience in
aging with HIV disease. Gerontologist. 2011;51:101–111.

24. Ageing in the twenty-first century: a celebration and a challenge. New York: United
Nations Population Fund; 2012.

25. HIV/AIDS prevention pushed for the 50+. Washington, DC: AARP; 2008. (http://
www.aarp.org/relationships/love-sex/info-02-2008/aids_prevention_for_50plus_
pushed.html).

26. Justman J. Population surveys to assess impact of HIV programming. Presented

at HPTN/IMPAACT meeting, 17 June 2015 (http://impaactnetwork.org/
DocFiles/2015AnnualMtg/Presentations/Joint_Plenary/PopSurveys_Justman_HPTN.
pdf).

27. Lamptey P, Dirks R, Torpey K, Mastro TD. Discussion paper on how to promote the
inclusion of the prevention and control of noncommunicable diseases within other
programmatic areas. Geneva: World Health Organization WHO GCM/NCD Working
Group 3.1; 2016 (http://www.who.int/global-coordination-mechanism/working-
groups/WHO_Background_paper_on_integration_of_NCDs_Peter_Lamptey_FOR_
DISPATCH.pdf).

98
99
100
conclusion

Advances towards vaccines and a cure

Vaccines are among the greatest public health innovations over the past 100 years.
Routine childhood immunization has made previously common, often fatal diseases such
as diphtheria, tetanus and whooping cough rarities in the twenty-first century. Recent
successes include the elimination of measles from the Americas and the reduction in cases
of poliomyelitis from hundreds of thousands per year globally to only a handful of cases in
Pakistan and Afghanistan.

Efforts to develop a vaccine for HIV have been characterized by years of frustration, but
Efforts to develop a
vaccine for HIV have recent progress has stirred renewed hope for a breakthrough. One candidate that has showed
been characterized by some efficacy, the so-called Thai vaccine (1), has been modified and improved to make it
years of frustration, more likely to work against the clades of HIV found in southern Africa, where the burden
but recent progress has is greatest. In 2016 the United States National Institute of Allergy and Infectious Diseases
stirred renewed hope for
announced the results of the HVTN100 study, which demonstrated that this improved
a breakthrough.
vaccine provoked immune responses that seemed to be associated with protection in the
previous Thailand trial (2). In fact the vaccine did better than the Thai vaccine in all five
of the immunological tests chosen to determine whether development and testing should
continue. A large phase III trial, which will enrol 5400 men and women at risk for HIV
infection, is the first HIV vaccine candidate to reach this stage for 7 years. Other candidates,
such as the “mosaic” vaccine being developed by Johnson & Johnson, are expected to follow.

Exciting experiments involving the simian immunodeficiency virus have shown that
a vaccine carried into the body by a modified cytomegalovirus can produce profound
widespread immune changes that can not only protect monkeys from infection but also
in some cases eradicate existing infection (3). Human versions of these experiments are
still in the early stages. Other techniques involving broadly neutralizing antibodies, which
block HIV in laboratory experiments, are also in the earlier stages of development (4).

A cure for HIV would be a dream come true for millions of people currently living
with HIV, and also for the ministers of health and finance facing ever-increasing costs
of treating more and more people with lifesaving antiretroviral therapy. So far, only
one person has been cured of HIV. Timothy Ray Brown, the so-called “Berlin patient”,
underwent a complex course of treatments for blood cancer unrelated to his HIV
infection. Among the treatments were bone marrow transplants from a donor with natural
resistance to HIV due to a genetic mutation. These procedures are painful, dangerous and
expensive and not an option for widespread use. Indeed, other people living with HIV
who have had bone marrow transplants have not been cured (5).

The apparent eradication of HIV from a baby in the American state of Mississippi who
received extremely early HIV treatment inspired great hope that a cure had been found for
infants. Unfortunately, after more than two years off treatment, the virus re-emerged within
the child (6). Despite the disappointment, the results led to a set of trials aiming to demon-
strate the effect of immediate treatment on infants who had only recently been exposed to
HIV. Early results show that there are benefits in terms of the size of the reservoir and of the
diversity of the virus within individuals (7). Similar studies have been done in adults.

101
 Another approach towards a cure seeks to “wake up” the HIV lurking in reservoirs within the
gut and bone marrow, while continuing antiretroviral therapy to kill off the resulting HIV in
the bloodstream (8). Several studies using different medicines are ongoing, along with alterna-
tive strategies to boost the immune response to maximize the impact on the reservoir.

As with all such research and development, HIV vaccines and cures are expensive undertak-
ings and will take some years to generate conclusive results. Funding for these endeavours
has largely followed global trends, with a clear plateauing of resources over the past few
years, and the large majority of funding coming from government and foundation sources
in the United States of America. It is, however, encouraging that the European Union is now
making substantial grants to European consortia for HIV vaccine research.

Addressing challenges across the life cycle

Reaching Fast-Track In the meantime, the expansion of HIV prevention, testing and treatment must continue at
Targets requires an the Fast-Track pace agreed by the United Nations General Assembly. There is overwhelming
additional US$ 7 evidence behind the services and structural actions in the results frameworks presented
billion annually. These within this report. Examining the AIDS epidemic through the lens of the human life cycle
investments must be
is a compelling way to use these frameworks to guide the specific policy and programming
made wisely across
the life cycle, using a decisions that must be made at national and local levels.
location–population
The global ambition to end AIDS is fuelled by past progress. The elimination of new HIV
approach.
infections among children is a reality in a small but growing number of countries. The
momentum established by the Global Plan towards the elimination of new HIV infections
among children by 2015 and keeping their mothers alive emphasizes the importance of
strategic partnerships among countries, civil society and the United Nations. Moving
forward, girls and young women must be empowered to gain control over their sexual and
reproductive health and rights. Boys and men must be adequately engaged to change the
harmful gender norms that put women and girls at risk, and to inspire the greater responsi-
bility and health-seeking behaviours among men required for consistent condom use, early
diagnosis of HIV, rapid initiation of antiretroviral therapy, and strong treatment adherence
for sustained viral suppression. Such measures can break the cycle of transmission among
adult women, adult men and young women in high-prevalence settings.

Among key populations, comprehensive community-led approaches have been proven

to overcome the huge societal barriers to HIV service access. South Africa and Peru are
showing that national-level action is not limited to high-income countries. In the longer
term, punitive laws and social norms that marginalize key populations within society must
be changed to achieve the service coverage required for sustained impact.

The expansion of antiretroviral therapy has transformed HIV into a chronic manageable
condition, and AIDS-related deaths are in steady decline. With roughly 2.1 million [1.8
million–2.4 million] new HIV infections occurring every year, however, lifelong treatment puts
increasing pressure on health systems in both higher-income and lower-income countries.
New adherence support strategies are required for the rapidly increasing number of children
living with HIV who are transiting into adolescence and adulthood. At the same time, larger
and larger numbers of people living with HIV reaching their fifties and sixties raise new chal-
lenges related to drug resistance and the interaction between HIV and age-related diseases.

102
Shared responsibility

The additional investments of low- and middle-income countries in recent years have
driven further progress against AIDS as international investments have plateaued. The
successful replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria in
September 2016, when donors pledged over US$ 12.9 billion for the next 3 years, rein-
forces international commitment to achieve Fast-Track Targets. Closing the US$ 7 billion
annual funding gap, however, will require additional investment by all countries within
the shared responsibility agenda promoted by UNAIDS.

These investments must be made wisely across the life cycle, using a location–population
approach to ensure that evidence-informed, high-impact programmes are available in the
geographical areas and among the populations in greatest need.

References

1. Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S, Kaewkungwal J, Chiu J, Paris R, et al.

Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. N
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2. Large-scale HIV vaccine trial to launch in South Africa. Press release. Bethesda, MD:
National Institute of Allergy and Infectious Diseases; 18 May 2016 (https://www.
niaid.nih.gov/news-events/large-scale-hiv-vaccine-trial-launch-south-africa).

3. Terry L. OHSU’s HIV vaccine moves toward clinical trial. The Oregonian, 1 June
2016 (http://www.oregonlive.com/health/index.ssf/2016/06/ohsus_hiv_vaccine_
moves_toward.html).

4. Rusert P, Kouyos RD, Kadelka C, Ebner H, Schanz M, Huber M et al. Determinants

of HIV-1 broadly neutralizing antibody induction. Nat Med. 2016;22:1260–1267.

5. Sanchez R, Wills S, Young S. HIV returns in two patients after bone marrow trans-
plant. CNN, 9 December 2013 (http://edition.cnn.com/2013/12/07/health/hiv-pa-
tients/index.html?hpt=hp_t3).

6. Ledford H. HIV rebound dashes hope of “Mississippi baby” cure. Nature News, 10
July 2014 (http://www.nature.com/news/hiv-rebound-dashes-hope-of-mississip-
pi-baby-cure-1.15535).

7. Martínez-Bonet M, Puertas MC, Fortuny C, Ouchi D, Mellado MJ, Rojo P, et al.

Establishment and replenishment of the viral reservoir in perinatally HIV-1-infected
children initiating very early antiretroviral therapy. Clin Infect Dis. 2015;61:1169–1178.

8. Jiang G, Mendes EA, Kaiser P, Wong DP, Tang Y, Cai I, et al. Synergistic reactivation
of latent HIV expression by ingenol-3-angelate, PEP005, targeted NF-kB signaling in
combination with JQ1 induced p-TEFb activation. PLoS Pathog. 2015;11:e1005066.

Compared with 2015 levels of coverage.

1

103
104
ANNEX

AIDS
by
the
numbers
AIDS IS NOT OVER, BUT IT CAN BE
 ENDING THE AIDS
EPIDEMIC BY 2030 AS
PART OF THE
SUSTAINABLE
DEVELOPMENT GOALS
Fast-Track Targets

By 2020 By 2030

Fewer than Fewer than

500 000
new infections
200 000
new infections

Fewer than Fewer than

500 000
AIDS-related deaths
200 000
AIDS-related deaths

ZERO
discrimination
ZERO
discrimination
AIDS is not over, but it can be
Huge progress has been made since 2000 and millions of
lives have been saved. But there are still important milestones
to reach, barriers to break and frontiers to cross. The world
has agreed to meet a set of global targets by 2020 as part of
UNAIDS Fast-Track strategy to end the AIDS epidemic as a
public health threat.

People living with HIV on New HIV infections

antiretroviral therapy

<1 18.2 30 3.2 2.1 <0.5

million million million million million million

2000 June 2020 2000 2015 2020

2016 target target

New HIV infections AIDS-related deaths

among children

490 000 150 000 <50 000

1.5 1.1 <0.5
million million million

2000 2015 2020 2000 2015 2020

target target
AIDS is not over, but it can be

Tuberculosis-related AIDS deaths Total voluntary medical male

circumcisions (14 priority
countries in Africa)

500 000 390 000 120 000 570 000 11.4 36.4
million million

2000 2014 2020 2010 2015 2020

target target

Condoms procured Number of pills to treat HIV

0.5 2.7 7
billion billion billion
20
billion 8
pills per day
1
pill per day
1
injection
(average) (pill)
for three
months

2000, 2015, 2020, 2020 2000 2015 2020

sub-Saharan sub-Saharan sub-Saharan global target
Africa Africa Africa target
Cost of antiretroviral medicines Investments for the
per person per year AIDS response

5 19 26
US$ US$ US$
10 000 100 100
first-line all available
regimens regimens US$ billion US$ billion US$ billion

2000 2015 2020 2000 2015 2020

target target

Countries that criminalize HIV-related travel restrictions

same-sex sexual relationships

92 74 0 59 35 0
countries countries countries

2006 2016 2030 2008 2015 2020

June target target
July 2016
Core epidemiology slides

CORE EPIDEMIOLOGY SLIDES

Global summary of the AIDS epidemic  2015

Number of people Total 36.7 million [34.0 million–39.8 million]

living with HIV Adults 34.9 million [32.4 million–37.9 million]
Women 17.8 million [16.4 million–19.4 million]
Children (<15 years) 1.8 million [1.5 million–2.0 million]

People newly infected Total 2.1 million [1.8 million–2.4 million]

with HIV in 2015 Adults 1.9 million [1.7 million–2.2 million]
Children (<15 years) 150 000 [110 000–190 000]

AIDS-related deaths Total 1.1 million [940 000–1.3 million]

in 2015 Adults 1.0 million [840 000–1.2 million]
Children (<15 years) 110 000 [84 000–130 000]
Global estimates for adults and children  2015

People living with HIV 36.7 million [34.0 million–39.8 million]

New HIV infections in 2015 2.1 million [1.8 million–2.4 million]

AIDS-related deaths in 2015 1.1 million [940 000–1.3 million]

About 5700 new HIV infections (adults and children) a day  2015

 About 66% are in sub-Saharan Africa

 About 400 are among children under 15 years of age

 About 5300 are among adults aged 15 years and older, of whom:
─ almost 47% are among women
─ about 35% are among young people (15–24)
─ about 20% are among young women (15–24)
Global estimates for children (<15 years)  2015

Children living with HIV 1.8 million [1.5 million–2.0 million]

New HIV infections in 2015 150 000 [110 000–190 000]

AIDS-related deaths in 2015 110 000 [84 000–130 000]

 Global HIV trend data in 2015

40
35
30
Number of people
25 living with HIV—global
20
15
10
Million

5
0
1990 1995 2000 2005 2010 2015

3.0
2.5
Number of children
2.0 living with HIV—global
1.5
1.0
0.5
Million

0
1990 1995 2000 2005 2010 2015

2.5 Number of AIDS-

2.0 related deaths—global
1.5

1.0

0.5
Million

0
1990 1995 2000 2005 2010 2015

4.0
3.5 Number of new HIV
3.0
2.5 infections—global
2.0
1.5
Million

1.0
0.5
0
1990 1995 2000 2005 2010 2015

18
16
Number of orphans due
14 to AIDS—global
12
10
8
6
4
Million

2
0
1990 1995 2000 2005 2010 2015
 2000 2005 2010 2011 2012 2013 2014 2015/(*2016)

28.9 million 31.8 million 33.3 million 33.9 million 34.5 million 35.2 million 35.9 million 36.7 million
People living with HIV [26.5 million– [29.4 million– [30.8 million– [31.4 million– [31.9 million– [32.6 million– [33.3 million– [34.0 million–
31.7 million] 34.5 million] 36.1 million] 36.7 million] 37.4 million] 38.1 million] 38.9 million] 39.8 million]

3.2 million 2.5 million 2.2 million 2.2 million 2.2 million 2.1 million 2.1 million 2.1 million
New HIV Infections
[2.9 million– [2.3 million– [2.0 million– [1.9 million– [1.9 million– [1.9 million– [1.9 million– [1.8 million–
(total) 3.5 million] 2.8 million] 2.5 million] 2.5 million] 2.4 million] 2.4 million] 2.4 million] 2.4 million]

2.7 million 2.1 million 1.9 million 1.9 million 1.9 million 1.9 million 1.9 million 1.9 million
New HIV infections
Global HIV data in 2015

[2.5 million– [1.9 million– [1.7 million– [1.7 million– [1.7 million– [1.7 million– [1.7 million– [1.7 million–
(aged 15+) 3.0 million] 2.3 million] 2.1 million] 2.2 million] 2.2 million] 2.2 million] 2.2 million] 2.2 million]

490 000 450 000 290 000 270 000 230 000 200 000 160 000 150 000
New infections (aged
[430 000– [390 000– [250 000– [220 000– [190 000– [160 000– [130 000– [110 000–
0–14) 560 000] 510 000] 350 000] 330 000] 290 000] 250 000] 220 000] 190 000]

1.5 million 2.0 million 1.5 million 1.4 million 1.4 million 1.3 million 1.2 million 1.1 million
AIDS-related deaths [1.3 million– [1.7 million– [1.3 million– [1.2 million– [1.2 million– [1.1 million– [990 000– [940 000–
1.8 million] 2.3 million] 1.7 million] 1.7 million] 1.6 million] 1.5 million] 1.4 million] 1.3 million]

18.2 million
[16.1 million–
19.0 million]
770 000 2.2 million 7.5 million 9.1 million 11 million 13 million 15 million (*June 2016)
People accessing
[680 000– [1.9 million– [6.6 million– [8.0 million– [9.6 million– [11.4 million– [13.2 million–
treatment 800 000] 2.2 million] 7.8 million] 9.5 million] 11.4 million] 13.5 million] 15.6 million] 17 million
[15.0 million–
17.7 million]
(end 2015)

Total resources
available for HIV (low-
4.8 billion 9.4 billion 15.9 billion 18.3 billion 19.5 billion 19.6 billion 19.2 billion 19 billion
and middle-income
countries)
 Region People living with New HIV infections AIDS-related deaths Total number
HIV (total) (total) accessing
total Aged 15+ Aged 0–14 antiretroviral
therapy

Eastern and southern 19.0 million 960 000 910 000 56 000 470 000
10 million
Africa [17.7 million–20.5 million] [830 000–1.1 million] [790 000–1.1 million] [40 000–76 000] [390 000–560 000]

Latin America and the 2.0 million 100 000 100 000 2100 50 000
1.1 million
Caribbean [1.7 million–2.3 million] [86 000–120 000] [84 000–120 000] [1600–2900] [41 000–59 000]

6.5 million 410 000 350 000 66 000 330 000

Regional HIV data in 2015

Western and central

1.8 million
Africa [5.3 million–7.8 million] [310 000–530 000] [270 000–450 000] [47 000–87 000] [250 000–430 000]

5.1 million 300 000 280 000 19 000 180 000

Asia and the Pacific 2.1 million
[4.4 million–5.9 million] [240 000–380 000] [220 000–350 000] [16 000–21 000] [150 000–220 000]

Eastern Europe and 1.5 million 190 000 190 000 47 000
…* 320 000
central Asia [1.4 million–1.7 million] [170 000–200 000] [170 000–200 000] [39 000–55 000]

Middle East and North 230 000 21 000 19 000 2100 12 000
38 000
Africa [160 000–330 000] [12 000–37 000] [11 000–34 000] [1400–3200] [8700–16 000]

Western and central

2.4 million 91 000 91 000 22 000
Europe and North …* 1.4 million
[2.2 million–2.7 million] [89 000–97 000] [88 000–96 000] [20 000–24 000]
America

* Estimates were unavailable at the time of publication.

Regional antiretroviral therapy in 2015

Percentage of adults Percentage of children Percentage of pregnant

(aged 15+) living (aged 0–14) living women accessing
with HIV accessing with HIV accessing antiretroviral medicines to
antiretroviral therapy antiretroviral therapy prevent mother-to-child
transmission of HIV

Eastern and
southern 53% [50–57%] 63% [56–71%] 90% [82–>95%]
Africa

Latin America
and the 55% [47–64%] 64% [54–76%] 88% [77–>95%]
Caribbean

Western and
29% [24–35%] 20% [16–25%] 48% [40–58%]
central Africa

Asia and the

41% [35–47%] 41% [30–37%] 39% [34–44%]
Pacific

Eastern
Europe and 21% [19–22%] …* …*
central Asia

Middle East
and North 16% [12–24%] 20% [16–25%] 12% [9–18%]
Africa

Western
and central
Europe 59% [56–68%] >95% [92–>95%] 92% [87–>95%]
and North
America

GLOBAL 46% [43–50%] 49% [42–55%] 77% [69–86%]

* Estimates were unavailable at the time of publication.

Adults and children estimated to be living with HIV  2015

Eastern Europe
North America and western and central Europe and central Asia
2.4 million 1.5 million
[2.2 million–2.7 million] [1.4 million–1.7 million]

Middle East and North Africa

230 000
[160 000–330 000]
Asia and the Pacific
Latin America Western and central Africa 5.1 million
and the Caribbean 6.5 million [4.4 million–5.9 million]
[5.3 million–7.8 million]
2.0 million
[1.7 million–2.3 million] Eastern and southern Africa
19.0 million
[17.7 million–20.5 million]

Total: 36.7 million [34.0 million–39.8 million]

Estimated number of adults and children
newly infected with HIV  2015

Eastern Europe
North America and western and central Europe and central Asia
91 000 190 000
[89 000–97 000] [170 000–200 000]

Middle East and North Africa

21 000
[12 000–37 000]
Asia and the Pacific
Latin America Western and central Africa 300 000
and the Caribbean 410 000 [240 000–380 000]
[310 000–530 000]
100 000
[86 000–120 000] Eastern and southern Africa
960 000
[830 000–1.1 million]

Total: 2.1 million [1.8 million–2.4 million]

Estimated adult and child deaths from AIDS  2015

Eastern Europe
North America and western and central Europe and central Asia
22 000 47 000
[20 000–24 000] [39 000–55 000]

Middle East and North Africa

12 000
[8700–16 000]
Asia and the Pacific
Latin America Western and central Africa 180 000
and the Caribbean 330 000 [150 000–220 000]
[250 000–430 000]
50 000
[41 000–59 000] Eastern and southern Africa
470 000
[390 000–560 000]

Total: 1.1 million [940 000–1.3 million]

Children (<15 years) estimated to be living with HIV  2015

Eastern Europe
North America and western and central Europe and central Asia
…* …*

Middle East and North Africa

11 000
[8600–14 000]
Asia and the Pacific
Latin America Western and central Africa 190 000
and the Caribbean 500 000 [140 000–170 000]
[400 000–630 000]
32 000
[27 000–38 000] Eastern and southern Africa
1.0 million
[930 000–1.2 million]

Total: 1.8 million [1.5 million–2.0 million]

* Estimates were unavailable at the time of publication.

Estimated number of children (<15 years)
newly infected with HIV  2015

Eastern Europe
North America and western and central Europe and central Asia
…* …*

Middle East and North Africa

2100
[1400–3200]
Asia and the Pacific
Latin America Western and central Africa 19 000
and the Caribbean 66 000 [16 000–21 000]
[47 000–87 000]
2100
[1600–2900] Eastern and southern Africa
56 000
[40 000–76 000]

Total: 150 000 [110 000–190 000]

* Estimates were unavailable at the time of publication.

Estimated deaths in children (<15 years) from AIDS  2015

Eastern Europe
North America and western and central Europe and central Asia
…* …*

Middle East and North Africa

1100
[<1000–1500]
Asia and the Pacific
Latin America Western and central Africa 12 000
and the Caribbean 43 000 [9800–14 000]
[32 000–57 000]
1800
[1400–2500] Eastern and southern Africa
47 000
[38 000–59 000]

Total: 110 000 [84 000–130 000]

* Estimates were unavailable at the time of publication.

 Number of people living with HIV on antiretroviral therapy, global, 2010–2016

18.2 million
19 17 million [16.1 million–
[15.0 million– 19.0 million]
18 15 million 17.7 million]
[13.2 million–
16 2015 target within the 2011 13 million 15.6 million]
People on antiretroviral therapy (million)

United Nations Political [11.4 million–

14 Declaration on HIV and AIDS 11 million 13.5 million]
[9.6 million–
12 9.1 million 11.4 million]
[8.0 million–
10 7.5 million
9.5 million]
[6.6 million–
8 7.8 million]

0
June
2010 2011 2012 2013 2014 2015 2016

Sources: Global AIDS Response Progress Reporting (GARPR) 2016; UNAIDS 2016 estimates.

Antiretroviral therapy coverage and number of AIDS-related deaths, global,

2000–2015

60 3

50

Number of AIDS-related deaths (million)

Antiretroviral therapy coverage (%)

40 2

30

20 1

10

0 0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

HIV treatment coverage (all ages) AIDS-related deaths (all ages)

Sources: GARPR 2016; UNAIDS 2016 estimates.

 New HIV infections among people aged 15 years and over, by region, 2010–2015

1200
New HIV infections among people aged 15 years and over

1000

800
(thousand)

600

400

200

0
2010 2011 2012 2013 2014 2015

Eastern and southern Africa

Western and central Africa
Asia and Pacific

250
New HIV infections among people aged 15 years and over

200

150
(thousand)

100

50

0
2010 2011 2012 2013 2014 2015

Eastern Europe and central Asia

Latin America and the Caribbean
Western and central Europe and North America
Middle East and North Africa

Source: UNAIDS 2016 estimates.

Distribution of new adult HIV infections and population by age and sex,
global and in sub-Saharan Africa, 2015

NEW HIV INFECTIONS AMONG ADULTS, BY ADULT POPULATION, BY AGE AND SEX,
AGE AND SEX, GLOBAL, 2015 GLOBAL , 2015

27%
25+
years old 39% 39%
39% 25+ 25+
25+ years old years old
years old
20%
15–24
11% 11%
years old 14%
15–24 15–24
15–24 years old years old
years old

NEW HIV INFECTIONS AMONG ADULTS, BY ADULT POPULATION, BY AGE AND SEX,
AGE AND SEX, SUB-SAHARAN AFRICA, 2015 SUB-SAHARAN AFRICA, 2015

31% 31%
25+ 25+ 33% 32%
years old years old 25+ 25+
years old years old

12%
25% 17% 17%
15–24
15–24 years old 15–24 15–24
years old years old years old

Source: UNAIDS 2016 estimates.

Distribution of new HIV infections among population groups, by region, 2014

5% 4% 6%
13%
15%
0.4%
EASTERN WESTERN
38% 33% EUROPE AND AND 2%
ASIA AND
PACIFIC 18% CENTRAL CENTRAL
ASIA AFRICA 10%
51%
2% 73%
6%
24%

2%

6% 4% 9% 4%
2% 6%
9%
36% LATIN MIDDLE EASTERN
AMERICA 30% 41% EAST AND 28% AND
AND THE NORTH SOUTHERN
CARIBBEAN AFRICA AFRICA

79%
3%
23% 18%

7% 1%
15% Sex workers

WESTERN People who inject drugs

28% AND
CENTRAL Gay men and other men who have sex with men
EUROPE,
Transgender people
NORTH
AMERICA Clients of sex workers and other sexual partners of key populations
49%
Rest of population

Source: UNAIDS special analysis, 2016.

Methodological note: Estimated numbers of new HIV infections by key population were compiled from country Spectrum
files submitted in 2015 to UNAIDS (2014 data), available modes-of-transmission studies and additional sources of data
drawn from GARPR reports. Where data were lacking, regional medians were calculated from available data and applied
to countries’ populations.
For more information: aidsinfo.unaids.org
The data provided in this document are just a sample of the data available from
UNAIDS.
Additional data are available at aidsinfo.unaids.org, including:
ƒƒ Additional Global AIDS Response Progress Reporting Indicators on
prevention, mother-to-child transmission, 90–90–90 targets, stigma and
discrimination
ƒƒ A Key Population Atlas of maps on key populations, including the latest
available data on key populations at increased risk of HIV infection.
ƒƒ Estimates of new HIV infections, people living with HIV and AIDS-related
deaths by different age groups, children (age 0–14 years), adolescents (age
10–19 years), young people (age 15–24 years), adults (age 15–49) older
people (age 50 years and over), and by sex
ƒƒ Subnational data for selected countries
ƒƒ Data in different formats: spreadsheet, maps, graphics
ƒƒ Comparable data over multiple years, and across countries, which can also
be extracted to spreadsheets for further analysis.

(sample screen shot from aidsinfo.unaids.org)

 annex on methods

UNAIDS methods for estimating mid-2016

antiretroviral therapy numbers

What data are used to construct UNAIDS estimates of the number of people
on antiretroviral therapy?

As agreed by the United Nations General Assembly, countries periodically submit

progress reports on their AIDS responses to UNAIDS, using a standard set of core
indicators. On a semi-annual basis, UNAIDS invites countries worldwide to submit
updates on the number of people on antiretroviral therapy, by age, sex and geographical
location at the end of the reporting period. For most countries, numbers of people on
treatment are reported through the Global AIDS Response Progress Reporting (GARPR)
online tool and represent aggregated country-specific programme and facility-level data.
For some countries, mostly high-income countries or countries in conflict, recent
numbers of people currently on antiretroviral therapy are not regularly available.
To monitor global progress, UNAIDS constructs estimates for these countries using
treatment numbers submitted during previous reporting periods or obtained from
national reports or other publications.

Treatment estimates published in this report cover 174 of 195 countries and account
for more than 98% of the world’s population. Data for 21 countries, most of which have
populations of fewer than 250 000 people and an extremely low burden of HIV, were
not available.

How were the mid-2016 estimates of the number of people on antiretroviral

therapy constructed?

UNAIDS used a two-step process to construct the mid-2016 estimates. In the first step, the
numbers of adults and children on antiretroviral therapy at the end of June 2016 reported
by the 124 countries that submitted data through GARPR were aggregated. A total of 14.8
million people were counted as being on antiretroviral therapy using this data source.
In the second step, UNAIDS constructed estimates for 50 countries that did not submit
data for mid-2016. Data previously provided to UNAIDS or other published data on
treatment were used to inform these estimates. Using these sources, UNAIDS estimated
that the numbers of people on treatment in these countries grew over the previous half
year (end of 2015 to mid-2016) by 0.2% among children and by 6.9% among adults. These
rates were applied to the end-2015 number on treatment for each of the 50 countries to
derive the estimates of children and adults on treatment in these countries on 30 June
2016. A total of 3.4 million people were estimated to be accessing antiretroviral treatment
using this approach.

The total reported and estimated numbers on treatment were combined to obtain the
global number of 18.2 million people on treatment, including 910 535 children aged
under 15 years.

132
What are the characteristics of the countries where numbers of people on
antiretroviral treatment are estimated?

Of the 50 countries with estimated treatment numbers for mid-2016, 18 countries were
in western and central Europe and North America, 11 in eastern Europe and central Asia,
11 in Latin America and the Caribbean, 5 in Asia and the Pacific, 4 in western and central
Africa, and 1 in eastern and southern Africa.

According to historical and published estimates, the countries in eastern and southern
Africa, western and central Africa, and western and central Europe and North America
had slower increases among adults compared with the average, while countries in Asia
and the Pacific, Latin America and the Caribbean, the Middle East and North Africa, and
eastern Europe and central Asia had higher average increases among adults. For children,
evidence for larger-than-average increases was seen only in Asia and the Pacific and the
Middle East and North Africa.

Among these 50 countries, the 10 with the largest estimated numbers of people on
antiretroviral therapy for the mid-2016 reporting period were the United States of
America, Ethiopia, the Russian Federation, France, Spain, the United Kingdom of Great
Britain and Northern Ireland, Italy, Colombia, Germany and Argentina.

What efforts do countries and UNAIDS make to validate reported numbers

of people on antiretroviral treatment submitted through GARPR?

Overall responsibility to guarantee the quality and accuracy of reports on the numbers
of people on antiretroviral therapy resides with national governments. Countries are
advised through global guidance on the construction of the core GARPR indicators (1)
that all efforts should be made at the facility and national levels to adjust the numbers
of people on treatment for potential loss to follow-up, including people who have died,
migrated out of the country or region, transferred to another facility, or disengaged from
treatment. Also, standard operating procedures should be in place to avoid duplicate
counting of individuals across facilities or over time, and to ensure that all facility-level
data are reported in a timely manner. This guidance also references the need for countries
to triangulate programme data with national procurement and drug monitoring systems,
and to adjust reported numbers as appropriate. Many countries undertake data quality
assessments or reviews that monitor the extent to which facilities are able to accurately
report the number of people on treatment during reporting periods and, to a more limited
extent, adjust treatment numbers to account for these inconsistencies.

For the mid-2016 estimates of people on antiretroviral therapy, UNAIDS validated all
data before publication. Validation activities for the mid-2016 reporting period included
comparing reported numbers with previous years’ data and other global procurement
and reporting sources to identify inconsistencies in the data over time and by age and
sex. UNAIDS also reviewed country submissions to ensure that private-sector data were
included, where available. Queries were subsequently sent to countries and resolved
before publication.

133
 To assess the validity and quality of the number of people on antiretroviral therapy
reported in previous years1, comparisons were made with a number of independent data
sources, including the WHO Global Drug Price Reporting Mechanism (GPRMS), WHO
antiretroviral regimen surveys, antiretroviral drug procurement and patient tracking data
from selected countries, Indian generic manufacturer transaction data, pharmaceutical
procurement data of PEPFAR and the Global Fund, numbers of people currently on
treatment reported to PEPFAR, selected countries’ data quality assessments, and national
population-based surveys that included measurement of antiretroviral drug metabolites in
the blood samples of survey participants.

Of the 17 million people who were estimated to be on antiretroviral therapy globally

at the end of 2015, 15.3 million were in low- and middle-income countries, of whom
13.9 million were in countries that have access to generic versions of antiretroviral
medicines. An additional validation exercise was conducted in 11 countries2 with the
highest reported numbers of people on antiretroviral therapy. These countries also
account for 80% of all people on antiretroviral therapy from generic-accessible low- and
middle-income countries.

Data were analysed on exports of antiretroviral drugs by Indian pharmaceutical

companies (including Mylan3, Hetero, Aurobindo and Cipla) that supplied approximately
77% of the generic antiretroviral medicines in generic-accessible low- and middle-income
countries in 2014. This analysis showed that the volumes procured in generic-accessible
countries could meet the needs of the reported numbers of people on antiretroviral
therapy. It suggested that a quantity of antiretroviral drugs to treat 13.7 million–15.7
million people was procured in 2014, compared to the reported 13.9 million people on
antiretroviral therapy in generic-accessible low- and middle-income countries (2).
Triangulation of reported antiretroviral therapy numbers from the 11 countries—using
data from national population-based surveys, GPRMS, data quality assessments and
PEPFAR and Global Fund procurement data— validated the overall numbers for the
majority of countries where alternative data sources were available. In some countries, the
quality of the data available at health facilities and reported to the national information
system, although improving over time, was of concern. Because of the uncertainty in data
quality in some countries, the estimated numbers of people on antiretroviral therapy
presented in this report are accompanied by ranges representing this uncertainty.

How does UNAIDS calculate ranges for the number of people on

antiretroviral treatment?

A recent secondary analysis of treatment data quality review audits in selected high-
burden countries conducted between 2011 and 2016 has been used as the basis for

1
End-2015 being the most recent year for which other published data sources were available.
2
Ethiopia, India, Kenya, Malawi, Mozambique, Nigeria, South Africa, Uganda, United Republic of Tanzania, Zambia
and Zimbabwe.
3
Mylan itself is not India-based, but its antiretroviral drug manufacturing continues to be primarily in India.

134
constructing upper and lower ranges around current and historical estimates of the
numbers of people on antiretroviral therapy. The review suggested a plausible upper
range due to underreporting of 4% and a lower range due to overreporting of 12%. The
primary reason for underreporting was missing or delayed reporting of facility data to the
national level. Overreporting was due primarily to not removing people from registries
who stopped treatment, died or transferred facilities. Other errors, such as incorrectly
abstracting data from facility-based registries or completing reporting forms, led to over-
and underreporting to varying degrees of magnitude.

There is some limited evidence from countries with multiple data quality assessments that
the accuracy of counting the numbers of people on treatment is improving. Increased
use of electronic medical records and patient monitoring systems may be contributing
to a reduction in reporting errors; however, the analysis for construction of the ranges
conservatively assumed that the quality of the reported data was unchanged between 2010
and mid-2016.

What future steps will UNAIDS take to ensure the quality and accuracy of
reported numbers of people on antiretroviral therapy?

UNAIDS, WHO and other partners continue to support countries to improve the
accuracy of the numbers of people reported to be on treatment. These efforts aim to
strengthen and expand HIV programme monitoring and surveillance systems, and to
build the capacity of national, regional and clinical staff to collect, report and analyse
data from these systems. UNAIDS and WHO are also working with drug producers and
countries to triangulate facility-reported numbers of people on antiretroviral therapy
with data from drug exports, in-country drug distribution systems, surveys and any other
relevant data.

UNAIDS methods for estimating the proportion

of young people aged 15–19 years living with
HIV who were vertically infected
The Spectrum AIDS Impact module estimates the number of people living with HIV
from 1970 to the most recent year. The model uses demographic data from the United
Nations Population Division to ensure demographic dynamics are captured in the
model. In addition, the model uses data on the number of pregnant women who received
antiretroviral medicines to reduce the probability of transmission to their children.
Children who are infected vertically are then exposed to a set of survival probabilities,
depending on whether they start antiretroviral therapy.
To estimate the proportion of young people living with HIV aged 15–19 years globally
who were vertically infected and the proportion who were infected through sexual or
injection-related transmission, two scenarios are run. The first scenario reflects best

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 available knowledge of the current number of children living with HIV, given the reported
scale-up of services to prevent mother-to-child transmission. A second hypothetical
scenario is run that assumes no HIV transmission occurred between mothers and children
since the start of the epidemic. All of the young people living with HIV aged 15–19 years
in this scenario were infected through sexual or injection-related transmission. The
difference in the numbers of young people living with HIV between the two scenarios is
the estimated number who were vertically infected.

References

1. Global aids response progress reporting 2016. Geneva: Joint United Nations
Programme on HIV/AIDS; 2016 (https://aidsreportingtool.unaids.org/static/docs/
GARPR_Guidelines_2016_EN.pdf).

2. ARV market report: the state of the antiretroviral drug market in low- and middle-
income countries, 2014–2019. Boston, MA: Clinton Health Access Initiative; 2015
(http://www.clintonhealthaccess.org/content/uploads/2015/11/CHAI-ARV-Market-
Report-2015_FINAL.pdf).

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