2016 Prevention Gap Report

UNAIDS
11 July 2016

Report of the Sec­re­tariat

Down­load

Source

Analysis of evidentiary value

This report was issued by the Sec­re­tariat of the Joint Pro­gramme in the United Nations on HIV/AIDS (UNAIDS)–a coali­tion of 11 UN agen­cies and the World Bank help­ing to coor­di­nate the global AIDS response by engag­ing with gov­ern­ments, civil soci­ety and peo­ple liv­ing with HIV.

UNAIDS is over­seen by a Pro­gramme Coor­di­nat­ing Board com­posed of rep­re­sen­ta­tives from 22 geo­graph­i­cally diverse coun­tries; the 11 UN agen­cies, includ­ing the World Health Orga­ni­za­tion, UN Women, and the United Nations Pop­u­la­tion Fund; and five non­govern­men­tal organ­i­sa­tions. UNAIDS is the only UN entity that has rep­re­sen­ta­tives of civil soci­ety on its board.

This report is based on evi­dence from 146 coun­tries over the last 10 years and explores the proven ties between HIV pre­ven­tion and inequal­ity.

Used as precedent

key and vulnerable populations

• “Recent stud­ies sug­gest that peo­ple who inject drugs are 24 times more likely to acquire HIV than adults in the gen­eral pop­u­la­tion, sex work­ers are 10 times more likely to acquire HIV and gay men and other men who have sex with men are 24 times more likely to acquire HIV. In addi­tion, trans­gen­der peo­ple are 49 times more likely to be liv­ing with HIV and pris­on­ers are five times more likely to be liv­ing with HIV than adults in the gen­eral pop­u­la­tion.” (p. 7)

• “Among gay men and other men who have sex with men, in 7 of 10 coun­tries with avail­able data, treat­ment cov­er­age was con­sid­er­ably lower than cov­er­age among all men liv­ing with HIV. Treat­ment cov­er­age lev­els among peo­ple who inject drugs were more sim­i­lar to cov­er­age among men gen­er­ally, but dif­fer­ences were still observed in 4 of 8 coun­tries. Female sex work­ers were also less likely to access treat­ment than the gen­eral adult female pop­u­la­tion, with just 3 of 12 coun­tries hav­ing sim­i­lar lev­els of cov­er­age. In Cam­bo­dia, trans­gen­der peo­ple had higher treat­ment cov­er­age than female sex work­ers but lower than the gen­eral adult female pop­u­la­tion.” (p. 57)

combination prevention

• “How­ever, few coun­tries have con­sis­tently applied a com­bi­na­tion HIV pre­ven­tion approach, which pro­vides pack­ages of ser­vices—includ­ing behav­ioural, bio­med­ical and struc­tural com­po­nents—tai­lored to pri­or­ity pop­u­la­tion groups within their spe­cific local con­texts. For exam­ple, young peo­ple in high preva­lence coun­tries need more than con­doms and behav­iour change com­mu­ni­ca­tions. They also require com­pre­hen­sive sex­u­al­ity edu­ca­tion and access to effec­tive HIV and sex­ual and repro­duc­tive health ser­vices with­out eco­nomic bar­ri­ers, such as pro­hib­i­tive costs, or struc­tural bar­ri­ers, such as parental con­sent laws. A com­bi­na­tion pack­age for gay men and other men who have sex with men should include easy access to con­doms, lubri­cant and PrEP, as well as efforts to address homo­pho­bia; a pack­age for peo­ple who inject drugs should fea­ture com­pre­hen­sive harm reduc­tion ser­vices, includ­ing nee­dle-syringe pro­grammes and opi­oid sub­sti­tu­tion ther­apy.” (p. 10)

• “Get­ting back on track to reduc­ing new infec­tions to 500 000 by 2020 requires con­tin­ued progress towards the 90–90–90 tar­get and inten­sive focus on five pre­ven­tion pil­lars deliv­ered through a peo­ple-cen­tred, com­bi­na­tion approach:Com­bi­na­tion pre­ven­tion, includ­ing com­pre­hen­sive sex­u­al­ity edu­ca­tion, eco­nomic empow­er­ment and access to sex­ual and repro­duc­tive health ser­vices for young women and ado­les­cent girls and their male part­ners in high-preva­lence loca­tions.” (p. 10)

• “Indi­vid­ual harm reduc­tion approaches are suc­cess­ful in reduc­ing the harms related to drug use, but they are even more effec­tive when deliv­ered as a pack­age, not only together but com­bined with other pre­ven­tion ser­vices such as con­dom pro­grammes and treat­ment. Con­dom pro­vi­sion within harm-reduc­tion pro­grammes can help to reduce the trans­mis­sion of HIV from peo­ple who inject drugs to their sex­ual part­ners. Ensur­ing HIV tests are offered rou­tinely to peo­ple who access nee­dle-syringe ser­vices and opi­oid sub­sti­tu­tion ther­apy helps to iden­tify peo­ple liv­ing with HIV as soon as pos­si­ble after infec­tion and the imme­di­ate ini­ti­a­tion of anti­retro­vi­ral ther­apy. Peo­ple liv­ing with HIV who inject drugs are more likely to remain on anti­retro­vi­ral ther­apy if they are also access­ing opi­oid sub­sti­tu­tion ther­apy; in addi­tion, early ini­ti­a­tion of treat­ment con­trib­utes to the sup­pres­sion of viral load and max­i­mizes the pre­ven­tion ben­e­fits of such treat­ment. Increas­ing the pro­vi­sion of such com­bined approaches—includ­ing those that incor­po­rate pre-expo­sure pro­phy­laxis for peo­ple who inject drugs at par­tic­u­larly high risk, and for their sex­ual part­ners—will enhance the ben­e­fits of harm reduc­tion.” (p. 52)

gender equality

• “Expe­ri­ences of phys­i­cal and emo­tional inti­mate part­ner vio­lence in set­tings with male con­trol­ling behav­iour and HIV preva­lence above 5% have been strongly asso­ci­ated with HIV infec­tion in women. In some regions, women who expe­ri­enced phys­i­cal or sex­ual inti­mate part­ner vio­lence were 1.5 times more likely to acquire HIV than women who had not expe­ri­enced vio­lence.” (p. 20)

• “Stud­ies have shown that increas­ing edu­ca­tional achieve­ment among women and girls is linked to bet­ter sex­ual and repro­duc­tive health out­comes, includ­ing lower rates of HIV infec­tion, delayed child­bear­ing, safer births and safer abor­tions, and other devel­op­ment out­comes.” (p. 23)

negative legal determinants

• “For exam­ple, when pos­ses­sion of inject­ing equip­ment or con­doms is used by crim­i­nal jus­tice sys­tems as evi­dence of drug use or sex work, peo­ple at high risk of HIV infec­tion are less likely to use these proven pre­ven­tion tools.” (p. 24)

• “Crim­i­nal­iza­tion of drug pos­ses­sion and use per­pet­u­ates risky forms of drug use, increases HIV risk, dis­cour­ages peo­ple who use drugs from seek­ing health care, and rein­forces the mar­gin­al­iza­tion of peo­ple who use drugs. Presently, 11 coun­tries have com­pul­sory deten­tion and 15 have death penal­ties for peo­ple who used drugs.” (p. 44)

• “Crim­i­nal jus­tice sys­tems that use pos­ses­sion of drug para­pher­na­lia or drug residue within inject­ing equip­ment as evi­dence of ille­gal drug pos­ses­sion or use are par­tic­u­larly dis­rup­tive to nee­dle–syringe pro­grammes. Syringe con­fis­ca­tion has been asso­ci­ated with increases in HIV infec­tion among female sex work­ers who inject drugs. In parts of east­ern Europe and cen­tral Asia, non­gov­ern­men­tal orga­ni­za­tions report that police may con­sider nee­dle–syringe dis­tri­bu­tion as pro­mo­tion of ille­gal drug use, which leads to a high rate of turnover among out­reach work­ers who fear they may be arrested for car­ry­ing inject­ing equip­ment.” (p. 50)

intersectionality

• “Women who inject drugs faced higher lev­els of stigma, dis­crim­i­na­tion and vul­ner­a­bil­ity to harm than their male coun­ter­parts. Those who had expe­ri­enced sex­ual vio­lence were more likely to be liv­ing with HIV than other women who inject drugs.” (p. 27)

• “HIV preva­lence among women who inject drugs is often greater than their male peers, high­light­ing a need for gen­der-sen­si­tive harm reduc­tion inter­ven­tions. In 24 of 35 coun­tries report­ing to the 2016 Global AIDS Response Progress Report, median HIV preva­lence among women was 50% higher, with a range of 2% to 530%.” (p. 44)

sexual rights

• “A mod­el­ling study esti­mated that elim­i­nat­ing sex­ual vio­lence against sex work­ers could avert 17% of HIV infec­tions in Kenya and 20% in Canada.” (p. 27)

harm reduction

• “Nee­dle-syringe pro­grammes reduce the spread of HIV, hepati­tis C and other blood­borne viruses. Opi­oid sub­sti­tu­tion ther­apy and other evi­dence-informed forms of drug depen­dence treat­ment curb drug use, reduce vul­ner­a­bil­ity to infec­tious dis­eases, and improve uptake of health and social ser­vices.” (p. 44)

• “Decades of expe­ri­ence within dozens of coun­tries sup­ports the effec­tive­ness of nee­dle–syringe pro­grammes. Across eight coun­tries in east­ern Europe and cen­tral Asia, a tripling of nee­dle–syringe pro­gramme cov­er­age between 2005 and 2010 reduced inject­ing risk behav­iour related to HIV and hepati­tis C and reduced new infec­tions. Many indi­vid­ual pro­grammes have achieved out­stand­ing results. Ten years of nee­dle–syringe pro­gram­ming in Aus­tralia reduced the num­ber of cases of HIV by up to 70% and reduced the num­ber of cases of hepati­tis C by up to 43%. In New York a sharp decrease in new HIV infec­tions among peo­ple who inject drugs between 1992 and 2012 has been attrib­uted to the imple­men­ta­tion and expan­sion of syringe exchange since 1992.” (p. 46)

• “Sub­sti­tu­tion ther­apy has also been shown to decrease the risk of hepati­tis C infec­tion, to increase adher­ence to anti­retro­vi­ral ther­apy for HIV, to lower out-of-pocket health expen­di­tures, and to reduce opi­oid over­dose risk by almost 90%. The scale-up of methadone main­te­nance ther­apy in diverse coun­try con­texts, includ­ing Por­tu­gal, Viet Nam and New Zealand, has also been asso­ci­ated with a decrease in crimes com­mit­ted by peo­ple who use drugs.” (p. 48)

stigma and discrimination

• “Among gay men and other men who have sex with men, in 7 of 10 coun­tries with avail­able data, treat­ment cov­er­age was con­sid­er­ably lower than cov­er­age among all men liv­ing with HIV. Treat­ment cov­er­age lev­els among peo­ple who inject drugs were more sim­i­lar to cov­er­age among men gen­er­ally, but dif­fer­ences were still observed in 4 of 8 coun­tries. Female sex work­ers were also less likely to access treat­ment than the gen­eral adult female pop­u­la­tion, with just 3 of 12 coun­tries hav­ing sim­i­lar lev­els of cov­er­age. In Cam­bo­dia, trans­gen­der peo­ple had higher treat­ment cov­er­age than female sex work­ers but lower than the gen­eral adult female pop­u­la­tion.” (p. 57)

comprehensive sexuality education

• “In sub-Saha­ran Africa, sur­vey data from 35 coun­tries show that only 36% of young men and 30% of young women cor­rectly iden­ti­fied ways of pre­vent­ing the sex­ual trans­mis­sion of HIV and rejected major mis­con­cep­tions about HIV trans­mis­sion. In 23 coun­tries out­side of sub-Saha­ran Africa, just 13.8% of young men and 13.6% of young women had cor­rect and com­pre­hen­sive knowl­edge about HIV.” (p. 71)