2020 Evidence Review of the UNAIDS Strategy 2016-2021
Analysis of evidentiary value
This review 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. At the time of this report’s release, UNAIDS’s Executive Director Winnie Byanyima was concurrently serving as the UN Under-Secretary-General–the third-highest position in the UN system.
This review assesses the progress of UNAIDS in implementing its 2016 program strategy, and in doing so, discusses remaining barriers to the end of HIV. Using the results of UNAIDS’ own disease surveillance, it investigates HIV responses and their ties to political leadership, intersectional inequality, and discrimination.
Used as precedent
key and vulnerable populations
“The epidemic’s disproportionate burden among key populations (including gay men and other men who have sex with men, people who inject drugs, sex workers, transgender people and prisoners) continues to grow. In 2019, these populations and their sex partners accounted for an estimated 62% of new HIV infections globally. Compared to the general population, the risk of acquiring HIV is on average about 26 times higher for gay men and other men who have sex with men, 29 times higher for people who inject drugs, 30 times higher for sex workers and 13 times higher for transgender people than for adults in the general public. Globally, HIV incidence among people who inject drugs, sex workers and transgender people since 2010 has remained high but relatively stable since 2010. New infections are on the rise among gay men and other men who have sex with men, who comprised 23% of new infections globally in 2019, including more than 40% of new infections in Asia and the Pacific and Latin America, and nearly two thirds (64%) of new infections in western and central Europe and North America. Marked increases in new infections among gay men and other men who have sex with men were reported in Brazil, Mexico, Pakistan and Philippines.” (p. 50)
“Prevention coverage is notably limited for key populations. In six of 13 countries that have conducted surveys since 2016 and reported those data to UNAIDS, less than half of transgender women stated that they were able to access at least two HIV prevention services in the previous three months, as did similar proportions of female sex workers (in 16 of 30 countries), gay men and other men who have sex with men (in 26 of 38 countries) and men who inject drugs (in 10 of 14 countries).” (p. 56)
“Punitive laws undermine HIV responses and increase the vulnerability of marginalized populations. Gay men and other men who have sex with men who live in countries that criminalize same-sex relations are 2.2 times more likely to acquire HIV than their counterparts in countries without such legal restrictions. Severe criminal penalties for same-sex relations are associated with a 4.7 times higher risk of HIV infection, compared with settings lacking such penalties. According to an analysis of 75 countries, the existence of anti-LGBT laws is also associated with substantially lower uptake of HIV testing services. Evidence-based modelling indicates that decriminalization of all aspects of sex work could avert 33–46% of new HIV infections among sex workers and their clients over 10 years. Another meta-analysis found that repressive policing of sex work increased the prevalence of HIV and other sexually transmitted infections by 87% and increased the risk of sexual or physical violence nearly three-fold. A 2020 study examining 10 countries in sub-Saharan Africa linked increasingly repressive laws regarding sex work with increased prevalence of HIV infection. According to a 2017 systematic review, more than 80% of pertinent studies have correlated criminalization of drug use with an increased risk of HIV, while a separate analysis found that repressive policing of drug use is associated with HIV infection, needle sharing and avoidance of harm reduction programmes. In some countries in eastern Europe and central Asia, laws require individuals seeking harm reduction services to register with authorities, a step that in turn makes the individual ineligible for a driver’s license. Although study evidence of the HIV-related impact of punitive laws on transgender people is scarce, the harm associated with repressive policing of transgender people is well-documented. Approximately 40% of transgender correctional inmates have experienced sexual violence in the previous 12 months, compared to 4% of the general prison population.” (pp. 72–73)
“The evidence base for removing punitive laws and policies has expanded. Numerous studies and meta-analyses on the impact of punitive laws on HIV responses (summarized in the status report above) provide evidence that bolsters the efforts of advocates and public health experts to remove such counterproductive laws. The publication of a consensus statement on the science of HIV in the context of criminal law has strengthened litigants’ and advocates’ arguments that HIV criminalization laws are not grounded in science. The 2018 release of a supplement to the previous report of the Global Commission on HIV and the Law underscored the consensus of public health experts that punitive laws undermine HIV responses, cause needless suffering and should be removed.” (p. 76)
combination prevention
“We have the tools to sharply reduce the number of new HIV infections, since evidence clearly demonstrates that combination prevention works. Evidence from both clinical trials and real-world implementation of combination prevention shows the effectiveness of diverse, layered HIV prevention strategies and approaches. Case studies of high-burden countries that have sharply lowered HIV incidence underscore the importance of changing sexual risk behaviours and the added prevention benefits of increased coverage of ART. Studies in Kenya and South Africa indicate that prevention and treatment work best when brought to scale simultaneously. Modelling exercises have quantified the number of infections averted for key prevention interventions. It is estimated that voluntary medical male circumcision averted about 250 000 new HIV infections by 2018 and could avert 1.6 million new infections by 2030, along with preventing other sexually transmitted infections, as well. It is estimated that condom use has averted nearly 50 million HIV infections since the beginning of the HIV response. Combination HIV prevention entails an expanding array of biomedical, behavioural and structural interventions. Studies have found that several interventions—including ART, PrEP, condoms and sterile injecting equipment—have a very high level of effectiveness (80–100%) if consistently used. Evidence also shows that voluntary medical male circumcision is an effective one-time procedure which reduces men’s risk of acquiring HIV from female partners by 38–66%. Opioid substitution therapy can reduce the risk of acquiring HIV by up to 54% for people who inject drugs and has a range of additional health and social benefits.” (pp. 52–53)
“The number of people reported to have received PrEP at least once in the previous year rose from fewer than 2000 in 2016 to more than 590 000 in 2019. In places where PrEP has been scaled up—e.g. Australia, Brazil and many countries in western and central Europe and North America—HIV incidence among gay men and men who have sex with men has declined. New data from the SEARCH trial indicates that scale-up of PrEP alongside intensified health services reduced HIV infections in 16 communities in Kenya and Uganda by 74%.” (p. 53)
“Similarly, implementation of effective harm reduction has improved prevention outcomes in Ukraine, where participants of peer-led community outreach are now more likely to use sterile injecting equipment, condoms and opioid substitution therapy and are achieving better outcomes on all stages of the HIV treatment cascade.” (p. 53)
“A number of countries have had striking success in reducing HIV incidence through the support of scaled-up combination prevention programmes. In Cambodia, a combination of strong political leadership, outreach to key populations, robust condom programming and high levels of viral load suppression led to a 95% reduction in new HIV infections over two decades. Likewise, the scale-up of combination prevention in Zimbabwe was associated with a reduction in new HIV infections of at least 80% over 25 years. In South Africa, where new HIV infections have decreased by 53% since 2010, reductions in HIV incidence between 2000 and 2008 were partially attributed to increased condom use. Since 2010, South Africa has achieved one of the steepest declines in HIV incidence in the region, a feat that is attributed to the country’s simultaneous expansion of ART and voluntary medical male circumcision.” (p. 55)
combination prevention, comprehensive sexuality education
“Comprehensive sexuality education has been shown to improve HIV-related knowledge and encourage safer sexual behaviours. It is also relatively inexpensive: one multicountry evaluation found that comprehensive sexuality education need avert only 4% of projected HIV infections to be cost-saving. Other behavioural interventions also have positive outcomes in specific contexts. Short-term HIV prevention campaigns in schools have been found to be effective in reducing sexual relations with older higher-risk partners, as well as teenage pregnancies. Combined behavioural and structural interventions using gender-transformative HIV prevention approaches are effective in changing sexual behaviours and in preventing HIV in some settings.” (pp. 53)
negative legal determinants
“The effectiveness of various structural approaches is also evident, including reforms to laws that criminalize drug use. Criminalization has been shown to undermine HIV prevention and treatment. It is estimated that decriminalization of sex work would reduce 33–46% of new HIV infections over a decade.” (p. 53)
“Countries urgently need to intensify efforts to eliminate stigma and discrimination, which continue to undermine HIV prevention efforts. This is true generally and but especially salient for key populations. Recent systematic reviews and meta-analyses found that African countries with oppressive anti-LGBT laws have low levels of HIV testing and awareness among gay men and other men who have sex with men, and their size estimates for those populations are either absent or unrealistically low. Gay men and other men who have sex with men who live in countries that criminalize same-sex relations are more than twice as likely to acquire HIV as their peers living in countries without such criminal penalties. Those living in countries with severe criminalization are almost five times as likely to acquire HIV as those living in countries without such criminal penalties.” (p. 57)
comprehensive sexuality education
“There is encouraging progress in the provision of comprehensive sexuality education, with 80% of countries surveyed reporting the existence of supportive policies or strategies. Most countries in Asia and the Pacific (21 of 25) have national HIV strategies that refer to the role of education, while most countries in western and central Asia have formal policies on life skills-based HIV sexuality education. Health ministers in Latin America and the Caribbean have committed to nationwide school-based sexuality and HIV education. Although policies on comprehensive sexuality education are increasingly aligned with national norms, the translation of these policies into actual programmes lags in many settings, which adds to young people’s vulnerability to HIV.” (pp. 54–55)
gender equality
“Sexual and reproductive health and rights are not upheld. Sexual and reproductive health and rights are central to empowering women and adolescent girls, fulfilling their human rights, ensuring their health and wellbeing, creating gender-equal societies and economies, and preventing HIV infections. In 57 countries, only 55% of married or in-union women (aged 15–49 years) currently using contraception are able to make their own decisions regarding their sexual and reproductive health including to refuse unwanted sex. Moreover, there is little sign of improvements in women’s agency.” (p. 66)
“Women’s lack of freedom and agency to make decisions regarding their sexual and reproductive health results in inadequate uptake of essential interventions and tools. More than half of the estimated 38 million sexually active adolescent girls (aged 15–19 years) in developing regions in 2016 who needed contraceptives because they were married or were unmarried and sexually active and did not want a child for at least two years, were not using modern contraceptives. Each year, 21 million adolescent girls become pregnant and approximately 12 million adolescent girls give birth, including 777 000 girls under the age of 15. One in three women living with HIV in 19 countries report experiencing at least one form of discrimination related to their sexual and reproductive health in a health-care setting in the previous 12 months (e.g. being advised not to have children, being offered ART on condition they use certain forms of contraception, or being denied sexual and reproductive health services).” (pp. 66–67)
gender equality, negative legal determinants
“Laws and policies prevent many adolescent girls from making decisions about their own sexual and reproductive health or accessing essential health services, including for contraception and HIV-related services. In 2019, 105 of 142 countries with available data required that adolescents have parental or guardian consent to access HIV testing. In 86 of 138 reporting countries, they needed similar consent to access HIV treatment and care. A recent multicountry review in sub-Saharan Africa found that laws allowing young people younger than 16 years to access HIV testing without parental consent were associated with a 74% increased likelihood of HIV testing utilization among adolescents. Discriminatory criminalization laws linked to HIV can disproportionately affect women, as women are more likely than men to know their HIV status as a result of routine HIV screening in antenatal care.” (p. 67)
gender equality, key and vulnerable populations
“Women who belong to key populations are at particular risk of experiencing violence. Women who use drugs are up to five times more likely to experience violence than non-drug-using women. It is estimated that 45–75% of female sex workers are assaulted or abused at least once in their lifetime, although mechanisms for reporting abuse or accessing survivor services are often blocked due to the criminalization of sex work. Women belonging to ethnic and other minorities, transgender women and women with disabilities face higher risks of violence.” (p. 69)
societal enablers
“Women’s access to property and inheritance rights can be vital for preventing HIV infection or mitigating its impact. Yet, customary laws and practices continue to inhibit women’s access to land in 90 countries, daughters do not have the same inheritance rights as sons in 34 countries, and widows lack inheritance rights in 36 countries” (pp. 74)