2020 Evidence Review of the UNAIDS Strategy 2016-2021

31 July 2020

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.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).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.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.

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.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%.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.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.

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.

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.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.

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.

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.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).

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.

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.

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