UNAIDS, Regional Support Team, Eastern and Southern Africa New targets post 2015: Leave No One Behind Jacqueline Makokha UNAIDS, Regional Support Team, Eastern and Southern Africa 20 August 2014

HIV epidemic in the ESA region (2013) Number of people living with HIV 18.5 million Number of children living with HIV 2.0 million Number of new HIV infections 1.1 million Number of new HIV infections among children 120,000 Number of AIDS deaths 730,000 Number of people receiving ART 7.7 million The region explains about 50% of the global burden of HIV, with about 18.5 million people currently estimated to be living with HIV. A lot of variation in the epidemics in the region and the rates at which incidence is falling. The pace at which we scale up the response in ESA will determine how quickly we can move towards an AIDS-free generation. Source: UNAIDS 2014

Overview of the HIV epidemic in the ESA region (2013) However, significant progress has been made by countries in the ESA region. The dramatic scale-up of ART (7.7 million people were receiving ART in the region in 2013) has resulted in a significant decline in AIDS-related deaths and has contributed to the reduction in HIV transmission. New infections in the region has fallen by 32% and AIDS related deaths by 46% between 2005 and 2013. Source: UNAIDS 2014

Overview of the HIV epidemic in the ESA region (2013) PMTCT coverage has reached 78% in 2013 in the ESA region. AS a result of the scale-up of PMTCT services to pregnant women, new infections among children has fallen significantly and the region is on track to reach the 2015 elimination target. Source: UNAIDS 2014

The importance of location and population If we want to control the HIV epidemic we need to focus on location and population group. In this region, it is important to particularly focus on young women, pregnant women, sex workers. However, men who have sex with men, migrant workers, people who are displaced, and people who are older than 50 years contribute substantially to the HIV burden and their needs should also be addressed.

HIV prevalence among young women and men aged 15-24 years in East and Southern Africa in 2013 This slide shows the substantial differences in HIV prevalence between young women and men aged 15-24 years and highlights the vulnerability of young women. Source: UNAIDS 2014

HIV prevalence among South African boys and girls in grades 9 and 10 in a rural district Extrsaordinary increase in prevalence among young women in grades 9 and 10 in a rural district in South Africa. By age 20, more than 15% of young women are infected with HIV, compared to less than 2% prevalence among young men of the same age. Source: Kharsany, A. B., M. Mlotshwa, et al. (2012). BMC Public Health 12: 231.

Challenges: Key populations (PHID, MSM, FSW) a substantial share of new infections Swaziland ≈ 12% Mozambique ≈ 20% South Africa ≈ 25% Kenya (incl. prison pop) ≈ 30% Studies that have been conducted in several countries in this region indicate that populations at high risk of infection, including men who have sex with men, female sex workers, people who inject drugs and prison populations contribute to substantial numbers of new HIV infections and highlights the importance of targeted interventions for these populations. Source: Gouws E, Cuchi P. Sex Transm Infect 2012;88:i76–i85

HIV prevalence among MSM in Africa Ranging from: 6% in Cairo to 31% in Cape Town This slide shows the high prevalence among MSM in Africa, ranging from 6% in Cairo to 31% in Cape Town. In most countries, prevalence among MSM is substantially higher than among men in the general population. Source: Griensven et al. Current Opinion in HIV and AIDS 2009

Global HIV prevalence among adult female sex workers, 2013 This map shows the global burden of HIV among adult women sex workers up through 2013. There are data from 79 countries and over 430,000 women. Source: Beyrer, et al, The Lancet, 2014.

Percentage of adults (aged 15+) and children (aged 0-14) living with HIV who were receiving ART in 2013, in 21 priority countries Coverage of ART has increased dramatically over recent years and good coverage among adults were observed in 213. However, ART coverage among children is lagging behind in most countries, with the exception of Botswana. Source: UNAIDS 2014

HIV treatment cascade for adults in sub-Saharan Africa aged 15 years or more, 2013 While ART coverage has increased dramatically, it is estimated that only 45% of people living with HIV in SSA know their status, 39% are receiving treatment, and 29% have viral load suppression. Clearly, a lot more needs to be done to get people tested, to put them on treatment, and to make sure that they adhere to treatment. There also need to be exceptional efforst to ensure that no-one is left behind and that marginalized populations are also reached.

Source: UNAIDS / UNICEF / WHO

Summary of the epidemic in ESA Remarkable progress has been made in the region Significant increase in ART and PMTCT coverage Significant decline in AIDS deaths and in TB/HIV deaths Important declines in new adult and child HIV infections Funding support for the HIV response has been extraordinary and has enabled countries to significantly expand their responses Increased focus on improving effectiveness and efficiency of the response

Population groups left behind

12 population groups left behind Adolescent girls Prison populations Immigrants People who inject drugs Older people who are HIV+ Older people who do not think they are at risk Sex workers Transgender women Children left behind on treatment Women of reproductive age HIV+ displaced persons People with disabilities Globally, adolescent girls and young women face gender-based inequalities, exclusion, discrimination and violence, which put them at increased risk of acquiring HIV. Adolescent girls and young women are most vulnerable to HIV in sub-Saharan Africa—and account for 1 in 4 new HIV infections. The prevalence of HIV, sexually transmitted infections, hepatitis B and C and tuberculosis in prison populations has been estimated to be between two and 10 times higher than in the general population. Globally, there are 230 million international migrants. With heightened vulnerabilities, migrants rarely have access to HIV-related health and social services. Approximately 13% of people who inject drugs are living with HIV. HIV prevalence is estimated to be 28 times higher in people who inject drugs than in the rest of the adult population.

Source: Human Sciences Research Council / Centers for Disease Control and Prevention / Human Rights Watch / Ukrainian Institute for Social Research after Olexander Yaremenko and United Nations Office on Drugs and Crime

Source: UNAIDS / UNODC

New targets post 2015

Why new targets are needed New targets are needed for four reasons: 1) Targets drive progress 2) New scientific evidence has emerged  3) New targets are needed to guide action 4) Bold new targets to end the epidemic demonstrates that AIDS is a winnable fight

HIV Treatment access gap And if we apply the new guidelines, the gap widens

To end the AIDS epidemic as a public health threat by 2030 the UNAIDS called on the world to adopt a new target ’90-90-90’ 90% reduction in new infection, 90% reduction in stigma and discrimination and 90% reduction in AIDS-related deaths In order to achieve these targets, firstly, need to build a strong momentum TO END AIDS by 2030 and secondly, ensuring an AIDS response that leave no one behind.

Ending AIDS, leaving no one behind Too many people are left behind today – a challenge 12 populations left behind by AIDS response (Sex workers, men who have sex with men; bisexual, transgender and intersex people; prisoners; people who inject drugs; migrant workers, people with disabilities; and women and girls) Need to address stigma and discrimination Close the gap between people who are reached with HIV services and people who are not Require research and innovation combined with protective laws Ending AIDS by 2030 is not possible, without a people-centred approach and we will not go far in the post-2015 era. As we saw in the new UNAIDS Gap report, 2014, our challenge boils down to one painful truth: too many are being left behind today. In the gap report, we saw that 12 populations left behind ( List them) We will not end this epidemic if we continue to stigmatize and neglecting the needs of the populations left behind. Not all have equitable access to HIV prevention, treatment and care and support services. Some populations do not have access because they are marginalized, others because of harmful gender norms, poverty, legal and social inequalities. Where HIV services are available, uptake is dependent on the quality of services as well as the levels of stigma and discrimination by service providers. Need to close the gap between people who are reached with HIV services and people who are not reached through services and this will require countries to have very good understanding of the mico-epidemics. This will require research and innovation combined with protective laws that promote freedom and equality for all people.

Thank you