World Aids Day UNAIDS Report 2015

WORLD
AIDS DAY
2015
On the Fast-Track to end AIDS by 2030
Focus on
location and
population
UNAIDS
Contents
05
07
Foreword
Introduction
Part 01
14
24
32
50
58
66
74
82
92
100
108
116
124
Efficiency and effectiveness

Eliminating stigma and discrimination and advancing human rights
909090
Voluntary medical male circumcision
Condoms
Pre-exposure prophylaxis
Adolescent girls and young women
Gay men and other men who have sex with men
Transgender people
People who inject drugs
Sex workers
Prisoners
Conclusion
Part 02
130
132
134
136
142
144
148
152
158
162
168
172
178
182
188
190
194
198
204
208
214
220
226
230
234
238
242
246
250
254
Where services are needed
260
References
Botswana
Brazil
Cameroon
Chad
China
Cte dIvoire
Democratic Republic of the Congo
Ghana
Haiti
India
Indonesia
Iran (Islamic Republic of)
Kenya
Lesotho
Malawi
Mali
Mozambique
Myanmar
Namibia
Nigeria
Pakistan
South Africa
Swaziland
Uganda
Ukraine
United Republic of Tanzania
Viet Nam
Zambia
Zimbabwe
THE WORLD HAS COMMITTED

TO END THE AIDS EPIDEMIC BY 2030
A S PA R T O F T H E S U S TA I N A B L E
DEVELOPMENT GOALS.
Foreword
Michel Sidib
UNAIDS Executive Director
The world has committed to end the AIDS epidemic by 2030 as part of the
Sustainable Development Goals. This ambitious yet wholly attainable objective
represents an unparalleled opportunity to change the course of history for ever
something our generation must do for the generations to come.
Today, we live in fragile communities where inequities can persist when essential
services dont reach the people in need. To change this dynamic we must quicken
the pace of action. We know that strengthening local services to reach key
populations will lead to healthier and more resilient societies.
The good news is that we have what it takes to break this epidemic and keep it
from reboundingthe course set out in the new UNAIDS 20162021 Strategyto
prevent substantially more new HIV infections and AIDS-related deaths and to
eliminate HIV-related stigma and discrimination.
Increasingly we are able to refine our efforts and be more precise in our ability to
reach people who might otherwise be left behind. With this attention to location
and population, countries are able to redistribute resources to improve access. With
the Fast-Track approach and front-loaded investments we can expect the gaps to be
closed faster. This means resources can go further to reach more people with lifechanging results.
Within the pages of this World AIDS Day report, Focus on location and population,
are more than 50 examples of how countries are getting on the Fast-Track. It shows
how governments are working with community groups and international partners
to scale up health and social services that put people at the centre and located where
they can do more people more good.
These examples show us that ending the AIDS epidemic is achievable if we focus
on people accessing the right services delivered in the right place. This report also
contains nearly 100 maps that display an unprecedented amount of subnational
data generated and reported by national HIV programmes.
These granular data drive the location-population approach of Fast-Track. The
maps are symbols of the innovation and integration that define the sustainable
development era. The 17 Sustainable Development Goals reflect a greater
understanding of how our efforts to end poverty, improve global health, eliminate
inequalities and address climate change are interconnected.
To leverage the power required for change, we must move forward together. Ending
the AIDS epidemic means that adolescent girls and young women have access to
education and appropriate HIV and sexual and reproductive health services. It
means key populations, such as people who inject drugs and transgender people,
have full access to health services delivered with dignity and respect. And it means
that every child is born free from HIV, and that they and their mothers not only
survive but thrive.
This is an exciting time in the AIDS response. We are building momentum towards
a sustainable, equitable and healthy future for all.
UNAIDS
E N D IN G THE A ID S E P ID E MIC IS
ACH IE VABL E IF W E F O C U S O N P E O P LE
AC C E SS IN G TH E R IGH T SE R V IC E S
D E L I VE RE D IN TH E R IGH T P LA C E .
Introduction
The world has committed to the Sustainable Development Goalsthe objective for
AIDS is absolute: ending the epidemic by 2030. This bold ambition stands on top
of the foundation of an unprecedented public health and human rights response
that has averted 30million HIV infections and saw 15.8million people accessing
antiretroviral therapy.
Progress has been achieved in each region of the world. But the pace is too slow.
Ending the AIDS epidemic will require extraordinary efforts in leadership,
investment and focus over the next five years to deliver even more services and
even greater social change. In anticipation of this challenge, UNAIDS launched a
global Fast-Track initiative on World AIDS Day 2014.
One year on, this report catalogues Fast-Track initiatives from around the globe.
Among these efforts, a common theme emerges: the Fast-Track approach be
guided at the national level, but it is realized at the local level. Fast-Track requires
cities, towns and communities to take charge of their HIV responses by analysing
the nature of their epidemic and then using a locationpopulation approach to
focus their resources on evidence-informed, high-impact programmes in the
geographical areas and among the populations in greatest need.
Ten Fast-Track Targets for 2020
The UNAIDS 20162021 Strategy has established a set of three people-centred

goals and 10 measurable targets that must be met by 2020 to end the AIDS
epidemic by 2030 (1). The knowledge and tools exist to reach these targets. To
Fast-Track, countries must recalibrate their HIV programmes to achieve these
targets, hold each other accountable for results and ensure that no one is left
behind.
Dozens of countries have produced investment cases and HIV response
effectiveness analyses that calculate an optimal mix of services and make specific
recommendations that call for tough choices: reallocation of resources away
from areas and services where there is little to be achieved, and front-loading
investment in high-priority areas to achieve long-term gains.
The potential power of front-loading has been calculated for Kenya, where an
estimated 1.4million people were living with HIV and 56000 new HIV infections
occurred in 2014 (2). HIV has lowered life expectancy, deepened poverty,
reduced economic growth, exacerbated hunger and worsened basic health
indicators (3). Kenyas leaders have declared a Prevention Revolutiona national
ambition to reach zero new HIV infections by 2030. If increases in expenditure
start small and increase steadily over time, a US$1billion investment in
combination HIV prevention over a 30-year period will avert 1.1million new
UNAIDS
infections. If that same investment is front-loaded with greater expenditure in

the early years, reaping reductions in future treatment costs, the number of new
infections averted will be increased by 22% (4). Front-loading changes the course
of the epidemic, putting countries on a Fast-Track.
Comprehensive, high-impact programmes
Part 1 of this report provides evidence of how elements of the Fast-Track

approach are already being implemented successfully in various locations and
with different populations. At the start of each chapter, data have been mapped
to illustrate the successes and challenges of a locationpopulation approach.
These examples show that Fast-Track is a comprehensive approach by health
systems working in close collaboration with civil society, including long-proven
programmes such as condom promotion and distribution, harm reduction, HIV
testing and antiretroviral therapy, combined with recent and emerging evidenceinformed programmes such as pre-exposure prophylaxis, voluntary medical male
circumcision and treatment for all people living with HIV. An increasing number
of countries are integrating HIV testing and treatment services into a continuumof-care cascade to achieve the 909090 treatment targets by 2020: 90% of people
(children, adolescents and adults) living with HIV know their status, 90% of
people living with HIV who know their status are accessing treatment, and 90%
of people on treatment have suppressed viral loads.
Mozambique has aligned its HIV testing programme to local population sizes and
HIV prevalence, identifying 27% more people living with HIV while decreasing
testing volume by 6%. The Blantyre district in Malawi has demonstrated the
power of HIV self-testing to newly diagnose people living with HIV and enrol
people into treatment. Guangxi in China has dramatically reduced AIDS-related
deaths by adopting the strategy recommended by the World Health Organization
of immediately offering antiretroviral therapy to all people diagnosed with HIV.
Rwanda is unplugging bottlenecks towards the elimination of mother-to-child
transmission of HIV. Khayelitsha in South Africa is improving HIV treatment
for children through adherence clubs within a community model of care. The
Sustainable East Africa Research in Community Health (SEARCH) trial in Kenya
and Uganda is combining HIV testing and treatment with the delivery of a range
of primary health-care services for every person within 32 rural communities in a
bold effort to reduce their collective viral load to zero, stop the spread of HIV and
improve overall health, education and economic productivity.
Impressive efforts are also being made to reduce new HIV infections, from
Kenyas Prevention Revolution to South Africas establishment of the worlds
largest condom distribution network, and from San Franciscos aggressive
scale-up of pre-exposure prophylaxis among gay men and other men who have
sex with men, to male circumcision being used as a gateway to HIV testing
and treatment among men in Maseru, Lesotho. The global commitment to end
mother-to child transmission of HIV is linking the goals of prevention with
accelerated testing and treatment strategies. Since the mid-1990s, programmes to
prevent mother-to-child transmission of HIV have averted 1.4million infections
among infants (5).
Focus on location and population
Reaching the populations in greatest need
In order for Fast-Track to be successful, services must focused on at key

populations and accessed within an enabling environment that protects
individual rights and moves society towards the goal of zero discrimination.
UNAIDS has identified 12 populations in danger of being left behind by the AIDS
response (6), including six populations at higher risk of HIV infection: adolescent
girls and young women, men who have sex with men, transgender people, people
who inject drugs, prisoners and sex workers. The importance of each of these
populations varies by region and within countries. For example, in southern
Africa, age-disparate intergenerational sexual relationships and transactional
sex place adolescent girls and young women at extremely high risk of HIV (7);
in eastern Europe and central Asia, most new HIV infections are associated with
people who inject drugs (6); and in the Latin American and Caribbean regions, the
largest proportion of new HIV infections is among men who have sex with men (6).
Decriminalization of possession of small quantities of drugs is increasing access
to services and reducing new infections among people who inject drugs in the
Netherlands, Portugal and Switzerland (8). Social media and mobile dating
applications are boosting HIV prevention among men who have sex with men
in Guatemala City. Transgender sex workers in Uruguay are advocating for
full access to health and social services. Sensitization education of health-care
workers is reducing stigma and discrimination in Thailand. Sex workers in
Namibia are collecting and using strategic information to advocate for improved
HIV services and to work with the local police to reduce harassment and
violence.
12 populations that have been left behind by the AIDS response
01. People living with HIV

02. Adolescent girls and young women
03. Prisoners
04. Migrants
05. People who inject drugs
06. Sex workers
07. Gay men and other men who have sex with men
08. Transgender people
09. Children and pregnant women living with HIV
10. Displaced persons
11. People with disabilities
12. People aged 50 years and older
Source: The gap report. Geneva: UNAIDS; 2014.
UNAIDS
All 12 populations require special efforts to counteract the social determinants

that increase their vulnerability to unemployment and homelessness and limit
their access to health care, education and other social services. The desperate
struggle of people displaced by conflict has been thrust into the international
spotlight by waves of women, men and children seeking refuge in Europe. In subSaharan Africa, conflict and post-conflict traumas are laced with elevated risk
of AIDS-related illness and death. In the Central African Republic, conflict has
destroyed 43% of health facilities and displaced thousands of people, resulting in
the loss to follow-up of a third of people accessing antiretroviral therapy. Political
and religious leaders, civil society groups and youth associations in the Central
African Republic have backed a special effort to reconnect people living with HIV
to treatment servicesand by September 2015, 1374 people had been located and
re-enrolled into treatment.
Granular data drive a location-population approach
An unprecedented amount of subnational data generated and reported by

national HIV programmes have been compiled within this report. Part 2 presents
maps of data from the first and second subnational administrative levels for 29 of
the 35 Fast-Track priority countries that account for 90% of the total burden of
new HIV infections globally. The maps reveal where new infections are occurring,
where antiretroviral therapy and other service gaps are largest, where key
populations are in need of prevention services and where discriminatory attitudes
persist. HIV programme managers at the local, national and regional levels are
using the data in these maps to identify and address programmatic gaps.
Cities critical to the Fast-Track approach
Cities contain large proportions of the total number of people living with HIV
in Fast-Track countries. Urbanization involves substantial, often abrupt shifts in
social systems, values and communal structures of authority, resulting in higher
rates of premarital and non-spousal sex. The vibrancy, stress and anonymity
of urban life, and its bustle of encounters and interactions, provide increased
opportunities for behaviours and sexual networking that may increase the risk of
HIV infection (9).
At the same time, cities offer the density and economies of scale, institutional
response frameworks, public and private sector infrastructure and health systems
that can help to address the AIDS epidemic in a more effective manner and
make a critical contribution to national and international efforts to ending the
AIDS epidemic (9).
10
Transforming exceptions to norms to end the AIDS epidemic
The case studies and maps within this report demonstrate the power of a FastTrack approach. Fast-Track is happening, but in too few places. Leadership
and investment are required within more communities, more cities and more
countries to replicate these examples at a global scale and build the momentum
required to achieve the 10 Fast-Track Targets by 2020 and realize the target within
the Sustainable Development Goals to end the AIDS epidemic as a public health
threat by 2030.
UNAIDS
11
12
Part
01
UNAIDS
13
Getting on the Fast-Track will require additional investmentand wiser use of

that investment.
Reaching the targets in the UNAIDS 20162021 Strategy will require an
estimated US$ 31.1 billion globally in 2020. This estimate assumes that significant
efficiency gains and reductions in commodity costs will be achieved.
Increasing evidence suggests that the provision of HIV services within many
countries have not been aligned to the locations and populations with the greatest
disease burden. For example, recent studies show large variations in the unit costs
Figure 1
Estimated new HIV infections in Kenya, 2014

Sixty-five per cent of new HIV infections in Kenya occurred in nine of the East African countrys 47 counties: Bomet, Homo Bay, Kisii, Kisumu, Migori, Nakuru, Nyamira, Siaya and Turkana. Kenyas Prevention
Revolution calls for a paradigm shift in the national HIV response, moving it from a one-size-fits-all
approach to one that is population-driven and geographically focused. A combination HIV prevention
strategy focused on priority geographic areas and populationscombined with increasing coverage
of antiretroviral therapycould avert more than 1.1 million new HIV infections and more than 760 000
AIDS-related deaths by 2030.
Sources: UNAIDS estimates; Kenya Ministry of Health.
14
FAST-TRACK TARGET
>> US$ 31.1 billion invested in the global HIV response in 2020.
FAST FACT
>> An estimated US$ 20 billion was spent on the global HIV response in 2014.
CHALLENGES AT A GLANCE
>> Wrong services: resources are not allocated towards scaling up the
programmes that are most cost-effective within the local context.
>> Wrong places: resources are not focused in locations with the
highest HIV burden.
>> Wrong people: resources are not focused on the populations
with the greatest need.
>> Wrong way: high-impact HIV services are not delivered in a way that meets
the needs of the target population or at the lowest possible cost. For
example, inefficient procurement of antiretroviral medicines can dramatically
raise the cost of HIV treatment.
>> Resistance to change: efficiency analyses have been conducted in many
countries, but the tough decisions required to follow up on the resulting
recommendations have not always been made.
of services within countriesa strong sign of a potential for efficiency gains.

Similarly, analyses of testing yield by facility show that an important proportion
of facilities yield no or very few HIV diagnoses, indicating that efficiencies are
possible if the placement of HIV testing sites is reconsidered (1). Making optimal
use of available funding to achieve the greatest health and human rights returns
from the resources available is critical.
Investment cases and similar efficiency analyses are increasingly being conducted
at national and subnational levels to guide the reallocation of available resources
in a way that minimizes new HIV infections and AIDS-related deaths. These
analyses primarily focus on whether the most effective HIV programmes are
being implemented and if they target the appropriate populations and geographic
areas.
UNAIDS
15
Moving forward, national and local leaders must make tough decisions about
reallocating resources according to the results of these efficiency analyses.
Additional efforts also are needed to do things the right wayoptimizing how
HIV services are delivered.
Kenyas Prevention Revolution
Women in Kenya are disproportionately affected by HIV: they accounted for

nearly 60% of adult new infections in 2013 and had an HIV prevalence of 7.6%
(compared to 5.6% for men) (2). Frustrated by the persistence of this imbalance,
the National AIDS Control Council and the Ministry of Healths National AIDS
and STI Control Programme joined forces with religious leaders, international
supporters and womens representatives from all over the country in 2014 to
declare a national ambition to reach zero new HIV infections by 2030. This
Prevention Revolution calls for a paradigm shift in Kenyas response, moving
it from a one-size-fits-all approach driven by the health sector to one that is
population-driven and geographically focused. This new approach emphasizes a
combination HIV prevention package that includes biomedical, behavioural and
structural interventions that make HIV prevention everyones business (2).
An analysis of epidemiological data found that just nine of Kenyas 47 counties
account for an estimated 65% of all new HIV infections (Figure 1), and that HIV
prevalence among key populations is extremely high: 29% among sex workers,
18% among men who have sex with men and 18% among people who inject
drugs. A combination HIV prevention strategycombined with increasing
coverage of antiretroviral therapy to 90% of eligible people living with HIV
could reduce the number of new HIV infections by 66%. Prioritizing this same
approach in the geographical areas in greatest need would reduce the number of
new HIV infections by 80% (Figure 2).1 Achieving these results would require an
additional investment of US$ 110 million in 2015 and more than US$ 500 million
by 2020 (3).
The analysis and the Prevention Revolution Roadmap provided important input
for Kenyas HIV response strategy for 20142019. The United States Presidents
Emergency Plan for AIDS Relief (PEPFAR) and other partners are supporting the
Kenyan health system to scale up to saturation in eight of the priority counties,
with the goal of reaching 80% coverage of antiretroviral therapy for all people
living with HIV by 2017. These eight counties are estimated to contribute 51%
of new HIV infections in the country; they also are estimated to be the home of
50% of people living with HIV, 53% of pregnant women living with HIV, 50%
of female sex workers, 58% of men who have sex with men and 45% of unmet
treatment need. Another 12 counties have been designated for aggressive scaleup by end of 2018. They contribute to an additional 30% of new infections,
30% of people living with HIV, 29% of pregnant women living with HIV, 28%
of female sex workers, 29% of men who have sex with men and 36% of unmet
treatment need (1).
1. Antiretroviral therapy eligibility in Kenya was <CD4 350 at the time of the analysis.
16
Figure 2
Number of new infections per year (thousands)
Projected rate of new HIV infections over time nationally

80
70
60
50
40
30
20
10
2010
2015
2020
2025
2030
Business as usual
Combination prevention
Combination prevention + geographical prioritization
Source: Kenya HIV Prevention Revolution road map: count down to 2030. Nairobi: Kenya Ministry of Health; 2014.
Geographic and population focus and improving implementation

in Zimbabwe
The achievements of Zimbabwes HIV response are among the most remarkable
in southern Africa. From 2004 to 2014, the number of people accessing
antiretroviral therapy increased from 11 800 to 788 000. Similarly, new HIV
infections declined by 46% between 2002 and 2014, and HIV prevalence fell from
25.9% in 2002 to 16.7% in 2014 (4).
To build on these accomplishments and put the country on track to end the AIDS
epidemic, the National AIDS Council worked with partners to develop a secondgeneration investment casean efficiency analysis of the HIV response within
the context of the countrys health delivery system as a whole. Several investment
scenarios were developed, and it was determined that simply maintaining the
current level of services would see the loss of hard-fought gains: annual new
infections would double between 2015 and 2025, and annual AIDS-related deaths
would climb from about 60 000 to nearly 90 000 over the same period (5).
Maintaining business as usual was clearly a poor option. In contrast, optimizing
the HIV responseincluding better geographic focus and prioritization of highimpact programmes, plus increasing investment by 30% over the next
decadecould put Zimbabwe on track to avert 560 000 new infections and
291 000 AIDS-related deaths by 2030 (5) (Figure 3).
UNAIDS
17
Key partners are adjusting their support in line with the investment case. Hotspot
mapping by the National AIDS Council and analysis of service yield data by
PEPFAR are improving the geographic focus of key services. HIV testing yield
data at 1724 PEPFAR-supported sites and community-based services show that
just 30% of sites had identified around 80% of all newly diagnosed people living
with HIV during the period October 2013 to September 2014 (Figure 4). Fortynine sites did not identify any new HIV cases during that time, and 123 sites
identified fewer than four HIV-positive people (1).
As a result of this analysis, PEPFAR is focusing future support on the 36
districtsincluding the major urban centres of Bulawayo, Chitinguiza, Harare
and Mutarethat are home to an estimated 80% of people living with HIV.
Within these districts, high-volume sites will receive additional PEPFAR support,
while support for lower-yield sites will be reduced to overarching activities (such
as the distribution of antiretroviral medicines and technical assistance to ensure
that patients continue to receive quality services). The target is to reach 80%
coverage of treatment in these districts by 2017 (1), complementing the service
scale-up supported by the Global Fund, domestic financing raised through the
AIDS levy and the efforts of other partners.
Focusing investments on populations with the greatest need in Sudan
Domestic investment in the AIDS response has declined in Sudan. Between 2011
and 2013, domestic public funding for the national HIV response declined from
US$ 6.6 million to US$ 3.7 million, while international funding declined from
US$ 14.5 million to US$ 9.1 million (6).
Figure 3
Two scenarios for Zimbabwe, 20152025: business as usual vs. enhanced coverage with efficiencies
AIDS-related deaths
100 000
150 000
80 000
Number of deaths
Number of new infections
New HIV infections

200 000
100 000
50 000
0
2015
60 000
40 000
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
20 000
2015
Enhanced coverage plus efficiencies

Source: Discussion paper: towards a second generation HIV investment case for Zimbabwe. Harare: Government of
Zimbabwe and UNAIDS; 2015.
18
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025
Business as usual
Figure 4
6000
120%
5000
100%
4000
80%
3000
60%
2000
40%
1000
20%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
0%
Cumulative % of new HIV cases identified
Number of people living with HIV
HIV diagnoses yield from PEPFAR-supported testing sites, Zimbabwe, 2014
Cumulative % of total sites
HTC HIV + yield

Cumulative percentage of HIV-positive people
Source: PEPFAR
Optimal use of limited HIV funding is increasingly important, both to serve

people who are in need of HIV services and to achieve the countrys HIV targets.
An analysis of Sudans low-level epidemic found that an estimated 31% of all HIV
infections occurred between sex workers and their clients, and that a substantial
proportion of infections within the general population are between clients of sex
workers and their regular sexual partners. Nearly 7% of infections are among men
who have sex with men. If no changes were made to the HIV response, a steady
increase in HIV incidencecombined with 1.5% population growthwould
drive a significant expansion of the epidemic through sexual and mother-to-child
transmission (Figure 5), as well as greater AIDS-related deaths (6).
If, however, the same US$ 6.4 million annual budget for the HIV response
was maintained but directed in a different way, significant results would be
realized. In particular, if it was reallocated from the general population to
prevention and testing services for female sex workers, clients of sex workers
and men who have sex with menand to more antiretroviral therapy for the
increased number of HIV cases that would be identified through the new testing
approachan additional 19 000 infections could be averted between 2014 and
2020. Considerable efficiencies could be achieved within efforts to prevent new
HIV infections among children and keep their mothers alive, and by exploring
synergies with other public health programmes (such as syphilis testing and
treatment) (6).
As well as optimization, the analysis of Sudans HIV response recommended
a minimum short-term investment of US$ 8.1 million per year until 2016 to
achieve a 25% reduction in cumulative incidence and deaths. Achieving more
ambitious targets of a 50% reduction in HIV incidence and AIDS-related deaths
would require US$ 34 million annually (6).
UNAIDS
19
Figure 5
New infections acquired per year (thousands)
Model-predicted evolution of annual HIV incidence

in Sudan, 20102030
14
Mother-to-child transmission
Men who have sex with men
Clients of sex workers
Female sex workers
Males 50+
Females 50+
Males 2549
Females 2549
Males 1524
Females 1524
12
10
8
6
4
2
0
2010
2005
2010
2015
2020
2025
2030
Note: Future projections hold 2013 spending levels constant
Source: Populated Optima model for Sudan.
The Government of Sudan has incorporated recommendations from the study

into its HIV response strategy. The analysis also was used as the basis for an
application for funding from the Global Fund to Fight AIDS, Tuberculosis and
Malaria. Integration of HIV services into mainstream health-service delivery
has begun, and the Government is exploring introduction of point-of-care
diagnostics to increase uptake of HIV testing (7). Additional investment and
scale-up will be required to reach UNAIDS Fast-Track Targets.
Location and population focus in Bangladesh
Bangladesh has maintained a low-level epidemic, with HIV prevalence in the

adult population below 0.1% (8). In 2012, however, Bangladesh was one of only
four countries in the Asia-Pacific region where the epidemic was still increasing
(9), and international resources available for the HIV response have become
more limited as the country sustains economic growth and moves towards
middle-income status (10). With an opportunity to decisively end the AIDS
epidemic in Bangladesh potentially slipping away, an investment case analysis was
conducted in 2015.
A key finding of the analysis was that focusing HIV testing, enrolling new
HIV cases into antiretroviral therapy and ensuring these new patients achieve
viral suppression could yield a significant treatment-as-prevention dividend:
a reduction in both AIDS-related deaths and new HIV infections. This impact
would be maximized by prioritizing the populations and locations with the
greatest need.
The countrys 64 districts were ranked according to the population sizes of people
at higher risk of HIV infection and those living with HIV. It was determined
20
that 23 districts contain 73% of the key populations and 81% of key populations
that are currently being reached with services. If an optimized strategy is put
into place, an average investment of US$ 16 million a year until 2020 would put
Bangladesh on track to reduce HIV infections to below 300 per year before
2030. At this level, HIV will no longer be a major public health concern. The
analysis also found that every US$ 1 spent under this scenario would save
US$ 21 on future treatment costs, thus making ending the AIDS epidemic a
cost-effective investment.
Increasing the efficiency and impact of voluntary medical male circumcision
Considerable progress has been made in the scale-up of voluntary medical male
circumcision over the last five years (see chapter on voluntary medical male
circumcision). These efforts, however, have faced a number of challenges around
both supply and demand.
In most countries, the initial focus of voluntary medical male circumcision
efforts was on men aged 1549 years, as they are the bulk of the sexually active
male population. Despite this focus, however, roughly 35% of clients were aged
1014 years, and in most of the 14 priority countries, men over the age of 25 were
accessing services at a lower rate. The situation raised questions regarding the costeffectiveness of circumcising men at different ages. In an effort to ensure services
are better focused and achieve greater impact, the Decision-Makers Program
Planning Tool (Version 2) was developed by USAID and applied in Malawi, South
Africa, Swaziland, Uganda and the United Republic of Tanzania (11).
The Tool projects epidemiologic impact, cost and cost-effectiveness based on
user-specified coverage targets. The results suggest that focusing services on men
aged 1534 years is one of the most cost-effective options in all countries studied.
It also shows that over a 15-year period, the inclusion of males aged 1014 years
leads to a small increase in the number of HIV infections averted, but at a higher
cost per averted infection. This is because adolescent boys are less sexually
active, so the benefit of circumcision is only realized when they are older and
have a higher risk of exposure to HIV. Over the long term (30+ years), however,
circumcising males aged 1014 years delivers the greatest reduction in HIV
incidence from male circumcision (compared with targeting other age groups).
Use of the planning tool has highlighted important age-dependent variation
in mens HIV incidence and willingness to undergo circumcision. It also has
revealed trade-offs between targeting increases in efficiency, immediacy of
impact, magnitude of impact and cost-effectiveness that can be achieved by
circumcising different age groups of clients. While an analysis focused on shortterm impact might lead one to conclude that circumcising adolescent boys should
not be a programme priority, turning these individuals away could reduce longterm impact. Such a move may create a negative perception of voluntary medical
male circumcision, both among the age group and within the wider community.
Furthermore, male circumcision, unlike any other HIV prevention service, is a
one-time procedure that provides a lifetime benefit. Considering only short-term
benefits would miss the point of this very cost-effective HIV prevention method.
UNAIDS
21
Additional efficiency gains appear possible in eastern and southern Africa
An important dimension of optimizing resources to minimize new HIV

infections and AIDS-related deaths is ensuring that high-impact services such
as antiretroviral therapy are delivered as efficiently as possible. When efficiency
analyses show large differences in unit costs within and across countries, that
is strong evidence of the potential for efficiency gains. For example, the average
annual visit cost per antiretroviral therapy patient in Kenya in 2012 was estimated
at US$ 61,2 but it ranged from US$ 37 for established patients at private facilities
to US$ 96 for new patients at district and subdistrict hospitals (12). Health
facilities with lower unit costs often are taking advantage of economies of scale
and economies of scope.
Economies of scale can be achieved, for example, when health-care facilities
provide antiretroviral therapy to more patients while fixed costs remain the same,
resulting in a lower cost per patient. Economies of scope can be achieved when
HIV treatment is integrated into the delivery of other health services, such a
tuberculosis treatment or maternal and child health care (13).
The Access, Bottlenecks, Costs and Equity (ABCE) project analysed individual
health facilities staffing, capital inputs and service provision in Kenya, Uganda
and Zambia to calculate an efficiency score for each facility, with a score of
100% indicating that a facility was maximizing its available resources. The
researchers calculated the average efficiency scores across all facilities that
provided antiretroviral therapy to be 51% in Kenya, 49% in Uganda and 49% in
Zambia. They also found that the range between the highest and lowest scores
among the facilities in each country was quite large. This suggests that many
facilities have the capacity to serve much larger patient volumes using their
current resources. For example, it was estimated that Zambia could increase
its HIV treatment patient volume by 117%, which means that Zambias health
system likely has the capacity to reach the national goal of providing universal
access to HIV treatment (14).
A separate study conducted in more than 300 service delivery sites in Kenya,
Rwanda, South Africa and Zambia suggests there also are efficiency gains to
be made in HIV testing and prevention of mother-to-child transmission. The
Optimizing the Response in Prevention: HIV Efficiency in Africa study (or
ORPHEA) estimates the average cost per unit of output for each service at each
service delivery site. It also assesses the relative level of efficiency of each service
provider and explores the major determinants of efficiency for each service (15).
In a preliminary analysis of potential gains that was made using these data, the
unit costs of each facility were ranked and then divided into quartiles controlling
for scale. It was then calculated that cost savings of between 40% and 70% could
be achieved if the 75% of facilities with the highest unit costs could achieve the
same level of efficiency as the facilities at the 25th percentile.
2 The cost per visit does not include the cost of antiretroviral medicines.
22
Fast-Track lessons learned
Analyses of HIV programmes in both high-level and low-level epidemics

consistently find that allocating resources to high-impact programmes in the
geographic areas that have both the greatest number of populations at higher risk
of infections and of people living with HIV will yield significant efficiency gains.
Studies of implementation efficiencies found in treatment and prevention
services in some of the highest-level epidemics in the world suggest there are
additional efficiency gains to be made by providing the right services to the
right people in the right placeand by providing these services in the right way.
Smoother integration of HIV services with complimentary health services can
eliminate parallel systems, reduce costs and achieve greater uptake. Even more
efficiencies can be gained through the lowering of the cost of commodities (such
as antiretroviral medicines) and the introduction of new technologies (such as
point-of-care diagnostics). Public health systems can extend service delivery
through partnerships with the private sector and civil society organizations that
have good reach and trust within communities of key populations. Additional
efficiencies may result from spacing appointments for stable antiretroviral therapy
patients. Finally, all of these efficiency efforts must be made alongside efforts to
ensure services are high quality and respectful of the rights of people living with
HIV and key populations at higher risk of infection.
As the what, where and how of HIV programme implementation become clearer,
another challenge emerges: building the political will for optimization and
additional investment. As the economies of low- and middle-income countries
develop, additional national funds need to be earmarked to sustain scale-up of
HIV responses, and these resources need to be spent as wisely as possible. This
often means taking resources away from a low-burden district and reallocating
them to a higher-burden one, or investing a greater share of resources in services
for highly stigmatized populations. These are difficult decisions for local and
national leaders to make, but making these tough efficiency choicesalong with
securing additional investmentis the leadership that is required to Fast-Track
the world towards the goal of ending AIDS as a public health threat by 2030.
UNAIDS
23
Eliminating stigma and discrimination

and advancing human rights
Promoting, respecting and protecting human rights is fundamental to human

development and ending AIDS as a public health threat by 2030. As such, any
attempt to Fast-Track the HIV response must use rights-based approaches and
tackle the widespread and deep-seated stigma, discrimination and other human
rights violations faced by people living with HIV and key populations that are at
higher risk of HIV infection.
Figure 6
Figure 7
Percentage of people (aged 1549) who report discriminatory

attitudes towards people living with HIV, Cte dIvoire
Among people who have heard of AIDS, the percentage who

had an HIV test within the last 12 months, Cte dIvoire
Measuring discriminatory attitudes towards people living with HIV is used to track progress towards the commitment to eliminate stigma and discrimination
made by United Nations Member States within the 2011 United Nations Political Declaration on HIV and AIDS. These maps of Cte dIvoire suggest that low
coverage of HIV testing and higher reported discriminatory attitudes go hand-in-hand.
Data source: Cte dIvoire Demographic and Health Survey, 20112012.
24
FAST-TRACK TARGETS
>> Elimination of HIV-related discrimination by 2020.
>> Ninety per cent of people living with, at risk of and affected by HIV report no
discrimination, especially in health, education and workplace settings.
FAST FACTS
>> Stigma and discrimination towards people living with HIV and key populations
remain widespread. In roughly 35% of countries with data available, more than
50% of women and men report discriminatory attitudes towards people living
with HIV (1).
>> HIV-related stigma blocks access to condoms, HIV testing and adherence to
antiretroviral therapy (2, 3). It also can have a deep negative psychological
impact on people living with HIV and key populations at risk of HIV infection.
>> Evidence from the People Living with HIV Stigma Index indicates that
an average of one in every eight people living with HIV is being denied
health services (4).
>> Intersection of stigma and discrimination: key populations affected by HIV
suffer from higher levels of stigma due to their increased risk of HIV infection
and cultural rejection of their sexual orientation, gender identities and
behaviour (such as sex work and drug use).
>> Punitive legal environments: the criminalization of sex work, drug use
and same-sex relationships, and overly broad criminalization of HIV nondisclosure, exposure and transmission.
>> Failure to recognize rights: people living with HIV and other key populations
who access services are seen as beneficiaries rather than people exercising
their basic rights. This can lead to poor treatment and service quality.
>> Poor access to justice: most cases of discrimination never make it to court.
This is due to absent or poorly functioning mechanisms of redress, as well as
harassment, violence and extortion from some law enforcement officers and
slow and protracted legal processes.
>> Insufficient funding and scale: too few countries have financing mechanisms
for civil society. As a result, civil society organizations promoting human rights
programmes and delivering community-based service delivery rarely have the
means to take their activities to full scale.
>> Widespread discrimination in health-care settings: denial of health services,
inadequate and poor quality of care, and other forms of discrimination in
health care affect people living with HIV and other key populations, depriving
them of the highest attainable standard of health.
UNAIDS
25
HIV-related stigma and discrimination is complex. Negative perceptions and

the mistreatment that stems from them are related to more than HIV status as
a health issue: they are associated with individual beliefs and attitudes, as well
as cultural and religious norms around issues such as sexual orientation, gender
identity, sexual rights, sex work and substance use. In addition, negative
attitudes and behaviours may be reinforced by punitive laws, such as overly
broad criminalization of HIV non-disclosure, exposure and transmission of
HIV, or the criminalization of same-sex sexual relations, cross-dressing, sex
work and drug use.
Discrimination and inequalities are present in many sectors, including health,
education, employment, community, law enforcement and justice (5). Refugees
and asylum seekers living with HIV also often face significant discrimination as
many countries restrict the entry of, or forcibly return, people living with HIV.
Within the health-care system, stigma and discrimination restrict the uptake and
utilization of services, and they also lead to rights violations (such as mandatory
HIV testing, lack of confidentiality in care, denial of health care, forced
sterilization and abortion). For example, the links between HIV-related stigma,
low uptake of HIV testing and limited engagement with prevention and care have
been well documented (2). A 2013 systematic review of studies on stigma and
discrimination covering almost 27 000 people living with HIV in 32 countries
found that HIV-related stigma had such a deep psychological impact that it
compromised adherence to antiretroviral therapy (3). Furthermore, although 69%
of countries who reported on the National Commitments and Policy Instrument
in 2014 indicated having non-discrimination laws to protect people living with
HIV (5), these laws are frequently poorly enforced, with the justice system
turning a blind eye to denial of services or incidents of violence or hate crimes.
Addressing HIV-related stigma and discrimination demands tackling
misconceptions about HIV transmission and prevention, while also addressing
harmful prejudice towards certain groups. This requires breaking down
discriminatory attitudes and harmful social norms based on sexual orientation
and gender identity, including those experienced by women, young people who
are sexually active, sex workers and their clients, people who use drugs, prisoners
and migrants.
Reducing stigma and discrimination among health-care workers in Thailand
Thailand offers free HIV testing and treatment under its universal health-care
scheme and, since October 2014, antiretroviral therapy has been provided to
people living with HIV regardless of their CD4 level. Data from treatment
registration in 2012, however, indicated that half of people living with HIV
started treatment quite late, with a CD4 count less than 100. Health authorities
recognized HIV-related stigma as a barrier to service uptake and they set a target
to cut HIV-related stigma and discrimination in half by 2016.
To achieve this target in a measurable manner using evidence-informed activities,
Thailand has been systematically monitoring stigma and discrimination in
health-care settings. Under the leadership of the Ministry of Public Health, a
multi-stakeholder research team reviewed and adapted global tools to the local
26
context, piloted the new tool in two provinces, refined it based on those initial
experiences and generated evidence to inform remedial actions.1
The results revealed that more than 80% of health-care workers surveyed had at
least one negative attitude towards people living with HIV and roughly 20% of
the respondents had observed colleagues who either were unwilling to provide
services to people living with HIV or had provided them with sub-standard
services. More than half of respondents used unnecessary personal protection
measuressuch as wearing two layers of surgical gloveswhen interacting with
people living with HIV. Among the people living with HIV who were surveyed,
about one quarter reported avoiding seeking treatment at local health-care
facilities due to fear of disclosure or poor treatment and about one third reported
having had their status disclosed without their consent (6).
The evidence triggered an acceleration of system-wide action. The Ministry of
Public Health, in collaboration with civil society and international partners,
developed initiatives to sensitize a broad range of health-care workers, including
those in non-clinical work settings. Early results suggest that improving the
attitude of health-care workers is not only key to providing better care to people
living with HIV, but that it also has wider social benefits because health-care
workers are highly regarded and seen as social role models.
The pilot also confirmed that stigma and discrimination within health-care
settings can be routinely measured, with the information gathered serving as
the basis for planning and managing action and evaluating the results. In 2015,
the measurement tool was used by the national monitoring system in six more
provinces; an additional 15 provinces have begun voluntarily using it.
The stigma and discrimination strategy also has been revised based on the
new framework. By 2016, stigma-reduction programmes will be implemented
throughout the country with domestic funding, and the tool will be routinely
used to monitor progress and inform further action.
People who use drugs seek justice for peers in Jakarta
People who use drugs in Jakarta, Indonesia, are working as paralegals to protect
their peers from human rights abuses.
Indonesia continues to apply the death penalty for drug-related offences and
people who inject drugs are struggling to protect themselves from HIV: an
estimated 56.4% are living with the virus. Jakarta is one of Indonesias provinces
most affected by HIV, with nearly 100 000 people estimated to be living with HIV
in the capital in 2013 (7).
The nongovernmental organization Lembaga Bantuan Hukum Masyarakat
(Community Legal Aid Institute) trains people who use drugs to provide legal
education and aid to their peers, and to support lawyers who represent people
who use drugs (8).
1. The team included the International Health Policy Programme (IHPP), Chiang Mai University and provincial health offices, with
technical support by RTI International, USAID and the UN Joint Team on AIDS in Thailand.
UNAIDS
27
When an individual is arrested for a drug-related offence, the Institutes paralegals

typically follow the arresting officers and detainees to the police station, where
they help negotiate access to medication for HIV treatment or drug use, mediate
detention or release conditions and contact the family of the detainees (if
necessary) to post bail. The paralegals are also trained to document individual
cases of rights violations, which is essential for helping negotiate the release
of detainees from custody and for supporting consultations with lawyers who
represent the detainees in court.
The training also enables the paralegals to conduct education workshops on
Indonesian law that are held by local HIV and harm reduction organizations.
Such workshops help people who use drugs to overcome stigma and better
understand their legal rights.
The decision to recruit paralegals from the community of people who use
drugs arose because of difficulties that were experienced when working only
with lawyers (the original service providers of the programme). Widespread
discrimination against people who use drugs made the client group wary of
lawyers, and it also deterred lawyers from signing up to participate. As a result,
the programme changed its approach: rather than training lawyers to be sensitive
to the needs of people who use drugs, it chose to provide legal training to people
who use drugs.
The programmes selection and training process is rigorous. Respect from
peers is a key criterion for a new trainee, but leadership skills are not. In fact,
selecting people who are not accustomed to being leaders helps preserve the
non-hierarchical structure of the programme, keeping the focus on outreach
and community education efforts (rather than internal politics). Training
includes intensive courses on Indonesian law and due process, which culminates
in examinations; it is supplemented by supervised outreach work in areas
with concentrations of people who use drugs. All paralegals have access to
the programmes directors to ensure that their experiences and concerns are
incorporated into future planning as the programme evolves.
Strengthening enforcement of rights protections in Ghana
Although Ghanas Constitution protects all citizens from discrimination in

employment, education and housingand ensures their right to privacythere
is ambiguity in the way these provisions apply to people living with HIV and to
key populations (9). The Patients Charter protects people living with HIV from
discrimination within the health-care system, but the Charters provisions are
difficult to enforce beyond public health facilities. In addition, the penal
code forbids consensual sex between adult males and criminalizes sex work,
which deters sex workers and men who have sex with men from seeking
health-care services.
Mechanisms exist in Ghana for the review and resolution of suspected rights
violations, but they are fragmented, with few avenues for referral. There also is a
lack of trust among people living with HIV, key populations and the civil society
organizations that represent them. To overcome these obstacles, the Commission
on Human Rights and Administrative Justice, the Ghana AIDS Commission
28
and the USAID-funded Health Policy Project developed a web-based reporting

mechanism, launched in December 2013.
People living with HIV can directly report to the Commission by short message
service (SMS) or through the reporting systems website, and they can choose
to remain anonymous. A report triggers a follow-up process of mediation,
investigation and adjudication, supported by human rights organizations and
legal representatives (who often work pro bono). The lawyers also can access
updates for cases they submit, and the aggregated data generated by the system
is an invaluable advocacy tool. By September 2015, 32 cases of discrimination
and abuses had been recorded, and 13 of them have been completely resolved.
Complaints include violence, blackmail and denial of employment, health care
and education (10).
Just as Ghanas reporting system was informed by similar systems in India,
Jamaica and Kenya, other countries can benefit from Ghanas experience. What
makes Ghanas model successful is its powerful combination of a legal framework
that supports the provision of pro bono legal aid, a committed national human
rights institution with a mandate to take action, a reporting system based within
the Commission and the positive engagement of key stakeholders (including
civil society).
Ending criminalization of HIV transmission in Australia
Overly broad application of criminal law to HIV non-disclosure, exposure and

transmission raises serious human rights and public health concerns. Such laws
disregard best available scientific and medical evidence relating to HIV, and they
ignore principles of legal and judicial fairness (11). They also perpetuate stigma,
deter people from seeking HIV testing and learning their status and put the
responsibility of HIV prevention solely on the HIV-positive partner.
In May 2015, the Australian state of Victoria repealed the countrys only HIVspecific law criminalizing the intentional transmission of HIV (12). The repealed
lawSection 19A of the Crimes Act 1958carried a maximum penalty of 25
years imprisonment, even more than the maximum for manslaughter (which
is 20 years). Cases of suspected intentional transmission will now be dealt with
under general laws that cover other forms of injury.
The legislation to repeal the law was developed through the collaboration of
several stakeholders, including legal, public health and human rights experts and
representatives of people living with HIV. It was heralded by rights activists as a
major step forward for the rights of people living with HIV (13).
Sex workers stand up for their rights in Asuncin, Paraguay
In 2013, the local government in Asuncin, Paraguay, passed legislation to

regulate sex work in the city. The legislation required sex workers to undergo
mandatory HIV testing and carry a health card at all times (14).A year
later, Paraguays foremost organization of female sex workers, Unidas en la
Esperanzawith support from UNAIDS, the Pan American Health Organization
and civil society organizationssubmitted a proposal to remove articles that
UNAIDS
29
violated the rights of sex workers and served as obstacles to an effective HIV
response in the city.
After an intense period of advocacy and debate, the local government approved
all the proposed modifications, including a clause calling for the participation of
sex workers in the implementation of the legislation. This example of successful
advocacy for the rights of sex workers underscores the importance of including
key populations in law reform. Not only did sex workers in Paraguay successfully
advocate for their own rights, but they also helped to raise awareness and reduce
discriminatory attitudes among local decision-makers.
Anti-stigma training in Jamaica changes attitudes of health and social workers
Health and social workers receive varying levels of training in the provision of
services to people living with HIV and key populations, but does this training
have an impact on the quality of services? In Jamaica, the Communication for
Change project, with funding from the United States Presidents Emergency Plan
for AIDS Relief (PEPFAR), conducted a study in 2011 to find out.
Clinical and non-clinical workers were surveyed at 48 health facilities and 39
social service agencies, and 300 female sex workers and 150 male sex workers
were surveyed through respondent-driven sampling. The majority of respondents
were not trained in HIV or working with key populations (15).
Among the health and social workers, between 19% and 45% reported they were
fearful of casual contact with people living with HIV, men who have sex with men
and sex workers. Between 3% and 50% of health facility staff expressed fear of
HIV transmission or a desire to avoid contact during clinical procedures, with the
proportion rising depending on the complexity of the interaction. Fear of clinical
interactions was much higher when serving people living with HIV (4450%)
than men who have sex with men (610%) and sex workers (34%) (15).
While most of the health and social workers surveyed believed that people
living with HIV and key populations were deserving of quality care, a high
percentage reported feelings of shame, blame and judgment against these
clients. Respondents were most judgmental about the perceived immorality of
homosexuality (6383%) and sex work (7561%), with significantly more clinical
staff than social services staff reporting those views (15).
Attending training in HIV prevention was positively associated with a lack
of fear or desire to avoid casual contact with people living with HIV and key
populations. Among health facility staff, for instance, those trained in HIV
prevention reported less shame, blame and judgment than untrained staff.
Among social services staff, however, a reverse trend was shown (15).
Sex workers were asked whether they had disclosed to health-care providers that
they were engaged in sex work. Nearly half of respondents [49.9%] indicated that
they had disclosed their sex work status; those who had done so were significantly
more likely to report being denied services, experiencing poorer quality of
services and feeling rushed by health staff during their exam than those who had
not disclosed their sex work status (15).
30
Based on these results, the researchers recommended that the health system train
all of its staff in HIV prevention and psychosocial support for key populations at
higher risk of HIV infection; they also suggested that the health system increase
the number of health providers focused on providing friendly services to key
populations. Strengthening the policy and legislative framework to sanction
health-care providers when confidentiality is breached and discriminatory
practices occur was also deemed an important change that should be made (15).
Fast-Track HIV responses bring HIV services closer to the communities where
they are most needed with a locationpopulation approach that includes
community engagement. This must be done in a way that is consistent with
human rights, applying safeguards to ensure that reaching out to people living
with HIV and key populations does no harm. Otherwise, an effort to make
services more acceptable and accessible could be misappropriated, becoming an
effort to track, discriminate and punish the very people it was meant to help.
Significant challenges remain. Persistent punitive laws and strongly held cultural
values against key populations are pervasive in many countries. Reforming such
laws, policies and attitudes remains one of the single most important elements of
efforts to increase access and uptake of HIV programmes and services (16).
Greater monitoring and reporting of stigma, discrimination and violence against
people living with HIV and key populations is needed to change negative cultural
values and practices through mechanisms such as Thailands health-system
monitoring tool and the Stigma Index.
Ghanas introduction of an online and SMS reporting system for discrimination
shows how information and communication technology can be harnessed for
timely action. The work of Lembaga Bantuan Hukum Masyarakat in Jakarta
teaches us that empowering key populations to know their rights and seek
redress when those same rights are violated can remove barriers to accessing
health services. Advocacy in Victoria, Australia, helped repeal a punitive law,
and in Asuncin, sex workers have shown that key populations can be powerful
advocates for legal and policy reform.
The Fast-Track Target is absolute and in keeping with the immediate nature of the
non-discrimination obligations instilled by human rights treaties: nothing other
than zero discrimination is acceptable.
UNAIDS
31
909090
In March 2015 the global HIV response reached a major milestone: over
15million people were receiving antiretroviral therapy globally. By June 2015 this
had increased to 15.8million people on treatment.
At the core of Fast-Track is an intensive effort to build on these achievements
and reach the 909090 treatment targets by 2020: 90% of people (children,
adolescents and adults) 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. Access to HIV testing and treatment is
also part of the fundamental right to health.
Figure 8
Number of people living with HIV who were not receiving antiretroviral therapy,
2014 and 2015
Source: UNAIDS estimates, 2014 or mid-2015 for the following countries: Cameroon, Cte dIvoire, Democratic Republic
of the Congo, Ethiopia, Ghana, Kenya, Malawi, Mali, Mozambique, Namibia, Nigeria, South Africa, Swaziland, Uganda,
Zambia, Zimbabwe.
32
FAST-TRACK TARGETS
>> Ninety per cent of people (children, adolescents and adults) living with HIV
know their HIV status.
>> Ninety per cent of people who know their HIV-positive status are
accessing treatment.
>> Ninety per cent of people on treatment have suppressed viral loads.
>> Zero new HIV infections among children, and mothers are alive and well.
FAST FACTS
>> In sub-Saharan Africa, an estimated 49% [4355%] of adults living with HIV do
not know their HIV status, approximately 57% [5361%] of adults living with
HIV are not receiving antiretroviral therapy and an estimated 68% [6277%] of
adults living with HIV are not virally suppressed (1).
>> In sub-Saharan Africa, half the infants whose mothers are living with HIV
do not receive a virological HIV test within the first two months of life, as
recommended by the World Health Organization (WHO). Only one third of
children living with HIV in 2014 were receiving antiretroviral therapy. Without
treatment, half of children living with HIV die before their second birthday.
>> The Latin America and Caribbean region is close to meeting its testing targets.
An estimated 70% of people living with HIV know their status (1).
>> Globally, only 41% [3846%] of adults and 32% [3034%] of children living
with HIV are receiving treatment (1).
>> Marked differences are seen in antiretroviral coverage among men and women.
Globally 46% [4353%] of adult women (15 years and older) are receiving
treatment while only 36% [3442%] of adult men are receiving treatment (1).
>> Among low- and middle-income countries, Brazil, the Lao Peoples Democratic
Republic, Malaysia, Mexico, Myanmar and the Republic of Moldova have
achieved viral suppression for more than 80% of people receiving
antiretroviral therapy (2).
UNAIDS
33
>> Stigma: fear of social rejection and discriminatory health-care workers are still
among the commonly cited reasons for avoiding an HIV test.
>> Discriminatory laws and policies: in many countries, mandatory disclosure
and criminalization of key populations continue to discourage HIV testing,
perpetuate myths and fears, and compromise scale-up of testing and
treatment.
>> Overly centralized procedures: in countries where HIV remains highly
medicalized, testing, prescribing and dispensing functions and responsibilities
are often confined to medical doctors and laboratory personnel, limiting the
number of tests that can be performed, delaying feedback to the individual
and creating service provision bottlenecks.
>> Availability of fairly priced medicines: the lack of coherence between trade,
human rights and public health policies is threatening the right of people
living with HIV, particularly infants, to receive good-quality medicines at a fair
price. High prices are especially important for the growing number of people
who need second- and third-line regimens. In addition, national procurement
and supply chain management systems require strengthening to avoid stockouts of essential medicines.
>> Inadequate access to key diagnostic tools: essential diagnostic methods,
including early infant diagnosis and viral load monitoring for all people
receiving antiretroviral therapy, remain inaccessible for many people living
with HIV, slowing scale-up, undermining treatment outcomes and increasing
programme costs.
>> Inadequate support for treatment adherence: although many people living
with HIV confront substantial barriers to treatment adherence, innovative
methods to support strong patient adherence, including ensuring food
security, have yet to be brought to scale.
Meeting the 909090 treatment targets requires approaching HIV testing and
treatment services as an interlinked HIV treatment cascade: ensuring easy access
to an HIV test both within the community and at health facilities, immediate
treatment following diagnosis for all people living with HIV and access to
support services to ensure good-quality care, retention and viral suppression.
Substantially greater focus must be given to the role of viral load tests to monitor
and guide adherence, switch patients to second- and third-line regimens
when needed, maintain high percentages of patients with viral suppression
and maximize the public health impact of antiretroviral therapy. Innovative
approaches to HIV testing and community-centred delivery of HIV treatment
will be needed.
An increasing number of communities, cities, provinces and countries are
committing themselves to achieve 909090, revising HIV testing policies and
crafting strategies to target the people most at risk of infection, consolidating
services and leveraging new technologies for good-quality patient and
34
public health outcomes. These efforts to move people towards viral

suppression are extending life expectancy, preventing illness and new infections,
and saving money.
The global commitment to end mother-to-child HIV transmission and halt new
paediatric HIV infections is a prime example of how prevention and treatment
go hand-in-hand. The prevention of mother-to-child transmission is a unique
intersect between HIV prevention for the infant with testing outreach to identify
women living with HIV, and simultaneously preventing transmission to the infant
and protecting the mothers health through antiretroviral therapy. In addition,
the four-prong prevention of mother-to-child transmission approach has enabled
programmes to accelerate access to paediatric treatment by prioritizing early
infant diagnosis and ensuring all those found to be living with HIV are entered
into immediate antiretroviral therapy. It has also highlighted the urgency of
following motherinfant pairs in order to ensure proper follow-up, and facilitate
adherence and viral suppression. What has also been highlighted is the urgency
of immediate treatment of a positive partner in a serodiscordant couple, in
accordance with WHO guidelines.
Scientific advancement and operational experience have continued to shape
the global response to the prevention of mother-to-child transmission. In 2013,
WHO issued guidelines recommending triple antiretroviral medicines to prevent
HIV transmission, with the medicines to be taken from 14 weeks gestation and
stopped at the end of breastfeeding. The guidelines also recommended life-long
antiretroviral therapy for women eligible under national antiretroviral therapy
guidelines. After reviewing the WHO recommendations, Malawi went one
step further, providing immediate and life-long antiretroviral medicines for
pregnant women living with HIV, thus avoiding an on-again, off-again approach
to antiretroviral therapy. The results were positive, and this approach is now
recommended by WHO.
The first 90: 90% of people living with HIV know their HIV status
The first and perhaps greatest challenge to achieving 909090 is reaching all
children, adolescents and adults at risk of HIV infection with simple, quick and
accurate HIV testing options. Early diagnosis of HIV infection and immediate
initiation of antiretroviral therapy safeguards the health of people living with HIV
and greatly reduces the chance of further transmission of the virus.
Most countries require substantial new investments and policy reforms to enable
rapid scale-up of innovative HIV testing outside of traditional health facilities. In
high-prevalence settings, community-based approaches bring HIV tests to more
convenient locations where people live and work. These include door-to-door
testing campaigns, multi-disease community screening initiatives, mobile testing
services, school and workplace testing, and self-testing methods.
Children at higher risksuch as orphans, vulnerable children, poor children,
malnourished children, children outside of school and children born to mothers
living with HIVrequire special attention. Diagnosis of HIV in children under
18 months requires a specialized virological test that identifies the actual viral
particles in the childs dried blood spot and provides the definitive diagnosis. This
UNAIDS
35
requires highly specialized laboratory equipment and personnel, which many

countries do not have in adequate numbers. Even when countries have such
laboratory equipment in place, reliance on centralized laboratories for early infant
diagnosis results in substantial delays in receiving test results as well as risks that
the test results will be lost. The emergence of point-of-care diagnostic tools will
reduce these delays. Among 21 priority countries in sub-Saharan Africa, only
49% of HIV-exposed infants received a virological test within two months of
birth.
In lower-level epidemics, sex workers, people who inject drugs and other
marginalized groups require targeted and innovative testing strategies that are
community-based and sensitive to stigma and privacy concerns.
More efficient and more effective HIV testing in Mozambique
Despite Mozambique having an extremely high burden of HIV, testing rates in

2011 were alarmingly low. In a survey conducted in 2011, only 14% of men and
26% of women reported being tested for HIV and receiving results within the
past 12 months (3). Two of every five sex workers in Nampula, the countrys third
largest city, had never been tested for HIV (4), and approximately 90% of men
living with HIV who have sex with men did not know their HIV status (5).
Mozambiques national AIDS programme, with support from the United States
Centers for Disease Control and Prevention, performed a comprehensive
evaluation that revealed HIV testing and counselling services were not aligned
with local population sizes and HIV prevalence, especially for key populations. In
response, Mozambique changed its HIV testing and counselling strategy in
an effort to increase HIV case detection. Additional emphasis was placed on a
key combination of prevention services and community-based testing focused on
areas with high HIV prevalence and concentrations of key populations. Service
delivery targets and implementing partner activities were then readjusted (6).
The changes rapidly produced dramatic results. In 2012, 27% more people living
with HIV were newly identified, increasing from approximately 86000 in 2011
to 109000 in 2012. These gains were achieved alongside a 6% decrease in testing
volume. The better-focused community-based testing identified more people
living with HIV than in the previous year, even though almost 50% less testing
was done through this modality (6).
Mozambiques success demonstrates the advantage of strategic and targeted
HIV testing approaches. It also underscores how attention to key populations,
diagnostic yield and programmatic prioritization can have a rapid and great
impact. As countries scale up to achieve the first 90, they must focus efforts
where there are testing deficits and prioritize resources and services where they
can make the most impact.
HIV testing in pharmacies and retail clinics in the United States of America
HIV testing uptake can be improved by providing the service in unconventional

venues. In the United States of America, only 45% of the population has ever
been tested for HIV, and 13% of people living with HIV do not know their HIV
36
status (7, 8). Within populations at elevated risk of HIV infection, testing rates
and knowledge of HIV status are even lower. In a study that covered 20 American
cities, only 49% of young gay men and other men who have sex with men living
with HIV (18 to 24 years) knew of their infection, whereas 76% of those aged 40
and older were aware of their HIV infection. (7).
Rapid point-of-care HIV testing was piloted in 21 community pharmacies and
retail clinics across the United States in 2011. More than 100 staff at selected
sites were trained to perform on-site rapid HIV diagnostics on oral samples and
deliver counselling and referral services. Over two years, 1540 HIV tests were
administered, with 70% of them performed on site during regular working hours
and the rest conducted at HIV testing events, such as local health fairs. The entire
HIV testing process could be achieved in less than 30 minutes, including pretest counselling and consent, waiting for test results and post-test counselling.
Individuals screening positive for HIV were referred to locations for confirmatory
HIV testing.
HIV testing services not only proved feasible in pharmacy and retail clinic
settings but also appear to be sustainable. Seventeen of the 21 sites indicated
they would seek assistance or support to continue HIV testing after the
programme ended.
Self-testing in Blantyre district, Malawi
HIV self-testing, whereby a person performs their own HIV rapid diagnostic
test and interprets the result in private, is an emerging approach with massive
potential for uptake due to its convenience and privacy. It empowers people who
have concerns about disclosure and stigma and health facilities and increases
access for people who are underserved by or face discrimination in facility-based
testing centres. In rural areas, self-testing could prove more sustainable than
community-based door-to-door approaches.
In Malawi, where over half of adults have not had an HIV test in the past 12
months and do not know their status (9), a feasibility study in 2012 demonstrated
that high coverage of HIV testing can be achieved through HIV self-testing. More
than 16000 residents in 14 neighbourhoods in Blantyre district were offered one
HIV self-test kit per year for a two-year period with accompanying instructions,
pre- and post-test counselling, and specific information on where to go for a
confirmation test and to enrol in treatment if the result was positive.
Within the first year, more than three-quarters of residents used their kits, and
76% of people who self-tested shared their results with a volunteer counsellor.
During a second round the following year, similarly high coverage was achieved
more quickly: 71% of residents self-tested within six months (9).The self-testing
approach also facilitated linkage to care. Within the first year, over half of the
people diagnosed with HIV were enrolled in HIV care; an additional 26% were
already receiving treatment.
Self-testing was well accepted by the participants: 95% of people who self-tested
were happy with the test kit, and 97% said they would definitely recommend it
to friends and family (9). HIV self-testing also reached people without a previous
UNAIDS
37
history of HIV testing: over a third of participants during the first year had never
been tested for HIV. The approach also successfully reached young people, who
were more likely than older people to report using their kits.
Reaching children living with HIV in Cte dIvoire
Rapid enrolment in HIV treatment is critical for children living with HIV.
Without treatment, a third of children living with HIV die before their first
birthday, and another half die before reaching their second birthday. If a child
starts antiretroviral therapy before 12 weeks of age, however, HIV-related
mortality is reduced by 75% (10). For children this young, the only effective HIV
diagnostic is virological testing.
Cte dIvoire is home to 230000 children who have been orphaned due to AIDS
(1). These children and many others, especially those born to mothers living
with HIV, are at higher risk of HIV infection. Despite their higher risk, the HIV
status of nearly 80% of orphans and other vulnerable children in Cte dIvoire
is unknown, and only 40% of children born to mothers living with HIV in 2014
received early infant diagnostic testing (11). Treatment coverage among children
in Cte dIvoire was estimated to be only 16% [1518%] in 2014 (1).
Fourteen neonatal clinics in the Gbk, Hambol and Poro-Tchologo-Bagoue
regions of Cte dIvoire are implementing a new approach to increase paediatric
HIV testing uptake and linkage to care. Supported by the Elizabeth Glaser
Pediatric AIDS Foundation with funding from the United States Presidents
Emergency Plan for AIDS Relief (PEPFAR), the Keneya Project counsels
parents and relatives of orphans and other vulnerable children on the benefits of
paediatric HIV testing and offers childrens HIV testing coupled with deworming.
Parasites that contribute to malnutrition and stunting are a significant health
concern for families in these areas; parents less inclined to seek HIV services
are attracted by the deworming services, thereby increasing uptake of HIV
services. HIV test results are offered on site, along with parental counselling and
immediate linkage to care for children who test positive for HIV.
Nearly 70% of the 20000 children served through the project in 20132014 had
an unknown HIV status. Through the new paediatric HIV testing strategy, over
half of them were tested. HIV prevalence was close to 4%, and all of the 272
children who tested positive were enrolled into care.
Coupling deworming with HIV testing was an effective and novel strategy
to reach and enrol more children into paediatric care. Understanding and
addressing why some children did not test will help to further expand paediatric
HIV care among orphans and other children made vulnerable by AIDS.
Accelerating access to point-of-care pediatric diagnosis in Africa
Even though prevention of mother-to-child transmission services have averted

1.2 million HIV infections among infants since the mid-1990s, 220 000 children
acquire HIV globally every year. There is an urgent need to ensure that HIV-
38
exposed children are promptly diagnosed so they can receive treatment. To

help overcome challenges associated with early infant diagnosis, new portable
diagnostic equipment is being piloted in community health-care facilities where
many women and children seek care.
In September 2015, UNITAID and partners launched a US$ 63 million, four-year
initiative to scale up HIV diagnosis among newborns in nine African countries.
In partnership with ministries of health, this initiative will make point-of-care
testing more widely available to HIV-exposed infants early in their lives, when
they are most at risk of dying, and enable those diagnosed with the virus to be
put on life-saving treatment more quickly. The project will also pilot point-of-care
diagnosis in a variety of child-centred services, such as paediatric clinics, where
HIV testing is frequently unavailable.
Through this initiative, UNITAID and partners intend to prove that point-of-care
HIV testing and treatment can be successfully scaled up to bring the world closer
to an AIDS-free future.
The second 90: 90% of people who know their HIV-positive status
are accessing treatment
Overwhelming evidence of the health and preventive benefits of early initiation

of antiretroviral therapy point to a clear conclusion: all people who test positive
for HIV should start immediate treatment upon diagnosis. WHO recommends a
treat-all approach: the offer of treatment to all people living with HIV regardless
of CD4 count or viral load (12).
Immediate treatment maximizes the preventive benefits of treatment, reducing
onward transmission of HIV. The immediate offering of treatment also helps plug
a leak in the HIV treatment cascade, reducing the number of people lost between
diagnosis and treatment initiation.
Additional efforts are required to remove barriers in availability, accessibility,
acceptability and quality of health services. Addressing stigma and discrimination
faced by people living with HIV in many health-care settings can encourage
more people to test and start treatment, while higher treatment access has been
associated with reductions in stigmatizing attitudes towards people living with
HIV. Decentralization brings medicines and care closer to home, and integration
of HIV treatment with services for tuberculosis, maternal and child health,
hepatitis, noncommunicable diseases and other health conditions simplifies
health care for patients. Food and nutrition support improves adherence and
treatment outcomes (13). To increase the share of HIV treatment services
delivered in community-based settings, immediate steps are needed to mobilize
and elevate the status of community health workers, including through focused
training programmes and regulatory reforms.
Several low- and middle-income countries have achieved high treatment
coverage, and other countries are rapidly expanding access to treatment. Over
60% of people living with HIV in Botswana and Rwanda receive antiretroviral
UNAIDS
39
therapy, and coverage in Cambodia and Cuba is over 70% (1). In Mozambique
and South Africa, coverage increased from around 15% in 2010 to more than
40% in 2014. These countries are proving to others that the second 90 is not an
aspirational, far-flung target. It is achievable now.
SEARCHing for people living with HIV in Kenya and Uganda
HIV is often not the first health issue on peoples minds, even in high-prevalence
settings. A child with persistent diarrhoea or malaria or a mother struggling with
diabetes may be a more immediate threat to a family.
In recognition of this, the Sustainable East Africa Research in Community
Health (SEARCH) project is accelerating HIV testing and treatment uptake
in 32 communities across three regions of Kenya and Uganda by integrating a
community-based treat-all approach within the delivery of a range of primary
health-care services. This initiative aims to demonstrate that antiretroviral
therapy for all people living with HIV reduces a communitys collective viral
load to zero, stops the spread of HIV and improves overall health, education and
economic productivity.
Mobile campaigns visit individual communities and offer HIV testing within
a suite of multi-disease prevention and treatment services. SEARCH not only
brings HIV services closer to peoples homes; it also reduces HIV-related stigma
and addresses gaps in each step of the HIV treatment cascade (14). If individuals
do not attend community health campaigns, they are approached at their homes
and receive follow-up over two months with home-based HIV testing and
other health services. People who test positive for HIV are immediately offered
antiretroviral therapya systematic linkage to care that is also made for people
diagnosed with malaria, tuberculosis, hypertension, diabetes and other diseases.
The procedures for initiation of HIV treatment and monitoring a patients
progress have been streamlined to fit the local environment and make adherence
easier for people.
Community health campaigns are also community-led. Local council leaders
and village elders helped design and implement community mobilization efforts
during the month before the campaign, tailoring efforts to local situations and
making health care more sustainable.
SEARCH has achieved impressive results in the locations it supports. More than
250000 people have been reached, and the percentage of adults testing for HIV
increased from 57% to 80% (14, 15). Among non-mobile residents, HIV testing
coverage reached 89%. Adult HIV prevalence was 9.4%, with a median adult
CD4+ count of 516 cells/L (16). SEARCH has demonstrated that it is reaching
new people too: 43% of HIV-tested individuals reported they had never been
tested previously (16). Preliminary treatment results show that 93% of people
diagnosed with HIV have been retained in care for at least six months, and 92%
of those in care have a viral load below 400copies/ml (17).
The initial results from the SEARCH initiation show that implementing an
integrated approach to mobile HIV and health service delivery is feasible in
a range of rural East African settings. They also demonstrate that community
40
engagement during planning and implementation of a community mobilization

campaign is critical to achieving strong uptake among the campaigns
target population. Getting to zero within the SEARCH communities
may be within reach.
Moving to treatment for all in Guangxi, China
Expansion of HIV testing in China in recent years has improved HIV case
detection. In 2014 twice as many HIV tests were conducted and over 2.5
times more people living with HIV were newly identified compared with 2010.
However, some regions in China, the worlds most populous nation, have
struggled to enrol people newly diagnosed with HIV in treatment and reduce
AIDS-related deaths.
In 2011, the Guangxi Zhuang Autonomous Region in southern China accounted
for 22% of all HIV-related deaths in the country. Over 70% of people living with
HIV were diagnosed at an advanced HIV stage, and nearly half of all HIV-related
deaths occurred in the same calendar year as diagnosis. Almost 80% of people
dying from HIV-related causes never received antiretroviral therapy. These
statistics revealed a major deficit in linkage to treatment.
In 2012 and 2013, health facilities in Guangxis Zhongshan and Pubei counties
began offering immediate initiation of antiretroviral therapy following diagnosis
of HIV. As a result, the average time between diagnosis of HIV and initiation of
treatment plummeted from 53 days to five days. The new approach also reduced
mortality by approximately two-thirds, from 27% to 10% (18). Guangxi has
shown that immediate initiation of treatment, as recommended by WHO, is an
effective strategy for plugging holes in the cascade, reducing HIV-related deaths
and putting HIV responses on track to achieve 909090.
Universal access to integrated prevention of mother-to-child transmission
services in Rwanda
In 2014 Rwanda had reduced new HIV infections among children by 88%
since 2009 and had an 18-month transmission rate of 1.8%. These results
have been achieved through continuous quality improvement and
willingness to innovate.
One such comprehensive review occurred in 2011. Programme data showed
that many health facilities that offer maternal, neonatal and child health
services did not offer HIV counselling and testing routinely, missing the
opportunity to provide women with prevention of mother-to-child transmission
services. In addition, only two-thirds of pregnant women were tested and
counselled for prevention of mother-to-child transmission, and only 24%
of pregnant women living with HIV received prevention of mother-to-child
transmission services. These missed opportunities were a result of limited
integration of prevention of mother-to-child transmission services in maternal,
neonatal and child health services.
To address this challenge, the decision was taken to integrate prevention of
mother-to-child transmission, services at different levels. First, programme funds
UNAIDS
41
were used to improve the capacity of the health systems through construction of
maternity units, procurement of laboratory diagnostic equipment and support for
human resources. Second, managers at public health facilities were empowered
to reorganize service delivery and to make decisions on how best to integrate
prevention of mother-to-child transmission services in maternal, neonatal and
child health services. They identified strategies to prioritize services for children
exposed to HIV, to strengthen follow-up until breastfeeding risk ends, to ensure
HIV test results are confirmed, and to confirm that all infants confirmed as living
with HIV are initiated on antiretroviral therapy. Linkages between maternal,
neonatal and child health staff and antiretroviral therapy staff ensure children
living with HIV are followed up in antiretroviral therapy services.
Publicprivate partnerships were established to ensure the private health sector
was involved in the prevention of mother-to-child transmission initiative.
HIV testing, drugs, training and monitoring tools were provided by the
government free of charge. In return, the private sector provides service
delivery data to the government through routine reporting systems. Integration
of prevention of mother-to-child transmission indicators into the maternal,
neonatal and child health registers has improved the quality of prevention of
mother-to-child transmission programme reporting and linkages with broader
child survival efforts.
Despite the gains made in the Rwanda prevention of mother-to-child
transmission programme, challenges remain, such as loss to follow-up of mother
infant pairs within the continuum of care and ensuring high uptake among
women at higher risk of infection HIV, such as sex workers. These challenges
need to be addressed for the country to move further towards eliminating
mother-to-child transmission (19).
The third 90: 90% of people on treatment have suppressed viral loads
Living a healthy life with HIV requires reducing the amount of the virus in
the persons body to undetectable levels. Although antiretroviral medicines
can reduce viral replication to undetectable levels, patients may still encounter
barriers to viral suppression: some patients are not sufficiently supported to
understand the importance of treatment adherence; some experience severe
life challenges that impede their ability to adhere to treatment regimens; other
patients experience treatment failure and need to change to second- or third-line
treatment regimens. Other barriers to treatment include medicine stock-outs;
patients having to travel long distances to health-care facilities or being cut
off from facilities during bad weather; conflict and natural disasters; and food
insecurity and poor nutrition.
Affordable once-a-day pills are readily available on the international market,
and viral load tests provide a much more accurate reading of a persons response
to treatment. Decentralization of treatment services, appropriate spacing of
appointments and the shifting of dispensing of medicines and other routine
tasks to community health workers can greatly reduce the time and money a
person living with HIV spends to continue treatment. Community groups can
support adults and children to adhere to their medications. Food and nutrition
support, including cash transfers, bolster the treatment outcomes of people on
42
low incomes. Advances in information technology can improve the management

of medicine purchases and distribution in low-resource settings. Health systems
successfully integrating these measures are more likely to achieve the
909090 target.
The priority given to viral suppression as the ultimate outcome of the 90-9090 target underscores the urgent need to ensure that every person living with
HIV has meaningful access to viral load monitoring. In 2014, partners in the
Diagnostics Access Initiative joined together with the Government of South
Africa to negotiate a share reduction in the price for a leading viral load testing
platform. This agreement has already led to savings exceeding US$ 13 million,
but additional efforts are needed to fully leverage this price reduction to expand
access to essential viral load testing.
Treatment as prevention in KwaZulu-Natal, South Africa
South Africa has the largest number of people on antiretroviral therapy

worldwide, with approximately 3.2 million people on treatment as of June 2015
(2). Antiretroviral therapy coverage has nearly doubled in South Africa in only
a few years, from 25% [2428%] of all people living with HIV in 2011, to 45%
[4349%] of all people living with HIV in 2014 (1).
HIV treatment expansion in South Africa has saved an estimated 1.3million lives
since 1995 (1). For example, in rural KwaZulu-Natal, over half of the estimated
1.8million people living with HIV in 2014 were receiving antiretroviral therapy,
and life expectancy increased by 11years from 2004 to 2011 (20). As treatment
coverage increases, the preventive effect of treatment on communities can also be
seen. A study in KwaZulu-Natal found that living in a community with 3040%
antiretroviral therapy coverage reduced a persons HIV risk by 38% compared
with living in an area with under 10% antiretroviral therapy coverage. The data
show that each 1% increase in antiretroviral therapy coverage reduces HIV
infection risk by 1.4% (21).
Evidence from KwaZulu-Natal also shows the preventive effect of treatment
within households. As antiretroviral therapy coverage in men in a household
increased, HIV infection risk in women decreased. A similar impact was seen
for increases in antiretroviral therapy coverage in women and infection risk in
men. For each 10 percentage point increase in opposite-sex treatment coverage in
households, HIV infection risk dropped by 6% (22).
Evaluations of antiretroviral therapy coverage impact in KwaZulu-Natal
confirm that treatment as prevention works in real-world settings outside
of clinical trials.
Ensuring antiretroviral medicines are in stock in Kenya
Kenyas Ministry of Health launched the Kenya HIV Situation Room, which
portrays data from the Kenya Medical Supplies Authority, showing the remaining
stock of essential HIV medicines, including efavirenz, a critical component of
HIV treatment in Kenya. These data are presented geographically on maps such
as the one for efavirenz shown in Figure 9. The size of the bubble illustrates the
UNAIDS
43
Figure 9
Remaining stock of efavirenz (size of circle) and how close they are to stock-out (colour
of the circle) in select counties in Kenya, 2015
less than 1 month of stock left

12 months of stock left
more than 2 months of stock left
Source: Kenya HIV Situation Room. Kenya: Ministry of Health; 2015.
quantities dispensed, and the colour coding indicates where there is less than one
month of stock remaining (red), one to two months of stock remaining (yellow)
or more than two months of stock remaining (green).
Such information is used as an early alert to help prevent stock-outs. This
information is important for planning and managing medical supply chains,
which can be complicated by seasonal changes when rains and floods reduce
access to some areas of the country.
Scaling up viral load testing and access to second-line
treatment in Zimbabwe
Viral load tests can provide an earlier indication of treatment failure than
the CD4 tests that are more commonly available in low- and middle-income
countries. WHO has strongly recommended the use of viral load tests since
2013, but many countries have been slow to switch due to the costs involved,
especially in rural areas where clinics are often far away from more centralized
laboratory services.
In 2012, second-line antiretroviral therapy services were decentralized to primary
care clinics in rural Zimbabwe. Around the same time, routine viral load testing
using dried blood spots was piloted in 26 clinics in the rural Buhera district,
accessible to 14000 people (23). A total of 92% of patients were reached by
44
routine annual viral load testing, which included enhanced adherence counselling
and repeat viral load testing after three months for people with unsuppressed
viral load. Fourteen per cent of patients had high viral loads, and 68% of them
received a repeat viral load test (23). Among people retested, 36.9% (1.1% of all
tested) were switched to second-line treatment.
Scale-up of viral load monitoring and decentralized access to second-line
antiretroviral therapy was proven feasible in this resource-limited setting.
These initiatives also revealed important information about viral suppression
on second-line antiretroviral therapy. While the majority (72%) of people had
re-suppressed viral loads after switching to second-line antiretroviral therapy,
nearly 28% did not respond adequately or at all, and 18% of those that initially
re-suppressed viral load experienced a rebound (24). This underscores the
importance of regular viral load monitoring and treatment adherence support.
Supporting children on treatment in Khayelitsha, South Africa
The treatment gap for children is larger than the gap for adults. An estimated 30%
[2832%] of children living with HIV are receiving antiretroviral therapy in subSaharan Africa, compared with 43% [3947%] of adults in the region (1). Reasons
for this treatment gap include delayed return of testing results, delayed initiation
of treatment, inadequate early infant diagnosis capacity and a paucity of testing
opportunities for older children. In addition, rates of treatment failure in children
are almost double those in adults. Improving treatment adherence and success in
children is now receiving increased attention.
In 2014 a total of 167000 children in South Africa were receiving antiretroviral
therapy, nearly half of all children living with HIV in the country (1). Improving
paediatric HIV treatment management has been a focus in Khayelitsha, a lowincome community in Cape Town. One adherence support programme has
developed family antiretroviral therapy adherence clubs that allow children and
their caregivers to benefit from a community model of care that supports longterm retention.
Overall, retention in care and treatment outcomes of children attending family
antiretroviral therapy adherence clubs were better than for children receiving care
through traditional services. Children in adherence clubs had a higher proportion
of viral suppression (95%) than children in mainstream care (77%). Some 71%
of children in care stayed in the clubs, whereas a quarter switched to mainstream
care due to missed club visits or high viral loads (25).
Family antiretroviral therapy adherence clubs also facilitated partial or
full disclosure of HIV status to the children, an important element in the
management of paediatric HIV. At least 79% of children aged seven years or older
were partially or fully informed of their HIV status (25).
Simple behavioural and clinical services in another programme in Khayelitsha
achieved high rates of re-suppression in children who had been failing
antiretroviral therapy. In this programme, children on treatment who were
experiencing treatment failure and their caregivers joined support groups,
including individual discussions on adherence barriers, home visits and
UNAIDS
45
genotyping to identify viral drug resistance. By second viral load follow-up, 72%
of participants had re-suppressed, which increased to 84% of participants at
the next follow-up (26).
The evidence from paediatric adherence and antiretroviral therapy support
programmes in Khayelitsha shows that structured adherence support, including
routine viral load testing and adherence support counselling, can achieve high
rates of re-suppression in children.
The HIV treatment cascade
Graphical presentations of a regions, countrys, citys or communitys HIV

continuum of care can link together key HIV response indicator data and reveal
where people living with HIV may face barriers to the ultimate goal of viral
suppression. These treatment cascades are powerful tools that can simultaneously
track programme performance and help convince leaders on what needs to be
done to close gaps and reach the 909090 treatment targets.
Subnational HIV treatment cascades can reveal important differences in the
provision of testing and treatment within countries and facilitate remedial action.
In Morocco, cohort HIV treatment cascades among adults were developed in
20092013 for eight sites (Figure 10). In Rabat, over 80% of people diagnosed
with HIV are receiving treatment, and 91% of people on HIV treatment are
virally suppressed. Conversely, in the region of Nador, less than 40% of people
Figure 10
Subnational HIV treatment cascades for Morocco, 20092013
Source: Antiretroviral medicine patients registers and referral centers, Ministry of Health, Morocco.
46
Figure 11
HIV treatment cascade for people who inject drugs and men who have sex with men
aged 18 years and over, across 27 sites (26 cities) in India, 20122013
100
Site-specific median, %
80
60
40
20
0
Living
with HIV
Aware of
HIV-positive
status
Linked
to care
Pre-initiation
of antiretroviral
therapy
Antiretroviral
therapy
initiated
Current
antiretroviral
therapy
initiated
Suppressed
viral load
People who inject drugs (N=2906)

Men who have sex with men (N=1146)
Source: Mehta SH et al. HIV care continuum among men who have sex with men and persons who inject drugs in India:
barriers to successful engagement. Clin Infect Dis. 2015.
diagnosed with HIV are on treatment, and a similarly low number of people on
treatment have achieved viral suppression.
The wide discrepancy between the Rabat and Nador regions is due largely to
limited human resources in Nador and the additional adherence challenges
experienced in areas where the HIV epidemic is mostly among people who inject
drugs. Rabat, by contrast, is a university centre with local clinical laboratory
support and social support from local nongovernmental organizations.
Efforts are under way to reduce gaps in the cascade in Nador, such as the launch
of a system to identify people living with HIV lost to follow-up and reintegrate
them into the HIV care system.
Indian cascade for people who inject drugs and men who have sex with men
Similar lessons can be learnt by developing HIV treatment cascades for specific
key populations. Although data are sparse, several countries have reported on
hard-to-reach populations such as men who have sex with men, people who
inject drugs and female sex workers.
Surveys in India estimated the cascade for people who inject drugs and for men
who have sex with men (Figure 11). The median proportion of people who
inject drugs living with HIV who knew their status was 41%, while among men
who have sex with men 30% of those living with HIV were aware of their status,
revealing large gaps in reaching the first 90. In later stages of the HIV treatment
cascade, drop-offs among people who inject drugs and men who have sex with
men in India appear to be less prominent. Ultimately, a median of 15% of people
UNAIDS
47
Figure 12
Cascade of care in British Columbia, Canada, by fiscal year, 19972014
100
First 90
Second 90
Percentage of adults living with HIV
80
Third 90
60
40
20
0
1997
2002
2008
2014
YEAR
Diagnosed with HIV

Receiving antiretroviral therapy
Suppressed viral load to 200 copies per mL
Source: British Columbia Centre for Excellence in HIV/AIDS Drug Treatment Program database (for antiretroviral
use, viral load and CD4 count) and administrative data (ex. Medical Services Plan billings; hospitalization data from
the Discharge Abstract Database).
who inject drugs and 10% of men who have sex with men had suppressed
viral loads (27).
Concerted efforts are needed to reach most-affected populations, such as men
who have sex with men, people who inject drugs and sex workers through
tailored services to ensure the 909090 treatment targets are reached for all
populations.
Cascade of care in British Columbia
Monitoring trends over time can improve efforts to focus services on those at
greatest need. In British Columbia, Canada, treatment cascades for people living
with HIV aged 18 years and over have been tracked over the past 17 years.
From 1997 to 2014, the proportion of adults diagnosed with HIV, the proportion
of adults diagnosed with HIV who are on antiretroviral therapy and the
proportion of adults on antiretroviral therapy with suppressed viral load have all
significantly increased.
Based on 909090 goals, the 2014 data show that 83% of adults living with HIV
had been diagnosed, 81% of those diagnosed have ever received antiretroviral
therapy and 96% of adults ever on antiretroviral therapy were virally suppressed.
48
Among all adults living with HIV in Vancouver, 65% were on treatment
and virally suppressed.
Recent achievement of the 15 by 15 target15million people on treatment

by March 2015provides a powerful steppingstone towards the attainment of
909090. Reaching the 909090 target will require focused and sustained
political leadership, robust financing, health workforce innovations and optimally
efficient service delivery. It will also require focused efforts to close treatment
gaps for groups who are being left behind, including children, adolescents, young
people and key populations.
Urgent steps are needed to align national policies with the latest scientific
evidence and to fully leverage technology innovations. The earliest possible
initiation of antiretroviral therapy confers powerful prevention and therapeutic
benefits. Immediate initiation of treatment can also be easier for health systems to
implement, reducing the number of patients lost between diagnosis and initiation
of treatment. Accordingly, WHO now recommends a treat-all approach. Viral
load testing must be rapidly brought to scale, including point-of-care viral load
testing technologies and early infant diagnosis for children. For stable patients,
appointments can be appropriately spaced so that capacity is freed up for new
antiretroviral therapy initiators and other people on antiretroviral therapy
needing clinical attention.
Communities play a critical role in bringing testing and treatment services closer
to the people who need them, building demand for services and improving
retention and adherence. Innovative community-centred models such as
adherence clubs and community antiretroviral distribution should be brought to
scale in high-prevalence settings and within key populations.
Finally, the whole HIV treatment cascade must be analysed and improved in
countries, with emphasis on subnational differences and differences among
key populations. Outcomes across the HIV treatment cascade need to be
carefully tracked and documented, and the results used to improve programme
performance and monitor progress towards 909090 and the ultimate goal of all
people living with HIV staying healthy and preventing transmission of the virus
to other people. Achieving that across the world will be a major contribution
towards ending the AIDS epidemic.
UNAIDS
49
Voluntary medical male circumcision is a priority programme in areas with high

HIV prevalence and low rates of male circumcision. It is a high-impact, one-time
procedure that reduces HIV acquisition risk by approximately 60%.
The primary preventative effect of male circumcision is for female-to-male
sexual transmission, but high coverage can create a protective effect for entire
communities. In Uganda, circumcision coverage in non-Muslim men increased
from 9% to 26%. Every 10% increase in circumcision coverage was associated
with a 12% reduction in HIV incidence (1).
Figure 13
CHAPS-supported voluntary medical male circumcision in Gauteng, South Africa,
2012 and 2014
Exponential scale-up of circumcision in southern Africa has been driven by innovation and partnership.
In Gauteng, South Africa, the public health system is overstretched. Private clinics are being leveraged
for scale-up. The two maps show the number of circumcisions in the province performed in 2012 and
2014 by public and private clinics being supported by the Centre for HIV and AIDS Prevention
Studies (CHAPS). The contribution of the private sector has grown considerably to 30% of
circumcisions in the province.
2012
Source: Centre for HIV and AIDS Prevention Studies.
50
2014
FAST-TRACK TARGET
>> Twenty-seven million additional men in high-prevalence settings are voluntarily
medically circumcised as part of integrated sexual and reproductive health
services for men.
FAST FACTS
>> Voluntary medical male circumcision has a 60% protective effect
against HIV acquisition.
>> By the end of 2014, more than 9 million men had been medically circumcised,
including approximately 3 million during 2014.
>> Financing: despite significant scale-up, funding for circumcision is not
keeping pace with need. Financial resource constraints pose a serious
challenge to realizing the procedures full potential.
>> Sustainability: as high-performing circumcision efforts move from scaleup to sustainability, they must be made more routine and integrated into
mainstream public health systems.
>> Maintaining momentum: maturing programmes will need to adapt their
approaches to maintain momentum, potentially including changes in
the adult age ranges that are engaged and the provision of
circumcision for infants.
In 2011, 14 countries in eastern and southern Africa were prioritized for

circumcision scale-up, with a target of 80% coverage of eligible males by the end
of 2016. Reaching this initial five-year target will require roughly 20.8 million
voluntary medical circumcisions.
As of December 2014, over 9 million medical circumcisions had been performed
in the priority countries. Significant progress has been achieved, but coverage
varies substantially between countries. Ethiopia and Kenya have exceeded their
80% coverage targets, and by July 2015, the United Republic of Tanzania had
nearly reached its target. However, five countriesLesotho, Malawi, Namibia,
Rwanda and Zimbabwestill have very low coverage, ranging from 6% to 26%.
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51
Accelerating male circumcision through private sector

engagement in Johannesburg
Orange Farma township in Gauteng province on the outskirts of Johannesburg

that was founded by laid-off farm workers in the late 1980s (2)could be
considered the birthplace of the use of voluntary medical male circumcision to
prevent HIV transmission.
The township was the location of the first of three randomized control trials
that proved the preventative effect of the procedure (3). Following the trial,
the researchers established the Centre for HIV and AIDS Prevention Studies
(CHAPS) in 2010 to contribute their experience to South Africas roll-out of a
national medical male circumcision programme.
Within two years, the programme had expanded from one public health facility
in Gauteng province to 20. At the same time, the public health system was
grappling with the rapid expansion of antiretroviral therapy and a dire shortage
of health-care workers, placing it under immense strain and causing delays in
the provision of services. A significant number of lower-income patients were
moving to private providers for more convenient health care.
To ensure continued expansion of the circumcision programme, CHAPS and
the National Department of Health turned to the private sector. Programme
managers strategically selected private-sector clinics by reviewing the geography,
demographics, infrastructure and service availability in Gauteng and other
priority areas. They then conducted baseline assessments of candidate facilities
in order to evaluate their service delivery and management conditions (4). After
confirming that a strict set of conditions had been fulfilled, CHAPS trained the
chosen private providers to deliver free voluntary medical male circumcision.
CHAPS reimburses private providers at a slightly lower rate than what the
providers themselves would normally charge. Providing the circumcisions for free
creates additional demand, however, and the higher volume generates economies
of scale that ensure the service remains profitable for the clinics. In one clinic, the
number of circumcisions performed daily increased from 20 to as many as 114
(5). In addition, 33% of new patients who come in for circumcision return for
additional paid medical services or refer others to the clinic (4).
CHAPS has so far trained and partnered with 12 private practitioners (4).
Between 2012 and 2015, a total of 247 355 medical male circumcisions were
performed by CHAPS; private practitioners collectively performed 57 696 of
this total. The percentage of circumcisions performed by the private partners
increased from just 5% during the final two months of 2012 (when the
programme began) to 16% in 2013, and then 29% in 2014 (4). Of these, 97% were
performed in Gauteng (Figure 13).
The partnership has benefited from cross-pollination. CHAPS has contributed
its innovative, World Health Organization-recommended MOVE approach for
high-volume, high-quality circumcisions; the private clinics have contributed
aggressive marketing and demand-creation strategies that include short message
52
service (SMS), billboards, radio and print advertising, and the use of branded
vehicles to recruit and transport patients to service locations.
High-performing clinics have achieved impressive numbers: the first private
practice included in the programme has performed over 15 000 medical
male circumcisions since 2012. A newer, mobile-based practice and provider
performed nearly 6500 procedures in rural areas in just one year (4).
Due to the great success of the private-provider model, CHAPS has supported the
launch of a similar programme in Swaziland, and it also provided initial advice to
partners of Namibias HIV programme.
Reaching men in rural areas of the United Republic of
Tanzania through mapping
In 2010, the regions of the United Republic of Tanzania now known as Iringa and
Njombe had some of the lowest circumcision prevalence (29%) and the highest
HIV prevalence (approximately 16%) in the country (6). Circumcision was only
offered within health facilities on scheduled days. Men in rural areas, where
demand was high, could not access these services and it was quickly realized that
a new approach was required to meet the 2015 targets for the region (7).
In 2012, mobile and campaign services were strategically implemented in rural
areas with the aid of a geographic information system (GIS). Service coverage,
HIV prevalence, demographic and facility data were geospatially mapped and
overlaid, revealing underserved populations (7).
Open-source database software and Google Maps were used to update the maps
regularly and link geocoded information, including project monitoring data, road
conditions, infrastructure and facility resources. Outreach teams were able to
identify low-performing sites quickly and focus on service provision in that area.
Road condition information facilitated decision-making on when and where to
deliver outreach services (7).
The proportion of circumcisions performed in rural versus urban areas radically
changed after the outreach campaigns were initiated. In 2011, similar proportions
of circumcisions had been performed in urban (52%) and rural (48%) areas; by
2012, the proportion of circumcisions in rural areas increased to 88%, reaching
93% in 2014. By 2014, 267 917 men had been circumcised in Iringa and Njombe,
with 259 144 of them aged 1034 years. This meant that 98% of the target for the
two regions was met (7).
The success of the strategy demonstrates how GIS-aided geographical focusing
can optimize service delivery and stimulate Fast-Track scale-up.
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53
Circumcision provides a gateway to HIV testing and

treatment in Maseru, Lesotho
Since its start in 2012, Lesothos voluntary medical male circumcision programme
has rapidly expanded to a total of 18 hospitals and private clinics, as well as
outreach sites at more than 100 health centres.
In light of historically low rates of linkage to care among newly diagnosed men in
Lesotho and high HIV prevalence in Lesothoan estimated 23.4% of adults aged
1549 were living with the virus in 2014 (8)the circumcision programme aims
to ensure that clients are tested for HIV and initiate antiretroviral therapy if they
are found HIV-positive.
Up to the end of 2014, nearly 85 000 men received voluntary medical male
circumcision as part of comprehensive HIV prevention services, and about 56%
of these clients were tested for HIV and received the results (9). Newly diagnosed
clients were initially given a referral slip and asked to enrol in HIV care at the
location of their choice. A review conducted in 2013, however, found that a high
percentage of these individuals were lost to follow-up. To improve the situation,
active linkages to care and treatment were introduced in October 2013 and, after
a successful pilot, expanded in March 2014 (10).
The most sophisticated linkage system is used in the capital, Maseru, at private
clinics run by Jhpiego, an international non-profit health organization affiliated
with Johns Hopkins University. Circumcision clients who test HIV-positive
are offered a CD4 test using a point-of-care machine that provides results
during the same visit. They are then offered the option to enrol into care at
the private clinic itself, or to be referred to free services at a public facility or a
specialized antiretroviral therapy clinic run by the AIDS Healthcare Foundation
(AHF). If the client requests to be referred to the AHF clinic, he is provided
with transportation. Clinicians and counsellors from both clinics cross-check
information and follow up to retain these patients and ensure continuity in HIV
care and treatment (10).
Among the 6540 men who were circumcised at the two clinics between October
2013 and August 2015, 83% were tested for HIV, resulting in 337 new diagnoses
(6% of the men tested). Among those new diagnoses, 78% had a CD4 test and
received the resultsmore than twice the percentage of patients at six district
hospitals without point-of-care CD4 testing. This result reinforces how the
percentage of patients lost to follow-up at various steps of the continuum of care
cascade can be greatly reduced by providing rapid test results, active referrals and
rapid treatment initiation (10).
The experience shows that voluntary medical male circumcision can be
leveraged to dramatically increase HIV testing and treatment among previously
undiagnosed men and male adolescents. Immediate initiation of all people
diagnosed with HIV, in line with the World Health Organizations latest
guidelines, should be considered to further avoid loss of these newly diagnosed
men to follow-up.
54
Figure 14
New HIV infections and voluntary medical male circumcision, Lesotho, 2014
In Lesotho, the roll-out of voluntary medical male circumcision is an opportunity to link men to HIV
counselling and testing. This map shows the location of eight health facilities being supported by Jhpeigo
to offer voluntary medical male circumcision within comprehensive HIV prevention, HIV testing and linkage
to care, as well as the number of circumcision they performed from October 2013 to August 2015. These
health facilities are located in areas with higher incidence of HIV.
Sources: Lesotho HIV and AIDS Estimates and Projections, 2014; Jhpeigo, 201315.
Non-surgical devices boosting scale-up in Zimbabwe
Circumcising an additional 10 million men by 2020 will require more efficient

methods of service delivery. Non-surgical procedures have the potential to
accelerate scale-up by making the procedure quicker, easier to perform, more
acceptable to the patient and more cost-effective.
In Zimbabwe, the PrePex device was introduced in April 2014 as an alternative
method to surgery. PrePex works by compressing the foreskin between a ring and
an elastic band, allowing it to be removed without incisions or sutures. The device
addresses some patient concerns about circumcision, including fear of having
a surgical operation or of losing wages due to an inability to work for several
days after the operation. In a survey of 500 men who had undergone a PrePex
circumcision, 465 (93%) said they would recommend PrePex to their peers (11).
UNAIDS
55
More than 12 000 men in Zimbabwe have benefitted from a PrePex circumcision
since its introduction, and its use is steadily increasing as additional clinics and
mobile teams are trained. The service is being integrated into primary healthcare facilities with nurses as the main providers, which will create additional
efficiencies. Additional demand is being generated by a Ring awareness
campaign conducted by Population Services International.
Voluntary medical male circumcision is on the Fast-Track. Three million

circumcisions were performed in priority countries in 2014 alone, nearly one
third of the total since 2011. This increase shows that large, healthy populations
can be effectively reached with HIV prevention services. High-performing
national programmes have excelled at building public trust and expanding
medical capacity in low-resource settings by partnering with the private sector.
Moreover, voluntary medical male circumcision programmes can be leveraged to
help increase HIV testing and treatment enrolment of men and boys in order to
achieve the 90-90-90 treatment targets.
The challenges will be to increase coverage in lower-performing countries while
maintaining the rate of scale-up in higher-performing countries. The demand is
largely there, but financial resources from external donors have flatlined. Similar
to antiretroviral therapy, programmes must transition from rapid scale-up to
sustainability.
New non-surgical devices are now being rolled out as an alternative to surgical
circumcision. These devices are simple, less resource-intensive, usable by nonphysician providers, acceptable to clients and providers, and as safe as standard
surgical male circumcision. Innovations such as these will help countries
circumcise an additional 27 million men by 2020. In the long term, lessons also
need to be learned from countries where male circumcision is part of societal
traditions, such as in many countries in West and central Africa.
56
THREE MILLION CIRCUMCISIONS

WERE PERFORMED IN
PRIORITY COUNTRIES IN 2014
A L O N E , N E A R LY O N E T H I R D O F
T H E T O TA L S I N C E 2 0 1 1 .
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57
Condoms
Condoms are proven and affordable methods of HIV prevention in both low-level
and high-level epidemics. In Zimbabwe and South Africa, increased condom
use has contributed to reductions in HIV incidence (1, 2). In India and Thailand,
increased condom distribution to sex workers and their clients, along with other
HIV prevention efforts, has been associated with reduced transmission of HIV
and other sexually transmitted infections (35). Putting condoms on the FastTrack would avert an additional 1.4 million new HIV infections by 2020 (6, 7).
Figure 15
Average number of male condoms distributed annually per male adult aged 15 years
or older in South Africa, by district, 20142015
The South African Government aims to annually distribute 1 billion male condoms (50 male condoms
per adult male per year) and 25 million female condoms by 2016. A rebranding of the freely distributed
Choice male condom and a distribution partnership with South African Breweries have contributed
to progress towards the target. In KwaZulu-Natal, strong political and technical leadership, community-based distribution, and a focus on high-transmission areas helped Fast-Track condom distribution
from 8.2 condoms per adult male in 2010 to a provincial average of 59.1 condoms per adult male in
2014, exceeding the national target along with Western Cape.
Gauteng
Source: National Department of Health, Republic of South Africa, 2015.
58
FAST-TRACK TARGETS
>> Ninety per cent of women and men, especially young people and those in highprevalence settings, have access to HIV combination prevention and sexual and
reproductive health services.
>> Twenty billion condoms available annually in low- and middle-income
countries for people of all ages.
FAST FACTS
>> Regular and correct use of condoms reduces the risk of HIV transmission by as
much as 95% (8).
>> Condoms have averted an estimated 50 million new HIV infections since the
onset of the HIV epidemic (6).
>> Condoms are an inexpensive HIV prevention tool and also prevent against other
sexually transmitted infections and unintended pregnancies. One condom costs
less than three cents to make (9).
>> Condom fatigue: condoms have been deprioritized and donors support for
condoms has flatlined (10, 11).
>> Insufficient access to condoms: there are gaps in condom access in key
populations and key locations, even in countries with highly promoted and
widely distributed free condom programmes (12).
>> Insufficient access to lubricants: less than 25% of men who have sex with
men in 165 countries have easy access to free lubricant (13), and sex workers
desire but lack access to lubricants. Most countries do not include lubricant in
their national strategic plans (14).
Over the past few years, however, condom fatigue has set in, especially in subSaharan Africa. Condoms have been deprioritized, and a business-as-usual
approach prevails in many countries. Donor support for condoms has flatlined,
with the United States Presidents Emergency Plan for AIDS Relief (PEPFAR)
and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)
spending less than 1% of their resources on condoms (10).
Within this difficult global situation, some programmes are sustaining their
condom programmes and rolling out innovations in condom promotion. In
UNAIDS
59
Zambia and Nicaragua, location-targeted strategies have increased condom

use in places where individuals meet new sexual partners or engage in sex,
and population-targeted approaches have improved condom use in diverse
populations, including students and young travellers in Sweden, people who
inject drugs in New York City, and truck drivers and their sexual partners in the
United Republic of Tanzania (1520).
Distribution of free condoms, widespread or targeted to key locations or
populations, is repeatedly shown to be a key component of successful condom
programmes. Social marketing of subsidized condoms has increased condom
use in several sub-Saharan African countries, including urban Zimbabwe
and Mozambique (2123). In India, condom programmes focusing on key
populations have been effective in increasing condom use and decreasing HIV
infection through community engagement of sex workers, men who have sex
with men and transgender people.
Public-sector distribution, social marketing and commercial sales can be
combined into a total market approach that emphasizes the strength of each
segment of the market and improves the overall efficiency and effectiveness of
condom promotion.
South Africa builds the worlds largest condom distribution programme
Although South Africa has made significant strides in improving access to

treatment and reducing mother-to-child transmission of HIV, continuing high
incidence of HIV among adults is a serious concern. An estimated 330000
[300000360000] new infections occurred among adults aged 15 years and older
in South Africa in 2014 (24).
A reported decline in knowledge levels about HIV and AIDS, an increase in risky
sexual behaviour and insufficient levels of condom use continue to drive the HIV
epidemic (25). Between 2008 and 2010, an average of only 13.4 male condoms
were distributed per adult male per year in South Africa. In five of the nine
provinces, fewer than 10 condoms were distributed per adult male per year. In
KwaZulu-Natal, the province with the highest HIV prevalence, 8.2 condoms were
distributed per adult male per year, in stark contrast with Western Cape, where
almost 40 condoms were distributed per male per year. Of additional concern
to the South African Government was a significant drop from 45.1% to 36.2%
in condom use at last sex across the country and among various subpopulations
between 2008 and 2012 (25).
In response, the South African Government set an ambitious goal in 2011 to
annually distribute 1 billion male condoms (50 male condoms per adult male per
year) and 25 million female condoms by 2016. It is also aiming to achieve 100%
condom use among people aged 1524 years.
The Governments free condoms have an empowering brand
nameChoicethat urges South Africans to take a decision to protect
themselves. Social marketing has helped to build awareness and increase the
use of Government-branded condoms. A strong emphasis is placed on free
distribution through public health facilities, identified outlets in hotspots and
60
other public sites to ensure access to condoms. To appeal to younger people, the
Choice brand was reinvigorated in 2015 with a new line of brightly coloured and
flavoured condoms that are being freely distributed in colleges and universities.
Other innovations were introduced. Subnational condom coverage data (26) are
used by district management teams in high-burden areas and low-performing
districts to adapt their strategies and operational plans to plug gaps in condom
distribution coverage and to align their efforts to achieve both the provincial and
national targets (27).
The Project Promote partnership with South African Breweries has strengthened
the condom supply chain and extended regular condom distribution. Each month
South African Breweries extensive distribution network delivers condoms to
11800 shebeens (taverns) across the country (28).
Figure 16
Condom promotion in South Africa: number of male condoms
distributed per male per year, by district, 20102011 to 20142015
Condoms per male per year (c/m/y)
60
50
40
30
20
10
0
Northern
Cape
Gauteng
20102011 male condoms

20142015 male condoms
North West
Eastern
Cape
Free State Mpumulanga Limpopo
Western KwaZulu-Natal
Cape
2016-2017 target
20142015 avg 38.6 c/m/y
20102011 avg 14.7 c/m/y
condoms per male per year (c/m/y)
Source: National Department of Health, Republic of South Africa, 2015.
In 2012, the Western Cape achieved its condom targets, having distributed 53.8
condoms per adult male. KwaZulu-Natal Fast-Tracked condom distribution from
8.2 condoms per adult male in 2010 to 58.9 condoms per adult male in 2014,
exceeding the national target. In total, 11 of the 52 districts reached the national
target in 2014.
UNAIDS
61
KwaZulu-Natals extraordinary progress has been aided by:

>> Strong political and technical leadership at the provincial and district level
and multisector oversight through regular review meetings of district AIDS
councils and local AIDS councils led by mayors to monitor targets and come
up with solutions.
>> Close collaboration with communities through Operation Sukuma Sakhe (a
provincial government anti-poverty initiative) working in wards to ensure
communities participate in the response.
>> Community-based distribution of condoms in shebeens, tertiary institutions
and community facilities, and community caregivers distributing condoms to
households during campaigns.
>> Scale-up of prevention services, including distribution of condoms in hightransmission areas.
An important feature of South Africas condom programme is that it is funded
by domestic resources; most other countries in the region rely heavily on donorfunded and donor-procured condoms. The estimated cost of South Africas
ambitious condom programme for 20122016 is US$160milliononly 1.5% of
the total estimated budget of the South African national AIDS programme (29).
South Africa has emerged as a global leader in male and female condom
distribution. Since 2010 there has been a 2.6-fold increase in the number of
condoms distributed in South Africa, and the country now boasts the largest
free condom distribution programme in the world, with over 712 million male
condoms and 19 million female condoms distributed in 2014, and another 100
million condoms sold at subsidized prices through social marketing programmes
and commercial sales. Gaps in condom distribution coverage across districts and
provinces have been addressed by geographical targeting, especially in high HIV
prevalence locations.
NYC Condom reaching key populations with focused distribution,
marketing and mobile phone app
New York City was the first city in the world to have its own municipally branded
condom, and it currently maintains the largest free condom programme in
the United States of America. Even in this high-income, cosmopolitan city,
free condom distribution is instrumental in preventing HIV, other sexually
transmitted infections and unintended pregnancies among key populations. Free
condom distribution is included as a cost-saving and cost-effective prevention
strategy within the 2015 Blueprint for ending the epidemic in New York State by
2020.
New York Citys free condom programme started in 1971, with free condoms
distributed through the citys clinics for sexually transmitted infections. An
increase of new HIV diagnoses due to heterosexual transmission was observed
between 2004 and 2007, mostly among low-income African-American people
and people of Hispanic descent. In 2007, the Health Department launched
the NYC Condom. Since then, every National Condom Awareness Day (held
62
Figure 17
5000
200.0
4000
160.0
3000
120.0
2007: Launch New York City Condom - 25M distributed/year
2000
80.0
1000
40.0
20072014 51.8% decrease
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Number of pregnancies per 1000 adolescent girls aged 1519 years
Number of HIV diagnoses
New HIV diagnoses in New York City, 20012014
0.0
Heterosexually transmitted HIV diagnoses

Women HIV diagnoses
Total HIV diagnoses
Pregnancy rates among 1519 year olds
Source: New York City Health Department.
on St Valentines Day) has included a change in the look of the NYC Condom
packaging or the addition of a new layer of social marketing to the programme.
The Health Department supplies male condoms, female condoms and lubricant
freely to any New York City organization or business that wishes to distribute
them. In 2011, the Health Department created the NYC Condom Finder, a
mobile phone application (app) that uses GPS to assist users to find condom
outlets across the city; this app has been downloaded more than 43000 times.
New York Citys Condom Availability Program (NYCAP) has over 3500 condom
distribution partners and in 2014 distributed over 37.1 million male condoms
and almost 1.2 million female condoms across the five boroughs. These partners
focus distribution on neighbourhoods with the highest rates of HIV in the city,
and to locations that serve people living with HIV and key populations, such as
gay men and other men who have sex with men.
The programme works to increase the awareness, availability and accessibility of
condoms to the residents of New York City by maintaining a strong community
presence. In 2014, NYCAP participated in over 105 community events, provided
825 presentations in the Health Departments clinics for sexually transmitted
infections, and participated in all official and unofficial Gay Pride events in the
city, reaching over 53500 individuals.
Awareness of and access to NYC Condoms is high among key populations.
Over 75% of individuals polled at Gay Pride events and an African American
Day Parade had seen or heard of NYC Condoms and had obtained them (29).
UNAIDS
63
At the Health Departments clinics for sexually transmitted infections, 86% of

people surveyed were aware of NYC Condoms and 76% had obtained them
(30). Condom use was also high, ranging from 69% to 81% among people who
obtained NYC Condoms (30, 31).
Since the launch of the NYC Condom, more than 300 million NYC Condoms
have been distributed. The trend in new diagnoses of heterosexually transmitted
HIV infections has been reversed, with a reduction of 52% between 2007 and
2014 (Figure 17).
Condoms are the bedrock of combination HIV prevention, and adequate

investment by governments and donors to further scale up condom promotion
is required to sustain responses to HIV, other sexually transmitted infections and
unintended pregnancies.
Sufficient numbers of condoms and lubricant must be distributed,
complemented by social marketing of subsidized condoms and commercial
sales. Condom programming for key populations and in key locations,
incorporated with community-based peer outreach services, is essential to
reduce new HIV infections. Setting ambitious national targets, disaggregated at
the subnational and subpopulation level, will facilitate targeted distribution and
access to condoms.
Changing legal and policy frameworks will increase access to condoms and use
for key populations. For example, sex workers will use condoms more confidently
if they are not fearful of being arrested for carrying them.
Innovations in condom design, promotion and distribution through the use of
new media and publicprivate partnerships can help reach younger populations,
and adolescents can be reached through school-based programmes. Shifting the
focus of marketing from disease protection to fun has popularized condoms in
some settings.
64
UNAIDS
65
Pre-exposure prophylaxis (PrEP) can be an effective prevention tool for

individuals at substantial risk of infection, including key populations,
serodiscordant couples and sexually active adolescents in populations with a high
incidence of HIV.
Daily oral PrEP containing the antiretroviral medicine tenofovir protects HIVnegative individuals from acquiring HIV. It empowers individuals to take control
of their own HIV risk. PrEP can be chosen and discretely used by individuals
Figure 18
Pre-exposure prophylaxis in San Francisco
In San Francisco, United States of America, PrEP is focused in areas where HIV prevalence among
gay men and other men who have sex with men is higher and viral suppression rates are lower. The
impact of PrEPas part of a strong combination of HIV prevention and treatment in a population that
is organized, free from stigma and well-informedhas been dramatic. In 2012, there were 426 new HIV
infections reported in San Francisco; in 2013, the number dropped to 359, and then to 302 in 2014.
Source: Magnet, San Francisco AIDS Foundation.
66
FAST-TRACK TARGET
>> Three million people on PrEP annually, focused particularly on key populations
and people at higher risk in high-prevalence settings.
FAST FACTS
>> High adherence to PrEP can effectively prevent HIV infection (14).
>> Demand for PrEP is rising among people at substantial risk of infection. A
multi-country survey of people at higher risk of HIV infection found that 61% of
respondents would definitely use PrEP if it was available (5).
>> Availability of PrEP is currently extremely limited, with less than 1% of
individuals at substantial risk of HIV infection having access to it.
>> Access: the medication is only slowly being approved by countries for HIV
prevention, and the cost of the PrEP regimen accounts for approximately two
thirds of a PrEP programme budget.
>> Awareness: many people who could benefit from PrEP are unaware of this
HIV prevention option.
>> Complimentary services: PrEP needs to be delivered as part of a
comprehensive, user-friendly package of HIV and sexual health services,
including testing.
>> Adherence: medicine must be taken daily to have maximum
preventative effect.
UNAIDS
67
at risk of HIV infection, which is especially important for those whose personal
prevention options are limited. This includes men and women who lack condomnegotiating power, are subject to intimate partner violence or who desire
conception or greater intimacy. The decision to use prevention is also more
considered, as taking PrEP is removed from the moment of sex.
There is strong demand for PrEP within populations where knowledge ofand
access toPrEP is high. Sixty-one per cent of those surveyed in several countries
in East and Central Asia, Latin America and Africa said they would definitely
use PrEP, and as many as 92% of men who have sex with men surveyed in India
said they would likely use PrEP (5). In the United States, 4479% of HIV-negative
gay men surveyed said they desired or would use PrEP (6-8).
The availability of PrEP is slowly growing. Australia, Brazil, France, Malaysia,
South Africa, Thailand and the United Kingdom of Great Britain and Northern
Ireland are moving towards the incorporation of PrEP into their national HIV
programmes. The United States Public Health Service recommends PrEP as a
prevention option for individuals who are at substantial risk of acquiring HIV
through sexual transmission or injecting drug use (9). There also are a growing
number of countries with pilot programmes that are demonstrating the feasibility
and potential impact of this powerful prevention tool.
PrEP scale-up is helping San Francisco get to zero new HIV infections
San Francisco, the second most densely populated city in the United States, has
been a global leader in HIV prevention strategies for gay men and other men who
have sex with men. The citys empowered gay community has driven a consistent
commitment to the HIV response. As a result, Fast-Track Targets have nearly
been met: the San Francisco Department of Public Health estimates that 94%
of people living with HIV know their status, 8491% of those diagnosed are on
antiretroviral therapy and 88% of those in care are virally suppressed (10)
San Francisco was among the early adopters of PrEP, officially rolling out the
service shortly after United States regulatory approval in 2012. The impact of
PrEPas part of a strong combination of HIV prevention and treatment in a
population that is organized, free from stigma and well-informedhas been
dramatic. In 2012, there were 426 new HIV infections reported in San Francisco;
in 2013, the number dropped to 359 and then to 302 in 2014 (11). PrEP roll-out
was driven by social and market forces alonea strategy that appears to attract
people who will benefit the most.
Greater impact can be achieved through continued PrEP scale-up. Current PrEP
use is only 29% of what would be required to reduce HIV infections by 70% from
2011 rates (12). Only one quarter of client demand is being satisfied, according
to a survey of individuals at the San Francisco AIDS Foundation STI clinic, and
information from other San Francisco clinics suggests that only one third of those
eligible for PrEP are using it.
San Francisco is committed to supplying this demand through both public and
private health-care facilities. The San Francisco Department of Public Health
is mobilizing additional resources and coordinating partner efforts around
68
a Getting to Zero HIV response strategy that focuses on expanding PrEP,

providing early diagnosis and immediate treatment of HIV and supporting
greater retention of patients who already are in care. A website has been launched
that provides short message service (SMS) reminders to new clients to help them
adhere to their medication and links them to medical professionals or peers
within an online social network in order to answer their questions. Patients are
also being supported to select health insurance plans that cover a portion (or all)
of the costs of PrEP.
By conveying a sense of urgency and shared responsibility among San
Franciscans, engaging and empowering a broad diversity of stakeholders,
developing robust metrics for success and reporting progress annually on World
AIDS Day, San Francisco aims to be the first city in the world to achieve the
Getting to Zero vision (12).
PrEPcombined with treatment and rights educationis protecting sex
workers in Zimbabwe
Zimbabwes HIV epidemic is among the worlds most severe. In a population of

approximately 13 million people, adult HIV prevalence is estimated at 15% (13).
Nearly half of sex workers are living with HIV (14), and approximately 12% of all
new HIV infections occur among sex workers and their clients (15).
The Sister with a Voice programme was initiated in 2009 to bolster Zimbabwes
HIV response among sex workers. Overseen by the Centre for Sexual Health and
HIV/AIDS Research Zimbabwe, the programme provides a range of integrated
HIV prevention and sexual and reproductive health services to more than
30000women (16). The programmes 36 sites include health clinics and outreach
services that are provided at informal settings such as truck stops.
Within the Sisters programme, the SAPPH-IRe1 project is working at
14locations. In this trial, women who test positive for HIV are offered immediate
antiretroviral therapy initiation, and women who test negative for HIV infection
are offered PrEP. Community-based adherence support is provided to both
groups. Each woman in the programme selects a sister, another woman in
the programme with whom she will attend monthly peer group sessions. HIV
status is kept confidential unless personally disclosed, and the programme sisters
support each other with medication adherence. SMS reminders are used to
encourage women to attend both clinic and medication refill appointments.
An important component of the Sisters programme is the legal advice provided
to participants by peer educators (including some who have been trained as
paralegals). Using materials developed by local human rights lawyers specifically
for sex workers and the unique issues they face, the peer educators inform sex
workers of their basic rights and how they can legally protect themselves against
violations of those rights.
1. Sisters Antiretroviral Therapy Programme for Prevention of HIVan Integrated Response.
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69
Figure 19
PrEP intervention and comparison sites for sex workers within the
SAPPH-IRe project, Zimbabwe
The SAPPH-IRe project in Zimbabwe is offering PrEP to sex workers who test negative for HIV, and
offering immediate antiretroviral therapy initiation to sex workers who test positive for HIV. The 14 PrEP
sites and seven comparison sites are located primarily on major transportation routes associated with
sex work and HIV transmission.
Source: Centre for Sexual Health and HIV/AIDS Research Zimbabwe.
From treatment success to PrEP in Sao Paulo and Rio de Janeiro
Provision of PrEP to key populations in Brazil is being piloted within an HIV

service delivery system that has a strong history of innovation and success. Brazil
has a comprehensive HIV service platform that integrates HIV prevention and
treatment into its universal health-care programme. It was the first country to
provide free combination HIV treatment and, in 2013, it became the first middleincome country to adopt the immediate offer of treatment to people living with
HIV regardless of CD4 count (17).
The PrEP Brazil Study is evaluating delivery of PrEP in Sao Paulo and Rio de
Janeiro to collect evidence for future national PrEP strategies. The studys focus
is on transgender women and men who have sex with men. National HIV
prevalence among men who have sex with men is 10.5%, over 20 times higher
than the general population (17), with HIV prevalence among men who have
sex with men at 18% in Rio de Janeiro and 24% in Brasilia (18). This includes
young men who have sex with men, a population that has accounted for an
70
increasing proportion of new HIV cases in Brazil: nearly 40% of all new cases
reported among men who have sex with men in 2014 were among young men
aged 2029 years old (17). Transgender women in Brazil also are at a higher risk
for HIV infection. In Southern Brazil, 25% of people seeking male-to-female sex
reassignment surgery were living with HIV, with higher prevalence among those
with a history of sex work (19).
A key component of the PrEP Brazil Study is its focus on innovative ways to
increase treatment adherence (such as SMS reminders). The first study is fully
enrolled, with results anticipated next year; the second study, with larger numbers
and expanded key populations, began this year. Preliminary results are promising:
uptake of PrEP was over 50%, with prior knowledge of the service and high-risk
sexual behaviour both associated with uptake among the participants (20).
Growing awareness of (and demand for) PrEP is expected to facilitate wider
roll-out. In a Brazilian online survey in 2011, only 22% of men who have sex
with men had heard about PrEP (21). Another survey conducted in 2015 showed
awareness had reached 60% among men who have sex with men in Sao Paulo
and Rio de Janeiro, and nearly 95% said they would like to use PrEP to prevent
HIV(20).
Dollar-a-day PrEP in Bangkok
Thailand hosted one of the trial sites in the iPrEx study that first proved PrEPs
efficacy. Since then, the country has participated in at least five other PrEP trials
that have engaged men who have sex with men, transgender women and people
who inject drugs.
Prevalence of HIV among men who have sex with men in Thailand has been
rising for a decade. As of 2014, 9.2% of Thai men who have sex with men were
living with HIV. Prevalence and risk factors are higher in urban settings: over
40% of older, urban men who have sex with men are living with HIV (22), and
incidence among young urban men who have sex with men has nearly doubled
since 2003. Only half of urban men who have sex with men report consistent
condom use (22). The transgender population is also at elevated HIV risk, with
HIV prevalence within five cities estimated at 13%.
The Thai Red Cross AIDS Research Centre in Bangkok is exploring the feasibility
of self-pay PrEP with both public and private partners. Launched in December
2014, the PrEP-30 project worked closely with Thailands leading social media
HIV outreach initiative, Adams Love, to raise awareness and recruit participants
into the pilot (23). As of September 2015, 106 individuals at higher risk of HIV
infection had started PrEP at a cost of 30 Thai baht (US$ 1) per day. The median
monthly household income in Thailand is US$ 585.
This user-fee model may be a sustainable model for scale-up. Participant
payments cover the majority of costs: medication, service and laboratory tests,
while the Thai government subsidizes part of the HIV testing costs (24). A
generic version of the medication, manufactured by the Thailands Government
Pharmaceutical Organization, helps to keep prices low. The willingness of people
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71
to continue to pay out of pocket and remain adherent to PrEP will be monitored
closely during the pilot.
Tailoring PrEP and immediate treatment to sex worker needs in
Johannesburg and Pretoria
Gauteng, which includes the cities of Johannesburg and Pretoria, is South Africas
smallest province by land area, but also its most populous, with more than
12million residents (25).
Within this densely populated urban environment, the Wits Reproductive Health
and HIV Institutes TAPS Demonstration Project (26) is evaluating whether it
is feasible, acceptable, safe and cost-effective for a combination HIV prevention
and care programme to roll out PrEP for female sex workers who test negative for
HIV and to offer immediate initiation of HIV treatment to sex workers who test
HIV-positive.
The pilot builds on years of strengthening community links and providing
services to sex workers. Female sex workers have been engaged in the
development and implementation of the service package. During focus group
discussions held in Johannesburg and Pretoria, sex workers discussed their
experiences with HIV service provision and access, including their idea of
optimal HIV prevention and treatment. Their attitudes toward PrEP, immediate
HIV treatment and frequent HIV testing also were considered.
Although the TAPS Demonstration Project is still in its early days, a preliminary
analysis of the focus group discussions shows that PrEP is a welcome addition to
a limited array of HIV prevention options. Stigma and violence were identified
as barriers that need to be addressed and education and adherence support from
clinic and community sources are needed. Nonetheless, the prevailing view was
that these challenges can be overcome. As of October 2015, only one participant
had withdrawn from the demonstration project, and no patients had been lost
to follow-up. Anecdotal reports from participants indicate that the friendly
environment within the clinics and supportive attitude of staff help maintain high
retention rates.
Continuing on the Fast-Track
PrEP has emerged as a powerful prevention tool for people at high ongoing risk
of HIV exposure. Roll-out of PrEP for female sex workers, gay men and other
men who have sex with men is beginning to gather pace, but for adolescents and
young men and women in high-prevalence settings, it is still early days. Two pilot
studies for adolescents started in 2014 in Cape Town through the Desmond Tutu
HIV Foundation:
>> Pluspills is examining the feasibility, acceptability and use of PrEP in 150
adolescent girls and boys aged 1519 years.
>> UChoose is examining female preferences for PrEP delivery through the use
of different contraceptive options (oral, injectables and vaginal rings) in 150
adolescent girls aged 1617 years.
72
PEPFARs DREAMS initiative also includes a PrEP component for young women
and adolescent girls. All of these initiatives are at the forefront of efforts to
empower young people to make their own decisions and establish an AIDS-free
generation.
With an estimated cost of less than 5% of an HIV programmes total budget, PrEP
is a key component of a Fast-Tracked response. It should be considered within the
context of combination HIV prevention, with strategies tailored to the needs of
specific key populations in specific environments. Strong adherence is required
to maximize its protective effect and to prevent the emergence of drug
resistance. HIV programmes incorporating PrEP must therefore include patient
support from both health-care workers and peers, as well as periodic HIV testing
and counselling.
Demand for PrEP is increasing, and awareness-raising will increase it further.
However, stigma and criminalization will continue to hamper HIV prevention
services, including PrEP, if they are left unaddressed.
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73
Adolescent girls and young women aged 1524 years are at increased risk of HIV.
This risk is driven by demographic and behavioural patterns and underlying
drivers of vulnerability, including harmful gender norms and inequalities,
poverty, food insecurity and violence. A Fast-Track approach analyses and
addresses these drivers and provides young women and girls with programmes
and services that help them to protect themselves. It also requires engaging men,
both to challenge harmful norms and to enrol them in HIV prevention and
treatment services.
Figure 20
New HIV infections among adolescent girls and young women (aged 1524),
sub-Saharan Africa, 2014
An estimated 80% of the women aged 1524 living with HIV are in sub-Saharan Africa, and 74% of new
HIV infections among adolescents in the region are girls. This increased risk is driven by demographic
and behavioural patterns and underlying drivers of vulnerability, including harmful gender norms and
inequalities, poverty, food insecurity and violence.
Source: UNAIDS estimates, 2014.
74
FAST-TRACK TARGET
>> Ninety per cent of young women and girls have access to HIV combination
prevention and sexual and reproductive health services, and live free from
violence.
FAST FACTS
>> More than 5000 young women and girls acquire HIV every week, the vast
majority of them in southern Africa. Adolescent girls and young women in
southern Africa acquire HIV five to seven years earlier than their
male peers (1).
>> Globally, only three in every 10 adolescent girls and young women aged 1524
years have comprehensive and correct knowledge of HIV.
>> In high-prevalence settings, women who suffer intimate partner violence are at
increased risk of acquiring HIV (2).
>> AIDS-related illnesses remain the leading cause of death among African women
of reproductive age (3).
>> Lack of local analysis of risk and drivers of vulnerability.
>> Insufficient coverage of programmes aiming to reduce new HIV infections
among young women and girls.
>> Inequalities and violence: pervasive gender inequalities put women and girls
at higher risk of acquiring HIV.
>> Poverty and food insecurity: in many countries, poverty pushes girls towards
age-disparate and intergenerational sexual relationships, which puts them at
higher risk of acquiring HIV.
>> Lack of access to education: keeping girls in school is linked to lower rates
of HIV infection and unintended pregnancy, but many girls drop out of school
early, jeopardizing their health and future prospects.
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75
Violence against women and girls, especially intimate partner violence, has been
shown to increase risk of HIV infection. A study in South Africa found that
women who were exposed to intimate partner violence were 50% more likely
to acquire HIV (4). Another study in South Africa found that the association of
intimate partner violence and HIV was stronger in the presence of controlling
behaviour and high HIV prevalence (5). Exposure to childhood sexual violence
increases girls risk of unwanted pregnancy, alcohol use and acquiring HIV and
other sexually transmitted infections (6).
Prevalence of recent intimate partner violence has been found to be higher
among adolescent girls and young women than it is among older women, and
child marriage is a risk factor for intimate partner violence: girls under 18 who
marry are more likely to experience violence within marriage than girls who
marry later (7, 8).
In southern Africa, age-disparate, intergenerational sexual relationships and
transactional sex combine with low awareness of HIV places young women at
extremely high risk of HIV (9).
Figure 21
Figure 22
Intimate partner violence among women aged 1524 years,

Zimbabwe, 201011
Intimate partner violence among women aged 2549 years,

Zimbabwe, 201011
Violence against women, especially intimate partner violence, has been shown to increase the risk of
HIV infection. Subnational data on recent intimate partner violence reflects variations within countries.
In most regions in Zimbabwe, for instance, prevalence of recent intimate partner violence was higher
among young women aged 1524 years than among women aged 2549 years.
Source: Zimbabwe Demographic and Health Survey, 20102011.
76
Recognition has grown in recent years that HIV services must be combined with
education, economic empowerment and social protection of young women and
girls to reduce new infections. Young women and girls must be empowered to
make decisions about their own health, including having access to sexual and
reproductive health services. They must be able to choose when to have sex (and
with whom), to negotiate condom use with a sexual partner, to decide whether to
marry (and at what age and to whom), and to elect when and how many children
to have (if any).
Programmes that address the HIV and sexual and reproductive health
service needs of young women and adolescent girlsas well as the structural
determinants that pose obstacles for their access (such as lack of access to
education, gender-based violence and inequalities)have been proven to work to
reduce the risk of HIV infections and other negative health outcomes. In South
Africa, for example, receipt of a government child support grant or a foster child
grant has been associated with reduced incidence of transactional sex (10).
Patterns of risk and vulnerability differ both within and across countries, and
between urban and rural areas; they also vary by age group, marital status and
cultural norms. Systematic efforts to analyse and address local risk and tailor
service packages to the local situation remain scarce. Greater efforts are needed
to ensure that more coherent programming targeting young women and girls is
brought to scale, including female-controlled HIV prevention methods, access to
education, school feeding and other forms of empowerment.
DREAMS of a better future for young women and girls in Lesotho
Nearly half of all new HIV infections among adolescent girls and young women
globally in 2014 occurred in 10 countries in eastern and southern Africa: Kenya,
Lesotho, Malawi, Mozambique, South Africa, Swaziland, Uganda, the United
Republic of Tanzania, Zambia and Zimbabwe.
An ambitious effort is underway to empower young women and girls in
these countries and reduce their vulnerability to HIVa programme known
as DREAMS: determined, resilient, empowered, AIDS-free, mentored and
safe women.
With support from the United States Presidents Emergency Plan for AIDS Relief
(PEPFAR), the Bill & Melinda Gates Foundation and Girl Effect, DREAMS
provides HIV services to young women and girls and addresses structural drivers
that increase their HIV risk, including poverty, gender inequality, sexual violence
and a lack of education (11).
In each country, DREAMS is being integrated into local systems and geographically
targeted to avoid duplicating existing services, to increase efficiencies and to
maximize impact. Advisory committeeswhich include government officials, civil
society organizations and representatives of adolescent girls and young
womenhave been established at the national and subnational level.
These committees address relevant policy issues, coordinate with other
initiatives that focus on this population, and provide data and feedback to
support implementation.
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77
Lesotho is a case in point. In February 2015, an initial stakeholder meeting took

steps to ensure that DREAMS does not establish services in parallel to existing
programmes. Stakeholders also agreed to prioritize young women and girls who
are most at risk of acquiring HIV.
Data from Lesothos AIDS programme, the Ministry of Education, the Ministry
of Social Development and the Bureau of Statistics were used to establish the
target population and prioritize the districts in greatest need. This process
focused on the following data in each district of the country: HIV prevalence,
new HIV infections by gender and age, unmet need for antiretroviral therapy,
rates of rural-to-urban migration, in- and out-of-school population sizes,
local availability of schools and universities, and the number of orphans and
vulnerable children.
Maseru and Berea were identified as priority districts. They had the highest
HIV prevalence and number of new infections among girls aged 1519
and young women aged 2024, and both had a significant unmet need for
antiretroviral therapy. Maseru and Berea also are residential and industrial
areas with mobile populations who make lengthy commutes between their
homes and jobs (12).
DREAMS aims to achieve a 25% reduction in incidence among adolescent girls
and young women within priority areas across eastern and southern Africa before
the end of the 2016, and a 40% reduction before the end of the following year (12).
Reducing risk in Botswana by keeping girls in school
Education empowers adolescent girls and young women, and the longer a girl
stays in school, the lower her risk of acquiring HIV (13). Some of the most
compelling evidence of the protective effect of education has come out of
Botswana, where a change in education policy in 1996 increased the length of
time adolescents attend secondary school by nearly one year.
Length of education is closely related to socioeconomic status and psychological
traits. It can therefore be difficult to measure the impact of education alone on
HIV risk. By comparing entire grade levels of girls in Botswana from before and
after change, however, it was possible to measure the specific impact that a longer
duration of education had on HIV risk (14).
Demographic data and HIV biomarkers of young respondents within the 2004
and 2008 Botswana AIDS Impact Surveys were compared. The cohort in the
earlier survey attended secondary school before the policy change, while
those in the later survey attended secondary school after the education reform
was implemented.
The results were striking: each additional year of secondary education reduced
cumulative risk of acquiring HIV by 8.1 percentage points relative to the 25.5%
78
prevalence of HIV at baseline for both women and men. For women, the contrast
was even sharper, with an 11.6% reduction. Not only did secondary school
education prove effective in reducing the risk of acquiring HIV, it also was
found to be cost-effective compared to other programmes being implemented in
Botswana (14).
Preventing violence against women through activism in Kampala, Uganda
In epidemics with HIV prevalence above 5%, a strong association has been found
between violence and HIV. To address this, more than 25 organizations are
using the SASA! Activist kit for preventing violence against women and HIV (15).
Regardless of whether the setting is religious, rural, refugee or urban, the SASA!
programme has been proven to inspire community mobilization to prevent
violence against women and reduce HIV-related risk behaviours. It achieves this
by reducing the social acceptability of violence and changing the attitudes and
behaviour of both men and women.
The SASA! programme has been used in Kampala, Uganda, where violence
against women is widespread: an estimated 52% of women aged 1549 years
reported experiencing physical or sexual partner violence in their lifetime,
and 8.4% [7.69.4%] of women were living with HIV in 2014 (16, 17). The
programmes focuses on shifting harmful gender norms by supporting
community members to discuss issues of gender inequality, violence and HIV.
Participants include ordinary members of the community who have been
trained to implement the programme, health-care workers, police and local
community leaders.
Men who had taken part in the Kampala SASA! programme were 50% more
likely to have an HIV test than men who hadnt taken part. They also were more
likely to communicate more effectively with their partners and participate more
frequently in domestic duties (18).
Male participants also were more likely to have discussions about condom use,
and they had double the rate of condom use compared to men in the control arm
of the study. Furthermore, women who participated in SASA! were more likely to
report being able to refuse sex and to make decisions jointly with their partners.
Despite significant declines in new infections and progress in curbing the

epidemic over the last 15 years, young women and girls in high-prevalence
settings continue to be at higher risk of HIV, and the number of new infection in
this group remains high. Insufficient programming for HIV prevention services
that specifically focus on young women and girls persists, although recent
effortsincluding those spearheaded by countries taking part in DREAMS
are promising. Several countries have used this opportunity to examine their
strategies around both HIV and young women and girls, and this has helped
UNAIDS
79
them to take their own steps to strengthen social protection and service provision
for young women and girls.
At the same time, long-standing structural factors and challenges that have
negative effects on the health of both women and mensuch as harmful gender
norms, inequalities and violenceremain pervasive and deep-seated in many
countries. Fast-Tracking the AIDS response for adolescent girls and young
women will require extraordinary effort to overcome these factors so that young
women and girls at risk of HIV can protect themselves, realize their rights and
advance their political, physical and economic autonomy. Intractable as these
problems may seem, there are ongoing efforts that are proven to work, not only to
end the AIDS epidemic, but also to reduce violence and advance gender equality.
Womens engagement in these efforts is key, not only as beneficiaries, but also as
partners and leaders.
80
RECOGNITION HAS GROWN

I N R E C E N T Y E A R S T H AT H I V
SERVICES MUST BE COMBINED
W I T H E D U C AT I O N , E C O N O M I C
EMPOWERMENT AND SOCIAL
PROTECTION OF YOUNG WOMEN
AND GIRLS TO REDUCE
NEW INFECTIONS.
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81
Gay men and other men who

have sex with men
Gay men and other men who have sex with men have been recognized as a key
population at increased risk of HIV since the earliest days of the HIV response.
Although many countries have seen steady overall declines in annual new
infections, the available data paint a different picture for men who have sex with
men. HIV epidemics among this population continue to expand in most low-,
middle- and upper-income countries, and HIV prevention and treatment services
are fragmented and lack adequate coverage (1).
Figure 23
HIV prevalence and coverage of services for gay men and other men who have sex
with men, Guatemala City, Guatemala, 20142015
In the greater metropolitan area of Guatemala City, where an estimated 9300 gay and other men who
have sex with men live, coverage of HIV services provided by the community organization Colectivo
Amigos contra el SIDA (CAS) in 2014 and 2015 was highest in the city centre and Amatitln. Service coverage is lower in other high-prevalence areas of the city, suggesting priorities for service expansion.
HIV prevalence
Coverage
Source: CAS.
82
FAST-TRACK TARGET
>> Ninety per cent of men who have sex with men have access to HIV
combination prevention services.
FAST FACTS
>> HIV epidemics among gay men and other men who have sex with men continue
to expand in most low-, middle- and upper-income countries (1).
>> Globally, only four in 10 men who have sex with men are being reached with
HIV services (2).
>> Same-sex acts between consenting adults are a criminal offence in 78 countries.
Five impose the death penalty (3).
>> Criminalization: in many countries, same-sex acts are against the law,
making it difficult for gay and other men who have sex with men to
access HIV-related services.
>> Static service delivery: HIV responses have been slow to react to the rapid
rise of smartphone and web-based services that are used to arrange casual
sexual encounters by gay men and other men who have sex with men.
>> Discrimination: fear of abuse or discrimination by health-care workers
reduces HIV testing and increases the number of HIV treatment patients lost
to follow-up.
>> Lack of services: insufficient political and financial commitment has left
programme for gay men and other men who have sex with men underfunded
and at insufficient scale.
>> Overlapping vulnerability: the use of drugsespecially stimulantsby
gay men and other men who have sex with men increases sexual risk
behaviour (4, 5).
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83
Multiple social and individual factors coalesce to put these men at higher risk.
Like other key populations, they often are marginalized, stigmatized and subject
to punitive laws. A 2014 survey found 78 countries where same-sex acts between
consenting adults are a criminal offence, including five where they carry the death
penalty (3). Punitive laws, counterproductive policies, human rights abuses and
violence fuel vulnerability. Even in countries where basic rights are guaranteed,
HIV infections among gay men and other men who have sex with men remain
persistently high (6).
Young gay men and other men who have sex with men are at particular risk.
Across all countries reporting to UNAIDS, condom use with last partner is
about equal between young men (<25) and older men, but HIV testing and
status awareness over the previous 12 months is lower among younger men (36%
compared to 43%) (7).
In the Internet era, smartphone apps and web-based social networks are replacing
gay saunas, other entertainment establishments and public venues as the
method of choice for meeting sexual partners. As a result, condom and lubricant
programming through traditional venues no longer has the same reach. This
means that the coverage of HIV prevention programming for this key population
is not only insufficient, it has actually declined: according to reports from 20
countries worldwide, coverage has dropped from 59% in 2009 to 40% in 2013 (7).
National and local government commitments to reach gay men and other men
who have sex with men are inconsistent, leading to HIV programmes for them
that often are under-resourced. Services are seldom tailored to the needs of this
key population, and they are typically organized in isolation from the rest of the
health-care system (8). In prisons and other closed settings, the existence of maleto-male sexual intercourse is often denied, as is access to condoms and lubricant.
Within the health system, failure to address discriminatory attitudes and abuse by
health-care workers increases the risk of losing patients within the continuum of
HIV testing, treatment and care.
Leveraging social media and dating apps to boost HIV prevention
in Guatemala City
HIV prevention efforts directed at gay men and other men who have sex with
men in Guatemala have shown alarming signs of decline. In 2007, 75% of
men who have sex with men reported they had been reached by prevention
programmes, and 64% had tested for HIV in the previous year (9). In 20122013,
however, a similar survey found that only 65% among men who have sex with
men in Guatemala City were reached by prevention programmes, and only 45%
said they had tested within the previous 12 months (10).
The Collective Friends Against AIDS (Colectivo Amigos contra el Sida, or CAS),
a community-based organization that focuses on gay men and other men who
have sex with men, has modernized Guatemalas strategy to reach this population
with comprehensive HIV prevention, testing services and linkages to care.
84
Since July 2014, outreach activities have been promoted on popular social
networking websites and gay dating apps, such as Grindr and Manhunt; they
are then carried out in popular meeting places like parks, pedestrian walkways,
saunas and nightclubs. HIV testing was promoted by peer educators who
offered to accompany clients to specific HIV and sexually transmitted infection
service locations.
Since October 2014, testing in Guatemala City has largely been conducted at a
facility that provides services according to a more flexible schedule and at a more
appropriate location (near one of the main cruising and dating sites). This clinic
receives an average of 49 visits per working day. All new HIV cases diagnosed
through the programme are linked to an HIV care facility within an average of
three days, and follow-up efforts are aided by short message service (SMS) (11).
The results have been encouraging. From July 2014 to August 2015, 7224 gay
men and other men who have sex with men in Guatemala City participated
in activities to promote condom use and other interventions to prevent HIV
transmission; nearly half were tested for HIV, and 41% attended a medical
consultation for diagnosis and treatment of sexually transmitted infections (12).
Compared to a similar effort in 2013 that covered the whole country, the number
of people reached with HIV prevention services was 61% greater, and the number
of people tested increased by 32%. In 2014, HIV diagnoses performed by CAS
represented half of the total received by gay men and other men who have sex
with men throughout the entire country (11).
The highest coverage has been in the district of Amatitln and Guatemala City
Centre; in other areas of the city where HIV prevalence among men who
have sex with men is higher than 10%, service coverage is alarmingly low
(Figure 23). This indicates that there is still much work to be done in this Central
American city.
Reaching men through Chinas largest gay dating app
For gay men and other men who have sex with men, smartphone apps have
revolutionized social interactions. The worlds largest dating app for men who
have sex with men is Chinas Blued, which has attracted 15 million users in its
first two years (13).
Blued has been hailed by lesbian, gay, bisexual and transgender activists in
China for helping users develop a positive self-image and fight stigma and
discrimination. The app also promotes HIV prevention in a country where HIV
prevalence among men who have sex with men is estimated to be 7.3% and rising,
compared to just 0.06% among the general population (14).
A red ribbon icon within the user interface of the app links users to information
about the importance of correct and consistent condom and lubricant use, as well
as the rights of men who have sex with men. Blued is also actively addressing
the fear of discrimination that deters many men who have sex with men from
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getting an HIV test. The app engages users to answer questions that are intended
to increase their knowledge of HIV treatment, prevention tools and care
options, and it points them to locations where they can access HIV testing and
counselling.
Blued engaged in HIV-related outreach with over 12500 people in 2014, 25%
of whom subsequently sought HIV testing through a linked testing centre.
Ultimately, 82 men learned they were living with HIV (15).
The app has attracted the praise of the Chinese government and interest from
venture capitalists who are keen to invest in Blueds overseas expansion (16).
Diagnosing men who have sex with men in Curitiba, Brazil, with
mobile and e-testing services
Brazil has been a consistent early adopter of progressive HIV prevention and
treatment policies; this has helped stabilize HIV prevalence in the general
population at 0.4% (17). In recent years, however, it has been a challenge to
mount a sufficient response to the HIV epidemic among gay men and other men
who have sex with men.
Curitiba, a city in southern Brazil with approximately 1.75 million inhabitants,
has recorded 10081 cases of HIV and 3310 AIDS deaths since 2002, with men
accounting for approximately two thirds of the cases (18). The city has launched
a new campaign under the slogan The time is now: testing makes us stronger
to make stigma-free HIV testing for men who have sex with men more accessible
and more closely linked to HIV treatment initiation and the continuum of care.
At the heart of this campaign is the Curitiba Governmental Orientation and
Counselling Centre, which has had notable success in reaching men who have
sex with men by establishing a welcoming environment. The centre performs
approximately 700 rapid tests per month for HIV, syphilis and hepatitis B and C.
Eighty per cent of its clients are men. Among a sample of 1145 men who have sex
with men who were tested at the Clinic, 117 (or about 10%) were diagnosed with
HIV, which is consistent with the national prevalence of HIV among men who
have sex with men (18, 17).
Mobile and community-based counselling and testing services run by a
nongovernmental organization are offered in other locations with the help of
health-care workers from the Centre. This collaboration facilitates access to
antiretroviral therapy and continuity of care for those who test positive for HIV.
There is also an e-testing platform available at www.ahoraeagora.org that provides
visitors with an interactive map of the 109 testing centres in the city. The website
also has an HIV-risk calculator, an order form for an oral-fluid-based HIV test kit
that is mailed to the user and a free 24-hour HIV counselling hotline (1416). The
site helps reach one of the programmes most challenging populations: young men
who have sex with men who do not identify themselves as gay. These individuals
tend to be disconnected from traditional HIV prevention channels.
86
Looking beyond these innovative efforts, there is still much unfinished business
in Curitiba. Putting the citys HIV response firmly on the Fast-Track will require
stronger efforts to address the social and economic exclusion that members of
key populations continue to face. More data are needed to better estimate the
size of key populations, and with support from the Ministry of Health, Curitiba
is improving HIV epidemic and behavioural surveillance, including developing
specific strategies for men who have sex with men (18). Better integration of HIV
services into the existing primary care structure and improved collaboration with
other cities also are required.
Sundown Clinics make HIV testing easy for gay men in Metro Manila
Decades of traditional HIV testing and treatment services have failed to achieve
high levels of coverage among gay men and other men who have sex with men.
Fast-Tracking requires a new approach. In the Philippines, Metro Manila is home
to one of the fastest-growing HIV epidemics in Asia and the Pacific, and young
men who have sex with men account for almost 90% of new HIV infections.
Figure 24
Population sizes of gay men and other men who have sex with men in Quezon City,
Metro Manila, Philippines, 2014
Quezon City public health officials, working closely with the community, conducted mapping exercises
to establish the areas where gay and other men who have sex with men gather. This heat map shows
eight primary clusters and the locations of the citys health clinics. Markers also denote the locations of
Sundown Clinics within two of the clusters.
Source: Quezon City Health Department.
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The stigma attached to being gay makes it difficult for them seek HIV services
through regular health-care channels.
To address this issue, Sundown Clinics are working to respond to the particular
needs of this key population. To do this, the clinics have hours of operation that
reflect the times when the key populations they serve are most able to access
services (22, 7). For example, Klinika Bernardo in Quezon City, Metro Manila,
opens its doors from 8am to 11am, and from 3pm to 11pm. The Clinic caters
to a clientele of predominantly gay men, other men who have sex with men
and transgender people. Meanwhile, the Social Hygiene Clinic primarily sees a
clientele of female sex workers from 8am to 3pm. The clinics staff of four, who
are supported by a small team of peer outreach workers, also are well trained in
providing stigma-free HIV services to men who have sex with men (7).
Within two months of opening in 2012, Klinika Bernardo conducted almost 250
sessions of HIV counselling and testing; by the end of 2014, it had conducted
more than 2500 tests, with just over 200 clients diagnosed with HIV. The clinics
peer outreach network has received support from the Quezon City mayors office,
and it is now serving Quezon Citys gay nightlife hotspots with mobile rapid
testing services (23). It also reaches out to church groups, religious leaders and
officials from local police and government to help them understand how social
acceptance of key populations is critical to achieving the citys public health goals.
The clinic also plans to take part in community population size estimations and
mapping, and to work with local media to ensure better reporting on HIV and
other issues impacting men who have sex with men, transgender people, people
who inject drugs, and children and young people living with HIV.
Klinika Bernardo has proven so successful that a second clinic opened in 2015.
Civil society successfully reaching men who have sex with men in Beirut
Against a backdrop of regional conflict, an escalating Syrian refugee crisis,

economic hardship, an overburdened health system and discriminatory cultural
attitudes, Lebanons HIV response for men who have sex with men is producing
exceptional results.
Recent surveys conducted in Beirut found that 67% of men who have sex with
men who are living with HIV know their status (24). This is thanks to extensive
efforts by a strong and robust civil society that is working in close partnership
with the national AIDS programme.
Marsa (The Dockyard) exemplifies the diversity of programmes for men who
have sex with men. Founded in 2010, the centre offers comprehensive and
holistic sexual and reproductive health services to all, with a special focus on
marginalized populations (25).
As well as providing voluntary counselling and testing, Marsa also supplies
subsidized medical consultations, specialized psychosocial support and dietetic
counselling for people living with HIV (26). Its referral system gives young people
access to medical professionals at subsidized prices while maintaining their
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Figure 25
Locations of men who have sex with men surveyed, Beirut, 2015
Beirut is the centre of social life for men who have sex with men living in Lebanon. A respondent-driven
sampling survey of men who have sex with men was conducted in 2015. The map shows the neighbourhoods where the 292 subjects lived. The study found that 67% knew their HIV status, and 84% of men
living with HIV reported they were receiving antiretroviral therapy. HIV prevalence among men who have
sex with men in the city is estimated at 13%.
Spatial distribution of the sample
Source: Heimer R, Khoshnood K, Crawford F, Shebl F, Barbour R, Khouri D and J Mokhbat. Size Estimation, Risk Behavior
Assessment, and Disease Prevalence in Populations at Project CROSSROADS: High Risk for HIV Infection in Lebanon.
Report to MENAHRA, 15 June 2015.
privacy in a supportive and non-judgmental environment. The Lebanese Ministry

of Public Health and the National AIDS Control Programme support Marsa by
managing the supply chain and logistics for HIV rapid test kits and training their
staff to provide HIV testing services. Between 2011 and 2015, Marsa provided
more than 2500 unique clients access to health services and over 4000 HIV tests
were performed. From those HIV tests 74 men who have sex with men were
newly diagnosed HIV positive (27).
Another pioneering programme run by the nongovernmental organization
SIDC (Soins Infirmiers et Developpement Communautaire) and HELEM
(Lebanese Protection for Lesbians, Gays, Bisexuals and Transgenders) is
receiving support from the International AIDS Alliance as part of its MENACT
regional programme.
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SIDC uses peer outreach to share vital HIV and health information with
men who have sex with men and other key populations. HELEM focuses on
awareness-raising and sexual health for the lesbian, gay, bisexual and transgender
community. It advocates with policy-makers and health practitioners at the
national, regional and international levels for repeal of homophobic laws, the
decriminalization of homosexuality and the advancement of human rights and
personal freedoms in Lebanon. Its main breakthrough was the passing of an act
declaring that consensual sex among men who have sex with men should not fall
under the penal codes criminalization of sexual acts against nature (28).
Safe spaces for men who have sex with men in Nigeria
In countries where homosexuality is illegal, gay men and other men who have sex
with men are forced to hide their sexuality and sexual relations out of a real fear
for their lives.
In Nigeria, same-sex sexual practices are criminalized and punishable by up to
14 years of imprisonment. HIV programmes focusing on gay men and other men
who have sex with men are extremely limited in this West African country.
In the capital, Abuja, and the states of Lagos, Rivers and Cross Rivers, the
Integrated MSM HIV Prevention Programme (IMHIPP) is providing safe places
for men who have sex with men to stay healthy and just be themselves. IMHIPPs
services include HIV prevention, care and support to men who have sex with
men, their female sexual partners and their dependents. Since the programme
began in 2009, it has reached over 12000 men who have sex with men in Lagos
alone (29). An impact evaluation survey conducted in 2013 revealed that 73% of
men who have sex with men reached through IMHIPP services from November
2012 to April 2013 reported correct and consistent use of condoms, compared to
43% in 2009 (30).
Within the IMHIPP community centres, men can freely embrace each other,
express their sexuality and access information on HIV and other sexually
transmitted infections, as well as on relationships, sexuality, human rights and
social activities. The centres also host support groups for men who have sex with
men living with HIV to improve access to counselling and palliative care (31).
The programme is a strong example of collaboration between development
partners and local human rights and HIV organizations that addresses the health
and human rights of a highly marginalized and criminalized population.1
1 Other partners who are participating in the collaboration include the United States Agency for International Development, the
Heartland Alliance for Human Needs and Human Rights (a nongovernmental organization from the United States of America) and
several Nigerian nongovernmental organizations: the Initiative for Equal Rights, Pure Professionals for Human Rights Advocacy, the
Initiative for Improved Male Health and the International Center for the Advocacy of Health Rights.
90
What works to reach gay men and other men who have sex with men with HIV
services has been well established. China and Guatemala City are showing that
the smartphone apps men use to socialize can be leveraged to link them to
HIV prevention, testing and treatment services. Quezon City and Curitiba are
demonstrating how to tailor these services to their clients specific needs. These
innovations need to be combined with technologies that have recently become
availablesuch as pre-exposure prophylaxisto strengthen HIV prevention
among men who are at higher risk of infection.
Beirut is demonstrating the critical role that civil society can play in reaching
key populations. Men who have sex with men, however, continue to be
underrepresented in local, regional and national AIDS response planning
processes (32). This must change to ensure the environment in which services are
delivered is more consistently appropriate.
Finally, brave human rights and HIV organizations in Nigeria are showing
that gay men can be reached and assisted, even in highly stigmatized and
criminalized environments. Ultimately, however, these punitive environments
are unacceptable. It is vital to end criminalization of consensual sex between men
and to train health-care workers to provide stigma-free services, and to ultimately
ensure these men can live their lives in dignity and free from stigma.
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Transgender people
Transgender people are among the most marginalized populations in nearly

every region of the world. In many countries, they are denied recognition of
their gender, which in turn deprives them of the identity documents they need to
access education, employment and gender-appropriate health care.
Figure 26
Transgender people and HIV in El Salvador: HIV prevalence, population size estimates
and prevention service coverage, 2014
Approximately one quarter of El Salvadors transgender people live in the capital, San Salvador. In
2014, comprehensive prevention community centres were established in San Salvador, San Miguel
and Santa Ana (the three most populous cities in the country) to provide a package of HIV prevention
and health-care services tailored to the specific needs of this highly marginalized population. The
centres make referrals to Ministry of Health-run sexually transmitted infection clinics, known as VICITS,
where staff are trained to provide appropriate and stigma-free services to transgender people and other
key populations.
Number=HIV prevalence (%)
Population size estimates
Coverage (JanuaryJune 2015)
Sources: Ministry of Health, El Salvador; Plan International Inc.El Salvador.
92
FAST-TRACK TARGET
>> Ninety per cent of transgender people have access to combination HIV
prevention services by 2020.
FAST FACTS
>> Transgender women are 49 times more likely to acquire HIV than other adults
of reproductive age (1).
>> In 15 countries with available data, an estimated 19% of transgender women are
living with HIV (1).
>> More than one quarter of transgender women who engage in sex work are living
with HIV (2).
>> Transphobia: transphobic attitudes among health-care workers, law
enforcement officers, education systems and the general public discourage
transgender people from seeking health and social services.
>> Violence: transgender people throughout the world live under threat of
physical and sexual violence and hate crimes.
>> Social isolation: a large percentage of transgender women face
discrimination in their immediate social environment. They often are
excluded from social activities, rejected by their families and expelled
from their homes.
>> Legal and policy barriers: lack of recognition of transgender
rights creates obstacles to accessing health services, education
and employment.
>> Stigma and discrimination: discrimination in the education system and
work places limits employment opportunities for transgender women and
contributes to a high proportion engaging in sex work.
>> Poor service coverage: too few transgender women are being reached by
existing HIV services.
>> Migration: transgender women often migrate from their home towns or
villages to seek less threatening places to live (usually cities). This creates
vulnerability and service continuity challenges.
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Family and social rejection are common, as are violence, harassment and
discrimination. This is particularly the case in the health system, where
transgender people may be denied care or mistreated by health-care workers.
Depression, drug and alcohol use, suicide and self-harm are all more common
among transgender people than the general population, while young transgender
people are particularly vulnerable to economic instability and homelessness.
Transphobia is widespread and often leads to institutional and interpersonal
violence towards transgender women. An international community-based
project to monitor murders of transgender and gender-variant people collected
1731 reported cases of killings in 62 countries between 1 January 2008 and 31
December 2014. Many more cases are believed to go unreported due to lack of
monitoring in many regions (3).
Cross-dressing is criminalized in many countries, leaving transgender people
vulnerable to arrest (4, 5). Furthermore, lack of recognition of gender identity in
binding international human rights instruments undermines the efforts of these
communities to advocate for their rights.
Transgender people also are at higher risk of HIV infection and they are severely
underserved within national AIDS responses. Transgender women are 49 times
more likely to acquire HIV than other adults of reproductive age, but transgender
people living with HIV are less likely to access or adhere to treatment (6). A
high proportion of young transgender women engage in sex work due to a lack
of employment options (7), and this puts them at much higher risk of acquiring
HIV: a 2008 systematic review and meta-analysis estimated crude HIV prevalence
among transgender women who engage in sex work to be 27.3%, almost twice
that of transgender people who did not (8). Studies also suggest that the risk of
acquiring HIV for transgender sex workers is on average nine times higher than it
is for female sex workers and three times higher than for male sex workers.
The challenges to Fast-Tracking HIV responses within transgender populations
remain huge. Community-led and dedicated services for transgender
people are required to cut through the high levels of stigma and
discrimination faced by transgender people and move towards the goal of
AIDS-free transgender communities.
San Salvador linking transgender people to tailored health and
human rights services
El Salvador is estimated to have more than 2000 transgender people, more

than one quarter of whom live in the capital city, San Salvador (9). They are
among the countrys most stigmatized groups, routinely subject to human
rights violations, including hate crimes (10, 11). Nearly half of the transgender
women in San Salvador report that their main income comes from selling sex,
and HIV prevalence among transgender women in the city is estimated at 16.2%
(compared to less than 1% among the general population) (9).
In 2014, El Salvadors Ministry of Health joined forces with an international
nongovernmental organization, Plan International, to reduce the rate of HIV
infections among transgender people and other key populations. Following
94
consultation with experienced transgender civil society organizations

such as ASPIDH Arcoiris, COMCAVIS Trans, ASTRANS and
Colectivo Alejandriathree comprehensive prevention community centres
were established.
Run by peers who were recruited through civil society organizations, the centres
provide a package of basic HIV prevention and health-care services tailored to
the specific needs of transgender clients. The services include general medical and
mental health services, HIV counselling and referral for testing, and behaviour
change communication on correct and consistent condom and lubricant use.
Mobile teams composed of two civil society peer educators, a laboratory
technician and a counsellor work in collaboration with the centres to offer HIV
testing and counselling in areas that are frequented by transgender people. Rapid
test kits are used to provide immediate diagnosis and make referrals to healthcare facilities as required. Using a strategy adapted from the private sector, the
teams focus on a specific geographic area and try to reach all points, businesses
and people within it. The goal is to increase the coverage of programmes,
especially in populations that have limited access to health services.
The centre and mobile units make referrals to Ministry of Health-run sexually
transmitted infection clinics (known as VICITS) that have staff who are trained
to provide appropriate and stigma-free services to transgender people and other
key populations. VICITS also provide a combination HIV prevention package,
integrated HIV and sexually transmitted infection diagnosis and treatment,
and so-called second-generation surveillance of key behavioural and biological
indicators for key populations and people living with HIV.1 Of the 13 VICITS
centres in El Salvador, three are located in San Salvador.
A total of 143 transgender peopleabout one quarter of San Salvadors
transgender populationwere reached with a basic HIV prevention package
during the first six months of 2015 (12).
Since they opened, the VICITS centres have further strengthened the efforts of
transgender women in San Salvador to claim recognition as a group distinct from
men who have sex with men, one with its own unique strengths, vulnerabilities,
risks and needs. As well as HIV services, the centres also provide information
and support on topics such as violence and other human rights violations, and
gender-affirming procedures, including hormone therapy.
Strong partnerships have enabled the establishment of this robust service-delivery
model, including commitments and inputs by the national AIDS programme,
the Ministry of Health, the Ministry of Interior, the Ministry of Education, the
Department of Social Inclusion, Plan International and a number of transgender
community organizations. The community-led methodology of the programme is
key to achieving earlier HIV diagnosis and treatment and it also collects data that
will help improve future services for transgender people in the country. Broader
structural interventions strengthen the knowledge, self-esteem and leadership
1. The VICITS strategy was established through technical assistance from the United States Presidents Emergency Plan for AIDS
Relief (PEPFAR) and is supported through the Central American Regional Office of the United States Centers for Disease Control and
Prevention (CDC).
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95
of local transgender communities, enhance their ability to claim their rights and
address stigma and discrimination (13).
Reaching four out of five transgender women in Andhra Pradesh, India
From 2003 to 2014, the Avahan India AIDS Initiative was among the worlds
most ambitious community-based efforts to reduce HIV infections among key
populations. Funded by the Bill & Melinda Gates Foundation, it pioneered a
number of approaches with transgender women, men who have sex with men
and female sex workers in six Indian states that at the time contained 83% of
Indias people living with HIV (14).
In Andhra Pradesh, Avahans community-led efforts successfully overcame
both structural and environmental barriers to reach transgender women with
a standardized package of evidence-informed HIV prevention services. These
included community-led outreach, clinical services to treat sexually transmitted
infections other than HIV, facilitation of community mobilization and
programme ownership by communities, advocacy for an enabling environment
and distribution of condoms, lubricants and other HIV prevention commodities.
The impact of Avahans work was evaluated in 2013. Between 2006 and 2009,
the programme reached more than four out of five [83%] transgender women
and men who have sex with men in Andhra Pradesh (15). This high level of
coverage was achieved despite deep stigma and superstitions within society.
Addressing transgender women was particularly challenging, because they belong
to hierarchical, closed-clan communitieswhich makes it more difficult to reach
them directlyand they are in danger of arrest due to the criminalization of sex
between men (a provision that also is used against transgender people) (16).
Avahan recognized that peers have a deep understanding of the issues facing their
communities, and that they can establish a higher level of trust than outsiders.
Relying on peer-led outreach also enabled Avahan to ensure that services took
into account the reluctance of transgender women and men who have sex with
men to interact with each other, and it tailored clinic services accordingly so that
they met the unique needs and lifestyles of the respective groups. Avahan also
trained medical staff on how to interact with client groups in a non-stigmatizing
manner and ensured that mobile clinics were open at times when transgender
women were most likely to use them (such as in the early morning and late
at night). Avahans advocacy efforts included tackling violence, harassment
and discrimination, all of which discourage transgender women from
accessing services.
The evaluation found no significant reduction in the incidence of HIV or other
sexually transmitted infections between 2006 to 2008. Avahan, however, did show
how it is possible to reach transgender women, even in settings where they are
extremely hidden. Through community-led programmes, it is possible to change
behaviour, foster community mobilization around shared concerns and sensitize
key stakeholders about the need to address discrimination and harassment
among both the wider community and public institutions.
96
Avahan also is a successful example of a large, donor-funded programme

transitioning to national ownership and sustainability. From the beginning,
the programme broadly emulated the Government of Indias own structure
for service delivery, and its focus, goals and priorities were largely aligned
with those of the Government when transition planning began in 2006. This
alignment was further reinforced within the Governments third national AIDS
response plan, when the plans domestic budget was significantly increased to
take into consideration the absorption of Avahan. Avahans programme costs
were fully aligned with the Governments cost guidelines at least six months
before transition, and the national and state AIDS programmes were supported
to strengthen their capacities in data-driven management and field supervision,
community mobilization, guideline development, effective management and
costing. Since the transition, state governments contract nongovernmental
organizations or community-based organizations to deliver services to key
populations under the guidance of the state-level technical support units (17).
Opening the door to better health for transgender women in Mexico City
Almost one in five people living with HIV in Mexico are in the capital,
Mexico City, and transgender women are among the populations hardest hit
by the epidemic (18). Stigma and discrimination are part of everyday life for
transgender people in the city, which greatly hinders their access to essential
services, including HIV prevention, treatment and care. Drug use, sex work and
unsupervised hormone therapy all put transgender women at higher risk of harm,
including violence, exploitation and infectious diseases.
A recent survey of 858 transgender women in the city found that 64% were living
with HIV. Mental health problems and substance abuse also were very high
compared to the general population and four in five [79%] reported experiencing
stigma and discriminationincluding isolation, verbal violence and physical
violencefrom police, family, friends and classmates (19).
The mounting health crisis among transgender people convinced the Mexico
City AIDS programme to launch the countrys first dedicated health centre
for transgender people in 2009. Located at Clnica Condesa in the Colonia
Hipdromo Condesa, the centre provides free-of-charge services, including
hormone replacement therapy, nutritional counselling, dental services and
testing, counselling and treatment for HIV and other sexually transmitted
infections (20). As of December 2014, a total of 1187 clients (85% transgender
women and 13% transgender men) had received services at the centre (21).
Thirty-eight per cent of clients were living with HIV (86% of them received
antiretroviral therapy from the centre), while 30% had hepatitis B and 2.5 % had
hepatitis C (21).
As well as providing vital health-care services for transgender women in the city,
Clnica Condesa has created a safe space where they can receive comprehensive
care, including treatment for injuries sustained during physical attacks or as a
result of using substances to feminize their bodies.
There are, however, still significant challenges to be met in order to address this
populations needs and reduce new HIV infections. To build on the work of
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97
Clnica Condesa, the Mexico City AIDS programme plans to establish a second
transgender-focused HIV centre in the East of the city, where poverty levels in
this community appear to be higher.
Claiming the health and social service rights of transgender
sex workers in Uruguay
Sex work by women in Uruguay has been recognized as work since 1995 and, in
2002, the Sex Work Law defined its legal conditions (22). It was not until 2009,
however, that the law was extended to cover male and transgender sex workers.
Even then, the high cost of social security contributions and a cumbersome
registration procedure for the countrys social security system made it difficult
for transgender sex workers to fully exercise their rights under the law. Without
registration, transgender sex workers were denied access to pensions and
coverage by the National Health Fund.
Since 2010, the Transgender Association of Uruguay has been advocating for the
rights of transgender sex workers, working closely with other sexual diversity and
human rights activist organizations and the UNAIDS country office. The first step
was to gather data on efforts by transgender people to secure state pensions (23).
The project also collated a database of transgender people who had been unable
to formalize their work. Social exclusion and marginalization were commonly
reported by the transgender sex workers who contributed to the databases.
These challenges were then raised repeatedly by the association in meetings with
congressmen and the countrys social security body, Banco de Previsin Social.
This advocacy bore fruit: a proposal was tabled for a new regulation that would
establish new social security contribution options for those who practiced nonconventional work.
The project initially struggled to gain the interest of transgender sex workers,
although education about their rights and the benefits of being covered by the
countrys social security system improved participation. After completing the
training, a group of transgender activists led discussions with key decisionmakers. The process made transgender sex workers more visible and empowered
them to advocate for change.
This work has since influenced a further expansion of social protection for
transgender populations. The Uruguay Social Card (Tarjeta Uruguay Social),
introduced in 2012, is provided to individuals and households with extreme
socioeconomic vulnerability. Support includes a monthly grant provided as a
debit card that can be used in a network of shops. Since transgender people have
extremely limited opportunities for education, health and work, the Ministry of
Social Development provides transgender people access to the card regardless of
their economic status. As of 2015, 985 transgender people had Uruguay Social
Cards. The Uruguay Works programme has complemented the social card by
including transgender youth within an employment quota system for populations
that have been excluded from work opportunities (24).
Data from Uruguay Social Card registration are being used by public health
programme managers. In the absence of transgender population size estimates,
98
geographical data collected during social card registration is used. These data
show, for example, that nearly half (43%) of the approximately 1000 transgender
people who have registered are living in Montevideo. When triangulated with
health service coverage data, this can identify service coverage gaps (24).
A Fast-Track AIDS response for transgender women relies on the meaningful

participation of community-led organizations and transgender networks.
Transgender people understand the health needs of their own communities and
they know how to reach their peers, provide them with information and link
them to services that are client-focused, rights-based and stigma-free.
Even with increased engagement and investment, transgender communities
cannot succeed without legal recognition of their gender identities and
enforceable protection of their basic human and civil rights. Tackling the
pervasive stigma and discrimination that hound transgender communities is a
critical Fast-Track action that will create waves of social impact that extend far
beyond efforts to end the AIDS epidemic.
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99
Worldwide there are an estimated 12.2million [8.521.5million] people

who inject drugs, and injecting drug use has been documented in at least 158
countries (1, 2). People who inject drugs are at higher risk of HIV infection, but
efforts to reach them with HIV prevention programmes are hampered by a
potent combination of punitive legal environments, violence, stigma,
discrimination and fear.
Figure 27
HIV prevalence and locations of methadone maintenance clinics in Yunnan
province, China, 2014
Yunnan is among the Chinese provinces most affected by HIV, including high HIV prevalence among
people who inject drugs. By analysing HIV case reports, the province has placed methadone maintenance clinics in counties with the highest HIV prevalence. Yunnans methadone programme now reaches
more than 13 500 people each month.
People living with HIV
HIV prevalence in sentinel surveillance sites
People living with HIV
Number= Number of methadone maintenance clinics

(Number)=Number of people receiving treatment
Sources: Chinese National Health and family Planning Commission, 2015;
National Center for AIDS/STD Control and Prevention, Yunnan Center for
Disease Control and Prevention, 2014.
100
FAST-TRACK TARGET
>> Ninety per cent of people who inject drugs have access to HIV
combination prevention services.
FAST FACTS
>> Almost a third of new HIV infections outside sub-Saharan Africa occur among
people who inject drugs (3).
>> The four countries with the largest numbers of HIV infections among people who
inject drugs are China, Pakistan, the Russian Federation and the United States
of America (1).
>> There has been an estimated 10% decline in new infections among people who
inject drugs in recent years, far short of global targets (3).
>> Criminalization: treating drug use and drug dependence by incarceration is
counterproductive to efforts to improve individual and public
health outcomes.
>> Arbitrary detention: detention without trial is a corollary of criminalization
and a severe human rights violation.
>> Widespread societal stigma: people who inject drugs struggle not only with
health challenges related to their drug use but also with societal stigma that
discourages uptake of health services.
>> Poor understanding of harm reduction services: too many countries treat
possession or distribution of injecting equipment as evidence of drug use or
drug use facilitation and view methadone as an addictive synthetic opioid
alternative rather than a medication.
>> Slow or no scale-up of harm reduction programmes: many existing laws
prohibit implementation of harm reduction services, reject opioid substitution
therapy or impede access to sterile needles and syringes.
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There is overwhelming evidence to show that harm reduction measures such as

opioid substitution therapy and distribution of sterile injecting equipment greatly
reduce HIV transmission among people who inject drugs. The provision of these
services is inadequate in most countries (4), however, and where such services are
available the criminalization of drug use may impede access.
Fast-Tracking the HIV response among people who inject drugs requires political
courage and additional investment. In a small but growing number of cities,
regions and even entire countries, drug dependence is no longer considered a
crime but a condition created by a complex combination of societal, behavioural
and health factors. Harm reduction programmes are being scaled up, bending the
trajectory of the HIV epidemic among this woefully underserved population.
Pilot to Fast-Track in China
Chinas experience exemplifies the gains to be made by a Fast-Track approach.

After a successful pilot in 2006, China rapidly expanded methadone maintenance
therapy in areas with significant heroin use. Chinas free voluntary methadone
programme is now the largest in the world, serving more than 410000 people
who use opioidsabout 21% of people who inject drugs in China (5). Methadone
clinics were first established in administrative areas with 500 or more registered
people who use drugs. Over time, the threshold was lowered to areas with 300
or more registered people who use drugs (6). From 2011 to 2014, China also
increased access to clean needles and syringes, with distribution rising from 180
to 204 needles per person who injects drugs per year (7).
The impact of the programme has been dramatic. People who inject drugs
accounted for less than 8% of people newly diagnosed with HIV in 2013,
compared with 43.9% in 2003 before the methadone programme began.
Moreover, sentinel surveillance data indicate that the national average of HIV
prevalence among people who use drugs dropped by half, from 7.5% in 2005 to
3.6% in 2013 (5).
China shows no signs of slowing down. The scale-up of methadone programmes
is occurring alongside a distribution programme for sterile injecting equipment
in 15 provinces, autonomous regions and municipalities. In 2013 there were
898 programme sites, more than 60000 people who use drugs participated
in the programme and more than 12million sterile needles and syringes
were distributed (8).
Peer-driven seektesttreatretain approach in Athens
Throughout the 2000s, the number of people newly diagnosed with HIV in
Greece never rose above 653 in any given year and fewer than 20 people who
inject drugs were newly diagnosed with HIV in any given year. In 2011 an
alarming increase occurred: in that one year, 266 people who inject drugs were
newly diagnosed with HIVa 16-fold increase compared with the previous
yearand the total number of new diagnoses of HIV rose to 969 (9). New
diagnoses among people who inject drugs more than doubled, to a peak of 551 in
2012 (Figure 28).
102
Figure 28
Reported cases of HIV in Greece, 20002014
1300
1188
Number of newly diagnosed cases
1200
1100
969
1000
921
900
806
800
653
700
465
600
500
406
400
604
573
610
551
517
492
397
434
442
272
266
300
200
100
0
119
18
15
2000 2001
17
11
11
19
16
2002
2003
2004
2005
2006
2007
2008
14
16
2009
2010
2011
2012
2013
2014
YEAR
Cases of HIV-1 infection reported in people who inject drugs

Total number of cases of HIV-1 infection reported in Greece
Source: ARISTOTLE programme.
In response to this dramatic spike in HIV cases, the University of Athens and
the Organisation Against Drugs designed and implemented the ARISTOTLE
programme, a seektesttreatretain approach to decrease HIV transmission
among people who inject drugs in the Athens metropolitan area (10).
The initiative used five rounds of respondent-driven sampling to engage members
of this hard-to-reach population. Seed participants were paid for their own
participation and for recruiting other people who inject drugs from their social
networks. Approximately 1400 people who inject drugs were reached in each
round, finding a total of 3320 individuals (Figure 29) (10).
More than 90% of the citys people who use drugs were reached between August
2012 and December 2013. Each of these people provided a blood sample that
was tested for HIV and other medical conditions. Each person completed a
questionnaire on a wide range of factors, including sexual behaviour, drug and
alcohol use and treatment, and previous HIV testing experience. The data yielded,
for the first time, a comprehensive picture of people who inject drugs in Athens,
including epidemiological data, sociodemographic social network characteristics,
the extent to which they had access to drug treatment, harm reduction and HIV
testing services, and the level of service uptake. A total of 499 participants tested
positive for HIV during their first testing visit, a crude prevalence rate of 15.1%
[13.916.4%] (10). Participants who tested positive for HIV were referred to
one of two nongovernmental organizations collaborating with the ARISTOTLE
programme for counselling and treatment follow-up. Services included the
provision of sterile injecting equipment, drug dependence treatment and linkage
to antiretroviral therapy.
UNAIDS
103
Figure 29
People who use drugs reached by ARISTOTLE programme, Athens, Greece, 20122013
In response to a dramatic spike in HIV cases, the University of Athens and the Organisation Against Drugs
designed and implemented the ARISTOTLE programme, a seektesttreatretain approach. More than
90% of the citys injecting people who use drugs were reached between August 2012 to December 2013.
Source: ARISTOTLE programme.
The initiative was highly successful in meeting its primary aims of screening
people who inject drugs for HIV, providing a prevention, treatment and care
package, and reducing the incidence of HIV within this population. There was
a 7080% decline in new infections during the course of the programme, from
August 2012 to December 2013 (5). Reported risk behaviours also reduced, with
greater adoption of safer injection practices regardless of HIV test result and safer
sexual practices among people living with HIV. Adherence to drug dependence
treatment also increased during the ARISTOTLE programme. The proportion of
participants who reported being on opioid substitution therapy increased from
10% to 20% over the five rounds (10).
In 2014 the number of new diagnoses of HIV among people who inject drugs
continued to decline but was still higher than that reported in the years before
2011. Preliminary data indicate that approximately 75% of the people reached by
the programme who tested positive for HIV were eventually linked to HIV care.
Harm reduction programme builds positive relationship with
police in Kyrgyzstan
HIV transmission in Kyrgyzstan is associated primarily with sharing needles and

injecting drugs. Progressive policies and programmes have been established to
104
address the situation. Personal drug use was decriminalized in 2008, a

needlesyringe programme and opioid substitution therapy have been in
place since 1998, and antiretroviral therapy is available in prisons (11).
Despite these policies, friction between local police and nongovernmental
organizations providing harm reduction and other HIV services was disrupting
service delivery. In response, the Ministry of Internal Affairs established a
programme that included revision of the national police academys training
curriculum to include training on the benefits of harm reduction, in-service
training seminars on HIV and harm reduction, and establishment of special
liaison teams in five regions to improve cooperation between local police and
AIDS service nongovernmental organizations.
More than 500 law enforcement and penal officers have been trained. In 2010,
more than 300 police officers were surveyed to assess the effectiveness of the
programme. About a third had participated in the training. Trained individuals
had better HIV transmission knowledge and better legal and policy knowledge.
They were also more likely to report familiarity and interactions with public
health organizations and more likely to agree that police should refer people who
are at risk to service programmes (12).
The Bridging the Gaps programme and AIDS Foundation EastWest are
facilitating collaboration among the public health system, the police and civil
society to provide people who use drugs with essential health and harm reduction
services. The project supports local civil society organizations to develop
comprehensive high-quality HIV and harm reduction services and to advocate
for policy reform and an enabling environment for service delivery. An e-learning
platform on HIV, tuberculosis and drug use improves the knowledge and skills of
service providers;1 the website has answered more than 2000 user questions. Two
support centres for females who use drugs have provided harm reduction to 762
women. Nearly 7000 people who inject drugs and over 600 people in prison have
received health, legal and social services, and more than 1200 people have been
tested for HIV (13).
Malaysias Cure and Care centres improve adherence to drug
dependence treatment
Efforts to reduce HIV infections in East and south-east Asia have been challenged
by the confinement of people who use (or are suspected of using) drugs in
compulsory drug detention and rehabilitation centres. In 2011, almost 240000
people were held in over 1000 such centres in six countries, according to a survey
conducted by the United Nations Office on Drugs and Crime (UNODC).2
Access to HIV prevention and treatment services is often absent in these centres,
despite the fact that a high proportion of the detainees are either living with
HIV or are at very much higher risk of infection (14). The centres have been
the subject of intense advocacy by human rights organizations, civil society
organizations in the region and the United Nations. In March 2012, 12 United
1 The platform can be found at http://www.hivplatform.kg.
2 According to information derived from responses by governments in East and South-East Asia in response to a questionnaire from
UNODC in August 2012.
UNAIDS
105
Nations agencies issued a joint statement on compulsory drug detention and

rehabilitation centres, calling for their closure and replacement with voluntary,
evidence-informed and rights-based health and social services in the community
(15).
There are signs of political will in the region to move away from compulsory
centres and expand access to voluntary rights-based drug dependence treatment.
Malaysia has transformed 10 compulsory detention centres into Cure and
Care centres, which provide voluntary, comprehensive and client-centred drug
dependence treatment and support services, including methadone maintenance
therapy (14). Health services include voluntary HIV counselling and testing,
antiretroviral therapy, and testing and treatment for tuberculosis and hepatitis
B and C (16). In addition to core clinical services, some Cure and Care centres
provide after-care housing assistance, vocational training and religious or
spiritual programmes. Interviews with patients suggest that this social support
and the voluntary nature of the services facilitate adherence to drug dependence
treatment (17).
Comparisons between compulsory centres and Cure and Care centres make
a strong case for accelerating the transition to voluntary drug dependence
treatment. The Malaysian AIDS Council has reported that a comparative study
between compulsory drug detention and rehabilitation centres and Cure and
Care centres found that 50% of people in detention centres relapse within a
month of release, and all relapse within a year, whereas less than 40% of people
treated in Cure and Care centres relapse within a year (18). In addition, Malaysias
National Anti-drugs Agency reported that the annual cost of detaining one
person in a rehabilitation centre is more than four times higher than the annual
cost of treating one voluntary patient at a Cure and Care centre (19).
It is already clear what needs to be done to reduce HIV vulnerability among

people who inject drugs. The key to Fast-Track is not only to make harm
reduction services available but also to remove the barriers that prevent people
who use drugs from accessing these services. Athens has shown that social
networks of people who use drugs can be leveraged to provide services to a hardto-reach population. Kyrgyzstan has shown the importance of the sensitization
of law enforcement officers. Malaysia has shown that voluntary drug dependence
treatment is more effective and more efficient than detaining people who use
drugs. China is demonstrating to the world that it is time to move beyond the
pilot study phase and take evidence-informed programmes to scale and truly
meet the needs of this highly marginalized and stigmatized population.
Vital steps will be the decriminalization of drug use and the defence of the
human rights of people who use drugs.
106
UNAIDS
107
Sex workers
Sex work is work, regardless of the reasons for engaging in it. Sex workers should
have the same rights to safe working environments as all other workers,1 and this
includes protection against violence, discrimination and unjust prosecution.
Figure 30
HIV prevalence among the general population and among female sex workers,
Burkina Faso, 2010
In Burkina Faso, sex workers are at higher risk of HIV infection. HIV prevalence among sex workers in the
capital, Ouagadougou, is 13.5% [9.618.7%]; in the countrys second-largest city, Bobo-Dioulasso, the
HIV prevalence exceeds 15%. The two cities host Yerelon HIV programmes that provide sex workers with
a range of free, peer-assisted health care, including sexual, reproductive and mental health services, HIV
prevention education, HIV testing, treatment of HIV and other sexually transmitted infections, and as
many condoms as they require. To measure the effectiveness of the Yerelon programme, 321 female sex
workers aged 1825 years were enrolled in a prospective, interventional cohort study in Ouagadougou.
During the 409 person-years of follow-up, there were zero new infections among the study participants.
HIV prevalence, 2010

Female Sex Workers
General population 15-49 year old
Sources: Institut National de la Statistique et de la Dmographie (INSD), Burkina Faso; Conseil National de Lutte
Contre le SIDA et les IST, (CNLS-IST), Burkina Faso.
1. The UNAIDS Guidance note on HIV and sex work defines sex workers as female, male and transgender adults, over the age of 18, who
receive money or goods in exchange for sexual services, either regularly or occasionally, and who may or may not self-identify as sex
workers.
108
FAST-TRACK TARGET
>> Ninety per cent of sex workers have access to HIV combination
prevention services by 2020.
FAST FACTS
>> Female sex workers are 13.5 times more likely to be living with HIV than women
in the general population (1).
>> Female sex workers in Africa bear a heavy burden from the HIV epidemic. One
model suggests that 92% of all sex workers dying from AIDS-related causes
resided in sub-Saharan Africa (2).
>> According to UNAIDS data, more than half of all sex workers worldwide newly
infected with HIV live in sub-Saharan Africa. Asia and the Pacific, Latin
America and the Caribbean each account for about one fifth of the sex workers
newly infected.
>> Lack of political and financial commitment: sex worker programmes
often lack political support, resulting in low and inconsistent funding, and
inadequate scope and coverage of services.
>> Societal and legal barriers: criminalization, stigma and discrimination limit
the availability, access to and uptake of HIV, health and social services for sex
workers. Policies that enable condoms to be used as evidence of sex work
deter sex workers from carrying them.
>> Violence: sex workers are vulnerable to physical and sexual violence that
limits their ability, for example, to negotiate condom use.
>> Insufficient strategic information: qualitative and quantitative data on local
sex worker populations and programmes is often not available to inform the
development and implementation of HIV services that respond to the needs
of sex workers.
>> Adapting to change: the range of ways for sex workers and their clients to
connect is increasing as the trade adopts the use of mobile technology and
social media, requiring HIV and sexual and reproductive services for sex
workers to evolve as well.
UNAIDS
109
Sex workers should have the means to protect themselves from HIV. Although
condoms and lubricant are a well-established prevention tool for sex workers,
availability is low in most countries and sex workers remain at higher risk for
acquiring HIV in all regions. Extensive experience has demonstrated that condoms
and lubricant must not only be readily available in sufficient quantities, but that sex
workers must also be empowered to insist on their consistent use (3, 4).
High levels of intimidation, violence and discrimination from clients, third
parties, police officers and the larger community must be addressed.
Most sex workers are women. However, growing evidence indicates a sustained or
increasing burden of HIV infection among male sex workers in many countries
and regions. Male sex workers are at higher risk of acquiring HIV because HIV
is efficiently transmitted in unprotected anal intercourse and because they have
many sexual partners, large and complex sexual networks and compounded
intersecting types of stigma. Like female sex workers, efforts to reach male sex
workers with HIV services have been stymied by the criminalization of sex work
and HIV non-disclosure. Countries that criminalize same-sex practices create an
additional barrier (5).
Changing the legal and policy environment can empower sex workers to access
HIV and other health services, and to report violence and abuse. For example,
considering the possession of condoms as evidence of sex work is hampering
HIV prevention in many places. Modelling conducted across diverse settings has
estimated that addressing specific key societal factors such as violence, police
harassment, safer work environments and decriminalization could reduce the
number of female sex workers newly infected with HIV by 3346% during the
next decade (5). Reducing stigma and discrimination at the societal level may also
enable the health-care system to reach sex workers with sexual and reproductive
health services, including the prevention and treatment of HIV and other sexually
transmitted infections.
Achieving zero new HIV infections among young sex workers
in Ouagadougou
Following a steady decline in the number of people newly infected with HIV,
Burkina Faso has in recent years experienced a worrying resurgence in its
epidemic. Over a decade, the estimated number of people newly infected with
HIV increased by more than 50%, from 2800 [21003800] in 2004 to 4300
[31005900] in 2014 (6). The HIV epidemic is mostly concentrated among key
populations in major cities and towns, including the capital city Ouagadougou
and the second largest city, Bobo-Dioulasso.
In 2009, budget cuts led to a reduction exceeding 65% of HIV prevention services
in Ouagadougou (7), one of Africas most rapidly growing cities and home to
an estimated 35% of Burkina Fasos people living with HIV. Under these severe
resource constraints, local programme managers, researchers and community
groups managed a remarkable result within a pilot project of comprehensive HIV
services for sex workers.
Sex workers in Ouagadougou are young, on average 25 years old, and 32%
have little or no education. Half (50%) have at least one child. Most (72%) have
110
between two and five clients per day and a monthly income between US$70
and US$200. The HIV prevalence among sex workers in Ouagadougou is 13.5%
(9.618.7%). Only 6% belong to a community-based organization (8).
Amid these challenges, a highly effective HIV prevention programme for
sex workers has been established in Ouagadougou. Modelled on the Yerelon
(meaning know yourself in Dioula) sex worker programme established in
Bobo-Dioulasso since the early 2000s, initial efforts in Ouagadougou focused
on 321 young women aged 1825 years who were engaged in either full-time
street-based sex work or part-time sex work alongside jobs within bars and
markets (9).
The women were provided with a range of free sexual, reproductive and mental
health services, including general health and HIV care, HIV testing, treatment of
sexually transmitted infections and as many condoms as they required. Peer-led
education sessions covered condom demonstrations, sexual and reproductive
health issues and risk behaviour. Between September 2009 and September 2011,
the participants reported 88462 sexual encounters (9) and there were zero new
HIV infections among them. Complete prevention of new infections was related
to very high levels of reported consistent condom use with casual (98%) and
regular clients (91%) and a reduction in the number of regular partners and
clients (10).
Following the study, continued community support, volunteers, local
partnerships and external seed funding have enabled the programme to be
continued and 3000 to 4000 sex workers have accessed services through the
programmes in Bobo-Dioulasso and Ouagadougou since 2011. During the
first six months of 2015 alone, 1105 sex workers visited the two clinics, 363
have started antiretroviral therapy and 4478 sex workers were reached with
community outreach and peer-education services (11). Among the sex workers
enrolled in the study cohorts (547 in Bobo and 321 in Ouagadougou), there were
no new HIV infections during the 20112014 follow-up period (9).
The evidence from Ouagadougou and Bobo-Dioulasso shows that HIV
prevention services combined with sexual and reproductive health care tailored
to the needs of sex workers can reduce HIV incidence within this key population
to zero. Providing a full continuum of care was crucial to obtaining high levels of
consistent condom use among the sex workers. The strong partnership among the
sex worker community, researchers, health workers and community workers and
providing non-clinical support such as nutritional support and schooling for the
sex workers children have been important features of this effort.
Plans have been drafted to scale up the Yerelon programme and replicate it in
other locations where there is a high HIV burden among sex workers. Political
and financial commitment to Fast-Track this approach could have a tremendous
impact on sex workers across Burkina Faso and the region, bringing western
Africa closer to the goal of zero new HIV infections.
UNAIDS
111
Kenya using strategic information to bring sex worker programmes to scale
Reaching more female sex workers and reducing the number of sex workers
infected with HIV is one of the central planks of the Prevention Revolution
declared in Kenya in 2014. An estimated 29.3% of the more than 130000 sex
workers in this country in eastern Africa are living with HIV (12, 13).
Understanding the diverse forms of sex work and where to target HIV services
for sex workers is critical to carrying out a 20142019 national strategy to put
Kenya on track to reaching zero new HIV infections by 2030. Mapping was
conducted across the country to inform the expansion of services. Interviews
with female sex workers, clients and other key informants identified 10670
locations where sex workers interact with clients within cities and other urban
areas. The locations included a range of venues, such as bars, massage parlours,
street sides, homes and truck stops. Nearly one quarter of the population were
in the capital city, Nairobi, followed by the Coast and Nyanza provinces. The
mapping also identified different types of sex workers in Kenya including venuebased, street-based and home-based (Figure 31) (14).
The mapping was used by the key population working group of Kenyas
National AIDS and STI Control Programme, which includes key population
representatives, to inform the development and implementation of sex worker
programmes that are focusing client-centred, community-supported services
to different types of sex workers in the locations of greatest need. In 2012, a
Figure 31
Distribution of female sex workers in Kenya by type of sex work

100%
6%
90%
80%
70%
59%
54%
40%
6%
5%
30%
4%
60%
49%
61%
56%
58%
3%
4%
3%
5%
19%
22%
16%
16%
Western
Rift Valley
88%
50%
20%
30%
10%
0%
5%
4%
5%
37%
35%
27%
7%
Nairobi
Street
Home
Road (truck stop)
Coast
Central
Eastern
Nyanza
Sex den
Venue
Escort
Massage parlour
Sources: Odek WO, Githuka GN, Avery L, Njoroge PK, Kasonde L, Gorgens M et al. Estimating the size of the female sex
worker population in Kenya to Inform HIV prevention programming. PLoS ONE. 2014;9: e89180.
112
national key population programme monitoring system was established that

monitors more than 40 output and outcome indicators, capturing biomedical,
behavioural and structural indicators from 82 key population programmes
across Kenya. Recent data from the system show that the number of condoms
distributed to sex workers has increased from an average of 16 per month in 2013
to 37 per month in March 2015. The proportion of cases of violence against sex
workers that has been addressed has nearly doubled, increasing from 38% in July
2013 to 72% in March 2015 (15). The number of sex workers attending clinics and
being screened for sexually transmitted infections also increased. Most dramatic
has been the reduction in the incidence of sexually transmitted infections, from
27% among those screened in 2013 to just 3% in 2015 (15).
Sex worker-led collection of strategic information and advocacy
drives scale-up in Namibia
For many years, tailored HIV programming for sex workers in Namibia was
hindered by a lack of strategic data and a restrictive policy environment. Sex
worker participation in programme planning and decision-making was also poor.
During the past several years, however, substantial progress has been made in
Namibia to build the evidence base on sex work and HIV, strengthen political
commitment and increase resource allocation.
Between 2011 and 2013, sex worker-led participatory assessments were
conducted in five towns identified as key locations for sex work in Namibia. A
decentralized, bottom-up approach was used. Sex workers led and documented
29 focus-group sessions with 212 sex workers on such issues as their safety at
work, their health, their interaction with people in the wider community and
their access to health services. These sessions revealed widespread physical
and sexual violence, including from law enforcement officers. Sex workers also
reported stigma and discrimination when accessing health services (16, 17).
The findings were presented at a national meeting co-organized by sex workers
(18), which helped convince the Government of Namibia and partners to improve
and scale up sex worker-focused programming with the support of the Global
Fund to Fight AIDS, Tuberculosis and Malaria and the United States Presidents
Emergency Fund for AIDS Relief (PEPFAR) (19). Stronger inclusion of sex
worker programmes in Namibias national HIV strategy are a direct result of sex
worker-led qualitative research and the participation of sex workers in policy
processes (20).
Since then, HIV services for sex workers have been expanded, including peer
education, condom and lubricant promotion and distribution, mobile HIV
counselling and treatment, treatment of sexually transmitted infections and
referral services. The number of condoms distributed to sex workers more than
doubled between 2012 and 2014, from 325 000 to 725 000. The number of sex
workers who accessed HIV testing increased sixfold in 2014, with 14 000 sex
workers tested compared to 2200 in 2013. Those found to be living with HIV
were linked to care and treatment. Additional emphasis has been placed on
sensitizing local police to reduce harassment and violence towards sex workers
(21, 22). In 2015, the capacity and representation of sex worker organizations has
been strengthened. A sex worker network has been established, and a sex worker
UNAIDS
113
organization is included within Namibias Country Coordinating Mechanism for

Global Fund resources.
Namibias progress in scaling up HIV services for sex workers demonstrates
how grass-roots advocacy can inform and influence policy change and increase
investment in the HIV response.
Empowerment through engagement in Karnataka, India
Karnataka, located in south-western India, is the eighth-largest state in the

country and a major science and technology hub (23, 24). There are estimated to
be more than 100000 female sex workers in Karnataka, mostly street- or homebased, with HIV prevalence as high as 25% in some districts (2528). Sex worker
community leaders in Karnataka are playing an influential role in bringing HIV
services to these women.
Social and community services have been steadily incorporated into ongoing
female sex worker programmes during the past decade. Sex workers, including
those living with HIV, were trained to represent their communities at district
AIDS committee meetings. In this capacity, sex workers worked alongside
district development department heads and chiefs of police to strengthen HIV
prevention and care activities. At the same time, community-based and sex
worker-owned organizations were created, and elected representatives from these
groups oversaw the management of HIV prevention programmes.
Sex workers also helped to develop and lead sensitization and educational
workshops on the role of sex work in local HIV epidemics and the societal
barriers preventing sex workers from accessing services. These two-day
workshops were mandatory for government and police department heads (29).
As a result, female sex worker membership in community-based organizations
notably increased, and more than 46000 female sex workers were enrolled to
receive government-sponsored social entitlements. Female sex workers were also
supported to redress more than 90% of 4600 incidents of violence and harassment
reported between 2007 and 2009 (29).
Community engagement has been a powerful force to empower sex workers
and reduce societal barriers to HIV services. There have also been changes in
behaviour and sexual health. Female sex workers with stronger participation
in community mobilization activities were more likely to have been tested for
HIV and to have used a condom with clients and regular partners than female
114
sex workers who had lower participation (30). They were also less likely to test
positive for gonorrhoea or chlamydia (30).
Zero new infections among sex workers can be achieved. Providing a full
continuum of HIV prevention, treatment and care service in a stigma-free
environment complemented by community outreach and peer support is crucial
to obtaining very high levels of service adherence and consistent condom use
among sex workers. However, insufficient investment in comprehensive HIV and
health services for sex workers constrains the HIV response globally, especially in
sub-Saharan Africa.
The individual and community empowerment of sex workers is critical for
providing effective services. Sex workers direct input into collecting more and
better data and developing and delivering programmes can inform where and
how to Fast-Track HIV services in order to enhance their effectiveness and ensure
that they are rights-based. Continuous programme performance monitoring and
regular review by service providers and community members is critical to inform
optimization of service delivery and scale up.
Mobile technology is changing the sex trade, and HIV responses must also adapt.
Just as sex workers can discretely use smartphones to contact a wide network of
clients, HIV programmes must use mobile technology to reach sex workers who
do not meet clients on street corners or in brothels (31).
Male sex workers are also at higher risk of HIV. Evidence-informed and human
rights-affirming services dedicated specifically to male sex workers are needed
to improve health outcomes for these men and the people within their sexual
networks (32).
Scaling up health and HIV services for sex workers will ultimately fail to achieve
the scale required to end the AIDS epidemic unless societal and community
factorssuch as criminalization, violence, stigma and discriminationare
squarely addressed alongside with sex worker community empowerment and
mobilization. Structural interventions are crucial to enacting more supportive
laws and policies, giving sex worker communities more opportunities to
support and mobilize themselves, and reducing inequalities related to gender,
race and unemployment.
UNAIDS
115
Prisoners
Every year, 30 million people (1) spend time in prisons or other closed settings,1
with more than 10.2 million incarcerated at any given time (2), including 700000
women (3) and more than 14 million held because of arbitrary and excessive use
of pre-trial detention (4).
Figure 32
HIV prevalence among people who inject drugs in prisons and other closed settings,
Islamic Republic of Iran, 20012008
During the first decade of the Islamic Republic of Irans HIV surveillance, surveys among people who inject drugs while detained in jail or incarcerated in prison were common. Prevalence was generally high,
with some of the lower prevalence sites attributable to inclusion of people who used drugs but did not
inject them. Irans response to these data was the creation of triangular clinics, offering harm reduction
services in the prison system.
Sources: Azarkar Z, Sharifzadeh G. Evaluation of the prevalence of hepatitis B, hepatitis C, and HIV in inmates with drug-related
convictions in Birjand, Iran in 2008. Hepat Mon. 2010;10(1): 2630. | Davoodian P, Dadvand H et al. Prevalence of selected sexually
and blood-borne infections in Injecting drug abuser inmates of Bandar, Abbas and Roodan correction facilities, Iran, 2002. Braz J
Infect Dis. 2009;13(5): 356358. | Ilami O, Sarkari B et al. HIV seroprevalence among high-risk groups in Kohgiloyeh and Boyerahmad
Province, Southwest of Iran, a behavioral surveillance survey. AIDS Behav. 2012;16(1): 8690. | Jahani MR, Kheirandish P et al. HIV
seroconversion among injection drug users in detention, Tehran, Iran. AIDS. 2009;2300923(4): 538540. | Moradi AR, Emdadi A et al.
Prevalence of Human Immunodeficiency Virus infection among injection drug users released from jail. Addict Health. 2012;4(34):
151155. | Rahimi-Movaghar A, Amin-Esmaeili M et al. HIV prevalence amongst injecting drug users in Iran: a systematic review of
studies conducted during the decade 1998-2007. Int J Drug Policy, 2012;23(4): 271278.
1. The term prisons and other closed settings refers to all places of detention within a country, and the terms prisoners and
detainees refers to all those detained in those places, including adults and juveniles, during the investigation of a crime, while awaiting
trial, after conviction, before sentencing and after sentencing.
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FAST-TRACK TARGET
>> Ninety per cent of prisoners have access to HIV combination prevention services.
FAST FACTS
>> At any given time, about 10.2 million people are being held in prison
settings globally (2).
>> Key populations at increased risk of acquiring HIVsuch as people who inject
drugs, men who have sex with men, transgender people and sex workersare
overrepresented in the prison population because their sexual orientation,
gender expression, occupation or behaviour is criminalized (5).
>> Making opioid substitution therapy and needles and syringes available in prisons
can reduce needle sharing by up to 75% (6).
>> Overcrowding: a total of 113 countries have prison occupancy exceeding
100%, including 22 with occupancy exceeding 200% (7). Overcrowding
exacerbates breakdowns in service infrastructure, the risk of violence and
abuse, tuberculosis (TB) risks and poor nutrition.
>> Violence and unsafe behaviour: widespread and underreported violence,
including sexual violence, and unsafe practices such as sharing injecting
equipment, lead to the transmission of HIV and hepatitis C within prisons.
>> Lack of access to basic health services: lack of commitment and budgets,
poor coordination between the justice and health sectors and misplaced
security concerns curtail access of people in prisons and other closed settings
to health services, violating their right to health.
>> Human rights violations, stigma and discrimination: people in prisons
face a multitude of human rights violations, with the most vulnerable
peoplegay and other men who have sex with men, transgender
people and young peoplemost severely affected and having the
highest disease prevalence rates.
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Prisons have higher prevalence of HIV infection, hepatitis B and C and TB, as
well as elevated risks for contracting such diseases and reduced access to health
services. The HIV prevalence in prisons and other closed settings is 210 times,
and in rare cases up to 50 times, higher than in the general population (8). TB
incidence rates are an average 23 times higher than in the general population
(9), and TB drug resistance rates and TB-related death rates are higher (10). The
prevalence of hepatitis C is far higher among people held in prison, especially
among those with a history of injecting drug use (11).
Prisoners predominantly comprise men aged 1935 years old (12), a segment
of the population that is at higher risk of HIV infection before entering prison.
People living with HIV and other key populations at higher risk of HIV, such as
people who inject drugs, men who have sex with men, transgender people and
sex workers, are overrepresented in the prison population. An estimated 5690%
of people who inject drugs will be incarcerated at some stage, and people who use
or inject drugs may comprise up to 50% of the population in closed settings (2).
Estimates indicate that one third of prisoners have used a drug at least once while
incarcerated (13).
These high incarceration rates stem from inappropriate, ineffective or excessive
national laws and criminal justice policies, such as overly broad criminalization
of HIV transmission, drug use, same-sex sexual relations, cross-dressing and
sex work (14). Reforming such punitive laws leads to public health benefits in
addition to upholding human rights. Decriminalizing personal use quantities of
illicit drugs has been linked to a reduction in HIV prevalence in prisons in the
Netherlands, Portugal and Switzerland (15).
All modes of HIV transmission occurring in the general, free population also
occur in prisons: the sharing of unsafe injecting equipment among people who
inject drugs (16); consensual or coerced unsafe sexual practices, including rape
(16); unsafe skin piercing and tattooing practices; sharing shaving razors; blood
brotherhood rituals (17); and improperly sterilizing or reusing medical or dental
instruments (18). Similar to in the community, HIV may also be transmitted
in prisons from mothers living with HIV to their infants during pregnancy
or delivery (18). Lack of access to condoms and sterile injecting equipment,
overcrowding and high levels of violence and abuse exacerbate the risk of
acquiring HIV.
Sexual violence and unsafe sexual practices are common in prisons. The actual
prevalence of sexual activity is likely to be much higher than reported, mainly
because of denial, fear of stigma and homophobia, and the criminalization of
sex between men in many countries (12). About 25% of prisoners suffer violence
each year, around 45% experience sexual violence and 12% are raped (19, 20).
Violence is more common in overcrowded prison facilities (21).
Virtually all prisoners return to their communities, many within a few months to
a year. Health in prisons and other closed settings is thus closely connected to the
health of the wider society, especially in relation to communicable diseases.
Health care in prison settings is typically limited and usually fails to reach the
level and quality available in the community. These shortcomings stem from
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budgetary constraints along with legal and policy barriers and limited political
will to invest in prisoners health (22). Treatment retention and adherence are
often jeopardized when people living with HIV are arrested and/or incarcerated.
In addition, services are often disrupted during institutional transfer and after
release from prison (23). Failure to provide people in prisons and other closed
settings with the necessary health care amounts to inhumane and degrading
treatment in violation of their human rights.2
Opioid substitution therapy, a proven HIV prevention approach for prisoners
who inject drugs, was available in prisons in only 43 countries in 2014. Globally,
only eight countries in 2014 implemented needle and syringe programmes in
prisons, all in Europe and central Asia. Worryingly, few countries or territories
supply condoms to incarcerated people, despite the low cost and the relative ease
of implementing condom distribution programmes (24).
People in prisons and other closed settings do not forego their human rights
while in detention, including their right to the highest attainable standard of
health. Strong evidence indicates that a comprehensive package of 15 services,
when applied holistically, has the greatest impact on upholding the highest
attainable standard of health for people in prisons and other closed settings:
(1) information, education and communication; (2) voluntary HIV testing and
counselling; (3) HIV treatment, care and support; (4) prevention, diagnosis
and treatment of TB; (5) prevention of mother-to-child transmission of HIV;
(6) condom programmes; (7) prevention and treatment of sexually transmitted
infections; (8) prevention of sexual violence; (9) drug dependence treatment; (10)
needle and syringe programmes; (11) vaccination, diagnosis and treatment of
viral hepatitis; (12) post-exposure prophylaxis; (13) prevention of transmission
through medical or dental services; (14) prevention of transmission through
tattooing, piercing and other forms of skin penetration; and (15) protecting
personnel from occupational hazards (25). Recent World Health Organization
guidelines also recommend pre-exposure prophylaxis for people at substantial
risk, which is likely to include prisoners in many countries.
Triangular clinics in prisons in the Islamic Republic of Iran providing HIV services, harm reduction and treatment of sexually transmitted infections
The HIV epidemic in the Islamic Republic of Iran is mainly concentrated among
people who inject drugs, and the government has expressed concern that an
uncontrolled epidemic among this key population may spill over into the general
population (26). Since the vast majority (94%) of people who inject drugs will
likely be incarcerated at some point in their lifetime, prisons present both a highrisk environment for HIV transmission and an opportunity to shape attitudes
towards harm reduction and encourage less risky behaviour (27). On average, 3%
of prisoners in the Islamic Republic of Iran are living with HIV, and according
to 2009 data from 27 Iranian prisons, 8% of prisoners have a history of injecting
drug use (28, 29).
2. See M.S. v. Russia, 10 July 2014, ECtHR, Application no. 8589/08; Reshetnyak v. Russia, 8 January 2013, ECtHR, Application no.
56027/10; Logvinenko v. Ukraine, 14.10.10, ECtHR, Application no. 13448/07; Plata v. Brown, C-01-1351 THE (N.D. Cal.) 23 July 2015,
California, United States.
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In the early 2000s, the Islamic Republic of Iran pioneered the introduction
of triangular clinics, which integrate services for harm reduction, treatment
of sexually transmitted infections and HIV care and support. In both the
community and in prisons in the Islamic Republic of Iran, triangular clinics are
now at the heart of the harm reduction programme.
In 20022003, only one prison provided methadone maintenance therapy for
opioid-dependent prisoners, covering just 100 prisoners. By 2009, 142 prisons
across all 30 provinces offered this vital harm reduction service, with more than
25000 prisoners being treated (28). One such prison is Rajaee Shahr, located in
Karaj, about 70 km north-west of Tehran, the capital. With 3200 inmates, Rajaee
Shahr is one of the most crowded and challenging prison environments in the
Islamic Republic of Iran.
The triangular clinic at the prison provides HIV counselling and testing, as well
as diagnosis of TB, hepatitis and sexually transmitted infections. It offers harm
reduction for injecting drug use, including methadone maintenance therapy and
needle and syringe exchange, as well as condom distribution and education about
HIV and sexually transmitted infections.
A recent analysis of the prisons triangular clinic services found that access to
these services positively changed knowledge and attitudes and modestly reduced
high-risk practices (27). However, the evaluation indicated that, although
triangular clinics are a good starting-point for harm reduction in prisons,
sustained efforts are needed to change long-standing habits and attitudes among
this population.
Reaching men who have sex with men in prisons in Ukraine
Among Ukraines prison population, homophobia drives maltreatment of men

who have sex with men. They are assigned to do the lowest-status and dirtiest
jobs in the prison and discriminated against by both fellow inmates and prison
staff. Under such harsh circumstances, they are especially vulnerable to acquiring
HIV. The Penitentiary Initiative, which has been providing HIV treatment, care
and support for inmates living with HIV in Ukraine since 2001, recognized
that men who have sex with men were not being reached. In 2008, the Initiative
partnered with the Nikolaev Association for Gays, Lesbians and Bisexuals to
develop an outreach model to reach incarcerated men who have sex with men
with services and to change the homophobic and stigmatizing attitudes of prison
staff members (30, 31).
The outreach model was implemented in four prisons in the Nikolaev region,
Lugansk and Cherkassy and in five prisons of the Donetsk, Kharkiv, Herson,
regions of Ukraine. Outreach teams look for allies within prisons to collaborate
with, such as a head of prison psychological services who invited outcast
prisoners to his office to meet project psychologists and establish support groups
for men who have sex with men and people living with HIV. Prison
staff members are also sensitized through seminars on men who have sex with
men (31).
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The programme brought both practical and psychological support to the men
who have sex with men in the prison. They were supplied not only with HIV
prevention kits containing condoms and lubricant, but also with supplementary
food rations and personal hygiene supplies, as well as rubber gloves and cleaning
materials for those forced to do the dirtiest jobs. The outreach workers were
able to overcome both the mistrust between counsellors and prisoners and the
pervasive stigma and homophobia; they also established peer support groups for
men who have sex with men. These support groups of between 14 and 17 men,
which are facilitated by a psychologist, enable inmates to participate in health
education programmes, learn more about their rights, boost their self-esteem and
overcome emotional stress. Upon release from prison, inmates are linked to social
support and outreach programmes offered by the Nikolaev Association for Gays,
Lesbians and Bisexuals, as well as referral to health services that are friendly to
men who have sex with men (31).
The project has also drawn wider attention to the issue of HIV among men
who have sex with men in prisons and helped to overcome their exclusion from
prison social life. The success of the Penitentiary Initiative in the four prisons
encouraged the organization to develop materials on HIV among men who
have sex with men, which are offered as a basic package of HIV services in other
Ukrainian prisons.
Peer outreach brings HIV services to prisoners in Ghana
A combination of peer education and outreach, providing simple personal

hygiene supplies and advocacy dialogue with prison staff, has transformed HIV
prevention and testing in Ghanas prisons.
Implemented by the Planned Parenthood Association of Ghana, a
nongovernmental organization that has been working on HIV prevention within
the prison system since 2001, the project was implemented in 35 of the 43 prisons
in Ghana from 2010 to 2014 through funding from the Global Fund to Fight AIDS,
Tuberculosis and Malaria. In 2015 it was expanded to cover all 43 prisons (32).
Training and supporting peer educators is a key part of the approach. Inmates
who are literate, have good communication skills, can maintain confidentiality
and have a strong spirit of volunteerism are selected as peer educators. The peer
educators undergo five days of training in HIV prevention, including training
on stigma and discrimination, sexually transmitted infections, sexual and
gender-based violence and facilitation skills. They receive training manuals and
communication materials, as well as branded T-shirts and bags, which act as cues
to generate discussion about HIV with their peers (32).
The peer educators run film sessions and drama performances on HIV-related
issues and distribute educational materials. Confidential HIV testing and
counselling are provided during quarterly outreach sessions, with referrals to
antiretroviral therapy, care and support services in government health facilities
close to the prison (32).
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Dialogue with prison officers to ensure that the peer educators work in a
conducive and enabling environment has been critical to the programmes
success. In 2014, the programme reached 218597 prisoners with HIV prevention
programmes, almost twice the number reached in 2013. The programme also
reached 248 prison officers with advocacy sessions (in addition to the 314 reached
in the previous year). Nearly 30000 prisoners received counselling and testing for
HIV in 2014, and 228 tested positive and were referred for treatment.
In addition to being expanded to all 43 prisons in 2015, this intervention has
been integrated with TB programmes. The Planned Parenthood Association of
Ghana collaborated with the National Tuberculosis Control Programme of the
Ghana Health Services to add a TB component to its HIV prevention work.
Republic of Moldovas comprehensive package of services reduces incidence
of communicable diseases
The Republic of Moldova is one of the few countries in the world in which nearly
all the 15 services that constitute the comprehensive packages of services of the
United Nations Office on Drugs and Crime (UNODC) are available in some
prisons (33).
Condoms, HIV counselling and testing and antiretroviral therapy are available
in 17 prisons. Needle and syringe and condom distribution programmes were
initiated in 1999, and in 2014, the average number distributed annually reached
90000 syringes and 35000 condoms. Most are distributed through indirect
methods, such as peer outreach, which improves confidentiality. Volunteers
selected among the prisoners are trained to provide peer-to-peer services and
remunerated with monthly food packages (33, 34). Needle and syringe sites
and volunteers also distribute alcohol swabs, antiseptic and anti-inflammatory
items and information and education materials. Opioid substitution therapy has
been provided since 2005. Civil society organizations carry out HIV counselling
and testing in partnership with the prison health service of the Department for
Penitentiary Institutions of the Ministry of Justice (35).
HIV prevalence in prisons declined from 4.2% in 2007 to 1.6% in 2013. Coverage
of antiretroviral therapy increased from 2% in 2005 to 62% in 2013. Deaths
among people living with HIV in prisons fell by nearly two thirds, from 23% in
2007 to 9% in 2013. The prevalence of hepatitis C decreased from 21% in 2007
(35) to 4.6% in 2015 (36). The incidence of TB among inmates declined fourfold:
from 550 cases in 2006 to 127 cases in 2013. In 2001, 10% (1100) of all inmates
had TB. The prevalence dropped to 2% (152 inmates) in 2013 and 1.3% (101
inmates) in 2015.
These successful models of comprehensive HIV and harm reduction in prisons

show that prisoners will access services when they are provided appropriately.
Evidence shows that prisoners will take up HIV counselling and testing if it is
made easily available, is voluntary and test results are kept confidential, whereas
mandatory testing is not only unethical but also costly and can have negative
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health effects on prisoners found to be living with HIV, especially if they are
segregated from other prisoners as a result of their HIV status (37).
Research has shown that making condoms available in prison reduces HIV
transmission and does not lead to increased sexual activity (3840). To address
the HIV risk associated with illicit drug use in prisons, opioid substitution
therapy has been shown to substantially reduce injecting drug use (by 5575%)
and needle sharing (by 4775%) (41). Needle and syringe programmes have been
proven feasible in prison settings and effective in reducing both unsafe needle
sharing and HIV transmission without increasing injecting drug use (42, 43).
Studies have found that adherence to HIV treatment is at least as high in prisons
as it is in the wider community. In fact, prisons can be an entry point to HIV care
for marginalized populations (44). However, adherence requires confidentiality
and positive relationships between prison staff and inmates (37).
If strategies are in place to ensure continuity of care for prisoners returning
to the community, comprehensive HIV service provision in prisons can have
long-term effects on the health of former prisoners (37). Providing naloxone to
prevent deaths from overdose after release is another important continuity of care
programme that can save lives (45).
Bringing the HIV responseprevention, care and treatmentto closed settings
is a cost-effective way of offering HIV services. It is also a human right. Prison
inmates have the same rights to health care as the wider community. This can be
a hard sell politically, creating challenges in securing adequate funding for HIV
prevention, treatment and care. Nevertheless, with the right services and proper
referral to care on release, closed settings can present an invaluable opportunity
to offer effective high-quality HIV services to populations at increased risk of
acquiring HIV and contribute towards ending the AIDS epidemic as a public
health threat.
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Conclusion
The first World AIDS Day was observed in 1988 to help mobilize the world
against the rapid spread of a deadly virus that had neither an effective treatment
nor a cure. Twenty-seven years later, the largest-ever global disease response has
not only achieved unprecedented resultsit has brought ending AIDS as a public
health threat within our reach.
The path to reach this goal is not an easy one. Maintaining the current level of
HIV services would allow the virus to regain the initiative; instead, a smarter,
accelerated Fast-Track must be taken. As the programmes described in this report
demonstrate, Fast-Track is not a slick slogan; it is a methodical and practical way
of working that delivers results.
Locationpopulation approach
The first step of Fast-Track is to use a locationpopulation approach to focus

resources on evidence-informed, high-impact programmes in the geographical
areas and among the populations in greatest need.
This approach has been firmly established through decades of experience.
Evidence-informed, high-impact programmes include condoms, voluntary
medical male circumcision and pre-exposure prophylaxis. They are powerful
tools for the prevention of the sexual transmission of HIV. Sterile injecting
equipment and opioid substitution therapy greatly reduce new infections among
people who inject drugs. HIV testing is the entry point for care and treatment,
and innovations like saliva-based test kits are making diagnosing HIV both
quicker and easier. Antiretroviral therapy is essential to ensuring healthy lives for
people living with HIV and for greatly reducing the chance of transmitting the
virus to others.
The populations in greatest need of HIV treatment are all children, adolescents
and adults living with HIV. The World Health Organizations latest HIV treatment
guidelines are straightforward: treat everyone upon diagnosis, regardless of their
clinical stage or CD4 count. The populations in greatest need of HIV prevention
are those at higher risk exposure: key populations who are too often left behind,
including adolescent girls and young women in high-prevalence settings, gay
men and other men who have sex with men, transgender people, people who
inject drugs, prisoners and sex workers.
The locations in greatest need are where the HIV epidemic is highly concentrated
and where services are lacking. Part 2 of this report presents maps of data from
the first and second subnational administrative level for 29 of the 35 Fast-Track
priority countries, which together account for 90% of the total burden of new
HIV infections globally. These maps reveal the rates of new infections, numbers
of key populations and gaps in the coverage of testing and antiretroviral therapy.
124
These data are being used by programme managers to address gaps and maximize
the use of available resources.
A location-population approach includes the rapid adoption of innovations that
make services simpler, easier and more effective. Eastern and southern Africas
scale-up of voluntary medical male circumcision is a case in point, with over
9 million medical circumcisions performed in the priority countries in just a
few years. The development of new non-surgical circumcision procedures and
increased engagement of the private sector can drive even greater success in the
future. Swift embrace of pre-exposure prophylaxis will reap similar rewards, as
will the continued shifting of tasks to the community level, including communitybased HIV counselling, testing and self-testing. Expanding viral load tests and
the continued refinement of antiretroviral medicines will keep more people living
with HIV healthy and help prevent new HIV infections. For example, the United
States of Americas Federal Drug Administration recently approved oral pellets
of a paediatric antiretroviral formulation that can be mixed into a childs food.
The treatment is heat-stable and more palatable than medicines that are currently
available, making it particularly suitable for treating very young children (1).
A location-population approach also includes addressing the underlying
dynamics that create vulnerabilities and block service uptake among key
populations. Young women and girls must be able to live free of the threat of
violence, and they must be empowered to make decisions about their own health
and future. Health-care systems must guarantee the right to health of all people,
regardless of their personal behaviour. Sex workers, gay men and other men
who have sex with men, and people who inject drugs must be able to consult a
doctor or receive the care of a nurse without fear of stigma or the threat of arrest.
Legal and policy reform is required to address social stigma, discrimination and
criminalization of same-sex sexual relations, sex work and recreational drug use,
as well as the overly broad criminalization of the non-disclosure of HIV status
and the exposure to (or transmission of) HIV.
Quickening the pace
The second step of Fast-Track is to quicken the pace.

In dozens of countries, investment cases and other efficiency analyses of the
HIV response have drawn up blueprints for success. The pace of change, however,
has been slow. National and local leaders need to seize the moment and make
tough choices to adopt the recommendations of their investment cases, relocating
resources away from areas and services where there is little to be achieved and
investing additional resources in priority areas and populations to achieve longterm gains.
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The front-loading of investment is required to achieve the momentum needed

to end the AIDS epidemic. In an optimized response, greater expenditure in the
short term reaps rewards over the long term: fewer HIV infections today mean
lower treatment costs tomorrow. Lower rates of illness and death translate into
macroeconomic gainsand the benefits of social transformation extend far
beyond measurements that can be made using health and economic indicators.
Moving forward at the global, national and local levels
The UNAIDS 20162021 Strategy sets a global agenda to take advantage of

a narrow window of opportunity. The content of the strategy is informed by
lessons learned by early adopters of Fast-Track at the national and local levels,
including front-loading investments, focusing on the locations, populations and
programmes that will deliver the greatest impact, catalysing innovation for people
who need it most and ensuring the meaningful involvement of people living with
HIV and populations at higher risk of HIV infection.
The UNAIDS Strategy defines what needs to be done, setting 10 targets that
must be met by 2020. These targets call for high coverage of the most important
services for the people at greatest need. The Fast-Track examples in this report
prove that these targets can be achieved through a location- and populationfocused approach. Expanding this approach through renewed commitment and
perseverance will help us end the AIDS epidemic.
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T H E L A R G E S T- E V E R G L O B A L
D I S E A S E R E S P O N S E H A S N O T O N LY
ACHIEVED UNPRECEDENTED
R E S U LT S I T H A S P U T T H E E N D O F
T H E A I D S A S A P U B L I C H E A LT H
T H R E AT W I T H I N O U R R E A C H .
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128
Part
02
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129
Where services are needed
Part 2 of this report presents data on HIV epidemics and the number of people
who need HIV services within maps of 29 of the 35 Fast-Track priority countries
that account for 90% of the people newly infected with HIV worldwide. These
data are disaggregated by the first and sometimes second administrative levels,
highlighting the heterogeneity of countries HIV epidemics and variation in
service coverage.
The variables shown in these maps include the following.
>> The number of adolescent girls and young women (1524 years old) who
were newly infected with HIV in 2014. Young women focus in these maps
because they comprise a disproportionate share of the people newly infected
with HIV in many Fast-Track priority countries. The data are estimates
developed by subnational models. In a few cases (Malawi, Mozambique,
Namibia and Swaziland), data on women 1549 years old were used because
data for women 1524 years old were not available. For Botswana, the number
of women newly infected in this age group was not available, and the HIV
prevalence among women 1524 years old is therefore presented.
>> The number of people (both adults and children) living with HIV who are
not receiving antiretroviral therapy. When possible, treatment coverage data
for mid-2015 have been used. Countries submitted the number of people
receiving antiretroviral therapy by province or region in the Global AIDS
Response Progress Reporting in mid-2015. The numbers of people living with
HIV are subnational estimates modelled by countries in 2015.
>> The number of adults (15-49 years old) living with HIV who have never been
tested. The calculations for these maps are derived from household surveys
in which respondents are tested for HIV but are not provided with the survey
test results. In the same survey, they also report having never been tested
for HIV. Where these data are available, they show an interesting pattern
of where additional testing is needed. The proportion of people living with
HIV who have never been tested comes from the household survey and
the number of people living with HIV (1549 years old) is derived from
subnational HIV estimates.
130
>> The percentage of the general adult population (1549 years old) with
discriminatory attitudes toward people living with HIV. The variable is
defined as the percentage of adults 1549 years old who state no to the
following question: Would you buy fresh vegetables from a shopkeeper
or vendor if you knew that this person had the AIDS virus? Where this
percentage is high, more information, education and communication efforts
are needed.
>> Population size estimates and HIV prevalence estimates for key populations.
Many countries have sparse data on key populations. The lack of data
identifies areas in which data collection efforts are needed. The key population
maps show two data points when available. The colour of the regions identifies
the estimated size of the key population. The number written above the region
is the estimated prevalence for the key population in that region.
The maps provide a quick overview of the information HIV programme
managers can use to focus their response on the geographical areas in greatest
need. Each map includes a short text of background information.
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Botswana
Overview
Geographically, the Kgalagadi Desert covers about 70% of the area of

Botswana, with most of the population being located in the northern
and eastern parts of the country. This is also the location of the cities,
Gaborone and Francistown. HIV has spread primarily along the eastern
corridor, which has the countrys busiest roads and trucking routes; it thus
remains clustered in the northern and eastern parts of the country. With
a relatively good transport system and roads, the population is highly
mobile, and there is therefore no significant disparity between urban and
rural areas in HIV prevalence.
The epidemic in Botswana is dynamic and heterogeneous, affecting
different subpopulations and locations differently. There is a strong
gender disparity in HIV prevalence. The age group with highest HIV
prevalence is 3539 years old at 44%; the prevalence is even higher
among women in this age group: 51%. The burden of disease is more
concentrated in the northern parts of the country than in the southern
parts. The HIV prevalence ranges from 11% in Kgalagadi South to 27% in
Selebi-Phikwe, a mining town in the eastern part of the country.
Progress
Important achievements have been made in reducing the number of

people newly infected with HIV in Botswana by providing such services
as HIV testing and counselling, safe male circumcision, services for
preventing mother-to-child transmission and antiretroviral therapy for
those eligible for HIV treatment. In its latest proposal for the Global Fund
to Fight AIDS, Tuberculosis and Malaria and Country Operational Plan of
the United States Presidents Emergency Plan for AIDS Relief (PEPFAR),
Botswana incorporated the geographical disparity in the HIV epidemic to
adjust the services and resources appropriately.
Botswana has made significant progress in preventing mother-to-child
transmission. A successful treatment programme has resulted in the
number of people dying from AIDS-related causes declining by about
70% in the past 10 years.
Opportunities
With the available new evidence, the country is in the process of moving
towards a treat all policy, and this could greatly enhance the Fast-Track
move towards achieving the 909090 treatment target.
The need for services is clustered near the capital city and other major
cities, enabling cost efficiency in reaching people living with HIV
treatment services and key populations with prevention services.
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Special attention needs to be paid to prevention programmes for

adolescents and young adults. Programmes should be designed to help
these people understand their risk of HIV infection. Initiatives are in place
to strengthen the adolescent and youth component of HIV programmes
through assessments that determine who is most affected, where and
what specific interventions are required to reach them. Comprehensive
sexuality education, condom programming for youth and providing
youth-friendly services have been identified as key gaps in youth
programming.
Botswana map 1
HIV prevalence among women (2024 years old), 2013
The overall HIV prevalence among women 2024 years old (16%) is three times
higher than among men in the same age group (5%). Eight districts had HIV
prevalence rates exceeding 20% for all women, but no districts had a prevalence
rate exceeding 20% for men. The high-prevalence districts for this age group
include three mining town areas and one tourist town, and the rest are situated
HIVtheprevalence
among female 20-24, 2012
along
eastern corridor.
Source: 2012 Botswana AIDS impact survey.
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133
Brazil
Overview
Most of the population of Brazil is located on the east coast of the

country, with major cities located in the south-east. The HIV epidemic
is currently considered to be stable in Brazil, based on the relatively
constant detection rate of around 20 people newly infected
per 100 000 population during the past five years. However, the
incidence varies between states. To address the regional disparities,
the Department of STI, AIDS and Viral Hepatitis is focusing specific
action and policies on these regions through a task force approach
involving civil society and the three levels of government: federal,
state and municipal.
Progress
Brazil was one of the first countries to implement the treat all strategy of
providing antiretroviral therapy to all people living with HIV regardless
of CD4 count. Health-related scientific progress is most effective when
guided by respect for human rights and combating prejudice and
discrimination. Brazil has adopted a zero-discrimination strategy by
enacting a law that criminalizes discriminatory conduct towards people
living with HIV.
Opportunities
Brazil has a strong commitment to reaching the 909090 treatment

target by strengthening and expanding combination prevention
strategies and reducing the gaps in the HIV continuum of care. Specific
plans include: reducing the number of people living with HIV who have
not started antiretroviral therapy; implementing new forms of diagnosis
and treatment, including shared HIV management in primary care and
scaling up the availability of high-quality health services; and committing
all segments of Brazilian society to remove social and cultural barriers to
ensure that the most vulnerable groups have access to health services.
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Brazil map 1
Number of people living with HIV who know their status and are not receiving
antiretroviral therapy, 2014
The largest numbers of people living with HIV who know their status are in the
south-eastern part of Brazil. Overall, the proportion of people living with HIV
who know their status and who are receiving antiretroviral therapy is quite high
in Brazil.
The recent change in national guidelines to the treat all strategy has enabled
Number
people
living thus
with
HIV and
notpoints
receiving
ART,
2014
treatment of
options
to be simplified,
enabling
additional
of HIV care
to
reach more people living with HIV.
Source: Department of STI, AIDS and Viral Hepatitis, Government of Brazil.
UNAIDS
135
Cameroon
Overview
The population of Cameroon is unevenly distributed over the national

territory, with large populations in the regions of Extrme-Nord, Centre
and Littoral. The urban proportion is 45%, with high concentrations in
Douala and Yaound (about 2.7 million inhabitants each). Most of
the population is located in the south-western part of the country. HIV
has spread primarily along the trucking routes and thus remains
clustered in the South.
Progress
Efforts in recent years have led to more than 145 000 people living with
HIV receiving antiretroviral therapy by December 2014, and about 158
000 by the end of July 2015. Important achievements have been made
in reducing the number of new HIV infections in Cameroon through
outreach to sex workers and other vulnerable populations, such as truck
drivers. In its latest national strategic plan, proposal for the Global Fund
to Fight AIDS, Tuberculosis and Malaria and Country Operational Plan of
the United States Presidents Emergency Plan for AIDS Relief (PEPFAR),
Cameroon incorporated the geographical disparity in the HIV epidemic
to adjust the services and resources appropriately.
Opportunities
The need for services is clustered near the capital city, Yaound, and
two other major cities, Douala and Bamenda, enabling cost-efficiency
in reaching people living with HIV with treatment services and key
populations with prevention services.
136
Cameroon map 1
New infections among women (1524 years old), 2014
The North-west and the Centre regions have the highest rates of new HIV
infections among young women. In response, Cameroon is focusing prevention
efforts in these areas through PEPFAR programmes. The other regions with many
new HIV infections among young women will benefit from Global Fund support
to implement activities targeting young women.
New
In the next two years, the national HIV programme will intensify prevention of
mother-to-child transmission community services in these regions to increase the
number of pregnant women HIV tested and initiating treatment, and to improve
the retention on treatment of mothers and children. This will reinforce the
cascade of prevention of mother-to-child transmission services and the related
monitoring. among young women (15-24), 2014
infections
Source: 2014 Cameroon preliminary subnational HIV estimates.
UNAIDS
137
Cameroon map 2
Number of people living with HIV not receiving antiretroviral therapy , mid-2015
Besides Yaound, the regions with the greatest antiretroviral therapy gap are in
the western part of Cameroon. In part, the currently low coverage levels in the
western regions are due to challenges in transport.
Number of people living with HIV and not receiving ART, mid-2015
Sources: 2014 Cameroon preliminary subnational HIV estimates and Global AIDS Response Progress Reporting on antiretroviral therapy, mid-2015.
138
Cameroon map 3
Female sex workers: population size estimate and HIV prevalence, 2014
The HIV prevalence among female sex workers is high in some of the main cities,
including the two largest: Yaound (Centre region) and Douala (Littoral region).
Prevention efforts were redoubled in these regions in the past year.
Source: HIV prevention for populations at risk in Cameroon: final report.

Yaound: Ministry of Public Health; 2014.
UNAIDS
139
Cameroon map 4
Men who have sex with men: population size estimate and HIV prevalence, 2013
Although the HIV prevalence among men who have sex with men is quite low
in most regions, it was very high in Yaound and Douala. Additional outreach
and services are needed in Douala and Yaound. The CHAMP project is already
responding to this need in the field.
Number=HIV prevalence (%)
Source: HIV prevention for populations at risk in Cameroon: final report.

Yaound: Ministry of Public Health; 2014.
140
I M P O R TA N T A C H I E V E M E N T S
H AV E B E E N M A D E I N R E D U C I N G
THE NUMBER OF NEW HIV
INFECTIONS IN CAMEROON
THROUGH OUTREACH TO SEX
WORKERS AND OTHER
V U L N E R A B L E P O P U L AT I O N S ,
SUCH AS TRUCK DRIVERS.
UNAIDS
141
Chad
Overview
The majority of the population of Chad reside in the southern provinces.

Higher HIV prevalence has been observed in the area of Lake Chad,
which borders on Cameroon, Niger and Nigeria. Although there has
been progress in reducing new infections among key populations and
through mother-to-child transmission, achievements are still inadequate.
Greater efforts are needed to ensure effective coordination within
regions and at the national level to achieve optimal use of resources and
improve service coverage, accessibility and use.
Progress
The number of people living with HIV accessing treatment has

steadily increased. Training community volunteers based on harmonized
tools has strengthened community-based prevention activities,
including scaling up the provision of services for preventing
mother-to-child transmission.
Opportunities
Implementation of the new World Health Organization treatment

recommendations has led to an increase in the number of people
living with HIV who are accessing treatment. Additional resources will
be needed to continue expanding treatment access, especially as free
treatment is provided by the Government through external funding.
Social marketing has contributed to the availability of high-quality
condoms and removing geographical, cultural and financial barriers to
their use. The decentralization of HIV services is an opportunity to reach
most of the population.
142
Chad map 1
Percentage of adults (1549 years old) who have discriminatory attitudes towards
people living with HIV, 2010
Discriminatory attitudes are highest in the far north of the country, where HIV
prevalence is low and many people are not familiar with HIV. Activities to raise
awareness about HIV and non-discrimination towards people living with HIV
and key populations among health-care workers, employers and the general
population are planned. It is also planned to provide legal support for people
living with HIV to enable them to seek redress for rights violations.
40%49%
Source: 2010 Multiple Indicator Cluster Survey.
UNAIDS
143
China
Overview
HIV was first identified in China in 1985, followed by an outbreak among

people who inject drugs in the border regions in the south-western part
of China in 1989 and among former plasma donors in central China
around 1995. In recent years, sexual transmission (including heterosexual
and between men) has become the dominant mode of HIV transmission.
The HIV epidemic in China has significant geographical diversity. Yunnan,
Sichuan, Guangxi, Xinjiang, Guangdong and Henan provinces are each
estimated to have more than 50 000 people living with HIV; together,
they account for 65% of the estimated national figure.
Clear evidence indicates a significant epidemic among men who
have sex with men, with increasing trends in HIV prevalence despite
implementation of core programme components. Heterosexual
transmission represents a significant proportion of the people newly
infected with HIV identified in China. Current data from sentinel surveys
suggest that the annual number of people newly infected through
heterosexual transmission is fairly stable. However, given the size of
the general heterosexual population and potential impact of further
spread in this population, investment must focus on this population to
better understand risks and identify ways to mitigate the spread of HIV.
Progress
China has made significant progress in its response to the HIV epidemic,
with positive results noted to date. These include successful harmreduction approaches for people who inject drugs, which is now
considered to be a global best practice, the reduction of secondary
transmission within serodiscordant couples, the reduction of mother-tochild transmission of HIV, which has shown decreased HIV transmission
rates in recent years, and significant scale-up of antiretroviral therapy
consistent with World Health Organization treatment guidelines.
144
Opportunities
Although programme implementation and coverage have improved in

China, there are challenges that need to be addressed including late
diagnosis of HIV, heterosexual HIV transmission, HIV transmission among
men who have sex with men, of people dying from AIDS-related causes
and mother-to-child transmission.
China has the potential to bring forward innovation in approaches
and strategies that will bring it closer to the goals for ending the AIDS
epidemic. Building on the experiences learned globally and considering
the local context, China is increasingly taking steps to go beyond its
initial success in rolling out large-scale programmes, and it is focusing
on how to reach the people who are currently not sufficiently reached by
prevention, treatment and care services.
UNAIDS
145
China map 1
Men who have sex with men: population size estimate and HIV prevalence
The HIV epidemic is growing among men who have sex with men in all
provinces, municipalities and autonomous regions. The national HIV prevalence
among men who have sex with men increased 5.5-fold in a decade, from 1.4% in
2005 to 7.7% in 2014. The proportion of newly diagnosed HIV cases attributed to
male homosexual contact increased from 3.4% in 2007 to 25.8% in 2014.
The HIV epidemic among men who have sex with men varies geographically
and temporally. Provinces in the south-east and north-east regions consistently
exhibit higher prevalence levels than other parts of China (the prevalence
exceeded 20% in several megacities in the south-east provinces). The HIV
prevalence in municipalities and capital cities of provinces (10.7%) was
significantly higher than in other non-capital cities (6.3%). In megacities such
as Beijing, Shanghai, and Tianjin, the proportion of newly diagnosed HIV cases
attributed to male homosexual contact is as high as 75%.
Currently, men who have sex with men represent about 24% of the sexually
active men in China (510 million).

Number = HIV prevalence (%)
Source: UNAIDS, World Health Organization and the Global Fund draft assessment of availability of subnational
data on HIV/STI prevalence, behaviours, coverage of HIV testing and size estimates for key populations in lowand middle-income countries. Forthcoming.
146
CHINA HAS THE POTENTIAL TO

B R I N G F O R WA R D I N N O VAT I O N
IN APPROACHES AND
S T R AT E G I E S T H AT W I L L B R I N G I T
CLOSER TO THE GOALS FOR
ENDING THE AIDS EPIDEMIC.
UNAIDS
147
Cte dIvoire
Overview
Most of the population of Cte dIvoire is located in the south-eastern

part of the country, in and around Abidjan, the economic capital, which is
both the largest and the most populous city (4.7 million inhabitants). HIV
has spread primarily along the trucking routes and thus remains clustered
in the southern part of the country.
Progress
The epidemic in Cte dIvoire is more severely affecting women, with

an HIV prevalence of 4.6% for women versus 2.7% for men according
to the Demographic and Health Survey for 20112012. In addition,
three key populations at higher risk of HIV infection have extremely high
prevalence: sex workers (29%), men who have sex with men (19%) and
the prison population (28%).
people newly infected with HIV in Cte dIvoire through outreach to sex
workers and other vulnerable populations, such as truck drivers. In its
latest national strategic plan, the country incorporated the geographical
disparity in the HIV epidemic to adjust the services and resources
appropriately. In addition, targeted services are implemented across the
country.
Opportunities
The need for services is clustered near the major cities, enabling
cost-efficiency in reaching people living with HIV with treatment services
and key populations with prevention services. In addition, the strong
mainstreaming of gender in most of the programmes has reduced the
vulnerability to acquiring HIV among vulnerable populations and key
populations at higher risk of HIV infection.
148
Cte dIvoire map 1

Women (1524 years) old newly infected with HIV, 2014
The number of young women newly infected with HIV is larger in the regions
in the southern part of the country along the coast. Programmes to reach these
provinces have been developed and are being implemented. However, the uptake
of prevention services among young people needs to be strengthening. According
to the 20112012 Demographic and Health Survey, 20% of women and 14%
of men 1524 years old have their first sexual intercourse before age 15 years.
Knowledge among women is still limited: according to the Demographic and
New
among
young
(15-24),
Healthinfections
Survey, only 16%
of women
1524women
years old were
able to 2014
correctly identify
how to prevent acquiring HIV and misconceptions about HIV transmission.
Source: Cte dIvoire 2014 preliminary subnational HIV estimates.
UNAIDS
149
Cte dIvoire map 2

Number of people living with HIV not receiving antiretroviral therapy, mid-2015
In Cte dIvoire, antiretroviral therapy has been free of charge for the entire
population since 2008. The prefectures with the largest numbers of people
who need antiretroviral therapy are along the coast, where most of the people
living with HIV reside and most of the HIV services are available. The current
decentralization of care and treatment services needs to be strengthened.
Sources: Cte dIvoire 2014 preliminary subnational HIV estimates and antiretroviral therapy from the
mid-2015 Global AIDS Response Progress Reporting.
150
Cte dIvoire map 3

Percentage of people (1549 years old) who have discriminatory attitudes
towards people living with HIV, 2012
Stigma and discrimination are still frequent in Cte dIvoire. The regions with the
highest discriminatory attitudes are also the regions with some of the lowest HIV
prevalence. The discrimination needs to be addressed through information and
education campaigns to reduce the discriminatory attitudes.
Percentage of adults (15-49) who have discriminatory attitudes

Source: 2012 Demographic and Health Survey.
UNAIDS
151
Democratic Republic of the Congo

Overview
The Democratic Republic of the Congos most populated regions are

Kinshasa, Katanga, Kasai Occidental, Kasai Oriental, Maniema and
Orientale province. Seven provinces where the largest cities are located
have the highest HIV prevalence and are home to 75% of people living
with HIV. The majority of key populations, including sex workers, men
who have sex with men and mobile populations, are in the cities of
Kinshasa and Lubumbashi in Katanga. In Orientale Province, sexual and
gender-based violence has been reported in humanitarian and conflict
contexts. Challenges include the facts that 84% of young women have
never been tested for HIV and people younger than 18 years of age
cannot access HIV testing without parental consent.
Progress
Since 2000, the number of new HIV infections has declined by 34%,
and AIDS-related deaths have declined by 26%. Between 2011 and
2014, access to services to prevent mother-to-child transmission and
treatment for people living with HIV has improved. HIV prevention and
care services for sex workers and men have who have sex with men
have been implemented in the cities of Kinshasa, Kisangani, Matadi
and Lubumbashi. Lessons learned and preliminary data have informed
national strategic plans, prioritizing key populations and young women
as well as geographical focus on Kinshasa, Katanga and Orientale
provinces in the concept note of the Global Fund to Fight AIDS,
Tuberculosis and Malaria and the PEPFAR Country Operational Plan.
Opportunities
The need for services is clustered in and around the capital and other
major cities, allowing for cost-efficiency in reaching people living with
HIV with treatment and key populations with prevention services.
Coordination among partners to increase synergy, harmonization and
efficiency and to avoid duplication at the operational level, as well as
city-led action plans that involve communities, including key populations,
people living with HIV and youth networks, provide further opportunities
to reach people needing HIV services.
152
Democratic Republic of the Congo map 1

In 2014, new HIV infections among young women occurred mainly in Katanga,
Maniema, Orientale, Kinshasa and Kasai Oriental provinces.
Katanga and Kinshasa provinces have benefited from the successful pilot of
Option B+, with support from UNAIDS, UNICEF, WHO and PEPFAR.
HIV prevention programmes and prevention of mother-to-child transmission
coverage among young women is low, particularly in Maniema, Province
Orientale, Kasai Oriental and Kasai Occidental. Katanga Province has been
New
infections
among
women
(15-24),
prioritized
in the
2015 PEPFAR
Country
Operational
Plan.2014
Source: Democratic Republic of the Congo 2014 preliminary subnational estimates.
UNAIDS
153

An estimated 81% of people living with HIV in the Democratic Republic of the
Congo are concentrated in the provinces of Kinshasa, Katanga, Kasai Occidental,
Kasai Orientale, Maniema and Oriental. Antiretroviral therapy coverage is less
than 10% in Kasai-Oriental and Maniema.
Treatment coverage scale-up is planned in Maniema and Kasai through a grant
from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Katanga Province
has been prioritized in the PEPFAR Country Operational Plan to reach the
909090 treatment targets.
Source: 2014 Democratic Republic of the Congo preliminary subnational estimates and mid-2015 antiretroviral therapy reported through the Global AIDS Response
Progress Reporting system.
154

Stigma and discrimination towards people living with HIV are strongly affecting
the HIV response across the country. Discriminatory attitudes are highest in the
Bas Congo, Bandundu and Kasai Oriental provinces.
UNAIDS and UNDP are currently implementing a project on HIV and the law
with parliament, ministers, lawyers and the police in Bas Congo, Bandundu,
Kasai Oriental, Kinshasa and Nord Kivu to address these challenges.
Percentage of adults (15-49) who have discriminatory attitudes towards people

living with HIV, 2014
UNAIDS
155

While size estimates are not available for several provinces, the available data
indicate there are large numbers of female sex workers in Katanga, Kinshasa and
Orientale provinces. HIV prevalence is more than 10% in Kinshasa, Lubumbashi
and Mbuji Mayi.
Condom distribution and social support programs for sex workers are currently
being implemented in Lubumbashi, Kisangani and Matadi.
Sources: Enqute intgre de surveillance comportementale et de seroprevalence en Republique Democratique du

Congo: Ministre de la Sant Publique: rapport denquete; Mars 2014
Rapport de lenqute sur lestimation de la taille des populations cls dans six provinces (Bas Congo, Katanga, Kinshasa,
Orientale, Nord et Sud Kivu) en RDC.
Prsidence de la Rpublique. Programme National multisectoriel de lutte contre le SIDA (PNMLS).
156
SINCE 2000, THE NUMBER OF

NEW HIV INFECTIONS HAS
DECLINED BY 34% IN THE
D E M O C R AT I C R E P U B L I C
OF THE CONGO, AND
A I D S - R E L AT E D D E AT H S H AV E
DECLINED BY 26%.
UNAIDS
157
Ghana
Overview
The population of Ghana is concentrated in the southern part of

the country along the coast and in the far North. National adult HIV
prevalence is less than 2%, with much of the transmission occurring
among key populations at increased risk to HIV.
Progress
Access to life-saving antiretroviral therapy has been increasing

dramatically in Ghana. The number of antiretroviral therapy sites in
Ghana increased from just 5 in 2004 to 197 in 2014, and more than
14 500 more people initiated treatment in 2014 alone. The number of
people newly infected with HIV across all ages declined by 46% (more
than the target of 20%) from an estimated 21 000 in 2004 to 11 000
in 2014, thereby reversing the epidemic. The number of people dying
from AIDS-related causes declined by 52%, from an estimated 19 000
to 9200 during the same period. Mapping, size estimation, behaviour
and biological surveys have been conducted for sex workers, men who
have sex with men and prisoners, and innovative outreach services have
been intensified among these key populations and also among people
with disabilities. In its latest successful proposal to the Global Fund to
Fight AIDS, Tuberculosis and Malaria (Global Fund), Ghana incorporated
the geographical disparity in the HIV epidemic to adjust services and
resources appropriately.
Opportunities
As Ghana moves into the implementation phase under the new

funding mechanism of the Global Fund, HIV prevention, treatment
and care services need to be intensified in the major cities and fragile
communities with high HIV prevalence to enable cost-efficiency,
accelerate the downward trend of the number of people newly infected
with HIV and move towards eliminating the mother-to-child transmission
of HIV. Both prevention and treatment programmes need to accelerate
and improve access to HIV testing and counselling, thereby identifying
people living with HIV, improving comprehensive knowledge and
condom use, especially among young people, and increasing the
number of people receiving treatment and having their viral load
158
suppressed. The level of stigma and discriminatory attitudes towards

people living with HIV needs to improve if the country is to achieve its
target of zero discrimination towards people living with HIV, and this
provides the opportunity to intensity anti-stigma campaigns, mobilize
HIV networks, build the capacity of policy-makers for monitoring policy
and public accountability, and actively involve all stakeholders in antistigma dialogue and education.
Ghana map 1
Percentage of people (1549 years old) who have discriminatory attitudes towards
The level of stigma in Ghana varies from region to region, with the percentage of
adults with discriminatory attitudes towards people living with HIV being higher
in the Northern Region and lowest in the Greater Accra Region.
Percentage of adults (15-49) who have discriminatory attitudes toward

people living with HIV 2014
Sources: Demographic and Health Survey.
UNAIDS
159
Ghana map 2
HIV prevalence among and population size of female sex workers have been
measured and mapped. A behavioural surveillance survey was conducted among
clients across the country in 2011. The overall HIV prevalence among female sex
workers was estimated to be 11%.The Greater Accra, Eastern and Ashanti regions
have the highest numbers of female sex workers. Programming to promote 100%
condom use, HIV testing and antiretroviral therapy among female sex workers,
all offered without stigmatizing attitudes, is crucial to reduce the number of
people newly infected with HIV in these regions.
Sources: Integrated biological and behavioural surveillance survey of female sex workers and behavioural surveillance
survey of clients of female sex workers in Ghana, 2011; Ghana AIDS Commission: 2011 mapping and population size estimation of female sex workers in Ghana.
160
Ghana map 3
The HIV prevalence among men who have sex with men has only been measured
in three sites. Prevalence was high in each site; Accra had the highest prevalence
and the largest population of men who have sex with men. Programming to
promote condom use, HIV testing and antiretroviral therapy among men who
have sex with men in a non-stigmatizing environment in both public and private
service centres is crucial to reversing the epidemic in this subpopulation in these
three cities.
Source: Ghana AIDS Commission: the Ghana mens study, 2011.
UNAIDS
161
Haiti
Overview
Much of the population in Haiti is located in the western part of the

country. This is also the location of the largest cities, where HIV has
spread primarily by heterosexual intercourse among people 2539
years old. In the general population, the HIV prevalence is higher in
urban areas.
Five years after the disastrous earthquake, Haiti has made significant
strides to recover and move forward. The accessibility and quality of
HIV clinical services are being improved, health-care infrastructure is
being built and surveillance and epidemiology, laboratory and health
management information systems are being strengthened. A special
focus is preventing HIV transmission by providing care and treatment to
people living with HIV and preventing mother-to-child transmission.
Progress

people newly infected with HIV in Haiti through services for preventing
the mother-to-child transmission of HIV with the implementation of
Option B+, increased availability and use of antiretroviral therapy, and
increased condom use through education and availability.
In 2006, about 20 institutions offered antiretroviral therapy services. In
2015 there are 134, with coverage in every department and province. In
addition, the programme for preventing the mother-to-child transmission
of HIV assures that all pregnant women will be tested and that treatment
is available for children.
Opportunities
Programmes addressing the most severely affected groups are among

the new developments in the HIV response, including the All In initiative
for adolescents. Implementing test and treat will promote progress
towards reaching the 909090 treatment target.
Alternative methods of mobilizing resource are being explored to
address decreasing funding leading to the loss of skilled workers and the
closing of clinics.
162
Haiti map 1
The highest estimated numbers of people newly infected with HIV live in the
Nord-Ouest, Ouest and Artibonite regions.
Women 1519 years old are a particularly vulnerable segment of the population
because of the absence or inadequacy of sexual education, resulting in
experimentation with drug use, alcohol consumption or sex work. Moreover, they
are often victims of sexual violence.
The ambitious adolescent initiative All In has been officially inaugurated with the
aim of addressing this specific population.
New infections among young women (15-24), 2014
No data
<100
100199
>=200
Source: 2014 Haiti preliminary subnational estimates.
UNAIDS
163
Haiti map 2
Number of people living with HIV not receiving antiretroviral therapy, 2014
The most populous part of the country has the greatest gap in antiretroviral
therapy coverage: the Ouest and Artibonite regions. In addition, almost 50% of all
antiretroviral therapy services for people living with HIV are located in the
Ouest region.
Greater strides to close this gap are expected with the new treat all strategy.
Number of people living with HIV and not receiving ART, 2014
Sources: Global AIDS Response Progress Reporting 2014 data on

antiretroviral therapy; 2014 Haiti preliminary subnational estimates.
164
Haiti map 3
The HIV prevalence among female sex workers is highest in the Nord region and
along the border with the Dominican Republic. Services for sex workers require
wider coverage than currently available. Services are more concentrated in the
Ouest and Artibonite regions, where they are provided by organizations such as
FOSREF and FEBS.

Source: HIV prevalence among female sex workers and men

who have sex with men in Haiti, 2011.
UNAIDS
165
Haiti map 4
The HIV prevalence among men who have sex with men is highest in six
departments: le Grand Nord (Nord, Nord-Est, Nord-Ouest and Artibonite),
Ouest and Sud. Men who have sex with men are very mobile and highly
stigmatized. Although services are available, men who have sex with men often
do not approach these services because of past experience with discrimination,
including by service providers.
Recently initiated programmes specifically address key populations. In addition,
the community of men who have sex with men itself is organizing associations.

Sources: HIV prevalence among female sex workers and men who
have sex with men in Haiti;
Global AIDS Response Progress Reporting 2015 and HIV prevalence
among FSWs and MSM in
Haiti. IBBS; 2011.
166
THE ACCESSIBILITY AND QUALITY

OF HIV CLINICAL SERVICES IN HAITI
A R E B E I N G I M P R O V E D , H E A LT H - C A R E
I N F R A S T R U C T U R E I S B E I N G B U I LT
A N D S U R V E I L L A N C E , E P I D E M I O L O G Y,
L A B O R AT O R Y A N D H E A LT H
M A N A G E M E N T I N F O R M AT I O N
SYSTEMS ARE BEING STRENGTHENED.
UNAIDS
167
India
Overview
With more than 1.2 billion people spread across 29 states and 7 union
territories, India is the second most populous country in the world and
the seventh largest by area. It has an epidemic concentrated among key
populations, including people who inject drugs, men who have sex with
men, transgender people and female sex workers.
India is home to the third largest number of people living with HIV
globally. At the national level, the number of people newly infected
with HIV has dropped and the number of people dying from AIDSrelated causes has also decreased with the expansion of prevention
efforts and the introduction and scale-up of antiretroviral therapy from
2004 onwards. Indias HIV epidemic is dynamic and continues to be
heterogeneous, especially in terms of its geographical spread, epidemic
trends and number of people living with HIV.
In recent years, the prevention, care and treatment efforts have rapidly
expanded across the country, with a focus on increasing service access
points through institutional scale-up and outreach.
Progress
Prevention and care as well as support and treatment constitute

the two main pillars of the HIV response efforts in India. Coverage
of related services has expanded over the years. In 20142015, the
prevention programme has covered 80% of female sex workers, 75%
of people who inject drugs and 68% of men who have sex with men.
HIV counselling and testing services have been provided through more
than 16 000 centres, and more than 15 million people and 12 million
pregnant women attending antenatal care have tested for HIV. Data
on transgender people are much more limited. There is a growing
commitment to improve strategic information on this group, which shows
the highest HIV prevalence in the country.
As of March 2015, care, support and treatment services were being
provided free of charge to about 850 000 people living with HIV.
Progress has also been made in reducing stigma and discrimination.
Opportunities
The great wealth of strategic information collected during the past two
decades, including HIV sentinel surveillance, HIV estimates, programme
monitoring, operational research and special studies, provides an
important opportunity to Fast-Track the national AIDS response
through universal access to HIV prevention, treatment, care and
support services. Analysis of data from various sources has been
intensified at local levels in states and districts, and it will continue to
be a focus, especially in the context of emerging epidemics in some of
Indias 36 states and union territories.
168
India map 1
Female sex workers are mainly concentrated in the southern states of India:
Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu. The HIV prevalence
in this population in these four states is higher than the rest of India. Andhra
Pradesh hosts the largest number of female sex workers, an estimated 156 000
individuals. Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu account
for more than 30% of the total estimated number of female sex workers in India.
(NACO 31 Indicator Programme Data, 2015; HSS 2010-11; HRG Mapping
Estimates 2008-09)
Many targeted programmes have been established in Andhra Pradesh, Karnataka,
Maharashtra and Tamil Nadu. Mapping estimates were taken into consideration
during the scaling up of the targeted programmes in these states. Prevention
services include behaviour change communication, condom distribution, referral
to HIV testing, care, support and treatment, as well as clinical services and
community mobilization.
Sources: Programme data for the National AIDS Control Organization

management information system (2014); HIV sentinel surveillance
20102011.
UNAIDS
169
India map 2
The HIV prevalence among men who have sex with men has been measured in
two thirds of Indian states through gradual expansion in the number of sentinel
surveillance sites. HIV prevalence among men who have sex with men is highest
in Chhattisgarh, Manipur and Nagaland, followed by Andhra Pradesh, Madhya
Pradesh and Maharashtra states. According to population size estimations, men
who have sex with men are mainly concentrated in Andhra Pradesh, Delhi,
Gujarat, Karnataka, Maharashtra and Tamil Nadu. These six states account for
66% of the men who have sex with men. (NACO 31 Indicator Programme Data,
2015; HSS 2010-11; HRG Mapping Estimates, 2008-09)
Targeted services for men who have sex with men are aligned with prevalence
and population size estimates, distributed across 26 states with a special focus
on Gujarat, Haryana, Karnataka, Kerala, Mumbai, New Delhi and Tamil
Nadu. Targeted services include information, education and communication,
condom and lubricant distribution, referral to HIV testing and regular sexually
transmitted infection check-ups.
Sources: Programme data for the National AIDS Control Organization management information system (2014); HIV sentinel surveillance 20102011.
170
India map 3
People who inject drugs: population size estimate and HIV prevalence, 2010
The HIV prevalence reported among people who inject drugs is highest in
the north-western and north-eastern states of the country. The highest HIV
prevalence is noted in Punjab, at 21%, and in the capital state of Delhi, at
18%. According to mapping information, people who inject drugs are mainly
concentrated in Delhi, Maharashtra, Manipur, Nagaland, Punjab, Uttar Pradesh
and West Bengal. These states account for 67% of the total estimate. (NACO 31
Indicator Programme Data, 2015; HSS 2010-11; HRG Mapping Estimates, 200809)
Targeted services and harm-reduction programmes for people who inject drugs
have been scaled up in these states. HIV programmes for people who inject drugs
include harm reduction (provision of sterile needles and syringes and opioid
substitution therapy), behaviour change communication, condom distribution,
and referral to HIV testing, care, support and treatment. Overdose management,
abscess management, clinical services and community mobilization are also
provided.
Sources: Programme data for the National AIDS Control

Organization management information system (2014); HIV sentinel
surveillance 20102011.
UNAIDS
171
Indonesia
Overview
Most of the population in Indonesia is located in the south-western

part of the country. This is also the location of the largest cities, with
high numbers of people living with HIV. HIV has spread primarily
along the economic centre and thus remains clustered in the
southern part of the country.
Progress
Important achievements have been made in increasing the number of

people tested, increasing the number of people living with HIV receiving
antiretroviral therapy and reducing the number of people newly infected
with HIV in the country. This has been done through comprehensive
prevention programmes, such as outreach to sex workers, men who have
sex with men, people who inject drugs and other vulnerable populations
(such as pregnant women). Increasing the number of facilities for people
living with HIV is also one of the achievements.
Its Indonesia gives priority to the response in 141 of more than 500
districts to implement the strategic use of antiretroviral medicines
through a comprehensive prevention programme. The geographical
prioritization is in line with the Strategic Plan of the Ministry of Health
20152019, and it is also incorporated into the National Strategy and
Action Plan on HIV/AIDS.
Opportunities
The need for services is clustered in the major cities, enabling

cost-efficiency in reaching people living with HIV with treatment services
and key populations with prevention services. The Governor of Jakarta
signed the Paris Declaration for Fast-Track cities in October 2015, and
other cities around the country are expected to follow Jakartas example.
172
Indonesia map 1
Female sex workers are working throughout the archipelago. Larger numbers are
found in large cities in Java island, including provinces with some of the highest
HIV prevalence rates. Papua, especially Mimika district, has the highest HIV
prevalence among female sex workers and moderately large numbers of women
selling sex. Programming for sex workers is needed throughout Indonesia.
Sources: Technical report: 2013 sero-surveillance survey and 2013 rapid behavioural survey/integrated biological
and behavioural survey, 2011 (http://www.aidsdatahub.org/ibbs-2011-integrated-biological-and-behavioral-survey-ministry-of-health-republic-of-indonesia); Size estimation of key affected population (KAPs) a2012 (http://www.
kebijakanaidsindonesia.net/jdownloads/Publikasi%20Publication/2012_size_estimation_of_key_affected_populations_
kaps.pdf).
UNAIDS
173
Indonesia map 2
Men who have sex with men live throughout Indonesia. Their numbers are
proportional to the population in the provinces, and higher in urban areas. The
HIV prevalence among men who have sex with men was highest in Surabaya
with 22.1% followed by Bandung (21.3%) and Jakarta (19.6%). Prevention and
treatment programs should be prioritized in these areas, while surveillance
should be expanded.
and behavioural survey, 2011 (http://www.aidsdatahub.org/ibbs-2011-integrated-biological-and-behavioral-survey-ministry-of-health-republic-of-indonesia); Size estimation of key affected populations (KAPs) 2012 (http://www.
kaps.pdf).
174
Indonesia map 3
The HIV prevalence among people who inject drugs varies among all regions
where it is measured. Large numbers of people who inject drugs are distributed
across Java and in northern Sumatra. HIV prevalence ranged between 27% in
Medan to 59% in Malang. Harm reduction programmes need to give priority
to these areas.
kaps.pdf).
UNAIDS
175
Indonesia map 4
Transgender people: population size estimate and HIV prevalence, 2013
Transgender people, primarily transgender women, are relatively concentrated in

Java, Sumatra and Sulawesi. HIV among transgender people reached over 30% in
two sites in Java. Prevention programmes should be given priority in the areas of
high concentration of transgender people and high HIV prevalence.
kaps.pdf).
176
INDONESIA GIVES PRIORITY

TO THE RESPONSE IN 141 OF
MORE THAN 500
DISTRICTS TO IMPLEMENT
T H E S T R AT E G I C U S E O F
ANTIRETROVIRAL MEDICINES
THROUGH A COMPREHENSIVE
PREVENTION PROGRAMME.
UNAIDS
177
Iran (Islamic Republic of)

Overview
The Islamic Republic of Iran is a largely urbanized country, with about

70% of the population living in urban areas. Close to half that urban
population is concentrated in just four cities: Tehran (the capital),
Esfahan, Mashhad and Shiraz. Historically, the HIV epidemic has been
driven by injecting drug use, and the country has responded to this
through its nationwide harm reduction programme. More recently,
however, sexual transmission has accounted for an increasing proportion
of new cases, and the national response is being re-engineered based
on the best available evidence to address this emerging development.
Progress
The countrys harm-reduction programme is frequently cited as a best

practice, and the HIV prevalence among people who inject drugs has
been stable at about 1415% for close to a decade. The country has
also begun to roll out its prevention of mother-to-child transmission
programme in phases through the primary health-care system, giving
priority to areas with the greatest projected need. antiretroviral therapy
is provided free of charge to everyone eligible in accordance with World
Health Organization guidelines, and the fourth national strategic plan has
been revised with a view to scaling up antiretroviral therapy coverage
significantly and bringing the country closer to achieving the 909090
treatment target. The country has also been a pioneer in positive
health, dignity and disease prevention, establishing 25
positive clubs around the country during the past decade. Finally,
the Islamic Republic of Iran has increasingly recognized the importance
of strategic information in guiding programme development and
implementation, and it is committing increasing resources to generating
timely, quality data.
178
Opportunities
The country has embraced the 909090 treatment target and is

restructuring its response within the framework of an ambitious fourth
national strategic plan, which aims to rapidly scale up core services: HIV
testing and counselling and antiretroviral therapy. An extensive primary
health-care system and the family physician scheme potentially provide a
platform for integrating complementary approaches (such as alternative
testing strategies) on a wider scale. The network of positive clubs can
also be integrated into this new set-up and play a more effective role
in treatment coverage, adherence and effectiveness. The country can
also build on its investment in strategic information by further building
subnational capacity to monitor and respond to the epidemic, thereby
helping to channel resources where they are most needed and to the
populations that most need them.
UNAIDS
179
Iran (Islamic Republic of) map 1

People who inject drugs: population size estimate and HIV prevalence,
2010 or later
The nationwide HIV prevalence among people who inject drugs has remained
steady at about 1415% since 2007, based on several rounds of biobehavioural
surveillance. However, reliable subnational estimates of prevalence or population
size are, with some exceptions (2), not yet available.
There are very few harm reduction service gaps. More than 1000 facilities
provide HIV testing and counselling services, more than 550 sites provide needle
and syringe services and nearly 6000 sites provide opioid substitution therapy
services. The country has begun to address these gaps by conducting subnational
size estimation exercises for the main key populations and is revising protocols
for biobehavioural surveillance to enable valid subnational prevalence figures
to be generated.
Sources: Published data from 2010-2015.
180
THE ISLAMIC REPUBLIC OF IRAN

H A S I N C R E A S I N G LY R E C O G N I Z E D
T H E I M P O R TA N C E O F S T R AT E G I C
I N F O R M AT I O N I N G U I D I N G
PROGRAMME DEVELOPMENT
A N D I M P L E M E N TAT I O N , A N D I T I S
COMMITTING INCREASING
R E S O U R C E S T O G E N E R AT I N G
T I M E LY, Q U A L I T Y D ATA .
UNAIDS
181
Kenya
Overview
The population of Kenya is distributed unevenly across the country

with the south-eastern coastal area and the far West having the highest
population density. The HIV epidemic in Kenya is also geographically
diverse, ranging from a high prevalence of 24% in Homa Bay County
in Nyanza region to a low of about 0.2% in Wajir County in the northeastern region. More than 70% of the adults acquiring HIV infection in
2014 lived in nine of the 47 counties. The epidemic is deeply rooted
among the general population, although key populations also have a
high HIV prevalence.
Progress
Important achievements have been made in reducing the number

of people newly infected with HIV through outreach to general and
key population groups, such as sex workers, men who have sex with
men and people who inject drugs. In its most recent national strategic
framework, proposal for the Global Fund to Fight AIDS, Tuberculosis and
Malaria and Country Operational Plan of the United States Presidents
Emergency Plan for AIDS Relief (PEPFAR), Kenya has adjusted service
and resource allocation to reflect the geographical disparity of the HIV
epidemic across the country.
Opportunities
The greatest need for services is mainly concentrated among counties

located in the Western and Nyanza districts and in the cities of Nairobi,
Kisuma, Mombasa and Nairobi. This allows for cost-efficiency in reaching
people living with HIV with HIV treatment services and key populations
with prevention services.
182
Kenya map 1
Number of women (1524 years old) newly infected with HIV, 2014
The numbers of women 1524 years old newly infected with HIV are highest
NewRift
infections
among
young
women
(15-24)
in the Nyanza,
Valley and Coast
regions.
More than
2000 women
were
estimated to be newly infected with HIV in Nyanza in 2014.
Source: 2014 Kenya subnational estimates.
UNAIDS
183
Kenya map 2
Most of the gap in antiretroviral therapy coverage is in the Nyanza and Rift Valley
regions.
More than 80% of the adults and children living with HIV are not accessing
antiretroviral therapy in Turkana County. More than an estimated 50 000
people in each of the Homa Bay, Kisuma and Siaya counties are not accessing
Number of people living with HIV and not receiving ART
Sources: 2014 Kenya subnational estimates; Global AIDS Response

Progress Reporting mid-2015 data on antiretroviral therapy.
184
Kenya map 3
Kenya has an estimated 138 000 female sex workers, with the greatest estimated
numbers in the Nairobi (29 500), Rift Valley (22 000) and Coast (20 000) regions.
The HIV prevalence among female sex workers in the Nairobi region was
estimated at 29%, more than four times the national HIV prevalence for
the general population. Sex worker programmes are spread across 32 of
the 47 counties.
Sources: Biological and behavioural surveillance for most at-risk populations in Kenya (http://healthpromotionkenya.org/
LIBRARY%20OF%20DATA/HIV/Project%20Reports/MARPs%20BOOK%20REPORT%20.pdf); Kenya most at risk populations
size estimate consensus report 2013; NASCOPNational AIDS and STI Control Programme, Kenya.
UNAIDS
185
Kenya map 4
Men who have sex with men: population size estimate and HIV prevalence
Kenya has an estimated 18 500 men who have sex with men, with an estimated
75% of men who have sex with men living in the Nairobi and Nyanza regions
(10 000 and 4000, respectively).
The epidemic among men who have sex with men varies greatly across regions.
The HIV prevalence among men who have sex with men is estimated at 18%
in Nairobi and 11% in Nyanza. Cultural norms and stigma still present barriers
to services for men who have sex with men in Kenya. Several efforts have been
implemented to promote condom use among men who have sex with men.
LIBRARY%20OF%20DATA/HIV/Project%20Reports/MARPs%20BOOK%20REPORT%20.pdf); Kenya most-at-risk populations
size estimate consensus. Nairobi: National AIDS and STI Control Programme, Government of Kenya; 2013.
186
Kenya map 5
People who inject drugs: population size estimate and HIV prevalence
The HIV prevalence among people who inject drugs in Kenya is 19% in Nairobi
and Nyanza versus only 5.3% [4.76.1%] in the general population. This figure
is attributed to high-risk injecting behaviour, such as needle sharing and blood
flushing, as well as unsafe sexual behaviour and practices among this population.
Kenya has an estimated 18 000 people who inject drugs. About 80% are in the
Nairobi and Coast regions (8500 and 6200, respectively). Recently, injection drug
use has been reported in Kisumu, too.
Since 2013, the country has made important steps towards addressing the
public health concerns of people who inject heroin. National standard operating
procedures for medically assisted therapy, as well as standard operating
procedures for needlesyringe programmes have been developed and launched.
With support from donor agencies, four sites are currently offering methadone to
people who inject drugs.
LIBRARY%20OF%20DATA/HIV/Project%20Reports/MARPs%20BOOK%20REPORT%20.pdf); Evidence of injection drug use
in Kisumu, Kenya: implications for HIV prevention (http://www.ncbi.nlm.nih.gov/pubmed/25861945); Kenya most-at-risk
populations size estimate consensus. Nairobi: National AIDS and STI Control Programme, Government of Kenya; 2013.
UNAIDS
187
Lesotho
Overview
Most of the people living with HIV in Lesotho are located in the largest
towns along the lowlands and foothills of the country. HIV has spread
primarily along the large towns of Leribe, Berea and Maseru City, which
are host to apparel factories, and in areas with huge infrastructural
development projects (Mohales Hoek and Mafeteng). It thus remains
clustered in the lowlands and foothills in the south-western part of the
country. The burden of disease from HIV and tuberculosis is largely
concentrated in the five major cities of the Maseru, Leribe, Berea,
Mafeteng and Mohales Hoek districts. About three of four people living
with both HIV and TB are located in these five districts, including high
risk and other vulnerable groupsyoung women and girls, sex workers,
men who have sex with men, factory workers and inmates.
Progress

people newly infected with HIV in Lesotho through outreach to young
people, especially women and girls, sex workers and other vulnerable
populations (such as factory workers and herd boys). In its latest national
HIV and AIDS strategic plan, proposal to the Global Fund to Fight AIDS,
Tuberculosis and Malaria and Country Operational Plan of the United
States Presidents Emergency Plan for AIDS Relief (PEPFAR), Lesotho
incorporated the population and geographical disparity in the HIV
epidemic to adjust the services and resources appropriately.
Opportunities
cities, enabling cost-efficiency in reaching people living with HIV with
treatment services and key populations with prevention services.
188
Lesotho map 1
The districts with the greatest need for antiretroviral therapy are those in the
lowlands and foothills of the country: Maseru, Leribe, Berea, Mafeteng and
Mohales Hoek, respectively. Collectively, they account for about 75% of the
burden of HIV and TB coinfection. This primarily results from challenges of
weak links and follow-up between the communities and health facilities in that
region, and from fewer men accessing HIV prevention and treatment services.
Further, many clients who test positive for HIV through community initiatives do
not reach the health facilities. Stigma and discrimination towards people living
with HIV is also still pervasive. Efforts are underway to strengthen partnerships
to mobilize communities through traditional, religious, political and communitybased organizations structures, including networks of people living with HIV, to
create accelerated demand for uptake of HIV testing and antiretroviral therapy
services. In addition, priority will be given to improving the logistics system in
the country and alerting the national system of critical medicine stock-outs.
Sources: 2014 submission for the Global AIDS Response Progress Reporting and
2009 Demographic and Health Survey to estimate the numbers of people living
with HIV by region.
UNAIDS
189
Malawi
Overview
Malawis most populated areas are the Southern and Central regions.
The HIV prevalence in Malawi varies considerably by sex, age,
socioeconomic characteristics and geographical location. The HIV
prevalence is highest in the Southern Region, which is more densely
populated. The areas most affected by HIV, however, are spread
across all districts, particularly along major transport routes and
commercial, agricultural and/or growing business centres.
Progress
Important achievements have been made in reducing the number of new

infections in Malawi. In a period of four years between 2010 and 2014,
the number of people living with HIV and receiving antiretroviral therapy
almost doubled. In the rural southern district of Chiradzulu, up to 27
000 people living with HIV (almost 10% of the district population) were
receiving antiretroviral therapy by June 2013. A household survey in the
same district showed that, despite a 17% HIV prevalence, only 4 new
HIV infections for every 1000 residents occurred each year, depicting
the best treatment outcomes at the population level documented that
had been anywhere in the world and illustrating the preventive effect of
Opportunities
Malawi decentralized antiretroviral therapy and prevention of mother-tochild transmission service provision as early as 2006, taking into account
the existing health system realities and constraints (such as healthcare staff shortages). Allowing nurses and medical assistants to initiate
antiretroviral therapy at the subnational level has contributed significantly
to the rapid scale-up. Access to antiretroviral therapy and prevention
of mother-to-child transmission services has greatly improved across
the country as a result of delivering these services at a variety of clinical
settings (including antenatal care, maternity care, under-five clinics,
antiretroviral therapy clinics and family planning clinics).
190
Malawi map 1
Malawi has recorded a 53% decline in new HIV infections during the past
decade. The distribution of new HIV infections is disproportionately higher in
the Southern Region compared with the Central and Northern regions. Out of
the countrys 28 districts, the six districts with the highest number of people
living with HIV are found in the Southern Region and account for 42% of
Malawis population. This region has more advanced urban economic centres, as
well as major transport routes that cover and connect the region more extensively
than those in the Northern Region.
The 2015 PEPFAR Country Operational Plan focuses on the 14 districts with
the highest number of people living with HIV, most of which are located in the
Southern Region. Other programmes to reduce new HIV infections, including
voluntary medical male circumcision, are implemented across the country, with
special focus on the 14 priority districts.
A number of partners are implementing programmes for key populations, such
as sex workers and men who have sex with men, in alignment with the national
strategic plan. However, to improve effectiveness, a mapping exercise for key
populations is in the pipeline.
New infections among adult women (15-49), 2014
Source: 2014 Malawi estimates.
UNAIDS
191
Malawi map 2
Percentage of adult women (1549 years old) who have discriminatory attitudes
According to the 2010 Malawi Demographic and Health Survey, women in the
Northern and Central regions are more likely to express accepting attitudes
towards people living with HIV than women in the Southern Region. Among
men, those in the Central Region are more likely to express accepting attitudes
than those in the Southern or Northern region.
Percentage
A national stigma index study is currently underway and will inform a new
set of national HIV anti-stigma and discrimination guidelines to address
of
adultsin (15-49)
challenges
this area. who have discriminatory attitudes towards
Source: 2013 Multiple Indicator Cluster Survey.
192
IN THE PERIOD BETWEEN 2010

AND 2014, THE NUMBER OF
P E O P L E I N M A L AW I L I V I N G
WITH HIV AND RECEIVING
ANTIRETROVIRAL THERAPY
ALMOST DOUBLED.
UNAIDS
193
Mali
Overview
Most of the population in Mali is located in the south-western part of

the country. This is also the location of the largest cities. HIV has spread
primarily along the trucking routes and thus remains clustered in the
southern part of the country.
Progress
Progress has been made in improving treatment access and preventing

children from becoming infected by providing antiretroviral medicines
free of charge for people living with HIV and adopting Option B+ for
preventing mother-to-child transmission. There is strong high-level
political commitment to the HIV response.
Opportunities
The need for services is clustered in and around the capital city and
other major cities, enabling cost-efficiency in reaching people living
with HIV with treatment services and key populations with
prevention services.
The decentralization of health services provides opportunities to expand
access to HIV services, with all regions of the country having HIV
centres. Most HIV centres are located in Bamako, Kayes, Koulikoro,
Sgou and Sikasso.
194
Mali map 1
The number of people not receiving antiretroviral therapy is highest in the

regions with the highest HIV prevalence. More than 30 000 people living with
HIV are not receiving antiretroviral therapy in Sgou region.
Sources: 2014 Global AIDS Response Progress Reporting submission for data on antiretroviral therapy and analysis of the
20122013 Demographic and Health Survey for the number of people living with HIV.
UNAIDS
195
Mali map 2
Discriminatory attitudes towards people living with HIV are high across
the country. In three regions, more than 50% of the general population
reports discriminatory attitudes towards people living with HIV. This is a
significant challenge to improving access to prevention and treatment services
and promoting a protective environment for the human rights of people
living with HIV.
Percentage of adults (15-49) who have discriminatory attitudes

towards people living with HIV
196
M O Z A M B I Q U E H A S R E C E N T LY
PA S S E D A L AW T H AT C O N F I R M S
T H E R I G H T T O P R I VA C Y A N D
C O N F I D E N T I A L I T Y O F H I V S TAT U S
AND SPECIFIES THE RIGHTS OF
SPECIFIC GROUPS OF PEOPLE
L I V I N G W I T H H I V, I N C L U D I N G
ORPHANS AND VULNERABLE
CHILDREN, WOMEN, DISABLED
PEOPLE LIVING WITH HIV
AND PRISONERS.
UNAIDS
197
Mozambique
Overview
Mozambiques most populated areas are the Nampula, Zambezia and

Tete provinces. Although the southern region accounts for only one
quarter of the population, it is home to 43% of new HIV infections and
remains the region with the highest HIV prevalence rates in the country.
The South is also where the largest cities and trade corridors to the
neighbouring country of South Africa are located.
Progress
Important progress has been achieved after Mozambique implemented

the Accelerated HIV/AIDS Response Plan in 2013, such as focused HIV
testing and counselling strategies, and scaling up antiretroviral therapy
and Prevention of mother-to-child transmission. The plan is evidenceinformed and gives priority to HIV services where they will have greatest
impact.
Opportunities
To reduce the number of new HIV infections, Mozambique still has room
to improve HIV diagnosis as well as uptake and retention on treatment,
especially for Option B+ and antiretroviral therapy for children, by
reinforcing linkages within health facilities and between community and
health facilities, improving the quality of services and addressing social
and cultural norms.
198
Mozambique map 1
About 90 000 new infections occurred in Mozambique in 2014, 55% of them

among women.
The HIV incidence among women is highest in Zambezia and Maputo Provinces
as a result of high population mobility to mines and farms in South Africa
through trade corridors and of the social and cultural norms that increase
womens vulnerability to HIV.
Women in Mozambique acquire HIV earlier and, as a consequence, HIV
prevalence is three times higher among women 1524 years old than it is among
men of the same age.
For this reason, the Government of Mozambique has recently recognized
girls and young women (1024 years old) as a priority population for the
HIV response. Operationalization plans to address this population are being
elaborated and will address social and cultural norms, gender inequality,
education
and social
protection,
in addition
to biomedical
New
infections
among
adult
women
(15-49), efforts.
2014
Source: 2014 Mozambique estimates.
UNAIDS
199
Mozambique map 2
In Mozambique, 42% [3656%] of all people living with HIV were receiving
treatment in 2014.
The greatest treatment gaps are found in Zambezia and Nampula, which account
for 37% of the countrys population and are among the locations with the lowest
rates of recent HIV testing. There are also many people living with HIV still not
receiving treatment in Maputo Province, an area with high HIV prevalence.
To address treatment gaps, the Government of Mozambique has expanded
antiretroviral therapy services, especially in Zambezia, where 64% of health
facilities now offer antiretroviral therapy services, although challenges remain.
Increasing HIV testing and human resources capacity where major gaps are
located and providing treatment at earlier stages of infection might contribute to
closing the treatment gaps in Mozambique.
Sources: 2014 Mozambique estimates and 2014 Global AIDS Response Progress Report.
200
Mozambique map 3
Discriminatory attitudes towards people living with HIV vary from 9% in

Maputo City to 43% in Cabo Delgado. Nevertheless, discriminatory attitudes
remain high throughout the country (28%), and constitute an important barrier
for access to HIV services.
In this context, the Government of Mozambique has recently approved Law no.
19/2014 that confirms the right to privacy and confidentiality of HIV status and
specifies the rights of specific groups of people living with HIV, including orphans
and vulnerable children, women, disabled people living with HIV and prisoners.
The law also spells out the responsibilities and rights of health-care professionals
with regard to HIV, including those of traditional medicine practitioners.
Percentage
In addition to the legal framework, national guidelines for integrating HIV

prevention, care and treatment for key populations within health facilities are
being developed to provide more user-friendly and higher-quality services for
groups.
ofthese
adults
(15-49) who have discriminatory attitudes towards
people
living with HIV, 2011
UNAIDS
201
Mozambique map 4
The HIV prevalence among female sex workers was very high in the three site
where it was measured: Beira, Maputo and Nampula. The estimated number of
women selling sex in each city suggests a high burden of disease.
Recognizing the health needs as well as vulnerability to HIV of female sex
workers, the Ministry of Health is planning to establish of 22 key populationfriendly health facilities throughout the country where treatment will be made
available for female sex workers and men who have sex with men living with HIV,
regardless of CD4 count.
Source: Inqurito integrado biolgico e comportamental entre mulheres trabalhadoras de sexo, Moambique 20112012
relatrio final (http://globalhealthsciences.ucsf.edu/gsi/IBBS-MTS-Relatorio-Final.pdf).
202
INCREASING HIV TESTING AND

H U M A N R E S O U R C E S C A PA C I T Y
WHERE MAJOR GAPS ARE
L O C AT E D A N D P R O V I D I N G
T R E AT M E N T AT E A R L I E R
S TA G E S O F I N F E C T I O N
MIGHT CONTRIBUTE TO
C L O S I N G T H E T R E AT M E N T
GAPS IN MOZAMBIQUE.
UNAIDS
203
Myanmar
Overview
Five of the 15 states and regions in Myanmar make up 60% of the total
population. These states are primarily in the central part of the country.
The HIV epidemic in Myanmar is concentrated among men who have
sex with men, people who inject drugs and female sex workers. Most
HIV and AIDS cases are reported from large urban areas, and from the
north-eastern and northern areas of the country where injecting drug use
is widespread.
Progress
There has been impressive scale-up in the numbers of people receiving

treatment. Patients enrolled in antiretroviral therapy at public sites
have increased from 12 692 in 2011 to 40 617 in 2013. In 2014, 18
947 new patients were started on antiretroviral therapy compared to
5146 in 2011. Retention in care of people on antiretroviral therapy at
12 months was 82%, and 78% at 24 months. HIVTB collaboration was
strengthened. HIV prevalence among new TB patients has decreased
from 11.1% to 8.5%. HIV testing and counselling as the entry point into
the continuum of care has been scaled up from 95 851 tests in 2012 to
666 752 in 2014. Testing among key populations has increased. There
have been increases in needle and syringe programmes and methadone
programmes for people who inject drugs.
Care and support for people living with HIV is provided through nine
national civil society networks. To meet the needs of migrants and
mobile populations, cross-border collaboration is being strengthened.
The review of restrictive laws impeding access to HIV prevention,
care and treatment services, especially for key populations, has
been initiated.
Opportunities
Building on the achievements and lessons learned from the past national
strategic plans, the 20162020 plan will Fast-Track the response, working
closely with key stakeholders, including civil society and affected
communities, to focus on the locations, people and programmes that
will deliver the greatest impact. HIV testing and counselling will be
promoted through both facility- and community-based model, prompt
HIV treatment for people living with HIV will be offered upon HIV
diagnosis, and access to viral load testing will be expanded. HIV-related
services will be integrated with other diseases.
204
Myanmar map 1
Female sex workers: HIV prevalence, 2014
HIV prevalence among female sex workers was measured in 10 sentinel sites.
The highest prevalence is noted in the south-west and the far North of Myanmar.
Prevention, care and treatment services for female sex workers are distributed
across the states and regions with emphasis on the mentioned sentinel sites.
Source: 1) Results of HIV sentinel sero-surveillance, 2014, Myanmar. National AIDS

Programme, Department of Health (draft report 2014).
UNAIDS
205
Myanmar map 2
Men who have sex with men: HIV prevalence, 2014
HIV prevalence among men who have sex is the highest in the southwest.
Prevention, care and treatment services for men who have sex with men are
distributed across states and regions with emphasis on the sentinel sites.

206
Myanmar map 3
People who inject drugs: HIV prevalence, 2014
HIV prevalence among people who inject drugs is highest in the Yangon area and
the northern and north-east regions near the Chinese border. Prevention, care
and treatment services for people who inject drugs are distributed in the most
affected regions of the country based on sentinel sites information.

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207
Namibia
Overview
Namibia has the second lowest population density in the world. The
north-central and north-eastern parts account for 60% of the population.
Two thirds of the population lives in rural areas. Namibia is an uppermiddle-income country, but its income distribution is among the most
unequal in the world.
Progress

new infections in the country through outreach to rural communities
and growing informal settlements around the cities, as well as special
programmes addressing sex workers and other vulnerable populations
(such as truck drivers).
Namibias antiretroviral therapy programme has been its flagship
achievement. The coverage of services for Prevention of mother-to-child
transmission exceeds 95%, among the highest in the world, and AIDSrelated deaths have been drastically reduced.
A combination prevention strategy has been developed to support the
implementation of the revised national HIV strategy. The government has
demonstrated significant political commitment by providing more than
60% of the AIDS response budget in a context of decreasing external
resources.
Opportunities
The revised national strategy now has adequate provisions to reach

people with disabilities and key populations, and to address widespread
stigma and discrimination, gender violence and legal barriers that
continue to impede the realization of human rights, HIV prevention and
health-care access among key populations.
208
Namibia map 1
Most new infections are in Khomas, Erongo and Hardap regions in the centre
of the country, and the Zambezi, Kavango, Oshikoto, Kunene, Ohangwena and
Omusati regions in the North and north-east.
The central regions, especially Khomas Region, have relatively more resources
and more HIV services than those in the North and north-east. Regions in the
North and north-east still face large HIV service gaps and challenges in terms
of reaching remote populations. The central and northern regions are the most
populated regions in Namibia. Along the northern border, sex work is increasing
along transit points for long-distance truck drivers.
Renewed government initiatives focusing on remote regions and communities,
and have increased the number of public services available for these communities
school-based services and services for young people have significantly
expanded. Recent efforts have extended services that address alcohol abuse that
contribute to higher-risk sexual behaviour in most of the remote communities.
The Health Extension Worker programme, which has recruited more than 4200
health extension workers, is proving to be a positive community development
initiative that is increasing prevention and treatment services and adherence in
the remote northern communities.
Civil society involvement could promote a more coordinated prevention
response, especially in regions with increasing new infections. Legislation
protecting the
rights
of womenamong
and girlsadult
is needed.
New
infections
women (15-49), 2014
Source: 2014 Namibia estimates.
UNAIDS
209
Namibia map 2
The number of people living with HIV is highest in the central and northern
regions. The number of people living with HIV and not receiving antiretroviral
therapy is highest within the same regions. As depicted in the map, the Khomas
and Kavango regions have the highest number of people living with HIV not
receiving antiretroviral therapy.
In Khomas Region, rural-to-urban migration has created vast informal
settlements around the city of Windhoek. Public utilities are limited within these
settlements, and alcohol and drug abuse is highly prevalent. There are many
people living with HIV in these communities who do not know their status, and
treatment dropout rates are high. In the north-eastern regions such as Kavango,
Zambezi and, Ohangwena, Omusati and Oshana, which border Angola, the
population is extremely fluid between the two countries, creating difficulty for
treatment programmes when following-up with clients. Dropout rates are also
high, and adherence to antiretroviral therapy is difficult to monitor.
The Ministry of Health and Social Services has started implementing a treat all
policy, with a commitment to improving adherence, particularly in these
high-impact regions.
Civil society can make an important difference in further antiretroviral therapy
increasing coverage and sustaining treatment adherence, especially in remote
Number
of people living with HIV and not receiving ART, mid-2015
communities.
Sources: 2014 Namibia estimates and Global AIDS Response Progress Report mid-2015.
210
CIVIL SOCIETY CAN MAKE

A N I M P O R TA N T D I F F E R E N C E
IN FURTHER INCREASING
ANTIRETROVIRAL THERAPY
C O V E R A G E A N D S U S TA I N I N G
T R E AT M E N T A D H E R E N C E ,
E S P E C I A L LY I N R E M O T E
COMMUNITIES.
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211
Namibia map 3
People living with HIV face various forms of stigma and discrimination in
accessing health-care services and in the workplace. Discriminatory attitudes are
less present in the regions with more people living with HIV. Women living with
HIV have reported forced and coerced sterilization as a result of their HIV status,
including being provided with insufficient information to give proper consent to
procedures or being denied access to HIV and health services unless they agree to
abortion or sterilization.
Key populations also report stigma and discrimination based on sexual
orientation, gender identity or occupation, which often intersects with HIVPercentage
of adults
(15-49) who have discriminatory attitudes towards
related
stigma and
discrimination.
212
N A M I B I A S A N T I R E T R O V I R A L
THERAPY PROGRAMME HAS BEEN
I T S F L A G S H I P A C H I E V E M E N T. T H E
COVERAGE OF SERVICES FOR
PMTCT EXCEEDS 95%, AMONG
THE HIGHEST IN THE WORLD,
A N D A I D S - R E L AT E D D E AT H S H AV E
B E E N D R A S T I C A L LY R E D U C E D .
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213
Nigeria
Overview
Nigeria has a very high population density, with most of the population
living along the southern coast, in the south-west and in the far North.
The HIV prevalence is highest in the southern coast regions and lowest in
the south-eastern region.
Progress
The number of HIV testing and counselling sites increased eightfold

between 2010 and 2014. The number of sites offering antiretroviral
therapy services has more than doubled. Specific efforts have been
made to reach young people and key populations at increased risk of
acquiring HIV with behaviour change and communication strategies.
Opportunities
A renewed effort by Nigeria and development partners to focus the

HIV response on the states with the highest burden of HIV infection has
the potential to markedly improve the HIV response in Nigeria. Several
challenges remain because of the sheer size, volume and coordination
required for the HIV response in such a diverse country.
214
Nigeria map 1
The number of women 1524 years old newly infected with HIV is highest in
Kaduna State, a state with high prevalence overall. The number of women 1524
years old newly infected is also large in some central, southern and south-western
states, as well as in northern states, including Katsina, Kano and Sokoto.
Programmes to ensure that young women have the information they need to
protect themselves are underway using the Family Life and HIV Education
training curriculum.
Source: 2014 Nigeria preliminary subnational estimates.
UNAIDS
215
Nigeria map 2
Although important gains have been made in reaching individuals with

antiretroviral therapy, many people living with HIV are not receiving
treatment. More than 300 000 people living with HIV in Kaduna State are not
receiving treatment.
The scale-up of antiretroviral therapy services has moved from being mostly
based in tertiary hospitals to secondary and even some primary health-care
facilities. Over the years, the government has initiated the decentralization of
antiretroviral therapy services to the primary health-care level to increasing
access to antiretroviral therapy. This decentralization process designates
primary health-care centres as antiretroviral therapy refill centres and integrates
the delivery of this service into the routine of health-care workers already
employed there. Nurses and community health workers at these primary healthcare facilities do not initiate antiretroviral therapy but perform rapid HIV
screening and can also provide support services for those already initiating
Source: 2014Nigeria preliminary subnational HIV estimates.
216
Nigeria map 3
The HIV prevalence among female sex workers is very high in all states where
measured. The numbers of sex workers across states are also large, suggesting a
very high burden borne by these women.
To respond to recent findings that condom use was decreasing among sex
workers, gender-sensitive prevention actions were intensified to address higherrisk behaviour among men. The changing dynamics of transactional sex are being
challenged through behaviour change and communication efforts focusing on
girls and young people. Programming for condom use is also being enhanced
among female sex workers and their communities, including among clients of sex
workers.
Sources: HIV/STI Integrated Biological and Behavioural Surveillance Survey (IBBSS), 2010. Abuja: Federal Ministry of
Health; 2010 (http://www.popcouncil.org/uploads/pdfs/2011HIV_IBBSS2010.pdf); Ikpeazu A et al. An appraisal of female
sex work in Nigeriaimplications for designing and scaling up HIV prevention programmes. PLoS One. 2014;9: e103619
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4131880).
UNAIDS
217
Nigeria map 4
HIV prevalence is very high in Abuja and Lagos, where many men who have
sex with men reside.
The national strategic plan emphasizes behaviour change communication for
HIV prevention among populations at higher risk. The programme uses social
networking approaches to reach hidden and stigmatized groups and establishes
referral systems to health services in clinics friendly to populations at higher risk.
Specialized training and capacity-building friendly to populations at higher risk
are conducted for private and public sector health-care providers as well.
Sources: HIV/STI Integrated Biological and Behavioural Surveillance Survey (IBBSS), 2010. Abuja: Federal Ministry of
Health; 2010 (http://www.popcouncil.org/uploads/pdfs/2011HIV_IBBSS2010.pdf); HIV epidemic appraisals in Nigeria: evidence for prevention programme planning and implementationdata from the first eight states. Abuja: National Agency
for the Control of AIDS; 2013 (http://sbccvch.naca.gov.ng/sites/default/files/Local%20Epidemic%20Appraisal_glossy%20
report.pdf).
218
Nigeria map 5
Injecting drug use remains relatively rare in Nigeria but is present, and people
who inject drugs have important prevalence levels.
The widespread availability of sterile needles and syringes at pharmacies and
patented medicine stores makes needle sharing less of a major route of HIV
transmission among people who inject drugs in Nigeria. However, no active
national HIV programme is targeting people who inject drugs.
Source: HIV/STI Integrated Biological and Behavioural Surveillance Survey (IBBSS), 2010. Abuja: Federal Ministry of
Health; 2010 (http://www.popcouncil.org/uploads/pdfs/2011HIV_IBBSS2010.pdf); HIV epidemic appraisals in Nigeria:
evidence for prevention programme planning and implementationdata from the first eight states. Abuja: National
Agency for the Control of AIDS; 2013 (http://sbccvch.naca.gov.ng/sites/default/files/Local%20Epidemic%20Appraisal_
glossy%20report.pdf).
UNAIDS
219
Pakistan
Overview
The majority of the population in Pakistan live in the eastern and

northern regions of the country. Pakistans HIV epidemic has been
characterized primarily by transmission through injecting drug use but
is increasingly characterized by sexual transmission. Although some
prevention programmes have been implemented, the use of sterile
injecting equipment and condom use continue to be low among people
who inject drugs. Condom use is especially low among sex workers,
in particular among male and hijra sex workers. The majority of key
populations in Pakistan are located in five major cities.
Progress
Important achievements have been made in the allocation of domestic

resources to the HIV response and securing funding from the Global
Fund to Fight AIDS, Tuberculosis and Malaria. Treatment services have
been scaled up and outreach to people who inject drugs, sex workers
and other key populations has been expanded.
Opportunities
Prevention efforts focused on the populations and locations, including

major cities, that have been most severely affected by the epidemic are
required to minimize HIV transmission and curtail the epidemic.
220
Pakistan map 1
Female sex workers work throughout Pakistan. HIV prevalence remains low
among female sex workers, but prevention services are still needed. The number
of sex workers is highest in the largest cities: Karachi, Lahore, Multan, Faisalabad
and Hyderabad.
Sources: HIV second generation surveillance in Pakistan: national report round IV, 2011 (http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3841725) and HIV-AIDS surveillance project. Mapping of key populations at risk of HIV. HIV second generation
surveillance in Pakistan. Islamabad: National AIDS Control Program, Government of Pakistan; 2012.
UNAIDS
221
Pakistan map 2
Male sex workers: population size estimate and HIV prevalence, 2011
Male sex workers work throughout Pakistan. The HIV prevalence remains low
among male sex workers, but prevention services are still needed. The highest
numbers of male sex workers were estimated in Karachi, followed by Larkana.
222
Pakistan map 3
People who inject drugs are found throughout Pakistan, with some larger
communities in the central and eastern part of the country, near Gujrat and
Faisalabad. More than half the people who inject drugs around Faisalabad
are living with HIV. Harm-reduction programs for people who inject drugs
need to be readily accessible in all provinces of Pakistan, with a focus on the
priority provinces.
The future of the HIV epidemic in Pakistan will depend on the scope and
effectiveness of HIV prevention programmes for people who inject drugs and
their sexual partners, as well as sex workers and their clients.
UNAIDS
223
Pakistan map 4
Transgender people: population size estimate and HIV prevalence, 2011
HIV prevalence among transgender people is heterogeneous. The HIV

prevalence suggests that Larkana and Karachi have an important need for
programmes to prevent infections among transgender people.

224
T R E AT M E N T S E R V I C E S I N
PA K I S TA N H AV E B E E N S C A L E D U P
AND OUTREACH TO PEOPLE WHO
INJECT DRUGS, SEX WORKERS
A N D O T H E R K E Y P O P U L AT I O N S
H A S B E E N E X PA N D E D .
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225
South Africa
Overview
About 54% of South Africas population of 52 million people lives in

three provinces: Gauteng, KwaZulu-Natal and Eastern Cape. South
Africa has the largest HIV epidemic in the world, with an estimated 6.8
million [6.5 million7.5 million] people living with HIV, of which 3 million
are accessing antiretroviral therapy. The country has the third-highest
tuberculosis incidence in the world, and about 62% of the people with
tuberculosis are living with HIV. The HIV epidemic is heterogeneous
within provinces, and an effective response is being developed through
localization. South Africa has also made tremendous progress in
reducing mother-to-child transmission of HIV.
Progress
Political commitment, domestic funding and the scale and quality of

HIV and tuberculosis services have increased dramatically. South Africa
has the largest number of people on antiretroviral therapy worldwide,
with more than 3 million people receiving treatment as of mid-2015.
HIV prevention programmes have also gained pace. According to the
2012 household HIV prevalence survey, 65% of South Africans had been
tested for HIV, and HIV testing and counselling services are perceived as
highly accessible. A massive condom promotion campaign is ongoing,
and about 2 million voluntary medical male circumcisions have been
carried out since 2010.
The benefits are increasingly evident. HIV treatment expansion in South
Africa has saved the lives of an estimated 1.3 million people since 1995.
The 2012/2013 MRC evaluation of the national prevention of motherto-child transmission programme effectiveness found that the HIV
transmission to infants at six weeks postpartum decreased. According
to the latest government development indicators report, life expectancy
increased from 52 years in 2004 to 61 years in 2014, and infant mortality
dropped from 58 to 29 deaths per 1000 live births between 2002 and
2014 (Rapid Mortality Surveillance, Medical Research Council).
226
Opportunities
The gains also highlight the enormous efforts that are still needed
to overcome South Africas HIV epidemic. Because of the life-saving
benefits of treatment, the total number of people living with HIV is
rising, which underscores the need for more effective prevention efforts.
Women (especially young women and girls) face inordinate risks of
acquiring HIV, which calls for a more effective enabling environment.
Programmes need to be tailored to the differing needs of groups at
higher risk in locations with a high burden of HIV infection. HIV testing
and counselling campaigns need to reach young people and men,
who have significantly lower testing rates. To move closer to the 80%
coverage target for voluntary medical male circumcision by 2016, scaling
up voluntary medical male circumcisions will require creating increased
demand at the community level and engaging traditional leaders around
integrating male medical circumcision into traditional practices.
Renewed social marketing of condoms is critical to increase condom
use, especially among people 1524 years old. To reduce the number
of women newly infected with HIV, especially adolescent girls and
young women, appropriate packages of combination services need to
be saturated in locations with a high burden of HIV infection for these
women and their male sex partners.
UNAIDS
227
South Africa map 1

Young women 1524 years old are up to eight times more likely to be living with
HIV than their male peers. In 2014, most young women 1524 years old newly
infected with HIV lived in KwaZulu-Natal, Gauteng and Eastern Cape provinces.
KwaZulu-Natal accounts for more than 15 000 of the 72 000 women 1524
years old newly infected annually. In response, the KwaZulu-Natal provincial
government runs an innovative, integrated multisectoral service delivery model.
Through this people-centred approach, services are taken closer to the people
through targeted service delivery in specific areas, such as transport routes where
key populations are located and taxi ranks.
Much more needs to be done to improve prevention efforts, especially for young
women. Other risk-enhancing factors (including alcohol abuse, violence against
women and socioeconomic insecurity) require concerted action.
Attention should to be given to mobility and migration, including internal
migration between rural and urban settings and cross-border migration.
Source: 2014 South Africa preliminary subnational estimates.
228
South Africa map 2

Since 2010, the sharpest gains in HIV treatment access have occurred in
KwaZulu-Natal, Gauteng and Eastern Cape, the regions with the highest HIV
prevalence. However, these provinces are also home to the largest number of
people living with HIV and not receiving antiretroviral therapy.
Knowledge of HIV status among people living with HIV has increased over
time. However, according to the 2012 South African National HIV Prevalence,
Incidence and Behaviour Survey, 62% of men living with HIV and 45% of
women living with HIV aged 15 years and older were not aware of their
serostatus. Closing the HIV testing gap will require promotion of services that
are innovative, safe, accessible, equitable and free of stigma and discrimination,
(including self-testing and other non-facility-based testing methods) enhanced
community engagement and timely emergence of new diagnostic tools, such as
point-of-care
earlyof
infant
diagnostic
Number
people
livingtests.
with HIV and not receiving ART, mid-2015
Source: 2014 South Africa preliminary subnational estimates.
UNAIDS
229
Swaziland
Overview
The population of Swaziland is fairly evenly distributed across the

country, with the largest city located in Manzini province in the centralwest part of the country. About 49% of the population in Swaziland is
younger than 20 years. Women, men who have sex with men and sex
workers are disproportionately affected by HIV.
The country is divided into four administrative regions: Hhohho,
Lubombo, Manzini and Shiselweni. Manzini region is the most populous,
with more than 30% of the population, followed by Hhohho region with
28% of the population. The estimated HIV prevalence is similar across
the four regions, although the numbers of people living with HIV differ.
Anecdotal evidence suggests that the areas most affected by HIV are
mainly major urban centres, cross-border points and towns around major
transport and trade corridors. Key among these is the southern transport
corridor between the cities Mbabane and Manzini.
Progress
Although the HIV incidence has decreased, it is still high. Several HIV
prevention programmes have been implemented, with increased
coverage in HIV testing and counselling from 147 facilities in 2010
to 264 in 2013. The percentage of people tested and counselled in
the past 12 months increased between 2010 and 2014. Scale-up of
male circumcision was initiated in 2008, resulting in improved uptake.
However, condom use has declined among women 1549 years old, with
a reduction in knowledge levels among people 1524 years old.
The country has shown significant progress in reducing new infections
among children and in antiretroviral therapy. The number of people
receiving antiretroviral therapy has increased, and retention in care at
12 months has increased among both adults and children. According
to the 2012 Swaziland HIV Incidence Measurement Survey, 85% of
people living with HIV who reported receiving antiretroviral therapy
were virally suppressed.
Opportunities
HIV services are clustered in urban areas, although about 70% of the
population lives in rural areas. Although people living with HIV are
concentrated in urban areas, service availability needs to be revisited
and reviewed to ensure that these areas have the greatest needs.
A geospatial analysis at the subregional level on the epidemic and
response is underway.
230
Swaziland map 1
The largest number of people living with HIV is estimated to be in the Manzini
region. Manzini is also the region with the highest estimated number of new HIV
infections among young women 1524 years old. Most health facilities in the
country are located in Manzini. Efforts are underway to continually review and
redirect programmes to reduce new HIV infections.
Source: 2014 Swaziland estimates.
UNAIDS
231
Swaziland map 2
Source: 2014 UNAIDS estimates.
232
T R E AT M E N T S E R V I C E S H AV E
BEEN SCALED UP AND
OUTREACH TO PEOPLE WHO
INJECT DRUGS, SEX WORKERS
A N D O T H E R K E Y P O P U L AT I O N S
H A S B E E N E X PA N D E D .
UNAIDS
233
Uganda
Overview
The population density of Uganda is highest in Kampala and around

the other major cities. People living with HIV are spread throughout the
country with pockets of high prevalence in a number of regions.
Key populations in Uganda are mainly in Kampala and major towns,
fishing communities along the lakes and along major transport
corridors.
Sexual transmission continues to be the root of HIV transmission.
Women, key populations and urban areas are particularly affected
by the epidemic.
Progress
New HIV infections have declined between 2010 and 2014 in Uganda
among both adults and children. Uganda is among the priority countries
of the Global Plan towards the Elimination of New HIV Infections
Among Children by 2015 and Keeping their Mothers Alive that had
more than a 60% reduction in new child infections between 2009 and
2014. This has been in part due to sustained expansion of the national
programme towards the elimination of new child HIV infections with
consistent and high-level commitment and prevention of mother-to-child
transmission coverage exceeding 90%.
Similarly AIDS-related deaths have declined, partly because antiretroviral
therapy has been rapidly scaled up.
The current national strategic plan and the PEPFAR Country Operational
Plan have incorporated the geographical disparity in the HIV epidemic
to adjust the services and resources appropriately. This is expected to
address the disparities in antiretroviral therapy coverage by sex, age
geographical reach and the high levels of stigma and discrimination
towards people living with HIV.
Opportunities
There is good political will and a decentralized health system. The

planned engagement of religious leaders, cultural leaders and private
sector leaders brings additional needed resources to positively
impact the response. There is potential for the country to establish
sustainable funding mechanisms to enhance human resources for
health, scale up antiretroviral therapy coverage and strengthen supply
chain management to cover districts and regions that currently have
suboptimal levels of services and high HIV prevalence.
234
Uganda map 1
New HIV infections have declined but remain higher among females than males.
The disparity between young men and young women has declined over the past
decade from a ninefold difference to a threefold difference. Of 10 regions, Central
and Western have the highest number of new HIV infections, followed by Mid
East and Mid North. The regions with the lowest numbers of young women
newly infected with HIV are West Nile, North East, East Central and Kampala.
Accordingly, the 2015 PEPFAR Country Operational Plan has given priority to
the regions with the highest number of new infections for scale-up.
Map 1. New infections among young women (15-24), 2014
Source: 2014 preliminary subnational estimates.
UNAIDS
235
Uganda map 2
The national strategic plan has given priority to scaling up antiretroviral therapy
and intensifying condom programming. The regions with the largest gap in
people receiving antiretroviral therapy are in the southern part of the country.
Source: 2014 preliminary subnational estimates.
236
Uganda map 3
In 3 of 10 regions, 30% or more of the general population reported discriminatory

attitudes towards people living with HIV in 2011. The lowest reported rates of
discriminatory attitudes were in Kampala and the North Region.
Although more than 90% of people reported they would care for a relative with
HIV in their own homes and about 80% thought a female teacher living with HIV
should be allowed to continue teaching, about one in five adults believed that
people living with HIV should be ashamed of themselves.
Urban women and men were somewhat more likely than rural respondents to
express accepting attitudes. Education is positively related to accepting attitudes.
The country has planned for a comprehensive stigma reduction campaign in the
Percentage
of adults (15-49) who have discriminatory attitudes
national strategic plan and a stigma study.
towards people living with HIV
Source: 2011 AIDS indicator survey.
UNAIDS
237
Ukraine
Overview
Ukraines population is unevenly spread across 27 regions (including

Crimea and Donbass), with 50% of the population living in 9% of the
regions and 70% of the population concentrated in urban areas.
While injecting drug use was historically the most important mode of
transmission, today most of the people newly infected with HIV acquire it
through sexual transmission. The HIV epidemic in Ukraine is subdivided
into three regional epidemics, with the highest prevalence in nine
regions with 40% of the estimated number of people living with HIV.
The highest HIV prevalence is in the south-eastern regions of Ukraine,
including Odessa, Dnipropetrovsk, Nikolayev, Donetsk and Kherson.
The HIV epidemic has stabilized since 2010, with declining HIV
prevalence among young key populations. About 50% of the registered
people living with HIV live in three regions, and 30% of the people
receiving antiretroviral therapy live in two regions. The HIV epidemic is
growing in four regions in the south-eastern part of the country: Odessa,
Dneipropetrovsk, Nikolayev and Donetsk.
Progress
Ukraine is implementing the 6th State AIDS Programme 20142018,

focusing on prevention services for key populations and antiretroviral
therapy. The HIV prevalence is the highest among people who inject
drugs, although it has declined from 61% in 2007 to 20% in 2013. The
HIV prevalence among female sex workers who inject drugs is four times
higher (27%) than among all female sex workers (7%). Antiretroviral
therapy was provided to more than 61 000 people living with HIV in
2014. Opioid substitution therapy is provided to more than 8000 people
who inject drugs.
Opportunities
The geographical concentration of key populations and the analysis

of the epidemic trends in the most populated regions provide an
opportunity for refocusing the distribution of services towards the
regions and sites with the greatest number of people living with HIV,
allowing for optimization of service delivery and cost-efficiency.
238
Ukraine map 1
The estimated number of female sex workers in Ukraine is 80 000. High HIV
prevalence among female sex workers is found in the southern and eastern parts
of the country, while the four regions with the highest prevalence, exceeding 10%,
are in the western and central parts of the country. Prevention and treatment
services for female sex workers are provided in all regions.
Sources: Balakirieva O et al. Summary of the analytical report Monitoring the behaviour and HIV-infection prevalence
among female sex workers as a component of second generation surveillance (according to the results of 2013 bio-behavioural survey). Kyiv: International HIV/AIDS Alliance in Ukraine; 2014 (http://www.aidsalliance.org.ua/ru/library/our/2014/
arep14/zvit%20FSW_summary_obl_ENG.pdf); Analytical report: estimation of the size of populations most-at-risk for HIV
infection in Ukraine as of 2012 based on the results of 2011 survey.
UNAIDS
239
Ukraine map 2
Ukraine has an estimated 176 000 men who have sex with men. There has been a
gradual decrease in the HIV prevalence among men who have sex with men. The
regions with higher HIV prevalence among men who have sex with men are the
eastern and some southern regions. The highest prevalence of HIV among men
who have sex with men has been registered in Donetsk (15%), Kyiv (17%) and
Cherkasy (11%).
Sources: Bolshov YS et al. Summary of the analytical report Monitoring the behaviour and HIV-infection prevalence among
men who have sex with men as a component of HIV second generation surveillance (according to the results of 2013
bio-behavioural survey). Kyiv: International HIV/AIDS Alliance in Ukraine; 2014 (http://www.aidsalliance.org.ua/ru/library/
our/2014/arep14/zvit%20MSM_obl_eng.pdf). Analytical report: estimation of the size of populations most-at-risk for HIV
240
Ukraine map 3
Ukraine has an estimated 310 000 people who inject drugs, mainly in Kyiv and six
regions in the eastern and southern parts of the country. About 50% of the people
who inject drugs living with HIV reside in four regions. The HIV prevalence
among people who inject drugs is high nearly everywhere. Almost half the
regions report an HIV prevalence among people who inject drugs above 20%.
Three regionsMikolayv Odessa and Dnipropetrovskhave 21% of the people
who inject drugs and report an HIV prevalence among this group above 30%.
Harm reduction services are available in all regions of the country.
The services are concentrated in large cities and are provided by
nongovernmental organizations.
Sources: Balakirieva O et al. Summary of the analytical report Monitoring the behaviour and HIV-infection prevalence
among people who inject drugs as a component of HIV second generation surveillance (according to the results of 2013
bio-behavioural survey). Kyiv: International HIV/AIDS Alliance in Ukraine; 2014 (http://www.aidsalliance.org.ua/ru/library/
our/2014/arep14/zvit%20IDU_obl_eng.pdf); Analytical report: estimation of the size of populations most-at-risk for HIV
UNAIDS
241
United Republic of Tanzania

Overview
The United Republic of Tanzania has two types of epidemics. The

mainland has a generalized epidemic, with significant variation among
regions. Half of the countrys people living with HIV are concentrated in
eight regions South, southern highlands, western highlands and Dar es
Salaam. Zanzibar has an epidemic with lower overall prevalence but with
high prevalence among key populations Regions in the North have lower
prevalence than the national average.
The HIV prevalence has steadily declined during the past decade. The
HIV burden shows marked heterogeneity with regard to age, sex, social
economic status and geographical location. The HIV prevalence is higher
among women than men and in urban than rural areas.
Progress
Starting in 2016, all children 014 years old living with HIV will receive
antiretroviral therapy regardless of CD4 count, and the criteria for
eligibility for adults will change from CD4 count <350 cells/mm3 to
<500 cells/mm3. Since October 2013, the United Republic of Tanzania
has been implementing Option B+ to prevent the mother-to-child
transmission of HIV.
Institutional and organizational skills and capacity of civil society
organizations, networks of people living with HIV and their members
have been developed to enable their active participation in and
contribution to a more effectively targeted national response to AIDS.
Opportunities
With the government focusing largely on providing primary and

secondary education free of user charges, there is an opportunity to
reach more young people by integrating HIV into the formal
education curriculum.
The establishment of the AIDS Trust Fund by the government has
created an opportunity to mobilize resources for HIV locally. There are
ongoing strategies to strengthen synergy between the public and private
sectors, such as by mainstreaming HIV in workplace programmes.
An investment case analysis has provided guidance in setting focused
priorities based on impact.
242
United Republic of Tanzania map 1

In 15 of 25 regions in the mainland, more than 30% of people 1549 years old
still have discriminatory attitudes towards people living with HIV. More than
50% of people 1549 years old in the Dodoma, Geita and Simiyu regions have
discriminatory attitudes towards people living with HIV.
Discriminatory attitudes towards people living with HIV could be associated with
low comprehensive knowledge of HIV. The level of comprehensive knowledge
about HIV is low in the mainland (less than 50%).
In the three regions where more than 50% of adults have discriminatory attitudes
towards people living with HIV, the level of comprehensive knowledge is below
the national average.
Percentage of adults (15-49) who have discriminatory attitudes towards people

living with HIV
Source: 20112012 AIDS Indicator Survey.
UNAIDS
243
United Republic of Tanzania map 2

Female sex workers: population size estimate and HIV prevalence
Female sex workers are present throughout the United Republic of Tanzania.
A study in seven regions (Dar-es-Salaam, Iringa, Mara, Mbeya, Mwanza,
Shinyanga and Tabora) indicated that the HIV prevalence among female sex
workers ranged from 38% in Shinyanga to 14% in Tabora. Stakeholders in
collaboration with the Ministry of Health and Social Welfare are implementing
intensive testing, treatment and prevention programmes among female sex
workers in 14 of 25 regions in the mainland.
In Zanzibar, an Integrated Biological and Behavioural Survey conducted in
20112012 estimated the HIV prevalence to be 19.3% among female sex workers,
an increase from 10.8% in 2007. An outreach programme by the Ministry of
Health and other stakeholders is providing testing, treatment and prevention
services to this population. Female sex workers living with HIV are provided with
antiretroviral therapy regardless of CD4 count.
Sources: Global AIDS Response Progress Reporting, 2015; Khalid F et al. Doubling of HIV prevalence among female sex
workers (FSW) in Zanzibar assessed through respondent-driven sampling (RDS) surveys, 2007 to 2011 (http://
globalhealthsciences.ucsf.edu/sites/default/files/content/pphg/posters/FSW-CROI-Poster-27Feb2013v3.pdf);
Consensus estimates on key population size and HIV prevalence in Tanzania, 2014. Dar es Salaam: National
AIDS Control Programme, United Republic of Tanzania; 2014 (http://www.healthpolicyproject.com/pubs/391_
FORMATTEDTanzaniaKPconsensusmtgreport.pdf).
244
S TA K E H O L D E R S I N C O L L A B O R AT I O N W I T H
T H E M I N I S T R Y O F H E A LT H A N D S O C I A L
W E L FA R E A R E I M P L E M E N T I N G I N T E N S I V E
T E S T I N G , T R E AT M E N T A N D P R E V E N T I O N
PROGRAMMES AMONG FEMALE SEX
WORKERS IN 14 OF 25 REGIONS ON THE
MAINLAND OF THE UNITED
R E P U B L I C O F TA N Z A N I A .
UNAIDS
245
Viet Nam
Overview
The HIV epidemic in Viet Nam is concentrated primarily among people

who inject drugs, men who have sex with men and female sex workers.
These populations are mostly concentrated in mountainous northern
provinces and large urban centres. In 2014, Viet Nam had an estimated
251 000 people living with HIV and 14 000 people newly infected with
HIV. Most of the people newly infected continue to be people who inject
drugs, but the number of low-risk women newly infected is increasing,
primarily among the partners of men who inject drugs, visit sex workers
or have sex with other men.
Progress
Under strong and consistent leadership, Viet Nam has achieved

important successes against the epidemic. However, HIV remains a
formidable challenge for Viet Nam. Although the number of people
receiving antiretroviral therapy has increased dramatically in recent years,
the level of coverage is not sufficient to control the epidemic. Stigma
and discrimination are significant barriers to the uptake of HIV services.
Rapidly declining donor support is a challenge for Viet Nams progress
against HIV, with about 75% of the funding for the HIV response coming
from external sources.
Opportunities
Fast-Tracking the response in Viet Nam will entail urgent action to

achieve the countrys commitment to the 909090 treatment target,
with a particular and intensified focus on innovative and effective service
delivery in the response among key populations and in geographical
settings where the need is greatest, elimination of stigma and
discrimination and efficient use of domestic funding.
246
Viet Nam map 1

Sex workers: population size estimate and HIV prevalence, 20132014
The HIV prevalence among sex workers in Viet Nam varies by province and is
highest in Ha Noi, Hai Phong, Can Tho and Ho Chi Minh City. Evidence also
indicates that street-based female sex workers have a higher HIV prevalence than
venue-based female sex workers, and an estimated 38% of female sex workers
also inject drugs. Peer outreach workers provide prevention services to female sex
workers.

* Disputed area boundaries.
Sources: Viet Nam AIDS response progress report. 2014; HIV sentinel surveillance with a behavioural component (HSS+)
and integrated biological and behavioural surveys (IBBS), 2013; Review of data on female sex workers for the Asian
Epidemic Model (AEM) (annex table); Global AIDS Response Progress Reporting 2015; 2013 HIV estimates.
UNAIDS
247
Viet Nam map 2

Men who have sex with men: population size estimate and HIV prevalence,
20132014
The estimates of the number of men who have sex with men suggest that the cities
have some of the larger populations. Although the HIV prevalence varies among
areas, it is highest in Hanoi and relatively high in Ho Chi Minh City. Behaviour
change communication and condom and lubricant distribution focusing on men
who have sex with men have been rolled out in recent years, and more than two
thirds of the men who have sex with men surveyed report using a condom the
last time they had anal sex with a male partner.

* Disputed area boundaries.
Sources: Viet Nam AIDS response progress report, 2014; HIV sentinel surveillance with a behavioural component (HSS+)
and Integrated Biological and Behavioural Surveys (IBBS), 2013; Global AIDS Response Progress Reporting, 2015; 2013
HIV estimates.
248
Viet Nam map 3

Many people who inject drugs live in the mountainous north-western provinces
near the China and Lao borders or in large urban centres. Some of the highest
HIV prevalence levels are recorded in these areas. In remote and mountainous
areas, socioeconomic development is not as advanced as in urban areas,
understanding of the risks of acquiring HIV risks is limited, transport is
difficult and access to HIV services is lacking. Recent expansion efforts in
community-based services in the North are providing HIV testing to many
people living in the mountainous areas.

* Disputed area territories.
Sources: Viet Nam AIDS response progress report, 2014; HIV sentinel surveillance with a behavioural component (HSS+)
and Integrated Biological and Behavioural Surveys (IBBS), 2013; Review of data on people who inject drugs for the Asian
epidemic model (AEM) (annex table); Global AIDS Response Progress Reporting, 2015; 2013 HIV estimates.
UNAIDS
249
Zambia
Overview
The population density in Zambia is highest in the predominantly urban

regions of Copperbelt in the central-northern part of the country and in
Lusaka, in the central-southern part of the country. The HIV prevalence
is also highest in these regions. These regions have populations of
migrants who temporarily move to other areas for work opportunities.
Progress
Zambias antiretroviral therapy programme continues to show impressive

performance. In 2014, 671 066 adults and children were receiving
antiretroviral therapy. Of these, more than 100 000 newly initiated
antiretroviral therapy during the year. Access to treatment within and
between provinces varies considerably. Services for preventing motherto-child transmission have been integrated into maternal and child
health programming while also shifting to providing lifelong treatment
to all pregnant women living with HIV. Zambia has endorsed the
implementation of task shifting, which allows nurses to be certified to
prescribe antiretroviral medicines.
250
Zambia map 1
Most of the women 1524 years old newly infected with HIV live in Lusaka and
Copperbelt.
Source: 2014 Zambia preliminary subnational estimates.
UNAIDS
251
Zambia map 2
The need for antiretroviral therapy is highest in Lusaka and Copperbelt provinces,
which are home to large populations.
Sources: 2014 Zambia preliminary subnational estimates and mid-2015 data on

antiretroviral therapy submitted through the Global AIDS Response Progress
Reporting.
252
Zambia map 3
The provinces with the lowest exposure to HIV have the highest discriminatory
attitudes. The Northern and Luapula provinces have the highest levels of
discriminatory attitudes, and Lusaka and Copperbelt provinces have the lowest
levels of discriminatory
attitudes.
Percentage
of adults
(15-49) who have discriminatory attitudes
UNAIDS
253
Zimbabwe
Overview
The population of Zimbabwe is spread unevenly among its rural

provinces, with the highest density in the eastern provinces and the
lowest in the southern region. Most new HIV infections are through
heterosexual sexual transmission. The HIV prevalence is higher in urban
areas than in rural areas. The HIV prevalence is 1.5 times higher among
women 1524 years old than among their male counterparts.
Progress
The number of new HIV infections is declining. More people living with
HIV know their status and are receiving HIV treatment, and AIDS-related
deaths have decreased. The number of men who opt for voluntary
medical male circumcision in the country has increased; tuberculosisrelated deaths among people living with HIV have also declined.
Opportunities
cities, enabling cost-efficiency in reaching people living with HIV with
treatment services and key populations with prevention services, as well
as focusing on the regions where most new infections are occurring.
Within the provinces, individual districts have been identified with high
HIV prevalence and need to be given priority.
There has been a decline in sexually transmitted infections recorded
at public health facilities, but there are recent reports of sexually
transmitted infections increasing among certain population groups,
including young people in Harare and mine workers in Mhondoro-Ngezi
district. This needs to be considered by HIV prevention efforts. The
limited data availability for key populations, including on HIV prevalence
and size estimates, needs to be addressed for effective planning and
service delivery.
254
Zimbabwe map 1
Manicaland in eastern Zimbabwe, bordering Mozambique, had the highest

number of new HIV infections among young women in 2013.
The country has implemented plans to improve matching of prevention responses
to where most new infections occur. A mapping exercise and analysis have
informed planning.
Many initiatives addressing young people are currently being implemented
through community-, health facility and school-based approaches.
New HIV infections among young females, 15-24, in Zimbabwe
Source: 2013 Zimbabwe subnational HIV estimates.
UNAIDS
255
Zimbabwe map 2
Number of adults (1549 years old) living with HIV who have never been tested
for HIV, 2010-2011
Data suggest that most of the people living with HIV who have never been tested
for HIV resides in the Midlands, Masvingo, Mashonaland West, Mashonaland
East, Manicaland and Harare provinces. Addressing gaps in the provision of HIV
testing services in these provinces would be important to increase the number of
people identified who are in need of treatment.
Percentage of adults (15-49) who have never been tested for HIV
Sources: 20102011 Demographic and Health Survey and 2013 Zimbabwe preliminary subnational HIV estimates.
256
Zimbabwe map 3
Percentage of people 1549 years old who have discriminatory attitudes towards
Percentage of adults (15-49) who have discriminatory attitudes towards

Sources: 20102011 Demographic and Health Survey and 2013 subnational HIV estimates.
UNAIDS
257
Zimbabwe map 4
Among the 290 000 people living with HIV in Harare, over 120 000 are not
receiving antiretroviral therapy. Efforts to reach people through testing outreach
and other community-based services are needed to close this gap.
Sources: 20102011 Demographic and Health Survey and 2013 subnational HIV estimates.
258
IN ZIMBABWE, THE NUMBER

OF NEW HIV INFECTIONS IS
DECLINING. MORE PEOPLE
LIVING WITH HIV KNOW THEIR
S TAT U S A N D A R E R E C E I V I N G H I V
T R E AT M E N T, A N D A I D S - R E L AT E D
D E AT H S H AV E D E C R E A S E D .
UNAIDS
259
Bank and the University of New South Wales

(Australia); 2014.
REFERENCES
Introduction
1 UNAIDS strategy 20162021. Geneva: UNAIDS
2015 (http://www.unaids.org/sites/default/files/
media_asset/20151027_UNAIDS_PCB37_15_18_
EN_rev1.pdf, accessed 14 November 2015).
2 UNAIDS estimate. Geneva: UNAIDS.
3 Shared responsibility and global solidarity for an
effective, equitable and sustainable HIV response
for the post-2015 agenda. Geneva: UNAIDS; 2015
(http://www.unaids.org/sites/default/files/media_
asset/20151028_UNAIDS_PCB37_PPT_1525_US.pdf, accessed 14 November 2015).
4 Hallett T et al. A 30 year combination prevention
intervention in Kenya: how does the pattern
of spending over time influence the impact
achievable? Unpublished; 2015.
5 UNAIDS estimate. Geneva: UNAIDS; 2014.
6 The gap report. Geneva: UNAIDS; 2014.
7 Leclerc-Madlala S. Age disparate and
intergeneration sex in southern Africa: the
dynamics of hyper vulnerability. AIDS.
2008;22(Suppl 4): S17S25.
8 Csete J, Wolfe D. Turning a page in drug control
and public health: advancing HCV/HIV prevention
through reform of drug law and policy. Future
Virol. 2015;10: 1726.
9 Ending the urban AIDS epidemic. Nairobi: United
Nations Human Settlements Programme; 2015
asset/20150918_Ending_urban_AIDS_epidemic_
en.pdf, accessed 14 November 2015).

1. Dee J. US Centers for Disease Prevention and
Control, personal communication, 1 October 2015.
2.
Kenya HIV Prevention Revolution road map: count

down to 2030. Nairobi: Kenya Ministry of Health;
2014.
3.
The costs and returns to investment of Kenyas

response to HIV/AIDS: HIV investment case
technical paper. Nairobi: Kenya Ministry of Health;
2014.
4.
Zimbabwe Ministry of Health and Child Care.

2015 Global AIDS response progress report 2015
(http://www.unaids.org/sites/default/files/country/
documents/ZWE_narrative_report_2015.pdf,
accessed 10 November 2015).
5.
Discussion paper: towards a second generation

HIV investment case for Zimbabwe. Harare:
Government of Zimbabwe and UNAIDS; 2015.
6.
260
Fraser N et al. Sudans HIV response: value for

money in a low-level HIV epidemic. Findings from
the HIV allocative efficiency study. The World
7.
Rahman T. UNAIDS, personal communication, 29

September 2015.
8.
UNAIDS HIV estimates, 19902013, unpublished.
9.
Global report, 2012. Geneva: UNAIDS; 2012, p. 11.
10. Government of Bangladesh, UNAIDS. Investment

Case: prioritizing investment options in
HIVresponse in Bangladesh to end AIDS by 2030.
11. Kripke K et al. Age targeting of voluntary medical
male circumcision programs using the DecisionMakers Program Planning Toolkit (DMPPT) 2.0.
Working paper, 2015.
12. Health service provision in Kenya: assessing facility
capacity, costs of care and patient perspectives.
Seattle, WA: Institute for Health Metrics and
Evaluation (IHME); 2014.
13. Siapka M et al. Is there scope for cost savings and
efficiency gains in HIV services? A systematic
review of the evidence from low- and middleincome countries. Bull World Health Organ.
2014;92: 499511AD (http://dx.doi.org/10.2471/
BLT.13.127639, accessed 26 October 2015).
14. IMHE and the University of Zambia. Assessing
facility capacity, costs of care and patient
perspectives. Seattle, WA: IMHE; 2014 (http://
www.healthdata.org/sites/default/files/files/policy_
report/2015/ABCE_Zambia_finalreport_Jan2015.
pdf, accessed 26 October 2015).
15. Bautista-Arredondo S. et al. Assessing cost
and technical efficiency of HIV prevention
interventions in sub-Saharan Africa: the ORPHEA
study design and methods. BMC Health Serv Res.
2014;14: 599.
Eliminating stigma and discrimination and

advancing human rights
1. Review of Demographic and Health Surveys and
AIDS Indicator Surveys conducted in 40 low- and
middle-income countries from 2009 to 2014.
2. Stangl A et al. A systematic review of interventions
to reduce HIV-related stigma and discrimination
from 2002 to 2013: how far have we come? J Int
AIDS Soc. 2013;16(3 Suppl 2): 18734 (http://www.
ncbi.nlm.nih.gov/pmc/articles/PMC3833106/,
accessed 27 October 2015).
3. Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser
SD, Bangsberg DR et al. Impact of HIV-related
stigma on treatment adherence: systematic review
and meta-synthesis. J Int AIDS Soc. 2013;16(Suppl
2): 18640 (http://www.jiasociety.org/index.php/
jias/article/view/18640, accessed 27 October 2015).
4. Review of data from People Living with HIV
Stigma Index surveys conducted in more than 50
countries.
5. 2014 National Commitments and Policies
Instrument (NCPI)countries. In: UNAIDS
[website]. Geneva: UNAIDS (http://www.

unaids.org/en/dataanalysis/knowyourresponse/
ncpi/2014countries, accessed 27 October 2015).
6. Pudpong N et al. Reducing HIV-related stigma and
discrimination in health care settings: an initiative
from Thailand. Poster presentation at International
AIDS Conference 2014 (http://pag.aids2014.org/
Abstracts.aspx?AID=11174, accessed 2 November
2015).
7. Indonesia: city focus key to the HIV response.
In: UNAIDS [website]. Geneva: UNAIDS;
17 April 2014 (http://www.unaids.org/en/
resources/presscentre/featurestories/2014/
april/20140417indonesia, accessed 27 October
2015).
8. Justice programs for health. A good practice
guide. New York: Open Society Foundations;
2015 (https://www.opensocietyfoundations.
org/sites/default/files/justice-programs-publichealth-20150701_1.pdf, accessed 27 October 2015).
9. Williamson RT, Wondergem P, Amenyah RN.
Using a reporting system to protect the human
rights of people living with HIV and key
populations: a conceptual framework. Health
and Human Rights Journal. 2014;1(16): 148156
(http://cdn2.sph.harvard.edu/wp-content/uploads/
sites/13/2014/06/Williamson1.pdf, accessed 27
October 2015).
10. Poku F N et al. Addressing human rights of key
populations and persons living with HIV in
Ghanaminimizing the human factor. Abstract
for a poster presentation submitted by the Ghana
AIDS Commission to the 18th International
Conference on AIDS and STIs in Africa (ICASA
2015), Harare, Zimbabwe, 29 November4
December 2015.
11. Ending overly broad criminalization of HIV
non-disclosure, exposure and transmission:
critical scientific, medical and legal considerations.
Geneva: UNAIDS; 2013 (http://www.unaids.
org/sites/default/files/media_asset/20130530_
Guidance_Ending_Criminalisation_0.pdf, accessed
27 October 2015).
12. Another step toward equality for people living
with HIV. In: Premier of Victoria, The Hon. Daniel
Andrews, MP [website]. Melbourne, Australia; 14
April 2015 (http://www.premier.vic.gov.au/anotherstep-toward-equality-for-people-living-with-hiv,
13. Victorian AIDS Council and Living Positive
Victoria. HIV groups welcome repeal of section
19A. Press release. 27 May 2015 (http://www.afao.
org.au/__data/assets/pdf_file/0020/24554/MediaRelease-HIV-groups-welcome-repeal-of-section19A-3.pdf, accessed 29 October 2015).
14. Ordenanza 278/2013. De habilitacin de casas de
citas, clubes nocturnos y moteles urbanos en la
ciudad de Asuncin.
15. Brown A, Tureski K, Bailey A, Rogers S, Cushnie
A, Palmer Q et al. Layered stigma among health
facility and social services staff toward most-at-
risk populations in Jamaica. Washington, DC:

C-Change/FHI360; 2012 (https://c-changeprogram.
org/sites/default/files/Layered-Stigma-Jamaica.pdf,
16. Global Commission on HIV and the Law
Report: risks, rights & health. New York: United
Nations Development Programme; 2012 (http://
www.hivlawcommission.org/resources/report/
FinalReport-Risks,Rights&Health-EN.pdf,
909090
1 UNAIDS 2014 estimates. Geneva: UNAIDS; 2014.
2 Global AIDS response progress reporting 2015.
Geneva: World Health Organization and UNAIDS;
2015.
3 Moambique: inqurito demogrfico e de sade
2011. Maputo: Instituto Nacional de Estatstica,
Ministrio da Sade and ICF International/
MEASURE DHS program; 2011 (in Portuguese)
(http://dhsprogram.com/publications/publicationFR266-DHS-Final-Reports.cfm).
4 Inqurito integrado biolgico e comportamental
entre mulheres trabalhadoras de sexo, Moambique
20112012: relatrio final. Maputo: Ministrio da
Sade; 2013 (in Portuguese).
5 Inqurito integrado biolgico e comportamental
entre homens que fazem sexo com homens,
Moambique 2011. Maputo: Ministrio da Sade;
2013 (in Portuguese).
6 Shodell D. Coordinating HIV testing with
combination prevention: a new strategic direction
for the CDC Mozambique program. Abstract no.
MOPE166. Presented at the 7th IAS Conference
on HIV Pathogenesis, Treatment and Prevention,
Vancouver, 1922 July 2015 (https://www.iasociety.
org/Abstracts/A200748281.aspx).
7 HIV Among Gay and Bisexual Men. United
States Centres for Disease Control and Prevention
[website]. (http://www.cdc.gov/hiv/group/msm/,
8 HIV in the United States: at a glance. Atlanta, GA:
Centers for Disease Control and Prevention; 2015
(http://www.cdc.gov/hiv/statistics/basics/ataglance.
html, accessed 14 November 2015).
9 Choko AT. Uptake, accuracy, safety, and linkage
into care over two years of promoting annual
self-testing for HIV in Blantyre, Malawi: a
community-based prospective study. PLoS Med.
2015;12:e1001873.
10 Violari A et al. Antiretroviral therapy initiated
before 12 weeks of age reduces early mortality in
young HIV-infected infants: evidence from the
Children with HIV Early Antiretroviral Therapy
(CHER) study. Abstract no. WESS103. Presented
at the 4th IAS Conference on HIV Pathogenesis,
Treatment and Prevention, Sydney, 2225 July

2007.
11 Global AIDS response progress reporting 2015.
2014.
12 Guideline on when to start antiretroviral therapy
and pre-exposure prophylaxis for HIV. Geneva:
World Health Organization; 2015 (http://www.
who.int/hiv/pub/guidelines/earlyrelease-arv/en/).
13 Consultation on nutrition and HIV/AIDS in
Africa: evidence, lessons and recommendations for
action, Durban, South Africa, 1013 April 2005.
Geneva: World Health Organization; 2005 (www.
who.int/nutrition/topics/Executive_Summary_
Durban.pdf).
14 Hayden E. How to beat HIV. Nature. 2015;523:146
148.
15 Havlir D. SEARCH: Uganda and Kenya. (http://
cdn2.sph.harvard.edu/wp-content/uploads/
sites/47/2015/05/Havlir.pdf, accessed 14 November
2015).
16 Chamie G. Universal HIV testing using a hybrid
approach in east Africa in the SEARCH trial.
Abstract no. 1101. Presented at the Conference
on Retroviruses and Opportunistic Infections,
Seattle, WA, 2326 February 2015 (http://www.
croiconference.org/sessions/universal-hiv-testingusing-%E2%80%9Chybrid%E2%80%9D%C2%9Dapproach-east-africa-search-trial).
17 Test and treat studies and African countries
showing that 909090 targets are achievable.
London: AIDS Ark; 2015 (http://aidsark.org/
newsinfo/treatmentnews/test-and-treat-studiesand-african-countries-showing-that-90-90-90targets-are-achievable/).
18 Zunyou Wu et al. Simplified HIV testing and
treatment in China: analysis of mortality rates
before and after a structural intervention. PLoS
Med. 2015;12(9):e1001874.
19 Best practices for elimination of mother to child
transmission of HIV: Rwanda country report.
African Union and United Nations Childrens
Fund; 2015.
20 Bor J et al. Increases in adult life expectancy in
rural South Africa: valuing the scale-up of HIV
treatment. Science. 2013;339:961965.
21 Tanser F et al. High coverage of ART associated
with decline in risk of HIV acquisition in
rural KwaZulu-Natal, South Africa. Science.
2013;339:966971.
22 Vandormael A et al. Use of antiretroviral therapy
in households and risk of HIV acquisition in
rural KwaZulu-Natal, South Africa, 200412: a
prospective cohort study. Lancet Glob Health.
2014;2:e209215.
23 Htung Naing Y et al. Introduction of a routine

viral load algorithm in rural Zimbabwe:
programmatic strategies for implementation
and impact on second line needs. Abstract no.
MOPED705. Presented at the 8th IAS Conference
Vancouver, 1922 July 2015 (http://www.ias2015.
org/WebContent/File/IAS_2015__MED2.pdf).
24 Htung Naing Y et al. Scaling up access to secondline antiretroviral therapy in rural Zimbabwe:
impact of routine viral load, model of care and resuppression after switch. Presented at the 8th IAS
Conference on HIV Pathogenesis, Treatment and
Prevention, Vancouver, 1922 July 2015 (http://
pag.ias2015.org/PAGMaterial/eposters/2826.pdf).
25 Wilkinson L, Henwood R, Patten G, Kilani C,
Dumile N, Gwashu F et al. Promoting paediatric
antiretroviral treatment (ART) adherence and
retention: outcomes of children receiving ART
in family ART adherence clubs in Khayelithsha,
South Africa. Abstract no. WEPED884. Presented
at the 8th IAS Conference on HIV Pathogenesis,
Treatment and Prevention, Vancouver, 1922 July
2015 (http://www.ias2015.org/WebContent/File/
IAS_2015__MED2.pdf, accessed 10 November
2015).
26 Bernheimer J et al. Managing children and
adolescents with HIV treatment failure: results
from a pilot project in Khayelitsha. Abstract no.
MOPEB204. Presented at the 8th IAS Conference
Vancouver, 1922 July 2015 (http://www.ias2015.
org/WebContent/File/IAS_2015__MED2.accessed
14 November 2015)
27 Mehta SH et al. HIV care continuum among men
who have sex with men and persons who inject
drugs in India: barriers to successful engagement.
Clin Infect Dis. 2015 [Epub ahead of print].

1. Alcorn K. Circumcision is reducing HIV incidence
in Uganda, Rakai community study shows. In:
aidsmap [website]. NAM Publications: London;
2015 (http://www.aidsmap.com/page/2949313/,
2. Orange Farm: beauty in the land of the poor. In:
Joburg, my city, our future. The Official Website
of the City of Johannesburg [website](http://
www.joburg.org.za/index.php?option=com_
content&id=932&Itemid=52, accessed 25 October
2015).
3. Geffen N. Orange Farm circumcision results dispel
concerns about risk compensation. HIV Treatment
Bulletin. 1 October 2011 (http://i-base.info/
htb/15826, accessed 25 October 2015).
4. Rech D. et al. CHAPS harnesses the private sector
to further national VMMC goals. Draft case study
prepared by CHAPS to be published in November
2015. Draft shared with UNAIDS on 23 September
2015.
UNAIDS
261
5. Partnering with private providers in South Africa

to offer medical male circumcision services: a
case study. PEPFAR; November 2014 (http://
www.healthcommcapacity.org/wp-content/
uploads/2015/01/CaseStudySA.pdf, accessed 25
October 2015).
6.
Stover J. The Contribution of Condoms to HIV

Prevention. Presented at the UNAIDS Global
Condom Meeting. Geneva, November 2014.
7.
Estimates. Geneva: Avenir Health and UNAIDS;

2015.
20. Egger M et al. Promotion of condom use in a highrisk setting in Nicaragua: a randomised controlled
trial. The Lancet. 2000;355: 21012105.
6. Tanzania: HIV/AIDS and malaria indicatory

survey. 200708. Dar Es Salaam (The United
Republic of Tanzania): TACAIDS, ZAC, NBS,
OCGS, and Macro International; 2008 (http://
dhsprogram.com/pubs/pdf/ais6/ais6_05_14_09.
8.
Pinkerton SD, Abramson PR. Effectiveness of

condoms in preventing HIV transmission. Social
Science & Medicine. 1997;44:13031312.
21. Agha S et al. The promotion of condom use in nonregular sexual partnerships in urban Mozambique.
Health Policy and Planning. 2001;16: 144151.
9.
UNFPA contraceptives price indicator. Geneva:

United Nations Population Fund; 2014 (http://
www.unfpa.org/sites/default/files/resourcepdf/UNFPA%20Contraceptive%20Price%20
Indicators%202014.accessed 14 November 2015).
22. Meekers D. The role of social marketing in STD/

HIV prevention in 4,600 sexual contacts in urban
Zimbabwe. AIDS. 2001;15: 285287.
7. Mahler H et al. Covering the last kilometre:

using GIS to scale-up voluntary medical male
circumcision services in Iringa and Njombe
regions, Tanzania. Global Health: Science and
Practice. 2015; 3(3): 503515 (http://www.
ghspjournal.org/content/3/3/503.full.pdf, accessed
25 October 2015).
8. HIV prevalence among adults (1549). In:
UNAIDS aidsinfo [website]. UNAIDS; 2015
(http://aidsinfo.unaids.org/, accessed 5 November
2015).
9. Global AIDS response progress report 2015:
Lesotho country report. Ministry of Health,
Government of Lesotho (http://www.unaids.
org/sites/default/files/country/documents/LSO_
narrative_report_2015.pdf, Accessed 5 November
2015).
10. Reed J. Jhpiego, personal communication. 16
October 2015.
11. Mavhu W et al. safety and acceptability of
the PrePex device when used in routine male
circumcision service delivery during active
surveillance in Zimbabwe. JAIDS Supplement.
Accepted for publication; not yet published.
Condoms
1. Halperin DT et al. A surprising prevention success:
why did the HIV epidemic decline in Zimbabwe?
PLoS Med. 2011;8:e1000414.
2.
3.
4.
5.
262
Johnson LF et al. The effect of changes in condom

usage and antiretroviral treatment coverage on
human immunodeficiency virus incidence in South
Africa: a model-based analysis. Journal of the
Royal Society Interface. 2012;9:15441554.
Boily MC et al. Positive impact of a large-scale HIV
prevention programme among female sex workers
and clients in South India. AIDS. 2013;27:1449
1460.
Rachakulla HK et al. Condom use and prevalence
of syphilis and HIV among female sex workers in
Andhra Pradesh, Indiafollowing a large-scale
HIV prevention intervention. BMC Public Health.
2011;11(Suppl. 6):S1.
Evaluation of the 100% Condom Programme in
Thailand. Geneva: UNAIDS; 2000.
10. How AIDS changed everything. Geneva:

UNAIDS; 2015 (http://www.unaids.org/en/
resources/documents/2015/MDG6_15years15lessonsfromtheAIDSresponse, accessed 14
November 2015).
11. Meeting report. The global condom push meeting:
global consultation on the role of condoms in the
prevention of HIV, other sexually transmitted
infections and unintended pregnancy. UNAIDS,
Geneva 67 November, 2014.
12. Fossgard IS et al. Condom availability in high risk
places and condom use: a study at district level in
Kenya, Tanzania and Zambia. BMC Public Health.
2012;12: 1030.
13. Access to HIV prevention and treatment for
men who have sex with men: findings from the
2012 Global Mens Health and Rights Study.
Oakland, CA: Global Forum on MSM & HIV;
2012 (http://23.91.64.91/~msmgf/wp-content/
uploads/2015/09/GMHR_2012.pdf, accessed 16
November 2015).
14. The GLAM toolkit: advocacy to improve access
to safe, condom-compatible lubricant in Africa.
New York: Global Advocacy for HIV Prevention;
2012 (http://www.avac.org/sites/default/files/
resource-files/GLAM_Toolkit_EN.pdf, accessed 14
November 2015).
15. Sandy IF et al. Targeting condom distribution
at high risk places increases condom utilizationevidence from an intervention study in
Livingstone, Zambia. BMC Public Health. 2012;12:
10.
16. Laukamm-Josten U et al. Preventing HIV infection
through peer education and condom promotion
among truck drivers and their sexual partners in
Tanzania, 19901993. AIDS Care. 2000;12:2740.
17. Wheres the best get-laid-place in the world?
Condom08 (https://vimeo.com/56025126, accessed
14 November 2015).
18. QR code condoms promote safe sex. Condom08;
2011 (https://youtu.be/Xw4DTcinBss, accessed 14
November 2015).
19. Des Jarlais DC et al. Combined HIV prevention,
the New York City condom distribution program,
and the evolution of safer sex behavior among
persons who inject drugs in New York City. AIDS

and Behavior. 2014;18: 443451.
23. Chapman S et al. Condom social marketing in

sub-Saharan Africa and the total market approach.
Sexual Health. 2012;9: 4450.
24. AIDSinfo. Geneva: UNAIDS; 2014 (http://aidsinfo.
unaids.org/#).
25. Shisana O et al. South African national HIV
prevalence, incidence and behavioural survey,
2012. Cape Town: HSRC Press; 2014.
26. Massyn N, Peer N, Padarath A, Barron P, Day
C, editors. District health barometer 2014/15.
Durban: Health Systems Trust; October 2015
(http://www.hst.org.za/sites/default/files/
Complete_DHB_2014_15_linked., accessed 14
November 2015).
27. Get ready for free flavoured condoms. 13
March 2015. Health24 (http://www.health24.
com/Sex/News/Get-ready-for-free-flavouredcondoms-20150313, accessed 5 November 2015).
28. SAB distributes more than 19 million condoms to
SA taverns. 1 December 2014. The South African
Breweries (http://www.sab.co.za/sablimited/
content/sab-press-releases?oid=134960&sn=Detail
&pid=62, accessed 5 November 2015).
29. Department of Health, Government of South
Africa. National Strategic Plan for AIDS, STIs and
TB, 20122016.
30. Burke RC et al. The NYC Condom: use and
acceptability of New York Citys branded condom.
American Journal of Public Health. 2009;99:2178
2180.
31. Burke RC et al. NYC Condom use and satisfaction
and demand for alternative condom products in
New York City sexually transmitted disease clinics.
Journal of Urban Health. 2011;88: 749758.
32. Endale Workalemahu Tilahun, MULU/MARPs
HIV Prevention Project, PSI/Ethiopia. Personal
communication, 15 October 2015.
1. Baeten JM, Donnell D, Ndase P, Mugo NR,
Campbell JD, Wangisi J et al. Antiretroviral
prophylaxis for HIV prevention in heterosexual
men and women. N Engl J Med. 2012;267:
399410.
2.
Choopanya K, Martin M, Suntharasamai P,

Sangkum U, Mock PA, Leethochawalit M et al.
Antiretroviral prophylaxis for HIV infection in
injecting drug users in Bangkok, Thailand (the
Bangkok Tenofovir Study): a randomised, doubleblind, placebo-controlled phase 3 trial. The Lancet.
2013;381(9883): 20832090.
3. Grant RM, Lama JR, Anderson PL, McMahan

V, Liu AY, Vargas L et al. Preexposure
chemoprophylaxis for HIV prevention in men
who have sex with men. N Engl J Med. 2010;363:
25872599.
4.
Thigpen MC, Kebaabetswe PM, Paxton LA, Smith

DK, Rose CE, Segolodi TM et al. Antiretroviral
preexposure prophylaxis for heterosexual
HIV transmission in Botswana. N Engl J Med.
2012;367:423434.
5. Eisingerich AB, Wheelock A, Gomez GB,

Garnett GP, Dybul MR, Piot PK. Attitudes and
acceptance of oral and parenteral HIV preexposure
prophylaxis among potential user groups: a
multinational study. PLoS One. 2012;7(1):e28238.
6.
7.
8.
9.
Barash EA, Golden M. Awareness and use of HIV

pre-exposure prophylaxis among attendees of a
Seattle Gay Pride event and sexually transmitted
disease clinic. AIDS Patient Care and STDs.
2010;24(11): 68991.
Krakower DS, Mimiaga MJ, Rosenberger JG,
Novak DS, Mitty JA, White JM et al. Limited
awareness and low immediate uptake of preexposure prophylaxis among men who have sex
with men using an Internet social networking site.
PLoS One. 2012;7(3): e33119.
Mimiaga MJ, Case P, Johnson CV, Safren SA,
Mayer KH. Pre-exposure antiretroviral prophylaxis
attitudes in high-risk Boston area men who report
having sex with men: limited knowledge and
experience but potential for increased utilization
after education. JAIDS Journal of Acquired
Immune Deficiency Syndromes. 2009;50(1): 7783.
Preexposure prophylaxis for the prevention of HIV
infection in the United States2014. A clinical
practice guideline. US Dept. of Health and the
Centre for Disease Control; 2014 (http://www.cdc.
gov/hiv/pdf/PrEPguidelines2014.pdf, accessed 25
October 2015).
10. Mascolini M. Wider PrEP use in San Francisco

could cut new HIV rate by 70%. Report on
the 22nd Conference on Retroviruses and
Opportunistic Infections, Seattle, Washington,
2326 February 2015. In:National AIDS Treatment
Advocacy Project [website]. NATAP: New York;
2015 (http://www.natap.org/2015/CROI/croi_08.
htm, accessed 25 October 2015).
11. San Francisco Department of Public Health,
Population Health Division, HIV Epidemiology
annual report 2014, HIV epidemiology section
August 2015 (in press)
12. Grant RM, Albert Liu A, Jen Hecht J, et al. Scale-up
of preexposure prophylaxis in San Francisco to
impact HIV incidence. Presented at the Conference
on Retroviruses and Opportunistic Infections,

23-26 February 2015. Seattle, Washington. Abstract
25.
13. UNAIDS HIV and AIDS estimates, Zimbabwe,
2014. In: UNAIDS countries [website] (http://
www.unaids.org/en/regionscountries/countries/
zimbabwe, accessed 14 November 2015).
14. The gap report. Geneva: UNAIDS; 2014.
15. UNAIDS PCB field visit to Zimbabwe: UNAIDS/
PCB (36)/15.CRP.5; June 2015.
16. Centre for Sexual Health and HIV/AIDS Research
Zimbabwe [website] (http://www.ceshhar.demo.
mayrah.net/key-populations, accessed 2 November
2015).
17. Boletim Epidemiolgico: HIV/AIDS. Ano III,
no. 1. Brasilia: Ministrio da Sade, Secretaria de
Vigilncia em Sade,Departamento de DST, Aids
e Hepatites Virais; 2014 (http://www.aids.gov.br/
sites/default/files/anexos/publicacao/2014/56677/
boletim_2014_final_pdf_15565.pdf, accessed 25
October 2015).
18. Ligia RFS Kerr et al. HIV among MSM in a large
middle-income country. AIDS. 2013;27: 427435.
19. Brandelli Costa A et al. HIV prevalence and
associated factors in male-to-female and femaleto-male transsexuals from southern Brazil: a
population-based study. Presented at the 20th
International AIDS Conference, Melbourne,
Australia, 2025 July 2014.
20. Hoagland B (presenter Grinsztejn B). Pre-exposure
prophylaxis (PrEP) uptake and associated factors
among MSM and TGW in the PrEP Brasil
demonstration project. Eighth IAS Conference on
HIV Pathogenesis, Treatment and Prevention (IAS
2015), Vancouver. Abstract TUAC0205LB. 1922
July 2015.
21. Priss ARS et al. Knowledge about HIV
preventative measures among MSM using internetbased social networks in Brazil. Presented at IAS
2013, Kuala Lumpur, Malaysia, 30 June3 July,
2013 (http://pag.ias2013.org/EPosterHandler.
axd?aid=1823, accessed 25 October 2015).
22. Thailand AIDS response progress report 2015.
National AIDS Committee, Government of
Thailand (http://www.unaids.org/sites/default/files/
country/documents/THA_narrative_report_2015.
23. Expanding pre-exposure prophylaxis (PrEP) for
HIV in Thailand. IN: amfAR [website]. amfAR;
2015 (http://www.amfar.org/expanding-preexposure-prophylaxis-for-hiv-thailand/, accessed
25 October 2015).
24. Colby D. PrEP demand, creation and monitoring:
the perspective from South East Asia, presentation
at PrEP and Adolescents UNICEF Consultation,
1718 July 2015 Vancouver.
25. Gauteng. In: The Local Government Handbook
[website] (http://www.localgovernment.co.za/
provinces/view/3/gauteng, accessed 25 October

2015).
26. Eakle R et al. Expanded use of ARV for treatment
and prevention for female sex workers in South
Africa. AIDS Research and Human Retroviruses.
2014;30 Suppl 1: a1312.

1. Dellar RC, Dlamini S and Abdool Karim
Q. Adolescent girls and young women: key
populations for HIV epidemic control. J Int AIDS
Soc. 2015;18(2 Suppl 1): 19408 (http://www.ncbi.
nlm.nih.gov/pmc/articles/PMC4344544/, accessed
31 October 2015).
2.
Durevall D and Lindskog A. Intimate partner

violence and HIV in ten sub-Saharan African
countries: what do the demographic and health
surveys tell us? Lancet Glob Health. 2015;3:
e3443.
3.
Womens health: womens health fact sheet No. 334.

Geneva: World Health Organization; 2013.
4.
Jewkes RK, Dunkle K, Nduna M, Shai M. Intimate

partner violence, relationship power inequity, and
incidence of HIV infection in young women in
South Africa: a cohort study. Lancet. 2010;376:
4148.
5.
Durevall D. Intimate partner violence and HIV in

ten sub-Saharan African countries: what do the
Demographic and Health Surveys tell us? Lancet
Glob Health 2015; 3: e3443 Published Online 21
November 2014.
6.
The magnitude of the problem: violence against

children survey from five countries. Together for
girls (http://www.togetherforgirls.org/wp-content/
uploads/violence_children_infographic_lg.png,
7.
The gap report. Geneva: UNAIDS; 2014.
8.
Marrying too young: end child marriage. New

York: United Nations Population Fund; 2012.
9.
Leclerc-Madlala S. Age disparate and

intergeneration sex in southern Africa; the
dynamics of hyper vulnerability. AIDS.
2008;22(Suppl 4): S17S25.
10. Cluver C et al. Child-focused state cash transfers

and adolescent risk of HIV infection in South
Africa: a propensity-score-matched case-control
study. The Lancet Global Health. 2013(1.6): e362
e370.
11. Working together for an AIDS-free future for
girls and women. In: PEPFAR [website]. U.S.
Government interagency website managed by the
Office of U.S. Global AIDS Coordinator and the
Bureau of Public Affairs, U.S. State Department
(http://www.pepfar.gov/partnerships/ppp/dreams/
index.htm, accessed 30 October 2015).
12. Saul J. United States Centres for Disease
Prevention and Control, personal communication.
9 October 2015.
UNAIDS
263
13. Jukes M et al. Education and vulnerability: the

role of schools in protecting young women
and girls from HIV in southern Africa. AIDS.
2008;22(Suppl 4): S4156. doi: 10.1097/01.
aids.0000341776.71253.04.
14. De Neve JW et al. Length of secondary schooling
and risk of HIV infection in Botswana: evidence
from a natural experiment. The Lancet Global
Health. 2015;3(8): e470e477.
15. Michau L et al. SASA! Activist kit for preventing
violence against women and HIV. Kampala,
Uganda: Raising Voices; 2009.
16. Uganda Bureau of Statistics (UBOS) and Macro
International Inc. Uganda demographic and health
survey 2006. Calverton, MD: UBOS; 2007.
17. UNAIDS 2014 estimates.
18. Nambusi K et al. The impact of SASA!, a
community mobilization intervention, on reported
HIV-related risk behaviours and relationship
dynamics in Kampala, Uganda. Journal of the
International AIDS Society. 2014;17: 19232.
Gay men and other men who have

sex with men
1. Beyrer C, Sullivan P, Millett G et al. The increase
in global HIV epidemics in MSM. AIDS. 07/2013;
27(17).
3. Itaborahy LP, Zhu J. State-sponsored homophobia:
a world survey of laws: criminalisation, protection
and recognition of same-sex love. Geneva:
International Lesbian, Gay, Bisexual, Trans and
Intersex Association (ILGA); May 2015.
4. Global Commission on HIV and the Law. Risks,
rights and health. New York: United Nations
Development Programme; July 2012.
5. Global AIDS response progress reporting
2014. Geneva: UNAIDS; 2014 (http://www.
aidsinfoonline.org, accessed 9 November 2015).
7. HIV and young men who have sex with men.
A technical brief. Geneva: World Health
Organization (WHO); 2015 (http://apps.who.
int/iris/bitstream/10665/179867/1/WHO_
HIV_2015.8_eng.pdf, accessed 9 November 2015).
8. Stein JA, Rotheram-Borus MJ, Swendeman D,
Milburn NG. Predictors of sexual transmission risk
behaviours among HIV-positive young men. AIDS
Care. 2005;17(4): 43342.
9. Adam PC, de Wit JB, Toskin I, Mathers BM,
Nashkhoev M, Zablotska I et al. Estimating levels
of HIV testing, HIV prevention coverage, HIV
knowledge, and condom use among men who have
sex with men (MSM) in low-income and middleincome countries. J Acquir Immune Defic Syndr.
2009;52(Suppl 2): S143S151.
264
10. Morales-Miranda S, Alvarez-Rodriguez B,

Arambu N, Aguilar J, Huamn B, Figueroa W
et al. Encuesta de vigilancia de comportamiento
sexual y prevalencia del VIH e ITS, en poblaciones
vulnerables y poblaciones clave. Ciudad de
Guatemala: HIVOS; 2013.
11. Memoria de labores RP HIVOS Guatemala, 2014.
Ciudad de Guatemala: HIVOS; 2015.
12. Informe de fase I: subvencin conteniendo la
epidemia de VIH en Guatemala: intensificacin
de las acciones de prevencin y atencin integral
en grupos vulnerables y reas prioritarias de
Guatemala GUA-311-G05. Ciudad de Guatemala:
HIVOS; 2014.
13. McWatters C. MSM stigma and HIV transmission
in modern China: investigating the 4th phase of
HIV infection. May 2015 (http://deepblue.lib.
umich.edu/bitstream/handle/2027.42/112081/
colinmcw.pdf?sequence=1&isAllowed=y, accessed
on 5 November 2015).
14. 2014 China AIDS response progress report.
National Health and Family Planning Commission
of the Peoples Republic of China. June 2014 (http://
www.unaids.org/sites/default/files/documents/
CHN_narrative_report_2014.pdf, accessed 10
November 2015).
15. Geng Le. Blued, personal communication. May
2015.
16. Larson C. Worlds largest gay dating app, born in
China, now attracts global investors. 10 December
2014. In: Bloomberg business: technology
[website] (http://www.bloomberg.com/bw/
articles/2014-12-10/chinas-main-app-for-gaysattracts-venture-capital#p2, accessed 9 November
2015).
17. The Brazilian respons to HIV and AIDS: global
AIDS response progress reporting (GARPR)
narrative report. Ministry of Health, Brazil. June
country/documents/BRA_narrative_report_2015.
pdf, accessed 10 November 2015).
18. Zanelatto GP. Abordagem economica para
acoes de saude relacionadas ao HIV/AIDS entre
populacao-chave em Curitiba. Universidad
Federal do Parana. Curitiba 2014 (http://
dspace.c3sl.ufpr.br:8080/dspace/bitstream/
handle/1884/38238/MONOGRAFIA36-2014-2.
pdf?sequence=1&isAllowed=y, accessed 10
November 2015).
19. UNAIDS: virtual platform offers innovative
HIV testing in Curitiba. 10 February 2015. In:
UN Brazil [website] (http://nacoesunidas.org/
unaids-plataforma-virtual-disponibiliza-testageminovadora-para-o-hiv-em-curitiba/, accessed 9
November 2015).
20. Plataforma virtual oferece teste de HIV que pode
ser feito em casa. 10 February 2015. In: Prefeitura
Municipal de Curitiba: Sade [website] (http://
www.curitiba.pr.gov.br/noticias/plataformavirtual-oferece-teste-de-hiv-que-pode-ser-feitoem-casa/35486, accessed 9 November 2015).
21. Curitiba mobilizes the population for HIV fast

testing. 20 April 2006. In: Department of STD,
AIDS and Viral Hepatitis [Brazil] (http://www.aids.
gov.br/en/noticia/curitiba-mobilizes-populationhiv-fast-testing, accessed 9 November 2015).
22. Day and night, an HIV clinic in Quezon City
serves as a beacon of hope. World Health
Organization Representative Office: Philippines;
2014.
23. Makati, Quezon City, lead in implementation
of world-class HIV counselling and testing
programs. 2013. In: Loveyourself [website]. Manila:
Love Yourself; 2015 (http://www.loveyourself.
ph/2013/02/makati-quezon-city-lead-in.html,
24. Heimer R, Khoshnood K, Crawford F, Shebl F,
Barbour R, Khouri D et al. Size estimation, risk
behavior assessment, and disease prevalence in
populations at Project CROSSROADS: high risk for
HIV infection in Lebanon. Lebanon: Middle East
and North Africa Harm Reduction Association
(MENAHRA); 2015.
25. The Global Forum on MSM & HIV (MSMGF).
MSMGF quarterly report, fourth quarter:
OctoberDecember 2013. 22 January 2013
(http://www.msmgf.org/files/msmgf/documents/
MSMGF_2013QR_Q4(1).pdf, accessed 10
November 2015).
26. The Global Forum on MSM & HIV (MSMGF).
Missing voices from the field: a selection of MSM
& transgender abstracts rejected from th 2012
International AIDS Conference (http://www.
msmgf.org/files/msmgf/About_Us/MSMGF_
RejectedAbstracts2012rev1.pdf, accessed 10
November 2015).
27. Global examples of HIV testing services: case
examples. World Health Organization. 2015 (http://
apps.who.int/iris/bitstream/10665/180212/1/
WHO_HIV_2015.22_eng.pdf, accessed 10
November 2015).
28. HELEM: a case study of the first legal, aboveground LGBT organization in the MENA region.
The National AIDS Control Programme, Ministry
of Public Health, Republic of Lebanon. 21 October
2008 (http://www.moph.gov.lb/Prevention/AIDS/
Documents/Helem.pdf, accessed 10 November
2015).
29. Sexual health. In: The Initiative for Equal Rights
[website]. Lagos: Initiative for Equal Rights: 2015
(http://www.theinitiativeforequalrights.org/sexualhealth/, accessed 9 November 2015).
30. Henderson M. On the ground: programmes
serving the needs of key populations. World Health
Organization; 2014 (http://apps.who.int/iris/
bitstream/10665/145002/1/WHO_HIV_2014.50_
eng.pdf?ua=1, accessed 9 November 2015).
31. Akoro JS. Nigeria LGBT community discovers
a safe place. 24 April 2014. In: The Initiative
for Equal Rights [website]. Lagos: The
Initiative for Equal Rights; 2014 (http://www.
theinitiativeforequalrights.org/nigeria-lgbt-
community-discover-a-safe-space/, accessed 9
November 2015).
[website] (https://www.amnesty.org/es/
latest/news/2015/07/ser-mujer-trans-en-elsalvadortengo-miedo-constantemente/, accessed 5
November 2015).
32. Advancing the sexual and reproductive health and

human rights of men who have sex with men living
with HIV: a policy briefing. Amsterdam: Global
Network of People Living with HIV; 2010.
12. Gomez C. Plan International Inc.El Salvador,

personal communication. 21 September 2015.
Transgender People
13. Miranda C. UNAIDSEl Salvador, personal

communication. 21 September 2015.
1. Baral S, Poteat T, Strmdahl T, Wirtz A, Guadamuz

T, Beyrer C. Worldwide burden of HIV in
transgender women: a systematic review and metaanalysis. The Lancet. 2013;13: 214.
14. Avahanthe India AIDS initiative: the business of

HIV prevention at scale. New Delhi: Bill & Melinda
Gates Foundation; 2008.
Transgender Europe. IDAHOT TMM press

release: 8 May 2015 (http://transrespect.org/en/
transgender-europe-idahot-tmm-2015/, accessed
29 October 2015).
15. Goswami P, Rachakulla HK, Ramakrishnan L et

al. An assessment of a large-scale HIV prevention
programme for high-risk men who have sex with
men and transgenders in Andhra Pradesh, India:
using data from routine programme monitoring
and repeated cross-sectional surveys. BMJ Open.
2013;3: e002183 (http://bmjopen.bmj.com/
content/3/4/e002183.full?rss=1, accessed 27
October 2015).
4.
Malaysia: end arrests of transgender women.

In: Human Rights Watch [website]. New York:
Human Rights Watch; 23 June 2014 (http://
www.hrw.org/news/2014/06/23/malaysia-endarreststransgender-women, accessed 27 October
2015).
16. Breaking through barriers: Avahans scale-up

of HIV prevention among high-risk MSM
and transgenders in India. New Delhi: Bill &
Melinda Gates Foundation, 2010 (https://docs.
gatesfoundation.org/Documents/breakingthrubarriers.pdf, accessed 27 October 2015).
5.
Concluding observations of the Human Rights

Committee on Kuwait (CCPR/C/KWT/CO/2)
2011, para. 30.
17. Sema K. Sgaier et al. How the Avahan HIV

prevention program transitioned from the Gates
Foundation to the Government Of India. Health
Affairs. 2013;32(7): 12651273.
6.
Sevelius JM, Saberi P, Johnson MO. Correlates of

antiretroviral adherence and viral load among
transgender women living with HIV. AIDS Care.
2014;26(8): 976982.
2.
3.
Operario D, Soma T, Underhill K. Sex work and

HIV status among transgender women systematic
review and meta-analysis. Journal of Acquired
Immune Deficiency Syndromes. 2008;48: 97103.
7. Van Devanter N, Duncan A, Raveis VH, Birnbaum

J, Burrell-Piggott T, Siegel K. Continued sexual risk
behavior in African American and Latino male-tofemale transgender adolescents living with HIV/
AIDS: a case study. J AIDS Clin Res. 2011;(S1):
002.
8.
9.
Operario D, Soma T, Underhill K. Sex work and

HIV status among transgender women: systematic
review and meta-analysis. J Acquir Immune
Defic Syndr. 2008;48(1): 97103. doi:10.1097/
QAI.0b013e31816e3971.
Hernandez Ayala FM, Nieto AI, Lara G. Estudio
de estimacin de talla poblacional, encuesta de
comportamiento sexual y prevalencia de VIH en
mujeres trans de El Salvador, 2014. San Salvador, El
Salvador: Ministerio de Salud de El Salvador; 2014.
10. The stigma and discrimination study. United

States Agency for International Development
(USAID) and Program for Strengthening the
Central American Response to HIV/AIDS
(PASCA); October 2011 (http://www.pasca.org/
userfiles/INFORME%20EYD%202013%20EL%20
SALVADOR%20VFINAL%20MARZO%202014.
11. Ser mujer trans en El Salvador: tengo miedo
constantemente. In: Amnista Internacional
18. Mexico City HIV/AIDS Programme. Model of

HIV control and prevention strategy through
integration of prevention and care services at
the primary care level. PowerPoint presented
at Fast-Track cities: ending the AIDS epidemic
consultation meeting, 2528 May 2015, Mumbai,
India.
19. INSP, CEC, PSI Mexico, Principales resultados de
la encuesta de salud con sero-prevalencia de VIH
a mujeres transgnero en la Ciudad de Mxico
(http://condesadf.mx/pdf/ecuesta_trans2013.pdf,
20. Clnica Especializada Condesa homepage. In:
Clnica Especializada Condesa [website]. Mexico
City: Condesa (http://condesadf.mx/, accessed 27
October 2015).
21. Tercer Congreso de VIH en las Amricas 2015. In:
Clnica Especializada CONDESA [website] (http://
condesadf.mx/rokstories/tercer-congreso-devihen-las-americas-2015.htm, accessed 27 October
2015).
22. Law no. 17,515.
23. The formalization of sex work by transgender
people in Uruguay. International HIV/
AIDS Alliance, REDLACTRANS Regional
Secretariat and the Transgender Association of
Uruguay; no date (http://www.aidsalliance.org/
assets/000/000/397/90588-Making-rights-a-reality-
Uruguay-case-study_original.pdf?1405522184,
24. Diversidad sexual y derecho a la salud: el acceso
de las personas trans. Montevido: Divisin de
Derechos Humanos, Direccin Nacional de
Promocin Sociocultural (DNPSC) and Ministerio
de Desarrollo Social (MIDES); 2 October
2015 (http://www.mides.gub.uy/innovaportal/
file/57928/1/doc_base_transforma_2015.pdf,

1. World drug report 2015. Vienna: United Nations
Office on Drugs and Crime; 2015.
2.
The global state of harm reduction 2014. London:

Harm Reduction International; 2014.
3.
Unpublished data. Geneva: UNAIDS; 2015.
4.
How AIDS changed everythingMDG6: 15

years, 15 lessons of hope from the AIDS response.
Geneva: UNAIDS; 2015.
5.
Halving HIV transmission among people who

inject drugs. Geneva: UNAIDS; 2014 (UNAIDS/
PCB (35)/14.27 (http://www.unaids.org/sites/
default/files/media_asset/20141125_Background_
Note_Thematic_Segment_35PCB.pdf, accessed 11
November 2015).
6.
Sullivan SG et al. Continued drug use during

methadone treatment in China: a retrospective
analysis of 19,026 service users. J Subst Abuse
Treat. 2014;47: 8692.
7.
Global AIDS response progress report 2015.

2015.
8.
National Health and Family Planning Commission

of the Peoples Republic of China. 2014 China
AIDS response progress report. Geneva: UNAIDS;
2014.
9.
Sypsa V et al. HIV outbreak in Greece: results of

the ARISTOTLE study. PowerPoint presentation.
10. Hatzakis A et al. Design and baseline findings of

a large-scale rapid response to an HIV outbreak
in people who inject drugs in Athens, Greece: the
ARISTOTLE programme. Addiction. 2014;110:
14531467.
11. Wolfe D, Elovich R, Boltaev A and D Pulatov.
HIV in central Asia: Tajikistan, Uzbekistan and
Kyrgyzstan. In: Celentano DD and Beyrer C,
editors. Public health aspects of HIV/AIDS in lowand middle-income countries. New York: SpringerVerlag; 2008: 55781.
12. Beletsky L et al. Police education as a component of
national HIV response: lessons from Kyrgyzstan.
Drug Alcohol Depend. 2013;132(Suppl 1): S48
S52.
13. PUD project Kyrgyzstan. Amsterdam: Bridging
the Gaps (http://www.hivgaps.org/projects/people-
UNAIDS
265
who-use-drugs-projects/pud-project-kyrgyzstan/,
7.
14. Kamarulzaman A, McBrayer J. Compulsory drug

detention centers in East and Southeast Asia. Int J
Drug Policy. 2015;26: S33S37.
15. Compulsory drug detention and rehabilitation
centres. Geneva: UNAIDS; 2012 (http://www.
unaids.org/en/media/unaids/contentassets/
documents/document/2012/JC2310_Joint%20
Statement6March12FINAL_en.pdf, accessed 11
November 2015).
16. Kaur S. Cure & care Malaysia clinic: towards an
integrated treatment and rehabilitation for people
who use drugs. Presented at the International AIDS
Conference, Washington, DC, 2227 July 2012.
17. Ghani MA et al. An exploratory qualitative
assessment of self-reported treatment outcomes
and satisfaction among patients accessing an
innovative voluntary drug treatment centre in
Malaysia. Int J Drug Policy. 2015;26: 175182.
18. Drug harms in Malaysia: a technical brief. Kuala
Lumpur: Malaysian AIDS Council; 2015 (http://
www.mac.org.my/v3/wp-content/uploads/2015/06/
SDP_Technical_Brief_on_Drug_Harms_in_
Malaysia_20150625.pdf, accessed 11 November
2015).
19. National Anti-drugs Agency. Presented at the Third
Regional Consultation on Compulsory Centres for
Drug Users in Asia and the Pacific, Manila, 2123
September 2015.
Sex workers
1. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL,
Decker MR et al. Burden of HIV among female
sex workers in low-income and middle-income
countries: a systematic review and meta-analysis.
Lancet Infect Dis. 2012 Jul;12(7): 53849. doi:
10.1016/S1473-3099(12)70066-X.
2 . Prss-Ustn A, Wolf J, Driscoll T, Degenhardt
L, Neira M, Calleja JMG. HIV due to female sex
work: regional and global estimates. PLoS ONE.
2013;8: e63476.
3.
4.
Steen R, Zhao P, Wi TE, Punchihewa N,

Abeyewickreme I, Lo YR. Halting and reversing
HIV epidemics in Asia by interrupting
transmission in sex work: experience and outcomes
from ten countries. Expert Rev Anti Infect Ther.
2013;11: 9991015.
Ashley L, Grosso AL, Lei EL, Ketende SC,
Peitzmeier S, Mason K et al. Correlates of condom
use among female sex workers in the Gambia:
results of a cross-sectional survey. Peer J. 2015;3:
e1076.
5. Baral SD, Friedman MR, Geibel S, Rebe K,

Bozhinov B, Diouf D et al. Male sex workers:
practices, contexts, and vulnerabilities for HIV
acquisition and transmission. Lancet. 2015;385:
26073.
6.
266
UNAIDS estimates, 2014.
Berthe A, Traore I, Salouka S, Sanou L, Rouamba

J, Ouedraogo D et al. Analyse de la situation de la
prostitution et de la rponse au VIH dans le secteur
du commerce sexuel Ouagadougou (Burkina
Faso). Bobo-Dioulasso: SHADEI-MURAZ; 2009.
8.
tude comportementale et de seroprevalence du

VIH et de la syphilis auprs des hommes ayant
de rapports sexuels avec dautres hommes (HSH),
les travailleuses du sexe (TS), a Ouagadougou et a
Bobo-Dioulasso, Burkina Faso. Rapport provisoire.
PAMAC, IRSS, AIDSETI: 2014.
9.
Traore IT. Department of Clinical Research, Centre

Muraz, personal communication. 28 October 2015.
10. Traore IT, Meda N, Hema NM, Ouedraogo D,

Some F, Some R et al. HIV prevention and care
services for female sex workers: efficacy of a
targeted community-based intervention in Burkina
Faso. J Int AIDS Soc. 2015;18: 20088.
11. Rapport dactivite Yerelon JanJuin 2015. BoboDioulasso: Projet IMT; 2015.
12. Kenya MARPs size estimation consensus report
2012/2013. Nairobi, Kenya: National AIDS and STI
Control Programme (NASCOP); 2013.
13. 20102011 Integrated biological and behavioural
survey among most-at-risk-populations in Nairobi
and Kisumu. Nairobi, Kenya: NASCOP; 2014.
14. Odek WO, Githuka GN, Avery L, Njoroge PK,
Kasonde L, Gorgens M et al. Estimating the size
of the female sex worker population in Kenya to
inform HIV prevention programming. PLoS ONE.
2014;9: e89180.
15. Key populations progress update, July 2013June
2015 [slide presentation]. Nairobi: Monitoring and
Evaluation Unit for Key Populations, NASCOP and
the Kenya Ministry of Health; 2015.
16. Greenall M et al. Sex work and HIVreality on
the ground: rapid assessments in five towns in
Namibia. Windhoek: United Nations Population
Fund and UNAIDS Namibia; 2011 (http://esaro.
unfpa.org/publications/sex-work-and-hiv-realityground, accessed 2 November 2015).
17. Shinana A, Zapata T, Sehgal S, Greenall M, Jonker
A, Masilani T et al. Empowering sex workers to
claim their right to access non-stigmatizing HIV
and AIDS, health and social services in Namibia.
19th International AIDS Conference, 2227 July
2012, Washington, DC (TUPE420).
18. Greenall M. Sex work, HIV and access to health
services in Namibia: national meeting report
and recommendations. Windhoek: UNFPA and
UNAIDS Namibia; 2011. (http://esaro.unfpa.org/
sites/esaro/files/pub-pdf/Sex%20work%20HIV%20
and%20Access%20to%20Health%20Services%20
in%20Namibia%20-%20National%20Meeting%20
report.pdf, accessed 2 November 2015).
19. Zapata T, Sehgal S, Van Renterghem H, Greenall
M, Shinana A, Aoxamub N et al. A case study on
advancing sex workers agenda through catalytic
HIV funding in Namibia. 19th International AIDS
Conference, 2227 July 2012, Washington, DC

(MOPE336).
20. Revised national strategic framework for HIV
and AIDS 2010/112016/17. Windhoek: Namibia;
2014.
21. Society for Family Health. Condom promotion
for key populations: the experience of Society
for Family Health (SFH) in Namibia. PowerPoint
presented at the Condom Push meeting:
reinvigorating condom programming in countries
in the East and southern Africa within the context
of fast-track strategy. 23 October 2015, Windhoek,
Namibia.
22. USAID. Key populations. PowerPoint presented
at the PEPFAR 2015 Country Operational Plan
validation meeting. June 2015. Windhoek,
Namibia.
23. Census of India. New Delhi: Government of India;
2011.
24. IT exports from Karnataka cross Rs50k cr.
Financial Express, 22 May 2007. Mumbai: Indian
Express Newspapers (Mumbai) Ltd; 2007.
25. National interim summary report, integrated
behavioural and biological assessment (IBBA),
round 1 (20052007). New Delhi: Indian
Council of Medical Research and Family Health
International; 2007.
26. Blanchard JF, Bhattacharjee P, Kumaran S, Ramesh
BM, Kumar NS, Washington RG et al. Concepts
and strategies for scaling up focused prevention
for sex workers in India. Sex Transm Infect.
2008;84(Suppl. 2): ii1923.
27. Ramesh BM, Beattie TSH, Shajy I, Washington R,
Jagannathan L, Reza-Paul S et al. Changes in risk
behaviours and prevalence of sexually transmitted
infections following HIV preventive interventions
among female sex workers in five districts in
Karnataka state, south India. Sex Transm Infect.
2010;86(Suppl. 1): i1724.
28. Blanchard JF, Halli S, Ramesh BM, Bhattacharjee
P, Washington RG, ONeil J et al. Variability in
the sexual structure in a rural Indian setting:
implications for HIV prevention strategies. Sex
Transm Infect. 2007;83(Suppl. 1): i306.
29. Gurnani V, Beattie T, Bhattacharjee P, Mohan
HL, Maddur S, Washington R et al. An integrated
structural intervention to reduce vulnerability to
HIV and sexually transmitted infections among
female sex workers in Karnataka state, south India.
BMC Public Health. 2011;11: 112.
30. Beattie TSH, Mohan HL, Bhattacharjee P,
Chandrashekar S, Isac S, Wheeler T et al.
Community mobilization and empowerment of
female sex workers in Karnataka State, South India:
associations with HIV and sexually transmitted
infection risk. Am J Public Health. 2014;104:
151625.
31. Wilson D. HIV programs for sex workers: lessons

and challenges for developing and delivering
programs. PLoS Med. 2015;12: e1001808.
32. Baral SD, Friedman MR, Geibel S, Rebe K,
Bozhinov B, Diouf D et al. Male sex workers:
practices, contexts, and vulnerabilities for HIV
acquisition and transmission. Lancet. 2015;385:
26073.
Prisoners
1. Dolan K, Moazen B, Noori A, Rahimzadeh S,
Farzadfar F, Hariga F. People who inject drugs
in prison: HIV prevalence, transmission and
prevention. Int J Drug Policy. 2015;26(Suppl. 1):
S125 (http://www.sciencedirect.com/science/
article/pii/S095539591400293X, accessed 2
November 2015).
2.
3.
4.
Walmsley R. World prison population list. 10th ed.

London: Institute for Criminal Policy Research,
and School of Law, Birkbeck, University of London;
2013 (http://www.prisonstudies.org/sites/default/
files/resources/downloads/wppl_10.pdf, accessed 2
November 2015).
Walmsley R. World female imprisonment list. 3rd
ed. London: Institute for Criminal Policy Research
and School of Law, Birkbeck, University of
London; 2015 (http://www.prisonstudies.org/sites/
default/files/resources/downloads/world_female_
imprisonment_list_third_edition_0.pdf, accessed 2
November 2015).
Open Society Justice Initiative. Presumption of
guilt: the global overuse of pretrial detention. New
York: Open Society Foundations; 2014 (https://
www.opensocietyfoundations.org/publications/
presumption-guilt-global-overuse-pretrialdetention-overuse-pretrial-detention, accessed 2
November 2015).
5.
Consolidated guidelines on HIV prevention,

diagnosis, treatment and care for key populations.
Geneva: World Health Organization; 2014.
6.
Larney S. Does opioid substitution treatment

in prisons reduce injecting-related HIV risk
behaviours? A systematic review. Addiction. 105:
216223.
7. World prison brief [database]. London: Institute

for Criminal Policy Research and School of Law,
Birkbeck, University of London (http://www.
prisonstudies.org/world-prison-brief, accessed 2
November 2015).
8.
Prison settings and HIV. Vienna: United Nations

Office on Drugs and Crime; 2015 (https://www.
unodc.org/unodc/en/hiv-aids/new/prisons.html,
9.
Baussano I, Williams BG, Nunn P, Beggiato

M, Fedeli U, Scano F. Tuberculosis incidence
in prisons: a systematic review. PLoS Med.
2010;7:e1000381.
10. Ruddy M, Balabanova Y, Graham C, Fedorin I,

Malomanova N, Elisarova E et al. Rates of drug
resistance and risk factor analysis in civilian and
prison patients with tuberculosis in Samara Region,

Russia. Thorax. 2005;60: 1305.
11. Larney S, Kopinski H, Beckwith CG, Zaller ND,
Jarlais DD, Hagan H et al. The incidence and
prevalence of hepatitis C in prisons and other
closed settings: results of a systematic review and
meta-analysis, Hepatology. 2013;58: 121524.
12. United Nations Office on Drugs and Crime,
UNAIDS, World Bank. HIV and prisons in subSaharan Africa: opportunities for action. Vienna:
United Nations Office on Drugs and Crime; 2007
(https://www.unodc.org/unodc/en/frontpage/hivand-prisons-in-sub-saharan-africa.html, accessed 2
November 2015).
13. Carpentier C, Royuela L, Montanari L. The
global epidemiology of drug use in prison. In:
Kinner SA, Rich J, editors. Drug use in prisoners:
epidemiology, implications and policy responses.
Oxford: Oxford University Press; in press.
14. Guidance note: ending criminalisation. Geneva:
UNAIDS; 2013. (http://www.unaids.org/sites/
default/files/media_asset/20130530_Guidance_
Ending_Criminalisation_0.pdf, accessed 2
November 2015).
15. Csete J, Wolfe D. Turning a page in drug control
and public health: advancing HCV/HIV prevention
through reform of drug law and policy. Future
Virol. 2015;10: 1726.
16. International HIV/AIDS Alliance and
Commonwealth HIV and AIDS Action Group.
Enabling legal environments for effective
HIV responses: a leadership challenge for the
Commonwealth. Hove: International HIV/AIDS
Alliance; 2010 (http://www.hivpolicy.org/Library/
HPP001810.pdf, accessed 2 November 2015).
17. Goyer KC. HIV/AIDS in prison, problems, policies
and potential. Pretoria: Institute for Security
Studies; 2003 (Institute for Security Studies
Monographs, 79).
18. World Health Organization, UNAIDS, United
Nations Office on Drugs and Crime. HIV/AIDS
prevention, care, treatment and support in prison
settings a framework for an effective national
response. Vienna: United Nations Office on
Drugs and Crime; 2006 (https://www.unodc.org/
documents/hiv-aids/HIV-AIDS_prisons_Oct06.
19. Prisons and health. Copenhagen: World Health
Organization Regional Office for Europe; 2014
(http://www.euro.who.int/en/health-topics/
health-determinants/prisons-and-health/
publications/2014/prisons-and-health, accessed 2
November 2015).
20. Wolff N. Rates of sexual victimization in prison
for inmates with and without mental disorders.
Psychiatr Serv. 2007;58: 108794.
21. Steiner B, Ellison JM, Butler HD, Cain CM. The
impact of inmate and prison characteristics on
prisoner victimization. Trauma Violence Abuse.
2015 pii: 1524838015588503 [Epub ahead of print].
22. Prisoners and HIV/AIDS. Brighton: AVERT; 2014

(http://www.avert.org/professionals/hiv-socialissues/key-affected-populations/prisoners, accessed
2 November 2015).
23. Montague BT, Rosen DL, Solomon L, Nunn A,
Green T, Costa M et al. Tracking linkage to HIV
care for former prisoners: a public health priority.
Virulence. 2012;3: 31924.
24. Stone K, editor. The global state of harm reduction
2014. Harm Reduction International; 2014 (http://
www.ihra.net/files/2015/02/16/GSHR2014.pdf,
25. United Nations Office on Drugs and Crime,
International Labour Organization, United
Nations Development Programme, World Health
Organization, UNAIDS. Policy brief: HIV
prevention, treatment and care in prisons and
other closed settings: a comprehensive package
of intervention. Vienna: UNODC; 2013 (https://
www.unodc.org/documents/hiv-aids/HIV_
comprehensive_package_prison_2013_eBook.pdf,
26. Nassirimanesh B, Trace M, Roberts M. The rise of
harm reduction in the Islamic Republic of Iran. The
Beckley Foundation Drug Policy Programme; 2005
(http://www.beckleyfoundation.org/pdf/paper_08.
27. Asl RT, Eshrati B, Dell CA, Taylor K, Afshar
P, Kamali M et al. Outcome assessment of a
triangular clinic as a harm reduction intervention
in Rajaee-Shahr Prison, Iran. Harm Reduction J.
2013;10: 41.
28. Farnia M, Ebrahimi B, Shams A, Zamani S. Scaling
up methadone maintenance treatment for opioiddependent prisoners in Iran. Int J Drug Policy.
2010;21: 4224.
29. Islamic Republic of Iran AIDS progress report:
on monitoring of the United Nations General
Assembly Special Session on HIV and AIDS.
Tehran: National AIDS Committee Secretariat,
Ministry of Health and Medical Education; 2012.
30. Kononenko L et al. HIV prevention and
psychosocial support for MSM in prisons of
Ukraine. 18th International AIDS Conference,
Vienna, Austria, 1823 July 2010 (Abstract
CDC0811).
31. Lessons from the front lines. Community-led
responses to HIV and AIDS among MSM and
transgender populations. New York: American
Foundation for AIDS Research; 2010 (http://www.
amfar.org/uploadedFiles/_amfarorg/Around_
the_World/Lessons-Front-Lines.pdf, accessed 2
November 2015).
32. A non-governmental organizations approach to
HIV and AIDS interventions in the Ghanaian
prison establishments. Planned Parenthood
Association of Ghana; 2015. Report submitted to
the Global Fund to Fight AIDS, Tuberculosis and
Malaria.
UNAIDS
267
33. Moldova: comprehensive package of services for

people who inject drugs (PWID) in Moldovan
prisons. In: UNAIDS Programme Coordinating
Board, Thirty-Fifth Meeting, Agenda item 11:
Thematic segment: halving HIV transmission
among people who inject drugs. Geneva: UNAIDS;
media_asset/20141205_35PCB_CRP2_Thematic_
Segment.pdf, accessed 2 November 2015).
43. Ferrer-Castro V, Crespo-Leiro MR, Garca-Marcos

LS, Prez-Rivas M, Alonso-Conde A, GarcaFernndez I et al. Evaluation of a needle exchange
program at Pereiro de Aguiar prison (Ourense,
Spain): a ten-year experience. Rev Esp Sanid Penit.
2012;14: 311.
34. Moldova: mechanism for national funding for

HIV prevention programmes for people who
inject drugs as a bridge from adequate policy
and legal framework to the actual funding in
reality. In: UNAIDS Programme Coordinating
Board, Thirty-Fifth Meeting, Agenda item 11:
Thematic segment: halving HIV transmission
among people who inject drugs. Geneva: UNAIDS;
media_asset/20141205_35PCB_CRP2_Thematic_
Segment.pdf, accessed 2 November 2015).
45. Zucker H, Annucci AJ, Stancliff S, Catania H.

Overdose prevention for prisoners in New York: a
novel program and collaboration. Harm Reduction
J. 2015;12: 51.
35. Monitorizarea controlului infeciei HIV n

Republica Moldova, anul 2014 [Monitoring
the control of HIV infection in the Republic
of Moldova in 2014]. Chisinau: Ministry of
Health, Republic of Moldova; 2015 (http://www.
cnms.md/sites/default/files/Monitorizarea%20
controlului%20infec%C5%A3iei%20HIV%20
%C3%AEn%20Republica%20Moldova%2C%20
anul%202014.pdf, accessed 2 November 2015).
36. Doltu S. HIV comprehensive package of services
in Moldovan prisons. Geneva: UNAIDS; 2015
asset/20151027_UNAIDS_PCB37_PPT_1521_Moldova.pdf, accessed 2 November 2015).
37. Schwitters A. Health interventions for prisoners:
update of the literature since 2007. Geneva:
World Health Organization; 2014 (http://apps.
who.int/iris/bitstream/10665/128116/1/WHO_
HIV_2014.12_eng.pdf?ua=1, accessed 2 November
2015).
38. Sylla M, Harawa N, Reznick OG. The first condom
machine in a US jail: the challenge of harm
reduction in a law and order environment. Am J
Public Health. 2010;100: 9825.
39. Butler T, Richters J, Yap L, Donovan B. Condoms
for prisoners: no new evidence that they increase
sex in prison, but they increase safer sex. Sex
Transm Infect. 2013;89: 3779.
40. Leibowitz AA, Harawa N, Sylla M, Hallstrom CC,
Kerndt PR. Condom distribution in jail to prevent
HIV infection. AIDS Behav. 2012;17: 2695702.
41. Larney S. Does opioid substitution treatment
in prisons reduce injecting-related HIV risk
behaviours? A systematic review. Addiction.
2010;105: 21623.
42. Moller LF, Van Den Bergh BJ, Karymbaeva S,
Esenamanova A, Muratalieva R. Drug use in
prisons in Kyrgyzstan: a study about the effect of
health promotion among prisoners. Int J Prisoner
Health. 2008;4: 12433.
268
44. Pontali E. Antiretroviral treatment in correctional

facilities. HIV Clin Trials. 2005;6: 2537.
Conclusion
1. New formulation of HIV treatment to save more
childrens lives. UNICEF and UNAIDS joint press
release. 5 June 2015. In: UNICEF: press centre
(http://www.unicef.org/media/media_82194.html,
UNAIDS
269
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World Aids Day UNAIDS Report 2015

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WORLD

On the Fast-Track to end AIDS by 2030

Efficiency and effectiveness

Where services are needed

THE WORLD HAS COMMITTED

The UNAIDS 20162021 Strategy has established a set of three people-centred

infections. If that same investment is front-loaded with greater expenditure in

Part 1 of this report provides evidence of how elements of the Fast-Track

Focus on location and population

Reaching the populations in greatest need

In order for Fast-Track to be successful, services must focused on at key

12 populations that have been left behind by the AIDS response

01. People living with HIV

All 12 populations require special efforts to counteract the social determinants

An unprecedented amount of subnational data generated and reported by

Focus on location and population

Transforming exceptions to norms to end the AIDS epidemic

Focus on location and population

Efficiency and effectiveness

Getting on the Fast-Track will require additional investmentand wiser use of

Estimated new HIV infections in Kenya, 2014

Sources: UNAIDS estimates; Kenya Ministry of Health.

Focus on location and population

of services within countriesa strong sign of a potential for efficiency gains.

Women in Kenya are disproportionately affected by HIV: they accounted for

Focus on location and population

Number of new infections per year (thousands)

Projected rate of new HIV infections over time nationally

Geographic and population focus and improving implementation

Number of new infections

New HIV infections

Enhanced coverage plus efficiencies

Focus on location and population

Cumulative % of new HIV cases identified

Number of people living with HIV

HIV diagnoses yield from PEPFAR-supported testing sites, Zimbabwe, 2014

Cumulative % of total sites

HTC HIV + yield

Optimal use of limited HIV funding is increasingly important, both to serve

New infections acquired per year (thousands)

Model-predicted evolution of annual HIV incidence

Note: Future projections hold 2013 spending levels constant

Source: Populated Optima model for Sudan.

The Government of Sudan has incorporated recommendations from the study

Bangladesh has maintained a low-level epidemic, with HIV prevalence in the

Focus on location and population

Additional efficiency gains appear possible in eastern and southern Africa

An important dimension of optimizing resources to minimize new HIV

Focus on location and population

Fast-Track lessons learned

Analyses of HIV programmes in both high-level and low-level epidemics

Eliminating stigma and discrimination

Promoting, respecting and protecting human rights is fundamental to human

Percentage of people (aged 1549) who report discriminatory

Among people who have heard of AIDS, the percentage who

Focus on location and population

HIV-related stigma and discrimination is complex. Negative perceptions and

Focus on location and population

When an individual is arrested for a drug-related offence, the Institutes paralegals

Although Ghanas Constitution protects all citizens from discrimination in

Focus on location and population

and the USAID-funded Health Policy Project developed a web-based reporting

Overly broad application of criminal law to HIV non-disclosure, exposure and