Tackle entrenched inequalities to end epidemics

Tackle entrenched inequalities to end epidemics

An anti-Aids campaigner holds a flag raising awareness about the disease that affects millions around the world. Bangkok Post photo

Like the HIV epidemic before it, Covid-19 is exploiting the extreme inequalities between countries and within them among disadvantaged and vulnerable communities. I am proud that decades of experience in responding to HIV are being used in the fight against the coronavirus and that activists all over the world are working hard to make sure that the disruption to HIV services is minimised.

But I am also deeply concerned.

Even before the onset of Covid-19, the world was failing in its commitment to end the HIV epidemic by 2030. The UNAIDS new “Global Report, Seizing The Moment: tackling entrenched inequalities to tackle epidemics”, shows that there were 690 000 Aids-related deaths in 2019 and 1.7 million new infections — far from the global targets of fewer than 500,000 deaths and 500,000 new infections a year that were set for 2020.

The collective failure to implement and sufficiently invest in comprehensive, rights-based HIV responses has come at a dreadful price. There were 3.5 million more HIV infections and 820,000 more Aids-related deaths from 2015 to 2020 than the world had aimed to achieve.

This is unacceptable when we have medicines to keep people living with HIV alive and well and an array of prevention tools to stop new infections. We are being held back by entrenched inequalities that put vulnerable and marginalised groups of people at higher risk of becoming infected with HIV and dying of Aids-related illnesses.

Of course, there are bright spots. South Africa has massively expanded the numbers of people on treatment in the last decade, from 1.4 million people in 2010 to 5.2 million people in 2019. Countries such as Eswatini and Lesotho are showing that new infections can be driven down by rolling out combination prevention options.

But in too many countries the epidemic is worsening. Infections have risen by 72% in Eastern Europe and Central Asia since 2010, with rises of 22% recorded in the Middle East and North Africa and 21% in Latin America.

As ever, it is the most vulnerable who pay the price. Every day, marginalised groups such as gay men, sex workers, transgender people, people who use drugs, prisoners and migrants are prevented from receiving proper health care and are criminalised and marginalised. Denied their right to health, these groups and their sexual partners comprised 62% of all new adult infections in 2019.

Meanwhile, women and girls are too often denied their sexual and reproductive health and rights, while gender-based violence and gender inequalities continue to drive the epidemic forward among young women and girls. In 2019, young women and adolescent girls accounted for 1-in-4 new infections in sub-Saharan Africa, despite making up about 10% of the total population.

It is estimated that globally 243 million women and girls aged 15-49 years have been subjected to sexual and/or physical violence perpetrated by an intimate partner in the past 12 months. Meanwhile, we know that women who experience such violence are 1.5 times more likely to acquire HIV than women who have not experienced violence. Among marginalised groups, a high prevalence of violence is also linked with higher rates of HIV infection. Female sex workers have a 30-times greater risk of acquiring HIV than the general population.

All this must change, and we have to act on multiple fronts. A multisectoral approach that respects the rights and dignity of women and of all marginalised groups is urgently needed to reduce HIV infections and guarantee their right to health and other essential services.

For example, completion of quality secondary education reduces the HIV vulnerability of adolescent girls and young women by half and also yields multiple other social and economic outcomes for advancing health, gender equality, economic empowerment and addressing gender-based violence.

In Thailand, spurred by growing concerns about how the Covid-19 outbreak has impacted the lives of sex workers, SWING, in collaboration with Planned Parenthood Association Thailand and Dannok Health and Development Community Volunteers, with support from UNAIDS, launched a community-led rapid assessment of sex workers throughout the country. The results from the rapid assessment have proven to be a strong tool for advocacy and decision-making. Stakeholders of the Aids response have collectively identified and started to implement priority actions including comprehensive and integrated approaches for HIV and Covid-19 prevention, as an immediate response to the needs of sex workers.

In Thailand, another important multisectoral approach for key populations is the Crisis Response System (CRS). CRS is a joint effort led by the Foundation for Aids Rights (FAR) and the Division of Aids and STIs of the Department for Disease Control in the Ministry of Public Health supported by the Global Fund to Fight Aids, Tuberculosis and Malaria and UNAIDS. CRS provides a web-based system to respond to human rights violations and stigma and discrimination against people living with HIV and key populations. April and May 2020 saw a significant increase in the number of reported cases, when the Covid-19 pandemic peaked. CRS has a “human touch” — being able to provide through a multidisciplinary team, in-person assistance and referrals for longer-term support.

Just like HIV, Covid-19 holds up a mirror to the stark inequalities and injustices that run through our societies. The Covid-19 pandemic will also be exacerbated unless we address the human rights impact on vulnerable people and their lack of access to health services, education, protection from violence and social, economic and psychological support.

And we need a global commitment that diagnostics, medicines, and an eventual vaccine against the coronavirus are available free at the point of use to everyone everywhere. When a vaccine becomes available it must be a People’s Vaccine.

Successful pandemic responses are grounded in human rights, implement evidence-based programming, and should be fully funded to achieve their targets.

Unfortunately, the funding gap for HIV responses is widening. Increases in resources for HIV responses in low- and middle-income countries stalled in 2017, and funding decreased by 7% between 2017 and 2019 after adjusting for inflation. The total HIV funding available in these countries in 2019 amounted to about 70% of the 2020 target set by the United Nations General Assembly.

HIV has been slipping down the international agenda for some years. Now, I am calling on leaders to convene a new United Nations High-Level Meeting On Ending Aids next year to address with urgency the outstanding issues that are holding us back from ending Aids as a public health threat by 2030.

We cannot drop the ball on HIV. The futures of millions of people are at stake.

The UNAIDS 2020 global report is a call to action. It highlights the terrible scale of the HIV epidemic and how it runs along the fault lines of inequalities.

We can and must close the gaps.