Remarks from the UNAIDS Global Prevention Coalition

The Global Prevention Coalition meeting is an opportunity for UN Member States, members of civil society, philanthropists, academics and international organizations to generate support for the launch of a global HIV prevention coalition. The meeting is currently taking place at UN Headquarters in Geneva, Switzerland.

For more information, please read our latest joint publication Reconsidering Primary Prevention of HIV: New Steps Forward in the Global Response and join the 175+ human rights leaders who have endorsed our accompanying Call To Action.

Remarks by George Ayala, Executive Director of MSMGF

“Excellencies, ministers, delegates, community colleagues, UNAIDS family, and friends, it is my honor to join you today as a proud representative of the Global Forum on MSM & HIV.

The uneven distribution of HIV risks and burdens across populations is a well-substantiated fact. Gay men and other men who have sex with men, people who inject drugs, sex workers, and transgender women are more likely to acquire HIV than all other adults age 15 years old and older. Globally, new infections among these groups account for 45% of all new HIV infections. This figure is likely to be an underestimate, given the intense stigma associated with disclosing and reporting acquisition risks for HIV among gay men, people who use drugs, sex workers, and transgender people. In addition, HIV epidemics in 90 of 120 low- and middle-income countries have concentrated epidemics involving one or more of these key populations. In countries with more broadly generalized epidemics, risks are still not evenly distributed and key populations still shoulder disease burden that is markedly disproportionate.

With an estimated 1.9 million new HIV infections a year, a lop-sided proportion of which are among key populations, we urgently need to support combination prevention approaches that are differentially and strategically deployed. Evidence-informed and rights-based intervention packages are well documented and covered in strong guidance and implementation tools published by WHO, UNAIDS, UNFPA, UNODC, UNDP, the Bill and Melinda Gates Foundation, and USAID/PEPFAR. The problem is that the primary prevention of HIV remains seriously undermined by low funding levels that are grossly misaligned with where new infections occur worldwide. Prevention coverage of key populations is exceptionally low. Underfunding exacerbates poor coverage of primary prevention approaches that work. And current investment consistently undervalues the role communities can play.

A recent study of budgets within new grants signed and approved over the 2014 and 2016 allocation period, conducted by the Global Fund, confirms underinvestment in HIV prevention programs for gay and bisexual men, people who use drugs, sex workers, and transgender people. Of the 5.9-billion-dollars approved in new grants over the 2014-2016 allocation period, just 12% was specifically dedicated to programs intended for all key populations. The study revealed that nearly 14% of the $724 million portfolio supported behavioral interventions, approximately 13% supported condom and lubricant programming, 7% supported syringe exchange programs, 4% supported opioid substitution therapy, and 0.39% supported PrEP. Less than 10% of funding earmarked for key populations is used to support interventions targeting upstream factors like service demand generation and community mobilization, supportive legislation, and stigma-free services.

To grasp the fullness of the problem when it comes to investment in programs for key populations, one must understand how the Global Fund contribution fits within overall funding for HIV. Consider the following:

  • The total estimated investment needed to achieve global HIV targets by 2020 must increase to $26.2 billion by 2020 – as of 2016, total investment from all sources was $19.1 billion;
  • Per UNAIDS, 25% of the total investment should be devoted to prevention;
  • The Global Fund’s contribution to the total global HIV response is estimated to be 10%;
  • As the largest international donor of evidence-driven prevention, U.S. PEPFAR program bilaterally contributes an additional 20% to the total (in addition to their contribution to the Global Fund), of which, 13-16% is directed towards prevention, including 4% for services focused on key populations;
  • Other bilateral contributions combined, add less than 10% to the total estimated HIV investment;
  • Approximately 63% of total HIV investment is now coming from domestic sources – but this investment remains overly generic, rendering key populations invisible.

Colleagues, prevention has its biggest impact when: a) they are collaboratively designed and implemented by members of the community for which they are intended; and b) individuals and communities are self-motivated and given the freedom to choose from a range of options they have worked to develop.  HIV and other sexual health services done with or led by community members for which the services are intended are more likely to yield better health outcomes because they result in earlier, more frequent service engagement, and improved retention. In addition, men who have sex with men, sex workers, people who use drugs, and transgender people are best equipped to help members of their own communities because they: 1) share experiences of stigma, discrimination, and/or violence; 2) have knowledge about and access to supportive networks of peers who can sensitively inform outreach and service implementation; 3) are more likely to be comfortable discussing sensitive matters concerning the experiences of being part of socially marginalized (and in many instances, criminalized) groups; and therefore 4) can more easily establish trust with service recipients and gain their confidence. As such, the global HIV response should pivot its prevention approach from a for community stance to a by community orientation.

The world needs governments and donors to invest in prevention and not allow political uneasiness to get in the way of openly addressing the HIV needs of key populations. Top-down blanket approaches won’t work. Governments cannot afford to leave key populations behind. Investment in prevention should follow evidence every step of the way.

So, here are a few things donors, governments, and other policy stakeholders can do to more boldly progress global HIV prevention:

  • Stop chasing magic bullets solutions and instead fund community-led combination prevention approaches.
  • Shed your reluctance to openly and positively addressing sex and drug use in your public health discourse and responses to HIV and support comprehensive sex education.
  • Be more nuanced in your rhetoric about gender, especially in relation to the specific needs of key populations. For example, stop public claims about the importance of engaging men, while ignoring, stigmatizing, humiliating, and arresting gay men when they show up for services.
  • And finally, embrace the fact that even the best prevention tools, including antiretroviral medications, will not work without assent from communities most impacted by HIV.

Thank you.”

For more on MSMGF’s position, please read our latest joint publication Reconsidering Primary Prevention of HIV: New Steps Forward in the Global Response and join the 175+ human rights leaders who have endorsed our accompanying Call To Action.

Remarks by Laurel Sprague, Executive Director of GNP+

“Excellencies and honourable ministers, UN family, NGO partners, and dear community partners and fellow people living with HIV, thank you for the opportunity to speak to you today about HIV prevention on behalf of GNP+ and people living with HIV.

Without diminishing too much the multiple complexities that people face in the world, I believe we all can acknowledge that life without HIV is less challenging for people, families, communities, and countries than life with HIV.

An important role that people living with HIV play in HIV prevention is that we can say two important messages very clearly. The first is that if you test positive for HIV, you will be okay. The second message is that HIV is for life and life is easier – much easier – without HIV.

For those who test positive, there is a further message. It is this:  You will need to learn about and INSIST on good HIV treatment and a life with dignity, no matter how people treat you, how sick you feel, or how much social prejudices make you want to hide – but you can find a community and support. Everything that you need to survive exists in this world.

These two messages – you will be okay but it’s better without HIV – are too often seen as contradictory, but they are not. Too often HIV prevention messages are designed to scare people about HIV and they do so by demonizing those who have HIV. This doesn’t work. The more that people fear the outcome of an HIV test, whether for medical reasons or because of social prejudice, the easier it is to push it from their minds. Let’s work together make it safe to talk about HIV, test for HIV, and have HIV, all of which makes it safer and easier to not have HIV.

People living with HIV have always been central to HIV prevention efforts. Our communities – lead by key populations – created HIV prevention. Prevention brought us together to organize around health for our communities – based on the love we have for each other.

People with HIV continue to lead the work to change the laws and abuses that leave us vulnerable and to promote the good things that both prevent new infections and keep people with HIV alive: housing, economic stability, jobs, education – and the collective social, economic, and political empowerment of girls and women and marginalized groups – which Michel and Natalia just spoke of eloquently.

Yet too often people living with HIV are excluded from prevention conversations as prevention failures. I would like to challenge anyone who has thought of people with HIV as failures of prevention to take a moment and re-imagine us — as your partners, as people with the most prevention knowledge.

The majority of new HIV infections come from people who do not know their HIV status, so we need to recognize the tremendous role already being played by people living with HIV. We know what prevention means in intimate spaces, vulnerable spaces, spaces where we need to hide, as well as in family spaces,  – spaces far beyond slogans and banners.

In fact, since 2011, GNP+ and PLHIV networks worldwide have promoted the Positive Health, Dignity, and Prevention Framework which provides a comprehensive rights-based approach to HIV prevention, treatment, care and support. Among other rights, this framework affirms that:

HIV prevention demands that we commit to the right to bodily integrity and respect for autonomy for all people – and especially for those you might see as different or other than you, or simply as young as in the case for girls.

From people living with HIV, what do we need to do to really commit to prevention?

  1. Stop blaming individuals for having HIV. Too often we presume that people are bad rather than that the context in which they live is bad or that the laws are bad. HIV is a collective concern that needs to be addressed collectively and with attention to the social and economic forces that put some people at much greater risk for HIV, as well as other struggles for health and wellbeing.
  2. Examine economic priorities that limit States’ ability to ensure the right to prevention, as a key component of the right to health.
  3. Put funding for prevention in the hands of communities, who have a huge impact and who are best positioned to do the work but are never resourced properly.

When we talk about economic barriers, we need to address three key issues:

  1. Affordability of medicines. States need to be supported to stand against the unjust intellectual property regimes that make treatment so costly that prevention funding is strangled.
  2. Costs of incarceration. We must end criminalization of sex workers, people who use drugs, LGBT people, and PLHIV, and guarantee real access to justice to women in all of our diversity. Not only can the resources be diverted from jails to health care, this allows us to be partners with you, rather than being forced to do our work to save our communities in fear, in the shadows.
  3. Effectiveness of economic stability for HIV prevention.

Commit to maintain existing prevention activities that work: condoms, harm reduction for people who use drugs, psychosocial support, economic support. We know what works: housing, education, employment, non-judgemental health care, economic stability. The are all reflected in the commitments governments have made in the SDGs.

I invite you to imagine a world of meaningful gender equality, in which we’ve closed the gap between the richest and poorest, and ensured an adequate income and health care for all – this is a world where HIV can no longer thrive.

If we want to prevent HIV prevention in our communities and countries, than we need to say that what matters is that we create social norms that promote a culture of care and support for all. We don’t have to agree. But we do need to support people’s dignity and ability to survive this often hard world that we are all together in.

The Global HIV Prevention Coalition is in no way a statement that people without HIV have more value or deserve more attention and support than people with HIV. This Coalition is not intended to divert resources from treatment and care for people living with HIV. Instead, this Coalition is here to recognize that we all matter, we all are worth saving. That means doing the hard work to ensure that people living with HIV are able to stay healthy, alive, and free from soul-crushing prejudice and discrimination AND the hard work to make sure that everyone who is not HIV-positive has the support and resources they need to remain HIV negative, no matter their place or community,…no matter how politically marginalized, none of us is dispensable.

Let me conclude by thanking UNAIDS and UNFPA and co-chairs for leading this work on HIV prevention and reaffirming that GNP+, representing people living with HIV, is committed to the global HIV prevention coalition being established.”

For more on GNP+’s position, please read our latest joint publication Reconsidering Primary Prevention of HIV: New Steps Forward in the Global Response and join the 175+ human rights leaders who have endorsed our accompanying Call To Action.

Remarks by Judy Chang, Executive Director of INPUD

Id like to thank UNAIDS for inviting me to speak on behalf of the International Network of People who use Drugs.

This reinvigorated focus on primary prevention presents a critical opportunity to convene and coordinate action on ending AIDS.

Key populations bear a disproportionate burden, and yet face the greatest barriers in accessing HIV prevention and treatment. Despite the knowledge bank we have built on effective HIV prevention strategies for people who inject drugs, new infections inexorably climb. We need to openly acknowledge that which is holding us back, and collectively pledge to challenge these barriers.

The WHO, UNODC and UNAIDS harm reduction package prioritises needle and syringe programs and opiate substitution therapy, which reduce HIV incidence by up to 75% and 54% respectively. NSPs are one of the most cost effective public health interventions; for every $1 invested in NSPs, return on investment can reach up to $5.5. Despite irrefutable evidence of the efficacy and cost-effectiveness of harm reduction, we live in a state of paradox in that coverage remains drastically low. Only 8% of people who need harm reduction services have access.

Political leadership, resource allocation and community empowerment are critical elements to a HIV prevention agenda. However, it is the criminalisation of key populations that primarily drive HIV infection rates. The correlation and causality between criminalisation and HIV transmission is well established. In countries where the majority of HIV infections is due to unsafe injecting drug use, incarceration rates of people who use drugs is correspondingly high. Law enforcement authorities criminalise the possession of needles and syringes and mount ‘crackdowns’ on our communities even when we are seeking treatment or visiting healthcare centres. All senior government officials must end this practice. If we are truly committed to ending AIDS, conflicting policies undermining public health must be repealed. Laws and policies that protect communities from stigma and discrimination also need to be enacted. Demand for HIV prevention services will be low as long as stigma and discrimination remains unchecked. Why would we go to clinics where we’re treated as dangerous or dirty, risk breaches to our confidentiality, or denied health services unless we stop using drugs.

Getting on track to the 2020 goals of reducing new infections by 75% necessitates conducive policies. Select countries have shown that with the right combination of policies, interventions can be rapidly brought to scale,  significantly impacting on incidence rates.

Until 2001 when it decriminalized drug use, Portugal had the highest HIV incidence amongst injecting drug users in the EU. The rate of new HIV infections fell from 1,016 cases in 2001 to only 56 in 2012. Ukraine and Kenya took pragmatic, decisive action by enacting progressive harm reduction policies in response to rising HIV rates. Australia has one of the lowest HIV prevalence rates amongst injecting drug users; this is attributed to both bold political decision-making which led to the early adoption of harm reduction, and meaningful community involvement in shaping policy and programming.

Looking forward, we need coherent and streamlined action centred on the principles of human rights and community ownership. In line with Item 4 of the Road Map 10 Point Plan, we urge national leadership to introduce the necessary legal and policy changes to create an enabling environment for prevention programs by : –

  1. Decriminalising drug use, sex and sex work
  2. Repealing laws and policies that criminalise the possession of HIV commodities
  3. Ensuring harm reduction features strongly in national HIV plans and drug policies including the provision of OST and peer outreach support.
  4. Repealing laws that hinder the empowerment of key populations to participate equally in social and political life, including national HIV planning and implementation processes, and enacting protective laws, such as anti discrimination legislation.

Communities, including people who use drugs have the right to health, self-determination and non- discrimination. We will only achieve the 2020 targets by adopting community-endorsed, evidence and rights-based principles of practice, which must be the engines driving the implementation of the HIV Prevention 2020 Road Map.

Thank you for your attention.

For more on INPUD’s position, please read our latest joint publication Reconsidering Primary Prevention of HIV: New Steps Forward in the Global Response and join the 175+ human rights leaders who have endorsed our accompanying Call To Action.

Remarks by Ruth Morgan Thomas, Global Coordinator at NSWP

With gay men and other men who have sex with men, people who use drugs, sex workers and transgender people accounting for 45% of all new infections it is essential that governments and international donors ensure sufficient resources are allocated to community-led, rights-based HIV prevention and sexual and reproductive health and rights programs, including access to safe abortion, for key populations.

It is unacceptable that sex workers report service providers only providing 5 condoms – when that number falls far below the number of clients they will have – and there are increasing reports of stock outs of condoms. We also need to ensure government departments work together and that we invest in and work with key population-led organizations to end hypocritical and wasteful practices such as Ministries of Health providing condoms for sex workers to use with clients, while police in those same countries confiscate and use the government issued condoms as evidence of crimes related to sex work.

While the roadmap identifies that new infections have ‘stagnated’ among sex workers, the HIV prevalence in Eastern and Southern Africa among sex workers tells a distressing story, six countries report that HIV prevalence among sex workers exceeds 50%, with one of those countries reports HIV prevalence exceeding 70%. It is no longer acceptable that governments around the world fail to uphold the human rights of sex workers, including the right to be free from violence and the right to safe and healthy work places, and that sex workers are not being reached by prevention and treatment programmes. We cannot continue to allow service providers to treat key populations with disrespect and for stigma and discrimination to continue unchecked and must ensure the inclusion of sex workers in adolescent girls and young women and prevention of mother to child transmission programmes. Nor can we afford to continue failing my community by ignoring the social and structural barriers that exacerbate sex workers, and other key populations, vulnerability to HIV acquisition. The Lancet Special Issue on sex work estimated that between 36-43% of HIV infections among sex workers could be averted if sex work were decriminalised.

We need to ensure that when allocating resources for prevention we include:

  • Key population-led programs that provide accurate and up to date information that allow individuals to identify and access the prevention options that are right for them.
  • Community empowerment and community system strengthening that enables key population-led organizations to address resource inequities, stigma and discrimination as well as harmful legal practices and which provide opportunities for social support and community development to build resilient and sustainable key population-led organizations

We need to do everything within our power to ensure unfettered access to HIV prevention and treatment for key populations if we are to realise the 75% reduction in new infections by 2020. We have the knowledge and the tools to reduce new HIV infections among key populations, if they are strategically combined and communities are meaningfully involved in the design, development, implementation, management and evaluation of programmes. We already have the Key Population Implementation Tools developed in partnership with the key population-led networks, which provide international normative guidance for community-led, evidence and rights based prevention, treatment and care programmes.

We need to ensure that 25% of national HIV expenditure goes towards prevention, but we also need to ensure those resources are allocated appropriately and that key population programs, that are led by key population communities,  are funded proportionate to the burden of disease they carry.

For more on NSWP’s position, please read our latest joint publication Reconsidering Primary Prevention of HIV: New Steps Forward in the Global Response and join the 175+ human rights leaders who have endorsed our accompanying Call To Action.