GLOBAL HIV/AIDS RESPONSE — Epidemic update and health sector progress towards Universal Access Progress Report 2011 GLOBAL HIV/AIDS RESPONSE Epidemic update and health sector progress towards Universal Access 2011 Progress Report For more information, contact: World Health Organization Department of HIV/AIDS Avenue Appia 20 1211 Geneva 27 Switzerland E-mail: hiv-aids@who.int www.who.int/hiv UA Cover 2011 for Pre-Report 13mm spine.indd 1UA Cover 2011 for Pre-Report 13mm spine.indd 1 24/11/2011 23:5524/11/2011 23:55 GLOBAL HIV/AIDS RESPONSE Epidemic update and health sector progress towards Universal Access 2011 Progress Report ACKNOWLEDGEMENTS This report would not have been possible without the collaboration and contribution of health ministries and national AIDS programmes that lead the work on HIV surveillance, monitoring and evaluation at the country level. WHO, UNICEF and UNAIDS also thank MEASURE DHS for providing access to data from country surveys for use in this report. iii Contents Foreword vii 1. Introduction 1 Building foundations: political commitment, investment and technical innovation 2 Scaling up the global HIV response 3 The roadmap to 2015 5 2. Update on the HIV epidemic 11 2.1 Global overview 12 2.1.1 HIV incidence continues to decline 13 2.1.2 Fewer people are dying from AIDS-related causes … 18 2.1.3 … but the trends vary by region 18 2.1.4 As treatment expands, the number of people living with HIV is rising 19 2.1.5 Half the people living with HIV are women 19 2.1.6 Positive developments among children 19 2.2 Sub-Saharan Africa 23 2.2.1 Sub-Saharan Africa remains disproportionately affected … 23 2.2.2 … but the incidence of HIV infection is declining in almost half the countries 24 2.2.3 The epidemics vary between the subregions 24 2.2.4 Fewer children acquire HIV infection and die from AIDS 25 2.2.5 Fewer people are dying from AIDS-related causes 25 2.2.6 HIV transmission in long-standing relationships and concurrent partnerships … 26 2.2.7 … and unprotected paid sex and sex between men remain signifi cant factors 26 2.2.8 Injecting drug use is a growing problem in some countries 27 2.3 Asia 28 2.3.1 There are signs that the epidemic is slowing down … 28 2.3.2 … but HIV infection trends among sex workers vary … 30 2.3.3 … large proportions of people who inject drugs are becoming infected … 30 2.3.4 … and the epidemic among men who have sex with men is growing 31 2.4 Eastern Europe and Central Asia 32 2.4.1 An epidemic that continues to grow 32 2.4.2 Very high HIV prevalence among people who inject drugs 33 2.5 Caribbean 35 2.5.1 Fewer people newly infected and fewer people dying from AIDS-related causes 35 2.5.2 Unprotected sex is the main route for HIV transmission … 36 2.6 Latin America 38 2.6.1 A stable epidemic overall 38 2.6.2 Unprotected sex between men is fuelling the epidemic 39 2.7 North America and Western and Central Europe 41 2.7.1 A largely stable epidemic 41 2.7.2 Unprotected sex between men is fuelling HIV transmission 42 2.7.3 HIV infection trends are showing signifi cant racial, ethnic and socioeconomic disparities 42 iv GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 2.8 Middle East and North Africa 44 2.8.1 Another growing epidemic 44 2.8.2 The major factors are injecting drug use and unprotected sex … 45 2.8.3 … including unprotected sex between men 45 2.9 Oceania 46 2.9.1 A small, stable epidemic 46 2.9.2 Unprotected sex is the main driver of HIV transmission 47 3. Selected health sector interventions for HIV prevention 61 3.1 Overview and challenges 62 3.1.1 Understanding the characteristics of the epidemic to inform prevention programmes 62 3.1.2 Promoting combination HIV prevention 62 3.2 Selected HIV prevention interventions in the health sector 63 3.2.1 Male circumcision in countries in sub-Saharan Africa with a high burden of HIV 63 3.2.2 Preventing and managing sexually transmitted infections 65 3.2.3 Safety of blood supplies 67 3.2.4 New HIV prevention technologies 69 4. Knowledge of HIV status 75 4.1 Overview of progress and key challenges 76 4.2 Policies and programmes for HIV testing and counselling 77 4.3 Availability and uptake of HIV testing and counselling 77 4.4 Coverage of HIV testing and counselling 78 4.5 Achieving universal access to HIV testing and counselling – the effectiveness of diff erent models 81 5. Scaling up treatment and care for people living with HIV 89 5.1 Overview and key challenges 90 5.2 Catalysing the next phase of scaling up treatment: the Treatment 2.0 initiative 90 5.2.1 Optimize drug regimens 91 5.2.2 Provide access to point-of-care and other simplifi ed diagnostics and monitoring tools 92 5.2.3 Reduce costs 92 5.2.4 Adapt delivery systems 93 5.2.5 Mobilize communities 96 5.3 Antiretroviral therapy 96 5.3.1 Global, regional and country progress in access to antiretroviral therapy 96 5.3.2 Access to antiretroviral therapy among women and children 102 5.3.3. Availability of antiretroviral therapy 103 5.3.4 Outcomes at the programme level: retention on antiretroviral therapy 104 5.3.5 Preventing and assessing HIV drug resistance 106 5.3.6 Supplies of drugs for antiretroviral therapy 108 5.3.7 Antiretroviral drug regimens 109 5.3.8 Antiretroviral drug prices in low- and middle-income countries 114 5.4 Collaborative TB and HIV activities 117 5.4.1 Reducing the burden of HIV among people with TB and their communities 117 5.4.2 Decreasing the burden of TB among people with HIV 118 5.5 Co-trimoxazole prophylaxis 119 v 6. Scaling up services for key populations at higher risk of HIV infection 125 6.1 Overview 126 6.2 Health sector interventions to prevent HIV infection among key populations at higher risk 126 6.2.1 People who inject drugs 126 6.2.2 Men who have sex with men 131 6.2.3 Sex workers 133 6.3 Knowledge of serostatus among key populations at higher risk of HIV infection 135 6.4 Treatment and care for key populations at higher risk of HIV infection 137 7. Scaling up HIV services for women and children: towards eliminating mother-to-child transmission and improving maternal and child health in the context of HIV 139 7.1 Global Plan towards the elimination of new HIV infections among children by 2015 and k eeping their mothers alive 140 7.1.2 Regional initiatives towards eliminating new HIV infections among children 141 7.1.3 Tracking the progress of the Global Plan 141 7.2 Preventing HIV infection among women of reproductive age 144 7.2.1 Strategies for primary prevention of HIV infection among women of reproductive age 145 7.3 Preventing unintended pregnancies among women living with HIV 148 7.4 Preventing the vertical transmission of HIV and improving the health of pr egnant women living with HIV 150 7.4.1 HIV testing and counselling among pregnant women 150 7.4.2 Antiretroviral medicine to prevent the mother-to-child transmission of HIV 152 7.4.3 Antiretroviral prophylaxis for infants born to mothers living with HIV 157 7.5 Treatment, care and support for children 159 7.5.1 Infant diagnosis 159 7.5.2 Co-trimoxazole prophylaxis for HIV-exposed children 160 7.5.3 Antiretroviral therapy for children 161 7.6 Measuring the impact towards eliminating mother-to-child transmission 164 8. Conclusions: achieving and sustaining Universal Access 171 A time of opportunities 171 Innovation and effi ciency: the unfi nished agenda 172 Reach and retain 172 Adapting services to meet clients’ needs 173 Preparing systems for reaching and sustaining universal access 173 Annexes 176 Annex 1 Reported proportion of women attending antenatal care tested for syphilis at the fi rst visit, women attending antenatal care seropositive for syphilis, sex workers seropositive for active syphilis, men who have sex with men seropositive for active syphilis, as reported by low- and middle-income countries in 2010 176 Annex 2 Reported number of facilities with HIV testing and counselling and number of people older than 15 years who received HIV testing and counselling, low- and middle-income countries, 2009–2010 179 vi GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 Annex 3A.1 Percentage of people who inject drugs who received an HIV test in the past 12 months and who know the results, 2010 183 Annex 3A.2 Percentage of men who have sex with men who received an HIV test in the past 12 months and who know the result, 2010 184 Annex 3A.3 Percentage of sex workers who received an HIV test in the past 12 months and who know the results, 2010 185 Annex 3B.1 Percentage of people who inject drugs who received an HIV test in the past 12 months and who know the results, 2006–2008 and 2009–2010 187 Annex 3B.2 Percentage of men who have sex with men who received an HIV test in the past 12 months and who know the results, 2006–2008 and 2009–2010 188 Annex 3B.3 Percentage of sex workers who received an HIV test in the past 12 months and who know the results, 2006–2008 and 2009–2010 189 Annex 4 People of all ages receiving and needing antiretroviral therapy and coverage percentages, 2009 and 2010 190 Annex 5 Reported number of people receiving antiretroviral therapy in low- and middle-income countries by sex and by age, and estimated number of children receiving and needing antiretrovital therapy and coverage percentages, 2010 195 Annex 6 Preventing the mother-to-child transmission of HIV in low- and middle-income countries, 2009–2010 201 Annex 7 Progress in 22 priority countries on key indicators for the Global Plan for eliminating mother-to-child transmission 208 Annex 8 HIV and AIDS statistics, by WHO and UNICEF regions, 2010 210 Annex 9 Estimated numbers of people of all ages and children younger than 15 years receiving and needing antiretroviral therapy and antiretroviral medicine for preventing mother-to-child transmission and coverage percentages in low- and middle-income countries by WHO and UNICEF regions, 2010 211 Annex 10 Classifi cation of low- and middle-income countries by income level, epidemic level, and geographical UNAIDS, UNICEF and WHO regions 212 Annex 11 List of indicators in the WHO, UNICEF and UNAIDS annual reporting form for monitoring the health sector response to HIV/AIDS, 2011 217 Explanatory notes 219 vii T his documents the extraordinary progress achieved over the past decade in the health sector response to HIV. Access to evidence-informed HIV prevention, testing and counselling, treatment and care services in low- and middle-income countries has expanded dramatically. This progress demonstrates how countries can surmount seemingly intractable health and development challenges through commitment, investment and collective action. The global incidence of HIV infection has stabilized and begun to decline in many countries with generalized epidemics. The number of people receiving antiretroviral therapy continues to increase, with 6.65 million people getting treatment at the end of 2010. Almost 50% of pregnant women living with HIV received effective antiretroviral regimens to prevent mother-to-child transmission, spurring the international community to launch the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. What would have been viewed as wildly unrealistic only a few years ago is now a very real possibility. Recent published evidence from clinical trials has confi rmed the powerful impact antiretroviral drugs have on the epidemic as part of an effective package of options for HIV prevention. For the fi rst time, the prospect of a microbicide that contains antiretroviral medicine is providing additional hope to the women in sub-Saharan Africa who continue to bear a disproportionate burden of the HIV epidemic in this region. Despite these advances, still too many people are acquiring HIV infection, too many people are getting sick and too many people are dying. Of particular concerns are trends affecting Eastern Europe and Central Asia, where the numbers of people acquiring HIV infection and dying from HIV-related causes continue to increase. New surveillance data confi rm that the epidemic disproportionately affects sex workers, men who have sex with men, transgender people, people who inject drugs, prisoners and migrants in both concentrated and generalized epidemics. Too often national AIDS plans omit these people, who face formidable legal and other structural barriers to accessing HIV services. Globally, more than 50% of the people eligible for treatment do not have access to antiretroviral therapy, including many people living with HIV who are unaware of their HIV status. Children have much poorer access to antiretroviral therapy than do adults, and attrition at each stage in the cascade of care has highlighted the need to strengthen links within HIV services and with other areas of health and community systems. Nevertheless, several critical developments over the past year have highlighted the capacity of the global response to innovate and learn from scientifi c and programmatic evidence. The Political Declaration on HIV/AIDS, adopted in June 2011 by the United Nations General Assembly, set ambitious targets aimed at achieving universal access and the health-related Millennium Development Goals by 2015. The WHO Global Health Sector Strategy on HIV/AIDS, 2011–2015, the UNAIDS 2011–2015 Strategy: Getting to Zero, and the UNICEF’s strategic and programmatic focus on equity will help to guide national and global efforts to respond to the epidemic and move from an emergency response to a long-term, sustainable model of delivering HIV services. These strategies emphasize the need to better tailor national HIV responses to the local epidemics, to decentralize programmes to bring them closer to people in Foreword viii GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 need and to integrate with other health and community services to achieve the greatest impact. These are important developments aimed at consolidating gains to date and improving the quality, coverage and effi ciency of HIV services. The past decade has seen a historically unprecedented global response to the unique threat the HIV epidemic poses to human development. Networks of people living with and affected by HIV, as well as civil society organizations, have continued to work with other partners, to demand and mobilize political leadership. This has led to increased funding, technical innovation and international collaboration that has saved millions of people’s lives and changed the trajectory of the epidemic. As capacity at all levels increases, programmes are becoming more effective and effi cient. Nevertheless, fi nancial pressures on both domestic and foreign assistance budgets are threatening the impressive progress to date. Recent data indicating that HIV funding is declining is a deeply troubling trend that must be reversed for the international community to meet its commitments on HIV. HIV has proven to be a formidable challenge, but the tide is turning. The tools to achieve an AIDS-free generation are in our hands. Let us move forward together on the ambitious goals set for 2015 and bring us closer to realizing our collective vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. Margaret Chan Michel Sidibé Anthony Lake Director-General Executive Director Executive Director World Health Organization UNAIDS UNICEF Chapter 1 – Introduction 1 1 Introduction T his report reviews progress made until the end of 2010 in scaling up access to health sector interventions for HIV prevention, treatment, care and support in low–and middle-income countries. It is the fi fth in a series of annual progress reports published since 2006 by the World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and Joint United Nations Programme on HIV/ AIDS (UNAIDS), in collaboration with national and international partners, to monitor key components of the health sector response to the HIV epidemic. The report reflects the commitment of United Nations Member States, civil society and United Nations agencies to ensure accountability for global progress in the response to HIV through regular monitoring and reporting. Since 2010 was the deadline established in 2005 for achieving universal access to HIV prevention, treatment, care and support, this report also represents an important benchmark, an opportunity to take stock and identify both achievements and outstanding gaps and to take a constructive look forward in the response at this critical point in the response to the HIV epidemic. The results of commitment, investment and collaboration over the past decade have translated into substantial improvements in access to evidence- informed HIV prevention, diagnosis, treatment, care and support interventions in the health sector (Table 1.1). Table 1.1 Key indicators for the HIV epidemic, 2002–2010 2002 2003 2004 2005 2006 2007 2008 2009 2010 Number of people living with HIV (in millions) 29.5 [27.7–31.7] 30.2 [28.4–32.1] 30.7 [28.8–32.5] 31.0 [29.2–32.7] 31.4 [29.6–33.0] 31.8 [29.9–33.3] 32.3 [30.4–33.8] 32.9 [31.0–34.4] 34.0 [31.6–35.2] Number of people newly infected with HIV (in millions) 3.1 [3.0–3.3] 3.0 [2.8–3.1] 2.9 [2.7–3.0] 2.8 [2.6–3.0] 2.8 [2.6–2.9] 2.7 [2.5–2.9] 2.7 [2.5–2.9] 2.7 [2.5–2.9] 2.7 [2.4–2.9] Number of people dying from AIDS-related causes (in millions) 2.0 [1.8-2.3] 2.1 [1.9-2.4] 2.2 [2.0-2.5] 2.2 [2.1-2.5] 2.2 [2.1–2.4] 2.1 [2.0–2.3] 2.0 [1.9–2.2] 1.9 [1.7–2.1] 1.8 [1.6–1.9] % of pregnant women tested for HIV a 8% 13% 15% 21% 26% 35% Number of facilities providing antiretroviral therapy a 7 700 12 400 18 600 22 400 Number of people receiving antiretroviral therapy a 300 000 400 000 700 000 1 330 000 2 034 000 2 970 000 4 053 000 5 255 000 6 650 000 Number of children receiving antiretroviral therapy a 71 500 125 700 196 700 275 400 354 600 456 000 Coverage of antiretroviral medicines for preventing mother-to-child transmission (%) a 9% b 14% b 23% b 33% b 43% b 48% b 48% c a In low- and middle-income countries. b The coverage data includes provision of single-dose nevirapine which is no longer recommended by WHO. c This data does not include single-dose nevirapine regimen which is no longer recommended by WHO. It should not be compared with the previous years. When including single-dose nevirapine, the coverage in 2010 is 59%. [...]... prevention in the general population GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 Chapter 4 presents global progress in expanding the availability and uptake of HIV testing and counselling Chapter 5 presents global progress in scaling up access to treatment and care for people living with HIV and highlights recent efforts to optimize... South Africa, Swaziland, Zambia and Zimbabwe GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 2004 and 2008 (11) The national HIV prevalence in Kenya fell from about 14% in the mid-1990s to 6% in 2006 (12) and has stayed there since 2006, while in Uganda it has been stable at between 6% and 7% since 2001, and in Rwanda it stayed at... with men New England Journal of Medicine, 2010, 363:2587–2599 21 Cohen MS et al Prevention of HIV-1 infection with early antiretroviral therapy New England Journal of Medicine, 2011, 365:493– 505 8 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 22 Getting to zero: 2011 2015 strategy: Joint United Nations Programme on HIV/AIDS Geneva,... criminalize homosexuality, drug use and sex work GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 Domestic and international HIV-specific funding has decreased from US$15.9 billion in 2009 to US$ 15 billion in 2010, well below the estimated US$ 22–24 billion needed in 2015 for a comprehensive, effective global response to HIV (14,15) The past... TB and malaria for 2009–2013 Additional innovations in global health funding followed By 2006, Brazil, Chile, France, Norway and the United Kingdom had agreed to create UNITAID, an international drug purchase facility financed through a modest levy on airline tickets UNITAID now finances GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011. .. from AIDS-related causes globally, 1990–2010 3.0 Millions 2.5 2.0 1.5 1.0 0.5 0 1990 18 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 The trends in AIDS-related deaths also differ For example, in Eastern Europe and Central Asia, the... This report is structured as follows Chapter 1 outlines the purpose of the report and reviews and analyses global progress towards universal access during the past decade Chapter 2 provides updated epidemiological information on the HIV epidemic, including global and regional trends in incidence, prevalence and mortality from AIDS-related causes Chapter 3 reviews progress in scaling up health sector. .. 16 2002 Predicted prevalence Upper bound 2004 2006 2008 2010 Lower bound ANC prevalence from women (15–24 years) 2001 to 2010: 16% decline GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 Togo Uganda 20 20 15 15 10 10 5 5 0 0 2000 2002 2004 Predicted prevalence Upper bound 2006 2008 2010 2000 Lower bound ANC prevalence from women (15–24... in resource-limited settings Lancet, 368:9534 8 WHO, UNAIDS and UNICEF Towards universal access: scaling up priority HIV/AIDS interventions in the health sector Progress report 2009 Geneva, World Health Organization, 2009 (http://www.who.int/hiv/2009progressreport /report/ en/index.html, accessed 15 October 2011) 9 Political Declaration on HIV/AIDS – United Nations General Assembly Resolution 60/262... (http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication /2011/ 20110609_JC2137_GlobalPlan-Elimination-HIV-Children_en.pdf, accessed 15 October 2011) 25 UNAIDS World AIDS Day report 2011 Geneva, UNAIDS, 2011 (http://www.unaids.org/en/resources/presscentre/ pressreleaseandstatementarchive /2011/ November /20111 121wad201 1report, accessed 21 November 2011) 26 United Nations General Assembly Political Declaration on HIV/AIDS: Intensifying Our . GLOBAL HIV/AIDS RESPONSE — Epidemic update and health sector progress towards Universal Access Progress Report 2011 GLOBAL HIV/AIDS RESPONSE Epidemic update and health sector progress towards. reproductive age. 2 Update on the HIV epidemic 12 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 2.1 Global overview Millions 40 30 20 10 0 1990. testing and counselling, low- and middle-income countries, 2009–2010 179 vi GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011 Annex