The decrease in new HIV infections in eastern and southern Africa since 2010 is larger than in any other region. Sustaining that progress demands more effectively addressing the gender dynamics of the epidemic. Three in five new infections in 2019 were among women, and the incidence of HIV infections among adolescent girls and young women (aged 15 to 24 years) remains inordinately high: they are 2.5 times more likely than their male peers to acquire HIV infection. A comprehensive approach is required, including combination prevention programmes that take account of gender inequalities, improving girls’ access to secondary education (which can have a protective effect against HIV), and increasing access to sexual and reproductive health services.
The region is closing in on the 90–90–90 testing and treatment targets. Seven countries have reached those Fast-Track Targets (Botswana, Eswatini, Namibia, Rwanda, Uganda, Zambia and Zimbabwe), and three others are very close to doing so (Kenya, Malawi and the United Republic of Tanzania). Despite considerable progress made in reaching people in the region with treatment, the percentage of children with a suppressed viral load was only 40% (compared to 66% among adults). Community-led services within differentiated care approaches are adding vital momentum to treatment programmes.
The roll-out of HIV testing and treatment programmes is reflected in the 49% decrease in AIDS-related deaths since 2010—a steeper reduction than in any other region. Nonetheless, an estimated 300 000 [230 000–390 000] people died due to AIDS-related illnesses in 2019. There is scope for increasing the coverage of HIV testing and treatment among men and young women.
A substantial proportion (roughly one quarter) of new infections are among key populations and their sexual partners, a reminder of the need for conducive laws and policies, and for programmes that serve the HIV-related needs of these populations.
There is a positive association between condom use at last higher-risk sex and completion rates of lower secondary school among adolescent girls and young women in eastern and southern Africa. Additionally, greater gains have been made in reducing new HIV infections among adolescent girls and young women in countries that have higher completion rates for lower secondary school (>50%). Keeping girls in school reduces both HIV risks and new infections (see Chapter 3).
The HIV epidemic in western and central Africa has not received the same domestic and international attention as in eastern and southern Africa. As a result, progress has been lower. Humanitarian challenges caused by armed conflict, population displacement, food insecurity and intercommunal strife continue to strain community resilience and health systems in several countries in the region.
Women and girls accounted for 58% of the estimated 240 000 [150 000–390 000] new infections in 2019, reflecting the continuing role of gender inequalities in the region’s epidemic. In particular, adolescent girls and young women remain at higher risk of HIV infection in western and central Africa. Furthermore, surveys conducted between 2015 and 2018 show that just 37% of young women (aged 15 to 24 years) in the region demonstrated comprehensive knowledge of HIV.
Prevention programmes also do not focus sufficiently on key populations, who make up a large share of new infections and who also contend with hostile legal and social environments. About two thirds of new adult HIV infections in 2019 were among sex workers (19%), gay men and other men who have sex with men (21%), and the clients of sex workers and the sexual partners of people belonging to key populations (27%).
The region remains a long way from reaching the 90–90–90 targets. Only 58% of people living with HIV were accessing antiretroviral therapy in 2019. An estimated 58% [40–78%] of pregnant women living with HIV received antiretroviral therapy to prevent vertical transmission of HIV and protect their own health in 2019, among the lowest coverage in the world.
Gaps along the continuum of services for the prevention of mother-to-child HIV transmission in western and central Africa are leaving too many children exposed to HIV. The vast majority of new child HIV infections in the region are due to the low coverage of antiretroviral therapy among pregnant women living with HIV: 42% of child infections in 2019 occurred because HIV-positive expectant mothers did not receive antiretroviral medicines during pregnancy. A further 18% of new child infections occurred because mothers living with HIV did not receive antiretroviral medicines during breastfeeding, and another 14% occurred because the mother seroconverted during breastfeeding.
HIV infections in Asia and the Pacific have declined slightly, with reductions in Cambodia, Myanmar, Thailand and Viet Nam offset by sharp increases in Pakistan and the Philippines. Key populations and their partners accounted for an estimated 98% of new HIV infections, and more than one quarter of new HIV infections were among young people (aged 15 to 24 years). Rising numbers of new infections among gay men and other men who have sex with men are a major concern. An overall slowing in reductions in new HIV infections coincides with a decline in political and programmatic commitment, alongside punitive laws and policies and rising stigma and discrimination that block effective AIDS responses.
Key populations are insufficiently served by HIV prevention programmes. Some progress has been made in introducing innovative prevention tools, such as pre-exposure prophylaxis (PrEP). A small minority of countries have both high coverage of needle–syringe programmes and moderate coverage of opioid substitution therapy. Evidence indicates increased use of methamphetamine drugs linked to HIV transmission, and there is a need for innovative harm reduction services that respond to changing patterns in drug use. Civil society organizations are widely involved in HIV prevention programmes, but these community-led services are not available at sufficient scale.
The 29% reduction in AIDS-related deaths since 2010 speaks to successful testing and treatment programmes in several countries. Australia, Cambodia and Thailand have achieved the 90–90–90 targets, but AIDS-related mortality rates are rising in Afghanistan, Pakistan and the Philippines. Late diagnosis and poor adherence to treatment are missed opportunities to prevent onward transmission and AIDS-related deaths. About half of key populations living with HIV are not aware of their HIV status, but assisted testing and self-testing could increase the rates of HIV diagnosis.
PrEP is an additional prevention choice for people at substantial risk of HIV infection. Outstanding examples have been set by Australia, Cambodia, New Zealand, Thailand and Viet Nam, with PrEP rolling out and PrEP provision increasing. The population-level prevention benefits of PrEP, however, have not yet been realized in most countries of the region because its availability and accessibility is still limited.
Gains have been made against the humanitarian crises in Latin America, but high levels of migration are stressing health care and education systems as well as labour markets. Marginalization of key populations, competing public health priorities and limited government investment in health systems has largely stalled progress against HIV. New infections have climbed in recent years.
HIV-affected populations in the region continue to experience high levels of stigma and discrimination and violence, preventing many from seeking and accessing services. Nearly a quarter of people living with HIV do not know their HIV status, and 40% are not accessing antiretroviral therapy.
Sustained progress has been made in HIV testing and antiretroviral therapy coverage among pregnant women in the region, leading to a reduction in the rate of mother-to-child HIV transmission, which declined from 20% [12–24%] in 2010 to 15% [12–18%] in 2019. Progress varies between countries, with several approaching the goal of eliminating mother-to-child HIV transmission.
Brazil is the only country in the region that provides pre-exposure prophylaxis (PrEP) through the public health system. However, PrEP is also available through private clinics, the Internet, nongovernmental organizations and pilot studies in Chile, Colombia, Costa Rica, Ecuador, Guatemala, Haiti, Mexico, Panama, Paraguay, Peru and Uruguay. The overall number of people on PrEP across the region remains insufficient to have a significant impact on the epidemic. HIV self-testing and the transition to dolutegravir-based first-line treatment regimens are moving forward in countries in the region.
Coverage of universal access to health care is higher than antiretroviral therapy coverage in at least 11 countries within Latin America, suggesting obstacles to accessing HIV-related services relative to other health services among people living with HIV. Recent Stigma Index studies show that 21% of people living with HIV in Peru and 2% in Brazil report having been denied health services due to their HIV status. In Guatemala, 6% of women living with HIV and 3% of men living with HIV said they had been denied health services. In Panama, 11% of transgender women living with HIV reported being denied health services, compared to 4% of women living with HIV and 2% of men living with HIV.
Across the Caribbean, progress has been made in reducing new HIV infections and AIDS-related deaths, with the incidence:prevalence ratio of the region decreasing steadily from 6.1% in 2010 to 3.9% in 2019.
Great strides continue to be made in the Caribbean towards the elimination of mother-to-child HIV transmission, with seven countries achieving revalidation. More than 90% of pregnant women living with HIV knew their status in five of the nine countries in the region that reported 2019 data to UNAIDS. Scale-up of effective strategies is needed to ensure early presentation for antenatal care and continuity of treatment for pregnant women living with HIV, including those in poverty and those who are migrants or survivors of gender-based violence.
Progress across the testing and treatment cascade has slowed, highlighting the need to expand proven methods of active case-finding and linkage to (and retention in) care, including through community-based programmes. Roll-out of comprehensive prevention interventions is also incomplete in the region. The Bahamas and Barbados remain the only countries that have national programmes providing pre-exposure prophylaxis (PrEP) through the public health sector. Nongovernmental organizations are providing PrEP in the Dominican Republic, and it is available in Jamaica and Suriname through the private sector and pilot studies.
An ongoing challenge for HIV responses in the region is high levels of migration that place health-care systems, education systems and labour markets under pressure. Government health systems are also struggling to absorb programmes that are traditionally funded by international donors, including HIV prevention and key population-focused initiatives. Innovative financing strategies are needed to ensure sustained progress.
Swift testing of infants exposed to HIV and an immediate start of antiretroviral therapy upon diagnosis are the first steps to ensuring the survival of children who have acquired HIV. Coverage of virological testing for early infant diagnosis in the Caribbean varies from 21% in Jamaica to 99% in Cuba.
The HIV epidemic in the Middle East and North Africa is still growing. The estimated 20 000 [11 000–38 000] new infections in 2019 marked a 25% increase over the 16 000 [8700–31 000] new infections in 2010.
The epidemic in the region is highly concentrated among key populations and their sexual partners. People who inject drugs accounted for 43% of new HIV infections in 2019, and gay men and other men who have sex with men another 23%. Combination prevention programmes focusing on key populations need to expand, including the use of HIV self-testing to increase coverage of PrEP and HIV treatment. Women living with and affected by HIV in the region are particularly vulnerable to gender-based violence and stigma and discrimination, resulting in limited access to HIV services. Coverage of services for the prevention of mother-to-child HIV transmission is among the lowest in the world.
The ongoing humanitarian emergencies in the region—and the associated large-scale movements of people—present massive challenges for public health systems in general and HIV programmes in particular. Community-based organizations can play important roles in the region’s HIV response, but they are constrained in many countries by limited civic space and resources. Punitive laws and widespread stigma against people living with HIV and key populations pose additional difficulties.
Ending the AIDS epidemic in the region by 2030 requires renewing political leadership, addressing gender equality, securing sufficient and sustainable financing and scaling up the implementation of innovative programmes, such as HIV self-testing and pre-exposure prophylaxis (PrEP) using rights-based and evidence-informed approaches.
Violence is both a cause and consequence of HIV. Findings from the LEARN MENA project have reinforced existing evidence on this two-way relationship between HIV and gender-based violence, and how that violence is underpinned and sustained by inequitable gender norms. More than half (54%) of the women participating in the project said that violence or fear of violence had affected their ability to protect themselves from acquiring HIV, and two thirds reported experiences of violence in health-care settings. Governments, development partners and civil society should ensure that women living with HIV and those affected by the epidemic are at the forefront of transformational and systematic change across all levels. There is an urgent need to review and reform laws and policies that expose women in all their diversity to gender-based violence.
Eastern Europe and central Asia is one of only three regions where the HIV epidemic is growing. In 2019, the incidence:prevalence ratio of 10.1 was higher than in any other region. There is an urgent need to scale up HIV prevention services, especially in the Russian Federation, and there is a large gap between HIV testing and treatment initiation. Just 63% [52–71%] of people living with HIV who know their HIV status in the region are on treatment, leaving only 41% [34–46%] of all people living with HIV in the region virally suppressed.
Key populations and their sexual partners are disproportionately impacted, accounting for 99% of new HIV infections in 2019. High levels of stigma and discrimination faced by lesbian, gay, bisexual, transgender and intersex (LGBTI) people and people living with HIV impede the provision of effective combination HIV prevention services. High levels of physical, sexual and emotional violence towards women and girls are also significant barriers to HIV services.
Major efforts are needed to reverse current trends, including increased provision of community-led HIV services—such as HIV self-testing, harm reduction and pre-exposure prophylaxis (PrEP)—that are focused on the most affected groups. Community-based organizations require increased capacity-building support and adequate funding to play their critical role. Improved domestic funding of the national HIV response is also required to minimize dependence on international donors, particularly for key populations programming.
Strong HIV responses in most of western and central Europe and North America have seen this high-income region achieve an incidence:prevalence ratio of 3.0, which signals steady reductions in new HIV infections and that most people living with HIV are accessing treatment and living long and healthy lives.
HIV testing and treatment coverage in the region is approaching the 2020 targets, with 88% [70–100%] of people living with HIV knowing their HIV status, 81% [62–98%] on treatment and 67% [53–80%] with durably suppressed viral loads. High coverage of pre-exposure prophylaxis (PrEP) in several cities of the region has contributed to reductions in new HIV infections among gay men and other men who have sex with men.
This aggregate success obscures many challenges. In western and central Europe, undocumented migrants living in insecure and precarious situations have less access to HIV services, including HIV treatment (Figure 13.1) and new prevention tools (such as PrEP). In the United States of America, black and Latino people are disproportionately affected by HIV, with HIV diagnosis rates that are several-fold higher than among whites and Asians.
Gay men and other men who have sex with men accounted for nearly two thirds of new HIV infections in the region in 2019. More than one third (36%) of total infections were among young gay men and other men who have sex with men (aged 15 to 24 years).