What does the UNAIDS Global Strategy 2021-2026 say about HIV Prevention Combination (PrEP, HIV Self-Testing, TasP/U=U) in relation to key populations?
STRATEGIC PRIORITY 1:
MAXIMIZE EQUITABLE AND EQUAL ACCESS TO HIV SERVICES AND SOLUTIONS
Result Area 1:
Primary HIV prevention for key populations, adolescents and other priority populations, including adolescents and young women and men in locations with high HIV incidence
HIV prevention efforts are not currently having the impact needed to end AIDS. The estimated 1.7 million people who newly acquired HIV in 2019 far exceeded the 2020 target of fewer than 500 000 new HIV infections. Insufficient resources and inadequate focus on preventing new HIV infections among key populations and their sexual partners and adolescent girls and young women in sub-Saharan Africa are the biggest reasons for the slow progress. The risk of HIV transmission among key populations and their sexual partners is the major contributor to new HIV infections globally and in every region outside of eastern and southern Africa. Although the likelihood of key populations acquiring HIV exceeds the risk among other populations, the gaps in HIV investment are disproportionately large for HIV prevention among key populations. HIV prevention efforts have also been slow to address how harmful alcohol or non-injecting drug use, such as “chemsex” and the use of other stimulant drugs that affect sexual behaviours and increase risks of HIV acquisition.
Political commitment and resources for evidence- and rights-based combination HIV prevention remains inadequate, and harmful social norms, stigma, discrimination and punitive laws still obstruct prevention efforts. Key populations continue to face these and other barriers to access HIV prevention services. Even though people in key populations are at a much greater risk of acquiring HIV, investments in HIV prevention for key populations are disproportionately low.
There are important opportunities to strengthen and transform HIV prevention efforts, including primary prevention, over the next five years and reduce the inequalities in access to HIV prevention. The new Strategy prioritizes the implementation and scale-up of evidence informed, rights-based, community-led combination prevention packages that are tailored to address the diverse needs, circumstances and preferences of the populations who need effective prevention the most and that can yield the greatest programmatic impact.
Strategic Priority Action:
Expand and promote equitable, affordable access to high-quality medicines, health commodities, science, technology, innovations and solutions for people living with hiv, key populations and other priority populations.
- Optimizing quality of life and well-being across the life-course, through integrated, people-centred services
- People-centred approaches enable individuals to receive the holistic, coordinated services they need in convenient, respectful and efficient ways. Integrating HIV and other health services is crucial to provide peoplecentred, outcomes-focused, coordinated care across the life-course. The populations most affected by inequalities in the HIV response are often least likely to receive integrated service packages that are designed to meet their needs
- Although many people could benefit from service integration, critical intersecting inequalities and integration gaps undermine HIV, health, well-being and quality-of-life outcomes for people living with HIV
- Similarly, women living with HIV are six times more likely to experience invasive cervical cancer and are more likely than HIV-negative women to die of cervical cancer even when receiving ART. Yet services for prevention, screening and treatment of cervical cancer are insufficiently integrated with HIV services and typically are not available at scale. Mental health, treatment services for drug and substance use, and services for the prevention and treatment of hepatitis C are rarely integrated and linked with HIV services, notwithstanding the high prevalence of HIV among people who use drugs, particularly people who inject drugs
EXPAND RIGHTS-BASED COMMUNITY CONTACT TRACING AND SCALE UP ACCESS TO THE LATEST TECHNOLOGIES FOR TB SCREENING, DIAGNOSIS, TREATMENT AND PREVENTION FOR PEOPLE LIVING WITH HIV AND ENSURE OPTIMAL LINKAGES TO HIV CARE.
- For people living with and at risk of HIV across the life course, promote and intensify comprehensive, integrated health and social services, community engagement for peer support and addressing stigma and discrimination, including linkages between HIV services and support services for other communicable and noncommunicable diseases, mental health, alcohol, drug use and substance dependence, and services for sexual and reproductive health, genderbased violence, harm reduction and mental health.
- Expand rights-based community contact-tracing and scale up access to the latest technologies for TB screening, diagnosis, treatment and prevention for people living with HIV and ensure optimal linkages to HIV care.
- Scale up integrated services for HIV, syphilis, viral hepatitis, sexually transmitted infections and other infections in antenatal and postnatal services and other settings, where needed.
- Leverage both HIV and broader health investments to transform data recording and reporting systems of vertical programmes and adapt integrated health data systems (including with other sectors such as social welfare and protection) to identify gaps, barriers and solutions to achieve effective integrated health services for people living with HIV and at risk of HIV.
STRATEGIC PRIORITY 2:
BREAK DOWN BARRIERS TO ACHIEVING HIV OUTCOMES
Result Area 4:
Fully recognized, empowered, resourced and integrated community-led HIV responses for a transformative and sustainable HIV response
If we are to reduce HIV-related inequalities and get the response on-track to end AIDS by 2030, communities living with or affected by HIV must lead the way. Communities living with and affected by HIV have been the backbone of the HIV response at every level, from global to national to community. They advocate for effective action; they inform local, national, regional and international responses regarding communities’ needs; and they plan, design and deliver services. They also advance the realization of human rights and gender equality, and support the accountability and monitoring of HIV responses. Communities give voice to people who are often excluded from decision-making processes. Effective community-led HIV responses must be adequately resourced and supported to enable communities to play their vital roles as equal, fully-integrated partners in national systems for health and social services.
As seen during COVID-19 pandemic, under-utilization of the potential of communities is compounded by an acute shortage of resources for community-led responses. Shrinking space for civil society in many countries, as well as persistent social and structural factors, exacerbate the pressures on community-led HIV responses and increase the risk of violence against organizations that serve key populations or other marginalized groups.
Reducing inequalities in the response will require the robust resourcing, engagement, capacity building and leadership of community-led responses. The false dichotomy between government-led health system responses and community-led health system responses must be transcended in national systems for health and social services, with communities fully integrated as essential partners in each and every aspect of the HIV response.
SCALE UP COMMUNITY-LED SERVICE DELIVERY TO ENSURE THAT THE MAJORITY OF HIV PREVENTION PROGRAMMES ARE LED BY KEY POPULATIONS, WOMEN AND YOUNG PEOPLE, AND THAT ALL HIV TESTING, TREATMENT AND CARE PROGRAMMES INCLUDE COMMUNITY-LED ELEMENTS.
- Support community-led monitoring and research and ensure that community generated data is used to tailor responses to the needs of people living with HIV and key populations, including young key populations.
- Scale up community-led service delivery to ensure that the majority of HIV prevention programmes are led by key populations, women and young people, and that all HIV testing, treatment and care programmes include community-led elements
- Integrate community-led HIV responses into all national HIV responses. Ensure urgent PRIORITY ACTIONS TO ACHIEVE TARGETS AND RESULTS: and adequate support for community-led responses at scale in all countries, especially those transitioning to domestic funding, in conflict zones and during humanitarian crises.
- Mobilize funding for sustainable community-led responses, ensuring financial support and equitable pay for community-led work and funding for activities led by networks of people living with HIV and key populations, including those led by women and young people.
Result Area 5:
People living with HIV, key populations and people at risk of HIV enjoy human rights, equality and dignity, free of stigma and discrimination
Stigma, discrimination and other human rights violations in the context of HIV both reflect and drive the inequalities that undermine HIV responses. Everyone, including people living with and affected by HIV, should enjoy human rights, equality and dignity. The goal of zero discrimination still eludes the world. In 25 of 36 countries with recent data, more than 50% of people aged 15–49 years displayed discriminatory attitudes towards people living with HIV.
Denial of health services to people living with HIV remains distressingly common, and the prevalence and effects of discrimination are often especially acute for members of key populations, who face multiple, overlapping forms of discrimination.
Efforts to anchor HIV responses in human rights principles and approaches, including the priority actions outlined below, can only be achieved through strong political leadership and the active engagement and leadership of community-led responses that are adequately resourced to advocate for, monitor and implement rights-based responses. In working towards the goal of zero discrimination, important progress needs to be continued, accelerated, scaled up and funded. Stigmatizing attitudes have declined notably in numerous countries, and U=U has the potential to accelerate anti-stigma efforts.
END STIGMA AND DISCRIMINATION THAT CONTRIBUTES TO INEQUALITIES IN THE HIV RESPONSE AND AFFECTS PEOPLE LIVING WITH AND AFFECTED BY HIV, INCLUDING ADOLESCENTS AND YOUNG PEOPLE AND KEY POPULATIONS, WOMEN AND GIRLS AND THOSE EXPERIENCING MULTIPLE AND INTERSECTING FORMS OF DISCRIMINATION.
STRATEGIC PRIORITY 3:
FULLY RESOURCE AND SUSTAIN EFFICIENT HIV RESPONSES AND INTEGRATE THEM INTO SYSTEMS FOR HEALTH, SOCIAL PROTECTION, HUMANITARIAN SETTINGS AND PANDEMIC RESPONSES
Result Area 8:
Fully funded and efficient HIV response implemented to achieve the 2025 targets
The inequalities that are slowing progress in the HIV response have increased the resource needs for the global response and have underscored the urgent need for sustainable HIV financing. Additional resources will be needed to reduce inequalities, account for deficits resulting from the failure to achieve the Fast-Track targets, close service gaps resulting from the COVID-19 pandemic and to put the world on-track to end AIDS by 2030.
HIV must remain a priority for health systems and financing, including to support Universal Health Coverage and achievement of the relevant SDGs. In working to mobilize robust, sustainable financing, there are important opportunities that must be seized. In light of the demonstrated value of HIV infrastructure for national COVID-19 responses, the HIV response should showcase how HIV investments build capacity, strengthen programme infrastructure, support pandemic preparedness and create platforms to address other health conditions, including noncommunicable diseases.
Domestic financing accounts for approximately 56% of available financing for the global HIV response. Although domestic financing overall has not increased quickly enough, domestic HIV investments in 2015–2019 rose substantially in several countries. That trend, while promising, masks disparities in funding allocation.
The negative economic impact of the COVID-19 pandemic has created additional challenges for many low- and middle-income countries to mobilize new domestic resources for their HIV responses. Declines in tax revenues and increases in government spending have resulted in higher debt and deficit levels, adding to existing unsustainable levels of debt in over 30 low-income countries. Several high burden countries now face the dual challenge of AIDS and COVID-19, while high levels of debt servicing significantly reduce their fiscal space to invest in their health and social sectors.
Financing for domestic HIV responses must leverage traditional and new partnerships to meet the challenging macrofiscal environment, resist a new era of austerity and identify a range of methods for mobilizing domestic and market resources. The Strategy calls for reforms that broaden the vision of financing for HIV and health financing to promote sustainability through addressing the structural drivers of inequality, promoting progressive taxation and Universal Health Coverage, and increased social spending.
EXPAND PARTNERSHIPS TO ADDRESS THE STRUCTURAL AND MACROECONOMIC BARRIERS TO INCREASED DOMESTIC PUBLIC SPENDING IN HIV AND IN HEALTH AS SOCIETAL AND ECONOMIC PRIORITIES
Mobilize the political leadership and global solidarity needed to secure the resources needed to get the response on-track to end AIDS as a public health threat and to realize the right to health, by taking actions to:
- enable increased efficiency, equitable and inclusive governance, policies and delivery platforms to achieve the Strategy’s targets and sustain the gains made to date in the HIV response, and ensure affected communities and key populations are at the forefront of the decision-making processes;
- expand partnerships to address the structural and macroeconomic barriers to increased domestic public spending in HIV and in health as societal and economic priorities;
- maintain and increase donor funding, including for addressing the root causes of inequalities through community-led responses, particularly for low-income countries with limited fiscal ability, and for key population- and community-led responses, including in middleand upper-middle income countries;
- mobilize political and advocacy support for the next Global Fund replenishment in 2022, and secure continued global solidarity for global, multilateral and bilateral, and domestic, funding for the AIDS response;
- promote and increase the volume and predictability of long-term, direct funding for community-led responses, including through establishing funding earmarks across countries and public funding of community-led responses; and
- promote increased domestic and international investments in the public sector, management processes, greater transparency and accountability, and reset public-private partnerships towards equitable outcomes.
Develop and implement contexts pecific sustainability financing strategies (including multisectoral contributions to HIV responses) that ensure universal access and improved health outcomes, by taking actions to:
- implement country-tailored financing frameworks that raise domestic revenues for the HIV response and social spending, increase the quality and coverage of HIV and health services, and improve resilience and sustainability of financing;
- ensure that financing, governance and social financing frameworks for Universal Health Coverage drive progress towards HIV targets, removing structural barriers and reducing inequalities; progress should be measured by the integration of the full range of HIV prevention, treatment and care services, reaching all populations with stigma free services, and public financing of community-led responses;
- abolish user fees for HIVrelated and other health-care services, starting with the most marginalized populations, women, girls, people living with HIV, key populations and other priority populations;
- build on the platforms and structures of the HIV response to promote Universal Health Coverage that includes gender and other equity considerations beyond socioeconomic status and income towards realization of people’s right to health;
- shift towards progressive health financing that provides Universal Health Coverage for the full range of HIV services, inclusion in national schemes and general tax contributions for resource pooling, and shifts away from voluntary or contributory schemes that are linked to benefit entitlements;
implement transition strategies and plans that ensure sustainable financing, engage with communities, donors and partners to identify country-tailored solutions, and secure sustainable funding for programmes for key populations
Result Area 9:
Integrated systems for health and social protection schemes that support wellness, livelihood and enabling environments for people living with, at risk of and affected by HIV to reduce inequalities and allow them to live and thrive
Existing health services often fail to address the HIV-related and other needs of people who need them most, due to discriminative attitudes or lack of sensitivity to the needs of key populations and priority populations and system capacity deficiencies. Dedicated HIV services do not always meet the broader health needs of people living with or affected by HIV.
When integrated service packages are tailored and delivered in ways that place people at the centre, they can help rapidly reduce inequalities in the HIV response as well as support Universal Health Coverage. Peoplecentered systems for health must ensure that health and community systems, and social and structural enablers optimize the impact and sustainability of HIV programmes. This can be achieved through inclusive governance structures that draw on community knowledge and perspectives. It also calls for a full range of health services to be integrated in primary health-care settings, with special consideration to acceptability for marginalized and other populations who experience stigma and discrimination.
BUILD ON EXPERIENCES IN THE HIV RESPONSE TO TRANSFORM HEALTH SERVICES TO BE PEOPLECENTERED, RIGHTS-BASED AND CONTEXT-RESPONSIVE, AND SYSTEMATICALLY ELIMINATE THE MULTIPLE, INTERSECTING FORMS OF STIGMA AND DISCRIMINATION EXPERIENCED BY PEOPLE WHEN ACCESSING SERVICES.
- Integrate HIV into systems for health and ensure that the integrated approaches are comprehensive, peoplecentred (with integrated and fully resourced community-led responses and systems) and gender-transformative and that they reduce inequalities and uphold people’s right to health.
- Build on experiences in the HIV response to transform health services to be people-centered, rights-based and contextresponsive, and systematically eliminate the multiple, intersecting forms of stigma and discrimination experienced by people when accessing services
- Support community-led responses and inclusive HIV and health governance as a central Strategy to improve service provision. Integrate communityled responses to strengthen national systems for health and social services at all levels. Place emphasis on investments in community-led differentiated service delivery to ensure effective and equitable access that meets the context-specific needs of particular groups, places and individuals based on evidence of what works.
Robust, people-centred social protection has a key role to play in reducing the intersecting inequalities that slow progress towards ending AIDS and enhancing the well-being, human dignity and productivity of households affected by HIV. Social protection reduces vulnerability, systematically removes barriers to service utilization and improves health, well-being, quality of life, enables food security and nutrition and social inclusion. All people living with and affected by HIV have an equal right to social protection, which must be mandated in national policy, legal and programmatic frameworks. These can include access to universal health services, social safety net transfers, insurance and pension benefits, and other state-facilitated systems that are available to the population. Countries are failing to ensure ready access to the social protection that people living with and vulnerable to HIV infection need. Only 29% of the world’s population has access to adequate social protection coverage; two thirds of children have no social protection coverage, and key populations are recognized as social protection beneficiaries in only 26 countries. Women and girls continue to bear the brunt of unpaid care work in the context of HIV.
Pandemics such as AIDS and COVID-19 highlight the pivotal role of social protection in addressing and mitigating the impact of health crises. Countries have expanded or started hundreds of new social assistance interventions in response to the COVID-19 pandemic and national expenditure levels for social protection have more than tripled. Many of these actions also help mitigate the impact of HIV and TB, reduce HIV risk and enhance access to HIV and TB services. In eastern and southern African countries, where health systems are fragile and overburdened, grassroots women’s organizations have often filled gaps in formal services by helping to deliver antiretroviral and other medicines, sanitary pads, personal protective equipment, COVID-19 information, food, and cash support to individuals and families in need.
SCALE UP INTERSECTORAL LINKAGES TO POVERTY REDUCTION PLATFORMS AND COFINANCING FOR PEOPLE LIVING WITH HIV, KEY POPULATIONS AND PRIORITY POPULATIONS TO INCLUSIVE SOCIAL PROTECTION PROGRAMMES, INCLUDING PROGRAMMES THAT ADDRESS THE ISSUE OF UNPAID CARE WORK PERFORMED BY WOMEN AND GIRLS IN THE CONTEXT OF HIV.
- Conduct demand-driven assessments, operational research, monitoring and quality evaluations of existing social protection schemes and programmes and ensure that they cover people living with and affected by HIV.
- Scale up intersectoral linkages to poverty reduction platforms and cofinancing for people living with HIV, key populations and priority populations to inclusive social protection programmes, including programmes that address the issue of unpaid care work performed by women and girls in the context of HIV.
- Strengthen the capacity of communities affected by HIV to participate in the governance of social protection systems and deliver complementary community-led social protection services. Ensure that existing social protection initiatives, such as the social protection floors, address the needs of people living with, at risk of and affected by HIV
Result Area 10:
Fully prepared and resilient HIV response that protects people living with, at risk of and affected by HIV in humanitarian settings and from the adverse impacts of current and future pandemics and other shocks
Reducing inequalities demands focused efforts to meet the needs of people who are most vulnerable and underserved, recognizing that people living with HIV and key populations in emergency and humanitarian settings are highly vulnerable to the socioeconomic impact of emergencies. They typically are least protected by national social safety nets and often experience multilayered inequalities which heighten their vulnerability. The Strategy calls for equal access to HIV services for people living with and affected by HIV in humanitarian emergencies (including refugees and internally displaced persons) and for ensuring that their health, food, nutrition, shelter and water basic needs are covered in humanitarian responses.
INTEGRATE REFUGEES, INTERNALLY DISPLACED AND OTHER HUMANITARIAN AFFECTED POPULATIONS INTO NATIONAL HIV POLICY FRAMEWORKS, PROGRAMMES AND FUNDING PROPOSALS, REFLECTING THEIR DIVERSE NEEDS, INCLUDING SUPPORT AND SCALE-UP OF COMMUNITY-LED RESPONSES AND ADAPTED SERVICE DELIVER
- Promote policy, frameworks and legislation that ensure national emergency response plans are tailored to specific contexts and that provide the initial minimum package and expansion to comprehensive HIV services to all people affected by humanitarian emergencies who are living with HIV or at risk of HIV, regardless of residency or legal status.
- Integrate refugees, internally displaced and other humanitarian affected populations into national HIV policy frameworks, programmes and funding proposals, reflecting their diverse needs, including support and scale-up of community-led responses and adapted service delivery
- Resource community-led responses and scale up the engagement of communities in developing emergency preparedness plans at national and subnational levels and in providing outreach, peer support and linkages to HIV programmes.
- Ensure granular, targeted, and adapted HIV and related programming that is based on improved surveillance, localized assessment of risks and vulnerabilities, access to services and outcomes, and strengthened community-based monitoring systems.
- Leverage and continuously adapt existing data collection approaches to respond to different project needs, contexts or sectors in order to monitor and better support people living with HIV in fragile and humanitarian contexts.
Given the profound and continuing effects of the COVID-19 pandemic, urgent efforts will be needed to enable HIV services and broader responses to build back better, address the vulnerabilities associated with COVID-19 (including increased incidence of gender-based violence), close pandemic related deficits and gaps, and recover momentum. In addition, the HIV response must protect people living with and affected by HIV from future unexpected challenges, such as a resurgence of COVID-19, other pandemics and financial crises.
Specific steps are needed to ensure that all people living with HIV, key populations and other people at risk of HIV are better protected in health emergencies (based on SDG indicator 3.d.1. International Health Regulations capacity and health emergency preparedness) and have access to health and other support services. Lessons from the HIV and COVID-19 responses should be used to strengthen preparedness.
REGIONAL PRIORITY ACTIONS
The COVID-19 pandemic and its impact on countries and communities afford governments and partners the opportunity to “build back better”— creating systems and approaches that are more resilient and that place people and communities at the centre. As leaders make political choices during the recovery from COVID-19, it is important that gains made in the HIV response are not just sustained but enhanced. Renewed political will and leadership is needed at every level to implement this Strategy in order to reduce inequalities by 2025 and accelerate progress towards ending the AIDS epidemic by 2030. Strengthened leadership is needed to reinforce and advance the principles, targets and commitments in this Strategy as well as those made by all UN Member States in the 2030 Agenda for Sustainable Development and other political declarations
To close the gaps in its HIV response, Asia and the Pacific should build on and replicate more broadly the important AIDS leadership that is evident in some countries. That leadership has facilitated successful and diverse models of differentiated HIV service delivery, including HIV self-testing, multimonth dispensing of antiretroviral regimens and key population-led health services that bridge gaps in traditional programming. It has also increased adoption of innovative approaches such as telehealth, take-home opioid substitution therapy, needle-syringe services and PrEP services, and it has built highly multisectoral response that capitalize on the strengths of civil society and other partners.
- Renew and intensify the focus on key populations in policies and programmes. Urgent, focused action is needed to bridge the significant prevention, testing and treatment service gaps for key populations, including adolescent and young key populations, through inclusive, youth-centered and gender-responsive approaches, adopting innovative strategies (including digital and virtual space interventions to reach unreached key populations), and enhancing civil society and community engagement.
- Modernize HIV service delivery. Priority must be given to scaling up combination prevention programmes for and led by key populations, including PrEP, self-testing, same-day ART and multimonth dispensing. Key population-led services must be prioritized, enabled and brought to scale. Adopting differentiated service delivery modalities involving nontraditional partners will allow for the integration of key population-led health services and reduce access barriers, tackle inequities, stigma and discrimination.
- Eliminating the barriers to equitable programme coverage among the most marginalized communities will require countries to recognize and address overlapping vulnerabilities. Concerted efforts are needed to address human rights issues in the context of HIV, promote gender equality and women’s empowerment and eliminate stigma and discrimination against key populations and people living with HIV, to identify and overcome barriers to services (including economic barriers), and to recognize and respond to gender-based violence against key populations and women and girls. Improving effectiveness and reducing inequalities also requires improved data disaggregation by age, gender, disability status, socioeconomic status and more. Law and policy reforms, including decriminalization of key populations, will be essential.
- Mobilize sustainable domestic financing for prevention. Domestic funding will be essential if HIV programmes are to be fully funded, including for key population-led and women- and youth-led health services under Universal Health Coverage. Domestic funding must cover expanded prevention programmes in order to achieve adequate national coverage among key populations in all settings.
- Commit to providing community-led responses with the resources and support they need to fulfil their role and potential as key partners in the HIV response 30% of testing and treatment services to be delivered by community-led organizations, with focus on: enhanced access to testing, linkage to treatment, adherence and retention support, treatment literacy, and components of differentiated service delivery, e.g. distribution of ARV (antiretroviral treatments) 34 80% of service delivery for HIV prevention programmes for key populations to be delivered by community-led organizations35 80% services for women, including prevention services for women at increased risk to acquire HIV, as well as programmes and services for access to HIV testing, linkage to treatment (ART), adherence and retention support, reduction/elimination of violence against women, reduction/elimination of HIV related stigma and discrimination among women, legal literacy and legal services specific for women-related issues, to be delivered by community-led organizations that are women-led. 60% of the programmes supporting the achievement of societal enablers, including programmes to reduce/eliminate HIV-related stigma and discrimination, advocacy to promote enabling legal environments, programmes for legal literacy and linkages to legal support, and reduction/elimination of gender-based violence, to be delivered by community-led organizations.
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