AIDS: HUGE PROGRESS BUT TIME FOR A RE THINK ON HOW TO END THE
EPIDEMIC FOR THOSE MOST AFFECTED
The progress made against AIDS in the last decade has been extraordinary. Antiretroviral treatment has been provided to close to 10 million people in developing countries in just the last decade. In sub-Saharan Africa, 60 per cent of people in urgent need of these medicines now have access to them, something unthinkable just a few years ago.
As a result, at a global level, we are seeing steadily declining rates of AIDS-related deaths and of new HIV infections: a third fewer in 2013 than in 2011. Of the 25 countries that have achieved a 50 per cent reduction in the rate of new HIV infections in the last 10 years, more than half are in sub-Saharan Africa.
This success has been possible through a combination of factors: advocacy and community mobilization, driven by groups such as “Act-Up” in the north, Treatment Action Group in southern Africa, and their many counterparts; courageous and compassionate political leadership; remarkable advances in science and technology, along with tremendous innovation in delivery, enabling new drugs and tests to reach parts of the developing world at unprecedented speed.
It is a global response that has treated AIDS medicines as a “global public good” funded through a combination of domestic and international financial support and made available at the lowest possible price.
It is the AIDS response that has generated extraordinary hope, hope that it may indeed be possible to end major epidemics in poor countries. Hope that we see reflected in headlines that predict “the end of AIDS”, or the possibility of an “AIDS-free generation” in our lifetimes.
Sadly, this is not the whole story because we may contrast this progress with the failure to respond effectively to HIV among so-called “key affected populations” - people who inject drugs (PWID), sex workers, men who have sex with men (MSM) and prisoners, as well as migrant and transgender populations, among whom the response to AIDS has often been a story of indifference and neglect.
It has long been assumed that key affected populations represent a modest share of the epidemic globally, and that the prevalence of HIV among them is largely confined to countries with low-level and so-called concentrated epidemics. However these key populations in fact represent most of the affected persons outside sub-Saharan Africa, and an increasingly recognized share of infections in urban settings in sub-Saharan Africa.
In low- and middle-income countries, men who have sex with men and female sex workers are
19 and 13 times more likely to have HIV, respectively, than the rest of the population. Key populations and their sex partners account for as much as 51 percent of new infections in
Nigeria, 33 percent in Kenya, 28 percent in Mozambique, 80 percent in Morocco, 47 percent in the Dominican Republic, and 65 percent in Peru. MSM alone account for more than 33 percent of new infections in China, and projections indicate that MSM could make up half or more of

2 all new infections in Asia by 2020.
And we have also failed to control the epidemic among gay men in the global North: the rate of new infections in the US has remained stable for a decade, as it has in France and the UK.
Compared to the general population, HIV prevalence is 20 times higher among people who inject drugs, 35 per cent of whom are infected with HIV with prevalence up to 70 per cent or more in some communities in Asia and in the Russian Federation.
The lack of progress addressing HIV among people who inject drugs in Eastern Europe – where injecting drug use accounts for over a third of reported cases – translates into a growing regional - and now possibly generalizing - epidemic.
This is despite the fact that there exists a clear understanding of what needs to be done.
Achievable coverage levels of needle exchange programs, opioid substitution therapy and antiretroviral treatment could result in large decreases in HIV incidence and prevalence in settings with high prevalence among people who inject drugs.
Key affected populations tend to be concentrated in cities. For many MSM and transgender people, for example, cities offer new freedoms for expression of sexuality and identity. At the same time, people in cities experience social dislocation and insufficient economic opportunities relative to demand. This produces contexts and patterns of vulnerability to HIV, including sex work and drug use, fuelled by inadequate access to prevention and treatment, as well as human rights abuses.
We ought to be gravely concerned that if we continue to fail in responding to these epidemics, there is a serious risk that AIDS will become increasingly concentrated everywhere .
This is so for two key reasons.
Firstly, epidemics such as those that are growing among gay men and drug users in African cities, are tremendously difficult to address because these populations are so marginalized.
Secondly, these epidemics are occurring in the current context of economic transition and growing urbanization accompanied by increasing economic and social disparities, all of which impact upon health and access to health services, including, but not limited to, HIV prevention and treatment.
And so it is clear that our future efforts to deliver global public goods, including HIV interventions to key affected populations, are tremendously dependent upon addressing the social, economic and political determinants of health. These include the well-known drivers of health inequities: lack of educational and economic opportunity, lack of appropriate, accessible health and community services, and lack of participation in decision-making around health by those who are most affected.
.
The response to the AIDS epidemic has certainly come a long way in the past three decades but

3 we urgently need a shift in the collective mindset to change the course of the epidemic for those key affected populations. There is a crucial need for a renewed health agenda to continue to drive equity, human rights and hope, to so many worldwide, who need it most. If we do not deliver the right response, we will fail to deliver an end to AIDS globally.
Professor Michel Kazatchkine is the UN Secretary General´s Special Envoy for HIV/AIDS in
Eastern Europe and Central Asia. This is an edited version of the Alison Chesney and Eddie
Killoran Memorial Lecture he delivered this week at the City Health 2013 conference in
Glasgow.