Tackling entrenched inequalities to end epidemics

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UNAIDS executive director Winnie Byanyima said millions have died needlessly from AIDS-related causes due to lacking access to existing therapies. Byanyima calls for a fairer approach from the start to tackling the coronavirus pandemic. AFP

Like the HIV epidemic before it, Covid-19 is exploiting the extreme inequalities between countries and within them to take root among disadvantaged and vulnerable communities. I am proud that decades of experience in responding to HIV are being used in the fight against the coronavirus and that activists all over the world are working hard to make sure that the disruption to HIV services is minimised.

But I am also deeply concerned. Even before the onset of Covid-19, the world was failing in its commitment to end the HIV epidemic by 2030. The UNAIDS new Global Report, Seizing The Moment: tackling entrenched inequalities to tackle epidemics, shows that there were 690,000 AIDS-related deaths last year and 1.7 million new infections – far from the global targets of fewer than 500,000 deaths and 500,000 new infections a year that were set for this year.

The collective failure to implement and sufficiently invest in comprehensive, rights-based HIV responses has come at a dreadful price. There were 3.5 million more HIV infections and 820,000 more AIDS-related deaths from 2015 to 2020 than the world had aimed to achieve.

This is unacceptable when we have medicines to keep people living with HIV alive and well and an array of prevention tools to stop new infections. We are being held back by entrenched inequalities that put vulnerable and marginalised groups of people at higher risk of becoming infected with HIV and dying of AIDS-related illnesses.

Of course, there are bright spots. South Africa has massively expanded the numbers of people on treatment in the last decade, from 1.4 million people in 2010 to 5.2 million people last year. Countries such as Eswatini and Lesotho are showing that new infections can be driven down by rolling out combination prevention options.

But in too many countries, the epidemic is worsening. Infections have risen by 72 per cent in Eastern Europe and Central Asia since 2010, with rises of 22 per cent recorded in the Middle East and North Africa and 21 per cent in Latin America.

As ever, it is the most vulnerable who pay the price. Every day, marginalised groups such as gay men, sex workers, transgender people, people who use drugs, prisoners and migrants are prevented from receiving proper health care and are criminalised and marginalised. Denied their right to health, these groups and their sexual partners comprised 62 per cent of all new adult infections last year.

Meanwhile, women and girls are too often denied their sexual and reproductive health and rights, while gender-based violence and gender inequalities continue to drive the epidemic forward among young women and girls. Last year, young women and adolescent girls accounted for one in four new infections in sub-Saharan Africa, despite making up about 10 per cent of the total population.

It is estimated that globally 243 million women and girls aged 15-49 years have been subjected to sexual and/or physical violence perpetrated by an intimate partner in the past 12 months. Meanwhile, we know that women who experience such violence are 1.5 times more likely to acquire HIV than women who have not experienced violence. Among marginalised groups, a high prevalence of violence is also linked with higher rates of HIV infection. Female sex workers have a 30-times greater risk of acquiring HIV than the general population.

All this must change, and we have to act on multiple fronts. A multi-sectoral approach that respects the rights and dignity of women and of all marginalised groups is urgently needed to reduce HIV infections and guarantee their right to health and other essential services.

For example, completion of quality secondary education reduces the HIV vulnerability of adolescent girls and young women by half and also yields multiple other social and economic outcomes for advancing health, gender equality, economic empowerment and addressing gender-based violence.

Just like HIV, Covid-19 holds up a mirror to the stark inequalities and injustices that run through our societies.

The leadership and engagement of communities remain central features of both HIV and Covid-19 responses in Cambodia. Theary So, a Cambodian woman, has been living with HIV for 15 years. She is one of the essential staff members of Antiretroviral Users Association, who provides counselling services every day at the Khmer–Soviet Friendship Hospital in Phnom Penh, the country’s first HIV treatment site that is now being used to respond to Covid-19.

The Covid-19 pandemic will also be exacerbated unless we address the human rights impact on vulnerable people and their lack of access to health services, education, protection from violence and social, economic and psychological support.

And we need a global commitment that diagnostics, medicines, and an eventual vaccine against the coronavirus are available free at the point of use to everyone everywhere. When a vaccine becomes available it must be a people’s vaccine.

Successful pandemic responses are grounded in human rights, implement evidence-based programming, and should be fully funded to achieve their targets.

Unfortunately, the funding gap for HIV responses is widening. Increases in resources for HIV responses in low- and middle-income countries stalled in 2017, and funding decreased by seven per cent between 2017 and 2019 after adjusting for inflation. The total HIV funding available in these countries last year amounted to about 70 per cent of the 2020 target set by the UN General Assembly.

HIV has been slipping down the international agenda for some years. Now, I am calling on leaders to convene a new UN High-Level Meeting On Ending AIDS next year to address with urgency the outstanding issues that are holding us back from ending AIDS as a public health threat by 2030.

We cannot drop the ball on HIV. The futures of millions of people are at stake.

The UNAIDS 2020 global report is a call to action. It highlights the terrible scale of the HIV epidemic and how it runs along the fault lines of inequalities.

We can and must close the gaps.

Winnie Byanyima is the UNAIDS executive director.