Ending AIDS Means Leaving No One Behind

Last week's announcement by the Elton John AIDS Foundation (EJAF) and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) commits $10 million of grants for organizations working to meet the HIV-related needs of lesbian, gay, bisexual and transgender (LGBT) people. Focusing on sub-Saharan Africa, it aims to break down barriers to HIV services for LGBT people by putting control back in the hands of local communities.

HIV and AIDS is still a major global public health issue. According to the United Nations' program on HIV/AIDS (UNAIDS), nearly 37 million people were estimated to be living with HIV in 2014 and 1.2 million died from AIDS-related illnesses. Yet reporting of HIV in the mainstream media has been sporadic, with the recent Ebola outbreak dominating health news coming out of the region.

It is now widely acknowledged that the HIV epidemic has reached a crucial turning point. Without action now, the epidemic will have rebounded by 2030. In recognition of this, UNAIDS have committed to ending the global HIV epidemic as a public health threat by 2030. This new "Fast Track Strategy" contains the ambitious 90-90-90 targets that call for 90 percent of people living with HIV to know their HIV status; 90 percent of people living with HIV to receive treatment; and 90 percent of people on treatment to have undetectable levels of HIV in their body by 2020. Successfully implementing these goals will prevent 28 million new HIV infections and 21 million AIDS-related deaths by 2030, according to UNAIDS.

Sub-Saharan Africa, where the EJAF/PEPFAR partnership will initially focus its efforts, accounts for the vast majority of people living with HIV—nearly 26 million in 2014. But the epidemic varies greatly across the region. Regarded as the epicentre of the global epidemic, southern Africa is by far the most affected area. Swaziland has the highest HIV prevalence of any country (27 percent) while South Africa has the largest number of people living with HIV—roughly six million.

One of the biggest achievements in recent years has been the dramatic scaling up of programs to treat people living with HIV. Effective antiretroviral treatment now means that people living with HIV can expect to live a relatively normal, healthy life. According to the World Health Organization (WHO), of the 15 million people receiving lifesaving HIV treatment in 2015, 13.5 million of these people were in developing countries—the vast majority in sub-Saharan Africa.

In 2015, the WHO announced that all people living with HIV, regardless of their CD4 count—a measure of the number of CD4 cells, a type of immune cell attacked by HIV—should start treatment. However many countries, particularly in sub-Saharan Africa, are already struggling under previous guidelines, and millions of people are going without the lifesaving treatment they need. According to UNAIDS, nearly eight out of 10 people (79 percent) in western and central Africa living with HIV are still not accessing treatment. Scaling up existing efforts is now a major priority.

Positively, many affected countries are relying less and less on international financing and are increasingly taking responsibility for combating their epidemics. For example, Kenya, Togo and Zambia have dramatically increased their domestic HIV spending in recent years while South Africa now mostly funds its own response, spending over $1 billion annually on its HIV and AIDS programmes.

Despite significant progress in countries with generalized epidemics, certain groups—including the LBGT community and young women in particular—are at a heightened risk of HIV. UNAIDS estimates that HIV prevalence of HIV among men who have sex with men is at15 percent across western and central Africa and 14 percent across eastern and southern Africa, while young women (aged 15-24) account for more than four in 10 new infections among all women.

Reaching these key populations is vital to ending the global HIV and AIDS epidemic. By making HIV services readily available to members of key populations, the impact of the global response can be maximized. The new EJAF/PEPFAR partnership reflects this change of focus.

However, HIV-related stigma and discrimination represents a major barrier to tackling the epidemic in sub-Saharan Africa. Cultural beliefs about HIV and AIDS, sexuality and religion have played a crucial role in the development of HIV-related discrimination and, in many places, is thought to have increased the number of HIV infections by preventing people, particularly those belonging to key populations, from accessing vital health services.

Where young women are concerned, cultural reasons mean that men often dominate sexual relationships and make it difficult for young women to practice safer sex, with gender-based violence a key driver of the epidemic in the region.

In order to overcome these barriers, LGBT and other key population issues relating to HIV need to be understood in a local context. It is vitally important that funding, similar to that announced by EJAF and PEPFAR, is allowed to be implemented at the grassroots level acknowledging cultural differences in order to bring lasting change. Only a case-by-case approach can ensure that people in need are not left behind.

William Oates is content editor at AVERT, an international HIV and AIDS charity based in the U.K.