20121120 UNAIDS Global Report 2012 En

7/29/2019 20121120 UNAIDS Global Report 2012 En

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GLOBALRepORt

UNAIDS RepoRt oN theglobAl AIDS epIDemIc | 2012


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Copyright 2012Joint United Nations Programme on HIV/AIDS (UNAIDS)

All rights reserved

The designations employed and the presentation of the material in this publication do not imply t he expression of any

opinion whatsoever on the part of UNAIDS concerning the legal status of any country, territory, city or area or of itsauthorities, or concerning the delimitation of its f rontiers or boundaries. UNAIDS does not warrant that the information

published in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

WHO Library Cataloguing-in-Publication Data

Global report: UNAIDS report on the global AIDS epidemic 2012

UNAIDS / JC2417E

1.HIV infections therapy. 2.HIV infections diagnosis. 3.HIV infections epidemiology.4.Acquired immunodeficiency syndrome prevention and control. 5.International cooperation. I.UNAIDS.

ISBN 978-92-9173-996-7 (Printed version) (NLM classification: WC 503.6)ISBN 978-92-9173-592-1 (Digital version)


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globAl RepoRt

UNAIDS RepoRt oN theglobAl AIDS epIDemIc | 2012


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FoReWoRD 4

INtRoDUctIoN 6

StAte oF the epIDemIc 8

tARget 1 Sexual transmission 16

tARget 2 People who inject drugs 34

tARget 3 HIV infection among children and keeping their mothers alive 42

tARget 4 Treatment 50

tARget 5 Tuberculosis and HIV 58

tARget 6 Resources and spending 62

tARget 7 Gender and the HIV response 70

tARget 8 Stigma, discrimination and the law 78

tARget 9 Eliminating restrictions on entry, stay and residence 86

tARget 10 Integration 90

ReFeReNceS 96

contents


6/1104

UNAIDS

Foreword


7/1105

2012 GLOBAL REPORT

Te progress highlighted in this report will inspire hope around the world. Countries

continue to achieve dramatic results in the AIDS response in lives saved and new

inections averted.

Even as the global economic recovery remains uncertain, our vision o getting to zero new

HIV inections, zero discrimination and zero AIDS-related deaths remains high on the

international agenda. Te data presented here indicates that countries are keeping their

commitments to reach the targets o the 2011 United Nations Political Declaration onHIV and AIDS.

Te pace o progress has quickened. Increments o achievement that once stretched over

many years are now being reached in ar less time. In just 24 months, 60% more people

have accessed liesaving HIV treatment, with a corresponding drop in mortality. New

inection rates have allen by 50% or more in 25 countries 13 o them in in sub-Saharan

Arica. Hal o all the reductions in HIV inections in the past two years have been among

children; this has emboldened our conviction that achieving an AIDS-ree generation is

not only possible, but imminent.

Yet, it is much too early to congratulate ourselves. AIDS is not over. Te data in this report

provided by a record 186 UN Member States, indicate that in many countries, people living

with and aected by HIV still ace stigma, discrimination and injustice. Women and girls

are still at higher risk because o gender inequity and sexual violence. Tere is still a 30% gap

between resources that are available and what is needed annually by 2015.

Tere are around 1000 days until the deadline or achieving the 2015 AIDS targets. Every

one o the next 1000 days will be a test o our commitment to bring an end to this epidemic.

We count on all partners globally, regionally and in countries to unite in advancing the

AIDS response and delivering breakthrough results or people. Our targets are in sight.

Michel Sidib

UNAIDS Executive Director

Under Secretary-General o the United Nations


8/1106

UNAIDS

IntrodUctIon

Te global community has embarked on an historic quest to lay the oundation orthe eventual end o the AIDS epidemic.

Tis eort is more than merely visionary. It is entirely easible. Unprecedented gains

have been achieved in reducing the number o both adults and children newly inected

with HIV, in lowering the numbers o people dying rom AIDS-related causes and in

implementing enabling policy rameworks that accelerate progress. A new era o hope

has emerged in countries and communities across the world that had previously been

devastated by AIDS.

However, a world in which AIDS has been eliminated can only be achieved throughrenewed and sustained commitment and solidarity and only i the available evidence

and limited resources are used as eciently and eectively as possible.

Recognizing the genuine opportunity to plan or the end o AIDS, countries pledged

in the 2011 United Nations Political Declaration on HIV and AIDS: Intensiying Our

Eorts to Eliminate HIV and AIDS (1) to take specic steps to achieve ambitious

goals by 2015. Drawing rom the 2011 Political Declaration, UNAIDS has articulated

10 specic targets or 2015 to guide collective action.

1.Reduce sexual transmission by 50%.

2. Reduce HIV transmission among people who inject drugs by 50%.

3. Eliminate new inections among children and substantially reduce the number omothers dying rom AIDS-related causes.

4. Provide antiretroviral therapy to 15 million people.

5. Reduce the number o people living with HIV who die rom tuberculosis by 50%.

6. Close the global AIDS resource gap and reach annual global investment o US$22 billion to US$ 24 billion in low- and middle-income countries.

7. Eliminate gender inequalities and gender-based abuse and violence and increasethe capacity o women and girls to protect themselves rom HIV.

8.

Eliminate stigma and discrimination against people living with and aected byHIV by promoting laws and policies that ensure the ull realization o all humanrights and undamental reedoms.

9. Eliminate restrictions or people living with HIV on entry, stay and residence.

10. Eliminate parallel systems or HIV-related services to strengthen the integrationo the AIDS response in global health and development eorts.


9/1107

2012 GLOBAL REPORT

In embracing the targets in the 2011 Political Declaration, countries committed to

monitor and report on progress and challenges encountered in their national AIDS

responses. o acilitate biennial reporting on national progress, UNAIDS collaborated

with partners to develop a set o core indicators against which countries would report (2).

In 2012, 186 countries submitted comprehensive reports on progress in their national

AIDS response. With 96% o the 193 United Nations Member States reporting in 2012,

the Global AIDS Response Progress Reporting system has among the highest response

rates o any international health and development monitoring mechanism a vivid

reection o the breadth and depth o global commitment to the response to AIDS.

Drawing on inormation provided by countries, this report summarizes the current

situation in the eort to reach the 2015 targets set orth in the 2011 Political

Declaration. In addition to providing a snapshot o the current situation or each

target, it identies key trends. Using a scorecard approach on key indicators, the report

allows individual countries to compare their own achievements with those o others.

Regional breakdowns enable comparison o progress between dierent parts o the

world. Tis report highlights instances where recommended policies and programmes

have yet to be implemented.

As part o global AIDS response monitoring, countries have completed extensive surveys

on national AIDS policy rameworks. Te National Commitments and Policies Instrument

obtains inormation on the process o national strategizing on AIDS, engagement o civil

society and other key constituencies as well as policy approaches or HIV prevention and

treatment.

Te results summarized here are encouraging, since progress achieved to date

conclusively demonstrates the easibility o achieving the targets set in the 2011

Political Declaration. However, the ndings also reveal that, to reach most o those

targets by 2015, a signicant additional eort is required.

186coUNtRIeS RepoRtINg

In 2012, 186 untris

sumittd mrnsiv

rrts n tir natina

AIDS rsns: 96% UN

Mmr Stats.

Introduction


10/1108

UNAIDS

stAte oF tHe ePIdeMIc

Although AIDS remains one o the worlds most serious health challenges, global

solidarity in the AIDS response during the past decade continues to generate

extraordinary health gains. Historic success in bringing HIV programmes to scale

combined with the emergence o powerul new tools to prevent people rom

becoming inected and rom dying rom AIDS-related causes has enabled the

oundation to be laid or the eventual end o AIDS.

Although much o the news on AIDS is encouraging, challenges remain. Te

number o people newly inected globally is continuing to decline, but national

epidemics continue to expand in many parts o the world. Further, declines in the

numbers o children dying rom AIDS-related causes and acquiring HIV inection,although substantial, need to be accelerated to achieve global AIDS targets.

The globAl epIDeMIc AT A glANce

Globally, 34.0 million [31.4 million35.9 million] people were living with HIV at the

end o 2011. An estimated 0.8% o adults aged 15-49 years worldwide are living with

HIV, although the burden o the epidemic continues to vary considerably between

countries and regions.

Sub-Saharan Arica remains most severely aected, with nearly 1 in every 20 adults

(4.9%) living with HIV and accounting or 69% o the people living with HIV

worldwide. Although the regional prevalence o HIV inection is nearly 25 times

higher in sub-Saharan Arica than in Asia, almost 5 million people are living with

HIV in South, South-East and East Asia combined. Afer sub-Saharan Arica, the

regions most heavily aected are the Caribbean and Eastern Europe and Central

Asia, where 1.0% o adults were living with HIV in 2011.

New INfecTIoNS DeclININg

Worldwide, the number o people newly inected continues to all: the number

o people (adults and children) acquiring HIV inection in 2011 (2.5 million [2.2

million2.8 million]) was 20% lower than in 2001. Here, too, variation is apparent.

Te sharpest declines in the numbers o people acquiring HIV inection since 2001

have occurred in the Caribbean (42%) and sub-Saharan Arica (25%).


11/1109

2012 GLOBAL REPORT

State o the epidemic

ga hIV trnds, 19902011

High estimate

Estimate

Low estimate

NUmbeR oF people lIvINg WIth hIv, globAl, 19902011

NUmbeR oF people NeWly INFecteD WIth hIv, globAl, 19902011

ADUlt AND chIlD DeAthS DUe to AIDS, globAl, 19902011

millions

millions

millions

0

0

0

1990

1990

1990

2011

2011

2011

40

5

3

Source: UNAIDS estimates.


12/11010

UNAIDS

In some other parts o the world, HIV trends (or children and adults) are cause

or concern. Since 2001, the number o people newly inected in the Middle East

and North Arica has increased by more than 35% (rom 27 000 [22 00034 000]

to 37 000 [29 00046 000]). Evidence indicates that the incidence o HIV inection

in Eastern Europe and Central Asia began increasing in the late 2000s afer having

remained relatively stable or several years.

Numr n intd it hIV, 20012011, rin

High estimate

Estimate

Low estimate

ASIA

Numberofpeoplenewlyinfec

tedwithHIV

(thousands)

02001 2011

800

02001 2011

30

Numberofpeoplenewly

infectedw

ithHIV(thousands)

cARIbbeAN

02001 2011

250

Numberofpeoplenewly

infectedwithHIV(thousands)

eASteRN eURope AND ceNtRAl ASIA

02001 2011

150

Numberofpeoplenewly


lAtIN AmeRIcA

02001 2011

50

Numberofpeoplenewly


mIDDle eASt AND NoRth AFRIcA

02001 2011

5

Numberofpeoplenewly


oceANIA

NumberofpeoplenewlyinfectedwithHIV(thousands)

SUb-SAhARAN AFRIcA

0

3 000

2001 2011



13/11011

2012 GLOBAL REPORT

During the past decade, many national epidemics have changed dramatically. In

39 countries, the incidence o HIV inection among adults ell by more than 25%

rom 2001 to 2011 (see table). wenty-three o the countries with steep declines in

HIV incidence are in sub-Saharan Arica, where the number o people acquiring

HIV inection in 2011 (1.8 million [1.6 million2.0 million]) was 25% lower than in

2001 (2.4 million [2.2 million2.5 million]). Despite these gains, sub-Saharan Arica

accounted or 71% o the adults and children newly inected in 2011, underscoring

the importance o continuing and strengthening HIV prevention eorts in the

region.

Epidemiological trends are less avourable in several other countries. In at least nine

countries, the number o people newly inected in 2011 was at least 25% higher than in

2001.

cans in t inidn rat hIV intin amn aduts 1549 ars d, 20012011,

std untris

a Countries with incidence rate changes less than 25% up or down.


Countries not included in this table have insufficient data and/or analyses to estimate recent trends in incidence among adults and to assess the impact of

HIV prevention programmes for adults. The analysis was either publ ished in peer-reviewed literature or was done through recommended modelling tools for

national HIV/AIDS estimation. Criteria for inclusion of countries with estimation models include that at least four years of HIV surveillance prevalence data were

available for countries with concentrated epidemics and three years for countries with generalized epidemics for each subpopulation used in the estimation,

that HIV surveillance data were available through at least 2009 and that the estimated trend in incidence was not contradicted by other data sources. For some

countries with complex epidemics, including multiple population groups with different risk behaviours as well as major geographical differences, such as Brazil,

China and the Russian Federation, this type of assessment is highly complex and could not be concluded in the 2012 estimation round.

State o the epidemic

Inrasin>25%

Bangladesh

Georgia

Guinea-Bissau

Indonesia

Kazakhstan

Kyrgyzstan

Philippines

Republic of MoldovaSri Lanka

Drasin2649%

Drasin50%

Burundi

Cameroon

Democratic Republic of the Congo

Jamaica

Kenya

Malaysia

Mali

Mexico

Mozambique

Niger

Sierra Leone

South Africa

SwazilandTrinidad and Tobago

Bahamas

Barbados

Belize

Botswana

Burkina Faso

Cambodia

Central African Republic

Djibouti

Dominican Republic

Ethiopia

Gabon

Ghana

Haiti

India

Malawi

Myanmar

Namibia

Nepal

Papua New Guinea

Rwanda

Suriname

Thailand

Togo

ZambiaZimbabwe

Saa

Angola

Belarus

Benin

Congo

France

Gambia

Lesotho

Nigeria

Tajikistan

Uganda

United Republic of TanzaniaUnited States of America


14/11012

UNAIDS

ReDUcTIoNS IN DeAThS fRoM AIDS-RelATeD cAUSeS

Te number o people dying rom AIDS-related causes began to decline in the

mid-2000s because o scaled-up antiretroviral therapy and the steady decline in HIV

incidence since the peak in 1997. In 2011, this decline continued, with evidence that

the drop in the number o people dying rom AIDS-related causes is accelerating inseveral countries.

In 2011, 1.7 million [1.5 million1.9 million] people died rom AIDS-related causes

worldwide. Tis represents a 24% decline in AIDS-related mortality compared with

2005 (when 2.3 million [2.1 million2.6 million] deaths occurred).

Te number o people dying rom AIDS-related causes in sub-Saharan Arica

declined by 32% rom 2005 to 2011, although the region still accounted or 70%

o all the people dying rom AIDS in 2011. Te Caribbean (48%) and Oceania

(41%) experienced signicant declines in AIDS-related deaths between 2005 and

2011. More modest declines occurred during the same period in Latin America

(10%), Asia (4%) and Western and Central Europe and North America (1%). wo

other regions, however, experienced signicant increases in mortality rom AIDS

Eastern Europe and Central Asia (21%) and the Middle East and North Arica

(17%).

A review o country experiences vividly illustrates the changes in AIDS-related

mortality patterns in the past several years (see table). In 14 countries, the annual

number o people dying rom AIDS-related causes declined by at least 50% rom

2005 to 2011. In an additional 74 countries, more modest but still notable declines o

1049% were recorded over the same six-year period.

Te scaling up o antiretroviral therapy in low- and middle-income countries has

transormed national AIDS responses and generated broad-based health gains. Since

1995, antiretroviral therapy has saved 14 million lie-years in low- and middle-

income countries, including 9 million in sub-Saharan Arica. As programmatic

scale-up has continued, health gains have accelerated, with the number o lie-years

saved by antiretroviral therapy in sub-Saharan Arica quadrupling in the last our

years. Experience in the hyper-endemic KwaZulu-Natal Province in South Arica

illustrates the macroeconomic and household livelihood benets o expanded

treatment access, with employment prospects sharply increasing among individuals

receiving antiretroviral therapy.

1.7mIllIoN DIeD

In 2011, 1.7 miin

rdid did rm

AIDS-ratd auss, dn

24% rm t ak in 2005.


15/11013

2012 GLOBAL REPORT

prnta an in t numr din rm AIDS-ratd auss, 20052011a

Dras50%

Botswana

Burundi

Cambodia

Cte dIvoire

Dominican Republic

Ethiopia

Guyana

Kenya

Namibia

Peru

Rwanda

Suriname

Zambia

Zimbabwe

Afghanistan

Algeria

Angola

Armenia

Australia

Azerbaijan

Bangladesh

Belarus

Belize

Brazil

Bulgaria

Cameroon

Canada

Cape VerdeColombia

Costa Rica

Cuba

Ecuador

Egypt

Equatorial Guinea

France

Gabon

Gambia

Georgia

Guatemala

Guinea-Bissau

Indonesia

Iran (Islamic Republic of)

Italy

Kazakhstan

Kyrgyzstan

Lao Peoples DemocraticRepublic

Latvia

Lebanon

Madagascar

Malaysia

Mauritania

Mauritius

Morocco

Mozambique

Myanmar

Nepal

Nicaragua

Niger

Nigeria

Pakistan

Philippines

Poland

Republic of Moldova

Romania

Russian Federation

Senegal

Serbia

Sierra Leone

Singapore

Somalia

Sri Lanka

Sudan

Tajikistan

Togo

UgandaUkraine

United Kingdom

United States of America

Uruguay

Venezuela

Viet Nam

Yemen

N an r dras


16/11014

UNAIDS

Adus and idrn iin wi hIv Adus and idrn nw infd wi hIv

SUb-SAhARAN AFRIcA2011

23.5 iin 1.8 iin[22 100 00024 800 000] [1 600 0002 000 000

200120.9 iin 2.4 iin

[19 300 00022 500 000] [2 200 0002 500 000

mIDDle eASt AND NoRth AFRIcA2011

300 000 37 000[250 000360 000] [29 00046 000

2001210 000 27 000

[170 000270 000] [22 00034 000

SoUth AND SoUth-eASt ASIA2011

4.0 iin 280 000

[3 100 0004 600 000] [170 000370 000

20013.7 iin 370 000

[3 200 0005 100 000] [250 000450 000

eASt ASIA2011

830 000 89 000

[590 0001 200 000] [44 000170 000

2001390 000 75 000

[280 000530 000] [55 000100 000

oceANIA2011

53 000 2 900

[47 00060 000] [2 2003 800

200138 000 3 700

[32 00046 000] [3 1004 300

lAtIN AmeRIcA2011

1.4 iin 83 000

[1 100 0001 700 000] [51 000140 000

2001 1.2 iin 93 000[970 0001 500 000] [67 000120 000

cARIbbeAN2011

230 000 13 000

[200 000250 000] [960016 000

2001240 000 22 000

[200 000270 000] [20 00025 000

eASteRN eURope AND ceNtRAl ASIA2011

1.4 iin 140 000

[1 100 0001800 000] [91 000210 000

2001970 000 130 000

[760 0001 200 000] [99 000170 000

WeSteRN AND ceNtRAl eURope2011

900 000 30 000

[830 0001 00 000] [21 00040 000

2001640 000 29 000

[590 000710 000] [26 00034 000

NoRth AmeRIcA2011

1.4 iin 51 000

[1 100 0002 000 000] [19 000120 000

20011.1 iin 50 000

[850 0001 300 000] [35 00071 000

globAl 201134.0 iin 2.5 iin

[31 400 00035 900 000] [2 200 0002 800 000

200129.4 iin 3.2 iin

[27 200 00032 100 000] [2 900 0003 400 000


Rina hIV and AIDS statistis, 2001, 2005 and 2011


17/11015

2012 GLOBAL REPORT

(1549 ars) ran, % pran, un (1524 ars), % AIDS-rad das an adus and idrn,2005 and 2011Women Men

4.9 3.1 1.32011

1.2 iin[4.65.1] [2.63.9] [1.11.7] [1 100 0001 300 000]

5.9 5.1 2.02005

1.8 iin

[5.46.2] [4.26.7] [1.62.7] [1 600 0001 900 000]

0.2


18/11016

UNAIDS

Getting to zero new HIV inections will require substantial reductions each year

in sexual HIV transmission, which accounts or the overwhelming majority o the

people who are newly inected. Although there is reason or optimism, including

avourable trends in sexual behaviour in many countries and the additive impact

o new biomedical prevention strategies, the current pace o progress is insucient

to reach the global goal o halving sexual transmission by 2015, underscoring the

urgent need or intensied action.

Getting to zero new inections will require eective combination prevention: using

behavioural, biomedical and structural strategies in combination, both intensivelyin specic populations in concentrated epidemics and across the whole population

in generalized epidemics (1,2).1 Critical programmatic elements o combination

prevention o the sexual transmission o HIV include behaviour change, condom

provision, male circumcision, ocused programmes or sex workers and men who

have sex with men and access to antiretroviral therapy.

behAVIoUR chANge IS helpINg To pReVeNT SexUAl

TRANSMISSIoN IN geNeRAlIzeD epIDeMIcS

Behaviour change programmes seek to promote saer individual behaviour as well

as changes in social norms that generate healthier patterns o sexual behaviour.

Behaviour change is complex; it involves knowledge, motivations and choices,

which are inuenced by sociocultural norms, as well as risk assessment in relation

to immediate benets and uture consequences. It involves both rational decision-

making and impulsive and automatic behaviour (3). HIV behaviour change

programmes have largely been measured against the outcomes o reduction in the

number o young people initiating sexual intercourse early and the number o sexual

partners and increase in the correct and consistent use o condoms among peoplewho are sexually active.

1 sexUAl trAnsMIssIon

1 Tis section reports on available inormation regarding sexual behaviour in the general population, coverage o male circumcision and HIV among sex workers and men who have sex with men. Unlessotherwise indicated, data are rom the 2012 country progress reports (www.unaids.org/cpr). Data on key populations at higher risk rom country progress reports typically derive rom surveys in capital c itiesand are not representative o the entire country. In particular, surveys in capital cities are likely to overestimate national HIV prevalence and service coverage.


19/11017

2012 GLOBAL REPORT

Fig. 1.1

Sua risks: ans in t rntas mn and mn 1524 ars d avin sr a 15 ars; mn and mn 1549 ars d avin muti artnrs; and ts

it muti artnrs usd a ndm at ast s, in std untris it adut hIVrvan ratr tan 1%, r std ars 20002011a

a Sex before age 15 years in Ethiopia is for the years 2000 and 2011.

Sources:nationally representative household surveys.

To measure progress towards these aims, countries monitor the percentage of young men and women who report having sex before age 15 years, the

percentage of men and women who report having more than one partner during a 12-month period and the percentage of men and women reporting more

than one sexual partner in the previous year who also report using a condom during their last episode of sexual intercourse.

Increasing risk behaviour,statistically significant

Increasing risk behaviour, notstatistically significant

Decreasing risk behaviour,statistically significant

Decreasing risk behaviour, notstatistically significant

Not available or based on fewerthan 50 respondents

Sexual transmission

Sx fr a 15 ars an15- 24-ar-ds

mui arnrs in as 12ns an 15- 49-ar-ds

cnd us a as i-risk sxan 15- 49-ar-ds

yars farisn

Women Men Women Men Women Men

bnin 2001 2006

burkina Fas 2003 2011

carun 2004 2011cn 2005 2009

c d'Iir 2005 2011

eiiaa 2005 2011

gana 2003 2008

guana 2005 2009

haii 2000 2005

Kna 2003 2008

ls 2004 2009

maawi 2000 2010

mai 2001 2006

mzaiqu 2003 2009

Naiia 2000 2006

Niria 2003 2008

Rwanda 2000 2010

Su Afria 2005 2008

Uanda 2000 2011

Unid Ruif tanzania

2004 2010

Zaia 2001 2007

Ziaw 2005 2010


20/11018

UNAIDS

2 Angola, Botswana, Burkina Faso, Burundi, Cameroon, Central Arican Republic, Chad, Congo, Democratic Republic o the Congo, Gabon, Ghana, Guinea-Bissau, Haiti, Kenya, Lesotho, Nigeria and ogo.

Fig. 1.1 indicates that sexual behaviour among men and women has changed

avourably in numerous countries with generalized epidemics. Favourable changes

in risky sexual behaviour are evident in many countries, including Kenya, Malawi,

Mozambique, Namibia, Nigeria and Zambia. In other countries such as Cte

dIvoire, Guyana and Rwanda increases in sexual risk behaviour are ound,

highlighting the need to intensiy support or behaviour change eorts.

Age-appropriate sexuality education may increase knowledge and contribute

to more responsible sexual behaviour. However, there are signicant gaps in

even basic knowledge about HIV and its transmission. In 26 o 31 countries

with generalized epidemic in which nationally representative surveys were

carried out recently, less than 50% o young women have comprehensive and

correct knowledge about HIV. Notably, young women are lacking in knowledge

concerning the eectiveness o condoms in preventing HIV transmission. In 21 o

25 countries with nationally representative surveys, young men had less than 50%

comprehensive and correct knowledge about HIV.

Although population-level behaviour change has been shown to reduce the

prevalence o HIV inection in several countries with generalized epidemics

(46), linking behaviour change programming to specic HIV outcomes

remains challenging. Te consistent association between behaviour change and

reduced incidence provides plausible support or the impact o behaviour change

programming in general, but more specic evidence showing which programmatic

elements have which eects is urgently needed to help guide wise investment (see

the section on the state o the epidemic or changes in the number o people newly

inected with HIV). Disentangling the attribution o eects between specic HIV

programme elements and more general changes in the enabling environment, such

as stigma reduction and universal education, is also dicult (see Section 8).

Tese challenges make it dicult to draw clear conclusions about the scale o

unding needed or behaviour change programming. Among the 26 countries with

generalized epidemics that submitted expenditure data or the most recent year, an

average o 5% o HIV expenditure was allocated to behaviour change programming

(including condom promotion), representing 36% o overall prevention spending.

Some evidence indicates absolute increases in spending: among 17 countries with

comparable data over multiple years,2 total expenditure on behaviour change

programming (including condom promotion) rose rom US$ 148 million in

2008 to US$ 190 million in 2010. Tese gures include spending on HIV-related

inormation, education and communication about HIV; community mobilization;

risk reduction or vulnerable populations; social marketing o condoms; preventing

sexually transmitted inections; behaviour change communication; and prevention

activities among youth, among others (Fig. 1.2).


21/11019

2012 GLOBAL REPORT

Fig. 1.2

enditur n anin aviur and rmtin ndm us in 17 untris itnraid idmis and avaia data, 20082010

200

160

120

80

40

0

exnditurinmillionsof

USdollars

2008

148

2009

161

2010

190

Source: 2012 country progress reports (www.unaids.org/cpr).

DISTRIbUTINg AND pRoMoTINg coNDoMS

Condom use is a critical element o combination prevention and one o the most

ecient technologies available to reduce the sexual transmission o HIV. Although

levels o reported condom use appear to be increasing in several countries with a

high prevalence o HIV inection, recent data rom nationally representative surveys

indicate declines in condom use in Benin, Burkina Faso, Cte dIvoire and Uganda

(Fig. 1.1). In addition, knowledge about condoms remains low in several o the

high-prevalence countries, especially among young women.

Te United Nations Population Fund (UNFPA) estimates that only nine

donor-provided male condoms were available or every man aged 1549 years in

sub-Saharan Arica in 2011 and one emale condom or every 10 women aged 1549

years in the region. Less is known about the procurement o condoms by low- and

middle-income countries directly. One estimate (7) suggests that low- and middle-

income countries directly procured more than 2 billion condoms in 2010 compared

with an estimated 13 billion condoms required or HIV prevention in 2015 (8).

Sexual transmission


22/11020

UNAIDS

Increasing condom use requires both adequate supply and adequate demand. A

recent study in Kenya estimated that, although condom use was low in the study

population, so was the unmet need or condoms, highlighting the importance o

building demand or condoms in the context o HIV prevention (9). Te demand or

condoms to protect against HIV inection may also be aected by other prevention

programmes, such as perceptions that risks are lower because o interventionssuch as male circumcision or post-exposure prophylaxis or that partners receiving

antiretroviral therapy will be less inectious, and similarly, the consequences o

HIV inection may be seen as less devastating in the era o eective therapy thus

decreasing the need or protection. Tese potential risk compensation eects are

being closely scrutinized, but the dynamics are complex to track.

lIMITeD pRogReSS IN bRINgINg VolUNTARy MeDIcAl MAle

cIRcUMcISIoN To ScAle

Male circumcision reduces the likelihood that men will acquire HIV rom a emale

partner. Since 2007, WHO and UNAIDS have recommended voluntary medical

male circumcision in countries with high rates o HIV inection and low rates o

male circumcision. Rapidly scaling up voluntary medical male circumcision has the

potential to prevent estimated 1 in 5 o the people who would have acquired HIV

inection rom doing so in eastern and southern Arica through 2025 (10). Most

countries in which voluntary medical male circumcision is recommended have

endorsed the intervention, adopted roll-out policies and begun training health care

workers in administering circumcision procedures.

>20%

Ethiopia

Kenya

Swaziland

Table 1.1

prnta t 2015 natina tarts r ma irumisins mt 2011


23/11021

2012 GLOBAL REPORT

Countries that have given priority to male circumcision have established national

targets or the number o voluntary medical male circumcisions to be perormed by

2015. Rolling out medical male circumcision in Kenya is ocused on Nyanza Province,

where 54% o the targeted 230 000 male circumcisions have been perormed as o

December 2011. Ethiopia and Swaziland achieved more than 20% o their national

target or voluntary medical male circumcision. In other priority countries, progress

has been much slower (able 1.1). In six countries (Malawi, Mozambique, Namibia,

Rwanda, Uganda and Zimbabwe), less than 5% o the target number o men had been

circumcised by the end o 2011 (11). Only two o the priority countries (Ethiopia and

Swaziland) have integrated male circumcision into inant care programmes.

Te unit cost o voluntary medical male circumcision is relatively low, and unlike

most other prevention or treatment eorts, requires only one-time rather than

lielong expenditure. Nevertheless, countries have allocated relatively ew resources

towards scaling up this intervention, with less than 2% o total HIV expenditure

allocated to voluntary medical male circumcision in 6 o the 14 priority countries

with data available (Botswana, Kenya, Lesotho, Namibia, Rwanda and Swaziland).

Some countries, such as Botswana, Kenya, Namibia and Swaziland, have increased

expenditure or rolling out circumcision more recently. Given the lielong risk

reduction that male circumcision coners, it is clear that, the earlier programmes

invest in ensuring high levels o coverage, the better.

pReVeNTINg hIV INfecTIoN IN Sex woRK

Te number o countries reporting data on epidemiological trends and service

coverage pertaining to sex workers signicantly increased rom 2006 to 2012, reecting

greater ocial recognition o the HIV-related needs o this population. Among

generalized epidemic countries, country-reported HIV prevalence is consistently

higher among sex workers in the capital city than among the general population with

a median o 23% (Fig. 1.4). Median country-reported HIV prevalence among sex

workers in the capital cities has remained stable between 2006 and 2011. Similarly, a

recent review o available data rom 50 countries, which estimated the global HIV

prevalence among emale sex workers at 12%, ound that emale sex workers were

13.5 times more likely to be living with HIV than are other women (12).

Nearly three quarters o reporting countries (73%) indicated they have implemented

risk-reduction programmes or sex workers. Among 58 countries reporting data

rom surveys in capital cities, the median coverage o HIV prevention services

or sex workers is 56% (able 1.2), only marginally higher than in 2010, with 11

countries reportedly reaching at least 80% o sex workers. Although country-

reported data remain limited and consistent comparisons across countries are

dicult, countries that lack legal protections or sex workers appear to have lower

median prevention coverage. According to data provided by 85 countries, 85% o sex

workers in capital cities report having used a condom the last time they had sex.

Sexual transmission

13.5fma s rkrs ar

13.5 tims mr ik t ivin

it hIV tan ar tr mn.


24/11022

UNAIDS

Programmes targeting sex workers are common but are ar less consistently available

or the clients o sex workers. Programmes that eectively target and engage the

clients o sex workers are a critical omission, as this is a large population in many

countries, and reducing the demand or unprotected paid sex is an important

complement to programmes that target sex workers themselves.

Te vast majority o countries (86%) address sex work in their multisectoral AIDS

strategies. Although most country reports on sex workers pertain to emales, a

growing number o countries (10% in 2012) also provided inormation on male sex

workers.

Funding or HIV prevention programmes or sex workers has increased signicantly

in recent years. Among 30 countries that reported spending or sex worker

programming (with data available or at least one year in 20062007, 20082009

or 20102011), total spending rose 3.7-old during 20062011. Funding patterns

raise questions regarding the uture sustainability o prevention programmes or

sex workers. International unding has generated almost all the increased unding

and accounted or 91% o total spending on HIV programmes or sex workers in

20102011.

Fig. 1.3

hIV sndin n rvntin rramms r s rkrs and tir ints30 low- and middle-income countries with available data, latest year available

35

20

25

30

15

5

10

0

International

Domestic public

2008 or 2009

M

illionsofUSdollars

2006 or 2007 2010 or 2011



25/11023

2012 GLOBAL REPORT

Sexual transmission

Fig. 1.4

prvan hIV intin amn s rkrs vrsus t nra uatin in untris itavaia data, 2012

Prevalence among sex workers (%) reported by the country (2012)

Afghanistan

Bolivia

Papua New Guinea

Czech Republic

Indonesia

Senegal

Philippines

Madagascar

Tunisia

Tajikistan

Cape Verde

Bulgaria

Suriname

Lebanon

Guyana

Romania

Chile

Burundi

Georgia

Honduras

Guinea

Armenia

Viet Nam

Estonia

Mexico

Dominican Republic

Sierra Leone

Jamaica

Guinea-Bissau

Chad

Nigeria

Uganda

Swaziland

0 10% 20% 30% 40% 50% 60% 70% 80%

Prevalence among people 1549 years old (2011)

Sources: prevalence for the general population: UNAIDS estimates for 2011; prevalence for sex workers: 2012 country progress reports (www.unaids.org/cpr).

Sex workers are classified as having received prevention services if they respond yes to whether they know where to get HIV testing and have been given

condoms in the past 12 months.

These data were reported in 2012, but countries may differ in methods. Surveys are usually conducted in capital cities and may not be nationally representative.

Data is only shown for countries which have reported a sample size greater than 100.

Belarus

Malaysia

Panama


26/11024

UNAIDS

Source: 2010 and 2012 country progress reports (www.unaids.org/cpr).


Table 1.2

Rrtd vra hIV rvntin rramms amn s rkrs in std untris,2012 untr rrts

75100%

Angola

Belarus

Cape Verde

China

Cuba

Djibouti

Estonia

Guinea

Haiti

JamaicaKazakhstan

Mauritius

Myanmar

Senegal

Tajikistan

Togo

Nn-rrin unris

5074%

Bulgaria

Burkina Faso

Chad

Cte dIvoire

France

Ghana

Lao Peoples Democratic Republic

Mexico

MongoliaParaguay

Philippines

Serbia

Thailand

Ukraine

Uzbekistan


27/11025

2012 GLOBAL REPORT

Sexual transmission

ReSpoNDINg To The globAl hIV epIDeMIc AMoNg MeN

who hAVe Sex wITh MeN

Te HIV prevalence among men who have sex with men in capital cities is consistently

higher than that in the general population (Fig. 1.6) (13). Te prevalence o HIV

inection among men who have sex with men in surveys in capital cities is on average13 times higher than that in the countrys general population. Studies in East Asia

suggest rising trends in HIV prevalence among men who have sex with men, and some

evidence indicates that the global prevalence o HIV inection among men who have

sex with men may have increased rom 2010 to 2012, although data are limited and the

use o diverse study methods creates diculty in comparing results across settings and

time (13,14).

Fig. 1.5

hIV sndin n rvntin rramms r mn av s it mn21 low- and middle-income countries with available data, latest year available

16

8

10

12

14

6

2

4

0

International

Domestic public

2008 or 2009

MillionsofUSdollars

2006 or 2007 2010 or 2011



28/11026

UNAIDS

Fig. 1.6

prvan hIV intin amn mn av s it mn vrsus t nra uatinin untris it avaia data, mst rnt ar

Bangladesh

Bulgaria

Czech Republic

China

Egypt

Fiji

Japan

Germany

Mongolia

Hungary

Philippines

Lebanon

Republic of Korea

Lithuania

Tunisia

Serbia

Algeria

Slovenia

Azerbaijan

Armenia

Cuba

Georgia

Greece

Kazakhstan

Mexico

Morocco

Netherlands

Nicaragua

Sweden

Yemen

Bolivia

Brazil

Costa Rica

Indonesia

Ireland

Madagascar

Nepal

Paraguay

Tajikistan

0 5% 10% 15% 20%

Argentina

Belarus

Ecuador


29/11027

2012 GLOBAL REPORT

Sexual transmission

31%

37%

35%

26%

Cameroon

Nigeria

Switzerland

Chile

Republic of Moldova

France

Viet Nam

Myanmar

Portugal

Ukraine

Malaysia

Cambodia

Uruguay

Senegal

Mauritius

Spain

Peru

El Salvador

Honduras

Latvia

Dominican Republic

Panama

Guatemala

emocratic Republic of the Congo

Sierra Leone

Central African Republic

Swaziland

0 5% 10% 15% 20%

Kenya

22%

23%

Thailand

Sources: prevalence in the general population: UNAIDS estimates for 2011; prevalence among men who have sex with men: 2012 country progress reports

(www.unaids.org/cpr): the surveys are from multiple years between 2005 and 2011.


Data is only shown for countries which have reported a sample size greater than 100.

Prevalence among men who have sex with men (%) reportedby the country (2012)

Total prevalence among people 1549 years old (2011)

Angola

Haiti

Togo

Burkina Faso

Uzbekistan


30/11028

UNAIDS

Prevention coverage remains inadequate or men who have sex with men. Globally,

the median prevention coverage measured in surveys in capital cities is 55%, with

a majority o countries reportedly achieving at least 40% coverage or men who

have sex with men (able 1.3). Te median proportion o men who have sex with

men who received an HIV test in the last 12 months is 38%, with ewer than 1 in 3

men being tested in the past 12 months in South and South-East Asia and Western

and Central Europe, where men who have sex with men play a substantial role in

national epidemics (able 1.4).

One o the reasons or the persistent epidemic among men who have sex with men

is that levels o consistent condom use are insucient. Although a majority o

surveyed men who have sex with men said that they used a condom during their

last episode o sexual intercourse in 69 o 96 countries reporting, in only 13 o these

countries did more than 75% do so (able 1.5). More inormation is needed on the

extent o non-condom use among regular partners o known concordant HIV status,

but rates o consistent condom use in this population clearly need to increase to curb

the epidemic.

More countries are acknowledging the existence o men who have sex with men as a

key population in relation to the epidemic, reected both in the inclusion o men who

have sex with men in national strategies in 146 countries and in increased reporting

o prevalence data. Te number o countries reporting data on HIV prevalence

among men who have sex with men rose rom 67 in 2010 to 104 in 2012, with an

additional 62 countries acknowledging the relevance o this indicator but reporting

that data were unavailable. Eleven countries reported that this indicator would be

irrelevant. Reporting on men who have sex with men has notably increased in sub-

Saharan Arica: rom 11 countries in 2010 to 22 countries in 2012. Te countries that

include men who have sex with men in national AIDS strategies reported data on this

population, whereas only 4 o the 15 countries that do not include this population in

their national strategies reported data on relevant indicators in 2012.

Funding or HIV programmes or men who have sex with men increased between

2006 and 2011. Among 21 countries reporting HIV spending data or men who have

sex with men (with data available or at least one year in each o 20062007, 20082009

and 20102011), total spending increased 3.2-old.

Although countries are increasingly recognizing the need to address HIV amongmen who have sex with men, recent increases in resources or HIV programmes or

men who have sex with men have primarily resulted rom the eorts o international

donors. In 20102011, international unding accounted or 92% o all spending on

HIV programmes or men who have sex with men. Among 58 countries reporting

expenditure or men who have sex with men, 45 relied primarily on external sources

or such programming, including 19 o 21 upper-middle-income countries.

38%teSteD

T mdian rrtin

mn av s it mn

rivin an hIV tst in t

ast 12 mnts is 38%.


31/11029

2012 GLOBAL REPORT

Sexual transmission

Table 1.3

Rrtd vs vra rvntin rramms amn mn av s it mn, mstrnt ar


32/11030

UNAIDS

Afghanistan

Algeria

Andorra

Antigua and Barbuda

Austria

Bahrain

Barbados

Benin

Bhutan

Botswana

Brunei Darussalam

Cape Verde

Chad

Comoros

Congo

Croatia

CyprusDemocratic Peoples Republic of Korea

Democratic Republic of the Congo

Djibouti

Equatorial Guinea

Eritrea

Ethiopia

Fiji

Gabon

Ghana

Grenada

Guinea

Guinea-Bissau

Hungary

Iceland

India

Iran (Islamic Republic of)

Iraq

Israel

Jordan

Kiribati

KuwaitLao Peoples Democratic Republic

Lebanon

Lesotho

Liberia

Libya

Liechtenstein

Malawi

Maldives

Malta

Mauritania

Micronesia (Federated States of)

Monaco

Mozambique

Namibia

Nauru

New Zealand

Niger

Oman

Pakistan

Palau

QatarRussian Federation

Rwanda

Saint Lucia

Samoa

San Marino

Sao Tome and Principe

Saudi Arabia

Sierra Leone

Slovakia

Solomon Islands

Somalia

South Sudan

Syrian Arab Republic

Tonga

Trinidad and Tobago

Turkey

Turkmenistan

Tuvalu

Uganda

United Arab Emirates

United Republic of TanzaniaVanuatu

Venezuela (Bolivarian Republic of)

Zambia

Zimbabwe

Table 1.4

Rrtd vs vra hIV tstin amn mn av s it mn, mst rnt ar


33/11031

2012 GLOBAL REPORT

Sexual transmission

Table 1.5

Rrtd vs ndm us amn mn av s it mn, mst rnt ar


34/11032

UNAIDS

Full and eective combination o available prevention strategies has conclusively

demonstrated the capacity to rapidly reduce the number o people newly inected

with HIV. o make the best use o these combination prevention options, countries

need to closely ocus on the driving orces and key populations at higher risk o

their national epidemics. Behaviour change, biomedical interventions and structural

approaches to reduce the underlying vulnerability to HIV inection should be

implemented in concert or maximum impact.

Newly emerging evidence rom Kenya and Malawi indicates that even quite small

cash transers can markedly aect the dynamics o sexual transmission o HIV. In

Kenya, young people who received a cash transer were less likely to have ever had

sex and, when sexually active, less likely to have had more than two sexual partners

in the past 12 months (15). In Malawi, a cash transer intervention led to signicant

declines in early marriage, teenage pregnancy and sel-reported sexual activity(16).

Te promise o antiretroviral therapy in preventing HIV transmission, with

well-established evidence in relation to mother-to-child transmission, has come

into sharp ocus during the past two years. In 2011, researchers reported that

antiretroviral therapy reduces the odds o sexual transmission within serodiscordant

heterosexual partners (17), and in 2012 WHO issued guidelines on serodiscordant

couples to recommend that the partner living with HIV be oered antiretroviral

therapy regardless o his or her CD4 count (18). In addition to the reduced

transmission o HIV resulting rom ully eective viral suppression among people

living with HIV, trials have also indicated that antiretroviral medicines can reduce

the likelihood that an uninected person will acquire HIV. Te potential public

health impact o this strategy in reducing HIV incidence greatly depends on the

extent to which potential HIV-uninected users o antiretroviral medicines or

prophylactic purposes are able to adhere to daily dosing regimens.

In priority countries in sub-Saharan Arica, additional steps are needed to accelerate

the scaling up o voluntary medical male circumcision. Although some countries

have reported strong demand or voluntary medical male circumcision where

such services have been oered, generating robust demand or the service remains

a challenge in other priority countries. Investing in community engagement and

mobilization represents an urgent priority to accelerate scale-up. Intensive eorts

are underway to evaluate potentially promising non-surgical devices or male

circumcision. By avoiding the need or scalpels or sutures in circumcision, it is

hoped that scale-up can be expedited through substituting trained nurses or

surgeons, thus alleviating health worker shortages and reducing mens resistance

MoVINg foRwARD TowARDS 2015: ReDUcINg SexUAl

TRANSMISSIoN by 50%


35/11033

2012 GLOBAL REPORT

to undergoing the procedure. In 2012, eld trials were underway in Rwanda and

Zimbabwe or PrePex (a device that enables non-surgical and sae adult male

circumcision) and in Kenya and Zambia or the Shang Ring (a circumcision tool

that helps health care providers with limited training to perorm circumcision). A

new device or inants (AccuCirc) is also being evaluated in Botswana. Whether

surgical or non-surgical, voluntary medical male circumcision is a procedure that

has important cultural resonance, underscoring the need or a meaningul cultural

discussion on the signicance and benets o circumcision.

Although encouraging progress has been made in stabilizing HIV prevalence and

promoting condom use among workers in sex work, substantially greater gains will

be needed to halve the sexual transmission o HIV among sex workers by 2015.

Accurate estimates o the size and distribution o sex worker populations will assist

countries in adhering to the know your epidemic, know your response approach

to prevention planning. Programmatic experience has also shown that review and,

where necessary, reorm, o legal and policy rameworks to reduce stigma and

discrimination towards sex workers can promote the increased use o prevention

services.

Services to reduce the sexual transmission o HIV among transgender populations

are also critical. Te severe marginalization experienced by many transgender

people, limited options or employment, persistent stigma and discrimination

and, in many cases, targeted violence, are all actors that increase the vulnerability

to HIV inection or this population (see Section 7 or additional inormation on

transgender populations).

Reaching a higher proportion o men who have sex with men with eective

programmatic eorts is critical i the world is to halve sexual transmission by 2015.

Tis is one o many areas where the lack o domestic unding allocated towards

sound programming not only jeopardizes the sustainability o these programmes

but also suggests that a lack o national ownership is hampering the success o

these eorts. HIV monitoring among men who have sex with men should be

strengthened, and punitive legal rameworks should be revised to bring AIDS

responses in accordance with human rights norms. In addition to eorts ocused on

HIV-related behaviour, access to antiretroviral therapy or men who have sex with

men who are living with HIV and the potential use o pre-exposure prophylaxis

should be combined together in a coordinated and accelerated eort to reduce the

sexual transmission o HIV. Research to develop rectal microbicides should also

continue as a potentially important measure or this population.

Sexual transmission


36/11034

UNAIDS

Te global goal o reducing the number o people who use drugs who acquire HIV

inection by 50% by 2015 recognizes both the epidemics extraordinary toll on this

population and the act that drug-related transmission is driving the expansion

o the epidemic in many countries. Several countries that have implemented

evidence-inormed programmes or people who use drugs have dramatically

reduced the number o these people who acquire HIV inection, with some countries

approaching the elimination o drug-related transmission. However, globally we are

ar rom halving the number o people who use drugs who are newly inected with

HIV by 2015.

people who INJecT DRUgS ARe exTRAoRDINARIly

bURDeNeD

People who inject drugs are among the population groups most severely aected

by HIV inection. In virtually all countries reporting data in 2012, the prevalence

o HIV inection is higher among people who inject drugs than among the general

population (Fig. 2.1). In 49 countries with available data, the prevalence o HIV

inection is at least 22 times higher among people who inject drugs than or thepopulation as a whole, with prevalence at least 50-old higher in 11 countries.

A 2007 study(1) estimated that about 16 million people inject drugs globally,

including many younger than 25 years and 3 million o whom are living with HIV.

In addition to imposing extraordinary burdens on people who use drugs,

drug-related transmission also undermines global eorts to lay the oundation or

the eventual end o AIDS. In Eastern Europe and Central Asia, one o two regions

where the number o people newly inected is rising, national epidemics are

typically driven by drug userelated transmission and by urther transmission to

the sexual partners o people who use drugs.

Low- and middle-income countries, however, have had limited progress in slowing

the spread o HIV among people who inject drugs. Nevertheless, transmission

can be reduced substantially. Such countries as Australia and the United Kingdom

that have implemented evidence-inormed HIV prevention strategies have sharply

reduced the number o people who inject drugs who acquire HIV inection, with

some approaching the elimination o drug-related transmission.

2 PeoPle wHo Inject drUgs

22p injt drus

av 22 tims t rat

hIV intin as t nra

uatin in 49 untris

it avaia data.


37/110


38/11036

UNAIDS

eVIDeNce-INfoRMeD pRogRAMMeS ARe beINg

INADeqUATely ScAleD Up

According to country reports, nearly 80% o people who inject drugs reached in

surveys in 49 capital cities have access to sae injecting equipment, with similar

access reported or men and women. However, evidence rom recently published

studies (2,3) suggests that accessibility to needle and syringe programmes is low

in most countries in which drug use among women is highly stigmatized and that

access to any HIV services among women drug users remains very low compared

with men drug users. In addition, country reports indicate that the scale o such

programmes is inadequate, with most countries indicating that programmes

annually provide ewer than 100 needles per person who injects drugs (able 2.1).1

A separate 2010 study(4) estimated that, globally, two needle-syringes (range 14)

were distributed monthly per person who injects drugs per month, and another

study(5) estimates that people who inject drugs only use sterile injecting equipment

or 5% o injections globally.

Emerging evidence indicates that women who inject drugs may experience risks

that are greater than or men who inject drugs (6). In particular, women who inject

drugs are more vulnerable to violence rom intimate partners, police and sex-trade

clients (7). Combined with homelessness (8) and comorbid mental disorders (9),

these vulnerabilities may act synergistically to increase the risk o exposure to HIV.

Clear evidence indicates that women who inject drugs and are living with HIV

who become pregnant have a substantially lower likelihood o accessing services to

prevent children rom acquiring HIV inection than do other women living with

HIV.

Countries also lag in scaling up other essential prevention measures or people who

inject drugs (ables 2.2 and 2.3). Reported condom use, or example, is lower among

people who inject drugs reached in surveys in capital cities than or sex workers

or men who have sex with men. Among 56 countries reporting data, the median

condom use or people who inject drugs is 40% (3048%), with only 3 countries

reporting condom use above 75%.

HIV testing services are also ailing to reach many people who inject drugs. Among

57 countries reporting, a median o 39% (2260%) o people who inject drugs

reached in surveys in capital cities reported having received an HIV test in the

previous 12 months, with 8 countries reporting testing rates o at least 75%.

1 racking the average number o needles distributed per person who injects drugs is dicult, since it requires reliably estimating the size o national populations using drugs.


39/11037

2012 GLOBAL REPORT

Table 2.1

Numr srins distriutd tru nd and srin rramms r rsn injts drus, mst rnt ar avaia

Oman and Slovenia reported data on the number of syringes distributed but did not have available data on the estimated number of people who inject drugs.


These data were reported in 2012, but countries may di ffer in methods. Surveys are usually conducted in capital cities and may not be nationally representative.

lw vra 200

Cambodia

China

Estonia

Hungary

Kazakhstan

Kyrgyzstan

LuxembourgMalaysia

Myanmar

Uzbekistan

Viet Nam

Algeria

Andorra

Argentina

Austria

Bahamas

Bahrain

Bhutan

Bermuda

Bolivia (Plurinational

State of)

Brazill

Brunei Darussalam

Canada

Chile

Colombia

Costa Rica

Cte dIvoire

Croatia

Denmark

Djibouti

Dominican Republic

Ecuador

Egypt

El Salvador

Fiji

France

Gabon

Germany

Ghana

Guatemala

Honduras

Iceland

India

Iraq

Ireland

Israel

Italy

Japan

Jordan

Kenya

Kiribati

Kuwait

Lao Peoples Democratic

Republic

Lebanon

Libya

Malawi

Maldives

Micronesia (Federated

States of)

Monaco

Mongolia

Montenegro

Netherlands

Nicaragua

Nigeria

Oman

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Portugal

Qatar

Republic of Korea

Russian Federation

Samoa

San Marino

Saudi Arabia

Sierra Leone

Singapore

Slovakia

Slovenia

Solomon Islands

South Africa

Spain

Sudan

Suriname

Swaziland


Taiwan, China

Timor-Leste

Togo

Tonga

Turkey

Uganda

Uruguay

United Arab Emirates

United Kingdom

United Republic ofTanzania

United States of America

Vanuatu

Venezuela (Bolivarian

Republic of)

Yemen

Zambia

mdiu vra100200

Nn-rrin unris wi w inj drusa

Australia

Bangladesh

Czech Republic

Finland

MadagascarMalta

New Zealand

Norway

Sweden

a Mathers BM et al. HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage.

Lancet, 2010, 375:10141028.

People who inject drugs


40/11038

UNAIDS

Table 2.2

Rrtd hIV tstin vra amn injt drus, mst rnt ar avaia

75100%

Canada

Indonesia

Luxembourg

Malaysia

New ZealandRomania

Seychelles

5074%

Belarus

Finland

Kazakhstan

Kenya

Kyrgyzstan

Lithuania

Netherlands

Paraguay

Senegal

SwitzerlandThe former Yugoslav Republic

of Macedonia

2549%

Albania

Australia

Bhutan

Bosnia and Herzegovina

Bulgaria

Cambodia

China

Czech Republic

Estonia

Germany

Mauritius

Mexico

Myanmar

Serbia

South Sudan

Sweden


Tajikistan

Thailand

Ukraine

United States of AmericaUzbekistan

Viet Nam


41/11039

2012 GLOBAL REPORT

75100%

5074%

2549%


42/110


43/11041

2012 GLOBAL REPORT

hAlVINg The NUMbeR of people who INJecT DRUgS

AcqUIRINg hIV INfecTIoN: TowARDS 2015

Available evidence indicates that the world is ar rom being on track to achieve

the global target or people who inject drugs. Substantially stronger commitmentis urgently needed to bring evidence-inormed responses to scale. As many

countries ail to report data on HIV and people who inject drugs, immediate steps

are needed to improve the reporting o sex-aggregated epidemiological and HIV

service coverage data or this population, with the aim o ensuring reliable national

estimates o the total number o people who inject drugs. Countries that do not

currently address the needs o people who inject drugs in their national AIDS

strategies should take immediate steps to rectiy this. Governments must urgently

commit major new resources to comprehensive evidence-inormed prevention

programmes or people who inject drugs and intensiy eorts to increase the scale o

HIV testing, opioid substitution therapy needle distribution and condom use.

Fig. 2.2

hIV sndin n injt drus18 low- and middle-income countries with available data, latest year available

35

20

25

30

15

5

10

0

International

Domestic public

2008 or 2009

MillionsofUSdollars

2006 or 2007 2010 or 2011

People who inject drugs



44/11042

UNAIDS

Te world has embarked on an historic eort to end new HIV inections among

children and reduce the number o women living with HIV who die rom

pregnancy-related causes. Stakeholders have joined together to develop the Global

Plan towards the elimination o new HIV inections among children by 2015

and keeping their mothers alive (1). In 2011, the world made additional progress

in advancing towards the 2015 goal, generating signicant condence in the

easibility o eliminating new inections among children by 2015.

The NUMbeR of chIlDReN Newly INfecTeD wITh hIV

coNTINUeS To DeclINe

In 2011, 330 000 [280 000390 000] children acquired HIV inection. Tis represents

a 43% decline since 2003 (when 560 000 [510 000650 000] children became newly

inected) and a 24% drop since 2009 (when 430 000 [370 000490 000] children

acquired HIV inection).

More than 90% o the children who acquired HIV inection in 2011 live in sub-

Saharan Arica. Tere, the number o children newly inected ell by 24% rom 2009

to 2011. Te number o children acquiring HIV inection also declined signicantly

in the Caribbean (32%) and Oceania (36%), with a more modest decline in Asia

(12%). Declines have also been modest in Latin America (24%), Eastern Europe and

Central Asia (13%). However, these three regions had already signicantly reduced

the numbers o children newly acquiring HIV inection. Te Middle East and North

Arica is the only region that has yet to see a reduction in the number o children

newly inected.

In countries with generalized epidemics that account or the overwhelming majority

o the children newly inected, major gains have occurred during the past decade.

In six countries (Burundi, Kenya, Namibia, South Arica, ogo and Zambia), the

number o children newly inected declined by 4059% rom 2009 to 2011. In 16

additional countries, declines o 2039% occurred during the same period.

3 HIV InFectIon AMong

cHIldren And KeePIng tHeIrMotHers AlIVe

409 000In t tr ars 2009 t

2011, antirtrvira rais

rvntd 409 000 idrn rm

auirin hIV intin in

- and midd-inm

untris.


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2012 GLOBAL REPORT

Table 3.1

prnta dras tn 2009 and 2011 in t numr idrn (014 ars d)auirin hIV intin in untris it nraid idmis

Sources: UNAIDS estimates.

Inrasd

Angola

Congo

Equatorial Guinea

Guinea-Bissau

119%

Benin

Burkina Faso

Central African RepublicChad

Djibouti

Eritrea

Gabon

Mozambique

Nigeria

South Sudan

United Republic of Tanzania

2039%

Botswanaa

Cameroon

Cte d'Ivoire

Ethiopia

Ghana

Guinea

Haiti

LesothoLiberia

Malawi

Papua New Guinea

Rwanda

Sierra Leone

Swaziland

Uganda

Zimbabwe

4059%Burundi

Kenya

Namibia

South Africa

Togo

Zambia

Progress has not been universally apparent, however, underscoring the importance

o intensied action to achieve the global goal o zero new inections among

children by 2015. In 11 countries, the number o children newly inected has

declined modestly by 119% since 2009, and this has actually increased in our

countries: Angola, Congo, Equatorial Guinea and Guinea-Bissau (able 3.1).

Although reductions in the number o adults acquiring HIV inection are helping

to lower childrens risk o acquiring HIV, recent gains in bringing antiretroviral- and

inant eedingbased prevention services to scale are primarily responsible or the

sharp reductions in the number o children newly inected. From 2009 to 2011,

antiretroviral prophylaxis prevented 409 000 children rom acquiring HIV inection

in low- and middle-income countries.

HIV inection among children and keeping their mothers alive

a Note: the baseline year for the Global Plan is 2008. Some countries had already made important progress in reducing the number of new HIV infections amongchildren in the years before 2009, notably Botswana which, by 2009, already had 92% coverage of antiretroviral medicines among pregnant women. In countries

with high coverage, further declines in HIV infections among children are harder to achieve.


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UNAIDS

Fig. 3.1

prnta rnant mn ivin it hIV rivin tiv antirtrvira rimns rrvntin mtr-t-id transmissin, rin, 2010 and 2011

Coverage for Eastern Europe and Central Asia is not reported because the data have not been completely validated.

Sources: 2012 country progress reports (www.unaids.org/cpr) and UNAIDS estimates.

100

80

60

40

20

0

2010

2011

Middle East andNorth Africa

South andSouth-East Asia

East Asia andOceania

Caribbean Sub-SaharanAfrica

Latin America Low- and middle-income countries

%

A blUepRINT To elIMINATe New hIV INfecTIoNS AMoNg

chIlDReN

Four key actions are recommended to reduce the number o children acquiring

HIV inection: (1) strengthen primary HIV prevention services to ensure that

reproductive-age women and their partners avoid HIV inection, (2) take steps(such as providing contraceptives and counselling) to meet the unmet need

or amily planning among women living with HIV, (3) provide HIV testing,

counselling and antiretroviral medicines in a timely manner to pregnant women

living with HIV to prevent transmission to their children and (4) ensure proper

and timely HIV care, treatment and support or women living with HIV, children

living with HIV and their amilies.

With respect to preventing children rom acquiring HIV inection, the state o

the art is rapidly evolving, as new evidence emerges regarding the most eective

methods o reducing the risk o transmission. Similarly, countries need to adaptexisting systems and approaches as new evidence becomes available. Critical

decisions include whether to maintain lielong triple antiretroviral therapy or

pregnant women living with HIV who initiate treatment at CD4 counts above

350 per ml, whether to include eavirenz in combination regimens or pregnant

women and the type and duration o recommended inant-eeding practices to

maximize prevention benets or the child.


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2012 GLOBAL REPORT

Table 3.2

prnta rnant mn rivin antirtrvira rimns (udin sin-dsnvirain) r rvntin mtr-t-id transmissin in untris it a nraididmi, 2011

Sources: 2012 country progress reports (www.unaids.org/cpr) and UNAIDS estimates.


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UNAIDS

Te percentage o pregnant women and inant pairs receiving antiretroviral

medicines to prevent mother-to-child transmission exceeds 50% in most countries

with generalized epidemics and available data. Coverage o antiretroviral regimens

exceeds 75% in 8 countries with generalized epidemics, with an additional 13

countries reporting coverage rom 50% to 74% (able 3.2).

In breasteeding populations, providing antiretroviral medicines to the mother

or the inant during breasteeding is also critically important or avoiding

transmission to the child (2). Among the 21 Global Plan priority countries in

sub-Saharan Arica, the proportion o pairs o women living with HIV and inants

provided with prophylaxis during breasteeding has increased since 2009.

Fig. 3.2 illustrates transmission rates among children in dierent sub-regions

o sub-Saharan Arica. As the results demonstrate, some regions have made

strong progress: southern Arica, the subregion in sub-Saharan Arica with the

highest coverage o services to prevent children rom acquiring HIV inection,

has achieved the lowest post-breasteeding transmission rate (17%). Te central

and western Arica subregion, by contrast, still has transmission rates close to

30% because o lower service coverage, especially or prophylaxis during the

breasteeding period.

Fig. 3.2

Trnds in mtr-t-id transmissin rats surin in su-Saaran Aria, 20002011


Western Africa

Central Africa

Eastern Africa

Southern Africa

prcnta

gofhIV-xosdcildrninfctd

0

2003 2011 2015

40


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2012 GLOBAL REPORT

For the children who do become inected with HIV, international guidelines

recommend that all children younger than two years start immediately on

antiretroviral therapy, whereas older children ollow dierent guidelines based on

their CD4 levels (3). In 2011, only 28% [2531%] o children 014 years old who

were eligible were receiving the lie-saving medicines. Depending on the age o the

child when inected, this could mean death within less than one year (4).

Ensuring treatment access or mothers living with HIV benets not only mothers

themselves but also their children, since studies indicate that children whose

mothers die also have an increased risk o death regardless o the childs HIV

status. Te percentage o treatment-eligible pregnant women living with HIV who

are receiving antiretroviral therapy or their own health in 2011 was 30% [27

32%] lower than the estimated coverage or all adults eligible or antiretroviral

therapy (according to WHO guidelines) o 54% [5159%]. Qualitative research is

needed to determine why, despite higher levels o access to health care, pregnant

women are not starting, or being reported to start, antiretroviral therapy. Recent

estimates suggest that pregnancy-related deaths among women living with HIV

have declined rom 46 000 in 2005 to an estimated 37 000 in 2010. More eort is

needed to ensure that pregnant women tested or HIV during antenatal care are

also tested or eligibility or antiretroviral therapy.

Since pregnant women living with HIV have a much higher risk o developing

B, B screening, prevention and inection control are integral components

o the package o care or eliminating mother-to-child transmission. Te risk

o developing active B is more than 10 times higher among pregnant women

living with HIV than among HIV-negative pregnant women. In addition, B

is associated with a range o extremely poor obstetric and perinatal outcomes,

including more than double the risk o HIV transmission to the unborn child, a

2.2- to 3.2-old increased risk o maternal mortality and a 3.4-old increased risk

o inant mortality(5). Since antiretroviral therapy reduces the risk o B by 65%

irrespective o CD4 count, combining early antiretroviral therapy with regular

B screening at each health visit helps ensure that eligible mothers are provided

isoniazid preventive treatment or early treatment or active B, giving both

mother and child a much better chance o survival.

Pregnant women living with HIV in humanitarian crisis settings are at particular

risk. o reach the objective o no child born with HIV inection and keeping their

mothers alive, humanitarian actors should scale up prevention services and ensure

that orcibly displaced women have access to HIV prevention services, treatment,

care and support.


30%tReAtmeNt coVeRAge

on 30% ii rnant

mn r rivin

antirtrvira tra r tir

n at in 2011, mard

it 54% r a ii aduts.


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UNAIDS

NATIoNAl polIcIeS NeeD STReNgTheNINg

Among the 22 priority countries included in the Global Plan,1 21 have developed

national targets or preventing children rom becoming newly inected with HIV

and have aligned their national strategies with the elements o the Global Plan.

However, available evidence reveals persistent shortcomings in policy rameworksand clinical practices in many o these countries. In 2011, or example, 32

countries (including 12 countries with a high burden o HIV inection) reported

they were still providing some pregnant women with suboptimal single-dose

nevirapine regimens or preventing children rom acquiring HIV inection.

Although breasteeding is the norm throughout most o sub-Saharan Arica and

many other parts o the world, only 10 o 43 countries in this region reported

the number o breasteeding women or inants who were receiving antiretroviral

prophylaxis during breasteeding. Tese disappointing results may be partly

explained by weak reporting mechanisms, but they are also likely to reect

challenges that countries are experiencing in linking breasteeding women with

needed services and support at both the acility and community levels.

National and global leadership in the quest to eliminate new inections among

children also needs to improve. Tirteen o the 22 Global Plan priority countries

reported on trends in spending on services to prevent children rom becoming

newly inected with HIV between 2008 and 2010. Te resources dedicated to

programmes to prevent children rom acquiring HIV inection has increased in

some countries (Botswana, Burundi, Cameroon, Ghana and Kenya), but declines

in unding (Angola, Chad and Namibia) or inconsistent spending patterns (the

Democratic Republic o the Congo, India, Lesotho and Nigeria) are reported

elsewhere, according to reported AIDS spending data.

elIMINATINg New hIV INfecTIoNS AMoNg chIlDReN AND

KeepINg TheIR MoTheRS AlIVe: TowARDS 2015

Achieving 57% coverage o services to prevent children rom acquiring HIV inection

represents a major accomplishment. However, reaching the global goal o eliminating

new HIV inections among children by 2015 will require not only accelerated eorts to

bring services to prevent children rom acquiring HIV inection to scale but also steps

to ensure that all programmatic elements o the Global Plan are ully implemented. In

particular, reaching global goals will be impossible without preventing reproductive-

age women rom acquiring HIV inection and enabling women living with HIV to

make decisions about their reproductive lie. Te most eective prophylactic regimens

must be used, and prevention eorts must extend beyond the antenatal period to

1 Te Global Plan priority countries include: Angola, Botswana, Burundi, Cameroun, Chad, Cte dIvoire, Democratic Republic o the Congo, Ethiopia, Ghana, India, Kenya, Lesotho, Malawi, Mozambique,Namibia, Nigeria, South Arica, Swaziland, Uganda, United Republic o anzania, Zambia and Z imbabwe.


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encompass the duration o breasteeding as well (6). Early diagnosis and treatment

will be critical or improving the survival o children exposed to HIV and or ensuring

high-quality programmes. Partners will need to collaborate to retrain nurses and

ensure that all clinical settings have access to essential medicines.

Intensied eorts are needed to deliver timely, high-quality treatment and care to women

living with HIV. An estimated 70% [6873%] o pregnant women with CD4 counts

below 350 per ml are not receiving antiretroviral therapy a pattern that undermines

womens health as well as global eorts to prevent transmission to their children.

Growing evidence indicates the wisdom o continuing to provide mothers

living with HIV with the same combination regimens they take as prophylaxis

during pregnancy or the remainder o their lives (Option B+). Tis approach

has the potential to reduce transmission rates or uture births, lower the odds

o transmission to sexual partners, improve maternal survival and promote

simplied treatment regimens (7). It is essential that this be implemented with the

inormed consent o the women concerned and in a rights-based manner.

Integrating comprehensive prevention and antiretroviral services with maternal,

neonatal and child health services will improve the eciency and eectiveness

o all interventions. By packaging services, women are more likely to obtain

the services they require and service eciency will be enhanced (8). Service

integration is especially important in countries with generalized HIV epidemics,

since HIV care is a substantial burden or already weak health care systems.

Additional eorts are also needed to minimize social and structural impediments

to scaling up. Community programmes that mentor mothers, support disclosure,

promote the involvement o men and boys and reduce stigma and discrimination

are all critical to promote access to essential services and retain amilies in care.

In addition, even in countries that have reached high levels o service coverage,

concerted eorts are needed to reach the most marginalized and vulnerable

populations, such as women who use drugs, women who sell sex, women in

prison, illegal migrants and ethnic minorities. Te marginalized groups, who are

ofen missed by mainstream maternal and child health services, experience rates

o HIV transmission rom mother to child that are nearly 2.5 times higher than

that o the general population (9).

Involving aected communities, innovation and commitment will be required

to alleviate the stigma that would deter women living with HIV and vulnerable

women rom attending antenatal care. Recognizing the unique opportunity to

eliminate new HIV inections among children by 2015, national and international

partners also need to ensure that competing health priorities do not crowd out

essential support or HIV prevention services.


2.5cidrn mtrs in

marinaid uatins

rin hIV transmissin

nar 2.5 tims ir tan in

t nra uatin.


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UNAIDS

4 treAtMent

Te rapid expansion o antiretroviral therapy one o the most remarkable

achievements in recent public health history continued in 2011. More people

initiated antiretroviral therapy in 2011 than in any previous year, with the number o

people living with HIV receiving treatment rising by 21% compared with 2010 based

on data rom country progress reports. Expanding coverage is saving lives, since about

hal o the people with a CD4 count less than 350 per ml, the current threshold or

initiating treatment, would be expected to die within two years i they did not get

antiretroviral therapy. Tis accelerating pace needs to be sustained i the world is to

achieve the goal o reaching 15 million people with HIV treatment by 2015.

pRoMISINg TReNDS IN TReATMeNT coVeRAge

Antiretroviral therapy reached 8 million people by the end o 2011 a 20-old increase

since 2003 (Fig. 4.1). Since 1995, antiretroviral therapy has added 14 million lie-years

in low- and middle-income countries, including 9 million in sub-Saharan Arica.

Fig. 4.1

Numr rivin antirtrvira tra in - and midd-inm untris, rin, 20022011


9

8

7

6

5

4

3

2

1

0

End 2002 End 2003 End 2004 End 2005 End 2006 End 2007 End 2008 End 2009 End 2010 End 2011

Millions

North Africa and the Middle East

Europe and Central Asia

East, South and South

Documents

20121120 UNAIDS Global Report 2012 En