South Africa has the biggest and most high profile HIV epidemic

 with an estimated 6.3 million people living with HIV in 2013. In the same year, there were 330,000 new infections while 200,000 South Africans died from AIDS-related illnesses.

South Africa has the largest antiretroviral treatment programme globally and these efforts have been largely financed from its own domestic resources. The country now invests more than $1 billion annually to run its HIV and AIDS programmes

However, HIV prevalence remains high (19.1%) among the general population, although it varies markedly between regionsFor example, HIV prevalence is almost 40% Kwazulu Natal compared with 18% in Northern Cape and Western Cape

Key affected populations in South Africa

South Africa's National Strategic Plan 2012-2016 identifies a number of key affected populationsthat are at risk of HIV transmission
Men who have sex with men (MSM) and HIV in South Africa

HIV prevalence among men who have sex with men (MSM) in South Africa is an estimated 9.9% with roughly 9.2% of all new HIV infections among this group. HIV prevalence among MSM varies geographically. For example, one study reported an HIV prevalence of 43.6% among MSM in Johannesburg and Durban. By contrast, 10% of self-identified MSM from urban areas in Western Cape are reportedly living with HIV.

Many MSM still face high levels of social stigma and homophobic violence due to traditional and conservative attitudes. A 2013 study found that only 32% of South Africans said that homosexuality should be accepted by society. As a result, MSM find it difficult to disclose their sexuality to healthcare workers, limiting their access to HIV services.

However, South Africa is the only country in sub-Saharan Africa where gay rights are formally recognised.Moreover, national policies strongly emphasise equity, social justice and forbid discrimination based on sexual orientation. These are prerequisites for the provision of HIV services for MSM as well as other members of the lesbian, gay, bisexual and transgender (LGBT) community. As a result, South Africa has the potential to provide a leading role in the improvement of HIV service provision for MSM throughout sub-Saharan Africa.
Sex workers and HIV in South Africa

HIV prevalence among sex workers varies between 34% and 69% depending on the geographical area. In 2010, sex work accounted for an estimated 19.8% of all new HIV infections in South Africa.

Female sex workers (FSW) are particularly affected with studies suggesting that HIV prevalence among this group ranges from 40% to 88%, significantly higher than among women in the general population (14.4%). Young female sex workers under 25 in particular carry a heavy HIV burden, highlighting the need for focused interventions for sex workers from an early age.

Sex workers in South Africa face high levels of stigma and discrimination and are restricted by the laws under which they have to work. Moreover, many sex workers also inject drugs, exacerbating their vulnerability to HIV infection.

Educational organisations have reported difficulties in delivering HIV prevention services to sex workers due to ongoing police harassment. One study found that up to 70% of women who sold sex had experienced abuse by the authorities:

"He put me on the floor. The police officer raped me, then the second one, after that the third one did it again. I was crying after the three left without saying anything. Then the first one appeared again… He let me out by the back gate without my property. I was so scared that my family would find out." - Female sex worker, Cape Town

In light of these issues, in 2016, the South African National AIDS Council (SANAC) launched South Africa's National Sex Worker HIV Plan, 2016-2019 that aims to ensure equitable access to health and legal services for sex workers in the country.
People who inject drugs (PWID) and HIV in South Africa

Data on HIV prevalence among people who inject drugs (PWID) in South Africa is very limited and where it does exists, is based on small sample sizes. In 2012, an estimated 16.2% of PWID in South Africa were living with HIV. However, PWID account for a comparatively low 1.3% of new HIV infections.

One study has reported that up to 86% of South Africans who inject drugs share injection equipment such as syringes and other drug paraphernalia. Another study reported that some PWID re-use equipment between 2 and 15 times.

PWID are also associated with other high-risk behaviours such as sex work and unsafe sexual practices. For example, the IRARE study demonstrated a strong link between drug use and risky sexual practices with up to 65% of PWID in South Africa thought to practice unsafe sex.
Children and orphans and HIV in South Africa

In 2012, an estimated 410,000 children aged 0 to 14 were living with HIV in South Africa. From 2002 to 2012, HIV prevalence declined among children, due mainly to programmes to prevent the mother-to-child transmission of HIV (PMTCT). The scaling up of antiretroviral treatment has reduced child mortality by 20%.

There are also 2.3 million children in South Africa who have been orphaned by HIV and AIDS.Orphans are particularly vulnerable to HIV transmission; they are often at risk of being forced into sex, have sex in exchange for support, and typically become sexually active earlier than other children.

The National Strategic Plan 2012-2016 aims to lessen the impact of HIV on orphans, vulnerable children and youth by ensuring they have access to vital social services, including basic education.
Women and HIV in South Afric

A survey in 2012 found that HIV prevalence among women was nearly twice as high as men. Rates of new infections among young women aged 15-24 were more than four times greater than that of men in the same age range, and this age group accounted for 25% of new infections in South Africa.

Poverty, the low status of women and gender-based violence have also been cited as reasons for the disparity in HIV prevalence between men and women in South Africa.

Despite these barriers, HIV prevalence among women aged 15-24 is thought to have declined between 2002 and 2012


HIV testing and counselling (HTC) in South Africa

The National Strategic Plan 2007-2011 aimed to get 25% of all South Africans to test annually and 70% of all people to have at least one HIV testIn 2010, a quarter of the population aged between 15 and 49 had been tested for HIV in the previous 12 months, meeting this target.

The launch of the national HIV counselling and testing (HTC) campaign in April 2010 resulted in a remarkable increase in the number of people accessing testing. Between 2008 and 2012, annual HIV testing increased from an estimated 19.9% to 37.5% among men, and from 28.7% to 52.6% among women. The higher testing figures seen among women have been attributed to the added effect of the PMTCT programme, which enables women to access HIV testing services when they go for antenatal appointments.

In South Africa, the link has also been made between an individual’s socio-economic background and the likelihood that they will test for HIV. Those who have taken an HIV test and know their status, are more likely to have a higher level of education, be employed, have accurate HIV knowledge and a higher perception of risk.

Another determining factor is whether an individual lives in an urban or rural setting. One study revealed that people living in rural areas are only half as likely to have been tested as those in urban areas, with mobile testing units suggested as a means of reaching rural populations.

In May 2015, the Pharmacy Council of South Africa lifted a ban preventing pharmacies from selling take-home HIV testing kits. It is hoped this will encourage more people to test for HIV.

"There are many people who want to test and who do not want to interface with the healthcare system. We believe the more people testing, the better. Let's get as many people to test as possible."

Antiretroviral treatment (ART) in South Africa

South Africa has the largest antiretroviral treatment (ART) rollout programme in the world, achieving a 75% increase in HIV treatment access between 2009 and 2011. In three provinces, the life expectancy of people receiving ART is now about 80% of normal life expectancy provided they do not start treatment late.

By October 2012, over two million people were receiving ART, surpassing the country's universal access target (80%) in accordance with the 2010 World Health Organisation treatment guidelines (offering treatment to people with a CD4 count under 350). However, the new 2013 WHO treatment guidelines (treatment for those with CD4 counts under 500) have since made many more people eligible for ART and coverage has fallen to 42%.

In order to achieve higher levels of ART coverage, the South African government employed task shifting. Task shifting refers to the reallocation of tasks among available staff. In this case, nurses (rather than doctors) initiate ART; lay counsellors (rather than nurses) carry out HIV tests; and pharmacy assistants (rather than pharmacists) prescribe ARVs. This increases the number access points to treatment and care by reducing the ‘bottlenecks’ in the healthcare system created by a shortage of staff able to provide vital HIV services

Though treatment programmes have expanded rapidly, many South Africans still begin treatment with a very low CD4 count. In 2009, it was reported that the average CD4 count at which patients started treatment in South Africa was just 87. One study based in two Durban clinics found that 60% of patients were tested when their CD4 counts were below 200. Of these patients, just 42% had begun treatment within 12 months. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment.


In other cases, individuals simply refuse treatment despite being eligible. A study in Soweto found that of 743 newly diagnosed HIV-positive adults eligible to begin treatment immediately, 20% refused. More than a third gave "feeling healthy" as the reason for refusing treatment despite having a low CD4 count, with many also co-infected with tuberculosis
HIV prevention programmes in South Africa

HIV prevention in South Africa is centred on the National Strategic Plan (NSP). The previous NSP (2007-2011) oversaw a dramatic scaling up of South Africa's antiretroviral treatment (ART) programme with the purpose of decreasing the number of new HIV infections by reducing viral load.

The current National Strategic Plan 2012-2016 is framed primarily around the UNAIDS vision of "zero new HIV infections, zero discrimination and zero AIDS-related deaths." It has also committed to "zero new infections due to mother-to-child transmission."
Prevention of mother-to-child transmission (PMTCT)

The latest NSP highlights South Africa's commitment to ending mother-to-child transmission (MTCT) of HIV. Over the past decade, the country has made great progress in this area due largely to improvements in the choice of antiretroviral drugs (ARVs) and the widespread accessibility of the PMTCT programme
When South Africa first launched its PMTCT programme in 2001, there was very limited intervention before and after childbirth. Guidelines have since been revised several times and are now largely based on WHO recommendations.

By 2010, PMTCT services were being offered at 98% of all healthcare facilities in the country. Moreover, by June 2011, the national HTC campaign had tested 274,000 women with 78.5% of those diagnosed as positive being referred onto treatment. As a result, mother-to-child transmission of HIV in South Africa has fallen to 3.5% - meeting the previous NSPs target of less than 5%. Between 2009 and 2011, new annual HIV infections among children fell from 56,500 to 29,100.

However, maternal mortality has not followed this trend. A review of a large district referral hospital in Johannesburg showed there had been no reduction in the proportion of maternal deaths since 2007, despite improvements in PMTCT.
The current National Strategic Plan aims to reduce MTCT rates to under 2% at six weeks after child birth and less than 5% at 18 months by 2016. With the latest WHO PMTCT guidelines implemented as of April 2013, it is widely believed that South Africa has reached a point where the elimination of paediatric HIV is possible.
Condom use and distribution

South Africa has responded to its HIV epidemic with a rapid expansion of its condom programme. Male condoms are widely available and the female condom programme is one of the biggest and most established in the world.

Between 2007 and 2010, the distribution of male condoms increased by 60%, from 308.5 million to 495 million a year. However, in terms of condoms per person this only represents a small increase - from 12.7 in 2007 to 14.5 in 2010. In the same period, the number of female condoms distributed increased from 3.6 million to 5 million. However, it is widely acknowledge that female condoms are not as readily available as they should be

In recent years, condom usage in South Africa has fallen. In 2008, 85% of 15-24 year old males reported using a condom during their last sexual encounter - by 2012, this had fallen to 68%. Condom use among men aged 25-49 also decreased, from 44% to 36%. The same survey reported that 53% of participants had never used condoms.
Voluntary medical male circumcision (VMMC)

During the development of the 2007-2011 National Strategic Plan, research emerged in sub-Saharan Africa that voluntary medical male circumcision (VMMC) can reduce the risk of female- to-male HIV transmission by up to 60%.
As a result, in 2010, the South African government quickly rolled out a national VMMC programme, which aimed to reach 80% of HIV-negative men (4.3 million) by 2016. In April 2010, KwaZulu-Natal became the first province to offer VMMC services and by late 2012, there were over 80 VMMC sites.

By April 2011, more than 150,000 circumcisions had been conducted with an estimated one new HIV infection averted for every five VMMCs conducted The VMMC programme in South Africa has mostly been well received with 78% of women preferring their partner to be circumcised according to the 2011 youth sex survey.
HIV education

Since 2000, the HIV and AIDS Life Skills Education Programme has been implemented in all public primary and secondary schools in South Africa. The main objectives of the programme are to integrate HIV education into the school curriculum to avert new HIV infections and provide care and support for pupils already living with HIV. The programme is mostly implemented through Life Orientation lessons

However, in many places there is a shortage of teacher training on these issues. Moreover, some schools are resistant to the subject matter. In 2008, teaching unions called for a Life Orientation module to be included in all teacher training. In some cases, gaps in the delivery of the Life Orientation curriculum are filled by independent organisations. In other instances, teachers report feeling uncomfortable about teaching a curriculum that contradicts with their own values and beliefs.

High dropout rates in schools also compromise effective HIV and sex education. It has been suggested that prevention programmes should be focussed towards younger children while more of them are in education and before they become sexually active.
HIV awareness

In South Africa, there have been a number of HIV awareness campaigns. The 2012 National Communication Survey on HIV/AIDS found that the country's HIV communication programmes were having a positive effect, particularly on youth (aged 15-24), with an increase in condom usage, uptake of HTC and male circumcision. By contrast, knowledge around safe breastfeeding practices among pregnant mothers living with HIV remains low. The main HIV awareness campaigns include:
Khomanani

Khomanani was an AIDS awareness campaign launched by the Department of Health. The campaign utilised mass media including radio announcements and situational sketches on television. It aimed to reduce the rate of new HIV infections by 50%. Compared with other campaigns, Khomanani had fairly mixed outcome with condom usage unchanged but knowledge of safe sex practices did improve significantly.
loveLife

Since 1999, the loveLife campaign has used a range of media to reduce new HIV infections among young people aged 12-19. It engages with youth through outreach and support programmes facilitated by peer educators. loveLife also runs youth centres or 'Y-centres' providing sexual health information, clinical services and skills development.
Soul City and Soul Buddyz

Soul City and Soul Buddyz were two government multi-media campaigns targeting adults and children respectively.

Soul City broadcasted TV dramas and radio programmes to audiences at prime time to maximise its reach. The intervention reached 70% of over 16s including 65% of rural people and 50% without any formal education. The initiative lead to a significant increase in HIV knowledge and encouraged positive behaviour change.

Soul Buddyz was judged to be the most successful family television show to be produced in South Africa. 67% of 8-12 year olds had watched, read or listened to Soul Buddyz (about four million children).
HIV and tuberculosis (TB) in South Africa

South Africa also has the world's third largest tuberculosis (TB) epidemic. The HIV epidemic in South Africa fuels the TB epidemic as people living with HIV are at a far higher risk of developing TB as a weakened immune system allows the development of the disease. 70% of people living with HIV in South Africa are also co-infected with TB.

However, the TB cure rate has improved in recent years. Between 2010 and 2011, the number of people living with HIV who received TB treatment nearly tripled, from 146,000 in 2010 to 373,000 in 2011.

"We cannot fight AIDS unless we do much more to fight TB." - Nelson Mandela
HIV funding in South Africa

Despite having the world's biggest antiretroviral treatment programme, South Africa had been paying significantly more than other low and middle-income countries for its antiretroviral drugs. In 2010, bound by the terms of its existing tender for ARVs, the government only bought one third of its products at internationally competitive prices.

Over the following two years, a 53% reduction in the cost of ARVs saved the country $640 million. This new tender introduced three-in-one or fixed-dose combination (FDC) drugs helping to reduce the pill burden and improve adherence to treatment.

South Africa largely funds its HIV and AIDS programmes domestically. However, based on National Strategic Plan 2012-2016 targets, the gap between funding requirements and availablefunding for HIV is expected to grow.

The future of HIV and AIDS in South Africa

South Africa has made great strides in tackling its HIV epidemic in recent years and now has the biggest HIV treatment programme in the world. Moreover, these efforts are now largely funded from South Africa's own resources.

HIV prevention initiatives are having a significant impact on mother-to-child transmission rates in particular, which are falling dramatically. New HIV infections overall have fallen by half in the last decade, however, there are still too many.

While the short term financing of South Africa's HIV epidemic is secure, in the longer term, the government needs to explore other strategies in order to sustain and expand its progress.

The beginning of the HIV epidemic

Harm reduction refers to strategies that aim to reduce the harms associated with injecting drug use. The earliest forms of harm reduction promoted abstinence from drug use and put reducing its occurrence at the centre of substance use policy and interventions.

The concept of harm reduction was re-invented in the early 1980s at  when healthcare workers started to provide clean syringes to people who inject drugs (PWID) rather than solely trying to achieve abstinence.
Since then, there has been slow but steady progress in support for harm reduction programmes as a component of the response to the HIV epidemic as well as other illicit drug use epidemics, with a wide range of initiatives implemented to date.

The beginning of the HIV epidemic

Harm reduction refers to strategies that aim to reduce the harms associated with injecting drug use. The earliest forms of harm reduction promoted abstinence from drug use and put reducing its occurrence at the centre of substance use policy and interventions.

The concept of harm reduction was re-invented in the early 1980s at  when healthcare workers started to provide clean syringes to people who inject drugs (PWID) rather than solely trying to achieve abstinence.
Since then, there has been slow but steady progress in support for harm reduction programmes as a component of the response to the HIV epidemic as well as other illicit drug use epidemics, with a wide range of initiatives implemented to date.

Treatment as prevention (TasP)

 refers to HIV prevention methods that use antiretroviral treatment (ART) to decrease the risk of HIV transmission. Antiretroviral treatment reduces the HIV viral load in the blood, semen, vaginal fluid and rectal fluid to very low levels ('undetectable'), reducing the risk of onwards HIV transmission.

For a number of years now, there has been growing evidence of the benefits of HIV treatment as a prevention method. In 2011 a landmark study, HPTN 052, showed early initiation of antiretroviral treatment in people living with HIV with a CD4 count between 350 and 550, reduced HIV transmission to HIV-negative partners by 96%.

A number of follow-up studies since have also reported significant reductions in HIV transmission, with new infections averted as a result.

This has led to the idea that treatment as prevention could be used as part of a 'test and treat' strategy - increasing testing and treatment coverage to decrease community viral load and reduce the rate of new HIV infections.

Following the results of HPTN 052, Executive Director of UNAIDS Michel Sidibé, commented:

"This breakthrough is a serious game changer and will drive the prevention revolution forward. It makes HIV treatment a new priority prevention option."

HIV treatment is already being used as prevention
Prevention of mother-to-child transmission (PMTCT)

Treatment as prevention has been used since the mid-1990s to prevent mother-to-child transmission (PMTCT) of HIV. In 1994, research showed how zidovudine reduced the vertical transmission of HIV from HIV-infected mothers to their babies from 25% to 8%.

Since then, testing pregnant women and treating HIV-positive mothers with antiretroviral drugs (ARVs) during pregnancy, delivery and breastfeeding has been found to reduce the risk of a mother transmitting HIV to her child by up to 90%.

One study from the United Kingdom (UK) and Ireland found that pregnant women who received at least 14 days of treatment reduced the risk of transmitting HIV to their babies to less than 1%.
Pre-exposure prophylaxis (PrEP)

Pre-exposure prophylaxis (PrEP) uses antiretroviral drugs to protect HIV-negative people from HIV before potential exposure. Trials have shown that when taken consistently and correctly, PrEP is very effective.

As a result, like TasP, it potentially has population-wide benefits. However, if not taken routinely and consistently, PrEP is much less effective. It is important that PrEP is offered as part of a combination package of prevention initiatives, and does not replace other, more effective methods like condoms.

In 2015, the World Health Organization released new guidelines and a policy brief recommending that PrEP should be offered as a choice to people who are at substantial risk of HIV infection. Previously, it was only recommended for certain key affected populations such as sex workers,men who have sex with men and people who inject drugs.
Microbicides

Microbicides are gels or creams containing antiretroviral drugs that are applied to the vagina to help prevent HIV infection. Vaginal microbicides are effective, so long as they are used consistently and correctly. One study observed 39% fewer infections, but its findings have not been replicated.

The main challenge is adherence – in other words, creating a product that women who are at high risk of HIV infection are able to use regularly. In this respect, the issues for microbicides and PrEP are comparable. In fact, a microbicide gel is essentially a different way to deliver PrEP and is sometimes referred to as ‘topical PrEP’.

There is also ongoing work into rectal microbicides suitable for use during anal sex.
Post-exposure prophylaxis (PEP)

Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment taken after possible exposure to HIV.

Since 1998, it has been used by healthcare workers who may have been exposed to HIV-infected fluids.More recently, it has been used to treat those who may have been exposed during a single event (for example sexual assault, unprotected sex or sharing drug injecting equipment).

More research is needed into the effectiveness of PEP as an HIV prevention strategy. One trial from the mid-1990s, which gave zidovudine to healthcare workers exposed to HIV, prevented transmission in 81% of cases.

However, its use in PEP has since been replaced by tenofovir as a component of a three-drug combination.
Test and treat strategies

'Test and treat' programmes are based on the premise that the rate of new HIV infections can be reduced by rolling out universal HIV testing in order to diagnose all people living with HIV, and initiate antiretroviral treatment regardless of CD4 count or viral load.

One study from South Africa estimated that the implementation of universal voluntary HIV testing for adults over 15 years old would decrease HIV prevalence to 1% within 50 years.

Trials testing the effectiveness of treatment as prevention for the general population in high HIV prevalence settings are currently ongoing. The HPTN 071 study, known as PopART, is currently carrying out a large scale trial in 21 communities across South Africa and Zambia.

The trial aims to measure the costs and benefits of a combination package of interventions that includes door-to-door voluntary HIV testing and immediate treatment for HIV-positive individuals regardless of CD4 count. The five-year project runs until 2017.

A 2016 study in India among men who have sex with men and people who inject drugs found a clear correlation between treatment, viral suppression and HIV incidence in large populations - although long-term follow up is needed.
Limitations of treatment as prevention
TasP is not 100% effective

Following the results of the HPTN 052 study, in 2013, the World Health Organization recommended that antiretroviral treatment be offered to all people living with HIV who have uninfected partners to reduce HIV transmission.

However, even if all mixed status couples had access to treatment, it is widely agreed that this would not bring an end to the epidemic. If the preventative benefits of treatment are overstated, people are more likely to engage in high-risk behaviours. Research from Switzerland showed how increased access to antiretroviral treatment can lead to a reduction in other HIV prevention measures such as condom use.
Furthermore, a study from China of 38,000 mixed status couples reported that treating the HIV-infected partners reduced the risk of HIV transmission to the uninfected partner by a comparatively low 26%.In the HPTN 052 study, 30% of HIV-positive people had an external partner.
Adherence is vital to its success

The success of treatment as prevention is highly dependent upon people adhering to their treatment. It is widely agreed that once treatment is initiated it should not be interrupted, as incomplete viral suppression causes the more sensitive strains of HIV to be suppressed and the resistant strains to become dominant. Resistant strains are harder to treat.

Adherence is an issue even where treatment is widely available. In 2011, one study from theUnited States of America (USA) reported that 15 years after the initiation of highly active antiretroviral therapy (HAART), and four years after the introduction of combination prevention, only 19% of 1.1 million people living with HIV in the country had an undetectable viral load.

In South Africa, which has the largest treatment programme in the world, a study found that only 64% of people who were initiated on treatment between 2002 and 2007 were still in care three years on.
Multidrug-resistant HIV

There are also concerns that the widespread use of antiretroviral treatment at a population level to reduce the number of new HIV infections could lead to a significant increase in levels of multidrug-resistant HIV.

The dramatic scaling up of treatment could see increases in non-adherence resulting in the development of resistant strains of the virus.One study from Los Angeles County, USA, reported that the use of 'test and treat' among men who have sex with men could almost double the prevalence of multidrug-resistant HIV cases from 4.8% to 9.1% by 2023 among this group.
Despite legitimate arguments about treatment adherence and drug resistance, many argue that interventions should be implemented regardless given the prevention benefits and how existing combination treatment has proved effective in suppressing viral load. Moreover, there remains a lot of scope to improve the current delivery of treatment through improved monitoring of treatment adherence as well as strengthening the links between treatment and care.
The future of treatment as prevention

Treatment as prevention has a lot of potential in reducing population level rates of HIV transmission by increasing uptake of HIV testing, offering treatment and linking people to care.

However, its effectiveness relies, at least in part, on the willingness and ability of people on treatment to remain in care and follow their prescribed course of antiretroviral drugs correctly. A number of studies have promoted a combination of cognitive, behavioural and mixed interventions including emotional support as a means of improving adherence.

Others have suggested that more research is needed in order to identify the most effective way of delivering TasP. Research from Botswana has modelled the benefits of targeting such a strategy at people with the lowest CD4 counts.

Bigger challenges and questions remain around its implementation in resource-limited settings. Its success depends much upon the ability of a country's healthcare service to deliver these services However, with trials ongoing, the burden of adding treatment-based prevention to already strained healthcare systems remains unknown.

Ethical and public health concerns have also been raised about how limited supplies of antiretroviral drugs in resource-limited countries are distributed - for treatment, prevention or both. One study concludes it is "unethical to watch patients with treatable AIDS worsen and die, even with supportive care, so that medications for treatment can be diverted for prevention."However, others maintain that while TasP requires large financial investments and poses significant implementation challenges, it is potentially a highly cost-effective approach to reducing both new HIV infections and the overall global HIV burden.

Overall, there is wide support for treatment as an HIV prevention measure, especially in those with CD4 counts under 350. Treatment for this group must be scaled up, with healthcare systems working to increase adherence and retention in care.

It is widely acknowledged that treatment alone will not end the global HIV epidemic. In order to be effective, treatment needs to be delivered as part of a comprehensive package of prevention methods including HIV and sexual and reproductive health education, condom use and behaviour chang

Human rights and equity in healthcare are key principles in all of these areas

While World Health Organistion guidelines propose simplified approaches to antiretroviral treatment (ART) for HIV, they do not recommend a ‘one size fits all’ approach.

Treatment programmes need to respond to the different needs of children and adolescents, of people with co-infections in addition to HIV, and of marginalised key affected populations.

. All human beings, rich and poor, strong and weak, male and female, of all races and religions, are to be treated equally and with respect.

While young people may have less autonomy than adults, the right of the child to health and the obligation of institutions to act in the best interests of the child are enshrined in human rights treaties.
However, stigmatising attitudes towards people living with HIV and towards groups that are more at risk of HIV can result in health services failing to respond adequately to their needs. Healthcare providers sometimes treat patients with dismissive or discriminatory attitudes or behaviour, for example neglecting patients, breaching confidentiality, verbally abusing patients or denying care.

Same-sex behaviour is criminalised in 78 countries, with anxiety about mistreatment often disrupting individuals’ access to healthcare. Many more countries criminalise sex work and the use of drugs, creating barriers for people with these behaviours to have trusting relationships with healthcare providers. Similarly, prosecutions for HIV non-disclosure, exposure and transmission have been recorded in at least 49 countries and may curtail open discussion with healthcare staff.
Evidence from the People Living with HIV Stigma Index demonstrates the impact of stigma and discrimination on the health of people living with HIV. One in eight respondents living with HIV reported being denied health services and one in five reported experiencing physical assault because of their HIV status.


Treating children

It is vital that infants and young children who are living with HIV receive HIV treatment as they are at an elevated risk of poor treatment outcomes - without treatment, half will die by their second birthday. Given the strong evidence of benefit, WHO recommends treatment for all children and prioritises it for the youngest infants and those with compromised immune function.

Despite this, children are less likely than adults to receive treatment: only 32% were receiving treatment in 2014 in comparison to 41% of adults.

Retention in care is frequently a problem in many countries, but thanks to robust systems for tracking patients and because healthcare is provided free of charge, China is an example of a country that has made great efforts to retain children in care.

Low rates of HIV testing in infants prevent those who need it getting prompt access to HIV treatment. Diagnosing and retaining children in care presents unique challenges because of their dependence on parents and caregivers. The limited range of antiretroviral drugs which are available in paediatric formulations – especially second- or third-line alternatives – makes treatment more challenging, especially given the potential difficulty of adherence to medication which may have an unpleasant taste and is associated with a stigmatised health condition.
Treating adolescents

Young people who have been living with HIV since birth, can face challenges in the transition from paediatric treatment services—where parents and guardians have primary responsibility for their care—to adult treatment services, where they will need to take much greater responsibility for their own care. As with any other long-term health condition, the transition to adult services should be carefully managed with full involvement of the young person as abrupt changes can be confusing and destabilising.

A failure to follow good practice in this area has resulted in poor rates of retention in care and low coverage of HIV treatment among adolescents. Adolescent-specific services are rarely available and healthcare providers may have little experience of providing services for young people. They may not understand the needs of adolescents living with HIV and may have judgemental attitudes towards those who are sexually active. Adherence may be challenging for adolescents due to unstable lives that are not conducive to daily medication and not being fully involved in treatment decision-making.

A study of 160 HIV clinics in Kenya, Mozambique, Rwanda and Tanzania found that young people aged 15 to 24 years were more likely to drop out of care, both before and after beginning HIV treatment, than other age groups. Young men were especially likely to drop out of care. However, drop out was considerably lower for adolescents who attended clinics that provided sexual and reproductive health services (including condoms) or provided adolescent support groups.

For adolescents who were not diagnosed in childhood and who may have acquired HIV during adolescence, laws and policies on the age of consent for HIV testing prevent many adolescents from knowing their HIV status and therefore accessing HIV treatment. Late diagnosis of HIV is a particular issue for adolescents who also belong other other key populations (for example, they inject drugs), as they are often reluctant to seek services because of stigma and discrimination.
Treating key affected population

Just as punitive laws, human rights abuses and stigma increase the vulnerability of key populations (such as people who inject drugs and transgender people) to HIV, they also act as barriers to key populations accessing HIV treatment. Accurate statistics comparing treatment access in different populations are rarely available but when they are, they frequently show limited uptake.

For example, transgender people often face stigma and ill treatment in healthcare settings, including refusal of care, verbal abuse and violence.Men who have sex with men living in low- and middle-income countries generally report low access to ART, with especially low rates in countries which criminalise same-sex behaviour and in men who feel they are subject to social stigma.

Services which are culturally and clinically sensitive to the specific needs of key populations can improve access. Peer-based interventions and multidisciplinary teams providing non-judgemental care show promise. Providing HIV treatment, hepatitis treatment and opioid substitution therapyat the same site can improve the engagement of people who inject drugs. Services for transgender people should consider the adverse interactions between antiretroviral treatment for HIV and hormone therapy.

The World Health Organisation has produced comprehensive guidance on HIV services for key populations.
Treating people with co-infections

Due either to untreated HIV’s suppression of the immune system or to overlapping risk behaviours, many people are living with both HIV and another infection. These additional infections are known as co-infections.

Globally, 1.2 million of the 9.6 million people who fell ill with tuberculosis (TB) in 2014 also had HIV. The burden of HIV/TB co-infection is heaviest in Africa, where 74% of people with an HIV/TB co-infection live.Moreover one third of people living with HIV who died in 2015 in fact died of tuberculosis (which is an AIDS-defining illness).Two other co-infections, malaria and cryptococcal meningitis, also cause significant illness and death in people living with HIV in Africa.

Chronic hepatitis B affects 5% to 20% of people living with HIV worldwide, and hepatitis C affects 5% to15% - but up to 90% among people with HIV who inject drugs. Liver disease caused by viral hepatitis is a major cause of death in people living with HIV in Eastern Europe.

However, health services do not always work in integrated ways and may even fail to provide screening for common co-infections. Although significant progress has been made in the past decade, only half of tuberculosis patients were tested for HIV in 2014. Equally, HIV-positive patients need to be screened for TB symptoms and viral hepatitis, especially in those regions and populations where the infections are prevalent.

Treatments for co-infections should generally be provided at the same time as treatment for HIV and the care carefully co-ordinated – for example the possibility of drug interactions needs to be managed. By strengthening the immune system, ART contributes to the management of co-infections.

The World Health Organization

Needle and syringe programmes (NSPs) are a type of harm reduction initiative that provide clean needles and syringes to people who inject drugs (sometimes referred to as PWID).(WHO) recommends providing 200 sterile needles and syringes per drug injector per year, in order to effectively tackle HIV transmission via this route.

Many programmes supply other equipment to prepare and consume drugs such as filters, mixing containers and sterile water. The majority are run by drug services or pharmacies and operate from a range of fixed, mobile and outreach sites.

Programmes aim primarily to reduce the transmission of HIV and other blood-borne viruses caused by the sharing of injecting equipment. Many also work to reduce other harms associated with injecting drug use by providing:
advice on safer injecting practices
advice on minimising the harm done by drugs
advice on how to avoid and manage an overdose
information on the safe handling and disposal of injecting equipment
referrals to HIV testing and treatment services
help to stop injecting drugs, including access to drug treatment (such as opioid substitution therapy) and encouragement to switch to safer drug taking practices
other health and welfare services (including condom provision)

"NSPs substantially and cost effectively reduce the spread of HIV among PWID and do so without evidence of exacerbating injecting drug use at either the individual or societal level."
How are needle and syringe programmes delivered?
Fixed sites

Fixed sites are typically located where the drugs are bought and sold openly. They are normally converted shops or offices and have a reception area for clients where they give out new, and receive used, injecting equipment.

At fixed sites, it is easier to offer additional services such as healthcare alongside testing and counselling for HIV and other blood-borne viruses.
Mobile programmes

Mobile programmes operate from a van or bus with needles and syringes distributed through a door or window. Some large mobile programmes act like fixed sites with testing and other healthcare services also available.

Others run in conjunction with fixed sites. In these instances, the fixed site is typically located in an area with high numbers of peopel who inject drugs with the mobile NSP focussing on harder to reach or smaller populations.

Mobile programmes can be more accessible than fixed sites and often face less opposition than fixed sites such as the Insite facility in Vancouver, Canada.
Outreach programmes

Outreach programmes take many forms including mobile units (such as a van or bus), backpacking services on the street or even home deliveries.
They typically operate where there is a shortage of funding for needle and syringe programmes. For example, it is the preferred method of delivery in Haryana, India, where peer educators reach out to people who inject drugs who do not openly buy or sell drugs.

Some outreach programmes exist to complement fixed or mobile NSPs where injecting drug users are not engaging with established services. Outreach workers are tasked with encouraging people who inject drugs to use existing fixed or mobile sites.
Syringe vending machines

Countries including the Netherlands, Germany, Italy and Australia use syringe vending machines in addition to other forms of NSPs.

Syringe vending machines accept coins and tokens (distributed by outreach workers) in return for harm reduction packs. In Australia, these packs include several needles and syringes as well as alcohol swabs, cotton wool, sterile water and spoons. Others contain educational materials.

The machines are typically mounted on the outside walls of fixed sites. They are also installed in places where needles and syringes are hard to access. Most provide needles and syringes 24 hours a day, 7 days a week.
Pharmacies

Pharmacy-based NSPs operate in a number of ways. Some sell needles and syringes directly to people, while others exchange harm reduction kits for vouchers.

The main advantage of this delivery mode is that pharmacy networks are often already well established and located near to large groups of people who inject drugs. In addition, their opening hours are often more convenient than those at fixed sites.

However, they are very limited in low-income countries. Even where they do exist, some pharmacists are reluctant to sell needles and syringes or deal with their disposal. Moreover, they rarely offer education and additional healthcare services.
Needle and syringe programme coverage

In 2014, there were 158 countries worldwide that reported people who inject drugs, but just 90 of these countries implement needle and syringe programmes. Five countries (the Dominican Republic, Colombia, Jordan, Kenya and Senegal) have introduced NSPs since 2012.

Only 90 needles per year are available per person who injects drugs globally - far below the recommended 200.
Asia and the Pacific

17 countries and territories in Asia implement NSPs. In Cambodia, Mongolia, the Philippines andThailand, provision exists on a very small scale. In others, provision has nearly doubled since 2012, such as in Malaysia and Australia. Despite progress in some countries, Bangladesh, China, Pakistan and Vietnam have reported a decline in the number of programmes since 2012. Vietnam has dropped the number of needles distributed from 180 per person who injects drugs in 2012 to 98 in 2014.

NSPs in Asia are delivered in a number of ways. In some places, fixed sites have been integrated with other facilities such as health clinics and pharmacies. In Laos, there is just one community-based programme on the border with Vietnam. NSP coverage is still too low to have a significant impact on HIV prevalence among injecting drug users, with a lack of human resources, inflexible hours and harsh drug policies cited as barriers to their access.

In the Pacific (Oceania), Australia and New Zealand are the only countries that have figures on people who inject drugs, and both provide NSP services. In fact, they have one of the highest coverage rates in the world. Political support and public funding for harm reduction services has helped to keep HIV transmission from unsafe injecting very low.
Eastern Europe and Central Asia

All 29 countries and territories in Eastern Europe and Central Asia have NSPs, although there is a huge disparity in the number available in each country. For example, there are 1,667 in Ukraine but only two in Albania. A report by the Eurasian Harm Reduction Network estimated that only 10% of people who inject drugs in Eastern Europe and 33% in Central Asia are able to access these services.

Since 2012, Bosnia and Herzegovina, Croatia and Ukraine have scaled up their NSP provision, but large drops have been recorded in Poland. Coverage remains very low across the region, with the lowest number of syringes distributed per injecting drug user (50).

The political reaction to harm reduction services in the area continues to be hostile, forcing many services to close. This severely affected Hungary, where its largest programme was shut down, reducing the number of clean needles available in the country by around 40%.


Western and Central Europe and North America

Generally, NSPs are widely available across Western and Central Europe and use fixed sites, pharmacy-based services, vending machines, outreach and mobile services.

The number of syringes distributed per person who injects drugs is generally around the 200 mark, as recommended by the WHO. However, some countries, including Germany, do not rank as providing high coverage due to a lack of data processing despite a high number of NSPs (1,000).

Barriers to access in the region include under 18s being denied servics, undocumented migrants not being reached, and rural areas having underdeveloped services.

NSPs are available in both the United States of America (USA) and Canada, but estimates of coverage are limited. The most recent estimates from 2010 found that only 23 syringes were distributed per person who injects drugs per year.
Latin America

The most recent data available suggest that only 2% of people who inject drugs are accessing NSP services in Latin America, with only 0.3 syringes distributed per person per year.

Only five countries in this region operate these programmes, with Brazil providing the most (between 150 and 450 sites). Argentina, Mexico, Paraguay and Uruguay make up the remaining four countries, however it is thought these services are being scaled back in all countries as a result of declining injecting drug use in the region.
The Middle East and North Africa

Nine countries in the Middle East and North Africa (MENA) currently implement needle and syringe programme Iran has doubled its provision since 2012, with many people who inject drugs continuing to get new needles from pharmacies.

Coverage throughout MENA is thought to be extremely limited and remains too low to have a positive impact on the transmission of HIV and other blood-borne viruses.
Sub-Saharan Africa

NSP provision throughout sub-Saharan Africa is limited to interventions by non-government organisations (NGOs), due to a lack of political and financial support from domestic governments.

However, in June 2012, the Kenyan government announced plans to distribute over 8 million needles and syringes to 50,000 people who inject drugs nationwide. In 2014, there were 10 operational programmes in the country. In Dar es Salaam, Tanzania, there were seven NSPs in 2014, up from just one in 2012.

Mauritius has the greatest coverage in the region with 83.8% of people who inject drugs using sterile injecting equipment in 2013.
The Caribbean

Data regarding people who inject drugs in the Caribbean are sparse, with reliable data only available for Puerto Rico and the Dominican Republic. They are the only two countries in the region that have NSPs.

NSPs have been available in Puerto Rico since 2007, with six operating as of 2014. Between 2007 and 2011, they led to a 17.1% reduction in HIV infections as a result of unsafe injecting. The Dominican Republic opened its first programme in 2012, and between June and December that year it distributed 4,000 new syringes.
Barriers to accessing needle and syringe programmes
Legal and social barriers
Criminalisation

In many countries worldwide, criminalisation of injecting drug use is a major barrier to NSP services.

Criminalisation of possession of illicit substances and injecting equipment often forces people who inject drugs to hide their equipment and engage in unsafe injecting practices, with many threatened, abused, extorted or arrested by the authorities. One study from Northern Morocco reported that 87% of this group had experienced police violence.
Legal restriction

Legal age restrictions for accessing NSPs in some countries prevent access to people who inject drugs under 18 years old, despite evidence that people now start injecting drugs at an earlier age.

Mandatory detention of injecting drug users in drug detention centres in countries such as China is also a barrier to accessing these services.
Stigma and discrimination

Even in places where it is legal to purchase needles and syringes, stigma, discrimination or disapproval from the community prevent many people who inject drugs from accessing NSP services.

They also experience stigma and discrimination from healthcare workers, or receive services that are not delivered in a culturally sensitive way.
Lack of political support and funding

In many countries, there is a lack of political will resulting in a shortfall of funding for the implementation of needle and syringe programmes

For example, in December 2011, the United States Congress reinstated a federal ban on funding for both domestic and international NSPs, marginalising existing programmes away from mainstream policy and funding.In Canada, a lack of federal support means that NSPs are typically delivered by NGOs, civil society groups, provinces and territories, with service numbers varying dramatically between and within provinces.

Russia doesn't provide state funding for NSPs with officials maintaining that they increase injecting drug use despite evidence to the contrary. However, international donors are funding a number of programmes in cities across the country.

Some countries have suffered from the withdrawal of international funding. For example, NSPs have proved highly successful in Romania, limiting HIV prevalence to 1% among people who inject drugs. However, since joining the European Union, the World Bank no longer classifies Romania as a developing country making it ineligible for a number of international grants, threatening a funding crisis.
Physical and geographical barriers

In other places, access to NSPs is limited by geographical distance, particularly in remote and rural areas. A number of studies have shown that people who inject drugs who live in close proximity to programmes are more likely to use the

HIV-positive woman to her child during pregnancy

Prevention of mother-to-child transmission (PMTCT) programmes provide antiretroviral treatment to HIV-positive pregnant women to stop their infants from acquiring the virus.

Without treatment, the likelihood of HIV passing from mother-to-child is 15% to 45%. However, antiretroviral treatment and other effective PMTCT interventions can reduce this risk to below 5%.
A comprehensive approach to PMTCT

Effective PMTCT programmes require women and their infants to have access to - and to take up - a cascade of interventions including antenatal services and HIV testing during pregnancy; use of antiretroviral treatment (ART) by pregnant women living with HIV; safe childbirth practices and appropriate infant feeding; uptake of infant HIV testing and other post-natal healthcare services.

The World Health Organization (WHO) promotes a comprehensive approach to PMTCT programmes which includes:
preventing new HIV infections among women of childbearing age
preventing unintended pregnancies among women living with HIV
preventing HIV transmission from a woman living with HIV to her baby
providing appropriate treatment, care and support to mothers living with HIV and their children and families.
World Health Organization PMTCT guidelines

In September 2015, the WHO released new guidelines recommending lifelong antiretroviral treatment for all pregnant and breastfeeding women living with HIV.
Guidelines for pregnant and breastfeeding women living with HIV

The 2015 guidelines recommend Option B+ where lifelong antiretroviral treatment is provided to all pregnant and breastfeeding women living with HIV regardless of CD4 count or WHO clinical stage. Treatment should be maintained after delivery and completion of breastfeeding for life.

Previously, the 2013 guidelines included another choice called Option B, where treatment was only continued after the completion of breastfeeding if the mother was eligible for antiretroviral treatment for her own health. The 2015 guidelines no longer recommend this option.
Guidelines for HIV-exposed infants

All infants born to HIV-positive mothers should receive a course of antiretroviral treatment as soon as possible after birth. The treatment should be linked to the mother's course of antiretroviral drugs and the infant feeding method.
Breastfeeding - the infant should receive once-daily nevirapine from birth for six weeks.
Replacement feeding - the infant should receive once-daily nevirapine (or twice-daily zidovudine) from birth for four to six weeks.

At four to six weeks old, all infants who are born to HIV-positive mothers should be given an early infant diagnosis. Another HIV test should be done at 18 months and/or when breastfeeding ends to provide the final infant diagnosis.
Global PMTCT targets

In 2011, a Global Plan was launched to reduce the number of new HIV infections via mother-to-child transmission by 90% by 2015.

The WHO identified 22 priority countries, with the top 10 (Angola, Botswana, Burundi, Cameroon, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana and India) accounting for 75% of the global PMTCT service need.

It was estimated that the effective scaling up of interventions in these countries would prevent over 250,000 new infections annually.


Progress in the prevention of mother-to-child transmission
Progress among pregnant and breastfeeding women

The proportion of pregnant women living with HIV receiving antiretroviral treatment more than doubled in 21 of the 22 Global Plan priority countries from 36% in 2009, to 80% in 2015. Perhaps more importantly, 93% of pregnant women receiving treatment, were receiving lifelong treatment, up significantly from 73% in 2014. India does not feature in the latest data.

In 2015, six priority countries (Botswana, Mozambique, Namibia, South Africa, Saziland andUganda) met the Global Plan target of reducing mother-to-child transmission by 90%.Outside of the priority countries, in mid-2015, Cuba became the first country to eliminate the mother-to-child transmission of HIV. In 2016, Belarus and Armenia achieved the same feat while Thailandbecame the first country in the Asia and Pacific region to eliminate MTCT.As PMTCT is not 100% effective, elimination is defined as a reduction of transmission to such low levels that it no longer constitutes a public health problem.

Many point to the implementation of Option B+ as a major reason behind coverage progress. By the end of 2015, all priority countries except Nigeria had rolled out Option B+. Consequently, AIDS-related deaths among women of reproductive age in the Global Plan countries declined by 43% between 2009 and 2015.

Another target of the Global Plan was to reduce the MTCT rate to 5% or less among breastfeeding women, and to 2% or less among non-breastfeeding women. Together, the 21 Global Plan countries reduced the MTCT rate among breastfeeding women from 22.4% to 8.9% between 2009 and 2015. Four countries (South Africa, Uganda, Swaziland and Namibia), achieved the 5% milestone. Botswana, the only non-breastfeeding Global Plan priority country, has a transmission rate of 2.6% - just above the threshold of 2%.

However, countries need to accelerate efforts to reduce new HIV infections among women. The Global Plan aimed to reduce the number of new infections among women of reproductive age by 50% but they declined by just 5% between 2009 and 2015. As a result, there were 4.5 million new infections among this group over this period.
Progress among children

Between 2009 and the end of 2015, there was a 60% decline in new HIV infections among children in the Global Plan priority countries, from 270,000 to 110,000, equating to 1.2 million averted infections. This compares to a fall of just 24% between 2000 and 2008, meaning that the rate of the decline in new infections since the launch of the Global Plan nearly tripled. Without Nigeria, the remaining countries reduced new HIV infections by 69%.

While this progress is encouraging, it is significantly below the 90% target. However, some countries got close to this target including Uganda (86%), South Africa and Burundi (both 84%). Botswana, Burundi, Namibia and Swaziland had fewer than 1,000 new infections in 2015. These are small enough numbers that, with determined efforts, could be reduced dramatically.

Other countries still face significant challenges to rolling out effective PMTCT services. Angola, Cote d’Ivoire and Nigeria have registered a less than 40% reduction in new HIV infections among children since 2009.
Barriers to the uptake of PMTCT programmes

As well as the scale-up of PMTCT, a number of barriers need to be overcome in order to increase access to these services.
Knowledge about HIV, MTCT and PMTCT

A number of studies have identified the link between knowledge of HIV, MTCT and PMTCT and uptake of PMTCT services.

For example, research from Togo reported a 92% HIV testing uptake among participants where:
77% of pregnant women agreed that unprotected sex increased the risk of HIV transmission to their child
61% recognised that the risk of HIV transmission to their child was higher for mixed breastfeeding than for exclusive breastfeeding.

Another study of over 500 pregnant and postnatal women in Botswana with high PMTCT knowledge found that 95% of participants believed that pregnant women should be tested for HIV.

Conversely, other studies have associated high levels of HIV, MTCT and PMTCT knowledge with lower acceptability of PMTCT.

One study from south west Nigeria recorded that while 99.8% of pregnant women were aware of HIV and had very high knowledge of MTCT (92%) and PMTCT (91%) - 71% had negative views towards PMTCT. This was due to factors such as stigma and discrimination.
Knowledge of HIV status

Knowledge of HIV status is vital in order that pregnant women access the appropriate treatment and care for themselves and their unborn infants.

Not knowing one's HIV status acts as a barrier to PMTCT services. For example, a South African study found that voluntary HIV testing and counselling was widely accepted among women already attending antenatal clinics (95%) but low among those who were not (37%).
Confusion over exclusive breastfeeding

One study from Malawi reported that while the majority of mothers chose to exclusively breastfeed because "that's the advice they give to HIV-positive women", most mothers reported mixed feeding in the first six months. A number of reasons were given for this including traditional feeding practices, a poor understanding of what exclusive breastfeeding involves, as well as poor communication about why women should exclusively breastfeed.

Research from Tanzania compared two hospitals that offered different infant feeding options. Hospital A promoted exclusive breastfeeding as the only infant feeding option, while hospital B followed Tanzanian PMTCT infant feeding guidelines which promote patient choice. Women in hospital A trusted the advice given and were confident in their ability to exclusively breastfeed, whereas women in hospital B expressed confusion and uncertainty about how to best feed their infants.
HIV stigma, discrimination and PMTCT

A body of research has highlighted how HIV-related stigma and discrimination affect a pregnant woman's decision to enrol on PMTCT programmes and interrupt adherence to treatment and retention in care.

It has been estimated that over 50% of vertical HIV transmissions from mother-to-child globally can be attributed to the cumulative effect of stigma.

One study has identified a range of HIV-related stigmas experienced by pregnant women:Enacted stigma

In some countries, pregnant women who disclose their HIV status may be physically or verbally abused or socially marginalised.

Research on the provision of HIV testing and counselling across Burkina Faso, Kenya, Malawi and Uganda found that 25% of women reported being made to feel bad because of their HIV status. Other women who disclosed their status experienced rejection or were divorced by their partners.
Anticipated stigma

Pregnant women may not seek PMTCT services because they fear stigma if they are found to be HIV-positive following an HIV test. A focus group participant in Soweto, South Africa reported:

"I didn’t book at an antenatal clinic because I was afraid that they would test me for HIV, so I avoided it as I told myself that I might be found to have this disease."
Perceived community stigma

Pregnant women living with HIV may avoid PMTCT and treatment for their own health if they believe that other HIV-positive pregnant women experience stigma and discrimination when using these services.

Women on a PMTCT programme in Malawi reported involuntary HIV disclosure and negative community reactions; unequal gender relations; difficulties accessing care and treatment; and lack of support from husbands.

Some pregnant women living with HIV internalise negative perceptions about people living with HIV and are therefore less likely to enrol in PMTCT and often suffer from mental health issues. Research on HIV-positive women in Karnataka, India said:

"...self-stigma was in many cases derived from moral judgment of one’s self for not fulfilling traditional gender roles of wife and mother."
Stigma in healthcare settings

Some healthcare workers are hesitant about handling the delivery of babies born to HIV-positive mothers for fear of HIV infection. A study from Ethiopia reported that:

"many health workers don’t have the necessary skill and equipment to confidently handle delivery for an HIV positive woman and given the risk of accidental exposure, most nurses shy away from dealing with such patients."

In more serious cases, women report direct abuse from healthcare workers. An HIV-positive woman from Mexico reported an interaction with her doctor:

"How can you even think about getting pregnant knowing that you will kill your child because you’re positive?!!!’ He threatened not to see me again if I got pregnant. He told me that I was ‘irresponsible’, a bad mother, and that I was certainly running around infecting other people."

Even though HIV testing is not compulsory, the way that some healthcare workers talk about it can lead women to believe that it is. As a result, many delay or avoid antenatal services, risking their health. In a study from South Africa, a woman from KwaZulu-Natal said:

"Testing was not optional, it was compulsory…If you didn’t test you didn’t have antenatal classes, everyone had to go through the tests."

One study has estimated that highly effective stigma reduction programmes leading to greater PMTCT access could reduce new HIV infections among infants by up to 33%.
Country and clinic resources

In resource-poor settings, shortages of PMTCT staff, interruptions in treatment and supplies of medical equipment, as well as a shortfall in counselling services, all act as barriers to PMTCT services.

These factors often mean long waiting times for post-test counselling and many leave without getting their HIV test results.

Research findings show how PMTCT workers can lack proper understanding of programme principles and fail to give adequate counselling to women. Some have put adherence issues around exclusive breastfeeding down to the poor quality of counselling women receive.Another study from Kenya reported that 92% of respondents lacked privacy in their counselling rooms.

Poor monitoring of PMTCT services by healthcare workers also leads to poor retention in care. Research from Ethiopia reported poor follow-up rates in the PMTCT programme because healthcare facilities did not have registered information on HIV-positive mothers.
Option B+ challenges

Though the implementation of Option B+ has been attributed to progress in PMTCT coverage, for some, the immediacy of treatment initiation is a challenge.

A study from Lilongwe, Malawi, noted that some participants needed time, whether it was for discussing their status with their partner or personally accepting their HIV status:.

“I couldn’t accept them [ART] for the reason of my partner…The child’s father, I can say we could have problems…I was scared that he would be mad and also our marriage could be jeopardized.”

“I wanted my relatives to know about my status, I can’t just receive the drugs and take them home while I came here for antenatal services, they would be surprised….”

Side effects were the most commonly reported barrier to adherence and were found to be more significant barriers compared to previous studies on barriers in non-B+ contexts.Another study from the same country revealed that women who started treatment in the context of B+ were five times more likely to be lost to follow-up compared to those who started treatment for their own health.
Cultural beliefs and gender dynamics

In many settings, traditional gender roles and cultural beliefs mean that men often make decisions determining women's participation in HIV testing. One study reported that in some countries, 75% of women said that their husbands alone make health decisions for their families.

In many communities in sub-Saharan Africa, pregnancy is viewed as a 'woman's affair', with a man's role primarily to provide financial support. Even where men view accompanying their partner to antenatal clinics or PMTCT services as good practice, many still feel their main role is to provide financing for registration and delivery fees.

Men also report negative attitudes from community members when escorting their spouses to antenatal clinics. One report from Uganda stated:

"Because of cultural beliefs, most men do not like to accompany their wives to the antenatal clinics. Men who accompany their wives to ANC are perceived to be weaklings by their peers."
Male involvement

Generally, research has highlighted the beneficial impact of male involvement in programmes to prevent the mother-to-child transmission of HIV to tackle new infections among infants.

A study of 15 countries found that supportive male partners who were willing to get an HIV test and communicate with their partner about sexual and reproductive health issues, increased the commitment of pregnant women to PMTCT programmes.

By comparison, women in relationships with unsupportive males who did not discuss reproductive issues have reported violence, abandonment or fear of abandonment. Many studies have reported shock, disbelief, violence and discrimination among male partners of pregnant women who disclose their HIV status.

Inviting men to use voluntary HIV testing and counselling services, offering PMTCT services at sites other than antenatal care ones (such as bars, churches and workplaces), as well as prior knowledge of HIV and HIV testing facilities have all been identified as ways of increasing male involvement.

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men and women report having discriminatory attitudes towards people living with HIV.

HIV-related stigma and discrimination refers to prejudice, negative attitudes and abuse directed at people living with HIV and AIDS. In 35% of countries with available data, over 50%

The consequences of stigma and discrimination are wide-ranging. Some people are shunned by family, peers and the wider community, while others face poor treatment in healthcare and educational settings, erosion of their an an rights, and psychological damage. These all limit access to HIV testing, treatment and other HIV services.
The People Living with HIV Stigma Index indicates that roughly one in every eight people living with HIV is being denied health services because of stigma and discrimination.

Why is there stigma around HIV and AIDS?

The fear surrounding the emerging HIV epidemic in the 1980s largely persists today. At that time, very little was known about how HIV is transmitted, which made people scared of those infected due to fear of contagion.

This fear, coupled with many other reasons, means that lots of people falsely believe:
HIV and AIDS are always associated with death
HIV is associated with behaviours that some people disapprove of (like homosexuality, drug use, sex work or infidelity)
HIV is only transmitted through sex, which is a taboo subject in some cultures
HIV infection is the result of personal irresponsibility or moral fault (such as infidelity) that deserves to be punished
inaccurate information about how HIV is transmitted, creating irrational behaviour and misperceptions of personal risk.
How stigma affects people living with HIV

HIV-related stigma and discrimination exist worldwide, although they manifest themselves differently across countries, communities, religious groups and individuals.

Research by the International Centre for Research on Women (ICRW) found the possible consequences of HIV-related stigma to be:
loss of income and livelihood
loss of marriage and childbearing options
poor care within the health sector
withdrawal of caregiving in the home
loss of hope and feelings of worthlessness
loss of reputation.
HIV stigma and key affected populations

Key affected populations are groups of people who are disproportionately affected by HIV and AIDS, such as men who have sex with men (MSM), people who inject drugs and sex workers. Stigma and discrimination are often directed towards these groups simply because others disapprove of their behaviours.

Stigma also varies depending on the dominant transmission routes in a country or region. In sub-Saharan Africa, for example, heterosexual sex is the main route of infection, which means that HIV-related stigma in this region is mainly focused on infidelity and sex work.

These people are increasingly marginalised, not only from society, but from the services they need to protect themselves from HIV. Half of all new HIV infections worldwide are among people belonging to key affected populations.

In 2015, the World Health Organisation (WHO) released new treatment guidelines that reflect the need to address barriers to accessing HIV treatment such as stigma and discrimination.
How stigma affects the HIV respons

The WHO cites fear of stigma and discrimination as the main reason why people are reluctant to get tested, disclose their HIV status and take antiretroviral drugs.

One study found that participants who reported high levels of stigma were over four times more likely to report poor access to care.This contributes to the expansion of the global HIV epidemic and a higher number of AIDS-related deaths.

An unwillingness to take an HIV test means that more people are diagnosed late, when the virus may have already progressed to AIDS. This makes treatment less effective, increasing the likelihood of transmitting HIV to others, and causing early death.

"The epidemic of fear, stigmatization and discrimination has undermined the ability of individuals, families and societies to protect themselves and provide support and reassurance to those affected. This hinders, in no small way, efforts at stemming the epidemic. It complicates decisions about testing, disclosure of status, and ability to negotiate prevention behaviours, including use of family planning services."
Forms of HIV stigma and discrimination

HIV and AIDS-related stigma can lead to discrimination, for example, when people living with HIV are prohibited from travelling, using healthcare facilities or seeking employment.
Self-stigma/internalised stigma

Self-stigma, or internalised stigma has an equally damaging effect on the mental wellbeing of people living with HIV. This fear of discrimination breaks down confidence to seek help and medical care.

Self-stigma and fear of a negative community reaction can hinder efforts to address the HIV epidemic by continuing the wall of silence and shame surrounding the virus.

"I am afraid of giving my disease to my family members-especially my youngest brother who is so small. It would be so pitiful if he got the disease. I am aware that I have the disease so I do not touch him. I talk with him only. I don’t hold him in my arms now." - woman in Vietnam
Governmental

A country’s discriminatory laws, rules and policies regarding HIV can alienate and exclude people living with HIV, reinforcing the stigma surrounding HIV and AIDS.

In 2014, 64% of countries reporting to UNAIDS had some form of legislation in place to protect people living with HIV from discrimination.

However, criminalisation of key affected populations remains widespread with 60% of countries reporting laws, regulations or policies that present obstacles to providing effective HIV prevention, treatment, care and support. In 2015, 75 countries worldwide listed homosexuality as a crime.
Healthcare stigma

Healthcare professionals can medically assist someone infected or affected by HIV, and also provide life-saving information on how to prevent it.

However, often healthcare is not confidential, contains judgement about a person’s HIV status, behaviour, sexual orientation or gender identity. These views are often fuelled by ignorance about HIV transmission routes among healthcare professionals.Studies by the WHO in India, Indonesia, the Philippines and Thailand found that 34% of respondents reported breaches of confidentiality by health workers.

This prevents many people from being honest to healthcare workers when they seek medical help and fear discrimination if they say they’re a sex worker, have same-sex relations, or inject drugs.
Employment stigma

In the workplace, people living with HIV may suffer stigma from their co-workers and employers, such as social isolation and ridicule, or experience discriminatory practices, such as termination or refusal of employment.Fear of an employer’s reaction can cause a person living with HIV anxiety:

"It is always in the back of your mind, if I get a job, should I tell my employer about my HIV status? There is a fear of how they will react to it. It may cost you your job, it may make you so uncomfortable it changes relationships. Yet you would want to be able to explain about why you are absent, and going to the doctors." - HIV-positive woman, UK

A man living with HIV in China filed a lawsuit in 2012 after he was denied a job as a primary school teacher when the employer found out he was HIV-positive. In January 2013, he won the case and received compensation. There is pressure now to remove health tests as part of any employment procedures in China.

By reducing stigma in the workplace (via HIV and AIDS education, offering HIV testing, and contributing towards the cost of antiretrovirals) employees are less likely to take days off work, and be more productive in their jobs. This ensures people living with HIV are able to continue working.
Community and household level stigma

Community-level stigma and discrimination towards people living with HIV can force people to leave their home and change their daily activities.

A survey of Dutch people living with HIV found that stigma in family settings - in particular avoidance, exaggerated kindness and being told to conceal one's status - actively contributed to psychological distress. A global study found that 35% of participants feared losing family and friends if they disclosde their HIV status.

Stigma and discrimination can also take particular forms within community groups such as key affected populations.

For example, studies have shown that within some lesbian, gay, bisexual and transgender (LGBT) communities there is segregation between HIV-positive and HIV-negative men, where men associate predominately with those of the same status.
Restrictions on entry, travel and stay

As of September 2015, 35 countries have laws that restrict the entry, stay and residence of people living with HIV. Lithuania became the most recent country to remove such restrictions.

Restrictions can include the mandatory disclosure of one's HIV status or be subject to a mandatory HIV test, the need for discretionary approval to stay, and the deportation of individuals once their HIV-positive status is discovered.

Deportation of people living with HIV has potentially life-threatening consequences if they have been taking HIV treatment and are deported to a country that has limited treatment provision. Alternatively, people living with HIV may face deportation to a country where they would be subject to even further discrimination - a practice that could contravene international human rights law.
Ending HIV stigma and discrimination

The use of specific programmes that emphasise the rights of people living with HIV is a well-documented way of eradicating stigma. As well as being made aware of their rights, people living with HIV can be empowered in order to take action if these rights are violated.

Ultimately, adopting a human rights approach to HIV and AIDS is in the public’s interest. Stigma blocks access to HIV testing and treatment services, making onwards transmission more likely. The removal of barriers to these services is key to ending the global HIV epidemic.

A few examples of successful programmes to reduce HIV stigma and strengthen the rights of people living with HIV are outlined below.
Reducing stigma and discrimination among healthcare workers in Thailand

In 2012, half of all people living with HIV in Thailand were starting treatment very late and had CD4 counts under 100. HIV stigma was identified as a major barrier to service uptake so health authorities set a target to cut HIV-related stigma and discrimination by 50% by 2016.

The Ministry of Public Health found that over 80% of healthcare workers had at least one negative attitude to HIV, while roughly 20% knew colleagues who were unwilling to provide services to people living with HIV or provided them substandard services.

More than half of respondents reported using unnecessary personal protection measures such as wearing gloves when interacting with people living with HIV. 25% of people living with HIV surveyed said that they avoided seeking healthcare for fear of disclosure or poor treatment, while a third had their status disclosed without their consent.

In response to these findings, the Ministry of Public Health, in collaboration with civil society and international partners developed initiatives to sensitise healthcare workers in both clinical and non-clinical settings.

Early results indicate that improving the attitude of healthcare workers doesn’t just improve care for people living with HIV but has wider societal benefits as they are seen as role models. By 2016, the stigma-reduction programmes will be implemented throughout the country with domestic funding.
Ending criminalisation of HIV transmission in Australia

Laws that criminalise HIV non-disclosure, exposure and transmission perpetuate stigma and deter people from HIV testing and puts the responsibility of HIV prevention solely on the partner living with HIV.

In May 2015, the Australian state of Victoria repealed the country’s only HIV-specific law criminalising the intentional transmission of HIV. The repealed law - Section 19A of the Crimes Act 1958 - carried a maximum penalty of 25 years imprisonment, even more than the maximum for manslaughter (which is 20 years).

The legislation to repeal the law was developed through the collaboration of several stakeholders, including legal, public health and human rights experts and representatives of people living with HIV. It was seen as a major step forward for the rights of people living with HIV.
Strengthening the rights of people living with HIV in Ghana

Although Ghana’s Constitution protects all citizens from discrimination in employment, education and housing and ensures their right to privacy, there is ambiguity in the way these provisions apply to people living with HIV and to key affected populations.

The Patients’ Charter protects people living with HIV from discrimination within the healthcare system, but they are difficult to enforce outside of public health facilities. In addition, consensual sex between adult males and sex work is criminalised, deterring sex workers and MSM from seeking healthcare services.

To overcome these obstacles, a web-based reporting mechanism was launched in December 2013. People living with HIV can directly report to the Commission by SMS or through the reporting system’s website, and they can choose to remain anonymous. This triggers an investigation involving human rights organisations and lawyers.