“A world without AIDS was almost unimaginable when the General Assembly held its first special session on the epidemic 18 years ago,” said United Nations Secretary-General António Guterres in the report. “Since then, the global determination to defeat one of history’s greatest health crises has produced remarkable progress … and … inspired a commitment within the 2030 Agenda for Sustainable Development to end the AIDS epidemic by 2030.”

The Secretary-General’s report shows that results once derided as impossible in low-income settings have now been achieved following a decade of progress in the response to HIV. Between 2008 and 2017, there was a 43% reduction in AIDS-related deaths, a 45% reduction in new HIV infections among children and a 19% reduction in new HIV infections among adults globally. The number of people living with HIV on treatment also increased, by 5.5 times, reaching 21.7 million of the 36.9 million people living with HIV in 2017.

“The enormous achievements in the response to HIV in recent decades, under the strong leadership of UNAIDS, is one of the best examples of multilateralism in action,” said María Fernanda Espinosa, President of the United Nations General Assembly. “It is most definitely an indication of what we can achieve when we work together around a common cause.”

The report shows that progress has been most marked in eastern and southern Africa, where AIDS-related deaths fell by 53% and new HIV infections among adults and children fell by 36%. An epidemic that once killed more than a million people in the region per year now claims fewer than 400 000 lives per year.

In other regions of the world, including Latin America, the Caribbean, Asia and the Pacific, western and central Europe and North America, increases in the coverage of HIV testing and treatment services have achieved significant reductions in AIDS-related deaths over the past decade. Most of those regions have also experienced declines in new HIV infections.

Notable exceptions are eastern Europe and central Asia, where the annual number of new HIV infections has risen by 30% since 2010, with an estimated 960 000 people newly infected over this time, and in the Middle East and North Africa, where deaths from AIDS-related illnesses increased by 11%, an estimated 140 000 people newly infected, over the same period.

The report notes that services focused on key populations within those regions are few and far between, and harsh punishments for same-sex sexual relationships, drug use and sex work in those regions and elsewhere are proving to be formidable barriers to the few services that are available.

In western and central Africa, insufficient domestic funding, weak health systems, formal and informal user fees for health care, humanitarian situations and high levels of stigma and discrimination continue to undermine efforts to scale up HIV testing and treatment.

Many challenges remain, including stigma and discrimination faced by people living with HIV and harmful gender norms. Laws and policies in many countries prevent young people, women, key populations―gay men and other men who have sex with men, sex workers, transgender people, people who inject drugs and prisoners and other incarcerated people―indigenous people, migrants and refugees from accessing health and HIV services.

Funding for HIV responses in low- and middle-income countries globally has also remained flat for most of the past five years. In 2017, donor and domestic investments in low- and middle-income countries were US$ 20.6 billion, about 80% of the 2020 target.

“As the Secretary-General’s report makes abundantly clear, to protect the gains we have made and to tackle the challenges that stand in the way of our promise to end AIDS by 2030, we need to firm up our resolve, strengthen our partnerships and say no to complacency,” said Gunilla Carlsson, UNAIDS Executive Director, a.i. “Let’s start with a successful replenishment that results in a fully funded Global Fund to Fight AIDS, Tuberculosis and Malaria that will enable it, along with its range of partners, including UNAIDS, to continue to deliver evidence-informed, people-centred and human-rights based support to the people and communities who need it the most.”

The report outlines that there is an important opportunity to seize the growing momentum to achieve universal health coverage, a core principle of which is leaving no one behind. Collaboration between health systems and community groups has been shown to reduce stigma and discrimination and to help to deliver services to the people in greatest need―a key recommendation of the report is the strengthening of the vital role that community groups play in the AIDS response.

In the report, the United Nations Secretary-General urges Member States to adopt the following recommendations to galvanize political will, accelerate action and build the momentum necessary to reach the 2020 targets agreed to by the United Nations General Assembly in the 2016 United Nations Political Declaration on Ending AIDS: (a) reinvigorate primary HIV prevention; (b) diversify HIV testing and differentiate the delivery of health care to reach the 90–90–90 targets; (c) establish enabling legal and policy environments in order to reach marginalized and vulnerable populations; (d) mobilize additional resources and allocate them where they are most needed; (e) support communities to enable them to play their critical roles; and (f) incorporate a comprehensive HIV response into universal health coverage

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Western and central Africa catch-up plan

Under the leadership of countries and regional economic communities, and in collaboration with UNAIDS, the World Health Organization, Doctors Without Borders and other partners, the catch-up plan in western and central Africa, which started implementation in late 2016, seeks to dramatically accelerate the scale-up of HIV testing, prevention and treatment programmes, with the goal of putting the region on the Fast-Track to meet the 90–90–90 targets by December 2020.

While the world witnesses significant progress in responding to HIV, with 57% of all people living with HIV knowing their HIV status, 46% of all people living with HIV accessing treatment and 38% of all people living with HIV virally suppressed in 2015, the western and central Africa region lags behind, achieving only 36%, 28% and 12%, respectively, in 2015. The gap is considerable: 4.7 million people living with HIV are not receiving treatment, and 330 000 adults and children died from AIDS-related illnesses in 2015.

“We cannot accept a two-speed approach to ending AIDS in Africa,” said UNAIDS Executive Director Michel Sidibé. “To put western and central Africa on track to end AIDS, we must address stigma, discrimination and other challenges to an effective response, allocate funding to support the most effective strategies and implement delivery strategies that reach the communities most in need.”

The catch-up plan will aim to increase the number of people on treatment from 1.8 million to 2.9 million by mid-2018, giving an additional 1.2 million people, including 120 000 children, access to urgently needed treatment.

The first call for a catch-up plan for the region was made at the United Nations General Assembly High-Level Meeting on Ending AIDS in June 2016. Since then, at least 10 countries (Benin, Cameroon, the Central African Republic, Côte d’Ivoire, the Democratic Republic of the Congo, Guinea, Liberia, Nigeria, Senegal and Sierra Leone) have developed country operational plans deriving from the western and central Africa catch-up plan with a focus on ensuring the needed policy and structural changes.

Two million community health workers

The community health worker initiative aims to accelerate progress towards achieving the 90–90–90 targets by 2020—whereby 90% of all people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads—and to lay the foundation for sustainable health systems. Championed by the President of Guinea and African Union Chair, Alpha Condé, the initiative seeks to confront the acute health workforce shortages across Africa and improve access to health services for the most marginalized populations, including people living in rural areas.

“Recruiting 2 million community health workers is a critical step towards achievement of the Africa-wide socioeconomic transformation envisioned in the African Union’s Agenda 63”, said Mr Condé. “Few tools have the ability of community health workers to drive progress across the entire breadth of the 2030 Agenda for Sustainable Development.”

Substantial evidence, from both Africa and elsewhere, demonstrates that well-trained, properly supervised community health workers provide an excellent quality of care and improve the efficiency and impact of health spending. Community health workers have helped devise some of the most effective service delivery strategies for HIV testing and treatment, and studies have also linked community-delivered services with increased rates of immunization, exclusive breastfeeding and malaria control coverage.

“Sustainable community health work is a matter of survival and development in Ethiopia, said Prime Minister of Ethiopia Hailemariam Desalegn. “My community health workers have made better health happen. Achieving universal health coverage is not possible without building community health systems.”

UNAIDS estimates that there are more than 1 million community health workers in Africa today, but most focus on a single health problem and are under-trained, unpaid or under-paid, and not well integrated in health systems. The new initiative endorsed by AIDS Watch Africa seeks to retrain existing community health workers, where feasible, and to recruit new health workers to reach the 2 million target.

“Few investments generate such a remarkable social and economic return as community health workers,” said Jeffrey Sachs, Director, Earth Institute, Columbia University. “Community health worker programmes are essentially self-sustaining, in that they avert illness, keep workers healthy and productive and contribute to economic growth and opportunity.”

While community health workers may hold the key in many settings to achieving the 90–90–90 targets, the benefits of this new initiative extend well beyond the AIDS response. The initiative will expedite gains across the health targets of Sustainable Development Goal 3, create new jobs that will strengthen local and national economies and offer new opportunities to young people. The new initiative is aligned with the World Health Organization’s Global Strategy on Human Resources for Health.

Start Free Stay Free AIDS Free

At the AIDS Watch Africa meeting, the participants also called on member states and development partners to support the African Union campaign to eliminate new HIV infections among children and keep mothers alive as part of the Start Free Stay Free AIDS Free collaborative framework.

“Complacency gives birth to regression of the gains made in reducing HIV prevalence, said, Yoweri Museveni, President of Uganda. “We in Uganda have rekindled the campaign to end AIDS; the science exists, as well as the medication. We can win this battle.”

AIDS Watch Africa is a statutory entity of the African Union with the specific mandate to lead advocacy, accountability and resource mobilization efforts to advance a robust African response to end AIDS, tuberculosis and malaria by

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