The Fight Against HIV/AIDS: Facts, Figures and Parliamentary Action

Honourable chairpersons,
Distinguished Parliamentarians,
Delegates and Friends,

Nine years ago, governments endorsed the UN Declaration of Commitment on HIV/AIDS, pledging to support a united response to the epidemic. But in the interim, the world has been hit by a range of crises - global financial collapse, environmental degradation, political instability, humanitarian crises, worsening poverty, and food insecurity.

With such a daunting scenario, we have been compelled to enter a new era in our response to HIV- shared responsibility, gretare partnership, and mutual accountability. The days of isolationism are over. We are committed to better coordinating our action to jointly attain all the MDGs, especially those which are lagging globally. And this September, we will be summoning our best resources to reflect on our collective shortcomings and triumphs. We will be judged for what we have and what we have not accomplished. One of our accomplishments is the united front taking shape between the sexual and reproductive health and HIV communities to finally bridge the artificial divide between MDGs 3, 4, 5, and 6.

During the coming week at this International AIDS Conference, the spotlight will clearly be on MDG6. Despite the progress in many parts of the world, HIV is still the leading cause of death in several countries and has stalled hard-won gains in development. But, as we all know, HIV is not only about health, but about human rights, gender equality, and social and economic disparities – features that HIV shares with sexual and reproductive health. And if we scrutinize the collage of news headlines today, we find stories on HIV highlighting those very issues that ignite the passions of parliamentarians worldwide – injustices begging for legal and policy reform. This is at the heart of HIV and sexual and reproductive linkages.

I have been asked today to spark discussion on three key related areas:

• The global AIDS epidemic as we experience it today;
• The importance of linking sexual & reproductive health and HIV; and
• What you, as parliamentarians, can do to strengthen this emerging linked response.

The most recent estimates indicate that there were 33.4 million people living with HIV as of 2008, with 2.7 million new infections attributed to that year alone. Southern Africa has been hardest hit by HIV, but despite vestiges of lingering denial, no region or country has been overlooked by the epidemic.

Although we have not yet achieved the ambitious aims of MDG6, there has been some limited but tangible progress worth celebrating.

By the end of 2008, 4 million people living with HIV in low and middle income countries were receiving antiretroviral drugs. This is an impressive ten-fold increase over the previous half-decade and saved an estimated 1.4 million lives in the last five years. Clearly not sufficient to meet the global needs of those still denied therapy, yet representing a momentum that was hard won by AIDS activists. We must now, despite the financial constraints, expand access to universal coverage, ensure sustainability, and introduce 2nd and 3rd line regimens to meet the growing with demand. We have witnessed a 17 per cent decrease in the annual number of new infections between 2001 and 2008. Clearly this is progress in the right direction upon which to build but is not sufficient.

For every 2 persons placed on treatment, 5 more become HIV positive. Especially in the setting of the global financial crisis we cannot afford - in financial or in human terms – to let this happen. Despite the ambitious target of 95 per cent of young people having knowledge about HIV transmission, we have only reached around the 40 per cent mark. Age appropriate sexuality education, which would prevent HIV transmission and unintended pregnancies, needs to be firmly entrenched. And despite young people accounting for 40 per cent of new infections, access to sexual and reproductive health and HIV services falls far below need.

The coverage of pregnant women receiving antiretroviral prophylaxis to prevent HIV transmission to their children has skyrocketed from a mere 10 per cent in 2004 to 45 per cent in 2008. If we continue to focus our efforts, those gains are expected to keep rising. But we know that antiretroviral prophylaxis to prevent HIV transmission to infants is not enough. Women need treatment for their own health, along with access to HIV prevention, and family planning, fully integrated with sexual and reproductive health services. One startling statistic that reverberated loudly this year was that HIV is the leading cause of death among women of reproductive age, and contributes significantly to maternal mortality.That was not a startling discovery to any woman living in Southern Africa, but it served to unite the resolve of the sexual and reproductive health and the HIV communities.

The HIV epidemic, like the agenda for reproductive health, is complex, and likewise, so must be our response. As each new concept in HIV has emerged there is a flurry of excitement that it will be the panacea to end the epidemic. But just as the epidemic has matured, our response has matured. We now know that there are a finite set of mutually reinforcing responses to HIV that can work, and we now recognize that these responses are integrally linked with those of sexual and reproductive health.

• Knowing your epidemic using modes of transmission studies to guide effective programming;
• Universal combination antiretroviral therapy offered early on, with adequate support for compliance, as laid out in the new WHO treatment guidelines launched in 2009;
• Increased investment in combination prevention characterized by a mix of rights-based biomedical, behavioural and structural approaches, to address those social, economic, legal, and cultural drivers affecting vulnerability;
• Increasing access to rights-based services for key populations and in humanitarian settings that are provided on a sufficient scale with effective coordination;
• Eliminating stigma and discrimination by removing punitive laws, creating social protection systems, and ensuring mechanisms for recourse against rights violations. Such rights violations are still commonplace against people living with HIV, sex workers, men who have sex with men, transgender persons, and people who use drugs. This is as important in the AIDS response as drugs, condoms, and health systems strengthening.

And finally, among the most recently accepted promising strategies is linking sexual and reproductive health and HIV. It is a clear win-win especially for MDGs 3, 4, 5, and 6, in concert with the other four MDGs. The reason HIV and sexual and reproductive health are so intertwined is clear:

• the vast majority of HIV infections occur through sexual contact;
• the risk of HIV transmission is significantly greater in the presence of certain sexually transmitted infections;
• infants can become HIV positive during pregnancy, delivery, and breastfeeding; and
• social drivers like gender inequality and marginalization affect both HIV and sexual and reproductive health.

The potential benefits are also well established. They include

• better uptake of services,
• improved access of people living with HIV and key populations to services,
• reduction in HIV-related stigma and discrimination,
• greater support for dual protection,
• improved quality of care,
• better understanding and protection of individuals’ rights, and
• enhanced programme quality and effectiveness.

Linkages are bi-directional and experience has been gained both in integrating sexual and reproductive health into HIV programmes, and the reverse.

But although integrating health services is essential, linkages require far more than that. Equally important are the systems concerns such as coordination mechanisms, capacity building, partnerships, and commodities security. And perhaps most pertinent to why we are assembled here today are the policy and legal issues that can either hinder or support this joint work.

Linking SRH and HIV requires addressing such human rights and development concerns such as age of consent for services, gender-based violence, child marriage, sexuality education, and the meaningful participation of key populations. Effective responses to tackle these issues require a multi-sectoral response, including through policy and legal reform.

So thus far, we have put our fingers on the pulse of the HIV epidemic and we have argued the merits of uniting the sexual and reproductive health and HIV responses. But if you leave this session without a clear idea of how you, as parliamentarians, can contribute to this united front of action, then this session will have failed. I can assure you that you each have a significant role to play.

An estimated 106 countries have laws and policies in place that impede an effective response to HIV, and there are untold numbers of countries with laws impinging on sexual and reproductive health. In the scant time remaining, I will touch on several key entry points for legal and policy action that will further the joint concerns of HIV and sexual and reproductive health.

People living with HIV and key populations – As of 2008, one third of countries had still not enacted laws protecting people living with HIV from discrimination. Nor do most countries have anti-discrimination laws to protect the human rights of sex workers, men who have sex with men, transgender persons, and people who use drugs, but rather, criminalize their practices, driving people and behaviours underground and inaccessible for prevention education. Recently, the High Court in New Delhi rejected a law criminalizing sexual contact between persons of the same sex, although the trend is in the other direction in many countries. Over 30 countries have HIV-specific laws that inappropriately criminalize HIV transmission or exposure. This approach is known to be counterproductive, driving key populations underground, and discouraging people from knowing their HIV status and from disclosing.

Even the selection of host country for these International AIDS Conferences has been limited by national laws restricting entry based on HIV status, although recently, some countries have reversed such travel restrictions. You could be at the vanguard of enacting laws that both respect human rights and support evidence-informed public health policy, addressing legislative reform in these and so many other areas. You would not be alone. UNDP and UNAIDS recently launched a Global Commission on HIV and the Law to increase understanding of “how laws and law enforcement can support, rather than block, effective HIV responses.” Similarly, you could also staunchly advocate for the meaningful involvement and leadership of key populations and of people living with HIV.

Addressing the policy and legal issues related to linking sexual and reproductive health with HIV has the potential to make wide-sweeping changes in the lives of women and girls. Almost a third of countries have still not yet enacted laws or policies to prevent violence against women, especially sexual violence.

Essentially any law or policy should warrant reform if it doesn’t further gender equality or empower women – both are non-negotiable conditions for addressing their vulnerability and mitigating impact. Such laws include those pertaining to gender-based violence, property and inheritance, credit and economic opportunities, education and information, marriage, sexual relations and child bearing decisions, care-giving, investment for women, and so many other human rights issues.

Information and services for young people – We know the toll that HIV and ill sexual and reproductive health is taking on young people. Too many lives are in the balance to hide behind the culture of silence that prevents young people from exercising their rights to lifesaving information and services. Laws and policies need to be brokered to break down the legal barriers to accessing rights-based, evidence-informed, age-appropriate sexuality education. Laws governing age of consent to HIV counselling and testing, and to youth-friendly sexual and reproductive health services also have to be reviewed and revised to enable more young people to make responsible decisions and to have the means to prevent HIV and unintended pregnancies, avoid coercion, and gain access to the related services and commodities to stay healthy and safe.

We now have evidence to show that when these services are available, success follows. Last week, I was so pleased and excited to hear that HIV prevalence among young people is falling in 16 of the 25 countries most affected by AIDS. Young people have shown that they can be change agents in the prevention revolution.

Young people and others are also mobilizing to end child marriage, which unnecessarily robs young girls of their health, youth, educational attainment, and social opportunities, and exposes them to HIV infection. This is another key area for which parliamentarians can have a major influence. It is unacceptable that this practice still endures in the 20th century.

And finally, parliamentarians need to support the right to health, treatment, and non-discrimination. UNAIDS recently signed a memorandum of understanding with the French Parliamentary Assembly to encourage parliamentarians in Francophone countries to adopt legislation that supports universal access to HIV prevention, treatment, care, and support, especially of key populations.

This is a model upon which we can build. And since operationalising integration starts with planning, joint planning and coordination mechanisms are essential to ensure that national AIDS plans and reproductive health plans are synergistic and linked to wider health plans.

At the recent UNAIDS Programme Coordinating Board Thematic Session on linking sexual and reproductive health and HIV, delegates boldly declared that “Political will is fundamental and it doesn’t cost anything”.
Time is running out to meet the MDG targets. You have chosen to attend this session because you are committed to making a difference in people’s lives. I know that statistics mask the poignant human stories behind them. But as we will demonstrate throughout this session, you, as parliamentarians can alter the human suffering.

Removal of punitive laws, institutionalization of sexuality education, elimination of gender-based violence and child marriage, and enactment of so many other life-affirming human rights laws must be a priority. And we count on you to deliver on your potential to make the difference.

Thank you.