Memorandum submitted by the Department
for International Development
EXECUTIVE SUMMARY
1. The UK Government welcomes the IDC focus
on this important subject. Marginalised groups constitute significant
proportions of the people living with HIV across the world: in
China, sex workers and their clients are estimated to account
for about 20% of people living with HIV; in South Africa, 41.4%
of prisoners are estimated to be living with HIV; injecting drug
use is estimated to account for just under a third of new HIV
infections outside sub-Saharan Africa, and yet coverage of HIV
prevention for this group is at best 5% (UNAIDS). And emerging
epidemics require urgent attention to ensure that they are contained
and reversed so as to avoid generalised AIDS epidemics taking
hold.
2. Any plans to achieve the goal of Universal
Access to HIV prevention packages, treatment, care and support
programmes by 2010 will fail unless we ensure that the needs of
marginalised groups—including men who have sex with men,
injecting drug users, prisoners and commercial sex workers—are
met. At the same time, our efforts to tackle emerging epidemics,
which usually start with concentrations of HIV prevalence within
marginalised groups, require urgent attention, and a strong focus
on meeting the needs of marginalised groups.
3. The UK is proud of its record in promoting
the rights of marginalised groups. We continue to provide global
political leadership on these issues. The UK is the second largest
bilateral donor to AIDS, committing £1.5 billion to AIDS
work over the period 2005-08. The commitment to Universal Access,
made under the UK's G8 Presidency at Gleneagles and endorsed globally
at the 2005 World Summit, was taken forward at the United Nations
General Assembly High Level Meeting on AIDS, where the UK played
a leading role in ensuring that marginalised groups were reflected
in negotiations. The UK has helped influence international discussion
on the importance of comprehensive prevention strategies, through
the EU Statement on HIV Prevention for an AIDS-free generation;
and has raised the profile of Harm Reduction to meet the needs
of injecting drug users, through the UK policy paper on harm reduction,
both published on World AIDS Day 2005.
4. The UK AIDS strategy Taking Action
set out the priority actions required to tackle emerging epidemics
and support marginalised and excluded groups. DFID continues to
support UNAIDS to provide effective global leadership on AIDS
and coordinate the international response. On the ground, DFID
country programmes in Africa, Asia, Eastern Europe, the Caribbean
and Latin America are supporting countries to meet the needs of
marginalised groups through our support to comprehensive AIDS
programmes, as well as targeted support to the most vulnerable
groups, and we have a long history of tackling emerging epidemics.
5. Yet much remains to be done. Difficult
international negotiations during 2006 have highlighted major
differences between countries' approaches to tackling vulnerability.
The UK remains committed to achieving Universal Access and will
continue to work hard to meet the needs of marginalised groups,
as the Secretary of State for International Development made clear
in his address to the UN General Assembly High Level Meeting on
AIDS in June (see paragraph 28).
HIV AND AIDS: MARGINALISED
GROUPS AND
EMERGING EPIDEMICS
6. DFID welcomes the IDC's decision to review
annually the Government's progress on tackling HIV and AIDS in
developing countries. We also welcome the decision to focus in
2006 on marginalised groups and emerging epidemics. These two
issues, as the Committee recognises, are fundamentally interconnected.
Progress in both areas is vital to moving towards the goal of
universal access to comprehensive prevention programmes, treatment,
care and support by 2010.
7. The Government is proud of the position
it has taken in support of marginalised groups and on the need
to take effective action now to tackle emerging epidemics. When
Taking Action (the UK's Strategy for tackling HIV and AIDS
in the developing world) was published in July 2004 it led the
way in identifying the need for a response to AIDS based on human
rights and emphasising that specifically targeting action towards
vulnerable groups was a key component of a comprehensive response
to AIDS. Since then, DFID has continued to actively support the
Joint United Nations Programme on HIV/AIDS (UNAIDS) and international
partners to pursue and adopt new and bold policies—especially
in the area of HIV prevention. This includes the promotion of
innovative and evidence-based harm reduction measures such as
needle and syringe programmes, safe injecting facilities and substitution
therapies to help ensure that injecting drug users have access
to support services, and harmonised approaches to AIDS programming.
8. The UK strategy, Taking Action,
has a particular focus on groups facing social, cultural and financial
barriers as well as stigma and discrimination, noting, for example:
"Women (particularly young and illiterate
women) refugees, sex workers, men who have sex with men and drug
users all face social, cultural and economic barriers as well
as stigma and discrimination which prevent them from accessing
health and other services. People in these groups are also less
likely to be able to express their particular needs to the institutions
that provide services. Where, for example, sex work is driven
underground, women who earn a living through prostitution are
unlikely to be able to access the specific services that would
enable them to protect themselves from HIV. Likewise, where homosexual
activity is illegal, it is virtually impossible for programmes
to specifically focus on the needs of men who have sex with men"
9. In many places throughout the world,
sex between men, sex work and injecting drug use are illegal,
heavily stigmatized and sometimes officially denied. These behaviours
also make people more vulnerable to HIV infection. Migrants and
prisoners are also routinely stigmatised, and their perceived
low status worsens further when they are associated with HIV and
regarded as a threat to public health. They may also suffer additional
discrimination resulting from this association. All people living
with HIV are often assumed to belong to one or other of these
excluded groups and this misconception may further intensify discrimination
and stigma.
10. As a result of stigma, vulnerable or
marginalised groups are often denied or by-passed by HIV prevention,
treatment, care and support services, while fear of stigma and
discrimination discourages many people from seeking these services.
In this memo we will focus principally on four groups that are
of particular concern, given that the resources delivered to them
are not proportional to their HIV prevalence or risk of infection.
These groups are: sex workers, males who have sex with males,
injecting drug users and prisoners. Taking Action also
focuses on other groups that are vulnerable either due to their
risk of infection or because of the impact of epidemic on them,
including women, young people, migrants, people with disabilities,
children and older people affected by AIDS. Whilst these latter
groups are of great importance, we have limited our focus in this
paper to those groups highlighted by the IDC and especially linked
to emerging epidemics. While work with marginalised groups is
not confined to emerging epidemics, the links are so strong that
we have addressed both together in this memorandum rather than
separating out our response in emerging epidemics.
CONTEXT: EMERGING
EPIDEMICS
11. The need to work closely with marginalised
groups is especially pronounced in emerging epidemics. Several
epidemics in Asia are increasing, particularly in China and Vietnam.
There are also alarming signs that other countries—including
Pakistan and Indonesia—could be on the verge of serious
epidemics. Only a handful of countries in Asia are making serious
enough efforts to introduce programmes focusing on injecting drug
use, commercial sex and sex between males—behaviours driving
the epidemics. The same applies in Eastern Europe and Central
Asia, where the number of people living with HIV rose in 2005,
and in Latin America, where growing numbers of women, especially
those living in poverty, are being affected
12. National HIV infection levels in Asia are
low compared with some other continents, notably Africa. However,
the populations of many Asian nations are so large that even low
national HIV prevalence means large numbers of people are living
with HIV. Latest estimates show some 8.3 million people (two million
of whom are adult women) were living with HIV in 2005—up
from 7.6 million in 2003. India has the largest number of people
with HIV of any country in the world. Despite the fact that less
than 1% of adults are infected, and recent evidence that prevention
programmes in some states in India are helping reduce new infections,
latest estimates show that two-thirds of Asia's cases of HIV are
in India. In Vietnam HIV has spread to all 59 provinces and all
cities with approximately 260,000 people living with HIV in 2005,
more than double the number in 2000. In Indonesia, although national
HIV prevalence remains very low at 0.01%, rapidly expanding AIDS
epidemics are being recorded amongst sex workers and injecting
drug users in Jakarta. Similarly in Bangladesh HIV infection levels
in injecting drug users increased from 1.7% to 4.9% between 2000-01
and 2004-05.
13. The epidemics in Eastern Europe and
Central Asia also continue to grow and are affecting ever-larger
parts of societies in this region. The number of people living
with HIV in this region reached an estimated 1.5 million in 2005—an
increase of almost 20-fold in less than 10 years. AIDS claimed
almost twice as many lives in 2005 as in 2003, causing the death
of an estimated 53,000 adults and children. The overwhelming majority
of people living with HIV in this region are young; 75% of reported
HIV infections between 2000 and 2004 were in people younger than
30 years (in Western Europe, the corresponding figure was 33%).
The patterns of the epidemics are changing in several countries,
with sexually transmitted HIV cases comprising a growing share
of new diagnoses. In 2004, 30% or more of all new reported HIV
infections in Kazakhstan and Ukraine, and 45% or more in Belarus
and the Republic of Moldova, were due to unprotected sex. Increasing
numbers of women are being affected, many of them acquiring HIV
from male partners who became infected when injecting drugs. The
bulk of people living with HIV in this region are in two countries:
the Russian Federation and Ukraine. Ukraine's epidemic continues
to grow, with more new HIV diagnoses occurring each year, while
the Russian Federation has the biggest AIDS epidemic in all of
Europe. Both epidemics have matured to the point where they constitute
massive prevention, treatment and care challenges. HIV has consolidated
its presence in every part of the former Soviet Union, with the
exception of Turkmenistan (where little information is available
on the HIV epidemic). Several Central Asian and Caucasian republics
are experiencing the early stages of epidemics, while quite high
levels of risky behaviour in south-eastern Europe suggest that
HIV could strengthen its presence there unless prevention efforts
are stepped up.
14. The number of people living with HIV
in Latin America has not risen since 2003 and remains 1.6 million.
In 2005, approximately 59,000 people died of AIDS, and 200,000
were newly infected. Primarily due to their large populations,
the South American countries of Argentina, Brazil and Colombia
are home to the biggest epidemics in this region. Brazil alone
accounts for more than one third of the estimated 1.6 million
people living with HIV in Latin America. The highest HIV prevalence,
however, is found in the smaller countries of Belize, Guatemala
and Honduras—where, by the end of 2003, approximately 1%
of adults or more were infected with HIV.
CONTEXT: MARGINALISED
GROUPS
15. Responding to the needs of marginalised
groups is not only important in itself, it is often key to halting
emerging epidemics, which usually start with concentrations of
HIV prevalence in certain groups. These concentrated epidemics
are perpetuated through sexual and needle sharing networks within
the vulnerable group, but can then spread beyond these contained
groups to the wider population. Once HIV moves beyond marginalised
groups, countries may face a "mixed", "generalised"
and ultimately "hyper-" epidemic where HIV can spread
exponentially as can be seen in many Southern African countries. In
settings where injecting drug users are closely networked with
the general population (eg through sex work), this epidemic growth
can be explosive.
16. There are thus both human rights and
public health rationales for countries facing emerging epidemics
to take immediate action to reduce vulnerability to HIV in marginalised
groups. To do this, marginalised groups must be explicitly considered
and targeted, as without this focus they are unlikely to access
services. Reaching these groups is vital to halting emerging epidemics;
it is also their human right to receive the AIDS services they
need.
17. In the 2006 Report on the Global AIDS
epidemic, half of the countries canvassed acknowledged the existence
of policies that interfere with the human rights of vulnerable
groups to AIDS services. These include laws criminalizing consensual
sex between males or prohibiting condom and needle access for
prisoners.
18. Amongst the marginalised groups sex
between men is one of the primary ways in which HIV and other
sexually transmitted infections are passed on. One in ten HIV
cases worldwide is attributed to injecting drug use. The sex industry
is generally illegal, a fact that limits sex workers' access to
health and other services which might otherwise serve their health
and safety needs. A number of studies have shown HIV prevalence
is higher in prison than in the broader community with the highest
prevalence in South Africa. 1[1]
There, estimates of people living with HIV or AIDS in the penal
system are as high as 41.4%.
19. Ironically, the people most affected
by AIDS or most at risk of HIV are often neglected by governments
and donors alike. So while sex between men is known to place people
at higher risk, a recent Swedish study reports that same-sex sex
remains criminalised in approximately 70 countries. 2[2]
And laws in at least six countries allow for the death penalty
in cases of consenting, adult homosexual acts. Other countries
provide for severe punishments, including lifetime imprisonment,
forced labour, and public whippings (UNAIDS). In 2002, in 13 Latin
American countries, men who have sex with men received disproportionately
less funds from national HIV prevention programmes than other
groups, given the prevalence of HIV among men who have sex with
men.
20. UNAIDS estimates suggest that HIV prevention
services are reaching just 36% of sex workers and 9% of men who
have sex with men and of approximately 13 million global injecting
drug users coverage of HIV prevention is at best 5%. While disaggregated
data remains patchy, marginalised groups are also less likely
to access formal health services for care and treatment. 3[3]
In prison settings, the availability of appropriate HIV prevention
measures, testing, care and treatment is overall extremely low.
Where treatment is provided, there have been reports of many prisoners
defaulting after their release due to not being able to integrate
back into general health services. At best these groups are ignored.
At worst enforcement of the "war on drugs" or anti-prostitution
or anti-sodomy legislation can force these people underground
and into even more risky behaviour, such as sharing syringes.
21. The impact of AIDS has largely been
managed by families and communities providing care and support
for those living with AIDS. However, people from marginalised
groups are often rejected by their families and communities, further
isolating them from circles of support. Government and civil society
assistance has frequently been ad hoc, incoherent and fragmented,
with the funding available not flowing effectively to community
level for many groups. Marginalised groups have been particularly
difficult to reach.
22. The international community made important
commitments in 2005 and 2006 to achieving universal access to
comprehensive HIV prevention, treatment, care and support services.
The challenge now is to deliver on these commitments—and
not just to the general population but also to those groups that
are hard to reach and especially vulnerable.
WHAT NEEDS
TO BE
DONE?
23. The international response to HIV has
accelerated markedly during recent years. There is now significant
political commitment to tackle the epidemic. But to reach marginalised
groups and to arrest the development of emerging epidemics, there
are uncomfortable realities that need to be faced. There is enough
evidence of what works, yet to make things happen norms and behaviours
that lead to the exclusion and stigmatisation of certain groups
must be confronted. Social change is essential to balance gender
relations, and to end the tolerance of AIDS related stigma and
gender violence; these are at the very roots of the epidemic.
24. Progress cannot be made without open
discussions about sex, sexuality and drugs, and a proper recognition
of the range of choices that people make or are forced into. The
voices of people living with HIV and AIDS and marginalised groups
are essential to guide governments and NGOs in providing the right
services so that people can protect themselves. In many places
there is a lack of demand for, and uptake of, services provided.
Effective community mobilisation of people with HIV and marginalised
groups can support focused activities—such as treatment
literacy campaigns—and reduce the stigma associated with
accessing services.
DFID: TAKING ACTION
TO SUPPORT
THE INTERNATIONAL
RESPONSE
Universal Access
25. The commitment to get as close as possible
to universal access to HIV treatment by 2010, made under the UK's
G8 Presidency at Gleneagles, was endorsed by the international
community at the 2005 World Summit. And the UK has been prominent
in helping to ensure that global efforts to turn this commitment
into action meet the needs of marginalised groups.
26. In the first quarter of 2006 the UK
co-chaired, with UNAIDS, the Global Steering Committee on Scaling
Up Towards Universal Access. This process brought together the
conclusions of over 100 national and seven regional consultations
on how to achieve Universal Access, and made a series of recommendations
to UNAIDS as priorities for action to achieve Universal Access.
These were presented to the UN Secretary General, prior to the
UN General Assembly (UNGA) High Level Meeting on HIV/AIDS in June.
The UK also co-chaired, with UNICEF, in February 2006, the Global
Partners Forum on Children Affected by AIDS. This Forum met to
discuss and articulate the priorities for action to ensure the
needs of children affected by AIDS are reflected in national responses
and play a central role in efforts to scale up towards Universal
Access. The Forum's conclusions also fed into the recommendations
made to the UN.
27. The UK played a leading role in ensuring
that the UNGA High Level Meeting agreed a Political Declaration
that set out the priorities for action to achieve Universal Access.
The Declaration that was adopted broadened the international community's
commitment to achieving by 2010 not just universal access to treatment,
but to comprehensive HIV prevention programmes, treatment, care
and support. The UK worked hard to ensure that language relevant
to marginalised groups was included in the Declaration, including
interventions to meet the needs of injecting drug users such as
the provision of sterile injecting equipment and male and female
condoms (paras 22 and 26). The Declaration also commits to tackling
stigma and discrimination, and to involve civil society, vulnerable
groups and people with HIV and AIDS in the response.
28. The negotiations were difficult, with
strong opposition from other governments who wished to remove
all references to "vulnerable groups". The strength
of this opposition meant that UK efforts to spell out those vulnerable
groups—to include injecting drug users, men who have sex
with men, commercial sex workers, prisoners—were rejected,
leading to intense criticism from civil society. The Secretary
of State, Rt Hon Hilary Benn MP, echoed their concerns in his
address to the UN General Assembly:
"We need to recognise that tackling AIDS
is not only about money. It's also about culture and social attitudes.
It's about recognising that while treatment is the key to keeping
alive people living with AIDS today, prevention is the key to
achieving an AIDS-free generation tomorrow. It's about being honest
about what the problem is and about telling the truth about what
works. I wish we could have been a bit more frank in our Declaration
about telling the truth: That some groups—like sex workers,
drug users and men who have sex with men—are more at risk.
That some young women—from choice or necessity—exchange
sex for money or food. That stigma, discrimination and the unequal
position of women and girls in societies make it more difficult
to fight this disease. That accurate information, access to sexual
and reproductive health and rights, and upholding human rights
all matter in this fight. That condoms protect people from HIV.
That clean needles stop injecting drug users from passing on HIV.
That abstinence is fine for those who are able to abstain, but
that human beings like to have sex and they should not die because
they do have sex."
29. The Declaration did include important
commitments to make additional resources available (in view of
UNAIDS' estimate that by 2010 $20-23 billion will be needed each
year to rapidly scale up AIDS responses); and to ensure that costed,
inclusive, sustainable, credible and evidence-based national AIDS
plans are funded and implemented. There was also provision to
monitor progress against these commitments through setting ambitious
national targets, including interim targets for 2008, for getting
close to Universal Access by 2010. DFID is working with UNAIDS
and many governments to support their efforts to set these targets
by the end of 2006, and to ensure these targets reflect the needs
of marginalised groups.
Prevention
30. During 2006 the UK has contributed to
achieving increasing international recognition on the importance
of a comprehensive approach to HIV prevention. As the IDC is aware
the UK fought hard for UNAIDS to agree a progressive policy on
Intensifying HIV Prevention in May 2005. This was in the face
of substantial opposition from some countries unwilling to see
reference to the full range of prevention approaches for which
there is substantial evidence and research proving their effectiveness
(eg needle and syringe programmes) essential to meeting the needs
of marginalised groups. The UK is now working closely with UNAIDS
to ensure that this progressive policy is translated into effective
guidelines that can mobilise effective country responses, and
to address some of the outstanding debates, such as on the role
of behaviour change in preventing sexual transmission of HIV.
31. In December 2005, under the leadership
of the UK Presidency, the EU published a common position on HIV
prevention—"The EU Statement on HIV Prevention for
an AIDS Free Generation". This clearly signifies that the
EU is ready to support country governments to enable all partners,
including civil society, to develop and implement coordinated
and effective HIV prevention programmes, and stresses the importance
of evidence-based prevention for marginalised groups.
32. The EU Statement advises that effective
programming includes: universal access to sexual and reproductive
health information and services for all people including young
people; provision of harm reduction programmes and services (see
para 35) to meet the needs of injecting drug users; reliable access
to essential sexual and reproductive health supplies including
male and female condoms and clean injection equipment; access
for all children to a secure education that includes life skills
and sexuality education; 4[4]
integration of HIV prevention interventions including voluntary
counselling and testing; action to confront and address gender-based
violence; investment in the development of new HIV prevention
methods such as microbicides and vaccines; promoting the adoption
of good workplace information and practice.
33. This statement has provided a strong
political signal about the importance of prevention, and of a
comprehensive approach to prevention—which was subsequently
endorsed by the international community at the UNGA High Level
Meeting on HIV/AIDS. We continue to use this statement to press
for comprehensive prevention services, especially for marginalised
groups.
Harm reduction
34. On World AIDS Day 2005, the UK Government
published its first policy position paper on Harm Reduction. Harm
Reduction strategies aim to reduce the health and social consequences
of drug injecting. The UK policy paper, agreed across Whitehall,
sets out the case for implementing a comprehensive approach to
harm reduction—including drug substitution therapy, sterile
needle and syringe access and disposal programmes, outreach programmes,
primary healthcare, prevention of sexual transmission among drug
users, provision of education and advice about HIV, and access
to affordable clinical and home-based care.
35. This document has been well-received
across the world, and has proved useful to proponents of harm
reduction in setting out the case for tackling HIV amongst injecting
drug users. DFID is currently working with other government departments
(notably the FCO and Home Office) and through the Informal Cross-Whitehall
Coherence Group on tackling HIV and AIDS in the Developing World
to look at how to implement this policy. Future efforts will include
working more closely with the UN Office on Drugs and Crime (UNODC—a
co-sponsor of UNAIDS), which has the international lead on harm
reduction efforts.
UK funding
36. The UK is the second largest bilateral
donor to AIDS programmes and has committed to spend at least £1.5
billion on AIDS work over the period 2005-08. The UK is helping
to deliver access to prevention, treatment, care and support services
to marginalised groups through our support to comprehensive AIDS
programmes as well as targeted support to the most marginalised
groups. UK funding is directed through bilateral programmes in
key countries, to some research and development programmes, and
through multilateral and international bodies.
UNAIDS
37. UNAIDS—which co-ordinates the
response of 10 UN agencies—leads the international response
to AIDS. UNAIDS has a strong record in supporting marginalised
groups and leading efforts to tackle emerging epidemics, including
through advocacy, dissemination of strategic information, policy
support and guidance. UNAIDS has published many important documents
relevant to these groups including a Policy Brief on men who have
sex with men, supporting research on injecting drug users; and
publishing best practice studies on injecting drug users and sex
workers in Eastern Europe, and men who have sex with men in Asia
and the Pacific. UNAIDS also supports the development of networks
of people with HIV and AIDS in countries and at global level,
as well as supporting responses in emerging epidemics. UNAIDS
and its co-sponsor WHO are collaborating on a programme (£6.6
million over three years) to support tracking emerging epidemics
and epidemics among marginalised groups with specialized surveillance
and epidemiological modelling. WHO is developing a compendium
of evidence on the success of various interventions to prevent
HIV (including activities targeted at marginalized groups). The
United Nations Office of Drugs and Crime (UNODC) has issued a
framework on HIV prevention in prisons and care for female IDUs.
38. To support UNAIDS work, including with
marginalised groups, DFID is providing £36 million core funding
to UNAIDS over four years (2004-08). An additional £8 million
has been given this year to recognise the high level of performance
and to support their work implementing the recommendations of
the Global Task Team on Improving AIDS Coordination among Multilateral
Institutions and International Donors (GTT). This year one of
the key activities related to the GTT has been the establishment
of a clearer division of labour on responsibilities for HIV prevention
among UNAIDS co-sponsors.
39. DFID supports UNAIDS to: provide effective
global leadership on AIDS and enable its Secretariat and country
coordinators to fulfil their coordination and catalytic role within
the UN family and at country level. This is essential to UNAIDS
role in implementing the "Three Ones" and GTT recommendations
at country level, including brokering partnerships outside the
UN. To ensure strong systems are in place to monitor the impact
of HIV and AIDS and responses to the pandemic, DFID is supporting
the Programme Coordinating Board and the Unified Budget and Workplan
to provide an effective governance structure for management of
UNAIDS' joint programme.
Marginalised groups and emergency situations
40. DFID recognises that populations destabilised
by armed conflict, humanitarian emergencies and natural disasters
(including both refugees and internally displaced people), and
particularly women and children in such situations, are at increased
risk of exposure to HIV.
41. DFID therefore funds a UN System-Wide
Work Programme for scaling up AIDS services for populations of
humanitarian concern. This programme (£6.6 million over three
years) is co-ordinated by the World Health Organisation and UNAIDS.
Partner agencies include other UNAIDS co-sponsors, in particular
WFP, UNICEF, UNDP and UNHCR. The programme aims to strengthen
the UN humanitarian response to provide better help to vulnerable
populations in acute and prolonged crisis and disaster situations.
42. This programme will implement national
strategies which incorporate different AIDS elements into programmes
or actions that respond to emergency situations, and where appropriate
AIDS components will also be factored into international assistance
programmes. Specific importance is attached to identifying gender-based
factors, including sexual violence, which heighten the vulnerability
of girls and women, and to addressing these through the appropriate
prevention, care and support interventions.
Global Fund to fight AIDS, TB and Malaria
43. The UK has been an important supporter
of the Global Fund since it was established in 2001. The UK sits
on the Board of the Global Fund (in a constituency with Australia)
and has committed £359 million to the Fund over the period
2002-08. This includes £100 million for 2006 and a pledge
of £100 million for 2007 subject to performance.
44. The UK's contributions have helped deliver
funds to support marginalised groups, for example through a US$
4 million Global Fund grant to the Russian Harm Reduction Network
to scale up access to HIV prevention and treatment in the Russian
Federation, and US$ 31 million over five years to Indonesia's
HIV/AIDS Comprehensive Care programme. The Russia programme aims
to strengthen HIV services for injecting drug users by; significantly
increasing the coverage and quality of HIV services for drug users
(including those who sell sex and people with HIV) in 33 cities;
increasing the demand for HIV prevention services; and providing
care and support for people with HIV and AIDS through community
mobilisation and capacity building at community level. The Indonesian
programme aims to reduce the number of HIV infections among female
sex workers and transvestites through increased awareness of risky
behaviours, condom use promotion and care and support services.
The programme aims to reach over 150,000 female sex workers and
transvestites through quality outreach programs managed by 150
local organizations.
Community organisations
45. Through Partnership Programme Agreements
(PPAs) DFID supports 26 NGOs, 18 of which identify AIDS-related
activities as part of the outcomes or success criteria they are
working towards. Of particular importance is DFID`s support to
the International HIV/AIDS Alliance which this year will receive
£3.75 million—a 36% increase on the previous year.
The Alliance focuses on action to address AIDS in marginalised
groups and emerging epidemics, and the DFID PPA focuses on four
strategic outcomes:
— Improved coverage of effective
community focused action on HIV and AIDS.
— Strengthened leadership and
capacity of civil society to effectively participate in national
responses to AIDS.
— Improved national and international
policy and financial environment for more effective civil society
responses to AIDS.
— An Alliance of national linking
organisations working effectively together.
46. In addition to more general NGOs, organisations
of people living with HIV and AIDS have a particular role in representing
the interests of people with HIV and giving them a voice wherever
policies and decisions are being made that affect their lives.
Strong movements of people living with HIV and AIDS can hold countries
and donors accountable. In Brazil, South Africa, Thailand and
Uganda, for example, people living with HIV and AIDS have been
able to put AIDS on the agenda and (in particular) lobby for treatment.
They have also demonstrated an ability to address the stigma related
to AIDS and reach the "hot spots" of an epidemic as
it emerges.
47. This year, DFID has committed £1.75
million (over three years) to strengthen global networks of people
living with HIV and AIDS and to build their and their organisations'
capacity to contribute to the formulation, development and implementation
of effective AIDS policies and programmes. This funding is being
provided to the following organisations:
— £1 million to the International
Treatment Preparedness Coalition (ITPC). ITPC is a global network
that brings a high level of technical expertise on HIV treatment
and care, with a particular strength in developing treatment literacy
programmes. DFID's funding will help the network strengthen its
communication and dissemination of this expertise at its grass
roots level.
— £375,000 to the Global
Networks of People living with HIV and AIDS (GNP+). GNP+ has played
a strong international advocacy role and the funding will help
strengthen their existing networks and increase the involvement
of people living with HIV and AIDS in the development and implementation
of policy.
— £375,000 to the UK based
International Community of Women living with HIV/AIDS (ICW). ICW
is the only international network run by and for HIV positive
women. This funding will help ICW maintain contact with women
living with HIV all over the world, share life-saving information
about their health and rights, influence policies and attitudes
and dispel myths about women and AIDS.
DFID TAKING ACTION
ON THE
GROUND
48. As already noted, action to support
marginalised groups and to halt emerging epidemics, is essential
to make real progress in scaling up towards Universal Access.
DFID supports countries to develop and commit to strong national
AIDS plans. But marginalised and excluded groups do not necessarily
benefit from broader national programmes because of social, cultural
and economic barriers and stigma and discrimination preventing
them from accessing services. And existing national laws and regulations
designed to protect people living with HIV from discrimination
are often not fully implemented or enforced. DFID supports approximately
100 projects and programmes that address AIDS-related stigma and
discrimination throughout the world. These programmes include
activities to foster respect and understanding towards people
living with HIV and AIDS, men who have sex with men, sex workers
and injecting drug users. They also support these groups to take
a stand against discrimination and fight for their rights.
Africa
49. In many of the generalised epidemics
in Africa, DFID is working with marginalised groups. In Ethiopia,
Ghana, Kenya, Malawi, Mozambique and Southern African Development
Community, DFID supports programmes that work towards legal and
policy frameworks protective of human rights of people living
with HIV and AIDS and vulnerable groups. In Kenya, for example,
DFID funding enabled the national network of people living with
HIV and AIDS and the National AIDS Commission to hire constitutional
lawyers to challenge new legislation on the criminalisation of
HIV transmission. Other programmes focus on legal education and
rights awareness of people living with HIV and AIDS (Malawi),
women with HIV and children affected by AIDS (Uganda), sex workers
(Togo) and young people (Niger and Rwanda).
50. In countries where Governments have
failed to adopt effective national programmes, DFID works with
international and national non-governmental organisations to develop
and implement AIDS strategies. For example DFID Zimbabwe has
committed £12.6 million to a four-year programme being implemented
by Population Services International (PSI)-Zimbabwe, and co-funded
by USAID to raise awareness of AIDS and striving to reduce social
stigma. The mass-media campaign (funded by DFID Zimbabwe) directed
at reducing prejudices and discrimination against people living
with HIV and AIDS, won the 2005 Global Media Award.
51. DFID Kenya's HIV and AIDS Prevention
and Care Project (HAPAC) supports the National AIDS Control Council
as well as a network of community based organisations working
with injecting drug users. DFID Kenya is also working with UNODC
to support the Kenyan Prison Service strengthen service provision
for those with HIV and TB. A policy seminar on Prisons and Prevention
of HIV is planned to be held in Kenya's largest prison (Kodiaga
Prison in Nyanza).
52. DFID Nigeria's programme Promoting
Sexual and Reproductive Health for HIV Reduction has some focus
on the needs of sex workers, males who have sex with males and
injecting drug users. An assessment of high risk areas in Lagos
State has been undertaken and trained community-based workers
visit these areas to provide condoms and facilitate discussions
on AIDS with commercial sex workers.
Asia
53. In Asia, DFID supports several programmes
on legal reform and the inclusion of the rights of vulnerable
groups and women in policies and laws. The programmes concentrate
on women's rights (Bangladesh, China, Pakistan), rights of injecting
drug users and sex workers (China, Vietnam), trafficking of children
and women into prostitution (China, Nepal), and empowerment of
migrants (Asia regional).
54. DFID India provides £123
million to support the National AIDS Control Programme of the
Government of India, focusing on eight states. A key plank of
the national response to HIV is to implement focussed prevention
programmes with high risk groups—known as Targeted Interventions.
In India these groups are primarily commercial sex workers, males
having sex with males and injecting drug users. By definition
they are marginalised because their behaviour is illegal. Both
financial and technical assistance is provided to these programmes.
55. To complement the Government of India's
programme DFID India also launched a Challenge Fund in 2005 to
support innovative pilot interventions with marginalised groups,
thus allowing civil society to respond to emerging epidemics and
challenges. It is intended that these interventions can inform
future policy and programming. DFID also supports efforts to reduce
stigma and discrimination.
56. DFID is also helping to finance an Asia-Pacific
regional consultation on male sexual health and HIV. The meeting
will focus on the risks faced by males who have sex with males
and cultural vulnerabilities and the risks of not addressing them
with adequate and appropriate HIV prevention, treatment, care
and support interventions, while highlighting the need for responsibility.
DFID is also supporting a number of regional activities to scale
up the HIV and AIDS response to marginalised groups, including
the NAZ Foundation (an NGO based in India) for work with males
who have sex with males in India, Pakistan, Bangladesh and Nepal
and some work in South East Asia; the WHO Western Pacific Regional
Office in Manila for harm reduction work in Vietnam and China;
and to Family Health International for HIV services directed at
Nepali migrant workers to India, for services in their home communities
in Nepal, and in destination communities in India. Funding NGOs
like the NAZ Foundation reinforces groups and individuals struggling
to implement evidence-based interventions such as needle and syringe
exchange which may be very different from the usual approaches
in certain countries.
57. DFID India is also supporting disability-friendly
AIDS programming by funding research looking at ways of reaching
disabled people with HIV prevention messages and other services.
The research includes both mental and physical disabilities and
is working with representative organisations as well individuals.
58. HIV infection rates are expected to
increase dramatically in China with a growing number of
drug users and sex workers and increasing internal migration.
Clusters of high HIV prevalence exist within certain geographic
areas and specific sub-groups (notably injecting drug users and
sex workers), particularly among the remote, mountainous regions
of the south west that are home to 85% of China's poor. In recent
years the Government of China has launched new policies on AIDS
and introduced new legislation on prevention, treatment, care
and support including anti-stigma and discrimination. China's
domestic funding for tackling AIDS has increased from £32
million in 2003 to £72 million in 2005. This is however still
short of the estimated annual need of £220-400 million for
an effective response.
59. DFID China has supported the Government
of China's AIDS efforts since 2000. Initially DFID committed £20
million to a Ministry of Health project in Yunnan and Sichuan
provinces to pilot new prevention work with injecting drug users,
sex workers and men who have sex with men. This was the first
project in China to routinely and extensively develop locally
appropriate interventions for injecting drug users, sex workers,
and men who have sex with men. It introduced condom promotion,
needle exchange and methadone substitution using participatory
peer education processes. Achievements included: increased consistent
condom use between female sex workers and clients; reduced needle
sharing; reduced discrimination by health providers.
60. This DFID-supported project demonstrated
that it is possible to implement affordable HIV prevention interventions
in China that are effective in changing high risk behaviours in
communities of female sex workers and their clients. It has made
a significant contribution to the development and implementation
of China's own policy at national, provincial and county level
to ensure that AIDS programmes focused on marginalised, high risk
groups.
61. Building on the success of the pilot
programmes DFID committed a further £30 million in August
2006 to help the Government of China's national AIDS programme
contain the number of people living with HIV and AIDS to 1.5 million
by 2010. The new project will build on the success of the pilot
programmes project and expand coverage to five new provinces (Xinjiang,
Guangxi, Guizhou, Hunan and Jiangxi).
62. The new funding is part of a £92
million programme also supported by the Global Fund to fight AIDS,
TB and Malaria. The programme focuses on seven provinces which
account for 89.5% of HIV and AIDS cases among drug users in China.
The programme will support a range of activities, including the
development of local plans on AIDS linked to the local government's
economic development plan for 50 counties, with a total population
of 28 million; contracting 70 civil society organizations to implement
activities in target counties; 45,900 female sex workers and their
clients receiving intervention services; 159,700 injecting drug
users receiving prevention services; 208,660 people with high
risk behaviours receiving voluntary counselling and testing services;
and 6,000 people with advanced HIV infection receiving ARV combination
therapy.
63. In Cambodia, adult HIV prevalence
has dropped from 3% in 1997 to 1.9% in 2003. The promotion, advertising
and distribution of condoms to sex workers and their clients (the
main drivers of the epidemic) through the 100% Condom Use Programme
is recognised as being a critical component of this success. DFID
has supported condom social marketing in Cambodia since 1994 with
total funding to date of £12.9 million. About 20 million
of the Number One brand condoms are sold annually with
a significant proportion being used by sex workers and their clients;
95% of sex workers report consistent use of condoms with clients.
About 160 million condoms have been sold to date. Other key target
groups for condom use are: the military, police, moto-taxi drivers
and "indirect" sex workers (who often work in karaoke
bars etc).
64. In Bangladesh, societal attitudes
result in extremely negative perceptions regarding sex work. Sex
workers are caught in a vicious cycle, rejected by their families
and society, denied access to basic services, and subjected to
varied forms of discrimination, stigmatisation, sexual and physical
abuse, and incarceration, while their children are treated as
social outcasts. The law generally ignores violence against sex
workers, and most cases are unreported because of the ambivalent
position of the law and the attitudes of the law enforcers. Police
themselves are often guilty of the worst offences, and sometimes
demand sexual favours in return for protection. Due to their social
marginalisation, lack of access to health services, and the inability
to negotiate safe sex with clients, sex workers are extremely
vulnerable to HIV infection.
65. In Bangladesh DFID supports an outreach
programme that empowers sex workers and their children to demand
their rights for basic services and raise awareness of the discrimination
and abuse they face among civil society, local government, education
authorities, and service providers.
66. Burma has one of the most serious
epidemics in South-East Asia. Although this is now a generalised
epidemic (national adult HIV prevalence is 1.3%), marginalised
groups (particularly sex workers and injecting drug users) are
most affected. Over one in three injecting drug users and commercial
sex workers are living with HIV. And it is estimated that 68%
of transmission is due to sexual transmission—with the rest
related to injecting drug use. The UN has called for increased
programming for the populations most at risk to HIV (especially
sex workers, their clients, injecting drug users and men who have
sex with men). DFID has recently approved a contribution of £20
million over five years to the multi-donor "Three Diseases
Fund"; a major proportion of this fund will be used to implement
AIDS activities, with particular attention paid to ensuring that
resources are directed to those marginalised and excluded groups
most in need of services.
Europe and Central Asia
67. DFID Belgrade is providing £1.5
million (April 2003-07) to the Western Balkans HIV Prevention
among Vulnerable Populations Initiative. This programme has successfully
used demonstration harm reduction projects with civil society
to influence policy. A recent independent evaluation acknowledged
that investments in harm reduction field activities generated
evidence and a range of recommendations for policy change; as
a result the Government of Serbia recognised that harm reduction
is one of the methods to fight HIV/AIDS and included it as an
important part of its national HIV and drug prevention strategy.
The programmes outputs also include; capacity strengthening for
HIV prevention organisations; transference of expertise and an
epidemiological evidence base.
68. DFID Russia has supported 30
harm reduction projects providing activities on needle exchange,
counselling and education of injecting drug users, distribution
of condoms and disinfectants, provision of medical services. In
addition DFID Russia is funding the Knowledge for Action Russia
project to generate epidemiological and behavioural research data
on target groups (injecting drug users, sex workers, young people,
etc) in two regions of the Russian Federation which will be used
as an evidence to inform regional and national policy development.
69. DFID Russia is now providing £500,000
to support the programme "Co-ordination in Action: implementing
the Three Ones principles in combating HIV/AIDS in the Russian
Federation" (Jan 2001- March 2007). The purpose of this programme
is to facilitate a major change towards a joined up, well co-ordinated
national response with a single coordinating authority and one
country-level monitoring and evaluation system. This programme
has provided indirect support to the national networks of people
with HIV and AIDS for national networking, strengthening of internal
expert groups within the networks and development of common position
documents on harm reduction and universal access.
70. DFID Ukraine is implementing
a number of projects that target men who have sex with men as
a marginalised group. Working with a local Ukrainian Charity,
"Health of Nation", DFID Ukraine is supporting a network
of community centres for men and providing HIV and STI prevention
through outreach work with men-having-sex-with-men in the two
biggest cities of Donbas, the main mining and heavy industry area
of Ukraine. This programme provides legal education and awareness
of rights as well as legal support to men who have sex with men.
71. DFID's approach also focuses on piloting,
and assisting in the national implementation of harm reduction
interventions including needle and syringe programmes, safe injecting,
substitution therapy, social marketing, outreach and peer education
through government partners, international and local NGOs.
Caribbean and Latin America
72. In Latin America, DFID is working
along with GTZ and UNAIDS to develop ways to provide technical
support to National AIDS Programmes in the region, through an
International Centre for Technical Cooperation on HIV and AIDS,
based in Brasilia. There is a strong focus on meeting the needs
of vulnerable and marginalised groups. The centre promotes low
cost appropriate means of providing technical support, to help
the various national programmes to improve implementation and
make better use of funds allocated by the Global Fund and other
donors.
73. In Central America, DFID is providing
additional funding to a World Bank programme designed to meet
the needs of cross-border migrants. These populations are very
vulnerable to HIV and the programme will work to develop innovative
approaches to working with these mobile populations.
74. A DFID Latin America programme
in the Atlantic coastal regions (in Honduras and Nicaragua, Central
America) is working to support the needs of selected vulnerable
migrant groups, including people living with HIV and AIDS. There
is a strong focus on working with young people, ensuring they
have access to services and raising their awareness of the links
between human rights, HIV and adolescents' rights to gain access
to reproductive health services. The programme is part of a larger
World Bank initiative in Central America and develops partnerships
with various local groups who are working with these hard to reach
populations.
75. In Nicaragua, a second programme
focuses on improving the legislative framework and policy environment
for protecting the rights of people living with HIV and AIDS.
76. In Latin America and Caribbean,
DFID Brazil and DFID Caribbean are jointly sponsoring the first
ever Regional Consultation to make Sex Work Safer, working closely
with UNAIDS and the innovative Brazil STD/AIDS Programme. The
event will take place in Lima, Peru in December 2006 and will
be an opportunity to compare the experiences from a wide range
of countries and develop ways to lobby for changes in the way
services are provided and to encourage legal amendments to promote
harm reduction and reduce stigma and discrimination.
77. DFID Caribbean is working with
the Pan-Caribbean Partnership Against HIV and AIDS to develop
a region wide "Champions for Change" programme, in part
to tackle extreme stigma and discrimination against men who have
sex with men and other marginalised groups. Events for political
leaders, music and cultural icons, and a forum for faith based
organisations have been held and a further focus on the role of
the electronic and print media is planned for December 2006.
78. DFID also recently announced support
of £2.5 million (over three years) for the "Accelerating
Private Sector Responses to HIV/AIDS in the Caribbean", a
programme being piloted in the tourist resort areas of Barbados
and Jamaica, one element of which is to address sexual behaviour
between men in the tourist industry.
CONCLUSION
79. The UK continues to provide global leadership
in the response to AIDS. We have been at the forefront of recent
developments which mean that the global response to HIV can realistically
talk of meeting the MDG goal to halt and reverse the spread of
HIV. Our strategy for tackling HIV and AIDS in the developing
world Taking Action identifies the importance of ensuring
that the needs of marginalised groups are met. It will be impossible
to achieve Universal Access without doing so. The UK is working
hard to ensure that marginalised groups have access to comprehensive
HIV prevention, treatment, care and support services; and are
included in both the dialogue around how to provide those services,
and the delivery of those services.
80. We will continue to work hard with this
objective. We look forward to the results of the independent interim
evaluation of Taking Action, which will include a working
paper specifically focussed on marginalised groups. The findings
from this evaluation will inform the UK's action on AIDS following
Taking Action.
October 2006
1 Dolan et al 2004. Back
2
1 SIDA (2005), LGBTI issues in the world: A Study on Swedish
policy and administration of Lesbian, Gay, Bisexual Transgender
and Intersex issues in international development cooperation.
Stockholm: Government Offices of Sweden. Back
3
UNAIDS 2006 Report on the Global Epidemic. Back
4
"Sexuality education" is the preferred term. Others
use the term "sex education" but this describes a more
limited, less progressive approach. Good sex or sexuality education
enables young people to acquire information and form attitudes
and beliefs about sex, sexual identity, relationships and intimacy
as well as developing the life-skills (eg negotiation, condom
use, how to access sources of contraception) necessary to ensure
healthy sexual and reproductive lives. All too often sex education
is limited to imparting information about genital anatomy and
basic science knowledge about sex and reproduction; and ignoring
the cultural and social attitudes that inform values and beliefs. Back
| 
