Reducing inequalities and social exclusion that affect HIV and health status

26 Oct - 10 Nov 2015
Go back to HIV, Health and Development Strategy of the United Nations Development Programme (2016-2021)

The defining call of the 2030 Agenda is ‘to leave no one behind’ and to reduce inequalities within and between countries – it is, in large measure, an ‘Agenda for Equality and Non-Discrimination’. The 2030 Agenda reinforces the UN system’s existing mandate on human rights, including the principles of equality and non-discrimination.

Inequalities are not only related to income and wealth. Other kinds of inequalities include, inter alia, inequalities in opportunities and outcomes in relation to education, health, food security, employment, housing, health services and economic resources.

Evidence shows that disparities in health outcomes tend to mirror inequities in broader society. This illustrates the interdependence of health and development. Gender inequalities, for example, including unequal power relations and discriminatory gender-based norms, stereotypes and practices, are a strong driver of poor health outcomes for women and adolescent girls with adolescent girls being at alarmingly high risk of acquiring HIV.

Many drivers of social exclusion, such as stigma, discrimination, criminalization and marginalization, limit access to HIV, health and other basic services and increase health risks for the most vulnerable people, such as men who have sex with men, transgender people and sex workers. The data is stark: Key populations in the context of HIV - including men who have sex with men, sex workers, people who inject drugs and transgender people – and their partners are at high risk for HIV and account for between 40% and 50% of all new HIV infections worldwide.

Cities and urban areas bear a large share of the HIV burden, particularly in Africa and Asia. Cities are places where the risk of HIV may be heightened for some populations, especially young men, poor women and girls and those marginalized by ethnic, gender and sexual differences.

Related resources:

 - Strategy Note on reducing inequalities and social exclusion that affect HIV and health status

 - Gender, HIV and health

 - Key populations

 

Proposed Guiding Questions

  • In the context of HIV and health, who is being left behind and why? What are the main challenges and gaps? What are the opportunities for addressing these gaps?
  • What contribution can UNDP make in this area?
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Comments (42)

David Owolabi • Programme Associate at UNDP

Dear All, It is important to mention that the UNDP HIV and Health Strategy Note 2016 - 2021 is timely and aligns with similar strategies like the UNAIDS Strategy 2016-2021. It is also an opportunity to contribute to the implementation of the newly adopted SDGs 3, 5, 10, 11, 16 & 17. Below are my reflections on the guiding questions on the consultations with respect to the action area 1:Consultation on UNDP’s HIV and Health Strategy Note 2016 - 2021Action Area 1: Reducing inequalities and social exclusion that affect HIV and health status;Questions:

  1. In the context of HIV and health, who is being left behind and why? What are the main challenges and gaps? What are the opportunities for addressing these gaps?
  • Those left behind are key populations (Transgender male and female sex workers, MSM,  Sex workers, migrant workers, prisoners, Injection Drug Users, vulnerable women and girls)
  • Challenges include: criminalizing laws, lack of enabling policy and legal environment
  • Lack of adequate research and data especially in terms of the trans-populations Opportunities to address these gaps?
  • Follow up to the GCHL such as through the conduct of the Legal Environment Assessment (LEA) as a strategy for policy and legal reforms
  • Scaling up of the urban health and justice initiative also known as the cities or municipal initiative on HIV and key populations for strengthened access to service by Key Populations; promotion of access to justice and promotion of their human rights and capacitation of local leadership for programming for key populations
  • Partnership with the GF within the context of Country and Regional Concept Notes
  • Integration of Key populations issues in National Strategic Plans (NSP) on HIV
  • Engagement at Regional, Sub-regional and national levels for alignment of policies and laws
  • What contribution can UNDP make in this area?
  • Mapping of policies, laws and services on GBV/HIV intersections and provision of technical assistance to governments to develop and implement action plan to address these nexus as a strategy for HIV prevention.
  • Mainstreaming of HIV in Conflict contexts
  • Promotion of the rights of key populations and advocacy for their participation in policy development, governance and programming. This will involve supporting research and qualitative analysis to understand the challenges faced by LGBTI as a way of determining the best way to programme to address the identified challenges
  • Conduct of operational research to develop indicators for monitoring of HIV and human rights programmes
  • Scale up of the cities work including partnership with the UNAIDS on leveraging the municipal and cities approach to address Key population issues

 

Qudratullah Nasrat

In the context of HIV and health, the ones who are left behind are the rural poor who do not have immediate access to health services. For Afghanistan, the situation is more severe because of the active fighting between armed opposition groups and the government forces. The major challenge in Afghanistan is the active insurgency which is breed by weak governance and rampant corruption. The prisoners and injection drug users are other crucial segments of the society. Due a high level of crime, number of inmate’s increase. On the other hand, due to lack of employment opportunities, the number of jobless people also increase. These jobless people usually resort to drug abuses. Among them are even women who lost their male family breadwinners in war and fighting. Organization for Research and Community Development (ORCD) in Afghanistan acknowledges the fact that research-based evidence is very limited with regards to HIV and AIDs in Afghanistan. 

lubna • from Pakistan

Dear All,In conventional societies like Pakistan, social taboo is attached with HIV disease. This prevents even educated people to keep no or little interaction with HIV affected individuals.   There are some "Myths" about HIV inflicted individuals, which prevail upon other individuals to distance from HIV patients. For example, they can transmit disease through handshake even. This social attitude is due to social fabrication of values in which transgender, sex workers and people with not straight sex orientation should not be treated with respect. The need of the hour is to change this mindset through awareness campaigns about causes and effects of HIV. These campaigns can be promoted through media or through dialogue with community heads. In this respect, health workers can play effective role with the coordination of elected members of parliament. I would like to make few suggestions in this regardAwareness campaign needs to be launched at university/college level by engaging student representatives or group of students. These groups may be assigned task to arrange interactive discussions on social exclusion of HIV affected individuals with health experts and HIV patients . Currently, seminars involve health experts and usually passive audience.RCT (Random Control Trials) based research on social exclusion of HIV affected patients can be undertaken with  financial support by agencies. The research may aim at comparing neighborhood effects for socially excluded HIV patients.Sometimes state itself backs /supports discriminatory policies against HIV patients. For example, Government of Pakistan does not acknowledge transgender as citizen of the country. Presently, transgender are not registered with National database and  registration authority (NADRA). This precludes transgenders, who are more likely to be affected with HIV, with opportunities to get gainful employment and education

Santiago Roberto Bertoglia

ESTIMADOS COLEGAS:Otra gran oportunidad para expresar soluciones a los problemas que afectan a miles de seres humanos en todo el mundo y en mí país la República Argentina. El VIH SIDA, como muchas otras enfermedades en la República Argentina continúa en aumento y no hay forma de razonar cuando los gobiernos se vuelven criminales haciéndoles faltar todo tratamiento médico y ni siquiera con orden judicial son atendidos los pacientes afectados. Según la Universidad de Buenos Aires y según el Gobierno es no ofrecer vida digna a las personas humanas sufrientes de la enfermedad. Hoy ni siquiera las personas humanas sanas están a salvo cuando concurren a los Hospitales para donar sangre.Conclusión:En la República Argentina los gobiernos criminales violan la Constitución de la Nación Argentina, la Carta de las Naciones Unidas y todos los Derechos Humanos. El virus VIH SIDA en esta condición aumenta su efecto en poblaciones empobrecidas y las extermina. La Salud Pública está amenazada por esta clase de gobiernos que no atienden a las personas afectadas.SOLUCIÓN:Es importante que la ONU y la Corte Penal Internacional comiencen a trabajar en el territorio de la República Argentina. Haciendo participar a las personas humanas afectadas en los Procedimientos y las Reparaciones de la Corte. Encaminados en ese proceso el Pueblo encontrará al GOBIERNO FEDERAL y las acciones se facilitarán de modo nunca antes vivido. También serán motivo de invitar a hacer lo mismo a otras personas humanas de otros países y encuentren todo tipo de inmunidades para el disfrute de los Derechos Humanos.Quedo atento a nuestro encuentro, recordando Carta de las Naciones Unidas, "Nosotros los Pueblos del Mundo".Gracias

bertrand livinec

Dear All,Talking about HIV and inequalities is a very interesting topic. Is it a technical or a geopolitical issue ?During last years, I was very surprised that UNAIDS never talk about income inequalities and their impact on HIV. The Gini coefficient is unknown by the institution.If we are taling about inequalities or health determinants in 2015 do we have to understand that the neoliberal period is now closed ? It is still taboo to say that racial and social determinants have been key issues in the HIV pendemic ?Best regards,Bertrand Livinec  

Santiago Roberto Bertoglia

ESTIMADA Bertrand LivinecESTIMADOS COLEGAS:Otra gran oportunidad para expresar soluciones a los problemas que afectan a miles de seres humanos en todo el mundo y en mí país la República Argentina. El VIH SIDA, como muchas otras enfermedades en la República Argentina continúa en aumento y no hay forma de razonar cuando los gobiernos se vuelven criminales haciéndoles faltar todo tratamiento médico y ni siquiera con orden judicial son atendidos los pacientes afectados. Según la Universidad de Buenos Aires y según elGobierno es no ofrecer vida digna a las personas humanas sufrientes de la enfermedad. Hoy ni siquiera las personas humanas sanas están a salvo cuando concurren a los Hospitales para donar sangre.Conclusión:En la República Argentina los gobiernos criminales violan la Constitución de la Nación Argentina, la Carta de las Naciones Unidas y todos los Derechos Humanos. El virus VIH SIDA en esta condición aumenta su efecto en poblaciones empobrecidas y las extermina. La Salud Pública está amenazada por esta clase de gobiernos que no atienden a las personas afectadas.SOLUCIÓN:Es importante que la ONU y la Corte Penal Internacional comiencen a trabajar en el territorio de la República Argentina. Haciendo participar a las personas humanas afectadas en los Procedimientos y las Reparaciones de la Corte. Encaminados en ese proceso el Pueblo encontrará al GOBIERNO FEDERAL y las acciones se facilitarán de modo nunca antes vivido. También serán motivo de invitar a hacer lo mismo a otras personas humanas de otros países y encuentren todo tipo de inmunidades para el disfrute de los Derechos Humanos.Quedo atento a nuestro encuentro, recordando Carta de las Naciones Unidas, "Nosotros los Pueblos del Mundo".Gracias

Saripalli Suryanarayana • from India

Our concerns to day are about Cancers, HIV, Diabetics, Thyroid affecting the women health.We are also worried about children born with defects because the mother carried these abnormalities unknowingly.As we discuss in HIFA, or Malaria community etc, we are well aware of many types of virus and bacteria affecting the communities apart from the hereditary problems coming out of Genes.We are developing the DNA sequencing which will eliminate certain problems coming to children out of the 22 or 23 pairs of chromosomes.The urban as well the rural people need education, not just write or read about social economic and a lesson on public health.Progressively we need technicians and engineers to assist the microbiologists, doctors and virologists.Let us start such institutes progressively in next 3 years, in each country, and in each province of that country.Write a comment

hukatoli

Greetings to All,I am from Nagaland North East India, HIVAIDS has been a long standing health and developmental issue where proper and effective programming need to be strengthened specially in our part of the country. The programmmes that has come forward to address the issue of HIV/AIDS could not give equal opportunity to all the Vulnerable Population of MSM, Sex Workers, Transgender, Migrants the reason for this lack of understanding the vulnerability of the this group and stigma and discrimination.UNDP can look into:-1. HIV strategies has to be designed according to the need of the Country and by the People of the country (As all different country cannot follow one protocol or guidelines).2. Equal opportunity should be given to all the Vulnerable Population taking into consideration of Geographical difference, culture, ethnicity and religion.3. Along with Strategic Programming Awareness Campaign should always be in the Agenda (All are at risk and Human behaviour, life circumstances, sexuality can change any time to Vulnerable Population) and this will also help in reducing stigma and discrimination which is also associated with improper information.4. Before launching any stragtegic programme Government has to be taken into Confidence with clarity of the goal, visions and specially Human Rights Issues, with equal participation of the Implemanting Agencies and the Vulnerable Population.5. Capacity Building of the Local Country People and the Vulnerable Population should be a priority to ensure sustainability

Dr. Anil Pratap Singh

Virtual Consultation on the HIV, Health and Development Strategy of the UNDP (2016-2021): * Reducing inequalities and social exclusion that affect HIV and health status:-Contributed By: Dr. Anil Pratap Singh, Secretary  & CEO- GLOBAL SCIENCE ACADEMY (GSA) INDIA BACKGROUND: As chief functionary of the Global Science Academy (GSA) we, at our level, contributed time to time, towards processes of setting global goals in HIV/AIDS and TB sectors and discussed on shortfalls in these mechanisms whilst setting out these goals. As we have witnessed slow pace progress (and inability to achieve) with respect to time-delimited goals like "3 by 5" initiative-aiming to place 3 million people in the developing world on ART by 2005 and "Health for All" by 2000. Likewise, Universal access by 2010 as well as Millennium Development Goals (MDGs) and likelihood of not achieving them by 2015 compel us to thought to these mechanisms in setting out these global goals. ART having life-enhancing qualities but still not gained access to the 6.7 million people worldwide. HIV/AIDS being a global health emergency as declared by WHO, need more effective involvement of implementers at all levels with holistic people directed initiatives. GSA believes that exploring synergies of efforts between professionals at organizational as well as individual levels that could better be intensified for universal access by taking considerations of peer-based research for mapping practices, sensitization of research organizations, operational research based interventions, intensifying interventions with technological advances and building capacities, inter-ministerial synergy and mobilization of more stakeholders, and empowering vulnerable populations through legislation. HIV REMAINS CONCENTRATED AMONG KEY POPULATIONS AND INEQUALITIES & SOCIAL EXCLUSIONS EVIDENT AROUND THE GLOBE:Across the continents, HIV remains concentrated among key populations and countries with their renewed political will focusing their responses by targeting these populations in purview of global vision of “Getting to Zero” (-‘Zero new HIV infection, Zero discrimination & Zero AIDS-related deaths’). Despite of existence of significant amount of social protection measures in many countries, key populations continue to victimize social exclusions and our planet has more sufferers of inequalities dwelling as fellow citizen. That is why more and more countries are now shifting towards rights-based approach in their responses on AIDS. A number of nations’ law enforcement approach keeps sex workers, men who have sex with men, transgender people and people who use drugs from accessing services and also preventing service providers from doing their work. On contrary, public health efforts seek to promote access to HIV services. Such conflicting approaches results in tensions between policy and legal changes at the national level become major impediments.In some national HIV programmes legal barriers and enacting laws to protect people living with HIV against discrimination. In India, I have got the opportunity by involving myself in consultation on drafting ‘HIV/AIDS Bill’ and happy to share that now India has a draft legal framework to address stigma and discrimination, and moreover, its national policy has been altered to allow access to opioid substitution therapy (OST) for those who inject drugs. Further, there is a good gesture of commitments by nations to address gender inequality as part of the AIDS response which I witnessed in recent past whilst attending various High Level Meetings (HLMs) as was part of plenty of talks even at esteemed UN floors.    DEVELOPING RIGHTS-BASED & GENDER-SENSITIVE AIDS RESPONSE WITH INTEGRATED APPOACH TO FUNDING GLOBAL HEALTH: In order to reduce inequalities and social exclusion that affect HIV and health status, we need to strategize AIDS responses wherein governments could enact laws that protect people living with HIV and key populations at higher risk against discrimination. Rights-based and gender-sensitive responses are need of the hour. In a gender-sensitive response, we must confront social barriers to health and rights with a meaningful participation of girls and women including those belonging to key populations as well as living with virus (HIV). It is extremely essential for governments either revise or remove their laws that fuel HIV-related discrimination and these resulted remedies are to be incorporated into national HIV policies and comprehensive, focused and funded programmes of activities. Meanwhile, law enforcement and authorities from judiciaries and health etc. are to be sensitized properly so that they could adopt HIV-friendly laws in order to reduce inequality and social exclusion. Furthermore, roles of human rights groups are crucially to be ensured in monitoring and publicizing instances of HIV-related rights’ abuses and discriminations and to use these evidences for advocating law and policy reforms in programmatic strategies which potentially address stigma and discrimination. Moreover, in prevailing crisis of global financing, it is not the time to scale down but need still to continue scale up which requires resource mobilization as well as cost-effective programmes with more integrated health systems e.g. child and maternal health programmes could better be integrated by HIV services. We also need to develop cost-effective and sustainable approach to HIV treatment as well. Collaborative efforts amongst professionals (scientists, AIDS advocates etc.), drug manufacturing companies as well as countries are also to be understood as essence in this context.   -Dr. Anil Pratap SinghSecretary & CEO, Global Science Academy (GSA),Satyawanpury, Block Road, BASTIDistrict: BASTI (Uttar Pradesh)Tele-fax No.: +91 5542 247186Mobile No.: +91 9336785696Website: gsaindia.org.in  

Ninoslav Mladenovic • HIV AIDS Officer at UNDP

If we talk about who is being left behind and why, there certainly remain unanswered problems and unaddressed populations within HIV and health. For example, the needs of migrants – and their descendants – from high-prevalence countries remain addressed poorly. These populations are very specific – tending to vary from country to country according to colonial and linguistic ties – may be very isolated within their adopted countries, and tend to have sex only within their own community, which can concentrate HIV to the point where prevalence is higher than it is in the home country.In most epidemics priority populations include a combination of key populations-sex workers, men who have sex with men, transgender people, people in prisons or other closed settings, people who inject drugs, and other country specific populations. Migrants also include MSM. Migrant MSM for obvious reasons come to the great cities with vibrant gay scenes, but with higher rates of both condom-less sex and injecting drug use. One of the main gaps and challenges is the profound lack of services and representation for migrants with and vulnerable to HIV. What contribution can UNDP make in this area?As also suggested by UNAIDS, HIV prevention programmes are most effective when they address social, gender and age groups with the highest HIV incidence rates and the largest numbers of new HIV infections while also being tailored to their sociocultural context. In all settings programmes should define priority populations based on regular epidemiologic and sociodemographic analyses of data to determine which population groups are most affected and their size, and these populations should be involved in designing, implementing and monitoring HIV prevention programmes. To this end, UNDP needs to continue its focused work with priority populations, commit resources and mobilize staff at all levels, with clear accountability mechanisms and implementation plan coordinated both globally and at country levels. Linkages to the Sustainable Development Goals (SDGs) and integration with larger Human Development response shall also be sought.

Shirley (not verified)
  • In the context of HIV and health, who is being left behind and why? 
  • Besides the key populations that are globally recognized, it is important to focus on other vulnerable populations, depending on the country/regional epidemic. Adolescents and youth, migrants and mobile populations, people who use drugs (not just injecting drugs), women, and indigenous and afro-descendant populations. Often these populations face challenges because they are not part of the recognized key populations, so it is more difficult to mobilize funding for them, or to ensure that the health and HIV services address their specific needs. 
  • What contribution can UNDP make in this area?
  • UNDP can support civil society and governments to address key populations' and other key populations' needs, reduce stigma and discrimination, reduce barriers to access health services. There is also a need to generate more research on these populations. UNDP can help build the capacity of community-based, national and regional organizations/networks to play a stronger role in the response. 
  • UNDP has been instrumental in the LAC region's adoption of stigma and discrimination targets. It can ensure that at country level, relevant stakeholders work on an action plan to make sure progress is made in the next five years in the relevant areas - especially legal reform, discrimination in health settings, access to justice. 
Dr. Anil Pratap Singh

Dear friends!!!I have posted my contribution on Reducing inequalities and social exclusion that affect HIV and health status on October 29, 2015 and would further welcome to have your thought through ideas, if any,  even beyond this on-going discussions. You may contact me/us through your e-mails at: globalaps@rediffmail.com   -Dr. Anil Pratap SinghSecretary & CEO, Global Science Academy (GSA),Satyawanpury, Block Road, BASTIDistrict: BASTI (Uttar Pradesh)Tele-fax No.: +91 5542 247186Mobile No.: +91 9336785696Website: gsaindia.org.in E-mail: globalaps@rediffmail.com

Saripalli Suryanarayana • from India

Third party monitoring,creating local NGO to assist and develop proper assistance in education of the deprived communities encouraging the availabulity and distribution of generic medicines.Creating the system of PPP  and set a mechanism for their earnings. 

Yunah Bvumbwe (not verified)

there is a pressing need to address power relations  between men and women. Culturally men have too much unfettered power over women about their sexual life.women and girls often find themselves in compromising  situations  when it comes to  safe sex as well as consent, they are too scared to negotiate for protected sex which always leave them vulnerable.  In my country ,statistics always highlight that women and girls are the most vulnerable to HIV and AIDS  , new infections among adolescent girls and young women are frightening. If boys are socialized at an early stage to treat their female counterparts  as equal to themselves, we won't see them in the future exercising  power over females. Leaving no one behind  includes focusing on those people who by nature have been failing to let their voices heard.

Clifton CORTEZ • Team Leader: Gender, Key Populations and LGBTI, UNDP at UNDP from United States Moderator

Dear colleagues, thank you for your many insightful and heartfelt comments to this discussion.  Seeing this level of interest and engagement, as well as the consistency of the issues to which you've addressed your comments, gives great confidence that the draft UNDP HIV, Health and Development strategy is taking on the issues that really matter.  First and foremost, it is clear that there is consensus among the discussants that we will not effectively respond to HIV and other health challenges if we are not effectively responding to inequality and exclusion, and a number of your comments focus specifically on the inequalities and exclusions that are the greatest barriers to progress: gender inequality and exclusion of the most marginalized in our societies.  Your comments also make it clear that the global, regional, country and community responses to our common health challenges must protect and support dignity and the rights of all people, and at the same time must be relevant for both urban and rural communities.  I'd like to probe a bit and ask: At this point in time, all stakeholders, including governments, acknowledge the importance of the voice of those most affected by HIV and other health challenges but again and again we see responses that do not engage well these critical voices.  How therefore do we ensure effective participation of women and marginalized people in national and local responses, including in resource allocation decisions?

Carlos CORTES FALLA • Programme Specialist at UNDP

Dear Clifton, as you mentioned the participation of women and other vulnerable groups in decision making processes is still far away from what is needed.  The lack of participation is a part of the inclusion deficit; is not only that they dont participate, but that they are actively marginilized and attacked. In Latin America progress has been made in recognizing the gender gap and women´s participation in politics; this positive evolution can be appreciated in the fact that we have three elected female presidents in big countries as Chile, Argentina and Brazil.Despite this apparent progress, crucial issues as gender based violence is still prevalent. The Inter-American Development Bank estimates that between 30% and 50% of the region’s women involved in intimate partnerships have suffered psychological abuse, such as insults or threats, in the context of their relationships, and that 10 to 30% have suffered physical violence by male family members (2010). At the same time, the political participation of women is very low, and less than 30 % of the elected members of parliament are women, in countries as Colombia.How can we ensure that there is a space for women in the decision taking processes, and in the search of solutions for issues as HIV, violence and labor discrimination?. We can find many answers for a complex dilemma. This same question should be made to the other side of gender discrimination: the LGBT community.  In Colombia, for the first time, an openly gay candidate was elected as Mayor of a small town in October´s elections, and this is considered a big step forward.Gender discrimination and promotion of inclusion must be searched outside the box of the traditional approaches. We have been supporting civil society initiatives and reinforcing women´s organizations, but it seems that it is not enough.Recently, the OSCE is discussing how to make compulsory to all its members to ensure a quota minima for women. A similar approach should be proposed to LGBT minorities. Using law to ensure participation and inclusion, may be part of the solution, but there is still lot to be done. I still believe that education is at the core of this dilemma; our schools are exclusion spaces, in which the reproduction of traditional macho values is prevalent. Despite the fact that in many countries there is a sexual education curricula, didactic strategies and effective tools for preventing gender discrimination are is not properly implemented, and kids are not receiving the opportunity for changing old exclusive behaviours and traditions.

bertrand livinec

Dear Clifton, First of all, I would like to thanks UNDP for organising this on-line debate on HIV and inequalities. Dear Carlos, I have read your post with interest. I would like to make few comments. About HIV & homophobia LGBT rights should be indeed improved. In the same time, safest practices should be promoted by LGBT movements. About HIV & gender gap Reducing the gender gap should be an objective by itself, I mean women should have the same rights as men, but I am not convinced this is the key determinant for HIV. If you look at countries in Austral Africa, where the HIV prevalence rate is the highest in the world, the gender gap is not so bad comparing with other sub-saharan countries. http://reports.weforum.org/global-gender-gap-report-2014/rankings/ South Africa is in 18n position in this world index, and before.....Canada and United Kingdom ! About HIV & violence You mention violence in latin america. As you know income inequalities are very high in latin america, and in sub-saharan countries also. There is a clear link between physical violence and income inequalities. I would like to mention that the USA have more than 2 millions of people in jail, more than any other country in the world. This is also the result of very unequal society. Violence is often the result of social and racial discriminations, the two are usually linked. Afro-americains are the first group infected by HIV in the USA, there are over represented in american jails. I do not imagine that you manage to reduce violence in a society if you do not reduce income inequalities. About HIV & income inequalities I have for example recommended in a recent article (More income inequalities means more HIV-AIDS An advocacy for Gini coefficients beside 0.3 ) to reduce the income inequality under a reasonable level (it is unfortunately in french). The correlation between HIV prevalence and income inequalities in Africa is high. The board with the list of african countries, their HIV prevalence rate, and the Gini coefficient measure at the end of the article is quite eloquent I think. http://www.jle.com/download/--mst-303916-plus_dinegalites_de_revenus_ce… About health, a political matter The fact is that health is a political or a philosophical subject. The way you imagine the desired society will draw the way you imagine health strategies or programs. The World Health Organisation or even UNAIDS do not present the best practices in public health in a rational way but try to present best recommendations from mainstream stakeholders, which is something very different. If you look at national health policies, it will in fact give you many informations on the groups that have been involved in writing it and not necessarily on the epidemiological situation and real national health priorities. As a french, I consider that France is not a best practice in public health because we have to many conflicts of interests that interfere with a rational vision. Scandinavian countries have lower health expenses but better results, among many reasons they do have lower income inequalities and better governance with really much more transparency. I personally wrote several articles talking about income inequalities and HIV, because I did not see from the main HIV institutions the wish to talk about that link. At the stage, unfortunately my feeling is that international institutions do not promote necessarily best practises. About HIV & the social-determinants Reducing inequalities between women and men, or struggling against homophobia should be promoted. But, if you let income inequalities at a high level, a vast majority of the population will be socially discriminated and it is a real non sense to imagine that you can reduce groups at risk in a very unequal society. My opinion, is that the main role of international institutions should be to tell the truth on all subjects linked with health. I would only recommend to mention all studies that have shown a impact on HIV, that is to say to understand the impact of all health determinants. Many studies have shown that medical resources count for maybe 20-25% in the health of a population, but socio-economic elements for maybe 40% ! http://publichealth.lacounty.gov/epi/docs/SocialD_Final_Web.pdf In a recent article, I have also suggested to present health strategies within 7 groups of health determinants (we can also consider them as rights), they all have a strong impact on health) : 

  • rights to have a healthy environmental (climate change, pollution, bio-diversity, etc...) ;
  • human rights (racial, gender, sexual, religious, etc..) ;
  • rights to have access to good food (including alcohol, tobacco, etc...) ;
  • socio-economic rights (employment, income inequalities, education, accommodation, etc...) ;
  • rights to have access to medical resources (infrastructures, people, drugs, etc... / prevention I to IV) ;
  • individual rights (includes rights to honest and complete information, behaviours and health promotion) ;
  • rights to good governance (the capacity of authorities to tell the truth, limit the conflicts of interest, transparency, clear and logical strategies, etc...).

 For example, why Cuba and the United States of America have the same level of life expectancy, when according to WHO Cuba spend only 1828 USD in health expenditures (per hab/per year) (or 8.8% of GDP) while the USA spend 9146 USD (or 17.1% of GDP, world record) ? This is the result of systemic approaches in public health on one hand with a good use of social determinants for Cuba and of neoliberal approach on the other hand for the United Sates with tremendous racial and social discriminations. I personally regret the strong influence of the USA in international health strategies, this is negative and as a result the use of social determinants have been avoided during many years in health strategies. I am pleased to see that debate with UNDP, but the impact of social inequalities on health is very well documented since the 1970s. At this stage, there are many gaps in the programs against HIV (or other diseases), there is a clear problem of governance, and I even consider activists very disappointing because they do not have a holistic vision of public health (their action has also generated inequalities between diseases and in many cases increased the fragmentation of health strategies). For my point of view, it is quite difficult to built efficient and rational health strategies if you do not clearly say the type of society you want. Once again, as a french I consider that scandinavians do better in many areas that affect health. All health determinants are interconnected including for HIV, we cannot continue to work by adding year after year a new idea here or there, it is necessary to have a global vision of what type of society we want. HIV struggle has been fragmented, expensive, inefficient ; it is time to change of paradigm. At the beginning of the 1980s we have seen the emergence of a neoliberal conservative revolution, and then it has progressively changed in a neoliberal libertarian revolution (economic neoliberalism plus human rights). The idea is now to change this in a social libertarian revolution, the world will be then really in a better shape. In conclusion, I would say that if we really want to be the most efficient in the struggle of HIV (and other diseases), the most simple think to do is to reduce the Gini coefficients, and this recommendation is valid for all countries. Talking a about LGBT and Women rights is necessary. But if the impact of income inequalities is not mentioned, I would consider this as a diversion. Therefore, I really hope that UNDP will put income inequalities as a key determinant against HIV, because this is proved. Nb : if some people find my comments quite tough, I suggest to read the last book of Joseph Stiglitz, (american, nobel prize of economy), “the great divide”. This is one of the strongest pamphlet against the neoliberal system. Best regards to all,Bertrand Livinec

bertrand livinec

Good morning Clifton,I would like to share these two studies about HIV and income inequalities (One in the USA, the second one in South Africa).http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1767180 https://gupea.ub.gu.se/bitstream/2077/39184/1/gupea_2077_39184_1.pdfSo, in the draft strategy note from UNDP, (2016-2021) I would have suggest to add a new chapter to invite countries to reduce income inequalities. The reduce of income inequalities is good for health, economy & growth, and reduce violence in the society. Besides, we should notice that countries with low income inequalities like scandnavian countries  have very well noted for women rights. Gender based violence (and other violences) cannot be seen as something independant from income inequalities.The world bank as recently shown that extreme poverty as increased in Africa from 1990 to 2012. The extreme poverty will not be resorbed until income inequalities go down, and should be seen as a tremendous threat for the stability of many countries. The more income inequalities are high, the more you will find extremist groups that will be keen to reduce humain rights.http://www.worldbank.org/en/news/press-release/2015/10/16/africa-gains-…, we can also notice that the defense of social rights are part of United Nations objectives. When the Gini coefficient is over 0,4 in so many countries are we still in environments where social rights are respected ?So, is there any argument that would not recommend to reduce the Gini coefficient in most countries against HIV and consider this as a priority ?I would be pleased to have the views from all of you about this topic.Best reagrds,Bertrand Livinec 

bertrand livinec

Dear Clifton,In addition to my previous post, I would also suggest to add a chapter on racial inequalities that does not seem to appear in the draft.If we have a look to statistics in south Africa, the prevalence rate among white people is very low, and medium for coloured people, but very high for black people. In the United States of America, we will have also a much more higher infection rate among afro-americans than for white people.If the gender inequality was the main reason, black and white women in South Africa should have equivalent infection rates, and this is not the case at all. So, the racial problem for HIV is evidence based.So, I would have suggest to divide the UNDP draft strategy as follow :

  1. Reduce income inequalities (Gini coef below 0,3 ?)
  2. Eliminating racial inequalities
  3. Promoting gender equality and eliminating gender-based violence
  4. Inclusion of key populations and other excluded groups

 Health inequalities have been an important subject for a while. I would like to share this introduction to the Black Report made in the UK in 1980 about health inequalities. As you can see, this report has been ignored by authorities for political reasons. In 2015, we can hope to be back to more rational and honest attitude toward all people discriminated. http://www.ncbi.nlm.nih.gov/pubmed/7118327Best regards,Bertrand Livinec

bertrand livinec

Good morning Clifton, I would like to share this editorial from Alison Katz (2009), a sociologist that worked for WHO. She wrote several papers on AIDS and I share her point of view because she is going straight to the key issues.http://www.socialmedicine.info/socialmedicine/index.php/socialmedicine/article/view/275/549 About income inequality, I also notice that UNDP mentioned it in this strategy note for 2012-2013 :“Gender inequality and income inequality are two of the most powerful and pervasive socio-economic factors that influence HIV epidemics.”https://info.undp.org/global/documents/partnerships/2012-2013_UNDP_Stra… in its strategy 2016-2021 mention for goal number 10 :http://www.unaidsstrategy2021.org/wp-content/uploads/2015/08/UNAIDS-Str… 

  1. Goal 10: Reduce inequality
    • §  Income inequality is linked to higher HIV prevalence; HIV affects excluded and disempowered communities most severely.

Two small lines about income inequality for a report of 69 pages does not seem very ambitious. We can also notice that UNAIDS refers to a study from the IMF dated June 2015, did we have to wait all this time to have such study ? Another recent study about income inequality and HIV among drug users :http://www.ncbi.nlm.nih.gov/pubmed/25875598 Is it necessary to concentrate strategies on groups at risks, when we know that we can reduce the impact of HIV on all groups by changing socio-economic strategies ? It would be probably better to understand why certain groups are more at risk and then change the system (discriminations / socio-economic policies / public health strategies). The bad governance (especially conflicts of interests), including generating income inequality, is making people sick. How many civil wars or serious troubles are due to income inequalities on this planet, with high impact on HIV when women are without any defence ?Prostitution, some people talk about sex workers (an expression that may be discussed), isn't favoured by income inequalities ?Unequal societies are letting many people left behind and are massively producing violence and diseases, and this is a jackpot for major laboratories for which net margins are today at an exceptional level.The international situation shows that many things have to be changed, including among international institutions and the United Nations agencies that should be totally independent from any private interest. We cannot continue with so high income inequalities and with countries that are more and more looking like plutocracies (I refer to Joseph Stiglitz analysis). In a plutocracy there is no public health (talking about social determinants must be avoid, but let's talk about innovation in new drugs !), there is only business in health and communication for the general public to keep them hope. This is key geopolitical point for public health in general, and for HIV in specific.If LGBT discriminations should stop everywhere, it is important to say that these groups do represent a significative percentage of people infected in rich countries. But in poor countries, especially in Africa that concentrate the pandemic, the vast majority of people infected are not LGBT. So the heart of the problem in Africa is not globally about sexual minorities but mainly about poverty and inequality. If UNDP has the same messages for rich and poor countries, il will not work and it will not be fair. I understand the messages from LGBT movements (where the leadership is in the US and Europe) and the influence they try to have in order to reduce discriminations worldwide but in the same time they cannot ignore the specific conditions in Africa and the dramatic income and racial inequalities that remain and impact HIV prevalence.When Barrack Obama spoke about LGBT rights in Addis Abeba in front of african presidents, he was right on human rights but forgot two things. First, homophobia in Africa has been clearly encourage by extreme pentecostal american foundations and this would have been his responsibility to denounce that, he did not. Secondly, the US have encourage economic deregulation (even privatizations in health) that have increased income inequalities and extreme poverty in Africa and this was clearly negative for human and social rights.Now, UNDP is a United Nations agency for development and I think is really focused on the development of poor countries. “UNDP works in more than 170 countries and territories, helping to achieve the eradication of poverty, and the reduction of inequalities and exclusion.”UNDP is perfectly aware about illicit financial flows from Africa which represent tremendous amounts of money, including for very unequal countries and some with high prevalence rate of HIV : http://www.undp.org/content/undp/en/home/blog/2015/4/9/The-political-economy-of-illicit-financial-flows-.htmlI think that the best work that UNDP could make against HIV is to really achieve the eradication of poverty and to reduce income inequalities in poor and middle income countries. This will have a clear impact on HIV in Africa for instance. But we see that the World Bank said recently that number of people in extreme poverty has increased in Africa these recent years, so strategies have to be changed. The gap is there and UNDP has to respond to the main priorities of different countries, African priorities are not European priorities. And this is the reason why i have suggested to have 4 chapters in the UNDP draft strategy 2016-2021 starting with more crucial aspects : income inequality (& poverty), racial discriminations (very linked with social discriminations), gender discriminations (poverty & income inequality do seriously impact gender discriminations especially about violence), and then LGBT & other groups (drug use is also linked with poverty). I hape that I have not let anyone behind.Best regards to all,Bertrand Livinec

bertrand livinec

Dear Clifton, dear all,If we are not using social determinants it means somewhere that HIV infection is an individual question and people might be blamed for that.Because I do not believe that it can be resumed to an individual question (and like most diseases) - we can clearly see strong differences between rate prevalences among different characteristic groups (including social class, minorities, etc...) or between countries - it is necessary to better understand the pandemic through social determinants.In a previous message, I mentioned the name of Michel Foucault, philosopher, whose work has been quite focused on questions related to power and the manner to practice it. What is a good government, or a good institution ? He would say a government or institution that first say the truth.So about all the groups infected or discriminations we should not have moral positions but just try to understand why they are infected and say the truth. The objective is not to discriminate people but to reduce infections.Lets take an example about jails. Is the objective to apply strong punishments for any offence and then to put in jail any person that has committed an offence or to manage to have the minimum of delinquency in the society ? This is two very different ways to govern.If we look at incarceration rates, the United States of America have a very high rate (nearly 700 prisoners for 100,000 hab), and far away from countries like Sweden (only 60 prisoners for 100,000 hab), and even higher than China (165) or Russia (450). Notice that incarceration rate is only 106 in Canada for north america, and so quite the same as in France (100).Even if incarceration rate is much higher in the US, the crime rate is well above that we see in european or canadian societies. So, I would then conclude that there is something not rational and probably due to moral positions, conflicts of interests (market of private jails, market of weapons, etc...) and insufficient work on social determinants.Now there are many studies about the relationship between income inequality and crimes. Like this one from the world bank dated 2002.http://siteresources.worldbank.org/DEC/Resources/Crime%26Inequality.pdfThe main conclusion of this paper is that an increase in income inequality has a significant and robust effect of raising crime rates.” So, the US might (among many other measures) reduce their crimes and therefore their incarceration rate by reducing their income inequalities. It is only a question of political will.And now if we come back to HIV, this is also what should be done, look after each social determinant that may have an impact on the pandemic.On their side, Canadians have done an impressive work in the past on social health determinants, you can observe that they introduce income inequality as the first one.http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.phpSo my suggestion is that the UNDP draft strategy should be the result of a logical approach using meta-analysis of studies about all determinants having a potential impact on HIV (new infections on one side, life of patients on the other side) and then suggest new measures and reforms if necessary. If we can agree about what UNDP has already written in the draft, I believe there are still gaps. The criticism we can make is that we do not see the approach that lead to final recommendations and for the clarity of debates it would better to show the construction of the whole analysis, this is the best way I think to cover the “gaps” and make sure anybody is left behind.I would say that recommendations should not be the result of opinions (I would like that because I am personally concerned or my groups to which I belong...etc...), but the result of a rational public health approach.Therefore, I would have suggested to present the UNDP draft strategy as follow :A. Introduction (how we work)How UNDP build its own recommendations against HIV ? Presentation of the framework or the entire approach.Who is taking part to the draft strategy ? Patients associations, doctors, scientists, epidemiologists, sociologists, economists, public health experts ?B. What is the problem ? (show reality)What is the epidemic situation ? How is it distributed in the population ?Which are the main groups infected ?What are the main differences per region or per country ?C. Why are people infected ? (tell the truth)What is the situation of health promotion ?What are the studies telling about the impact of social health determinants on new infections (Use of the canadian matrix or the WHO matrix from the commission of health determinants) ?Have we isolated key gaps on evidence based ?D. What is the situation of people infected (tell the truth)Are people discriminated ? Who, how and why ?Which support do receive patients ?Are treatments affordable and accessible ? Who is left behind ?What are the studies telling about the impact of social health determinants on patients life (Use of the canadian matrix or the WHO matrix from the commission of health determinants) ?Have we isolated key gaps on evidence based ?E.Recommendations (promote good governance by being rational)Do we know how to take new measures or make structural changes in order to :

  • Reduce the impact of new infections (general population or specific groups)
  • Reduce discriminations
  • Improve treatments access and patients life

 Will our recommendations have other potential benefits for other diseases or for other areas in the society ?How UNDP can help and follow countries in implementing these new recommendations ? NB : when we talk about human rights it is important to make a difference between political & civil rights on one hand and socio-economic rights on the other hand. They are both important and we can have discriminations inside the two domains. We could also talk about environmental rights, cultural rights, etc... Best regards to all,Bertrand Livince

bertrand livinec

Dear All,I would like to share with you this recent study from IMF (22 october, 2015) :http://blog-imfdirect.imf.org/2015/10/22/empowering-women-tackling-inco…"Our study finds that gender inequality is strongly associated with income inequality across time and countries of all income groups, even after controlling for the standard drivers of income inequality, which include financial openness and deepening, technological progress and labor market institutions." This is the reason why I have and many others before (read Alison Katz analysis for example) said that reducing gender inequality without adressing income inequality was a neoliberal diversion. UNAIDS should have highlighted this link many years ago, a precious time has been lost and so many lives.Article writen in 2002 quite remarquable and should be re-read with new data that IMF or others have recently produced (cannot say we did not know) :http://wwwisis.unam.na/hivdocs/katz2002.pdfAs IMF confirms today, income inequality has direct consequences on many other determinants that we know impact HIV pandemic. Shouldn't it be a major pillar against HIV and new infections (access to treatments may also be easier with low income inequality) ?This is something that scandinavian countries have experienced for decenies, because their governments are not too bad in saying the truth to their populations.Best regards to all,Bertrand Livinec

Eco Global • from Panama

Clifton Cortes jefe de Equipo: Género, poblaciones clave y LGBTI y colegas del panel Debo coincidir con la gran mayoría de los participantes a esta consulta virtual  donde se destacada que: “La desigualdad de ingresos está vinculada a una mayor prevalencia del VIH.  El VIH afecta a los excluidos y a las comunidades sin poder; más severamente”En Panamá los esfuerzos desde la sociedad civil en conjunto con los proveedores de servicios de salud y educadores / promotores Pares, se mantiene en vigencia; sobre todo para acercar a las poblaciones claves de trabajadoras sexuales femeninas, hombres que tienen sexo con hombres y personas transgénero para que se involucren en los procesos de detección, atención y seguimiento de los grupos PEMAR frente a la epidemia de VIH.En estos momentos se enfrentan grandes desafíos desde la sociedad civil; como es el de afrontar de manera cohesionada y como grupo de apoyo y abordaje; a los pares de la población PEMAR, los más vulnerables y que viven con el VIH.Se está construyendo un vínculo para respuesta y educación desde los programas establecidos por el PNUD, el Fondo Global, otras agencias cooperantes regionales y las instancias del gobierno nacional junto a los organismos no gubernamentales ONG, representados en la sociedad civil y grupos de base comunitaria; pero el tiempo y la epidemia corren más veloz que la respuesta efectiva.  Esperamos que entre el 2016 y el 2018 se active un frente más sólido, fortalecido y cohesionado de acciones nacionales frente al VIH.Se pueden cerrar lagunas que permitan acciones más directas empoderando a todos los actores con vínculos solidos pero se requiere facilitar respuestas y menos procesos burocráticos.La labor del PNUD será vital para orientar y guiar a las agencias nacionales tomadores de decisión y proveedores de servicios de salud para hacerle frente a la epidemia del VIH y sus secuelas.No debemos olvidar también que vivimos en una sociedad multicultural y multiétnica y que las respuestas no solo vendrán de la atención en salud sino que hay que acceder a los procesos culturales que permitan vías para educar a la población en el tema del VIH sobre todo e los procesos de prevención.Este tipo de Consulta Virtual que ha permitido dejar escrito aportes y recomendaciones son muy válidas y queremos aplaudir su propósito; pues permiten presentar la voz e inquietud y a la vez conocer el know-how de otros actores a nivel regional y global. Itzel Damaris RojasEcoGlobal Una Alianza para el Desarrollo Local / Panamá

bertrand livinec

Dear all, About gender equality, I would like to mention that corruption is one the major barrier for women rights. You can have a look to this two index :

  • first one from Transparency international, you can see that scandinavian countries (Norway, Sweden, Denmark, Finland) are among the best evaluated against corruption :

 https://www.transparency.org/cpi2014/results

  • second one from the world economic forum about the gender gap, and you can also notice that scandinavian countries are at the top :

 http://reports.weforum.org/global-gender-gap-report-2014/rankings/ I shall also say that those countries have among the lowest income inequality. What does UNDP says about corruption (I like this paragraph) : “Corruption also strikes at the heart of democracy by corroding rule of law, democratic institutions and public trust in leaders. For the poor, women and minorities, corruption means even less access to jobs, justice or any fair and equal opportunity.” http://www.undp.org/content/undp/en/home/ourwork/democraticgovernance/f… And unfortunately, Health is a very corrupted sector. To let laboratories (or other private companies that may have an impact on health) funding the civil society or international institutions should not be allowed because it modifies health strategies. If health prevention and promotion of health are weak it is also because of corruption in health. Scandinavian countries are very good in prevention because corruption is low and they know how to use health determinants. So if gender inequality is a goal to reach, we must fight against all conflicts of interests, especially in health. The rise of income inequality is not a question of innovation but a question of corruption and it is a political choice. The famous trickle-down theory of neoliberals should be seen has a communicating strategy to let richest interests corroding rules of laws. Drugs prices for HIV or Hepatitis are too high, this also the result of too many conflicts of interest in health. Too many HIV (the same situation for other diseases) stakeholders are depending on funding from laboratories, this is clearly a problem. Unequal societies do represent a jackpot for laboratories, they do not have any interest to exhort countries reducing their income inequality. The more the civil society is funded by private companies, the less they may require to use social determinants in health but only exhort their governments to spend more and more in medical services. What I have observed is that there is a clear difference in messages from NGOs financially independent and others which received money from laboratories, and unfortunately those which receive a lot of money from private sector are among the most powerful and have the strongest capacity to communicate toward the public. For instance in France, we have a movement called “clean hands in health' that denounce outrageous drugs prices and conflict of interests from many medical experts that are in relationship with laboratories and do influence public health strategies. This is a clear problem of democracy, of public health strategies, of public finance and public trust in leaders. Reducing inequality (income or gender) will also go through a moralisation of business practices in health and for the financial independence of people or institutions that do work on public health strategies. If we wish to have the objectives of zero new infection and zero discrimination for HIV, I believe it would be necessary to have in addition zero conflict of interest. Corruption increase income inequality and consequently increase tensions in the society, and then increase the power of populist, conservative, anti-feminist, fundamentalist or racist movements that will in return increase discriminations. This is what we call a vicious circle. In definitive, discriminated groups that try to be financed by powerful financial interests will let in place the socio-economic system that discriminate them. At a certain time, it might be quite useful to be rational. To claim rights is a good thing, but we all need to understand that rights and obligations are linked. A nation is a group of people that share rights and obligations. An individual is never empowered by himself but always depends on the relationship he has with others, a convivial society requires a good balance in all rights and obligations. In the debate we have (thanks to UNDP), poorest people do not have the capacity to claim their rights in such on-line debates and so we have also the moral obligation to think about all people that do not have the speech. I wish that UNDP will highlight the need to tackle corruption and conflicts of interest in health, worldwide. It is also a root cause of discriminations of all kinds. Public trust is very important. If during the last decencies institutions like IMF, World Bank, WHO and other UN agencies have been so criticised, it is mainly a question of lake of independence from powerful financial interests. All the best to all,Bertrand Livinec

Rachel Morrison • HIV/Aids Programme Officer at UNDP

Eventhough a lot of progress has been made to  shift the focus to supporting key populations , such as MSM, TG and young girls, more needs to be done to target sub populations which can present within these groups, which as a result of other vulnerabilities makes them even more  excluded from accessing key services and increasing their risk of exposure to HIV. So for example, it is clear that young adolescents with no access to youth friendly SRH services are at risk, however,  the added layer of poverty and a culture of transactional and transgenerational sex increases their vulnerability .  Supporting the development of a youth friendly clinic will increase the opprotunity to access SRH but it can do  nothing to address challenges facing a young person in relation to poverty or cultural norms and values. And so the gap in a lot of the existing  programs that are now on offer is that they are looking at addressing only one part of the problem,oftentimes because of the limited resources available for project implementation.The development of a more holistic centre looking at small scale economic enteprise, skills training, career development, self efficacy  and providing SRH would be the more useful investment. There is of course  no easy way to ensure this level of cohesivity in national  programs and projects,  but UNDP can leverage  its role in countries to advocate and support more cross linkages between HIV related programming and other development initiatives. In ensuring project beneficiaries are individuals facing multiple layers of vulnerabilities , only then can we can have the greatest impact on reducing exclusion and ensuring no one is left behind.

Dr. Anil Pratap Singh

Dear friends!I have requested my friends/followers at LinkedIn to contribute with their ideas for this ongoing consultation. You can login to:https://www.linkedin.com/pulse/article/regarding-virtual-consultation-hiv-health-development-singh/Best!!! -Dr. Anil Pratap SinghSecretary & CEO, Global Science Academy (GSA),Satyawanpury, Block Road, BASTIDistrict: BASTI (Uttar Pradesh)Tele-fax No.: +91 5542 247186Mobile No.: +91 9336785696Email: globalaps@rediffmail.comWebsite: gsaindia.org.in

Carol Bangura • Senior Development Officer at Schools Without Borders, Inc.

In order to reduce inequalities and social exclusion that affect HIV and health status, the lack of culturally and linguistically appropriate health service should be addressed. In urban and rural communities in developing countries, basic and health literacy is an underlying issue. It impacts behavior and choices of individuals that are most vulnerable. Having access to health services that meet the cultural and linguistic needs of diverse communities that are inclusive of education, prevention, screening, testing, and care will reduce inequalities that affect HIV and health status. The standard of care in underserved communities will improve and result in reductions in health disparities.Carol Bangura

Barbara Rogers • from United Kingdom

I am saddened that HIV would be considered in relation to women with nothing but token references to sexual and reproductive health. I note that you have worked with UNFPA but only on an HIV programme! Until women have full access to good pregnancy and maternity care, and a real choice about when or whether to have children, the reference to including women will be merely tokenist. You include gender-based violence (yes, that's important) but exclude any discussion of integrating HIV with a real campaign to promote reproductive health and choice. Shame on you.   I suggest you sit down with UNFPA and WHO, and put your money where your mouth is about supporting women's health. UNFPA is very poorly funded compared to other agencies and is expected to do all of this on its own.

Ernest Rukangira (not verified)

The impact of AIDS on individuals, families and communities, particularly in Africa, is devastating. In some settings, AIDS has been reported to be a contributor to   the reduction of quality of health and  the increase of poverty at family level.HIV therapies are complex, expensive and extremely demanding on the patient. The human costs for people living with HIV are high. Many cannot work, and others can still suffer ill-informed prejudice and discrimination. Children with HIV have an especially difficult time – as well as the effects on their own health they may face losing one or both of their parents prematurely.Preventing poor sexual health depends on everyone having the information, skills and services that they need. Skilled professionals in health, education, social care and voluntary services play vital roles in HIV and STI prevention and raise awareness of sexual health and help people to get the information and services they need.Some Governments tend to deny the problem of HIV/IAID for various reasons:  economic, social and cultural. Successful HIV prevention is about enabling individuals, couples and communities to be open about sexuality matters, including debate and education about  sexual behaviour and cultural norms associated with it. Stigma and discrimination towards People Living With HIV (PLWH) and vulnerable groups present major barriers to eradicate the epidemic.Cultural concepts and beliefs, discrimination and stigma promote the denial of HIV/AIDS and contribute to hiding the disease which can hamper access to information, services, care and support.Fear of stigma and discrimination can discourage people from getting tested and, when they know they have HIV, from disclosing their status or accessing treatment and care.HIV/AID could have been eradicated if there were no stigma and discrimination in many countries. The public and HIV/AID patients should be educated to understand that HIV/AIs is a disease like many other diseases.The impact of poverty on someone living with HIV is particularly detrimental. Poverty can worsen an HIV positive person’s health, as they are unable to afford the nutritional food, appropriate housing or heating they need to remain well when living with a compromised immune system.It can also make adherence to treatment more difficult - when people struggle to provide the basics in life for their families, looking after themselves and taking their treatment become a lower priority.This is fundamental to achieving success in other areas; knowledge is essential to prevention and testing, to planning and delivering health, social care and support services and to ending the stigma and discrimination that people living with HIV still face.In Europe and North America, the epidemic continues to disproportionately affect minority ethnic communities in urban areasIn developed and developing countries, poverty affect  marginalised groups such as  people with no education, landless people, ethnic minorities, ex-offenders, drug misusers,  trafficked women, sex workers, orphans, single mothers, etc. These groups live in poor urban areas mainly urban slums.There is an also new phenomenon of sex corruption in urban areas especially in relation to access to employment, health, education, government positions and other services. Vulnerable and neglected groups, mainly the poor, women and girls,  orphans and vulnerable children, and the illiterate are  the ones trapped by their cultural believes are the ones who are left behind because they have no support and encouragement to take the steps to  be tested HIV/AIDS and do not know what to in cased they are tested positive. Some groups need targeted sexual health information and HIV/STI prevention because they are at higher risk, are particularly vulnerable or have particular access requirements. These include stigma, discrimination, poverty and social exclusion, language, access problems, low awareness and concerns about confidentiality. Other vulnerable, minority and neglected groups include: 

  • Migrants ,black and minority ethnic groups in large cities of developed countries
  • Trafficked women and girls
  • Women affected  by or at risk of FGM
  • Gay and bisexual men
  • injecting drug misusers
  • Sex workers
  • People in prisons and youth offending establishments

 These include stigma, discrimination, poverty and social exclusion, language, access problems, low awareness and concerns about confidentiality. We know that women and men face different risks and barriers in relation to the AIDS epidemic and in accessing services. Gender inequalities mean that women and girls cannot always decide if, when, how and with whom they have sex, or when to access basic services.  Multiple partners, women’s roles, women‘s economic status can significantly increase the risks of HIV infection.In Africa, there are little or no protections against discrimination in employment, housing, and other areas based on sexual orientation and gender identity.The potential consequences – job loss, lack of access to healthcare, homelessness – can push individuals into risky behaviours that greatly increase their HIV risk and severely limit their ability to obtain adequate care once infected.The solutions to tackle HIV/AIDS should not be only women being able to refuse sex, and men using condoms and making condoms available to everyone. It is all about the level of education, poverty, cultural barriers and irresponsible behaviour and attitudes toward sex. The donor community and government should focus on these elements.Female genital mutilationFemale genital mutilation (FGM) – sometimes known as female circumcision – should be made illegal, unacceptable, and a violation of the human rights of the young girls (usually aged between four and ten) who suffer it.All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons should be made illegal.Wherever there are people from cultures with a tradition of FGM there is a need to raise the awareness and skills of health, education and social services professionals. Local services need to support community initiatives aimed at stopping this practice.Health professionals’ contribution to the eradication of female genital mutilation (FGM) needs to include appropriate child protection measures (as the practice is traditionally performed on girls between the ages of 4 and 10). UNDP and partners’ role:More research needs to be carried to generate detailed knowledge of the epidemic – including the drivers, risks, trends and connections with other health conditions. Research findings should be made available in local languages  in the countries, communities and families affectedProvide the capacity building to Governments in collecting reliable data and evidence about the status of HIV/AIDS and services. Better collection, monitoring and use of data are needed to improve outcomes. The data should  be regularly published to warn to the public  about the threats caused by the disease and to learn about what is being done to tackle the problem. Collate available evidence, assess what works and make clear recommendations on future approaches.UNDP and its partners should promote measures and opportunities to reduce drug prices and increase access to more affordable and sustainable treatment over the long term.Promoting strong national political leadership: This has demonstrated to be an effective strategy to reduce the level of HIV/AIDS. Case studies and measures of success should be documented and disseminated to enable the exchange of experience about  HIV prevention programmes, treatment, care and support.UNDP should help the Governments to develop national strategies and action plans as UNDP has done so in other areas such as the environment. This will help the Governments to effectively allocate resources to most people at risk or affected, define the indicators and outcomes to be achieved in short, medium and long term. Supporting training of the media and social movements about HIV/AIDs reporting, women’s rights, counselling and advocacy is essential. Ensure Poverty Reduction Strategy Papers and other national development plans should reflect AIDS plans in relation to neglected targeted groups. Ensure equitable access to safe, affordable, essential drugs and commodities for all in need by working with drug manufacturers and combating fake and ineffective drugs Promoting the implementation of education programmes that help young people, both those in and out of school, to have safe and healthy sexual relationships, free from stereotyping, violence and exploitation Work in partnership with Food Services and Agencies to fight against malnutrition, hunger and fighting against food insecurity. Promote Research on local and neglected foods that contribute to increasing the human  immune system. Agriculture policies, programmes and plans should integrate the outcomes in relation to fighting HIV/AIDS. Ensure that all staff working in sexual health and HIV are properly trained and supported so they can deliver respectful and non-discriminatory care Ensure there is positive and accurate coverage about HIV in the media, with the focus on evidence, improving information on behaviour and attitudes, need assessment for people affected by HIV/AID. Training and education is provided for frontline staff in key public services, such as health, social care, police and education, so that people living with HIV no longer experience stigma and discrimination when accessing such services Supporting the development and implementation of community programmes reaching priority most-at-risk populations (including men who have sex with men, young people, refugees, domestic workers). Promote programmes that eradicate HIV-related stigma and discrimination and ensure that people living with HIV are aware of and access their rights. Support the Prison Services in preventing the spread of HIV/AIDSs in prison, offering information and treatment of substance misusers. In targeting these groups commissioners and providers need to work together to overcome the common barriers to accessing information and prevention services.There is a range of service and health promotion initiatives that can help, including staff training on discrimination, outreach health promotion and targeting hard to reach or stigmatised groups.  Everyone providing sexual health information and HIV prevention needs better access to up to date information. In urban areas, exploit the wide range of media available for providing information on sexual health, especially in urban areas: social media, TV and Radio. Undertake research and recognise relevant factors, such as alcohol use, drug misuse, homelessness, sex related corruption, social exclusion and life in urban slums Support the Civil society working with LGBT to make people more aware of the benefits of testing and of where testing, treatment and care are available. Increase antenatal HIV testing to reduce mother-to-infant HIV infections. Address the causes that heighten the vulnerability of women and girls to trafficking and HIV Identify service delivery and operational lessons from the work that has been done, and any factors that help them to be successful. Organise public awareness campaigns  aimed at breaking the culture of silence on  GBV and HIV/AIDs while raising awareness of gender inequality, human rights, and the importance of women’s participation in public life. Provide funding to Community Based Organisations (CBOs) which directly work or HIV/AID patients at community level. Many CBOs are small, under-funded groups formed in response to the essential needs of their families and members’ communities. Make mandatory to Health Services to report annually on numbers of people with HIV and AIDS and review what services are in place or planned.National HIV/AIDS Strategy to explicitly include gay and bisexual men and transgender people in its plan to reduce infections, increase access to care, and reduce disparitiesUndertake the review of the implementation of the Abuja Declaration on HIV/AIDS, Tuberculosis, and Other Related Infectious Disease: http://www.un.org/ga/aids/pdf/abuja_declaration.pdfResearch priorities

  • What are the needs of  minority and  targeted groups ( mentioned above)
  • What is the impact of ethnicity, culture, deprivation, and other socio-economic factors in sexual health
  • The impact of costs of treatment, HIV drug affordability and completion of treatment
  • Why some groups do not access services or not engaged in sexual and reproductive health interventions
  • What are available formal and informal routes for women and girls to seek redress and report the risks to  gBV and HIV/AIDs and how these routes are effective or ineffective in helping women and girls?
  • What are the barriers women and girls are facing in asserting their rights and seeking protection against GBV and HIV/AIDs?
  • What support is needed to empower and assist women to enable them to assert their rights
  •  What appropriate and effective service delivery arrangements that have contributed to the success in fighting HIV/AIDs
  •  What types of governance structures, legal, institutional mechanisms and practices guide successful  GBV and HIV/AIDs Service Delivery management at the community level?
  •  What HIV/AIDs service delivery models that can be replicated in different countries taking into account the country’s social, cultural, economic, legal and political context?

  Ernest RukangiraConserve Africa Foundation1st Floor, 57 The Market SquareLondon N9 0TZWeb: http://www.conserveafrica.org.uk/

bertrand livinec

Dear Ernest, About Female Genital Mutilation, there is some literature about the link with HIV, although probably minor. Hepatitis B and C viruses are more resistant and virulent than HIV viruses and might be at higher risk with FGM.https://www.giz.de/fachexpertise/downloads/giz2011-en-fgm-hiv.pdf I would not say it is a major risk of transmission for HIV but exists, and it should be clearly abandoned as soon as possible for many other adverse effects (the impact on neonatal and maternal death is proved) than have been well documented. Therefore, you are perfectly right to mention this problem, and not only for medical reasons. If you look at UNICEF or countries literature about FMG we can notice that education for all (including of course for girls) is certainly the best determinant to reduce the prevalence. Health professionals can as you mentioned a role in prevention, and never of course practice FMG, but education for all is probably the key driver. In some countries, including Egypt where it started, FGM practice is really going down as soon as girls education rate is going up. It could possible to eradicate FGM in two generations by the mass education and of course inter-sectorial prevention. Sorry to mention still income inequality. But when I did investigate on FGM I suggested to reduce income inequality in order to facilitate the access to school for many families and therefore to increase the impact of education determinant.One again, the use of social determinants in all health policies should be a good principle that is not yet adopted by all health institutions, Ministries of health, or even the civil society. This is a big gap. NB : I did also read with interest the message from Barbara Rogers. Family Planing was an objective of the Alma Ata declaration (1978), but I agree that it has not been followed, no more than many other principles presented in this declaration. Family Planing would be easier if all girls may already have the opportunity to go to school and this questioned about the priorities given to development, especially from international financial backers. Family planing is clearly a key driver for development and should be consider as a human right. Is there any evidence that family planing might play a positive role in reducing HIV pandemic and then would be integrated in all HIV strategies ?http://www.euro.who.int/__data/assets/pdf_file/0009/113877/E93944.pdfBe… regards,Bertrand  

Ernest Rukangira (not verified)

Dear All,Thank you very much for your excellent contributions and knowledge exchange about this important topic. In addition to my contribution, to illustrate the problem of GBV, I have attached a research proposal about  “Research, capacity building and awareness raisingin responding to GBV: Exploring the level of efficiency and effectiveness of Gender-Based Domestic Violence Service Delivery in South Sudan.” I understand  that this is not a forum for fundraising. However, if the Moderator allows, I would very much appreciate if any funder could support the attached  proposal. Yours sincerely Ernest =--=-=Ernest RukangiraConserve Africa Foundation1st Floor, 57 The Market SquareLondon N9 0TZTel/Fax: +44(0)2088036161E-mail: ernest.rukangira@conserveafrica.org.ukWeb: http://www.conserveafrica.org.uk/

Brice Millogo • Conseiller VIH at UNDP

Nous pouvons mentionner en préalable que la « Note de stratégie VIH, Santé et Développement » développée par le PNUD pour la période 2012 – 2013 donne beaucoup d’éléments qui constituent des enjeux toujours actuels et sur lesquels la prochaine stratégie 2016 – 2021 pourrait continuer à s’investir à travers les trois axes retenus. Néanmoins les points ci-dessous nous semblent importants à considérer.       

  1. Réduction des inégalités et de l’exclusion sociale 
    • Les populations clés, les jeunes de 15 – 24 ans, les adolescents et les enfants demeurent les « laissés pour compte » de la réponse comme le montrent les prévalences au niveau mondial qui ont très peu baissé sinon en hausse dans certaines populations[1]. En raison de plusieurs facteurs : défaut de pleine jouissance de leurs droits humains, discrimination et stigmatisation persistantes, environnement socioculturel hostile, insuffisance dans la prise en compte dans les stratégies de riposte et/ou inadaptation des stratégies, très peu de communication/information pertinente sur les questions auxquelles ils sont confrontés : comment vivre avec le VIH, la sexualité et VIH… au moment où il est constaté une précocité des relations sexuelles ;
    • Renforcer l’implication de ces cibles et/ou des spécialistes en la matière dans les cadres d’orientation, de planification et programmatique de la réponse au VIH et des services de santé;
    • Le PNUD peut aider aussi les pays dans la production de données fiables, à établir des cartographies des populations clés et/ou vulnérables pour un ciblage plus efficient des interventions
    • Les résultats des interventions développées dans la prise en compte du VIH, du genre et du Sida dans les processus d’Evaluation de l’impact environnemental pourraient être valablement considérés à ce niveau

[1] Rapport mondial ONUSIDA 2013, «le nombre d’enfants nouvellement infectés a baissé de seulement 35 % par rapport à 2009 », « La prévalence du VIH chez cette population semble avoir augmenté légèrement à l’échelle mondiale pour atteindre un niveau très élevé ces dernières années ». 

Rodrigo Schoeller de Moraes

Esteemed colleaguesI believe that the three topics proposed on the Discussions (26 Oct – 10 Nov 2015) are entwined. They interconnect with themselves specially regarding the necessity/feeling of belonging (1 topic); to the cooperation networks implementation methods (2 topic); to proportional impacts on the three dimensions of sustainability (economic, social, environmental) (3 topic).This is due to the need for a multidisciplinary and intersectorial approach so as to obtain integral healthcare and proposals effectiveness regarding HIV.Furthermore, it seems indispensable to foster planning and management actions (on behalf of those who act and/or intervene on the covered systems), to practice the proposals, adapting them to local reality.Regarding UNDP, we believe that the program may promote this convergence, notably with the Sustainable Development Goals (SDGs) and HABITAT III directives in sight.I emphasize that development (within any scope, e.g. Goal 3: Healthcare), so as to generate effectiveness, sustainability and peace (internal and external) must qualify as Harmonic Sustainable Development (HSD).In this context, we submit the same suggestion for the three proposed topics at Discussions (26 Oct – 10 Nov).These suggestions are aligned with the document: Systemic Planning and Management Action SDG and Habitat III 09-11-15 (attached and in http://pgsistemicos.blogspot.com.br/2015/09/apresentacao-criterios-e-ma… - English version below - Please use the Slide Show mode for PowerPoint slides) and with our manifestations on other discussion environment, as follow: Participation in the Urban Dialogues of Habitat III (https://www.habitat3.org/the-new-urban-agenda/summaries): Esteemed Colleagues: In the Urban Dialogues we realize that there is a convergence with regard to WHAT TO DO.We believe it is very important to establish HOW TO DO. In other words, how to implement in practice the proposed.To this aim, the methodology/action of Systemic Planning and Management (SPM) was created. We believe that it can contribute in some way.As mentioned in the previous manifestation, this method allows, from the focus priority chosen and emphasizing the family context, vision, and resource integration, multidisciplinary and cross-disciplinary (and between institutions). Focus priority can be established, for example, in the Sustainable Development Goals (SDGs), in the thematic topics for the New Urban Agenda (social cohesion and equity, urban frameworks, spatial development, urban economy and urban ecology and environment), and, more specifically, in a flooding, in the construction of a hydroelectric plant, in the health of vulnerable populations, (indigenous population, homeless people, people affected by ecological catastrophes), in the improvement in the quality of life of the population of certain slum and etc. Thus, one can establish what to do, and who, where and when / why and how to map and integrate all these components. Therefore, it is important to be perceived a common mission, to be implemented with the assistance of the physiological, psychological (safety, belonging and self-esteem) and self-fulfillment, generating commensurate impacts on the three pillars of sustainability (economic, social - health, education, citizenship and security - and the environment) and through cooperation networks. Thus, public effects are produced by adding value to sustainable activities.        This common mission, envisioned as public purpose, requires and favours the formation of cooperation networks for systemic action, allowing the integration of the three sectors (public, private and civil society) and the whole community. This context favors democracy, participatory and representative, providing Harmonic and Sustainable Development (HDS), the consciousness of unity and survival of all living beings.Increasingly, it requires the cooperation of every part. However, sometimes, when making planning and management of public policy, some people forget the importance of integration, too, with the Justice System. In case of ineffectiveness of public policy (often due to a linear actuation - not realizing the interconnections), the Justice System undoubtedly will intervene, directly affecting the course of development that we want (something that can be evidenced by example, the "judicialization of health"). So the System of Justice should participate in the cooperation network.The Systemic Planning and Management action has achieved many positive results. Therefore, we are building, with the National Confederation of Municipalities, the document: Systemic Planning and Management action focusing on Sustainable Development Goals (SDGs) and HABITAT III. HOW implement the SDGs in the local community and in the context of the HABITAT III. Moreover, Starting on September 30, 2015, we will be promoting the implementation of the action of Systemic Planning and Management (SPM) in all municipalities of Brazil, with the National Confederation of Municipalities.We believe that this document (Systemic Planning and Management action focusing on Sustainable Development Goals and HABITAT III) can contribute to implementation of SDGs and for the preparation of New Urban agenda. The document will be available at the following address: pgsistemicos.blogspot.com.br and rodrigoschoeller.blogspot.com.br, in early September (including an English version). OBSERVATION: Currently the name of this document is: Presentation Criteria and Convergence Matrix for the Systemic Planning and Management Action (SPM) focusing on the Sustainable Development Goals (SDGs) and Habitat III: HOW TO cooperate on implementing and adapting  the SDGs and Habitat III directives to local reality. (updated version on 11-09-15) (versions in Portuguese and English available at: http://pgsistemicos.blogspot.com.br/2015/09/apresentacao-criterios-e-ma…  and attached).        Further information can be obtained in the following materials - at the same address and: 1- What development do we want? - (an English version can be found on the link)quedesenvolvimentoqueremos.webnode.com/news/que-desenvolvimento-queremos-/2- Lecture Values, Systemic Planning, and Management and Public Ministry (English version)http://rodrigoschoeller.blogspot.com.br/2010/10/pgs-lecture-values-syst…     +3 - La Gestion and PGS (Spanish version)http://rodrigoschoeller.blogspot.com.br/2010/10/pgs-la-gestion-e-pgs_26…+4- Primer Systemic Planning and Management Action focusing on Health, 2015 version (in Portuguese). Further information (including guidelines for implementation) are on the Primer for PGS Action focusing on health:http://pgsistemicos.blogspot.com.br/2015/08/acao-de-planejamento-e-de-g… hope that the documents, which are public domain, can contribute in some way.Rodrigo Schoeller de Moraes,Public Prosecutor,Manager Strategic Projects of the Public Prosecutors Office/Public Ministry. E-mail: rsmoraes@mprs.mp.br     and rsmoraes@mp.rs.gov.brwww.rodrigoschoeller.blogspot.com.br Phones:                         + 55 51 9628-4254                      + 55 51 3295-1050     

Fathin Faridah • from Indonesia

Dear All,I may have an opinion for this discussion.In Indonesia, prevention and treatment of HIV / AIDS there are already a  legal regulations of the Ministry of Health (Minister Regulation No. 21 of 2013). Some of the things that became evaluation of prevention and control of HIV / AIDS are:1. Programs that have not been thoroughly integrated in because of the vast Indonesian territory and social conditions are very complex and diverse.2. Funds are still low, both for adequate care as well as for promotion or prevention.3. Stigma against people living with HIV / AIDS, particularly LGBTI groups in society. Some strategies may be applied in handling the issue of HIV:1. Integrating existing systems or make grooves prevention and treatment that can be applied in various areas, including remote areas. 2. Growing participation of the community, starting from academia. This can be done with the distribution, both through the dissemination of scientific and other media to classes and college.3. Equality can be done through access to social security, as in Indonesia, Universal Coverage newly implemented in 2014. The establishment of any pact related to LGBTI would be a serious controversy in Indonesian society. Thus, the best way is through equality in access to social security services, so that the group affected by HIV can get the service they deserve.

Rachel Albone (not verified)

I welcome the priority of the Inclusion of key populations and other excluded  groups in the UNDP strategy note. People aged 50 and over are consistently left behind in the HIV response and lack equitable access to HIV and broader health services and support. UNAIDS has recognised that responding to the needs of people aged 50 and over has been a significant gap in the response. Epidemic monitoring and data collection has tended to focus on people aged 15-49, excluding people who fall outside this age bracket. As a result very few national or regional strategies and responses have included people aged 50 and over. The work undertaken by UNAIDS over recent years to start to close this data gap and to highlight and address the challenges faced by people living with HIV in their older age in ‘HIV and Aging: a special supplement to the UNAIDS report on the global AIDS epidemic 2013’ and ‘The Gap Report’ has marked a crucial step forwards. The adoption of the Sustainable Development Goals also provides a key opportunity to address the needs of people across the lifecourse, including in older age, with a global goal on health to ‘Ensure healthy lives and promote well-being for all at all ages’. HIV and Ageing 

  • HIV has pronounced impacts on people in older age but they are largely unrecognised and little understood
  • There is a significant and increasing number of people aged 50 and over living with HIV:
  1. 5.5 million people aged 50 and over are living with HIV globally[i], up from 4.2 million in 2014[ii]
  2. Estimate that 9 million people 50 and over will be living with HIV in sub-Saharan Africa by 2040[iii]
  3. 120,000 people aged 50 and over acquire HIV each year[iv]
  • Millions of older people are caring for family members affected by HIV. UNICEF data shows grandparents care for 40-60% of children orphaned as a result of AIDS in east and southern Africa.[v] The World Bank made similar findings - 81% of double orphans in Zimbabwe[vi]

 People in older age, whether at risk of infection, living with HIV or in their role as carers, must be included in the HIV response. In line with international targets, all people, irrespective of age, must be reached with services that achieve:

  1. a reduction in new infections
  2. increased access to testing and ART, resulting in viral suppression
  3. zero discrimination
  4. the mitigation of the impact of HIV on their psychosocial and socio-economic wellbeing

 I also welcome the priority of Promoting gender equality and eliminating gender-based violence in the UNDP strategy note. Women in older age experience multiple and intersecting forms of discrimination. Gender-based and other inequality can accumulate over a life time and be exacerbated in older age. This can have devastating effects for women in older age unless specifically addressed.  Women living with HIV in older age face discrimination on the basis of their age, sex, HIV status and level of income security. http://www.helpage.org/what-we-do/hiv-and-aids/age-sex-and-hiv-older-womens-stories/ With violence against women recognised as a key factor influencing women’s health it is crucial that the current gaps in understanding of when and how women experience violence across the lifecourse are filled. For example, current data tools and surveys that address violence against women are restricted to women between the ages of 15 and 49 meaning there is limited understanding of violence against women in older age. Sexual and reproductive health and rights is another area where women in older age are frequently neglected because of a focus on women of reproductive age, yet SRHR needs remain throughout a woman’s lifecourse.  [i] UNAIDS 2015 UNAIDS 2016-2021 Strategy: On the fast track to end AIDS[ii] UNAIDS 2014 The Gap Report[iii] Jan AC Hontelez, Sake J de Vlas, Rob Baltussen, Marie-Louise Newell, Roel Bakker, Frank Tanser, Mark Lurie, and Till Bärnighausen. The impact of antiretroviral therapy on the age composition of the HIV epidemic in sub-Saharan Africa. AIDS 2012. in press[iv] See iivUNICEF, State of the world’s children 2007: women and children, the double dividend of gender equality[vi] Beegle K et al, Orphanhood and the Living Arrangements of Children in Sub-Saharan Africa 2009    

Kingsley (not verified)

The subject of inequalities and social exclusion is such an important one. Our current case study find some key challenges in the access of care especially of the key populations. One of the great limitations of PLHIV is their access to social support and empowerment programmes. The recommendations of most interviewed was about gaining some economic indepence as the majority have lost their jobs due to one, their condition as PLHIV and also as Key population. The call for some form of entrepreneural support or startup capitals would go along way in ensuring their sustainable access to the needed care. I don't know if that is out the mandate of UNDP as I find assisting persons in that light establishing their economic freedom would be key to addressing their inequalities and social exclusion most especially for person in the economically challenged sub-saharan Africa where "poorman has no friend".

Kingsley (not verified)

The subject of inequalities and social exclusion is such an important one. Our current case study find some key challenges in the access of care especially of the key populations. One of the great limitations of PLHIV is their access to social support and empowerment programmes. The recommendations of most interviewed was about gaining some economic indepence as the majority have lost their jobs due to one, their condition as PLHIV and also as Key population. The call for some form of entrepreneural support or startup capitals would go along way in ensuring their sustainable access to the needed care. I don't know if that is out the mandate of UNDP as I find assisting persons in that light establishing their economic freedom would be key to addressing their inequalities and social exclusion most especially for person in the economically challenged sub-saharan Africa where "poorman has no friend".

Kingsley (not verified)

The subject of inequalities and social exclusion is such an important one. Our current case study find some key challenges in the access of care especially of the key populations. One of the great limitations of PLHIV is their access to social support and empowerment programmes. The recommendations of most interviewed was about gaining some economic indepence as the majority have lost their jobs due to one, their condition as PLHIV and also as Key population. The call for some form of entrepreneural support or startup capitals would go along way in ensuring their sustainable access to the needed care. I don't know if that is out the mandate of UNDP as I find assisting persons in that light establishing their economic freedom would be key to addressing their inequalities and social exclusion most especially for person in the economically challenged sub-saharan Africa where "poorman has no friend".

Senamede Prosper COMLA • from Togo

Bonjour,Le thème "Réduire les inégalités et l'exclusion sociale qui affecte le VIH et l'état de santé"  semble à mon avis répondre aux différentes questions déjà posées. En ce sens que si aujourd'hui on met plus l'accent sur les déterminants sociaux de la santé, l'on aura corriger ce qui est à la traine. Sur un plan particulier qui se fait voir aujourd'hui, la question des populations clés est à la page sans oublier les lois en matoère de la stigmatisation et de discrimnation. Une autre chose sur laquelle il faut réfléchir est le manque de recherches fiables et particulièrement de données à base communautaire. En prenant en compte ces préoccupations et en cherchant leurs origines, je pense que plusieurs possibilités se présenteront pour combler ces lacunes. Quant-à la contribution du PNUD,  elle est toujours nécessaire en terme d'accompagnement et de promotion de nouvelles orientations suites aux recherches effectuées. 

rhon reynolds (not verified)

This is one of UNDP's strenght and comparative advantage in the fight agaist HIV. I think this sectioned could be strengthened with the specific inclusion of men and boys in combatting gender inequality. Specifically the strategy should detail how UNDP will  work to involve men and boys in programmes to stop gender-based violence. Men need support in recognising and overcoming the ways that traditional norms of masculinity place themselves and their partners at risk. While we agree that violence and the criminalisation of key populations make them increasingly vulnerable to HIV, I would have liked to have seen the specific mention of how the application of criminal laws against people living with HIV for non-disclosure, exposure and transmission being addressed. The section that refers to the inclusion of key populations and other excluded groups fails to mention that key populations are people living with HIV, this section would be bolstered by a specific mention of how UNDP would engage PLHIV networks, CSOs in upholding and defending rights of KP.

Priya Kanayson (not verified)

The NCD alliance supports Priority 1.1, to promote gender equality and eliminate gender-based violence, as an important component of this new strategy. The need for gender-sensitive and responsive health systems is particularly important in developing countries, where many women are unable to seek care owing to the lack of female caregivers, stigma, social and cultural norms. Lack of access to and availability of quality, affordable essential medicines, vaccines, and technologies further exacerbates the problem.  Women and children in LMICs often bear a triple burden of poor health related to reproductive and maternal health, communicable diseases, and non-communicable diseases. Increasing exposure to NCD risk factors affects not only women’s health, but also increases the vulnerability of future generations to ill-health. For example, excessive consumption of alcohol, a behaviour that often develops in adolescence and a leading risk factor for NCDs, is also a factor in violence against women and girls, which can manifest in health issues such as HIV and other chronic conditions. Moreover, alcohol has been identified as a leading risk factor for death and disability globally, accounting for 3.8% of death and 4.6% of DALYs lost in 2004 alone.Universal health coverage is a means to reducing inequality and social exclusion as it relates to health systems and services, as it focuses greater attention on coverage of quality services, health equity, and financial risk protection. 

Josefina Valencia Toledano (not verified)

By making a count of the groups who have faced bigger exclusion in the response around HIV, lesbians and bisexual women are one of the most excluded. This situation responds to various reasons related to discrimination and misogyny. Prejudices about sexuality between women, have come to generate the false belief that sex between women is not considered as such and therefore is not seen as an activity with potential risks for HIV transmission. However, the diversity of sexual practices among these populations shows otherwise, as well as the multiple ways to have sex between women, identity is a definition that does not necessarily correspond nor should corresponder to sexual practices; i.e. some lesbians and bisexuals for different reasons and at different times of their life cycle, have sex with men. Closed and biased conceptions about the practices of these women has caused: lack of research and information about the level of risk . There is not enough biomedical information; diagnostics; or safety protocols to reduce risks.  In any case, lesbians and bisexuals are ignored and ignore the possible consequences of having unprotected sex, or the consequences of not attending regular medical reviews. All of this seriously impacts the health of lesbian and bisexual women, because the lack of information  increases the risk and vulnerability. Moreover, many of the women attending health services that reveal their sexual orientation, far from receiving care related to the specific needs of their sexuality, usually face discrimination or do not receive timely and adequate information, which often generates that lesbians do not attend regular consultation to take timely diagnosis on sexual health care. Al hacer un recuento de las poblaciones que han enfrentado mayor exclusión en las acciones de respuesta en torno al VIH se encuentran las lesbianas y las mujeres bisexuales. Dicha situación responde a diversos motivos vinculados a la discriminación  y la misoginia. Los prejuicios  sobre la sexualidad entre mujeres, han llegado a generar la falsa creencia de que el sexo entre mujeres no es considerado como tal y por lo tanto no se concibe como una actividad con potenciales riesgos para la transmisión del VIH. Sin embargo, la diversidad de prácticas sexuales entre estas poblaciones muestra lo contrario, pues además de las múltiples manifestaciones que tiene el sexo entre mujeres, la identidad es una definición que no necesariamente corresponde -ni tendría que corresponder- a las prácticas sexuales; es decir las lesbianas y las bisexuales por diversas razones y en distintos momentos de su ciclo vital, tienen relaciones sexuales con hombres. Las concepciones cerradas y sesgadas sobre las prácticas de estas mujeres ha provocado que no se desarrolle suficiente investigación, ni se sistematice información en torno al nivel de riesgo que existe. No hay suficiente información biomédica; generación de diagnósticos sobre la materia; ni protocolos de seguridad para reducir los riesgos. En todo caso, se omiten e ignoran las posibles consecuencias de tener prácticas sexuales sin protección o las consecuencias de no asistir a consultas de revisión regulares. Todo lo anterior  impacta seriamente la salud de las lesbianas y mujeres bisexuales, pues la falta de información y difusión de conocimientos incrementa el riesgo y la vulnerabilidad  y deriva. Por otro lado, muchas de las mujeres que acuden a servicios de salud y revelan su orientación sexual lejos de recibir una atención que atienda las necesidades específicas que de su sexualidad derivan, enfrentan discriminación o no reciben información oportuna, ni adecuada, lo que con frecuencia genera que las lesbianas no acudan a consultas regulares que permitan tener diagnósticos oportunos en materia de atención a la salud sexual. Finalmente no debemos ignorar que por diversas razones, entre ellas la violencia hacia las mujeres, el VIH ha incrementado su incidencia en ellas y que por esta razón el tema en cuestión debe estar presente en las investigaciones y acciones de respuesta y prevención del VIH.