聯合國表示，不平等正在阻礙愛滋病大流行的終結
資料來源：達.累斯.薩拉姆/日內瓦，2022 年 11 月 29 日/新聞稿/世衛組織 / 財團法人台灣紅絲帶基金會編譯
——聯合國在世界愛滋病日之前的分析顯示不平等正在阻礙愛滋病的終結。 按照目前的趨勢，世界將無法實現議定的全球愛滋病防治目標。 但聯合國愛滋病規劃署的新報告《危險的不平等》顯示，採取緊急行動解決不平等問題可以使愛滋病防治工作走上正軌。
聯合國愛滋病規劃署今年早些時候指出，愛滋病應對工作正處於危險之中——世界許多地方的新感染病例不斷增加，死亡人數不斷增加。 現在，聯合國愛滋病規劃署的一份新報告表明，不平等是根本原因。 它展示了世界領導人如何解決這些不平等問題，並呼籲他們勇敢地遵循證據所揭示的內容。
危險的不平等揭示了性別不平等、重點人群面臨的不平等以及兒童和成人之間的不平等對愛滋病防治工作的影響。 它闡明了日益惡化的財務約束如何使解決這些不平等現象變得更加困難。
該報告顯示了性別不平等和有害的性別規範如何阻礙愛滋病大流行的結束。
「世界將無法在強化父權制的同時戰勝愛滋病」，聯合國愛滋病規劃署執行主任 Winnie Byanyima 說。「我們需要解決女性面臨的交叉不平等問題。 在愛滋病毒負擔高的地區，遭受親密伴侶暴力的婦女感染愛滋病毒的機率要高出 50%。 從 2015 年到 2021 年，在 33 個國家/地區中，只有 41% 的 15-24 歲已婚女性可以就性健康做出自己的決定。終結愛滋病、實現可持續發展目標以及確保健康、權利和共享繁榮的唯一有效路線圖是女權主義路線圖。婦女權利組織和運動已經站在前線開展這項大膽的工作。領導者需要支持他們並向他們學習」。
性別不平等對女性感染愛滋病毒風險的影響在撒哈拉以南非洲尤為明顯，2021 年女性佔新增愛滋病毒感染者的 63%。
在撒哈拉以南非洲，青春期女孩和年輕女性（15 至 24 歲）感染愛滋病毒的可能性是同年齡組青春期男孩和年輕男性的三倍。 驅動因素是權力 (power)。一項研究顯示，讓女孩在完成中學教育之前能夠繼續上學，可將她們感染愛滋病毒的可能性降低多達 50%。 當透過一系列賦權支持強化這一點時，女孩的風險會進一步降低。領導人需要確保所有女童都能上學，免受暴力侵害，而暴力通常是常態化的，包括未成年婚姻，並有經濟途徑保證她們有一個充滿希望的未來。
透過中斷權力動態 (the power dynamics)，政策可以降低女孩感染愛滋病毒的脆弱性。
有害的陽剛之氣阻礙了男性尋求治療。 到 2021 年，雖然 80% 的愛滋病毒感染女性正在接受治療，但只有 70% 的男性正在接受治療。 在世界許多地方增加性別變革計畫是遏制這一流行病的關鍵。 推進性別平等將使每個人受益。
該報告顯示，愛滋病防治工作因成人和兒童在獲得治療方面的不平等而受到阻礙。 雖然超過四分之三的感染愛滋病毒的成年人正在接受抗反轉錄病毒治療，但只有略多於一半的感染愛滋病毒的兒童正在接受救命藥物。 這造成了致命的後果。 2021 年，兒童僅佔所有愛滋病病毒感染者的 4%，但卻佔所有愛滋病相關死亡人數的 15%。 縮小兒童治療差距將挽救生命。
對重點人群的歧視、污名化和定罪正在奪去生命並阻礙世界實現商定的愛滋病目標。
新的分析顯示，在西非和中非以及東非和南部非洲地區，男同性戀者和其他男男性行為者的新感染病例沒有顯著下降。 面對傳染性病毒，未能在關鍵人群方面取得進展會破壞整個愛滋病應對措施，並有助於解釋進展緩慢的原因。
當進步得越快越好，但在世界範圍內，超過 68 個國家仍然將同性性關係定為犯罪。報告中強調的另一項分析發現，生活在法律最嚴厲的非洲國家的男同性戀者和其他男男性行為者越不明瞭自己愛滋病毒感染狀況的可能性是生活在法律最不嚴厲的國家的同齡人的三倍以上。生活在性工作被定罪的國家的性工作者感染愛滋病毒的機會是性工作合法或部分合法的國家的 7 倍。
該報告顯示在消除不平等方面取得進展是可能的，並強調了愛滋病防治取得顯著進展的領域。例如，雖然針對重點人群的調查往往強調重點人群的服務覆蓋率較低，但肯亞的三個縣在女性性工作者中的愛滋病毒治療覆蓋率高於一般女性人群（15-49 歲）。這得益於多年來強有力的愛滋病毒規劃，包括社區主導的服務。
「我們知道如何結束不平等現象」，Byanyima 女士說。「確保我們所有的女孩都在學校，安全而強壯。解決基於性別的暴力。支持婦女組織。促進健康的男子氣概——取代加劇每個人風險的有害行為。確保為感染愛滋病毒的兒童提供服務並滿足他們的需求，縮小治療差距，以便我們永遠終結兒童愛滋病。將同性關係中的人、性工作者和藥癮者合法化，並投資於社區主導的服務，使他們能夠融入社會——這將有助於為數百萬人打破服務和關懷的障礙」。
新報告顯示，捐助資金正在幫助促進國內資金的增加：2018 年至 2021 年期間，PEPFAR 和全球基金為各國增加的外部愛滋病毒資金與大多數國家政府的國內資金增加相關。迫切需要新的投資來解決與愛滋病相關的不平等問題。在最需要國際團結和資金激增的時刻，太多的高收入國家正在削減對全球衛生的援助。2021 年，低收入和中等收入國家可用於愛滋病毒計畫的資金短缺 80 億美元。 增加捐助者的支持對於使愛滋病防治工作重回正軌至關重要。
預算需要優先考慮所有人的健康和福祉，尤其是受愛滋病相關不平等影響最嚴重的弱勢群體。 需要擴大低收入和中等收入國家衛生投資的財政空間，包括通透過大量取消債務和透過累進稅。 結束愛滋病比不結束愛滋病的成本要低得多。
2021年，65萬人死於愛滋病，150萬人新感染愛滋病毒。
「世界領導人需要做的事情非常清楚」，Byanyima 女士說。「一言以蔽之：均衡。平等獲得權利，平等獲得服務，平等獲得最好的科學和醫學。平等化不僅會幫助邊緣化群體。這對每個人都有幫助」。
Inequalities are blocking the end of the AIDS pandemic, say UN
DAR ES SALAAM / GENEVA, 29 November 2022 / PRESS RELEASE / WHO
—Analysis by the UN ahead of World AIDS Day reveals that inequalities are obstructing the end of AIDS. On current trends the world will not meet agreed global targets on AIDS. But the new UNAIDS report, Dangerous Inequalities, shows that urgent action to tackle inequalities can get the AIDS response on track.
UNAIDS set out earlier this year that the AIDS response is in danger—with rising new infections and continuing deaths in many parts of the world. Now, a new report from UNAIDS shows that inequalities are the underlying reason why. It shows how world leaders can tackle those inequalities, and calls on them to be courageous to follow what the evidence reveals.
Dangerous Inequalities unpacks the impact on the AIDS response of gender inequalities, of inequalities faced by key populations, and of inequalities between children and adults. It sets out how worsening financial constraints are making it more difficult to address those inequalities.
The report shows how gender inequalities and harmful gender norms are holding back the end of the AIDS pandemic.
“The world will not be able to defeat AIDS while reinforcing patriarchy,” said UNAIDS Executive Director Winnie Byanyima. “We need to address the intersecting inequalities women face. In areas of high HIV burden, women subjected to intimate partner violence face up to a 50% higher chance of acquiring HIV. Across 33 countries from 2015-2021 only 41% of married women aged 15-24 could make their own decisions on sexual health. The only effective route map to ending AIDS, achieving the sustainable development goals and ensuring health, rights and shared prosperity, is a feminist route map. Women’s rights organizations and movements are already on the frontlines doing this bold work. Leaders need to support them and learn from them.”
The effects of gender inequalities on women’s HIV risks are especially pronounced in sub- Saharan Africa, where women accounted for 63% of new HIV infections in 2021.
Adolescent girls and young women (aged 15 to 24 years) are three times more likely to acquire HIV than adolescent boys and young men of the same age group in sub-Saharan Africa. The driving factor is power. One study showed that enabling girls to stay in school until they complete secondary education reduces their vulnerability to HIV infection by up to 50%. When this is reinforced with a package of empowerment support, girls’ risks are reduced even further. Leaders need to ensure all girls are in school, are protected from violence which is often normalized including through underage marriages, and have economic pathways that guarantee them a hopeful future.
By interrupting the power dynamics, policies can reduce girls’ vulnerability to HIV.
Harmful masculinities are discouraging men from seeking care. While 80% of women living with HIV were accessing treatment in 2021, only 70% of men were on treatment. Increasing gender- transformative programming in many parts of the world is key to halting the pandemic. Advancing gender equality will benefit everyone.
The report shows that the AIDS response is being held back by inequalities in access to treatment between adults and children. While over three quarters of adults living with HIV are on antiretroviral therapy, just over half of children living with HIV are on the lifesaving medicine. This has had deadly consequences. In 2021, children accounted for only 4% of all people living with HIV but 15% of all AIDS-related deaths. Closing the treatment gap for children will save lives.
Discrimination against, stigmatization and criminalization of key populations are costing lives and preventing the world from achieving agreed AIDS targets.
New analysis shows no significant decline in new infections among gay men and other men who have sex with men in both the western and central Africa and eastern and southern Africa regions. Facing an infectious virus, failure to make progress on key populations undermines the entire AIDS response and helps explain slowing progress.
Around the world, over 68 countries still criminalize same sex sexual relations. Another analysis highlighted in the report found that gay men and other men who have sex with men who live in African countries with the most repressive laws are more than three times less likely to know their HIV status than their counterparts living in countries with the least repressive laws, where progress as far more rapid. Sex workers who live in countries where sex work is criminalized have a 7 times greater chance to be living with HIV than in countries where sex work is legal or partially legalized.
The report shows progress against inequalities is possible and highlights areas where the AIDS response has made remarkable progress. For example, while surveys among key populations often highlight lower service coverage among key populations, three counties in Kenya have achieved higher HIV treatment coverage among female sex workers than among the general population of women (aged 15-49 years). This has been helped by strong HIV programming over many years, including community-led services.
“We know what to do to end inequalities,” said Ms Byanyima. “Ensure that all of our girls are in school, safe and strong. Tackle gender based violence. Support women’s organisations. Promote healthy masculinities—to take the place of the harmful behaviours which exacerbate risks for everyone. Ensure services for children living with HIV reach them and meet their needs, closing the treatment gap so that we end AIDS in children for good. Decriminalize people in same-sex relationships, sex workers, and people who use drugs, and invest in community-led services that enable their inclusion — this will help break down barriers to services and care for millions of people.”
The new report shows donor funding is helping catalyse increased domestic funding: increases in external HIV funding for countries from PEPFAR and the Global Fund during 2018-2021 were correlated with increases in domestic funding from a majority of national governments. New investments to address HIV-related inequalities are urgently needed. At a moment when international solidarity and a surge of funding is most needed, too many high-income countries are cutting back aid for global health. In 2021, funding available for HIV programmes in low- and middle-income countries was US$ 8 billion short. Increasing donor support is vital to getting the AIDS response back on track.
Budgets need to prioritize the health and well-being of all people, especially vulnerable populations that are most affected by HIV-related inequalities. Fiscal space for health investments in low- and middle-income countries needs to be expanded, including through substantial debt cancellation and through progressive taxation. Ending AIDS is far less expensive than not ending AIDS.
In 2021, 650 000 people were lost to AIDS and 1.5 million people newly acquired HIV.
“What world leaders need to do is crystal clear,” said Ms Byanyima. “In one word: Equalize. Equalize access to rights, equalize access to services, equalize access to the best science and medicine. Equalizing will not only help the marginalised. It will help everyone.”