A new UNAIDS report launched on 14 July 2021 hows that people living with HIV (PLHIV) face a double risk, HIV and COVID-19, while key populations and children continue to be left behind in access to HIV services. The UNAIDS Global AIDS Update 2021 draws attention to the evidence that PLHIV are more vulnerable to COVID-19, but that widening inequalities are preventing them from accessing both COVID-19 vaccines and HIV services. Lack of access to vaccines is the biggest cause of the widening inequalities People living with HIV are at a higher risk of severe COVID-19 illness and death, yet the vast majority are denied access to COVID-19 vaccines. Key and vulnerable populations (KVPs) and their sexual partners account for 65% of new HIV infections but are largely excluded from both HIV and COVID-19 responses. Of more than 10 million PLHIV unable to access cheap and available life-saving treatment, 800,000 of these are HIV-positive children. Studies from England and South Africa found that the risk of dying from COVID-19 among PLHIV was double that of the general population. Sub-Saharan Africa is home to two-thirds (67%) of PLHIV (Figure 1).

Figure 1 | HIV prevalence among adults (aged 15–49 years), global, 2020

However, the region’s highest rates of one-dose COVID-19 vaccination coverage in June 2021 were in Equatorial Guinea (19%), Botswana and Zimbabwe (9% each), and Namibia (6%). Less than 3% had received at least one dose of a COVID-19 vaccine by July 2021 and no other countries in the region exceeded 5% (Figure 2).

Figure 2 | Percentage of the total population that has received at least one COVID-19 vaccine dose, by country, as of 23 June 202 Source: Official data collected by Our World In Data (https://ourworldindata.org/covid-vaccinations).

Note: The vaccine coverage indicated may not equal the share that are fully vaccinated if the vaccine requires two doses After spending decades fighting for access to the HIV medicines available in rich countries, the rights to health of PLHIV in the developing world are once again being impacted by an international system that puts profits over people. At the same time, due to lockdowns and other pandemic restrictions, KVPs, as well as children and adolescents, are less likely to access HIV prevention and treatment services. The report states that COVID-19 vaccines could save millions of lives in the developing world but are being kept out of reach as rich countries and corporations hold on tightly to the monopoly of production and delivery of supplies for profit. This is having a severe impact around the world as health systems in developing countries become overwhelmed, such as in Uganda, where football stadiums are being turned into makeshift hospitals. Making hay while the sun shines Wealthier people are accessing COVID-19 vaccines and leaving the poorer nations behind. The new UNAIDS report highlights how COVID-19 lockdowns and other restrictions have badly disrupted HIV testing — in many countries this has led to steep declines in HIV diagnoses, referrals to care services and HIV treatment initiations. In KwaZulu-Natal, South Africa, for example, there was a 48% drop in HIV testing after the first national lockdown was imposed in April 2020. There were also fewer new HIV diagnoses and a marked drop in treatment initiation. This occurred as 28,000 HIV community health-care workers were shifted from HIV testing to COVID-19 symptom screening. The UNAIDS report shows that in 2020 the 1.5 million new HIV infections were predominantly among KVPs and their sexual partners. People who inject drugs (PWID), transgender women, sex workers (SWs) and gay men and other men who have sex with men, and the sexual partners of these KVPs, accounted for 65% of HIV infections globally in 2020. Key populations accounted for 93% of new HIV infections outside Sub-Saharan Africa, and 35% within Sub-Saharan Africa. However, they remain marginalized and largely out of reach of HIV services in most countries. The report shows that many of the 19 countries that achieved the 90–90–90 targets by 2020 have been leaders in differentiated service delivery, where facility-based services are complimented by community-led services. Most have also included KVPs as central to their responses. In Estonia, for example, the expansion of comprehensive harm reduction services was followed by a 61% countrywide reduction in HIV infections and a 97% reduction in new HIV infections among PWID. HIV testing and treatment has been scaled up massively over the past 20 years. Some 27.4 million of the 37.7 million PLHIV were on treatment in 2020. However, gaps in service provision are much larger for children than for adults. In 2020, around 800,000 children aged 0–14 years who were living with HIV were not on HIV treatment. Treatment coverage was 74% for adults but just 54% for children in 2020. Many children were not tested for HIV at birth and remain unaware of their HIV status, making finding them and bringing them into care a major challenge. Confronting inequalities also shows that women and girls in Sub-Saharan Africa continue to be at a higher risk of HIV infection, with gender inequality and gender-based violence (GBV) at the centre of that risk. Gender inequalities and GBV rob women and girls of their fundamental human rights, including the right to education, health and economic opportunities. This increases their risk of HIV infection and blocks access to services. In Sub-Saharan Africa, adolescent girls and young women account for 25% of all new HIV infections despite representing just 10% of the population. Poverty and lack of schooling are also formidable barriers to health and HIV services. The report shows how family planning services for women and voluntary medical male circumcision (VMMC) for men and boys are much less likely to be accessed by people living in poverty. In 2020, the number of VMMC dropped by more than 30% in 15 priority countries in eastern and southern Africa. Poverty is also a driver of migration, which has been shown to severely impact access to HIV services and puts lives in danger as migrants flee conflict and poverty in the hope of safety and economic security. The International Monetary Fund has warned that the COVID-19 pandemic has exacerbated pre-existing inequalities and poverty. The world’s richest countries have ratcheted up budget deficits and allocated trillions of dollars to their COVID-19 responses, cushioning their economies and populations from the worst health emergency and economic shock in decades. Just a sliver of this largesse has gone to developing countries, however, with only an extra $10 billion of official development assistance made available amid warnings of future cuts in development aid. Inequalities do not occur naturally. They are the result of policy and programmatic actions that divide rather than include. For example, KVPs are marginalized and criminalized for their gender identities and expression, sexual orientation and livelihoods. New analysis included in the report shows a positive correlation between better HIV outcomes and the adoption of laws that advance non-discrimination. A study from Sub-Saharan Africa found that HIV prevalence among SWs was 39% in countries that criminalized sex work, compared to 12% in countries where sex work was partially legalized. “We are 40 years into the fight against HIV. Both the successes and the failures have taught us that we cannot prepare for or defeat a pandemic unless we tear down inequalities, promote people-centred, rights-based approaches and work together with communities to reach everyone in need,” said Ms Byanyima. Rethinking the impact of COVID-19 on those living with HIV COVID-19 is riskier for PLHIV than originally thought—upping the odds of dying by 30%, according to a new study of 15,000 cases across 24 countries.

• Nearly half of HIV-infected men over 65 years old hospitalized for COVID-19 may die; and
• The data suggest that people with HIV should be prioritized for vaccines

The findings contradict earlier, smaller studies that indicated HIV had no bearing on the risk of severe illness or death from SARS-CoV-2. The study was shared in advance of the International AIDS Society conference last week. “HIV knocks out all the brakes on the immune system, and as a consequence you get this inflammatory response that’s robust and sustained — and now you got Covid on top of that,” said Steven Deeks of the University of California, San Francisco”.