HIV Prevention in the Spotlight: An Analysis from the Perspective of the Health Sector in Latin America and the Caribbean, 2017

ISBN: 978-92-75-11979-2

© 2017 Pan American Health Organization and Joint United Nations Programme on HIV/AIDS

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Suggested citation. Pan American Health Organization and Joint United Nations Programme on HIV/AIDS. HIV Prevention in the Spotlight: An Analysis from the Perspective of the Health Sector in Latin America and the Caribbean, 2017. Washington, D.C.: PAHO, UNAIDS; 2017.

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• Preface
• Acknowledgments
• Acronyms and abbreviations
• Executive summary
• Why publish this report?
• Methodology
• Results
• The number of new HIV infections did not decline
• A complete set of recommended prevention interventions is not offered
• More people have access to HIV prevention through support from the Global Fund
• Access to HIV testing
• Prevention and control of sexually transmitted infections
• Pre-exposure prophylaxis (PrEP)
• Post-exposure prophylaxis (PEP)
• Use of condoms and lubricants
• Overcoming structural barriers
• Financing and sustainability of HIV prevention
• Conclusions and recommendations
• Annex

This report presents the countries’ achievements and challenges in HIV prevention and calls on them to renew their commitment and efforts to reduce new HIV infections. It also highlights the progress made toward meeting the targets set by the governments of this Region to end AIDS in the coming years. This edition is particularly timely and relevant, as the number of new HIV cases in Latin America and the Caribbean has remained constant since 2010. We have not seen the decline needed to end the epidemic.

This new edition continues the successful series of in-depth analyses of HIV in Latin America and the Caribbean that began in 2012 with Antiretroviral treatment in the spotlight. It addresses different aspects of the HIV response from a public health perspective and provides information to guide governments and partners in the improvement of their efforts.

This edition is also presented in support of the Plan of action for the prevention and control of HIV and sexually transmitted infections 2016-2021, adopted by the PAHO Member States at the 55th Directing Council of 2016.

The framework for this report is the new “combination HIV prevention” approach, which covers biomedical interventions and the promotion of healthy behaviors, as well as aspects of the enabling environments needed for the implementation of prevention measures.

The analysis and recommendations in this report focus primarily on the health sector and, in particular, the three populations most affected by the HIV epidemic: female sex workers, transgender women, and gay men and other men who have sex with men.

This publication is based on data reported by national programs throughout the Region and information furnished by civil society in more than 12 countries. Various aspects of the health sector response in HIV prevention were examined—such as access by the key populations to HIV testing, antiretroviral treatment, pre- and post-exposure prophylaxis, condoms and lubricants, and barriers to access such as discrimination in health services—in order to evaluate the progress made toward meeting the regional prevention targets.

Furthermore, this report addresses sustainability and warns about the Region’s dependence on international funds to advance prevention activities for the key populations and the challenges that this entails. The report also underscores the critical role of civil society in guaranteeing a more effective HIV response, particularly in the area of prevention.

We trust that the information presented in this publication will help all of us, as stakeholders, in our enhanced and coordinated efforts to reduce new HIV infections and end AIDS by 2030.

Dr. Carissa F. Etienne, Director
Pan American Health Organization

We may be able to reduce the number of new HIV infections in the world to fewer than 500,000 by 2020, and to fewer than 200,000 by 2030, which would end the AIDS epidemic as a public health threat. Using 2010 as a baseline, these numbers would signify a 75% reduction in new HIV infections between now and 2020 and a 90% reduction by 2030. Meeting these targets will require specific, high-impact HIV prevention measures, testing, treatment, programs to fight discrimination, and an unbreakable commitment to respect protect, and promote human rights.

Nonetheless, despite these significant global advances, Latin America and the Caribbean have not seen a substantial decline in new infections. In fact, there was an increase in 2015, compared to 2013 and 2014. A high incidence of HIV persists among key populations—especially among MSM and among transgender women.

Reducing the incidence of the disease will require strengthening various aspects of HIV prevention and the implementation of combination prevention packages that offer a range of high- impact HIV prevention measures of proven effectiveness that are tailored to local epidemics.

HIV prevention in the spotlight is the product of a multisectoral consultation involving the national AIDS programs of the countries of the region, international cooperation agencies, civil society, and people living with HIV, who have contributed their knowledge and experiences to the discussion. With the valuable information obtained from different sources, this publication presents a joint analysis by PAHO/WHO, UNAIDS, and civil society of the status of HIV prevention efforts and the progress made toward meeting the national and regional prevention targets set by the Latin American and Caribbean countries within the framework of the 2015 Call to Action issued in Rio de Janeiro.

It also presents examples of combination HIV prevention measures and highlights some common challenges, such as inadequate investment and resistance to meeting the specific needs of young adults, adolescents, and key populations in connection with their sexual and reproductive rights, while offering recommendations to address these issues.

The combination prevention approach described herein is fundamental. Countries must recommit to this type of action and seriously examine the importance of targeting interventions to key populations and the need to promote the integration and intensification of HIV prevention programs, while improving their performance and broadening their scope.

A multisectoral commitment, close collaboration with communities, and investment in sustainable prevention are essential if regional agreements are to be transformed into country action. As this publication demonstrates, the prevention targets for implementing the Fast-track Strategy at the regional level can be met if a greater return on each dollar invested can be ensured through efficient investment using a location population approach tailored to the characteristics of each epidemic.

Good practices include the successful interventions of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, targeted to the key populations and described in this publication.

Let us not miss this opportunity to end new HIV infections and improve people’s lives overall, thereby contributing to the realization of the 2030 Agenda for Sustainable Development. AIDS has not ended, but it can end. HIV prevention in the spotlight will be an excellent tool for steering us in the right direction.

Dr. César Antonio Núñez, Director
Regional Support team for Latin America and the Caribbean UNAIDS

ACRONYMS AND ABBREVIATIONS

• ART Antiretroviral treatment
• GAM Global AIDS monitoring
• GARPR Global AIDS Response Progress Reporting
• GIPS Greater involvement of people living with HIV/AIDS
• LAC Latin America and the Caribbean
• MSM Men who have sex with men
• NASA National AIDS spending assessment
• PEP Post-exposure prophylaxis
• PEPFAR President’s Emergency Plan for AIDS Relief
• PrEP Pre-exposure prophylaxis
• STIs Sexually transmitted infections
• FSW Female sex worker

The governments of Latin America and the Caribbean (LAC) have made a commitment to putting an end to the AIDS epidemic by 2030. This commitment is aligned with the Political Declaration on HIV and AIDS issued by the United Nations General Assembly in June 2016, with specific targets set in Latin America for 2020 and 2030.

Within this context, the purpose of this publication is to highlight the efforts and challenges to preventing infection with the human immunodeficiency virus (HIV) in LAC through a critical review of the HIV prevention measures adopted by the health sector. The report was prepared with a participatory multisectoral approach involving the compilation of published data and additional data collection through questionnaires and both face-to-face and virtual consultations.

The review and recommendations focus on the health sector and three key populations: female sex workers (FSWs), transgender women, and gay men and other men who have sex with men (MSM).

This report is particularly relevant and timely, because the number of new HIV cases in LAC has remained the same as it was in 2010— that is, approximately 120,000 new infections each year—and the number of new infections in adult males is estimated to have increased between 2010 and 2016. Furthermore, in 2016, young men between the ages of 15 and 24 continued to account for one-third of all new HIV infections.

For the analysis in this report, the indicators listed below have been selected, using the combination prevention approach and essential health sector interventions for HIV prevention as a framework, with emphasis on the key populations, regional prevention targets, and the indicators reported at the international level (GARPR/GAM):

• estimated number of new infections in 2010 and 2016;
• access by MSM, FSWs, and transgender women to HIV testing;
• distribution of condoms and lubricants and condom use by MSM, FSWs, and transgender women;
• HIV policies and prevention services;
• civil society financing of the AIDS response and HIV prevention;
• situation with respect to PrEP, PEP, the provision of antiretroviral treatment (ART) to all people diagnosed with HIV; the distribution of condoms; nationwide diagnosis, treatment, and monitoring of STIs.

In addition to these indicators, given the great importance of the structural component of combination prevention, a brief analysis is included of this component in LAC, focusing on a review of laws, policies, and practices, the reduction of stigma and discrimination, community empowerment, and violence prevention.

Information Sources

The main source of quantitative information was the 2017 country reports for global AIDS monitoring (GAM).

Other sources of information include

• Estimates of new infections in 2017, calculated using the UNAIDS Spectrum system.
• Country reports in response to the HIV prevention questionnaire: 28 national programs completed a questionnaire on health sector HIV prevention interventions, with support from the PAHO and UNAIDS focal points.
• Twelve in-person and virtual national consultations with representatives of national and civil society HIV programs: their purpose was to consider the quantitative information and analyze qualitative aspects of the response, such as significant civil society involvement, the characteristics of the services, structural barriers, and how to improve the supply and demand for services. Prior to the consultations, every participating country received a fact sheet summarizing the data collected from the GAM.
• Information on prevention interventions and their coverage in projects of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
• Other relevant publications and reports, such as the 2017 PAHO/WHO survey on LGBT people entitled Addressing the causes of disparities in health service access and utilization for lesbian, gay, bisexual and trans (LGBT) persons. Assessing the health situation and access to care for LGBT people in the Americas.

An estimated 120,000 [98,000- 140,000] new HIV infections were observed in LAC in 2016, a figure similar to that of 2010.

New HIV infections in Latin America and the Caribbean have trended downward in the past 16 years. Nevertheless, new infections have plateaued since 2010 (with 120,000 new infections that year), although there was a slight decline in 2015 and 2016 (Figure 1). This suggests that LAC is off track in meeting the established global and regional targets of a 75% reduction in new HIV infections by 2020 (Table 1).

Males over the age of 15 accounted for 70% of all new infections in Latin America and 51% in the Caribbean.

In contrast, among females in the same age group, the data show a decline in new infections in the Caribbean (an 8% decline) during the same period. In 2016, in Latin America, males over the age of 15 accounted for 70% of all new infections in Latin America and 51% in the Caribbean. Notably, Haiti is the only Caribbean country with more new infections in females than males (28% more).

Males and females aged 15-24 accounted for one-third of the total estimated population with new HIV infections in both Latin America and the Caribbean in 2016 (Figure 3).

In this age group, females accounted for a high percentage of the new infections in the Caribbean, while males had two-thirds of the new infections in Latin America.

New HIV infections in young people have not fallen at the desired rate

The regional target is a 75% reduction in new infections in young people by 2020. In the past six years, there has been a 5% decrease in new HIV infections among those aged 15-24 (3% in males and 5% in females) (Table 1).

The number of new infections in young women aged 15-24 in the Caribbean fell by 10% from 2010 to 2016. Among males in the same age group, new infections in that period remained stable (increasing by around 1%) (Figure 4).

The LAC countries have made a commitment to improving access to HIVs testing and people’s knowledge of their HIV status. Three targets have been set: 1) 90% of people with HIV will know their status by 2020; 2) focus efforts on timely access to HIV testing in the key populations, so that by 2020, more than 90% will have been tested in the past 12 months; and 3) reduce late HIV diagnosis to 10% or less (9).

Significant improvements have been made in HIV-positive people’s knowledge of their HIV status in LAC. In 2016, an estimated 81% [58%-89%] of people with HIV in Latin America knew their status and 64% [51%-74%] in the Caribbean. In both cases, improvements were observed over the previous year, when 77% and 57% of such people, respectively, knew their status.

The gaps in access to HIV testing among the key populations are still significant. Furthermore, many countries do not have data on testing for transgender women or FSWs. Some 88% of the countries have at least one figure for this indicator for MSM, 67% for FSWs, and 36% for transgender women. In most of the countries, this target is monitored through behavioral studies in the key populations, from whom data are obtained in some urban centers. Many countries (around one-third, or over 10) have received international financial assistance to conduct these studies.

One out of three diagnoses is late

The median HIV testing coverage in the past 12 months is 48% for MSM (with figures ranging from 5% in Peru to 19% in the Dominican Republic, and up to 95% or more in Suriname and Saint Kitts and Nevis, according to program data), 65% for FSWs, and 75% for transgender women (with figures ranging from 43% in Colombia to over 95% in Guatemala and Paraguay) (Figure 9 and Table 3 of the Annex).

The regional analysis of this information has limitations, since some countries (Guyana, Panama, Paraguay, and Peru) use data from the health care services. The results are not always representative of all the key populations, and there may be selection and information biases in the data reported, among other limitations.

i) The late diagnosis indicator is the percentage of HIV+ people who have a CD4 count of less than 200 cells/mm3 in their first CD4 test.

Another indicator for evaluating the degree of access to HIV testing is late diagnosis.i In LAC, one-third of cases are diagnosed late. The regional average has not changed substantially in the past four years (Figure 10).

Furthermore, in an analysis of the data by country, 59% (13/22) had the same or worse results in 2016, compared with 2015, while 41% (9/22) showed improvements.

Regionally, late diagnosis is more common in men (30% in 2016) than in women (19%). There were no substantial changes in this indicator for men in comparison with 2015. However, an improvement was seen in women (down from 24% in 2015).

In short, these data show that access to testing has improved. However, the gaps are still substantial and access is inadequate. Furthermore, the information systems in many countries do not contain information on testing disaggregated by the key populations.

Regionally, late diagnosis is more common in men (30% in 2016) than in women (19%).

This makes it hard to measure inequities in access and timely testing in these populations. The LAC countries face a series of barriers to providing adequate access and testing for the key populations, the most important of which are detailed below.

a. Up-to-date algorithms and the use of rapid tests to increase access. Countries such as Chile, Ecuador, Peru, Suriname, and Trinidad and Tobago are modifying their algorithms to optimize the testing process and reduce waiting times to confirm a positive diagnosis. Simplification of the diagnosis algorithms can help yield reliable and timely results.

b. Decentralization of testing and use of diversified strategies to offer the test. Some 68% of the countries report that testing is offered in community centers. Some 43% of the countries (13/30) allow HIV testing to be done by trained individuals who are not health professionals (e.g., Argentina, Dominica, Guatemala, Jamaica, Mexico, and Paraguay). However, in countries that offer testing in community centers, the majority of tests in the country (90%) are done by health centers and only 10% by civil society organizations or private laboratories. That is, the number of tests done by community- based services or civil society organizations is small and is normally in connection with grants from international donors.

c. Distribution of centers that offer testing. In the majority of the countries, these centers are concentrated in large cities. This creates problems for people living in communities far from urban centers.

d. Hours of operation tailored to the needs of key populations. Some 62% of the countries (16/26) offer services with flexible hours for HIV testing, generally provided by civil society organizations. Flexible hours enable the key populations to get tested at times that are more convenient for them— for example, late afternoons or evenings.

e. Use of self-testing. This type of test, which can increase the number of people who know their HIV status, is now on the market in different countries, including the Bahamas, Brazil, El Salvador, Jamaica, Peru, and Trinidad and Tobago. However, no government has yet documented a subsidized cost or using it to expand testing to hard to reach groups or to establish mechanisms to link people with the health services.

In the majority of LAC countries, the age of consent is 18 for young people to seek HIV testing on their own.

f. Legal barriers. The age of consent for a young person to seek HIV testing at the health services on his or her own is 18 in 61% of the countries.

g. Procedures to ensure confidentiality and informed consent. The written informed consent requirement persists in several countries. This can be a barrier to broadening access to HIV testing. WHO has noted that, in most settings, verbal consent is enough to obtain an HIV test (11).

h. Stigma and discrimination. Ninety-two per- cent (24/26) of the countries provide sensitivity training for health workers involved in HIV screening for key populations. However, civil society organizations in 12 countries that par- ticipated in national consultations on HIV prevention reported a lack of sensitivity among these professionals. The factors associated with this situation may be:

• high rotation of human resources
• ack of mechanisms to monitor and evaluate the quality and results of training
• lack of investigation and follow-up of reports of mistreatment or institutional discrimination
• lack of mechanisms to encourage good practices and expand friendly services free of discrimination
• lack of involvement in training by individuals from the key populations.

Response to STIs in Latin America and the Caribbean

Latin America and the Caribbean are facing a resurgence of STIs in some population groups and an increase in gonococcal resistance to antimicrobial drugs (16). In response to the STI epidemics, the LAC countries have approved the Plan of action for the prevention and control of HIV and sexually transmitted infections 2016-2021 (17), which is aligned with the Global health sector strategy for sexually transmitted infections 2016-2021, whose goal is to end STI epidemics as major public health concerns (18).

In recent years, great strides have been made in the STI response—for example, screening of pregnant women for syphilis and improved surveillance of congenital syphilis. There is a firm political commitment to achieve the dual elimination of mother-to- child transmission of HIV and syphilis (19), and to provide greater access to vaccination against the human papillomavirus. Almost 60% (16/27) of the LAC countries have national STI prevention and treatment strategies or plans, but fewer than half of them (11/27) indicate that they are consistent with the targets of the global strategy (to reduce the incidence of syphilis and gonorrhea by 90% by 2030, eliminate congenital syphilis, and guarantee over 90% HPV vaccination coverage).

Only 63% of the countries (17/27) report having strategies to actively search for the contacts of people with an STI, although all of them (100%) report offering HIV screening and distributing condoms in STI treatment centers (Figure 11).

Furthermore, 88% (25/27) of the countries indicate that they have STI treatment guidelines, although only a little more than half (59%, or 16 out of 27) are consistent with WHO recommendations. In fact, only a minority (four countries) have updated their guidelines in the past two years, and more than half have not done so for over five years. In the absence of up-to-date national guidelines, health care providers sometimes follow the international recommendations of WHO or the CDC.

Rapid test for screening and diagnosis of syphilis

Some 66% of the countries (20/30) use rapid syphilis tests to screen and diagnose pregnant women, and 42% (13/31) report using them with the key populations (Table 7 of the Annex).

Surveillance of STIs in LAC countries

There are few data on STIs in LAC. Surveillance of these infections and response monitoring are inadequate, and even when surveillance systems are in place, they are sometimes characterized by deficient data and limited analysis and dissemination of the information.

Some 89% (32/36) of LAC countries report having some type of STI surveillance, and 88% (22/25) have designated active syphilis as a reportable event. Reporting syphilis in adults makes it possible to detect outbreaks and adopt effective targeted prevention and control measures. Congenital syphilis is reportable in the majority of the countries (94%, 30/32); only Haiti and Bolivia do not require reporting of congenital syphilis cases (Figure 12 and Table 8 of the Annex).

Treatment of gonococcal infection and antimicrobial resistance (AMR)

Of all the STIs, gonorrhea is the most antibiotic-resistant. This resistance has rapidly increased in recent years, reducing treatment options, and it varies with the different strains of Neisseria gonorrhoeae, making local surveillance essential to drafting guidelines for proper treatment. Cases of multi-drug- resistant N. gonorrhoeae have recently been detected that are unresponsive to monotherapy with broad-spectrum cephalosporins. WHO has published gonorrhea treatment recommendations suggesting that the choice of treatment in each country be determined by the local resistance data obtained through systematic resistance monitoring (21).

In LAC, 36% of the countries that provided information (12/33) conduct systematic surveillance of gonococcal resistance to antimicrobial drugs (Table 7). Furthermore, according to the country data reported through the Latin American AMR Surveillance Network (ReLAVRA), ciprofloxacin resistance has steadily grown, with isolates increasing from 35% in 2009 to 62% in 2015 (Figure 13). Moreover, reduced sensitivity to broad spectrum cephalosporins and macrolides is beginning to emerge (Figure 14).

With regard to gonorrhea treatment guidelines, only 8% of the countries (2/24) report the use of ceftriaxone plus azithromycin, as recommended in the WHO guidelines; more than half (67%, 16/24) report the use of ceftriaxone or ciprofloxacin as the treatment of choice (Table 8 and Figure 15).

Table 8 / Drugs for gonorrhea treatment indicated in treatment guidelines of Latin American and Caribbean countries

Source: PAHO. Country responses to the HIV Prevention Survey, May 2017.

Pre-exposure prophylaxis or PrEP is the use recommends the use of antiretroviral drugs for HIV prevention in seronegative people. Who currently recommends the use of regimens that include oral tenofovir (e.g., tenofovir and emtricitabine), a drug widely used throughout the world for HIV treatment.

WHO (22, 23) recommends offering PrEP to people at high risk of contracting HIV as an additional intervention from the package of combination prevention interventions. This is a strong recommendation based on high-quality evidence.

In July 2017, WHO published a tool (24) for implementing PrEP programs with suggestions for the introduction and use of PrEP based on the available evidence and experience. This document includes information not only for clinicians, but for educators and activists, counselors, opinion- makers, pharmacists, regulatory agencies, planners and evaluators, HIV test providers, and PrEP users themselves.

PrEP is the use of antiretroviral drugs for HIV prevention in seronegative people.

Clinical trials and acceptability studies throughout the world show:

• high effectiveness of PrEP in preventing sexual transmission of HIV in different populations;
• high degree of acceptance among potential users, especially if prophylaxis is subsidized or affordable;
• low impact of PrEP in terms of emergence and transmission of resistant viruses in the population (risk of resistance is higher in people who begin PrEP during the window period or acute infection period);
• as yet inconclusive data on increase in risky behavior among users (greater number of sexual encounters without use of condoms); i.e., risk compensation effect has not been demonstrated; and
• greater connection of PrEP users who exhibit high-risk behaviors with HIV and STI prevention services: increase in HIV and STI testing and greater access to prevention measures (use of condoms and lubricants, behavioral management/risk reduction methodologies, sexual health services, etc.).
• low impact of PrEP in terms of emergence and transmission of resistant viruses in the population (risk of resistance is higher in

PrEP in Latin America and the Caribbean

The use of PrEP as an intervention in HIV prevention packages is considered critical to the prevention response in LAC. Thus, having PrEP pilot projects in the countries is a first step, which is why it was set as a regional target in 2015 (see Table 1).

PrEP implementation has been slow (25) but is occurring in pilot demonstration projects for its adoption. It is also being offered in the public health services of the Bahamas and will soon be available in Brazil and Barbados (Table 9). The target of 10 projects is about to be reached. Seven countries are already planning public PrEP programs or projects with various modalities and sources of financing.

Several key informants have indicated that the number people who use PrEP outside the health sector has increased, a phenomenon known as “PrEP in the wild.” These users purchase the PrEP drugs in pharmacies and drugstores inside and outside the country or on the Internet, or else they obtain them through friends in social settings and self-administer them. This type of access does not guarantee compliance with the recommendations regarding interventions,

including, for example, providing information about their use, helping the patient continue treatment, monitoring side effects, and going for regular HIV and STI testing. Moreover, it does not enable national programs to monitor its use and outcomes. Other users obtain PrEP by prescription from a private physician, making it difficult to ensure the quality of care and adherence to national protocols and guidelines, which in many cases are still lacking.

Source: WHO. Guidelines on post-exposure prophylaxis for HIV and the use of co-trimoxazole prophylaxis for HIV-related infections among adults, adolescents and children. Recommendations for a public health approach - December 2014.

Five countries (Antigua and Barbuda, Dominica, Grenada, Jamaica, and Saint Lucia) report that MSM run the risk of prosecution and prison. Civil society organizations in nine countries have reported cases of people who have been arrested or prosecuted in the past three years because they had sex with people of the same sex.

Six countries report that sex work is considered criminal behavior (Antigua and Barbuda, Bahamas, Barbados, Dominica, Grenada, and Jamaica) and four describe the partial criminalization of sex work (Bolivia, Costa Rica, Mexico, and Suriname). Civil society organizations in 15 countries report that female and male sex workers have been arrested or prosecuted for their sex work in the past three years.

Although no government reports the criminalization of transgender people, in the GAM reports, civil society organizations in nine countries (Antigua and Barbuda, Argentina, Costa Rica, the Dominican Republic, Honduras, Mexico, Paraguay, Peru, and Venezuela) state that in the past three years, transgender people have been arrested or prosecuted for activities related to their gender identity.

Of the 24 countries that provided information, 10 (Brazil, Colombia, Costa Rica, Dominica, Haiti, Honduras, Panama, Saint Lucia, Saint Vincent and the Grenadines, and Trinidad and Tobago) described access barriers to justice facing key populations and people with HIV. Some examples include barriers erected by the judicial system itself, which does not guarantee confidentiality; lack of trust in the judicial system; lack of sensitivity on the part of justice officials; and ignorance of judicial procedures.

• Community empowerment and greater involvement of people living with HIV (GIPS) (27) are guiding principles for HIV programs and activities. GIPS is a principle aimed at enabling people with HIV to exercise their human rights and responsibilities, including the right to health and to participate in decisions that affect their life. Similarly, community empowerment is a social process that enables the key populations to address the structural limitations to health, human rights, and well-being to promote change, improving their health and well-being and increasing their access to health services.m Community empowerment broadens the scope and improves the effectiveness of services for the key populations (28).

One of the commitments assumed as part of the follow-up to the U.N. Political Declaration on HIV/AIDS in 2016 (29) was to empower people living with HIV, at risk of contracting it, or affected by it to know their rights and have access to justice and legal services in order to prevent and report human rights violations. In the past two years, 17 countries have reported having extensive training and capacity-building programs for people with HIV and the key populations to educate them and make them aware of their rights.

Addressing stigma and discrimination in the health services ⁿ

The goals established in the WHO Global Health Sector Strategy on HIV/AIDS 2016-2021:

• End policies and practices that reinforce stigma and discrimination (especially in health care settings), particularly for people living with HIV and key populations.
• Create institutional and community environments that make it safe for people to access HIV services without fear of discrimination, involving communities in the planning and delivery of services.

m) Community empowerment is the individual and collective ownership of programs in order to achieve the most effective HIV responses and take concrete action to address social and cultural barriers to their broader health and human rights (WHO. Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions. Geneva; 2015. Available from: www.who.int/...

n) Definition of discrimination: Any action or omission by an individual or institution (for example, in the health sector) that produces and reproduces inequalities in access to resources and services (Diccionario de la lengua española. 23rd edition. Madrid, Spain).

In this regard, the Joint United Nations Statement on Ending Discrimination in Health Care Settings demonstrates the commitment of UN entities to working together to help Member States adopt coordinated multisectoral measures to eliminate discrimination in health care settings.

According to representatives of the key populations, health services are not welcoming and in some cases, abusive, which explains why the demand among these groups is very low.

This unfriendly attitude is one of the main barriers to timely access to HIV and STI diagnosis and treatment in the key populations. These informants also identify the main facilitators of discrimination in the health sector as the lack of sensitivity training for health professionals; ignorance among health professionals and users about rights and current laws and regulations.

Inconvenient hours of operation; the institutional behavior of health center professionals and authorities; bias among professionals; difficulty lodging complaints and grievances; and, in some cases, the failure to recognize civil society organizations as key partners in improving services.

A number of civil society organizations in 25 LAC countries reported having a mechanism for reporting discrimination and human rights violations in health care settings, such as reporting procedures, compensation mechanisms, and grievance procedures or systems to protect and respect patient privacy or confidentiality.

A full 97% of the countries reported having sensitivity training for health workers who offer HIV testing to people in the key populations. However, given the way it is carried out, many stakeholders and studies question the effectiveness of these interventions in eliminating stigma and discrimination in the health services against the key populations (30-32).

Based on the comments of consultation participants, these training activities are neither monitored nor evaluated, and high staff turnover means that many health workers do not receive any training. The participants considered the strategy of hiring peer counselors and community navigators to be successful, as these individuals improve knowledge and understanding of the needs of each population and provide ongoing sensitivity training and interventions that actively involve the key populations and people living with HIV in the design, implementation, and evaluation of health services. For example, the sensitivity training conducted by organizations of the key populations, such as RedTraSex, have been successful in reducing discrimination in the health services. In addition, the programs need policies and codes of conduct to discourage stigma and discrimination. Government and civil society representatives described protocols, resolutions, and standards for preventing and penalizing discrimination. However, many health professionals, center administrators, and users were unaware of their existence or how to apply them.

End violence against the key populations

Violence against the key populations heightens the risk of HIV and STIo exposure (35). Multiple structural factors influence the vulnerability to violence, including discriminatory laws, institutional repression, cultural and social norms that legalize stigma and discrimination, as well as their coexistence with the activities of groups operating outside the law (for example, gangs in Central America). There are high rates of reported verbal and physical violence against FSWs and transgender women that sometimes result in death (36 ), as well as high rates of homophobic violence. For example, according to the Observatory of Murdered Trans People, 2,016 transgender people were murdered in the period 2008-2015, 1,573 (78%) of them in LAC (37). This reflects the gravity of the violence and crimes against trans people, which are correlated with the prevalence of HIV, late diagnosis of HIV, and the high level of mortality in this population.

Civil society organizations and national programs are working to reduce violence against the key populations and create an enabling environment that promotes physical, sexual, and emotional well-being, in addition to safety. There is an inherent constraint, however: health programs and services fall under the ministries of health, while uniformed personnel and programs to fight organized crime are under another portfolio. The directors and technical personnel of the programs consulted agree that lack of coordination among ministries and programs is a major constraint.

The critical facilitators for mitigating violence include: 1) mechanisms for documenting and monitoring violence; 2) training people in the key populations, people with HIV, and other stakeholders to understand human rights; and 3) strengthening intersectoral efforts to promote responsibility among law enforcement personnel to prevent violence and human rights violations.

As part of the efforts to prevent institutional violence in the health sector, it will be necessary to review policies and procedures for the application of standards, provide sensitivity training for professionals, train the key populations, and create human rights oversight mechanisms.

o) The Inter-American Commission on Human Rights (IACHR), the Inter-American Commission of Women (CIM), UNAIDS, and PAHO call on OAS Member States to eradicate stigma and discrimination surrounding HIV in the Americas (December 2012). Available from: onusidalac.org/...

The global targets in HIV prevention include allocating one-quarter of the HIV budget to prevention and ensuring that at least 30% of the services are community-operated by 2030.

Based on the data from 33 countries, UNAIDS estimates that LAC investment in the HIV response in 2013 was US$ 3 billion (38). Some 88% of the HIV expenditure was financed with domestic sources and 12% by international sources. In addition, 23% (US$ 690 million) of the expenditure allocated to the HIV response that year was devoted to prevention.p According to the data from the 23 countries that reported preventive expenditure targeted to the key populations, 7% of the expenditure on prevention in 2014 was allocated to programs for these populations (US$ 44 million of the US$ 639 million for prevention) (38).

With regard to the sustainability of the purpose, 68% of the countries (17/25)q have a dedicated budget line for this purpose in their HIV budget. However, 82% (27/33) depend on external funds for prevention, and only six countries finance 100% of their prevention activities with domestic funds (Table 10). This dependency is seen primarily in prevention for the key populations; the figure ranges from 5% in the Bahamas to more than 95% in Haiti, but in more than half the countries it is estimated at less than one-third of the total prevention funds.

Hence, we can see that we are faced with a dual challenge: first, reaffirming the political will to allocate domestic funds to financing in this area, and second, determining the real needs in order to increase the allocation for prevention in the key populations.

In 2014, funding for prevention activities in LAC was distributed among the key populations as follows: 6% for FSWs, 30% for MSM, 23% for the partners and clients of the key populations, 3% for transgender women, 2% for drug users, and 36% for the general population. The GARPR reports of several countries have indicated very little or no spending on prevention programs for the key populations. Some countries have difficulty quantifying the expenditure allocated to these populations and, based on the conclusions of studies in several of them (for example, GOALS and other similar studies), the proportion of the expenditure allocated to the key populations must be increased to ensure a greater reduction in new infections (39-43).

p) Considering only public funds, the percentage of the total allocated to HIV prevention is 20% and 28% in Latin America and the Caribbean, respectively.
q) According to information based on LAC country responses to the HIV Prevention Survey, May 2017.

• The funds currently allocated are inadequate, since: 1) the comprehensive service packages offered are incomplete; except for the Bahamas and, very soon, Brazil and Barbados, no country offers a complete package of services or subsidized self-testing under the national program; and 2) service coverage for the key populations is inadequate.
• It is not known what magnitude of expenditure is required to meet these needs at both the regional and country levels.

The countries also need to improve their information on the financing of HIV prevention—for example, by institutionalizing the development of national health accounts, using the methodology recommended by WHO (44) and considering systematic NASA exercisesr (at a cost of roughly US$ 5,000) or similar studies, whose low cost will enable them to monitor expenditures on prevention activities in key populations.

Furthermore, 60% of the countries (15/25) report that they have domestic resources to fund civil society interventions. In some countries, however, these funds take the form of supplies, and the amount of the financing has not been quantified.

r) NASA: National AIDS Spending Assessment. For more information, visit: www.unaids.org/...

In conclusion, in LAC, there is a high level of dependence on external funds for prevention activities targeted to the key populations, and inadequate funding for civil society

organizations, which are the most effective entities for reaching these populations. Some informants from the key populations in countries with 100% domestic financing stress the inadequacy of domestic financial support to civil society organizations for HIV prevention activities in these groups. Governments should create lines and mechanisms for funding civil society with domestic sources to support HIV prevention interventions, and countries that already have them should increase the funding, establishing fair and transparent mechanisms for the selection of service providers.

The current amount allocated to HIV prevention in key populations is insufficient; there are interventions that are not offered or if offered, the coverage is low.

This report analyzes the elements that show the main persisting gaps in HIV prevention in LAC. Use of the combination prevention approach can help LAC make progress toward meeting the 2020 and 2030 targets. However, given that two years after the LAC countries embraced the regional prevention targets, the number of new HIV infections has still not fallen, this report issues guidelines for reorganizing efforts and heightening their impact to achieve the sustainability of the outcomes. The following are the main areas where efforts should be focused in LAC:

• There is a dual gap in LAC: first, in delivery of the complete set of prevention interventions of proven efficacy, resulting in a loss of synergy for achieving a greater reduction in transmission of the infection; and second, in service coverage, since in the few cases where a complete package of services is provided, coverage is very limited; thus, the good practices of the interventions have had very little impact on the course of the epidemic.
• The combination prevention approach is only rarely incorporated into the work of institutions or civil society. Training and dialogue on this approach should be promoted to determine how to apply it through interventions tailored to national realities.
• The services or interventions are often provided in isolation and are fragmented. There are many opportunities for improvement in this regard: when providing services, greater advantage should be taken of the opportunity to address prevention needs, considering a broader range of available interventions.
• Progress has been made in improving access to HIV testing, and more people with HIV are aware of their diagnosis. However, a high percentage of people with HIV still receive a late diagnosis. Efforts should be made to continue expanding the measures adopted to increase HIV testing in the key populations, addressing legal, technological, service delivery, and other barriers.
• Despite the clear, evidence-based recommendations of WHO, even with significant information from studies in LAC on interventions such as PrEP, self-testing, and PEP, countries have been slow to adopt these new combination prevention tools. Greater political commitment, implementation facilitated by more structured dialogue, and collaboration between government institutions and civil society organizations are urgently needed to fast track the expansion of prevention services for the key populations.
• Even in countries dependent on external financing, most prevention measures (prevention of mother-to-child transmission, blood safety, STI treatment, etc.) are financed with government resources. However, prevention interventions and services for the key populations are highly dependent on external funds.
• The cost of meeting the prevention targets in LAC is unknown, and so is the investment gap. There are no accurate country estimates of the cost of covering all prevention needs, nor of how many services civil society provides for the key populations. Systematic NASA studies and the dissemination of study findings should be increased, both as a reporting mechanism and in order to monitor gaps and progress toward meeting commitments.
• In order to improve the performance of the health services and boost their efficiency, their fragmentation must be addressed, promoting integrated health services networks and services focused on the needs of the key populations and taking advantage of the social engagement and support of civil society organizations.
• A lack of data and analysis of the key indicators associated with HIV prevention in the key populations has been detected, revealing a weakness in strategic information systems on the outcomes and impact of programs geared mainly to these populations.
• Although we have certain good practices and have made progress in addressing stigma and discrimination in the health services, the strategies employed should be reviewed to increase their effectiveness, involving people from the key populations in finding solutions to this problem.

There is a strong leadership by governments and civil society to end AIDS in LAC, but much remains to be done to improve the situation of the key populations and the quality of care in health centers. These are the pillars for mounting an integrated HIV and STI response in the coming years, which will require more and better information, as well as an increase in technical and financial resources. The conditions are ripe for implementing the combination prevention approach. We hope this report will serve as a catalyst for creating the mechanisms and structures recommended by the new Global HIV Prevention Coalition in its fast-track action plan to reach the targets for 2020 in this next phase of the response to the HIV epidemic.