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HIV/AIDS and other STIs

  • Page updated onMarch 22, 2025
HIV/AIDS and other STIs
Photo: Bruno Abarca

Since its origin in the 1980s, the HIV/AIDS epidemic has marked the lives of millions of people. It has been responded to with numerous global health efforts, leaving many lessons learned along the way. Today the challenge of combating HIV/AIDS and other sexually transmitted infections (STIs), nuclear to the exercise of sexual and reproductive rights, still remains fraught with challenges. This is especially so in contexts of humanitarian crises where financial, logistical, technical and operational constraints force the concentration of efforts on minimum packages of services that must be expanded as soon as possible.

From the discovery of HIV/AIDS in the 80's to its expansion in the 90's

HIV and AIDS were discovered in the early 1980s

On June 5, 1981, the U.S. CDC reported, in an epidemiological bulletin, a rare finding that had occurred over the previous eight months. It involved five cases of Pneumocystis carinii pneumonia in active homosexual males in their 30s in Los Angeles. They were not known to each other and had no common partners. In addition, they had had cytomegalovirus and Candida coinfections. The bulletin was completed with a short note commenting on the unusualness of this event: these were infections that normally occurred only in severely immunocompromised patients, now affecting apparently healthy young people up to that point. The note ended with a sentence that is now history: "All of the above observations suggest the possibility of cellular immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis and candidiasis",

In the months following the discovery of Acquired Immunodeficiency Syndrome (AIDS), it became evident that it also affected intravenous drug users, regardless of sexual orientation or practices. Additional cases were identified in other countries, such as Belgium. In 1983, French researchers isolated the causative virus, the Human Immunodeficiency Virus (HIV). By 1985, the first diagnostic test, ELISA, was developed. By then, over 17,000 AIDS cases were reported globally with no treatment available. It wasn’t until 1996 that combined antiretroviral therapy turned AIDS into a manageable chronic condition.

The HIV/AIDS epidemic had a massive impact in subsequent years

In the 1980s and 1990s, AIDS had a massive health, social, and cultural impact worldwide. It was not just an epidemic but also a significant source of fear, prejudice, marginalization, discrimination, and stigma against homosexual individuals and people who injected drugs.

The slow governmental response was a catalyst for thousands of social and activist movements worldwide. These groups not only provided information about AIDS prevention and safe sex with condoms but also promoted a human rights-based approach that neither blamed nor victimized people living with HIV/AIDS. At the same time, they demanded greater action in public health, research, political support, and even access to antiretroviral medications.

The impact of the epidemic was not uniform: Africa was by far the most affected region

It is believed that in Africa, HIV circulated for years before its detection in 1981, leading to an explosion of cases in many countries in the following decades. Thus, during the 1990s, while diagnostic techniques improved and treatments capable of reducing mortality and transmission emerged in the West, in Africa, AIDS was multiplying.

In 1997, the year when the number of new HIV infections reached its peak globally (3.02 million), Africa accounted for 78% (2.36 million) of these infections, despite having only 13% of the world's population. Similarly, in 2004, the year when AIDS-related deaths peaked worldwide (1.6 million), Africa alone accounted for 81% of all deaths (1.3 million).

Mortality due to HIV/AIDS

The global health response to HIV/AIDS

The AIDS epidemic largely shaped our understanding of global health. The response to this crisis required a coordinated international effort that transcended borders, with successive initiatives and programs aimed at tackling the spread and impact of the disease.

In 1987, the Global Programme on AIDS was launched

Until 1987, no major global initiative was launched to address the new epidemic. That year, the World Health Organization launched the Global Programme on AIDS (GPA). It was an ambitious program that in just 3 years became the largest in the organization's history. The GPA outlined a strategy for mobilizing countries and a framework for their policies and responses. This was done from a vision of global solidarity and a (much-needed) human rights-based approach. It was also the first time that the WHO worked alongside activist groups, patient organizations, and NGOs. Among the latter were both new organizations and others that adapted their activities to respond to the new crisis, such as FHI 360.

Of course, since there were still no treatments, the focus of this program's actions was on prevention through the promotion of condom use, sexual education in educational centers, and syringe exchange programs for people who inject drugs.

In 1996, UNAIDS was created

At the beginning of the 1990s, even though there were no truly effective treatments yet, most affected countries developed national HIV/AIDS control programs. These programs, however, were not enough to respond to the crisis. For this reason, in 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) was launched to replace the GPA. This occurred amid a contraction of financial contributions from major donors.

Unlike the program that preceded it, UNAIDS was able to take advantage of recent advances in the discovery of combination antiretroviral therapy. It also focused on more inclusive multisectoral strategies for prevention. In addition, it addressed the fight against the stigma and discrimination associated with HIV/AIDS.

Other major global initiatives in the 2000s boosted the fight against AIDS

A few years after the creation of UNAIDS, new global initiatives injected economic capital into the fight against AIDS. These included the World Bank’s Multi-country HIV/AIDS Program (2000), the Global Fund to Fight AIDS, Tuberculosis and Malaria (2002), and the U.S. President's Emergency Plan for AIDS Relief or PEPFAR (2003).

This financial push emerged within a context of growing political mobilization and social activism, which also led to the United Nations Declaration of Commitment on HIV/AIDS in 2001 and, in the same year, the Doha Declaration of the World Trade Organization. This allowed millions of patients in the Global South to finally access affordable generic antiretroviral drugs, although it wasn’t enough. New initiatives like UNITAID, launched in 2006 and supported by the WHO (along with many others), continue to contribute to these goals and fight for access to essential medical products at affordable prices for the populations that need them.

The priority of the 2000s was clear: diagnosing and treating

In 2006, the World Health Organization proposed a public health approach to HIV/AIDS focused mainly on improving access to diagnosis and antiretroviral treatment. It also suggested applying simplified protocols that could be viable in resource-limited contexts. A few years later, in 2014, goals centered on progress in diagnosis and treatment were established, aiming to end the AIDS epidemic as a global threat by 2030. These goals included reducing the annual number of new infections to 200,000 among adults and achieving the 95-95-95 target in AIDS treatment. This means that 95% of people living with HIV should be diagnosed, 95% of these diagnosed should be on antiretroviral treatment, and 95% of those on treatment should have suppressed viral loads.

Progress on this triple diagnosis and treatment target has been notable (86-89-93 globally in 2023), greatly reducing mortality. However, the number of new cases has not decreased as expected. In 2023, there were 1.3 million new HIV infections.

The fight against HIV/AIDS continues today with a new 2021-26 strategy

Currently, the perception of HIV/AIDS is often clouded by the optimism of the early 21st-century trend reversal. Moreover, a portion of the general public views this epidemic as an old problem now under control. Unfortunately, HIV/AIDS remains a huge global health problem, especially in Africa. In response to it, successive global strategies have had insufficient success.

In response to slow global progress in reducing new HIV infections, a new, more holistic strategy was proposed in 2021, with significant changes from earlier approaches. The strategy emphasizes access to diagnosis and treatment, reducing inequality (related to gender, stigma, and discrimination), and prevention of infections.

New global HIV/AIDS strategy goals include not only objectives related to diagnosis and treatment but also access to services and combined prevention, empowerment of community-led organizations, reducing legal barriers to services, and tackling stigma, discrimination against people with HIV and key populations, gender inequality, and gender-based violence.

HIV/AIDS in fragile settings and humanitarian emergencies

Vulnerability to HIV increases in humanitarian emergencies

The relationship between HIV and the drivers of humanitarian emergencies is complex. It may even be different in each situation.

In general, in humanitarian crises, vulnerability to HIV increases. This is due to the deterioration of social protection and care networks, the loss of livelihoods, the rise in sexual and gender-based violence, and the disruption of access to health services, including HIV diagnosis and antiretroviral treatment for opportunistic infections. Additionally, in these contexts, HIV-related stigma and discrimination intensify, as well as its impact on mental health, especially in key populations. Another major threat is food insecurity, as people with HIV have higher energy requirements than HIV-negative individuals.

However, in some cases, the increase in vulnerability does not lead to a rise in HIV transmission. This may be partly due to the reduction in social interactions. This occurs when violence leads to movement restrictions or when displaced populations remain isolated, with sufficient health services provided by humanitarian assistance. In some crises, it has been shown that displaced populations from conflict zones had a lower HIV prevalence than the host population in the destination region.

Key HIV/AIDS actions and minimum package of health services

As a humanitarian standard, a set of HIV/AIDS-related interventions is included in the latest edition of the Minimum Initial Service Package (MISP) for sexual and reproductive health in emergencies. These interventions are considered a minimum requirement, regardless of the local epidemiology.

These include preventive actions such as safe and rational blood transfusion services (minimizing the risk of HIV, hepatitis or syphilis transmission), the application of standard precautions (frequent hand washing, use of gloves, protective clothing, safe sharps handling, proper waste disposal, use of single-dose vials, instrument processing, and cleanup of body fluid spills), or ensuring availability of lubricated condoms at multiple sites. In contexts of high prevalence of parenteral drug use, the provision of sterile syringes and needles is also considered.

It also includes curative actions, such as the provision of antiretrovirals to continue the treatment for individuals already receiving therapy before the emergency (including women in PMTCT programs, which stands for Prevention of Mother-to-Child Transmission of HIV), ensuring access to post-exposure prophylaxis for survivors of sexual violence and in cases of occupational exposure, the provision of cotrimoxazole prophylaxis for opportunistic infections in people with HIV (either previously or newly diagnosed), and ensuring syndromic diagnosis and treatment of sexually transmitted infections in health centers.

In emergencies, multisectoral support is also required for people living with HIV

In addition to the MISP actions, numerous organizations also advocate for a package of multisectoral interventions to support people living with HIV, even in the early phases of emergencies. These include, beyond access to antiretrovirals and health services, improved access to water, housing, and food (to meet the higher caloric needs), cash transfers and economic support, psychological and mental health care, and HIV training for social and health service staff.

When the situation stabilizes, HIV/AIDS health services must be expanded

Community mobilization at this stage is a priority. This requires disseminating information about HIV, how it is transmitted (and how it is not), and the available prevention, diagnosis, care, and support services. Additionally, it is essential to defend the rights of people living with HIV and take steps to reduce their stigma and discrimination. They should be given the opportunity to participate in all stages of the programs, from design to implementation, monitoring, and evaluation.

Among the prevention services is voluntary HIV counseling and testing for individuals who wish to know their serological status. Additionally, it can be encouraged for healthcare personnel to recommend testing, which users can refuse if they wish. In high-risk contexts and generalized epidemics, this can greatly increase counseling and treatment coverage. Moreover, access to antiretrovirals for HIV prevention is crucial at this stage, including post-exposure and pre-exposure prophylaxis for those at substantial risk of infection. Prevention of Mother-to-Child Transmission is also a priority, with integrated HIV counseling and testing in prenatal care, antiretroviral medications if the mother is positive, and other measures.

As soon as possible, access to antiretroviral therapy for people living with HIV must be ensured, including new diagnoses. Support for these individuals should be comprehensive and multisectoral, with psychosocial support, social protection, adherence assistance, information about living with HIV, diagnosis and treatment of tuberculosis, and prophylaxis against opportunistic infections, family planning, food assistance, home or community care, and palliative care.

We must respond to the needs of key populations living with HIV

Depending on the context, there are certain groups and populations that may have a higher risk of infection. These may include men who have sex with men, people who inject drugs, sex workers, refugees and internally displaced people, transgender individuals, military personnel, youth and adolescents, prisoners, and people with disabilities.

These populations require interventions tailored to their specific needs, supported by a strong rights-based approach, ensuring not only access to services but also safe spaces and protection, access to legal services, empowerment, and measures that reduce stigma, discrimination, and even violence against them.

Other sexually transmitted diseases

In addition to HIV/AIDS, other sexually transmitted infections (STIs) also pose a significant public health challenge in humanitarian contexts, such as chlamydia, gonorrhea, syphilis, trichomoniasis, HPV, herpes, and hepatitis B. In emergencies, exposure to these STIs increases due to the disruption of healthcare services, barriers to access, increased sexual violence, transactional sex, and other factors. They are also significant due to the injuries they cause, which can facilitate HIV transmission, as well as leading to infertility, ectopic pregnancies, and specific cancers.

To prevent and manage STIs in emergency settings, a multisectoral approach is recommended, which includes distribution of condoms and culturally adapted sexual health education. Additionally, when resources are limited, syndromic management is advised. Humanitarian health actors should facilitate access to antibiotics and integrate sexual and reproductive health services into primary care, supporting those affected by sexual violence. This requires coordination among multiple stakeholders, a human rights approach, and advocacy for resource mobilization and changes in policies that perpetuate stigma.

Sexual and reproductive health

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