#TalkInequality: Promoting Health Equity in Eastern Europe and Central Asia

What Role Should UNDP Play in the Context of Sustainable Human Development, the SDGs and Health 2020?

Inequalities are a priority theme for UNDP across all its programmatic areas and UNDP’s Regional Bureau for Europe and CIS has launched the Istanbul Development Dialogues. During the upcoming Istanbul Development Dialogues #TalkInequality in February 2016 and together with civil society partners and leading specialists of the region, UNDP aims to identify key analytical and programming areas to craft more effective responses to the region’s inequality challenges across various thematic areas:

  • Measuring inequalities
  • Labour markets and inequalities
  • Gender inequalities
  • Inequalities and health
  • Inequalities and inclusive governance
  • Inequalities and natural capital

In the run-up to the event and as part of its work on the Regional Human Development Report 2016, UNDP’s Regional HIV, Health and Development Team is seeking input, comments and advice from all UNDP partners, experts and the interested public audience via this e-discussion the following questions in order to direct its further programming.

1.What is UNDP’s role in addressing Social, Economic and Environmental Determinants (SEEDs) of health and health equity  in a whole-of-government and whole-of-society approach? Which programmatic actions should UNDP implement at national and subnational level and in terms of broader regional partnerships to support the implementation of Health 2020 and to contribute to improving health equity and well-being as a central goal of the sustainable human development agenda?

2.How should UNDP address HIV in the EECA region meaningfully as an integrated part of a SEEDs of health and health equity[i]  concept using a whole-of-government and whole-of society approach on regional, national and sub-national level? Would such an integrated approach add value in times of transitioning funding for national HIV responses in the EECA region from external to domestic resources and in which way?

Please contribute to this e-discussion using the comment function (click on ‘comments’ right to the heading of this post) and follow @cahamelmann on twitter for further updates. Use #TalkInequality when you share and help us encourage participation in this e-discussion.

Continue reading below for further background on the e-discussion questions.

Health and Health Inequities in EECA

Following the collapse of the former Soviet Union and the associated breakdown of social institutions, economic decline, privatisation and rising unemployment, the EECA region saw steep drops in life expectancies unprecedented in absence of war, natural disaster or epidemics[ii] . To this date, EECA life expectancies lag far behind the EU average due to a high burden of premature mortality at working ages.  In addition, life expectancy shows distinct gender differentials: women in the EECA region generally live longer than men, but the quality of life and well-being they experience is often not satisfactory. There are considerable women’s heath inequalities along the life course in terms of risk exposure, quality of services and health outcome across and within countries, and high rates of loss of healthy life years[iii].

In addition, the EECA region has seen the highest rise in officially recorded HIV incidence (30%) worldwide, while HIV-related mortality more than tripled over the past 15 years[iv]. In contrast, HIV incidence and mortality have declined in all other regions besides the Middle East and Northern Africa during this period. As typical for concentrated epidemics, HIV affects mainly marginalised populations in EECA, such as gay men and other men who have sex with men, women, people who use drugs, sex workers and their clients and partners, prisoners, migrants and ethnic minorities. Similar inequities in exposure, morbidity and mortality can be seen for other communicable diseases (CD) including tuberculosis[v].

The region is also experiencing a high burden of non-communicable diseases (NCDs), such as cardiovascular disease, cancer, respiratory diseases and diabetes, accounting for 77% of the disease burden and almost 86% of premature mortality[vi]. Various dimensions of inequity such as gender, age, education, income, rural/urban, ethnicity, disability, migrant status etc. impact on differential exposure to SEEDs of NCDs, to specific risk factors like tobacco use, harmful use of alcohol, physical inactivity and unhealthy diet, on quality of services and on the distribution of the NCD burden within and across countries[vii].

Promoting Health Equity in EECA

Realizing the basic human right to health and tackling the health and development burdens of CDs, NCDs and health inequities requires addressing these root causes in social, economic and environmental spheres – rather than changing individual behaviour in isolation. Working alongside specialist health partners, actors outside the health sector are well positioned to address the SEEDs of health and health equity.

The current policy landscape is conducive to addressing SEEDs of health and health equity: The SDG Agenda aspires to address inequality across all of its 17 goals and explicitly through SDG 10 specifically focusing on reducing inequality within and across countries. Health 2020, the European policy framework supporting action for health and well-being across government and society, envisions stronger equity as one of its two strategic objectives. Health 2020 has been adopted by all 53 WHO Europe member states in 2012, including all countries of the EECA region.

UNDP’s mandate is to promote sustainable human development and resilient inclusive societies by working with governments, civil societies and other stakeholders across the social, economic and environmental spheres using a rights-based intersectoral approach[viii].

References

[i] Ruth Bell, Laura Grobicki, Christoph Hamelmann. Ensure Healthy Lives and Well-Being for All: Addressing Social, Economic and Environmental Determinants of Health and the Health Divide in the Context of Sustainable Human Development: Analysis of the Project Portfolio of the UNDP Regional Bureau for Europe and the Commonwealth of Independent States.2014: UNDP. At http://www.eurasia.undp.org/content/dam/rbec/docs/UNDP-RBEC-HIV-SEEDS.pdf

[ii] Rechel et.al., Health and health systems in the Commonwealth of Independent States, 2013. Online: http://dx.doi.org/10.1016/S0140-6736(12)62084-4

[iii] WHO, Beyond the mortality advantage. Investigating women’s health in Europe, 2015. At: http://www.euro.who.int/en/health-topics/health-determinants/gender/publications/2015/beyond-the-mortality-advantage.-investigating-womens-health-in-europe

[iv] UNAIDS, AIDS by the numbers 2015, 2015. At: http://www.unaids.org/sites/default/files/media_asset/AIDS_by_the_numbers_2015_en.pdf

[v] WHO, Towards the end of tuberculosis in the WHO European Region, 2015. At: http://www.euro.who.int/en/health-topics/communicable-diseases/tuberculosis/publications/2015/towards-the-end-of-tuberculosis-in-the-who-european-region-2015

[vi] WHO, Noncommunicable diseases, 2015. At: http://www.euro.who.int/en/health-topics/noncommunicable-diseases/noncommunicable-diseases

[vii] UNDP, Addressing the Social Determinants of Health. Discussion Paper, 2013. At: http://www.undp.org/content/dam/undp/library/hivaids/English/Discussion_Paper_Addressing_the_Social_Determinants_of_NCDs_UNDP_2013.pdf

[viii] UNDP, Changing with the world. UNDP Strategic Plan, 2014-2017. At: http://www.undp.org/content/dam/undp/library/corporate/UNDP_strategic-plan_14-17_v9_web.pdf

 

16 thoughts on “#TalkInequality: Promoting Health Equity in Eastern Europe and Central Asia

  1. NGOs are relatively weak throughout the EECA region, although some countries have an increasing number of competent organisations, usually with links to international NGOs. Throughout the region, there is also lack of community organisations, or organisations of patients for specific diseases, who can advocate on behalf of those affected. So, there should be equal opportunities for community representatives and civil society organizations to apply for the support through the open and independent competitive processes, but not through the “appointments” or “assignments’ by any national, regional, global organizations or even UN agenies. UNDP has all the tools for such an approach.
    In tems of specific topics to raise, it is important to stress the following: (a) continuous criminalization of drug users and compulsory drug testing for different group of population, including young people; (b) imrpovement of referrals between health care and criminal justice systems in service provision for people living with HIV and vulnerable populations (drug users, sex workers, prisoners); (c) criminalization of HIV.

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    1. I have partly touched upon the second question related to the sustainable financing along with overview for the fist question. UNDP Country Office has extensive experience working with local leaders and communities, engaging various sectors of central and local governments. As health equity is closely linked to other social determinants such as poverty, education and access engaging all relevant sectors of the Government institutions, CSOs and religious workers will ultimately contribute to achieving tangible results in the field of HIV prevention. Issues of health equity and sustainable development need to be addressed together because they are both part of social justice.

      As such in the context of Tajikistan, the process of moving from international into domestic financing of HIV response plan is crucial for further sustainability of HIV programme. Therefore, UNDP should use currently ongoing programmes for demonstrating HIV infection burden and epidemic consequence of infection and gradual increase of domestic funding , which comes from central and local sources, through continuously advocating and capacity building process in cooperation with other development partners.

      UNDP Country Office in Tajikistan, at this stage, has planned to putting efforts closely working at grassroots levels using the ongoing Mid-Term Expenditure Framework and ensure financing of established services (mostly NSEP and OST) and improving social determinants of health equity in the system.

      UNDP is also in the position to recommend use of wide range of disaggregated indicators, including financial expenditures by activities in the programme design and its implementation. In this process, the availability of realistic data base for assessment of health equity and further advocacy for financial sustainably of services to target group population is crucial.

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  2. UNDP plays an important role concerning health access, quality of care, as well as influencing broader social change, thus offers an innovative and powerful form of action aimed at transforming the healthcare systems, modifying people’s experience of illness, and addressing broader social determinants of health and diseases of diverse communities. The inter-sectorial nature of UNDP’s work enhances public participation in social policy and regulation, democratises the production and dissemination of evidence-based knowledge, strengthens capacities at national and subnational levels to impact on policy realms, thus forges strategic alliances with movements targeting other sectors, such as the environmental one. UNDP also utilises a broad range of tactics in its work, including: engaging in the legal realm; shaping public health research to promote new approaches; employing creative media tactics to highlight the need for structural social change and true disease prevention; engaging within the policy arena to enhance public’s monitoring and regulation power.
    Addressing fundamental determinants of health requires a range of responses, both to change the cause and mitigate the effect, at all levels of the social organisation. Above all, a shift in perspective is needed to give greater emphasis to equity when assessing the effects of any proposed policy changes on health and social wellbeing. For instance, approaching health equity through a rights-based perspective will have a potential to emphasise the link between the health status on one hand, and issues of dignity, nondiscrimination, justice and participation on the other.
    In order to support the implementation of Health 2020, UNDP should implement an array of programmatic actions addressing access to, or provision of, healthcare services, as well as health inequity based on race, ethnicity, gender, class and sexuality. UNDP could successfully leverage embodied experiences of its past and ongoing work, thus forge a new pathway in improving health equity and wellbeing as part of the sustainable human development agenda. Furthermore, UNDP should act as a critical enabler ailed at democratising and reshaping social policy and regulation, in a way that will transform the socioeconomic conditions that underline distribution of health and diseases among populations. Last but not the least, UNDP should consider integrating law as a factor in the development of the structural interventions addressing social determinants of health. A focus on law will help emphasise, or at least illustrate, that very deep social structures are not “natural” or inevitable, but they’re result of both social momentum and deliberate policy choice. Because “the law is all over,” it is a promising vehicle for change from the bottom up and from the top down.

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  3. Numerous examples show that existing health resources (human, technical, knowledge…) in EECA are not so different from those in western countries, but their use is far less efficient, leading to inequalities. A common conclusion could often be summarized that “existing health budget (or state budget in general) is insufficient to address all public health needs and to do it in appropriate and sufficient way”. So, usually, the only way out is seen in international financial support to health and health related programmes. But, experience from internationally supported programmes shown they are often unsustainable and after the foreign donors withdrawn, activities financed by them stop. One of the reasons for that is the lack of sustainability components inside of internationally supported programmes and weak health systems (particularly health management and financial management) in EECA countries.
    UNDP could play significant role in health system strengthening, which will allow better (efficient) use of existing resources (which includes change and strengthening of legal health frameworks), through securing allocative and technical efficiency background, and by promoting better understanding of the link between development and health, by translation of SEED, SDG and Health 2020 key messages into practical, easily understandable messages which will be broadly accepted by the stakeholders and society

    Liked by 1 person

  4. Training programs that build capacity in research methods, research administration, program development/evaluation, and knowledge dissemination are needed to increase the local public health workforce. Countries with advanced public health infrastructure and training have learned that addressing global health challenges has required a coordinated, multi-component, and intersectoral approach — but it took a long time to learn this lesson. EECA countries can translate this knowledge into practice in an accelerated manner by bringing together researchers, government and NGO agencies, and community leaders.

    Liked by 1 person

  5. UNDP country office is developing a unique expertise in the public procurement of medicine and medical commodities. The first time in Ukraine (I believe in the EECA region) the government and particularly the Ministry of Health of Ukraine provides big contribution for procuring medical products through UNDP and 2 other internationl organizations, and acts as a donor. Simultaneously, government of Ukraine is developing and implementing the strategy on public health and health procurement reform. I think that proposed topic of inequality and governance is very much addressed to UNDP Ukraine strategic programming and link to the UNDP exclusive expertise in governance and anti-corruption, promoting integrity, transparency and accountability principles. The intellectual property reform might be another challenge that ensures the health rights of patients to accesses quality medicine and treatment.

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  6. The comprehensive approach of UNDP to development envisages that in order to achieve positive change in a complex issue like public health, it is crucial to address determinants that contribute to health problems and hamper access to healthcare. That is why the focus on social, economic and environmental determinants of health is crucial to ensure that health related SDGs are achieved. As to interventions that UNDP needs to support at national and subnational levels, UNDP should prioritise high-level advocacy with governments, capacity building for relevant stakeholders and support to civil society. In doing so, it is important to engage not only healthcare, but all relevant sectors, including social welfare, education, justice, finances, economy, environment, etc. UNDP should also mobilise technical partners and donor community to provide relevant technical and material support, in order to achieve maximum impact.

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  7. UNDP as a trusted partner is working across sectors with multiple stakeholders and has ability to influence policies and build capacities. This is crucial when addressing Social, Economic and Environmental disparities contributing to the high burden of Non-communicable Diseases (NCDs) and increasingly complex development issues in EECA region. More than half of cases of NCDs occur due to health inequalities among people with low socioeconomic status who have lack of accessibility to timely diagnosis and treatment of NCDs.
    UNDP-EECA works with national partners to empower people by promoting better governance and human rights. The right to health is a basic human right. According to, the committee on Economic, Social and Cultural Rights (CESCR) general comment on the right to health (General Comment 14), the “Right to health embraces a wide range of socio-economic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health.” In other words, the underlying determinants of health can be thought of as “a wide range of socio-economic factors that promote conditions in which people can lead a healthy life.”
    Therefore, UNDP’s role in addressing SEEDs of health and health equity in whole-of-government and whole-of-society approaches may include but not limit to:
    • Assisting governments to provide adequate policies on safe food and nutrition
    • Strengthening civil society to promote safe and healthy working conditions
    • Building capacities to improve environmental conditions
    • Empower people by promoting access to health-related education and information including on sexual and reproductive health

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  8. Perhaps most relevant for the discussion on HIV in the EECA region is the issue of affordability and sustainability of universal and continued access to HIV treatment. While access to HIV treatment in the high-income countries of Northern and Western Europe is nearly universal, among many of the EECA countries treatment access is extremely low. Namely, research and development have yielded state of the art medical products, devices and diagnostic tests, which prevent or treat HIV infection and improve the quality of life of PLHIV. Nonetheless, many people in the low and middle-income EECA countries still do not benefit from those, as access remains limited and non-equitable.

    Moreover, Price and Quality Reporting Mechanism of the Global Fund has indicated that the countries in the EECA region pay one of the highest prices for anti-retroviral treatment, exceeding several times the GFATM median prices for certain medicines. In the context of the overall decrease of international funding of the HIV response, as well as taking into account the new Global Fund Strategy 2017-2022 and the New Funding Model of the Fund, which requires substantial national contributions, it is of utmost importance for countries in the EECA region to assess the levels of preparedness of national healthcare systems to meet the new challenges in their response to HIV. This process will require reducing the costs of medicines thus making the HIV treatment more cost-effective, while at the same time maintaining high levels of quality of care and improving levels of access.

    As part of a SEEDs of health and health equity concept, UNDP should explore various means and ends that may well influence reduction of prices in the EECA region thus encourage containment and efficiency of public spending, such as supporting dialogue between civil society and governments on a number of issues, including: intellectual property legislation and trade regimes; health sector procurement, patenting, licensing and registration regulations; differential pricing schemes that would offer lower prices on originators’ medicines to countries in need; voluntary licensing through pooling of pharmaceutical patents; yet other methods to increase access to affordable quality, safe and efficient ARVs and medicines for treatment of co-infections.

    To this end, there is considerable work to be done by UNDP to build political commitment, coordination and investment to address the above mentioned issues. Such work will have to be accompanied by capacity building in health information systems in order to capture the data necessary to make informed decisions about the allocation of resources. The paucity of good data to be used for tracking health care expenditure and revenue streams, and analysing liabilities, deficits and arrears, is a constraint on abilities in a number of EECA countries to effectively manage their expenditures. UNDP could also play a vital role here.

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  9. It is important not only to define what should be done in terms of healthcare, which targets to be reached but, importantly, how the issue should be address in the most effective way, provide policy advice on possible consequences of the planned activities. In this regards UNDP is a unique organization in a sense that we have all the capacities and knowledge to address inequalities in healthcare in a comprehensive manner.
    There are three key issues that should be borne in mind while addressing inequities. First, all activities should be evidence based. Factual and the most recent data is the basis for planning and making decision. UNDP has both experience and capacities to be applied to provide support and assistance to the countries. In terms of HIV in Belarus, for instance, with its changing narcological pattern and, as a consequence, increase of HIV prevalence in PWID, UNDP supported including into national HIV surveille sections on type of drug used by PWID. Thus, Government now has official grounds on taking decisions for further HIV related actions.
    Second is prompt reaction. We are now living in a world of rapidly changing environment – social, financial, economical, ecological. This requires development of tools that help to promptly update strategies, plans, programmes in order to adjust them to the changing situations. Literally – update figures, press the button, get the optimal solution. UNDP had very good experience in playing the leading role in development of the tool for HIV allocative efficiency analysis. This practice to help governments in identifying optimal investments should be further developed by UNDP.
    Third relates to advocacy at high level. High level conferences, meetings, where decision makers could discuss health related issues with representatives of key affected populations and NGOs, and make decisions supported by signing common documents for eliminating inequities – resolutions, action plans, etc. –are another activity where UNDP could bring people and nations to work together towards development and eliminating inequities.

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  10. Recent experience from the transition between GF and domestic sources of HIV financing in numerous countries have shown two important weaknesses – weak health system, which prevents effective financing of HIV programmes within health sector (HTC, treatment, OST, biosafety…) and legal and political barriers which prevent effective financing of NGO HIV programmes.
    Health system strengthening and benchmark, promoted and supported by the UNDP could make a substantial benefit.
    The most of the countries in EECA are very centralized, and this fact also influences sustainable and effective HIV response, particularly in terms of the equal access to prevention, treatment and care, equal quality, and financing at the sub-national and local level. Advocacy for decentralization, especially in decision-making autonomy and financing is needed and could be initiated by the UNDP.
    The importance of SDG and Health 2020 must be promoted, as many, especially health care workers, are not aware of them.
    There is also a need for collaboration between countries in the region in HIV response, sharing good experiences and joint programmes. UNDP could play key role by moderating this collaboration.
    As many of the countries in the region are EU candidate countries or would like to become candidates, collaboration between EU institutions and UNDP could also bring some benefits to the region.

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  11. UNDP may address one of the core problems in fighting HIV in the EECA region – namely, under funding by governments of treatment and prevention of HIV – by concentrating in general on under funding of healthcare in post-Soviet states in comparison to developed European countries (in percentage of GDP and absolute numbers). Many post-Soviet countries do not pay enough attention to healthcare, including in terms of funding, setting other priorities for funding, which in many cases do not have such an importance for society as protection of health. Raising awareness of the governments and civil society on imbalances in state funding policy may cause better funding of healthcare, which is important for the attaining the highest standard of health. More engagement with the ministries of finance is of particular importance.

    Another important issue is general inefficiencies of post-Soviet healthcare systems, which cause inefficient response to HIV. There are significant gaps in healthcare services quality, assessment of patients needs (outdated monitoring and evaluation systems), corrupted or not-competitive procurement systems, etc. To address these problems, it is important to advocate governments (ministries of health, in particular) on the need of national healthcare reform.

    Among more focused on HIV interventions that UNDP could focus on is triggering quick antiretroviral treatment coverage expansion, which constitutes the core of effective HIV response. Treatment coverage expansion is hindered in EECA countries by many factors, among which the most important are: treatment programs under funding, high prices of even relatively old first line ARVs and use of not recommended by WHO and high cost ARVs in first line schemes. To ensure achievement of Fast-Track goals UNDP could focus on (i) advocating governments for better, more focused funding of HIV response, by concentrating on expansion of antiretroviral treatment coverage; (ii) encouraging countries to use TRIPS-flexibilities to improve market competition for old first line patented ARVs, (iii) encouraging more rational prescribing/procurement practices of ARVs, to avoid non-compliance with WHO recommendations.

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  12. The factors that contribute to the HIV epidemic and to inequalities in access to HIV services in the EECA region extend beyond just the healthcare sector. Thus, it is important not only to focus on improving the public health systems in EECA countries, but also to address social, economic, environmental, and other determinants in order to bring about positive change vis-à-vis the HIV epidemic in the region.

    Education, poverty, stigma and discrimination, and involvement in political and social dialogue at the national and local levels all have an impact on how the HIV epidemic will affect a population. The UNDP is well situated to address these factors and can play an invaluable role in eradicating HIV in the region. Key interventions, in which the UNDP should be involved include building the capacity of civil society organizations and organizations representing key populations, promoting and protecting human rights in the region, providing technical assistance for building evidence bases on HIV in the region, and facilitating cooperation and the sharing of best practices between countries of the region.

    Pursuing such an integrated approach would also add value in times of transition from external to national funding of HIV responses. National and local HIV responses will be better equipped to respond to the HIV epidemic with a comprehensive approach. In addition, by promoting greater dialogue between countries and civil society organizations of the region, countries will be able learn from the examples of their neighbors and facilitate a smoother transition to national funding of HIV responses.

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  13. The UNDP has a good reputation and status, which facilitate the process of discussion with government agencies in the region, building an internal policy and its integration, inclusion of human rights standards into the curricula at preparation of specialists and raising awareness of already working professionals, especially medical specialists.
    Also, the majority of countries in the region historically has a common base: the law, the language, the education system, well-established communication, common problem areas. Because of this, certain steps taken in a neighboring and familiar country to develop and improve the situation, including in the field of health case, are much better understood and perceived. It would be very useful to enhance the cooperation and exchange of experiences between the countries of the region, to highlight successful experiences and actions that led to such changes.
    For example, some of the countries in the region already have successful experience on the use of replacement therapy, the others are often reluctant to use it. In those countries where it operates, many health professionals and decision-makers had initially refused to recognize its effectiveness and usefulness. After several years of work their opinion have changed. Their arguments could play an important role in determining the future state policy during direct communication with the experts from the countries, in which they refuse to apply the replacement therapy.
    It seems important in this field to provide assistance in strengthening the cooperation between non-governmental organizations working with advocacy.
    It would be useful to strengthen the exchange of information available to the UNDP, in particular selections of international standards, the WHO protocols, analysis of certain issues in the health care area, non-governmental organizations and bodies of decision-makers, in the language of the region, since the English-language resources because of the language barrier and the lack of information about their existence are not available for the majority of individuals who are participating in the development and implementation of policies (eg officials, prosecutors, health workers, police, judges).

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  14. Gender inequalities and Gender-based violence must be an integral part of a SEEDs of health, and HIV response in EECA in particular. Women living with and affected by HIV continuing to be underrepresented in many HIV policy making bodies. Most officials and even civil society leaders don’t realise clear linkage and intersection between gender, HIV and violence. We need build a strong movement around the SDGs and enable communitites (key populations, men and women living with HIV) to be active participants.
    HIV response cannot be effectively addressed within healh sector only. It’s always about political will, proper laws and funding. Countries where laws is used as weapon against most at risk and marginalised populations, where governments invest nothing to HIV prevention and treatment, where women and girls have no voices, no education, no choices for protection – they can not defeat AIDS.

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