“We in cities have become used to taking responsibility for larger problems. Cities, by definition, have the strongest connections to their people, and the deepest sense of urgency in meeting their needs and addressing their challenges.”
Bill de Blasio, Mayor of New York, at the opening of the High-Level Meeting on Cities Ending the AIDS Epidemic, New York, 6 June 2016.
The Political Declaration on HIV and AIDS, adopted by all member states during the United Nations General Assembly High Level Meeting on Ending AIDS in June 2016 (1), calls on countries to Fast-Track the HIV response towards ending the AIDS epidemic by 2030. The Declaration, as part of the 2030 Agenda for Sustainable Development, affirms the need to intensify efforts towards the goal of comprehensive HIV prevention, treatment, care and support, while protecting the human rights and dignity of all people living with, at risk of, and affected by HIV and AIDS.
Developments in scientific and biomedical research have made it possible to control the HIV epidemic (2) and modelling studies have shown that ending the epidemic will be possible if effective testing, treatment and prevention services are rapidly scaled up to reach ambitious targets, including the 90-90-90 treatment targets by 2020 (3,4). These targets call for 90% of people living with HIV to know their HIV status, 90% of people who know their status to be accessing HIV treatment, and 90% of people on HIV treatment to have suppressed viral loads by 2020. However, this will require strong political leadership and commitment, sustained international and domestic financing, a rights-based approach with dedicated community engagement, and ensuring that all affected populations have access to essential services.
Cities have historically taken the lead in the implementation of science and delivery of services (5), and play a critical role in accelerating the AIDS response and addressing the needs of affected and vulnerable populations. Cities have the power to drive the agenda, and the leadership and actions taken in cities will, to a large extent, determine success at a national and global level in achieving the Fast-Track targets and in ending the AIDS epidemic by 2030.
Why an urban focus is important
More than half the world’s population currently live in cities and population growth in the future is expected to be mainly urban. By 2030, an estimated 60% of the global population will live in cities, and 90% of the urban growth between now and 2030 is expected to be in low-and middle-income countries, mostly in Africa and Asia (6). Because of their high population density, cities account for a large and growing proportion of people living with HIV, tuberculosis (TB) and other diseases. In addition, the risk and vulnerability to HIV and TB infection is often higher in urban compared to rural areas because of urban dynamics such as migration, unemployment, overcrowding, poverty and social/economic inequalities.
Urbanisation often involves shifts in social systems, values and communal structures, while the vibrancy and anonymity of urban life can provide increased opportunities for high risk behaviours and greater sexual networks. Key populations are therefore often concentrated in cities, where sex-work can become an important survival tactic and source of income. Figure 1 illustrates the disproportionate HIV burden in selected priority cities across the world and shows that in several countries, a single city can explain up to 30–60% of the national HIV burden. In the United States of America, 50% of all people living with HIV reside in 12 cities (Atlanta, Baltimore, Chicago, Dallas, Houston, Los Angeles, Miami, New York, Philadelphia, San Francisco, Tampa, Washington DC) (7) while 80% of new diagnoses in 2015 were concentrated in large metropolitan areas (with Miami, Baton Rouge and New Orleans among the most heavily affected) (8). Data from national population-based surveys conducted in 25 countries across sub-Saharan Africa in recent years showed that HIV prevalence is on average twice as high in urban compared to rural areas (9).
Cities present economic opportunities as well as social challenges
Despite the high HIV burden associated with urban areas, cities offer important opportunities and have inherent advantages in accelerating the response to HIV, TB and other diseases. Cities are uniquely positioned to take transformative action to ensure that services are delivered to all its citizens, and to forge inclusive and participatory responses to complex multi-dimensional problems such as HIV. Cities often have their own resources and regulatory powers, have infrastructure that is inclusive and accessible and can reach large numbers of people, and are centres for economic growth, education, innovation, positive social change and sustainable development.
Yet cities often face social challenges and rapidly changing demands. These include high levels of migration into and out of the city, poverty, high levels of social and economic inequalities, fragile communities such as those living in informal settlements, crime, violence and discrimination. Concentrations of key populations including sex workers, people who inject drugs and men who have sex with men, all of whom are vulnerable to HIV infection, are often stigmatized and marginalized, and often lack access to basic services such as HIV prevention, testing and treatment. Epidemics such as HIV, TB and other diseases can therefore only be controlled when cities embrace inclusive policies with a human rights approach that ensures access to basic social and health services for all its citizens, including the most marginalised.
Cities are taking the lead in the HIV response
Since the beginning of the AIDS epidemic, cities have been leading the response through the implementation of new medical and scientific research, community advocacy and sustained political leadership. Innovative approaches have been adopted to reach out to affected populations, to reduce HIV transmission and AIDS-related deaths, while efforts have been made to address issues related to human rights, social exclusion, risks and vulnerabilities. In addition, the HIV response has acted as a pathfinder to addressing other health and social challenges including social inequities and strengthening infrastructure and health systems.
More recently, cities have been encouraged by and are supported through the Fast-Track Cities initiative to take additional action and to accelerate the HIV response towards ending AIDS by 2030. Strong leadership and political commitment from a number of city leaders, with support from the Fast-Track Cities core partners, including the City of Paris, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United Nations Human Settlements Programme (UN-Habitat), and the International Association of Providers of AIDS Care (IAPAC), have led to the development and launch of the Paris Declaration on Fast-Track Cities Ending the AIDS Epidemic in December 2014 (11). To date, more than 200 cities and municipalities across the world have signed the Paris Declaration and pledged their commitment to achieving the 90-90-90 targets, and to addressing disparities in access to basic services, social justice and economic opportunities (10).
Cities signing the Paris Declaration commit to achieving the following objectives: 1. Ending the AIDS epidemic in cities by 2030; 2. Putting people at the centre of the AIDS response; 3. Addressing the causes of risk, vulnerability and HIV transmission; 4. Using the city AIDS response for positive social transformation and building societies that are equitable, inclusive, responsive, resilient and sustainable; 5. Building an appropriate response to local needs; 6. Mobilizing resources to integrate public health and development; 7. Uniting as leaders, working inclusively and reporting annually on progress.
Examples of cities accelerating the response, taking action and making progress towards reaching targets and ending the AIDS epidemic
A report released by UNAIDS and Fast-Track Cities partners during a high-level meeting on Cities Ending the AIDS Epidemic in New York in 2016 (10), is testimony to the leadership and commitment of city authorities and of the progress that cities are making in responding to HIV.
Several cities in the Global North, including Amsterdam, London, Melbourne, New York, Paris, San Francisco and Vancouver have reached or are close to reaching the 90-90-90 treatment targets and have reduced the number of new HIV infections to low levels. These cities have shown that, with leadership and political commitment and by ensuring that essential services are delivered to all populations in need, it will be possible to end the epidemic in the near future (10). Mayors of several of these cities are also making sure that HIV prevention, treatment and care programmes are accompanied by social support including nutrition and housing.
In Africa, there are numerous examples of cities that have made significant progress in the HIV response, in scaling up treatment and prevention services, and in significantly reducing the number of new HIV infections and AIDS related deaths (10). Windhoek and Harare are examples of cities with large epidemics in the general population that have provided HIV services for the prevention of mother-to-child transmission of HIV (MTCT) to more than 95% of pregnant women living with HIV. For many countries in Africa, the elimination of MTCT is a priority and in cities such as Blantyre, the Mayor has made it his personal mission to end vertical transmission of HIV. Several cities in the region have made good progress towards the 90-90-90 targets. In Nairobi, for example, an estimated 74% of people living with HIV knew their HIV status at the end of 2015, 64% were receiving treatment and 55% of all people living with HIV had a suppressed viral load (12). Harare has made significant progress in reversing epidemic trends: HIV prevalence in the city, which at its peak was about double the national prevalence, declined from about 20% in 2005 to 13% in 2013 (13), following significant declines in HIV incidence starting in the early 1990s (14). More recently the city has started to implement a comprehensive testing and treatment approach with services available in all city clinics and hospitals.
Many cities in Africa are addressing the needs of key populations (10). For example, sex workers in Cape Town have been educated and are supported by the Women’s Legal Centre, a grantee of the Open Society Foundation, on their legal rights and receive legal information, advice and assistance with court hearings and filing of complaints against abuse. Nairobi is working to improve testing, treatment and prevention services for key populations in health facilities that are free from stigma and discrimination, and Casablanca has been one of the first cities in Morocco to introduce methadone maintenance programmes in prisons. Several cities, including Johannesburg, Dar es Salaam and Kigali are strengthening HIV and sexual and reproductive health services for young people and adolescents, among whom HIV infection rates have been high. Outreach programmes in schools, campaigns, peer education and support programmes, and youth-friendly centres have led to improved knowledge, as well as an increase in the demand for, access to, and uptake of key interventions (10).
Several cities have shown innovation in their response to HIV. In Abidjan, the use of mobile phone technology is being tested as a way of improving HIV services, retaining patients in care, ensuring adherence to treatment, and breaking down stigma and discrimination.
Cities are also recognizing the importance of strategic partnerships in moving the HIV response forward. Lusaka is galvanizing support from community-based organizations to expand services to reach more people. Libreville is joining hands with international organizations in France to provide decentralized services in the prevention of MTCT. In addition, mayors and governors from several cities in the region, including Abidjan, Durban, Lusaka, Kinshasa and Accra have taken leading roles in mobilizing their regional counterparts to adopt a Fast-Track cities approach through active recruitment and leading by example.
While this paper only provides a snapshot of progress in cities, there are many more examples of the commitment of cities across Africa to accelerate the HIV response, deliver on the goals of the Paris Declaration and to use the response for positive social transformation (10). The innovation, progress and achievements of these cities serve to inspire and encourage the many other cities that still face numerous challenges and where much still needs to be done in order to reach their targets and end AIDS by 2030.
Integrating the AIDS response into broader urban health and development programmes
Integrating the AIDS response into the Sustainable Development agenda presents opportunities to respond more effectively, not only to HIV and TB, but also to other communicable and non-communicable diseases while addressing many of the associated social problems.
For the AIDS response to be successful a unified approach is required, involving key partners across health and social sectors, to reach marginalized populations and informal settlements and to support the basic health and social needs of all people living with and affected by HIV. Poverty, violence, inequality, punitive laws and discriminatory social norms all play a role in fuelling the HIV epidemic and in creating inequities in access to health care, education, housing and economic opportunity. By investigating these and other contextual factors associated with HIV, city leaders can take a multi-sectoral approach to tackling and transforming some of the most intractable social problems. Equity, inclusiveness, resilience and sustainability are not only central to a successful health care strategy, but they form the basis for creating a healthy and sustainable future.
In conclusion, city leaders across the world are showing commitment and are providing political and technical leadership in dealing with local issues and barriers to delivering health and social services where they are needed. Cities are taking action, through their networks and by involving affected communities, to achieving the HIV Fast-Track targets by 2020. Ending the AIDS epidemic in cities will have profound, long-lasting benefits for urban communities and for countries and the global community. The key characteristics of the AIDS response: multi-sectoral, evidence-based and people-centred action, community engagement, strategic partnerships, innovation to overcome barriers and improve outcomes, a focus on concrete targets and accountability for results, a commitment to human rights and gender equality, and an insistence that no-one is left behind in the response, can help to inspire new coalitions, innovative delivery platforms and broad-based action to ensure growth and prosperity in the era of sustainable development.