Through tackling stigma, community leadership and improving education, as well as strengthened global and domestic investment, HIV transmission can be reduced in Madagascar. (Photo by Sally Hayden/SOPA Images/LightRocket via Getty Images)
Poverty, inequality, gender-based violence, conflict and climate shocks — these are the conditions in which HIV thrives. Here in Madagascar, two in every three people are living in poverty, and the damage wrought by cyclones and drought, and pressures on livelihoods, are set to become even more severe with climate change. The effect is clear: HIV infections have almost trebled since 2010, while Aids-related deaths have risen by 158%.
In my mission to Madagascar on behalf of the United Nations, I was struck by the rising intensity of the HIV epidemic. Nearly 9% of people in Ambilobe, more than 5% of people in Mananara Avaratra, and 4% of people in Fenoarivo Atsinanana are estimated to be living with HIV. This data is troubling in itself, but more concerning still is that we know it is not the full picture. Gaps in data gathering and weak surveillance systems obstruct the work of estimating spread and assessing needs.
The difficulties are not for lack of interest among the public. A study found that more than half of young people in Fenerive Est wanted to be tested for HIV. But fewer than a third were able to be tested. Of those tested, the study found 3% to be HIV positive. That means many people living with HIV are without treatment because they do not know their status because they cannot access testing.
We can see the effect across Madagascar. Just 23% of adults and 10% of children living with HIV are estimated to be on treatment, meaning the overwhelming majority do not have the medicines and care they need to live full, healthy lives, or to suppress their virus to untransmissible levels.
It doesn’t have to be like this. While Eastern and Southern Africa has the highest-concentration of HIV in the world, it is the region that is achieving the fastest progress. In the past 13 years, new HIV infections have come down by almost 60% and Aids-related deaths by 57%. Yet here in Madagascar, while the total numbers of people may still be lower than neighbouring countries, the infection trend is moving dangerously in the wrong direction.
We know the path to ending Aids. It includes addressing poverty and inequality, protecting people’s rights, tackling stigma and improving access to education and HIV services.
Madagascar has strong foundations. The government is clear on the need for stronger data and decisive action to turn around the HIV epidemic. The prime minister and health minister emphasised that we cannot reach people with HIV services if they live in fear. But significant barriers remain, with little access to reproductive healthcare.
Improving laws is an essential step, but that alone is not enough. We also need to address the laws in people’s hearts, informal laws, stigma and discrimination planted in people’s hearts by our religions, beliefs and traditions. There is much to do to support people to be accepting of one another. That is why UNAIDS works closely with faith and cultural leaders to challenge stigma and discrimination against people living with HIV and people affected by HIV.
We have long known that the HIV response can only succeed if it is led by people in affected communities — and that is also true for tackling stigma. So, it is vital to support anti-stigma campaigning by community leaders, churches and faith leaders, NGOs and civil society groups. We all need to stand up for the human rights of people living with HIV, of women and girls, of LGBTQ+ people, and all those at risk. We cannot protect everyone’s health, unless we protect everyone’s rights.
That is true, too, of the right to education. We know that enabling girls to complete secondary education can reduce their vulnerability to HIV by up to 50%, increasing their lifelong earnings, and tackling poverty in the long term. But fewer than 9% of girls in Madagascar complete upper secondary school, and less than 35% complete lower-secondary.
Multiple layers of stigma and discrimination mean that, in the region of Menabe, as many as 55% of Malagasy women under 50 are illiterate. Illiteracy is high among Malagasy men in the region as well at 26.9%. Investment in education — and targeted programmes to reach affected communities — will be essential if we are to turn these figures around and drive down HIV transmission in Madagascar.
A call for strengthened domestic and international investment is no small ask to make, but both are vital. In a country where crippling debt repayments eat up nearly a third of all budget spending — 2.5 times more than spending on health spending and almost four times more than on education — it is understandable that 92% of funding for Madagascar’s HIV response comes from external donors and agencies. But, in an increasingly turbulent world, where international funding for the HIV response is anything but certain, it is critical that Madagascar builds up its own capacity to sustain the HIV response.
Winnie Byanyima is the UNAIDS executive director and United Nations under-secretary general.