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Addressing inequalities in a society stretched by effects of sanctions and economy downturns is an immediate priority. But it does not rule out deep and wide historical inequalities in the communities.
Addressing chronic gender issues is another transformative priority which has already shown up itself in variety of ways.
Despite many achievements regarding education especially for girls, which has revealed itself in a higher number of female university graduates needs to be translated in higher rate of female job occupancy levels especially at decision making positions.
There are numerous examples of community/cities developments in conjunction with CSOs and other social development actors, however such achievements are under threat and need to be nurtured and transformed to a sustainable development.

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Although much progress has been made in the HIV response in Brazil, there still a few legal barriers that need to be addressed regarding punitive laws drug use. From a broader perspective, there are many inequalities that impact populations vulnerable to HIV in the country. The country is considered one of the most unequal with discrimination of LGBTQIA, indigenous, homeless, and black populations. Adding to this is the high rates of crime and violence in the poorer neighborhoods and regions of the country. Despite the change of government to one that is more liberal, almost half of the country are very conservative which regards topics of gender as toxic. Toxic masculinities, gender, and racism are pervasive and need to be addressed. To address these inequalities, as the major barriers to ending AIDS in Brazil, it will require a multi-sectoral response that up to now has been led by the Ministry of Health. Since May 2023, initial steps are beginning with a national level decree on the elimination of TB, HIV and other diseases with a interministerial and multisectoral approach to ending these diseases.

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Transformational change is required in the removal of legal barriers and strengthening of judicial systems and redress mechanisms: currently in South Sudan, aspects of sex work (soliciting) is illegal. In addition, sex between men and possession and use of drugs are criminalised by law. These coupled with weak legal systems in the country, high levels of stigma and discrimination and impunity among others, lead to high levels of intimidation, indiscriminate arrests and threats of arrests of sex workers, people who use drugs (PWUD), men who have sex with men (MSM), and people who provide services to these key populations. As a result of these are currently no HIV programmes that specifically target MSM and PWUDs in the country.

Transformation in design and delivery of health and HIV services: HIV services are largely delivered in vertical programmes that are not integrated in the primary health care system. These stem from the fact that the health delivery systems are donor-driven and characterised by different donors working in different service delivery facilities with different service packages and delivery models. Where different donors work in the same facilities, there is little integration of their services. A more transformative and sustainable way of dealing with service delivery will be a combination of pooled funding and other funding mechanisms that deliver a comprehensive package of service that are integrated in the PHC system in the country.

Transformational change is also required in addressing deep social norms that drive gender inequalities such as early marriage and other gender-based violence against women and girls.  There is also the need for transformational change in the financing of HIV by leveraging humanitarian funding to strengthen the health sector and increasing domestic funding of the social services sector (including health and HIV).

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There are few areas that require transformational change to accelerate reaching the 2030 targets. two key areas stand out: protecting and defending the rights of key populations by repealing discriminatory laws. The second issue is ensuing the mainstreaming of HIV in humanitarian settings.

The wind of intolerance and negative propaganda gander against key population and increased access to sexual and reproductive health is gaining momentum in many countries in the subregion at a time when we thought that we have gone passed those days of blame and conspiracy theories.

Unfortunately, this is not the case as increased intolerance is being manifested by communities that we hold in high esteem and who are expected to demonstrate more tolerance and support. This poses an entrenched challenge to ending AIDS as a public  health.

The other key issue that requires transformation is building resilient and sustainable systems for health to withstand the challenges posed by climate related humanitarian crisis such as floods and cyclones and health emergencies and disease outbreaks.

Paying attention and addressing the human rights and ensuring continuity
of HIV services delivery in emergency situations will significantly contribute
to Malawi reaching the 2030 targets.

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Transformational change in the HIV response in Ghana is needed in the folowing areas:
- Removing legal barriers and scale-up access to justice: Current legislations penalize same-sex sexual relationships and sex work. Also, a new anti-LGBTIQ+ bill attempting against the Humar Rights of LGBTIQ+ people is being discussed at parliament. Also, the different mechanisms to report HR violation and abuses against PLHIV and key populations must be improved to provide support and real resolution to reported HR violations.
- Ensuring sustainability of HIV response: Government and national partners need to work in increasing domestic investment in the HIV response to be able to achieve sustainability in a short or mid-term. Supply chain of medicienes and commodities, efficiency in spending, allocation of more government funds, and also transparency in the use of funds are critical areas to work.
- Empowerment of AGYW: Gender inequality and gender violence remain as a challenge in the country. Empowerment of AGYW and strengthening of their advocacy skills will be a game changer in the HIV response. The HIV prevalence in AGYW is higher than the one in men.
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In Tunisia, transformational change will be needed in two areas : allowing a safe legislative environment through eliminating punitive laws addressing key populations : this will very quickly allow a greater access of these to testing and prevention and care services. Transformational change will also be needed in decentralizing treatment and in particular generalizing community based service provision. It is transformational as it will need going beyond the actual rules and that it will need creative ways of involving and empowering communities and mobilizing partnerships.

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In Morocco, there are several areas in the HIV response where transformational change is most needed. These areas align closely with the broader social, economic, and health challenges the country faces.

Reducing Stigma and Discrimination: It is paramount to address the persistent stigmatization and discrimination against key populations and vulnerable groups. Many individuals living with HIV/AIDS are subject to social rejection, violence, and other forms of discrimination. It is crucial to implement comprehensive measures aimed at educating the public, reducing stigma, and promoting acceptance and understanding.

Access to Prevention and Care Services: Inequity in access to HIV prevention, treatment, and care services is another significant issue. The country needs a robust strategy that aims at expanding the reach of these services to all regions, with a particular emphasis on rural and underprivileged areas.

Economic Independence of Women and Young Girls: A vital component of the HIV response is the empowerment of women and young girls through economic independence. Many women and girls are vulnerable to HIV infection due to economic dependencies, gender-based violence, and inequalities. Therefore, efforts should be made to provide them with educational opportunities, vocational training, and access to the job market, which will not only decrease their vulnerability to HIV infection but also contribute to the overall development of the country.

To bring about transformational change in these areas, a multi-sectoral approach is required that involves government institutions, non-governmental organizations, healthcare providers, and community leaders. Collaboration and coordination among these actors can help ensure the successful implementation of strategies and policies that are aimed at these areas.

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Decriminalization of sex work through the repealing of harmful punitive laws affecting sex workers is most needed in South Africa for sex workers to be able to work in a safe and secure manner. Specifically, repealing the Sexual Offences Act of 1957 and Section 11 of the Criminal Law (sexual offences and Related Matters amendment act of 2007 that decriminalize the sale and purchase of adult sexual services. Decriminalisation of sex work, including decriminalisation of both selling or buying sex, will have a transformative change on the health, safety and wellbeing of sex workers, including decreasing the risk of violence perpetrated by clients, police and other third parties. Evidence strongly shows that decriminalization of sex work is associated with a reduction in HIV infection rates when sex worker’ rights are respected, protected and fulfilled, enabling sex workers to organise themselves within their communities, protect themselves from violence, force and exploitation, demand safer sex from their clients, and have access to health information services and commodities. The COVID-19 pandemic highlighted these vulnerabilities acutely, disproportionately affecting people such as sex workers who are already criminalized, marginalized, and living in financially precarious conditions, outside of social protection mechanisms.

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Addressing stigma & discrimination across society including in healthcare settings, by political and community leaders (e.g. religious leaders), policy makers and even within the UN system.

Empowerment and meaningful engagement of KPs and CBOs, who should be part of evidence-informed decision-making.

Fostering and facilitating multisectoral alliances and collaboration to address intersecting inequalities, root causes of HIV-related vulnerabilities, and basic needs of PLHIV and KPs.

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We will make a significant progress towards controling the epidemic if the key populations in general, and the female sex workers, in particular, can made their voice heard at decision making levels.
Sex work is not criminalised in Mozambique, but police often target sex workers through other laws. For instance, public decency laws around what is acceptable to wear in public or the law that requires people to carry identity cards are used as the basis for arrests. The relationship between sex workers and health providers can also be difficult, with many sex workers complaining of poor treatment, discrimination and abuse.

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- Community led response: In Chad, AIDS response is mostly implemented by government institutions with few civil society organizations therefore remaining far behind the target of 30-80-60. A meaningful engagement of community, key populations organizations, PLHIV network and civil society is paramount to end the epidemic by 2030.

- Removing social and cultural barriers and reducing stigma and discrimination: social and cultural barriers prevent people to access health resources particularly women and children. Key populations face stigma and discrimination that prevent them accessing prevention, treatment and care services.

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David in India - Inequalities and community engagement

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David in India - Inequalities and community engagement

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Government financing of community-led interventions. India currently finances 96% of the HIV response through domestic government financing. A substantial part of the community-led interventions, particularly in prevention services/activities remain externally supported.  We need a transformational approach to look at ways / new approaches / mechanisms that will protect this dynamic approach as HIV is transitioned back into the mainstream health system.

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In Malaysia, transformational change is needed in addressing inequalities. Despite the country having adequate health care services in KL, the same health care isn't seen in more remote areas, like Sabah. There are varying degrees of access to education, finance, livelihood. This is exacerbating the ability to provide and access HIV services to those most at need.

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In Rwanda transformational change would be for the parliament to accept and adopt the use of condoms/contraceptives for young people age 15. This will contribute to reducing HIV and STIs transmission as well as teen pregnancy. Adolescents education and awareness raising on the same is critical for uptake. Parents and Community mobilization is key for this to work to be effective.

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1- Creating conducive judiciary environment which guarantee the rights for all
In Mali, stigma and discrimination against key populations and minorities are still high because the society is largely conservative.  The same sex is forbidden even if there is no law regarding this subject. The age of consent for testing is 16 years.  All these factors have a negative impact on the HIV response.
2- Removing the cultural barriers
The testing rate for pregnant women  who attend prenatal consultation is low (around 35%) because of the cultural barriers as women are afraid to go for testing as she can be stigmatized if she is tested positive.
3. Combatting the harmful practices: Female genital mutilation and early marriage are still persistent and threaten the health and well-being of girls and women.

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Removing societal impediments for the equality, resilience and health of females: Social norms do not favour the female gender and result in inequalities in access to resources, education and information, sexual and gender based violence that increases their vulnerability to HIV. Changing social norms will require concerted efforts in engaging opinion leaders such as religious, political and traditional.
Removing legal barriers criminalizing sex work and same sex: The laws in the country that criminalize sex work and same sex result in stigma and discrimination of these populations sometimes with physical harassment, persecution by law enforcers, internal stigma, negative attitudes of health workers etc all of which impact the uptake of health services and drive these populations underground. This will require continued engagement of the parliamentarians and the Justice, Law and Order Sector.

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1.       Human Rights. Both Togo and Benin have HIV laws in place that can with minor reforms be considered as sufficient. However, there are many other laws that are restrictive and even punitive for key populations and adolescents. In Togo, we did in 2020/21 an assessment of existing laws to determine where there are flaws in existing laws. National legislative and government partners are somewhat reluctant in both countries, fearing that proposed changes may be used by some people in society to create havoc which may be detrimental to advances made. So, we must navigate that carefully but with determination. Benin maybe it a bit more promising.

2.       Gender. Many African societies still have gender norms where women are generally subordinate in public and in private life. As well Benin and in particular Togo (with a woman prime minister, a woman as president of the parliament and a notable increase of female parliamentarians) progress has been made over the last years. Togo is one of the best-ranked African countries in terms of gender environment, but both countries still need a lot of work. We did a gender assessment in Benin, in Togo that still needs to be done.

3.       Social inclusion. As well Togo as Benin have written this in their development plans. Both countries are engaging in Universal Health Coverage. In both countries, we did an assessment ‘Social protection and HIV’ in the last two years. Results show that there are major problems. Benin as a HDI of 0,545 and ranks 158 and Togo 0,515 and ranks 167 (out of 189). So, poverty is ramping with an estimated poverty rate of 38,5% in Benin and 53,5% in Togo. So, there are huge economic inequalities that leave a lot of people behind.

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Decriminalization of same sex relationships amongst consenting adults. The crime of buggery has been in existence since the 1800s and this has been cited as a major challenge for LGBTIQ+ people access services for fear of stigma and discrimination and violence associated with it.

A transformative change will certainly occur when there is legal reform that prevents discrimination on the basis of sexual orientation and gender identity and sexual characteristics. Such a transformation will lead to the promulgation of non-discriminatory and protective legislation for marginalized key populations to improve their access and uptake of critical health services to improve their health and wellbeing.

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Alberto A Stella, MCO Southern Cone Countries

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Alberto A Stella, MCO Southern Cone Countries

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In Paraguay, the levels of stigma and discrimination towards the key and most vulnerable populations, especially LGTBI and sex workers, is very significant, being the factor that most hinders progress in the HIV response. The conservative and anti-right groups have economic resources and manage, through mass communication, to install their ideas in society. A transformative process is fundamental that, based on the evidence of experiences in other countries, shows society and governments the importance of the universality of human rights as a fundamental element for sustainable development. A process that generates changes in the legal legal framework is necessary, but above all in society towards a culture of rights and inclusion as a necessary condition for peaceful coexistence and development. The evidence must be the only ethically valid element on which to base the discussions of this process, evidence that shows that societies that are founded on law, inclusion and respect for diversity in all its expressions, have a greater social development. and better innovation rates.

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It is estimated that there is a total of 30 890 people with HIV in the country.
88% know their diagnosis (91% men and 87% women), 73% are on antiretroviral treatment (85% men and 67% women), and 60% have viral load suppression (78% men and 61% women). These figures show that women with HIV face greater challenges and disadvantages in accessing comprehensive HIV care.
In addition, the history of violence in Guatemala, the current prevalence of gender-based violence and the inequalities and imbalances in gender relations that persist in the country continue to be a major factor of vulnerability associated with the HIV epidemic.