Participatory approaches to reaching the Sustainable Development Goals: Monaco: “Vers Monaco sans sida”: an integrated policy on HIV/AIDS

Participatory approaches to reaching the Sustainable Development Goals: MONACO “Vers Monaco sans sida”: an integrated policy on HIV/AIDS 2Participatory approaches to reaching the Sustainable Development Goals Key messages In developing integrated HIV/AIDS policy, it is important to consider the following measures. „ Pool all actions under a common goal to increase overall effectiveness. The successful implementation of an integrated HIV/AIDS policy calls for the participation of people from all parts of society, and the convergence of all actors in the fight towards a common goal. Creating a feeling of collectivity increases the scope and effectiveness of such a policy. „ Involve civil-society organizations from the outset. Civil-society organizations represent an entry point to the general public that governments may not have. In Monaco, the strong involvement of nationally and internationally established associations has helped ease access to the general public and gain the trust of the target populations. Their involvement makes it possible to step up prevention, support and assistance activities. „ Stay active in international HIV/AIDS networks. Being part of international HIV/AIDS networks has been invaluable to Monaco. Benefiting from their expertise fosters new and innovative dynamics and allows ideas to emerge that can be used in policy-making. „ Ensure financial coverage of people at high risk for HIV/AIDS. Doing so can help curb the spread of the disease. In Monaco, health insurance covers pre-exposure prophylaxis (PrEP) for persons at risk and is financed by public social-security funds for high-risk populations. For such a policy to work, health-insurance funds should cover the full cost of HIV/AIDS treatment to be sure that no one is left behind (1). © @ fi g h taid sm onaco © @ fi g ht ai d sm o n ac o 3MONACO Summary Monaco has been implementing an integrated policy on combating HIV/AIDS since 1988 and continues to expand it. The policy has resulted setting up a free, anonymous screening centre, organizing prevention and screening campaigns in schools and businesses and through the media, and mobilizing civil society through associations, such as Fight Aids Monaco, which is chaired by H.S.H. Princess Stéphanie in partnership with the public authorities (2,3). In 2018, Monaco became a member of the Fast Track Cities network (4) and signed the Paris Declaration ”Vers Monaco sans sida” [“Towards Monaco without AIDS”] (5,6), committing to the pursuit and implementation of new action towards achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of 90-90-90 treatment for all to help end the AIDS epidemic (7). It is hoped that “Towards Monaco without AIDS” will surpass its objectives. Monaco’s integrated policy to combat HIV/AIDS mainly addresses Sustainable Development Goal (SDG) 3 (good health and well-being), specifically target 3.3, “…by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” (8). It also covers four of the five strategic directions of the Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well- being, namely: 1. advancing governance and leadership, by working towards making links between all relevant stakeholders; 2. leaving no one behind, by opening up access to screening and treatment for all and focusing on providing support and social follow-up for patients; 3. preventing diseases and promoting a multisectoral and lifelong approach with the involvement of stakeholders from different sectors, as well as starting early, targeting youth; and 4. strengthening the road to universal health coverage by offering free-of-charge services for all (9). Motivation For many years, the fight against HIV/AIDS has been a priority concern of the Government of Monaco. According to HIV/AIDS surveillance in Europe 2018 (10), Monaco currently has no new cases of HIV/AIDS. Having obtained good results in terms of prevention, and since there is always a risk of the emergence of new infections, Monaco has embarked on measures to strengthen its HIV/AIDS control policy and reach an even higher level of vigilance. 4Participatory approaches to reaching the Sustainable Development Goals “Towards Monaco without AIDS” – strengthening the national policy to combat HIV/AIDS The national policy to combat HIV/AIDS is built around three main lines: prevention, screening and treatment. Specifically, this translates to the requirements that: 90% of people with the disease must be diagnosed; 90% of those diagnosed must be on treatment; and 90% of those on treatment must have an undetectable viral load. The continuous strengthening of prevention activities has been a major component of the policy in the past few years. Increasing the number of partners and activities and including a variety of stakeholders in its implementation have also been important measures. Stakeholders include: the public authorities (through the Directorate of Health Action); the Directorate of National Education, Youth and Sports; civil-society associations, such as Fight Aids Monaco and the Monegasque Red Cross; health professionals (including doctors and pharmacists working in the City of Monaco and professionals working in public hospitals, nursing training institutes, and medical biology laboratories) and the local media. It is important to note that, owing to the country’s small size, there are close links between the public authorities and the health professionals working in the prevention or treatment of HIV/ AIDS. This allows the health professionals to make recommendations that ultimately influence policy. Prevention Information and communication are essential to raising public awareness about good practice in the prevention of HIV/AIDS. Many of these actions are carried out in school settings, through the media and at the municipality level. Information sessions, regularly organized in schools for young people by relevant associations, are essential for raising public awareness about the disease. These interactive events have been well received by the target audience and the forum they provide for asking questions has helped dispel the many prejudices about the disease. Awareness-raising is also tackled through the media and at the municipality level through numerous campaigns, such as those organized by the Government of Monaco, the City of Monaco and Fight Aids Monaco. These prevention campaigns aim to reach the entire Monegasque population and go beyond putting up posters in towns, companies and public administrations, and distributing information in newspapers. Television programmes and radio spots are also used to spread the word. One example is “Jungle Fight”, a live programme on AIDS prevention, which Radio Monaco broadcasts each month when prevention stakeholders (doctors, representatives of associations) and listeners are invited to express their views on the subject. Another example is a programme specially broadcast on World AIDS Day when dedicated conferences and debates led by health professionals are also held. The local television channel, Monaco Channel, also broadcasts information about the work being carried out in the prevention of AIDS. One of the measures taken to meet the commitments of “Towards Monaco without AIDS” (5,6) was the communication campaign on the theme, “Undetectable = Untransmissible”, launched on 5MONACO 1 December 2018. Its aim was to change public perception of HIV transmission and encourage early and regular treatment. The campaign, which was part of the international Prevention Access Campaign, was led by health professionals, researchers, media managers, journalists, lawyers, and representatives of associations (11,12). Monaco’s AIDS/HIV prevention policy is also reflected in the establishment of a network of condom distributors in the City of Monaco and the availability of substitution maintenance therapy for drug users, who represent the second-largest mode of transmission of the disease. Screening The Monegasque Screening Centre, which has a long-standing commitment to prevention, organizes individual, anonymous screening for HIV infection, other sexually transmitted diseases and hepatitis free of charge. These services are open to both residents and non-residents. Monaco’s recent participation in the Fast Track City network (4) puts a spotlight on the vast number of health professionals involved in HIV/AIDS screening in the country (doctors and professionals working in medical-biology laboratories and public health establishments) through information posted on the internet, including the UNAIDS website. Organized civil society has played an important role in the prevention, screening and treatment of HIV/AIDS. Fight Aids Monaco is authorized to carry out rapid diagnostic tests and regularly organizes “test-in-the-city days” during which free tests are carried out in strategic, visible locations, such as shopping centres, bar and restaurant exits, or busy city streets (13). These test opportunities help raise public awareness of the problem of HIV/AIDS. Treatment Treatment is provided directly at the Princess Grace Hospital Centre, Monaco’s public hospital, and caters for the needs not only of residents, but also of people living in neighbouring French towns and the approximately 100 000 people who contribute to the Monegasque social-security system but do not live in Monaco. All treatments are covered fully by health-insurance agencies and are available regardless of patient status and condition (age, gender, sexual preference, drug user or non-drug user). In addition, substitution treatment is provided for drug users. People receiving treatment also benefit from comprehensive and adapted psychological care and medical-psychosocial support, which are provided by health professionals and associations that run activity groups related, for example, to theatre, yoga, meditation, discussion, cultural outings and sports. Impact Action taken to meet the commitments of “Towards Monaco without AIDS” (5,6) is bearing fruit. HIV-infection monitoring data show a controlled epidemic with very low numbers of new HIV infections (between 0 and 1 per year) over the latest 10-year period (10). 6Participatory approaches to reaching the Sustainable Development Goals Monaco aims to maintain these results and a high level of prevention by continuing to strengthen communication and prevention measures with a focus on young people, targeting teenagers in schools and young adults in general. In 2018, a night “test-in-the-city” screening campaign was carried out to reach young people during their evenings out. Increasing the number of people screened is also essential to ensure that all infected people receive the treatment they need and to minimize transmission. Given the importance of the disease in terms of public health, the public authorities monitor HIV/AIDS closely every year with a view to adapting policies in this area as effectively as possible. Lessons learnt Monaco’s experience in implementing ”Towards Monaco without AIDS” (5,6) has resulted in valuable lessons to share with other countries that have similar programmes. Most importantly, good results should not encourage the public authorities to be less vigilant in the fight against HIV/AIDS. In Monaco, to stay on top of the HIV/AIDS epidemic, it will be necessary to continue or increase action and ensure the necessary human and financial resources to fulfil the commitments of “Towards Monaco without AIDS” (5,6). Monaco’s integrated policy to combat HIV/AIDS has indeed led to a very low level of new infections, but the epidemic is still present. The three new cases of HIV infection detected in 2017 serve as a reminder of this (10). The policy should also be able to pick up on behavioural or lifestyle changes in the population that might put people at a higher risk for infection. In Monaco, the emergence of high-risk behaviour, such as having multiple sexual partners, in combination with drug use and failure to use contraception, can increase new infections. To be effective, it is essential that national HIV/ AIDS policies be adapted to take such behavioural changes into account. References1 1. Fiche info. Truvada [Info sheet. Truvada]. In: Base de donné publiques des medicaments [website]. Paris: Ministère de la Solidarité et de la Santé; 2019 (http://base-donnees-publique.medicaments.gouv.fr/ extrait.php?specid=69481664, accessed 23 February 2019). 2. Ordonnance n. 3.836 du 05/07/2012 portant creation du entre Monégasque de Dépistage [Sovereign Order no. 3.836 of 05/07/2012 establishing the Monegasque Centre for Screening. Monaco: Official Journal of Monaco; 2019 (https://www.legimonaco.mc/305/legismclois.nsf/ViewTNC/ A8026A5358A18036C1257A3E00313DD1!OpenDocument). 3. 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Déclaration de Paris “Vers Monaco sans sida” [Paris Declaration “Towards Monaco without AIDS”]. Monaco: Fight AIDS Monaco; 2018 (http://www.fightaidsmonaco.com/wp-content/uploads/2018/07/ D%C3%A9claration-sign%C3%A9e.pdf). 7. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. In: UNAIDS [website]. Geneva: Joint United Nations Programme on HIV/AIDS; 2019 (http://www.unaids.org/en/ resources/909090). 8. Sustainable Development Goals. In: Sustainable Development Goals Knowledge Platform [website]. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/?menu=1300, accessed 14 March 2019). 9. Roadmap to implement the 2030 Agenda for Sustainable Development, building on Health 2020, the European policy for health and well-being. Copenhagen: WHO Regional Office for Europe; 2017 (http:// www.euro.who.int/en/about-us/governance/regional-committee-for-europe/past-sessions/67th- session/documentation/working-documents/eurrc679-roadmap-to-implement-the-2030-agenda-for- sustainable-development,-building-on-health-2020,-the-european-policy-for-health-and-well-being). 10. HIV/AIDS surveillance in Europe 2018. 2017 data. Copenhagen: WHO Regional Office for Europe; 2018 (http://www.euro.who.int/__data/assets/pdf_file/0004/386959/HIVAIDS-surveillance-in- Europe-2018.pdf?ua=1). 11. About. In: Prevention Access Campaign [website]. Prevention Access Campaign; 2019 (https://www. preventionaccess.org/about, accessed 25 February 2019). 12. Fight Aids Monaco launches its “Undetectable = untransmittable Campaign”. In: News [website]. Monaco: Government of the Principality of Monaco; 2019 (Neehttps://en.gouv.mc/A-la-Une-du- Portail/Fight-Aids-Monaco-Launches-its-Undetectable-Untransmittable-Campaign). 13. Arrêté ministériel n. 2012-264 du 27/04/2012 fixant les conditions de réalisation des tests rapides d’orientation diagnostique de l’infection à virus de l’immunodéficience humaine (VIH 1 et 2) [Ministerial Order No 2012-264 of 27 April 2012 laying down the conditions for carrying out rapid diagnostic tests for human immunodeficiency virus infection (HIV 1 and 2)]. Monaco: Official Journal of Monaco; 2019 (https://www.legimonaco.mc/305/legismclois.nsf/ViewTNC/ FD05B83A96E68CD1C1257A0700316701!OpenDocument, accessed 23 February 2019). Coordinated and reviewed by: Bettina Menne (Coordinator, Division of Policy and Governance for Health and Well-being, WHO Regional Office for Europe) and Francesco Zambon (Coordinator, Investment for Health and Development in Healthy Settings, WHO European Office for Investment for Health and Development). Authors and contributors: Alexandre Bordero (Director of Health Action, Monaco); Delphine Lanzara (Section Chief, Department of Health and Social Affairs, Monaco); Julie Malherbe (Administrator, Directorate of Health Action, Monaco); Chloé Petruccelli (Secretary for External Relations, Department of External Relations and Cooperation, Monaco) and Leda E Nemer (Consultant, WHO European Office for Investment for Health and Development, Division of Policy and Governance for Health and Well-being). Cover: © UN Photo/Cia Pak and © UNHCR/S. Baldwin © World Health Organization 2019 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. 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