GAIN Issues Brief No.5
August 1st, 2005Overview
1) A high-level meeting of the United Nations General Assembly is planned for June 2 2005 for an interim technical review of the goals set out by the Declaration of Commitment (DoC), adopted by the UN General Assembly Special Session on HIV/AIDS (UNGASS) in 2001. The DoC has become an important benchmark in the cause of AIDS activism not least because it was the product of the first meeting of the General Assembly solely on HIV/AIDS (and, indeed, solely about a disease), but because the recommendations- divided into sections on leadership, prevention, care, support and treatment, human rights, reducing vulnerability, orphans and vulnerable children, social and economic impacts, research and development, conflict and resources- represented a series of achievable goals that both set the activist agenda, and gave realistic targets to work towards. The review will probably outline modest progress on the goals, with some- leadership, research and resources- due for praise, and some- reducing vulnerability, orphans and vulnerable children, and conflict- probably showing declines in progress since 2001. The outcome of the meting, and especially the production of anything as critical as the Declaration of Commitment, will be one of the major events to watch in the next few months.
2) Also on the immediate agenda for the United Nations is the Security Council debate on AIDS as a threat to global security, and a review of Resolution 1308, which focuses mainly upon armed forces, and particularly peacekeepers (as these fall under the remit of the Security Council.) UNAIDS is working on a report on the subject to be submitted shortly to the Secretary-General. A lot of issues arise from peacekeeping operations- the largest being funding and testing- and these need to be followed up. Resolution 1308 is often cited as the first time the Security Council debated HIV/AIDS as a security issue. While this is true, some may feel that it’s narrow focus on peacekeepers on UN missions needs to be expanded, and will look to the report to provide other recommendations in addition to this.
3) The annual World Health Organisation’s World Health Report 2005 has been launched. It details modest progress in achieving world health goals- and some setbacks- but notes that the most worrying new global health trend is the persistence of high child mortality rates in less-developed countries, for which HIV/AIDS can be seen as a significant contributor. About 6-8% of child deaths in Africa are directly attributable to paediatric AIDS, with diseases such as cholera, malaria, measles and tuberculosis contributing to larger numbers of deaths. This disguises, however, the deterioration in care and nutrition of children that are indirectly related to HIV/AIDS through greater burdens put on the family and community by HIV/AIDS, and the raised incidence of child mortality due to these factors. High child mortality rates indicate that mother-to-child transmission of HIV/AIDS remains a real problem; and the report states explicitly that the progress on the MDG of reducing child mortality is generally improving in most world regions, but that progress, measured globally, is static or getting worse just because of the poor situation in Africa . High child mortality remains a benchmark indicator of the effects of HIV/AIDS, as not only does it reflect high levels of infection, but also lower levels of development, which can be caused by HIV/AIDS. The report is at: http:/www.who.int/whr/2005/en/index.html
4) A new report from ActionAid, ‘ Square pegs, round holes, and why you can’t fight HIV/AIDS with monetarism’, launches a useful explanation and critique of the paradox whereby the less-developed, and especially highly-indebted, nations are encouraged to scale-up HIV/AIDS programmes, but the funds needed to be spent to do this are vetoed because they would represent increases in governmental spending that would compromise IMF anti-inflationary policies. The report finds that even if all less-developed nations were on course to meet the Millennium Development Goal’s targets by 2015, IMF caps on public spending would prevent these being achieved. The report articulates the concern held by many that low-inflation economic growth, while desirable, is only factor that contributes to economic development; and that this neo-liberal economic orthodoxy discounts the contribution of any other factors, such as a healthy or well-educated population, in the process of development. The specific argument on HIV/AIDS is that the unique social effects of the epidemic constitute greater long-term harm to an economy, than the short to medium-term effects of inflationary economic growth. The report can be accessed at: http://www.eldis.org/cf/search/disp/docdisplay.cfm?doc=DOC18436&resource=f1
GAIN Consultation, April 2005
5) A consultative meeting of the African Civil Society Governance and AIDS Initiative (GAIN) was held in Abuja , Nigeria , April 26-27 2005, consisting of twenty-two members of the GAIN core group, new GAIN partners, and specially invited Nigerian partners, hosted by the Open Society Initiative. Its purpose was to lead thematic discussions and review sessions on the research activities of different GAIN members, to set and review research priorities for the group, and to discuss the broad strategic direction of the coalition.
6) As a prelude to the meeting, and as a recognition of the unique opportunities offered in hosting the session in Nigeria , an interactive seminar was arranged by the GAIN partner Centre for Democracy and Development on HIV/AIDS and governance in Nigeria ; in which GAIN partners met in round-table forum with local, Nigerian-based NGOs. After presentations of GAIN research on conflict (Justice Africa), and on medical professionals and drugs (Open Society Justice Initiative) the sessions was turned over to invited participants to discuss and share their approaches to and problems in their work.
* The first issue to emerge was from Community Action for Popular Participation, which felt that the monitoring of the epidemic in Nigeria was insufficient. In particular, the lack of care made by medical professionals in reporting rural incidence meant that statistics, even when accounting for an urban bias, still maintained one.
* In Nigeria , The Women’s Environmental Programme felt, the Federal Government’s energies were directed too much at prevention, in which progress is being made in the media, and very rarely on services for people living with HIV/AIDS (PLWA).
* The Society for Community Development, Abuja , saw corruption as the major problem blocking action on HIV/AIDS in Nigeria . Corruption in both the government, and the United Nations organisations, in both giving and receiving bribes, prevented effective coordination, hindered capacity, prevented government commitment, and created inequality and recrimination in the distribution of drugs.
* ActionAid stated that a lack of transparency and accountability hindered action on HIV/AIDS, with funds diverted and disappearing from programmes, which leaves projects unfunded, and donors cautious in providing further funding.
* The religious angle in Nigeria , as seen by Caring Hearts Abuja, was being promoted by a concerted church campaign to persuade couples marrying to take HIV tests. This is only an effective measure if education comes before it, and it needs promoting especially in rural areas.
A full transcript of the consultation accompanies this briefing, and includes the resolutions agreed upon for action by Nigerian NGOs. These issues are of ongoing relevance and importance to GAIN; and if any individuals or organisations that receive this briefing would like to add their comments to these, please do contact Justice Africa by return email, or through our website www.justiceafrica.org.
Clingendael Conference on AIDS, Security and Democracy, May 2005
7) A major initiative to gather together leading academics, policy-makers and activists working in the field of the political and social response to HIV/AIDS, met under the auspices of the Clingendael Institute in the Hague, 2-5 May 2005, sponsored by the Dutch Ministry of Foreign Affairs, Harvard University, the Social Science Research Council, and UNAIDS. The high-level panel discussed issues relating to HIV/AIDS, security and democracy in seminar session, and then opened up their conclusions to a wider array of policy-makers, with the aim of structuring, and providing intellectual impetus to, these issues, and discussing at the highest levels strategies for moving HIV/AIDS away from the medical arena, and into the social and political arenas. The seminar was attended by Justice Africa, and other members of the GAIN core group, and made recommendations in the areas of the military, security, gender, governance and participation, and international governance. The Dutch government is preparing to launch a Global AIDS, Conflict and Security Initiative, as a permanent body to address the issues raised at the conference, and further progress on this will be detailed in future GAIN briefs. The report of the findings and outcomes of the conference accompanies this briefing.
4: West Africa Update
8) As part of an ongoing focus by GAIN on HIV/AIDS on West Africa , it is appropriate to review the progress of work there. The April 2005 GAIN consultation held in Abuja threw up one major complaint, echoed elsewhere, that the West African epidemic seems to be ignored, and West African NGOs and activists have a more difficult time securing funds and support, and coordinating between themselves, than elsewhere on the continent. The issues of real concern in West Africa can be broadly reduced to 1) The lingering impression that the West African epidemic was less severe than that in southern Africa , a legacy of higher levels of HIV-2, the less virulent strain, than HIV-1. General intermixing and adaptation of the virus in the region has generally made this argument moot; but the impression remains. 2) High levels of social dislocation, population displacement and conflict in the region, which hinder monitoring programmes, change social understanding of the region, and produce new vectors for the transfer of HIV/AIDS. 3) The Nigerian epidemic generalising in a population of 130 million, which has meant 2 million cases of HIV in that nation alone; the fourth highest national total in the world. 4) Large intermixing of people due to good communication routes, economic integration, and fairly prosperous economies.
9) What is the epidemiological situation in West Africa ? The UNAIDS Epidemic Update of December 2005 made a point of stating that Africa should no longer be seen to have one epidemic, but several separate regional and even sub-regional epidemics, and that the West African epidemic seems to have stabilised at below generalised-levels in most, and especially Sahelian, nations, and at somewhat above generalised-levels in Côte d’Ivoire, Cameroon and Liberia, where levels are 7%, 6.9% and 5.9%, respectively. This is a good recognition that HIV/AIDS needs regional as well as national and continental attention; given that problems of population movement, healthcare resources, political stability and economic development cut across borders, so tackling HIV/AIDS solely at either national or international levels can leave the impression of atomisation or, alternatively, incoherence.
10) Where the UNAIDS approach fails, however, as outlined in GAIN Briefing Four, is in its unusually broad idea of what ‘West Africa’ is. UNAIDS includes in its region Mauritania , Chad and the Democratic Republic of Congo; or, put another way, that area of land including all points between Algeria and Zambia . While giving progressive approval to the idea that HIV/AIDS activism needs a regional face, claiming that West African prevalence is stabilising is unfair of UNAIDS. As GAIN has pointed out, HIV/AIDS in West Africa proper (membership of ECOWAS is a much better guide) is still of growing concern, and the presence of the world’s largest number of armed conflicts, and some of its worst humanitarian crises, in or bordering that region, must make West Africa a cause for real concern for policy makers.
11) The major security situation continues to be Côte d’Ivoire , which has gone from a regional position of prosperity in the midst of disorder, to civil war in the midst of reconstruction. The recent South African-brokered peace agreement has allowed progress where the RPR party’s Alassane Ouattara, who was not born in Côte d’Ivoire , will be allowed to contest Presidential elections in June, and both government and rebel forces have agreed to disarm in a zone either side of the UN controlled front line that separated Côte d’Ivoire . The deal has effectively prevented either the government-backed programme of Ivoirité, or the excluded rebels, to come out of the conflict victorious, so it remains to be seen whether the concessions on both sides will be enough to forge a peaceful, one-nation, Côte d’Ivoire .
12) The epidemiological implications are that it may be possible for a national monitoring system to be re-instituted in Côte d’Ivoire to include the north of the country. Prior to 2002, Côte d’Ivoire posted nearly 11% national adult prevalence; but for the last three years surveillance has been restricted to the south, and has not taken into account the large displaced population (75,971 refugees in 2003, and a total population of concern of 131,931, according to the UNHCR) that includes not only Ivoirian displaced, but also those of other nationalities- particularly Ghanaians and Burkinabe. National surveillance needs to be reinstituted quickly in this previously progressive country, not only for national reasons; but regional too.
Report of the Commission for Africa
13) The long-awaited report of the Commission for Africa , established by British Prime Minister Tony Blair in 2004, was produced on March 17, 2005. The Commission, established to provide a context for the G8 discussions on Africa at Gleneagles, Scotland, in July 2005, are the culmination of a loosely-constructed ‘year for Africa’ celebrating 20 years of Band Aid and a renewed global attention on the continent that is the collective product of Darfur, AIDS, the newly activist African Union, and the tenth anniversary of both the Rwandan genocide and the first free elections in South Africa. The Commission has received much attention and not a little criticism, not least because of the constant repetition that 2005 is a ‘make or break year’ for Africa, which suggests that Africa is doomed should Britain not sort the continent out before January 1, 2006. The report has, controversially, pledged to raise aid levels among the OECD nations to the agreed international target of 0.7% of GDP by 2015; this is in addition to individual pledges of as much as $650bn over the same period.
14) The difficulty in believing these figures for aid, aside from whether one believes they will be so high, is that they don’t seem to match up. First of all, why are both individual pledges needed in addition to the 0.7% target? The target is for ten years hence, but even given yearly increments of progress from the current 0.15%, this would still come to more than $650bn. Secondly, of the $650bn, only $305bn is specifically accounted for, with the remainder being unspecified. The point here is not that a bit of money remains unspecified, there is after all a lot to do, and estimates can never be precise, but that more than half of the money remains unspecified. Having acknowledged the challenge in getting G8 nations- and thereafter all of the OECD- to sign up to the report, the British government are expecting to sell the report as a plan to spend literally hundreds of billions of dollars, donated by nations who would never pass national budgets with so much unaccounted money. Third, no strategy is contained in the plan for how to enforce its recommendations. At the launch, Tony Blair made it plain that Britain would enact its recommendations unilaterally if necessary; increasing Britain’s aid to Africa by more than £1bn per year to fund projects based on plans that require many times that amount of money to work. While the Commission deserves praise for its scope, caution should be advised in expectations for its outcomes.
15) What are the implications for HIV/AIDS of the recommendations of the report? It should be stated that there are a number of good and very specific commitments for HIV/AIDS; including money for the Global Fund and UNAIDS, for the Global AIDS Vaccine Initiative (GAVI), for advance purchase of vaccines, and for other related health programmes; but a number of problems emerge from the report’s approach. First, while calling for an extra $2bn per year for the Global Fund, it offers little opinion on how this is spent, or even on whether non-Global Fund projects could do with the money. Second, and perhaps most critically, while acknowledging that governance is ultimately more important than money, it offers little opinion on what to do about this, and still makes the increase in funding the centre-piece of it’s recommendations. Third, it does not acknowledge that health systems need reform, other than in growing capacity to take more money. Fourth, a confusion in the report’s aims leads it to continually reference the aims of the Millennium Development Goals, which it implicitly acknowledges has failed Africa due to the need for their to be a strategy just for the G8, leading to uncertainty as to whether the report guarantees anything new, or merely promises to do better in meeting targets already committed to. As leading development stakeholders, AIDS activists will be wary of trusting in a document that seems to place limited trust in itself.
16) A longer document on funding, HIV/AIDS and the report of the Commission for Africa can be found in Research Papers.
Recent Developments in Uganda
17) Uganda continues, again, to make the HIV/AIDS headlines. Uganda is repeatedly cited when discussing the fight against AIDS, along with Senegal and Thailand (as is South Africa , although for entirely opposite reasons), but perhaps a re-appraisal of the situation there is needed. The civil war in northern Uganda has raged in various intensity since the NRM seizure of power in January 1986. As a guerrilla-led insurgency against the government, the campaign of the Lord’s Resistance Army gradually faded in the late 1990s and early 2000s as the rule of the NRM became ever more secure, and the Ugandan army became ever more powerful and effective (whether it was more disciplined or professional is more open to debate).
18) The situation, as of early 2003, was assumed to be one of strengthening peace where the Ugandan army, although fond of overstating their strength, was gradually chasing the LRA into extinction in Southern Sudan, since the protocol signed with Sudan in March 2002 that allowed Uganda to mount Operation Iron Fist. In August 2002, President Museveni offered the LRA a number of safe havens in the north where they could assemble, be disarmed and returned to their homes without imprisonment. This was rescinded after the LRA attacked a displaced persons camp near Gulu in February 2004. Despite several attempts at ceasefires, and mediated talks, the policy since has been to continue the military strategy to destroy the LRA, one by one if necessary. This has occurred at the same time as Uganda referring the LRA leaders to the International Criminal Court (ICC)- the body’s first major investigation and indictment process- as part of a new era of Ugandan impatience with the LRA, and pursuit of a twin strategy of ensuring the insurgents never return to civilian life through both the gun and the courts.
19) The epidemiological situation in the north has been the subject of some speculation; particularly as Uganda has been so important in the understanding of HIV/AIDS (not least in understanding how to confront HIV/AIDS). While it is true that southern Uganda is still one of the best epidemiologically-monitored regions in Africa, it was never possible to say this of northern Uganda (any point roughly north of Masindi), and it may be the case that a generally lower rate of incidence in northern Uganda has obscured the fact that surveillance has never been as extensive or as easy as in the more densely populated areas in the south. As such, verifiable declines in incidence in Uganda were much more accurate in the south than the north (which is not to say that monitoring in places such as Arua, Gulu and Kitgum weren’t relatively good compared to sites outside of Uganda , they were just less extensive.)
20) Recently, questions have been asked about the extent to which Uganda can continue trading on it’s reputation of uniquely bringing down it’s rate of incidence. Indeed, figures released recently show that Uganda ’s adult prevalence rate has risen to 7%- very close to the Sub-Saharan African average- from a previous estimate of 6.2%, and technically erasing Uganda ’s reputation, often overstated, as having uniquely produced an independently verified fall in incidence within a generalised epidemic. Critically, the gender gap has widened markedly in Uganda, with a gender-split incidence of 6.0% for men and 7.9% for women, which would show, anecdotally, that AIDS is progressing rapidly enough in Uganda for new social trends to emerge with worrying rapidity.
21) A body of evidence is building to suggest that the effects of the insurgency in Uganda are having a complex effect on HIV/AIDS, with some promotion and some suppression of the epidemic; scotching working assumptions held by many that HIV/AIDS in conflict zones is uniform, and uniformly bad. The current evidence in Uganda suggests that a lot more caution is needed in dealing with HIV/AIDS, especially in areas of conflict or that are home to mass vulnerable populations. Once problems of access are resolved, the Ugandan government is reviewed more critically as source of information, and the media in Uganda reports on HIV/AIDS with as much accuracy as it does openness, then Northern Uganda will be able to add considerably to the understanding of the complicated presence of HIV/AIDS in zones of conflict and massive social disruption.
Global Coalition on Women and AIDS
22) As noted in the last GAIN Briefing, the main result of the 2005 World AIDS Campaign focusing on women was the establishment of the Global Coalition on Women and AIDS. The work and advocacy of the coalition will be important for Africa as the continent is the world region where HIV+ women significantly outnumber HIV+ men, and so by extension, globally, HIV+ women outnumber men because of this (and in most world regions the number of positive women relative to men is growing as well.) From the governance point of view, the long-term gender shifting of the epidemic has a number of effects, both conceptually and in practice. It means, first of all, a vindication of social approaches that examine HIV/AIDS at the household level, rather than just at the macroeconomic. It means, secondly, that HIV/AIDS, and its treatment, is even more dependent upon social justice as the epidemic proves that its effects are both widespread, and will disproportionately be felt among vulnerable groups. It also means, finally, that any lingering notions that HIV/AIDS is still exclusively a disease of homosexual men, or of urban intravenous drug users, and that social and moral responses to the epidemic can proceed from those assumptions, can be put to rest.
23) As part of the global campaign, the United Nation’s Secretary General formed a Task Force on Women, Girls and HIV/AIDS in Southern Africa . The report, published in 2004, found that women and girls are critical in the fight against HIV/AIDS in southern Africa ; and that a successful continental intervention to combat HIV/AIDS will fail unless substantial progress is made for women. The report makes seven major recommendations.
* Tackle the exploitation of young women and girls by older men, including prostitution, sexual trafficking, and economic survival sex; particularly in vulnerable sub-groups.
* Increase female enrolment in school; and prevent their removal due to HIV/AIDS or care for those living with the disease.
* Protect girls and women from sexual and non-sexual violence
* Protect the rights of girls and women to inherit property and land, and so remain financially secure in the event of the death of a father or spouse.
* Establish a ‘Volunteers Charter’ to protect the legal and economic rights of those that provide care to the sick
* Violence, stigma and discrimination must be addressed as barriers to treatment for women and girls.
24) The report can be accessed in full at:
http://www.womenandaids.unaids.org/regional/docs/Report%20of%20SG%27s%20Task%20Force.pdf
25) As part of the mainstreaming of both HIV/AIDS and the campaign for women and HIV/AIDS within the United Nations system, UNAIDS made a statement to the UN Commission on Human Rights’ 61 st session on ‘Protecting Human Rights of Women and Girls.’ The statement made the point that HIV/AIDS is one of the greatest obstacles to achieving sexual equality worldwide, and that women’s rates of HIV infection are rising in every region of the world, even while men’s are falling in many places. The submission judged a lack of equal rights to employment, access to credit facilities, property ownership, social assistance and political participation, as factors contributing to female vulnerability to HIV/AIDS. The Special Rapporteur on Violence against Women, Dr. Yakin Ertürk, reported that violence against women is growing worldwide as both a cause and a consequence of HIV/AIDS. Unequal power relations and stigma are combining with HIV/AIDS in complexes that prevent the progress in social justice and equality that lead to greater social and economic development. In a worrying new trend, Ertürk reported, in many places new infections of HIV/AIDS are becoming common even within marriage, as this institution fails to provide a universal brake on sexual promiscuity and exploitation. Exploitation and sexual violence in areas of conflict were highlighted as of special concern, and the situation in Darfur was listed as a case study visited by the Commission, and providing very troubling evidence of the increase of exposure of women to HIV/AIDS in this conflict.
26) The report, and its recommendations can be accessed at:
http://www.womenandaids.unaids.org/documents/CHR%2061%20statement%20final1.pdf
