GAIN Issues Brief No.6
October 1st, 2005Overview
1. Several high-profile long-term review processes have occurred in recent months. The United Nations General Assembly made a four-year review of the Declaration of Commitment (DoC) made at the Special Session on HIV/AIDS (UNGASS) in June 2001. UNGASS was proposed by several groups, notably the International Council of AIDS Services Association (ICASA), to encourage progress on the Millennium Goal of halting and starting to reverse the AIDS epidemic by 2015. The news is that since 2001, there has been regress on this goal, with larger numbers of people living with HIV/AIDS worldwide, and with little indication that global growth will have slowed and declined in ten years. On a positive note, what small but significant progress can be seen is seen in Africa, where in nations such as Mozambique, Senegal and Tanzania, there are some indications the epidemic is slowing down. This is attributed to official AIDS efforts, but other possible causes are not examined. The report also notes good progress in the expansion of funding since 2001, as well as in the numbers of people being tested. This falls way short, however, of the target of a 25% reduction globally of the numbers of young people- 15-24, living with HIV. The press release may be accessed at: www.unaids.org/NetTools/Misc/DocInfo.aspx?LANG=en&href=http://gva-doc-owl/WEBcontent/Documents/pub/Media/Press-Releases03/PR_UNGASS_02Jun05_en.pdf
2. The Third International AIDS Society Conference on HIV Pathogenesis and Treatment was held in Rio de Janeiro in July. In the keynote address to the conference, Stephen Lewis , Special Representative of the United Nations Secretary General for AIDS in Africa, made a sombre, and at times downbeat, plea to the scientific community to become more activist in their search for new vaccine developments and drugs to combat HIV/AIDS. In typically rhetorical style, Lewis told delegates “I am neither a scientist nor an expert. I am an observer. I have spent the past four years travelling throughout Africa, and primarily southern Africa , watching people die. I think I understand, better than most, why your collective scientific and academic work can be said to be the most important ongoing work on the planet…I beg you to never underestimate that authority. And I beg you to use it beyond the realms of science.” One of the most notable presentations at Rio was that by INSERM, a French research institute, which has run the first ever random-controlled trial (RCT) in South Africa on the effect of male circumcision on transmission of HIV/AIDS. The study found that there was a verified 65% reduction in HIV transmission for circumcised males in the test group against the whole control group, and a 75% reduction when circumcised males were excluded from the control group. This in a cohort taken from a population base of 31.6% adult infection. The results from the trial have been so overwhelming, that the trial has been halted early, and all participants offered circumcision as a method to prevent HIV transmission.
3. The UN Security Council was briefed on July 18 by Peter Piot, Executive Director of UNAIDS, on the progress of the work enacted in response to Resolution 1308, passed in July 2000. The session that led up to Resolution 1308 has been famously described as the first time that a single disease has been debated by the Security Council as a threat to international peace and security. The review marked the launch of the UNAIDS report ‘On the Front Line’, detailing UNAIDS’ experience in implementing 1308, as well as it’s further recommendations. Addressing the Council, Piot said, “Although we have made significant inroads in educating peacekeepers and national uniformed services about the risks of HIV, AIDS is still not a core part of military business everywhere”.
4. The UNAIDS report is upbeat about the progress made in recent years, including implementing 53 national programmes worldwide to assist uniformed services, providing technical services to military and police forces with various competencies and resources in combating HIV/AIDS, and establishing educational extension programmes and training initiatives. Centrepiece of these is the recent invitation by the government of India to perform these services for it’s 1.3m-strong armed forces. UNAIDS points out that, understanding and progress still fall short of what is needed. At stake are the ability, and crucially the legitimacy, of peacekeeping operations to occur, given the dangerous politics of perception that surround the issue of whether peacekeeping operations help or hinder the fight against HIV/AIDS. However, the UNAIDS report and the Security Council debate revealed as much about the political constraints on dealing with this issue, as about AIDS and international security itself. UNAIDS had commissioned a research study from LSEAIDS preparatory to the Council session, in fulfilment of its promise to present an ‘evidence-based report’. The LSEAIDS study was not in fact presented. It seems that the sensitivities of certain states, including China and Russia , hinder frank discussion of the issue. It is also unclear whether UNAIDS possesses the capacity and mandate to deal with the broader issues of AIDS and security or is restricted to addressing the question of HIV and peacekeepers. For these reasons, the Security Council debate yielded nothing new.
5. As an immediate outcome of the British Government’s Commission for Africa, the British government will be hosting the final round of the Global Fund for AIDS, Tuberculosis and Malaria replenishment process in London in September. What is on the agenda? Most important is to fill the funding gap. The funding gap is straight forward, the amount of money the Global Fund envisages spending in 2005, $2.3bn, filling it is more tricky. Currently $700m (31%) short, this money needs to be pledged in London otherwise the funding process will run out of time for the year. The British government has already made a large pledge, running to $100m, and Canada and France have already pledged more in this round than in previous. Most other donor nations are still some way behind contributions made in previous years. The largest current shortfalls are in donations from the US and EU, which are both more than 9% behind their historic shares of contributions to the fund; and this is where the bulk of the remaining $600m will need to come from. These are probably not insurmountable deficits, but they come on the heels of several years of the Global Fund falling short of what it aims for, with the combined all-years shortfall estimated at $1bn in 2005, and a massive $5.1bn in 2006 and 2007 combined. The Fund estimates that a failure to resolve the issue in London (which would need massive increases by all donors) would lead to one, two or even all three funding round cancellations in 2006 to clear the back-log of programmes that funding has already been promised for.
6. The global campaign to fully fund the Fund can be accessed via the Stop AIDS Campaign http://www.stopaidscampaign.org.uk/actionGlobalFund.asp
American Policy/Sex Workers
7. Contrary to expectations, President George W. Bush has focused on Africa including HIV/AIDS to a degree that surpasses any previous administration. The President’s Emergency Plan for AIDS Relief (PEPFAR) is one of the major international development achievements that can be claimed by the administration. But this generosity comes with an agenda. The two major sticking-points for activists here, and reporting on the issue rapidly gets dragged into the poisonous politics surrounding it, is firstly the ban on PEPFAR money going to groups that promote, or are involved with groups that promote, condom use, and secondly the ban on money being used for healthcare services that may be construed as legitimising prostitution.
8. The issue of funding services for sex-workers is an important one here, and needs to be seen as adjunct to the condom issue, which has been a political issue for a number of years. Again, any statement in favour or opposing the tight controls on sex-worker programmes is in danger of being submerged by the politics of the issue in America . However, this is important and deserves to be seen separately from the ‘wedge’ issue of condom-use (which, after all, many successful AIDS strategies, not least in Uganda , are based on; the issue being the ABC prevention campaign including ‘Condoms’ as well as ‘Abstinence’ and ‘Be faithful’.) The influx of PEPFAR money, therefore, into the international effort to combat HIV/AIDS, has major structural effects on the implementation of HIV/AIDS policy, as PEPFAR now accounts for a significant part of the global funding total; 20% of all funding needs, and at least 40% of all funds pledged to 2010, according to the Kaiser Foundation. Current policy requires groups that receive funds to pledge to oppose commercial sex work and sex trafficking, which “sabotages the very victims the law purports to defend” according to an editorial in the Houston Chronicle (07/08/05), which goes on to say that “ Distorting and hobbling [PEPFAR] with ideological bullying is neither moral, effective or humane.”
9. The wider issue here, which gets lost in the politics, is that the international funding regime for HIV/AIDS, which includes the Global Fund, UNAIDS, UN Specialised Agencies, especially WHO and UNDP, as well as the money donated unilaterally by national governments and, increasingly, large foundations such as Gates and Ford, has run to billions of dollars a year for some time; but progress on the coordination and coherence of this spending is some way behind the money available. This is an issue, therefore, for governance activists and political and social policy-makers, as the effect of multi-billion dollar funding commitments being subject to the whim of international politics- and as the American example shows, increasingly domestic and even local politics too- is creating a rupture between the resources now being mobilised, and the political will necessary to coordinate and effectively manage this.
Gleneagles Summit, July 2005
10. The annual meeting of the G8 nations occurred at the Gleneagles Hotel, Scotland, July 6-8. Much fanfare was made of the summit being the centre-piece of the British Government’s ‘Year for Africa’, where a loose coalition of the great and the good- the Make Poverty History Campaign, the Live 8 concerts, and culturally-themed seasons at the British Museum and across BBC broadcasting and the wider media- found itself unusually aligned with British Government policy on aid, debt and political reform in Africa. For HIV/AIDS the key resolution at Gleneagles was a commitment to provide universal ART in Africa by 2010.
11. The commitment to provide universal ART by 2010 is welcome. It doesn’t, however, provide enough information on the commitments that will be needed to make this a reality. One of the problems faced is not knowing exactly what the numbers of people who will need ARVs in 2010 will be. Epidemiological projections are often only useful for about three years, before the numbers of variables introduced just become too large to effectively manage. The one million new people put on ARVs by the 3 by 5 initiative- which has largely been judged a success- represents only 16% of those in need of the medication. This would be even more welcome as a commitment if the exact figures of what the G8 nations will be spending in the next few fiscal years specifically to achieve the universal access commitment were shown. The summit showed little discussion and probably very little expert input into the whole issue of HIV/AIDS, and the call for universal access feels like a headline issue that is rhetorically satisfying, but probably futile without concurrent commitments to dramatically increase global funding for HIV/AIDS, starting with plugging the Global Fund’s budget hole, and binding G8 members to introduce legislation to ensure cheap drugs are provided to high-impact nations. For this to work, both money and political and legal reform are needed. Realistically, the bulk buying of drugs with donor funds will need to be continued, and greatly expanded. In addition, legal reform is necessary in international rules of trade, as well as domestic law, to ensure that generic drugs can be freely produced and public interest patents protected. Further still, funds are needed to create the expansion of drug-production necessary so that the market for Anti-Retrovirals reduces the price even further from the thousands of dollars per year that treatment regimes cost in the early-1990s, to the low-hundreds that they cost now, and down to the few-dozen dollars necessary for universal access to be achievable.
12. On HIV/AIDS and health- much in the Communiqué cannot be separated out- there are some practical outcomes. There is an encouraging focus on the need for African nations to train and retain medical staff, and the creation of mechanisms to increase human resource capacity such as the establishment and support of African medical and training institutes. Criticism, however, can be made of the reluctance to tackle the demand-side of the human resource equation, with no concurrent effort to cut down on the recruitment of African health workers outside of Africa . Two areas of real progress, and where credit is due, are the progress made on international vaccine development- long a controversial issue- where Public Private Partnerships and Advance Purchase Commitments may go some way to freeing drug development from the absolute control of the market, and also commitment to fully fund the International Polio Eradication Initiative, which represents an important strategic goal of the WHO to prove that international disease eradication strategies do work.
13. Will the legacy of Gleneagles be positive or negative? It is of course too early to know, and would be unfair to pretend in this briefing that the outcome is already certain, and certainly bad. Gleneagles certainly may prove the ‘tipping-point’ at which global efforts on Africa finally achieved success. The immediate resumption of what might be termed as ‘politics as usual’, especially the politics surrounding the war on terror, may prove otherwise. Many would question the assumption that cleaner government and economic improvements are leading to developmental improvements without a focus on wider, and still developing problems, such as food and soil security, environmental distress, or rapid urbanisation. The point here, for activists, is that if progress is to be made on any of the problems identified at Gleneagles, social justice will need to be considered as much as economic growth.
Niger/Sahelian Food Security
14. In recent weeks the emergent food security crisis in Niger , and the wider Sahelian region, has come to displace Darfur in the international media’s attention as Africa ’s worst humanitarian crisis. What is the cause of the crisis? Ultimately it is three-fold. First, both the government of Niger (under pressure from the IMF) and aid agencies produced insufficient stockpiles of food in the run-up to the current drought. Slight changes in the already restricted political economy of the region can lead to major reductions in the food supply. This is connected to the second cause: general drought in the Sahel region, which is a recurrent, and expected, feature of the region, but which has been particularly acute in the last few years due to poor environmental management and desertification. Third, Niger and the Sahel have been confronted with a major locust problem in the last three years, which has led to decreased crop yields.
15. Although the region is food insecure, the decline in production in 2004/2005 across the region is only 11% down on the five-year average, according to the Famine Early Warning System, and is 22% up on the bad harvest of 2000/2001, when famine was averted. What is driving the crisis is an insufficient food distribution capacity born out of poor stockpiling of cereals in preceding years (despite neighbouring countries taking this decision, often by buying Nigerien cereals); a fall in the price of livestock; agricultural protectionism in the region’s largest market, Nigeria; and a refusal by policy-makers in Niger to label the crisis as famine, which has caused the situation in Niger and the wider Sahel to escape international attention.
16. As with the other Sahelian nations, and much of North Africa, the progress of HIV/AIDS has been relatively slow in Niger . Unfortunately this is also trend mirrored in efforts to treat those who are HIV-positive, and in prevention efforts designed to reach those who may become so. This is unfortunate; good funds exist for HIV/AIDS in Niger , including $25m over five years from the World Bank, and an extra $12m from the Global Fund, for an HIV-positive population of 144,000, or 1.2% adult prevalence. Unfortunately, there is only limited epidemiological surveillance (the 1.2% is an urban estimate), and no coordination of policy, with Niger failing the ‘Three Ones’ test of having one national AIDS strategy, one national AIDS control organisation and one country-level monitoring and evaluation system. The persistent lack of HIV/AIDS infrastructure, and the problems that arise from this, are apparent in Niger . In June 2005, the government offered free ARVs for 4,000 people, but had to declare the scheme a failure when only 350 people came forward to participate.
17. What is at stake here is whether nations, even the poorest-resourced, are able to make the necessary progresses in governance, in democracy and participation, and in building coherent national development coalitions that not only tackle the problems of HIV/AIDS as they are, but are able to manage the effects of HIV/AIDS yet to emerge. The evidence in resource-poor settings such as Niger and across the Sahel is that major social crises such as food-insecurity and HIV/AIDS are first problems of public management, and only secondly of environment or circumstance. Poor planning, deficient resource-management, opaque governance, and external pressure have led to a situation where starvation is apparent in Niger , and is not far-off in Mali , Mauritania and Burkina Faso , but is not being labelled famine because of political refusal to cross a rhetorical Rubicon. It is notable that these very same features- poor planning, deficient resource-management, opaque governance and external pressure- describe also the acknowledgement of HIV/AIDS in Niger, and the national will to confront the epidemic.
UNAIDS Scenarios Project
18. One of the most interesting, and certainly one of the most idiosyncratic, efforts to look at the future of the AIDS epidemic in Africa has been the ‘AIDS in Africa: Three Scenarios to 2025′ project released by UNAIDS in the first half of 2005, which aimed to construct “…rigorous stories about the future, embodying a wide variety of ideas and integrating them in a way that is communicable and useful. By building scenarios, we are trying to penetrate the deep structure of the problem at hand and communicate what we see in terms of a few images and, possibly, some new expressions.” The project had been clear since the outset that a number of scientific scenarios for the future of AIDS in Africa existed, that very little evidence existed to indicate which of the projections ranging from hopefulness to hopelessness was most accurate, and that what was needed was a high-level debate about the nature of scenarios, how they were to be constructed, and what they could achieve, rather the adoption of one overarching scenario that may never come to pass.
19. Creating scenarios for AIDS in Africa presents several challenges. One difficulty is that the scenario methodology is well-suited for the dynamics of politics and the marketplace, in which the participants are well aware of all the possible causal linkages and outcomes. It is less well-suited to a novel epidemic which brings completely unknown factors into play. Although there was expert input into the scenario exercise, the main tasks of scenario building were undertaken using a large panel of laypeople including a wide range of Africans active on AIDS.
20. Another challenge is that the scenario exercise is not a predictive tool. Rather it is a means of examining what people believe about the epidemic and its implications, exploring those facets and their implications. The three different scenarios presented, which are generically labelled ‘optimistic’, ‘pessimistic’ and ‘realistic’, are more useful as tools to examine what we understand as optimism and pessimism, than as actual forecasts for the future. These subtleties were lost in the media coverage of the launch of the Scenario Project, in which journalists reported that UNAIDS was ‘predicting’ more than 80 million AIDS deaths by 2025. UNAIDS was doing no such thing. But it could have been more careful in presenting this in its public relations.
21. The report, as impressive as it is, falls between several worlds, which may damage its’ credibility in each. Its awkward marrying of empirical analysis with focus-group opinion formation doesn’t seem to speak entirely to either scientists or to those at the social marketing end of the spectrum, including activists, social researchers and government planners. Although occupying a unique niche in the information gathered, and the audience aimed at, it is unclear what its ultimate aim is: to provoke or to rationally analyse. The final criticism of the scenarios that can be levelled is that in presenting so much detail based on what seems to be a lack of aims is that no concrete outcomes seem to be ascertainable. Is the report a call to arms, or a detailed plan of action? The answer is that it is actually neither, but is hoped to serve both purposes if necessary.
22. One important point of the exercise is that the course of HIV/AIDS in Africa over the next twenty years, while having many predictions and projections, is not just unknown, but largely unknowable. Even as understanding of the epidemic increases at a fast pace, HIV/AIDS remains such a fast changing and enigmatic epidemic that scientific projections rapidly fail in accuracy beyond more than a few years, and are often, still, proved deficient for planning and impact mitigation. Great strides have been made recently in both the medical and, latterly, economic and social sciences to learn about and how to combat HIV/AIDS. But these do not escape the fact that HIV/AIDS is a multi-generational, problem that will leave a different Africa to the one that it first entered. Much has been made of the efforts to firstly devolve HIV/AIDS from medicine, and latterly to re-incorporate it as the need for the medical and scientific and the social and activist professions to work together became apparent. The scenarios project can be seen as a part of this.
TAC Demonstrations in South Africa
23. Police in South Africa fired rubber bullets and tear-gas at a crowd of 1,000 demonstrators at a Treatment Action Campaign rally protesting against the pace of the rollout of ARVs at the Frontier Hospital, Queenstown, in the Eastern Cape province, on July 12. Fifty-four protestors were injured. The protest had been organised for several reasons: the intransigence the TAC felt the provincial and local health authorities maintained towards public access of information on the numbers of people tested, counselled and treated, and the efficacy of Eastern Cape public HIV/AIDS intervention strategies; the decree, since December 2004, of the Eastern Cape Health Department that clinics should not admit any more patients onto ARVs, and that those on them should be referred centrally to the Frontier Hospital; 2,000 people in Frontier Hospital’s district estimated to need ARVs, but only 200 patients receiving the drugs; anecdotal information showing that more people in the district had died while on the waiting-list for treatment, than were actually receiving medication; and the refusal of both the provincial and national Ministers of Health to meet with the TAC about the issue. Several TAC demonstrators occupied the hospital and refused to leave.
24. Condemnation of the tactics of the police have been broad- from UNAIDS, the World Council of Churches, and from several national governments- which led to the South African government swiftly distancing itself from the actions of the Eastern Cape police, and the police service itself issuing a full apology for the incident. It is undoubtedly a poor image of the South African fight against HIV/AIDS; and the image of riot-control tactics being used against AIDS activists- including several people living with HIV/AIDS- is an unfortunate one given the strength of feeling about the government of South Africa’s approach to HIV/AIDS, it’s treatment of those living with HIV/AIDS, and the bitter memory of the use of teargas and rubber-bullets against protestors by police in South Africa’s past. It should be noted that political protests against unemployment and lack of social services are a daily reality in various parts of South Africa , and the violence in Queenstown was nothing exceptional
25. Action’s such as July 12 th ’s reverberate loudly and beyond South Africa , in a way that is probably disproportionate to the incident itself. Treatment access has become a potent issue across Africa, but in South Africa the dissonance between the numbers needing ARV medication, and the numbers receiving medication, despite the relative economic advantages that South Africa enjoys, is louder than in most places. This represents something bigger than just one demonstration in one country. The bounding up of issues of HIV/AIDS, human rights, democracy and racism, may be cruelly playing out in South Africa , but until they are tackled as inter-related problems, then South Africa will continue to face problems, and events such as police strong-arming AIDS demonstrators will generate surprisingly large amounts of media attention and public reaction.
