GAIN Issues Brief No. 7
February 21st, 2006Overview
1) World AIDS Day was celebrated, as is now routine, on December 1, 2005. In a break with previous AIDS Days, 2005 did not feature a particular theme (2004 had been women) but saw the launch of a longer term campaign to ensure that promises are kept in relation to international commitments- funding and otherwise- on HIV/AIDS. The campaign, called “Stop AIDS. Keep the Promise” will be five-year ‘super-theme’ on accountability, recognising the enormous strides made in the global public education efforts on HIV/AIDS, and the success in increasing international funding for HIV/AIDS since the United Nations Declaration of Commitment on HIV/AIDS in 2000. There are two things to say here. Firstly, merely raising the profile of HIV/AIDS as an international policy issue is no longer the point. HIV/AIDS is widely recognised as among the most important global issues, and of special importance for realising progress on development objectives. In this respect, the Declaration of Commitment was very successful. Although having had an inauspicious start, and having been criticised for entrenching a system that placed most priority on southern Africa at the expense of northern and western Africa and indeed the rest of the world, the Declaration of Commitment is genuinely regarded as a ‘break-through’ moment in international relations at which HIV/AIDS became a policy issue of international significance. The establishment of the Global Fund, and the momentum sustaining HIV/AIDS as a critical issue, is seen as proof that constantly making the new case for HIV/AIDS is less important that redoubling efforts to prevent current successes from being reversed.
2) The second point to come out of the accountability drive is that simply raising money for HIV/AIDS is no longer the point either. UNAIDS’ Global Resource Tracking Consortium reports that $8.3bn was provided, globally, to combat HIV/AIDS in 2005, which will grow to $8.9bn in 2006 and to $10bn in 2007. Of this figure, multilateral funding is due to shrink, in a relative sense, from roughly 40% of the current total to 25%, mainly due to an increase in bilateral funding, of which PEPFAR makes up roughly half. These figures, of course, only take into account the minimum pledges made by donor nations. At the Gleneagles G8 summit this past summer, $25bn of funding for 2005-2015, just for HIV/AIDS in Africa, remains ambiguous given the difference between specific and non-specific commitments, and those commitments made on the belief that future targets for accountability and transparency are met. The point, therefore, is whether or not the disbursement mechanisms for funding are efficient enough, and whether ambiguous pledges made add up to the full totals that they imply. Certainly, the relative shift away from multilateral commitments to bilateral commitments (of which a significant proportion is, admittedly, taken up by PEPFAR) would indicate that it is the efficiency with which money is spent, rather than resource needs, that currently preoccupies donors.
3) The 14th International Conference on AIDS and Sexually-Transmitted Infections in Africa Associations (ICASA) was hosted in Abuja, Nigeria, at the beginning of December 2005. The headline news from this conference was that there was relatively little headline news at all; potential flashpoints such as treatment access and Global Fund funding produced neither controversy nor any real progress. The conference may be suffered from an unfortunate fatigue in the international reporting of HIV/AIDS, and its’ place on current policy agendas,
or from ICASA being perceived as a poorer, ‘off-year’, substitute for the International AIDS Conferences. It also served as a launch for the 2006 Global AIDS Campaign on children and the family; a campaign that has seemed anaemic so far compared to the previous year’s flagging of the campaign on women. One highlight was a keynote presentation by Prof. Robert Gallo, co-discoverer of HIV, who reminded that while scientific advances towards a vaccine for HIV have progressed enormously in the last few years, a generally-available vaccine was still some way off, and no stock can be placed in this as a way to reduce HIV for the foreseeable future.
4) A recent report came to international prominence reporting that the HIV virus was diminishing in virulence, based on an article published in the journal AIDS. The article, Replicative fitness of historical and recent HIV-1 isolates suggests HIV-1 attenuation over time, by Arien et.al., makes the claim that two different sample pools of HIV unexposed to anti-retroviral drugs taken in Antwerp, Belgium, fifteen years apart, shows a general decline in HIV virulence between 1986-1989 and 2002-2003. This report- actually a contribution to the understanding of HIV mutability, rather than its’ transmission- was inevitably seized upon throughout the global media and reported as, for example, “Aids virus ‘could be weakening’” (BBC News, 29/09/2005). This is a little misleading. Firstly, it did not show that the AIDS virus is weakening; it showed that HIV-1 in a very small pool of people, in a specific location, experienced a mutation that may have sacrificed viral fitness in exchange for an increased ability to evade an immune response. Secondly, it ultimately showed what scientists already know: that HIV mutates very rapidly, and in this instance may have changed sufficiently so has to sacrifice a small biological advantage for a large biological advantage. Thirdly, the report is based on only 24 samples: twelve from the late-1980s and twelve from the early 1990s. While scientifically significant, the sample is too small for people to get very excited about. Fourthly, these samples were made in Antwerp, Belgium. Whatever the changes in HIV-1 pathology in Europe, this cannot be generalised as true for the whole world, and especially for Africa where 80% infected with HIV live.
5) The issue here for activists is the public information and journalistic fight against HIV/AIDS. While an important scientific contribution to the field, and one worth reporting, studies such as these can’t help but be reported as “Aids virus ‘could be weakening’”, and inevitable and implicit assumptions could be drawn to the effect that AIDS is becoming less of a problem. Even if HIV fitness was decreasing- and this has not been shown to be generally true- this would neither resolve questions about whether this was just a passing biological characteristic of a highly mutable virus, nor would address the fact that even if HIV starts to decline in power, 40 million people live with the infection, and 3 million still become infected each year. AIDS activists should resolutely reject any attempts to seize on any bad news related to HIV/AIDS and use this to justify their existence or to secure funding and support. At the same time, though, is the need to encourage sensible and moderate reporting of HIV/AIDS, and to make the best-quality information available to the widest number of people to prevent the twin dangers of stigma and denial. This is a difficult balance to maintain, and is perhaps an argument for better media advocacy on all aspects- social and technical- related to HIV/AIDS.
6) The report can be read at:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16184024&dopt=Citation
7) The Global Fund lifted a suspension on the disbursement of grants for Uganda worth $367m on November 11. Uganda was handed the penalty in August after the Fund got impatient with Uganda for its inability to provide appropriate receipting for funds already received. The problem is actually a little more specific than just the Ugandan government failing to account for money received and spent. At issue- which was highlighted in the Ugandan public enquiry that was launched under Supreme Court Justice James Ogoola to
investigate the causes of the suspension- was the payment of nearly $150,000 commission to a brokerage firm whose involvement in handling the grant money on behalf of Uganda remains unclear, and the payment of $19.7m through the DFCU bank, which used eleven separate exchange rates over two years to calculate transactions costs from dollars to Ugandan shillings. Several other companies, whose commercial purposes in Uganda have not been fully ascertained, and who have been involved in Global Fund dispersal or brokerage, have been named in the ongoing probe, including, recently, Prime Info Group, who handled more than $20,000 of grant money. In addition to the claims of mismanagement and corruption was the slow pace of the implementation of these grants from the Fund: an average of 6.4 months from award to national dispersal, which is very poor by Fund dispersal standards. There is actually little evidence of government-level systemic misappropriation of funds, and the willingness of the Ogoola probe to indict individuals without obvious government interference, and the implementation of external oversight of funding dispersal by the consultancy firm Ernst and Young, was enough to convince the Fund to reinstate these grants.
8) What there is evidence of is a lack of government oversight of how Fund grants are disbursed, and the deliberate manipulation of this by middlemen who set themselves up as agents negotiating the deals through which a very large pie gets cut up into small pieces. Unfortunately, politics intruded into this issue when the Global Fund was accused by certain American evangelical groups of being excessively harsh with Uganda as punishment for accepting money from PEPFAR for abstinence-only programmes. This is actually a little bit of a storm in a tea-cup. Uganda has deftly accepted money for some time from both secular groups, who have tried to emphasise the ‘C’ in the ABC approach, and from religious groups who have tried to emphasise the ‘A’. The messages contained in public health strategies have remained largely unchanged for some time, and the international success of the strategy has meant that these compromises have gone largely unchallenged. However, the combination of the Global Fund and the other international bodies losing patience with Uganda on accounting issues, plus the political controversy of PEPFAR money being used to support abstinence-only programmes have come to a head. In addition to this, evangelical groups in Uganda have been seen to be very successful in Uganda of late, not least because Janet Museveni, the President’s wife is seen as a cheer-leading figure-head of this movement, and the President himself is seen to have gone ‘soft’ on this issue, means that events have become far more politicised than common sense would normally permit. This probably won’t be the last time Global Fund disbursement becomes an issue of domestic or international political controversy, or that the political differences between those managing the Global Fund and PEPFAR (or any other bilateral programme) are played out in African parliaments or courtrooms.
9) Justice Africa has been at the forefront of commissioning the latest and most relevant new research on the social effects of HIV/AIDS in Africa. Working with established African researchers, a number of small-scale studies have been produced that contribute to both the overall understanding of these issues and the need to support and nurture an African research base that will successfully engaged with this. Under this programme, new research has been commissioned on the reporting of HIV/AIDS in the media in Uganda, HIV/AIDS and Ugandan civil society organisations, the effects of HIV/AIDS on parliamentarians in Kenya, and on the effects of HIV/AIDS on political leadership across Africa. A selection of the new research accompanies this briefing, and is summarised below.
New Justice Africa Research: HIV/AIDS and CSOs in Uganda
10) Kintu Nyago has completed a report on HIV/AIDS-related civil-society organisations based in Kampala, include The AIDS Services Organisation (TASO), The AIDS Information Centre (AIC) and the Ugandan Business Coalition on HIV/AIDS, among others. Why is CSO research so critical? First, civil-society organisations have far greater capacity to represent the
views and circumstances of people living with HIV/AIDS and people affected by HIV/AIDS than governments. Second, CSOs are very often front-line HIV/AIDS service providers and scientific or anecdotal monitors of the epidemiological and social circumstances of the populations they cover. Nyago reports, for example, on the AIDS Information Centre, which has had representation in 111 separate AIDS centres or community projects across Uganda in the space of just one year. Third, civil society organisations, whether through diversity or mandate, can provide a clearer picture of social and epidemiological patterns than governments can because of the scope they achieve, aside from whether information from governments is promoted for political purposes or not.
11) Throughout Nyago’s findings, the clear point is made that Uganda is experiencing the ‘middle-age’ of its’ epidemic, with activists pleased with the certain achievements made in Uganda- by both government and civil society, but above all by the people- but that the achievements made only last so far, and vast challenges still remain in this nation in promoting human development and defeating HIV/AIDS. Rather than asking the Ugandan government or external NGOs, Nyago has targeted those Ugandan-run community organisations, and recorded their opinions and experiences of fighting HIV/AIDS in their communities. The use of this research is in its’ contribution to an African knowledge base on how best to confront HIV/AIDS.
12) Several interesting trends emerge from the NGO’s that Nyago talked to. Most importantly, although each group has specific grievances about poor funding, or financial constraints on their work, it is a common point about political commitment needed at all levels of government, from local to national, that determines whether their programmes survive or fail. Some other important trends emerge. Many groups and individuals agree that people living with HIV/AIDS are, in the words of one interviewee, ‘senior partners’ in the fight against HIV/AIDS for the impact this group will have in reducing community stigma, and will often be sufficiently radicalised by their HIV status to lead community prevention efforts. Women are widely seen as the key to preventing HIV/AIDS, and it is taken as an article of faith that if efforts can be made to reduce the numbers of women becoming infected, then overall levels of infection will drop commensurately. An interesting trend, mentioned by several participants, is the need to keep proper medical records at community level of people infected with HIV, and not just for medical reasons, but also as an important tool in de-stigmatizing the disease. The full results accompany this briefing.
New Justice Africa Research: Effects of HIV/AIDS on Parliament and Parliamentarians in Kenya
13) Ephraim Kimotho, a Kenyan development professional, was commissioned to undertake new research on the effect of HIV/AIDS on parliament and parliamentarians in Kenya. Kenya is a useful African nation to watch in terms of HIV/AIDS and governance, given its’ above average adult infection rate, its’ location between the Great Lakes, Horn and East African regions, and it’s difficult experience with parliamentary democracy. A critical evaluation of the effects of the epidemic on the national parliament and parliamentarians in Kenya is instructive in demonstrating the practical effects of HIV/AIDS on governance in an African nation. Kimotho undertook interviews and group workshops with numerous people inside, outside and connected to Kenya’s parliament, and has produced a very lucid and instructive contribution to understanding the very mechanics of HIV/AIDS’ interaction with governance in an African context.
14) The most striking trend in this research is that the effects of HIV/AIDS are felt directly by parliamentarians and parliamentary staff themselves in Kenya, and that this problem is not hidden, and indeed could not be hidden given the effect’s of the epidemic on the lives of parliamentarians and their work in parliament. The problem of HIV/AIDS among these parliamentarian’s constituents is seen as of great concern too: but this generally does not effect how such parliamentarians do their jobs. There is, however, tacit assumption among parliamentarians that prolonged excess adult mortality will threaten the legitimacy of Kenyan democracy, particularly if parliamentarians are returned to office with decreased turn-out. In addition to this, the point about party political erosion due to HIV/AIDS is an important one and is worth highlighting. The leadership challenge in Kenya- particularly at the grass-roots level- that HIV/AIDS poses has become a political challenge, and is seen as both a disadvantage bureaucratically, and democratically, in terms of undermining the legitimacy of a system where democratically elected candidates fall ill and die in significant numbers. This leads to a fear, for many, that in the absence of visible democratic successes, Kenya is in danger of falling back into bad old ways of patrimonial politics, graft, and leadership based on bloodline and carved out by several families, fuelling ethnic and tribal political struggles.
15) On the point of the effects of HIV/AIDS on parliamentarian’s constituents, this study reports that the biggest challenge here could be the fear among Kenyans that HIV/AIDS is leading towards rural economic collapse; and obvious attendant democratic challenges exist here. It is interesting that this is seen as an important threat to Kenyans, in addition to the obvious social trauma of mass mortality. Among parliamentarians, rural economic collapse is feared because it will be interpreted as a political problem, as well as a constitutional and democratic problem. Parliamentarians, while concerned about hospitals and treatment for the sick and such, seem to have developed, according to this study, a ‘big-picture’ approach to HIV/AIDS, which views it as a challenge to democratic legitimacy, a threat to parliamentary government, and a development challenge that is as political as it is social. Plenty of specific instances of democratic failure exist- voter fraud, bribery, existence of dead people on voter rolls, and politically-inspired violence- that may be exacerbated and complicated by the presence of HIV/AIDS. However, it is the more pervasive sense that HIV/AIDS is degrading the very infrastructure of civil life, and through this attacking the very legitimacy of Kenya, that is so commonly articulated and is of particular concern.
16) What defence does Kenya have against this degradation? Nyago points out two systems in Kenya that should be halting this slide, but are meeting difficulties. First, a stabilising factor in Kenyan politics has been the presence of community development schemes whereby communities have been integrated into their own poverty reduction strategies, that have generally had a benevolent effect upon Kenyan democracy, development and civic governance. Cooperative movements such as ‘Harambee’, which are community savings schemes, have been responsible for the building and maintenance of many rural schools and clinics in Kenya, and have been a traditional forum for civic leadership and activism. Nyago reports that a general shift in these group’s expenditure towards absorbing excess medical costs- and also declining revenues- means that schemes will spend less on new community services, and more on medical bills for members. As well as eroding the development gains promoted by such schemes, the effect of HIV/AIDS, therefore, may be to undermine civic morale and effectiveness.
17) The second system is the association of churches and religious groups throughout Kenya. Often overlooked when gauging both the effects and the resources to combat HIV/AIDS, Nyago points out that the resource challenges to church groups in Kenya are remarkably similar to those facing government. Churches play a crucial role in providing community leadership, developmental planning, and service provision including education, healthcare and social and physical pastoral care. However, churches’ traditional place in Kenya, as activists and campaigners for democratic governance and human freedoms, has been called into question in recent years because of corruption scandals, a lack of accountability, and involvement in national politics. Just as a need for community leadership by churches and churchmen in Kenya has arisen, the public perception, and general trust of these institutions has fallen. Nyago points out that an institution that has usually given so much leadership, and
for which there is a great need, is suffering from avoidable political deficiencies which are to the detriment of all Kenyans. The full results accompany this briefing.
New Justice Africa Research: The Political Economy of AIDS Leadership in Developing Countries
18) Nyago has collected new evidence on the political effects of HIV/AIDS in Kenya, and these largely point to similar conclusions drawn in the third Justice Africa-sponsored piece of new research. Jacob Bor, working through Harvard University and the University of Cape Town, has provided an analysis of the political economy of AIDS leadership, drawing on two important pieces of high-level African research: the Afrobarometer project, and the 2003 AIDS Programme Effort Index (API) developed by UNAIDS, and others, to measure the progress in implementation of the 2001 United Nations Declaration of Commitment on HIV/AIDS (DoC). The study, an important contribution to the understanding of political decision-making in relation to HIV/AIDS, makes a number of key points about the nature of leadership, and the treatment of HIV/AIDS as a political issue.
19) Using the quantitative data provided on AIDS leadership in 54 developing countries, Bor has analysed the API and makes a few key points. Of particular concern to Bor is to show whether a generalisation can be made about why HIV/AIDS has become a national priority in some countries, while in other it has not, even when comparing nations with similar levels of economic development and adult infection rates. A ‘soft’ analysis in answer to this would be that some nations have been blessed with leaders who through their own courage and willingness to risk their political careers have decided to make HIV/AIDS a political issue; and some have been fortunate in having this work as a political strategy. In opposition to this, of course, are a number of nations who have had the misfortune to have leaders who through negligence and prejudice have sidelined HIV/AIDS as a political issue, and ignored the needs of those living with the infection. Bor challenges this assumption, and promotes, moreover, the idea that good leadership on HIV/AIDS starts with the political commitment of individual leaders to the issue of HIV/AIDS, but has to include, moreover, a commitment to socio-economic justice, developmentalism as a national social objective, and freedom within the private, civic, and most especially media sectors.
20) The interesting trend that Bor defines in relation to leadership, good governance and HIV/AIDS, is that the empirical data, based on people’s political opinions and choice-making, indicates that ‘democracy’, understood as free and fair elections, has a negligible impact on public perceptions as to whether a nation is pursuing the right political policies related to HIV/AIDS, and whether political leaders are succeeding in fighting HIV/AIDS. A panacea of ‘democracy’, through which governments are elected or rejected by electorates based on whether they are best qualified to fight HIV/AIDS, in both high and low-prevalence developing nations, is not supported by the empirical evidence; as tempting as it may be to believe that one exists. In particular, little evidence can be provided to support the claim that peoples’ hopes or frustrations related to HIV/AIDS are expressed through the ballot box. Bor’s analysis of the various data shows however that on the micro-level, HIV/AIDS does have considerable sway over democratic policy-making. While Afrobarometer data shows that HIV/AIDS ranks low as a priority of voters at election time, it is far more apparent as an issue cited in citizen’s concern and activism over specific policy-choices; and this will translate as positive or negative perceptions of how political leaders are responding to the needs of their electors.
21) Bor postulates that ‘democracy’, when defined solely as elections, has little discernable impact on HIV/AIDS, and vice versa. However, when the definition is broadened to include more populist agendas of liberal rights and socio-economic justice, the effects of HIV/AIDS on these processes can be delineated. One particular trend, and this is born out by other new work, is that a free and independent media is crucial to political success in combating HIV/AIDS, and statistical evidence can be pointed to in this regard showing the correlation between media independence from government and national success in confronting the political problems related to HIV/AIDS. This particular area of research- the effect of political leadership and charisma on HIV/AIDS- is starting to make real empirical contributions to the political understanding of HIV/AIDS, and is slowly becoming one of the successes that social activists can point to in their efforts to confront HIV/AIDS. The full results accompany this briefing.
Academic/NGO Seminar: Mapping the Future of HIV/AIDS, Security and Conflict in Africa
22) On December 6 2005, GAIN partners Justice Africa and the Conflict, Security and Development Group of the International Policy Institute, together with the research centre LSEAIDS, held a one-day research seminar on the issues of HIV/AIDS, security and conflict in Africa. The seminar, which was attended by post-graduate students, academics and development professionals, touched on the various differing interpretations and approaches to this new and emerging area of analysis. HIV/AIDS, security and conflict is an important area of enquiry; but one around which many generalisations and factual inaccuracies lie. A number of areas need further analysis, and were touched on during the day. First, what is the definable relationship between HIV/AIDS and conflict? Arguments that causal relationships exist between HIV/AIDS and violence, and that these are universal, are very tenuous and very often based on critical assumptions that remain unquestioned or unaddressed. Nevertheless, key aspects related to violent conflict, and anecdotal evidence from conflicts in zones of high HIV infection, shows that a number of factors related to conflict and AIDS are becoming important, while acknowledging that no universal relationships between violence and AIDS are likely to emerge. These would include, broadly, the impact of violent conflict on the maintenance of HIV/AIDS monitoring and surveillance regimes; the impact of violent conflict on the allocation of medical resources; the impact of HIV/AIDS on refugee and displaced populations; the impact of HIV/AIDS on armed forces, including combatants and peacekeepers; the impact of HIV/AIDS on the application of international law and order; and the impact of HIV/AIDS on women in zones of conflict.
23) Professor Tony Barnett gave an insightful and useful introduction to the issues of the day, as well as a thoughtful meditation on HIV/AIDS as a social problem and how social researchers should approach it. Professor Barnett recounted how UN Security Council resolution 1308 (2001) had both a positive and a negative effect upon the issue of HIV/AIDS and security, as well as HIV/AIDS as a wider social issue, by both legitimising HIV/AIDS and security as a field of enquiry, but also by seeming to encourage hasty work and speculation on the issue that was based as much on keeping up with the intellectual zeitgeist as it was on hard facts. Of particular concern here is the constant citation, often in the mainstream media, of studies- some of which are more than a decade old- that reported that HIV infectivity shot up in post-conflict environments. These studies, which become misquoted, taken out of context, or repeated to the point of banality, then have become assumptions- or ‘factoids’- upon which further studies have been based. These studies, again, get misquoted, taken out of context, and repeated to the point of banality. A danger inherent, therefore, in the literature on HIV/AIDS and conflict, is that of faulty assumptions, and perceived problems based upon conjecture rather than evidence; and this has already led to inappropriate policy-making on the issue.
24) In a sense, as pointed out by Dr. Tim Allen in his presentation, there is a very real danger that some of the literature on this implies an argument along the lines of: violent conflict is a development problem, HIV/AIDS is also a development problem, therefore put them both together and the problem becomes calamitous. While the interaction of HIV/AIDS in zones of conflict is of concern because of the ability of both violent conflict and of HIV/AIDS to depress human development, the empirical evidence to show that HIV/AIDS provokes conflict, or that conflict causes HIV/AIDS to rise is lacking. In fact, as much anecdotal evidence exists to support the idea that violent conflict can depress HIV infection, because of the reduced number of sexual encounters that would be expected among a given population during a period of conflict, as it does to suggest that it increases HIV infection. The one truth that can be taken from analyses of HIV/AIDS and conflict is that if no universal relationships can be shown to exist, a great deal of new research is therefore needed into the various specific aspects of the interaction of HIV/AIDS and conflict; and a good starting point will be the articulation of what these specific aspects are.
25) Dr. Jenny Kuper, of the LSE Department of Law, provided critical analyses of one of the specific aspects: the effect that law and international law has on HIV/AIDS and conflict. One of the key problems identified by Dr. Kuper is whether human rights are directly transferable to legal obligations, and the effect that HIV/AIDS therefore has on the relationship between the individual and the state. The most obvious here is, of course, the right to treatment and access to medication; and if such a right exists within an international human rights framework- and it is not easy to define whether it specifically does- does this transfer to legal obligations to provide treatment access on the state? Kuper showed that international thinking settles on the idea that international policy is not automatically transferable to domestic legal obligation, even if explicitly intended to be so, without the deliberate incorporation of binding frameworks into international treaties that are ratified by various states parties. Any future international legal framework on the human rights of people living with HIV/AIDS would therefore need to incorporate provisions for action to be taken against states-parties by the international community or internationally-mandated bodies to promote compliance, and would only be as successful if numerous nations could agree on a regime tough enough and fair enough for this to be effective. An important point to note, as Kuper pointed out, is that the principle of human rights is important everywhere, but in most human rights regimes, an important exemption for issues concerning public health is regularly incorporated. An agreed legal treatment of HIV/AIDS is therefore still a work in progress, and highlights the structural problems, and need for reform, in international legal structures.
26) The edited transcripts from the seminar accompany this briefing.
