In This Edition
1. Overview/Toronto 2006
2. South African AIDS policy
3. The G8 and HIV/AIDS
4. Male circumcision
5. Extensively Drug Resistant (XDR) Tuberculosis
6. AIDS and the MDGs – a pre-emptive assessment
7. HIV/AIDS, Police Services and Other Non-Military Uniformed Services

Overview/Toronto 2006

1.) Twenty-five years since the first isolation of HIV/AIDS by the Centers for Disease Control in the United States, the global HIV/AIDS community met in Toronto this August for the 16th International AIDS Conference. What began in the 1990s as a summit of scientists and heath specialists has now grown into something resembling an international trade fair, with a ‘Global Village’ of stalls and demonstrations alongside the scientific papers presented. The slogan of the five day event –“Time to Deliver”– reflected the frustrations of many activists and HIV/AIDS professionals, and the acknowledgement that the spectacular increase in resources- a five-fold increase in money available since the signing of the Declaration of Commitment in 2001 from $1.6bn annually to $8.3bn in FY2005- need to show commensurate successes in halting and reversing numbers infected with HIV, and ultimately mortality from AIDS.

2) Twenty-five years on, AIDS is now recognized as a long-wave event (see for example LSEAIDS) which will require a sustained response for many years to come; as such major strategic planning is needed, as many commentators have highlighted, to prepare for the next twenty-five years and more. UNAIDS Executive Director Peter Piot spoke of moving the AIDS response from one characterized by emergency, to one concerned with the development of long-term sustainable intervention. Despite the potential of major scientific and social advances to prevent and treat HIV/AIDS, as well as the global wealth to put these into operation, the epidemic continues to grow largely unchecked. Although financing for HIV has grown fourfold from the levels provided in 2001, this accounts for barely a third of the donor support that will be required by 2008 to reach the 2015 target of reversing the epidemic.

3) New treatment developments, including improved treatment access and the roll-out of new triple combination therapy were discussed, as well as the potential for circumcision (see below), pre-exposure prophylaxis and microbicides. The conference also highlighted the continuance of high HIV incidence rates. Despite many years, we still don’t seem to know what really works (except for honorable, and entirely localized exceptions) and prevention and treatment programmes have yet to record extended or cross-border successes in turning back the epidemic and its wider impact. A greater political and practical commitment is urgently required, but Mark Heywood of the AIDS Law Project argued that leadership was a theme most notable in its absence from the conference.

4) In June the ambitious goal of universal access by 2010, pledged last year by the G8 in Gleneagles, was reaffirmed at the UN General Assembly High Level Meeting on HIV/AIDS. Toronto provided the first opportunity for the international AIDS community to meet and discuss the strategies to meet this target. And many commentators stressed that it had to mark a turning point in the AIDS response. To what extent this can be translated into greater pressure to rapidly step-up delivery will be seen over coming months, but the degree to which the conference actually achieved this been criticized by some. The Lancet editor Richard Horton attacked the squandering of an opportunity to plan for the next decades and criticized the attention accorded to celebrity delegates such as Bill Gates and Bill Clinton. But with four times the financing of PEPFAR, the $62 billion in AIDS funding on offer from the Gates Foundation, free of the political constraints of other major funding arrangements, does have the potential to dramatically shape intervention programmes. It has already injected $500 million into the Global Fund, and has been vocal in tackling taboo subjects such as services targeted at sex-workers for example. Gates also adopts a more pragmatic and less doctrinaire attitude to who gets funds; its resources allow it to comfortably work with or around governments. In contrast the US $15 billion PEPFAR fund came under fire from the special envoy for AIDS in Africa, Stephen Lewis, for “incipient neo-colonialism” in its continued focus on abstinence campaigns.

5) Although usually published in time for World AIDS Day, the annual Report on the Global AIDS Epidemic was brought forward in time for the conference. Five years after UNGASS it assesses the response. It notes advances in epidemiology, with improved overall surveillance, including population surveys and extension into rural areas, and a broader set of indicators now employed. Data on more countries is provided– 126– and provides the first systematic reporting of services for at risk populations. The most important assessment is that of the eight major targets for 2015, including numbers on ARVs, reductions of children living with HIV, and access to clinical services for pregnant women, only the funding goal has been met fully. In addition to an overall survey of country-level response, it picks up several subjects, including at-risk populations, impact and civil society. That the epidemic is outpacing the response is a key theme, and it warns that neither the 2010 or the 2015 targets will be met unless a massive scale up in the response, and better value for resources expended, occurs. It notes that 94% of countries have national plans but implementation is lacking; and draws attention to a persistent lack of knowledge amongst youth, pervasive stigma, and insufficient respect for human rights. The marginal position of women and children is also highlighted, National governments, it says, are not providing sufficient care for orphans and vulnerable children and notes than in Sub-Saharan African three women are infected for every two men, and three for every one in the 15-24 age group.

6) The update reports lower prevalence estimates, in some areas massive differences are presented, such as a drop from around 38% to 24%. This fall is in part due to the inclusion of adults older than 49 years in the figures, and more data from rural areas with lower HIV levels. This extension in the age ranges of data capture illustrates an acknowledged increase in infection amongst older adults. Reported trends include a leveling off of epidemics across Africa, although at exceptionally high levels in Southern Africa, with key exceptions in Kenya, Zimbabwe (which is among the world’s highest) and in urban areas of Burkina Faso. In Asia developing epidemics are observed with increases in China and Indonesia, and resurgent epidemics are reported in the US and amongst gay men in Europe and Latin America. The end of the WHO’s Three by Five campaign, as reported in the last GAIN Brief, was of mixed success. Although there was progress in the numbers receiving treatment, as the Global Report notes, gains were slimmer in Africa, and increases are largely accounted for by just a few countries (Botswana, Kenya, South Africa, Uganda and Zambia) and the fact that South Africa receives 25% of all ARVs is indicative of the limited impact of such campaigns in infrastructurally-poor environments. West Africa continues to report much lower prevalence, but there are concerns that a concentrated sex-worker epidemic could explode, and in Nigeria which although has low prevalence, has the 3rd highest HIV positive population and infection rates that vary on a massive scale (which thus indicate the poor quality of monitoring) from 2.6 to 6.1%.

7) Two sections on the impact and reduction of impact of AIDS are presented. Dedicated space to these questions is welcome, yet the fact that discussion of the public sector and governance impact goes little beyond collecting together familiar speculative assessments and possible outcomes shows how much work still needs to be done to really measure and provide for the impact of the epidemic. It is disappointing that little in the way of data from the studies that have been undertaken is presented. Without evidence this section loses the weight that so critically needs to be applied to the impact wave of the epidemic.

South African AIDS Policy

8) Leadership is a key theme of the report, and was a major feature of discussion in Toronto. Unsurprisingly, the lack of African political leadership was widely criticized, and in particular the response of Thabo Mbeki’s administration in South Africa. The last GAIN Brief reported on the furor surrounding Jacob Zuma’s rape trial acquittal and the damaging messages on AIDS and violence against women that this had produced. As Zuma dealt a blow to prevention efforts (declaring before the court that he believed showering after sex would confer protection against HIV), Manto Tshabala-Msimang continues to undermine the treatment campaign from her desk in the Ministry of Health. Tshabala-Msimang has been scorned by AIDS activists as “Dr Beetroot” for her insistence that particular foodstuffs and traditional treatments are as comparably effective as antiretrovirals. Criticism intensified during the Toronto conference, due in no small part to the inclusion of lemons, garlic and beetroot alongside condoms and ARVs as part of its prevention and treatment display. It is reported that ARVs were only added by a staff member at the last minute after journalists began to question their absence.

9) In a country of 5.5 million people living with HIV/AIDS and a prevalence of 18.8%, the inconsistency and inaction which has characterized South African policy towards HIV/AIDS has drawn vocal criticism. Stephen Lewis lambasted the “lunatic fringe” approach of the South African government, while Mark Heywood referred to the rest of the world’s silence on the issue as an example of “global geopolitics and the rules of ‘diplomacy’”. The decision to mount the treatment display in such a way, and the intransigencies and idiosyncrasies of the politics behind it only adds provides more ammunition for critics of the ANC government, and charges that South Africa’s AIDS crisis represent the worst failure of post-1994 South African democracy. The response from treatment activists has been strong. In Toronto, and again at the Congress of South African Trade Unions (COSATU) conference, the Treatment Action Campaign called for the dismissal of Tshabalala-Msimang, and tackled Deputy President Phumzile Mlambo-Ngcuka over the government’s failure to fully address the crisis. In an apparent attempt to manage the government’s response profile and strike a conciliatory tone, whilst also forcing activists to share the burden of responsibility, Mlambo-Ngcuka moved away from the inflexible denialism of other ministers. Acknowledging that there was no substitute for treatment, she called for a new working relationship between government and activists, and cited collective hostility as a reason for the current failure to address the epidemic. Since Toronto, a new inter-ministerial committee has been established, with the deputy president as its chair. Tshabalala-Msimang has denied this shows an attempt to sideline her involvement, but it demonstrates an attempt to improve the Government’s image without the scandal of removing her from office. It also offers some hope that in moving responsibility for HIV/AIDS out of the health ministry a stronger and more comprehensive intervention can be created. The high level of attention focused on the health minister’s stance has detracted from the important debates on methods and strategies, moving attention away from her could would allow a greater focus on these, particularly in the media, and would put a stop to the damaging perception of conflict between ‘western’ and traditional medicine.

10) Pieter Fourie provides a retrospective analysis of the policy response to AIDS in South Africa in a new book “The Political Management of HIV and AIDS in South Africa: One Burden Too Many?”. His assessment is insightful in its careful documenting of the policy shift over a 22-year period, particularly in the different ideological positions that have been employed to justify particular activity or inaction. Focusing on the history of the policy-making process highlights an under-examined aspect of the epidemic, but one that offers important lessons. He also asks difficult questions of the relationship between government and civil society and argues that the forceful position of activists has also had negative consequences. A full review of the book by Justice Africa associate Jon Harle is accompanies this briefing:

Review of Fourie: The Political Management of HIV/AIDS in South Africa

The G8 and HIV/AIDS

11) South Africa is not the only state to have been accused of a lack of leadership on AIDS, and responsibility has been put on wealthy nations for their own lack of action and reluctance to tackle HIV/AIDS at the global political level. In his closing speech at Toronto, Stephen Lewis was again critical, this time of the G8’s “Pavlovian betrayal” despite promises made at Gleneagles last year. 2006 saw a $500 million shortfall in this year’s promised share of the money to be delivered by 2010. According to a report from the University of Toronto’s G8 Research Group, only 33% of the HIV/AIDS specific promises made at Gleneagles have been met. They note that three countries (Japan, Russia and the US) plus the EU have complied with their commitments, Italy had not, and Canada, France, Germany and the United Kingdom were deemed to be in progress. In St Petersburg this year the G8 made further AIDS pledges, including a collaborative international research unit and greater co-operation in surveillance. Many pledges were however repeats of old promises, and these were not backed up by concrete timetables or plans. Despite previous commitments, there is still a huge funding gap, with promised support yet to be provided, and with Russia the only nation to make a new spending commitment to refund the costs that the fund had incurred in programs there. Showing a recognition of the stalling of G8 action over AIDS, and pressure from other leaders, the German chancellor Angela Merkel promised to make Africa a focus of next year’s summit.

Male circumcision and prevention strategies: an ‘African solution to an African problem’?

12) The potential of male circumcision as a preventative strategy to bring down the rate of HIV infections has received considerable coverage recently. So far complete data is only available from one study in South Africa, which reported a 60% decline in the transmission of HIV to circumcised men; despite a ‘male’ intervention, there is hope that it will also benefit infection rates amongst women. Preliminary results from two further studies from Kenya and Uganda, due to report their findings soon, were discussed in Toronto. So significant was the South African study in showing declines in infection rates, that it was stopped early on ethical grounds. The two outstanding studies are expected to support the conclusions already drawn from South Africa. These results are backed up by other surveys that suggested that regional variation in HIV prevalence is strongly influenced by variations in the rate of circumcision. Despite hope of a major preventative tool, the unfortunate effects of donor politics have already been demonstrated, with PEPFAR deciding not to renew funding for a programme in Swaziland until further results are available.

13) The keenly awaited results from Uganda and Kenya will determine whether WHO, UNAIDS and other major funders modify their own intervention programmes to take circumcision into account, but already the reputed benefit of circumcision has already led to a massive demand for operations with Zambia and Swaziland launching national programmes. The numbers are compelling. A simulation conducted by Dr Kyeen Mesesan, a researcher at Yale University, using data from Soweto, estimated the reductions in new infections from a circumcision programme targeting 10% of men over a 20-year period could result in a drop in prevalence from 17% to 14%; conversely ignoring circumcision could lead to a rise in prevalence to 23%. Projections have calculated that routine circumcision could prevent as many as 6 million new infections in two decades; around 3 million lives could be saved. Other models suggest that in five years 32,000 lives could be saved if circumcision rates were raised by 10% each year; 52,000 lives, if rates could be raised by 20% each year.

14) Circumcision offers new hope where existing prevention programmes have been unable to curb new infections at the rate urgently required. Vaccines and microbicides are a long way from being rolled out to those most at risk and while condoms can be the most effective preventative against HIV when used perfectly, practically this is rarely the case. Condom use is often irregular, and while condom-based programme successes have been reported in very concentrated epidemics, such approaches have not proven effective in reducing infections in generalized population-level epidemics such as those that many countries now face. The Global Report notes that condoms were only used by 9% of non-married or co-habiting couples during sex. Circumcision, on the other hand offers a relatively rapid intervention method, requires just a one-off intervention, and could be implemented relatively cheaply. Zambian surgeons have reportedly begun performing the operations for as little as $3. Even if figures of $55 per adult male, as quoted in Toronto, prove to be true, this would still represent an enormous saving on future AIDS treatment costs of around $2,400 per person.

15) Circumcision is a common cultutal practice in many areas, particularly in West Africa, although less so in Eastern and Southern Africa where HIV rates are highest, but it needs to be made plain that the practice has different social and cultural meanings across societies (and not just in Africa). Research has suggested the possibility that the lower rates of HIV observed in West Africa may in part be explained by greater circumcision. While some are skeptical of its long-term efficacy, and point out the significant socio-cultural barriers to be overcome in some areas, it has been hailed by others as a much-needed ‘African solution to an African problem’. While it is true that existing cultural practices will prevent the straight-forward roll out of circumcision programmes across all countries, extreme caution should be given in ascribing male circumcision status yet as a ’magic-bullet’ before extensive research can confirm its’ efficacy across borders and cultural norms. However, the data collected to date, which is growing well beyond the anecdotal, has so far been well received. Surveys have indicated that many men would be keen to be circumcised if it was shown to reduce the risk of infection (which is a trend as desirable as the efficacy of circumcision itself, in terms of promoting long-term success). A major problem encountered by prevention campaigns to date has been the promotion of condom use in the face of considerable resistance. Conversely, circumcision commands growing support across those African regions where the practice is familiar, with doctors in some regions unable to keep up with the pace of new requests. Circumcision could therefore offer dramatic results if service was simply expanded to meet this demand, without the need for new education campaigns at present. A commonly expressed fear over the promotion of circumcision is that it could lead to reduced condom use and increased risky behaviour. Encouraging signs from the ongoing Kenyan trial however suggest that circumcised participants reported more consistent condom use and less frequent visits to sex workers than previously.

AIDS and the MDGs: a pre-emptive assessment

16) In just a few months, in 2007, we will have reached the halfway point of the 15 year target set to achieve the Millennium Development Goals (MDGs). Any mention of the MDGs, individually or as a whole, is usually followed by strong warnings that they will not be met unless there is a significant escalation of effort. These warnings are not simply despondent and bleak assessments, but are instead intended as drivers to action towards targets which are– or should be– achievable with the necessary commitment. Thus far, the goals in Africa are divisible into those for which some progress has been made (such as improvements in maternal health and primary education); little progress has been made (such as child mortality) and those which have actually got worse (such as environmental sustainability) Civil society activists continue to lobby national governments and international institutions to push them to fulfil their own commitments, while the UN Millennium Campaign was created to provide a focus for these initiatives across the world.

17) Two recent reports, produced towards the end of the first half of the first 7-year term, offer assessments of the current achievements that have been made towards the MDGs. The disparity between regions distorts the averages. The UN report strikes a note of optimism, noting that progress is being made in some areas, but noting that much is still to be achieved, uses this acknowledgement of success as a lever to greater achievement. For HIV/AIDS most attention has focused on Goal 6, combatting HIV/AIDS, malaria and other diseases, and specifically to have halted and begun to reverse their spread. In Africa prevalence appears to be in decline, but there is little reason for over-optimism, as levels still remain high, but deaths are increasing, and infections have yet to be checked, which presage the impact still to come. Tuberculosis is also on the increase, with a worryingly dramatic rise in cases and also in drug resistant forms. Excluding HIV positive people from the data still reveals an epidemic which has near doubled in Sub-Saharan Africa from 1990 to 2004; if HIV was to be included the figures would be even more disturbing. There is growing acceptance that HIV/AIDS cuts across many aspects of social, economic and political life. Rather than simply being a development goal in its own right, HIV/AIDS – as malaria and TB are– is a key feature of each of the other seven goals, complicating other problems and making their resolution much harder. The UN 2006 Report on the Global AIDS Epidemic notes that progress in goals for poverty reduction, universal primary education, gender equality, child mortality, and maternal health is particularly jeopardised by AIDS.

18) Goal 1 is the elimination of extreme poverty and hunger. According to a recent World Bank report, several countries in Africa “might” be on course to meet the target of halving poverty, while in contrast the UN MDGs Report 2006 shows that in practice, while Asia has done well, declines in Africa of people at or below the $1 a day mark have been slim – from 44.6 percent to 44.0 percent. Proportionally chronic hunger has declined, although the number of people actually going hungry increased. The impact of AIDS on food security is an area of real concern, and it received considerable attention in Toronto. Famine renders people more susceptible to HIV due to its weakening of the immune system, the impact of AIDS-related illness and mortality reduces household agricultural productivity and diverts money from food to treatment, and in some areas hunger is a driver of greater risk behaviour including commercial sex or migration to areas of greater prevalence. The marginal position of women in many communities means they are particularly vulnerable to both HIV and inadequate access to food.

19) An increase in net primary enrollment from 53 to 64 percent is reported from 1990 to 2004 (Goal 2). While this shows some success, Sub-Saharan Africa still lags behind other regions, and a significant gender gap persists. Perhaps most importantly, and an issue often overlooked in many statistics is that universal primary education will be measured by completion rates rather than simply by enrollment; current figures suggest that while enrollments may increase, the ability of pupils to remain in school to complete a full period of education is often threatened by a myriad of factors associated with domestic poverty, and this is something acutely threatened by the family burden of HIV/AIDS. The importance of education for health is also clear, with children in schools in a much better to gain correct knowledge about HIV/AIDS. According to the UN 2006 Report on the Global AIDS Epidemic, in general HIV knowledge levels are doubled by primary education and increased fourfold by attendance at secondary and higher education. With young women’s awareness generally lower than men’s, educating girls is of particular importance.

20) As a measure of women’s position in society and progress to wards Goal 3, the promotion of gender equality and women’s empowerment, the report cites data on women’s position in labour markets and women’s political representation in parliament. In the latter Sub-Saharan Africa shows encouraging progress, with more than double the number of female members in parliament, but gains in the overall labour force are much more modest. The explicit target for Goal 3 is the elimination of gender inequality in education at all levels, and measures already quoted for Goal 2 show the pace towards this is far too slow. Across the world, and particularly in Africa, women bear the brunt of HIV/AIDS, both in terms of greater risk of infection, in the additional burdens they face as widows trying to support children after massive loss of household income, in losing land and property rights, or in being forced in survival sex work to support their families. HIV/AIDS presents one of the greatest areas of gender inequality, and further compromises other attempts to redress this balance, such as access to education.

21) Goal 4 pledges to reduce child mortality, specifically by two thirds of the under-five rate. While there have been international gains, Africa once again lags behind; mortality is still at the rate of 16.8 percent of children still dying before the age of five, and AIDS is key. 2 million children under 15 live with HIV in Sub-Saharan Africa, 90 percent of HIV positive children worldwide; worldwide almost 17% of deaths due to AIDS and 14% of new infections are amongst children; treatment rates are lower than 5% and there are around 12 million who have lost one or both parents as a result of the virus. Pharmaceutical companies have shown little interest in paediatric drug development, and reducing child deaths and providing a future for vulnerable children will depend on a raft of social investments in women and children, including maternal education and welfare, better prevention of mother to child HIV transmission, better reproductive health and greater support for children who lose parents, suffer abuse or who are forced to work to support impoverished families. Maternal health is the target of Goal 5, the reduction of the maternal mortality ratio by three quarters. The report measures this in terms of assisted delivery at childbirth, which it shows has increased across the world, but only by very slight margins in much of Africa, and with massive rural and wealth disparities. To achieve both these goals the WHO has estimated 100,000 additional fulltime health professionals will be needed across 75 countries where child mortality is highest.

22) Goal 7 tackles environmental sustainability and approaches the interactions between development and climate change. On a global scale it will be the efforts of rich world and growing Asian economies which determine whether the climate change-inducing effects of excessive energy consumption, pollution and resource depletion are checked, but on a country level this is to be measure by access to drinking water and sanitation and improving the quality of life in urban slums. Although the relationship between environment and AIDS appears less obvious, such targets will be important in the matrix of factors driving the AIDS epidemic as part of overall improvements in health. The 2006 Report of the Global AIDS Epidemic cites the example that the loss of skilled fisherman to AIDS in Uganda has led to fish stock depletion due to over-fishing by inexperienced young replacements; additionally households suffering an AIDS deaths tend to be unable to afford fuel and instead gather more firewood. The impact of environmental degradation on poverty, whilst rising on the general development agenda, is as yet untested for HIV/AIDS. The environment is critical in the ecology of human health, poorly understood, and even less well planned for, as yet little data or analysis has been collected on interpreting what the upper-levels of man-made climate change (as defined by the IPCC report of 2005 of above 3C by 2100) could mean for developmental disease ecologies, and could be a critical factor in the evolution of the virus and the intervention response.

23) Finally, Goal 8 addresses international development architectures including aid, debt relief, trade agreements, access to essential drugs, and new technology. Trade agreements intersect crucially with pharmaceutical production and supply in AIDS treatment, highlighted by the inability, despite provisions being made, for national governments to manufacture generic drugs. Aid has increased, but an increasing proportion of this is taken account of by debt relief, making these two measures indivisible; greater donor funding is urgently needed specifically for AIDS, and despite new mechanisms and funds, donors, particularly the G8, are still not meeting the commitments that they have repeatedly affirmed.

Extensively Drug Resistant (XDR) TB

24) The emergence of an extensively drug resistant strain of TB (XDR-TB) is a worrying development not only in global TB treatment, but also for HIV/AIDS. Of particular concern is the association between drug resistance, rapid spread and co-infection of TB and HIV. The two are frequently treated together because TB further compromises the body’s response to AIDS and as a result is the most common cause of AIDS-related death, and both pathogens have learned to co-adapt at the microbial level. As HIV infection has increased, TB has become increasingly widespread. Multi-drug resistant TB – resistance to first line treatments – is already a major problem in parts of the former Soviet Union, India and China, and requires much more expensive and more toxic treatments. XDR-TB describes a strain that demonstrates an additional resistance to one of three second line treatments. While still relatively rare, a large number of cases have recently been diagnosed in the South African province of KwaZulu-Natal, and the strain already accounts for an estimated 15% of TB in South Korea and 19% in parts of the former Soviet Union. High TB-mortality is observed in areas of high HIV prevalence. In KwaZulu-Natal over 100 cases have been detected and high mortality rates have been reported amongst HIV positive people who contracted the new drug resistant strain. HIV renders people much more susceptible to resistant TB, and once infected the disease progresses more rapidly, meaning the time available for diagnosis and treatment is dramatically reduced. Of 53 patients who contracted XDR-TB, 52 had died within 25 days; of 60 reported deaths, 44 were HIV positive. In a worrying parallel, recent clinical trials for female microbicides in the same region suggested rising HIV rates of between 38 and 50%

25) XDR-TB will require new drug development, and mean that HIV and TB programmes will need to be increasingly tightly coordinated to prevent a potentially devastating impact on AIDS treatment scale-ups. Although cases have been diagnosed in South Africa, prevalence across the wider region is largely unknown. It is probable that South African diagnoses have more to do with the better surveillance and diagnostic abilities of the country’s health system, than with a particularly high rate of infection, which further hints at what may as yet remain undetected in other parts of Southern Africa. The level of concern over the new strain is highlighted by recent events. A meeting of WHO and SADC health experts was convened in Pretoria in mid October to develop an emergency plan, and the Global Fund has agreed to redirect existing grants to TB programmes. Addressing XDR-TB is crucial to AIDS efforts and it is welcome that swift action has this in mind. At the same time new money must be found, rather than existing money diverted from other essential programmes.

26) Resistance to TB drugs develops when patients take the wrong combinations of drugs for the wrong length of time; with treatment duration varying from six months to two years, adherence becomes a particular problem, as does financing the expensive drugs required. Supervision of pill-taking by patients – the Directly Observed Treatment Short Course (DOTS) strategy– has been shown to reduce the incidence of drug resistance. Although in the short-term treatment supervision demands greater resources, this is outweighed by what will be saved from future programme costs were drug resistant strains of TB to become more prevalent. This method has been introduced by many countries to increase adherence to treatment, yet its actual implementation has been complicated by HIV, which has reportedly increased the number of TB cases five or sixfold. It is important that we understand what effect extensively resistant strains are likely to have on people already undergoing ARV treatment.

27) XDR-TB highlights the shortcomings of public health systems, and offers pertinent lessons for HIV/AIDS. The spread of TB and development of drug resistance is largely the result of inadequate surveillance and of poor treatment monitoring. With a highly mutable HIV virus, the same could become true of AIDS. There are also strong warnings against inadequate or under-supervised rollout of antiretrovirals, particularly in resource poor areas. Treatment in itself, as this proves, and as AIDS-specific studies have also demonstrated previously, is not enough to begin to control the epidemic, and it brings into question the tensions between individual and public level interventions. While new AIDS drugs will be needed to take account of natural resistance buildup, were ARVs to be provided without the necessary health workers to supervise treatment, increased resistance could develop relatively quickly. This would lead to a much greater burden on scientific development to provide the necessary drugs. An expansion of AIDS treatment is urgently needed; treatment keeps people alive, and public services, industries and communities functioning. It is vital however that expansion is not pursued alongside attempts to make savings at the delivery stage. Amongst recent calls for an urgent TB response were suggestions that incarceration and legal action be employed to prevent its spread. While the example of Cuba’s response to HIV/AIDS is often cited, on the whole the human rights case has been strong enough to avoid a more widespread recourse to this approach. This is imperative: stigma makes prevention much harder and will mean the epidemic will take much longer to control. If attempts were made to control TB through restricting individual freedoms and identifying infected people, it would set a disturbing precedent for AIDS. On a more positive note, the present urgency around TB may help generate a renewed vigour in HIV/AIDS programming.

HIV/AIDS, Police Services and Other Non-Military Uniformed Services

28) Justice Africa, as part of an on-going focus on the social aspects of HIV/AIDS, has begun a major research programme into police forces and other uniformed services. A number of analyses have been made of the effect of HIV/AIDS on armed forces, and upon the security sector and international political stability generally. The international AIDS, Security and Conflict Initiative, a partnership led by the Netherlands Institute of International Relations ‘Clingendael’, and the Social Science Research Council (SSRC), have promoted the need for long-term multi-disciplinary research on HIV/AIDS and security, and a number of key publications (Docking, T: ‘AIDS and Violent Conflict in Africa’ United States Institute of Peace Special Report [2001]; Elbe, S: ‘HIV/AIDS and the Landscape of War in West Africa’; International Security [2002]; Ostergard R L: ‘Politics in the hot zone: AIDS and national security in Africa’; Third World Quarterly [2002]; Barnett T and Prins G: HIV/AIDS and Security, Fact, Fiction and Evidence’; UNAIDS [2005], etc.) have contributed to understanding in recent years.

29) Research on AIDS and security, as useful and as measured as some of it is, often gives the unfortunate impression that ‘security’ is only synonymous with national armed forces. This overlooks a key reality across Africa that security is often not compartmentalised separate to civil society, and that the linkages of civilian life, security services, police and the military are complex. Even if the linkages weren’t complex in Africa (or anywhere else for that matter), it would still be striking to consider how narrowly focused on military personnel research on AIDS and security has been to date, without considering a range of professional cohorts encompassing police, border and immigration agents, militia, paramilitary groups, and the range of other professions that make up the security sector.

30) The reality is that the ‘security sector’ is not limited to military personnel; and the police and other non-military uniformed forces deserve at least as much attention as soldiers do. The police are in fact the front line in the maintenance of law and order. Two things can be said; that substantive, quantitative research on the effect of HIV/AIDS on police and non-military uniformed services are under-researched in Africa, and that police and domestic security services are a crucial constituency to understand in the transmission of HIV/AIDS due to the demographic profile of police and uniformed forces, the relative social and physical mobility of members of this group, and the relative exposure of personnel to high-risk social behaviours. The police have a special role insofar as they are also responsible for enforcing laws and regulations concerning commercial sex work, and their methods and attitudes can thereby be an important determinant of the HIV risk levels in this sector. The police are also the first line of recourse for victims of sexual and gender-based violence and exploitation, and how they handle these cases can have an important impact on HIV vulnerability.

31) As part of a new research programme, Justice Africa is seeking new approaches to the conceptualisation of, and planning for, HIV/AIDS within the security sector, including security sector reform, post-conflict reconstruction, human rights, and the effect of HIV/AIDS on the modern notion of human security. Issues that are important to this work and will be considered include prevalence and patterns of HIV in police forces; the impacts of AIDS-related illness and death on the staffing and functioning of police services; the incorporation of HIV/AIDS prevention into training and support facilities for police forces; the enforcement and regulation by police forces of commercial sex and drug trafficking; police and judicial practices in the treatment of victims of sex- and gender-based violence and exploitation; and HIV/AIDS in prisons and the prison service, including prevalence estimates, current practices in prevention and treatment, and the impact on the prison service. Those interested in such research can contact Alastair Roderick at Justice Africa alastair@justiceafrica.org

This entry was posted on Wednesday, November 29th, 2006 at 2:45 pm and is filed under GAIN Brief, HIV/AIDS, Justice Africa News. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.