Memorandum submitted by UNAIDS (continued)
Challenges and next steps
5.4.13 The main challenge is to ensure that
the growing enthusiasm among donors, such as for the International
Partnership Against AIDS in Africa, results in a steady increase
in concrete support to national HIV/AIDS prevention and control
programmes - in Africa and elsewhere. To do this, emphasis must
be placed on building partnerships between donors and the most-affected
countries. In this way, a sense of shared responsibility can be
created both for improving prevention and care as well as for
addressing the formidable, multifaceted development challenges
this epidemic presents.
5.4.14 Working closely with the DAC, UNFPA
and the Netherlands Interdisciplinary Demographic Institute (NIDI),
the UNAIDS Secretariat plans to convene a meeting of donor country
representatives to agree on a common methodology for reporting
on HIV/AIDS components within integrated development projects
and HIV/AIDS allocations within sector wide approaches and common
basket funding schemes.
5.4.15 To supplement its monitoring of donor
country HIV/AIDS obligations, the UNAIDS Secretariat is in the
process of establishing a process to systematically monitor pledges
and allocations to HIV/AIDS.
Debt relief
5.4.16 Of the 39 so-called heavily indebted
poor countries identified by the World Bank, 32 are in Africa.
Together they owe more than US$ 2.2 trillion in debt. Lack of
funds for an expanded response to AIDS has been worsened by these
high levels of foreign indebtedness. Across Africa, national governments
pay out four times more in debt service than they spend on health
and education. In order to mount effective national AIDS prevention
programmes, countries in Africa will need to spend at least US$
1-2 billion a year, far more than is currently being invested.
Sources that might be tapped for these additional resources include
increased donations from the private sector and foundations, expansion
and redirection of development assistance, and reallocations within
countries' own public budgets.
5.4.17 Relieving countries' debt burden
is one of the more promising new approaches that could increase
the funds flowing into programmes to roll back the AIDS epidemic
in Africa. By relieving debt in the poorest countries—which,
often, are the ones with the highest HIV and AIDS figures—money
now exported to service debt could be reinvested into AIDS prevention
and care. A major initiative to reduce debt over the next few
years will take place under the Highly Indebted Poor Country
initiative (HIPC), supported by all the major creditor governments
from the OECD countries and implemented by the World Bank and
International Monetary Fund.
5.4.18 In a typical debt relief agreement,
portions of a country's debt will be cancelled in exchange for
the debtor government's commitment to mobilize domestic resources
for specific purposes, such as a poverty eradication scheme or
an intensified national AIDS effort. Such transactions have succeeded
since the 1980s in the field of environmental conservation, for
instance, by protecting rainforests from logging.
5.4.19 At the heart of debt reduction deals
under HIPC lies the challenge of agreeing on significant goals
in poverty reduction and on measurable indicators of progress
towards these goals. Lending countries will have greater incentives
to reduce debt if there are clear and measurable ways of assessing
the benefits. For example, a medium-term AIDS-related target might
be to provide low-cost treatments to a specific percent-age of
the population suffering from the most common opportunistic infections.
Measurable indicators for monitoring progress would likely include
the availability of specific generic medicines in primary health
care centres. During the first months of 2000, several countries
in Africa have started to feature HIV/AIDS more prominently in
their poverty-reduction strategies and in related HIPC debt relief
agreements. This is encouraging. But a concerted effort by a coalition
of interested African government officials, civil society representatives,
creditor governments, and United Nations and multilateral agencies
will be required to ensure that debt relief is actually used to
mobilize substantially increased funding for AIDS.
(B) The UN
5.4.20 Starting in 1986, the World Health
Organization was assigned the lead responsibility in the United
Nations system for assisting governments to establish national
HIV/AIDS programmes. By the mid-1990s, however, it had became
clear that the pandemic's devastating impact on all aspects of
human life and on social and economic development constituted
an emergency which would require an expanded United Nations effort.
As a consequence, in 1996 the United Nations established an innovative
joint venture, the Joint United Nations Programme on HIV/AIDS
(UNAIDS), which now has seven co-sponsoring organizations: UNICEF,
UNDCP, UNDP, UNFPA, UNESCO, WHO and World Bank.
UNICEF
5.4.21 The United Nations Children's Fund
(UNICEF) brings to UNAIDS its operational field capacity in over
160 countries, network of national committees, and considerable
experience in communication and advocacy. UNICEF's priority programme
areas include youth health, school AIDS education, programme communication,
children and families affected by AIDS, and mother-to-child HIV
transmission.
5.4.22 Mandated to advocate for the protection
of the rights of children to help meet their needs and expand
their life choices, UNICEF is their chief advocate, acting within
the framework of the Convention on Rights of the Child. UNICEF,
its national committees and allies mobilize the moral and material
support of governments, organizations and individuals worldwide
in a partnership committed to giving children a first call on
societies' resources.
UNDP
5.4.23 An important objective of the HIV/AIDS-related
activities of the United Nations Development Programme (UNDP)
is to support countries to strengthen and expand their capacity
to respond to the development implications of the epidemic. Activities
are focused on identifying effective and sustainable policy and
programme responses surrounding the epidemic's social and economic
implications. The aim is to strengthen capacity for an effective
response within governments and civil society as well as within
UNDP itself.
5.3.24 Through its network of over 130 country
offices serving over 150 nations, UNDP plays an important complementary
role to that of other UN organizations; within the operational
activities of development cooperation through a system of UN,
national and other executing agencies; it provides technical support
in cross-sectoral, multidisciplinary area of technical assistance
relating to sustainable human development; and it has overall
responsibility for assisting the Secretary-General in improving
the coordination of operational actives for development, including
strengthening the Resident Coordinator System.
UNFPA
5.4.25 The United Nations Population Fund
(UNFPA) contributes to overall UNAIDS work by providing access
to its worldwide network of country offices which support national
reproductive health programmes; its accumulated expertise in reproductive
health promotion and service delivery, with a special focus on
the needs of women and adolescents, and on male responsibility;
its experience in logistics management of reproductive health
commodities, including condoms; its experience in working with
non-governmental organizations; and its experience in organizing
technical assistance and strengthening national capacity-building
through UNFPA Country Support Teams.
5.4.26 A major focus of UNFPA support at
the country level is reproductive health, including family planning
and sexual health. UNFPA considers prevention and management of
sexually transmitted diseases (STDs) and prevention of HIV/AIDS
to be integral components of reproductive health. In the context
of reproductive health, the preventive interventions include appropriate
and effective information, education and communication (IEC) in
support of safe sexual behaviour; interpersonal counselling (for
both sexual and mother-to-child transmission); improved access
to, and provision of, condoms; and good clinical practices to
prevent exposure to HIV-infected blood.
UNDCP
5.4.27 The United Nations International
Drug Control Programme (UNDCP) is entrusted with exclusive responsibility
for coordinating and providing effective leadership for all United
Nations drug control activities. UNDCP addresses all aspects of
the drug problem, including such wide-ranging activities as demand
reduction, comprising prevention, treatment and rehabilitation;
supply reduction, including alternative development and law enforcement;
and legislative and institutional advisory services to enhance
government's capacity to implement the international drug control
conventions.
5.4.28 The use of psychoactive drugs has
facilitated the spread of HIV infection in several ways. The most
direct is by HIV transmission through needles shared by injecting
drug users. The disinhibiting properties of psychoactive substances
also lead to sexual and other high-risk behaviours that individuals
might otherwise avoid. Through sexual contacts, HIV infection
is spread from the drug-using community to others. International
drug control is therefore a vital tool for HIV prevention. In
this context UNDCP is active in supporting HIV/AIDS prevention
in programmes to reduce the demand for illicit drugs. Youth and
high-risk groups are particularly targeted. Coordination within
the UN system has resulted in more effective programming responses
to drug use and the AIDS epidemic in a number of countries.
UNESCO
5.4.29 The mandate of the United Nations
Educational, Scientific and Cultural Organization (UNESCO) is
to foster international cooperation in intellectual activities
designed to promote human rights, help establish just and lasting
peace, and further the general welfare of mankind.
5.4.30 Although not a funding agency, UNESCO's
contribution to UNAIDS is in the fields of its technical competence-education,
science, culture and communication, its interdisciplinary and
cross-disciplinary approaches combining technical skills and ethical
requirements, and its experience acquired over 50 years of intellectual
cooperation. UNESCO's co-sponsorship of UNAIDS is based on the
conviction that actions against AIDS should be developed in an
integrated, cross-disciplinary manner.
WHO
5.4.31 The World Health Organization (WHO)
is the directing and coordinating authority on international health
work. Its objective is "the attainment by all peoples of
the highest possible level of health", health being defined
as "a state of complete physical, mental, and social well-being
and not merely the absence of disease or infirmity" (WHO
Constitution, 1948).
5.4.32 Through its new Initiative on HIV/AIDS
and sexually transmitted infections (HSI), WHO as a Co-sponsor
of UNAIDS strengthens the response of the health sector through
the development of norms, standards and guidelines; research;
advocacy; technology development; and technical cooperation with
countries. The areas covered include: prevention of HIV and sexually
transmitted infections (STIs), particularly for those vulnerable
and/or at increased risk; ensuring safe blood supplies; vaccine
development; surveillance of HIV, AIDS and STIs; and the development
and evaluation of STI/HIV policies and programmes. In the area
of care for people with HIV or AIDS, WHO's activities include
strengthening the capacity of health systems to provide a continuum
of comprehensive care involving referral site, hospitals, home,
and care and support initiatives in the community; ensuring access
to essential drugs; and improving access to other relevant drugs
through negotiations with the pharmaceutical industry and other
channels.
World Bank
5.4.32 The mandate of the World Bank is
to alleviate poverty and improve the quality of life. Between
1986 and early 1999, the World Bank committed over US$ 750 million
for more than 75 HIV/AIDS projects worldwide. Most of the resources
were provided on highly concessional terms through the International
Development Association. To more effectively address the devastating
consequences of HIV/AIDS on development, the Bank is undertaking
a new response to the epidemic, working partnership with UNAIDS,
donor agencies and governments. The strategic plan for the Intensifying
Action against AIDS builds upon the strong comparative advantages
possessed by the partners to rapidly increase the level of action
and available resources and to bring to scale the interventions
needed for prevention and impact mitigation.
5.4.33 In its policy dialogue with borrowing
countries, the Bank stresses that HIV/AIDS is a development priority,
needing top-level political commitment, systematic health care
reforms, human rights protection, and a range of multisectoral
reforms to help reduce the factors contributing to HIV spread.
Whenever possible, Bank-assisted activities are advised technically
by the other Co-sponsors or the UNAIDS Secretariat and are planned
and executed by individual governments, in collaboration with
the concerned nation and international partners.
UNAIDS
5.4.28 UNAIDS brings together the efforts
and resources of these organizations to help the world prevent
new HIV infections, care for those already infected, and mitigate
the impact of the epidemic. Its aim is to help mount and support
an expanded response—one that engages the efforts of many
sectors and partners from government and civil society.
UNAIDS is guided by a Programme Coordinating
Board with representatives of 22 governments from all geographic
regions, the UNAIDS Co-sponsors, and five NGO representatives.
The Co-sponsors and the UNAIDS Secretariat also meet separately
as the Committee of Co-sponsoring Organizations. Apart from the
Co-sponsors, UNAIDS has working agreements with other organizations
within the UN system, such as FAO, ILO, UNHCR and OHCHR.
The Secretariat
5.4.29 Through staff based in Geneva and
in over 50 countries, the UNAIDS Secretariat works with and on
behalf of its seven Co-sponsors in the following major areas.
(1) Facilitation: The Secretariat helps spark,
coordinate and streamline action by the UNAIDS Co-sponsors and
other UN bodies to bring the epidemic under control.
(2) Best practices: The Secretariat plays
a key role in the management and dissemination of knowledge that
is fundamental to combating AIDS. It identifies and analyses sound
strategies and approaches—what can be called "best
practices" for preventing new infections, providing care
to those already infected, or alleviating the epidemic's impact
on households, communities and various sectors of society.
(3) Tracking the epidemic: A key function
of the Secretariat is to gather, analyse and disseminate information
on the evolving epidemic and on the global response to it. Globally,
an accurate picture of the epidemic and of its disastrous impact
keeps AIDS high on the agenda of development assistance agencies
and donor governments.
(4) Advocacy: Both internationally and within
countries, UNAIDS advocates for an expanded response to the epidemic.
It works to build committed and supportive governments, donors
and private companies, and to bring on board a wide range of other
partners, including religious organizations, NGOs, people living
with HIV/AIDS and those whose lives are otherwise affected or
threatened by the epidemic.
5.4.30 Current priority areas for the Secretariat
include:
— highly vulnerable populations;
— prevention of mother-to-child HIV
transmission;
— developing and implementing community
standards of AIDS care;
— vaccine development; and
— special initiatives for hard-hit
regions, including sub-Saharan Africa.
Challenges and opportunities for the future
5.4.31 Three of the key opportunities and
challenges confronting the UNAIDS Secretariat and its Cosponsors
at the threshold of the new millennium are maintaining and intensifying
political mobilization, strengthening and accelerating well-coordinated
national responses, and facilitating improved access to care and
to prevention of mother-to-child transmission of HIV. To achieve
these tasks, UNAIDS seeks to work with a wider range of partners.
The International Partnership against AIDS in
Africa
5.4.32 All the above challenges come together
in the International Partnership against AIDS in Africa (IPAA).
The IPAA is a coalition of actors including African Governments,
the United Nations, donors, the private sector and the community
sector, who, based on a set of mutually agreed principles, have
chosen to work together to achieve a shared vision, common goals
and objectives, and a set of key milestones. Its purpose is to
establish and maintain processes by which governments, civil society,
national and international organizations working against AIDS
in Africa are enabled to work together more effectively to curtail
the spread of HIV, sharply reduce its impact on human suffering,
and halt the further reversal of human, social and economic development
in Africa.
5.4.33 The Partnership, through its international
outreach and visibility, provides swift and focused assistance
to African governments—in other words, more resources, more
expertise, and more alternatives. Through advocacy and mobilization
involving all sectors of society at the highest level, it encourages
governments, business and multilateral agencies to increase their
resources to fight AIDS, either by reorienting or improving the
way they use existing funds, or by seeking new funds if needed.
The IPAA provides that extra push, the spark needed to assist
countries in moving their programmes forward.
5.4.34 The IPAA's key role is at country
level. It supports strategic plans to fight AIDS, and builds upon
what already exists and works. By replicating proven successes,
the Partnership helps channel isolated actions into coherent,
cohesive plans. This capitalizes on individual efforts and avoids
duplication, dramatically enhancing the impact of any one action
by using it as a foundation for others.
6. KEYS TO
SUCCESS
6.1 Two decades of action against the epidemic
have generated important insights into an effective response.
First of all, there is an absolute need to translate global political
mobilisation into country level action. While international political
mobilisation is key to raising additional financial, human and
technical resources, it can never substitute for work in countries.
It is necessary to ask how international commitments translate
into practical actions, bringing real gains to countries, to communities,
and to individuals. The value that global initiatives add to country
work needs to be reflected. Work that has been done in moving
the IPAA forward in countries shows that the concerns in Geneva,
or New York, or London are often not known about at country level,
and perhaps do not always reflect the needs and realities of countries
and communities. Therefore, it is important to ensure that there
is not a growing gulf between international political rhetoric
and real and lasting gains at country level.
6.2 While international political, financial
and technical support are important, lowering incidence and mitigating
the epidemic's impacts must be a nationally driven agenda. To
be effective and credible, national responses require the persistent
engagement of the highest levels of government. Countries that
have adopted forward-looking strategies to fight the epidemic
are reaping the rewards in falling incidence. Other countries
are yet to see the fruits of their efforts, and in the absence
of rapid and visible results, sustaining a response becomes more
difficult.
6.3 When we look at successful action at
country level or at state, district or community level, it has
clear characteristics, which, over the past few years, UNAIDS
has documented. Successful actions are characterised by seven
features:
1. the impact of all actors coming together
under one powerful strategic plan;
2. visibility and openness about the epidemic,
as a way of reducing stigma and shame, and involving people living
with HIV/AIDS;
3. addressing core vulnerabilities through
social policies;
4. recognising the synergy between prevention
and care;
5. targeting efforts to those who are most
vulnerable to infection;
6. focusing on young people; and
7. encouraging and supporting strong community
participation in the response.
6.4 In supporting such action at country
level, all actors should agree to make two major commitments.
First, to intensify prevention efforts, particularly in children
and young people, recognizing that real progress against the epidemic
will only come when the next generation of young men and women
are empowered to protect themselves through information, readily
available commodities and an enabling social environment that
reduces their vulnerability to infection. Young people, particularly
girls are very vulnerable to HIV infection.
6.5 Such a recommitment to action should
draw on:
— firm evidence from Thailand, Senegal
and Uganda demonstrates that prevention on a large scale works.
— evidence that preventing mother-to-child
transmission is technically feasible, affordable, brings much
needed hope to women and their families. If universally available
MTCT could prevent HIV infection in over half a million babies
every year. The recent demonstration that a $4 single dose regimen
of nevaripine (produced by the German company Boehringer Ingolheim)
is nearly as good as a more complicated and expensive regimen
of AZT has opened the door to larger scale implementation of MTCT
prevention programmes in the developing world.
— commitment to ensuring affordable
and sustainable access to services and essential commodities to
contain the epidemic. Such commodities include male and female
condoms, diagnostic tests, drugs and breast milk substitutes for
the prevention of mother-to-child transmission of HIV.
— commitment to ensure that the infrastructure
to deliver goods and services is in place through a variety of
channels, particularly private and voluntary sector: this is not
a task for the public sector alone. This will need to include
facilities for voluntary counselling and testing, condom social
marketing, and youth-friendly health services.
— precise costing estimates are being
developed by the World Bank and the UNAIDS Secretariat, in particular
for sub-Saharan Africa, where it is estimated that approximately
$ 1.6 billion a year are needed to mount an adequate response
to the epidemic in Africa (exclusive of the cost of antiretroviral
drugs). No estimates are available as yet for other parts of the
world.
— delivering on the commitment to protect
children and young people from HIV infection leads to the heart
of the international development agenda, in terms of freeing up
the resources to deliver comprehensive prevention programmes,
and in promoting education, employment opportunities and equal
rights for children and young people.
6.6 The second commitment should be to provide
care and support for people living with HIV and support to people
affected by AIDS. Experience over the last decade has shown the
synergistic effect of prevention and care in communities, in addition
to the value of care in its own right. It is simply not credible
to address programmes to the non-infected, when a significant
proportion of the adult population is HIV-positive and thereby
nearly all members of a community are affected by HIV. In addition,
the lack of at least minimal care is a disincentive for voluntary
counselling and testing, which is a major element of prevention
programmes, promoting openness about AIDS and countering associated
stigma.
We have no choice but to tackle this issue,
while recognizing that opportunities are determined by economic
issues and by the status of health care and social support systems.
While it is true that comprehensive care for all people suffering
from AIDS is beyond both health budgets, and the capacity of systems
to deliver, it remains true that in all cases, it is possible
to do something. Improving care and support needs to be incremental,
starting from rationalizing use of current meagre public and private
resources for care and support, to addressing the longer term
need for dramatic improvements in care and support through strengthening
systems, expanding financing, and lowering of price of drugs,
both for the treatment and prevention of opportunistic infections,
and antiretroviral therapy.
6.7 Therefore, we need:
— commitments of governments to ensuring
that a significant percentage of HIV-infected people have access
to an appropriate continuum of care in accordance with locally
established standards, with at least access to drugs for common
opportunistic infections;
— governments, the pharmaceutical industry
and international organisations working in concert to make HIV-related
drugs more accessible, including through preferential pricing
for low-income countries, strengthening of health care infrastructure,
identification of financing mechanisms and rational prescribing.
Industry and governments need to work together in balancing the
difficult issue of intellectual property rights with the urgent
need to develop and make available key life-saving drugs for people
with HIV infection;
— commitment by governments and the
international community to support children and young people orphaned
by AIDS through such measures as community level monitoring of
their well-being, and assured access to basic education, vocational
training and social services.
6.8 In short, the challenge is now to be
strategic, skillful, coordinated, and disciplined in applying
what we know and catalysing a social movement against AIDS, fully
involving those living with HIV. We know that half hearted measures
do not work, and we should offer nothing less than whole-hearted
support. Indeed, how the rich nations take up their responsibility
and ensure that the poorer populations have all the means to prevent
the spread of HIV and have access to life saving care will be
one of the great moral tests of our time.
UNAIDS
July 2000
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