House of Commons - International Development

Select Committee on International Development Third Report

Section 4 — Responses and Responsibilities

National political leadership

229. On one thing all the evidence is agreed. There can be no effective response to the HIV/AIDS epidemic which is not spearheaded by the national governments of the developing countries themselves. Dr Lob-Levyt said "with quite strong confidence that political commitment is the most important thing and that is what is required to make the difference and that has to be translated into societies' open and free dialogue of the issues and the very sensitive issues around HIV".[287] Uganda in particular was cited by many as an example of how an early and clear position of the need to combat HIV/AIDS and use condoms has resulted in a decline in infection rates amongst young people. What has been as clear is that at least until very recently such political commitment was tragically lacking elsewhere in the region. Whilst Dr Lob-Levyt did now see a "higher level of political commitment from African leaders" this was only in "the last year or so".[288] The setting up of a National AIDS Committee in Botswana was praised but "The sad thing is that it is coming at such a late stage in the epidemic".[289]

230. Clare Short gave the poor response of national governments as a reason why DFID had been constrained in its own HIV/AIDS expenditure, "the major barrier to more effective action in many countries, but particularly in Africa, where the consequences are so great, has been the unwillingness of African governments to move — with the great exception and fine lead given by Uganda and Senegal ... we cannot be a substitute for a government that will not take action".[290]

231. Dr Lob-Levyt did consider that the situation was changing.[291] Dr Peter Piot thought that amongst African leaders, "The awareness is now very high. I can see the difference. I have met nearly all heads of state in Africa — it is really the target of most of my travel. Until about a year ago I always had to start by saying, 'this is such a problem, it is going to do this to you, your population here are dying and your teachers are dying', and so on. They are asking me today, 'What should we do?'. The awareness is very high".[292] As evidence of the new seriousness on HIV/AIDS amongst leaders in Africa Dr Piot cited the establishment of National AIDS Commissions charged with coordinating and leading the national response to the epidemic. Ms Graham of DFID had told us that too often in the past National Aids Commissions were situated in the Department of Health. This was a mistake since "obviously it does not give it the political weight bit needs to drive programmes forward across all sectors".[293] Dr Peter Piot emphasised that in the last year in such countries as Nigeria, Malawi and Kenya National AIDS Commissions were located in the President's or Vice-President's offices.[294]

232. Particular controversy has turned on the attitude of President Mbeki of South Africa to the HIV/AIDS epidemic. South Africa now has more HIV-positive people than any other country in the world. President Mbeki has been quoted as questioning the fact that the HIV virus causes AIDS. Moreover, he established an Advisory Panel on AIDS, of which half the membership also questioned the link, despite this opinion being shared by only a tiny and discredited group. There was much disappointment when at the Durban Conference President Mbeki failed in his keynote speech to say clearly that he believed the HIV virus caused AIDS. Confused and contradictory statements can cause untold damage to the work being done against HIV/AIDS. Professor Whiteside said, "The tragedy is that his havering has had repercussions across the world, not just in South Africa and not just in southern Africa. Throughout the world people know that a world leader of great stature has asked these questions".[295] Clare Short took a more optimistic view. Whilst stressing that "There is no doubt that HIV causes AIDS. It is ridiculous to question that. The science is absolutely clear",[296] she thought the controversy might well have mobilised open discussion of the epidemic in South Africa.

233. We have been grateful for informal briefing from Her Excellency Cheryl Carolus, South Africa's High Commissioner in the United Kingdom, and from Dr Ayanda Ntsaluba, Director General of the South African Health Department, and Dr Nono Simelela, Chief Director of the National AIDS Project. They made clear to us that the whole of South Africa's response to the epidemic is based on the premise that HIV causes AIDS. We are of course pleased to receive this assurance and have no reason to doubt it. This does not, however, preclude the need for clear political leadership from the head of state downwards on this issue. Whatever the policies on HIV/AIDS, their effectiveness relies on the public believing and acting on safe sex messages. Even without the sort of doubts expressed by President Mbeki, it is difficult enough to change people's sexual behaviour. To encourage doubts as to whether the HIV virus causes AIDS is grievously irresponsible and can only undermine whatever good work is being done elsewhere on HIV/AIDS.

234. South Africa is not the only country where even now political leadership seems to waver. The Zambian Government recently withdrew HIV/AIDS information on state television after complaints from church groups that it encouraged promiscuity. An estimated 20 per cent of Zambian adults are HIV-positive. The church has advocated abstinence as the solution to the epidemic and President Chiluba of Zambia has recently been quoted as saying that condoms promote casual sex. Another senior Minister has questioned the effectiveness of condoms in preventing the transmission of HIV/AIDS. Donors are said to have had meetings with government representatives to express their disquiet at the withdrawing of the condom advertisements.

235. The Zambian case shows that the political leadership required is not cost-free. The stigma of which we have previously spoken affects politicians as much as anyone else. We have not heard of a single politician in office in sub-Saharan Africa who has "come out" as HIV-positive, though there must certainly be many infected. Even to advocate vigorously effective action against HIV/AIDS can result in vociferous opposition. Political leadership requires bravery in such circumstances. We should not, moreover, overlook the effect that personal denial over HIV/AIDS may have on the decisions and messages of leadership. The reality of opposition and stigma at home, plus the fact that HIV/AIDS might be a personal and difficult issue for many in positions of leadership in these countries, means that donors need to be sensitive in how they advocate action on HIV/AIDS in the developing world.

236. Moreover, President Mbeki has been emphasising an important aspect of any consideration of HIV/AIDS and one which we have stressed in this Report, namely the relationship between the spread of HIV/AIDS and the poverty of those affected. It is certainly wrong to discuss HIV/AIDS outside the context of the other communicable diseases affecting these countries and more generally the poverty which has multiplied both the infection rates and impact of HIV/AIDS. Moreover, the All-Party Parliamentary Group on AIDS states, "Recent exchanges between President Thabo Mbeki and Western leaders emphasise the importance of sensitivity and respect for sovereignty as we offer advice and support to African countries as they struggle to respond to AIDS. Our interventions are always experienced within a post-colonial context and, if not made with care, run the risk of alienating African leaders".[297] Professor Alan Whiteside considered that donors had made mistakes in the past when discussing HIV/AIDS. The first was to convince leaders that AIDS was a problem but not one relevant to them, not a problem which they needed to act on. The second, once leaders were convinced that it was after all 'their' problem, was not to make clear what they could do about it.[298]

237. It is only political leadership which can spread nationally and effectively the safe sex message, through schools, clinics and the media. It is only that leadership which can ensure that all government departments are acting to combat the spread of HIV/AIDS and mitigate its impact. A great deal can be achieved simply through the unequivocal and unembarrassed message of the need to use condoms. Leadership can be encouraged by donors but is far more effectively generated by ordinary people within the country itself. Trade Unions, faith groups, community organisations need to press governments to act decisively on HIV/AIDS. We heard evidence in particular on the role of faith groups. Jeff O'Malley believed that "there are problems in the hierarchies of certain denominations, particularly around condom use, and it is very important to challenge that".[299] By contrast good work was being done at the grassroots amongst both Christian and Muslim groups in encouraging condom use even where sexual relations did not conform to the religion's prescribed behaviour.

238. Parliaments also have a role in the fight against HIV/AIDS. We would encourage the setting up of parliamentary AIDS groups in all countries significantly affected by the epidemic and suggest that UNAIDS and the InterParliamentary Union act together to promote such groups. An IPU Committee on HIV/AIDS might be usefully set up to promote the establishment of such groups as well as support Members of Parliament who declare publicly their HIV-positive status. Alan Whiteside told us that "In one provincial parliamentary grouping there was a person who was admitted to hospital living with HIV and AIDS. A friend of mine from an NGO was called in to counsel that person, and the hospital administrator said, 'This member of the provincial cabinet said he did not want to see anyone from government because then they would know he was HIV-positive'".[300]

239. Despite the difficulties, the fact remains that the response to the HIV/AIDS epidemic, particularly in sub-Saharan Africa, has been a culpable and serious failure in political leadership and governance. At relatively low cost there are certain basic interventions which all governments must introduce — a sustained, comprehensive and effective information campaign on HIV/AIDS; ensuring the widespread availability of condoms; National AIDS Commissions located in the office of the head of state with independent budgets and real authority in their relations with government departments; the reorientation of the current health budget to take account of the epidemic. But they have all too rarely occurred. Donors should consider carefully, and target effectively, before providing funds to any government which has not attempted these basic interventions.

The European Community

240. There was some consensus as to the record of the European Community on HIV/AIDS. The expertise in Brussels on HIV/AIDS was praised by many. Clare Short said, "The EC's technical work — there have been some very, very good people in Brussels doing some very good thinking that the Department admires, but not much implementation. It is better to have good thinking in the middle than bad thinking in the middle and not much implementation, so that is an advance, but we think that with an agency of that size and with that funding the EC could do more to implement and release good analysis".[301] Dr Julian Lob-Levyt agreed with this analysis, emphasising that the problem was at the country level where they had "the general concerns which many share on the effectiveness of EC programme aid".[302]

241. Other witnesses raised questions as to how HIV/AIDS was integrated into developmental thinking in Brussels. Jeff O' Malley of the International HIV/AIDS Alliance said in written evidence that "The European Commission's support to HIV responses in developing countries has been particularly strong in certain areas of research, especially regarding the links between STDs and HIV. Unfortunately the Commission seems to lack the necessary political will, bureaucratic structures and technical expertise to effectively support community and civil society responses to AIDS". This had "constrained the development of appropriate responses".[303] He expanded on this in oral evidence, making the point that such a large donor drew for HIV/AIDS expertise on only a couple of persons, who had other responsibilities as well. He felt, "There is no way that one or two people are going to be able properly to advocate for, and advise on, how to spend the amount of resources which the EC should be spending on AIDS".[304] They were even less able to advise on sensitivity to HIV/AIDS in the whole range of the EC's developmental and other activity. He regretted the loss of the AIDS task force which previously had assisted Dr Lieve Fransen, the EC's HIV/AIDS expert, in her work. Professor Alan Whiteside also suggested that there was a problem in implementation. He had worked with the EC on the production of a toolkit for "putting AIDS into development projects and, frankly, it has sunk without trace".[305] There was a need for someone auditing the sensitivity to HIV/AIDS in all donor projects.

242. A more positive evaluation came from Glenys Kinnock MEP in her evidence to the Committee on a previous inquiry, the Effectiveness of EC Development Assistance.[306] She considered the EC's Health, HIV/AIDS and population programmes (HAPs) to be "one example of effective development despite scarce resources".[307] Dr Lieve Fransen had joined the Commission in 1987. Since that time spending on these sectors had increased from 1 per cent of EC aid in 1986 to more than 8 per cent in 1998. In 1999 the EC committed around 700 million euro to health, AIDS and population, making it the second largest donor behind the World Bank. Innovative partnerships had been established with national governments, a multi-sectoral approach was being pursued and toolkits for multi-sectoral planning had been issued (it is not clear whether these are the same toolkits so despondently referred to by Alan Whiteside). According to Glenys Kinnock Dr Fransen headed a team of five — but she admitted that there were resource constraints on Dr Fransen's work. The establishment of the Service Commun Relex (since further changed) had deprived DG Development of "much needed human resources".[308]

243. There was agreement that important work had been done centrally in Brussels on the linkages between HIV/AIDs and STDs and other communicable diseases. Late in 2000 the Commission produced a Communication "on accelerated action targeted at major communicable diseases within the context of poverty reduction".[309] The Communication advocates a three-pronged strategy involving optimising the impact of existing interventions; increasing the affordability of key pharmaceuticals through a comprehensive global approach; and increasing investment in research and development of new medicines and vaccines targeted at HIV/AIDS, TB and malaria.

244. We have made clear in previous Reports that we see great potential in the development programme of the EC. In discussing the EC's record on HIV/AIDS work Clare Short prefaced her remarks by pointing out just how much leverage effective multilateral expenditure could introduce.[310] Glenys Kinnock quotes Dr Fransen, "I am still convinced Europe has a major role to play and is a major donor. We have money, instruments, some good people and the expectations of the countries we have been working with. We do well by bringing the best out of bilateral donors and we can be stronger on influencing the different scenes. We do not do that enough at the moment but I think we can".[311] The Communications sums up the EC's comparative advantages, "The range of Commission competencies and instruments across the vital areas of humanitarian assistance, development, environment, trade and enterprise, research and international health is unique and provides potential for greater synergy between main policy areas. In addition, the EC is active in all developing countries and provides substantial grant aid assistance. The developing country partners (in particular the Least Developed Countries) have a greater role in all aspects of the aid management cycle than with most other donor aid".[312]

245. We agree that there is potential for the EC to use its comparative advantages to a make a difference on HIV/AIDS. We would congratulate the Commission on the initiatives it is taking on access to drugs for communicable diseases, where there is a clear value to the EC as a whole getting involved. From the evidence we have received the areas for improvement seem to be the old ones, rehearsed previously by the Committee and others: the shortage of expert staff in Brussels (though it is clear that those in post are very highly regarded); the lack of effective implementation in country. We recommend that the EC consider increasing the number of HIV/AIDS experts in Brussels, and in particular that certain officials be charged with examining the HIV/AIDS sensitivity of all EC policies relating to the developing world. There must also, on the lines recommended earlier in this Report, be an audit of how development planning and implementation in-country is taking account of the new realities arising from the HIV/AIDS epidemic (we were disappointed to hear of neglect of the toolkit devised by Professor Alan Whiteside). We also request information from DFID on how the EC is coordinating its HIV/AIDS strategy and activities with those of member states, and other multilateral donors.

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