International Development CommitteeWritten evidence submitted by the UK Consortium on AIDS and International Development
Background
1. The UK Consortium on AIDS and International Development (UK Consortium) is a network of UK-based 80 non-governmental, faith-based and academic organisations, working at the heart of the global response to HIV and AIDS since 1986.
2. The UK Consortium also endorses submissions made by Action for Global Health and Bond Beyond 2015 UK. In light of this, the UK Consortium’s submission is used predominantly to articulate the case for a continued focus on addressing HIV within an overarching post-2015 framework.
Lessons learned from the adoption of the International Development Targets and the Millennium Development Goals: in particular how effective has the MDG process been to date;
3. The Millennium Development Goals (MDGs) have been a powerful mechanism to mobilise governments and popular support behind the scale up of development efforts since 2000, increasing financing for development, and improving coordination efforts. Tremendous progress has been made in the response to HIV and AIDS and related issues over this period. In 2003, 400,000 people were on antiretroviral treatment for HIV; that figure has now grown to more than 8 million people in low and middle-income countries, over half of all those in need.i The numbers of people on treatment saw a 20% increase between 2010–11 alone, and 10 countries have achieved the goal of universal access to treatment. In addition, HIV transmission rates continue to decline in the areas most affected (with the exception of Central Asia and the Caucasus, see below), and the number of people dying of AIDS-related causes fell to 1.8 million in 2010, from a peak of 2.2 million in the mid 2000s.ii
4. The political momentum created by MDG 6 has undoubtedly played a substantial role in the successes of the HIV response, which has benefited hugely from the establishment of multilateral and bilateral institutions like the Global Fund to fight AIDS, TB and Malaria (The Global Fund) and United States President’s Emergency Plan for AIDS Relief (PEPFAR), as well as increased domestic spending (more than 50% of the HIV response in lower and middle income countries now comes from domestic spending).iii
5. However, there are multiple lessons learned from the MDGs which are critical to consider when developing a post-2015 framework. Notably, progress has been inequitable between and within countries and population groups. This is particularly critical in relation to the HIV response, where many countries have concentrated epidemics affecting particular communities (eg people who inject drugs, sex workers, men who have sex with men and transgender people). These communities often do not have the access to services they require, due to legal and social barriers including discrimination and criminalisation. This has had severe ramifications for the spread of HIV, as noted by the continued growth in new infections in the Caucasus and Central Asia, of which injecting drug use is a major cause.iv The same is also true for women, especially in sub-Saharan Africa, where for example women have on average a 60% higher risk of HIV infection than their male counterparts.v
6. This also highlights another critical lesson from the MDGs: they do not explicitly address and articulate the human rights of those most affected. The HIV epidemic cannot be addressed without putting the rights of all people living with HIV, and key populations, at the heart of any post-MDG framework.
7. Creating separate goals in the MDGs without clearly articulating synergies between the individual goals, has resulted in missed opportunities for efficiencies and coordination, potentially undermining overall progress made. For example, addressing gender inequality (MDG 3) is central to an effective HIV response (MDG 6). Women, especially in Sub-Saharan Africa, are disproportionately affected by HIV, where they comprise 60% of all people living with HIV. Moreover, studies have shown that intimate partner violence is associated with an increased risk of HIV in women and girls, as are other gender imbalances.vi
8. Equally, there is a need for stronger linkages between sexual and reproductive health and HIV responses (covering MDGs 4, 5 and 6). The rationale is indisputable. The majority of HIV infections are sexually transmitted or are associated with pregnancy, childbirth and breastfeeding.vii One in five maternal deaths in 2011 were directly related to HIVviii and HIV is the leading cause of death and disease among women of reproductive age worldwide.ix Globally, 10% of child mortality is related to HIV, while this ranges from 27–42% in high HIV-prevalence countries.x Moreover, sexual and reproductive ill-health and HIV share root causes, including economic inequality, limited access to appropriate information, gender inequality, harmful cultural norms and social marginalisation of the most vulnerable populations.xi
9. Promoting and implementing the linkages between HIV and other relevant areas—including gender, sexual and reproductive health, maternal and child health, TB, education and hunger/nutrition—brings wider benefits for development. A post-2015 framework must therefore ensure goals and targets support synergies between areas. In particular, it must ensure that addressing HIV is part and parcel of a coherent and holistic approach strengthening overall health, social protection and legal systems.
10. This does not mean disease-specific or other specific targets should be abandoned in a new framework. The UK Consortium feels strongly that an HIV-specific goal should be retained. This is because there is an urgent need for continued action on HIV. The 2011 Political Declaration on HIV/AIDS recognised that “HIV and AIDS constitute a global emergency, pose one of the most formidable challenges to the development, progress and stability of our respective societies and the world at large and require an exceptional and comprehensive global response that takes into account the fact that the spread of HIV is often a consequence and a cause of poverty”.xii
11. The post-2015 agenda must therefore ensure sustained action on and scale up of the HIV response through a disease-specific goal, as well as being integrated within an overall holistic framework. Again, it is key to ensure synergies between goals are better framed and reflected in targets, and to ensure that all health-related goals are mutually supporting/reinforcing.
How should the “Sustainable Development Goals” being established following Rio +20 relate to the development goals being considered by the High-Level Panel?
12. It is critical that the Sustainable Development Goals and a post-2015 framework are developed and implemented together in one integrated process to ensure the two processes are mutually reinforcing, and do not work in parallel.
The coverage of future goals: should they be for developing countries only or should progress be monitored in all countries?
13. A new development framework must address global challenges. HIV is a critical issue globally which all countries have a responsibility to address at local, national and global levels. It is key that a post-2015 framework recognises this and holds all countries to account in the global response. A post-2015 framework may look at global goals therefore, with contextualised national targets for less economically developed and OECD countries, and robust mechanisms to hold all countries to account for their commitments to global and national responses.
14. It is also critical to note that middle-income countries (MICs) must be an essential component of any post-2015 framework. Poverty and inequities remain high in MICs, with an estimated 960 million poor people living in MICs as of 2011.xiii Some of the countries with the highest HIV and TB burdens are MICs—including three of the top five countries with the highest HIV burden, and eight of the top 10 countries with the highest TB burden. Coverage of antiretroviral treatment for people living with HIV is also lower in MICs.xiv Furthermore, many MICs have concentrated HIV epidemics among key populations (such as men who have sex with men, transgender people, people who use drugs and sex workers) but fail to address the needs and rights of these groups. It is therefore critical to ensure a rights-based approach underpins the new framework (as articulated in paragraphs 5–6, above), to ensure poor and marginalised groups in MICs are reached.
The process: are the right voices being heard? What are the opportunities for and constraints to global consensus?
15. It is vital that the new process to develop a post-2015 framework is led by the Global South, and includes the voices and views of civil society and affected communities, including people living with HIV. The process must ensure country ownership of the resulting framework through effective and meaningful consultation, and alignment with national strategies. It must also build in structures which will enable civil society and affected communities to hold their own and donor governments and other actors to account against their commitments.
16. Lessons can be learned from the global HIV response, and broader global health environment, which have systematically incorporated civil society representation and meaningful consultation in their major governance structures (eg Boards of the The Global Fund, UNITAID, UNAIDS, GAVI, and Global Fund Country Coordinating Mechanisms etc). HIV activism has seen the enshrining of the GIPA principle (“Greater Involvement of People Living with HIV”) throughout all dimensions of the HIV response, ensuring the rights of people living with HIV are protected and promoted, and utilising the vital knowledge of those affected. The development of a post-2015 framework should use and build on these examples, and ensure the voice and rights of people living in poverty are at the heart of the process to develop new goals.
Targets: was the MDG “target-based” approach a success? Should it be retained? How should progress be measured?
17. The MDG “target-based” approach was highly successful in mobilizing governments and, to some extent, the public behind development efforts, and in helping to measure progress. The MDGs benefited from being clear and easy to communicate, measurable, time-bound and achievable. It is key to retain targets in a post-2015 framework which can galvanise efforts by state and non-state actors, mobilise the public in their support, and facilitate holding world leaders to account for commitments made. It is also critical that progress made against the existing MDGs is not lost, and scale-up in these key areas is not neglected in future.
18. However, targets for a post-2015 framework need to learn from the MDGs, and incorporate qualitative (not just quantitative) measures.
19. As described above, cross-sector targets may be required to articulate synergies between areas of development cooperation, previously framed as distinct (eg food sovereignty/nutrition and HIV). Health goals should also be mutually supporting/reinforcing, and fit within an overall holistic, rights-based framework.
Financing global goals: are new mechanisms needed?
20. Long term and sustainable funding for development must be secured as part of a post-2015 framework. Goals must incorporate mechanisms to hold all countries to account for their financial responsibilities in building a shared future, articulating (for example) required national spending commitments, aid and development cooperation efforts, and funds committed to multilateral institutions like the The Global Fund, which have already proved highly effective at tackling critical development challenges. This may build upon existing pledges made, eg the Abuja Declaration for African governments to spend 15% of their budget on health, and OECD countries commitments to spend 0.7% of their GNI on development assistance.
21. In addition, donor countries like the UK should commit to supporting innovative financing mechanisms, to supply additional funds required to meet existing and new global goals. A Financial Transaction Tax (FTT) could raise up to $409 billion per year in additional funding for development, by leveraging a tax of just 0.05% on financial transactions like bond and share sales, for example.xv The HIV response has already seen effective innovative financing mechanisms utilised to raise additional funds, such as the airline tax levied in a range of nine OECD and low income countries to support UNITAID’s interventions. UNITAID’s airtax revenues alone have raised $1.3 billion for HIV, TB and malaria programmes since it was established in 2006.
The role of the private sector and other non-state organisations
22. It is critical that the private sector and other non-state organisations mobilise behind a set of new development goals, and that the framework articulates the roles and responsibilities of non-state actors in supporting aims to be achieved.
23. In addition, the new framework must present coherence across other global agendas eg trade and intellectual property enforcement, land rights etc. For the HIV response, this must include stronger pharmaceutical industry collaboration on access to HIV treatment, including in Middle Income Countries, via for example, licensing critical HIV medicines’ patents to the Medicines Patent Pool. Pharmaceutical industry actors must also be prevented from pursuing action to undermine access to medicines, as in the current case of Novartis suing the Indian government over a patent on a cancer drug, which could weaken India’s strong public health protection in its patent law, thereby facilitating protection of companies’ monopolies.xvi
24. The role of Communities in delivering a new framework must be enshrined in any post-2015 agenda. Communities have been at the heart of delivering the HIV response, with community-based organisations acting as effective intermediaries between affected populations and the formal health sector, whilst families and communities have also played a significant role in the area of care and support.xvii
The content of future goals: what would be a good set of global goals? What continuity should there be with the MDGs, and how should the unfulfilled MDGs be taken forward?
25. The UK Consortium endorses Action for Global Health’s submission, and reiterates that it is critical that health is recognised as a right in and of itself in future goals, as well as a key driver of poverty eradication.
26. Going beyond this, the Consortium stresses that an HIV-specific goal must be retained in a post-2015 agenda, and that the global HIV response should remain a priority for development. Each day more than 7000 people are newly infected with HIV, including 1000 children.xviii 46% of people in need of HIV treatment are still unable to access this. 1.1 million people living with HIV acquired TB in 2010, which remains the leading cause of death in HIV positive people.xix Only 57% of expectant mothers living with HIV received treatment for the prevention of mother to child transmission in 2011,xx and HIV is the leading cause of death and disease among women of reproductive age worldwide.xxi
27. A post-2015 framework must not turn its back on MDG 6 and other (unmet) existing goals—including those set out in the 2011 Political Declaration on HIV/AIDS. At the same time, it must go beyond existing commitments to ensure progress to date is not lost and to remain relevant. We are at a crucial juncture in the history of the global HIV response. The strength of past investments and an increasing understanding of what works have resulted in a drop of new infections, more people on treatment and fewer AIDS-related deaths. Combined with the evidence for the role of treatment as prevention, we now have a genuine chance to bring an end to the HIV epidemic. This must be reflected in the post-2015 framework.
28. The UK Consortium also supports the submission of Bond Beyond 2015 UK, and emphasises the need for a new framework to comply with the key principles they articulate including ensuring a holistic approach, inclusivity, equity and equality. As stressed in paragraphs 5–6 above, equity and a rights-based approach should be at the heart of a new framework. This should include sexual and reproductive rights. A holistic approach, pursuing health outcomes in a comprehensive way is also critical.
29. As articulated by Action for Global Health, Universal Health Coverage (UHC, when all people have access to all health services without fear of falling into poverty) may offer one potential health goal for a new framework. Continued exploration of a UHC goal is required to determine how social determinants of health may be incorporated in this, and to define further what such a goal might look like. This must take place alongside the development of a new HIV goal for the post-2015 framework.
October 2012
References
i UNAIDS (2012), Together we will end AIDS, Geneva.
ii United Nations (2012), The Millennium Development Goals Report 2012, page 39.
iii UNAIDS (2012), Ibid., p.104.
iv United Nations (2012), Ibid.,p.39.
v Monica Akinyi Agadi (2011), Understanding the gender disparity in HIV infection across countries in Sub-Saharan Africa: evidence from demographic and health surveys.
vi UNAIDS (2012), Ibid. p.70, 72.
vii UNAIDS (2010) Thematic Segment: Sexual and Reproductive Health (SRH) services with HIV interventions in practice, Background paper for the UNAIDS Programme Coordinating Board, Geneva, 22-24 June 2010
viii Lozana, R et al. (2011), Progress towards Millennium Development Goals 4 and 5 on maternal and child health: an updated systematic analysis. The Lancet, Vol. 378 No. 9797 pp. 1139-1165
ix WHO (2009), Women and Health: Today’s Evidence, Tomorrow’s Agenda. WHO: Geneva, p.43
x Alban, A and Andersen, NB (2007), HIV/AIDS’ spread and impact on other health-related millennium development goals. Danish Medical Bulletin, Vol. 54(2), pp. 163-166
xi UNAIDS (2010), Thematic Segment: Sexual and Reproductive Health (SRH) services with HIV interventions in practice, Background paper for the UNAIDS Programme Coordinating Board, Geneva, 22-24 June 2010
xii United Nations General Assembly Resolution (2011) Political Declaration on HIV and AIDS: Intensifying our efforts to eliminate HIV and AIDS, p.2.
xiii Andy Sumner (2011), The New Bottom Billion : What if Most of the World’s Poor Live in Middle-Income Countries?, p.1.
xiv Developed Country NGO Delegation to the Global Fund to Fight AIDS, TB and malaria (2012), The Global Fund to Fight AIDS, Tuberculosis and Malaria and Support for Middle Income Countries, p.2.
xv A Financial Transaction Tax for Global Health, see http://www.healthpovertyaction.org/wp-content/uploads/downloads/2011/09/Final-FFT-Health-paper-July-2011.pdf
xvi See http://www.msfaccess.org/content/qa-patents-india-and-novartis-case
xvii UK Consortium on AIDS and International Development (2012), Positive Gains: Promoting Greater Impact on Health Through HIV and AIDS Programming, p.12.
xviii UNAIDS (2011) “Uniting for universal access: towards zero new HIV infections, zero discrimination and zero AIDS-related deaths”. UNGASS HLM 2011 Report of the Secretary General.
xix UNAIDS (2012), Ibid,p.24
xx UNAIDS (2012), Ibid.,p.18, 24, 30.
xxi WHO (2009) Women and Health: Today’s Evidence, Tomorrow’s Agenda. WHO: Geneva, p.43.