Memorandum by International HIV/AIDS Alliance
1. THE INTERNATIONAL
HIV/AIDS ALLIANCE'S
INTEREST IN
THE ROLE
OF INTERGOVERNMENTAL
ORGANISATIONS TO
CONTROL THE
SPREAD OF
HIV/AIDS
The International HIV/AIDS Alliance ("the
Alliance") is a partnership of civil society organisations
working together to strengthen community responses to AIDS. Established
in 1993, the Alliance has a secretariat in Brighton, UK, and civil
society partners in 32 developing countries in Africa, Asia, Latin
America, the Caribbean and Eastern Europe.
The Alliance receives Programme Partnership
Agreement (PPA) funds from the UK Department for International
Development, and is supported also by development funding from
the US Government and the European Union, along with development
funding from the Governments of Sweden, Norway, Canada, Denmark
and the Netherlands, along with support from private foundations
and the Global Fund for AIDS, TB and Malaria.
For over five years the Alliance has had a collaborative
centre agreement with UNAIDS, the global co-ordinating organisation
of the UN response to AIDS. The agreement acts as a focal point
for our many joint activities. We also have a long history of
working closely with WHO and Unicef to advance community based
HIV treatment and care, and to advocate for child-centred responses
to the needs of orphans and other children affected by HIV/AIDS.
This work with these intergovernmental agencies
on AIDS is "fed" by our HIV programming experience at
the grass roots. Working with communities in 32 countries who
are delivering HIV prevention, treatment and care services brings
with it much valuable experience and insights.
We therefore think that the Alliance is uniquely
placed to respond to this inquiry—as an organisation that
is responding to AIDS "on the ground", as well as working
in partnership with intergovernmental organisations, and observing
the practice of others.
2. THE GLOBAL
HIV/AIDS EPIDEMIC
UNAIDS/WHO estimate[1]
that the number of people living with HIV in 2007 was 33.2 million.
Of those 33.2 million, they estimate that 2.5 million were newly
infected in 2007.
The number of people who died of AIDS in 2007
was 2.1 million, despite advances in anti-HIV treatment.
These figures mean that on average 6,800 people
become infected with HIV every day, and over 5,700 people die
from AIDS, mostly because of inadequate access to HIV prevention
and treatment services.
These figures provide a compelling answer to
the Committee's question as to the progress being made to reduce
the spread of communicable diseases.
UNAIDS and WHO continue to assert that the HIV
pandemic remains the most serious of infectious disease challenges
to public health.[2]
3. THE MAIN
UNDERLYING CAUSES
OF HIV INFECTION,
AND CHANGES
IN INCIDENCE
AND PATTERN
HIV continues to be spread largely by unprotected
sex and injecting drug use. The global prevalence of HIV infection
is remaining at a steady level, although the number of people
living with HIV is increasing because of ongoing new infections
with longer survival times, measured from a continuously growing
population.[3]
In the recent past UNAIDS has illustrated a
reduction in AIDS-related deaths, partly attributed to the recent
scale up of treatment access.[4]
Some localised reductions in HIV prevalence has been observed
in some countries, along with a reduction in the number of annual
new HIV infections.
Global and regional trends in HIV epidemiology
point to two main patterns in the evolution of HIV/AIDS[5]:
— Generalised epidemics—affecting
large numbers of people from the general population—exist
in many sub-Saharan African countries, particularly Southern African
countries.
— Epidemics in the rest of the world
that are primarily concentrated amongst marginalised populations—men
who have sex with men, injecting drug users, sex workers and the
sexual partners of sex workers.
4. THE MAIN
NON-HEALTH
CAUSES OF
HIV/AIDS
Vulnerability to HIV/AIDS is shaped by a range
of social and cultural factors. These vary in different settings,
reflecting different cultural and social processes. Sexuality,
the status of women, cultural traditions or taboos in relation
to drug use, poverty and access to health care are all social
factors that influence HIV vulnerability. Some of these particular
social processes are described here.
4.1 Men who have sex with men
Sex between men, particularly anal intercourse
without a condom, is one way in which HIV and other sexually transmitted
infections are transmitted. Although HIV prevalence rates among
men who have sex with men are high in some countries; due to the
relative invisibility of male to male sex, sex between men is
likely to be an unrecognised factor in many national and regional
epidemics.
In a few societies sex between men is widely
accepted; in some it is tolerated, and in many it is the subject
of strong disapproval, legal sanctions and social taboos. Official
indifference or hostility means that there are few HIV prevention
and care programmes for men who have sex with men in developing
countries. It also means that little research has been undertaken
to discover HIV prevalence rates, how many men are at risk and
how best to provide them with the information and skills they
need to protect themselves and their sexual partners.
4.2 Sex workers
Sex workers are key to the dynamics of most
HIV epidemics; the potential for a large number of sexual partners
increases the likelihood of exposure to HIV for sex workers and/or
the possibility of exposing others to HIV.
HIV prevention in the context of sex work rests
on a range of factors including the legal and policy environments
in which sex work occurs; the legal, social and economic status
of sex workers; and the capacity of sex workers to organise themselves
and to identify and implement effective responses to the challenges
they face, including HIV.
Although many countries criminalise sex work
and thereby subject the act of buying or selling sex for money
to criminal sanction; sex workers have the same human rights as
everyone else, particularly rights to education, information,
the highest attainable standard of health, and freedom from discrimination
and violence, including sexual violence.
4.3 Injecting drug users
Injecting drug use is estimated to account for
one-third of new infections outside Sub-Saharan Africa.[6]
Despite the importance of preventing HIV among
injecting drug users, coverage of HIV prevention for this population
is at best 5% globally.[7]
Use of contaminated injection equipment during
drug use is the major route of HIV transmission in Eastern Europe
and Central Asia, where it accounts for more than 80% of all HIV
cases. Unsafe injecting is also the entry point for HIV epidemics
in a wide range of countries in the Middle East, North Africa,
South and South-East Asia and Latin America.
Beyond the physical risks associated with drug
injection, drug users are vulnerable to HIV because of their social
and legal status. Ironically, in many countries this means that
HIV interventions are not legally available to drug users, or
that drug users are unable or unwilling to access them for fear
of recrimination or arrest.
4.4 Prisoners
Prisons are sites for drug use, unsafe injecting
practices, tattooing with contaminated equipment, violence, rape
and unprotected sex. Conditions in most prisons make them extremely
high-risk environments for HIV transmission, leading them to be
called "incubators" of HIV, hepatitis C and tuberculosis.
They are often overcrowded and offer poor nutrition with limited
access to health care.
Both male and female prisoners often come from
marginalised populations, such as injecting drug users or sex
workers, who are already at increased risk of HIV infection.
4.5 Women and girls
The vulnerability of women and girls to HIV/AIDS
is particularly significant in sub-Saharan Africa where 60% of
those living with HIV/AIDS are women. That figure increases to
75% amongst 15 to 24 year olds. Sexual violence, early marriage,
sexual harassment and harmful traditional practices such as female
genital mutilation all increase womens' vulnerability to HIV/AIDS.
The reproductive rights of women living with
HIV/AIDS are regularly violated. HIV positive women experience
generally very poor access to services to prevent mother to child
HIV transmission, and HIV positive women are stigmatised for both
not having children when social norms require that of women, as
well as discouraged from for having children because of their
HIV status.
4.6 HIV/AIDS is fuelled by human rights violations
and human rights violations exacerbate the impact of AIDS
Despite the fact that we have understood the
relationship between HIV and human rights almost since the beginning
of the epidemic,[8]
human rights abuses continue to fuel AIDS and human rights violations
continue to exacerbate the impact of the disease.
The destruction wrought by HIV/AIDS is fuelled
by a wide range of human rights violations, including sexual violence
and coercion faced by women and girls, stigmatisation of men who
have sex with men, abuses against sex workers and injecting drug
users, and violations of the right of young people to information
on HIV transmission.
HIV prevention programmes continue to be stalled
and undermined by these abuses, and assessments of the effectiveness
of particular interventions continually fail to address the problem
of the abjectly hostile policy environment for HIV prevention,
treatment and care in the countries in which we work.
Human rights violations only add to the stigmatisation
of people at highest risk of infection and thus marginalise and
drive underground those who need information, prevention services
and treatment most desperately.
Abuses also follow infection. People living
with HIV/AIDS are subject to stigmatisation and discrimination
in society, including in their communities, in the workplace and
in accessing services.
One of the most prominent and enduring insights
arising out of the Alliance's HIV programming in the last twelve
years is that effective prevention of the epidemic will be impossible
as long as the human rights abuses that fuel infection, and follow
it, go unaddressed.
4.7 No commitments to vulnerability reduction
Global HIV prevention efforts continue to prioritise
risk reduction and impact reduction interventions over vulnerability
reduction interventions.
Programmes that provide information to drug
users about safe injecting, but then jail drug users for the possession
of clean injecting equipment, only to rapidly intensify their
vulnerability to HIV in prison. Programmes that provide sexual
health services to sex workers but then provide no protection
from violence and coercion to engage in unsafe sex. Programmes
that educate girls about HIV transmission undermined by inadequate
police and judicial responses to rape and by social and cultural
norms that condone rape. Programmes that seek to educate men who
have sex with men about HIV transmission undermined by violence,
imprisonment and social exclusion.
Just as human rights are essential to reducing
vulnerability and mitigating the impact of AIDS, effective HIV
programming depends on good governance, supportive laws and policies
and the transparent and comprehensive application of the rule
of law.
In many of the countries in which we are working
there is a profound and widening gap between what is said about
the importance of human rights in relation to fighting the epidemic,
and what is actually being done.
4.8 The global AIDS services gap
The latest available data for coverage of services
for HIV/AIDS prevention, care and support in low and middle income
countries provides a compelling demonstration of the HIV services
gap for sex workers, men who have sex with men and injecting drug
users.
Data from a UNAIDS/USAID/WHO/Policy Project
study[9]
estimates coverage of basic HIV services for injecting drug users
at an appalling 5%. The same study estimates coverage of basic
HIV services for men who have sex with men at 11% and for sex
workers, 16% coverage. In the UNAIDS report for 2006[10]
they cite coverage data from 2005 that shows only 9% of men who
have sex with men received any type of HIV prevention service
in that year, and that less than 20% of injecting drug users received
any HIV prevention services.
5. THE PRINCIPAL
BLOCKAGES TO
ACHIEVING PROGRESS
IN THE
PREVENTION AND
CONTROL OF
HIV/AIDS
The July 2005 G8 commitment to universal access
to HIV treatment, care, support and prevention marked a significant
development in global AIDS policy. From that momentous commitment
followed the 2005 World Summit Outcome (resolution 60/1), whereby
all UN Member States committed to a massive scaling up of HIV
prevention, treatment and care with the aim of coming as close
as possible to the goal of universal access to treatment by 2010
for all who need it.
And on 2 June 2006 at the High Level Meeting
on AIDS, the UN General Assembly committed to scale up towards
the goal of universal access to comprehensive HIV prevention,
treatment, care and support by 2010.
These commitments underline the imperative for
rapid scale up of services to prevent and treat HIV/AIDS, and
that support and care for those affected by AIDS.
One of the chief tests of the commitment to
universal access both at the national and international level
must be to close the HIV services gap for those most at risk of
HIV.
Closing the HIV services gap, and improving
the legal and policy environment for effective AIDS responses,
requires significantly more resources than those that are available,[11]
along with better instruments to deliver those resources to those
most in need.
The Alliance asserts here that neither the resources,
nor the instruments to properly invest in fighting AIDS, are currently
available.
6. PATENT AND
INTELLECTUAL PROPERTY
LAWS ARE
IMPEDING ACCESS
TO ANTI-HIV
MEDICINES
The high cost of anti-retroviral treatment (ART)
has been a significant barrier to universal access. This barrier
has been substantially overcome in many countries at the onset
of competition from generic manufacturers. Generic competition
has reduced the price of first-line ART from $10,000 per patient
per year to the current level of approximately $130 per patient
per year. The impact on access to ART as a result of these price
reductions cannot be overstated.
New and future ART[12]
will not be so cheap. New intellectual property legislation in
countries like India is pricing treatment beyond the reach of
poor countries and poor people.
Flexibilities within the TRIPS Agreement should
be supporting countries to import and export generic medicines
to protect public health. Yet the technical complexity of these
flexibilities, along with political pressure—that often
accompany Free Trade Agreements—undermine the ability of
countries with high HIV burdens to benefit from these flexibilities.
"Patent pooling", which allow for
the collective management of intellectual property rights, offer
some important potential solutions to overcoming the barriers
to generic drug production.[13]
Patent pooling is on the agenda of the WHO-led Intergovernmental
Working Group on Access to Medicines, due to conclude its plans
and recommendations at the end of April. Progress on patent pooling,
along with other measures to advance generic competition and to
strengthen the global research and development effort, will be
crucially important to the future of access to ART.
7. UK GOVERNMENT
COMMITMENT TO
INTERGOVERNMENTAL BODIES
FOR THE
FIGHT AGAINST
AIDS
7.1 UNAIDS and WHO
The Alliance welcomes the UK Government's support
for UNAIDS and WHO as key technical agencies in the fight against
HIV/AIDS. The normative guidance on HIV prevention, treatment
and care provided by both agencies is vitally important, and in
the main, of a high quality and drawing on the latest available
evidence of effectiveness.
WHO have importantly set out the evidence base
for controversial but effective approaches to preventing HIV with,
for example, injecting drug users. The Alliance welcome this guidance,
but are advocating for a much bolder and active role for WHO in
country dialogues with national governments who continue to ignore
best practice and favour less controversial, less effective AIDS
interventions.
Discrimination in health care settings is widely
reported by people living with HIV. WHO can play a much greater
role in challenging HIV-related stigma and discrimination in health
care settings by addressing the unscientific and discriminatory
attitudes to HIV/AIDS held by health care workers across the world.
7.2 Unicef
In a similar way, the Alliance values the normative
and co-ordination role played by Unicef as the global technical
lead agency on HIV and children and young people. The UK Government
supports this global co-ordination and leadership role played
by Unicef. However, the UK Government also supports Unicef's operational
role as a programmer of services to children affected by HIV and
AIDS at a country level. It is this role—as an operational
programming agency—that is questioned here.
The programming of services at national and
sub-national levels is best undertaken by organisations that can
promote sustainability and that can build capacity. The Alliance
holds that UN agencies offer only limited potential as operational
agencies, they have high transaction costs, and are unable to
demonstrate impact. In the period of the last UK global AIDS strategy,
the UK Government invested substantially in Unicef as the lead
agency to deliver programmes to children affected by AIDS in Southern
African countries. The success of this investment is unclear.
7.3 UNODC and the International Narcotics
Control Board
The UK Government supports the UN Office on
Drugs and Crime (UNODC) as the UN agency responsible for co-ordinating
international illicit drug control activities. The illicit drug
control system that the UNODC advances has as its primary purpose
the restriction of the production, distribution and use of controlled
drugs. This international system of law enforcement and drug control
often clashes with and undermines the more health-oriented "harm
reduction" approach to drug use, particularly in light of
the particular vulnerabilities to HIV of drug users. This clashing
of approaches results in the routine and large scale incarceration
of drug users, and undermines needle exchange services, access
to methadone and other opiate substitution treatment for drug
users, as well as peer outreach services that educate drug users
about HIV prevention.
In amongst this clashing of approaches, UNODC
are increasingly acting as operational agents—like Unicef—of
HIV and harm reduction programmes across Asia. Whilst other parts
of UNODC support governments who continue to routinely incarcerate
drug users.
UNODC policy on HIV/AIDS, harm reduction and
drug use is variable, and often unscientific. And UNODC practice
often undermines the commitments made by UNAIDS and its co-sponsors
to advance the human rights of marginalised populations vulnerable
to HIV/AIDS.
This inconsistency is costly—both in financial
and human terms. The Alliance urges the UK Government to play
a much more active role in pursuing cohesiveness and consistency
in UN policy on HIV/AIDS and drug use, which means for UNODC,
a greater focus on protecting health and reducing the harm caused
by drug use.
7.4 The Global Fund to fight AIDS, TB and
Malaria
The Global Fund is a crucial source of international
funding for health, providing approximately 21% of funding for
AIDS, 67% of malaria funding, and 64% of TB funding. By mid-2007,
and since 2003, it has disbursed US$3.7 billion in 132 countries.
These resources have provided ART for 1.1 million people, TB treatment
for 2.8 million people, and distribution of 30 million insecticide-treated
bed nets to protect against malaria. Many millions have received
counselling, care, support and training. The Global Fund estimates
that programmes supported by their funding have saved 1.8 million
lives to date.[14]
The UK Government has always been a strong supporter
of the Global Fund and we assert that this must continue, and
expand. We acknowledge some of DFID's concerns about the Global
Fund—that an additional financing institution adds to transactional
costs, and adds to the complex task of donor harmonisation at
a national level. But the performance of the Fund, to make a substantial
AIDS impact in only four years, is impressive. It is difficult
to see comparable impact from some of the other intergovernmental
agencies that DFID supports.
The Alliance, along with other UK based international
development NGOs,[15]
are calling for a tripling of the UK Government's current annual
contribution—from US$200 million in 2007 to US$600 million
in 2010, in order to achieve the universal access commitments
made in 2006.
The Global Fund is a uniquely transparent and
accountable financing mechanism that promotes country-led as
distinct from donor-led or government-owned approaches. A cross-section
of interests, particularly those of people with HIV/AIDS and other
representatives of civil society, is represented in the governance
of Global Fund. These open governance structures are supported
by a variety of systems and processes—critically at both
country level and internationally—that explicitly promote
transparency and accountability. This is valued highly by global
civil society and other stakeholders.
This culture and practice of openness contrasts
sharply with the culture and practice of other international institutions.
7.5 The World Bank
The World Bank's progress on addressing AIDS
has been variable. Its "business as usual" approach
in the first decade of the AIDS epidemic, whereby AIDS was mainstreamed
into broader development programmes, has been widely critiqued.
In response to this criticism, the World Bank's Multi-country
AIDS Programme (MAP), was established to resource much more substantial
AIDS-focused programmes.
The Alliance supports programmes such as the
World Bank MAP that elaborate clear and precise AIDS targets,
and that involve a range of stakeholders, including governments,
but also importantly, civil society, in the planning and delivery
of interventions.
Given the UK Government's substantial investment
in the World Bank as an intergovernmental agency involved in the
global AIDS response, the Alliance urges much greater transparency—
in terms of the UK Government investment, and in terms of the
Bank's AIDS programmes and their impact.
8. THE LIMITATIONS
OF GOVERNMENT-TO-GOVERNMENT
RESPONSES TO
HIV/AIDS
Whilst there is demonstrable progress in the
amount of global resources available for HIV/AIDS, and progress
on the number of people receiving anti-HIV treatment, UNAIDS evidence
vast gaps in access to basic HIV services, particularly for those
most marginalised.
DFID acknowledge the special needs of these
marginalised populations, yet invest large proportions of AIDS
resources in national governments and in intergovernmental institutions
that relate primarily to governments. This will never be enough
to stop AIDS.
The problem of national governments and their
inability to direct resources to marginalised populations is evidenced
by Sharma et al[16]
who demonstrate the inability or unwillingness of national governments
to know about or respond to HIV epidemics amongst marginalised
populations:
... most countries surveyed are providing
few resources to prevent or reduce epidemics amongst groups most
vulnerable to HIV infection. In some cases, epidemiology and resource
allocation are going in opposite directions. In most cases, some
resources are provided, but as such low levels they are unlikely
to have any significant impact on epidemics.[17]
This problem is also recognised by UNAIDS:
While funding for HIV programmes has increased
in recent years, many countries fail to direct financial resources
towards activities that address the HIV prevention needs of the
populations at highest risk, opting instead to prioritise more
general prevention efforts that are less cost effective and less
likely to have impact on the epidemic.[18]
The independent evaluation of the UK Government's
global AIDS strategy identifies this problem as well:
There are concerns that PRSPs may not be an
effective mechanism for reaching priority groups, as a result
of poor national prioritisation and political barriers to addressing
sensitive and contentious issues.[19]
The reviewers go on to recommend a flexible
mix of financing instruments to address this problem.
The National Audit Office, in its enquiry on
global AIDS spending by the UK Government, highlighted how weak
DFID's performance management of multilateral institutions was.[20]
There has been little progress to address these weaknesses since
they were identified in 2004.
The Alliance acknowledges that national governments
should always be the principle partners of the UK Government in
AIDS and other development efforts. We also acknowledge that intergovernmental
organisations provide critically important technical support to
governments, along with important leadership and co-ordination
roles. But to really reach the hard to reach—the criminalised,
the marginalised, the hidden and at-risk populations—the
UK Government needs to diversify its range of investments beyond
national governments and intergovernmental institutions that relate
primarily to national governments, to more substantial investments
in civil society-led responses. Its investments in intergovernmental
institutions should be performance-related, transparent and consistent
with its commitments set out in its global AIDS strategy.
February 2008
1 UNAIDS (2007) AIDS Epidemic Update
http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/default.asp Back
2
ibid p 4. Back
3
UNAIDS (2007) AIDS Epidemic Update
http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/default.asp Back
4
ibid. Back
5
ibid. Back
6
UNAIDS (2006). Report on the global AIDS epidemic. http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp Back
7
UNAIDS (2006). Report on the global AIDS epidemic. Back
8
UNAIDS, HIV/AIDS and Human Rights: International Guidelines,
September 1996. Back
9
USAID, UNAIDS, WHO, CDC and the POLICY Project, Coverage of
selected services for HIV/AIDS prevention, care and support in
low and middle income countries in 2003, Washington, June
2004. Back
10
UNAIDS (2006) Report on the Global AIDS Epidemic. Back
11
UNAIDS, in Financial Resources Required to Achieve Universal
Access to HIV Prevention, Treatment, Care and Support (September
2007) estimate that the global resources gap for AIDS in 2008-09
is $20.2 billion. Back
12
Newer ART may be safer, more effective and/or necessary as second-line
therapy for those developing side effects or resistance to first-line
drugs. Back
13
Discussed in more detail in the Stop AIDS Campaign briefing Shaping
the UK's HIV/AIDS Strategy,
http://www.stopaidscampaign.org.uk/IfNotNow/documents/ShapeUKHIVStrategy4Page.pdf Back
14
Results at a Glance, Global Fund for AIDS, TB and Malaria,
June 2007. Back
15
Stop AIDS Campaign www.stopaidscampaign.org Back
16
Sharma, McCallum and Burrows, Is there anyone left in the general
population? AIDS Projects Management Group, August 2005, www.aidsprojects.com Back
17
Ibid p 6. Back
18
UNAIDS, 2006 Report on the Global AIDS Epidemic. Back
19
Drew R and Attawell K, Interim Evaluation of Taking Action:
the UK Government's Strategy for Tackling HIV and AIDS in the
Developing World, February 2007. Back
20
Responding to AIDS, National Audit Office HC 664 Session
2003-2004: 18 June 2004. Back
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