VII. National Responses to AIDS

In every country, HIV prevention and AIDS treatment and care are complex problems that exceed the capability of any one sector. For an effective response, it is important to:

• combine strong national leadership and ownership
• ensure good governance, resource mobilization, multisectoral planning and coordination
• reinforce capacity to use resources well and implement programmes
• closely monitor and evaluate the AIDS response
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• significantly involve communities, civil society and the private sector.

Political commitment has recently increased in the hardest-hit countries. In sub-Saharan Africa, as well as some countries in Asia and the Caribbean, more leaders have taken personal responsibility for implementing the national AIDS response. For example, in Lesotho in March 2004, Prime Minister Pakalitha Mosisili and more than 80 senior civil servants were publicly tested for HIV, in an attempt to break the stigma that discourages testing.

However, in many countries where HIV is quickly spreading, such as those in Asia and Eastern Europe, a lack of leadership may result in a delayed response. Furthermore, in low prevalence countries where the epidemic is concentrated in key populations at high risk, such as sex workers and injecting drug users, many senior political leaders remain detached from the response to AIDS.

Leadership must translate into concrete action. Efforts to measure country-level commitment (carried out by the United States Agency for International Development, the UNAIDS Secretariat, WHO and the United States-based Policy Project) have shown a general pattern of improvement, particularly in providing resources, treatment and care.

There has been an increase in the number of countries with comprehensive, multisectoral national AIDS strategies, and government-led national AIDS coordinating bodies. But the existence of plans and bodies does not always translate into efficient and concerted action. In several Latin American countries, for example, programmes for injecting drug users and men who have sex with men are scarce even though these populations suffer from high infection rates.

In some countries legislation has not kept up with policy and strategic planning. Nearly one-third of countries lack policies that ensure women's equal access to critical prevention and care services. Most countries have ratified international conventions on human rights but these are not effectively implemented. Only 40% of countries have legal measures that prohibit discrimination against populations vulnerable to HIV, such as men who have sex with men. Almost 50% of countries in sub-Saharan Africa have yet to adopt legislation to prevent discrimination against people living with HIV.

Leadership has come from all sectors of society -- faith-based organizations, community groups, groups of people living with HIV, and other civil society organizations.

National AIDS authorities are increasingly turning to formal partnership fora to stimulate civil society participation and increase national ownership of the response. But much more needs to be done. A recent assessment of NGO participation in the Global Fund's first round of grants showed government commitment to working with NGOs appeared to be somewhat hollow. Many appeared to cooperate with NGOs to secure funding, and then lost interest in collaborating.

Business can contribute to the AIDS response at different levels. Although workplace AIDS programmes are increasing in many affected countries, employers and trade unions could still play a much larger role. Only 20% of transnational companies have adopted comprehensive workplace policies on AIDS. At country level, implementation of workplace policies is generally poor.

Decentralizing AIDS efforts from central to district and local management is another challenge to countries. Strong financial and political investment is needed to create effective district and local coordination bodies.

As the number of AIDS funding and implementing agencies increases, there is also an urgent need to deal with the now well-documented risks of duplication of the response at a country level. In an effort to achieve greater harmonization of AIDS funding, UNAIDS led an effort with the US, UK and other leading donor countries to agree to what is known as the "Three Ones" -- one national AIDS plan, one national AIDS authority and one monitoring and evaluation system in each country.

Next Agenda

• Strengthen and sustain national leadership in the fight against AIDS.
• Harmonize multisectoral responses, donor activities and monitoring and evaluation so that countries can succeed in their national responses. Three-quarters of countries report that monitoring and evaluation is a major challenge.
• Produce scientific data and strategic information to guide the response.
• Improve countries' capacity to use their AIDS funds.
• Establish accountability mechanisms to track resources and demonstrate that they are being used effectively.
• Create mechanisms for civil society and business to contribute to the AIDS response, through public-private partnerships.
• Ensure that decentralization is a cornerstone of national AIDS responses.

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