IV. Global, Regional and National Responses to AIDS
Until recently, the response to AIDS lacked an essential element: political recognition and commitment at the highest global and national levels. Today, AIDS is on the world's global political agenda and is considered an issue of utmost urgency in nearly every country. Given the societal root causes, the breadth of impact of HIV and the continuing stigma it attracts, a purely medical or public health response is insufficient. Political leadership at the highest levels is needed to mobilize an effective multisectoral response.
Joint United Nations Programme on HIV/AIDS
In 1996, to mobilize the main United Nations agencies in a coordinated response and individually in their respective areas of work, the United Nations drew together six agencies -- the United Nations Children's Fund (UNICEF), the United Nations Development Programme (UNDP), the United Nations Population Fund (UNFPA), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health Organization (WHO) and the World Bank -- in a joint and co-sponsored programme, the Joint United Nations Programme on HIV/AIDS (UNAIDS). A seventh, United Nations International Drug Control Programme (UNDCP), joined in 1999. The urgent need for concerted action on AIDS was further emphasized in April 2000, when the Administrative Committee on Coordination called on all United Nations agencies to engage in AIDS through policy development and resource allocation to HIV/AIDS activities, and developed measures designed to improve support to United Nations staff and dependents living with HIV or AIDS.
UNAIDS co-sponsors have made significant progress in mainstreaming HIV/AIDS into their programs, and AIDS is now an institutional priority in the respective organizations (for individual co-sponsors' activities, see Annex II). Collectively, UNAIDS co-sponsors and the UNAIDS secretariat have established a joint budget and work plan and are developing a United Nations system-wide strategic plan on HIV/AIDS. Cooperation with non-co-sponsoring United Nations organizations and agencies, including the Food and Agriculture Organization of the United Nations (FAO), the International labor Organization (ILO), the Office of the United Nations High Commissioner for Human Rights, the United Nations Development Fund for Women (UNIFEM) and the World Food Programme (WFP) is also expanding.
International development agencies have taken significant steps to elaborate comprehensive strategies on HIV/AIDS and to increase technical and financial resources for the fight against the epidemic. Most donor countries have also begun to mainstream AIDS into their overseas development cooperation programs, and have developed global HIV/AIDS strategies as an integral part of their overall development assistance programs.
Non-profit foundations are increasingly in the forefront of the response. For example, the Bill and Melinda Gates Foundation has made large grants to support AIDS prevention among youth and health-care work in several African countries. The United Nations Foundation (UNF) funds AIDS-related activities in a Southern Africa initiative and in Ukraine, and will expand efforts to support activities in India, South Asia and Central America in 2001. UNF has also funded several other projects that integrate AIDS work into broader projects on education, health and development. Support early on in the epidemic was provided by the Rockefeller Foundation.
Civil society has led the way on some of the most sensitive issues, such as drug-related prevention, human rights promotion and protection of people living with HIV/AIDS. NGOs have made significant contributions to the development of appropriate models for community care and support. Along with several treatment action groups, they have initiated advocacy programs and placed the issue of equitable and affordable access to care, treatment and support onto global and national agendas. Civil society groups are also key actors in regional and international partnerships, such as the International Partnership Against AIDS in Africa.
The corporate sector has an important contribution to make, particularly in the regions of the world hardest hit by HIV/AIDS. Organizations involving and representing businesses, such as the Global Business Council on HIV/AIDS, are taking the lead in promoting the involvement of business in cross-sectoral partnerships with Governments and NGOs. Such companies as MTV, Standard Chartered Bank, Coca-Cola and Unilever are increasingly showing leadership in the partnership field.
As well as researching and developing new HIV drugs, multinational pharmaceutical companies have initiated corporate responsibility programs to help support global responses to HIV/AIDS, including training of health-care professionals in developing countries and support for community-based organizations. As part of broader endeavors to improve access to HIV care, support and treatment in developing countries, five companies agreed in May 2000 to collaborate with the UNAIDS secretariat, WHO, UNICEF, the World Bank and UNFPA by reducing the prices of their medicines. This reflects an increasing acceptance by the industry of tiered pricing of commodities and treatments (namely, significantly reduced pricing for developing countries), within a wider review of options for improving access to and the affordability of HIV-related commodities and services. The manufacture and distribution of generic drugs in line with international agreements and the provisions that they make provide further opportunities to widen access to care and treatment. However, much more needs to be done. All options for improving access to care should be pursued at the global and national level. Options at the country level would include support for strategic plans for care that address the needs of health and social systems, as well as equity issues and the use of public subsidies for commodities and medicines. Globally trade policy provisions need to be used more effectively to increase access to care. The availability of low-cost generic drugs needs to be expanded, in accordance with national laws and international trade agreements and with a guarantee of their quality. The relevance of compulsory licensing and the development of national manufacturing capacities need further expansion.
Research and Academic Organizations
With no cure for HIV/AIDS in sight, further research on effective prevention and care technologies -- such as vaccines, microbicides and potent new treatments -- remains crucial. International initiatives, such as those on vaccines development, including the International AIDS Vaccine Initiative and the African Vaccine Initiative, are becoming increasingly essential to the response. Academic research institutions from both the public and private sectors also have an important role to play. In addition, new technologies, innovative financing and delivery systems need to be developed so that access is as prompt and broad as possible.
While global responses to AIDS are essential, regional and national responses are key elements in halting the spread of the epidemic, both in their own right and since regional responses facilitate support to national-level initiatives. The real success in the fight against HIV and AIDS will be fought or won at the national level.
United Nations Theme Groups on HIV/AIDS
The principal avenue of United Nations support to national-level AIDS responses is provided by United Nations theme groups on HIV/AIDS, made up of co-sponsoring and other relevant agencies, bilateral donors, NGOs and representatives of the host country. Working through the United Nations resident coordinator system, theme groups -- guided by national priorities and by Governments -- support national efforts to curb the epidemic by working together on joint programme design and planning, monitoring and resource mobilization, while increasing their own HIV/AIDS activities.
Non-Governmental Organizations and Community-Based Groups
Civil society, especially non-governmental organizations and community-based groups at the national level, such as groups of people living with HIV/AIDS, have made critically important contributions to responses to HIV/AIDS. This has often been done with the support of international organizations, international networks of groups representing people living with HIV/AIDS, AIDS-specific NGOs and mainstream NGOs, ranging from faith-based groups to membership organizations and service groups, that go beyond a basic response to HIV/AIDS and address the development issues that fuel the epidemic.
Businesses -- both large and small -- can provide HIV prevention and related programs in the workplace, including support for employees infected or affected by HIV. As well as participating in HIV/AIDS programs in the local communities where they are based, businesses can be active in cross-sectoral partnerships with Governments and NGOs. The emergence of national business coalitions on HIV/AIDS helps to engage and support the response of local companies.
African leaders are courageously breaking the silence surrounding the epidemic, publicly and repeatedly declaring AIDS a national emergency and establishing the institutions and mechanisms needed to respond swiftly to the spread of HIV.
While the epidemic in Africa continues to spread, there is well documented evidence of successes in the response to HIV/AIDS, particularly among young people. The epidemiological information coming from Zambia, Uganda and the United Republic of Tanzania is evidence of a new generation responding to the threat of HIV/AIDS by changing their behavior in ways that appear to be protecting them from HIV. Infection rates among young women in Lusaka have been halved since 1993 through prevention efforts, which have also resulted in less premarital sex, increased male sexual abstinence and less frequent casual sex. In some parts of Uganda, the first African country to reverse its own epidemic, infection rates among teenage girls dropped dramatically during the 1990s, as did teen pregnancies. Successes have also been recorded in the Mbeya region of the United Republic of Tanzania, where prevention efforts have reduced HIV infection rates among pregnant women attending clinics by 25 per cent.
Partnerships are being established at several levels. The International Partnership Against AIDS in Africa (IPAA) is a coalition of United Nations agencies, donors and the private and community sectors, under the leadership of African countries, which is designed to intensify the response to AIDS across Africa. A number of partnerships are being established at national level, including a partnership forum in Tanzania and a local-level care and support initiative in South Africa's Gauteng province.
Strong national strategic responses are being forged through single, powerful national AIDS plans involving a wide range of actors -- government, civil society, people infected with and affected by HIV, the private sector and donors. More than 30 countries in sub-Saharan Africa have completed strategic planning processes which have helped build consensus and mobilize resources, at times leading to successful round-table discussions with all interested parties and to significant funding commitments, as was the case in Malawi and Zambia in 2000. In many countries, high-level councils and national AIDS commissions have been created under the responsibility of the head of State to provide leadership for a true multisectoral response. Nevertheless, with some important exceptions, there has been insufficient engagement from social and economic sectors outside the health sector, which remains a key challenge for national responses.
Africa has demonstrated to the world the importance of local responses to HIV/AIDS, which aim to empower communities through local partnerships consisting of social groups, service providers and facilitators. Initiatives are being implemented in Burkina Faso, Ghana, the United Republic of Tanzania and Zimbabwe, for example, with increasing involvement in the response of local leaders, such as mayors or traditional leaders.
Beyond Governments and development institutions, civil society -- made up of NGOs, religious groups and the private sector -- is intensifying its involvement in the response against HIV/AIDS. An increasing number of communities are mobilizing to face the multiple challenges of prevention and care, including denial, silence and the predominantly negative attitudes adopted towards people living with HIV/AIDS.
There is increasing evidence that businesses are recognizing the impact of HIV on the human, financial and social costs of their operations and host communities. They have responded in many different ways, from action to protect workforces to community outreach and philanthropy. In Zimbabwe, a workplace-based peer education programme in 20 companies resulted in 30 per cent fewer HIV infections than in 20 companies without a similar programme. In Côte d'Ivoire, the national electrical company has implemented prevention methods, improved medical monitoring of employees and increased participation by companies in employee health insurance schemes. Companies have also begun to collaborate through business coalitions on HIV/AIDS at the national level.
Children are especially vulnerable to the epidemic, and examples abound of responses to mobilize political will, reallocate national resources, bolster the capacity of families and communities to care for and support orphans, stimulate and strengthen community-based responses and ensure that Governments protect the most vulnerable children.
The vast majority of children living with HIV or who have already died of AIDS in Africa were born to HIV-infected mothers. The most vulnerable of populations, these children acquired the virus in the womb at about the time of childbirth or during breastfeeding. Making HIV counselling and testing services widely available so that infected women can decide whether to take preventive drugs during pregnancy is a measure that could save the lives of hundreds of thousands of children. This technology, which has been demonstrated in pilot settings, has enormous potential to affect the epidemic. The challenge is to apply the technology on a large scale. The Uganda AIDS Information Centre, which has provided voluntary counselling and testing (VCT) to over 350,000 clients since 1990, is beginning to introduce same-day VCT services; previously, clients had to wait two weeks to receive their HIV test results, and 25-30 per cent did not return to get them.
The provision of HIV care is a major challenge for many African countries, where health services face dwindling resources and are already hard pressed to cope with a host of older diseases. The need to invest in prevention and essential services has, in the past, taken precedence. However, building on the strengths of local communities, grass-roots home-based care services have played a critical role in providing basic care for people living with HIV/AIDS. The feasibility of incorporating care into broader HIV public health programs has been increasingly accepted, and many more African countries are developing national strategic plans, which include a strong care component, helped by wider discussions on options to improve the affordability of HIV-related commodities and treatments.
An enormous resource gap continues to exist, however, even though resources are being mobilized by African Governments and international donors. In South Africa, the nation's regular budget includes substantial allocations for AIDS prevention and care programs. In Zimbabwe, the Government mobilized additional funds for AIDS by instituting an AIDS levy among the general population.
Additional -- albeit insufficient -- funds are also forthcoming through debt relief, and AIDS now figures prominently in funding activities for Africa. Through the heavily indebted poor countries initiative, some US$ 30 billion in debt reduction had been achieved by the end of 2000, with specific funding set aside for AIDS representing US$ 20 million in 2001. The World Bank is reviewing its portfolio in countries to retrofit unused funds into the fight against AIDS, and has created a multi-country AIDS project to make more funds available to the HIV/AIDS response. AIDS is a priority among United Nations agencies and major multilateral and bilateral partners in sub-Saharan Africa, many of whom are mainstreaming AIDS into all their sectoral interventions.
Funds are also made available through round-table mechanisms, which bring together all interested parties at the country level to mobilize funds for implementation of the strategic plan. Some US$ 121 million in Malawi was recently made available in this way, with support from the United Nations system and international donors, and an additional US$ 113 million in Zambia.
Asia and the Pacific
Success is also evident in Asia, and includes Thailand's community-based care models and its successful 100 per cent condom programme model, now being tested in Cambodia; peer outreach projects with sex workers in Calcutta, Kerala and Dhaka; projects with injecting drug users in Nepal, India and Malaysia; and the enactment of supportive national AIDS legislation in the Philippines. While diversity and Asia's huge population exacerbate the difficulties of mounting timely and effective responses, opportunities abound in a region where overall HIV prevalence is still low but where the incidence of new infections is rising. The opportunity cost of failing to act vigorously and urgently could be enormous.
In South Asia, the problem of underdevelopment inevitably constrains the response to HIV/AIDS. The growing gap between rich and poor, the huge numbers of rural poor, and the systematic underfunding of health and other social sector spending provide a challenging backdrop for the response to HIV/AIDS.
Despite Asia's diversity, the region faces some common challenges. One challenge is to act "upstream" to prevent or minimize new infections rather than reacting "downstream" to the impact of AIDS. This means vigorous prevention activity among those most at risk -- the millions of migrant workers and the many thousands of refugees. It means addressing large-scale sex-related activities, including the trafficking of girls and women. It also means tackling human development issues of particular significance to Asia, such as gender inequalities. It also requires dealing with taboo and ensuring widespread information and services are available to all, especially young people.
Another challenge lies in confronting the pervasive exclusion and stigmatization that afflict people living with HIV, especially in low-prevalence situations, an issue highlighted at the last regional conference on AIDS in Asia and the Pacific, held in Kuala Lumpur in October 1999. A further challenge is to adapt and apply lessons learned from successful or effective pilot projects and to step up the response. This is now being attempted among sex workers and drug users through the Kathmandu Valley Initiative in Nepal and in Tamil Nadu in India, where the AIDS prevention and control project to promote safer sex behaviors among vulnerable groups is being expanded.
Recent positive developments in facing up to these challenges include increased political activity. The Asian Forum of Parliamentarians on Population and Development brought together political leaders from 11 South-East and East Asian and Pacific countries last year, enhancing their personal commitment to HIV/AIDS prevention and care programs. Member States of the Association of Southeast Asian Nations (ASEAN) have included AIDS on the agenda of their November 2001 summit in Brunei.
There is also growing recognition of the need for a broad-based response involving different sectors and for innovative partnerships, especially between the public and private sectors. For example, the involvement of Rotary and Lions Clubs and of business coalitions in the response to AIDS in Thailand is being reflected in similar partnerships in India, the Philippines and Bangladesh. Uniformed and armed forces are increasingly involved in prevention programs, notably in Cambodia and India, as well as in Viet Nam, the Lao People's Democratic Republic and China. Religious leaders and groups have become more prominent in the AIDS response.
Eastern Europe and Central Asia
Despite an explosive spread of HIV in several countries in the region, the epidemic is still in its early stages and confined mainly to injecting drug users and their partners. High levels of injecting drug use and sexually transmitted infections, coupled with socio-economic turmoil and a rapid rise in sexually transmitted infections after the breakdown of the Soviet Union, could lead in a few years to larger scale and more generalized epidemics. A unique opportunity still exists for effective targeted interventions, particularly among injecting drug users.
However, recent political and legal reforms in some countries are opening more effective avenues to HIV prevention. Ukraine and Belarus, for example, now have multisectoral committees at the highest political levels, and have removed legal barriers to needle exchange programs, substitution treatment and other approaches to HIV prevention among injecting drug users.
Further evidence of a mobilizing response comes from national strategic plans that are in various stages of development in 13 countries. Joint action to support and strengthen national responses to HIV/AIDS now focuses on three regional strategic priorities: expanded coverage of HIV prevention, targeting injecting drug users; prevention and control of sexually transmitted infections; and meeting the needs of vulnerable young people. Mechanisms have also been established to improve coordination between regional support and national responses.
A range of initiatives supports the response to HIV/AIDS in the Russian Federation, including projects on HIV prevention among injecting drug users, strategic planning processes in 17 regions, and a joint response initiative launched recently by the United Nations theme groups on HIV/AIDS. However, there is still an urgent need to step up advocacy, social mobilization and effective use of existing resources, and to dismantle barriers, such as lack of political commitment and supportive legislative environments and lack of financial resources. Substantial support from the international community is imperative if the critical transition from short-term project activities to long-term sustainable and expanded national programs is to be made.
A number of regional initiatives also help support the response to HIV/AIDS. The Baltic Sea initiative marks the start of a wide process of consultation on strategic priorities, including a Baltic Sea action plan on HIV/AIDS. In parallel, several Governments in the region and Western Europe have established a task force on communicable diseases in the Baltic Sea region to recommend joint actions. An initiative in Central Asia is seeking to reinforce collaboration among countries and agencies to develop a joint strategic framework and action plan.
Notwithstanding a growing number of local and national initiatives, the response remains uneven and insufficient. The development of effective, sustainable national responses has been constrained by insufficient high-level political leadership, a climate of economic hardship, stigmas concerning sexual behavior and injecting drug use, and legal barriers.
Latin America and the Caribbean
Prevention efforts in parts of Latin America have met with considerable success: mortality and AIDS incidence are falling, while care is increasingly widespread throughout the region. For example, according to a 1999 survey in Brazil, prevention campaigns have increased condom use during first sexual contact from 4 per cent 15 years ago to 48 per cent today -- and up to 70 per cent among certain groups, such as students from more privileged socio-economic backgrounds. Targeting prevention programs towards men who have sex with men continues to be a major challenge, however.
While in some countries treatment of basic health needs, such as opportunistic infections, is problematic, other countries have responded to demands from groups of patients, doctors and human rights organizations to provide access to antiretroviral drugs. With a rights-based approach to care, together with local production of generic antiretrovirals in some countries, coverage of patients is increasing in Brazil, Argentina, Chile and Uruguay, where HIV-positive people are living longer, healthier lives. Since the introduction of antiretrovirals, reported AIDS deaths in Brazil have dropped more than 25 per cent.
Providing AIDS drugs has also been at the centre of rapidly emerging South-South cooperation, a strategy anchored in the understanding that partners sharing knowledge become more powerful and effective. At present, 19 Latin American and Caribbean countries are involved in the Horizontal Technical Cooperation Group on AIDS, a key instrument in fighting the spread of AIDS. Brazil has also championed technical exchange with other countries in the region, as well as with lusophone Africa, integrating the benefits of South-South cooperation into its response.
The Forum 2000 conference on AIDS held in Rio de Janeiro in November 2000 demonstrated the extent of regional cooperation and the strong role of non-governmental organizations in the response of the region, as well as a continuing need to expand programs targeting men who have sex with men. While homosexual transmission constitutes 40 per cent of transmission in Latin America, less than 1 per cent of AIDS programme budgets goes to prevention for men who have sex with men, with the exception of Brazil, which devotes significant resources to this area.
In the Southern Cone of Latin America, an important aspect of the epidemic is HIV transmission through injecting drug use. A subregional initiative to address this issue and to intensify the policy dialogue is currently under way.
In the Caribbean, ministries of health have long been aware of the escalating epidemic and its implications for the region, but a series of high-level meetings during 2000 ushered in a new level of public awareness and visibility for AIDS. HIV/AIDS has emerged as an urgent development priority, and a regional strategic plan of action was developed by the Caribbean Task Force on HIV/AIDS, chaired by the Caribbean Community (CARICOM), which brings together a wide range of members from national Governments, international and regional institutions, NGOs and donors. The newly established Pan-Caribbean Partnership illustrates the increasing commitment of Caribbean Governments to address HIV/AIDS, and has led to new resource commitments by the World Bank and the European Commission.
In Central America, vulnerable mobile populations are the main focus for regional action programs being developed with the support of the National Institute of Public Health in Mexico, with Proyecto Acción SIDA de Centroamerica and with the Regional Initiative for HIV/AIDS and other projects for the prevention and control of sexually transmitted diseases in Latin America and the Caribbean. National strategic AIDS plans are under implementation in all Central American countries. Central America is also emerging as a region where the epidemic is increasing its pace and where greater attention needs to be placed on directing responses to priority areas, such as the epidemic among men who have sex with men.
In high-income countries, HIV infections are concentrated principally among injecting drug users and men who have sex with men, although transmission through heterosexual sex is on the rise. Prevalence in the total population remains low. While some communities and countries have acted aggressively to limit HIV infection among injecting drug users, other countries have not. Needle exchange and other prevention programs have been effective where implemented, but often the political costs of these programs have been considered too high for implementation on a large scale. Among men who have sex with men, prevention programs are more widely accepted and implemented, and as a result risk behavior and the resulting HIV infection rate has dropped significantly since the mid-1980s. However, there is some recent evidence that risk behaviors may again be on the rise in some communities. There is a strong need for continued support for increased preventive efforts among men who have sex with men.