Combatting AIDS: What More Needs to Be Done?

The first disease to be the subject of debates in the United Nations, both in the Security Council and the General Assembly special sessions, AIDS is one of the top ten leading causes of death worldwide. A quarter of a century into the epidemic, it has become one of the defining issues of our time. According to the Human Development Report 2005, published by the United Nations Development Programme, it is responsible for "the single greatest reversal in human development".

In many respects, AIDS is the ultimate global, as well as local, problem. Originally regarded as affecting gay men in North America, it occurs in every country in the world. Half of all adults living with HIV are female. However, although AIDS has become a global threat, it is by no means a homogeneous epidemic. Clearly, more is needed to be done to address the issue, but what needs to be done will vary from place to place. Different regions are affected to varying degrees, with prevalence and impact highest in Southern and East Africa. In Botswana, Lesotho and Swaziland, one in four adults is HIV-positive. Compare this with Latin America, where in Argentina and Brazil around 1 in every 200 adults is living with HIV.

There may be a number of different localized epidemics within a country. In the northeast part of India, for example, AIDS is predominantly fuelled by injection drug use, while in other areas most infections result from unprotected sex. Major discrepancies often exist between rural and urban areas, with infections being much more concentrated in cities. The impact of AIDS also varies between social groups. It is pre-eminently a disease of inequality. Economic and gender inequalities have a direct influence on sexual behaviour and thus the potential for HIV transmission. Research in Kenya, for example, highlights that, where women's economic and social safety is largely dependent on their partners' occupation and status, they have little choice in determining their own sexual safety. It is therefore important for economic development strategies to adopt a "pro-poor", as well as "pro-women", approach to avoid the risk of increasing income inequalities and inadvertently fuelling the HIV epidemic.

Since the turn of the century, there has been a marked increase in attention and action on AIDS. Governments have agreed on a set of international targets, such as Millennium Development Goal 6: to "halt and reverse the spread of AIDS by 2015". UN Member States in 2001 issued a Declaration of Commitment on HIV/AIDS and in 2006 committed to scale up towards universal access to HIV prevention, treatment, care and support by 2010 and to draw up national targets and plans for achieving it. The aspiration is global, but to achieve it will depend on the progress made by individual countries. Success at the national level will be based largely on the current state of the epidemic and the response to it.

A number of countries in Latin America, Southest Asia and Africa already appear to be well on the way to providing universal access to HIV treatment and have significantly increased access to drugs that prevent mother-to-child HIV transmission. Botswana, for example, has achieved a 90-per cent coverage of antiretroviral (ARV) therapy, 90 per cent of pregnant women living with HIV can obtain drugs to protect their children from infection, and some 30 per cent of the population have been tested for HIV. But, as in many other countries, action on HIV prevention lags way behind and HIV-related stigma still prevails. It is salutary to look at Botswana's advances in the context of the global movement towards universal access. Just one third of those requiring HIV treatment in low- and middle-income countries are taking it. Only 10 per cent of women needing drugs to prevent transmission to their children can access them.

Clearly, there is no room for complacency. In many parts of the world, there are links between progress on AIDS and the MDGs. Headway on the first three Goals -- eradicating extreme poverty and hunger, achieving universal primary education and promoting gender equality -- reduces inequalities, thus enhancing people's capacity to protect themselves from infection and to access treatment for HIV, when available. At the same time, as seen in Cambodia, progress on AIDS can contribute to advances on maternal and child health. Progress also depends on our abilities to intensify and sustain political leadership, often in the face of conflicting priorities, to ensure that attention and action continue over the longer term. Electorally driven short-term political time frames make this particularly difficult at the national level. It is, therefore, critical that civil society and the international community advocate consistently to keep AIDS high on their agenda.

Political attention is essential to securing adequate funding. In 2007, $10 billion were committed to HIV programmes in low- and middle-income countries. This is a significant increase from the $250 million spent in 1996, the first year the Joint United Nations Programme on HIV/AIDS (UNAIDS) became operational, but it falls a long way short of what is required to secure universal access to HIV services. Two thirds of this funding derives from international sources, principally the specially created mechanisms-the United States President's Emergency Programme for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The remainder is provided by countries themselves.

Clearly, if we are to accelerate progress towards universal access to HIV services, we need to scale up funding from existing sources and explore new ones. We must also ensure that the money available is put to the best use. At UNAIDS, our principal task is to help "make the money work" so that more gets done on AIDS. Five key elements are required.

First, it means helping countries design and implement strategies that are based on knowledge about the local epidemic. It involves studying where the epidemic is and what drives it, acting upon that knowledge and then monitoring and evaluating the actions taken. It also requires better surveillance, greater disaggregation of epidemiological data (sex, age, urban/rural) and more analysis. Otherwise, there can be serious disconnects between the dynamics of the epidemic and our response to it. Recently, we learned of one country where AIDS strategies were based on assumptions about the country as a whole. HIV prevalence at the national level was 1.8 per cent, but among sex workers it stood at 80 per cent. Some 75 per cent of new infections in men in the capital were among clients of sex workers, but only 0.8 per cent of HIV interventions focused on sex work, meaning that the country missed a major opportunity to direct interventions where they would have the most impact.

Second, it means ensuring that programmes are comprehensive and multi-sectoral. It is widely accepted that AIDS cannot be regarded just as a health issue. Much more needs to be done to make a multi-sectoral response a reality and to ensure that Governments allocate budgets and deploy resources across departments. Education is a case in point. The Global Campaign for Education has calculated that if every child received a complete primary education, at least 7 million new cases of HIV could be prevented in a decade. Today, one in five children of primary-school age are still not being educated. It is also vital to ensure that HIV services are integrated with other health services, such as for tuberculosis, and reproductive health. There is growing evidence that AIDS investment can strengthen these services. In Ethiopia, for example, a major scale-up of access to voluntary HIV counselling and testing, including ARV treatment, has produced a large corps of medical workers trained in comprehensive treatment of, for instance, sexually transmitted diseases and opportunistic infections, tuberculosis and HIV.

Third, coordination and cooperation are prerequisites for an effective multi-sectoral AIDS response among different stakeholders, including government departments, donors, communities, people living with HIV and international organizations. Coordination lies at the core of the UNAIDS mandate, bringing together the work of the ten organizations that make up the Programme,* providing policy guidance and technical support on different aspects of the epidemic. For this reason, UNAIDS is deeply committed to the principle of "Delivering as One UN". Over the past three years, one of its priorities has been to turn the "Three Ones" principles into action: one agreed AIDS action framework, one national AIDS coordinating authority, and one agreed country-level monitoring and evaluation system. At the same time, responses must come from within the country if they are to have real impact. That is why we attach such importance to strengthening national capacity to tackle the epidemic in locally appropriate ways.

Fourth, making the money works means that AIDS strategies must be grounded in human rights. We must address inequalities and injustices that drive infection levels upwards and prevent people from accessing HIV treatment, care and support when they need it. In 2008, the stigma attached to HIV infection remains one of the biggest obstacles to achieving MDG 6 and the universal access to HIV services. Other obstacles include gender inequities, homophobia and discrimination against sex workers, injection drug users, indigenous populations and migrants. For instance, where women have little choice in determining their own sexual safety, their susceptibility becomes greater when they are part of a marginalized population. Recent research in Viet Nam, for example, revealed that women migrant workers were twice as likely as other women to become HIV-positive.

Lastly, there must be a much greater emphasis on HIV prevention. At the global level, we face a situation where for every one person who starts taking ARV treatment, another four become infected. As we have seen, there is a real risk that progress on HIV prevention will continue to lag way behind advances in treatment, meaning that the queues for treatment will become longer. But intensifying prevention is both complex and challenging. No single approach will work on its own, and nothing will work unless we deal better with the socio-economic inequalities and injustices that fuel the spread of HIV and improve our capacity to measure and report on prevention gains.
Progress in all these five areas is critical if we are to make a real impact on the epidemic. As we move ahead, it is important not only to remain realistic but also optimistic. So far, there has been too much focus on what is not happening on AIDS. We need to get better at assessing what is happening, learning lessons from what is working and ensuring that capacity exists to act and build on what we have learned. If we can do this, we will be in a far better and stronger position to make universal access to HIV prevention, treatment, care and support a reality.

* The ten UNAIDS partners are: Office of the United Nations High Commissioner for Refugees (UNHCR), United Nations Children's Fund (UNICEF), World Food Programme (WFP), United Nations Development Programme (UNDP), United Nations Population Fund (UNFPA), United Nations Office on Drugs and Crime (UNODC), International Labour Organization (ILO), United Nations Educational, Scientific and Cultural Organization (UNESCO), World Health Organization (WHO) and World Bank.