NIBR researcher holds disputation on African HIV/AIDS problematic

Siri Bjerkreim Hellevik of NIBR’s Department of International Studies will publicly defend her PhD “Multisectoral coordination of HIV/AIDS programmes. A study of TanzaniaApr 26, 2012 01:15 PM – 04:00 PM at the Domus Academica of the University of Oslo.

Siri Bjerkreim Hellevik (Photo:

The title of the trial lecture is
Discuss to what extent and how internal factors, and in particular political and economic conditions, can participate in explaining the challenges of coordination in the HIV/AIDS work in Tanzania.

Poor coordination undermines efforts to tackle HIV/AIDS in Tanzania

Hellevik discusses in her dissertation efforts to improve coordination at the national and local levels in Tanzania, and at the global level by African countries and the three major HIV/AIDS programmes: World Bank Multi-country HIV/AIDS Programme for Africa (MAP); Global Fund to Fight HIV/AIDS, TB and Malaria; and US President’s Emergency Plan for AIDS Relief (PEPFAR/Emergency Plan).

National ownership of the HIV/AIDS response in Tanzania is still low. There has been some progress in coordinating the global HIV/AIDS programmes. However, because the individual programmes’ political priorities overlap in practice and because no one takes responsibility for the response as a whole, coordination continues to suffer. The major global health programmes have encouraged greater coordination over the past ten years as a means of getting national and local authorities to give political priority to HIV/AIDS, and engage with the illness a massive social problem. The programmes encourage better coordination because it increases efficiency and supports recipient country ownership of aid provided by the programmes.

National and local authorities in Tanzania, Hellevik notes, lack the capacity to coordinate the country’s HIV/AIDS response. This is partly because it is not a political priority of the government, and partly because global programmes fund most of the country’s HIV/AIDS effort. And since the work of the health sector is given priority, it makes it harder for the authorities to coordinate the HIV/AIDS response across and between involved sectors.

Click here for the University of Oslo’s presentation of the trial lecture.

Siri Bjerkreim Hellevik has written several posts on the HIV/AIDS problematic at the NIBR International Blog. Click here for a list of all articles on this subject.

Governing an Epidemic: HIV/AIDS and scales of Governance

The HIV/AIDS epidemic has acted as a catalyst for rethinking ‘appropriate’ governance responses to health and development crises. NIBR is holding a conference that explores some key issues in this somewhat confusing landscape of governance interventions and responses.

by Berit Aasen, Peris Jones and Siri Bjerkrem Hellevik.

A Bewildering Array of Models
New initiatives, such as the public-private partnership models of the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNITAID, regional, national and local level coordinating institutions and committees, reflect a bewildering array of models of governance. This workshop focuses on the following:

What are the predominant patterns of governance at play? Do these models of governance serve public health coverage and access, development needs and political responses? Do interventions differ according to what scale – whether global, regional, national, and/or local level- is prioritised? What is the role of national and local governments in these HIV/AIDS specific governing responses? And how do global bilateral and multilateral programmes, such as the World Bank MAP, the President’s Emergency Plan for AIDS Relief, influence the governing institutions at the national and local level? Are these governance interventions enabling or disabling sufficient forms of social mobilisation?

This workshop is open for all disciplines that focus on HIV/AIDS and governance at global, national, or local levels – and especially those that combine these levels in analysis. Although the thematic is most relevant for Sub-Saharan Africa, debate will also be on other parts of the world.

The workshop takes place on Thursday November 25, 2010 at the MF building, (Gydas vei 4, Majorstua, Oslo) November 25-26, 2010; and s coordinated by the authors of this post. More info here.

Read more about the NFU conference, where NIBR also organizes a workshop on Rethinking the Climate Crisis.
Read more posts on the subject HIV/AIDS, written by NIBR researchers.

Image: Wikimedia Commons.

Rethinking Crises: Vulnerability, Community and State in Development Research

NIBR, together with the MF Norwegian School of Theology and Diakonhjemmet University College are organizing the annual Norwegian Association for Development Research Conference (NFU Conference). NIBR hosts two workshops on the climate crisis and HIV/AIDS governance. Updates from the conference will be posted on the NIBR International Blog.

Crisis Management in Weak and Fragile States
Many societies and communities in the South are faced with multiple crises in the form of armed conflicts, HIV/AIDS, climate change and financial breakdown. Weak and fragile states and community institutions have particularly high difficulties dealing with such vulnerable situations. Societies’ ability to meet the crises at the community level are often overlooked, poorly researched into, and not used when informing national and international policies and strategies for interventions. Developing a better understanding communities’ and states resilience in situations of crisis and how this may affect their ability to withstand pressure and not develop into armed conflict or humanitarian crises, is vital.

The Dynamics behind Crises and Resilience

While many conferences recently have focussed on opportunities and new positive developments in the South, the NFU Conference 2010 will focus on how states and communities address crises and respond to them. The main emphasis will thereby not be on the crises themselves, but on the dynamics behind them, and responses to them, and how we as researchers address this research field. This new research agenda needs to link peoples’ everyday resistance to crisis, community resilience and civil organizations’ roles in building resilience, and state capacity and political settlement in peace building and society-building in post-conflict situations.

Plenary Sessions
– Plenary 1: Conflicts and political settlements: James Putzel, LSE, comments by Magdalena Sepúlveda Carmona and NIBR’s Marit Haug

– Plenary 2: Religion, conflict and development: Jeffrey Haynes, UCL, comments by Stein Villumstad

– Plenary 3: Climate Change and the Urban Poor in the Global South: David Satterthwaite, IIED, comments by Karen O’Brien

– Plenary 4: Policy discussion: Silent crises, politics, mobilization and development research: Sarah Cook, Hege Hertzberg, Atle Sommerfeldt, Malcolm Langford (moderator)

See full program here.

NIBR to Host Workshops
There will be four parallel workshop sessions during the two days, two of which will be organized by NIBR. Click links for descriptions.

Rethinking the Climate Crisis: From Social Vulnerability to Social Transformation (Trond Vedeld)

Governing an Epidemic: HIV/AIDS and scales of Governance (Berit Aasen, Peris Jones, Siri Bjerkreim Hellevik).

The conference takes place at the MF building, Gydas vei 4 (Majorstua), Oslo November 25-26, 2010. Berit Aasen represents NIBR in the conferences’s organizing committee.

To download conference brochure, click icon below.

International conference: “The governance of HIV/AIDS prevention in North-West Russia”

The international conference “The governance of HIV/AIDS prevention in North-West Russia” will take place in Arkhangel’sk on December 2, 2010.

The conference is being organized by Arkhangel’sk International School of Public Health of the Northern State Medical University in collaboration with the Norwegian Institute of Public Health, the Norwegian Institute for Urban and Regional Research, Fafo Institute of Labour and Social Research, and with participation of the Ministry of Health and Social Development of the Arkhangel’sk region.

Main themes of the conference:

1. Efficient HIV/AIDS prevention – what works and what are the major obstacles?

2. Coordination, cross-sectoral collaboration, division of responsibilities between federal, regional and municipal levels, and between different health institutions

3. Perspectives of the different actors in HIV/AIDS prevention: policy-makers, professional groups, civil society, HIV positive and vulnerable groups, general population

4. International collaboration on HIV/AIDS prevention

The conference is arranged for presentation of the first results of the project “The Governance of HIV/AIDS Prevention in Northwest Russia”, an international multidisciplinary and multicentre project performed in Arkhangel’sk, St. Petersburg and the Leningrad region. The project was supported by the Norwegian Research Council and Ministry of Foreign Affairs of Finland. There will be presentations by the leaders of the project from both Russian and Norwegian sides as well as by a project advisor from Finland and researchers from theUniversity of Tromsø (Norway), Yale University (USA), universities and health care institutions and NGOs from Arkhangelsk as well as from the Norwegian research institutes.
General information:

Conference venue: Pur-Navolok hotel, Naberezhnaya Severnoy Dviny 88, Arkhangel’sk 163000, Russia.

Conference time: The conference starts 2 December, 2010 at 9.00.

If you have any questions, please contact the local organizing committee in Arkhangelsk by phone (+7 8182 263226), e-mail or fax +7 8182 263226 (Alexander Kudryavtsev)


Conference programme

List of participants

Welcome to Arkhangel’sk. (Photo: Mikkel Berg-Nordlie).

Situation Critical for HIV/AIDS Prevention in Russia

Aadne Aasland recently held a 5-minute lecture on his project on HIV/AIDS prevention in Russia, at the 2010 CIENS Days, Click here to watch the video (in Norwegian).

by Aadne Aasland (lecture) and Mikkel Berg-Nordlie (written summary).

Main points from the lecture:

Although HIV/AIDS has long been a taboo subject in Russia, since 2005-06 the authorities have been giving the issue more attention and funding. Despite this, the number of HIV-infected Russian citizens is on the rise: currently, approximately 1,1% of the population between 15-49 years of age are estimated to be infected. Injecting drug users make up a large risk group – more than 70% of Russian HIV-carriers have been infected through the use of unclean syringes.

Why does the authorities’ new commitment have so little effect?

– HIV/AIDS competence and treatment concentrated at few, central hospitals and little involvement of other societal sectors.

– Stigma and discrimination of HIV-positive people and high risk groups (injecting drug users, MSMs, prostitutes) still widespread, among authorities, health personell and the general population. Campaigns targeted towards high risk groups are controversial and few.

– Methadone treatment illegal in Russia, needle exchange-programmes controversial and underfunded.

– Regional differences in level of commitment to and way of organizing campaigns and treatment.

– Influence of individuals and personal relations between key stakeholders important.

Myths debunked through findings in this project:

– “Most Russians have little knowledge about how HIV/AIDS passes from person to person”. In fact, people – including risk groups – in the areas studied are generally well informed about how one can be infected.

– “Most Russians are sceptical towards targeted HIV-prevention programs, they have ‘conservative views’ on this”. Representative surveys in Arkhangel’sk and St. Petersburg found that 90% support education on sexual issues in the schools, more than 70% support needle exchange-programs, and a majority supported methadone treatment.


– Despite increased Federal attention, Russian authorities at different levels are still reluctant to fund programs targeted at risk groups.

– The authorities do not take much note of international recommendations when it comes to these issues, reforms depend on increased pressure from the inside.

Illustration: Map showing number of HIV-infected people in the Russian Federation by province (federal subject), from lightest (1-10 per 100,000) to darkest (500+ per 100,000).(Source: official Russian statistics).

HIV Nightmare Averted – For Now

But uncertain future for universal access

by Siri Bjerkreim Hellevik

Last week donors met in New York for the replenishment meeting of the Global Fund to fight AIDS, Tuberculosis, and Malaria. Result: $ 11, 8 billion was mobilised for the period 2011-2013. The US made the largest contribution with $4 billion USD, followed by France ($1,440,8), Germany ($822 million) and Japan ($800). The Norwegian government increased its funding by 1/5 and contributed with $230,2 million. (Source for all numbers).

The Global Fund had itself stipulated that $13 billion was the least it could get “to allow for the continuation of funding of existing programs” (Source). However, with these $13 billion the new programs that the Global Fund has accepted “could only be funded at a significantly lower level than in recent years” (Op. Cit). In other words, the new grants that have been made or are to come in next years have to be reduced (Grants for rounds 10, 11, and 12 – more details here).

As the Executive Director of the Global Fund has stated as published on the Global Fund website “I deeply appreciate the efforts of all the public and private donors who with this replenishment have shown their continued confidence in the Global Fund (…) However, we need to recognize that this amount is not enough to meet [the] expected demand. It will lead to difficult decisions in the next three years that could slow down the effort to beat the three diseases”.

Read more about HIV/AIDS on the NIBR Blog here.

Image: Result from replenishment meeting of the Global Fund, October 2010.

Is an HIV Nightmare on the Way?

If the Western world scales down or flat-lines its financial contributions to the fight against HIV/AIDS, the pandemic is set to become worse.

By Siri Bjerkreim Hellevik

Since 2003, several Western countries, including Norway, have financed the scaling up of anti-retroviral treatment (ARV) globally, so that currently 5,2 million HIV positive people are now receiving such life-saving medicines. In total, about 1/3 of the people living with HIV/AIDS globally who are in need of such treatment , are now getting it.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria; and the American President’s Emergency Plan for AIDS Relief (PEPFAR) finance 94% of the treatment given – with the exception of Western countries. The rapid scale-up of treatment is regarded as a huge success achieved by these two programmes, supported and financed by a number of Western countries, with the US government as the major sponsor of both.

Entering the Replenishment Phase

Currently, people on ARV treatment face the risk of not being able to access free treatment in the near future. The risk has become evident throughout 2010 as the Global Fund has entered into the replenishment phase. The replenishment of the Fund takes place every 3 years, and implies that the Fund asks countries to pledge financing for it for a 3 year period. The replenishment phase will end in October 2010 with a high level meeting in New York, chaired by UN

Logo of the Global Fund to Fight AIDS, Tubercolosis and Malaria. (Image: Wikimedia Commons).

Waning Support for the Fight Against HIV/AIDS?

The Global Fund relies on funding from a number of Western countries, and has stated that it needs at least $ 13 billion for 2011-2013 to maintain the current level of support and fund projects that have been approved. Although we won’t know until October what Western countries will bring to the table, several countries have, directly or indirectly (through, for instance, signals of future budget cuts to foreign aid) signalled that they will not be able to scale up substantially their funding towards the Global Fund, making $13 billion an unachievable goal. In addition, the proposed US Government budget from the Obama administration that came in late January showed that the PEPFAR program will only see a 2,2% increase in funding for the coming year (pending on US Congress approval).

The Moral Dillemma of the West

Even if the US Congress suggests some additional funding for PEPFAR, there is reason to be concerned for the future of anti-HIV/AIDS funding. Western countries face a major moral dilemma: if they do not continue funding anti-retroviral treatment for the ones having already started on treatment, they will contribute to the deaths of many HIV-positive people. A person with HIV who has started on treatment, has to continue taking these drugs for the rest of her/his life. If he/she discontinues treatment for even a short period of time (f. ex. 48 hours), he/she increases his/her chances of becoming resistent to the drug regimen. Although other drugs exist (often referred to as second-line or third-line drugs) these are very expensive and often not a viable option in low-income countries. The Clinton Foundation is currently working to lower the prices on these drugs.

With a cut in HIV/AIDS funding to the Global Fund and PEPFAR, the G8 commitment of universal access to treatment and care by 2010 made in 2005 (and expanded to prevention in 2006) will not be met. The PEPFAR goal of scaling up treatment (from 2 to 4 million people) will also become unachievable. A number of countries have already reported on having to turn away pregnant women and others who are eligible for treatment, because of the lack of funding (see sources listed below).

Long Term Commitment is Needed

Funding anti-retroviral treatment requires long term commitment, because the treatment costs are so high that, in particular, African countries may not afford to pay them. The G8 countries and some other Western countries, including Norway, signalled that they were willing to take on this commitment to treatment and the costs involved when they started supporting the Global Fund and other initiatives with funding. If the same countries now do not step up to the plate with regards to the Global Fund, the same countries will soon find themselves having contributed to an “HIV nightmare” in African countries, as the UNAIDS Executive Director Michel Sidibé has stated.

This blog was published as an op-ed piece in the Norwegian business and financial affairs newspaper Dagens Næringsliv 2 July 2010, and has been translated to English by the author.


Médécins Sans Frontiers (2009) ‘Punishing Success? Early Signs of a retreat from commitment to HIV/AIDS care and treatment’,

International Treatment Preparedness Coalition (2010): ‘Rationing Funds, Risking Lifes: World Backtracks on HIV Treatment’

Stockman, Farah ‘US seeks to rein in AIDS program. Overseas clinic costs have tripled to $ 7 b in 6 years’, Boston Globe 13 April 2010-08-10

Universal Access and Robin Hood. Thoughts After the 2010 International AIDS Conference

As a political scientist and researcher on governance of HIV/AIDS, I always find it most interesting to attend the sessions in a conference where there are real debates among decision-makers, trying to dissect their political messages of the future directions of HIV/AIDS policies and political priorities.

by Siri Bjerkrem Hellevik

Apart from the political themes surrounding harm reduction, human rights and criminalization as already described my colleagues in previous posts, key themes that emerged were the future of funding/universal access to treatment, the Robin Hood tax, the need for more efficient programs, integration of HIV/AIDS into existing health services/health systems strengthening, and the test and treat debate. Below, I try to sum up and give food for thought on the future of these issues which will continue to be part of the political debate (at least I hope!) in years to come.

Universal Access – A Feasible Goal or Unachievable?

The number on people on anti-retroviral treatment (having now surpassed 5 million) is an extraordinary achievement in itself, recognized and applauded at the conference. But what did the AIDS 2010 conference leave us in terms of the future of HIV/AIDS funding, and in particular the future of scaling up universal access to treatment, prevention and care?

There was surely attention to the challenging situation we face for securing funds for the continued scale-up towards universal access, as highlighted by several speakers and activists. Activists made their points clear with posters in the main hall, challenging the US government, the Austrian government and the G8 to give more funding as the replenishment process of the Global Fund continues up to the Millennium Development Goals Summit in New York this October.

I sat in on two interesting debates on universal access during the conference where the speakers were challenged by chairs to comment upon whether universal access was still a feasible goal to reach or unachievable. One of the speakers, Dr Peter Mugyenyi from the Joint Clinical Research Center in Uganda, argued that although the 2010 target of universal access has been missed, there is still a possibility to reactivate it.

Combating HIV/AIDS – the sixth Millennium Development Goal (MDG). (Image: Wikimedia Commons).

A Fair-Weather Promise?

Professor Nicoli Nattrass, University of Cape Town, pointed to the unique economic context in which the commitment to universal access was made, the context in which we had had the longest period of economic growth in our era of capitalism. She further described the turnaround now taking place in terms of analysing UNAIDS publications, stating that UNAIDS is no longer talking about big figures. She also reminded the audience of Bill Clinton’s message that we should be lucky that the US’ President’s Emergency Plan for AIDS Relief (PEPFAR) has only been flat-lined and not had its budget decreased, as is the case with other issues. But, in an interview on CNN, he also said that there might be hopes that the Congress will increase funding for HIV/AIDS when they are deciding on the budget for next year.

External Aid for Low-Income Countries Only?

Nattrass further pointed to the UNAIDS Outlook report published right before the Vienna conference and its graph which shows how different countries can afford to scale-up their own government funding for prevention, care, and treatment. The graph essentially shows that the low-income countries in sub-Saharan Africa are the ones that can not meet their needs without external assistance, while countries like India, Viet Nam, Pakistan, Ukraine, Thailand, Argentina, Mexico, and the Russian Federation may at least “meet substantial proportions of their resource needs” (UNAIDS 2010: 60). The problem is, as the UNAIDS report acknowledges, to get these countries to fund services for the affected groups, which in many cases belong to groups that are criminalized or discriminated against, such as Injecting Drug users, commercial sex workers, men who have sex with men, etc. This problem is a political problem more than a funding problem in for instance Ukraine and Russia.

A Russian AIDS-awareness stamp from 1993. (Image: Wikimedia Commons).

The Response to Flat-Lining: More Efficient Programs

The US government was heavily attacked by several people for its proposed flat-lining of PEPFAR funding in next budget year and the uncertainty of funding for future years. The US Global AIDS Coordinator, Dr Eric Goosby, head of PEPFAR defended his government’s stand confirming that the US government is committed to HIV/AIDS funding and will increase funding in the long run. He also pointed to that PEPFAR is working to get more efficient programs.

Bill Gates’ New Antivirus Program

Both former US President Bill Clinton and Bill Gates of the Bill and Melinda Gates Foundation touched upon the need for future programmes to become more efficient. Bill Gates focused on the need to scale up ‘existing tools’ that are efficient, listing male circumcision, “right interventions for right people” (that is, target prevention to risk groups and affected groups), using treatment as prevention. He said that he had been sceptic of using male circumcision as a prevention tool, thinking that few men would sign up for it, but was glad he was wrong. He also focused on new prevention technologies that were underway, such as ARV-based prevention (antiretroviral drugs – such as gels, pills, etc), but also the continued work in finding vaccines. Bill Gates’ entire speech can be downloaded here and watched online here.

Bill Gates speaks to the 2010 International AIDS Conference.

Strengthening Country Ownership

A strategy for the PEPFAR program seems to be to ensure better country ownership and alignment to the Global Fund and other programs as well as working closer with the government. The US Global AIDS Coordinator Dr. Eric Goosby mentioned the need for strengthening country ownership. But exactly how the US is going to go ensure such country ownership is still not clear to me when they are not willing to put their funding on the national budgets. As the issue stands today, country ownership has so far been translated into Partnership Framework agreements between PEPFAR/the US Government and a recipient country’s government. Such frameworks have been agreed to in Angola, Caribbean, Ghana, Tanzania, DRC, Lesotho, Malawi, Swaziland, as well as one regional framework agreement for the Caribbean and one for Central America (more information on this here).

Integration Between Health Systems and HIV/AIDS

Integration was an important theme in Vienna, including integration of HIV/AIDS into health services, integration of HIV/AIDS and sexual and reproductive health services, integration of HIV/AIDS and health systems strengthening, integration of HIV/AIDS into global health issues. Bill Clinton touched upon the wider issue of integration of global health and HIV/AIDS in his speech, pointing to the tension and debate in the US and the voiced concerns from activists and researchers over US policies potentially shifting focus from HIV/AIDS to other global health issues. He argued that there existed no such tension in real terms and that combining HIV/AIDS and global health is the way forward and stated that the Obama administration remains committed to the fight against HIV/AIDS.

The PEPFAR logo. (Image: Wikimedia Commons).

On the issue of integrating HIV/AIDS with other health services, studies done by Médécins Sans Frontiers of their own efforts to integrate services showed benefits from integration. Dr Eric Goemaere from Médécins Sans Frontiers argued that “decentralisation naturally builds integration” in terms of that services are delivered at local small clinics, by non-specialists. He also pointed to the need of addressing the linkages between overall health systems-strengthening and community systems-strengthening. An example of integration between the two would be to involve community and district planning personnel into health systems planning.

From Bilateral aid to Robin Hood Tax?

An ongoing debate related to the issue of financing is how to raise funding by finding and using innovative mechanisms. UNITAID’s important and successful work in this matter (having been able to collect funding by an airline tax) as well as the new fee that people can pay when booking airline tickets on internet is two examples of new ways to find additional sources for HIV/AIDS outside the ‘normal’ bilateral aid. The main initiative that was on everyone’s lips for this conference (although it has been around for quite a while) was the Robin Hood tax initiative. ‘No retreat, tax and retreat’ was the slogan that activists used when interrupting the plenary session before Bill Gates’ speech. The Robin Hood tax is a new way of talking about the Tobin Tax as suggested by ATTAC several years ago. This suggested tax of 0,005% on all financial transactions could go to HIV/AIDS treatment and assist in solving the current dilemma of future funding needs. Several activist initiatives and appeals from the main stage as well as around in the conference halls were made on the Robin Hood tax. More details on the Robin Hood tax can be found here.

Robin Hood-themed protesters captured the stage before Bill Gates.

It is estimated that this small tax could raise as much as $ 33 billion a year according to theCoalition PLUS. The tax is technically feasible to implement, it is only a matter of political will in countries. In the discussion on innovative mechanisms for global health, head of Global Fund, Dr Michel Kazatchkine and head of UNITAID, Philippe Douste-Blazy both supported the tax, but underlined that it would not substitute the need of continued bilateral and multilateral funding towards HIV/AIDS. Hopefully, the question of this tax will be further discussed in October’s New York summit.

Test and Treat – Only an Option in Western Countries?

In a courtroom type setting, different actors involved in delivering treatment were questioned on when to start treating people with ARVs in different settings. Professor Steven Deeks from the University of San Franscisco provided us with a perspective from the San Franscisco setting and argued for starting treatment as soon as possible after a person has been diagnosed with HIV, provided that he/she is willing to start on treatment. Using a ‘test and treat approach’ is a public health benefit in the long run, he argued.

Dr Peter Mugyenyi, head of the Joint Clinical Research Centre in Uganda provided us with the perspective from the African continent. He described the situation in Uganda as being one where the test and treat option is not feasible, given the limited resources for ARVs and also that the patients often come in very late for treatment. Mugyenyi, however, constructively listed a number of possible options for saving funding and treating more people, such as by doing fewer tests of CD4 counts,*** pointing to scientific evidence demonstrating that we can afford to treat more people if we eliminate such tests. Another cost-saving effort is to start treating early discordant couples. He further stated that we need more resource to look at the public health management of HIV/AIDS and studying the community benefits of treating people in general.

The HIV virus (green). (Image: Wikimedia Commons).

The Donor Perspective and the New PEPFAR Strategy

Providing us with the donor perspective, the Global AIDS Coordinator of the US Government, Dr Eric Goosby, said that donors think about starting early on treatment, but that it is a matter of funding. His message was that programs always have to focus on the sickest patients first and those in exceptional risk, such as those with tuberculosis and pregnant women who risk vertical transmission (transferring the disease to their children). Touching upon the accusations of flat-lining of PEPFAR funding, Goosby stated that resources will go up in the long run and repeated elements of the new PEPFAR strategy: focusing on country ownership and better alignment with Global Fund programs at the country level to ensure that there are no parallel systems. To sum up, ‘test and treat’ seems like an option that all agree is favourable, but in practice, it is a decision to be made by the patients (in Western countries) and by the availability of external funding (in low-income countries).

Adressing the Linkage Between Violence Against Women and HIV

Everjoice Win, Head of Women’s Rights at Action Aid in Zimbabwe held a powerful speech at the plenary session Tuesday morning about women’s rights, violence and the connection to HIV/AIDS. She pointed to the public health crisis that is taking place with regards to violence against women and HIV in both the Global North and the Global South and the fact that violence against women in many cases aim towards maintaining gender stereotypes and existing power relations in a society. Men who transgress gender norms are also victims of gender-based violence, she further stated. Examples of violence by state actors were also given, such as forced sterilization and coerced abortion.

She further said that there were encouraging signs from the donors in terms of putting more focus on women in HIV/AIDS programs, and encouraged donors to recognize and give priority to programs addressing the linkages between violence against women and HIV, as well as strengthening reporting systems, etc, since there is much underreporting.

Summing up, as one of the plenary speakers repeated several times, “actions speaks louder than words”, so the coming months and in particular, the Global Fund replenishment conference in October will give us some clear messages about where we are heading in the coming years with regards to further scale up universal access and integration of HIV/AIDS with broader global health issues.

*** CD4 count refers to a test counting the number of CD 4 cells in the blood. 4 cells are a type of lymphocyte (white blood cell). They are an important part of the immune system. “CD4 cells are sometimes called T-cells. There are two main types of CD4 cells. T-4 cells, also called CD4+, are “helper” cells. They lead the attack against infections. T-8 cells (CD8+) are “suppressor” cells that end the immune response. CD8 cells can also be “killer” cells that kill cancer cells and cells infected with a virus”. Read more on this here.

All photos by author unless otherwise stated.

Read more NIBR dispatches from the 2010 International AIDS Conference:

Jones, Peris: Surreal But All Too Real.

Aasland, Aadne: Rights Here, Right Now – The Reality for Injecting Drug Users in Russia.

For more on NIBR’s HIV/AIDS research, see this webpage, where NIBR’s posters will be available from Thursday 22 July.

Surreal But All Too Real

By Peris Jones

An embrace of the surreal is necessary equipment to get through a week at the XVIII International AIDS Conference in Vienna. Very real themes emerge, however, such as the importance of human rights, funding and treatment in overcoming the fight against HIV/AIDS and improving health systems.

Careering down the packed corridors of this enormous gathering of 20,000 activists, donors, researchers, practitioners, pharmaceutical companies, politicians and the odd princess and pop star here and there, requires stamina at the best of times.

The New Adventures of Methadone Man

Methadone Man’ and his ‘Buprenorphine babe’ -activists dressed in super hero costume- make the task even harder, as they dish out a copy of their comic adventures. The stigma and discrimination against drug users highlighted at the conference certainly warrants a superhero response to stem vulnerability to AIDS. A very vocal and colourful display of condom use is being demonstrated at the same time. And a Haitian activist demonstration is gathering momentum, while I collect my free ‘Love condoms’ t-shirt, which I can only have if I wear it there and then.

AIDS – The Next Haitian Earthquake

This is merely some of the corridor action on the way to one of the many sessions taking place. I eventually find my way to the main morning plenary session, where pop star Annie Lennox is acting as moderator. While we are about to get underway the ‘Haitians Living With AIDS’ protest emerges into the packed auditorium. People in suits must wait to present while the activists seize the stage chanting under a banner that reads: ‘AIDS- Haiti’s next earthquake: Housing, foods, jobs and treatment NOW!’.

Amidst the devastation of the earthquake it is easy to forget that as many as 120,000 HIV positive people in Haiti will die if they can not access these live sustaining goods. Beyond the surreal issues of great importance are integral to conference proceedings.

Treatment as Prevention

The sessions get under way, and one of the key topics for the conference is unveiled by one of the speakers: Treatment for HIV/AIDS as a key component of prevention. This concept emerged at the previous conference in Mexico in 2008. In Vienna it is strongly underlined and several sessions address the potential and offer new evidence for AIDS drugs to be used not only in the wake of infection but also before infection takes place as ‘pre-exposure prevention’ (used before an episode exposing someone to infection) and/or, ‘post-exposure prophylaxis’ (used immediately after exposure has taken place).

Microbiocide breakthrough

The precedent has already been set by the huge success in reducing mother to child transmission of HIV infection (‘vertical infection’) by using treatment for pregnant women and during labour and birth to ensure the virus if not passed on to the child. Several speakers during day 2 and 3 highlight further potential for treatment as preventing infection. The momentum towards this initiative was confirmed by the palpable excitement generated by announcement of the results from an important South Africa-based trial by CAPRISA. The trial found that by using a very small dose of one drug, Tenofavir, mixed in a gel (‘Micro-biocide’), this can be used by women with up to a 50% reduction in chances of transmission of infection (in the first year of use). In a context of women often unable to negotiate safe sex with condoms, the application of this gel by the women in the vagina offers the opportunity to pass some degree of control and prevention back to women to prevent HIV/AIDS.

The Human Immunodeficiency Virus (HIV). (Illustration: Wikimedia Commons).

The Efficiency of ARV

One of the best attended sessions in a packed auditorium during day 3 was also dedicated to ARV drug use in prevention. One presenter estimated a rather modest reduction in infections if treatment was used. Even more sobering, however, were several issues that severely qualified the use of treatment for prevention. For post-exposure prevention the need to take treatment very quickly and other complications means that it is only cost effective in very specific circumstances (such as victims of rape who can access and take treatment soon after the incident). And pre-exposure effectiveness required more information concerning identifying the specific drug that would be beneficial to a certain individual’s circumstances. It was demonstrated that in one study for men who have sex with men (MSM) only a very small minority, around 4%, have sexual encounters more than 5 times a week.

Thus, only a small number would benefit and perhaps need to be targeted for a regular dose of treatment, which means taking treatment regularly for prevention is less appropriate for others.

Timing the Treatment

Another major issue concerned the timing for the treatment- at what stage of development of HIV infection should it be used in those already infected? And, those respondents who do not ‘plan’ to have sex are also those most at risk, further qualifying the potential. Other issues concerned the different implications male and female anatomy has for effectiveness of the drug. Well established issues associated more generally with treatment concern the level of adherence of a patient to treatment, and therefore the overall efficacy of treatment, equally apply if used for prevention. Finally, lack of evidence and ongoing long term trials also muted the approach as was evident in barbed exchanges between the President of the International AIDS Society, Julio Montaner, and a leading US scientist, Myren Cohen, who offered a much more sober analysis.

Overall, whether treatment as prevention will serve to undermine more standard prevention approaches (giving information and access to condoms, for example), is also an important consideration.

Fear of Blackmail from Health Workers

One of the most encouraging themes of the conference has been the strong renewed emphasis given to the unfinished business of securing human rights, which many interpret as necessary also for good public health outcomes. So much funding has contributed to building HIV resilience within communities and underpinned by access to services. But the conference has provided a very welcome reminder that ‘universal’ access can never be genuine unless barriers are removed in respecting, protecting and promoting rights. Many of the sessions highlighted specific hurdles by many People living with AIDS and how these are worsened for certain groups -such as drug users and men who have sex with men (MSM) and sex workers.

One such discussion drew on a study of MSM and how fear of blackmail (concerning ‘outing’ their sexual orientation) by health care workers was a major barrier in seeking health services.

Prisons as Pandemic Incubators

Unfortunately stigma continues to be resilient and lays foundations for discrimination, particularly when juxtaposed with marginalised identities. Some presentations did feel déjà vu and as if sometimes that the wheel of research investigation is being invented all over again, especially stigma. Other issues were, however, strongly promoted. The criminalisation and subsequent harsh policing of drug issues – with harassment, incarceration and discrimination in access to services for methadone and ARVs were further raised. Some sessions highlighted also the profound impact violence has upon regulating women’s access. Both have severe consequences for efforts to promote public health. Ex-police men suggested the foolishness of many countries’ drugs policy, citing how this was counter-productive to controlling and tackling the problem of drug use.

Locking drug users up simply encouraged the spread of HIV in prisons and amongst prisoners who would be released back into communities at some point.

Patent Pooling

The plenary on day three also addressed the ongoing and to date unresolved issue of the last decade, namely, intellectual property rights. What is at stake is whether the great advances in technology and knowledge mentioned above will be adversely affected and undeveloped if patent law and merely commercial interests disable production of cheaper generic copied drugs. The implication is that as long as patented drugs are protected then lack of competition by generics greatly inflates prices of patented drugs. The UNITAID initiative towards ‘patent pooling’ therefore represents a significant development to ensure possibility of generic production.

It remains, however, a voluntary process whereby companies must agree to pool and share their licences for others to produce in return for royalties.

South Africa ends Pariah Status – Celebrates with Vuvuzelas

Another important development was the very strong endorsement of the centrality of science and human rights in the fight against AIDS presented powerfully by the Minister of Health for South Africa, Dr. Aaron Motsoaledi. The Minister spelt out the great policy shifts currently underway in South Africa. The state is throwing its considerable weight behind NGO and activist efforts in encouraging a huge scaling-up of testing and plans to place an extra 500,000 on ARV drugs by March 2011. Indirectly referring to the years of civil society conflict with former President Mbeki and his former Minister of Health – who had preferred to promote garlic instead of ARVs – the present Minister, Motsoaledi, instead chose to thank AIDS activists and donors, in a speech that was met by loudly blown Vuvezelas.

Human Rights and AIDS Policy

In doing so the Minister reiterated a strong link between South Africa’s new and rigorous policy on AIDS and human rights: ‘I want to assure you all that in 2010 all of South Africa is united on prevention and treatment…democracy and human rights are not a threat but a prerequisite for good governance’. These and additional comments concerning the need for accountability and universal access all added up to a deeply symbolic and strongly worded statement of commitment to ARVs that effectively ended the South African government’s pariah status at many of these previous conferences and indeed, in general, global public opinion. Blow the Vuvezelas indeed!

Illustration based on data from UNAIDS 2008 Report (Image: Wikimedia Commons).

AIDS Funding and Health Care Strengthening

Also overlapping with the Minister of Health’s own presentation, is the final theme addressed here, and one mentioned earlier in the week by Bill Clinton and the focus of various sessions: the relationship between AIDS funding and broader health issues. Some observers rightly raise questions about whether broader health initiatives are undermined by siphoning off desperately needed funds and human resources to the AIDS ‘sector’. But evidence presented refutes this and cites numerous examples of important knock on effects of AIDS funding (for example, as a catalyst for global responses to other diseases, such as malaria and tuberculosis, and indeed health systems strengthening).

Millennium Development Goals

Powerful endorsements have been made at the conference concerning the intrinsic link to broader strengthening of health systems and net benefits to health by AIDS funding. In asking aloud if there was any contradiction, Motsoaledi said ‘no, no, no’ and stated that the health MDGs (Millenium Development Goals) – for example, maternal and child mortality – will not be met in South Africa without a full on response to HIV/AIDS. In some country studies increased uptake of treatment for AIDS has seen improvement in mother and child mortality statistics and a strong correlation between up take of testing for HIV/AIDS (‘VCT’ testing) and family planning initiatives and other benefits for non-HIV health sector issues.

Circus and the Serious

I end the day back in the packed corridors as I make my way out of this huge venue. I queue for free coffee and then, upon being engulfed by a wave of noisy and angry protestors, I realise this is paid for by a pharmaceutical company. I decided to move on to the Global Village section of the Conference – the noisy, vibrant, colourful, activist area designated for alternative activities. An artistic replica of an Austrian red light bordello has the flashing neon word ‘MORAL’ in big letters on the outside, which as I watch, turns to ‘ORAL’.

A Kenyan theatre troupe from the slums of Nairobi is enacting an AIDS awareness play. Then amidst hundreds of stalls, and all manner of video broadcasts, speeches, protests, amidst the hordes of people, 30 Austrian cyclists suddenly arrive inside the venue with their bikes following a ride from Innsbruck to Vienna to raise awareness, they tell me. A fittingly surreal end to the day at what is simultaneously frustrating, even circus like, but always compelling, and indeed, providing necessary relief in a sector permeated by the real world issues and choices literally a matter of life and death.

The Moral Bordello (Picture: Peris Jones).

Read more NIBR dispatches from the 2010 International AIDS Conference:

Hellevik, Siri Bjerkrem: Universal Access and Robin Hood.

Aasland, Aadne: Rights here, right now – the reality of injecting drug users in Russia.

For more on NIBR’s HIV/AIDS research, see this webpage, where NIBR’s posters will be available from Thursday 22 July.

”Rights here, right now!” – the reality of injecting drug users in Russia?

The slogan of this year’s International AIDS Conference in Vienna (18-23 July) is Rights here, right now! NIBR is represented in Vienna by three of its researchers from the Department of International Studies.

By Aadne Aasland

Today we have been listening to powerful speeches of among others Bill Clinton and Bill Gates and observed the active involvement of our crown princess Mette-Marit. One of the presentations that has made the largest impression on me so far was given by Anya Sarang, who is president of the Andrey Rylkov Foundation for Health and Social Justice and and started outreach work for injecting drug users (IDUs) in Russia in the mid-1990s. At that time HIV and AIDS was hardly considered an issue in Russia, but has since become a serious public health concern. The virus has up until now mostly been spread among IDUs using unclean syringes, but is more and more often spread through so-called bridging populations from high-risk groups to other population groups as well.

Fighting HIV/AIDS in Russia

While substitution treatment programmes (such as the use of methadone) are illegal in Russia, needle exchange and other harm reduction programmes have been tolerated. Their coverage has been rather limited, however, and they have mostly been implemented through projects run by non-government organizations (NGOs) and funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. As a middle-income country Russia is no longer eligible to receive grants from the Global Fund. In 2008 the Russian government indicated that it would continue to support successful harm reduction programmes.

In 2009 government statements, however, it was announced that such programmes will be terminated as the Global Fund grants run out while Russian HIV prevention efforts will be targeted at the general population through more general health promotion measures. The Global Fund went to the extraordinary decision to prolong it’s support to Russian harm reduction programmes and to review it’s eligibility criteria.

User preparing heroin for injection (Wikimedia Commons)

Fear of Punishment for Addiction

Anya Sarang confirmed that this is the situation in Russia at present: the government provides no funding for harm reduction programmes to IDUs. The prevention focus is on the so-called general population and the promotion of healthy lifestyles. Drug use is seen as a criminal offence and is treated accordingly. Sarang pointed to the international evidence showing that this policy leads to fear among the drug users, who will be afraid of accessing the health services that they need. Thus the effect on HIV rates is likely to be negative.

Furthermore, many health workers are skeptical of giving anti-retroviral drug treatment (ART) to IDUs since they are seen as unable to follow the regime for taking the medicines. Sarang, who also touched upon drug criminalization issues in countries such as Thailand, China and Iran, advocated strongly for access to health and protection of human rights as well as dignity, for people who use drugs.

The Vienna Declaration

Incidentally, Sarang’s speech is in line with the Vienna Declaration, the official declaration of the conference, which is a statement seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies. At the time of writing the declaration had been endorsed by 10,738 people.

In the early evening Peter Meylakhs from the Centre of Independent Social Research in St. Petersburg presented findings from semi-structured interviews with 24 IDUs in three Russian regions in North-West Russia. The findings are part of a larger project on the governance of HIV/AIDS prevention in North-West Russia, coordinated by NIBR.

Peter Meylakh delivering his speech at the 2010 International AIDS Conference (picture: Arne Grønningsæter).

Drug-Users Trust NGOS, not State

Meylakhs confirmed that prevention campaigns directed towards the general population are inefficient for IDUs. Though most IDUs trust information given by various information sources, they do not always act upon it. In smaller towns and villages IDUs are particularly vulnerable with respect to the availability of HIV/AIDS services, presence of NGOs and confidentiality issues. In some cases this leads to the avoidance of seeking services. Apart from information campaigns none of the informants had encountered other government prevention measures. Many of the informants underscored the necessity of targeted interventions, such as needle exchange programmes. Most of the IDUs preferred to work with NGOs rather than state agencies. However, they generally expressed trust in and good relationships with their doctors.

Read more NIBR dispatches from the 2010 International AIDS Conference:

Hellevik, Siri Bjerkrem: Universal Access and Robin Hood.

Jones, Peris: Surreal But All Too Real.

For more on NIBR’s HIV/AIDS research, see this webpage, where NIBR’s posters will be available from Thursday 22 July.