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.