Select Committee on International Development Minutes of Evidence

Memorandum submitted by UNAIDS (continued)

Challenges and next steps

  5.4.13  The main challenge is to ensure that the growing enthusiasm among donors, such as for the International Partnership Against AIDS in Africa, results in a steady increase in concrete support to national HIV/AIDS prevention and control programmes - in Africa and elsewhere. To do this, emphasis must be placed on building partnerships between donors and the most-affected countries. In this way, a sense of shared responsibility can be created both for improving prevention and care as well as for addressing the formidable, multifaceted development challenges this epidemic presents.

  5.4.14  Working closely with the DAC, UNFPA and the Netherlands Interdisciplinary Demographic Institute (NIDI), the UNAIDS Secretariat plans to convene a meeting of donor country representatives to agree on a common methodology for reporting on HIV/AIDS components within integrated development projects and HIV/AIDS allocations within sector wide approaches and common basket funding schemes.

  5.4.15  To supplement its monitoring of donor country HIV/AIDS obligations, the UNAIDS Secretariat is in the process of establishing a process to systematically monitor pledges and allocations to HIV/AIDS.

Debt relief

  5.4.16  Of the 39 so-called heavily indebted poor countries identified by the World Bank, 32 are in Africa. Together they owe more than US$ 2.2 trillion in debt. Lack of funds for an expanded response to AIDS has been worsened by these high levels of foreign indebtedness. Across Africa, national governments pay out four times more in debt service than they spend on health and education. In order to mount effective national AIDS prevention programmes, countries in Africa will need to spend at least US$ 1-2 billion a year, far more than is currently being invested. Sources that might be tapped for these additional resources include increased donations from the private sector and foundations, expansion and redirection of development assistance, and reallocations within countries' own public budgets.

  5.4.17  Relieving countries' debt burden is one of the more promising new approaches that could increase the funds flowing into programmes to roll back the AIDS epidemic in Africa. By relieving debt in the poorest countries—which, often, are the ones with the highest HIV and AIDS figures—money now exported to service debt could be reinvested into AIDS prevention and care. A major initiative to reduce debt over the next few years will take place under the Highly Indebted Poor Country initiative (HIPC), supported by all the major creditor governments from the OECD countries and implemented by the World Bank and International Monetary Fund.

  5.4.18  In a typical debt relief agreement, portions of a country's debt will be cancelled in exchange for the debtor government's commitment to mobilize domestic resources for specific purposes, such as a poverty eradication scheme or an intensified national AIDS effort. Such transactions have succeeded since the 1980s in the field of environmental conservation, for instance, by protecting rainforests from logging.

  5.4.19  At the heart of debt reduction deals under HIPC lies the challenge of agreeing on significant goals in poverty reduction and on measurable indicators of progress towards these goals. Lending countries will have greater incentives to reduce debt if there are clear and measurable ways of assessing the benefits. For example, a medium-term AIDS-related target might be to provide low-cost treatments to a specific percent-age of the population suffering from the most common opportunistic infections. Measurable indicators for monitoring progress would likely include the availability of specific generic medicines in primary health care centres. During the first months of 2000, several countries in Africa have started to feature HIV/AIDS more prominently in their poverty-reduction strategies and in related HIPC debt relief agreements. This is encouraging. But a concerted effort by a coalition of interested African government officials, civil society representatives, creditor governments, and United Nations and multilateral agencies will be required to ensure that debt relief is actually used to mobilize substantially increased funding for AIDS.

(B)  The UN

  5.4.20  Starting in 1986, the World Health Organization was assigned the lead responsibility in the United Nations system for assisting governments to establish national HIV/AIDS programmes. By the mid-1990s, however, it had became clear that the pandemic's devastating impact on all aspects of human life and on social and economic development constituted an emergency which would require an expanded United Nations effort. As a consequence, in 1996 the United Nations established an innovative joint venture, the Joint United Nations Programme on HIV/AIDS (UNAIDS), which now has seven co-sponsoring organizations: UNICEF, UNDCP, UNDP, UNFPA, UNESCO, WHO and World Bank.


  5.4.21  The United Nations Children's Fund (UNICEF) brings to UNAIDS its operational field capacity in over 160 countries, network of national committees, and considerable experience in communication and advocacy. UNICEF's priority programme areas include youth health, school AIDS education, programme communication, children and families affected by AIDS, and mother-to-child HIV transmission.

  5.4.22  Mandated to advocate for the protection of the rights of children to help meet their needs and expand their life choices, UNICEF is their chief advocate, acting within the framework of the Convention on Rights of the Child. UNICEF, its national committees and allies mobilize the moral and material support of governments, organizations and individuals worldwide in a partnership committed to giving children a first call on societies' resources.


  5.4.23  An important objective of the HIV/AIDS-related activities of the United Nations Development Programme (UNDP) is to support countries to strengthen and expand their capacity to respond to the development implications of the epidemic. Activities are focused on identifying effective and sustainable policy and programme responses surrounding the epidemic's social and economic implications. The aim is to strengthen capacity for an effective response within governments and civil society as well as within UNDP itself.

  5.3.24  Through its network of over 130 country offices serving over 150 nations, UNDP plays an important complementary role to that of other UN organizations; within the operational activities of development cooperation through a system of UN, national and other executing agencies; it provides technical support in cross-sectoral, multidisciplinary area of technical assistance relating to sustainable human development; and it has overall responsibility for assisting the Secretary-General in improving the coordination of operational actives for development, including strengthening the Resident Coordinator System.


  5.4.25  The United Nations Population Fund (UNFPA) contributes to overall UNAIDS work by providing access to its worldwide network of country offices which support national reproductive health programmes; its accumulated expertise in reproductive health promotion and service delivery, with a special focus on the needs of women and adolescents, and on male responsibility; its experience in logistics management of reproductive health commodities, including condoms; its experience in working with non-governmental organizations; and its experience in organizing technical assistance and strengthening national capacity-building through UNFPA Country Support Teams.

  5.4.26  A major focus of UNFPA support at the country level is reproductive health, including family planning and sexual health. UNFPA considers prevention and management of sexually transmitted diseases (STDs) and prevention of HIV/AIDS to be integral components of reproductive health. In the context of reproductive health, the preventive interventions include appropriate and effective information, education and communication (IEC) in support of safe sexual behaviour; interpersonal counselling (for both sexual and mother-to-child transmission); improved access to, and provision of, condoms; and good clinical practices to prevent exposure to HIV-infected blood.


  5.4.27  The United Nations International Drug Control Programme (UNDCP) is entrusted with exclusive responsibility for coordinating and providing effective leadership for all United Nations drug control activities. UNDCP addresses all aspects of the drug problem, including such wide-ranging activities as demand reduction, comprising prevention, treatment and rehabilitation; supply reduction, including alternative development and law enforcement; and legislative and institutional advisory services to enhance government's capacity to implement the international drug control conventions.

  5.4.28  The use of psychoactive drugs has facilitated the spread of HIV infection in several ways. The most direct is by HIV transmission through needles shared by injecting drug users. The disinhibiting properties of psychoactive substances also lead to sexual and other high-risk behaviours that individuals might otherwise avoid. Through sexual contacts, HIV infection is spread from the drug-using community to others. International drug control is therefore a vital tool for HIV prevention. In this context UNDCP is active in supporting HIV/AIDS prevention in programmes to reduce the demand for illicit drugs. Youth and high-risk groups are particularly targeted. Coordination within the UN system has resulted in more effective programming responses to drug use and the AIDS epidemic in a number of countries.


  5.4.29  The mandate of the United Nations Educational, Scientific and Cultural Organization (UNESCO) is to foster international cooperation in intellectual activities designed to promote human rights, help establish just and lasting peace, and further the general welfare of mankind.

  5.4.30  Although not a funding agency, UNESCO's contribution to UNAIDS is in the fields of its technical competence-education, science, culture and communication, its interdisciplinary and cross-disciplinary approaches combining technical skills and ethical requirements, and its experience acquired over 50 years of intellectual cooperation. UNESCO's co-sponsorship of UNAIDS is based on the conviction that actions against AIDS should be developed in an integrated, cross-disciplinary manner.


  5.4.31  The World Health Organization (WHO) is the directing and coordinating authority on international health work. Its objective is "the attainment by all peoples of the highest possible level of health", health being defined as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (WHO Constitution, 1948).

  5.4.32  Through its new Initiative on HIV/AIDS and sexually transmitted infections (HSI), WHO as a Co-sponsor of UNAIDS strengthens the response of the health sector through the development of norms, standards and guidelines; research; advocacy; technology development; and technical cooperation with countries. The areas covered include: prevention of HIV and sexually transmitted infections (STIs), particularly for those vulnerable and/or at increased risk; ensuring safe blood supplies; vaccine development; surveillance of HIV, AIDS and STIs; and the development and evaluation of STI/HIV policies and programmes. In the area of care for people with HIV or AIDS, WHO's activities include strengthening the capacity of health systems to provide a continuum of comprehensive care involving referral site, hospitals, home, and care and support initiatives in the community; ensuring access to essential drugs; and improving access to other relevant drugs through negotiations with the pharmaceutical industry and other channels.

World Bank

  5.4.32  The mandate of the World Bank is to alleviate poverty and improve the quality of life. Between 1986 and early 1999, the World Bank committed over US$ 750 million for more than 75 HIV/AIDS projects worldwide. Most of the resources were provided on highly concessional terms through the International Development Association. To more effectively address the devastating consequences of HIV/AIDS on development, the Bank is undertaking a new response to the epidemic, working partnership with UNAIDS, donor agencies and governments. The strategic plan for the Intensifying Action against AIDS builds upon the strong comparative advantages possessed by the partners to rapidly increase the level of action and available resources and to bring to scale the interventions needed for prevention and impact mitigation.

  5.4.33  In its policy dialogue with borrowing countries, the Bank stresses that HIV/AIDS is a development priority, needing top-level political commitment, systematic health care reforms, human rights protection, and a range of multisectoral reforms to help reduce the factors contributing to HIV spread. Whenever possible, Bank-assisted activities are advised technically by the other Co-sponsors or the UNAIDS Secretariat and are planned and executed by individual governments, in collaboration with the concerned nation and international partners.


  5.4.28  UNAIDS brings together the efforts and resources of these organizations to help the world prevent new HIV infections, care for those already infected, and mitigate the impact of the epidemic. Its aim is to help mount and support an expanded response—one that engages the efforts of many sectors and partners from government and civil society.

  UNAIDS is guided by a Programme Coordinating Board with representatives of 22 governments from all geographic regions, the UNAIDS Co-sponsors, and five NGO representatives. The Co-sponsors and the UNAIDS Secretariat also meet separately as the Committee of Co-sponsoring Organizations. Apart from the Co-sponsors, UNAIDS has working agreements with other organizations within the UN system, such as FAO, ILO, UNHCR and OHCHR.

The Secretariat

  5.4.29  Through staff based in Geneva and in over 50 countries, the UNAIDS Secretariat works with and on behalf of its seven Co-sponsors in the following major areas.

    (1)  Facilitation: The Secretariat helps spark, coordinate and streamline action by the UNAIDS Co-sponsors and other UN bodies to bring the epidemic under control.

    (2)  Best practices: The Secretariat plays a key role in the management and dissemination of knowledge that is fundamental to combating AIDS. It identifies and analyses sound strategies and approaches—what can be called "best practices" for preventing new infections, providing care to those already infected, or alleviating the epidemic's impact on households, communities and various sectors of society.

    (3)  Tracking the epidemic: A key function of the Secretariat is to gather, analyse and disseminate information on the evolving epidemic and on the global response to it. Globally, an accurate picture of the epidemic and of its disastrous impact keeps AIDS high on the agenda of development assistance agencies and donor governments.

    (4)  Advocacy: Both internationally and within countries, UNAIDS advocates for an expanded response to the epidemic. It works to build committed and supportive governments, donors and private companies, and to bring on board a wide range of other partners, including religious organizations, NGOs, people living with HIV/AIDS and those whose lives are otherwise affected or threatened by the epidemic.

  5.4.30  Current priority areas for the Secretariat include:

    —  young people;

    —  highly vulnerable populations;

    —  prevention of mother-to-child HIV transmission;

    —  developing and implementing community standards of AIDS care;

    —  vaccine development; and

    —  special initiatives for hard-hit regions, including sub-Saharan Africa.

Challenges and opportunities for the future

  5.4.31  Three of the key opportunities and challenges confronting the UNAIDS Secretariat and its Cosponsors at the threshold of the new millennium are maintaining and intensifying political mobilization, strengthening and accelerating well-coordinated national responses, and facilitating improved access to care and to prevention of mother-to-child transmission of HIV. To achieve these tasks, UNAIDS seeks to work with a wider range of partners.

The International Partnership against AIDS in Africa

  5.4.32  All the above challenges come together in the International Partnership against AIDS in Africa (IPAA). The IPAA is a coalition of actors including African Governments, the United Nations, donors, the private sector and the community sector, who, based on a set of mutually agreed principles, have chosen to work together to achieve a shared vision, common goals and objectives, and a set of key milestones. Its purpose is to establish and maintain processes by which governments, civil society, national and international organizations working against AIDS in Africa are enabled to work together more effectively to curtail the spread of HIV, sharply reduce its impact on human suffering, and halt the further reversal of human, social and economic development in Africa.

  5.4.33  The Partnership, through its international outreach and visibility, provides swift and focused assistance to African governments—in other words, more resources, more expertise, and more alternatives. Through advocacy and mobilization involving all sectors of society at the highest level, it encourages governments, business and multilateral agencies to increase their resources to fight AIDS, either by reorienting or improving the way they use existing funds, or by seeking new funds if needed. The IPAA provides that extra push, the spark needed to assist countries in moving their programmes forward.

  5.4.34  The IPAA's key role is at country level. It supports strategic plans to fight AIDS, and builds upon what already exists and works. By replicating proven successes, the Partnership helps channel isolated actions into coherent, cohesive plans. This capitalizes on individual efforts and avoids duplication, dramatically enhancing the impact of any one action by using it as a foundation for others.


  6.1  Two decades of action against the epidemic have generated important insights into an effective response. First of all, there is an absolute need to translate global political mobilisation into country level action. While international political mobilisation is key to raising additional financial, human and technical resources, it can never substitute for work in countries. It is necessary to ask how international commitments translate into practical actions, bringing real gains to countries, to communities, and to individuals. The value that global initiatives add to country work needs to be reflected. Work that has been done in moving the IPAA forward in countries shows that the concerns in Geneva, or New York, or London are often not known about at country level, and perhaps do not always reflect the needs and realities of countries and communities. Therefore, it is important to ensure that there is not a growing gulf between international political rhetoric and real and lasting gains at country level.

  6.2  While international political, financial and technical support are important, lowering incidence and mitigating the epidemic's impacts must be a nationally driven agenda. To be effective and credible, national responses require the persistent engagement of the highest levels of government. Countries that have adopted forward-looking strategies to fight the epidemic are reaping the rewards in falling incidence. Other countries are yet to see the fruits of their efforts, and in the absence of rapid and visible results, sustaining a response becomes more difficult.

  6.3  When we look at successful action at country level or at state, district or community level, it has clear characteristics, which, over the past few years, UNAIDS has documented. Successful actions are characterised by seven features:

    1.  the impact of all actors coming together under one powerful strategic plan;

    2.  visibility and openness about the epidemic, as a way of reducing stigma and shame, and involving people living with HIV/AIDS;

    3.  addressing core vulnerabilities through social policies;

    4.  recognising the synergy between prevention and care;

    5.  targeting efforts to those who are most vulnerable to infection;

    6.  focusing on young people; and

    7.  encouraging and supporting strong community participation in the response.

  6.4  In supporting such action at country level, all actors should agree to make two major commitments. First, to intensify prevention efforts, particularly in children and young people, recognizing that real progress against the epidemic will only come when the next generation of young men and women are empowered to protect themselves through information, readily available commodities and an enabling social environment that reduces their vulnerability to infection. Young people, particularly girls are very vulnerable to HIV infection.

  6.5  Such a recommitment to action should draw on:

    —  firm evidence from Thailand, Senegal and Uganda demonstrates that prevention on a large scale works.

    —  evidence that preventing mother-to-child transmission is technically feasible, affordable, brings much needed hope to women and their families. If universally available MTCT could prevent HIV infection in over half a million babies every year. The recent demonstration that a $4 single dose regimen of nevaripine (produced by the German company Boehringer Ingolheim) is nearly as good as a more complicated and expensive regimen of AZT has opened the door to larger scale implementation of MTCT prevention programmes in the developing world.

    —  commitment to ensuring affordable and sustainable access to services and essential commodities to contain the epidemic. Such commodities include male and female condoms, diagnostic tests, drugs and breast milk substitutes for the prevention of mother-to-child transmission of HIV.

    —  commitment to ensure that the infrastructure to deliver goods and services is in place through a variety of channels, particularly private and voluntary sector: this is not a task for the public sector alone. This will need to include facilities for voluntary counselling and testing, condom social marketing, and youth-friendly health services.

    —  precise costing estimates are being developed by the World Bank and the UNAIDS Secretariat, in particular for sub-Saharan Africa, where it is estimated that approximately $ 1.6 billion a year are needed to mount an adequate response to the epidemic in Africa (exclusive of the cost of antiretroviral drugs). No estimates are available as yet for other parts of the world.

    —  delivering on the commitment to protect children and young people from HIV infection leads to the heart of the international development agenda, in terms of freeing up the resources to deliver comprehensive prevention programmes, and in promoting education, employment opportunities and equal rights for children and young people.

  6.6  The second commitment should be to provide care and support for people living with HIV and support to people affected by AIDS. Experience over the last decade has shown the synergistic effect of prevention and care in communities, in addition to the value of care in its own right. It is simply not credible to address programmes to the non-infected, when a significant proportion of the adult population is HIV-positive and thereby nearly all members of a community are affected by HIV. In addition, the lack of at least minimal care is a disincentive for voluntary counselling and testing, which is a major element of prevention programmes, promoting openness about AIDS and countering associated stigma.

  We have no choice but to tackle this issue, while recognizing that opportunities are determined by economic issues and by the status of health care and social support systems. While it is true that comprehensive care for all people suffering from AIDS is beyond both health budgets, and the capacity of systems to deliver, it remains true that in all cases, it is possible to do something. Improving care and support needs to be incremental, starting from rationalizing use of current meagre public and private resources for care and support, to addressing the longer term need for dramatic improvements in care and support through strengthening systems, expanding financing, and lowering of price of drugs, both for the treatment and prevention of opportunistic infections, and antiretroviral therapy.

  6.7  Therefore, we need:

    —  commitments of governments to ensuring that a significant percentage of HIV-infected people have access to an appropriate continuum of care in accordance with locally established standards, with at least access to drugs for common opportunistic infections;

    —  governments, the pharmaceutical industry and international organisations working in concert to make HIV-related drugs more accessible, including through preferential pricing for low-income countries, strengthening of health care infrastructure, identification of financing mechanisms and rational prescribing. Industry and governments need to work together in balancing the difficult issue of intellectual property rights with the urgent need to develop and make available key life-saving drugs for people with HIV infection;

    —  commitment by governments and the international community to support children and young people orphaned by AIDS through such measures as community level monitoring of their well-being, and assured access to basic education, vocational training and social services.

  6.8  In short, the challenge is now to be strategic, skillful, coordinated, and disciplined in applying what we know and catalysing a social movement against AIDS, fully involving those living with HIV. We know that half hearted measures do not work, and we should offer nothing less than whole-hearted support. Indeed, how the rich nations take up their responsibility and ensure that the poorer populations have all the means to prevent the spread of HIV and have access to life saving care will be one of the great moral tests of our time.


July 2000

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