Africa

The Future of UNAIDS

Geneva, SWITZERLAND: UNAIDS Executive Director Peter Piot during a press conference at the United Nations Office in Geneva. (Photo: FABRICE COFFRINI/ AFP/ Getty Images)

The United Nations agency coordinating the global response to HIV/AIDS (UNAIDS) has come a long way since its creation in 1995. Under the skillful leadership of Dr. Peter Piot, the UNAIDS since it became operational in 1996, has become the essential entity in the fight against HIV/AIDS worldwide. In addition, the organization is now the fulcrum of worldwide mobilization of resources against the pandemic. UNAIDS is also the indispensable technical resource for best practices in the fight against HIV/AIDS. The Organization played a critical, stabilizing role in convincing tentative politicians and heads of governments to assume greater responsibility in the fight against the pandemic. As Michel Sidibe begins a new leadership of UNAIDS on January 1, 2009, it is important to review unavoidable issues that UNAIDS will face in the future.

Like all organizations that have been under the same leadership for the past 12 years, UNAIDS has grown to such a stature where it is almost synonymous with its leader. The UNAIDS of 2008 faces challenges that call for the total and comprehensive review of the purpose, goals and objectives of the organization. Today, HIV/AIDS is the dominant issue in the burgeoning field of global health diplomacy. HIV/AIDS is the lynchpin of the widely accepted paradigm of health-development link. HIV/AIDS gave birth to a creative, new financial instrument, the Global Fund against HIV/AIDS, Tuberculosis and Malaria (GFATM). It also spawned the creation of the biggest development assistance program focused narrowly on specific set of diseases: the US President Emergency Plan for HIV/AIDS, TB and Malaria (PEPFAR). New civil society organizations and private sector entities have arisen as part of the fight against HIV/AIDS. The United Nations has organized two highly successful General Assembly sessions focused on HIV/AIDS. Resources available to fight the pandemic have grown beyond wildest expectations since 2001.

Despite these extraordinary achievements, significant challenges abound. Some of these challenges have remained unresolved since the creation of UNAIDS. Potential future challenges loom as the fight against the pandemic searches for the tipping point that will mobilize technical, financial and logistic resources at a scale unprecedented in human history.

In particular, UNAIDS faces three significant challenges.

The first major challenge is that the HIV/AIDS pandemic is still a formidable foe. According to the August 2008 estimates from UNAIDS, 33 million people lived with HIV in 2007. Every day, at least 6,000 people die of AIDS. More than two thirds of individuals that need antiretroviral therapy are unable to access these lifesaving medicines. Last year alone, 2.7 million people contracted HIV and 2 million died of AIDS. Sub-Sahara Africa continues to account for two thirds of all individuals living with HIV. In Southern Africa, the situation is grim: 35% of all new HIV infections in 2007 and 38% of all worldwide deaths from AIDS occurred in the region. Half of all individuals living with HIV are women. At least 2 million children less than 15 years of age live with HIV, 90% of them from Africa.

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The second challenge is that the future of the global response against HIV/AIDS today rest on four intricately linked shaky foundations:

  • The fight against HIV/AIDS is now at family and community levels. Today, the weakest link in the fight against HIV/AIDS is the lack of capacity to prevent HIV transmission at individual levels, and, the lack of capacity to mobilize care and support at family and community levels.
  • The fight against HIV/AIDS urgently needs new or strengthened partners. The youth are yet to join the fight against HIV at critical mass levels. The fight needs younger leaders and scientists with fresh ideas and sense of purpose. The organized private sector is yet to fully mobilize against HIV/AIDS. Foundations, philanthropies and wealthy individuals are yet to become the backbone of the fight against HIV/AIDS. Individuals at risk of contracting HIV and those living with HIV/AIDS continue to be utilized as token participants in the fight against the pandemic. Resource-challenged target populations and governments remain at the outside, looking in. Organizations operating at local levels are yet to become integrated within national and international HIV/AIDS remedial programs.
  • The multiple roles of UN agencies in the fight against HIV/AIDS remain an issue. What is the difference between the powerful HIV/AIDS program of the World Health Organization and that of UNAIDS? The stated difference is that the WHO will focus on clinical/treatment issues of HIV/AIDS. However, it is now known that a tighter integration of preventive and clinical care programs is critical in HIV/AIDS remedial efforts. Another important issue is whether there is a compelling need for UN agencies to have separate HIV/AIDS programs? What is the future role of UNAIDS in view of the dominant financial role of GFATM and PEPFAR? How should Africa fight HIV/AIDS? Through a strengthened UNAIDS, through a unified UN system response or through a continental initiative?
  • The role of bilateral agencies in the fight against HIV/AIDS will become increasingly difficult to predict as economic crises hit industrialized countries. How will industrialized countries respond to HIV/AIDS in resource challenged countries if the economic crises continue longer than expected? In addition, the European Union may launch its own PEPFAR type response to HIV/AIDS to consolidate the reduced contribution of its member states to development assistance. Whither UNAIDS in the face of a consolidated EU response to HIV/AIDS coupled with the financial muscle of Global Fund and PEPFAR? If these entities eventually become engaged in policy and advocacy, what will be the role of UNAIDS? As the current financial turmoil linger, how will the increasingly powerful economies of China, Brazil and India respond to an inevitable global clamor for them to provide more resources in the fight against the pandemic. Will China, Brazil, India and other emerging economies with hefty national reserves ramp up their support for UNAIDS and GFATM or will they team up to focus exclusively on the poorest countries in the world? What will be the future of UNAIDS as these scenarios emerge?

The third significant challenge is the twin slow progress in the search for HIV vaccine and the quest for universal access to HIV/AIDS services on or before 2010. The slow progress in the search for HIV vaccine means that there will be no magic bullet, at least for a decade, in the fight against the pandemic. The slow progress in achieving universal access to HIV/AIDS services means that millions of individuals will contract HIV and millions will die of AIDS. As these twin issues remain unresolved, there is always a possibility that a new global alliance to address the pandemic may arise. How is UNAIDS positioned to address or accelerate progress on these twin issues?

Michel Sidibe as the new chief of UNAIDS faces the ultimate challenge of leading an organization whose future role may expand or contract depending on decisions that other entities may make. For example, if HIV prevalence rises exponentially in China, India and Brazil, and if the economic downturn continues unabated in North America and Europe, there may be a major realignment of the key global players in the HIV/AIDS response. The issue of consolidating global response to HIV/AIDS, starting with the UN system, may arise sooner rather later if the organized private sector and foundations assume greater share of financial resources in the fight against HIV/AIDS. Whither UNAIDS as these issues inevitably arise?

The future of UNAIDS will depend considerably on how its leaders anticipate potential changes in the fight against the pandemic. To anticipate these potential changes, UNAIDS should undergo a comprehensive, independent strategic, policy and operational review. This forward-looking review should include new individuals and organizations that have not been part of UNAIDS normal circle of leadership, advisers and supporters. It should involve young activists, researchers and policy makers. The review should also involve individuals and organizations with proven expertise in community-based response to health issues, since the final battle against HIV/AIDS will be fought at personal and community levels.

In conclusion, the fight against HIV/AIDS is evolving. UNAIDS under the leadership of Peter Piot has played a pivotal role in mobilizing support for the fight against the pandemic. The UNAIDS now should plan for the future, anticipating potential changes in the strategies and lead stakeholders. UNAIDS under Michel Sidibe should conduct a comprehensive, independent review that will reposition the organization for the challenges ahead in the long term struggle to contain the HIV/AIDS pandemic.


Materials Utilized in the Preparation of this Document

Peter Piot (2008). Statement at the UN General Assembly High Level Meeting on AIDS, New York, 10 June 2008. Available at http://www.unaids.org

Ban ki Moon (2008). The Secretary-General Address to the International AIDS Conference, Mexico City, 3 August. Available at http://www.un.org

UNAIDS (2008). Key Facts by Region – 2008 Report on the Global AIDS Epidemic.  Fact Sheet. August 2008. Available at http://www.unaids.org

UNAIDS (2008). Sub-Sahara Africa. Fact Sheet. August 2008. Available at http://www.unaids.org

UNAIDS (2008). UNAIDS: The First 10 Years. Available at http://www.unaids.org

Kaiser Family Foundation (2008). XVII International AIDS Conference. Looking to the Future – The Epidemic in 2031 and New Directions in AIDS Research. August 6, 2008, Mexico City. Available at http://www.kaisernetwork.org

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