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Peter Piot holds the AIDS annual epidemic update report during a press conference on Nov. 21 at the United Nations Office in Geneva. (Photo: Fabrice Coffrini / AFP-Getty Images) |
As the international community marks 25 years of H.I.V./AIDS, there is much to cheer regarding the global response, especially in the last five years. In the last five years, H.I.V./AIDS became a mainstream political issue, engaging policymakers in the United Nations and at the highest levels of national governments, bilateral and multilateral institutions, and regional organizations. H.I.V./AIDS also became universally accepted as a national and international security issue.
The need for individuals living with H.I.V./AIDS to have timely access to lifesaving antiretroviral drugs is now accepted in the highest political and legal circles. The right of poor national governments to take all legitimate steps to provide lifesaving medicines and other public health goods to their citizens living with H.I.V./AIDS, whether generic or otherwise, is no longer in doubt. Legal protection against stigma and discrimination is now settled internationally. Various governments either have updated their legal statutes or are in the process of doing so to end stigma and discrimination. The special needs of women on H.I.V. prevention and AIDS clinical care is widely recognized and receiving the attention of policy makers.
Global expenditure on H.I.V./AIDS in low- and middle-income countries reached $8.3 billion in 2005, well within the 2001 U.N. Declaration of Commitment target of $7 billion to $20 billion for 2005. The Global Fund to Fight AIDS, Tuberculosis, and Malaria is up and running, reaching many at-risk individuals in some of the most resource poor countries. Various bilateral and multilateral initiatives on H.I.V./AIDS are reporting success on preventive and clinical care programs in host nations and target communities.
However, after 25 years, the fight against H.I.V./AIDS is still in its early stages. The newly released update on the global AIDS epidemic by UNAIDS is a timely reminder of the long road ahead. An estimated 39.6 million individuals worldwide live with H.I.V./AIDS. About 4.3 million individuals worldwide contracted H.I.V. in 2006 and an estimated 2.9 million individuals died of AIDS. Less than 50 percent of young people, according to UNAIDS, have "comprehensive knowledge" of H.I.V. preventive strategies compared to the 2001 U.N. Declaration of Commitment on H.I.V./AIDS to reach 90 percent of young people by the end of 2005. Only 9 percent of pregnant women worldwide receive antiretroviral therapy that can prevent H.I.V. infection in newborns and infants. To date, there is no comprehensive remedial effort to meet the needs of 15 million AIDS orphans worldwide.
Africa remains the epicenter of the pandemic, accounting for nearly two-thirds (63 percent) of all individuals living with H.I.V./AIDS and 72 percent of deaths due to AIDS in 2006. Currently, only 20 percent of individuals clinically qualified to receive antiretroviral therapy are on these lifesaving medicines. The fate of the 80 percent that do not have access to these lifesaving medicines is unknown, including those that will die in the next year due to lack of access to these medicines.
It is important to note that most of the remarkable achievements of the last five years on H.I.V./AIDS remedial efforts were emergency actions to stave off imminent disaster, realign the international moral and political compass on how best to respond to the needs of vulnerable populations, as well as reaffirm the universal resolve to do what it takes to win the fight against a dangerous foe. As noted by Peter Piot, the head of UNAIDS, at the 2006 Toronto International AIDS conference, it is critical to "put in place a long-term sustainable response." Piot advised that the horizon for sustained response to H.I.V./AIDS should not be 5 or 10 years but 25 years or more in the future.
This long-term sustainable response in my view should be anchored on three critical principles:
After 25 years, it is critical for all national, continental, and international stakeholders to move into a "mature" phase of H.I.V./AIDS remedial efforts that focuses on results, holding individuals and organizations accountable for promises made, and having a firm handle on baseline and trend data as the foundation for transparent monitoring and evaluation mechanisms. It is also crucial to craft new strategies and practices that empower individuals and families as the first and most important line of defense against H.I.V./AIDS. I briefly review the proposed accountability, benchmarking, and personal responsibility issues.
A very visible sign of the maturing process in global H.I.V./AIDS remedial effort is how seriously domestic, continental, and international stakeholders tackle the issue of accountability in remedial efforts. As the enormity of the pandemic becomes clearer in the coming years, it will be important to hold organizations accountable for their promises so that enough financial, material, and technical resources continue to flow toward remedial efforts. In this regard, there are four important accountability issues in global H.I.V./AIDS remedial efforts:
A. Ensuring that all domestic, continental, bilateral, and multilateral financial, technical, material, and logistics promises are kept, and according to agreed upon timelines. The International Treatment Preparedness Coalition in its November 2006 report indicated that by the current rate of adding 600,000 new people on antiretroviral therapy every year, the international treatment target of 9.8 million people by 2010 will fall short by a staggering five million or more people. A focused accountability approach to H.I.V./AIDS remedial efforts will ensure that all promises made by G-8 nations, bilateral and multilateral institutions, continental organizations, and national governments are kept in order to achieve agreed upon preventive and clinical care targets set in 2010 and subsequent years. Access to treatment is one of the most important and visible signs of the international commitment to the fight against H.I.V./AIDS. In this regard, it is important to hold all responsible parties accountable to their promises. A global H.I.V./AIDS remedial effort that fails to reach more than 50 percent of individuals in need of lifesaving medicines cannot be good enough.
B. Realigning the roles and responsibilities of bilateral and multilateral organizations to ensure that accountability mechanisms receive high priority attention. Under this scenario, policy oriented entities such as the UNAIDS will have to realign its responsibilities for a major push on accountability and outcomes from all stakeholders in the fight against H.I.V./AIDS, TB, and malaria.
C. Developing internationally acceptable guidelines and metrics for monitoring and evaluating accountability mechanisms of H.I.V./AIDS remedial efforts. This is critical to the development of a transparent and verifiable process for real-time monitoring and evaluation of H.I.V./AIDS remedial efforts.
D. Empowering civil society organizations at national, continental, and international levels to become indispensable partners on accountability mechanisms for H.I.V./AIDS remedial efforts. For civil society organizations to play a critical role in this regard, they will require major investments from the international community on technical issues such as policy analysis, management information systems, program reviews, operations research, and monitoring and evaluation. Depending on the area of expertise or involvement, civil society organizations may need to beef up expertise on subject matter areas such public health, primary health care, poverty reduction, governance reforms, and debt relief/cancellation, to mention only a few examples. Civil society organizations are extremely important in any serious effort to enthrone accountability in H.I.V./AIDS remedial efforts.
It is extremely important that in the next few years, policy makers, advocates, and other stakeholders should have access to epidemiologically validated prevalence and incidence data on H.I.V. and AIDS and associated risk factors. Currently, as noted by UNAIDS, most data on H.I.V./AIDS from developing countries, including endemic ones, come from sentinel surveys of pregnant women attending antenatal clinics. Although it is gratifying to note that 126 countries submitted "full reports" to UNAIDS as part of the 2006 global epidemic update, it is important to move quickly to establish validated baseline and trend data on H.I.V./AIDS in each country.
In the next five years, there should be an international technical assistance initiative to assist national governments in the developing world to conduct national sero-prevalence studies and risk factor analyses in order to establish baseline national data. The national baseline data should then be updated on a regular basis, according to internationally accepted epidemiology and statistical standards. In addition, national governments should conduct regular policy and program audits of H.I.V./AIDS remedial efforts and share findings with continental and international stakeholders. The ultimate goal of national baseline and trend data and national audits is to create a transparent and verifiable process for monitoring and evaluating agreed upon benchmarks and outcomes in the fight against H.I.V./AIDS.
After more than 25 years, it is now known that H.I.V. is transmitted in ways that are amenable to personal risk reduction practices and behaviors. In Africa, the predominant mode of transmission is heterosexual contact. In other parts of the world, in addition to heterosexual transmission, men having sex with men, illicit injection drug use, blood transfusions, and accidental exposure in hospital and other settings are also other possible modes of transmission.
For the next 25 years, it will be important for the international community to take specific steps to empower individuals and families to serve as the first and most important line of defense against H.I.V. transmission. Information, education, and communication campaigns against H.I.V. transmission should emphasize the ultimate responsibility of individuals and families to reduce or eliminate risk taking practices and behaviors that can lead to H.I.V. transmission. To achieve this purpose, the international community will have to address contextual issues that may overcome personal and family resolve to avoid H.I.V. transmission.
These issues include abject poverty, rape, gender inequalities, unsanitary living and working conditions, and limited safety risk practices in healthcare and other settings. Some of these issues such as poverty cannot be solved overnight. However, international development partners can assist poor nations in their poverty reduction programs to ensure individuals living in poverty do not have to choose between food on the table and high-risk behavior. Other issues such as rape and gender inequalities could be tackled in the immediate future through effective laws and enforcement policies.
After 25 years, the global response to H.I.V./AIDS should begin a "maturation" process that scales up what works, holds organizations accountable to their promises, encourages transparent and verifiable monitoring and evaluation activities through appropriate benchmarks, and empowers individuals and families to become the first and most important first line of defense. For the next 25 years, it is critical for all H.I.V./AIDS policy makers, advocates, and stakeholders to emphasize remedial efforts that can reach at risk populations, on time, and according to promises made. The most effective way to keep up the remarkable political and financing progress on H.I.V./AIDS remedial efforts achieved in the last five years is to focus relentlessly on holding nations, organizations, and individuals accountable on promises made yesterday and today, and on promises that will be made in the future.