Unicef Associate Director Pascal Villeneuve, Executive Director of the Global Fund to fight AIDS Michel Kazatchkine, France First Lady Carla Bruni-Sarkozy, and current UNAIDS Executive Director Michel Sidibe attend a press conference in Paris on December 1, 2008 to commemorate World AIDS Day. (Photo: Philippe Wojazer / AFP-Getty Images)
In two previous articles, I had indicated the need for the United Nations Joint Program on HIV/AIDS (UNAIDS) to be reorganized with a major focus on consolidating the United Nations' system response to the AIDS global epidemic, and the need for revitalized global leadership on HIV/AIDS. At the core of the noted articles is the unmistakable fact that the vaunted global alliance on HIV/AIDS is faltering. The famously tension-packed but successful coalition between governments, the private sector and civil society organizations that ultimately led to exponential increases in AIDS funding and dramatically improved access to lifesaving drugs is now showing clear signs of running out of steam.
Today, more than 6 million individuals living with AIDS do not have access to lifesaving drugs. Millions of individuals at risk of contracting HIV cannot be reached with preventive messages. AIDS funding worldwide had a shortfall of at least $10 billion in 2007. The round-the-clock organizing and advocacy work that made governments around the world listen, pay attention and take action on AIDS relief is no more. In this article, I discuss five strategies for strengthening the global alliance against HIV/AIDS. These strategies are anchored on the need for a fresh start in the fight against the pandemic.
It is important to note that as the global response to the AIDS epidemic has matured, tactics or strategies that may have worked in the past are unlikely to be successful today or in the future. The days of naming and shaming government officials are probably gone. The days of outrage and appeal to personal consciences of policy makers are also numbered. The current global economic crises suggest that regular sources of financial support for AIDS relief may no longer be reliable.
The increasing longevity of individuals living with HIV/AIDS who are on antiretroviral therapy will continue to give comfort to high-risk populations that they are not so vulnerable, after all. Some of the earliest street organizers and activists in the fight against AIDS are now more famous and comfortably middle-aged. Some of them run foundations that promote their personal interests in the fight against AIDS. As the AIDS paradigm moved from inevitable death to the possibility of prolonged lifespan due to lifesaving drugs, the response has become tempered.
The inevitable mature response to AIDS has led to the creation of policy, scientific, media and activist superstars. The retirement of Peter Piot as the head of UNAIDS represents a true changing of the guard, as most of his colleagues from the earliest days of the fight against AIDS are either retired or looking forward to their days in the sun. The more than 25-year old fight against HIV/AIDS has led to inevitable attrition. I briefly discuss proposed strategies for strengthening the global alliance against AIDS with the aforementioned realities in mind.
Strategies to Strengthen the Global Alliance on AIDS
The first strategy is to go back to having simple goals and objectives. Not long ago the global alliance had such goals on making lifesaving medicines available — reducing the cost of medicines to specific price ranges, and supporting poor countries in pursuing access to generic medicines. The revitalized alliance should have measurable, mobilizing goals that can energize various interest groups and stakeholders to come out of their comfort zones and make a difference.
The AIDS alliance may have the following goals:
1. Ensure that the annual funding shortfall in AIDS relief ends on or before 2015, or double the 2008 AIDS global expenditure on or before 2015.
2. Enroll all individuals that qualify in antiretroviral therapy on or before the end of 2011.
3. Implement a combined preventive and treatment service in all AIDS programs on or before the end of 2010.
The second strategy is to customize the AIDS alliance in such a way that it is global in outlook, but regional in practice. Today, the response to AIDS is radically different from the earlier days of aggressive demonstrations against governments and pharmaceutical companies. Although the AIDS epidemic continues to have global implications, in practice, various parts of the world have vastly different priorities.
In most Western countries, access to lifesaving medicine and advanced medical care is taken for granted. In these countries, however, housing for individuals living with AIDS remains a challenge. In most parts of Africa, overwhelming numbers of individuals living with HIV/AIDS do not have access to lifesaving medicines or clinical care. In general, African governments are not focused on the housing needs of the target population, and poverty remains a formidable obstacle. In Russia and the former Soviet states, injection drug use is a major problem. In Southeast Asia, stigma and official silence in the corridors of power remain important issues. The global alliance should be customized to fight the epidemic in Africa, Southeast Asia, Russia and former Soviet States, the Caribbean and Latin America.
The third strategy is to create a big funding pool from multiple donors. Today, two entities dominate the field of AIDS funding: the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Another organization, the Gates Foundation — the biggest philanthropist in the world — has the deep pockets to become the third major force in global AIDS funding. China, India, Brazil and Middle East Gulf states could easily come together and create a formidable war chest against AIDS.
A serious global alliance against AIDS should focus on how best to pool financial support for program operations; how to minimize overlap in ground operations; and how best to identify and scale up promising projects. The alliance should also begin contingency planning, based on the possibility that increased pooled funding from a few powerful organizations may lead to the potential intersection of funding and policy making. As these donor organizations become more powerful, they will inevitably push into policy making roles, seeking to link their funding with specific policy goals. A credible global alliance should plan ahead to deal with this possiblilty.
The fourth strategy is to focus relentlessly on human resource issues in the fight against AIDS. The global alliance needs new partners and stakeholders that will play specific roles in the long fight ahead. High-risk populations, especially the youth, need to have important, verifiable roles. Individuals living with HIV/AIDS should play a critical part in the design and implementation of AIDS relief efforts. Community-based health workers who are at ground zero in the fight against AIDS should have a strong voice. The organized private sector has a major role to play, especially in workplace HIV/AIDS programs and the logistics of providing services in remote, inaccessible areas.
Civil society organizations need to become better organizers and advocates at local and national levels. In particular, such organizations need to develop expertise in specific technical areas such as policy-based advocacy, legislative processes to help change laws, and budgetary analyses to keep up with local and national expenditures. Civil society organizations should also become better equipped on how to monitor program operations and the logistics of care. There is also the need to create new stakeholders that can tackle the relationship between HIV risk factors and poverty, which is one of the weakest links in the current global fight against the pandemic. HIV-preventive programs will continue to run into the reality of risky behaviors based on the need to put food on the table or to survive harsh living conditions.
The fifth strategy is for the Global AIDS Alliance to articulate and push for special, worldwide initiatives. The plight of AIDS orphans in Africa has remained largely unaddressed because of global inattention and inaction. The revitalized alliance can begin an urgent global initiative to address the plight of AIDS orphans around the world. In a 2006 book, a colleague and I had indicated that in Africa, where frail grandmothers are raising most of the AIDS orphans, it is not expensive to meet the economic, health and social needs of such children.
Other possible special, global initiatives include organized activities to end stigma against individuals living with HIV/AIDS; initiatives to keep children, especially girls, in school; and developing national coalitions to help widows, especially those whose husbands have died of AIDS, to improve their quality of life and that of their children. Efforts to improve the plight of widows will include the passage of enabling laws and legislation on property rights and inheritance. The key to launching proposed special, urgent initiatives is to attract focused global attention and action.
The fight against HIV/AIDS is going to be long and hard. It will require a continuous review of strategies and objectives. The struggle against the pandemic had its glorious years between 2001 and 2007 when funding streams increased exponentially, the global alliance blossomed and more individuals at risk benefited from relief efforts. The worldwide coalition of governments, the private sector and civil society organizations against HIV/AIDS is showing signs of becoming ineffective, and it needs to come alive again with renewed missions and focused action steps.
Selected reference materials for this article:
1. Chinua Akukwe (2008). The Future of UNAIDS.
2. Chinua Akukwe (2009). Global HIV/AIDS: Five Leadership Issues.
3. Chinua Akukwe (2008). (Editor). Healthcare Services in Africa. Overcoming Challenges, Improving Outcomes. Adonis & Abbey Publishers, London, U.K.
4. Rhoi Wangila, Chinua Akukwe (2006). Africa, AIDS Orphans and their Grandparents. TSEHAI Publishers, Los Angeles.
5. UNAIDS (2008). UNAIDS. The First 10 Years. Available at www.unaids.org.
6. UNAIDS (2008). 08 Report on the Global AIDS Epidemic. Available at www.unaids.org.
7. UNAIDS (2008). AIDS Outlook/09. UNAIDS World AIDS Day Rreport. Available at www.unaids.org.