AFRICA: Taking stock of the AIDS response

KIGALI, 26 June 2007 (PlusNews) - When some of the world's largest donors to the global AIDS response organise a conference for "implementers", there is none of the chaos and rush of larger AIDS gatherings, or any of the free goods and gimmicks hawked by large pharmaceutical companies: no conference bags; no protests; no glittering opening ceremonies - it was all business last week when conference delegates met in Kigali, Rwanda, at the 2007 HIV Implementers' Meeting.

The gathering, organised by the US President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria, the World Bank and UN agencies, was an opportunity to share lessons learned, and take stock of AIDS programmes.

UNAIDS deputy executive director Michel Sidibe told the estimated 1,500 conference delegates that it was time to "take a cold hard look at what we are doing today, and assess what is working and what is not."

The invitation couldn't have come at a better time. It has been 10 years since the World Bank launched the Multi-Country HIV/AIDS Programmes for Africa, five years since the Global Fund was created, and four since PEPFAR was formed; all of which have funded thousands of interventions to slow or shrink the pandemic.

In May this year, US President George Bush asked Congress to spend US$30 billion over five years to fight AIDS - doubling the current $15 billion PEPFAR campaign. A week later, leaders from the G8 announced a projected $60 billion investment in AIDS, tuberculosis and malaria, and the strengthening of health systems in Africa.

These pledges still fall short of the money needed. According to Sidibe, funding for the global AIDS response will be $8 billion shy of the $18 billion required in 2007. "This funding shortfall makes it all the more important that we spend the money we do have on the right things in the right place, at the right time."

The Global Fund's new executive director, Michel Kazatchinke, told journalists on the first day of the conference that the emphasis was now on results, as donors wanted to see "how the money is spent to achieve the results".

Prevention efforts lag behind

Some progress has been made: HIV infection levels are falling in several populations in East Africa, the Caribbean and Asia, and over two million people are now accessing antiretrovirals (ARVs) in the developing world - a 20-fold increase over the past four years.

But for every person who begins taking life-prolonging ARVs, another six become infected with HIV. In Uganda, the much-lauded prevention gains of the 1990s are being lost as infections rates begin to climb.

David Apuuli, of Uganda's AIDS Commission, told delegates that 42 percent of new infections took place during marital sex. This, coupled with mother-to-child transmission, resulted in more new infections than either casual sex or commercial sex, which accounted for only 14 percent of new infections.

It will take a long time to match what we are getting from external sources, so that brings an issue of sustainability - if the resources were to dry up, what would happen?

Clearly, existing prevention campaigns are not hitting the mark. David Wilson, of the World Bank, warned that prevention campaigns would be futile if policymakers did not do more to understand what drove the epidemic. "Sufficient evidence leads to intelligent action," he commented.

Take gender inequalities, for example. According to Sarah Kambou, of the International Centre for Research on Women, existing AIDS responses "curtail women's autonomy" and focus on men's pleasure rather than women's.

Although it was established that empowering women and girls by transforming gender roles was likely to make them take a leading role in negotiating gender and sexuality, not enough programmes were addressing this, she added.

But male circumcision as a prevention method dominated the conference programme, although Gayle Martin, senior economist with Constella Futures, a US-based research organisation, warned that the level of expenditure required to roll out male circumcision was "not trivial".

"The indirect costs [to health services] shouldn't be underestimated ... the financial and human resource implications are significant, but not insurmountable," she said.

Kevin de Cock, director of HIV at the World Health Organisation, admitted that despite the convincing data showing that male circumcision could reduce the risk of HIV transmission by up to 60 percent, "many countries and donors, including PEPFAR, were unsure of what to do". De Cock told delegates that there was a need for technical data and consensus in order to move forward and begin rolling out the new prevention strategy.

The human resource crisis was also hampering AIDS interventions. Despite efforts to increase the numbers of healthcare staff, it would take time, and it was essential to find alternative models to quickly expand the workforce.

This would require "task-shifting", in the form of moving appropriate tasks to less specialised workers. Chris Molomo, director of Botswana's National AIDS Council, told PlusNews that smaller countries, such as Botswana and Lesotho, "have no choice; we're already doing it, it's a necessity".

Mark Dybul, US Global AIDS Coordinator, emphasised "partnerships" between donors and recipients, and called for a shift from the old top-down donor-recipient approach.

Partnership is about 'making sure programmes implemented at country level are owned, and resources coming into the countries are aligned to national priorities'

But Sidibe told PlusNews that partnership was about "making sure programmes implemented at country level are owned, and resources coming into the countries are aligned to national priorities". He stressed that "We need to think about how resources will not create distortions in country systems ... it's not about charity, it's about development."

Rwanda's permanent secretary in the health ministry, Caroline Kayonga, told IRIN/PlusNews that keeping a balance was a major challenge. "We do have the resources available ... but this is largely external; yes, government is putting in what we can but ... it will take a long time to match what we are getting from external sources, so that brings an issue of sustainability - if the resources were to dry up, what would happen?"

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Theme (s): HIV/AIDS (PlusNews),

[This report does not necessarily reflect the views of the United Nations]