The United Nations and Aids: learning from failure

Tim France
29 May 2006

The five-year day of reckoning for the most significant political promises and commitments on HIV/Aids has arrived. At a special session of the United Nations general assembly in New York on 31 May-2 June 2006, member-states can either come clean by admitting collective failure to deliver adequate HIV/Aids programmes in the most-affected counties, or they can simply move the goalposts. True to form, the joint UN programme on HIV/Aids (Unaids) and its eight agency co-sponsors seem to favour the second option and are moving headfirst towards a new goal of "universal access". A potential risk of moving so hastily is that the opportunity for genuine evaluation of the past five years, and the invaluable lessons that must be extracted, will be lost.

The five-year Aids report card publishedby UN secretary-general Kofi Annan calls the special session of the UN general assembly on HIV/Aids (Ungass) in 2001 a "landmark in global efforts to respond to the AIDS crisis". For the first time in the history of a global pandemic that has claimed 25 million lives, a series of time-bound targets were adopted and codified in a "declaration of commitment on HIV/Aids", then signed by leaders from 189 countries.

In 2001-06, Annan asserts, the declaration of commitment has "galvanised global action, strengthened advocacy by civil society and helped guide national decision-making."

This is optimistic talk. How well does it correspond with the reality of how the UN programme has performed?

Tim France has worked for the World Health Organisation's Global Programme on AIDS, the United Nations Joint Programme on AIDS, and various non-governmental organisations; his main focus was writing and editing HIV/Aids-related technical guidelines and policy materials, as well as developing information-dissemination strategies. He was co-founder of Health & Development Networks and scientific editor of the British Journal of Haematology and the European Journal of Cancer. He lives in northern Thailand.

Also in openDemocracy on the politics of HIV/ Aids:

Glenn Brigaldino, "Living with Aids: the experience of Botswana" (November 2002)

Ian Hodgson, "Loaded but lonely: the moralisation of US Aids policy" (November 2005)

Ian Hodgson, "Dazed and confused: the reality of Aids treatment in South Africa" (January 2006)

The record

Kofi Annan's own speech to the UN special session ("Ungass+5") will be a significant indicator. For despite some progress in expanding access to HIV prevention and treatment, Annan is expected to dryly advise most governments that they are being outpaced by the epidemic because HIV programmes are still failing to reach the very people and communities most vulnerable to HIV.

The secretary-general's own report offers evidence for this view. For example, a mere 9% of men who have sex with men received any type of HIV-prevention service in 2005. Among people who inject drugs, fewer than 20% receives HIV-prevention services. A condom was used on average, the report estimates, in only 9% of "risky" sex in the past year.

Meanwhile, fewer than 10% of pregnant women with HIV have access to the relatively simple drug treatments that prevent mother-to-child transmission: the main reason 3 million children were born with HIV in the past five years. Care and support reaches fewer than 10% of the 15 million children orphaned by Aids and millions more children made vulnerable by the epidemic.

One of the few global targets that has been achieved in 2001-06 is the amount of money that governments, international agencies and other partners said they would need to tackle Aids. In 2005, approximately $8.3 billion was spent on Aids programmes in low- and middle-income countries, reaching the declaration of commitment financing target of $7-$10 billion per year.

An inescapable conclusion from these results is that while the money is available, the end results do not justify the amount spent. But rather than insisting on a frank analysis of why in that case there has been a failure to make a difference, the UN agencies tackling HIV/Aids (Unaids and its co-sponsors) claim that "the foundation for an extraordinarily stronger and sustained response is largely in place."

This positive assessment is leading the UN to turn away from reflection on the true record of these years in favour of a heavy promotion of "universal access" – the goal of providing a comprehensive package of HIV/Aids treatment, care, support and prevention. This is a new and untried strategy based on what is, at best, a confusing and ambiguous statement of intent by governments.

Unaids argues now that the "ambitious commitments" made by the international community have "brought the Aids response to another historic juncture". Its upbeat position has its roots in a single sentence from the G8 meeting in Gleneagles, Scotland, in July 2005, later incorporated into the declaration following the UN general assembly's sixtieth anniversary world summit in September 2005:

"We commit to … developing and implementing a package for HIV prevention, treatment and care with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all who need it….."

The problem is that in the midst of the other 177 paragraphs of the UN world summit document, this one is not particularly striking. Similarly, the G8 is good at making ambitious commitments, and this one too is not especially "historic" when placed alongside the endless HIV/Aids promises it has made – and then promptly broken – over the past five years.

The proposal

In late 2005, a UN resolution requested Unaids to find out what was preventing "universal access" from being achieved. Even as the ink on it dried, the agency's most efficient operation ever – led by the British government as well as Unaids itself – was unveiled to pursue the goal. Almost overnight, plans were in motion to coordinate more than a hundred national consultations, set up seven regional consultations and establish a global steering committee.

When the UN system moves with the speed and efficiency as it has around universal access, and goes to such lengths to make the process appear inclusive and country-driven, it's generally a sure sign that a major policy shift is brewing.

Sure enough, Unaids has since claimed: "Thousands of people from all walks of life have mobilised to seize this extraordinary opportunity." The universal-access "initiative" has indeed taken a large number of people along with it – unfortunately not in a common understanding, but in a collective misunderstanding. Why? Because the terms "access", "utilisation", "availability" and "coverage" are often used interchangeably to stand for what most people understand by the term "universal access": that people in need of essential Aids services and commodities to protect their health are actually going to get them. Many people, quite reasonably but quite wrongly, take the "promise" of universal access to mean what the words imply.

There is also a widespread misconception that "universal access" refers to the goal of increasing access to anti-retroviral drugs, rather than to the intended one of improving access to a comprehensive range of HIV prevention, care, support and treatment services.

Universal access offers an easy enticement, especially given the disappointing outcome of the recent World Health Organisation (WHO)-led Aids treatment initiative – "3-by-5" – that promised to provide anti-retroviral (ARV) drugs to 3 million people with HIV in poor countries by the end of 2005, but delivered them to less than half that number.

A core consideration underlying the universal-access strategy is the effort to harmonise and align donor support for Aids between Unaids and national governments. A Uniads document declares that "scaling up" towards universal access is a "partnership between the country and its external development partners", facilitated by Unaids and aimed at linking better "increased financial support to agreed-on policy and programme goals".

The problem with this strategy is that a significant shift to rebuild the global Aids response on the basis of individual, national plans risks consigning to history the past five years of accountability in relation to Ungass's declaration of commitment.

The placing of universal access centre-stage would dilute the most significant and specific political promises on HIV/Aids overnight. The adoption of different universal-access roadmaps would also turn the strategic clock back a decade, to a period when support for national Aids programmes was channelled by donors to national governments through WHO's global programme on Aids.

The head of Unaids, Peter Piot, told a recent London meeting that he hoped that Ungass+5 will not be "one of those summits where we say: 'We've failed, we've failed, and we have no results and we need more money' – and then we go home."

But the current status of the Aids pandemic – and the appalling record in providing essential HIV-related services to the people and communities who need them – demands that the review meeting be truthful and authentic. This means going further than even Piot fears: asking why we have failed, before new targets or frameworks on Aids such as "universal access" are adopted.

Each UN member-state has a unmistakable choice before it at the general assembly this week: either strongly reaffirm the Ungass declaration of commitment of 2001 and ask candidly why the global community is addressing Aids so slowly; or move on with blind faith that we are in fact succeeding against the worst pandemic in history.

The first option calls for political nerve and pragmatism in order to learn fully from our failures. The second requires a disregard for the lessons and warnings of the past five years, and for the needs of the 40 million people living with HIV.

The UN position on universal access is indeed an immense leap of blind faith that evades the single evident fact that should be bringing the Aids response to a true "historic juncture": the world is not addressing the epidemic effectively.

There is a lot of rhetoric at present about "knowing what to do about Aids". The reality is that all involved clearly need to learn a lot more before Aids programmes will reliably provide basic prevention and treatment services to the people who need them.

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