Uncertain Goals

According to the 2010 AIDS epidemic update published by the Joint UN Programme on HIV/AIDS (UNAIDS), 2.6 million people were newly infected with HIV during 2009.

AIDS clinic, South Africa © Daily Mail & Guardian

Despite billions of dollars of investment over the last two decades, this global rate of infection has fallen by only a quarter from its peak of 3.5 million in 1996. The decline in AIDS-related deaths is also modest, from a peak of 2.2 million in 2004 to 1.8 million in 2009.

Although incidence has dropped significantly in sub-Saharan Africa, the region accounted for 69% of new infections in 2009. Central Asia and Eastern Europe are the only regions where the rate is rising.

Despite the accuracy of these statistics relative to those for poverty or hunger, the framework for assessing progress of the Millennium Development Goal (MDG) for HIV and AIDS is a little shambolic.

Goal 6 aims "to halt and begin to reverse the spread of HIV/AIDS" by 2015. According to the UN’s official list, the principal monitoring indicator is “HIV prevalence among population aged 15-24 years.”

Prevalence refers to the percentage of people living with HIV but has proved unsuitable as a measure of progress. Modern drug therapy, for those fortunate to receive it, extends life expectancy but without removing the presence of the virus.

This outcome therefore increases prevalence and misleadingly suggests negative progress. By the end of 2009 there were 33.3 million people living with HIV, treble the corresponding figure for 1990, the MDG baseline year.

Recent UN progress reports for the MDGs have omitted any reference to the prevalence indicator. Nothing has replaced it.

The urgency of the AIDS crisis has however never been in doubt and led to a fresh UN Political Declaration approved in 2006. This committed world leaders to work "towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010."

The concept of “universal” in this context is more concerned with equal access to affordable services than with 100% delivery. Each country interprets universal access through its own percentage targets for prevention, treatment and care, typically around 80%.

This goal has also proved flawed in its unrealistic aspiration. Despite significant progress, especially in 2009, only 8 out of 144 low and middle income countries had achieved their universal targets by the end of that year. Far too much remains to be done in 2010.

UNAIDS is now advocating yet another goal, that of total eradication of HIV and AIDS. Whilst this is an inspiring vision, it may have limited resonance for health workers grappling with the immediate challenge.


UNAIDS highlights some areas of positive progress from its 2010 Epidemic Update
Funding Sources

Spending on HIV and AIDS in low and middle income countries has increased exponentially, rising from $260 million in 1996 to $15.9 billion in 2009. These costs are met partly by foreign aid from the richer countries and partly from individual national budgets.

The largest single source is the US government which channels its funding through the President's Emergency Plan for AIDS Relief (PEPFAR). Commitment to PEPFAR has trebled in the six years to 2010, rising to $6.8 billion in that year.

Olayinka Jegede-Ekpe, Nigerian HIV activist © unknown / Prerana (Associate CEDPA)

The Global Fund to Fight AIDS Tuberculosis and Malaria was established in 2002 to "attract and disburse additional funds."

It receives funds from governmental and other donors (including PEPFAR) amounting to $9.7 billion for the three years ending 2010.

To put these figures in perspective, the total amount of foreign aid for development in sub-Saharan Africa in 2009 was $24 billion. It is clear that the AIDS sector attracts a generous slice of the funding cake. This weighting is justified in the context of the devastating impact of HIV and AIDS on a country's social and economic fabric.

In sub-Saharan Africa, the loss of teachers, health workers and even MPs has disrupted the functioning of public life, lowered economic growth and undermined poverty reduction plans. Life expectancy in many countries has fallen below 50 years.

A colder analysis of commerce conveys the same message of economic expediency. In Zambia business research has valued the loss of an experienced worker at $9,000 whilst an HIV prevention programme costs just $47 per employee. Major companies throughout southern Africa have invested in AIDS-related support services for staff and local communities.


A film introducing the work of the Global Fund to Fight AIDS Tuberculosis and Malaria.
Women

A distressing characteristic of the impact of HIV has been its exposure of the unequal gender relations and the threat of domestic violence that exist in many developing countries. By the end of 2009, more than half of all adults living with HIV were women. The virus has no sympathy for the weak position of young women to negotiate safe sex or no sex.

HIV positive mothers need treatment for themselves and their families © UN Integrated Regional Information Networks

Married women are exposed to the infidelities of their husbands, especially those whose work takes them away from home. In many countries, fear of exclusion and violence deters women from testing their HIV status.

As if these relational risks were not enough, women are much more susceptible than men to transmission of the virus during sex with an infected partner. As a result, in the 15-24 age group in southern Africa, 75% of those living with HIV are women. AIDS remains the principal cause of death of women of child-bearing age.

This profile and its underlying causes have galvanised the efforts of international women's groups. They stress the importance of education for girls, equal economic opportunities for women and the integration of HIV programmes with those related to reproductive health services and violence against women.

In consequence a controversial morality dimension unsettles the humanitarian fight against AIDS. Its most extreme manifestation is the continued refusal of the Roman Catholic church to countenance the use of condoms in most circumstances, restated during the Pope’s 2009 visit to Cameroon.
Children

There were 2.5 million children living with HIV in 2009. These are the most heartbreakingly innocent victims in that almost all were infected during pregnancy, birth or through breastfeeding. A total of 370,000 new infections of children occurred in 2009, down from 500,000 in 2001.

Children at the Nyaka school for AIDS orphans in Uganda © Nyaka AIDS Orphans School

The science of paediatric treatment lags that for adults; the virus is difficult to detect in babies and its advance can be very rapid. Children under age 15 accounted for one in seven of all AIDS deaths in 2009.

Knowledge of prevention of mother-to-child transmission (PMTCT) is more advanced. In rich countries a combination of special drugs for both mother and child, caesarean delivery and formula milk reduces the risk to just 1%-2%.

In the complete absence of treatment the risk is 30%-35%. This was the position for 47% of all babies born to mothers with HIV in low and middle income countries in 2009.

Over 90% of these women live in sub-Saharan Africa. UNAIDS believes that the virtual elimination of the risk of transmission can be achieved by 2015.

There is perhaps greater public awareness of the problems of the 14 million children in sub-Saharan Africa who have escaped HIV but who have lost one or both parents. However, there is uncertainty over this statistic in light of the many other causes of death of parents in poor countries. Development agencies increasingly prefer not to single out “AIDS orphans” for special care.
Human Rights

In many countries the virus often takes hold initially amongst “high risk groups” such as sex workers, men who have sex with men, and injecting drug users. In varying degrees, such groups exist on the wrong side of the law, experiencing social exclusion and discrimination in both rich and poor countries.

As a result they present the greatest difficulties for delivery of prevention and treatment support, with both provider and patient potentially reluctant to engage. Yet denial of HIV services not only leaves the disease unchecked but offends principles of human rights.

AIDS activists in Kenya protest against discrimination © Internews Network, Inc.

The same applies to those who experience discrimination directly as a result of their HIV positive status; a combination of stigma and ignorance has often resulted in loss of employment and public services.

There has been resistance to the inclusion of human rights language in international HIV and AIDS agreements. However, the 2006 Political Declaration includes a clause in which governments undertake to introduce legislation to ensure "enjoyment of all human rights and fundamental freedoms by people living with HIV."

Although over 90% of countries claim that their national programmes for HIV and AIDS address issues relating to discrimination, this rarely extends as far as legislation. Indeed, the UNAIDS Global Report for 2010 claims that “more than 80 countries
across the world have laws against same-sex behaviour.” Revoking such laws on grounds of human rights would advance the fight against HIV and AIDS.
Prevention

The human immunodeficiency virus, first identified in California in 1983, is transmitted by bodily fluids exchanged in sexual relations, or by contaminated blood, or through mother-to-child transmission. As prolonged and intensive efforts to identify a vaccine remain unsuccessful, behaviour change is the only route to prevention.

Box for anonymous questions at Diemo School, Kisumo, Kenya © Peter Armstrong

Despite years of creative educational initiatives supported by many exemplary acts of political leadership, the MDG Progress Report for 2010 states that a thorough and accurate understanding of HIV is limited to “less than one third of young men and less than one fifth of young women (aged 15-24) in developing countries.” Although this assessment relates to 2008, the target for these indicators is a hopelessly impossible 95% by 2010.

Concerns about the sluggish pattern of behaviour change encouraged the World Health Organisation (WHO) to add male circumcision to its list of approved preventative measures. Research shows that the risk of infection is reduced by 60% for circumcised men. This makes no difference to the risks for women and great efforts are going into the development of HIV-resistant microbicide gels.

Questions arise as to whether national strategies pay sufficient attention to the evidence about new infections. This is particularly so in those Asian countries where the epidemic is “concentrated” within high risk groups. Many governments find it politically unappealing to direct prevention funding into these communities.

In sub-Saharan Africa where the epidemic has become “generalised” amongst heterosexuals, it is possible that a very different form of denial is at play. The preferred behavioural code is the ABC concept of Abstinence, Be faithful and use Condoms, each principle having priority over the next but not to an unrealistic extent. Many argue that this sidesteps the deeper cause which is cultural tolerance of multiple and concurrent partners for men.
Treatment

On average a patient with the HIV virus can live a normal life for 10-11 years without treatment. A cocktail of drugs known as antiretroviral therapy (ART) should commence when the strength of the immune system (measured by the CD4 count) falls to a defined threshold.

The virus is not removed by ART but the risk of onset of Acquired Immune Deficiency Syndrome (marked by one of a range of serious illnesses associated with immune deficiency) is reduced by about 80%, giving the prospect of a reasonably normal lifespan.

That is the position for people living with HIV in developed countries. In poorer countries, successful treatment faces a range of obstacles.

The patient may be amongst the 60% of those living with HIV who are unaware of their infection, there may be no available test for the CD4 count, there may be no government funds to pay for the treatment, and health workers may lack skills to prescribe and monitor antiretrovirals.

Circumstantial setbacks can be triggered by the complexities of tuberculosis, often dormant but liable to be activated by HIV. Poverty and malnutrition conspire against the discipline of lifelong uninterrupted observance of the prescription. Retention rate figures for 2009 show that 18% of patients in poor countries discontinue treatment within a single year.

Annie Kaseketi Mwaba, an HIV positive pastor in Zambia © Centre for Development and Population Activities

By the end of 2009, only 36% of those in need were receiving antiretroviral treatment - far behind the dream of universal access. This figure would have been 52% but for a decision by the World Health Organization to recommend that treatment should commence at a CD4 threshold of 350 rather than 200. This triggered an instant increase of those in need from 10.1 million to 14.6 million.

Progress has nonetheless been significant. The number receiving ART has increased by a factor of twelve in just six years. In 2009 alone, treatment numbers in sub-Saharan Africa increased from three to four million patients.

As treatment histories lengthen, researchers are excited to discover that the risk of passing on the virus is greatly diminished. Antiretrovirals could potentially play a role in future prevention strategies.
Pressures on AIDS Funding

There are already signs that the global economic recession will disrupt government budgets and donor resources for AIDS funding. In October 2010 the Global Fund appealed for a new round of three-year funding within the range of $13-$20 billion. International donors limited their commitments to $11.7 billion.

Nairobi Clinic © The Global Gag Rule Impact Project

President Obama has made ambitious budget proposals for his Global Health Initiative of which PEPFAR is part. But there are concerns that the strengthened Republican influence in Congress will have very different ideas about spending.

Adverse pressures also exist within the aid community. The announcement of a $40 billion initiative for maternal health at the 2010 MDG Summit was conveyed with a sense of urgency reminiscent of high level AIDS gatherings of a decade ago. Some MDGs are even further behind than the HIV and AIDS Goal and demand greater shares of funding.

Performance of AIDS programmes is always very sensitive to the price of antiretroviral drugs. Developing countries cannot afford the cost of drugs manufactured by major pharmaceutical corporations and instead purchase generics, usually made in India.

The complex interplay between corporations protecting their patents and the World Trade Organization rules which govern access to low cost generics is a constant source of anxiety for AIDS budgets. In 2009 low income countries paid an annual average of $137 per capita for ART prescriptions.

Future expenditure on ART will also be shaped by its inherent exponential trajectory. Growth will be driven not just by progress towards universal access but also by necessity to prescribe drugs throughout lifetimes of lengthening duration.

There will never be an appropriate time to cut global expenditure on antiretrovirals. Patients can develop resistance to the drugs if unable to sustain 95% adherence to the prescription. The consequence is even more expensive second line treatments.
Strategy Revision

Agencies responsible for raising funds for the global response to HIV and AIDS are overturning some of their long-cherished positions.

The most recent plans published by PEPFAR and the Global Fund acknowledge that the narrow "vertical" world of AIDS-related intervention must shift towards "horizontal" development support for general public health facilities.

Instead of observing that other MDGs cannot progress without first bringing HIV-related sickness and deaths under control, fundraisers now express greater enthusiasm for coordinating with crucial MDG agendas such as food security and maternal mortality.

There is a drive towards more efficient use of funds through attention to overheads and losses through corruption. Programmes are exploring the potential of “task-shifting” – the allocation of tasks to lower levels of health workers.

An inevitable consequence of tighter resources within the donor community will be requests that developing countries should meet a greater share of costs from their national budgets.