Millennium Development Goals and HIV/AIDS

According to the 2007 AIDS epidemic update published by the Joint UN Programme on HIV/AIDS (UNAIDS), 2.5 million people were newly infected with HIV during that year. Despite the wide range of potential error conceded in the report, there is consensus that the global rate of infection has fallen from a peak in the late 1990s and that the crisis may be levelling off in the most seriously affected region of sub-Saharan Africa.

AIDS clinic, South Africa © Daily Mail & Guardian

Beneath such optimism lies a host of uncertainties, not least that the rate of infection, known as incidence, is just one of a bewildering range of indicators that have been adopted to assess progress in the fight against HIV/AIDS. The original framework for the Millennium Development Goals (MDGs) focused on the reduction of prevalence as the measure for the target (in Goal 6) "to halt and begin to reverse the spread of HIV/AIDS" by 2015. Prevalence refers to the percentage of people aged 15-49 living with HIV/AIDS; for example, in 2007 there were 33.2 million people living with HIV/AIDS, 95% in developing countries, implying global prevalence of 0.5%. However, modern drug therapy, for those fortunate to receive it, extends life expectancy without removing the presence of the virus, an outcome which increases prevalence and suggests negative progress.

In the event, the inadequate wording of the MDG and its flawed benchmark were swiftly overwhelmed by new political resolve in response to civil society activists who argued that failure to combat HIV/AIDS would undermine the entire MDG programme. The Declaration of Commitment on HIV/AIDS signed at a UN General Assembly Special Session in 2001 related targets to individual rights rather than populations, for example acknowledging the right of all young people to have access to information necessary to reduce their vulnerability to HIV infection. By the time of the Edinburgh G8 summit in 2005, this principle was extended to the provision of treatment for those already infected, so that a UN Political Declaration approved in 2006 committed world leaders to work "towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010".

The official UN MDG framework has now been supplemented by a new AIDS target for universal treatment by 2010 but, in the context of HIV/AIDS, the MDG agenda has had minimal impact. The UN High Level meeting on HIV/AIDS due in June 2008 has been called to review progress against the Declaration of Commitment rather than the MDGs.

Funding HIV/AIDS

Such dramatic scaling up of targets, together with a tight deadline, requires unprecedented financial commitments from the international community. Spending on HIV/AIDS in developing countries has indeed increased exponentially, rising from $260 million in 1996 to over $10 billion in 2007, with funds sourced primarily from governments, international development agencies and philanthropists. The largest single source is the US government which appears likely to approve funding of $30 billion over 5 years from 2008 through renewal of the President's Emergency Plan for AIDS Relief (PEPFAR). About 25% of all global AIDS projects are granted by the Global Fund to Fight AIDS Tuberculosis and Malaria, established in 2002 to "attract and disburse additional funds".

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

UNAIDS says that annual spending needs to quadruple the 2007 figure to $42 billion by 2010. Considering that the entire 2006 foreign aid budget for sub-Saharan Africa was less than $40 billion, it is clear that the AIDS lobby aspires to a generous slice of the funding cake. Other human development sectors sometimes suggest that the AIDS priority has been overdone, comparing the 2 million annual deaths caused by AIDS with 10 million through hunger, 5 million due to unsafe water and 3 million stillborn babies. There have even been accusations that AIDS agencies inflate estimates of the number of people living with HIV/AIDS in order to attract funding. There are indeed significant difficulties in data collection; the most recent UNAIDS report absorbed new lower prevalence figures from India and other countries where statistical analysis has been improved and the agency has agreed to review its financial needs estimates.
Impact of HIV/AIDS

The reason why HIV/AIDS has attracted generous funding is that 90% of its victims are carried off in the prime of life, ripping the heart out of a country's social and economic fabric. Life expectancy, one of the three core measures determining the UN Human Development Index, has fallen dramatically in many African countries; women in Zimbabwe and Zambia are more likely to die before rather than after their 40th birthday. The loss of teachers, health workers and even MPs in sub-Saharan Africa has disrupted the functioning of public life and undermined poverty reduction plans. Donor agencies have been responding to an emergency as much as development.

Nafsiah Mboi, Secretary of the National AIDS Commission in Indonesia © Centre for Development and Population Activities

The less emotional analysis of commerce conveys an equal message of urgency. The World Bank has estimated that HIV/AIDS prevalence of 8% knocks 1% off a country's rate of economic growth. 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 HIV/AIDS services for staff and local communities.

Whilst sub-Saharan Africa attracts headline stories about the impact of HIV/AIDS, the latent threat of HIV in many other regions of the world is of no less concern. There are many countries where low prevalence disguises a rising rate of infection, the reverse of the position in Africa. New infections in Eastern Europe and Central Asia increased 150% over the period 2001-2007, mostly in Russia and Ukraine. In Southeast Asia, prevalence is increasing in Vietnam and in particular in Indonesia. UNAIDS attributes these trends to the combined influence of sex workers and injecting drug users, aggravated by increasing mobility of labour and leisure.
Women and HIV/AIDS

HIV positive mothers need treatment for themselves and their families © United Nations' Integrated Regional Information Network

A distressing characteristic of the impact of HIV/AIDS has been its cruel exploitation of the unequal gender relations and the threat of domestic violence that exist in many developing countries. The virus has no sympathy for the weak position of young women to negotiate safe sex or no sex. Married women are exposed to the infidelities of their husbands, especially those whose work takes them away from home. 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 sub-Saharan Africa, 75% of people living with HIV/AIDS are women. This profile and its underlying causes have galvanised the efforts of international women's groups and strengthened the call for HIV programmes to integrate with broader reproductive health services. 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. And US PEPFAR funding still carries some conditions imposed by religious conservatives which bias its prevention programmes towards abstinence rather than safe sex. Apart from naivety, the flaw in these impositions is the presumption that the balanced gender relations found in the West are replicated in poor countries.
Children and HIV/AIDS

Schoolchildren bury a friend in Zambia © United Nations Children's Fund

Children living with HIV/AIDS are the most heartbreakingly innocent victims in that almost all were infected during pregnancy, birth or through breastfeeding - over 400,000 new infections occurred in 2007, mostly in sub-Saharan Africa. The science of paediatric treatment lags that for adults; only about 10% of infected children receive proper treatment and one sixth of all AIDS deaths are children under age 15.

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% and this is the position for the majority of babies born to mothers with HIV in the highest risk countries. Although increasing efforts are made to provide at least some treatment, many mothers are faced with impossibly difficult choices between the risk of breastfeeding and the presence of contaminated water in milk substitutes.

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

There is perhaps greater public awareness of the problems of the 12 million children in sub-Saharan Africa who have escaped HIV but who have lost one or both parents. Although cultural traditions often support the security to be found in extended families or foster parenting, there are natural limits to the capacity of communities devastated by AIDS. For example, in Zambia it is estimated that one third of all children will be orphans by 2010.
Human Rights and HIV/AIDS

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. Association of these groups with HIV has aggravated the prejudice that they

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

already experience in both rich and poor countries alike so that access to HIV/AIDS prevention and treatment services has been very low. Quite apart from leaving the disease unchecked, such an approach offends principles of human rights. 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/AIDS commitments and AIDS activists themselves have been harassed in countries such as China. 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".
Prevention of HIV/AIDS

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

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. Despite prevention services absorbing 50% of HIV/AIDS spending, in 2006 only 50% of young people in developing countries were assessed to have sufficient knowledge to take control of the risks. Achieving universal awareness is a formidable and expensive task although the challenge of communicating effectively to young people in schools and in local communities has provoked endless creativity, with new technologies playing a part where possible.

Advocacy of behaviour change must tackle the strong bonds that exist within local custom, gender relations, the stigma of AIDS and the realities of poverty. Although intervention can only be effective through local community groups, there has been broad application of the ABC concept of Abstinence, Be faithful and use Condoms, each principle having priority over the next but not to an unrealistic extent. Concerns about unavailability or failure to use condoms are such that the World Health Organisation (WHO) has added male circumcision to its list of approved preventative measures, following research showing that the risk of infection was reduced by 60% for circumcised men. For similar reasons great efforts are going into the development of HIV-resistant microbicide gels which would restore a degree of control to women.

Early successes in HIV prevention have been attributed to Thailand, Uganda and Senegal - and more recently in Rwanda and Burkina Faso - with a common feature of determined political leadership at the highest level. By contrast, public doubts expressed by President Mbeki concerning the link between HIV and AIDS denied the natural opportunity for South Africa to display regional leadership and to tackle its status as home to the world's largest number of people living with HIV/AIDS.
Treatment of HIV/AIDS

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 immune system has weakened to a measurable threshold. The virus is not eliminated by ART but the risk of onset of Acquired Immune Deficiency Syndrome (marked by the establishment of one of a range of serious illnesses associated with immune deficiency) is reduced by about 80% giving the prospect of a reasonably normal lifespan. In about 10% of patients the treatment fails, and an alternative "2nd line" therapy is substituted.

Such is the position for people living with HIV in rich countries. In poor countries circumstances often conspire against the progress of modern medicine. The patient may be unaware that he or she is HIV positive, or there may be no available test for the ART threshold, or there may be no government funds to pay for the treatment. Other obstacles include the complexities of tuberculosis, often dormant in people living with HIV but liable to be activated by the virus. For those receiving ART drop-out rates of between 46% and 85% in Africa after just 2 years betray the shortage of skills for prescribing and monitoring antiretroviral treatment.

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

By the end of 2006, only 2 million people were receiving treatment in developing countries out of 7.1 million in need. Some estimates suggest that 14 million will be in need by 2010, the target date for universal treatment. Prospects are much dependent on the price of drugs which is a constant source of tension between the humanitarian concern to save lives and the profit motive of multinational pharmaceutical companies armed with 20 year patent protection. Although World Trade Organisation (WTO) rules permit the least developed countries (LDCs) to acquire or manufacture low cost generics until 2016, middle income countries such as India, Thailand and Brazil depend on less concrete concessions in WTO rules for health emergencies.

There are concerns that the current fashion for regional and bilateral Free Trade Agreements will close down these concessionary clauses, preventing the development of generics for prohibitively expensive 2nd line ART drugs. These painful lessons about equitable distribution of drugs may prove invaluable if the daunting problems associated with finding a vaccine for HIV are eventually overcome.
Towards Universal Access

Achievement of the promises for 2010 will require a fundamental revision in the priorities of AIDS donors whose reports betray a narrow "vertical" world of AIDS-related intervention. The Global Fund boasts of providing drug treatment to 1.6 million and HIV tests to 52 million beneficiaries but, however admirable these figures, they tell little of the progress towards universal access. It is exclusion that should feature in reports - such as the estimated 80% of people living with HIV/AIDS in low and middle income countries who are not even aware of their condition.

Nairobi Clinic © The Global Gag Rule Impact Project

This conceptual adjustment would illuminate the practical reality that universal access to HIV/AIDS services cannot be ring-fenced from other health issues. For example, uptake of voluntary counselling and testing (VCT) might improve if integrated with less sensitive clinic services. More important still is the need for sufficient numbers of qualified health workers and adequate facilities. The most recent plans published by PEPFAR and the Global Fund do reflect this shift away from a sense of emergency towards "horizontal" development support for general public health facilities. Strengthening the infrastructure in which other development sectors operate would reconnect HIV/AIDS with the broader MDG and development agendas.

Help us to complete OneWorld Guides
Many important development issues are missing from our range of Guides. OneWorld wants to fill these gaps as part of our efforts to improve understanding of the issues faced by developing countries. We receive no funding for the production of our educational resources. Every small contribution helps!