3 The Political Economy of the Global AIDS Response

Question 1

Overview Summary

Answer 1

Welcome to session 3. This session explores the synergy between politics and science in the context of the HIV epidemic. This includes an introduction and overview of past, current, and future responses to HIV at multiple levels (local, national, international), key players and issues, and the importance of political leadership and resources.

Question 2

Overview Aims

Answer 2

The aim of this section is to provide students with an overview and understanding of the complex political economy of the global HIV response.

Question 3

Overview Learning outcomes

Answer 3

By the end of this session you should be able to: Understand the historical synergy between science and politics in the context of HIV/AIDS; Examine how different international declarations and treaties have shaped the course of the epidemic in specific settings and worldwide; Identify key political players, issues and concerns involved in the global response to HIV; Analyse the complexities inherent in both the provision of and access to HIV prevention, care, and treatment services, and understand ways to address these challenges; and Explain the role that activists played in the struggle for universal access to antiretroviral treatment, and their role in deriving global benefits from local actions.

Question 4

Key terms AIDS activism:

Answer 4

Communication and behaviours intended to serve individual (self-advocacy) and common (social activism) interests in relation to the rights of those affected by HIV and AIDS (Brashers 2000)

Question 5

Key terms HIV treatment (antiretroviral medicines/ antiretrovirals (ARVs)/ antiretroviral therapy (ART):

Answer 5

‘Since the discovery of AIDS in 1981 and its cause, the HIV retrovirus, in 1983, dozens of new antiretroviral medicines to treat HIV have been developed. Different classes of antiretroviral medicines work against HIV in different ways and when combined are much more effective at controlling the virus and less likely to promote drug-resistance than when given singly. Combination treatment with at least three different antiretroviral medicines is now standard treatment for all people newly diagnosed with HIV. Combination antiretroviral therapy stops HIV from multiplying and can eradicate the virus from the blood. This allows a person’s immune system to recover, overcome infections and prevent the development of AIDS and other long-term effects of HIV infection’ (UNAIDS 2019a).

Question 6

Key terms Human immunodeficiency virus (HIV):

Answer 6

infects cells of the immune system, destroying or impairing their function. Infection with the virus results in progressive deterioration of the immune system, leading to “immune deficiency.” The immune system is considered deficient when it can no longer fulfil its role of fighting infection and disease. Infections associated with severe immunodeficiency are known as “opportunistic infections”, because they take advantage of a weakened immune system’ (WHO 2017).

Question 7

Key terms Acquired immunodeficiency syndrome (AIDS):

Answer 7

is a term which applies to the most advanced stages of HIV infection. It is defined by the occurrence of any of more than 20 opportunistic infections or HIV-related cancers (WHO 2017).

Question 8

Key terms Global public good:

Answer 8

This theory states that there are global benefits from positive public actions in another country or region (Piot 2011).

Question 9

Key terms Human security:

Answer 9

Emerging post-Cold War, this multidisciplinary concept favours a human-centred rather than state-centred vision of security (UNDP 1994).

Question 10

Key terms Political economy:

Answer 10

A broad theoretical framework that can help us better understand the many economic, political, and socio-historical forces which shape contemporary health problems, and our approaches to these problems (Minkler et al. 1994).

Question 11

1.1 The Global Prevalence of HIV/AIDS: Introduction

Answer 11

Great successes in the HIV response in many countries have inspired bold new global targets and commitments, including to end the AIDS epidemic as a public health threat by 2030 as part of the Sustainable Development Goals. Yet, with nearly 2 million people newly infected with HIV in 2018 and about 1 million AIDS-related deaths in the same year (UNAIDS 2019), the end of AIDS is by no means in sight. Amidst indications of diminishing funds and weakening global resolve, growing complacency could result in a resurgence of the epidemic, particularly in the context of the world’s largest-ever generation of young people. Tens of millions of people will need sustained access to HIV treatment for the decades to come. Remarkable efforts to scale up access to HIV treatment, reaching 23.3 million people in 2018 (UNAIDS 2019), must be matched by equivalent attention to scaling up primary HIV prevention (Bekker et al. 2018). Despite remarkable innovation in science, advocacy, and programmes, politics continues be a force that can drive, stifle, and even reverse great progress in the HIV response.

Question 12

1.1 The Global Prevalence of HIV/AIDS: Introduction

Answer 12

Political economy can be broadly defined as a theoretical framework that can help us better understand the many interactions between political, economic, and socio-historical forces and how they shape contemporary health problems, as well as our approaches to these problems (Minkler et al. 1994). Indeed, politics is at the very heart of global and public health: scientific evidence alone is very desirable, but insufficient for setting policy and changing practice, and politics can be dangerous if it rejects scientific evidence. Political economy analyses are therefore a critical tool for understanding the factors that impact and influence health policy, programmes, and practice.

Question 13

1.1 The Global Prevalence of HIV/AIDS: Introduction

Answer 13

The global HIV epidemic has always been inherently political, and the synergy between science and politics has affected HIV prevention, treatment, and care. Epidemiology, science, financing, and programmatic responses have rapidly changed in the past decades with shifting political climates and have affected today’s responses in different ways.

Question 14

1.1 The Global Prevalence of HIV/AIDS: Introduction

Answer 14

The introduction of ARVs added a new set of complexities in the 1990’s, including both pharmaceutical companies, as well as human rights activists in the struggle to provide universal treatment.

Question 15

1.1 The Global Prevalence of HIV/AIDS: Introduction

Answer 15

Different countries and organizations responded differently to the crisis, challenging the prevailing political and social status quo and resulting in widely different outcomes. Global (UN General Assembly Special Session, US PEPFAR) and regional (PANCAP, OAU/AU) political initiatives have had a major impact on the HIV epidemic, both on a global as well as a local scale.

Question 16

1.1 The Global Prevalence of HIV/AIDS: Introduction

Answer 16

Alongside political leadership, the epidemic also tracks closely with investments made in national HIV responses. Despite previous progress in increasing resources available for HIV over the past decades, investments in the HIV response are stagnating. A worrying decrease of US$900 million in funding for the HIV response in low and middle-income countries in just one year from 2017-2018 (UNAIDS 2019) highlights the scale of the problem and the challenges associated with sustaining the global HIV response over the long-term (UNAIDS 2019b). Resource shortages have prompted concerns about the future life-long treatment costs and the most cost-effective approaches to prevention and treatment services in the future. Additionally, human security issues have been raised in recent years, and were previously taken up by the UN Security Council in 2000, as the population of people living with HIV globally reached 37.9 million in 2018. The political challenges continue today, from the stigma attached to the nature of HIV transmission to the challenges faced by programs affected by governmental terms.

Question 17

1.2 Global Prevalence of HIV/AIDS over time

Answer 17

The HIV/AIDS disease epidemic took the world by surprise by spreading rapidly and affecting populations around the world. The figure below shows that in 1985, there were only a few countries in the world that had a serious HIV/AIDS problem. The disease was discovered in the US, but it was in central Africa that we had the first generalised epidemic but still at low levels.

Question 18

1.2 Global Prevalence of HIV/AIDS over time

Answer 18

As figure 2 shows, by 1995 most of Sub-Saharan Africa was already seriously affected. The virus had also spread in Southeast Asia, particularly Thailand partly due to the commercial sex industry and in general a growing epidemic everywhere.

Question 19

1.2 Global Prevalence of HIV/AIDS over time

Answer 19

10 years later in 2005, the virus had spread across the globe (see figure 3 below). Sub-Saharan Africa, particularly the southern and eastern part, was the most affected region but also with a growing epidemic in countries that were previously part of the Soviet Union.

Question 20

1.2 Global Prevalence of HIV/AIDS over time

Answer 20

As figure 4 shows below, in recent years we have seen remarkable successes in eastern and southern Africa. These countries are home to 54% of the world’s population of people living with HIV, with AIDS-related mortality declining by 44% from 2010 to 2018, and annual new HIV infections falling by 28% during the same period (UNAIDS 2019b). However, between those same years, HIV infections increased in the regions of eastern Europe and central Asia (29% increase) and the Middle East and North Africa (10% increase), and in Latin America (7%). In the time of antiretroviral treatment, AIDS-related deaths in Eastern Europe increased by 5% from 2010 to 2018, and by 9% in the Middle East and North Africa (UNAIDS 2019b).

Question 21

1.3 Milestones in the response to HIV/AIDS

Answer 21

The classic first response to the emergence of HIV/AIDS was denial, both from society in general and international organisations. From a global health policy perspective, this was also true for the most prominent international organisations involved in health in those days, the WHO, the United Nations Children’s Fund (UNICEF), and the World Bank to a degree. Dr Mahler, then Director General of the WHO, asked not to make AIDS a front-page issue concerned it would move attention from malaria and other diseases. Fortunately, in 1987, he changed his mind, stating in the General Assembly that HIV/AIDS was a problem and that WHO was committed to global HIV prevention.

Question 22

1.3 Milestones in the response to HIV/AIDS

Answer 22

Similarly, UNICEF was also in denial. Jim Grant of UNICEF refused to include a reference to AIDS in the 1989 Convention on the Rights of the Child. Later on, particularly with Carol Bellamy as Director, UNICEF became very active on HIV/AIDS. Figure 5 below shows the prevalence and numbers of people living with HIV and some milestones in the HIV response. In the beginning, there were a number of scientific breakthroughs. It took a few years to document that AIDS was caused by a virus, in light of the isolation of the virus and antibody tests becoming available, and the increased knowledge on transmission. Later on, there were fewer scientific breakthroughs and hardly any global response. Please reflect on the various events highlighted here.

Question 23

1.3 Milestones in the response to HIV/AIDS

Answer 23

A game-changer in the global response came from a technological breakthrough in July of 1996. That breakthrough was the discovery that treatment of AIDS was possible by using at least 3 different drugs, Antiretrovirals (ARVs). Azidothymidine (AZT) had been used as monotherapy, but it didn’t work because the virus rapidly develops resistance to the treatment. By administering three drugs the statistical probability that a virus will be resistant to all three is very low.

Question 24

1.3 Milestones in the response to HIV/AIDS

Answer 24

Almost immediately after this breakthrough, the treatment was available in high-income countries. It not only changed the lives of people living with HIV but it also changed the way we see this epidemic, which now was no longer considered a death sentence. However, since treatment was so expensive, it was not available to all, particularly those living in low and middle-income countries.

Question 25

2 The HIV/AIDS response in the global political context

Answer 25

Why is HIV/AIDS so political? Why is it more political than other health issues such as diarrhoea or diabetes? There are a few reasons: Sex and drugs: AIDS is associated with sex and drugs. Drugs are illegal in about every country and sex is always a difficult matter to discuss, especially related to same-sex sexual relations. New pandemic: It was a new and unexpected pandemic, affecting young adults in particular. Cost and impact: It was clear from the beginning that the human and economic costs are huge. The costs and impact in heavily affected countries can be enormous. Activism: In the HIV response we saw a new form of activism related to health. In the west, HIV/AIDS affected predominantly gay men, many of whom were well educated and managed to organise themselves to fight for their rights. This happened later on in countries like South Africa or Brazil.

Question 26

2.1 How do we conceptualise AIDS in the global political context?

Answer 26

Over time the way HIV/AIDS was conceptualised changed. Policy problems – and health issues more broadly - can be positioned in many different ways so as to suggest certain values and perceptions, and to inspire particular responses. Framing, in this context, refers to making some aspects of a perceived reality more salient than others to suggest a particular definition of a policy ‘problem’ and its causes, and a range of possible solutions (McCombs 2005). The list below describes the evolution in thinking and framing of AIDS. Therefore, there are many different aspects and lenses through which to address a problem. This is something we should always bear in mind when we approach a health problem and when we consider health policy.

Question 27

2.1 How do we conceptualise AIDS in the global political context? A biomedical and health problem:

Answer 27

In the beginning, scientists considered HIV/AIDS as a purely biomedical and scientific problem. HIV/AIDS was solely an infection with a virus and nothing more than that.

Question 28

2.1 How do we conceptualise AIDS in the global political context? Related to human rights:

Answer 28

Jonathan Mann was the first director of the World Health Organisation (WHO) programme on AIDS. He said that the HIV epidemic was due to a gross violation of human rights. He explained this by pointing to the fact that the most affected people are those in the poorest countries in the world, the most vulnerable groups that suffer from stigma and discrimination.

Question 29

2.1 How do we conceptualise AIDS in the global political context? A development/human security issue:

Answer 29

Following this, we observed over time a shift in how we look at development, social and economic development, and what security means. The concept of human security was developed in response to the HIV epidemic, driven in particular by the United Nations Development Programme (UNDP) and Japan. They stated that security is more than the absence of war and conflict; it is also about the development of individuals, opportunities, and equality. In this sense, HIV/AIDS was defined as a risk and obstacle to development, due to its social and economic costs.

Question 30

2.1 How do we conceptualise AIDS in the global political context? Related to state security:

Answer 30

Finally, in the late 90s and early 2000s, particularly in the US at the National Intelligence Council and the Centre for Strategic and International Studies, AIDS was redefined as affecting state security. This would be the case, for example, if military troops faced high rates of new HIV infections which could make them less combat ready. Similarly, it was debated that international peacekeeping troops from all over the world may come from countries with a high HIV prevalence, travel to one with low HIV rates and transmit HIV, as we observed in Cambodia in the 80s and 90s, or the other way around.

Question 31

2.2 HIV/AIDS as a Global Public Good

Answer 31

Why should country A deal with an epidemic in country B, 5000km away from here? There is a theoretical reason why the international community should deal with an issue like AIDS. The theory of Global Public Goods states that there are global benefits from actions conducted somewhere else (Piot 2011), which is certainly the case for contagious diseases. For example, if an epidemic such as influenza is contained thousands of kilometres away it will benefit the whole world since there will be less people infected. There are global benefits from local actions. We also have a network of organisations that are operating across borders. These international networks include international organisations and civil society. Typically, the international organisation that most closely works across national borders to address AIDS is the UN, and UNAIDS in particular, but civil society organisations are also important actors. In addition, some foundations are global players with important impact such as the Bill and Melinda Gates Foundation, the Wellcome Trust, and others. Moreover, we must also consider the role of the pharmaceutical industry in developing and selling HIV treatment. These are all elements of the global dimension of dealing with HIV/AIDS.

Question 32

3.1 Leadership on HIV/AIDS: Brazil prioritising HIV treatment

Answer 32

From the early days of the epidemic, political leadership made an enormous difference. Brazil was the first country among low- and middle-income countries to offer HIV treatment to its citizens free of charge. Only months after the announcement that antiretroviral therapy was effective, Brazil began providing treatment. President Cardoso was a crucial actor that made this possible. In the midst of an economic and financial crisis and during a time when the IMF which was pushing for savings by cutting social programs including ARV treatment; President Cardoso declined to do so and announced treatment as a priority for the country. Brazil also has a very progressive constitution which came out after years of military dictatorship, which includes a clause on the right to health and health care. This means health care is enforceable in court. Another reason for Brazil’s response is the vibrant civil society in the country, originally focused on gay activism, and later other forms of activism, fighting for the rights of people living with HIV and for government subsidies and support of treatment.

Question 33

3.2 Leadership on HIV/AIDS: The role of Uganda

Answer 33

President Museveni in Uganda and President Diouf in Senegal were the first African leaders that recognised AIDS as a problem. The way Museveni tells the story he, being a guerrillero himself, sent soldiers to Fidel Castro in Cuba for training. At the time, Fidel informed him that half of these soldiers were diagnosed with HIV and urged him to do something to address the problem. Another phenomenon happening in Uganda was the creation of The AIDS Support Organisation (TASO). Founded in 1987 by Noerine Kaleeba, it began as a group of 16 colleagues to provide support for people and communities affected by HIV/AIDS, either people living with HIV or their loved ones such as spouses or family members, originally a self-help group. TASO quickly developed into a community support group, and today has grown into one of the largest NGOs in the world, reaching hundreds of thousands of people. Uganda shows the importance of two things: leadership at the top and Musevini’s ‘top down’ approach, and community leadership and the ‘bottom-up’ approach - when these two come together enormous progress can be made.

Question 34

3.3 Leadership on HIV/AIDS: The South African case

Answer 34

A country with an extremely complex approach to HIV/AIDS was South Africa. On the one hand, it was the country with the largest number of people living with HIV, with well over 5 million people affected. On the other hand, President Mbeki did not recognise AIDS as a genuine disease and, as a result, the government response to AIDS was limited. But there was an enormous response from the community, with millions of people affected by HIV becoming a political force. The Treatment Action Campaign, TAC, campaigned for access to treatment, prevention of mother-to-child transmission and access to condoms and information. The TAC was formed by a coalition of people who don’t necessarily agree on everything. It included the Anglican Church, the Communist Party, the Chamber of Mines, COSATU, the confederation of trade unions, a UN organisation, UNAIDS, MSF and scientists. Together they formed a solid and very influential coalition that was trying to convince the government to invest in the lives of its citizens living with HIV. In South Africa, TAC had a very smart strategy, combining classic street demonstrations, street action and civil disobedience with legal action. Activists were suing the South African government where health is also recognised as a right in the constitution, similar to Brazil.

Question 35

3.4 Leadership on HIV/AIDS: Raising awareness

Answer 35

Today we have made enormous progress in the fight against HIV/AIDS, but it didn’t happen by accident. Some countries had important civil society movements and good leadership but in order to develop a worldwide movement much more was needed. UNAIDS, through its director at the time Professor Peter Piot, developed a strategy to bring AIDS to the forefront of public opinion, and one major ally that needed to be on board was the media. When HIV/AIDS was a front-page issue in the New York Times for the first time, showing figures that would otherwise often only interest an epidemiologist, it was clear something was changing. However, in today’s world there’s more than newspapers and television. In order to reach people, it was crucial to use their media, such as Facebook, Twitter, or, as occurred at the time, MTV.

Question 36

3.4 Leadership on HIV/AIDS: Raising awareness

Answer 36

MTV reached about 800 million young people at its peak, and UNAIDS developed a partnership with MTV called ‘staying-alive’, which resulted in the Staying Alive Foundation later on. This was bringing very open messages about HIV, how to protect yourself, condom promotion, things that were not very popular in the regular media, but that reached a young public that would not have been reached by regular media outlets. Today, the MTV Staying Alive Foundation’s award-winning drama series called MTV Shuga is designed to help millions of young viewers in French and English-speaking Africa protect themselves from HIV. With its broad reach and popular appeal across Africa, the ‘edutainment’ show embeds sexual health messages in their storying lines and has the potential to stimulate awareness of and demand for HIV prevention and treatment services.

Question 37

4. Setting a global agenda

Answer 37

International summits, both global and regional, made a big difference in the HIV response. A breakthrough occurred in 2000 during the first meeting of the UN Security Council that addressed HIV/AIDS. This was an enormous opportunity as it was the first time the Security Council discussed a non-traditional security item, a social or health issue.

Question 38

4. Setting a global agenda

Answer 38

Chaired by Vice-president Al Gore, whose job it was to set the agenda, and then Secretary General Kofi Annan, they proposed discussions on security in Africa and the first meeting was on HIV/AIDS in Africa. This was also important because the Security Council is the only body in the UN whose decisions are, in theory, legally binding. At the time, it was said that HIV/AIDS was a threat to human security, and also that the UN must act to avoid the spread of HIV amongst peacekeepers and the populations in the countries they were working in. This is a critical example of out of the box thinking, bringing a health issue to a body that deals with serious security issues.

Question 39

4. Setting a global agenda Regions working together

Answer 39

The first regional meeting took place in 2001 in Barbados. Here all the members of the Caribbean community represented by their prime ministers, signed off on the launch of so-called PanCAP, the Pan Caribbean Partnership in Aids Programme. PanCAP brings together the resources, political power and the community power of Caribbean countries in the fight against HIV/AIDS. Since many of the islands are very small, they don’t have the capacity to deal with an issue alone. However, when they collaborate together, they can really have an impact on world politics. Importantly, these Caribbean countries pushed for a UN high level session on non-communicable diseases that was held in September 2011. A few months later, the African countries did the same at a special summit, and this was even more important globally since Sub-Saharan Africa was the worst affected region and its political leaders were largely in great denial about HIV/AIDS. This in turn paved the way for what we can see retrospectively as the tipping point in the global response to HIV. Another important event was the UN General Assembly in 2001. A special session on HIV/AIDS was organised where all countries of the world came together and, after 3-day meeting, agreed on a declaration of commitment on HIV/AIDS. This was a turning point because it put AIDS onto the world’s top agenda and there was agreement on a way forward.

Question 40

4.1 International declarations addressing HIV/AIDS

Answer 40

HIV/AIDS has become a truly global issue over time and due to its political nature, there have been many political declarations. The list below shows some of the most important declarations related to HIV/AIDS. UN General Assembly, 1987 (the earliest declaration).; Denver Declaration on rights, 1987: This was an important declaration made by people living with HIV who petitioned not be treated as patients, but as part of the solution, and wanted to be at the table when HIV/AIDS programs are discussed.; London Inter-ministerial Declaration, 1987; Paris Declaration, 1994; and Millennium Declaration, 2000: The Millennium Declaration in 2000 was endorsed by all the member states of the UN. This declaration included the Millennium Development Goals (MDGs), which attempted to address a number of development issues such as poverty, malnutrition, equal rights and maternal mortality by 2015. AIDS was included in MDG 6, illustrating the significance of HIV/AIDS, less than 20 years after its discovery.

Question 41

4.1 International declarations addressing HIV/AIDS

Answer 41

We can also see declarations specifically dealing with HIV/AIDS: Abuja Declaration of the OAU, 2001: Convened by President Obasanjo of Nigeria, the African Union (then the Organisation of African Unity) was the first time the silence was broken and commitments were made in Africa regarding AIDS.; Declaration of Commitment UNGASS, 2001: Importantly, the UN General assembly had a special session which resulted in a declaration of commitments, a roadmap of what to do with HIV/AIDS.; G8 communiqués 2001/5/7/8: The G8, comprised by the 8 richest countries in the world, also had several communiqués on HIV/AIDS, one of these the G8 communiques 2001/5/7/8.; The 2030 Agenda for Sustainable Development: Member states committed to end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases by 2030.; and The 2016 United Nations Political Declaration on HIV and AIDS: On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030. Member states agreed to urgent action to accelerate efforts toward ending the AIDS epidemic by 2030. It provides a global mandate to fast-track the AIDS response ahead of 2020. Over time, we’ve seen the emergence of many declarations on HIV/AIDS, most of which have not had significant effects. The list above are the most important declarations on HIV/AIDS.

Question 42

Activity 1 Considering the close relationship between HIV prevention, universal ARV treatment, politics and human rights, draft a plan for a local campaign focusing on these elements. How would a global campaign run by an international organization differ from this local initiative?

Answer 42

Write around 500 words on this and post your answer on the discussion board. Respond to two other student’s answers.

Question 43

5. Funding the response to HIV/AIDS

Answer 43

With a growing momentum of recognising that HIV/AIDS is a threat to the lives and the security of people and development of the worst affected countries, there were still no resources available to address the problem. The biggest obstacles were from donor countries and donor agencies. There was an initial resistance to confront HIV/AIDS due to the high costs. In addition, nearly all donors were concerned that they would need to cover the long-term costs of treatment. Therefore, there was enormous resistance to fund this lifesaving treatment, with the exception of France and Luxembourg. Furthermore, there was lack of coordination among the various donors, which is a problem that occurs with other development issues. Donors would attach conditionalities to the money they gave, some of which were very detrimental for the AIDS efforts.

Question 44

5.1 High costs, low funds

Answer 44

One of the biggest obstacles to the HIV response was the high cost of treatment. When ARVs became available, it cost around US$ 12,000 per person per year for treatment. It was also too expensive for governments and states to finance so bringing that price down was a priority for the HIV/AIDS movement. As you can see in figure 6, the price of ARV therapy in Uganda decreased from more than US$10,000 in 1998 to less than US$100 5 years later. This was the result of a complex interplay between negotiations with pharmaceutical companies and of pressure on politicians.

Question 45

5.1 High costs, low funds

Answer 45

Another phenomenon happened around the year 2000 and that is that Indian pharmaceutical producers improved their manufacturing procedures and began selling these in the global market, which led to a decrease in prices. An important element was also that the World Trade Organisation (WTO) changed its policies on TRIPS, trade-related intellectual property rights. Up to then these were an obstacle to selling ARVs in 3rd countries such as those in sub-Saharan Africa. Importantly, it was the combined action of the leadership of the United Nations led by Kofi Annan and UNAIDS that really led all the negotiations. During this time, we saw increasing political commitment and a decrease in the price of drugs. However, what was needed now was a way to finance the treatment. As figure 7 shows, there was a very slow increase in the resources available for HIV/AIDS until about 2001. The tipping point in 2001 was due to political mobilisation the existence of treatment, and the reduction in the price of treatment. However, we also needed special mechanisms to disperse that money.

Question 46

5.1 High costs, low funds

Answer 46

As a result, two mechanisms were established: The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). The Global Fund was a multilateral body created in 2002 to address AIDS, Tuberculosis (TB) and Malaria. TB and Malaria have been around for centuries but have previously never benefitted from this scale of funding and attention, and, for the first time, thanks in large part to resources earmarked for HIV/AIDS, there was an increase in available resources for TB and malaria, still not enough but a major increase. What is unique about the Global Fund is that the funding proposals come from recipient countries. A classic donor will impose far more of what it wants to do with its money but, in this case, the requests are driven by low and middle-income countries themselves.

Question 47

5.1 High costs, low funds

Answer 47

The second mechanism, PEPFAR, was established in 2003 in the USA when then President Bush asked the congress for US$ 15 billion for AIDS, primarily for Africa. The USA became the largest funder of the Global Fund as well as the largest funder of AIDS programs across the world. This gave rise to a program known as PEPFAR, which the subsequent US Presidents have continued to fund. HIV/AIDS was one of the few issues on which politicians in the USA from both sides of the political spectrum could agree on.

Question 48

Activity 2 Heterosexual transmission is uncommon outside of Africa - true or false

Answer 48

False) HIV is spread through heterosexual transmission in many settings. For example, in locations where HIV incidence is high among adolescent girls and young women, HIV is primarily spread through heterosexual transmission.

Question 49

ARVs significantly enhance the quality of life of HIV positive people - true or false

Answer 49

True)

Question 50

HIV prevention is not working - true or false

Answer 50

False) Combination prevention programs are leading to fewer new HIV infections in many countries and are part of the reason why mother-to-child transmission as substantially decreased.

Question 51

Investments in HIV are made to the detriment of local health systems - true or false

Answer 51

False) Funds for AIDS are strengthening health systems. The Global Fund and PEPFAR, for example, have funds earmarked specifically for supporting human resources, infrastructure and monitoring and evaluation.

Question 52

Mother-to-child transmission can be effectively prevented - true or false

Answer 52

True)

Question 53

6 Challenges in the HIV/AIDS response

Answer 53

Good progress was being made the beginning of 2000, financing mechanisms were in place, there was good political commitment, the price of drugs was declining, but some problems remained.

Question 54

6.1 Poor leadership

Answer 54

One of these was denial of the importance of the disease in two large countries, China and Russia. When you try to put something on the political agenda, for example a health issue, you need to think very carefully about what to do that in the context; the cultural, historic and political context of that specific country.

Question 55

6.1 Poor leadership

Answer 55

China had HIV epidemics among people who use drugs in certain parts of the country, heterosexual HIV transmission, growing HIV transmission through same-sex sexual relations, and, in a few provinces, such as the Hunan Province in central China, a major problem with HIV infection through illegal blood transfusions. After many years, a breakthrough was reached when Professor Piot gave a speech to the Central Party School of the Communist Party of China. He spoke about HIV/AIDS, human rights issues, discrimination and the need for Chinese society to tackle this problem. Following this, China adopted, under the leadership of Prime Minster Wen Jiabao, a very progressive HIV/AIDS policy, including providing syringes and needles to people who use drugs and developing methadone substitution therapy programs.

Question 56

6.1 Poor leadership

Answer 56

This was something that turned out to be impossible in Russia. Russia has the fastest growing HIV epidemic in the world, driven primarily by injecting drug use and heterosexual transmission. The government has still not allowed methadone substitution therapy for people who use drugs and needle and syringe exchange programs are only tolerated in a few cities.

Question 57

6.1 Poor leadership

Answer 57

Whereas China is an example where, after long hesitation, the authorities really showed great leadership and developed policies; in Russia, such progress was not possible. Advances in Russia are still blocked mainly due to discrimination against the most affected populations and a context of severe homophobia. This was combined with public authorities with a tradition of repression and a police approach to health problems, rather than a public health approach.

Question 58

6.1 Poor leadership

Answer 58

Another country that had a difficult path was South Africa. Under the influence of so-called denialists, particularly from California, President Mbeki started doubting that HIV even existed. This led to the tragic deaths of hundreds of thousands of South Africans because of the delay of introducing ARV therapy in the country. As we saw earlier, it was only through the combined action of civil society, action groups, businesses, churches and the trade unions that the government changed its position. Mbeki’s minister of health, Dr Manto Tshabalala-Msimang, even went so far as promoting vegetables as treatment for HIV.

Question 59

6.1 Poor leadership

Answer 59

This shows that where political leadership can save lives but a lack of leadership or the wrong leadership can kill people. Wherever we have seen progress against HIV/AIDS it has been because of good leadership, wherever we have seen a retrograde response it was because of bad leadership.

Question 60

6.2 Donor coordination and sufficient resources

Answer 60

Another problem is the multitude of actors dealing with HIV/AIDS. On the one hand, this is good news, the more people dealing with an issue, the more we have a critical mass and are more likely to generate good ideas. However, it can get out of control and make it difficult for the governments in low- and middle- income countries to coordinate the different actors leading to poor efficiency and effectiveness of foreign international aid. This is something that is being addressed in several conferences, particularly organised by the OECD, with the Committee on Development Assistance, but it is something that requires a far more resolute and determined approach by the government of the low- and middle- income countries themselves.

Question 61

6.2 Donor coordination and sufficient resources

Answer 61

Alongside a coordination challenge, we are also facing a funding gap in the global HIV response. The majority of people newly infected with HIV live in poorer countries, with around two thirds of new infections occurring in sub-Saharan Africa, where resources available for HIV are stagnating. Increasing donor funding for the HIV response is critical. However, at the same time, many low and middle-income countries are increasingly dedicating greater domestic resources to their HIV/AIDS programmes (UNAIDS 2019b). While this is indeed a positive step forward for sustainable financing and programming of national AIDS responses, as donors manage transitions of health programmes to low- and middle-income countries, there is also a risk of diminished funding for key populations that are particularly vulnerable to HIV. Looking ahead, attention is needed on ensuring effective and equitable country transition plans (Bekker et al. 2019).

Question 62

6.3 Achieving results

Answer 62

All the policy and political developments discussed have now resulted in achievements, primarily saving human lives. Over time the number of people receiving HIV treatment has tremendously increased since the beginning of the century. However, it took nearly 10 years before 1 million Africans had access to antiretroviral therapy, 10 years after Europeans, Americans and Australians. In 2018, 23.3 million people, 62% of all people living with HIV, were accessing antiretroviral therapy, up from 7.7 million in 2010. AIDS-related deaths have gone down following the wider availability of antiretroviral therapy. AIDS-related deaths have fallen by more than 55% in 2018 since the peak in 2004.

Question 63

6.3 Achieving results

Answer 63

Antiretroviral medicines save lives and they also help to prevent new HIV infections and restore respect and dignity to people living with HIV. More than 20 years of evidence now demonstrates that HIV treatment is also highly effective in preventing HIV transmission. The evidence shows that, when adhered to, antiretroviral therapy can suppress the viral load in people living with HIV to undetectable levels. People living with HIV with an undetectable viral load cannot transmit HIV sexually, which can really be life-changing news for people living with HIV, and has come to be known as U=U (Undetectable=untransmittable) (UNAIDS 2018). Now the issue is to make sure that we are not only expanding the number of people with access to treatment but also to sustain that effort. In addition, without a focus on HIV prevention, we will always fall short in terms of the treatment we can offer. A combination approach to HIV prevention—comprising a range of biomedical, behavioural, and structural approaches—has achieved good progress in reducing new HIV infections in many countries. Alongside other longstanding evidence-based measures such as consistent condom programs and voluntary medical male circumcision, significant investments are underway to expand access to new and promising effective prevention methods such as oral pre-exposure prophylaxis (PrEP). This is the next big challenge in AIDS that will require a new type of societal and political mobilization in addition to new technologies.

Question 64

7. Integrating activity Research how the AIDS activists’ fight for ARV treatment was different from that of other global campaigns.

Answer 64

Your answer should have included some of the following reasons: 1. Coalition from health, security, business, development and UN organisations working together.Multi-sector responses are critical for challenging future health threats, including and beyond HIV. 2. Widespread media coverage.3. Firm grounding in human rights principles.4. Successes in lower income countries such as Brazil, Thailand and Uganda showed it could be done.5. As a result of their fight to loosen TRIPS, low- income countries had a legal basis to use generic drugs.6. The support of knowledgeable and charismatic activists at the right time, including the direct engagement of people living with and affected by HIV. 7. Cheaper generic ARVs allowed for a scale up of international donor’s support.

Question 65

8. Summary

Answer 65

What did it take to achieve the many successes in the HIV response? How could we put AIDS on the worldwide agenda? What are the ingredients? These include the following: 1. Your evidence base has to be very solid: You have to make sure that your basic epidemiological facts are correct. That’s easier said than done because health information in many countries is not of the best quality and it is also expensive to collect this data. 2. Think through how you define an issue: If the international community had only used the medical jargon and looked at an issue only as a public health problem, the likelihood that it would have made it to the top of the agenda would have been fairly small. We need to be able to translate issues in lay-man terms, see what it means for society, not only what it means in public health terms. 3. It’s not enough to say that we have a problem, we also need solutions: This requires research. The solution can be a relative thing, what made a difference in HIV/AIDS was the fact that we had antiretroviral therapy but we all know that while it is not the magic bullet for the HIV/AIDS problem, it has had a measurable impact. 4. Let’s forget that we can change the world on our own, as public practitioners we’ve got to look outside our own orbit and form coalitions: The examples from South Africa and from other countries are testimony to that, so develop coalitions! 5. Good leadership is fundamental: It is the leadership that will put things on the agenda at the right moment and in the right forum. 6. Finally, never take no for an answer and never give up. Persistence is really the key!

Question 66

8. Summary

Answer 66

From this session, hopefully it is clear that to have an impact on people’s lives through health policy you need to have a synergy between science, politics, and evidence-based health programs. Science without political engagement remains in its ivory tower; politics without science can be pretty dangerous, it’s not based on evidence; and without the programs on the ground, you will not reach affected populations.