NGLS Roundup 94, July 2002
XIV INTERNATIONAL CONFERENCE ON HIV/AIDS
The leading cause of death in sub-Saharan Africa, and the fourth leading cause of death globally, AIDS continues to devastate entire regions of the world, setting many nations decades back in their development. The spread of HIV/AIDS has exacerbated poverty and the number of children orphaned by the pandemic is escalating. Last year, more than 40 million people around the world were living with HIV/AIDS.
The XIV International Conference on HIV/AIDS, held from 7-12 July 2002 in Barcelona (Spain) under the theme “Knowledge and Commitment for Action,” aimed to ensure that knowledge gained from science and experience is translated into action. Over 14,000 scientists and clinicians, advocates, health care workers, public health agents, people living with AIDS, politicians, NGOs and journalists participated in the conference, roughly equivalent to the same number of people calculated to become HIV infected around the world each day.
In his opening remarks, Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS) Peter Piot told the audience that they must face the challenge of mobilizing political commitment, scale up AIDS prevention and treatment, eliminate stigma, develop a vaccine and find US$10 billion to fight AIDS. Failing to do so, Dr. Piot warned, would prevent the international community from keeping the promises they made to respond effectively to AIDS.
Dr. Piot also warned that failing to act immediately would have catastrophic consequences. “We stood by while AIDS overwhelmed sub-Saharan Africa. Never again. We cannot stand by as passive observers while other continents repeat history, and we must not fail Africa now, in her attempts to turn back the epidemic's devastation.” He said the forces of global inequality underpinning the AIDS epidemic must also be addressed to make real progress against the epidemic: “International trade negotiations may have as great an impact on how many people get AIDS treatment as any number of national treatment access plans,” he said.
Financing
How to finance the response to HIV/AIDS was one of the most contentious issues of discussion at the XIV International AIDS Conference. “For countries struck by floods and civil strife, we take it for granted that humanitarian assistance, increased aid and accelerated debt relief is needed. We need to do the same for countries ravaged by AIDS, a disaster infinitely more devastating,” said Zéphirin Diabré of the United Nations Development Programme (UNDP).
Kevin Watkins, Head of Research and Policy at Oxfam called for immediate and complete debt cancellation for countries seriously impacted by the AIDS epidemic. A recent Oxfam briefing paper written by Mr. Watkins says more than one-third of the world's people living with HIV and AIDS live in the 38 countries classified as Highly Indebted Poor Countries. Large chunks of public resources that need to be allocated towards HIV/AIDS prevention and treatment are instead sent to creditor countries in the North to service the crippling debt burden. Oxfam is calling for a ceiling of 5% to be set on the share of government revenue allocated to debt repayments and even lower for countries with financial difficulties in dealing with HIV/AIDS, which it says would mobilize an additional US$1.6 billion annually.
Angry activists, protesting that the Bush Administration had not pledged more money to fight the global epidemic, disrupted US Secretary of Health and Human Services Tommy Thompson's speech. The protesters began blowing whistles and shouting “Shame! Shame!” and “No more lies!” as Mr. Thompson came to the podium. Many activists believe the richest nations should provide money for research and prevention programmes, and criticize what they perceive as the US's lack of commitment to fighting the spread of HIV and AIDS.
“This meeting was tinged with fear, anger and a great deal of concern over what's happening in Africa and what could happen in other parts of the world,” said Robert Gallo, director of the Institute of Human Virology at the University of Maryland's Biotechnology Institute. Dr. Gallo is credited, along with French scientist Luc Montagnier, with pinpointing the link between HIV and AIDS. “I don't want to say there was pessimism, but there was a realization that a lot of the critical issues—like providing follow-up studies and continuing care to the neediest countries—are about policy, and are out of the realm of AIDS scientists.”
Gender Inequality
Several experts warned that women are most at risk for HIV and are suffering a “disproportionate” share of the burden of the growing HIV/AIDS epidemic. According to the United Nations Population Fund (UNFPA), although women and girls around the world have little knowledge about how to protect themselves from HIV/AIDS, they are increasingly becoming the prime victims of the epidemic, with 75% of new HIV infections globally now being attributed to heterosexual sex. Men are eight times more likely to transmit HIV/AIDS to women through unsafe sex than women are to transmit it to men, and the HIV infection rates among teenage girls are five times higher than rates among teenage boys. Once women contract the virus, they are more likely to be ostracized and to face discrimination and even violence, as well as being blamed for spreading the epidemic.
“Socio-economic inequality between women and men is now fatal,” said International Center for Research on Women Executive Director Geeta Rao Gupta. According to Ms. Gupta, who is also a social psychologist, the stigma women bear from being afflicted with HIV/AIDS is the “single greatest challenge” to efforts to stem the spread of the epidemic and leads to tragic circumstances in which pregnant women fear death less than HIV testing.
According to UNAIDS, of the more than 40 million people living with HIV/AIDS worldwide, an estimated 18 million are women. In sub-Saharan Africa, women account for 55% of adults infected with HIV.
Children on the Brink
An international report, published jointly by the US Agency for International Development (USAID), UNAIDS and UN Children's Fund (UNICEF), with estimates provided by the US Bureau of the Census, finds that an already grim global orphan crisis is set to get much worse as more and more adults with children die from AIDS, especially in sub-Saharan Africa.
Children on the Brink contains statistics on the historical, current and projected number of children orphaned by HIV/AIDS, and finds more than 13.4 million children have lost one or both parents to the epidemic in the three regions studied, a number that will increase to 25 million by 2010. In addition to the millions of children orphaned by AIDS, millions more are being adversely affected by the disease. The report calls for action at all levels to assist children, families and communities who are affected by the unprecedented emergency. It also says today's prevalence rates will largely determine the pattern of orphaning for the next decade. In countries where HIV/AIDS prevalence has recently escalated, the full impact on the estimated number of orphans has yet to emerge.
Some of the report's major findings include:
—Africa has the greatest proportion of children who are orphans. In 2001, 34 million children in sub-Saharan Africa were orphans, one-third of them due to AIDS. By 2010, the number of orphans will reach 42 million, and 20 million of these children—or almost 6% of all children in Africa—will be orphaned due to AIDS.
—Asia has the largest number of orphans. In 2001, there were 65 million orphans, with approximately 2 million of them orphaned due to AIDS. The populations in many Asian countries are so large, however, that even at a low prevalence, the number of people with HIV/AIDS threatens to surpass the numbers in some of the most severely affected African countries. Even a relatively small increase in prevalence could lead to even greater numbers of orphans due to AIDS.
—Orphan populations are concentrated, reflecting broader trends in HIV prevalence and population. In 2001, 12 countries in sub-Saharan Africa accounted for 70% of the orphans. The three countries with the largest populations also had the most orphans—Nigeria, Ethiopia and the Democratic Republic of Congo.
Referring to the publication in his statement to the conference, Ken Casey of World Vision said the 14th International AIDS Conference could be summed up in one phrase: “the world on the brink,” adding that it was not the threat of nuclear war or terrorism but AIDS putting it there. He said that “Meeting the needs of those widows, orphans and other children at risk because of AIDS should be of primary importance to those wealthy nations, including those donating to and administering the Global Fund for AIDS, Tuberculosis and Malaria. Unless and until meeting the needs of those affected by AIDS becomes a priority, the world will edge closer and closer to the brink.”
Economic and Social Impact of HIV/AIDS
According to the International Labour Office (ILO), the economic and social impact of HIV/AIDS in sub-Saharan Africa is far more severe than previously thought and will seriously undermine the development prospects of affected countries. ILO experts told the conference that previous attempts by economists to measure the costs of HIV/AIDS in sub-Saharan Africa “are likely to be significant underestimates of the social and economic value of the losses of 'human capital' that are being experienced.”
“The epidemic affects social and economic life in ways we have never seen before,” said Franklyn Lisk, Director of ILO's Global Programme on HIV/AIDS and the World of Work. “The main socio-economic impact of HIV/AIDS is its decimation of the labour force and the level and allocation of savings and investment. This portends a huge humanitarian disaster with dire economic and social consequences.”
An ILO study launched at the conference, entitled Human capital and the HIV epidemic in sub-Saharan Africa, shows that across all occupational sectors in sub-Saharan Africa it is becoming increasingly difficult to replace skilled as well as unskilled labour lost to HIV/AIDS and that many countries are increasingly unable to find the resources badly needed to sustain even current levels of economic development.
“Decades of gains in development, training, skills and education are being lost forever,” Mr. Lisk said. “The belief that these losses can be replenished from a vast pool of unemployed or underemployed labour is a fallacy.” The ILO report also called for greater involvement of both employers and organized labour in efforts against HIV/AIDS and for support to governments in assessing and mitigating the impact of the epidemic.
Former South African and US Presidents Speak on AIDS
Speaking at the close of the conference, former South African President Nelson Mandela and former US President Bill Clinton called on world leaders to recognize AIDS as a threat to international peace and economic stability. Mr. Clinton said, “One hundred million AIDS cases mean more terror, more mercenaries, more war, destruction and the failure of fragile democracies.” He called on donor governments to “figure out what our share is” of the US$10 billion the UN says is needed annually to fund global programmes to combat HIV/AIDS. The United States should increase its spending by nearly US$2 billion, he stressed, an amount that would be “less than two months of the Afghan war, less than 3% of the requested increase of defense and homeland security budgets.” He cautioned, “If we don't do it, we will be spending far, far more than that to clean up the mess of this humanitarian tragedy.”
In an interview with reporters, Mr. Clinton also expressed regret about not doing more to combat HIV/AIDS when he was president and urged leaders in the developing world to speak out strongly and develop national action plans to stop its spread.
Mr. Mandela, in his speech, called AIDS “a war against humanity...which requires the mobilization of entire populations,” and called for access to anti-retroviral medication “for all those who need it, wherever they may be in the world, regardless of whether they can afford it.”
Non-Governemental Organizations
NGOs voiced their disappointment that the conference ended without any firm political commitment or new pledges to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. “None of the delegations took advantage of this opportunity,” said Intermon Oxfam spokeswoman Adela Farre, noting that wealthy countries sent technical specialists but very few high-level political representatives. She said that without new political commitments and a “clear” declaration about outstanding pledges to the Global Fund, the main problem of the HIV/AIDS epidemic has gone unresolved—that millions of people in developing countries have been “sentenced to death” by the virus.
Criticizing the lack of action from wealthy countries, Médecins Sans Frontières (MSF) Secretary General Rafael Vila-Sanjuan said apart from a “minimal” pledge from the World Bank, there was “not a single” new political commitment made by developed countries at the conference. MSF and Health Gap (Global Access Project) also said that, because so little funding is available, precious time is being wasted debating the “cost-effectiveness” of prevention over treatment interventions, when in fact it is necessary to implement both simultaneously. This debate could be put to rest if resources were not so scarce and if allocated funds could go towards the lowest price drugs.
MSF said that relying on the goodwill of pharmaceutical companies instead of making use of generic competition and bulk purchasing means that some countries are paying three times more than necessary for antiretrovirals (ARV) cocktails. “The refusal of the US, the European Union and other donor governments to commit funds for lowest cost medicines has already condemned millions to death,” said Alan Berkman, MD, founding member of Health GAP. “The feasibility of treatment has never been more certain. But as long as wealthy countries refuse to pay, feasibility does not matter. Donors must be held accountable for their wilful neglect.” Jose Luis Garcia, an Action Aid project coordinator in Mozambique, accused pharmaceutical companies of being interested only in generating profits “at whatever the price.”
In spite of the criticism, many NGOs welcomed the mainstreaming of the concept of treatment in countries hardest hit by the HIV/AIDS epidemic which, according to Mr. Garcia, was an idea that was dismissed at the last AIDS conference held two years ago in Durban (South Africa).
The International AIDS Society, UNAIDS and the Royal Thai Government have concluded an agreement to hold the XV International AIDS Conference in Bangkok (Thailand) from 11-16 July 2004.
Background Documents
A Conceptual Framework and Basis for Action:
HIV/AIDS Stigma and Discrimination
The World AIDS Campaign for 2002-2003 focuses on stigma, discrimination and human rights. A document in the UNAIDS Best Practice Collection, entitled A Conceptual Framework and Basis for Action: HIV/AIDS Stigma and Discrimination, provided background material for the meeting. The report stresses that stigma and discrimination associated with HIV and AIDS are the greatest barriers to preventing further infections, providing adequate care, support and treatment and alleviating impact. In its conclusion, the report says that if effective responses to HIV/AIDS-related stigma and discrimination are to be promoted, work has to occur simultaneously on several fronts: communication and education to encourage better understanding; action and intervention to establish a more equitable policy context; and legal challenge, where necessary, to bring to account governments, employers, institutions and individuals.
Global HIV/AIDS Epidemic 2002
On 2 July UNAIDS released its Report on the Global HIV/AIDS Epidemic 2002, with the results indicating that 60 million people have been infected since the epidemic began two decades ago. In the most severely affected nations, the disease is reversing the gains of economic development and shortening life expectancy. According to the report, the most potent way to avert the devastating impact of HIV/AIDS is to act before the epidemic takes hold. Calculations of the rates of return on Thailand's investments in HIV/AIDS prevention suggest that, in 1990-2020, the avoided medical expenditures alone will have yielded rates of return in the order of 12-33%. Brazil's widely praised efforts to provide universal treatment and care, in addition to its well-planned prevention programmes, are estimated to have avoided 234,000 hospitalizations in 1996-2000.
The report details demographic impacts, as well as impacts on households, education, health, macro-economic, and labour sectors, and covers a variety of subjects, including AIDS and human rights, prevention, voluntary counselling and testing, preventing mother-to-child transmission, and national responses among others.
Extracts from Report on the Global HIV/AIDS Epidemic 2002:
—In 2001, HIV/AIDS claimed an estimated 3 million lives.
—In the 45 most affected countries, it is projected that between 2000 and 2020, 68 million people will die prematurely as a result of AIDS. The projected toll is greatest in sub-Saharan Africa where 55 million additional deaths can be expected.
—The under-five mortality rates of seven countries in sub-Saharan Africa have increased by 20-40%, due to HIV/AIDS. The number of excess AIDS-related deaths among South Africans aged 15-34 is projected to peak in 2010-2015, with an estimated 17 times as many deaths as there would have been in the absence of AIDS.
—Women are almost invariably left bearing even bigger burdens as workers, caregivers, educators and mothers. At the same time, their legal, social and political status often leaves them more vulnerable to HIV/AIDS. Securing the right of women and children to retain the land and assets of a deceased husband/father can help households cope.
—A decline in school enrolment is one of the most visible effects of the epidemic. According to the World Bank, the number of primary school pupils in 2010 will shrink by 24% in Zimbabwe, 14% in Kenya and 12% in Uganda.
—Nationwide AIDS-related deaths among South African teachers rose by more than 40% in 2000-2001. The loss of teachers can be especially devastating in rural communities where schools depend heavily on only one or two.
—The vast majority of people living with HIV/AIDS worldwide are in the prime of their working lives. By 2005, Zimbabwe will have lost 19% of its workforce to AIDS, Botswana 17%, South Africa 11%, the United Republic of Tanzania 9% and Côte d'Ivoire 8%.
Young People and HIV/AIDS: Opportunity in Crisis
According to the joint report !!Young People and HIV/AIDS: Opportunity in Crisis, compiled by UNAIDS, UNICEF and the World Health Organization (WHO), findings show that young people around the world are poorly informed about the risks of HIV/AIDS, the means of transmission and their own vulnerability. UNAIDS, UNICEF and WHO are calling for new political commitment to increase the effort to fight HIV/AIDS in the 15-24 age group.
The report (available online www.unaids.org/barcelona/ presskit/youngpeople.htm) estimates that 6,000 young people are newly infected with HIV every day and urges expansion of prevention and education campaigns. “In every country where HIV transmission has been reduced, it has been among young people that the most spectacular reductions have occurred,” said Peter Piot, UNAIDS Executive Director.
The report acknowledges that young people are at the centre of the HIV/AIDS epidemic: they are both the hardest hit by the disease and are also the key to overcoming it. Yet despite this, the report notes, strategies for responding to the epidemic generally disregard young people.
“We have two dovetailing trends here that are, in large part, driving the HIV/AIDS crisis. One is that young people have sex, something the world must acknowledge as a pre-condition to mounting effective prevention programmes,” said Carol Bellamy, UNICEF Executive Director. “The other is that young people actually don't have the proper knowledge to protect themselves. The tragic consequence is that they are disproportionately falling prey to HIV.”
The report highlights that in countries where the spread of HIV/AIDS is subsiding or declining, such as Thailand and Uganda, it is primarily because young men and women are being given the knowledge, tools and services to adopt safe behaviours. It says there is a strong linkage between what young people know and how they act, and that a safe and protective environment is crucial for them to develop the skills necessary to avoid infection. In addition, it says special efforts are needed to reach especially vulnerable young people, such as injecting drug users and commercial sex workers.
“Young people have unquestionably demonstrated that they are capable of making responsible choices to protect themselves when provided support, and they can educate and motivate others to make safe choices,” said Gro Harlem Brundtland, Director-General of WHO.
The report outlines ten steps that countries should take as part of their prevention efforts, including ending silence, stigma, and shame; equipping young people with life skills to turn knowledge into practice; providing youth-friendly services; promoting voluntary and confidential HIV testing and counselling; and engaging young people who are living with HIV/AIDS, among others.