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Africa: Universal Access Initiative

AfricaFocus Bulletin
Mar 4, 2006 (060304)
(Reposted from sources cited below)

Editor's Note

AIDS activists and observers say the new "universal access by 2010" initiative is disturbingly vague and short on specific targets, with at least 4 million people still facing premature death from AIDS if they do not receive treatment. The "3 by 5" initiative, launched in 2003, targeted having 3 million people in developing countries on antiretroviral treatment for AIDS by the end of 2005. The last report, in June 2005, showed that the number had more than doubled, from 400,000 at the end of 2003 to approximately 1 million. But the year-end target was missed by at least 1 million, and there is still no detailed report for December 2005.

The official information available on "The Road Towards Universal Access" (http://www.unaids.org/en/Coordination/Initiatives) leading up to the UN session on the issue in early June, certainly seems to justify the critique that it is long on generalities and "UN-speak" and short on specifics that can help hold international agencies and governments accountable. Information on the 3x5 campaign, that is no longer being updated, is at http://www.who.int/3by5/en. There is no indication when and if a December 2005 report on the campaign will be available.

This AfricaFocus Bulletin contains excerpts from a report called "Missing the Target: A Report on HIV/AIDS treatment access from the frontlines," by the International Treatment Preparedness Coalition (ITPC; http://www.aidstreatmentaccess.org), as well as excerpts from notes by Gregg Gonsalves, an ITPC activist and one of the civil society representatives at the Global Steering Committee meeting for the universal access initiative. For additional background on the initiative see http://www.aidstreatmentaccess.org/universal.htm.

Gonsalves warns that "the international community is retreating sharply from the ambition charted out by the 3x5 initiative, airbrushing the past few years out of collective memory, and beginning to shove HIV/AIDS into the big bag of intractable social ills that will take centuries to solve if they are ever solved at all."

For earlier AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

Missing the Target

A report on HIV/AIDS treatment access from the frontlines

International Treatment Preparedness Coalition (ITPC)

[Excerpts only. For full report see
http://www.aidstreatmentaccess.org]

28 November 2005

Executive Summary

The campaign for global AIDS treatment delivery has reached a defining moment. The first years of programme scale-up demonstrated that AIDS treatment can be delivered effectively, even in the poorest settings. But "3 by 5", an initiative by the World Health Organization (WHO) to treat three million people by the end of 2005, is coming to an end and it has fallen at least one million men, women and children short of the target. This leaves at least four million people who urgently need antiretroviral drugs today in order to have any hope of survival. Although progress has been made over the past few years, we cannot call this success.

G8 leaders have pledged a new goal of coming as close as possible to universal AIDS treatment access by 2010. This will be a hollow promise unless governments and international agencies learn the lessons of the early years of treatment delivery and dedicate increased resources, capably address barriers, collaborate more effectively, and hold themselves accountable for steady, measurable progress. The "3 by 5" initiative failed to treat even 50% of people in need of antiretroviral treatment (ART). If the organisations responsible for carrying out this programme are to accomplish an even greater goal in five years' time, it will take courageous new leadership from all parties to confront the monumental task ahead. The status quo will not get us there.

...

The International Treatment Preparedness Coalition (ITPC) is a global alliance of over 600 treatment activists that includes people living with HIV/AIDS (PLWHA) and their advocates. The ITPC AIDS Treatment Report is the first systematic assessment of treatment scale up based on the research of people living in communities in six countries where the epidemic has hit the hardest the Dominican Republic, India, Kenya, Nigeria, Russia and South Africa. The report is based on their experiences and first-hand knowledge of the situation on the ground. ...

Clearly, much more work needs to be done to understand the complexity of this challenge. But what we found tells an important story of individuals exhibiting dedication and courage while caught in desperate situations; and of institutions often struggling to transition, be efficient, and throw off bureaucratic obstacles that stand in the way.

The ITPC AIDS Treatment Report is a prescription for the future. As ART has started to roll out in these six countries, the ITPC research teams have identified barriers that could imperil efforts to make treatment more widely available. The teams have also made concrete recommendations for governments and international institutions.

...

Need for improved leadership at the national level

In every country surveyed there were concerns about inadequate leadership at the national level and the subsequent failure to dedicate sufficient resources or mobilize governments. ...

We also found that each country has a different constellation of challenges and potential solutions. ...

In Kenya treatment services are being scaled up through new funding from the Global Fund, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and other programs. Yet people in need of care and service providers from around the country are confronting significant obstacles that include widespread stigma and discrimination against PLWHA and women, misinformation, lack of treatment literacy, and insufficient resources to meet basic nutrition needs or afford travel to health clinics for care.

In Nigeria the government has set new and ambitious targets for treatment delivery, but services remain concentrated in a few "cluster zones" while people in rural areas struggle to get care. Lack of adequate funding and human resources complicate treatment expansion. The high costs of CD4 and viral load tests put these diagnostic tools out of reach of most people in treatment. Stigma and a lack of treatment literacy programs both undermine scale up efforts. ,,,

In South Africa activists and providers have forged ahead with treatment delivery even as the national government continues to drag its feet and fails to combat misinformation and pseudo-science. Multilateral agencies have been largely invisible and the CCM is widely criticized. Many practical problems inhibit scale up as well, including a severe shortfall in nurses and other providers, limited access to HIV testing, and inadequate availability of drugs.

Need for a better functioning global system

All implementation is local, but the international community has to do better at identifying and quickly addressing impediments to the flow of resources and delivery of services. Each of the component parts of the multilateral system has strengths that are needed in AIDS treatment scale up, but UNAIDS, WHO, GFATM, and PEPFAR need to work in more efficient partnership both within countries and in Geneva. Countries need additional assistance from the international community in several areas, from logistical problems (like drug procurement) to long-term challenges (like reducing stigma).

What gets measured gets done. A much more systematic approach to setting goals, measuring progress, and assessing and addressing barriers is needed.

Rich countries need to stay true to their word and provide increased and sustained support for the Global Fund and other AIDS treatment programmes. The G8 countries cannot defensibly set a goal of universal access and then under-finance the response by billions of dollars.

African countries need to live up to their commitment as part of the 2001 Abuja Declaration to devote 15% of their budgets to addressing health priorities, including HIV/AIDS.

UNAIDS, WHO, the Global Fund, and PEPFAR and other bilaterals must keep the world's vision focused on treatment scale up. The operational plan for universal access now under development should emphasize improved collaboration among agencies and include defined countryspecific strategies, with hard timelines and milestones, and clear assignments of responsibility for specific tasks. Incremental targets for treatment delivery to children and marginalized populations are needed, as are action plans for delivery of secondand third-line regimens. In the next six months we want to see concrete evidence of a more collaborative system that more effectively meets the diverse needs of countries.

The International Monetary Fund and the World Bank need to end macroeconomic policies that unnecessarily constrain public spending so that countries heavily affected by AIDS can train and hire more doctors, nurses and teachers.

If the international community succeeds in treating the vast majority of people with HIV/AIDS who need it, we will have indeed changed the world. The delivery of antiretroviral therapy will only be possible with a revolution in global public health, which makes primary care available to those who have never had it before. This will pave the way for the treatment of countless other diseases that are now left untreated and unaddressed in most communities around the planet. The goal is before us. We should seize this moment in history together. ...


UNAIDS/DFID Meeting on Universal Access

Gregg Gonsalves, Gay Men's Health Crisis and the International Treatment Preparedness Coalition

Healthgap listserv, Jan 19, 2006

Last week (Jan 9-10) UNAIDS and the UK's Department for International Development sponsored the first of three meetings of the Global Steering Committee of the Universal Access initiative, the "sequel" to WHO's 3x5 program, which sought to get 3 million people on antiretroviral treatment by the end of last year. The Universal Access initiative extends the promise of 3x5 targeting "universal" access to treatment, care and prevention, by 2010. ...

...

Let's say things did not start off well. The first night of the meeting began with a "working" dinner at which everyone in the group of about 30 people was to quickly say a few words about what they expected from the process. Much to my complete horror, the first up at the microphone was none other than ...South African Health Minister Manto Tshabalala-Msimang, who proceeded to ramble on for about 15 minutes about how she was a nice person, but misunderstood [and] the glories of the South African AIDS response ... no one, except a few of the community members in attendance, challenged a word she said that evening. ...

These working group discussions were short-only a few hours long and then everyone convened back into the larger group for report-backs. Sadly, much of what was said descended into vagueness. In the first working group on sustainable and predictable financing, there was no rallying cry for supporting the Global Fund nor any critique of the IMF and World Bank's macroeconomic policies; in the group on affordable commodities, no one talked about the crisis around access to second-line therapies such as the new formulation of Kaletra and tenofovir or pediatric formulations or the failure of the current intellectual property framework under TRIPS to provide for any real way for countries to manufacture generic equivalents of pricey ARVs.

So, where are we? Well, we're in deep shit.

It's clear that the momentum for scaling-up access to treatment is dissipating. The Universal Access initiative wants to be all things to all people and will end up being nothing for millions infected with HIV/AIDS or at risk of contracting the virus. ...the main fact is that without targets for treatment, care and prevention, with milestones, deadlines and consequences for inadequate performance, incentives for achievement, with detailed operational plans from the district level on up in each country, nothing is going to happen. ...

All of this makes our work together more important than ever. We have to raise our voices locally, with our governments and demand access to treatment and prevention services, we have to hold our leaders accountable. ...

The UNAIDS/DFID meeting on universal access last week was a wake-up call for me. Access to AIDS treatment, in fact, even the larger fight against the epidemic, is in danger of being swallowed up and treated as just another intractable social ill. ...


Notes from the 2nd meeting of the UNAIDS/DFID Global Steering Committee on Universal Access to HIV Treatment, Care and Prevention

Gregg Gonsalves

Healthgap listserv, Feb. 25, 2006

This meeting (Feb. 21-22) opened with an invocation of the Chatham House Rule, which state:[participants are free to use the information but not to reveal the identity or the affiliation of the speakers]. ...

Going into this meeting, the civil society delegation lost one of its key members, Rodrigo Pascal from Chile, who withdrew from the Global Steering Committee for personal reasons. However, to compensate for Rodrigo's loss, the GSC added Rolake Nwawgu, a fierce activist from the Treatment Access Movement in Nigeria. The other original members of the civil society delegation remained intact: Lillian Mworeko from ICW in Uganda, Elizabeth Mataka from the Zambian AIDS Network, Anandi Yuravaj from the International HIV/AIDS Alliance in India, Susan Chong from APCASO in Malaysia, Raminta Stuikyte from the Central and Eastern European Harm Reduction Network.

In preparation for the meeting this week in Geneva, the Global Steering Committee civil society delegaton asked several people to develop briefing papers for us. Thus, David McCoy (UK), Eric Friedman (USA), Lola Dare (Nigeria) and Rene Loewenson (Zimbabwe) developed two papers on health systems strengthening; Rick Rowden (USA) developed a paper on macroeconomics and financing; Richard Elliot (Canada) and Joe Amon (USA) developed a paper on human rights.

We also requested that some of these community experts attend a pre-meeting on Monday, February 20th with the civil society delegation and be invited to the GSC meeting itself as observers. Thus, Joe Amon from Human Rights Watch, Nomfundo Dubula from Treatment Action Campaign (South Africa), Jonathan Berger from the AIDS Law Project (South Africa), Andrew Hunter from the Asia-Pacific Network of Sex Work Projects (Thailand) and Sandra Batista from REDLA+ in Brazil joined our ranks for the meeting. Kieran Daly from ICASO also attended, though not as a member of the Global Steering Committee. He is though essentially staffing the process and playing a vital role in supporting the civil society delegation's work.

The extra preparation and the extra community experts in attendance were very important at this meeting, since the final document that will be drafted for the UN General Assembly and Secretary-General Kofi Annan in time for the UNGASS meeting and which will provide the overarching framework for the Universal Access initiative as well as some key policy recommendations, began to take shape in the day's discussions. With these briefing papers in hand and community experts in attendance, we were able to submit written language for the text or provide detailed technical input from the community's perspective on the spot.

...

The formal Global Steering Committee meeting opened on Tuesday, February 21st. ...

After this opening session, I went to the session on macroeconomics and sustainable financing chaired by Mr. H and Mr. I while other community colleagues fanned out to the other working groups. In our pre-meeting we had developed five key points for this working group on loosening deficit-reduction and inflation-reduction targets, reclassifying public investment and capital expenditure rather than current expenditure, calling on donors to make higher, predictable long-term commitments of foreign aid and to directly fund civil society. Of course, Mr. I maintained that institution J was flexible on macroeconomic policy and that its policies would never stand in the way of any credible, sustainable national AIDS plan. What a shocker it was then the next day, when Ms. K complained in the plenary that she had 4000 nurses that she would like to hire but was being prevented from doing so by her Ministry of Finance since it would expand public spending to unacceptable levels.

In the subsequent coffee break, Mr. I and Ms. K pointed the finger of blame at each other, while 4000+ health professional still remain out-of-work in country L. What was discussed and agreed upon in these working groups will become the basis of the high-level political commitments for consideration at the UNGASS meeting in June and the G8 meeting in Moscow. Thus, there was significant jockeying over the wording of each of the statements that would be reported out on the second day of the GSC meeting.

What was particularly disappointing, well, in fact, enraging to me, was that basic precepts around supporting the Global Fund or linking financing to real targets, was challenged by Mr. M from country N, who crowed in an email after the meeting about how his country was the single biggest donor to the Fund and how other countries have yet ascend to N's level of generosity and how he could never accept global targets for universal access and was particularly opposed to any targets imposed upon bilateral actors. Clearly Mr. M and his government ... have the epidemic under control and we should all relax and let Big Daddy take care of it all.

... This is the kind of battle we are facing-where countries that should be leading the way have a creepy aversion to supporting any multilateral solutions to HIV/AIDS and in fact want to dampen expectations about what can be accomplished by the international community.

This is the key lesson from the second GSC meeting. Someone put it fairly bluntly in a discussion during dinner after the first day's working group sessions were over: public health goes through phases, there are ambitious times, where targets are put forth to drive the international response, and then there are times where targets are avoided, usually after previous targets have been missed, and which herald a maintenance phase, in which aspirations are scaled back substantially. ...

Our working group was the first to report-back. We have been posting many of the documents associated with these meetings and the universal access initiative to the ITPC's temporary website at http://www.aidstreatmentaccess.org/universal.htm and we will post documents from this meeting soon, so I'll just give the main points from these report-backs here. ... We stressed the need for donors (and national governments themselves) to financially and otherwise support any credible, sustainable national AIDS plan, for governments, donors, and civil society to be held accountable for targets set for 2010, and for civil society to be involved in crafting national AIDS plans and monitoring budget allocations and expenditures.

... We also pushed for increased financing and for both industrialized and developing countries to honor previous commitments, while expressing support for new mechanisms proposed to support the GFATM and other AIDS efforts (e.g. airline tax) and for conditionalities to be restricted to basic fiduciary responsibilities and outcomes ... We finally discussed ideas for ensuring accountability and holding everyone to the targets set for countries for 2010, including an idea championed by a former World Bank vice-president that would establish independent, high-level Global Issues Networks to monitoring compliance with goals and targets set for various international initiatives (see Jean-Fran ois Rischard, Global Issues Networks: Desperate Times Deserve Innovative Measures, Washington Quarterly, Winter 2002-2003, at http://www.twq.com/03winter/docs/03winter_rischard.pdf). ...

The next group that reported back was on health systems strengthening. The report back from this group was strangely vague and sketchy, mostly rehearsing platitudes about the subject than making specific, concrete recommendations. To be fair, according to the members of the civil society delegation and community observers that attended this session, the presentation didn't reflect the richness of the previous day's discussions. ...

The next group to report back was on affordable commodities. This group had worked early into the evening on its recommendations and provided some of the most interesting ideas of the meeting, including a discussion for the need for a list of essential commodities, akin to the WHO's list of essential drugs and medicines. The group also called for a report by UNAIDS and the WTO to examine why countries haven't utilized the flexibilities in the TRIPS agreement to deal with access and affordability of AIDS drugs.

Next up was the group on human rights. The group had several specific recommendations, including empowering a new Special Rapporteur on HIV and Human Rights under the auspices of the new UN Human Rights Council; ... directly support[ing] broader rights and advocacy efforts by PLWHA and civil society.

Finally, the group on targets and milestones closed out the meeting with a rousing, inspirational call for NO NEW GLOBAL TARGETS. The group largely discussed a set of core indicators for treatment, care, prevention, human rights and for national goverments, donors and civil society, with one or two indicators for each of these areas and constituencies and with supplemental indicators based on specific national or regional concerns. They concluded with an inconclusive mention of the need for accountability, which this entire process will talk a great deal about but most likely end up ensuring that no one is accountable for the mounting death toll from HIV/AIDS around the world and the millions of new infections every year. ...

So what now? Over the next week or so, UNAIDS, with assistance from DFID will begin to draft a 20-page document, which will be the document that is sent up to the General Secretary of the UN, Kofi Annan, at UNGASS, with the recommendations within being the basis of negotiations among members states for a communique on universal access. The document will thus chart out a short list of political commitments, with technical and operational details relegated to an annex at the back of the book. All this for that. Dozens of regional and country consultations (some of which will happen after the document is long-completed-so much for country-driven), three GSC meetings, hundreds of emails, tens of conference calls, lots of money and effort and all we get are 20 pages of UN-speak. ...

The UN communique will shape the next four years, by sending a signal to national governments, about the consensus of the international community about what to do about HIV/AIDS. And right now the news is not good. As I said above, the international community is retreating sharply from the ambition charted out by the 3x5 initiative, airbrushing the past few years out of collective memory, and beginning to shove HIV/AIDS into the big bag of intractable social ills that will take centuries to solve if they are ever solved at all. ...

The civil society delegation to the GSC and the community observers will be working to try to influence the final document that goes to the UN and the G8, but the forces arrayed against us, led by Mr. M and his government, some of the UN agencies that cower in fear of their member states, will push the document towards inconsequence.

Thus we need another strategy. I would strongly endorse ActionAid and other's call for a Global Week of Action on 20-26 May 2006 in which groups coordinate national mobilizations across the world leading up to UNGASS. ...

In any case, this is where we are now. This is the state we're in.

Universal Access: Global Week of Action 20-26 May 2006

" ..., to significantly reducing HIV infections and working with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010." - G8 Communique July 2005

While we are all tired of the political rhetoric by the international community and the broken promises, we have in the this latest target a concrete tool to hold all our governments as well as international institutions to account in scaling up the fight against HIV & AIDS.

Within the communique the international community also recognises some of the systemic barriers to achieving this target such as limited health systems capacity, lack of sustained financing, high cost of commodities such as medicines and diagnostics and the prevalence of stigma and discrimination. The universal access agenda offers a strong lever for civil society globally to press for urgency in tackling the above systemic barriers.

While governments and international agencies are involved in reviewing the progress they have made in the fight against AIDS since 2001 and will be presenting this at UNGASS (31 May - 2June) in New York, HIV/AIDS campaigners know how little has been achieved and how unrealistic the new target for 2010 is unless we begin to resolve some of the structural barriers highlighted above. We should use the UNGASS event and the political and media attention it brings to launch a more sustained campaign for universal access within our own countries that would involve mobilising a wider coalition of civil society against HIV & AIDS.


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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