Rethinking the Global War on AIDS

Endless rows of coffins fill a graveyard in South Africa, where AIDS has taken a staggering toll. (Photo: -/AFP-Getty Images)

The H.I.V./AIDS pandemic is now widely acknowledged as a major crisis of our time. As we gradually move to the third decade, the pandemic shows no sustained signs of slowing down, especially in hardest-hit parts of the world. It is crucial to step back and rethink current global remedial efforts.

According to the United Nations agency coordinating the fight against the pandemic (Unaids), almost 40 men, women and children worldwide live with H.I.V. Since the early 1980’s, more than 20 million individuals have lost their lives to AIDS. Nearly 5 million people became infected in 2004 and 3.1 million died of AIDS during the same period. Sub-Saharan Africa continues to be the epicenter of the pandemic, accounting for more than 60 percent of all global infections although it represents only 10 percent of the global population. Southern Africa represents only 2 percent of the global population but accounts for 30 percent of all individuals living with H.I.V./AIDS. Nearly half of all adults living with H.I.V. are women. In sub-Saharan Africa, 57 percent of infected adults are women. The rate of H.I.V. transmission has also increased exponentially in other parts of the world in the last two years: nearly 50 percent in East Asia and 40 percent in Eastern Europe and Central Asia, respectively.

Despite these sobering statistics, the global war on AIDS includes clearly positive developments. It would be difficult to find a senior policy maker worldwide who has never heard of H.I.V./AIDS. Uganda’s rate of H.I.V. fell from 13 percent in the early 1990’s to 4.1 percent in 2003 through comprehensive prevention programs, according to Unaids. Spectacular advances in research led to the creation of life saving antiretroviral drugs that changed the pandemic from a deadly to a chronic and manageable condition in the West, with rates of AIDS death falling by up to two-thirds. The creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria is a shining testament of global resolve to fight the pandemic. The unprecedented $15 billion, five year H.I.V./AIDS, TB and Malaria program of the United States in 15 developing countries represented another milestone in the scale and scope of a remedial effort.

Significant Obstacles to Remedial Efforts

However, in low and middle-income countries, extraordinary obstacles still loom. According to Unaids, although six million people qualified for life-saving antiretroviral treatment in December 2004, only 700,000 were on treatment. The commitment by the World Health Organization and Unaids to have three million people in the hardest hit countries to be on antiretroviral treatment by the end of 2005 has fallen short. The funding crisis for H.I.V./AIDS remedial efforts will soon reach crisis proportions as managers of the Global Fund scramble for money to meet future and current long-term commitments. I had addressed the looming H.I.V./AIDS funding crisis in another article on

In addition, significant obstacles impede access to preventive programs. Less than 20 percent of adults in hard-hit low- and middle-income countries, according to Unaids, have access to preventive programs. Unaids estimates that as much as two-thirds of all new H.I.V. infections in this decade could be prevented by expanding prevention programs to those in need. Fewer than 10 percent of pregnant women have the opportunity to receive services that can prevent maternal transmission of H.I.V. Less than 1 percent of adults aged 15 to 49 have access to voluntary counseling and testing services. No more than 3 percent of AIDS orphans receive any form of social support, especially in Africa. According to Unaids, by 2010, 18 million AIDS orphans will live in Africa.

What Is the Battle All About?

The bottom line is that new individuals become infected every day with H.I.V. Today, there is no known cure to H.I.V./AIDS. Every day, men, women and children die of AIDS. Every day, children graduate into the uncertain world of AIDS orphanhood. Every corner of the world is at risk. Some parts of the world are already waging a titanic life and death struggle with AIDS. Every day, about 13,423 individuals become infected with H.I.V. worldwide and approximately 8,493 die of AIDS.

It is critical to renew the fight against H.I.V./AIDS. We can build upon lessons learned in global remedial efforts. We can also modify or change ways of doing things as new challenges emerge so that individuals and families infected and affected by H.I.V./AIDS will have the best chance of survival.

What to do? I will briefly discuss possible changes in AIDS fighting strategies.

Proposed Changes in Global and Remedial Efforts

I propose that rethinking global H.I.V./AIDS remedial efforts should focus on the following issues:

1. End the ideological hard line battles over AIDS remedial efforts.

2. End all forms of means testing in AIDS programming.

3. End all obstacles to providing antiretroviral therapy to those in need.

4. Consolidate global H.I.V./AIDS remedial efforts in recipient countries into five areas of competency.

5. Deploy targeted resources for the training and retraining of health workers in AIDS-hit countries.

6. Governments of recipient countries should lead country-level remedial efforts.

7. Align poverty alleviation efforts with H.I.V./AIDS remedial programs.

8. Focus on community-based H.I.V./AIDS remedial efforts.

The foundation of a sustainable global response to H.I.V./AIDS is the availability of funds for the implementation of preventive, clinical and support programs. Unaids is now providing increasingly sophisticated and better-validated data on funding needs for global H.I.V./AIDS remedial efforts. The looming challenge is how to raise the $22 billion that Unaids estimates it would take to fight AIDS in 2007. In this regard, the United States has a special moral and fiduciary responsibility to ensure that enough financial resources are made available in the fight against AIDS. With strong U.S. leadership, other Group of 8 nations [Canada, France, Germany, Italy, Japan, Russia and the United Kingdom] will likely come through with additional resources. The pledge by Group of 8 nations during the 2005 summit in Scotland to fund fully H.I.V./AIDS programs worldwide by 2010 is commendable. However, the United States and other Group of 8 nations should ramp up their support to meet identified needs.

First, end the increasingly ideological and hard-edged battles over AIDS remedial efforts.

Today, international H.I.V./AIDS remedial efforts are overshadowed by ideological battles between liberals and conservatives, between advocacy organizations and governments, between advocacy organizations and research pharmaceutical companies, and, between faith-based entities and secular organizations. Even Western countries face off from time to time, as shown during the 2004 International AIDS Conference in Bangkok when France accused the United States of attempting to force other nations to accept its strategic AIDS remedial policies. It is difficult to fathom how strident ideological battles can provide timely assistance to those in need. Anybody familiar with the suffering of families battling AIDS in Africa will fail to be persuaded on how ideological battles that delay or end remedial efforts can be useful to those in need.

All stakeholders in global H.I.V./AIDS remedial efforts should close ranks in the interest of the millions of individuals who die every year. I am not aware of any valid reason why closer cooperation and collaboration should not be the norm between generic and research pharmaceutical companies, between governments and advocacy organizations, between the private sector, governments and the civil society, and between Western nations and less-developed countries if the noble goal is to provide timely assistance to those in need. In this regard, the U.S. government has the capacity and influence to lead a global tone-down of the harsh ideological rhetoric on AIDS remedial efforts. No target population or individual at risk should be denied H.I.V./AIDS remedial assistance because of ideological differences.

Second, it is time to end any overt or covert means testing in H.I.V./AIDS preventive programs.

Since needless infections and subsequent deaths may occur with every day of delay, it is crucial for all stakeholders to embrace the ABC preventive approach (A for abstinence; B for being faithful to one uninfected partner; C for consistent condom use). No component of the ABC strategy should be given prominence over the other. In the war against H.I.V./AIDS, every proven method of deterrence must be utilized. As with all multiple strategic approaches, frontline workers and their managers who work directly with those at risk will have to customize their remedial efforts to meet the needs of their target population.

Rather than engage in battles over ABC, it would be better for AIDS planners, managers, researchers, advocates and funding organizations to focus on three key elements of behavioral change: the knowledge, attitude and perception (KAP) of risk taking and risk avoiding behaviors. In many developing countries, the KAP of the target population is rarely elicited, integrated or utilized in the implementation of H.I.V./AIDS remedial efforts. H.I.V. remedial efforts should also focus on how to empower at-risk populations to take charge of their health and avoid risk-taking behaviors that may lead to H.I.V. transmission. As noted by a group of prominent AIDS prevention researchers recently in the Lancet, a British medical journal, each and every individual ultimately has the responsibility for avoiding H.I.V. transmission.

Third, tackle all obstacles that impede access to antiretroviral drugs by individuals clinically qualified to receive these drugs.

According to Unaids estimates, six million people living with H.I.V./AIDS can begin receiving antiretroviral therapy, immediately. It is now accepted that access to lifesaving AIDS therapy is critical to expanding H.I.V. preventive programs. Consequently, any supporter of a comprehensive H.I.V. prevention program should also embrace the need for unimpeded access to antiretroviral therapy for those clinically qualified to receive these drugs.

There is a huge moral burden on governments, multinational corporations, financial titans, rich men and women, and major philanthropic organizations to determine why nearly 25 years after the emergence of H.I.V., individuals continue to die in the millions due to lack of access to readily available drugs. It is difficult to justify the current situation whereby living with H.I.V./AIDS and living in a developing country is a kiss of death.

To solve this moral hazard, it is important for three critical stakeholders to go beyond the call of duty:

A. Pharmaceutical executives worldwide, generic and research, should come together and implement a Global Access to Antiretroviral Therapy Emergency Plan to make these medicines available to the six million individuals who will benefit, immediately.

B. Governments and multilateral agencies of the Group of 8 nations should provide adequate financial, technical and logistic support for the Global Access to Antiretroviral Therapy Emergency Plan. In particular, the U.S. State Department’s Office of the Global AIDS Coordinator, which manages the $15 billion H.I.V./AIDS, TB and Malaria initiative, should work closely with both generic and research pharmaceutical companies to make lifesaving medicines available to those in need, and on time.

C. The Global Fund to Fight AIDS, Tuberculosis and Malaria deserves long-term support from Western governments and the private sector as a credible avenue for implementing multisectorial, country-originated H.I.V./AIDS programs and services in target populations.

To ensure the effectiveness of strategies that improve access to antiretroviral therapy, it is necessary to create a mechanism whereby available monies reach intended target populations in a timely fashion. The lag time between announcement of awards for AIDS programs and disbursement of funds is still troubling. The Global Fund, despite strategic, policy and operational priorities on program efficiencies and effectiveness, is occasionally slowed down by difficult negotiations with recipient countries or disputes over accountability issues. Global AID remedial efforts should minimize red tape. The ultimate solution is to devise innovative and simple accountability mechanisms that meet acceptable standards of financial and administrative probity in both donor and recipient countries.

Fourth, it is time to start consolidating global H.I.V./AIDS remedial efforts.

In the United States, as in other major donor nations, multiple agencies manage international AIDS programs. Most multilateral agencies have AIDS programs active in developing nations. International foundations and private sector organizations also manage AIDS programs in the developing world.

It is not possible to fight an effective global war against H.I.V./AIDS if bilateral and multilateral agencies, nongovernmental organizations and philanthropic foundations provide similar services and jockey for operational space in target countries. Perhaps during the incipient stages of the pandemic, it was necessary to elicit a response from multiple agencies and programs as scientists, health professionals and policy makers grappled with an unknown infectious disease. However, at this stage, it is difficult to justify even the remote possibility that H.I.V./AIDS remedial efforts may suffer from duplication of services or lack of coordination. In addition, resource-challenged countries battling H.I.V./AIDS should not bear the additional burden of managing the multiple demands, priorities and objectives of external donor-funded projects.

I suggest the consolidation of international AIDS programming into five core competencies, with bilateral and multilateral philanthropies and advocacy organizations eventually aligning their expertise and functions in target countries over a defined period. The consolidated core-competency approach to H.I.V./AIDS remedial efforts will ensure that the expertise of affected organizations become aligned with the needs and priorities of the target population. Every organization aligned to a specific area of competence will work together to coordinate their activities and share resources.

Today, most of the discussions on how to minimize duplication of services and potential wastage of scarce resources by external donors in recipient countries focus on country level coordinating mechanisms rather than the consolidation of service delivery. A consolidated H.I.V./AIDS remedial effort based on core-competencies will be beneficial as inherent economies of scale kick in when these organizations pool their financial and technical resources to tackle an identified need on the ground.

The five H.I.V./AIDS core competences include:

A. Research and evaluation (basic, clinical, quantitative and qualitative studies and vaccine development).

B. Strategy development, policy coordination and partnership issues.

C. Information, education and communication campaigns.

D. Clinical care and support.

E. Financing and logistics of care.

On research and evaluation, research institutions in donor and recipient countries are most likely to assume leadership roles. This consolidated approach will most likely accelerate ongoing efforts to implement genuine partnerships (twinning) between research institutions in the West and their counterparts in the developing world.

Regarding strategy development, policy coordination and partnership issues, Unaids is most likely to retain its current role as the technical lead strategic partner. In addition, Unaids’ deep bench of policy guidelines and publications will serve as a guide on generic strategy or policy issues. However, deep-pocketed philanthropies such as the Gates Foundation will share a global partnership development role with Unaids since it currently finances some of the most ambitious global alliances against targeted diseases and health conditions.

For large-scale information, education and communication programs against H.I.V., bilateral agencies, foundations and advocacy organizations are likely to continue their leadership role as funding agents while host governments and community-based organizations in recipient countries lead implementation efforts at local levels.

On clinical care and support, the World Health Organization and medical institutions in both recipient and donor countries will continue to provide leadership, including long-term strategies for the training and retraining of local health staff.

A consolidated financial and technical core competency in recipient countries is most likely to be led by three entities with the huge economies of scale: The Global Fund, the World Bank and the Office of the United States Global AIDS Coordinator. The sheer size of the financial outlays of these organizations and their focus on eliminating financial and logistic hurdles to AIDS remedial efforts guarantees strong influence in this area.

In each recipient country, remedial efforts will also be organized around these five core competences to ensure seamless integration with external donor programs.

Fifth, training and deployment of health workers in Africa and other hard-hit regions is critical.

AIDS is messing up an already stretched health system in Africa. At least 95 percent of Unaids staff working in Africa in a 2004 survey indicated that lack of a qualified health workforce is a major hindrance in AIDS remedial efforts. Between 19 percent and 53 percent of deaths by government health workers in Africa is due to AIDS, according to Unaids. The health worker to population ratio in Africa is terrible: 1.4 health workers per 1000 people compared with 9.9 per 1000 in North America. This situation is made worse by the continuous migration of health workers from less-developed countries to the West. A revitalized international AIDS remedial effort should include a substantial outlay on the training and retraining of health workers in Africa and developed regions of the world. As of the time of this writing, I am not aware of a comprehensive, functional program to tackle the health worker crisis in Africa. In an earlier article on, my colleagues and I proposed an international volunteer H.I.V./AIDS services corps for Africa.

Sixth, government leaders in hard-hit countries should lead the fight against H.I.V./AIDS.

Two decades into this devastating pandemic, it is time to move beyond rhetorical and symbolic leadership on AIDS. Governments in Africa, the Caribbean, Asia and Eastern Europe should show long-term commitment by raising, substantially and permanently, the national budget on H.I.V./AIDS remedial efforts. In addition, national allocation to other healthcare programs should increase. Furthermore, no government in hard-hit countries should tolerate corruption and mismanagement of domestic and international funds. It is also crucial for governments of developing nations to seek ways of involving their nationals who live and work in the West in the fight against H.I.V./AIDS.

Seventh, align AIDS remedial efforts with poverty alleviation programs in hard hit countries.

Poverty remains a powerful inducement for high-risk personal behaviors that facilitate H.I.V. transmission. According to Unaids, poverty is at the center of the male dominated sexual networking in hard-hit countries that facilitate heterosexual transmission of H.I.V. Poverty alleviation programs should be aligned with AIDS remedial efforts at national and local levels.

This alignment must go beyond the poverty strategy papers favored by the World Bank and other development institutions. This alignment should focus on creating opportunities for wealth creation for low-income families. A key objective should be the implementation of female-friendly economic policies that promote entrepreneurship, property rights, human rights and wealth creation among women, especially young widows with small children.

Additionally, societal fault lines in hard-hit countries that could jeopardize hard-won gains in the fight against AIDS should be addressed. These fault lines include the role and status of women in the 21st century, enduring political and religious prosecutions of sections of the population, violent conflicts and wars over disputed lands and mineral resources, and damages to fragile ecosystems that destroy centuries-old means of livelihood. For example, in the Democratic Republic of Congo, a successful H.I.V./AIDS remedial effort is unthinkable while the multicountry conflict persists and rape remains a prized bounty of war. A major AIDS initiative in the Niger Delta region of Nigeria, which produces the country’s oil wealth, will require resolution of ongoing political, economic and environmental conflict between local inhabitants, oil companies and the central government.

Finally, shift the global war on AIDS to families and communities struggling to cope with the effects of the pandemic. The global war on H.I.V./AIDS should shift to villages, small towns, urban area and slums where families infected or affected by H.I.V./AIDS struggle to cope with the disease. To implement community-based AIDS strategies, it is important to develop measurable indicators for monitoring the impact of internationally funded programs.

As a start, I recommend that every H.I.V./AIDS remedial effort should respond to simple questions such as:

A. How many at-risk individuals changed their knowledge, attitude and perception regarding H.I.V. transmission, and ultimately changed their personal behavior through participation in specific international funded programs?

B. How many individuals clinically qualified to receive antiretroviral drugs receive them in a timely and consistent fashion through participation in specific internationally funded programs?

C. How many families infected or affected by H.I.V./AIDS receive support from specific internationally funded programs to meet nonhealth needs such as food, shelter, school fees, basic sanitation and so on?


The ultimate legacy of a successful global war on AIDS is how remedial efforts prevent new H.I.V. infection and how individuals living with H.I.V./AIDS receive timely clinical care and support services, including access to lifesaving antiretroviral drugs. Every year, millions of people contract H.I.V. Millions die of AIDS despite heightened global efforts. It is time to rethink current strategies. The war against H.I.V./AIDS is a race against time.

Chinua Akukwe teaches graduate courses on public health at the George Washington University School of Public Health, Washington, D.C. He has written extensively on health and development issues.

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