The United Nations, AIDS, and the Long Battle Ahead

U.N. Secretary General Kofi Annan speaks May 31 during the opening plenary session of the United Nations High Level meeting on AIDS in New York. Annan called for universal access to H.I.V. prevention by 2010, and chided member states for their "distressing" failure to meet targets set five years ago. (Photo: Stan Honda / AFP-Getty Images)

As heads of state and government, diplomats and technical leaders ended the recent United Nations High Level meeting on AIDS, which took place May 29 to June 2, the attention of the world once again turned to other major world events. However, for individuals, families, and communities battling a pandemic that is now 25 years old, the struggle for life continues.

As noted by 2006 Assembly President Jan Eliasson during his closing speech, at least 20,000 people lost their lives to AIDS and more than 30,000 contracted H.I.V. in the time that the General Assembly met to discuss the issue. The situation is grim but participants at the meeting affirmed, "We now have the means to reverse the global pandemic and to avert millions of needless deaths." The task ahead could not be bigger. It is a race against time to save lives and prevent new infections.

As policy makers, experts, and advocates regroup, it is important to review the challenges that lie ahead. The declaration the United Nations adopted to bolster their fight against AIDS recognizes the enormity of what lies ahead, including the need to commit substantially more resources to the fight against the pandemic, up to $20 billion to $23 billion a year by 2010, and the imperative of a multisectoral, multifactorial response to the pandemic, ranging from the impact of trade imbalances to the need for new, safe, affordable and accessible H.I.V./AIDS medicines, products and technologies.

Before the discussion on what lies ahead, it is important to review briefly the current state of H.I.V./AIDS remedial efforts.

Where Are We Today on H.I.V./AIDS?

This meeting builds on an earlier meeting in 2001, where delegates from member nations effectively put the pandemic in the political arena. This led to an unprecedented attempt by the international community to deploy creative alliances and initiatives at a scale hitherto unknown in medicine, public health, and development to tackle specific obstacles to H.I.V./AIDS remedial efforts. Initiatives to improve access to available H.I.V./AIDS medicines accelerated worldwide. Individuals and civil society organizations are now leading the fight to end the stigma associated with H.I.V./AIDS and to confront gender, social, economic and demographic discrimination that increase risk status and undermine remedial efforts.

Businesses in the West and developing countries formed alliances on H.I.V./AIDS and now organize remedial programs for their workers and family members. Increasingly, a growing number of countries with huge numbers of people living with H.I.V./AIDS or with high rates of infection are mobilizing resources to fight back. Botswana, South Africa, and Nigeria now have ambitious national rollout plans to provide AIDS medicines to those in need. Uganda and Senegal continue to be leaders in H.I.V. prevention efforts. Political leaders worldwide now understand that stopping AIDS is an important part of their work.

Regarding rates, figures and numbers, the situation is mixed. According to the May 2006 progress report by UNAIDS, there had been notable success in deploying financial resources in the fight against AIDS. Between 1996 and 2005, the amount of money devoted to H.I.V./AIDS worldwide increased from $266 million in 1996 to $1.7 billion in 2001, and, then rose to about $8.3 billion in 2005. The expenditure in 2005 is within the range of the $7 billion to $10 billion a year requested in the 2001 U.N. General Assembly declaration.

In sub-Saharan Africa and in moderately middle-income countries, domestic expenditure on H.I.V./AIDS was about $2.5 billion in 2005. The number of people accessing voluntary testing and counseling services in more than 70 countries, according to UNAIDS, increased from 4 million in 2001 to 16.5 million in 2005. In a stunning reversal, testing for H.I.V. in transfused blood is now a routine occurrence in most developing countries.

Despite these successes, there have been failures in H.I.V./AIDS remedial efforts. Today, according to UNAIDS, only 9 percent of pregnant women worldwide have access to antiretroviral therapy that prevents maternal transmission of H.I.V. to newborns. It is thus not surprising that in the last five years at least 3 million newborns contracted H.I.V. either in utero or shortly after birth.

Support efforts for 15 million AIDS orphans remain largely ineffective: less than 10 percent of these children have any form of care or social support. In addition, less than 50 percent of young people are knowledgeable about H.I.V. transmission patterns. At least 50 percent of countries that submit reports to UNAIDS acknowledge that they still have policies and legal statutes in place that prevent effective prevention and treatment programs. Human rights violations of those living with H.I.V./AIDS and their families remain widespread in many countries, including those in the frontlines of the fight against the pandemic.

The most striking failure of worldwide remedial efforts against H.I.V./AIDS is the fact that millions of people die every year despite the availability of lifesaving antiretroviral therapy. According to UNAIDS, in sub-Saharan Africa only 17 percent of the 4.7 million people who qualify for antiretroviral therapy receive it.

The failure of the World Health Organization's 3 by 5 initiative (to put 3 million out of about 6 million people in need of treatment, in antiretroviral therapy by the end of 2005) is a vivid illustration of the work that lies ahead if we are to meet the needs of those who desperately need lifesaving medicines. One is left to wonder how many of the 2.8 million people who died of AIDS in 2005 would have been saved if they had had access to lifesaving therapies.

Critical Unresolved Issues in H.I.V./AIDS Remedial Efforts

1. Most individuals and families living with HIV/AIDS are not benefiting from ongoing remedial efforts. The biggest challenge before policy makers, technical experts, and advocates is the indisputable fact that most individuals and families living with or affected by H.I.V./AIDS are not getting help despite the rapid scale up of domestic, regional, and international H.I.V./AIDS programs.

For the 2006 United Nations meeting to become as historic as the 2001 meeting, policy makers worldwide, especially those in bilateral and multilateral agencies and governments on the frontlines of the pandemic, should come up with specific strategies for translating AIDS remedial efforts into measurable indicators and measurable impact at individual and family levels.

2. At least half of the individuals at risk of contracting H.I.V. are out of the reach of current preventive programs. Prevention remains a fundamental flaw of ongoing global program efforts. The incidence of H.I.V. continues to rise because of a steady cohort of at-risk population that eventually contracts the virus. Domestic and international organizations active in the planning and implementation of the information, education, and communication campaign against H.I.V. transmission now have the huge task of designing strategies that meet the preventive needs of risk populations.

3. Community-based systems of care are not yet a major focus of H.I.V./AIDS program efforts. Today, most active H.I.V./AIDS programming occurs at a national level. The emphasis is on national strategic plans, national policies, national AIDS committees, and national programs. What is glaringly missing is a systematic, organized, and comprehensive effort to implement H.I.V./AIDS remedial programs at community levels. A community-based system of care will bring H.I.V./AIDS remedial efforts closer to individuals and families in urgent need of assistance. Policy makers and technical experts should seek ways of transforming international and domestic AIDS remedial efforts into community-driven and community-based initiatives.

4. Lack of access to antiretroviral therapy and other forms of care remains a major problem. In all likelihood, the long-term success of the 2006 meeting, especially in the next five years when a major review is scheduled, will rest largely on how the international community successfully resolves the current anomaly whereby millions of people must die because they cannot be provided with available lifesaving medicines. The meeting rose to the challenge, reaffirming that "access to medication in the context of pandemics, such as H.I.V./AIDS, is one of the fundamental elements for progressively achieving the full realization of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."

A global movement to dramatically improve access to lifesaving medicines and supportive care would require specific initiatives that unite research and generic pharmaceutical companies in the urgent task of making antiretroviral therapy medicines available to those in need, and unite governments of rich and poor nations in a shared vision to save lives. In this regard, rich nations will make resources available on time for specific remedial initiatives and recipient nations will implement AIDS remedial programs with the highest levels of accountability and effectiveness. There is a need, too, for an initiative to unite professional associations in the West and developing nations in organized efforts to overcome health worker shortages and crises in recipient countries.

In this regard, it is a welcome development that the 2006 meeting unambiguously reaffirmed that "the World Trade Organization Agreement on Trade-related Aspects of Intellectual Property Right does not and should not prevent members from taking measures now and in the future to protect public health." The meeting also resolved to "assist developing countries to enable them to employ the flexibilities outlined in the World Trade Organization Agreement on Trade-related Aspects of Intellectual Property Rights, and to strengthen their capacities for this purpose."

International initiatives to improve access dramatically to antiretroviral therapy, other medical products, and supportive care will require verifiable timelines for action, dedicated resources, and transparent monitoring and evaluation mechanisms. As of today, I am not aware of any insurmountable obstacle that would prevent pharmaceutical companies, national governments of H.I.V./AIDS endemic countries, and the rich nations of the world from dramatically improving access to lifesaving medicines in developing countries. Today, one in six people living with AIDS in sub-Saharan Africa face inevitable death due to lack of access to these medicines. The newborn infants of 42 percent of the pregnant women in Swaziland living with H.I.V./AIDS face an uncertain future and may never have the opportunity for a healthy start in life.

5. Implement universal access strategy to prevention, treatment, and support care. As I noted in an earlier article, there are major challenges to a meaningful and effective universal access strategy. The United Nations meeting resolved to move "toward achieving the goal of universal access to comprehensive prevention programs, treatment, care, and support by 2010." The way forward in universal access is to move beyond the rhetoric to specific strategies on how best to meet the needs of 38.6 million people worldwide who currently live with H.I.V./AIDS. To be adopted, universal access strategies should be measurable, have timelines, indicate unambiguous responsibility centers, and have dedicated financial and technical resources.


The ultimate tribute that the distinguished men and women who participated in the 2006 meeting can pay to individuals and families living with H.I.V./AIDS is to use their respective positions and spheres of influence to meet their treatment and supportive care needs. They should also work toward specific strategies and initiatives on how best to assist at-risk populations to change their behaviors and avoid contracting H.I.V. History beckons as the world renews its battle against a deadly pandemic.

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