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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is no longer being updated, is at http://www.who.int/3by5/en.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
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