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Africa: World Backtracks on HIV Treatment

AfricaFocus Bulletin
May 21, 2010 (100521)
(Reposted from sources cited below)

Editor's Note

"Around the world thousands of doctors, nurses, legislators, and activists helped make treatment scale-up possible. Now a few power brokers and politicians who claim AIDS receives too much money seem intent on bringing to an end this remarkable effort, in effect saying to millions of people: drop dead. Without treatment, this is certainly their fate." - Gregg Gonsalves, International Treatment Preparedness Coalition

Uganda's Peter Mugenyi, who testified before the U.S. Congress earlier this year about the devastating effect of cutbacks in U.S. AIDS funding commitments on patients in Uganda (, provides the foreword for the latest report from the International Treatment Preparedness Coalition, which documents early warning signs of declining international and national commitment to universal access to treatment for AIDS, in Kenya, Malawi, and Swaziland as well as 3 non-African countries (India, Latvia, and Venezuela).

The report is the latest documentation of the threat of "AIDS fatigue," which is allowing governments in rich countries to backtrack on commitments to the Global Fund to Fight AIDS, TB, and Malaria and to the U.S. bilateral PEPFAR Program. Despite renewed efforts to call attention to the danger, and new commitments in key countries such as South Africa, the odds of providing universal access by the end of this year have reached the vanishing point. Today some 4 million people of the approximately 10 million who need AIDS treatment worldwide are receiving it, a dramatic advance from a decade again when most assumed that treatment for those in poor countries was impossible. But at least 6 million are not being treated (and under new WHO treatment guidelines the number needing treatment may increase by as much as 4 million more). The danger is that the global effort will falter rather than building on its successes.

This AfricaFocus Bulletin, available on the web, but not sent out by e-mail, contains a press release and substantive excerpts from the ITPC report. The full ITPC report is available on

Another AfricaFocus Bulletin sent out today has recent statements by AIDS activists calling for governments to meet their commitments. Demonstrations earlier this month included one in New York targeting a speech by U.S. President Barack Obama, and one in Dar es Salaam targeting the meeting of the World Economic Forum.

For previous AfricaFocus Bulletins on health issues, visit

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Evidence from Six Countries Confirms Fears of People Living With HIV/AIDS: Treatment Rationing Is Escalating

New report documents early warning signs of devastating impact to come from flatlining and cutting AIDS funding

International Treatment Preparedness Coalition

26 April 2010


Kay Marshall, New York, +1 347-249-6375,

Aditi Sharma, Delhi, +91 991 0046 560,

DELHI & KAMPALA - Rationing Funds, Risking Lives: World Backtracks on HIV Treatment, the new report from the International Treatment Preparedness Coalition (ITPC), documents early warning signs resulting from the global pullback on AIDS commitment and funding: caps on the number of people enrolled in treatment programs, more frequent drug stock outs, and national AIDS budgets falling short.

"AIDS is not over. ITPC's report clearly shows that the response is being starved, not overfunded. Governments, North and South, cannot afford to put the clock back and return us to the days when HIV was a death sentence," said Aditi Sharma of ITPC, coordinator of the report. The effect of government budget cuts and flatlined funding from major donors like U.S.' PEPFAR (President's Emergency Plan for AIDS Relief) and the Global Fund to Fight AIDS, Tuberculosis and Malaria are already being felt in the developing world. The Fund would need $20 billion over the next three years to help meet the health-related Millennium Development Goals (MDGs), but G8 nations and other donors are warning that raising even $13 billion (the lowest target which will mean a dramatic slow-down in pace of delivery) is a "huge stretch."

"In my home country, Uganda, for the first time since 2004, some HIV-positive men and women who are in need of life-saving antiretroviral treatment are being turned away because of funding cuts. Our greatest fear is that we may have to ration HIV medications for those already receiving treatment. How do you tell an HIV-positive mother that she can no longer have the drugs she needs to stay alive? ITPC's report makes it painfully clear that Uganda is not alone in facing an escalating treatment crisis," said Peter Mugyenyi of the Joint Clinical Research Centre in Uganda and author of the foreword.

As evidence mounts that AIDS treatment is inexorably linked with other health issues, including maternal health and tuberculosis, ITPC argues that it will not be possible to build sustainable, credible health systems as the waiting lines for AIDS drugs grow.

"Providing access to AIDS treatment for four million people has been the most ambitious public health effort in history," said ITPC's Gregg Gonsalves. "Around the world thousands of doctors, nurses, legislators, and activists helped make treatment scale-up possible. Now a few power brokers and politicians who claim AIDS receives too much money seem intent on bringing to an end this remarkable effort, in effect saying to millions of people: drop dead. Without treatment, this is certainly their fate."

Rationing Funds, Risking Lives documents numerous gains in providing access to HIV treatment in six countries. However, people living with HIV often struggle to afford medicines for opportunistic infections, transport costs, food, and second-line medications and continue to face stigma and discrimination. Programs to prevent vertical transmission of HIV run contrary to WHO guidelines in several countries and fail to reach most women. International Treatment Preparedness Coalition

In several countries, the financial sustainability of AIDS treatment programs is in question, effectively ending any hope of achieving universal access to HIV treatment or the MDGs. India: access to second-line antiretrovirals (ARVs) is severely limited because of strict eligibility criteria for the government program and high cost in the private sector. "As an emerging economy, India is facing dwindling support from donors," said Vikas Ahuja, of Delhi Network of Positive People (DNP+). "At the same time, we need to meet growing need, expand treatment access for most at risk populations and increase access to second-line ARVs and prevention of vertical transmission services. The government must urgently develop and implement sustainable plans to keep people alive."

Kenya: donor cutbacks and a lack of adequate domestic funds will cause the financing gap for treatment to further widen this year. "The outlook in Kenya is bleak. In the last few years, we've made progress on expanding access to treatment, but 90 percent of AIDS treatment funding comes from external sources," said Rosemary Mburu, of the Kenya AIDS NGO Consortium (KANCO). "We are now facing cutbacks from some donors, which will devastate our already over-burdened treatment programs. The government must step up and find ways to fill the financing gap."

Latvia: the government is imposing limits on the number of patients provided with free ARVs as HIV treatment costs are shockingly high compared to most other middle-income countries. "Latvia has been hard hit by the economic downturn and AIDS treatment programs are likely to be one of the causalities of government cutbacks," said Inga Paparde of Apvieniba HIV.LV. "HIV rates here are among the highest in the European Union, so this is no time to cap treatment programs and limit access. The government needs to move quickly to bring the price of HIV drugs down, including by using generic medicines."

Malawi: the health care system is further weakened by a severe shortage of qualified doctors and nurses. "In Malawi, some health facilities only distribute ARVs once or twice a week, to allow overworked healthcare workers to also focus on other health concerns," said Martha Kwataine of the Malawi Health Equity Network (MHEN). "We face a severe shortage of doctors and nurses, and we cannot adequately scale up HIV treatment or other health programs until this crisis is addressed."

Swaziland: tuberculosis is the leading killer of people living with HIV, yet effective integration of TB and HIV treatment is lacking. "Here in Swaziland, TB is the major cause of death for Swazis living with HIV, said Tengetile Hlophe of Swaziland for Positive Living (SWAPOL). "Far too many people are living with both diseases, but may only be receiving treatment for one. Many of those lives could be saved if TB and HIV treatment programs are better integrated."

Venezuela: the government is working from an outdated national AIDS plan and lacks reliable data on the number of people living with HIV or those in need of treatment. "We don't know how many people in Venezuela are living with HIV and how many need treatment--the government has no reliable figures," said Renate Koch of Acci¢n Ciudadana Contra el Sida (ACCSI). "The government must take responsibility for improving epidemiological data and must work with civil society to develop a National Strategic Plan in order to increase awareness, testing, and treatment of HIV."

The report, the 8th in the Missing the Target series, is published by International Treatment Preparedness Coalition (ITPC). The full report is available at /ENDS

Missing the Target

Rationing Funds, Risking Lives: World backtracks on HIV treatment

On-the-ground research in India, Kenya, Latvia, Malawi, Swaziland, and Venezuela

April 2010

International Treatment Preparedness Coalition

contact information Aditi Sharma:

Sarah Zaidi:

Gregg Gonsalves:


In March 2010, I was invited to give testimony before the U.S. Congress by the House Subcommittee on Africa and Global Health. The focus of the gathering, at which I was joined by other health and HIV advocates from around the world, was the Obama administration's budget request for the 2011 fiscal year for the landmark U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The proposed budget would increase funding for PEPFAR by 2.2 percent.

First and foremost, I would like to express our thanks and great appreciation to the American people for PEPFAR. More than three million people are now getting lifesaving antiretroviral treatment (ART) in resource- constrained countries, most of them in Africa. These people-- and their mothers, husbands, wives and children--got a chance to live. This is a chance they simply would not have without these drugs.

However, the AIDS crisis is not over. On the contrary it has gotten worse because it was left to get far out of hand before any serious international intervention took place. The logical response following the start of PEPFAR (in 2003) and the launch of the Global Fund (in 2002) was a long-term commitment to match funding support with the inevitable rise in demand, while building up the capacity of the hard-hit countries until the back of the epidemic is broken. That commitment was made, most noticeably at the summit of G8 leaders in Gleneagles, Scotland in 2005. Within three years, however, most countries had abandoned it.

Yet even in light of the fact that about 60 percent of people in urgent need of lifesaving ART are still not accessing it, some would say, and have said, that even matching last year's level, let alone an increase, is remarkably generous given the current economic and political climate in the United States and much of the world. I don't agree. Along with other major donor nations, the United States made a commitment at Gleneagles to significantly ramp up funding and support for pressing global development concerns, including HIV/AIDS. It is not alone in having failed to honour that pledge in recent years, and a paltry increase of 2.2 percent for PEPFAR will do nothing to get it back on track. The gravity of the situation being as it is, there is nothing generous about this development or trend.

Donor governments' inability or unwillingness to meet their commitments is one of the main reasons the ambitious--but certainly never irrationally unobtainable--goal of achieving universal access to HIV treatment by the end of 2010 will not be met. The consequences are dire both for the millions who have been able to access lifesaving treatment in recent years and the millions more in need.

In my home country, Uganda, lower-than-anticipated funding support from PEPFAR and other donor entities in the past couple of years has forced many facilities to turn away new HIV-positive patients seeking ART. Individuals already on treatment and their health care providers are worried that insufficient funding could force a rationing of care that would lead to some patients having their ART access revoked entirely unless they pay for it--if the medicines are even available in pharmacies and at clinics--out of pocket. Given the costs of ARVs and high levels of poverty, that is not an option for most people in Uganda or elsewhere in the developing world.

The findings of this issue of Missing the Target make it painfully clear that Uganda is not alone. The invaluable research by local advocates in the six focus countries--India, Kenya, Latvia, Malawi, Swaziland and Venezuela--acknowledges and highlights the remarkable progress made over the past decade in increasing access to HIV treatment, prevention and care services around the world. Yet even though contexts and challenges differ in the six countries, all face major constraints on their ability to increase and sustain HIV treatment scale-up. They need substantially more, not less or incrementally increasing, financial and technical support. Their own governments can and must do more, but they cannot cover the gaps on their own. Nor should they be expected to. The international community must remember that achieving universal access was once seen as a necessary global priority toward which all partners would contribute.

This step should be complemented by redoubled efforts by advocates and policymakers to understand and combat another trend gaining influence in recent years: that "too much" money is spent on AIDS. This argument, which is part of the so-called backlash against disease-specific funding and programming (including for HIV/AIDS), is based on a belief that money spent on AIDS would be better spent from a cost- benefit analysis on addressing other health needs or for broader investments in health systems.

Such assumptions and calculations are not only heartless but misguided. For one thing, there is no finite amount of resources for global health or--as evidenced by the hundreds of billions of dollars found by the United States and other governments for domestic economic stimulus in the past two years--for any other priority. AIDS should have been on a priority list for stimulus money, considering the sheer numbers and carnage in its wake. It doesn't get too much money; instead, it and other global health needs all get far less than they should. Political will, not available resources, is the real obstacle.

This Missing the Target report is an important reminder that despite all we have gained, we stand to lose it all and much more. The HIV epidemic is a global epidemic that requires global solutions. The drive for universal access was such a solution because not only did it (at least initially) more closely link countries of different needs and resources, but it also began the important process of closing gaps within countries. HIV remains a highly stigmatized disease. It can only become less so when treatment is available to all in need, including members of vulnerable populations such as women, injecting drug users and men who have sex with men. Without the promise of treatment, these individuals will remain on the margins of society in many countries, thereby reinforcing discrimination and stigma. The future of all nations and the world overall cannot afford to let that happen.

Peter Mugyenyi Executive Director Joint Clinical Research Centre Kampala, Uganda

Executive Summary

The six country reports of Missing The Target 8 show early warning signs of the negative impact of the global backtracking on AIDS commitment and funding--some governments are beginning to cap the number of people enrolled in treatment programmes and drug stockouts are more frequent. If this trend continues, the result will be suffering and death for millions of people around the world currently living with HIV and the millions more who will be newly infected this year and the years to come.

Funding from major donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is stalling or flatlining, and reports from several African countries over the past year (the Democratic Republic of Congo, Mozambique, South Africa, Uganda and Zambia, for example) indicate that their government-run antiretroviral treatment (ART) programmes are turning patients away because of cuts in both domestic and external funding.

Stalling the AIDS response dooms the effort for stronger health systems that is now popular among major donors. It will not be possible to build sustainable, credible health systems as the waiting lines for AIDS drugs grow. The report's findings clearly demonstrate that programmes that have achieved hard-won successes against AIDS are now being starved of financial support--a development that prevents them from coming close to the goal of delivering universal access to HIV treatment, prevention and care by 2010.

Today, some 4 million people have access to HIV treatment but another 6 million people who need treatment do not have it. New guidelines from the World Health Organization (WHO) recommend that ART be started sooner in the course of HIV infection to preserve health and prevent transmission. Millions of lives depend on the continued scale up of treatment programmes.

The world's progress in tackling AIDS has also had substantial benefits for health systems strengthening; training of health care workers; the treatment of TB and other infections; health care for marginalized and vulnerable groups; and the engagement of civil society in setting national health policy. Strong political leadership and increased funding have been crucial to this progress.

AIDS Funding Cutback: Writing cheques that bounce

G8 and the Global Fund

Promised: $10 billion a year

Delivered: $3 billion a year

2001: Created with the full support of the G8 club of rich nations, the Global Fund was intended to be a "war chest" worth $10 billion a year.

2008: Paltry donations followed the bold promises and by 2008, donors scraped together only $3 billion a year.5 In 2009, ambitious and sound proposals from developing countries were met with "efficiency" or budget cuts of 10-25%.

2011-2013: In March 2010, the Global Fund estimated that it would need $20 billion over the next three years if it is to expand its funding and help meet the health-related Millennium Development Goals (MDGs).

Donors are using the global economic crisis as an excuse to continue short-changing the fund. Some warn that raising even $13 billion (the lowest scenario, which would mean a dramatic slow down in pace of delivery) is a "huge stretch."

President Obama and PEPFAR

Promised: $48 billion over 5 years

Delivered: Flatlined funding trajectory

2007: Barack Obama pledges $50 billion over five years for PEPFAR during his campaign.

2008: U.S. Congress commits to $48 billion over five years in bipartisan legislation endorsed by candidates Obama, McCain and Clinton.

2010: The global economic crisis is being used as an excuse to flatline PEPFAR funds compared to much higher year-on-year increases in previous years, especially from 2006-2009. The effects are already visible with new patients being turned away from treatment in PEPFAR-funded programs in Africa.

Short-changing health

African leaders

2001: In the Abuja Declaration, African leaders pledged to allocate at least 15% of their annual budgets to health spending.

2007: Of the 52 nations, only three countries (Botswana, Djibouti and Rwanda) attained the target in 2007, while three others (Burkina Faso, Liberia and Malawi) attained the target for some of the period between 2001-2007, leaving 46 countries that have yet to fulfil their commitment even once.

President Obama and the Global Fund

2007: During his campaign, Barack Obama pledges to contribute the United States' fair share to the Global Fund.

2010-11: U.S. Congress allocates $1.05 billion to the Global Fund, which is about $1.7 billion less than the country's fair share towards the Fund's overall needs. In 2011, President Obama is proposing to cut funding to the Global Fund and provide only $1 billion.


The response to AIDS has been remarkable over the past decade, but the successes are fragile and are vulnerable to quick collapse. Abandoning the AIDS response now will inevitably lead to a return to headlines about people dying of AIDS that we read at the beginning of the decade. Without the continued political will in tackling AIDS, there is no chance of the world meeting the 2015 Millennium Development Goals (MDGs) by 2015. The consequences of a retreat on AIDS are severe: millions of needless deaths.

Five current Myths v. current Realities

Myth: Too much money is being spent on AIDS

Reality: Funding for AIDS is billions of dollars short of what is needed11 o Needed in 2010: $25.1 billion o Invested in 2008: $13.7 billion o Funding gap for 2010: $11.4 billion-- assuming the world maintains its pre-economic crisis commitment to AIDS.

Myth: Money spent on AIDS is at the expense of other health needs or investment in health systems

Reality: The total amount of development assistance for health quadrupled from $5.6 billion in 1990 to $21.8 billion in 2007--much of this catalyzed by the increased funding and commitments to HIV/AIDS.

Although the Global Fund and PEPFAR are among the largest global AIDS funders, they are also some of the biggest investors in health systems, with 35%13 and 32%14 of their respective funding devoted specifically to health systems strengthening.

Myth: Strengthening health systems alone will help address health problems including AIDS

Reality: Strong health systems alone do not guarantee equitable and universal health care. Past public health approaches failed to reach the most marginalized--women, MSM, sex workers, IDUs, the very poor and those living in rural areas. Health systems need both breadth and focus.

Myth: Prevention is more important than treatment

Reality: Activists never pit prevention and treatment against each other--on the ground they work together. Treatment can enable more effective prevention by reducing transmission and encouraging testing and prevention makes treatment affordable.

Myth: AIDS has been addressed unlike maternal health or other diseases

Reality: The AIDS crisis is not over. AIDS activists have been the most effective advocates for health in history. The energy and passion of AIDS activists can be used to build stronger health systems, and tackle maternal and child health--since all these issues are interlinked in the first place. Let's stop pitting disease against disease.

Country Findings

Research conducted for Missing the Target 8 in six countries (India, Kenya, Latvia, Malawi, Swaziland and Venezuela) has revealed that access to treatment for people living with HIV (PLHIV), while making some gains, remains hindered by a variety of barriers in their countries.

From high-burden and relatively poor nations in sub-Saharan Africa (such as Kenya, Malawi, and Swaziland), to large emerging economies (India), to middle-income countries with relatively small epidemics (Latvia, Venezuela), in-country researchers found that the future of even the currently inadequate treatment programmes are in question. At a time when international guidelines are calling for more people to be put on treatment both for their own health and to more effectively control the AIDS epidemic, countries are headed backwards. Governments are finding various ways to cap the number of people enrolled in treatment programmes. Stock-outs of medicines to treat opportunistic infections (OIs) have become more common, and diagnostics machines are lacking in quantity and/or quality at the very time that they are needed more than ever, given the changes to the WHO guidelines for treatment initiation.

In all of these countries, PLHIV are struggling to cover the many uncovered costs of, for example, OI medications, medical consultations, transport costs, food, and second-line medications. Also in many countries, laws to protect vulnerable and marginalized groups like MSM and sex workers are still lacking, and many PLHIV interviewed spoke of high levels of discrimination in health care settings. Several countries continue to give confusing advice about infant feeding options and use single-dose nevirapine as the prophylaxis to prevent vertical transmission of HIV contrary to WHO guidelines. Finally, weak health systems, many plagued by great shortages of health care workers, lead to poor conditions and services that impede AIDS treatment and broader health care access.

In addition to these overarching themes, there were unique findings in each country:

  • In India, a financing gap of $67 million remains for the implementation of the National AIDS Control Programme (2007 to 2012). The government has yet to meet its commitment on diagnostic testing in terms of the frequency, affordability, or quality of the tests. In addition, important medicines for the treatment of OIs and TB are not always available at all facilities, while access to second-line ART is severely limited because of strict eligibility criteria for the government program and high cost in the private sector. Prevention of vertical transmission programmes do not focus on the woman's own health and continue to use a less effective antiretroviral prophylaxis that is not in line with the latest WHO guidelines.
  • In Kenya, donor cutbacks and a lack of adequate domestic funds will cause the financing gap for HIV/AIDS treatment and services to further widen this year--making it even more unlikely that the government will meet its universal access goal by 2013. PLHIV struggle with the burdens of the costs of important health care services, including medicines, consultations and diagnostics to treat OIs and many inpatient services, as well as transportation and nutrition costs. Lack of sufficient--and sufficiently trained--health care workers is a chronic problem, and in rural areas in particular, there are too few facilities providing ART. HIV-related stigma throughout society continues to hinder many people from seeking out HIV services, from testing to ART.
  • In Latvia, as part of its budget-tightening steps in the face of a severe economic downturn, the government is cutting the HIV and health services budget and imposing restrictions on the number of PLHIV provided with ART free of charge. Generic medicines are not procured, and as a result, the cost of treatment to the government is shockingly high compared to many other middle-income countries. Many primary care providers are reluctant to treat PLHIV because they have insufficient or limited knowledge about HIV, or because of the stigma associated with illicit drug use. This makes efforts to decentralize services difficult (currently there is only one main comprehensive ART centre in Latvia). Lack of integration of HIV care and drug treatment services is another key reason why injecting drug users--an especially vulnerable and affected population in Latvia--lack access to HIV treatment.
  • In Malawi, cutbacks in government support for the National AIDS Commission are causing a reduction in the depth and scope of HIV/AIDS services. The health care system suffers a severe shortage of qualified doctors and nurses. The burden of transport and other out-of-pocket costs bar access to treatment and services for many PLHIV, and a high percentage of PLHIV entering hospitals for treatment are not aware of their HIV status. Second-line drugs are not available to PLHIV, while OI drug stock-outs and limited CD4 testing availability have also been reported.
  • In Swaziland, the government has yet to meet the 2001 Abuja Declaration commitment to allocate at least 15 percent of its annual budget to the health sector (allocating just 13.5 percent in its most recent budget, unveiled in April 2010). A lack of HIV awareness and testing, and trust in traditional health beliefs and practitioners who are not grounded in the science of HIV, prevent people from accessing necessary treatment. TB is the leading cause of death of PLHIV in Swaziland, yet TB programmes have high default rates. Long lines and delays are reported at hospitals, where doctors and nurses are too few in number and there is a limited amount of diagnostic equipment. The costs of obtaining OI medicines (which are not provided free of charge), consultations, and transportation bar access for PLHIV to comprehensive HIV treatment.
  • In Venezuela, the National AIDS Program (PNS) lacks up-to-date and reliable data on the number of people living with HIV and those in need of ART, however most advocates believe it is growing.

    The National AIDS Strategic Plan of 2003-2007 is out of date and civil society is calling for a new plan to be drafted in consultation with civil society organizations. Currently, there is a lack of coordination between government and civil society organizations in delivering services for PLHIV. In most rural areas, patients must rely on small outpatient-oriented facilities that provide only basic services--and most do not offer HIV/AIDS care, including ART. Limited HIV awareness is a major barrier to early treatment uptake across the country, and PLHIV cite a lack of support from health care workers among the reasons for low adherence to ART regimens. Consequences of a weak health system--such as long delays for routine services, unsafe and unhygienic conditions, lack of adequately trained personnel, low salaries, deterioration of facilities, and shortages of basic materials--have had negative impacts on the quality and effectiveness of HIV treatment services.

Treatment access needs remain great, and backtracking will stall efforts to deliver other health care goals as well. Improving the AIDS response has improved health care systems, including by establishing reliable methods of medicine delivery for all populations, ensuring quality and availability of diagnostics equipment, reaching out to vulnerable populations, supporting more doctors and nurses, and so on--all fundamental blocks of strong health care systems.

And let us not forget: AIDS is not only a major killer of people but devastates communities and economies. World leaders who rushed to plow money and effort into bailing out the financial institutions that caused the global economic crisis cannot justify short-changing a crisis that kills over 5,000 people each day. Let's prevent the tragedy of letting our progress fall apart, just at a time when the return on investment--lives saved--is beginning to pay off.

Our Recommendations

Priority actions at the global level aimed at improving access to AIDS treatment and care include the following:

1. Donor governments: Pay up--contribute your fair share to the global fight against AIDS.

Rich countries and leaders should not abandon their political commitment to tackling AIDS just as we see some glimmers of hope. Sixty percent of people who need HIV treatment still do not have it and many more should receive treatment if we are to stop over 7,000 new infections every day.

2. Developing country governments: Make the health of your citizens a top priority in your budget.

Hungry and sick people cannot contribute to the growth of their nation. The economic and political cost of not saving the lives of your people is far higher than the increased resources required to effectively control HIV/AIDS or meet their basic health needs.

3. UNAIDS: Reject universal access targets set by some governments that do not aim to provide equitable access for all. Setting a low bar does nothing to advance the cause of why AIDS should continue to remain high on the global political agenda. The goals are achievable and the excuses are wearing thin.

4. Health and social justice movements: Unite to demolish the "AIDS backlash" that seeks to pit disease against disease or food against medicines.

Activists know that communities do not live their lives in separate programmatic areas--a young HIV-positive woman in a rural area does not just need ARVs, but a means of earning a living, adequate food to feed herself and her family, a functioning antenatal clinic and the right to live free of discrimination and violence. We need to mobilize against the false debates taking place in hallowed circles far away from the realities of this young woman.

5. Donors and international agencies: Put your money where your mouth is and pledge extra resources to end the crisis of health workers and health systems.

It is not AIDS that is starving the health systems but wrongheaded macroeconomic policies and decades of underinvestment. The answer is not to cut AIDS or vertical funding and go back to old ways of providing "generalized health support". The latter did not achieve as much for the health of people as the AIDS movement which has delivered measurable progress in numbers of lives saved; in reducing the cost of medicines; in building up crumbling health systems; in improved training for nurses and doctors and most importantly in securing more resources for other neglected diseases and health overall.

6. Governments and international agencies: Build on the public health lesson that AIDS has taught us - without reaching women, children, MSM, sex workers, IDUs, your efforts to control AIDS will fail. Public health can be advanced only when the fundamental human rights of the most marginalized and vulnerable groups are respected, protected and fulfilled. Criminalizing MSM, sex workers and IDUs and discrimination and violence against women remain major barriers to effective AIDS programmes and the goal of universal access. The AIDS response has shown how much more can be achieved when governments meaningfully engage and work together with representatives of civil society, in particular, those most affected by the disease.

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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