UN Statement 'Commitments on HIV/AIDS must be matched by actions'

Is it just me or is the final statement coming out of the last few days of meetings more than a little bland? It feels just a little like the world is treading water and marking time rather than really having any sense of urgency about tackling AIDS.

Nevertheless, a message to all delegates from the President of General Assembly on June 12 did emphasise the following five priorities for the next two years:

1. Focus on developing all health systems to respond to the pandemic as a public health issue - that is tackling brain drain of health workers, strengthening supply chains and public health systems (including monitoring and evaluation), etc, etc.
2. Human rights and gender equality must be central to any National HIV Strategy
3. Access to treatment, prevention and support services must improve considerably
4. Civil Society (including faith based groups, community organisations and networks of people living with HIV & AIDS) must be included in the process of planning, implementing and monitoring any effective National HIV Strategy.
5. Political leadership and accountability are vital - if there is not a commitment from the top of government, and at every other level of society (right down to local community leadership), no National HIV Strategy can be truly effective
   

These are welcome comments, but mainly echo what we have all been saying at one time or another. However, if the UN will commit itself to getting national governments to address these five priorities, one role we can have as FBOs is holding our governments to account for delivering the targets set in 2001 and 2006. But for that, we must be more engaged not only with our governments, but also with wider Civil Society.

Meanwhile, the Civil Society statement issued on June 11 reminds the world that the commitments are not being met and much needs to be done still

Civil Society Declaration on the UN High Level Meeting on AIDS
As civil society participants to the 2008 High Level Meeting on AIDS, we came here to review progress in implementing the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/ AIDS. We were disappointed that few heads of state chose to attend this meeting and many governments, from both resource-rich and resource-poor countries, failed to report the reality on the ground.

None of the UNGASS goals were achieved in 2003 or 2005, despite the efforts of some governments and key stakeholders. We are deeply concerned that given the current rate of progress, due to a lack of commitment and the ever-increasing funding gap, universal access will not be achieved by 2010, perpetuating the cycle of underdevelopment and poverty.

We urge governments to fulfil their commitment, human rights obligations and ensure the implementation of universal access to the treatment, prevention, and care for all by 2010. We raise the attention of governments, the UN system and all stakeholders to the following issues:

Universal access by 2010 requires comprehensive, non-discriminatory access to prevention, treatment, care and support for all people affected by HIV in high and low prevalence countries, including women, girls, children, young people, transgender, men who have sex with men, sex workers, migrants, prisoners and those who are institutionalized, older people, lesbians, bisexuals, disabled people, care givers, people who use drugs, indigenous people and other groups marginalized because of their ethnicity, religion, legal and economic status, or gender identity, regardless of their geographic location (rural/ urban). Universal access includes comprehensive sexual and reproductive health services and treatment for all co-infections, including TB.

Human rights must be at the centre of all responses to HIV.

The criminalization of HIV transmission and population behaviours marginalizes the vulnerable and affected groups (mentioned above). It is a violation of human rights and is a barrier to accessing prevention, treatment, care and support. All laws criminalizing transmission and behaviours must be abolished. We urge all governments to abandon travel restrictions that block people living with HIV/AIDS to move freely across the world, as well as all coercive measures such as mandatory testing and deportation.

It is critical that women’s, especially young women and girls’, human rights are central to the goals of halting this pandemic.

The parallel 2009 High Level Meeting on Drugs must reflect commitment to public health and human rights as championed by the High Level Meeting on AIDS.

Resourcing the response to HIV/AIDS. We are concerned about the shift of financial priorities from AIDS to other issues, and the lack of transparency and meaningful participation of civil society in decisions about funding allocation and priorities. Therefore we urge the governments of high-income countries, especially the G8, to fulfil their commitment of contributing 0.7 percent of their gross national product to official development assistance. In order to achieve universal access by 2010, 42 billion USD is needed. There should be sufficient support for the development of long-term solutions including research, vaccines and microbicides.

Access to treatment: Countries should be enabled to use the full safeguards enshrined in the TRIPS agreement and confirmed in the Doha declaration of 2004, such as compulsory licensing. The impact of international trade agreements needs to be evaluated further, as set out in the 2001 UNGASS Declaration of Commitment (para 26).

Involvement of Civil Society: Greater involvement of civil society has been identified by the UN as a critical strategy to combat AIDS. In a resolution tabled late in 2007, civil society was specifically encouraged to be involved in this year's high-level meeting. The involvement of civil society in official national delegations must be effective, not just tokenistic.

We join the three excluded organizations; Gays and Lesbians of Zimbabwe, Jamaica Forum for Lesbians, All-Sexuals and Gays, and the Egyptian Initiative for Personal Rights; from this year’s meeting in appealing to the UN General Assembly to ensure that the rhetoric of "universal access" is matched with participation and inclusion of all voices. It is necessary to develop a mechanism to monitor accountability that ensures meaningful participation of civil society, especially people living with HIV and marginalized groups (as listed above), in country level and international processes.

Accountability: Many countries have failed to report the realities on the ground to this assembly, almost forty countries did not report at all. There is a need to address the discrepancies between the official country reports and the civil society reports, by strengthening accountability mechanisms at all levels. Indicators against which reports are prepared must include qualitative dimensions, and governments should report data disaggregated by age, gender and sub- population (as a minimum requirement).

We call on UNAIDS to adequately and effectively monitor and evaluate the national response with full participation of all civil society, particularly people living with HIV.


We have come to this high level meeting to demand your partnership and renewed commitment to achieving the goals set at the UNGASS 2001 and the high level meeting in 2006. Real partnership between donors, governments, civil society, UN agencies and affected populations requires a balance of power in making decision. Only through genuine partnership can we overcome the challenges to and achieve universal access to prevention, treatment, care and support for all people by 2010.

This statement supports further recommendations from the women’s caucus statement “Women Demand Action and Accountability Now!” and the Youth caucus statement. It draws on the positions developed by each regional caucus for the High Level Meeting on AIDS.

NB - although ninety nine Civil Society Groups signed this, only two that I could identify were faith based; World Vision International and the Pastoral Ecumenical Alliance for HIV – Argentina (there may be others that I did not recognise as faith based). I think that to some extent this reflects on the level of engagement of many FBOs around the world not just at the High Level Meeting, but also in our engagement with government and the rest of Civil Society.

Final Thoughts

This was quite a different meeting to UNGASS 2006 - it was only two days instead of three, there were fewer delegates, and there seemed to be a lower energy level. There was also no clear document coming out of this - the UN General Secretary having released the progress report and recommendations prior to the meeting. This meant that there was a slow 'fizzle out' rather than an energetic series of negotiations to find an agreement that all UN members states could sign up to.

Maybe the main issues coming out were the need to lift international travel restrictions for people living with HIV. Human rights issues in general were to the fore, and concerns that criminalisation of some at risk groups and those living with HIV was becoming more common. This can make access to prevention, care and treatment very difficult.

Overall, the huge treatment gap, and the failure to keep pace with rates of new infection were highlighted. And maybe evidence of a swing in emphasis in the global response back towards prevention after so much energy has gone in to treatment over the last four or five years.

However, I think it is even more interesting what was not talked about - e.g. multiple concurrent partnerships as a major factor in rapid spread of the pandemic in Southern and Eastern Africa in particular, the fact that a generalised heterosexual pandemic does not seem to be emerging outside of Africa, and how these two facts should influence where prevention initiatives need to be focussed. Globally the need to engage heterosexual men in any prevention effort has also been barely mentioned, and yet we constitute at least half the problem in Africa, and are a major contributory factor where HIV is most prevalent among commercial sex workers.

There is an ongoing, and maybe mounting feeling among some commentators that the UN bodies and the traditional Civil Society networks are focussing more on politically correct navel gazing than in engaging with these emergent issues. This may be harsh, but it comes from many who have been on the inside of the UN system, some of whom are now suggesting that UNAIDS has had its time and a more generalised response to global health issues is needed. This is certainly a debate that needs opening up, if only so that we can make sure that resources are being targeted on prevention and treatment strategies that actually work.

Furthermore, apart from two farcical half hour caucuses on June 11 that were hi jacked by well meaning but ignorant (and bigoted) American Conservatives, there were very limited discussion on orphans, children and families. Surely the support of families, both those free of the virus in areas where there is a major heterosexual epidemic, and those affected by the virus, are vital in limiting the spread, caring for the affected, supporting and empowering a future generation to remain AIDS free, and ensuring that vulnerable children and adults are care for. Not engaging and supporting families is as big a deficit in the current conversation on prevention as not engaging with heterosexual men.

Finally, another key issue that has not really be debated is the engagement and empowerment of local communities in scaling up responses to HIV & AIDS. This is something that churches and FBOs are particularly good at, and which is increasingly proving to be effective in both care and prevention strategies.

Empowering local communities, engaging with and supporting families and heterosexual men, tackling head on the attitudes and behaviour that leads to multiple concurrent sexual partnerships among men and women, are all issues that need addressing along with the more familiar strategies to do with empowering women and girls, increasing access to condoms, family planning, voluntary testing and counselling for HIV and STDS and ARV therapy.

Recommendations for CHAA and its members
From the FBO side of things, one thing CHAA should be doing is getting out the stories of what our members are doing, encouraging member to put forward and develop spokespeople, and make sure that the good news and success stories get heard by our governments, the UN and other civil society and faith based organisations.

We should be advocates for work that is actually making an impact, and at the same time scrutinising the policies and practices of the British Government and holding it to account for the commitments that it has made. For that reason we need to be looking at new avenues of engagement with government and wider UK Civil Society with respect to HIV and AIDS strategies (both domestic and global).

If we can get at least one FBO representative on to the UK delegation for 2010, that will be a major step forward in gaining recognition for the work our members are actually doing, and ensuring that the voices of FBOs are being heard in the global as well as national arenas.

Closing Civil Society Caucus

General Secretary had sent a message encouraging us that though we did not have a final document, but it was a chance to increase the amount of pressure on the 150 member states attending (the highest number ever).

The treatment gap (getting the next six million on to treatment) is high on the agenda, as is pressure to t travel bans on PLWHA.

Youth statement and declaration on women will be in the report [I have hard and electronic copies - if you want them, email me].

UNGASS on drugs (due in 2009) and UNGASS on HIV need to be consistent with one another in their approaches to decriminalisation and human rights as pre-requisites to increasing access to treatment, care and prevention initiatives.

WHO coverage stating that AIDS was not a heterosexual epidemic in the press will be addressed, and a clearer message stating the need for ongoing action and pressure would be made.

Civil Society statement on UNGASS will be published on www.ungassforum.wordpress.com & www.icaso.org

Other matters
The governments seem to have sent mainly Civil Society representatives from their delegations to the Civil Society hearing and other hearings where we were presenting. So in effect we were talking to ourselves rather than directly to government delegations. President of General Assembly has recognised this as a problem and will be seeking to address this at future meetings. There seems to have been an assumption by governments that these sessions were just for Civil Society rather than seeing these as part of a dialogue between governments and Civil Society.

There was a bit of a feel of a lack of energy and engagement by Civil Society as a whole. Some seemed to be focussed just on their government delegation, and seemed less able to vocalise concerns. Involvement of Civil Society in national delegations is to be applauded and it is an improvement over 2006, but it may compromise or silence a lot of Civil Society voices.

FBO Closing Caucus

Several issues were raised

• FBOs seem to have been far lower profile at the meetings this year - very few (only 2 in fact) FBO delegates were speakers at forums. They were not being talked about much, and often when they were it was with antagonism from both governments and other civil society delegates.
  
• There was an overall sense of fatigue - maybe because the 2011 will be the main meeting reviewing how close we got to the 2010 targets, possibly because of all the energy going in to the Mexico World AIDS Conference in August, and maybe because there is no declaration coming out of this meeting, and it was not so clear how we input in to the process, other than to continue to make governments aware that civil society is scrutinising them.
  
• On a positive side, there were more civil society voices, and in particular PWLHAs were given more chance to make official speeches and were part of government delegations - a major step on from 2006.
  
• Leadership at the UN is also an issue - as Peter Piot is standing down from UNAIDS soon, there is a change of president of the General Assembly, General Secretaries of UN and WHO, and there seems a lack of impetus in that new leadership compared to those leading in 2006.
  
• It was agreed by the caucus that we need to continue to hold our governments and the UN to scrutiny, and that we should be preparing now for 2011 meeting - including preparing those who can speak, getting evidence together on how HIV strategies are being implemented. We are providing a lot of the care and prevention services in many parts of the world - we need to make sure that we tell our stories because what we do gives our voices credibility.
  
• We did not discover details of the national delegations until late in the day, so our chances to engage and lobby were frustratingly limited.
  
• FBOs were also not well represented at the civil society briefings and caucuses. We do need to be more proactively engaged with wider civil society if we are to have any credibility.
  
• We also need to be honest about where we disagree with one another and wider civil society, but also being strong on the areas where we agree and can work together. Otherwise we either dissolve in to wider civil society or hive off as a ghetto.
  
• There was a debate about whether we should focus on new targets or on holding our governments to account for achieving the 2010 goals. It seems that for now our energies are best deployed on the latter, and review where we focus re 2015 MDG targets once we have reached the 2011 UNGASS review.
  

PEPFAR

Intro
Funding initially committed was $15bn - ended up nearer $19bn, and in the next five year cycle will be up to about $30bn. Mixed success, and while there has been a scale up in treatment, rates of infection continue to rise.

Lack of access to medical services has inhibited efficacy of roll out of ARV. Monitoring of immune and HIV status is a key service. Vital to deploy modern techniques to test for TB, and other laboratory testing in order to accurately inform treatment planning.

First threshold was getting ARV prices down, the next threshold is scaling up other medical services and systems to support therapy.

Warner Bros.
have created a 2 minute thirty second video trail to explain PEPFAR.

Have also created a video game to teach teenagers an HIV prevention message, and will be distributed through PEPFAR target countries. It will be acculturated and localised for each nation, will be linked in to a mentorship programme.

PEPFAR has also been working with MTV on an anti-trafficking campaign, also working on multimedia prevention campaigns with John Hopkins, and a values based programme in South Africa.

Pangaea Global AIDS Foundation
Understanding the demographics of communities, and how to reach and target them effectively is key.

Testing to identify early treatment failure will be critical to minimise risks of multi drug resistance.

Faith Based Groups
Not clearly separate from other sectors - people of faith in secular bodies, and secular bodies work with secular. PEPFAR has acknowledged vital role of faith based groups in care, prevention and advocacy.

Shepherd Smith
PEPFAR contributions can be so large that they can exceed the whole annual health budget for some recipient nations - this means that a sudden withdraw would be disastrous - in fact long term sustainability of interventions. It is taking health professionals from other sectors, so in the process of scaling up HIV services can be in danger of damaging other aspects of healthcare delivery. So local and sensitive solutions, not going in thinking we have all the answers. PEPFAR is leaning more about how to do this. It is also integrating faith based responses in to the whole.

Treatment is also becoming a potential enemy to prevention - people are not as concerned as they once were because effective therapy is available.

Revd. Herb Lusk; Philadelphia
You need to serve at home and abroad. Has been working for some years with OVC in several African countries. But we cannot rely just on government engagement and funding, there needs to engagement through and within communities, and faith communities are key networks for responding to crises.

Comments from the Floor
Transparency is needed about how PEPFAR money is being used by recipient govts.

Need to build capacity, and the best way to do this will be to get in to a good working relationship with orgs that have capacity.

Kent Hill expressed a strong hope that the PEPFAR Bill will get through congress, hopefully it will mean $41bn for HIV/AIDS and $9bn for TB & Malaria over the next five years. Culture wars have been an issue, with left unhappy with AB programmes and right unhappy with C - but seeing a growing consensus appearing from both sides. Furthermore, PEPFAR have a "big tent" approach, get all groups from all sectors and perspectives to have as wide an approach as possible to care and prevention.

UNFPA - integration of reproductive health and HIV prevention services

The Caucus for Evidence Based HIV Prevention was set up for the Toronto World AIDS Conference in 2006, with the aim of pulling together evidence based models of prevention. It is re-forming and re-focusing on the Mexico World AIDS Conference this August.

The focus of this meeting was on models that integrated family planning services and HIV prevention - that is that all services providing family planning, maternal and child health services also provide HIV prevention interventions, and all HIV prevention services are at least linked, if not fully integrated with family planning services.

Research suggests that 25% of pregnancies in high HIV prevalence areas are unplanned. Increased access to contraception, family planning advice, women's health services, etc. can reduce the risk of HIV transmission by ensuring women have children when they want to, and have access to the full range of health services that prevent mother-to-child transmission. This has raised controversy, as some believe that this advocates abortion and stopping children being conceived at all, but the primary focus is on allowing women to have more control when they become pregnant.

Research on the benefits of this kind of integration is limited - it does suggest that communities where these services are at least linked, if not fully integrated, tend to have higher levels of awareness, and there is higher uptake in voluntary testing and counselling. But as few if any control trials have been undertaken, and studies on the impact on HIV prevalence, stigma, costs and cost benefit ratios have yet to be undertaken.

PEPFAR and Integration
While this was not a feature in the original PEPFAR programme, ongoing advocacy by the FPA and others has encouraged a recognition of the need for integrated or linked services. However both the religious right and the left wing HIV advocacy groups were antagonistic. On the right this was over the issues of abortion promotion and contraception, while the HIV movement did not see maternal and neonatal health issues as a priority and feared this would divert funding from prevention services among at risk marginalised groups such as commercial sex workers and MSM. As a result it has not been a major feature of the last PEPFAR renewal bills. But, while opposition remains, there is hope that this will feature on the next renewal bill. The problem seem to be a misunderstanding and mistrust of the language around reproductive health and family planning. The need for dialogue between all three camps would seem to be very important - the HIV and family planning sectors seem to be doing this, but religious groups need to be more active in working in this area and clarifying what services are provided when we talk about reproductive health.

It is also worrying to note that the US funding for all maternal health, child health and family planning services faces an 18% cut in 2009.

One of the FPA team raised the issue that integrated HIV and reproductive health services must address heterosexual men - the one group that tends to be left out of the discourse on HIV prevention, but who are at least 50% of the problem in achieving a reduction in HIV rates.

Political Leadership

panel 2 The challenges of providing leadership and political support in countries with concentrated epidemics. – see http://www.un.org/webcast/aidsmeeting2008/index.asp?go=105

Qatar is speaking on the importance of the family. Danger that the focus on at risk groups and risky behaviour is ignoring the family unit. Strengthening the family is key as they are first line of support or stigma, the first line to be infected and affected. How can we support political leadership to support the family more effectively in national responses to HIV. Seems to be getting some mixed reception - some booing from the floor, some cheering from the gallery.

http://www.un.org/webcast/aidsmeeting2008/index.asp?go=105

Most presentations focus has been on engagement with Civil Society, focus on at risk groups, human rights issues for marginalised groups and tackling issues marginalising them and making them more vulnerable, in particular legislation that criminalises them.