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.

Scaling up to Universal Access

See http://www.un.org/webcast/aidsmeeting2008/index.asp?go=104 for the webcast

Margaret Chan
Predictable and sustainable funding is crucial - you cannot start a programme without commitment to ongoing funding (literally, life long). We should be looking at our strategy for the next 27 years, learning from the lessons of the first 27 years of responding to the pandemic.

Integration of health and social services once again emphasised. Over and over we hear that rather than scale down HIV services to invest in other area, why not scale up both? Surely what has been learnt about coordinating massive national and global epidemic responses shows us what we can do in mobilising resources to respond to other major health needs.

Norway
Need to catch up, scale up and sustain. We also need to link up with other health and social issues; AIDS response can be a driver towards achieving all the MDGs.

Netherlands
Need to hold governments to account - internationally holding one another accountable, and nationally Civil Society should be holding their governments to account.

USA
Need to make sure 12-16% of all funding for therapy scale ups should be for paediatric therapy - current draft PEPFAR Bill is focussing on funding therapy in these proportions. Others should be aiming for this kind of scale up.

Russia
Scaling up treatment on a three year budgeting cycle - i.e. to 2011. c$1B

UK
Need to scale up all health systems. Not just ARVs but palliative medicines, opiate substitution therapies.

Also increase health workers, with specific targets such as 2.3 nurses per 100,000 population.

UK has announced a long term financing commitment to spend $12billion up to 2015

Civil Society Hearing

See http://www.un.org/webcast/aidsmeeting2008/index.asp?go=102 for the webcast.

The main themes that struck me coming out of the Civil Society hearing are:

• We must address factors excluding vulnerable groups from access to treatment, support and prevention, including legal restrictions that criminalise certain behaviours, certain populations and even being HIV positive. This includes lifting travel bans on HIV positive people.
  
• Grace Violetta spoke passionately about the need to overcome these legal barriers.
  
• Another issue highlighted was the lack of access to paediatric formulations of ARVS. Also that only 10% of HIV+ pregnant women in developing countries have access of PMTC services.
  
• Impressive presentation from a 16 year old HIV+ young woman from Australia - Stephanie Reaper. Her hopes for her studies, marriage and parenthood were very moving and encouraging. Her plea for others in her situation to be allowed the same opportunities are to be taken seriously.
  
• Business and labour unions need to be actively engaged in prevention, care and maintaining the rights and well being of those with HIV in the workplace.
  
• Finally, a challenge. As several countries (including, as I have noted before the USA) have failed to report, we have a real gap in knowing how far off target we are for 2010. And how can we increase accountability of governments that are not democratic, when we are struggling to get democratic nations to be more accountable.

UNGASS Day 1

Opening Plenary
See http://www.un.org/webcast/aidsmeeting2008/index.asp?go=102 for webcast

Interesting that Ban Ki Moon raised (quite rightly) in his opening address the issue of removing travel bans on HIV+ people, as did Peter Piot. Had several conversations about that yesterday, and at the same time found that there are plans to lift the US restrictions within the next PEPFAR Bill - only seven conservative Republicans, lead by Senator Coburn are allegedly trying to block the PEPFAR renewal bill with wrecking amendments. But the US is not the only offender here - this is a problem both with short-term and long-term visas for the majority of nations. The Civil Society delegate is now raising the same issue. Looks like this is going to be one of the main themes this morning.

With de Cocks' statement yesterday it is also becoming clear that targeted prevention, treatment access and de-stigmatisation of vulnerable groups should be the main focus of prevention, rather than focussing primarily on general populations (although there is a strong case for maintaining prevention efforts in the wider population, as they still face risks, nevertheless outside of Africa, this is not where the epidemic is really happening). And decriminalisation of vulnerable communities and stopping treating HIV and AIDS as a separate issue, and looking at wider health and social issues are all essential steps. Encouraging to note that DFID has grasped the nettle of strengthening wider health infrastructure.

Dr Anthony Fauci raised the issue of shortage of health personnel as one of the key obstacles to Universal Access, and that wider health and social development. Will this new 'holistic' approach to HIV service development serve to strengthen wider health needs and infrastructure? It is not clear that it has been in the past, and has even detracted from other health priorities. Funders, NGOs and Governments do need to make that wider health and social infrastructure issues are addressed. Again, am encouraged that DFID at least seems to be committed to this approach.

Good to hear Fauci emphasise that we need to learn from countries where prevention has worked, and to engage with Civil Society and faith groups. And sustained, long term funding. I remain ambivalent about the money being poured into vaccine and microbicide research when so little seems to have been achieved in terms of successful prevention to date. However, if either of these approaches ever do work, they could be life savers. But it will be years or even decades and vast amounts of funding to get us to that point - so the question we should be asking is are there shorter-term priorities that should be the focus of these resources?

We are now into individual country reports and feedback. This can followed at http://www.un.org/webcast

We are now heading in to the Civil Society Hearing

Prevention Shibboleths

Had some very interesting and eye opening discussions with various people yesterday, mainly around the issues of gender, the human rights based approach to prevention, and above all the way our understanding of the epidemiology of HIV & AIDS is shifting.

Although I did not attend it, there was a caucus on gender and HIV yesterday that was well attended – by about eight times as many women as men. Like most men I had assumed that this meeting would be primarily about empowering women and tackling stigma and discrimination – areas I felt myself unqualified to contribute to, so had focused my time and energy elsewhere. My error – because of course men are a gender as well as women, and any attempt to address women's rights must address men as much as it addresses women. It shows how rapidly we have polarized debates and failed to engage one another on issues that affect us all.

For example, how can we tackle the sex industry and human trafficking head on to protect vulnerable girls and women (and some boys and men) if we do not first address male sexual behaviour? Why do men pay for sex, and are there effective strategies that can reduce this behaviour? Is criminalising buying (rather than selling) sex a more effective way forward, or does it create other problems? Models developed in countries like Sweden bear watching over the long term.

But this highlights another problem – we are concerned rightly about making sure that we target prevention on vulnerable groups without stigmatizing them, and we are rightly concerned that only effective and evidence based approaches are used. But the evidence emerging from epidemiology is showing us that human sexual behaviour and choices are vastly more complex that we had initially thought.

Firstly, an article in yesterday's Independent carried a statement from Dr Kevin de Cock admitting that the long feared generalised epidemics are not on their way. India's epidemic is focussed around the sex industry, and spreads from there to the families of the men who use female and male sex workers, but not really and further. Why? Ironically because the position of women in Indian society means it is very unlikely that woman will have one or more sexual partners outside the marriage. Likewise, China's epidemic is mostly among IVDUs or is iatrogenic – the latter creating a few large clusters that have so far failed to spread dramatically. In most of the rest of the world, HIV is largely confining itself to specific groups, not spreading significantly to the wider population.

Why? Or more to the point, why are almost all the generalised epidemics confined to Africa? No one is 100% certain, but the newly emerging picture from epidemiology is that the pattern of sexual relationships in Southern Africa in particular is what is now being called "multiple concurrent partnerships". This is where an individual will have several sexual partners in steady, long term relationships simultaneously. What is more, this is not primarily a male behaviour – it is equally common between the genders. As these are regarded as stable relationships, condom usage is low. The potential for sudden explosive clusters of new infections to occur is very high – especially as the newly infected are the most infectious – HIV can rip though a network of relationships very rapidly.

We do not know much about this pattern of sexual relationships because people seldom report that it is going on, but there is growing evidence that it does occur, although at what level is unclear. It is also apparent that due its hidden nature, this is not a pattern readily amenable to behaviour change strategies – whether getting people to use condoms or remain faithful to one partner only.

Because it seems to be most common in certain segments of certain societies there is also a political dimension here – it is hard to focus on this issue without being seen as stigmatising and even racist. So much more work needs to be done on understanding this phenomenon and seeing how we can pull together a consensus between governments and civil society on how to tackle this. And how can the churches tackle this head on within their own congregations and the wider community?

Once gain this highlights the need for wider ranging strategies that address stigma, sexual behaviour change ('zero grazing', delayed sexual debut, etc), effective use of condoms, open access to HIV testing, encouraging open, public discussion of sex and sexuality, involvement of all levels and sectors of society in communicating prevention messages, clear national leadership, etc, etc. This is what Uganda and Senegal did successfully before it became the subject of heated politicised debate and reduction to arguments over "abstinence only" versus "condoms only" programmes, and other misdirected battles over prevention ideology.

One African leader from a faith based/civil society network admitted to me last night that the prevention strategies in his country were suffering from the influence of Western donors who were pushing one ideological position or another – rather than letting his nation continue to develop their strategies based on what they know works within their own communities. We can only tackle HIV by cooperation around evidence based strategies, and letting local knowledge and understanding allow appropriate and contextualised responses to be developed from within the community, rather than being imposed by external (usually Western liberal and conservative) ideologies and funding priorities.

There will be more debate around this over the next few days

AIDS Implementers Meeting

With 2.5 million new infections a year and only 1 million more people on therapy in the last twelve months, you can see easily see that key to reaching Universal Access targets (and maintaining them - an issue that has not even begun to be addressed as far as I can see) is scaling up prevention initiatives and strategies.

Hence the welcome response from the AIDS Implementers Meeting that has just finished in Uganda. It was also heartening to know that Ian Campbell (formerly of the Salvations Army, and someone who has shown time and again just how low cost community mobilisation and empowerment has more impact than costly top down models of care and prevention) was given a chance to address one of the plenary sessions on June 4.

Again, that is what we should mean by Civil Society - the local engagement and community mobilisation. De-professionalise AIDS care and prevention, and de-mystify it. But the challenge for Christians is how we get churches to even recognise that they have a vital role in this.

Civil Society Caucus - addendum

A call has just come from the floor for a Civil Society political declaration to come out of the meeting. Particularly to focus in the issues raised below, and others being discussed (empowering women, human rights, tackling discrimination, etc, etc.). This was something that came up in 2006 - at the very least it encourages Civil Society internationally to reach some kind of unanimity and consensus to put pressure on governments.

The trouble is it that is not always possible for all of us to sign up to everything in these statements. Many faith based groups come from a quite different starting point from the human rights based groups, and while we agree with each other on many issues, there are fundamental points of departure. So we either produce a statement that not all of us can sign up to, or we end up with just as bland a statement as comes from the official consensus achieved between governments.

It looks as if this will be taken forward - more on that as things become clear.

Civil Society Caucus

Am in the Civil Society Caucus at the UN as I write.

Seems that the same heart cry to world governments is coming out from the Civil Society Caucus today - please work with us! In many countries the involvement of Civil Society is either non-existent or tokenistic. PWLHA groups and vulnerable groups are ignored, excluded or badly engaged with. Sad to say that this has been the plea for as long as I can recall - some countries are listening, but in the most affected parts of the world in particular Civil Society engagement is very poor. Despite the commitments in the Paris Declaration, a lot of programmes are note being driven by the expressed needs of Civil Society groups - especially of PLWHA and vulnerable groups.

Is Civil Society just being used as a rubber stamp - to make government policies look good to the International Community? It would seem so in many cases, and it is for the International Civil Society networks to hold governments to account for adhering to the commitments to engagement that they have signed up to. Also, Civil Society is often being marginalised by legislation that criminalises some vulnerable groups, and denies human and civil rights to those living with the virus.

Meanwhile the targets being set at each of these UN General Assembly meetings - from the 2000 Millennium Summit onwards, are not being met. The 2010 promises are in danger or being ignored now, and we are in danger of just looking to the 2015 MDGs - i.e. a way of shifting goal posts so we can overlook where we have fallen short of our aspirations. Again, this is a cause that is vexing most of the Civil Society delegation, and letters have already been written to Margaret Chan (WHO) and Peter Piot (UNAIDS) pleading that 2010 targets on Universal Access not be forgotten.

A US delegate pointed out that although the US is openly opposed to harm reduction procedures around IVDUs, in practice local groups and municipal authorities are engaging at this level. I.e. the headlines say one thing, what is happening on the ground is quite different. Something I think all of us are well aware of.

It is interesting to note that there was no US country report submitted for this meeting - at least not on the UNGASS official site (and I note, no shadow reports from Civil Society for either the US or UK this time - why I have no idea, but I wonder if Civil Society groups have lost some of their critical edge towards our governments' policies in both nations).

The UK did get a country report in, which showed a 9% growth in new infections and problems with increasing access to and awareness of the need to get tested. 31% of all those living with HIV the UK are doing so untested, and possibly in ignorance that they are at risk of being infected (in some cases). I think the UK still thinks its main role is as the second biggest bilateral donor on AIDS, but we are a way off hitting all the targets at home.

The UK does have a decent (if hard one) reputation for Civil Society engagement, although I think there are still questions to be raised about how well they are working with churches and FBOs - at a UK and at an international level. DFID is finally mentioning faith based groups in their strategic document on achieving access for all by 2010 - but how well they engage in practice is still not clear - past evidence suggests they have quite a way to go, but also that they may have made some progress in the last couple of years.

The meeting is about to break now... more later.

CHAA One of nearly 700 Civil Society Groups Accredited for 2008 UN High Level Meeting

CHAA has been accredited to attend the 2008 high-level meeting on AIDS at the United Nations headquarters in New York on 10 - 11 June. The global gathering will review progress made in implementing the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV and AIDS. The high-level meeting will provide an important forum for various stakeholders, including people living with HIV & AIDS, governments and civil society participants to review progress made on the goals set out in the previous declarations, and at how together we can work to achieve them.

The active involvement in this process of people living with HIV & AIDS, civil society and faith based groups like CHAA and its members is to be welcomed. HIV and AIDS remains one of the major health and social challenges facing all societies around the world. Only a concerted effort by all sections of society can hope to respond effectively.

Steven Fouch, Secretary of CHAA will be representing the Alliance at the meeting.