Free and Public

EBOLA AND WHO REFORM: WHO CARES? By Charles Clift, Senior Consulting Fellow, Centre on Global Health Security, Chatham House

The ongoing Ebola story has highlighted the importance of the World Health Organization (WHO) in coordinating international action to combat emerging infectious disease threats. But it has also revealed the deficiencies in its performance which have now allowed a disease outbreak in West Africa to turn into a major international emergency. But in the current crisis in West Africa blame for its performance has been more prevalent than praise. As even its senior officials now admit WHO was too slow to recognize the potential seriousness of the outbreak – while also blaming the cutbacks in its emergency response capability agreed by its member states, as well as the unusual nature of the outbreak which it says caught the international community as a whole on the hop. The officials also point out that WHO is a technical assistance agency: there to help and advise governments on how to respond and supply needed expertise rather than run emergency healthcare operations on its own account.

On the other hand, some NGOs such as MSF, working to combat Ebola on the frontline, have criticized WHO’s slow response. They say that it should have recognized much earlier than it did the need to take the lead in mobilizing funding and personnel from other international actors to strengthen the weak healthcare infrastructures in the affected countries, as well as intensifying its own efforts to support governments with technical assistance and expertise.

Others blame WHO’s slowness and lack of leadership on its fundamental structural problems, which the reform programme launched by Margaret Chan in 2010 was intended to address. These structural problems include both its funding and its unique structure of regional offices which elect their own leaders. Much adverse comment has been directed at the role of WHO’s Africa regional office in Brazzaville which Peter Piot recently described as being staffed with political appointees rather than the most capable people, and the alleged lack of good cooperation between Brazzaville and Geneva. While there is undoubtedly financial stringency in WHO, and a severe shortage of experienced staff in HQ, the case is different with country staffing. The three most affected countries have country office staff exceeding 100 in total, there are nearly 750 in the country offices in the West African region as a whole, and there is nearly 600 staff in the regional headquarters in the Congo. In addition the African region has nearly 2500 contracted staff involved in polio eradication. It is hard to believe that more could not have been done with all these staff on the ground if properly mobilized and managed.

A report on WHO reform published in May this year, based on the deliberations of a working group convened by Chatham House, noted that WHO’s core functions as defined by WHO excluded explicit reference to promoting and maintaining global health security, specifically including its response to disease outbreaks and public health emergencies.

But the report focused mainly on the WHO’s structural problems that the ongoing internal reform process in WHO was not dealing with. The Ebola story illustrates many of these. The report asked: whether WHO really needed six semi-autonomous regional offices? Was this not a recipe for conflict and slow and poor decision-making? And did it need 150 country offices? How did politicization and the politics of patronage adversely affect WHO’s performance, credibility and effectiveness at all three levels of the organization? Was its complex governance structure not the main reason that it spends one third of its budget on administration and management at the expense of its technical programmes? Were there not more efficient ways to do what WHO needed to do? Why was WHO often reluctant to lead rather than to follow its member states? Why did the member states countenance this state of affairs?

The report has evoked practically no response at all – from governments, the academic community, NGOs or anyone else for that matter. Why is this?

A plausible explanation, which was suggested often by one of the members of the Chatham House working group, is that no one cares sufficiently about WHO reform to do anything about it. The status quo is too comfortable, or not sufficiently uncomfortable, for any member state to want to change things.

The weird financing arrangements, whereby 75% or more of WHO’s income is in the form of voluntary contributions, suits member states for different reasons. A few rich countries (and charities such as the Bill and Melinda Gates Foundation), by directing their voluntary contributions in ways of their own choosing, get to control what WHO does in spite of being a small minority in the World Health Assembly, or not in it at all. Yet because of this effective subsidy, poorer countries pay contributions which are a quarter of what they would be if WHO was wholly financed by member state subscriptions. Thus for the great majority of member states WHO membership is a bargain. They get a WHO country office whose budget (paid for by WHO) will normally exceed by a large margin their WHO contribution.

Because WHO regional offices are run as semi-autonomous replicas of WHO in Geneva, ministries of health also get the opportunity to influence appointments to regional and country offices where those chosen can access UN-related salary and benefit packages. Thus it is not just a financial bargain but often carries actual or personal benefits for senior country officials. So there is little mystery about why change should be resisted. Even where it is recognized that a WHO country office may have outlived its utility (in a country like Thailand for instance) it would be a brave politician or official who suggested closing what is essentially a free gift from the international community.

So no mystery there. The non-response of the ‘public interest’ NGO movement is more puzzling on the face of it. But perhaps the answer is not totally dissimilar. These NGOs have no financial stake in WHO and therefore no direct influence on its governance. Many regard the WHO as a forum where they may express their views and the annual World Health Assembly as a perfect gathering of notables in the global health community to pursue advocacy and influence member state delegates. While NGOs may be critical of the WHO, as in the case of Ebola, they also hold it in great esteem as the one international organization with the responsibility of striving for “the attainment by all peoples of the highest possible level of health”. The NGO mindset is therefore to seek to defend this noble objective and, in particular, protect it from political and commercial pressures which are seen as a threat to this mission.

Moreover the WHO secretariat is generally regarded as providing objective technical leadership and support to member states in a world dominated by governments and corporations whose motivations and interests may run counter to health objectives. For that reason NGOs are generally only likely to be critical of the WHO secretariat if it appears to be supine in its dealings with commercial stakeholders, or with governments deemed to be unduly influenced by commercial rather than public health interests.

At the same time NGOs, notably Oxfam, have campaigned actively for member states to increase their secure funding of WHO to protect its core functions, such as those which support enhanced access to essential medicines. But member states have to date paid little heed.

So it seems that the political preconditions for fundamental reforms of WHO funding and governance are absent. Nevertheless the world badly needs a global body that can take on a leadership role in global health policies and help control disease outbreaks before they turn into international crises. The panic engendered by the Ebola crisis should result in a reality check for all concerned. The WHO reform process, begun 4 years ago, does not seem to be on course to deliver a WHO that can be relied upon as fit for purpose.

 

Share

The EC is still trading away access to medicines By Leïla Bodeux, Policy Officer, Oxfam-Solidarité

Today, 29 September, Cecilia Malmström will be auditioned by the European Parliament (EP) to confirm if she is to become the European Commission’s (EC) new Trade Commissioner. This is a very timely moment for the release of a joint paper by Oxfam and Health Action International Europe (HAI) on the impact of European Union (EU) trade policies on access to medicines, both in Europe and far beyond.

Stakes are high for Ms. Maelstrom who will be leading the EC Directorate-General for Trade’s (DG-Trade) agenda for the next five years. This will include negotiating Free Trade Agreements (FTAs) with other countries on behalf of EU Members States. She will be especially in the spotlight over the negotiation of the controversial FTA between the EU and the US that will affect millions of people: the Transatlantic Trade and Investment Partnership (TTIP).

Profits before patients in TTIP?

Leaked documents clearly show that the TTIP is a huge threat to European public health systems, due to its clear favouring of pharmaceutical companies’ commercial interests. One objective of the Pharmaceutical lobby is patent harmonization based on US law. This would mean more patents and less generic competition, thus more monopolies and unaffordable medicines. Another item on Pharma’s negotiating wish list is a ‘voice’ in EU Member States’ pricing and reimbursement policies. Increased companies’ voice in medicine would challenge Member states’ ability to take measures, such as price control, to control expenditure on medicines. Moreover, the Pharma lobby is seeking to restrict public access to clinical trials data, undermining the EU’s recent efforts to foster transparency in this area[1].

One of the TTIP’s most controversial elements is the inclusion of an Investor-State Dispute Settlement (ISDS) mechanism. ISDS gives foreign investors the right to sue governments for compensation if laws, policies, court decisions or other actions interfere with expected profits from investments. Governments’ actions such as price control or patentability standards could be challenged in court. While it may seem extreme, this threat is far from hypothetical. Following the legitimate invalidation of two of its patents, the American pharmaceutical company Eli Lilly is suing Canada for 500 million Canadian dollars compensation under the North American Free Trade Agreement  ISDS provision.

More worryingly still, the impact of the TTIP will not stop at EU or US borders. The TTIP would set a new global standard for strict intellectual property (IP) protection around the world, which could be imposed on developing countries through other trade deals[2].

FTAs have regularly been used by DG-Trade to introduce strict investment and IP rules (so-called “TRIPS-plus” measures), which go beyond the internationally-agreed IP standards set by the World Trade Organization. Such standards promote the commercial interests of the pharmaceutical industry even at the expense of public health. (See the EC’s latest document on the pharmaceutical industry).

The EC’s brand new strategy on IP enforcement in third countries explicitly describes IP as a means to boost Research and Development (R&D) and economic growth in the EU, ignoring how IP can also hinder innovation and competition. The proposed measures to enhance the enforcement of IP rights include FTAs and the identification of “priority countries”, as per the notorious US Special 301 report[3]. The EU list includes India and Thailand, two countries which have sought to balance IP rules and public health needs. The list foresees possible financial sanctions for countries repeatedly “infringing” IP rights. Sanctions could include restricting third countries’ participation in, or funding from, specific EU-funded programmes.

The EU’s “black sheep” on IP in trade policies

India and Thailand have bitter experiences of the EC heavy-handed approach to IP rights. Negotiations for a FTA between the EC and India started in 2009 and are currently on hold. India’s progressive IP law only grants patents for ”real” innovation (i.e. it rejects patents on products too similar to an existing product). This has allowed the country’s vibrant generic pharmaceutical sector to play an important role in driving the prices of medicines down in developing countries. As “the pharmacy of the developing world”, India provides over 80 percent of the world’s generic anti-retroviral medicines to treat HIV/AIDS. The EC’s attempt to impose TRIPs-plus provisions in the EU-India FTA caused a great outcry throughout the world, thankfully forcing the EC to backtrack on some of the most controversial provisions.

Yet, despite the EC’s commitment to stop pushing for TRIPS-plus measures in subsequent FTAs, the FTA being negotiated with Thailand since March 2013 (also currently on hold due to the military coup) contained similar controversial provisions. Instead of supporting Thailand’s good track record of pro-public health policies and its use of TRIPs flexibilities[4] to improve access to medicines, the EC tried to stop Thailand’s use of these legal, internationally-agreed measures.

Negotiations with both countries will resume in the near future.

Are IP rights really promoting health-driven innovation?

DG Trade – aligned with the pharmaceutical industry- portrays IP as the panacea to boost investments in R&D, thus justifying the inclusion of TRIPs-plus provisions in FTAs. However, it is clear that the current R&D system, which relies heavily on the profits generated by expensive, unaffordable medicines to provide incentives for innovation, fails to meet public health needs.

The current Ebola crisis and the controversy surrounding wildly unaffordable new medicines to treat Hepatitis C, clearly illustrate the R&D crisis. No medicines or vaccines are currently available to deal with the Ebola virus due to the lack of a market incentive; Ebola only affects some of the world’s poorest countries, where no company could ever make a profit. In the meantime, the pharmaceutical company Gilead priced its new and highly-effective medicine to treat Hepatitis C (marketed as Sovaldi) at $84,000 for a 12-week course. Even the discounted price that Gilead offered to some countries is still too high to treat all patients[5].

This raises serious questions about a system based on monopoly that keeps effective medicines from reaching the people that need them. Clearly alternative R&D models which are geared to address health needs must urgently be explored.

Change is needed, now!

The coming five years represent an   important opportunity for the EU to lead on trade and R&D policies which meet health needs, and which don’t favour commercial interests over patients’ needs.

Oxfam and HAI Europe urge the future Trade Commissioner Cecilia Maelstrom, to resist the pharmaceutical lobby and to ensure trade policies are aligned with the EU’s development and (global) health objectives. To reach this aim, DG Trade should ensure better coherence and coordination of work with other DGs. The newly elected parliament must ensure that EU trade and R&D policies prioritise access to medicines for all citizens around the world.

More concretely, the EC should:

  • Stop including TRIPS-plus and investment protection measures in FTAs which jeopardise access to medicines for millions, including in its negotiations with the US, India and Thailand;
  • Support generic competition to allow broad access to medical products in Low- and Middle-Income countries; and
  • Support new models of innovation, both those under development at the World Health Organisation, and in its own programmes.

References


[1] For a detailed analysis, see: Commons Network, HAI et al. (2014) ‘The Trans Atlantic Trade and Investment Partnership (TTIP): A Civil Society response to the Big Pharma Wish list’, joint position paper, http://www.prescrire.org/Docu/DOCSEUROPE/20140324CivilSocietyResponseBigPharmaWishList_final.pdf

[2] C. Gerstetter, M. Mehling, A. Eberle and K. Salès (2013) ‘Legal implications of the EU-US trade and investment partnership (TTIP) for the Acquis Communautaire and the ENVI relevant sectors that could be addressed during negotiations’, EP Directorate General for Internal Policies, http://www.europarl.europa.eu/RegData/etudes/etudes/join/2013/507492/IPOL-ENVI_ET(2013)507492_EN.pdf

[3] See USTR website: http://www.ustr.gov/about-us/press-office/press-releases/2014/April/USTR-Releases-Annual-Special-301-Report-on-Intellectual-Property-Rights

[4] In 2001, the WTO ministerial conference adopted the Doha Declaration on TRIPS and Public Health. It affirms that the WTO rules on IP should not prevent countries from taking measures to protect public health.

Doha Ministerial Declaration on the TRIPS Agreement and Public Health, WT/MIN(01)/DEC/W/2, 14 November 2001, http://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm

[5] http://www.globalhealthcheck.org/?p=1630

 

Share

The IFC’s Health in Africa initiative is failing to reach the poor By Jessica Hamer, Report Co-Author

Question: What do the following have in common?

  • A $6.1 million private health insurance scheme for IT workers in Lagos, Nigeria, reaching fewer than 40 per cent of its target beneficiaries; and
  • A luxury IVF clinic launched in a country bearing 14% of the entire global maternal mortality burden

One answer might be that these projects are not designed to deliver health services for the poorest sections of the population. The Lagos insurance scheme excludes all informal sector workers, while one IVF cycle at The Bridge Clinic costs $4,600.

A second might be that both projects make a deeply questionable contribution towards a country’s attainment of Universal Health Coverage (UHC), given their provision of services to small, predominantly urban, and comparatively wealthy elite.

A third is that they have both benefited from investments made as part of the International Finance Corporation’s (IFC) Health In Africa Initiative.

Health In Africa is a $1 billion investment project launched by the IFC in 2008, which aimed to ‘catalyze sustained improvements in access to quality health-related goods and services in Africa [and] financial protection against the impoverishing effects of illness’, through harnessing the potential of the private health sector. Specifically, it sought to improve access to capital for private health companies, and to help governments incorporate the private sector into their overall health care system. Health In Africa would do this through three mechanisms: an equity vehicle, a debt facility, and technical assistance.  Perhaps of most importance, the initiative would make extra efforts to ‘improve the availability of health care to Africa’s poor and rural population’.

Emanating from the World Bank Group, Health In Africa’s focus on delivering health care for people living in poverty makes sense. Anything contrary would be at odds with the Bank’s mandate and overarching goal to end extreme poverty by 2030. Oxfam welcomes World Bank President Jim Kim’s emphasis on the centrality of achieving Universal Health Coverage (UHC) to see this goal attained, and the Bank’s target to deliver health care for the poorest 40% by 2020.

However, it seems that with the Health In Africa initiative, the IFC may be working deeply at odds to these stated World Bank aims. Today, Oxfam launched Investing for the Few, analysing the investments made as part of Health In Africa to date. Oxfam’s assessment of the sporadic investment information available finds that far from delivering health care for the poorest, Health In Africa has favoured high-end urban hospitals, many of which explicitly target a country’s wealthy and expatriate populations.  The initiative’s biggest investment to date has been in South Africa’s second largest private hospital group Life Healthcare.  This $93 million endowment no doubt supported the company in its subsequent expansion (Life Healthcare acquired a 26% stake in one of India’s largest hospital groups in 2011), but there is no evidence it has used this investment to expand access to health care for the 85% of South Africans without health insurance.

Oxfam’s findings show that Health In Africa has also failed to deliver expansion of health care at any sufficient scale or pace to meaningfully contribute towards UHC. Instead the initiative has supported high-cost, low-impact investments. The Lagos health insurance scheme mentioned above cost triple the annual Nigerian government per capita health expenditure for example, and took over five years to secure fewer than 9,000 enrolees. In Nigeria, scaling up to reach UHC at this rate would take over 100,000 years.

Another major concern is the absence of sufficient attempts by Health In Africa to measure its performance. The initiative’s own mid-term evaluation found Health In Africa had failed to define and assess its anticipated results, and that the performance indicators it has used are inadequate to measure any development impact. Whilst an equity fund employed by Health In Africa boasts of its success at reaching patients at the so-called ‘base of the pyramid’, one of the annual income targets used to define this group include all but the top five per cent of earners in sub-Saharan Africa. It is likely Health in Africa’s use of financial intermediaries contributes to this failure to effectively measure impact on poor women and men. Such an arms-length approach to investment brings inherent problems around oversight and transparency.

Oxfam is clear that the IFC must improve the transparency and accountability of the Health In Africa initiative. Our report calls on the IFC to cease all Health In Africa investments until a robust, transparent and accountable framework is put in place to ensure that the initiative is pro-poor, and geared towards meeting unmet need. In addition, it calls on the World Bank Group to conduct a full review of the IFC’s operations and impact to date in the health sector in low- and middle-income countries, to investigate how they are aligned with, and are accountable to, the overarching goals of the World Bank Group: to end extreme poverty and promote shared prosperity.

The IFC needs to fundamentally rethink its activities in health, and ensure any potential projects are aligned with the Bank’s goals. The World Bank Group should focus on supporting African governments to expand publicly provided health care – a proven way to save millions of lives worldwide.

 

Share

Ebola: Some thoughts from my time in Liberia By John Spray, ODI Fellow, Ministry of Commerce and Industry, Liberia.

 

A lot has been written about the Ebola crisis in West Africa in the last few weeks. Many excellent articles have highlighted the plight of those suffering with Ebola (Newsweek), and the people on the frontline trying to tackle the virus (Time) and the consequences on the affected countries as a whole (How we made it in Africa). However, the real tragedy is how an inherently preventable virus was able to spread like wildfire throughout West Africa and why public health facilities failed on such an enormous scale.

I first heard about Ebola in March 2013, four months after the first patient died of the virus in a small village in south-eastern Guinea, the first ever in West Africa.
With the death toll rising across the border in Guinea, discussions in Monrovia turned to the threat of it reaching the capital: “no previous outbreak has killed more than 300 people”, “it is easy to avoid just don’t go near sick people and you are safe”, and “the disease kills people so quickly it will die out before it reaches Monrovia”. The general message was “it is scary, but we can control it with basic public health.”

Despite these reassurances, everyday you check the news: how many infected? How many died? How many health clinics were beginning to shut due to healthcare workers leaving their posts? Despite the growing chaos, we in Monrovia continued to rationalize the situation. We knew things were getting worse but we didn’t act in time.

So when did it get “out of control”? Was it when MSF declared it to be so in June? Was it when the virus hit Conakry, Freetown and Monrovia, making control of the disease in crowded urban environment increasingly hard? Perhaps it was when the Liberian-American Ministry of Finance consultant died after flying to Lagos, inadvertently putting a planeload of passengers and Africa’s most populous country at risk.

Whenever it was, there is no question that we are now in the middle of an unprecedented crisis. Every day, I dread reading the news. The front page of every newspaper is full of articles discussing the bleak picture of Liberia’s largest slum quarantined like something out of a science fiction novel. I read about the almost complete collapse of the government’s health care facilities and the justifiable fear of the healthcare workers too scared to go to work. We hear terrifying stories of suspected cases being turned away from treatment centres because there is no space to treat them, and bodies left on the street for days without someone coming to pick them up. Most of all, I fear for the secondary threats should countries follow through on plans to impose economic embargoes on the country.

Already five airlines have stopped flying to Liberia through fear of the disease. Earlier reports that West African ports have refused entry to vessels which have docked in Liberia appear false, but raise an alarming prospect of the country cut off from essential imports. This is dangerous given that Liberia is completely dependent on imports with an import bill equal to 60 percent of GDP including two of the most important commodities, fuel and rice. Even without an economic blockade importers are worried.

Early reports suggest for the last four weeks the number of import certificates are down 30 percent from the previous year. Not to mention, the travel restrictions inside the country making movement of agricultural goods from farm to market next to impossible. These developments will raise the price of essential goods necessary for the Liberian economy to function and will harm the very poorest. They also raise the possibility of riots on the street and a return to the days of anarchy last seen during Liberia’s bloody civil war.

So how did this happen? The underlying causes of this outbreak are many and difficult and will be discussed for years to come. Fundamentally, they focus on the fragility of West African states and the failure of emergency planning to tackle the crisis when it was at a manageable level.
What can we do about it? Despite the fear, there are many brave West Africans and foreigners continuing to fight this disease. The Ministry of Health is working to open new treatment centres, MSF continues to fight the battle on the front line and are managing patient care alongside national governments. The World Bank has promised USD200million to fight the disease in West Africa. The African Development Bank has promised USD210million to build West African public health facilities. The World Food Program has begun the process of bringing in food to tackle the secondary crisis. NGOs on the ground, including Oxfam, have begun gearing up awareness campaigns to get the message out that Ebola is preventable. These things are vital to the immediate fight and the world needs to react, and react fast.

Once the immediate crisis is brought under control, we must consider measures to strengthen the state institutions especially the health service in order to effectively deal with health threats in the region.

Share

Lost in translation: reflections from the 20th International AIDS Conference (July 2014) By Gracia Violeta Ross: UNITAID Board Member for Communities Living and Affected by HIV/AIDS, TB and Malaria

With great enthusiasm I started my 33 hours flight from Bolivia to the big country-continent: Australia. But my first night in Melbourne was filled with tears as I turned on the television and heard of the attack to the Malaysian flight MH17.

The opening ceremony of the 20th International AIDS Conference paid respect to the scientists and advocates who died in this tragedy. Throughout the conference, almost all plenary speakers spoke about the “now more than ever” feeling and the importance of Stepping Up the Pace of the AIDS response. In this blog I share some of my reflections from my week in Melbourne.

The highlights

• I was reinvigorated by the effective activism on Hepatitis and HIV as activists protested against the hypocrisy of the big pharmaceutical industry pricing life-saving medicine beyond the means of people and governments

• It was interesting to learn about the issue of “Grey HIV” as we are seeing people living with HIV getting older in developing countries. Getting old with medications and with HIV looks scary for me because I am also living with HIV and I am already 37!

• It was inspiring to hear daring talks about sexuality in conservative contexts such as those in some Muslims countries and Christian conservative settings. I was pleased to hear that faith leaders are increasingly tackling this issue and talking to their peers

• Although the theme of the conference was “No one left behind”, I heard a lot of the discourse of “shared responsibility” in the AIDS response. Ultimately, this is the idea that countries will have to “find your own funding”. For Middle Income Countries (MICs), the pressure is already mounting and there is a real risk that these countries will be left behind

• I did not hear a lot about women and girls as a key population and the links to gender based violence and HIV. Moreover the debate on vulnerability to HIV infection and impact must recognize that each community and country has its own vulnerabilities that need to be considered in AIDS response

• Children living and affected by HIV were notably absent and this is a fundamental mistake, given the fact that this group is really voiceless and vulnerable. There are huge gaps in the coverage of treatment for HIV and TB for children. I am really enthusiastic about UNITAID because it invests in shaping the market for diagnosis and treatment of children

• As someone coming from Latin America, I felt the strong absence of my region, not only in that very few delegates from Latin American and the Caribbean were present, but also in the fact that the UNAIDS’ “global analysis” included incomplete data from these two regions. At the conference, I realized that there is much misunderstanding about Latin America and the Caribbean. Some donor countries seem to believe these two regions have universal coverage of treatment and prevention services. The reality is that Latin American countries vary a lot and there is huge inequality and disparity.

At the end, I left Melbourne without seeing the sun nor one Kangaroo!

Share

Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind By Georgia Burford (CAFOD)

Reflections on AIDS 2014 – Stepping up the Pace and Leaving No one Behind By Georgia Burford (CAFOD) The International AIDS Conference in Melbourne 20-25 July 2014 is the 20th gathering of the largest regular conference of any health or development issue, bringing together politicians, scientists, epidemiologists, practitioners, policy makers, the private sector and communities of people living with and affected by HIV. There is uniqueness in this fight against HIV in that it is a social movement, pulling people together and putting people at the forefront of the response to sustain our efforts on addressing HIV. It’s a powerful reminder that HIV has not gone away and is still affecting the lives of many today. The theme of this year’s conference was ‘Stepping up the Pace,’ summarised by Bill Clinton when he said ’It says much good work has been done, but it’s not an excuse to slow down. Right now we must redouble our efforts on areas like stigma and discrimination, which after 30 years is still increasing in some regions. We have the tools; we need to step up the pace.’ There has been remarkable progress since the 1980s, when HIV was a condition that had no name, no tools to diagnose, prevent or treat it. Today, there are 15 million people on treatment, yet there are still alarming challenges that must be tackled in order to even contemplate an AIDS free generation. Statistics from 2013 show there were 1.5 million HIV deaths, 2.1 million new infections and 35 million people living with HIV. Of the 35 million people living with HIV, 55% (19 million) don’t know they have the virus. They haven’t been tested and if they don’t find this out, they will die. The conference highlighted many reasons as to why people do not access or drop out of treatment. Reasons can be due to lack of services; however, a large part is due to stigma. Studies and personal testimonies have shown that:

  • Men are less likely to come forward for testing [1] when their wives are being tested during pregnancy because:” pregnancy is about women not men”. Men may be testing but not telling their partners, claiming that “they’re too busy”
  • Women, who may often discover a positive test whilst pregnant, will opt out of treatment and out of disclosing to their partners for fear of loss of trust, abandonment and violence from their partner for bringing HIV into the home[2],[3].
  • For youth, where 2 out of 3 new infections is amongst girls aged 15-19 years old, HIV remains the biggest killer of adolescent girls. This can be attributed to the lack of education around sex and HIV[4],[5], the stigma and barriers to youth friendly sexual health and HIV services[6] and links between poverty and transactional sex[7].
  • For Key populations, including sex workers, men who have sex with men and injecting drug users, many are inhibited from seeking testing and treatment because of legislative, structural and societal barriers – fear of judgement or reprimand[8],[9].

In many cases it may be easier to ignore the positive status than deal with the consequences of seeking support. The need for this is highlighted in a recent report produced by STOPAIDS Entitled “Increasing DFID’s contribution to Addressing HIV among key populations which makes a series of recommendations about ways to advance the rights of communities who are disproportionately affected by AIDS. The report was launched at the conference alongside a recent film focusing on people who use drugs in Moldova. We must tackle stigma and discrimination at every level including state policies. The AIDS 2014 conference organisers released the AIDS 2014 Melbourne Declaration, calling for an end to discrimination against people with HIV and the eradication of criminalising laws and practices. [10] Another key issue highlighted at the conference is the importance of monitoring viral load to ensure PLHIV are able to access necessary medication in order for treatment to be optimally effective. However, currently very few high-burden countries routinely offer viral load testing to people receiving HIV treatment. Since 2012, UNITAID has supported projects working to make viral load testing technologies available in resource-limited settings in Sub-Saharan Africa, but these do not yet address viral load monitoring needs on the large scale required. More efforts are needed to make new viral load testing technologies must be affordable and appropriate for poor resource settings in order to be used effectively. In Melbourne, UNAIDS launched the Diagnostics Access Initiative which calls for improving laboratory capacity to ensure that all people living with HIV can be linked to effective, high-quality HIV treatment services. Lack of access to Treatment is still a huge concern especially that there is a 10 fold price increase from 1st line to 2nd line treatment. In reality, the international community is facing huge challenges to control HIV. Therefore, governments, policy makers, funders, and civil society need to:

  • Have a renewed focus to work on the Key Populations and those most at risk and focus on stigma, discrimination and the legislative barriers
  • Address the dysfunctional health systems that hinder treatment
  • Continue campaigning for effective, affordable and appropriate new medicines and medical technologies (e.g. viral load equipment)
  • Challenge the notion that HIV is over and ensure that decision makers realise that  we are at a critical tipping point, where if we don’t step up the pace now we will miss the opportunity to contain the epidemic
  • Ensure the unfinished business of MDG 6 is taken forward post 2015 into the health goal

In the expressive words from Sir Bob Geldof, ‘We have come so far but there is a preposterous reluctance to fund the last mile. The advocates get tired, the same message goes out to the same people and it becomes less effective.’ I can’t help but think that many of the UK based members of the STOPAIDS network feel the same. It’s not only a challenge on the global stage, but often within many of the organisations we work in. We must not become those tired advocates beating the same drum, but come back from the conference championing the successes of our work over the last 30 years and enter a phase of renewed energy to ensure we step up the pace and most importantly leave no one behind.


 

References

[1] Intrahealth International at AIDS 2014 Conference

[2] Rev Phumzile Mabizela, INERELA+, Pre Interfaith Conference
[3] Jennifer Gatsi Mallet, Namibia women’s health network, ICW, Plenary Session AIDS 2014 Conference
[5] UNESCO poster at AIDS 2014 Conference
[6] YWCA, PNG, Pre Interfaith Conference
[7] Cluver, L, Boyes, M, Orkin, M, Pantelic, M, Molwena, T, Sherr, L. Child-focused state cash transfers & adolescent HIV infection risks: A prospective multi-site study in South Africa. The Lancet Global Health
[8] Rev Phumzile Mabizela, INERELA+, Pre Interfaith Conference
[9] Khuat T. Oanh, MD, Vietnam, Diane Havlir, MD, United States, Daisy Nakato Namakula, Uganda, James Ward, BA, Australia, Wednesday Plenary Session AIDS 2014 Conference
Share

« Previous Entries

Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.