The Causes, Contours and Consequences of the Multi-Sectoral Response to hiv/aids franklyn Lisk Centre for the Study of Globalisation and Regionalisation University of Warwick, uk



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The Causes, Contours and Consequences of the Multi-Sectoral Response to HIV/AIDS

Franklyn Lisk

Centre for the Study of Globalisation and Regionalisation

University of Warwick, UK

Paper prepared for the Globalisation Forum

The Australian Global Studies Research Centre

University of Western Australia (UWA)

Perth

13-14 August 2009



  1. The causes of the global HIV/AIDS epidemic


i) Origin of HIV/AIDS

HIV/AIDS was first recognized as a medical condition in the early 1980s, although it is now known that symptoms resembling the ‘human immunodeficiency virus’ (HIV) that causes the ‘acquired immune deficiency syndrome’ (AIDS) had been recorded by researchers as early as the 1950s.1 In October 2008, the scientific magazine, Nature, carried an article in which it was reported that researchers in 1998 had isolated the HIV-1 sequences from a blood sample taken in 1959 from an African woman in Leopoldville (now Kinshasa), the capital of Zaire (now Democratic Republic of the Congo – DRC), implying that the virus has been around for at least 50 years.2 Many uncertainties and conspiracy theories surround the origin of its HIV/AIDS and the evolution of the disease into a global epidemic: one ‘theory’ was that that the virus had originated from African monkeys and transferred to humans apparently through consumption of monkey meat; another was that the virus ‘escaped’ accidentally during experimentation on chimpanzees by American scientists working on an oral polio vaccine project in the DRC.

The earliest cases of AIDS were reported in the United States in 1981 when doctors noticed cases of an extremely rare disease linked to immune deficiency syndrome among homosexual men in the ‘gay’ communities mainly in New York and San Francisco. The first official report of this particular health condition was recorded in the weekly journal of the U.S Centers for Disease Control and Prevention (CDC) in June 1981.3 Similar cases were later identified by U.S. doctors among other groups, mainly hemophiliacs and recipients of blood transfusion, and later among injecting drug users who shared needles. By then, it was apparent that immune deficiency syndrome was not restricted to gay men: previously labeled ‘Gay-Related Immune Deficiency Syndrome (GRID), the disease was renamed ‘Acquired Immunodeficiency Syndrome’ (AIDS) by the CDC in 1982. In 1983, HIV was identified as the possible cause of AIDS, and by the mid 1980s, it was possible to test for the virus with reasonable accuracy.
Upon reading the June 1981 CDC report, some doctors in Belgium and France realized that they had encountered similar conditions among patients in central and western African countries since the mid 1970s. It was in Zaire in the early 1980s that the epidemiology of the heterosexual foundation of HIV/AIDS was first determined, laying the foundation for a generalized pattern of the epidemic that was to spread throughout Africa and beyond with devastating effects. A team of Western doctors, including Peter Piot from Belgium (who later became the first executive director of UNAIDS), had visited a hospital in Kinshasa in October 1983 to follow up on reports about an immune dysfunctional disease affecting men and women equally. The team reported their observations about the occurrence of AIDS among heterosexuals in Africa to medical institutions in the United States and Europe, and initial reactions ranged from suspicion to disbelief. It took quite some time to convince Western medical establishments about the validity of AIDS among heterosexual, and for the CDC to eventually agree to fund a research project, ‘Projet SIDA’ which was launched in Kinshasa in June 1984. The project was led by an American public health specialist, Jonathan Mann, who later became the first director of the WHO’s Global Programme on AIDS (GPA) in Geneva.
ii) Initial response to HIV/AIDS by the international system

The initial response to HIV/AIDS by the World Health Organisation (WHO) was slow. Despite reports in the early 1980s of HIV infection cases by African member states, including statements by health ministers from the region at the annual World Health Assembly, the global health agency continued for some time to acknowledge the existence of HIV/AIDS as a new disease among specific groups in rich countries. Reports of HIV/AIDS among the general population in Africa were perceived as cases of sexually transmitted infections, and referred to a small unit at the WHO’s headquarters in Geneva that dealt with this condition. It was much later in 1987 that WHO came up with an official determination of the cause of AIDS and acknowledged the disease as a major public health concern.4 Before then, WHO had only cautiously endorsed separate research findings by two Western scientists, Dr. Luc Montagnier of the Pasteur Institute in France and Dr. Robert Gallo on the National Institutes of Health in the United States, around 1984 which confirmed that AIDS was caused by a retro-virus, HIV, and that the main modes of transmission were blood and semen. Until the mid-1980s, the WHO’s role in addressing HIV/AIDS was essentially that of monitoring developments in member states, reporting and sharing information on outbreaks, and providing guidance to countries on how to minimize the risk of infection.


By continuing to regard HIV/AIDS as a health problem of rich countries which could afford to respond effectively to the disease, the WHO missed the initial opportunity to act against the rapid spread of the epidemic in Africa and also in the Caribbean and to contain its explosion into a global problem. As we now know, failure by the international health community to appreciate the scale and potential catastrophe of HIV/AIDS, and delay in the emergence of a coordinated global response by the international system, was to have grave and profound consequences worldwide.
Furthermore, from what we now know about the epidemiology of HIV/AIDS, it is obvious that we are confronted with a global epidemic for which there is no known cure or a successful vaccine against the virus. The destructive consequences of HIV/AIDS in terms of mortality and morbidity and impact on future generations have resulted in one of the worst humanitarian tragedies in the history of public health, as well as a major development challenge for some of the poorest countries in the world. From the experience so far of efforts to combat the HIV/AIDS epidemic, it has become clear that an effective response would require a multi-sectoral approach that transcends the domain of health. Such an approach implies multiple efforts by the major stakeholders at all levels – governments, donors, international and regional organizations, local authorities, the private sector, civil society and, last but not least, the people living with HIV/AIDS (PLWHA) themselves.



  1. The impact of globalization on the spread and control of HIV/AIDS

It can be argued that the current phase of globalization of the world economy has influenced both the spread and control of the global HIV/AIDS epidemic. Growing interdependence of economic interests between countries and the era of budget travel bought about by globalization have resulted in large increases in the movement of people and the pathogens they carry across international borders. This, in turn, facilitates the global transmission of infectious diseases and epidemics such as HIV/AIDS and the current outbreak of swine flu. In a world of unequal partners, globalization does not seem to be benefiting poor countries with marginalized economies – many of which are seriously affected by HIV/AIDS, This situation , to some extent, has been attributed to the management of globalization which is based mainly on decisions taken in key global economic institutions like the International Monetary Fund (IMF), World Bank and the World Trade Organisation (WTO) which are controlled by a handful of powerful countries from the North. For many poor and marginalized countries of the South, the outcomes of globalization as currently managed have resulted in anxieties rather than expectations and in global risks rather than global opportunities. HIV/AIDS has increased these anxieties and risks, at the same time as the adverse effects of globalization on economic growth and employment opportunities have limited the capacity of poor countries to confront the threat of HIV/AIDS on their economies and populations. While globalization has created opportunities for technological advances leading to the accelerated development of life-extending drugs and advanced therapies to tackle HIV/AIDS and other infectious diseases, poor and marginalized countries are less likely to benefit from such breakthroughs.
Analysis of the global response to HIV/AIDS from the perspective of global governance has highlighted the imbalances and tensions in the power relationship between the North and the South.5 The South includes some of the poorest countries in the developing world which are also highly affected by the HIV/AIDS epidemic, but with limited resources to deal with the problem. In contrast, the North is made up of the developed and rich industrialized countries that have the resources and knowledge to ensure an effective global response, but are less affected by HIV/AIDS.
Attention therefore should be focused on the conditions and requirements for better management of globalization and arriving at fairer outcomes of the process in terms greater economic well-being and social justice for all. The market-driven process of globalization should be made more conducive to a more egalitarian style of economic development and a more broad-based pattern of social development. This would also require improved global governance of multilateral institutions, as is discussed in the last section of this paper.


  1. The link between HIV/AIDS and poverty

There is a two-way causative relationship between HIV/AIDS and poverty. HIV/AIDS can cause poverty at the household level, through loss of productive capacity and earnings due to illness or death and through additional expenditure on treatment and care of AIDS. Poverty can cause HIV to spread, such as when lack of income ‘drives’ women and girls to engage in risky transactional sex with multiple partners, and can cause needless deaths from AIDS through inability to afford the cost of treatment.6 In sub-Saharan Africa where poverty is widespread, the adverse effects of HIV/AIDS on productive capacities and income-earning opportunities is making poor households become even poorer, and increasing poverty is in turn contributing to greater risk of infection and the spread of HIV. Poverty conditions also act as a constraint on effective response to the epidemic at national level. Low-income and resource-poor countries are likely to be less effective in responding to the threat posed by HIV/AIDS to their economies and populations than the rich industrialized countries. At the same time, failure to reduce poverty impedes progress in HIV/AIDS treatment and prevention programmes.
Understanding the bi-directional relationship between HIV/AIDS and poverty is critical to any global strategy for combating the global epidemic and its impact at all levels. The manifestations of poverty in unsustainable livelihoods and constraints on socio-economic development drive the poorer segments of the population towards higher risks of HIV infection, and leave resource-poor countries with reduced capacity to take action against the epidemic. Failure to effectively respond to HIV/AIDS undermines efforts to reduce poverty. Not surprisingly, the United Nations has identified the HIV/AIDS epidemic as a major obstacle to the achievement of the Millennium Development Goals (MDGs) which are time-bound targets established in 2000 to halve extreme poverty worldwide by 2015.



  1. The contours of the global HIV/AIDS epidemic

    1. The ‘exceptionality’ of HIV/AIDS

HIV/AIDS has killed at least 25 million people worldwide since it was diagnosed as a generalized epidemic in the early 1980s. More worrying, is the fact that HIV/AIDS has continued as a killer epidemic for more than a quarter century and with no sign of abating; the ‘longevity’ of HIV/AIDS is without precedence in the history of global public health. The epidemic has aptly been described by one expert as a “long wave event whose path is not easy to predict”.7 This makes HIV/AIDS ‘exceptional’ and different from previous global epidemics or more threatening than recent outbreaks of deadly infectious diseases with the potential of a global epidemic , such as Ebola fever, the SARS epidemic, the avian flu and, currently, the swine flu.
Unlike other past and recent global epidemics, HIV/AIDS has been around as visible epidemic for nearly three decades without interruption, This is a considerably long period for the persistence of a single epidemic condition, and one with no sign of being brought under control, despite unprecedented international attention and substantial financial resources that HIV/AIDS prevention and treatment have received and continue to attract. Human behaviour plays an exceptionally important role in the spread of HIV/AIDS compared to other health problems or medical conditions. In the absence of a cure or a vaccine, the prevention of HIV and the control of its spread depend crucially on the responsibility of individuals not to put themselves and others at risk of infection.
The exceptionality of HIV/AIDS is also linked to the multi-dimensional characteristic of the epidemic. HIV/AIDS has profound and lasting non-health implications which include negative impact on development and threat to human and national security. In addition, the impact of HIV/AIDS on individuals and societies has given rise to complex legal and ethical issues that are linked to stigma and discrimination directed at sufferers of the disease and consequent violations of fundamental human rights principles. This multi-dimensional characteristic of HIV/AIDS, and the severity and longevity of its impact, have made the disease become ever more complex in terms of volatility, instability and dynamism and, hence, more difficult to contain.
HIV/AIDS has spread worldwide and evolved into global epidemic. According to the latest available statistics provided by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO, an estimated 33.2 million men, women and children worldwide are infected with HIV. Sub-Saharan Africa bears the brunt of the burden of the global HIV/AIDS epidemic: with just over 12 percent of the world’s population, the region is nevertheless home to about two-thirds of the total number of persons infected with HIV worldwide, and accounts for nearly three-quarters of the global total of known AIDS-related mortality.8 Many Africans already infected with HIV and who do not have access o adequate treatment and care will certainly die from AIDS-related illnesses within he next 10 years, even if a cure for the disease were to be found now, Although there is now treatment for AIDS that can prolong the lives of those infected with the virus, access to such treatment on a sustainable basis is still beyond the reach of the vast majority of HIV-positive people in low-income countries.
Equally worrying, from the perspective of Africa’s future and long-term development, is the fact that an estimated 15 million children in the region are orphans due to the loss of their parents to AIDS. Many f these are deprived of adult support and guidance for their development, and often left to fend for themselves under hazardous and risky conditions. In addition, about 700,000 babies in the region are born infected with HIV each year; this is altogether an unacceptable situation created by lack of access to existing medicines for preventing transmission of the virus from mother to child. The consequences of the impact HIV/AIDS on children and infants are to inter-generational deficits in future human capital requirements for sustainable development.
The significance of HIV/AIDS and its impact goes beyond the grim statistics presented above. HIV/AIDS is a unique epidemic with exceptional characteristics which amplify its impact on human well-being now and the threat it poses to human development in the future. The demographic, economic and social impacts of HIV/AIDS multiply from an infected individual to human groups – couples, families, households – leading to: rising infant, child and adult mortality and plummeting life expectancy at birth;9 destruction of livelihoods and increasing impoverishment; and disruption in the social structure of households and communities.
A distinct and again worrying feature of HIV/AIDS is the fact that the majority of those affected by the disease are from the working-age population. The disease disproportionately affects those in the prime of their productive lives who have critical economic and social roles in society. Given the very high mortality rates associated with HIV infection in developing countries, the economic and social consequences of AIDS-related deaths at household and national levels are bound to affect progress and sustainability of human and national development. Many poor countries are already incurring huge additional expenses to cope with the losses in labour productivity and national output caused by AIDS-related morbidity and mortality. The epidemic dissipates existing stocks of human capital and imposes huge strains on already limited national budgets. The impact of the epidemic on human capital constitutes a major development challenge for resource-poor, low-income developing countries, and further compounds existing challenges of poverty and underdevelopment. With no known cure for AIDS or a successful vaccine against HIV infection, the HIV/AIDS epidemic has the potential to change the course of global development in terms of the gap between rich and poor countries. This is on account of the differentiated impact of the epidemic between the global North and the global South, with respect to demographic parameters and socio-economic conditions, including the severing of vital connections between one generation and another.
In addition, as already noted, the impact of HIV/AIDS on individual and human groups has given rise to complex ethical, security, gender equality and human rights issues that need to be addressed. HIV-related discrimination is a violation of basic human rights and a breach of the fundamental principle of non-discrimination and the equality of all people, as enshrined in the Universal Declaration of Human Rights of 1948 and other human rights instruments. Human rights violations linked to HIV/AIDS are particularly serious in the context of the ‘world of work’ in terms of access to employment and income-earning opportunities.10 There are also human rights implications with respect to the impact of the epidemic on vulnerable groups such as women, children and migrants which compound existing problems of discrimination, xenophobia and gender inequality.


    1. The “internationalization” of HIV/AIDS

The substantial attention given to HIV/AIDS on the international agenda in recent years has resulted in some of the biggest vertical programmes in the history of public health and healthcare focused on a single disease. Over he past decade, two well-resourced, specialized global institutions, UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), have been established to bolster the global effort against HIV/AIDS. International partnerships involving private sector organizations and philanthropic foundations, such as the Global Business Coalition on HIV/AIDS and the Bill and Melinda Gates Foundation, are now major contributors to the global HIV/AIDS response. Global advocacy bodies, such as the International AIDS Society and the International AIDS Alliance have been created to promote and coordinate HIV/AIDS policy and action programmes, including lobbying for reduction in the costs of antiretroviral drugs. The World Bank has created special flexible and concessionary facilities o increase access of poor countries to financial resources for addressing HIV/AIDS. Since 2001, the UN General Assembly has convened a number of special sessions and high-level meetings devoted exclusively to HIV/AIDS, including summits of heads of states ad governments. One of the 8 Millennium Development Goals set by the UN Millennium Summit in 2000 concerns the control and reversal of the spread of HI/AIDS.
HIV/AIDS is today prominent on the international agenda. This is reflected in declarations by the UN and the international community to take action against the epidemic, such as the Millennium Declaration (2000), the UNGASS Declaration of Commitment on HIV/AIDS (2001), the Political Declaration of the UN High-level Meeting on HIV/AIDS (2006), and recent G8 summit communiqué (2005, 2007, 2008). Concerns about the security implications of the global HIV/AIDS epidemic at the international level resulted in the historic debate on HIV/AIDS at he UN Security Council in January 2000, when for the first time a health issue was discussed at the Council. In addition, a number of initiatives and partnerships have emerged on the international scene specifically to help mobilize resources and provide technical assistance to countries for a strengthened and effective HIV/AIDS response. Funding from various sources for the global HIV/AIDS response has skyrocketed from US$300 million in 1996 to nearly US$ 10 billion in 2008. No other single global health problem or international humanitarian concern has received so much attention of financial resources from the world community.
The UN and the international donor community are largely in agreement on the need for more resources to address the daunting multiple challenges of the global HIV/AIDS epidemic. There has been an upsurge in international cooperation among rich and poor countries to support the global HIV/AIDS response. This has resulted in external transfers and subsidies from richer countries to fund HIV/AIDS responses in resource-poor and low-income countries, primarily because the epidemic is seen as a global threat. Mobilizing international support to control the spread of the global HIV/AIDS epidemic should be seen as a cost-effective investment on the part of rich countries, while at the same time could yield benefits to those poor countries facing deep and intractable development challenges due to the impact of HIV/AIDS.


  1. The Multi-sectoral Response to HIV/AIDS

i) More than a health issue

The HIV/AIDS experience and lessons so far from initiatives and programmes to combat the epidemic at all levels clearly indicate that an effective response has to be grounded on a multi-sectoral approach, and supported by a broad-based cooperative effort involving multiple stakeholders including those infected and suffering from the diseases. This is a multi-dimensional task that requires the expertise of policy-makers from other sectors in addition to health. The non-medical dimensions of the epidemic include not only social and economic impact, but also culture, religion, human rights and politics. Because of this multi- sectoral characteristic of HIV/AIDS, the response at the global level through the United Nations apparatus has avoided the usual single specialized agency/mandate model and opted instead for a joint and co-sponsored programme, the ‘Joint United Nations Programme on HIV/AIDS’ (UNAIDS), that involves the participation of several individual UN agencies (WHO, ILO, UNDP, UNESCO, WFP, UNFPA, UNODC, UNHCR, UNICEF and the World Bank) that collectively are perceived to be capable of responding adequately to the totality of the multiple problems and possible solutions to HIV/AIDS. The emerging consensus of the international community at the time of the establishment of UNAIDS by an ECOSOC resolution - following the demise of the WHO’s Global Programme on AIDS (GPA) due among other things, to inter-agency rivalries – was that the coordination of the global response needed collective action by multiple stakeholders, based on the recognition of the multi-dimensional nature of the epidemic and its impact.



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