The battle against AIDS has slowed down. And UN’s new strategy won’t be enough
A new UNAIDS document, End inequalities, end AIDS: Global AIDS Strategy 2021-26, to be presented to its Board of Management on March 25, has come at a critical juncture of failing global response to AIDS. The strategy attempts to identify “where, why and for whom the HIV response is not working” and to “build back better, supporting systems for health to be more resilient and place people at the centre”.
It bases rest of the strategy on ending inequalities, identified as the most important reason for failed AIDS response. It tries to identify inequalities in every setting that prevent access to services. Inequalities exacerbate the spread of not just HIV but many communicable diseases, with Covid-19 being the latest example. But basing the entire strategy on correcting inequalities as a precondition for ending AIDS runs the risk of non-performance by countries who are indifferent to addressing such imbalances and where the programmes are failing and infections are on the rise.
The missing piece in the document was a bold, honest and impartial assessment of why the response has not been working. The roles played by country leadership, the joint United Nations (UN) programme, donors and civil society should have been critically analysed and lessons learnt identified to lay the foundation for a new well thought out strategy for the next five years.
The paper has not adequately addressed the role leadership and political commitment play in a global programme such as AIDS. The single most important reason for the response going off the track was the declining political support for AIDS programmes for various reasons. The joint UN programme should be accountable for rejuvenating this commitment, country by country.
A critical requirement for successful implementation of AIDS programmes is the functioning of efficient governance structures to deliver services. Global AIDS programme was the first to advocate for dedicated structures under the “Three Ones” principle for AIDS governance. Much of the success achieved earlier was due to strong country level buy-in of the Three Ones structures — one national level coordinating authority, one national AIDS control programmes and a single monitoring and evaluation system. These served as effective platforms for a truly multisectoral response for AIDS by bringing the non-health state actors, the UN system and the civil society into a unique partnership, not seen earlier in any national programme.
In the last few years, the multisectoral nature of AIDS response has all but evaporated and AIDS has been relegated to the narrow confines of the health ministries at the country level. This, in a large measure, is responsible for the lack of visibility and failed response in the last few years.
The strategy paper gives a strong push for full integration of HIV services under Universal Health Coverage (UHC). It does not recognise that the health system itself has a stigmatising impact on the key marginalised populations who do not feel encouraged to access services from the heath system. While bio medical interventions like antiretroviral treatment (ART) and elimination of mother to child transmission (eMTCT) services can be progressively integrated into UHC, prevention of HIV among key populations needs to stay strongly rooted in communities.
While it is essential to bring the inequality lens to evaluate the scenario, the strategy paper should have advocated for a strong public health approach to put the response back on track by re-establishing strong political commitment followed by resources, improving the governance structures, focused primary prevention among key populations, maximising treatment access through community based test and treat programmes and introduction of new technologies such as Pre Exposure Prophylaxis (PreP) and HIV self testing.
The joint UN programme should assume the role of being a strong and fearless advocate and activist for re-establishing AIDS response into national priorities to regain their lost importance at policy and implementation level.
(JVR Prasada Rao is a former health secretary government of India and a former UN special envoy on AIDS. The views expressed are personal.)