UNGASS+5: The clock is ticking

UNGASS+5 Daily Diary - 31 May 2006

The UN General Assembly special session to review progress on HIV and AIDS over the past five years (UNGASS+5) gets underway here in New York this morning. For the past couple of days people have been running all over town pulling their hair out. What is on their minds? The current version of the ‘outcomes document’ – the piece of paper summarising the collective views of 190 or so governments, which will be spat out of this UN circus at the end of the week.

If you are already confused how an ‘outcome document’ can be prepared before the meeting has actually happened, welcome to the Alice in Wonderland world of the United Nations. ‘Outcome’ in UN-speak means: What do we (governments) know going into the meeting, and what do we want to say happened during the session?

Even though many participants are being as diplomatic as they can muster, I have yet to meet anyone here who thinks the current version of the outcomes document is acceptable. Why?

To start with, the reasons why we need another UNGASS ‘declaration’ are not clear. A meeting of this magnitude is an obvious a chance to get governments and the UN to give a genuine assessment of how well/badly we have done since the first UNGASS –(that is, after all, what I thought a ‘review’ was) – to re-state their commitment to stopping AIDS as well as previous commitments, and to map out their forward-looking plans for turning the epidemic around. So a document of some kind capturing those elements sounds like a good idea.

Sadly, the current draft outcomes document reads more like a Hollywood re-run of the UNGASS 2001 Declaration of Commitment – a new wish-list. As one delegate stated candidly, “It’s like the first draft was a Christmas tree, and we have all come along and stuck our respective decorations onto it.” The document re-opens a lot of the original declaration content and adds a sprinkling of new issues and themes that have emerged since 2001.

What is needed is an outcome document that reaffirms and builds on the original Declaration and adds the specific issues and priorities that have arisen since then. That would provide a framework to guide the global and national AIDS responses for the next five years.

Given the track record of the past five years, since the UNGASS 2001 AIDS promises were made, the report of this meeting should also include some humility and an expression of regret by people in positions of power and authority for just how badly we have done to address the epidemic.

Another main reason the current document is very weak is that AIDS is obviously now a political issue, and once you enter the political arena, it seems consensus is pretty much impossible on anything. Each government has political points to score this week as well as ‘do’ something about AIDS. So many are trying to move the UNGASS review conclusions closer to their own stance and preferred policies – and not just AIDS policies, but also trade policies; foreign policies; conservative moral policies; human rights and democratic policies – and these are unfortunately more important to some governments than the thousands of people who dies as a result of AIDS or are newly infected with HIV every day. This is the down-side for the past five years of asking for AIDS to be made more political so it carries more weight in international affairs, and gets more extensively funded.

Similarly, many NGOs and other civil society organisations see the UN review as an opportunity to get their priority themes onto the international agenda for the next five years, giving their advocacy and funding arguments the official ‘backing’ of all UN Member States.

So what happens when all these agendas are vying for position? All too often our well-intentioned talk fails us – as they have here already at UNGASS.

Instead of creating something new and realizing the opportunities that are just out of our collective reach, we polarize, entrench and focus on differences of opinion. When the stakes are high, add in a sense of pressure and the international AIDS ‘community’ hardens around positions that we then defend by advocacy within our own stakeholder groups. Governments argue with governments about whether they can use words like condom, for example, and NGOs disagree about whether integrating AIDS with TB is more vital than with sexual and reproductive health services.

We typically walk away without learning about what we might have done differently; what we did to get the result we got, or what to do next time. The sense of fragmentation and separation gets reinforced.

Meanwhile the clock is ticking.

UNGASS+5: Failure to learn will be the harshest judgement of all

The five-year day of reckoning for the most significant political promises and commitments on HIV/AIDS is upon us. At a special session of the UN General Assembly later this week, Member States can either come clean by admitting collective failure to deliver adequate HIV/AIDS programmes in the most affected counties, or they can simply move the goalposts. True to form, the Joint UN Programme on HIV/AIDS (UNAIDS) and its eight UN agency co-sponsors seem to favour the second option and are moving us headfirst towards a new goal of ‘universal access’. One of the potential risks of moving so hastily is that the opportunity for genuine evaluation of the past five years, and the invaluable lessons that must be extracted, will be lost.

According to the five-year AIDS report card published recently by UN Secretary-General Kofi Annan, a 2001 special session of the UN General Assembly on HIV/AIDS (UNGASS) was a “landmark in global efforts to respond to the AIDS crisis.” For the first time in the history of the pandemic, a series of time-bound targets were adopted, and set out in a ‘Declaration of Commitment on HIV/AIDS’, signed up to by leaders from 189 countries.

In the five years since then, Annan asserts, the Declaration of Commitment has “galvanized global action, strengthened advocacy by civil society and helped guide national decision-making.”

Buoyant talk, given just how badly we have actually done over the past five years – or perhaps the past 25 years – to address a global AIDS pandemic that has already claimed 25 million lives.

Later this week, all UN Member States meet in New York for a five-year progress review of the promises they made in that Declaration. Despite some progress in expanding access to HIV prevention and treatment, Annan is expected to dryly advise most governments that they are being outpaced by the epidemic in most places because HIV programmes are still failing to reach the very people and communities most vulnerable to HIV.

According to Annan’s report, for example, a mere 9 per cent of men who have sex with men received any type of HIV prevention service in 2005. Among people who inject drugs, fewer than one in five receives HIV prevention services. A condom was used on average, the report estimates, in only 9 per cent of “risky” sex in the past year.

Less than 10% of pregnant women with HIV have access to the relatively simple drug treatments that prevent mother-to-child transmission: the main reason three million children were born with HIV in the past five years.

Care and support reaches fewer than one-in-ten of the 15 million children orphaned by AIDS and millions more children made vulnerable by the epidemic.

One of the few global targets that was achieved is the amount of money that governments, international agencies and other partners said they would need to tackle AIDS. In 2005, approximately $8.3 billion was spent on AIDS programmes in low- and middle-income countries, reaching the Declaration of Commitment financing target of between $7 billion and $10 billion per year.

One inescapable conclusion is that while the money is available, the end results are not. But, rather than insisting on a frank analysis of why we have all failed so terribly to make a difference, the UN agencies tackling HIV/AIDS (UNAIDS and its cosponsors) is claiming: “…the foundation for an extraordinarily stronger and sustained response is largely in place.”

How can such disappointing performance be hailed as a foundation for anything? Exhaustive learning from the past five years would be more appropriate.

Instead, ‘universal access’ – the goal of providing a comprehensive package of HIV/AIDS treatment, care, support and prevention – is now being promoted heavily by the UN. This is a new and untried strategy based on what is – at best – a confusing and ambiguous statement of intent by governments.

The upbeat UNAIDS position has its roots in a single sentence from the Gleneagles G8 meeting last year and the subsequent World Summit declaration:

“We commit to … developing and implementing a package for HIV prevention, treatment and care with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all who need it….”

According to UNAIDS: “These ambitious commitments have brought the AIDS response to another historic juncture.”

Alongside the other 177 paragraphs of the World Summit document this one sadly does not stand out as particularly striking. Similarly, the G8 is good at making ambitious commitments, and this one is not especially “historic” when placed alongside the endless HIV/AIDS promises they have made – and then promptly broken – over the past five years.

The UN position on universal access is an immense leap of faith, and one that currently trumps the one obvious fact that should actually be bringing the AIDS response to an historic juncture: We are failing to address the epidemic effectively.

Despite popular rhetoric about “knowing what to do about AIDS” we clearly need to learn a lot more before AIDS programmes will reliably provide basic prevention and treatment services to the people who need them.

But even as the ink dried on a late-2005 UN resolution requesting UNAIDS to find out what was preventing ‘universal access’ from being achieved, the agency’s most efficient operation ever was unveiled. Almost overnight, plans were in motion to coordinate over a hundred national consultations, set up seven regional consultations and establish a global steering committee.

UNAIDS has since claimed: “Thousands of people from all walks of life have mobilized to seize this extraordinary opportunity.” The UNAIDS- and UK government-led universal access ‘initiative’ did take a large number of people along with it – unfortunately not in a common understanding, but in a collective misunderstanding. Why? Because the terms ‘access’, ‘utilization’, ‘availability’ and ‘coverage’ are often used interchangeably to stand for the general idea that most people thought they meant when talking about ‘universal access’: That people in need of essential AIDS services and commodities to protect their health are actually going to get them. Many people take the ‘promise’ of universal access literally.

There is also a widespread misconception that ‘universal access’ applies solely to the goal of increasing access to antiretroviral drugs, rather than to the intended one of improving access to a comprehensive range of HIV prevention, care, support and treatment services.

Universal access offers an easy enticement, especially given the disappointing outcome of the recent World Health Organisation (WHO)-led AIDS treatment initiative – 3by5 – that promised to provide antiretroviral (ARV) drugs to three million people with HIV in poor countries by the end of 2005, but only delivered them to less than half of that number.

When the UN system moves with the speed and efficiency that it has shown around universal access, and goes to such lengths to make the process appear inclusive and country-driven, it’s generally a sure sign that a major policy shift is brewing.

Underlying the universal access strategy are recent debates – also largely led by UNAIDS and the UK government – about how donor support for AIDS can be more harmonized and aligned.

A UNAIDS document reveals that:

“Scaling up towards Universal Access is a partnership between the country and its external development partners facilitated by UNAIDS.....It is aimed to better link increased financial support to agreed-on policy and programme goals.”

A significant shift to re-build the AIDS response on individual national AIDS plans risks consigning the past five years of accountability against the UNGASS DoC to a moment in history. Placing universal access centre stage dilutes the most significant and specific political promises on HIV/AIDS overnight.

Adopting individual universal access road-maps would also turn the strategic clock back about ten years to when support for national AIDS programmes was channelled by donors to individual national governments through WHO’s Global Programme on AIDS (GPA). Back then, aid was less tied to international frameworks – with more cash provided directly for government-managed country priorities.

At a recent meeting on AIDS in London, the head of UNAIDS, Dr Peter Piot, commented that he hoped the UNGASS+5 review later this week will not be: “One of those summits where we say: ‘We’ve failed, we’ve failed, and we have no results and we need more money,’ and then we go home.”

Given the Secretary-General’s five-year AIDS report, how could we possibly claim anything other than a collective failure? The current status of the AIDS pandemic – and the appalling track record of providing essential HIV-related services to the people and communities who need them – demands that the UNGASS+5 review meeting be truthful and authentic by going further than even Dr Piot fears, by concluding: “We’ve failed, we’ve failed, and we need to candidly ask why, before we set ourselves new targets or frameworks on AIDS.”

Each and every UN Member State has an unmistakable choice before it at the UN General Assembly later this week: Either strongly reaffirm the UNGASS DoC of 2001 and ask candidly why we are addressing AIDS so slowly; or move on with platitudes and blind faith that we are succeeding against the worst pandemic in history.

The first option calls for political nerve and pragmatism in order to learn fully from our failures. The second requires a disregard for the lessons and warnings of the past five years, and for the needs of the 40 million people living with HIV.