AIDS: A multigenerational challenge - Providing a robust and long-term response

Gregg Gonsalves of ARASA has delivered a hard-hitting speech at UNGASS, rebutting the arguments of conservative public health officials who claim that over-expenditure on AIDS ignores other developing world health needs.

2008 High Level Meeting on AIDS General Assembly, United Nations, New York

AIDS: A Multigenerational Challenge – Providing a Robust and Long Term Response

By Gregg Gonsalves
AIDS and Rights Alliance for Southern Africa (ARASA) and the Global Network of People Living with HIV/AIDS (GNP+)

11 June 2008,  11h30-13h00, Conference Room 4

Good morning.

I've only got a few minutes with you today.

Before I talk to you about the importance of HIV to overall development, the role of social protection, the urgent need for a combined approach to tuberculosis and HIV, the value of health systems strengthening, and the promise of scientific innovation—the topics before us on this panel---I think you need a little context.

We've made a great deal of progress over the past few years in HIV/AIDS. Despite the still staggering death toll and the wave of new infections, we now have, for instance, 3 million people on antiretroviral therapy, something that would have been unbelievable 10 years ago.

This modest progress is in danger though. We've entered the era of the AIDS backlash. You all know what I am talking about. It's from those who say AIDS gets too much money, from those who say AIDS programmes are distorting health systems. You see it in the New York Times, in the British Medical Journal. What they'd like to see is AIDS cut down to size, distributing the pieces of a too small pie to other worthy priorities, to spread the inequity around so AIDS can languish as so many other health and development priorities have done for decades. But the backlash takes more insidious forms. For instance, the International Health Partnership and related initiatives represent a radical shift away from supporting disease control programmes. All of them essentially involve writing a blank cheque based on a broad health compact to developing country governments—in an amount which won't cover all of what needs to be done, so will force these nations to make the untenable choices about who lives and who dies. It will allow governments to spend money as they see fit, though people like me will never get to know where it goes because it's all in one pot now. What all of these new initiatives point to is the past—going back to old school development theories instead of building on the progress we've made with HIV/AIDS, the innovations that we've pioneered. If we don't stop this backlash, the war on AIDS will stop here with us, in my generation. And we will have lost. More importantly, we will have forgone the promise that AIDS offers of thinking about health and development differently.

Solving AIDS is important to achieving the Millennium Development Goals, to reaching our broader human development objectives. For example, mitigating the epidemic's impact will advance Goal 1 – eradicating extreme poverty and hunger and Goal 3 – to empower women and promote gender equality. With more than half of all HIV-infected infants dying before age two, the prevention of mother-to-child HIV transmission and the provision of paediatric HIV treatment together contributes towards Goal 4 – reducing child mortality. This is all well and good, but how are we going to get there? First we need the cash on the table. We need 0.7% of GDP from OECD countries to be devoted to development, including health, including AIDS, and we need
developing countries to spend at least 15% of their own GDP on health. These promises have been made, but no one ever delivers. And we need to be able to follow this money—to track its allocations and its expenditures. Ensuring accountability means theoretically sound concepts like budget support must have transparency built in up front as a condition of aid. If we're to meet our goals of universal access and the MDGs we need greater accountability, transparency and civil society engagement and oversight. Instead of people complaining about how AIDS activists have secured so much attention and funding for HIV, why don't we try to build a larger movement in which more, not less of us are calling for countries to pay their fair shares and to deliver on their promises? It is AIDS activism, if broadened out to fight for other development issues that will help us towards the MDGs, not going back to the way we used to do things, where governments North and South, were largely left to their own devices and left off the hook for their failures.

Social protection, including family and child support programmes, helps mitigate the social and economic impact of AIDS on families and communities and builds social support foundations for long-term development. Children orphaned by AIDS and other vulnerable children require special attention to reduce their vulnerability and to ensure access to education, health care, and legal support to address child
abuse and inheritance rights. They also need to be protected from stigma and discrimination. But these services cannot be built for orphans and vulnerable children alone. We need to build upon our success with AIDS to provide for the next generation—education, healthcare, freedom from violence and sexual abuse, the right to freedom from discrimination---are essential human rights. We need to fight for them as we've fought for AIDS. This means challenging ideas of sustainability, which told us that poor countries couldn't afford antiretroviral drugs a decade ago. It means making education, healthcare, legal services, yes: entitlements. Some at the World Bank have spoken out about AIDS entitlements lately—they would be mortified that I am asking for a broader range of interventions to be thought of as permanent investments, but they do this as they send their children to nice schools, never worry if their children have a cough, have life insurance and wills and testaments that ensure their children will never know destitution, a life on the streets. We have to challenge the idea that while we live comfortable lives, others can do with less because, well, we're not our brothers or sisters' keepers, we have to be fiscally responsible, cannot promote a "culture of dependency" when our cultures slosh around in excess even in precarious economic moments like we are living in now.

HIV responses that integrate HIV and tuberculosis prevention and treatment programmes into poverty reduction strategies and national development plans can address the long-term and multi-generational  challenges of these co-infections. Tuberculosis, particularly drug-resistant tuberculosis, poses an urgent threat to people living with HIV. It is critical to build the capacity of affected populations to respond to tuberculosis and HIV, helping to ensure programme relevance, transparency and improved accountability. TB is the leading killer of people living with AIDS. It's a completely preventable and curable illness, but we've been unable to beat it. I would say that TB holds a lesson for us about how not to do battle against a deadly disease. Until recently, TB was an example of the old way of thinking about health interventions-it was a technical issue for WHO, health ministers, doctors and healthcare workers, a top-down solution in which even the patients had to be spoon-fed their pills once a day. Lately, though TB is turning political, in which communities are starting to ask about why our TB programmes are so dismal in so many places, why the investment by our governments in new drugs and diagnostics is so meagre, why we've let drug-resistant TB get out of control. From Botswana, South Africa, Lesotho, to India, Nepal, Pakistan, to Argentina, Brazil, Chile—activists are starting to "act up" about TB. This politicization of TB won't go down well with politicians and bureaucrats, but it's exactly what the field needs—pressure from the ground up to hold these very people accountable for their failures. This is a lesson from AIDS: one we've now brought to the TB world and I hope we're never going back to the bad old days. We need to campaign for TB testing for HIV+ people; for
preventive therapy for those at risk; for basic infection control; for engaging patients as partners, not passive vessels for medications; for MDR treatment that doesn't involve locking someone up for 18 months.

Health system strengthening aims to improve the building blocks of health systems, managing their interactions to achieve more equitable and sustained improvements across health services and health  outcomes. The challenge is to achieve the right balance between HIV disease interventions and broad health system strengthening. AIDS activists are leading the call for comprehensive primary care, for AIDS to be the wedge for health for all, a slogan that according to Paul Farmer: "became the butt of ridicule in international health circles" since Alma Ata thirty years ago. We are calling for the financial investments necessary to provide comprehensive primary health to all and not a return to the notion of selective primary health care—doing less with less, which is essentially what the International Health Partnership and other initiatives are pimping for, pushing for, since in their push to kill disease control programming, these initiatives also make no call for the money needed to ensure that countries can meet all their health needs. AIDS, TB need not be exceptional, but the answer isn't as the architects of the IHP would have it: to make
these diseases as unexceptional as everything else in a race to the bottom for health services for poor people. If the champions of the IHP want to push for comprehensive primary health care, for the fiscal commitments to make it a reality, for a partnership in which civil society isn't an afterthought, AIDS activists will be leading the charge with them. But we're not going back to the old days, in which "cost-effectiveness" was essentially a death warrant for people with AIDS, in which World Bank and International Monetary Fund policies trumped the right to health, where governments could get away with spending less on the provision of public services and poor people remained quiet and were told to be grateful for any medicines or health care that they got. Never.

We need to support scientific innovation and prepare for rapid implementation of new technologies. From male circumcision, to pre-exposure prophylaxis, to new diagnostics and drugs for TB, we need to push for implementation of what works, push for what we need and get ready to make sure people have access to new and effective interventions. Despite some setbacks, the search for new technologies to prevent HIV transmission has been rewarded by the compelling findings of male circumcision trials which have proven to reduce the risk of female-to-male sexual transmission by approximately 60%. A number of countries are now introducing or scaling up male circumcision services within comprehensive prevention programmes emphasising safer sex practices. Trials of pre-exposure prophylaxis hold out for hope for discordant couples and those at high risk. However, the main diagnostic test for TB is over 120 years old, and there have been no new anti-tuberculosis drugs in 40 years. If we're to support new tools for health, we need first and foremost a vast increase in public sector investment in research---that means governments boosting funding for science and technology. Despite the public-private partnerships that are the darling of big foundations,
it is the post-world war 2 public investments in biomedical research funding that paved the way for modern medicine in the West. We need to go back to basics and make sure we are creating a new generation of
researchers, who will have the resources they need to do their work. We've also got to hold the big foundation's feet to the fire and keep them accountable as well—private wealth creates public policies on
research which can distort the field---good governance, transparency and accountability are not just for the public sector. For those new interventions that come along every decade or so, from antiretroviral therapy, to circumcision, we need to pay for their implementation, offer the technical expertise necessary for their deployment to countries, to engage communities as well as governments to ensure rapid roll-out.

Well, I've bankrupted half the G-8 with my prescriptions today, sound like Rosa Luxemburg on speed, am a dreamer, unrealistic, ignorant about how the world really works.

Well, AIDS activists are the pioneers of a new movement for social justice. So many of the things we take for granted in New York, or London or Tokyo didn't come cheaply, our own health and human development required massive investments and political will. In a post-Reaganite, post-Thatcherite world, we've been accustomed to changing the rules for poor nations, asking them to depend on "growth" to pull them out of a deep hole in the ground we helped to dig. The fact is that many poor countries won't be able to provide for basic services we take for granted unless we think of the world in new ways in which rich and poor countries share the burden for a planet without borders, unless we make a declaration of interdependence--for as the
British journalist Will Hutton has said, great societies are marked by essential core values, a social contract that enhances its citizens' lives, an honest and enlightened economy, a vital public realm, and a recognition that the world is an interdependent place, one best governed under international law and respect for human