Opinion: What next after HIV Implementers meet in Uganda?

By Raymond Baguma. The writer is a journalist
Note: This blog brought you uncensored updates from the HIV Implementers Meeting in Kampala between June 3rd and 7th. Now here is my opinion about the meet. Read on...

THE HIV Implementers meeting that ended this afternoon, Saturday, in Kampala had all the trappings that come with big money: rich donors like U.S. government, the Global Fund, and the World, 1,700 participants, media from around the world, the luxurious surroundings of two of Kampala’s most expensive hotels and a stunning menu of well-funded research on every imaginable aspect of the HIV/AIDS. Yet one conclusion was inescapable: we are not winning the war against HIV.

Some prominent speakers acknowledged that more money as yet has not brought a positive answer to that basic question. “Many of our most trusted interventions … are at best unproven, at worst disproven,” noted David Wilson from the World Bank’s Global AIDS Team.

Wilson said the “best preventive intervention in the history of the epidemic, male circumcision, is barely advancing,” and even though reducing the number of sexual partners has been the major contributor to reducing HIV transmission, except for in Uganda early in the epidemic, that has happened “despite, not because of formal programs.”

Wilson spoke against a backdrop of steadily rising HIV/AIDS funding. Under the US Presidential Emergency Plan for AIDS Relief (PEPFAR), funding has shot to US$6 billion in 2008 compared to the US $2.3 billion in 2004, according to Dr. Thomas Kenyon, from PEPFAR. In Uganda, PEPFAR’s pledge for this year is US$283 million this year, compared to US$236 million in 2007. Also, the six-year-old Global Fund to fight AIDS, TB and Malaria has committed more than US$11b in 136 AIDS-affected countries in the developing world, with sixty percent of its funding going to African countries.

Ironically, progress was more dramatic 25 years ago when there was little funding. The UNAIDS boss, Dr. Peter Piot said with every two people on treatment worldwide, five people are becoming infected with HIV daily.

First Lady Janet Museveni wonders whether all the new money has been a good thing. “In the late 1980s and the early 90s, there was a sense of urgency to stop AIDS and we had many volunteers,” she says. “At that time, there was no money and expected no financial rewards. Then money started coming in, and we lost volunteers when we institutionalised recruitment.” Today, the rate of new infections in Uganda is rising by as much as 2% in some areas.

Various explanations have been offered for why the dramatic rise in spending has brought a less than dramatic reduction in the rates of HIV-infections. Some say the easy battles have all been won. Others blame changing morals or complacency. But others ask whether the huge establishment created by HIV spending is losing sight of simple things that make a difference.

As Wilson put it, “We must understand, but not overcomplicate.” That may be hard because the HIV/AIDS sector has become a massive industry, sometimes concerned with perpetuating itself. In fact, conference sponsors already were thinking about the next big HIV/AIDS gathering.

During last week’s meeting, they refused to release research papers and presentations to the media because the same presentations will be made at the International AIDS Conference to take place from 3 rd to 8th August in Mexico City. Apparently, they did not want the Kampala meeting to pre-empt the Mexico agenda.

Meanwhile, the HIV/AIDS sector’s size has brought duplication of services, donor programmes and poor coordination of AIDS activities at different country levels. The donor market dedicated to combating HIV/AIDS is crowded and donor agencies have begun fighting for attention and space, observed the UNAIDS deputy executive director, Michel Sidibe. “We are trying to deal with the magnitude of the epidemic. But on many occasions, we have been doing it in an uncoordinated manner,” Sidibe said, “We need to simplify and coordinate the aid money. We need to improve the performance of national systems.” The World Bank’s Operations Advisor Jonathan Brown acknowledges that duplication and competition of donor activities is alive but perhaps a natural thing to occur.

In line with the theme, Sidibe said that partnerships and coordination of HIV/AIDS response programmes is important to the long-term response to the epidemic.

In the competition for funds, some anti-HIV activists feel squeezed out. Phillip Mitchell who is a director of Hope Clinic Lukuli in Kampala said that the implementers meeting did not encourage networks and explain how small NGOs can access funding. “To scale up, you have to bring in more people. They are large multi-country companies that have PEPFAR money. But they are not bringing in new organisations. Donors should make it easier for new implementers to get into the system. They have created a barrier for us to access funds,” said Mitchell.

These problems are not limited to Uganda. In Rwanda, Agnes Binagwaho, the executive secretary of the National AIDS Control Commission said lack of coordination has led to fragmentation of donor programmes run by World Bank, Global Fund and UN. “Aid is lost in overhead, and aid funding is unpredictable and comes late,” she said.

The anti-HIV effort also suffers because donors sometimes do not have the same priorities as beneficiaries. Several African countries have weak, non-functional health systems and keep requesting for technical support to infrastructure development – to increase capacity and systems of storage for donated drugs, for instance.

Uganda’s state minister for primary health care Emmanuel Otaala said, “Donors cannot allow us to put up infrastructure, or train human resource. In the end, we only distribute drugs but lack human resource. But we have initiated a move to build evidence that we need to strengthen our health systems.” While health officials deal with such questions, there are ominous signs that the HIV epidemic could grow worse.

According to Dr. Peter Piot AIDS is remains the first cause of death after malaria and respiratory tract infections. Today, 3 million people living in the developing world are on ARV treatment and another 6 million people need ARV treatment. But health experts forecast that by the year 2010, the number of people in need of ARV treatment will be 10 million worldwide. Still, universal access to ARVs cannot be achieved by 2010, given that twenty percent of people worldwide today, know their HIV status, which is prerequisite to accessing treatment. While there are clear and ambitious targets for ARV treatment, there are no clear targets on prevention, as Piot points out. “We need combination treatment and combination prevention. With this, millions of lives would be saved,” Piot said.