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The global HIV/AIDS movement

Published on 27/11/17 at 10:31am

Increasingly collaborative efforts have seen the threat of HIV recede and brought hope to demographics and communities most vulnerable to the condition. Casper Erichsen, Head of Influence at the International HIV/AIDS Alliance, discusses why these movements are crucial to ending the disease.

The Global Response to HIV has in many ways been unique as a public health effort. By the mid 2000s, what started as medical response evolved into a complex global movement, involving members from all levels of society and across sectors. Over the past decade this movement has grown larger and stronger, fed by political resolve and vast sums of money to control the global epidemic.

The HIV movement emerged from a confluence of grassroots activism, broad political engagement, growing public health response and apparatus to deal with an epidemic that was both untreatable and, initially at least, unmanageable. No one sector or actor had all the answers or the tools to deal with the epidemic. The impact was felt across social, racial, cultural and national barriers. The health response alone could not cater for the psychosocial needs of individuals and families affected by the disease. In many cases, especially in Southern and Eastern Africa, health systems as a whole came under severe stress and had to call on civil society actors and communities to help implement health services and communications. Although it was not always a convenient relationship, the bonds grew over the years, and the biannual coming together of the global AIDS community has often been described as a family reunion.

Some of the great examples of how the response merged into a bigger movement come from countries like the Netherlands, where the National Government realised already in the late 1980s that it did not have the tools to reach and care for drug users being infected with HIV. It called upon civil society actors to step in, and this relationship helped the Netherlands control its epidemic. In countries like Namibia, where in the early 2000s one in four adults was living with HIV, a Government-led multi-sectoral approach, spanning most ministries, NGOs and development partners, resulted in Africa’s largest, best-sustained and most effective condom programmes, and later led to one of the best treatment roll-outs on the continent. The partnership model to some extent saved the health system from collapse, in a country that now pays upwards of 70% of its own HIV response, and in which civil society continues to work side by side with the state.

The results produced by the global HIV movement are evident and impressive. New infections were reduced from 3.3 million people at its peak in 1997 to the, admittedly still high, current figures of 1.8 million people per annum. The incremental treatment roll-out between 2004 and 2017 is another major milestone. There are now a fully impressive 18 million people receiving treatment, the overriding factor in bringing down AIDS-related deaths from 1.8 million deaths in 2005 to 1.1 million today. The [coup de grace] in our list of results is surely our realistic aspiration no longer to prevent but to fully eliminate mother to child transmissions.

Another major impact of the global movement has been the incremental societal change occurring in developing countries over the last 20 years. The HIV movement, often working from community settings, has helped challenge paradigms, prejudice and policy on otherwise politically taboo subjects like drug addiction, same sex relations, and gender equity. In order to bring down barriers to end AIDS, conversations were had in the usually safe confines of a health response, which might not otherwise have been had. These contributions to global development must not be overlooked or trivialised.

However impressive the movement and its impact on the world, it is likely to undergo existential changes in the coming decade. One bellwether is the waning political interest, evidenced in the 2030 SDG Agenda in which HIV was relegated from the privileged position of a designated goal to forming part of a communicable diseases target. The political landscape has also changed: among some of the most prolific health donors such as the US, UK and Holland, there have been shifts in foreign policy and associated priorities. Allied to this, there has been a demonstrable overall decline in targeted HIV funding.

The existential moment in which the HIV movement will soon find itself is neither surprising nor unreasonable. The large international investments in HIV over the past three decades are not viable in the long term, and have mostly been sustained for fear of the cost of underinvestment or inaction. Fortunately, we are in all likelihood at a stage of epidemic control where we might not need a blanket investment. This is perhaps a contentious point, and not one often heard from civil society. As the epidemiological map is filled in, it is ever more evident where the remaining gaps are, geographically and demographically. And so, the large sweeping efforts of the 2000s must yield to more precisely targeted and less resource-demanding interventions. This, coupled with the growing ability of many southern governments to fund national responses, is sure to change the dynamic and scale of the response(s) in coming years.

What will happen with the global HIV movement in the future? This is a question that is being discussed a lot. There are certainly many lessons to be drawn from the movement and communities can play a central role. This is true of humanitarian disasters and major epidemics, such as Ebola for example which drew heavily on the lessons of HIV in mobilising a response.  Another is that a response is more effective when it is not siloed, mystified and ‘technicalised’. More than this, immense capacity has been built in developing countries across the world that countries will hopefully continue to utilise and which will continue to influence public policy and public health efforts.

However, the global movement is not yet dead and gone, and the work to end AIDS is far from done. We have only yet covered 50% of people living with HIV with life-saving treatment. New infections have remained stubbornly high, with only a drop of 200,000 since 2010. And many of the major barriers, that prevent full access to friendly, equitable health services, remain: criminalisation of populations, gender disparity, stigma and discrimination. It is these barriers that makes HIV and public health challenges so difficult to overcome. They drive populations underground, and sow fear and trauma. Organisations like the International AIDS Alliance, which works with communities to integrate health and rights in national and community responses, will continue to have a role in ending AIDS and making the world a better place while we do it.

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