Wednesday, March 25, 2009

UNAIDS: a Development Paradox

A recent UNAIDS newsletter demonstrates the paradox of the existence of such an institution as UNAIDS, whose brief is a single, sexually transmitted virus, HIV. The newsletter concentrates on homophobia, harm reduction programmes for drug users, sex work and the role of condoms in reducing HIV transmission (and, presumably, other sexually transmitted infections and unwanted pregnancies).

The paradox stems from the reflection that all these issues predate HIV, they will probably all continue after the HIV pandemic has subsided, if that ever happens, and they are all very important issues in themselves. That is, their importance goes well beyond their connection with the transmission of HIV. Therefore, there were already programmes to address these issues before HIV was even heard of, so where does UNAIDS fit in?

Homophobia, for example, is abhorrent and an infringement on human rights. There are organisations all over the world fighting homophobia. Does the arrival of UNAIDS add to the work that these organisations are doing or does it water the message down? The message seems to become 'homophobia is bad because it plays a part in spreading HIV'. Homophobes may even see this as an endorsement of their position. Perhaps I'm wrong, perhaps UNAIDS strengthens these organisations and has a genuine role to play.

Harm reduction for drug users is another issue that has been associated with HIV transmission. Yet, evidence that harm reduction programmes work for injecting drug users has been around for a long time. It's only political pragmatism that has prevented such programmes from being implemented in many countries. Does relating these programmes to HIV reduction strengthen or weaken advocacy for harm reduction programmes?

UNAIDS have embraced the view that there is no single approach to HIV, that each country needs to gather detailed data on how HIV spread in their country and implement different approaches as appropriate to that context. I am one hundred percent in agreement with them as this is one of my own findings. But I saw that as an indication that UNAIDS may therefore be superfluous, however well intended. I think of all development issues are addressed, HIV reduction will not be such an intractable problem.

Commercial sex work (or transactional sex) is surrounded by numerous factors in the transmission of HIV. Sex workers are vulnerable because they are poor, or poorer than their clients, they are unprotected by the law and perhaps even victims of abuse by officers of the law, they are stigmatised by the public, they have little access to health and other social services, stemming from their poverty, lack of those services, their legal position, etc.

Sex workers suffer terribly, they have multiple vulnerabilities and, as a result, they often play an important part in the transmission of HIV. But they have suffered abuse and been denied their rights for as long as anyone can remember. This relates to HIV but HIV transmission stems from many other problems that are not just about HIV. Where does UNAIDS fit in here? Do they become advocates for the decriminalisation of sex work? This would be great but should they join other organisations already involved in such advocacy or is there a niche for them, somewhere?

The (male) condom is something of a symbol of the fight against HIV. They appear on websites about HIV, in particular, on UNAIDS's site. But condoms have been around for a long time and played a significant part in the decades of work carried out by those who believed that development simply meant population control. Those organisations, FHI (Family Health International), PSI (Population Services International), TFGI (The Futures Group International), and others, were spectacularly unsuccessful in getting condoms accepted. However, they were considered the most deserving recipients of hundreds of millions of the dollars that were subsequently ploughed into HIV reduction.

Is UNAIDS going to become one of them, a family planning organisation? There is no doubt that sexual and reproductive health are very important issues; they are also an important part of the fight against HIV but I think UNAIDS see themselves as playing all of the above roles. Yet they are playing all of those roles in an importantly qualified way. It seems that they are playing those roles to the extent that this will reduce HIV transmission.

Every single factor in the transmission of HIV needs to be addressed but also, every single factor that I can think of needs to be addressed, irrespective of its part in HIV transmission. Each factor in the transmission of HIV is also an area of underdevelopment. HIV spread in places where there are high levels of economic and gender inequality, poverty, poor health, low standards of education, low levels of social services, poor infrastructure, especially in the area of water and sanitation. Governance, legal institutions and civil society are also factors in the transmission of HIV.

UNAIDS have some of the best personnel in the HIV world, they have some of the best resources and they have access to pots of money. But I'm still at a loss to understand why HIV has been singled out from all other diseases and development problems and given this special UN institution. Especially as many of these other diseases and development problems played a crucial part in the spread of HIV.

I suppose the paradox is that there is a sense in which UNAIDS is concerned with all of these issues but is, at the same time, only concerned with HIV.



Tin Angel said...

hi simon! a thoughtful post. it's important to question the role of unaids, and other enormous development organisations, because if they get it wrong they waste so much money. one good reason for setting up such an organisation is the potential for large-scale, timely interventions, if appropriate, to save so many lives and so much money by averting great impacts which happen later. in the early, exponential phase of an epidemic, a reduction in transmission rate can indeed avert many future impacts. we are now approaching or experiencing the endemic phase, especially in ssa, so unaids needs other reasons to justify its existence.

Simon said...

Hi Tin Angel, thank you for your comment. Yes, I question UNAIDS and big institutions but I don't wish to sound like I am knocking them completely. In fact, I am quite at a loss to know how to resolve the apparent paradox. I think they may well do some good work but I don't, ultimately, think it has worked to exceptionalise HIV. It has been counterproductive and HIV us spreading in ways that we are only just picking up on now. UNAIDS and others have been unable to keep pace with the epidemic in the sense that they have yet to describe the mechanisms of transmission adequately and some things seem to keep changing (although UNAIDS can't be blamed for that).

HIV is bigger than UNAIDS and probably always will be. But I don't think a reasonable level of health is beyond, say, the WHO and other health institutions. That's why it would seem better not to spend such huge amounts of money on interventions that are aimed at one disease, many of which don't appear to be working anyway. There are plenty of development issues we know a lot about and we know the effect they will have on people's health, so maybe it would be better to concentrate on some of these.

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it's important to question the role of unaids, and other enormous development organisations, because if they get it wrong they waste so much money. one good reason for setting up such an organisation is the potential for large-scale, timely interventions, if appropriate, to save so many lives and so much money by averting great impacts which happen later.