Xth International Conference on HIV/AIDS and STDs in Africa The Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa Annex 3 Presentation
by Dr. Peter Piot A. DIMENSION OF THE PROBLEM/EPIDEMIC As we speak today, the number of people living with HIV globally is growing by something like 16,000 new infections every day, adding to the total of the 30 million or more adults and children now living with the virus. As 1997 draws to a close, with close cooperation between the Joint United Nations programme on HIV/AIDS (UNAIDS) and one of its cosponsors, the World Health Organization (WHO), we estimate that, indeed close to 6 million new infections will have occurred during the year, and that nearly 2.3 million will have died of AIDS and HIV-related illnesses this year alone. And yet 1997 has witnessed growing perceptions and proclamations that the worst is over, that the world has turned the corner as far as AIDS is concerned, that man’s ingenuity has once again overcome the challenge. Where then do we stand? True, there is a new dawn in the treatment of AIDS. True there are reports of an overall decline in the incidence of HIV in Western Europe and the USA. True too there are equally encouraging reports of a declining incidence of new HIV infections among some populations of the developing world. But the TRUTH is also that, globally, HIV/AIDS has continued its relentless progression, albeit very differently from one region to another, from one country to the next, and even within the same country. The REALITY is that HIV infection is even far more common than previously thought. And the overwhelming truth is that the advances in treatment and the hope that these bring to millions have also underlined the gaping and ever-increasing divide between the industrialised and the developing world. Over 90% of all new infections today are in developing countries: one in every 100 sexually active adults worldwide. If current transmission rates hold steady, by the year 2000 the number of people living with HIV/AIDS will soar to 40 million. Because over 90% of people with HIV live in the developing world, where there are few facilities for voluntary testing and counselling, UNAIDS estimates conservatively that 9 out of 10 HIV-positive people have no idea they are infected. Many would probably want to know, provided they felt protected from stigma and discrimination. Infection rates in Asia are lower, but the numbers are large In Asia, the epidemic is more recent than in Africa, and only a few countries in the region have developed sophisticated systems for monitoring the spread of HIV. In India, infection rates, at under 1% of the total adult population, are still low by the standards of many countries, although well over 10 times higher than in neighbouring China. While surveillance remains patchy, the indications are that between 3 and 5 million people are living with HIV, making India, even at the most conservative estimate, the country with the largest number of HIV-infected people in the world. In Southeast Asia the picture is mixed. It is bleakest in Cambodia, where one in 20 pregnant women, one in 16 soldiers and policemen, and one in two sex workers tested HIV-positive in the most recent monitoring surveys. Myanmar and Viet Nam are also seeing a rapid spread of HIV. In contrast, sustained prevention efforts in Thailand are continuing to produce evidence of a fall in new infections, especially among sex workers and their clients. Latin America and the Caribbean In Latin America and the Caribbean, the HIV/AIDS epidemic is taking a heavy toll, especially on men who have sex with men and injecting drug users. Now, there is increasing evidence of spread among poorer and less educated parts of the populations, as well as among women. Drug use drives HIV in Eastern Europe Drug injection is behind the dramatic surge in HIV infection in several Eastern European nations, accounting for the majority of the 100, 000 new infections estimated to have occurred in 1997. In Ukraine, where around 70% of infections have been in drug users over the last three years, some 25,000 cases of HIV infection have been reported so far, half of them in 1997. With the number of cases of sexually transmitted diseases rocketing in countries such as Belarus, Moldova and Russia, concern is also increasing over the potential for HIV spread in this region through unprotected sex. AIDS is falling in the industrialised world The growing gap between the developed and the developing world concerns not only the scale of HIV spread but also mortality rates from AIDS. In North America, Western Europe, Australia and New Zealand, newly available anti-retroviral drugs are reducing the speed at which HIV-infected people develop AIDS. To a large extent, this has given hope but has given rise to a perception that the epidemic is over. This notion is certainly false as have been seen in the other regions. It is even more dramatic here in Africa. Unprecedented infection rates in sub-Saharan Africa We are now realising that global rates of HIV transmission have been grossly underestimated — particularly in sub-Saharan Africa where the bulk of infections have been concentrated to date. The situation is even more desperate than had been thought with AIDS, which is now as big a killer as malaria. An alarming 7.4% of all those aged between 15 and 49 years are now thought to be infected with HIV in sub-Saharan Africa. Levels of infection vary, however, widely across the continent. Southern Africa continues to be the worst affected area. It now estimates that one in 10 adults are living with HIV — up by more than a third since 1996. By early 1997, the Government of South Africa had estimated that 2.4 million South Africans were living with HIV, amounting to an adult prevalence rate of about 10%. In Botswana, the number of adults infected with HIV has doubled over the last five years, now reaching 25% to 30% of the adult population. In Zimbabwe, infection was estimated at one in five adults in 1996 and, in one town with a large population of migrant workers, seven pregnant women in ten were already testing HIV-positive in 1995. In Beit Bridge, a major city, the proportion of pregnant women infected shot from 32% in 1995 to 59% in 1996. In very badly affected countries such as these, the development gains achieved over the last few decades are already being wiped out by the epidemic. In Botswana, life expectancy, which rose from under 43 years in 1955 to 61 years in 1990, has now fallen to levels previously found in the late 1960s. Already a quarter more infants are dying in Zambia and Zimbabwe than would be the case if there were no HIV. On current trends, Zimbabwe’s infant mortality rate can be expected to rise by 138% by the year 2010 because of AIDS, and its under-five mortality rate by 109%. B. IMPLICATIONS FOR AFRICA The epidemic continues to spread at a frightening speed around the world — at a time when many developing countries are working to sustain hard won development gains, to balance sectoral, economic, social, health, environmental and political interests, to use national and external resources in more efficient and equitable ways, all within an increasingly complex and changing global environment. What do these mean, especially for us gathered here today? The undeniable socio-economic determinants and impact of HIV, in particular the inequalities and the inequity that undermine social and economic progress, must increasingly be factored into development policies and strategies, at all levels. For many countries in this region, the biggest DUAL challenge is to address the short- to medium-term risk factors and risk situations AND ALSO to address these inequalities and the needs for long-term sustainable human development that can reverse the trends. This means the imperative to create — and to maintain — social cohesion and economic progress, often in the face of shrinking resources, high levels of poverty and worsening income inequality. African populations are very young. This is especially true of cities where, in addition to natural population increase, there is a lot of rural-to-urban migration, often of the young — both men and women. The number of people living in cities is expected to more than double in 35 years. Cities throughout Africa are seeing increasing rates of HIV infections among women and men in their most economically and socially productive years. These disturbing trends, as we know, have repercussions on all aspects of life and development. Therein lies another enormous challenge — to prepare cities and the settlements around them not merely to absorb this population but to create an environment in which people can live healthy and productive lives. Clearly additional resources are needed — for development and for addressing HIV/AIDS in its various dimensions. We must all expand our efforts to mobilise additional resources. And new and existing resources must be wisely used to ensure equitable development for this generation and generations to come. Every country must define its own development agenda and goals. Yet, in an increasingly integrated world, no country can attain these goals in isolation. As the epidemic has evolved, so too has our understanding of its implications and impact — on individuals, families, communities and nations. It is clear that while HIV and AIDS remain a very serious public health issue, effective responses require leadership, commitment and action on a broad range of human, social, economic and political endeavors, and the active involvement of political leaders at all levels who can mobilise and support civil society organisations and groups. It is also clear that the personal, community and societal losses associated with the epidemic are both socially and economically unaffordable and ethically unacceptable. As the Administrator of UNDP has observed:
Yes, we have heard the statistics but let us keep in our minds the human faces of this epidemic — the countless women, men and children who are finding innovative and creative ways, often with limited resources, to provide care and support and comfort to those infected and affected, and to keep families and communities together. These community-based efforts are critical for an effective and sustained response to the epidemic. C. CHALLENGES The theme of this satellite revolves around HIV, development and governance. In particular, the latter refers to the way in which society governs itself (local government and civil society). For the state, this means organising public services, creating an enabling environment for sustainable human development (both for private sectors and civil society, e.g., non-government organisations and groups of people living with HIV and AIDS). In a similar gathering supported by UNDP at the Asia Pacific Regional Conference on AIDS last October, the role of decentralisation and the interface between government (including local) with civil society clearly demonstrated that appropriate responses involving a variety of sectors maximised availability of already limited and stretched resources, increased efficiency and most of all increased the credibility of the government and civil society participants among its community. As one of the speakers said:
Local government can and does contribute to social and economic development in many ways. For example, through the wise allocation and utilisation of public resources coupled with laws and regulations that together create and maintain a social and economic environment in which human development takes place. Some governments have already come to the realisation that they have to broaden their response to the epidemic and this has to involve the rest of civil society in policy and programme development. There is much to be done. Many of you in this room understand the difficulties and daily challenges that confront those trying to mobilise effective responses to the epidemic:
D. CALL FOR ACTION, RESPONSES AND POLITICAL WILL These are the same challenges that many of you have to face in managing transparent and accountable local governments that respond to the epidemic. As Mayors, you need to lend your weight to functions where community activities relating to AIDS occur and NOT just to those that are organised by the City but your other partners as well. This would include your commitment and affirmative action to: 1. Protect your youth. As your populations are very young, and they are most vulnerable to HIV, it is essential that structures be developed to protect your youth from HIV. They need not be a problem but rather the solution. In part, this means supporting job creation schemes for youth, especially young women, in both formal and informal sectors, through local partnerships of the City with the private sector. It also means developing activities, particularly for hard to reach youths to access prevention activities, e.g., peer education programmes which again need support of the city government and the private sector. 2. Identify and mobilise local capacities for prevention, care and support. There exist everywhere institutions and structures which have roles to play in prevention, care and support (including possibilities for income generation programmes) and these need to be assessed for their capacity for an effective response and then mobilised. Church and religious groups, for instance, have traditionally provided care and support. Or in West Africa, for instance, it is very common to find Savings Societies which are forms of mutual insurance in the face of family disasters. These could have bigger and different roles to play and MAY already be facing tasks that are beyond their capacity because of HIV-related illnesses and death. In the same category are Funeral Societies — with intensified problems because of the epidemic and which could widen their roles to become a broader base for prevention andcare. 3. Provide leadership and commitment in establishing a local supportive environment that makes prevention, care and support possible. One of the biggest obstacles is the absence of a supportive local framework — reflected in varied forms from discrimination in local employment codes (including both City rules and procedures) as well as attitudes in private and public sectors. This demands political will — political action of government matched with community action. For this to happen, two related actions need to be undertaken. One, as leaders of your City, you must set a lead in addressing discriminatory practices and laws within your own jurisdiction, and through training establish a supportive local environment. This takes your commitment to a programme of action — to review what is happening and then to make changes to systems and practices and to create a locally open and inclusive environment where issues can be discussed relating to the epidemic in a non-discriminatory way. Two, the City should seek out ways of strengthening capacity amongst NGOs and other organisations such as networks of people living with HIV and AIDS. If there is anything that the epidemic has taught us, it is through involvement of people infected and affected, that we have achieved breakthroughs in the response. 4. Develop local services Finally, it is essential to develop local services which have a direct role to play in the response to the epidemic. This may mean non-formal education for all ages of the population as ways of increasing awareness of the issues, access to user-friendly counselling and testing facilities, ,and access to primary health care, including access to inexpensive STD and other drugs. These are all very important local services but generally still poorly, if ever, available. Again, the close cooperation between your local and central government, and partnerships with other private sector groups, including the community and religious groups, are essential. CONCLUSION Clearly, the epidemic is far from over. The more we know about it, the worse it appears to be. The overriding goal of UNAIDS is to enhance national capabilities to mount an effective multi-sectoral response to the epidemic. UNAIDS pursues this goal primarily through the work of its six co-sponsors. Thus, UNAIDS at country level is essentially the HIV/AIDS programmes of the World Bank, WHO, UNESCO, UNFPA, UNICEF and UNDP, plus any such programmes which these agencies may execute jointly or in partnership. UNAIDS also provides back-up for its co-sponsors’ programmes through technical collaboration services, assistance for selected research and development activities, and limited levels of financial support. The role of UNDP in facilitating the participation of Mayors at this forum is to be commended. The contribution of mayors and municipal leaders is critical in both areas of governance and HIV for an effective and sustainable response. Your leadership, commitment, energy and inspiration can make a difference. On behalf of the UNAIDS secretariat, I would like to congratulate you all for the initiative you are launching. |
