The Epidemic

African countries often face greater development challenges than other developing countries. Income per capita has been declining in many, and ethnic strife is devastating parts of the continent. Within this environment, the HIV/AIDS epidemic is spreading at an alarming rate, with an estimated 22.5 million men, women and children now living with HIV/AIDS. Social and economic factors are critical in both the spread and the impact of the epidemic, including gender inequality, poverty, migration, and civil unrest.
More than one and a half million African children were estimated to be infected with HIV by the end of 1998.

The impact is enormous: all the health and development gains of the recent decades are in jeopardy. HIV has affected primarily men and women in their most economically and socially active years, a time when they are also responsible for the financial support and care of others. Evidence already exists to demonstrate the negative economic impact upon farming systems; private businesses; formal and informal sector enterprises; public services such as health, education, and public administration; other services such as water and communications; and security, both police and military.

Children are affected by the epidemic in different ways. More than one and a half million African children were estimated to be infected with HIV by the end of 1998. Close to 10 million children are thought to have lost their mothers to the epidemic in the region, including 1.7 million in Uganda alone, leading to the phenomenon of child-headed households. In Zimbabwe, in mid-1996 it was estimated that 8% of children under age of 15 had lost their mothers to HIV/AIDS. The coping mechanisms of communities affected by the epidemic are stretched to their limits as people shoulder the responsibility of caring for those who are infected and their survivors, including orphans.

Response to Date

Responses in developing countries to the HIV/AIDS epidemic have often involved top-down approaches, driven by the political need to produce quick results. Many initiatives have assumed that people simply need to be told "the truth" about the HIV epidemic; that simply telling stakeholder groups to collaborate will ensure that it happens; and that technology-focused interventions in the absence of an enabling political and social environment will have a sustained impact.

It is now widely acknowledged that such programmes have neither slowed down transmission rates nor generated effective responses to the challenges the epidemic presents to human development. Indeed, many problems that need to be solved are not yet fully understood, even by experts. For example:

· The epidemic in one country may differ from its manifestation in another;
· The problems at one stage may differ from those at a later stage;
· The way the epidemic spreads is influenced by different development strategies, economic systems, and political situations;
· Responses to the epidemic depend just as much on personal and community commitment as on what external observers may view as necessary; and
· There are no obvious technical solutions, or even models of programme design, which are readily transferable from one context to another.

In addition, the epidemic requires discussion of many sensitive issues: sexuality, fear, stigma, discrimination, illness and death. These represent real threats to the people and communities most directly affected, but are also major obstacles to reducing further transmission. The epidemic has given rise to difficult questions about rights and responsibilities, and the need for mechanisms for achieving societal and individual behavioural change.

Clearly, the response to the epidemic needs to be broad and multisectoral, and to take into consideration the full range of political, development, gender, and human rights. There have been initial successes in response to the epidemic in Uganda, which has adopted just such a broad, multi-sectoral approach, mobilizing communities, civil society, politicians, and employers to minimize discrimination and to address factors that intensify vulnerability. Effective responses require the adoption of innovative strategies and of new partnerships that cross disciplines, sectors, and other hitherto separate spheres of activity.

The Alliance

The Alliance of Mayors and Municipal Leaders on HIV/AIDS in Africa was launched in December 1997 in the Ivory Coast, at a Symposium sponsored by the United Nations Development Programme (UNDP), in collaboration with UNAIDS and other partners. In their Abidjan Declaration, the leaders declared,

Aware that precarious economic conditions in our cities intensify the impact of HIV/AIDS on vulnerable communities, in particular women and youth, and jeopardize our long term local development plans;

Recognizing that our cities are increasingly becoming centers of demographic growth in our countries and that, given the powers invested in them, our municipalities have an important role to play in responding to the many challenges posed by the HIV/AIDS epidemic;

We hereby commit ourselves to search for solutions relevant to local needs and realities, in accordance with the goals and principles of the United Nations and our own laws and regulations, in order to respond more effectively to HIV/AIDS in our communities.

The Declaration called on all mayors and municipal leaders in Africa to join the Alliance, which committed itself to respond on a priority basis and to invest in community and individual capacity to cope with HIV/AIDS. In January 1998, the Alliance adopted Statutes with 23 Articles setting out its aims and mode of operation. It developed a two-year action plan, appointed a Coordinator, and established a secretariat at the office of the Abidjan Mayor.

The Alliance now covers 17 countries, with more expressing interest in joining, and 70 municipalities. Its Coordinating Committee met during the World Alliance of Cities Against Poverty (WACAP) Forum in Lyon in October 1998, at which time the Alliance participated in a plenary panel presentation on HIV, Poverty and the Role of Local Government. The Committee launched a logo contest to raise awareness among individuals and organisations and to contribute to the UNAIDS 1999 Campaign "Listen, Learn and Live". Young people from age 15 to 25 in member municipalities were encouraged to send their ideas for a logo that will illustrate the principles of the Alliance.

In partnership with UNDP and within the framework of UNAIDS, the Alliance has developed AMICAALL - the African Mayors' Initiative for Community Action on AIDS at the Local Level - a $10 million, eight-country pilot project with a clear strategy to address HIV/AIDS where the impact is greatest and success is most likely.¹ Funds are being raised, and country-specific plans have already been developed for Ivory Coast and Tanzania. Tanzanian mayors formally joined the Alliance in August 1999, holding a seminar attended by municipal leaders from Swaziland, Ivory Coast, Kenya, Uganda, and Zambia.

Strategy

Since the emergence of the HIV/AIDS epidemic two decades ago, the burden of the disease has fallen squarely on the shoulders of local communities. This has happened, in part, because many national governments are faced with depleted resources, both economic and social. Nevertheless, national governments have an important role to play - if better ways can be found for those representing government to identify and respond to the interests of their client communities and civil society.

This can only happen if local governments and political leaders can gain the technical skills and resources they need to create relationships of trust and dialogue with their constituencies. This relationship of trust and dialogue is at the root of the AMICAALL initiative, and hinges on several key points:

· National government officials may be too far away to hear citizens' complaints, but local officials-mayors included-are not.

· Local problems and local efforts to resolve them are the purview of local governments and mayors.

· The greatest impact of the epidemic is occurring in the cities of Africa.

· The role of local governments and mayors is vital and has been very little noted - until the creation of the Alliance.

In addition, experience has shown that some fundamental changes are required in the approach to HIV/AIDS:

· in people's perceptions of their own roles and capacities in enhancing human development;

· in the ways individuals and institutions relate to one another;

· in the focus of analysis from the virus to people and their relationships; and

· in the nature of what needs to be done, who needs to do it, and where and how to begin.

The AMICAALL approach rests on the premise that if individuals and communities are to take responsibility for addressing the various dimensions of HIV/AIDS, they will require a supportive policy and social environment characterized by good governance, decentralization and political leadership. It is labor-intensive work to put neighborhoods and communities in the driver's seat - it demands local coordination, planning and action, supported by enabling national and international policies.

AMICAALL aims to strengthen the capacity of local governments and political leaders to identify the socio-economic causes and consequences of HIV/AIDS, and to support multi-sectoral community-based responses to the epidemic. The project will especially focus on protecting the most vulnerable groups within communities (particularly children, young people and women) affected by the epidemic, by creating safety nets for their survival. It will build on local knowledge and capabilities, capitalizing on techniques traditionally used by communities themselves to support their sick, orphaned, and dying members.
AMICAALL aims to strengthen the capacity of local governments and political leaders to identify the socio-economic causes and consequences of HIV/AIDS, and to support multi-sectoral community-based responses to the epidemic.

The methodology used by AMICAALL is both new and exciting because:

· One size does not fit all. The AMICAALL initiative will take into account the fact that different households, neighborhoods, and towns have been affected differently by this epidemic. For example, girl-headed households require assistance different from that of boy-headed households. Women of childbearing age require different approaches from men or older caretakers.

· AMICAALL will not work within one single stakeholder group. The social, economic, and development implications of HIV/AIDS requires the involvement of many stakeholders to bring about sustainable solutions. But simply telling stakeholder groups to "collaborate" does not ensure that it happens - and often the inability of stakeholders to work outside their sector or discipline poses the greatest obstacle to problem-solving. AMICAALL will train stakeholders on ways to work together, and help them define their roles.

· AMICAALL will provide experiential learning for effective decentralization. Developing the capabilities of local teams to analyze local problems and understand what is happening in their neighborhoods and cities will yield mechanisms for effective decentralization. AMICAALL will link local needs to local governments and through to national policy makers, defining the role that each level plays in ensuring sustainable solutions.

· AMICAALL will harness the political will of mayors and local governments. It targets the very group that has the political will to sustain policy changes.

The AMICAALL approach to partnership at the local level has been described by Dr. Peter Piot of the UNAIDS secretariat, as representing "a unique opportunity to bridge gaps between rhetoric and mobilization for sustained action at local level, and enhance capacity for the development of a supportive and enabling policy and social environment".

Action

Through different tools and approaches, AMICAALL will

· support municipal leaders, local government agencies and national policy makers in understanding the specific developmental determinants and consequences of the epidemic in their countries and cities;

· develop the capabilities of municipal authorities and community stakeholders to identify and analyze needs and develop appropriate policies and programmes;

· help community groups to access and utilize local funds and other resources to address the specific needs they have identified - these may include prevention and behaviour change, or care and support for people living with or affected by HIV/AIDS;

· identify, strengthen, and use local capacity, including trainers and facilitators capable of scaling up and mainstreaming AMICAALL processes and methodologies in other cities within the country and abroad; and

· document the process to support learning and sharing of lessons.

Within each country, AMICAALL will work at three distinct levels:

The AMICAALL Municipal Team will be inter-sectoral, have direct contact with neighbourhoods, and bring together local government authorities, NGOs, and community-based organisations from two or three representative towns. Development experience shows that poor communities put enormous resources into bare survival, and need support to obtain technical know-how and resources beyond what they have. The Municipal Team will receive training and technical assistance in how to analyze, prioritize, implement and monitor activities, and will in turn train community groups affected by the problem.

The AMICAALL Policy Roundtable will include mayors and managers at the local, regional and/or departmental level, and will develop and share appropriate responsibilities between different levels of government. If, for example, schools need to provide extra tutoring for children who have missed school due to illness or death in families, or if schools are experiencing increasing illness and deaths among school teachers as a result of HIV/AIDS, the mayors, ministry of education, and other relevant ministries will realize that this problem requires action from their end. The Roundtables will be organised by the National AMICAALL Coordinator, and may be held in different pilot cities so that policy makers can see first-hand the implications of the epidemic, as well as people's courage and resources.

The AMICAALL National Committee will consist of the national association of mayors in the country, key policy-makers from relevant ministries, and the AMICAALL Municipal Team. The National Committee will help initiate and monitor the process in the country, and link to the African Alliance to exchange experience and lessons learned.

The project will partner UN Theme Groups on HIV/AIDS at country level, and link to several global initiatives, including the Leland Initiative of USAID, which will develop a Web page on the Internet that the mayors can use to share the information and lessons within and outside the region, as well as UNDP's Municipal Management Project and Urban Management Programme.

Pilot project duration will be on average 24 months from the moment of its launch in each of the eight countries selected. The sequence of tasks is expected to be as follows:

· Launching seminar;
· Appointment of AMICAALL National Coordinator and Mayors' Task Force;
· Selection of pilot cities;
· Forming and training of AMICAALL Municipal Teams;
· Holding AMICAALL Policy-makers' Roundtables;
· Preparation of community proposals and mechanisms for disbursement;
· Implementation of community-based activities;
· National workshop to review experience and develop scaling up strategy; and
· Case study and dissemination of experiences.

Outcomes

In addition to tangible improvements in the lives of individuals and communities living with HIV/AIDS, the following outcomes are expected:

· Change in official attitudes. Through the AMICAALL process, government officials will see those affected by the epidemic as a source of ideas, experiences, and solutions rather than a source of problems.

· Real definition of the problem. The communities will articulate their own realities rather than being told what the problem is.

· Appropriate solutions. Community institutions will plan and negotiate resources for solutions appropriate to them, leading to integration of site-specific data into municipal plans.

· Enhanced management capacity. Community capacity to manage development will be strengthened as a result of hands-on management of communal services and micro-projects, determination of how labor and other resources will be used, and decision making during implementation.

· Effective collaboration and communication. Inter-sectoral teamwork and team approaches to problem-solving will become more frequent, more open, and more likely to address local problems resulting from the HIV/AIDS epidemic.

Data collection and reporting on private behaviours are difficult to track. For this reason, in addition to a number of quantitative indicators, process evaluations will be conducted at the end of each phase of activities. The evaluations will use participatory methods that note changes in how people are talking about the epidemic, changes in how institutions are addressing HIV/AIDS, and others.

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In conclusion, the AMICAALL approach ensures that those affected by HIV/AIDS will not be marginalized, or trapped into an endless cycle of poverty. Through the processes established, the voice of those affected will be heard, and the means to resolve these problems will be made more available.

1 The foundation of AMICAALL is the UNDP HIV and Development Programme, which has supported national and regional networks to address the ethical, legal and human rights dimensions of the epidemic; promoted the involvement of people living with HIV/AIDS; and helped to build local capacity for multi-sectoral action on HIV/AIDS. UNDP's Urban Management Program is also lending its support to the AMICAALL initiative, through its access to mayors across the continent, training and participatory methodologies. The proposal builds on other experience, including the Community Involvement in the Management of Environmental Pollution programme overseen by the U.S. Agency for International Development.