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Combating HIV/AIDS – the German input

US study warns of dramatic rise in the HIV infection rate

People living with HIV as target group counsellors in Argentina

Empowerment of girls in Africa

Russia's underrated epidemic

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The Global Fund to Fight AIDS, Tuberculosis and Malaria

Work on the development of vaccines



02/2003
  

Combating HIV/AIDS – the German input

Thomas Kirsch-Woik and Kerstin Fährmann

AIDS is one of the greatest threats to peaceful development in the world, and an end to it is not in sight. The number of people infected worldwide at the end of 2002 was estimated to total 42 million, with an annual increase of about 5 per cent. Most of them live in developing countries. The pandemic is not expected to reach its peak until 2050 to 2060. What measures can the world community take to check it?

HIV/AIDS have long been unable to be seen as a purely health problem; it is a challenge for the whole of society. The impacts of HIV/AIDS are economic decline and the collapse of state and social structures, quite apart from the disastrous private consequences for the people affected and their families. Without combating HIV/AIDS there can be no sustainable development. Global efforts to reduce poverty will then also fail.


Current state of the epidemic

During the last two years the subject of HIV/AIDS has been handled at the highest international levels. The UN Security Council dealt with a health topic for the first time since its establishment, and the UN Special General Assembly in June 2001 and the G8 Summit in Genoa the following month had it on their agendas. The result was the founding of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), which, it is hoped, will mobilise additional resources to combat HIV/AIDS.

These global efforts were triggered by the ongoing worldwide spread of the pandemic. With about 30 million infected people, Africa South of the Sahara is the worst-hit region. But the dangers of the epidemic are not to be underestimated even in countries with currently low prevalence rates. According to UNAIDS estimates, there is an especially acute risk of a massive increase in infections in China, India, East Europe and Central Asia.

The majority of the newly-infected are young adults, and most of them do not know that they are carrying the virus. Contrary to all hopes, the epidemic has not even reached its peak in high-prevalence countries such as Botswana or South Africa. In some regions of Southern Africa, 40 per cent of all pregnant women are already infected with HIV. UNAIDS Executive Director Peter Piot is right when he warns that our efforts to date have neither checked the spread of AIDS nor will they do so in future.

The financial and psychological impacts of AIDS are disastrous, influencing not only the lives of the people today but also the opportunities of future generations. In many communities in Southern Africa, AIDS results in discrimination, impoverishment and hunger, and the chain of knowledge passed from generation to generation is broken. Most of the great number of AIDS orphans will not receive the upbringing and support they need, neither from their families nor their communities. Many of them will have to drop out of school and work to support their families. Others will go downhill into crime, join paramilitary organisations, or contribute to the political and social instability of their countries in other ways.

The impacts of HIV/AIDS on the economic power of the regions affected is manifold. Since the victims of the virus and the full-blown disease are mainly young, economically active people, the World Health Organisation's Commission on Macroeconomics and Health (CMH) estimates that due to AIDS annual economic growth in Southern Africa will drop by several percentage points. It says that between 11.7 per cent (a conservative estimate) and 35 per cent of the gross domestic product of sub-Saharan Africa will be lost. This means that private sector companies will suffer ever greater losses in productivity and profit. Commerce and industry has already reacted to that: investment in Southern Africa has fallen markedly in recent years.

In addition, new challenges for the international community are arising due to the rapid spread of HIV/AIDS in world regions which previously were little affected, especially in Asia, East Europe and the former Soviet Union. Also, the ready availability of life-prolonging medications for AIDS sufferers (so-called anti-retroviral therapy, ART) in industrialised nations has led to a debate on whether these must not also be made available to poor sections of the population in developing countries.


Effective strategies

Twenty years after the epidemic began, the successes in combating HIV/AIDS are alarmingly small. But there are also positive developments; during the last 20 years we have learnt which strategies are successful. Countries such as Thailand and Uganda have shown that the number of new infections can be reduced. Effective programmes to combat HIV/AIDS, such as the GTZ project to fight AIDS in Uganda and Tanzania, stand out for the following components:
  • The HIV/AIDS problem must be recognised early at the highest political level and combating it classified as the most important goal of government action at all levels in order to develop a climate of responsibility.
  • In fighting HIV/AIDS, a wide array of actors in the international, national government, public welfare and private sectors must be included.
  • People living with HIV/AIDS must play an active part in the prevention measures.
  • Social policy measures in favour of poor and disadvantaged sections of the population can reduce their susceptibility to HIV infection.
  • The prevention programmes must include all sectors important for the development of a country (multisectoral approach), and not be restricted to the health sector.
  • By the interaction of a great number of measures (education, combating addictions, access to condoms, support of home care, etc.), individuals must be given the choice of options that enable responsible dealing with HIV/AIDS.
  • Village communities must be integrated in a national strategy in order that participatory measures at local level support families in coping with the socio-economic consequences of AIDS. The required group-specific prevention programmes include measures that promote the men's sense of responsibility, empowerment activities for young girls, better access for women to advisory services, legal advice for married women and widows, and measures for especially high-risk groups such as soldiers, mine workers, intinerant and seasonal workers, prostitutes, homosexual men, users of intravenous drugs, prison inmates, truck drivers, and so on.
  • Care of infected people must range from advice before and after testing to care and treatment of the disease. That also includes access to anti-retroviral therapy, which is currently undergoing pilot tests in a number of countries.
The German focal points in the cooperation

Based on the present international state of knowledge in combating AIDS, the German government's support measures are focused on the following four elements:
  • Prevention, in order to curb the further spread of the disease. Teenagers and young adults are the main target group. Measures to promote young people in order to show them perspectives on life in difficult situations, as well as 'social marketing' for condoms, have proved to be effective prevention.
  • Basic social services, whose establishment, especially in the public health sector, is equally indispensable for prevention, diagnosis, therapy and care of the affected and sick.
  • Political dialogue with our partner countries in order to encourage them to make their own efforts, for which we offer our support.
  • Partnership with the private sector and civil society, which enables a comprehensive combating of HIV/AIDS, such as by in-company prevention measures or the free provision of medications to prevent infection.
New methods: mainstreaming and a multisectoral approach

A multisectoral approach means that fighting the epidemic and its impacts can no longer be solely the task of AIDS projects or the public health sector. Since all sectors, from education to agriculture to commerce and industry, are affected, they must also be included together in the affected region. Preventive measures for maintaining and promoting personnel resources can, for instance, be integrated relatively easily in all development cooperation projects and programmes.

To also ensure the sustainability of the German development cooperation in the long term, the following questions relevant to HIV/AIDS are included in the early stage of the preparation of projects and programmes before strategies appropriate to the respective situation are developed together with the partner countries:
  • Does the sector in which the project is located, or its instruments, contribute to the spread of HIV/AIDS? This can be so in many respects, such as in the case of infrastructure measures, projects which promote mobility or create temporary social structures.
  • Does the sector have instruments and starting points that can be used for stemming the spread of HIV/AIDS? These include, for instance, projects that work with young people and school students, employ participatory methods in promoting communities, or work via intermediaries such as teachers, state advisory services, and so on.
  • Are the sector's strategies in regions especially hard hit by HIV/AIDS taking effect, or must new strategies be developed? The application of proven instruments of German development cooperation, such as promoting micro-credit programmes, establishing health insurance systems or food security measures is usually based on the assumption of stable social structures and healthy family members. In many cases, families affected by HIV/AIDS are no longer reached by these programmes.
In this connection, sensitisation of and coordination with political decision-makers and actors at national, regional and local level, including the private sector and voluntary workers, is the most important starting point. The first positive experiences with this approach have been gained in the sectors of health, education, rural development, poverty reduction, young people, decentralisation, promotion of democracy, and transport.

Implementation of the multisectoral approach in the individual sectors, including the development of the required competence in dealing with HIV/AIDS on the part of the development cooperation and partner personnel is promoted and accompanied by the BMZ-initiated "Special Initiative Mainstreaming AIDS in German Development Cooperation" (SIMA) . The compiled experiences are to lead step-by-step in the individual partner countries to synergies within German development cooperation and to sustainable support of the partners in checking the HIV/AIDS epidemic.


Medications

The anti-retroviral medications developed in the industrialised nations are in most cases not available to AIDS sufferers in developing countries. The question of how therapy for them with these drugs can be ensured will in future become more important from the point of view of German development cooperation. For methodical access to combating HIV/AIDS it will be imperative that prevention and treatment go hand-in-hand.

To date, however, essential prerequisites for the successful carrying out of anti-retroviral therapies have frequently been lacking. These include the development of a national medications policy, skilled public health systems and the establishment of national research institutions. There is also often a lack of affordable anti-retroviral drugs. Therefore the German Federal government promotes initiatives to supply vital substances and medications in the developing countries at prices lower than in the industrialised nations or even free of charge.

Due to price cuts by the pharmaceuticals industry in recent years the number of people who can afford such therapy has grown. The question of global justness in supply and access to essential medications for the poorest people as well has thus become a priority subject on the international agenda. To what extent medicinal prevention of mother-to-child transmission of HIV and better access to anti-retroviral therapy can actually slow the spread of the pandemic must be researched concomitantly.


Prospects

Following the stage of international political mobilisation and provision of additional funds for combating HIV/AIDS, the main task this year will be to support our partners in the further development and extension of known and effective strategies to fight them. The use of new financing sources and instruments such as the GFATM, as well as the systematic extension of measures to combat HIV/AIDS in all sectors relevant to development, present a huge challenge to all involved in both the developing and the industrialised countries.

The spread of the HIV/AIDS pandemic has in recent years manifested a growing threat to poorer sections of the population and a greater risk of slipping into poverty due to the consequences of infection. This raises the question of the success of poverty reduction , which is not only the most important goal of German development cooperation but was also the focus of the UN Millennium Summit in September 2000. The latter's declared aim was to halve the number of people living in extreme poverty around the world by 2015. Without the simultaneous combating of HIV/AIDS this will not be achieved and sustainable development will not be possible.


Dr. Thomas Kirsch-Woik is Senior Planning Officer and head of the HIV/AIDS Division of the GTZ, Eschborn.
thomas.kirsch-woik@gtz.de.

Kerstin Fährmann is deputy head of Division 415, Health and Education, at the BMZ, Bonn.
faehrman@bmz.bund.de

1) UNAIDS: Report on the Global HIV/AIDS Epidemic. Geneva, December 2002
2) ebd., pp. 6-7
3) Kassalow, Jordan S.: Why Health is Important to US Foreign Policy. New York 2001
4) Sachs, Jeffrey, et al.: Macroeconomics and Health: Investing in Health for Economic
Development. Report of the Commission on Macroeconomics and Health. Geneva, WHO 2001, pp. 31-32
5) ebd., p. 39
6) Contact: Dr. Julia Katzan, Special Initiative Mainstreaming AIDS in German Development Cooperation, Bonn Office, Im Tulpenfeld, Haus 7, Zimmer 21-24,Theodor-Heuss-Allee 2-10, D-53113 Bonn.
7) BMZ: Poverty Reduction – a Global Task. Action Programme 2015. The contribution of the German Federal government to worldwide halving of extreme poverty. BMZ Information Materials No. 106. Bonn, April 2001