How Bill Gates Blew $258 million in India's HIV Corridor

The article below is well done and quite important. There is also a need to document the impact that Gates programs have had in India on organizations of people living with HIV/AIDS and on collectives of sex workers. If anyone is interested in these subjects, please contact Steve Baird at baird.steve@gmail.com.

How Bill Gates Blew $258 million in India's HIV Corridor
Forbes India Magazine of 19 June, 2009

The purpose was noble, the money generous. But the software mogul's charity for HIV prevention in India has failed to make a lasting impact.

On a humid afternoon, former sex worker Fathima (name changed) welcomes a group of illiterate women - still in the trade and needing protection from HIV - into the Mukta clinic in Pune. As a "peer educator," it's her job to convey to them the message of safety. But the visitors shuffle tentatively as expensive-looking posters in English paper the walls around them.

Why would a clinic serving illiterate visitors use more English than Indian languages?

The answer lies in where that money comes from. The Pune clinic is part of a network one hundred-plus non-governmental organisations (NGOs) working under the umbrella of Avahan, India's largest HIV prevention initiative. Avahan, or "call to action," is a brain childof the world's largest philanthropist: Bill Gates.

Gates had announced the 10-year, $100-million initiative to stop the spread of HIV/AIDS in India during his much heralded visit to the country in November 2002. This was to be the largest of its kind for the Bill & Melinda Gates Foundation.

The timing couldn't have been more appropriate. After nearly two decades of piecemeal efforts to counter HIV, India was hurtling towards an AIDS epidemic. Millions of poor people exposed themselves to the dreaded virus due to a lack of awareness. Government agencies and NGOs didn't have the money to preach safety or treat the infected. Gates showed his seriousness by later raising the budget to $258million.

Seven years later, back at the Pune clinic, Fathima has counseled the women, given them the sheaths of safety and sent them back. It is time to worry about the future. The bad news is Avahan is ready to pack and go; and Fathima is set to lose her income. She doesn't want to slip back into prostitution. At the age of 45, she doesn't have much of a career there anyway.

When it started on the ground in 2003, Avahan set for itself three goals: Arrest the spread of HIV/AIDS in India, expand the program from the initial six states to across the nation, and develop a model that the government can adopt and sustain so that the project could be passed on to it. More than five years later, Avahan hasn't achieved any of these goals. Doubtless, the initiative has made a dent into the HIV/AIDS problem, but the impact is marginal for a bill of $258 million. And now Avahan is leaving, handing over the reins to the government-run National AIDS Control Organisation (NACO), which doesn't want to inherit it. It is too expensive for the budget-starved establishment that is as nimble as a sloth. If NACO takes over, it will try to prune the costs of the program. Salaries for peer educators will go.

A Five-Star Initiative

When Gates Foundation got down to work in India, the priority was clear. It decided to hire the best minds in business to run its initiatives using sound principles of management. Avahan was ready to spend what it takes to get the best bosses and started its search at McKinsey, the consulting powerhouse. The recruiters zeroed in on Ashok Alexander, who had spent 17 years turning Indian businesses into global challengers. "They made me an offer I couldn't refuse," Alexander recalls, sitting at his plush office in New Delhi. "I liked the ambitious arch of the HIV/AIDS program and it was a chance for me to do something new."

Soon, the 15-member team was in place. Ten of them had come from a private-sector background. The team members tackled HIV/AIDS much as they would a problem at McKinsey. Alexander's office is papered with data and maps containing hundreds of coloured dots plotting the disease across the country. The argot is sheer B-school: Avahan is a "venture," its HIV/AIDS prevention program a "franchise," the sex worker the "consumer."

The classical business principles helped Avahan start on a big scale in six states simultaneously. But the lack of public health experience also led to a compromise on quality. Tejaswi Sevekari, director at Saheli, a sex workers' collective for HIV/AIDS in Pune, remembers observing the kinks during her stint at Pathfinder International, an NGO that works with Avahan. Data collection and reporting were entirely in English and had no pictures. Five years later, the scene is the same; the project hasn't fully given up on English though no "consumer" understands the language.

Avahan operated in a pyramid, with Alexander and his team overseeing the work of more than 100 NGOs. The lack of practical experience at the top manifested itself in different ways. When Avahan introduced sleek mobile vans to bring clinics directly to the brothels, the expensive-looking vehicles were sometimes met with intense suspicion. At the Mukta clinic, Dr. Laxmi Mali says sex workers initially thought the van was from the police or the government. They refused help.

False Moves

The early missteps are largely anecdotal. But in 2005, an internal evaluation showed a big portion of Avahan's efforts had gone to waste. As many as 31,000 community members had been contacted by Avahan's outreach program, but only 11,000 actually visited the clinics. The Avahan executives had assumed the peer educators would already know what the prevention services were without explanation; the reality was they didn't.

Avahan's craving for scale also meant it overshot quite a bit. It started with a bang in six states, with 50 sites for truckers in the south. But by mid-2005, only 12 percent of truck drivers were even aware of their services, and only 7 percent took advantage of them. This forced Avahan to reduce the sites to 20. For similar reasons, Avahan's 6,000 sexually transmitted infection (STI) centers were brought down to just 800.

Alexander's team tried to fix the glitches. For example, Avahan tried to allay the fears of sex workers (such as those who had met the mobile van with suspicion) by hiring them to act as intermediaries between the programme and communities. An insider could be more persuasive. Good idea, but Avahan's decision to pay them a salary has come in for criticism, because other NGOs can't recruit sex workers as volunteers.

A series of evaluations published in the AIDS Journal in 2008 show that the jury is still out on the program's impact. The evaluations, funded by the Gates Foundation, were mostly on the methods of data collection. One study, which sought to determine whether Avahan was responsible for the decline in HIV prevalence in Karnataka, failed to prove that it played a key role.

Where Has All the Money Gone?

At the core of Avahan's failure to make a serious difference to India's fight against AIDS is the way it spent money. It was an expensive operation, never tired of throwing money at the problem. In a country where a branded condom sells for just 10 cents, what did Avahan spend on? It's difficult to say because Avahan's finances are largely opaque. Avahan's outlets sell five million condoms a month and distribute another 10 million. Asked how so much could be spent on condoms, Alexander laughs, saying, "It's a bit more complicated than that." Probed further, Alexander says he doesn't know the financials off-hand, nor can he give them later.

Travel would have been one drain. Jonty Rajagopalan, Avahan Program Officer from 2006 to 2008, says she would take flights every month from her base in Hyderabad to her focus areas in Andhra Pradesh and Tamil Nadu, instead of being based in a focus area. Another large chunk: salaries. Alexander's annual package is $424,894, the second-highest in the foundation globally, not including the presidents and operating officers. Avahan's targeting intervention (TI) officers are also paid three or four times what a typical NACO TI officer is paid.

Avahan's marketing was done in style too. Eldred Tellis, head of Sankalp, an HIV/AIDS-focused Mumbai NGO that has worked with Avahan, says he has seen a lot of money go into fancy publications on high-quality paper, reporting the programme's work. Very little went to the people on the ground. Vijay Mahajan, chairman, Basix, a microfinance institution, comments on Avahan: "There is too much money and too many really smart people with too little coming out."

An Uncertain Torchbearer

Knowing that it would have to inherit the project, NACO sent out evaluation teams to sites in four states to get some clarity on costs. NACO's head, Dr. Sujatha Rao, says the evaluation threw up one clear message: Large parts of the program are not sustainable by NACO. "We told them you can't create a huge number of assets and then just leave and expect the government to take over everything," says Rao.

But Alexander disagrees. "We are not perpetual funders. We try to be catalytic," he says, ebulliently confident that the HIV/AIDS epidemic will soon be contained, with or without the foundation. Either way, it will have to be - Avahan is now repositioning, focusing on maternal and newborn health. Ashok Row Kavi, consultant for UNAIDS and chairman of Humsafar Trust for gay and transgender health, says Avahan's expectations were unrealistic. "They wanted HIV to disappear in five years. For that to happen, a lot of people would have to die."

NACO's annual budget is Rs. 1,100 crore ($225 million), none of it spent on Avahan currently. Rao just can't find enough money to continue the project. "We can never offer a replicable model. And if we are unable to sustain the programme, all of their effort will be for naught," she says, shaking her head. When probed about the difficulties of handing over the massive program to the government, Alexander says the transfer is going just fine. Kavi differs; he says that the transfer discussions between NACO and Gates Foundation are "running into a brick wall right now. Costs need to be brought down, but they can't figure out how." He also fears Avahan's now-experienced MBA-graduate TIs, facing shrinking salaries, will depart. The question of running air-conditioned clinics like Avahan doesn't even arise.

The biggest hole in quality will arise where it can hurt most. Hussain Makandar, HIV counselor at the Mukta clinic, is worried about condoms; the ones from Avahan lubricate; the ones from NACO break and the sex workers stop using them. Alexander insists that only a 10th of the project will transfer to the government this year and the rest will happen slowly over the next five. "We're doing a transition program. We're not saying, 'here's the program, and we're off.'" But NACO and Mukta officials, among others, are confused over the timeframe.

So, the final report card on Avahan:

Goal 3: Develop a model for HIV prevention that can be implemented by the government sustainably. NACO's resounding vote: Not achieved.

Goal 2: Expand the programme nationwide. Avahan could not go beyond the six states it started with. Not achieved.

Goal 1: Arrest the spread of the disease. The number of Indians living with HIV/AIDS has been officially corrected from 5.1 million to 2.4 million. This was a statistical change, not an improvement in health. Impact not known.

Back in the great Indian sex bazaar, prostitution is a growth industry and condom an exception. "New faces keep coming in every month (to the brothels)," says Dr. Mali. "Twenty percent of the people we now see are infected, the same as when we started."

Day 1 UNAIDS PCB Meeting - 22 June 2009

Opening Plenary Remarks

Chair of session:

“Discussion on the migrants and mobile populations [MMPs] is crucial as they often excluded from the agenda of HIV/AIDS prevention, focusing on various intersections including vulnerability and human rights of migrants.”

“National policies and programs need to include particular groups such as MMPs in order to address their vulnerability.”

Deputy Executive Director of UNAIDS Secretariat:

“Mobility does not make people vulnerable; it’s the situation that had made them vulnerable to HIV/AIDS. The myth of migrants bringing in the infection had hampering the stigmatisation on MMPs.”

“We are talking about real people, real problems and real issues here…”

Challenges: to try to recognize the diversity on the MMPs issues.

Thematic Segment – “People on the Move – Forced displacement and migrant populations”

Panel 1 – Universal Access and HIV-related Restrictions on Entry, Stay and Residence

HIV-related restrictions were most put in place in 1980s. Such restrictions are out of line with today’s reality because:
• HIV is everywhere.
• World had become smaller.
• Travel and migration are important.
• HIV treatment had already enhanced and made PLHIV live longer with great productivity and good health condition.
• Universal Access committed by the government means Universal Access for both nationals and non-nationals.

Restrictions require political will and leadership to eliminate. Armenia and Tajikistan had removed the restrictions in part, which means post it under different department other than immigration. Namibia, China, Ukraine and USA will lift the ban, while Czech Republic surprisingly had moved backward and add more PLHIV from some certain countries into their restriction list.

Panel 2 – Universal Access, Mobility & Labour

The focus need to be put on employment-related mobility and economic migrants. Inclusion of internal migration in the discussion is essential because the issue is quite significant in some countries such as Viet Nam, Indonesia and India. Internal migration does not have any tracking system as the international migration through immigration ports.

Panel 3 – Universal Access and Humanitarian Situation & Forced Displacement

Issues faced in the context are still affected by armed conflicts and natural disasters which made the social and community networks fall apart as well as break down in institutional presence and support. Increasing rates of sexual violence due to displacement are leading to a much higher likelihood of contracting HIV. The need to include displaced populations in the national strategies and provision of access to health are severely compromised.

Panel 4 – Universal Access and Economic Drivers & Push Factors for Mobility

Economic migration is often caused by globalisation, based on new needs, new ideas and new values in migration. People migrate in search o better living or keeping themselves away from unsafe situation such as abuses, conflicts, disasters, etc. Some people migrate because it is the tradition in their family or society, some other migrate seeking for new adventure.

Overall, it was concluded that protection of rights and promotion of health services for migrants and mobile populations are in utmost necessity.

How mobility affects HIV vulnerability?

Especially for undocumented migrants and refugees, being hidden due to their legal status is seriously increases stigma against them and hinders access to prevention, care and treatment.

Lacks of information on HIV/AIDS, as well as STIs are often the factors that migrants have. They were not informed about prevention of HIV and STIs.

There are factors in the whole migrations that become the background of risks for migrants. People need to understand the history of why migrants were not using condoms, for example, that made them vulnerable to HIV. There are a lot of factors, including economical factors. Among other factors, culture and tradition within the migrants’ community are also push factors for their risky behaviour. Peer pressure plays an important role in encouraging the conduct of risky behaviour.

Other push factors that often mentioned are loneliness and homesickness. The needs of companionship and biological urgency also plays important role for them to get involve in casual sex relationship, and this often has great impact to their relationship with their spouses, partners and family back home. Nevertheless, the impact on family who is left behind requires extra attention as well. The spouses and partners are as vulnerable as the migrants themselves. Carrying the same reasons of loneliness and needs of companionship, spouses and partners often get involved into casual sex relationship that made them vulnerable to HIV. The existence of HIV among the family is upsetting the family and personal relationship.

Another push factor that considered made migrants and their spouses vulnerable to HIV is the “single entry” migration policy in many destination countries had made migrants unable to take their family along to migrate causing the depression, psychological as well as biological problems both for migrants and their spouses.

What are the barriers to Universal Access caused by HIV-related restrictions?

Misconception and prejudice on HIV due to lack of information still caused stigmatisation on PLHIV. There is a trend for PLHIV who travels to countries with restrictions to stop their treatment [ART] to avoid entry ban. This step caused resistance to the treatment.

Universal Access had been misinterpreted in many ways. Every country has their own definition of Universal Access. Many of countries define it as access to health for their nationals only, and seeing the non-nationals need in healthcare as economic burden or budget to the country.

The restriction is also considered raising false sense of security to the nationals because it interprets HIV as a foreign problem brought in by migrants or foreigners to the country, despite the fact that the epidemic is already in the country. Many of foreigners who migrate to countries with restrictions as workers or students failed to follow the consistency of treatment because they kept changing clinics, doctors and treatment using different names and identity to protect their true identity. PLHIV are forced to go around the system and become the criminal for disclosing their status for health reasons. And the lack of referral system in the home-country of migrants had also caused inconsistency of treatment.

The government of Brazil thought that health services should never have any relations with private information such as nationality and HIV status. Thus, Brazil has a long term treatment program aimed not only for nationals but also for non-nationals, documented and undocumented, residing or visiting Brazil. According to Brazil, it is impossible for one country to fall into bankruptcy just because of the inclusion of treatment for migrants in their national budget.

All countries have to remember that all UN member states were signed on to the International Health Regulations which does not single out any diseases, including HIV. This regulation must be the baseline of advocacy for treatment provision in the country. Influential countries such as USA and China should take on the leadership on this regard and be a good role model for other countries when they actually eliminate the restrictions.

PLHIV have to be able to work in order to enable them accessing treatment. Denial of work permit and visa will only limit their access to work and source of income which affecting their health conditions.

What are the concrete actions that government, CSOs and International Organisations can do in the next year to further the elimination of HIV-related restrictions?

Government should revisit the restriction policy with better understanding that by implementing the restrictions, they do not remotely protect their nationals because HIV is not a foreign problem. The review also has to be based on empirical and better data collection, sharing experience and separating health services from the immigration control. Especially for EU countries, there is a need to focus on the Czech Republic since this country is going to the opposite direction. The government and regional authorities have to take the lead in removing the restrictions within the region. Since EU countries endorsed the UNAIDS recommendations regarding travel restrictions, a significant step towards Czech Republic need to be taken.

Additional steps to engage broader range of stakeholders than just HIV-focused organisations is necessary. Particularly engagement with Human Rights-based organisations who can work together to hold the government accountable is highly suggested because HIV now had overlapped with a lot of other issues outside health.

Multi-pronged strategy that looks at building internal and external pressure on eliminating the restrictions is recommended. Political will and leadership from the government is essential.

The policies on access to treatment for immigrants need to be strengthened both by governments and NGOs. CSOs and NGOs should advocate on integrating HIV prevention and treatment into the agenda of strong migrants’ organisations in the countries of destination as well as advocating for inclusion of migrants and mobile populations into the agenda of National HIV/AIDS Prevention in the sending countries. Apart from that, government should conduct training on HIV/AIDS and the impact of travel restrictions to Immigration Officials in order to raise awareness.


What can we do to make sure that we achieve some of the points mentioned?

• Global Fund as a major funding agency could encourage grants to extent access to services for people on the move.
• Stop ignoring the evidence and use them strategically to impact at critical moment in political mobilisations.
• Engage Trade Unions and employers’ organisations. Link up with the upcoming International Labour Conference which theme is “HIV/AIDS in the World of Work”. Migrants and mobile populations should be specifically included in the documents for the conference.
• Build and raise awareness on separating health services and immigration control.

Day 2 UNAIDS PCB Meeting - 23 June 2009

During the report back from the thematic segment, NGO delegates made a statement that NGO report will come with the decision points on the issues that raised repeatedly i.e. inclusion of MMPs in the agenda of the National HIV/AIDS Prevention.

Key message:

“Mobility itself does not make migrants vulnerable nor facing risk in HIV, it is the whole situation which is the reoccurring on lack of treatment, care and support provision and protection for MMPs that make migrants vulnerable and facing risk in HIV.”

Remarks and Comments:

“MSM, sex worker, youth and transgender were not clearly reflected in the key messages during the report back.”

India was very concerned on how to reach migrant workers in the informal sectors. And as a country with a high rate of a cross-border migration, India suggested to review the topic on cross-border migration.

Comprehensive and cultural-sensitive programs are essentials, therefore Iran recommended UNAIDS to develop a Core Working Group to design the programs on MMPs.

France was expecting EU mobilisation in eliminating the restrictions as well as further distinction over migrants, refugees and forcibly displaced people. Countries without restrictions should be more involved in influencing other countries to eliminate the ban. Human rights should be the base of approaches in eliminating the travel restrictions.

Report of UNAIDS Executive Director, Michel Sidibe

Crisis, Opportunity & Transformation: AIDS Responses at the Crossroads

The world is facing a huge crisis at the moment, HIV is now “competing” with other crucial issues such as H1N1, food crisis, global warming and poverty, with 2 million deaths in a year.

UNAIDS had laid out several key objectives:
• Integrated HIV and TB services.
• End two-tiered system of treatment.
• Ensure people in need are on treatment.
• Urgent need to ensure affordable treatment.
• Break the trajectory on HIV epidemic.
• Focus on HIV prevention.
• Combination of prevention.
• Effective Harm Reduction Program.
• HIV prevention.
• Sexual transmission of HIV.
• Reducing sexual transmission of HIV.
• Halting sexual transmission of HIV.
• Focus on reaching more people most at risk.
• Engage country by country.
• Protect and promote human rights.
• Remove punitive law that blocks AIDS responses.
• Rights-based approaches to national policies on IDUs and migrants.
• Confront discrimination and decriminalisation of HIV and PLHIV.

HIV Prevention Research on the Cure
• Optimising and expanding partnerships.
• Intensive consultation.
• Strengthening partnerships.

• Partnerships with women’s movement by forming a committee and move the agenda on women forward, addressing women, girls, gender equality and HIV.

There is a need in the UNAIDS to transform itself into a more effective organisation that focus on limited set of priorities, accountable and carry clear objectives. Clarification on roles and links with other organisations are also necessary to be done as well as innovations in business practices. Internal changes within the Secretariat aimed to strengthen the accountability by establishing new department, evaluate the performance of ethic and organisation; and conduct second independent evaluation.

Report by Chairperson – Ethiopia

The world is severely facing crisis at the moment. Even though President Obama had committed to continue PEPFAR, other urgent issues such as H1N1 had affected the agenda of HIV. WHO will revisit the treatment guideline since there were so many concerns raised regarding treatment, while the World Bank will release a report on “The Impact of Financial Crisis on HIV” in a few weeks. This report will be a good baseline to do advocacy accordingly to the statement from WFP which mentioned that the economic crisis had a great impact on poverty that affects the livelihood of PLHIV.

Unified Budget and Workplan [UBW]

The focus is on vulnerable groups including mother & children, youth, migrants. It is essential to include those groups, but strengthening health system is another important area that needs extra attention. Efforts to link the work of HIV with Sexual & Reproductive Health [SRH] is necessary to ensure the provision of treatment, care and support of SRH for women living with HIV.

Country with concentrated epidemic was given more focus on programs for IDUs, sex workers and MSM. UNAIDS must continue its work to protect human rights of PLHIV.

HIV versus global crisis i.e. H1N1, global warming and financial crisis

HIV is not the only issue with urgency at the moment. The fact that H1N1 had attack most part of the world, the global warming and financial crisis that struck the whole world had drown HIV into the lower level of priority at the moment than those issues. However, HIV should be treated as an emerging issue due to its close relation to issues mentioned above.

NGO Delegation’s Report

The report of NGO delegation was focused on the barriers to achieving of the Universal Access based on 380 online surveys and 35 Focus Group Discussion of key networks.

Barriers to achieving the Universal Access were identified as:
• 2/3 of the respondents said stigma and discrimination is the key barrier.
• Identifying and reaching the key populations.
• Criminalisation needs extra attention.
• Violence.
• Lack of evidence-based prevention for IDUs.
• Lack of services.

Hepatitis-C co-infection was to be discussed as a part of HIV treatment, while implications of financial crisis, especially regarding concerns on how countries are going to meet the Universal Access’ target in 2010 with the current crisis situation is yet to be further discussed separately.

UNAIDS needs to ensure that PLHIV are not excluded, detained or deported, especially with no access to treatment, even in the country that has no travel restrictions. USA expressed a strong support on the inclusion of non-discriminatory approaches as methodology to meet the Universal Access’ goals and to be the 4th pillar of the Universal Access as proposed by the NGO delegates. The UK addressed that whatever approaches that used as methodology, it is necessary to ensure that it does not go out of the track or go out of the initial prevention and CST program planning. Furthermore, incorporation of human rights elements in the HIV responses is essentials.

There were a lot of supports on stigma and discrimination from the member states, but it needs to be framed correctly i.e. asking when do they start to do it.

Day 3 UNAIDS PCB Meeting - 24 June 2009

HIV Prevention Among Injecting Drug Users

Highlight:

"In 2008 there were numbers of IDUs in 148 countries around the world and the HIV infection among IDUs recorded and reported in 120 countries."

The Harm Reduction Programs that is run in many countries offered a series of package such as:
• Needle Syringe Program
• Substitution program [opioid]
• VCT
• ART
• Prevention and treatment of STIs
• Condoms distribution for IDUs and partners
• Targeted information
• Vaccination and treatment of Hep C
• Prevention, diagnosis and treatment of TB

Key emerging challenges for this area is that there are needs of forming and recognizing special sub-groups of drug users such as female drug users, young drug users, migrant drug users, MSM drug users, prison setting drug use as well as sex work and drug use.

Japan claimed that they were not adopting the NSP and substitution program because NSP is considered as encouraging the using of drugs while substitution program is considered not effective and causing other form of dependency. The implementation of the programs should be based on the situation and circumstances within the region, even within the country. Based on that, Japan requested UNAIDS to review and redraft the decision points. Russia shared that basic approaches should be a moral change, especially for young people to keep them away from drugs. There is a clash between the moralists and scientists in tackling this issue within the Russian Federation countries. Scientific-based finding regarding opioid therapy and NSP are not necessarily the best solutions to tackle the drug use problems. Therefore, Russia is supporting Japanese Delegates and claimed that the tackling of this issue should not be carried out in such a rush.

The NGO Delegation from Europe questioned on how much UNAIDS and the co-sponsors had spent on drug use. All interventions made should be done with the consultation with the key populations and not based on the benefit of certain parties, countries or institutions. A proposal to include spouses and partners of IDUs in a more comprehensive prevention program was addressed. This proposal was endorsed by France with emphasizing on prevention on sexual transmission among IDUs and their spouses/partners.

Denmark, together with its constituents [Switzerland, Austria and Nordic Countries] addressed the concern of low services for IDUs. They considered the access to NSP and information is crucial for all drug users. In addition, they also addressed that the term ‘harm reduction’ is adequate to signify that illicit drugs is harmful, therefore this term should be widely familiarise. Another thing regarding addiction that they mentioned was the need to consider alcohol as one of the substances that add the vulnerability of HIV through sex transmission. Above all, responses to the issues should be under human rights base.

Strengthening the statement from France, Netherlands and its constituents [Belgium, Luxemburg and Portugal] expressed that the Universal Access for IDUs is still very low and that needs to be scaled up based on best practices. Harm Reduction program had evidently demonstrated its effectiveness in reducing the HIV prevalence among drug users, therefore Netherlands and its constituents is calling for designing comprehensive programs for IDUs and in fully support to the recommendations made by the NGO Delegations.

Brazil made comments that access to health is hampered by the attitude of the health workers towards the drug users. Furthermore, even though the Harm Reduction Policies are in place, there is always a huge outcry from the conservative groups within the country. However, Harm Reduction should be explicitly mentioned in the decision point’s document. Brazil specifically sees that there is a need of a clear framework in achieving the goal to reduce HIV prevalence and wants to see the follow up of this issue in the next PCB.

United Kingdom stated that ensuring rapid expand of Harm Reduction Program in the most affected countries is crucial. Apart from that, there is an urgent need to address stigma and discrimination against people who use drugs because it will be impossible to achieve the goals as long as people who use drugs are still criminalised and stigmatised. However, it has to be acknowledged that there is also a significant gap in the drug use trends stated in the Drug Policy Report.

United States of America once again raised the issue of ‘Harm Reduction’ terminology. The UNAIDS, UNODC and WHO Technical Guide had mentioned the term ‘Harm Reduction’ even though the difficulty around the usage of that term had been discussed formerly. The term is considered encouraging the use of illicit drugs and therefore the USA cannot endorse the use of that term. USA requested explicit explanations on the term ‘Harm Reduction’ and would like to see the possibility to revise it and move forward with the prevention agenda.

INPUD expressed their concern about how people who use drugs are often being blamed as the failure of the development of policies. Based on that, INPUD calls UNAIDS to develop integrated responses on treatment of HIV and Hep-C, research for psycho-social support and involvement of people who use drugs in the assessments of all UNAIDS’ outcomes.

Cooperation with Global Fund: Support Mechanisms for African States

Highlight:
“Solutions must be sustainable on both financial and capacity grounds”

Challenges faced in investing in African States:

• Lack of strategic interactions and dialogue between Global Fund and PCB members from the African States.
• Effective participation constrained mostly by language issue.

Way forward:
• Improve communication.
• Regional Consultation to ensure effective involvement of the African States.
• Increased number of delegations from African region in the PCB.
• Availability documents in French.

El Salvador with its constituents from Central America addressed that apart from French, the documents of PCB should also be translated into Spanish, considering more than 500 million people in the world speaks Spanish.

The NGO Delegates from Africa supported the decision points made, but still need more details on how the Regional Consultation will have meaningful involvement of the CSOs. It was also addressed that the national and regional processes need to continue to uphold the meaningful involvement of CSOs.

Global Fund explained that a policy paper is currently in the developing stage and will be presented in the meeting in September. Incorporated in the policy paper are option for funding, focal points and several of other inputs.

Decision points:
• Establish a position for an independent communication focal point at the P3 level.
• Provide support and funding for 4 [four] Regional Consultation Meetings.
• Fund the participation of 52 delegates to the meeting.
• Provide funding for 5 [five] additional delegates from Africa to the PCB meeting.
• Implement the efficient and effective mechanisms to translate all governance documents from English to French.

Gender Sensitivity of AIDS Responses

Women, Girls, Gender Equality and HIV
It was requested that UNAIDS provides assistance within the country level to accelerate the support on the ongoing work and result achieved.

MSM, Transgender and HIV
Framework:
• To enhance and furthering human rights.
• Strengthen and promote evidence-based data.
• Strengthen and ensuring better responses.

The NGO Delegations from Latin America and the Caribbean expressed that the discussion about women started far too late. It should be done 10 years a go or even in the beginning of the epidemic. The involvement of men in gender equality is important but women’s empowerment is a crucial part of the intervention, while human rights-based approaches are a necessity. The framework introduced by UNAIDS is not involving women at the grassroots levels. It is also necessary to include the different situation and background of women in the framework document. The delegate indicated that there were several missing points such as sexual & reproductive health and rights, violence and sex education. Thus, the delegates recommend forming an Advisory Group for women’s framework that will develop and monitor the plan.

Zambia expressed the need in conducting trainings on HIV/AIDS in the emergency situation. Another thing highlighted by Zambia was that they have a law against MSM and currently a lot of advocacy had been done in order to change the law.

There were numerous suggestions in terms on the framework which consists of importance of inclusion of experts and grassroots people with life experiences in program designing as well as in the advisory group; recognition on women’s diversity; the importance of the framework to address particular groups such as migrants, transgender and MSM in the less developed countries.

ILO specifically addressed that they were working towards the new standard of the code of practice on HIV at the workplace with recognition of gender diversity.

“One UN” Country Pilot

“The biggest challenge in fighting AIDS is in the mindset of people and on how to change their attitude…”


“Delivering as One” has several key issues as mentioned below:
• Commitment UN leadership at Head Quarter level.
• National leadership and ownership need to be scaled up.
• Harmonisation and simplification of business practice within the UN bodies.
• Increased transaction costs.
• Lack of clear accountability and incentive for agency staff.
• Capacity of UN agencies.
• Adherence to the Paris Declaration agenda.

Conclusions:
• ‘Delivering as One’ initiative is working.
• UNAIDS served to be a useful model.
• Need to sustain the programs.

The NGO Delegations requested clarification on the difference role of the UNAIDS HQ and Regional Offices, especially anything related to technical assistance. Better communication needs to be built.

Zambia mentioned that the document of ‘Delivering as One’ did not reflect any impacts in financial sector. Meanwhile, The UK and its constituents [Ireland and Italy] expressed the need for agencies and HQ to reconfirm their commitment accordingly to the TOR. On the other hand, Turkey and its constituents [Australia, Canada, Greece and New Zealand] addressed that there is a need to see the developing of a more comprehensive program implementation indicators, while Switzerland recalled keeping the UN reform process on top of priority and Netherlands together with its constituents [Belgium, Luxemburg and Portugal] requested UNAIDS to maximise its engagement in developing countries. ‘Delivering as One’ can learn a lot, on the other hands there must impacts that change the environment. France and its constituents [Germany, Lichtenstein and Monaco] mentioned that mainstreaming and harmonising the programs in the field is fully supported. However, the document did not practically present the actions to be taken and further details on the costing should be discussed separately.

The Second Independent Evaluation on PCB

Oversight objectives:
• A credible and independent evaluation.
• A high quality, forward-looking report relevant to the future of UNAIDS

There is a need to streamline the working methods of the PCB in line with existing resolutions, establishing the Joint Programme as well as implementing decision by PCB and respecting the role & responsibility of Executive Director. Decided to establish an ad-interim Working Group [WG] to review the working methods of the PCB and prepare proposals for the 25th PCB meeting. Taking into consideration the conclusions and recommendation of the 2nd Independent Evaluation. The WG should be established by the PCB Bureau following to the composition of 2 member states per region and 2 NGO representatives.