Countries across Eastern and Southern Africa are actively accelerating the scaling up of HIV and AIDS programmes against a series of nationally developed Universal Access targets - many of which have highlighted the end of next year, 2010, as a key delivery target.

The push towards Universal Access in countries builds on the 2001 the United Nations General Assembly special session on HIV/AIDS (UNGASS) Declaration of Commitment. In 2006, at the second United Nations General Assembly High Level Meeting on HIV/AIDS, countries agreed to work towards the goal of "universal access to comprehensive prevention programmes, treatment, care and support" by 2010. These global commitments complement the United Nations Millennium Development Goals, which established targets to reduce child mortality, improve maternal health and combat HIV/AIDS, malaria and other major diseases by 2015.

People living with HIV, community groups, civil society organisations, governments and international organisations participated in a country-led process to set ambitious targets for achieving universal access. This process gave national leaders and a wide range of participants in the response to HIV the opportunity to better understand HIV transmission patterns, identify obstacles to effective national responses, revisit existing systems of programme delivery, ascertain community needs and select priority intervention.

The goal of Universal Access is reinforced in existing global and regional declarations and commitments, the most important for Eastern and Southern Africa include:

The Abuja Declaration and Framework Plan of Action on HIV/AIDS, TB and other related infectious diseases (2001)

Heads of State from across Africa met in Abuja, Nigeria, in May 2001 to agree on an action framework for AIDS, tuberculosis and a number of other related diseases. The Summit, which heard from civil society organizations including people living with HIV, agreed an ambitious Declaration and Plan of Action often referred to as the 'Abuja Declaration' which outlined a number of time specific goals and targets to tackle HIV and AIDS - including financial commitments from national budgets - with the first set of targets to be reached in 2006.

Declaration of Commitment on HIV/AIDS (2001)

Later in 2001 Member States gathered for the first-ever United Nations General Assembly Special Session on HIV/AIDS, unanimously embracing a series of time-bound targets in the 2001 Declaration of Commitment on HIV/AIDS. Many of these built on the goals and targets in the Abuja Declaration. The Declaration of Commitment covers ten priorities, from prevention to treatment to funding. It was designed as a blueprint to meet Millennium Development Goal 6 to halt and begin to reverse the spread of HIV by 2015.

Brazzaville Commitment on Scaling up Towards Universal Access to HIV and AIDS prevention, treatment, care and support in Africa by 2010 (2006)

In 2006, a Special Summit was held in Brazzaville, Congo, to review the status of the implementation of the Declarations and Frameworks for Action that came out of the 2000 Summit on Roll Back Malaria and the 2001 Summit on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases, both held in Abuja, Nigeria. The Summit issued Brazzaville Commitment on Scaling up Towards Universal Access to HIV and AIDS prevention, treatment, care and support in Africa by 2010, which identifies the major obstacles to the rapid and integrated implementation of existing national HIV programmes and services and makes recommendations to overcome identified obstacles to universal access.

Political Declaration on HIV/AIDS (2006)

At the 2006 High Level Meeting on AIDS in New York, USA, governments committed themselves in the Political Declaration on HIV/AIDS.  Rather than setting new global targets, the Declaration called on all countries to set ambitious national targets on HIV prevention, treatment, care and support by the end of 2006 that reflect their commitment to move towards the goal of universal access by 2010.

Countries in Eastern and Southern Africa have established ambitious targets required for scaling up Universal Access to prevention, treatment, care and support. In most countries, setting targets was integrated within the process of drafting National Strategic Plan on AIDS and was carried out through inclusive consensus building exercises.

To date, 20 countries set targets for provision of treatment to all people living with HIV, 18 countries set at least one prevention-related target and 14 countries set a target in each of the programmatic areas (treatment, care, prevention and national commitment).

Treatment

Universal Access indicator: Percentage of women, men and children with advanced HIV infection who are receiving antiretroviral combination therapy[1]

Close to 3 million people were receiving antiretroviral therapy at the end of 2007. However, global coverage of antiretroviral therapy is still limited, reaching 31% of the 9.7 million people in need at the end of 2007.

The greatest increase in the number of people receiving treatment in 2007 was in sub-Saharan Africa. 54% more people were receiving treatment at the end of 2007 than in 2006. Regional antiretroviral therapy coverage was 30% in 2007 versus 21% in 2006 and just 2% in 2003. Coverage is higher in eastern and southern Africa (32%) than in other regions of Africa.

Fifteen countries accounted for 75% of the 3 million people receiving treatment in low- and middle-income countries in 2007. Of these, eleven were in eastern and southern Africa. Some of these countries substantially increased the number of people receiving treatment in 2007 as compared with 2006, with rates of increase exceeding 100% in countries such as Mozambique and Tanzania.

Despite this progress, treatment in many of these countries remains well below the estimated need. Coverage exceeded 50% Botswana and Namibia, while in Ethiopia, Mozambique, South Africa and Zimbabwe, coverage was below the global average for low- and middle-income countries (below 31%, including adults and children).

Care and support

Universal Access indicator: Percentage of orphans and vulnerable children (boy/girl) aged under 18 living in households whose household have received a basic external support package The support package could include food, education, health care, family/home and/or community support)[2].

As the number of orphaned and vulnerable children continues to grow, adequate support to families and communities needs to be assured. In practice, care and support for orphaned children comes from families and communities. As a foundation for this support, it is important that households are connected to additional support from external sources.

Compared to other regions in the world, countries of eastern and southern Africa have generally made the most progress in developing and implementing national responses. In countries where household surveys were conducted between 2005 and 2007, the proportion of orphans and vulnerable children whose households received basic external support ranged between 11 percent in Uganda and 41 per cent in Swaziland, with a median value of 12 per cent. Such support included education assistance, medical care, clothing, financial support and psychosocial services.

Prevention

In the 2001 Declaration of Commitment on HIV/AIDS, recognizes HIV prevention as "the mainstay of the response" and commits countries to implement comprehensive, evidence-informed strategies to reduce the number of people newly infected with HIV.

More than 25 years into the global HIV epidemic, southern Africa remains the region carrying the highest burden of HIV and AIDS globally. Eight countries in the region have reported an adult prevalence rate in excess of 15%. In 2007, 1.5 million new infections occurred in the region accounting for almost one-third of all new HIV infections.

Although the epidemic in eastern and southern Africa has stabilized to a degree, some countries need to urgently redouble their HIV prevention efforts. This will be possible through combining a number of proven social and medical approaches to achieve maximum impact on HIV prevention.

Universal Access indicators:

1. Coverage of preventing mother-to-child transmission[3]

Sub-Saharan Africa, which accounts for nearly 90% of all pregnant women living with HIV in low- and middle-income countries, has made the most progress in the past three years. Coverage with antiretrovirals in eastern and southern Africa, which includes 12 of the 20 countries with the highest numbers of pregnant women with HIV, increased four-fold, reaching 403 000 women in 2007 versus 106 700 women in 2004 (coverage of 43%).

In South Africa, PMTCT coverage reached 57 per cent of the estimated 220,000 pregnant women living with HIV in 2007, up from 15 per cent in 2004. In the same years, coverage in Mozambique rose from 3 per cent to 46 per cent and in Zambia from 18 per cent to 47 per cent. The increase is related to antenatal care coverage rates of 85 per cent or more in all these countries. In comparison, antiretroviral coverage below 10 per cent in Ethiopia in 2007 may reflect this country's below-average levels of antenatal care (28 per cent).

2. Coverage of HIV testing and counselling [5]

Coverage of HIV testing and couselling is usually calculated on the percentange of people who received an HIV test in the 12 months preceding the survey relative to those who had ever received a test.

The percentage of people tested in the 12 months preceding the survey varies among countries in eastern and southern Africa. In Ethiopia less than 3% of women and men responding to the survey had received an HIV test in the 12 months prior to the survey. In Namibia, Swaziland (men) and Zambia (women), the percentage exceeded 15%.

3. Number of condoms distributed annually by public and private sector[7]

Countries in the eastern and southern Africa have not reported against this indicator.

4. Percentage of young men and women who have had sex before age 15 [8]

In recent years, data from selected countries such as Tanzania and Zimbabwe indicate that significant, population-wide changes in sexual behaviours can be achieved and that such behavioural shits have the potential to reverse national epidemics.

Across the whole of sub-Saharan Africa, the share of males reporting sex prior to the age of 15 declined from 18 percent in 2005 to 12 percent in 2007, with comparable rates for females falling from 22 percent to 17 percent. Globally, males are significantly more likely to report sex prior to the age of 15 especially in sub-Saharan Africa, where adolescent girls under 15 are almost 50 percent more likely than boys to be sexually active.

Angola, Mozambique and Madagascar reported the highest levels of early sex with almost one in three reporting sex before the age of 15.

National Commitment

Universal Access indicator: Amount of national funds disbursed by governments in low and middle income countries (in US$ million) [13]

Financial resources for the HIV response have significantly increased in recent years. The US$10 billion made available for HIV programmes in 2007 from all sources, including domestic public funds and out-of-pocket spending, represented a 12% increase over expenditures in 2006. However, substantial additional resources will be required to support a robust and sustainable HIV response in the coming years. Based on the country-defined targets for 2010, it is estimated that an investment of US$ 25.1 billion (US$ 18.9 billion-US$ 30.5 billion) will be required for the global AIDS response in 2010 for low- and middle-income countries. Of this total, nearly US$ 11.6 billion will be required for HIV prevention and US$ 7 billion for treatment.

In Eastern and Southern Africa, an investment of US $ 5.3 billion will be required for the AIDS response in the region. Of these, US $ 800 will be required for HIV prevention and nearly US $ 3 billion for treatment.

In February 2009, UNAIDS new Executive Director Michel Sidibe' announced Universal Access as UNAIDS corporate priority. In a Letter to Partners, the executive director urged all partners to concentrate on areas where progress toward Universal Access is lagging and build a new and reenergised era of collaboration. As the letter indicates, Universal Access is a key vehicle for the realisation of the goals set in the 2006 United Nations Political Declaration on HIV/AIDS and the Millennium Development Goals.

[1] Global Report on the AIDS Epidemic, 2008

[2] UNICEF: Third Stocktaking Report, 2008

[3] Unless otherwise stated, all data is drawn from UNICEF, WHO, UNAIDS, Towards Universal Access, 2008

[4] National Survey, 2008

[5] Unless otherwise stated, all data is drawn from UNGASS Country Progress Reports, 2008

[6] National Survey, 2008

[7] All data is drawn from the respective countries' national surveys

[8] UNGASS Country Progress Reports, 2008; Global Report on the AIDS Epidemic, 2008

[9] UNGASS Country Progress Report, 2007

[10] National Survey, 2008

[11] UNGASS Country Progress Report, 2007

[12] National Survey, 2008

[13] Global Report on the AIDS Epidemic, 2008