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4^th Southern Africa AIDS Conference, Durban, South Africa, 31 March 2009

UNAIDS coordinated a satellite session with the title 'Universal Access - where do we go from here?' at the fourth Southern Africa AIDS Conference held in Durban in March 2009. The session brought together experts such as Mrs Elizabeth Mataka, UN Special Envoy on AIDS in Africa, Ms Vuyiseka Dubula from the Treatment Action Campaign, Dr Khumo Siepone, Director of Botswana's HIV/AIDS Department, Dr Fareed Abdullah from the Global Fund and Dr Brian Brink from Anglo-America to discuss what needs to be done to sustain and accelerate progress in achieving Universal Access in the region.

During the session delegates were asked to reflect on the promises that have been made on Universal Access to HIV prevention, treatment, care and support by 2010, and to consider what still needs to be done in delivering on these promises.

The main question asked was: 'How can Eastern and Southern Africa renew its focus on Universal Access and ensure that the gains made so far are protected and improved upon, particularly in the light of the current economic climate?'.

Progress

The consultation revealed that progress is being made across Southern Africa, but not in South Africa, Swaziland and Mozambique.

Across Southern Africa, 40% of those who live with HIV and 50% of pregnant women living with HIV have access to antiretroviral treatment (ART). This means that countries in the region are half way towards fulfilling their promise on access to treatment.

However, countries like Botswana and Namibia have shown that Universal Access to treatment is indeed an achievable target.  For instance, Botswana has achieved over 90% access to treatment, while HIV counselling, testing and treatment services can be accessed virtually everywhere in the country.

Lessons from the public sector

Botswana's remarkable achievements would have not been possible without strong political leadership in the response to HIV, which has ensured the availability of resources, as well as effective and well targeted strategies to tackle the epidemic. Botswana's response to AIDS is almost wholly financed by national resources (around 90%), with little reliance on foreign aid (10%)

Accountability was also discussed as key in reaching Universal Access. Governments must be held accountable for the promises they have made.

In Botswana, partners from international development organisations, the community and the private sector carry out their activities in accordance with government's national plans and strategies, and are closely monitored by government.

In the face of the current global economic crisis, the Botswana government has made it clear that AIDS remains its priority.

An important factor in the success of the Universal Access strategy in Botswana is that the country has a strong and effective primary health care system, which facilitated the roll out of treatment.  The health sector is now investigating other high-impact strategies such as male circumcision.

The area where Botswana has not succeeded is HIV prevention. Prevalence is still extremely high with 17% of the general population and 33,4% of pregnant women are living with HIV. The widespread availability of antiretroviral treatment has caused many people to consider HIV as a manageable disease just like any other.

Another area that needs to be strengthened with regards to the response to HIV in Botswana is community participation.

Lessons from the private sector

The experience of Anglo-American in South Africa is that 'the more we put into our programme, the less it costs us'. Early diagnosis of HIV and early treatment means the company does not lose on productivity and that it saves on training and on healthcare costs.

However, the strategy of providing antiretroviral treatment to all employees who need it can only be sustained if the rate of new infections is controlled.

It is important to focus HIV prevention interventions on providing comprehensive sex education for adolescents and reproductive health services for women. The key to successful HIV prevention is to have interventions that are based on evidence and communicate clear and consistent messages.

The challenge now for Anglo-American is to widen the net of support and to extend the same level of care not only to families of employees, but also to their communities.

It is also necessary to fill gaps (i.e. provide contractors with the same level of care).

It is necessary that more companies in the private sector are equipped to provide such support, especially small businesses,, which sometimes find it difficult to provide health insurance to their employees.

For Anglo-American early treatment is not only possible, but it makes economic sense. However, South Africa is far off the mark of providing Universal Access and AIDS continues to be a strain on the economy.

The experience of the Bushbuckridge community health centre, a 'best practice' site located deep in a rural area, shows that providing Universal Access can be achieved in any setting.

The way forward

Among the themes that emerged from the session were the importance of strong political leadership, clear messaging around HIV and AIDS and holding leaders and government institutions accountable for the promised they have made around AIDS. The national response to HIV should involve community, faith-based and traditional leaders whose role is important in influencing shifts in those cultural patterns and societal norms that drive the epidemic. While leadership at local level needs to be encouraged and supported, the health sector needs to engage further with local communities.

Universal access implies that all people should be able to have access to information and services that are equitable, accessible, affordable, comprehensive and sustainable.  More attention should be paid to addressing the health needs and rights of migrants and refugees living with HIV.  HIV programmes need to be more focused and reach those most at risk of HIV infection such as sex workers and men who have sex with men. Priority should be given to evidence-informed, results-driven HIV interventions and more emphasis should be put on achieving cost-effectiveness. Moreover, prevention must not be accorded second class status, but rather prevention efforts should be more targeted at specific populations and geographic areas.

A more nuanced approach to HIV prevention should include better understanding of the drivers of the epidemic, greater involvement of local organisations and increased regional cooperation aimed at stemming the spread of HIV across national borders..

Health services need to be strengthened, but this measure on its own is not enough to increase access to treatment.

Another much debated topic during the consultations was Eastern and Southern Africa' high dependency on foreign aid and the need to increase country-level ownership of the AIDS response. Countries in Eastern and Southern Africa should diversify their sources of financing for the AIDS response, and use existing resources more efficiently.

The Global Fund should be used only to fill the gaps and provide additional support. With a gap of $4bn between what countries have requested and what the Global Fund is able to give, countries are being asked to look at how they can use their budgets more efficiently. This funding gap is expected to rise significantly in the face of the current global economic crisis.