Summaries
Leadership Program

SCALING UP. Two-thirds of the 10 million infections projected to occur in Asia between 2004 and 2010 could be prevented through the scaling up of effective prevention measures. Currently, however, fewer than 1 in 5 people at risk worldwide have access to HIV prevention interventions, and fewer than 1 in 10 who need ARVs are able to obtain them. Substantial unused capacity exists at country level -- especially among civil society organizations -- but donors often fail to provide the operational support required to put this unused capacity to use. Efforts to expand HIV/AIDS treatment access must be accompanied by creative strategies to strengthen health systems and build sustainable human capacity in countries.

RESOURCE MOBILIZATION. Annual resources needed to mount a comprehensive response to the global epidemic will reach US$20 billion by 2007 -- a four-fold increase over amounts that will be available in 2004. Such sums could be generated, however, if donor countries allocated 0.7% of GDP for HIV/AIDS assistance. In Asia alone, HIV/AIDS spending must increase 25-fold by 2007 to reach the US$5.1 billion annual target for a comprehensive response. On Monday, the Asia Development Bank announced that it had reserved US$140 million in funds for HIV/AIDS programs in the region. Resources that are currently available for HIV/AIDS are often not used to maximum effect as a result of donors' failure to coordinate with each other and with national stakeholders. Countries increasingly report that donors pursue their own agendas, often ideologically driven, rather than tailor HIV/AIDS assistance to national needs. In many countries, prevention resources are often poorly targeted, failing to reach marginalized populations at highest risk, including IDUs, sex workers, and MSM.

MOBILIZATION OF PEERS. Opportunities exist for international NGOs to assist local NGOs in developing enhanced management and financial systems. Two sessions focusing on the role of donor agencies emphasized the need for donors to harmonize their efforts and eliminate duplicative administrative burdens on recipients.

ACCOUNTABILITY. Although numerous conferences and global gatherings have generated multiple statements of commitment from political leaders, most of these commitments have never been kept, underscoring the need for greater accountability in the global response. The UN Secretary-General reported at the opening session that many countries are at risk of falling short of the targets for 2005 set forth in the Declaration of Commitment. To increase the accountability of political leaders, NGOs should work where possible to speak with a single voice.


TUESDAY
13 July

Tuesday's Leadership Programme focused on challenges in bringing essential programmes to scale. In addition, several sectors met in sector-specific leadership forums, producing statements of commitment that will be used to develop a comprehensive Bangkok Statement of Leadership Commitment. A special "Meet the Leaders" session included one-on-one interviews with Dr. Denzil Douglas, Prime Minister of St. Kitts and Nevis, who is representing the Caribbean Community; UNAIDS Executive Director Peter Piot; and South African AIDS activist Zackie Achmat.

SUPPORTIVE POLICIES. As HIV/AIDS becomes increasingly "feminized," with women accounting for 1 in 2 HIV infections worldwide, legal and economic measures are urgently needed to empower women and reduce their vulnerability to HIV. A Leadership Programme session on the policy environment needed to promote treatment access generated a lively discussion; while industry representatives emphasized the importance of intellectual property rights in preserving economic incentives to develop new drugs and vaccines, industry critics urged countries to make maximum use of the flexibility available under international trade treaties to increase the affordability and accessibility of medicines.

SCALING UP. Unprecedented action is needed to ensure achievement of the WHO/UNAIDS goal of delivering ART to 3 million people by the end of 2005. To facilitate treatment scale-up, WHO and UNAIDS now recommend that HIV testing be routinely offered to patients in all health care settings (with an opt-out option). As treatment access increases, special efforts are needed to ensure equitable access to ART, especially for populations with historically limited health care access, such as women and injecting drug users. On the prevention front, failure to target resources where they are most needed reduces the impact of existing funding. A cost-effectiveness analysis in Nepal indicates that enhanced targeting of HIV prevention to the most vulnerable populations would reduce the average cost of averting a case of HIV from US$1,048 to US$655. Although 7 million women worldwide have received services to prevent mother-to-child transmission (PMTCT), PMTCT coverage remains low. PMTCT programmes are actively working to overcome barriers to scale-up, assisted by a growing body of evaluation data and the increasing available of ART for HIV-infected pregnant women who enrol in such programmes.

RESOURCE MOBILIZATION. In a message delivered to the conference, French President Jacques Chirac called on the US, Europe and other donors to ensure at least US$3 billion annually in contributions to the Global Fund. Over the last two years, corporations have significantly increased their financial and in-kind contributions to the fight against AIDS. The impact of existing resources is diminished by the failure of donors to coordinate and harmonize their efforts and to ensure that donor efforts adhere to nationally determined strategies.

MOBILIZATION OF PEERS. Regional bodies -- such as the Pan-Caribbean Partnership on HIV/AIDS and the Asia/Pacific Leadership Forum -- provide opportunities for political leaders to encourage their peers to do more to fight the epidemic. The number of corporate members of the Global Business Coalition on HIV/AIDS -- an organization designed to mobilize business leaders to fight AIDS -- has doubled since 2002.

ACCOUNTABILITY. The gravity of the HIV/AIDS crisis demands accountability from every stakeholder in the fight. Government accountability on HIV/AIDS is strengthened when the national response is overseen by a single body; in Asia, however, no national AIDS body is headed by the country's foremost political leader. Civil society plays a vital role in ensuring greater accountability, as reflected by the growing global commitment to expand treatment access, a trend traceable to strong and tireless community advocacy.


WEDNESDAY
14 July

On Wednesday, leaders from 15 different sectors gathered to develop the Bangkok Statement of Leadership Commitment, which will be presented to conference participants at the closing ceremony. A special "Meet the Leaders" session included a leading AIDS scientist; the CEO of Pfizer Inc.; one of the world's leading PLWHA activists; and actor Rupert Everett. Another session examined why donors often fail to coordinate their efforts, and numerous sessions focused on the HIV-related challenges confronting women and young people.

SUPPORTIVE POLICIES. Countries need a comprehensive legislative framework to reduce women's economic and social vulnerability. Education operates as a "social vaccine" that helps reduce vulnerability to HIV; to promote universal girls education, countries should eliminate school fees. User fees should be abolished for young people, as they can deter utilization of essential health services in the absence of parental consent. Countries should actively involve young people in the development and implementation of programmes and specifically acknowledge young people's right to honest and accurate information about HIV/AIDS and human sexuality. Companies that offer VCT and ARVs to their workers report that many employees avoid such services due to HIV-related stigma, underscoring the need for innovative and aggressive action to combat HIV-related prejudice and discrimination. Special efforts are needed to reduce the stigma suffered by AIDS orphans and HIV-infected children. Structural interventions exist to reduce vulnerability by altering the social and physical environment through government action; examples include condom provision in prisons, legalization of homosexuality, and changes in laws to promote a public health approach to injecting drug use.

SCALING UP. Global efforts to rapidly expand access to ART represent one of the most challenging and ambitious public health initiatives ever undertaken. To accelerate treatment uptake, optimal use must be made of rapid testing and other strategies to promote knowledge of serostatus and linkage to services. With respect to prevention services, numerous sessions focused on the limitations of the standard "ABC" model. In particular, women whose only risk factor is having monogamous sex with their husbands are not well served by ABC-based strategies. Services to address the AIDS orphan crisis represent a major gap in the global response; thus far, for example, the Global Fund has received relatively few proposals that focus on the physical and psychosocial well being of children made vulnerable by the epidemic. Efforts to ensure an adequate and reliable supply of condoms should be strengthened and accelerated.

RESOURCE MOBILIZATION. In addition to providing substantial new resources, donors must improve their cooperation with one another and with national stakeholders. In particular, donors should adhere to the "Three Ones" -- one national HIV/AIDS strategy, one national coordinating mechanism, and one national framework for monitoring and evaluation.

MOBILIZATION OF PEERS. Youth advocates expressed the desire for global mechanisms to facilitate networking and information-sharing among young people. Increasing efforts are underway to promote greater engagement by employers in the response to HIV/AIDS. In particular, it was suggested that CEOs of large multinational corporations could be extremely influential in encouraging business leaders in developing countries to adopt sound, comprehensive HIV/AIDS workplace policies.

ACCOUNTABILITY. Greater transparency is needed to promote accountability among donors. Donors, national governments and NGOs should set and monitor progress toward concrete service targets, such as the number of people treated, number of orphans served, etc. AIDS stakeholders should also be more willing to acknowledge and examine failures or shortcomings.


THURSDAY
15 July

Leaders from 14 sectors agreed on a Bangkok Statement of Leadership Commitment, which Graca Machel will present to the full conference at Friday's closing ceremony. In addition, Leadership Programme sessions focused on regional leadership in strengthening the response, on critical elements of leadership that enable countries to move denial to action, and on the importance of strengthening research and development on new prevention technologies.

SUPPORTIVE POLICIES. Given the difficulties of confronting AIDS, most countries initially opt for denial, necessitating strong, courageous and sustained leadership to deliver unpopular messages and information until they are embraced by those who can make a difference. In moving from denial to action, it is especially vital to involve leaders from all walks of life in national responses. In this regard, the media can play an important role -- not merely in providing information but in offering a venue where the voices of people affected by AIDS can be heard. In November 2004, the Caribbean community will hold its first conference on fighting HIV/AIDS stigma and discrimination. A Leadership Programme session on monitoring and evaluation underscored the importance of better linking choice of interventions with timely and reliable epidemiologic information. To accelerate the development of vaccines, microbicides, and other prevention technologies, public policy changes are needed to create a legal and investment environment that encourages strong R&D, timely clinical testing, rapid approval and licensure, and adequate manufacturing capacity.

SCALING UP. In many parts of Asia, up to 90% of people at highest risk have never been educated about HIV. Despite the critical prevention deficits in Asia, the region also offers some of best examples of effective prevention programmes, most notably in Thailand and Cambodia. In India, the number of schools offering HIV education has increased from 20,000 to 60,000 in the last two years. In a skills building session for media leaders, BBC Trust showcased the use of multimedia approaches in Cambodia to support design, production and dissemination of messages to support effective behaviour change. A session on scaling up ARV treatment highlighted experience in Cameroon, Rwanda and Barbados, where the feasibility of scaling up ARVs has been definitively demonstrated. A major obstacle to expanding access to ARVs in the least developed countries is the acute shortage of human resources. On the R&D front, too few resources are currently being devoted to the search for a preventive vaccine, and the vaccine development pipeline remains far too narrow. Clinical trials are proceeding on other possible prevention strategies, including ongoing treatment of HSV-2 and adult circumcision.

RESOURCE MOBILIZATION. In the Caribbean, resources for HIV/AIDS have increased five-fold since 2000. Drastic declines in the price of ARVs -- from US$12,000 per year in 2002 to roughly US$200 today -- means that even stable resources permit countries to provide treatment to many more people with HIV than in earlier years. In Cameroon, financial support for ARV scale-up through the World Bank's Multicountry AIDS Programme has been supplemented by debt relief through the HIPC initiative.

MOBILIZATION OF PEERS. Caribbean leaders cited the need to create a regional business council on HIV/AIDS to facilitate mobilization of the private sector. In Afghanistan, 75,000 religious leaders have received HIV/AIDS training. In November 2004, UNICEF and the World Conference of Religion for Peace will convene a meeting in South Asia to explore further strengthening religious engagement in the fight against AIDS.

ACCOUNTABILITY. The response to AIDS should increasingly rely on clear and concrete benchmarks that permit an ongoing assessment of progress. Donors must be held accountable for adhering to the Three Ones, ceding ultimate authority over HIV/AIDS to affected countries themselves.