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From Africa Recovery, Vol.14#4 (January 2001), page 1

African Development Forum

African leaders declare war on AIDS

By Gumisai Mutume in Addis Ababa

"Let us strike back by declaring war, total war on HIV/AIDS -- not a national war that only appears in speeches at conferences and meetings, but a war that becomes part and parcel of the life of this continent," exhorted former Zambian President Kenneth Kaunda at this year's African Development Forum in Addis Ababa.

Mr. Kaunda does not underestimate the enemy. Sub-Saharan Africa is home to 25 million of the 36 million people living with HIV/AIDS -- or roughly 70 per cent of the global total. Out of the cumulative total of nearly 22 million AIDS deaths worldwide, 16 million were African.

According to figures released just before the conference by the Joint UN Programme on AIDS (UNAIDS), there were 3.8 mn new infections in sub-Saharan Africa in 2000, slightly down from 4 mn the year before, but still an alarming number. In economic terms, the World Bank estimates that AIDS is costing Africa about 1 percentage point of economic growth each year. For the hardest-hit countries, the cost is as high as 3-4 percentage points. Over a decade, total output in these countries could be 35 per cent less than it would otherwise have been.

The call for a determined war against the scourge of AIDS was reinforced at the 3-7 December conference by Ugandan President Yoweri Museveni (see box 1, below) and the other participating African presidents and prime ministers, donor officials and civil society representatives. The gathering was the second annual African Development Forum of the UN Economic Commission for Africa (ECA), this time also co-sponsored by the seven agencies that make up UNAIDS.

The participants adopted a collective commitment to confront HIV/AIDS as the continent's biggest development challenge. Their "African Consensus and Plan of Action" is to be presented for adoption and implementation to African heads of state and government, convening in Abuja, Nigeria, on 25-27 April at an Organization of African Unity (OAU) special summit on HIV/AIDS.

The consensus sets a general framework of action and calls for: greater financial commitment from the international community in the form of grants, rather than loans; more transparent national budgeting for HIV/AIDS programmes; a substantial reduction in the prices of anti-retroviral medicines and a continent-wide strategy to ensure provision of affordable essential drugs and treatments; and the expansion of debt relief as an important source of anti-AIDS funding.

Beyond the specific recommendations of the conference, UN Secretary-General Kofi Annan highlighted its importance in demonstrating committed African leadership. The African presidents and prime ministers who took part, he said, "understand that official recognition of the problem is the first step towards dealing with it. They are also showing that the leadership we need in Africa cannot come from outside, but rather must flow from within."

ECA Executive Secretary K.Y. Amoako agreed. "No one is going to save us from this crisis but ourselves," he affirmed. "But we also have a right to expect international solidarity when we are taking proper ownership and leadership of this disease."

Africa's development partners, including the UN and the World Bank, pledged to increase their commitments to fighting HIV/AIDS and assist in raising an estimated $3 bn needed annually to treat at least half of those infected in Africa and to launch effective prevention campaigns.

UN Development Programme Administrator Mark Malloch Brown declared, "For our part, we have singled out HIV/AIDS as one of our top corporate priorities around which we are focusing the new UNDP. So we are redoubling our global advocacy role to try and raise awareness and resources." However, except for a $500 mn loan facility launched earlier this year by the World Bank and widely debated at the conference, no firm financial commitments were announced during the Addis Ababa forum.

So far, despite the devastating impact of HIV/AIDS in Africa, resources to address the epidemic have been limited compared with those for other priority areas. In 1998, external spending on HIV/AIDS was about $165 mn, according to the UN Children's Fund (UNICEF), although it has increased somewhat since then. By comparison, childhood immunizations -- also an important programme on the continent -- received more than $650 mn in external funding that year.

Being overwhelmed?

While the consensus document adopted at the African Development Forum is full of good intentions, it is not the first time the continent's leaders have resolved to beat AIDS. A series of OAU summits since Tunis, in 1992, have seen heads of state and government commit and recommit their nations to mobilize resources against the disease.

Among the first resolutions was a pledge that, by mid-1993, heads of state and government would ensure that all adults in their countries would know how HIV is transmitted and how to protect themselves and others from infection. They also were to have adopted national AIDS treatment plans, including the provision of essential drugs for HIV-related illnesses and plans for family-based or community care and support for AIDS orphans.

"Regrettably, many of these commitments have not been translated into action," acknowledged OAU Secretary-General Salim Ahmed Salim. "It seems that we are being overwhelmed in this battle. We are losing ground, and we are being attacked at the most vulnerable points."

Coordinating strategies

The International Partnership against AIDS in Africa (IPAA) says action against the epidemic at all levels is being compromised by fragmentation, with different actors pursuing agendas in isolation from each other. The IPAA, a grouping of African governments, UN and other donor agencies, the private sector and community-based organizations, was officially launched at the conference by Secretary-General Annan, culminating a process that began more than a year ago as the different partners came together to develop a more coordinated response to Africa's HIV/AIDS crisis.

The group's mission over the next decade is to help reduce the number of new HIV infections in Africa, promote care for those living with the virus and mobilize financial resources to halt the advance of AIDS.

So far, the various actors -- government or non-governmental, UN or private -- have tended "to address HIV/AIDS as an area for designing and implementing multiple, often small-scale projects, with their own objectives, management, monitoring and evaluation systems," instead of working within nationally agreed strategic agendas, noted a conference theme paper. Many countries in Africa still do not have strategic national plans to fight HIV/AIDS.

The consensus document has no binding legal force. But ECA has been mandated with ensuring that it remains on the agenda of African nations. The conference urged all African countries to hold, by mid-February, national planning workshops to determine how the consensus can be turned into concrete action at the national level. It also recommended that an April OAU conference of planning and finance ministers in Algiers work out strategies to wed policies for poverty reduction, debt relief and HIV/AIDS, and to come up with a common position on international funding for Africa's anti-AIDS strategy. By the end of 2001, all countries are expected to have national AIDS commissions and strategic plans of action in place, backed by legislation and clear allocations of national budgetary resources.

Leadership challenge

The official theme of this year's African Development Forum was "AIDS: Africa's greatest leadership challenge," highlighting not only the seriousness of the crisis but also the key role of political leadership in combating it. In the view of many of the 1,500 participants, the continued spread of the epidemic has reflected a deficiency in such leadership.

"Too often in Africa, our leaderships have failed to address themselves to issues that affect people's lives," remarked Mr. Omololu Falobi, project coordinator of Journalists Against AIDS in Nigeria. "Our leaders have tended to become re-actors, rather than pro-actors. They have delighted in mouthing slogans that have no practical meaning in action, in addressing issues as 'business as usual.'"

According to Mr. Amoako, the ECA executive secretary, leading the battle against the AIDS epidemic overlaps with many of the continent's broader development challenges. "Leadership on HIV/AIDS calls for so many of the fundamental things we should have been doing anyway."

Generally, politicians' denials of the extent of HIV in their countries is now a thing of the past. Yet the conference noted that the problem still persists in certain countries, while some governments continue to cloud the issue by disputing the level of HIV infection or the link between HIV and AIDS.

In a session on HIV and the military, armies and police forces were singled out as institutions still reluctant to admit the high levels of infection within their ranks.

Governments in Africa rely heavily on their armed forces for survival, noted a conference theme document, and many feel that to admit to high levels of infection could cause demoralization and a crisis of confidence.

The time for denial is over, Ms. Charlotte Mjele, a 22-year-old who is HIV positive, told the delegates. Associated with the Hope Worldwide Jabavu Clinic in Soweto, South Africa, she challenged the conference participants to take up the leadership challenge just as she had done.

"Not many have the courage to do what I'm doing," she said in a speech that riveted delegates at the opening plenary. "I made a conscious effort to be a leader in showing that an HIV diagnosis is not the end of one's life. Many in a similar situation would not even go out to learn and update themselves with information about this virus that is affecting us so much."

"Not many," she continued, "can stand the risk of being discriminated against. Many are still dying in fear and many are still in the victim mindset. We need to help them make the transition from victim to victor."

Grants, not loans

The Addis forum heard some spirited debate over whether or not Africa should accept loans to fight HIV/AIDS. The argument was most animated in a session devoted to youth, which in a declaration expressed "outrage" at the World Bank's $500 mn loan facility.

The World Bank recently approved applications from Ethiopia and Kenya under its Multi-Country AIDS Programme (MAP) for Africa. The two countries' loans -- extended through the Bank's concessional lending arm -- the International Development Association (IDA), will mature in 40 years with a 10-year grace period. Like other IDA loans, 65 per cent of the amount is in grant form, while interest rates on the remainder are nominal. Most countries in sub-Saharan Africa are eligible for IDA borrowing. Further applications for MAP currently are under consideration from Benin, Burkina Faso, Cameroon, Eritrea, Gambia, Ghana, Nigeria, Uganda, Zambia and Zimbabwe (see box 2, below).

Critics argued that one of the problems with such loans is that they are rooted in the Bank's Country Assistance Strategies, which make assistance conditional on economic reforms set by the Bretton Woods institutions. Some also noted that fighting HIV/AIDS is not an income-generating project and maintained that therefore it is immoral to finance such efforts through any form of interest-bearing loans.

World Bank officials tried to sell their plan to the conference. Ms. Debrework Zewdie, the lead HIV/AIDS coordinator at the Bank, took pains to explain that it is wiser to spend borrowed money on HIV/AIDS prevention programmes now than to have to spend more at a later stage for treatment. Already, in the worst-hit countries, sound investments in other areas are proving uneconomic and unsustainable due to the epidemic.

The World Bank estimates that by spending an average of $200, a country can prevent one HIV infection. On the other hand, medical costs for treating one infection, even without using expensive anti-retroviral drugs, which attack the virus directly, would cost about $700 per person each year.

"The choice is stark and simple," said Ms. Zewdie. "Pay now, or pay a lot more later. If a country fails to invest adequately in HIV/AIDS, it will have to pay larger costs in the future that will themselves be unsustainable."

With some 10,000 new infections each day, African governments often feel they have little choice. They could try to secure more grants from donors and use World Bank credits to fill the gap. But significant grants have not been forthcoming so far, and to wait until HIV/AIDS programmes can be fully funded from grants would facilitate the epidemic's further spread.

Having already committed more than $1 bn on HIV/AIDS projects in 56 countries around the world, the Bank will continue to be a big player as more countries turn to it in response to the growing epidemic. The Bank has publicly committed itself to ensuring "unlimited" resources for well-designed national HIV/ AIDS programmes. It is one of the seven organizations that comprise UNAIDS. The others are UNICEF, UNDP, the UN Population Fund, the UN Education, Scientific and Cultural Organization, the World Health Organization and the UN International Drug Control Programme.

AIDS and debt

A number of participants remained unconvinced by the Bank's arguments. Mr. Holo Hachonda, a youth delegate, said that by providing loans to a continent that cannot afford to repay existing debts, the Bank is further tightening the noose around the necks of African countries with stagnating economies.

Many heavily indebted African countries find themselves in positions similar to that of Zambia. Ravaged by HIV/AIDS, the Southern African nation was able to spend only $76 mn on health care in 2000, while its debt servicing outlay reached $170 mn. According to UNAIDS, HIV-infected patients occupy 50-80 per cent of all beds in Zambia's urban hospitals, a proportion that reaches similar levels in Côte d'Ivoire and Zimbabwe. During the first 10 months of 1998, Zambia lost 1,300 teachers to the epidemic -- equivalent to two-thirds of all new teachers trained annually.

Given such dire circumstances in many African countries, Mr. Michael Kelly, a Zambian economist, proposed that rather than saddling Africa's future generations with more debt, the World Bank might instead use its influence to pressure the big multinational pharmaceutical companies that are resisting efforts by African countries to import or manufacture cheaper generic versions of their own expensive medicines. To applause from the delegates, he told the Bank, "Down the line, you can start squeezing these companies as you have been squeezing us all these decades."

For a 'new deal' on medicines

One of the recommendations of the African consensus on HIV/AIDS is to rapidly devise a common strategy to ensure the provision of essential, affordable anti-retroviral medicines. This would help in providing comprehensive care and treatment for people living with HIV/AIDS.

"The world needs nothing less than a new deal between the pharmaceutical industries and society," said UNAIDS Executive Director Peter Piot, "a deal that elevates the principles of public interest and humanitarian need to universal values embraced on all sides, while at the same time continuing to provide incentives for industrial innovation."

UNAIDS estimates that if sub-Saharan Africa were to provide anti-retroviral treatment to all those now in need, it would cost between $100 bn and $160 bn at current prices, far beyond the continent's reach. The debt relief that some countries will receive under the Heavily Indebted Poor Countries (HIPC) initiative of the World Bank and International Monetary Fund will permit some savings to be reallocated to health needs, but still only a fraction of the total requirement.

Mr. Piot also drew attention to some of the longer-term implications of AIDS that African planners have not yet begun to absorb. "How will education continue when teachers are dying faster than they are being replaced?" he asked. "How can agriculture be maintained when farming skills are lost?"

Even economically better off African nations will feel the pinch. Diamond-rich Botswana, the country with the highest per capita GDP in sub-Saharan Africa, will see the epidemic slice 20 per cent off the government's budget and bring a 13 per cent reduction in the incomes of the poorest households within the next 10 years.

From war to life

"Lack of resources is not a sufficient excuse," noted Ms. Graça Machel, who heads Mozambique's national AIDS commission. "When governments lead their countries to war they can spend as much as 45 per cent of the country's resources on that war."

"What percentages of national budgets are currently being spent to vanquish HIV/AIDS?" she asked. "Our governments must show the leadership to allocate greater proportions of our admittedly limited budgets to ridding our continent of the threat of AIDS. If you can mobilize resources for war, why can't you mobilize resources for life?"

The conference heard many words of praise for Senegal and Uganda, two countries that have done well in slowing the spread of HIV/AIDS. They have used a mixture of leadership commitment, constant relaying of the AIDS message in the media, education programmes, condom promotion and acknow-ledgement of the problem.

Until recently, Uganda was synonymous with AIDS. In 1993, 15 per cent of its population was infected, making it the worst-affected nation at the time. "It is very little consolation that since 1993, we have moved from number one to number 14," said President Museveni. "However, the decline in the prevalence of HIV in the last seven years in Uganda is a clear indication that, given the will, we can ultimately overcome the HIV/AIDS pandemic."

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BOX 1:

Uganda faces the 'lion in the village'

Uganda's success in implementing AIDS prevention and education programmes -- which have reduced the rate of new infections despite poverty and war -- has been held up as a model for other developing countries. One key, Ugandan President Yoweri Museveni told African leaders at the African Development Forum, has been the personal involvement of the head of state. "When a lion comes to the village, you don't make a small alarm. You make a very loud one. When I knew of this problem, I said we must shout and shout and shout and shout."

During an address punctuated by laughter and applause, the former rebel leader departed from his prepared remarks to call for aggressive political leadership in what he termed the "war" against AIDS. "When we started, our Ministry of Health were putting out a small advertisement after TV news. But in 1986 we only had 100,000 television sets. How many people would hear about it? I told them this alarm of yours is a silent alarm. The best channel for making a loud alarm are the political leaders."

"When a district health officer comes to address a meeting, 20 people turn up," he noted. "But if Museveni is coming to address a rally, 20,000 people turn up. That is the time to pass the message. Talk about your politics, but talk about AIDS also." He cautioned, "you cannot just leave it to the bureaucrats. They will just put [AIDS messages] when people are going to work and say 'we've put it there.' They don't care. So the leadership must supervise this war."

Women were another key to Uganda's success, the president observed. "In our struggle, we empowered women. One woman is vice-president, four are ministers, and 40 are members of Parliament." The presence of even a few women leaders, he said, has had a big impact on public attitudes. In the fight against AIDS, he said, "Women now started saying no to men" who insist on unsafe sexual practices. "That has helped."

Uganda also mobilized civil society, the schools and the media to spread the message. "In churches and mosques," he continued, "you can get a lot of people." In the public schools, "there are school assemblies where the whole school is assembled. That is where the headmaster should give a message about AIDS." Mass media are another tool for AIDS prevention and education, he explained. "In Uganda now we've got 12 million radio sets. Each family has [on average] about 3 radios. This is a very good channel."

As a result, he asserted, "Awareness now in Uganda is 100 per cent. Everybody is aware of what AIDS is and how it spreads." Awareness is vital because of the stigma and misconceptions that still accompany the disease. During his movement's insurgency in 1984, he recalled, "I started hearing on the radio that there was a new disease for homosexuals and drug addicts [in countries in the North] and I said that is none of our business." But with Africans now accounting for over 70 per cent of the world's AIDS sufferers, he concluded, "AIDS is now an African disease. We can't leave it to the Europeans and the drug companies only. We African governments must take up this battle ourselves."

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BOX 2:

1 in 3 African countries ineligible for AIDS loans

Three of the countries hit hardest by the AIDS pandemic in Africa -- Botswana, South Africa and Zimbabwe -- are among 15 African countries currently ineligible for funding through the World Bank's $500 mn Multi-Country AIDS Programme (MAP) for Africa. MAP offers low-interest loans for HIV/AIDS research, prevention and treatment projects for African countries through the Bank's International Development Association (IDA), which provides concessional financing to countries unable to borrow on commercial capital markets. At the programme's launch on 12 September, World Bank President James Wolfensohn noted that MAP fulfilled an earlier commitment to expand funding for HIV efforts. "Last April we promised that no sensible AIDS program in Africa would want for funding," he said. "Today, we deliver on that promise."

With 1 in 4 Zimbabweans estimated to be infected with the deadly virus, and a per capita income of less than $600, Zimbabwe was considered likely to be an early beneficiary of the MAP programme. However, the country was placed on "non-accrual" status on 3 October, when it missed a deadline for a $47 mn payment on $889 mn in outstanding Bank loans and credits. When that happened, Bank officials told Africa Recovery, Zimbabwe became ineligible for any additional financing, including through MAP, until it clears the arrears.

Botswana and South Africa do not qualify under IDA guidelines because they have per capita gross domestic products above the facility's permitted maximum of $885. Seven other countries -- Cape Verde, Equatorial Guinea, Gabon, Mauritius, Namibia, Seychelles and Swaziland -- also are deemed too prosperous to qualify. The Democratic Republic of Congo, Republic of Congo, Liberia, Somalia and Sudan -- like Zimbabwe -- are ineligible because they too are delinquent on previous World Bank loans.

Some African governments, already overburdened with foreign debt, have been reluctant to borrow further to finance HIV/AIDS programmes. In early October, Zambian Health Minister David Mpamba announced that Zambia would join Malawi in refusing to apply for World Bank AIDS loans. Zambia wanted to ease its debt obligations, he said, and borrowing to finance AIDS projects "would not help" in that regard. Instead of new loans, "What we want now is for the World Bank to facilitate the price reductions of AIDS drugs so that the drugs are made available to many people." A US government offer of $1 bn in commercial loan guarantees for the purchase of US-made anti-AIDS drugs has, to date, found no African takers.

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