HIV and AIDS

AIDS is a global epidemic of unprecedented proportions. The impact of HIV and AIDS in the world's poorest regions is extensive and extreme, constituting both an emergency and a chronic threat to development and governance. As the impacts of HIV and AIDS are well documented this page aims to be solution focused, providing ideas for policy and action. It provides insights into comprehensive approaches to combating HIV and AIDS, vulnerable groups requiring special consideration and regional case studies. However this topic guide is only an introduction and does not attempt to provide exhaustive coverage of the wide literature and myriad factors relating to governance and HIV and AIDS.

Page contents

Where is a good place to start?

Moran, D., Butcher, K., Curtis, D. and Laurence, C., 2003, Commissioned Desk-Based Research Literature Review on HIV/AIDS and Governance.
Key issues discussed are the impact of HIV on service delivery, macroeconomic stability, marginalisation and 'voice', HIV and justice issues, conflict and corruption. Key findings included the absence of information on public sector institutions other than the education sector, and the complexity of the issues and difficulties of comparing data between countries.
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Mainstreaming and national strategies

Many early strategies addressed HIV and AIDS as public health concerns. It is now recognised that more comprehensive and multi-sectoral approaches are essential. National strategies and approaches that mainstream HIV and AIDS concerns into development practice have been advocated for poor countries.

This paper aims to provide clarity about what HIV/AIDS mainstreaming is and how it may be effectively achieved.

Elsey, H., and Kutengule, P., 2003, HIV/AIDS Mainstreaming: A Definition, Some Experiences and Strategies, HIV/AIDS Knowledge Programme, Liverpool School of Tropical Medicine, Liverpool, UK and the Health Economics and HIV/AIDS Research Division (HEARD), University of Natal, South Africa.
This report aims to contribute to the clarity of understanding of HIV/AIDS mainstreaming by sharing experiences from several African countries that are attempting to address HIV/AIDS within all the sectors of government. It looks at what government sectors can do both internally and externally to mainstream HIV/AIDS and covers key issues.
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This paper critiques the prevailing view that national commissions are successful strategies for combating HIV and AIDS.

Putzel, J., 2004, 'The Global Fight Against AIDS: How Adequate Are the National Commissions?' in Journal Of International Development, Vol. 16, No. 8, pp. 1129 - 1140
Since the late 1990s, the donor community has placed increasing emphasis on promoting a 'multisectoral' approach to fighting the HIV/AIDS epidemic in developing countries. This paper from the Journal of International Development assesses the contribution of stand-alone National AIDS Commissions - the essential pre-requisite to receiving HIV/AIDS funding as stipulated by the World Bank – to fighting HIV/AIDS. By imposing an 'organisational template' to encourage a multisectoral approach, is the World Bank needlessly jeopardising existing and frequently successful, state-inspired HIV/AIDS strategies?
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Governance and political commitment

HIV and AIDS impact on governance and development, but governance also impacts on HIV and AIDS. This paper argues that the principles of democratic governance can be used to strengthen societies in their fight against AIDS:

Hsu, L-N., 2004, Building Dynamic Democratic Governance and HIV/AIDS Resilient Societies, UNDP and UNAIDS, Bangkok
Outside the domain of public health, responses to HIV/AIDS remain limited. How can existing knowledge and experience be utilised to build resilience to the pandemic? This paper from the United Nations Development Programme proposes that principles of democratic governance should be applied at all levels, allowing societies to build their own ability to bounce back from such crises.
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'Political commitment' is cited as a key factor in the successful responses of Uganda, Senegal, Thailand and Brazil to national HIV/AIDS reduction and prevention. For this reason it is often considered integral to any strong response to HIV/AIDS. The following paper explores what is really meant by political commitment and how a policy focus on better governance may be more appropriate:

Patterson, D., 2001, 'Political Commitment, Governance, and HIV/AIDS', in Canadian HIV/AIDS Policy and Law Review, Volume 6, Number 1/2
Is the notion of political commitment useful for programming and advocacy? Is it more beneficial to focus on better governance rather than greater political commitment? This article by the Canadian HIV/AIDS Legal Network looks at both political commitment and governance as methods of increasing the success of AIDS programs.
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Human rights

HIV and AIDS and human rights interact in a complex relationship. The spread of HIV and AIDS is facilitated when human rights are not realised. The human rights of those infected and affected by HIV are frequently violated. In recognition of this inextricable link and the need for comprehensive strategies, human rights approaches are central to programming on HIV and AIDS. The International Guidelines on HIV/AIDS and Human Rights developed by UNAIDS form the cornerstone of rights-based approaches to HIV and AIDS.

The following document provides an annotated guide to the International Guidelines on HIV/AIDS and Human Rights and how they may be implemented in practice:

UNAIDS/IPU, 1999, Handbook for Legislators on HIV/AIDS, Law and Human Rights: Action to Combat HIV/AIDS in View of its Devastating Human, Economic and Social Impact, UNAIDS/IPU, Geneva.
What role can parliamentarians and other elected officers play in fighting AIDS? What are the advantages of a rights-based approach to HIV/AIDS? This handbook, developed jointly by UNAIDS and the International Parliamentary Union, is designed to assist legislators in decision-making on HIV-related law and policy reform. It provides examples of best practice from around the world for each of the 12 International Guidelines on HIV/AIDS and Human Rights, developed by UNAIDS and the Office of the United Nations High Commissioner for Human Rights.
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This paper explores what is meant by rights-based approaches in the context of HIV and AIDS and how donor agencies have implemented this in their work.

Patterson, D., 2002, Reviewing Programming on HIV/AIDS, Human Rights and Development, Canadian HIV/AIDS Legal Network for the Canadian International Development Agency, Montréal
The protection of human rights is receiving increased attention in international legal obligations aimed at reducing the spread and impact of HIV/AIDS. Can a rights-based approach offer an effective framework for confronting HIV/AIDS over the longer term? How does a rights-based approach differ from other development approaches? This paper, compiled for the Canadian HIV/AIDS Legal Network, explores rights-based approaches to HIV/AIDS in development funding and examines the extent to which donors and other agencies have incorporated these into their programmes.
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Security and conflict

Populations affected by conflict and insecurity are often at a heightened risk of HIV infection. Vulnerable populations such as women, children and refugees face a particularly acute threat. The strain of coping with HIV and AIDS weakens the fabric of society and may contribute to insecurity and conflict.

This paper explores the bidirectional relationship between HIV and conflict, particularly focusing on the threat of HIV in Africa to the international arena.

Singer, P.W., 2002, 'AIDS and International Security', in Survival, vol. 44, No. 1., pp. 145-158
What is the relationship between AIDS and conflict? Does AIDS constitute a threat to international stability? This article from the journal Survival argues that AIDS should not be viewed as a disease in isolation. The security implications of the epidemic can be seen at various levels, through its impact on global stability, state structures and the military. Furthermore, the combination of disease and conflict perpetuates warfare and intensifies the threats to international security.
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This paper presents a framework for understanding conflict and HIV. Interestingly it challenges the prevalent assumption that conflict is associated with increased HIV infection.

Mock, N.B. et al., 2004, 'Conflict and HIV: A Framework for Risk Assessment to Prevent HIV Conflict-Affected Settings in Africa', in Emerging Themes in Epidemiology, vol. 1, no. 6
What is the relationship between conflict and HIV/AIDS? Conflict is generally understood to accelerate HIV transmission but is this really true? This research by Tulane University argues that this view is simplistic and disregards complex interrelationships between factors that can inhibit and accelerate the spread of HIV in conflict and post conflict settings, respectively. The paper provides a framework for understanding these factors and discusses their implications for policy formulation and programme planning in conflict-affected settings.
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Prevention and treatment

Until recently prevention strategies were exclusively advocated for addressing HIV in poor countries where resource constraints limited access to effective treatment. Prevention and treatment are now both considered essential elements of any HIV and AIDS strategy.

Behaviour change is an essential element of effective prevention techniques that is notoriously difficult to achieve. Prevention techniques that rely on behaviour change have had limited impact, partly because they fail to recognise the needs of vulnerable groups who are unable to exercise control over risky behaviours. See the sections on gender and vulnerable children and orphans below for a discussion of the particular risks facing these groups.

The article below presents the lessons learned about effective behaviour change communication in resource poor settings.

Larivee, C.,and Franklin, B.A.K., 2001, 'Behavior Change Communication to Reduce Risk and Vulnerability in Resource-Constrained Settings', Chapter 6 In Lamptey, P.R. and Gayle, H.D. (eds), HIV/AIDS Prevention and Care in Resource-Constrained Settings: A Handbook for the Design and Management of Programs, Family Health International, Virginia, pp137-158.
What lessons have been learned in 20 years of responses to the AIDS pandemic? This handbook by Family Health International suggests that progress is made only when communities and nations wholeheartedly embrace the fight against AIDS. Furthermore, there is no “one-size-fits-all” solution in designing and delivering the most effective prevention and care initiatives. HIV feeds on social inequality, especially the inequality between men and women. The study concludes that we must confront the need for long-term, structural change to address the pandemic effectively.
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Anti-retroviral therapy (ART) is not a cure for AIDS but if correctly administered it can provide years of healthy life for people living with HIV and AIDS. Access to ART has become a realistic prospect for poor countries over recent years. The following two documents provide guidance for the provision of equitable access to ARTs in poor countries.

Grubb, I., Perriëns, J. and Schwartländer, B., 2003, A Public Health Approach to Antiretroviral Treatment: Overcoming Constraints, WHO, Geneva
What is the most effective way of overcoming obstacles to scaling up antiretroviral treatment in resource constrained settings? This study by the World Health Organisation (WHO) reviews the experiences of ARV programmes already underway in countries with very severe HIV epidemics but severely constrained resources. It aims to identify some common elements to consider when scaling-up HIV/AIDS treatment.
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World Health Organisation, 2004, Guidance on Ethics and Equitable Access to HIV Treatment and Care, WHO, Geneva
What ethical issues arise in the scale-up of anti-retroviral therapy (ART) and other HIV-related treatment and care programmes? How can governments develop ethically sound programmes which are as fair, beneficial and sustainable as possible? This guidance document from the World Health Organisation and UNAIDS is intended to raise awareness of the ethical issues and to help with the planning and implementation of an equitable scale-up.
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When combined, prevention and treatment are mutually reinforcing. As access to ART in poor countries increases, prevention techniques will need to adapt for optimal results, as indicated in the following paper.

Global HIV Prevention Working Group, 2004, HIV Prevention in the Era of Expanded Treatment Access
Governments, international agencies, drug manufacturers and private organisations are now mobilising substantially to make access to life prolonging antiretroviral therapy (ART) in the developing world a global priority. This report from the Global HIV Prevention Working Group, convened by the Gates Foundation and the Kaiser Family Foundation, makes recommendations on how to effectively integrate HIV prevention into expanding treatment programmes, including new prevention approaches that consider the differing needs of HIV-positive and HIV-negative people.
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Care and carers

Care in the context of HIV and AIDS extends beyond access to drug treatments and the formal health sector. Care for the sick and dying and their dependents often occurs in the home, extended family and community. This can place an extreme burden on particular groups that become carers, as illustrated by the following two documents that consider the roles of women and older people respectively.

Ogden, J., Esim, S. and Grown, C., 2004, 'Expanding the Care Continuum For HIV/AIDS: Bringing Carers into Focus, Horizons Report', Population Council and International Center for Research on Women, Washington, D.C.
Who are the primary carers for poor people affected by HIV/AIDS and what challenges do they face? What are the issues associated with the provision of care to HIV/AIDS patients? This review of existing literature and initiatives, produced jointly by the Population Council and the International Centre for Research on Women, focuses on Africa. It calls for the creation of a truly holistic and comprehensive care agenda for HIV/AIDS and identifies areas for further research.
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International HIV/AIDS Alliance and Helpage International, 2003, Forgotten Families: Older People and Carers of Orphan and Vulnerable Children, International HIV/AIDS Alliance, Brighton
As a result of HIV/AIDS, family structures are changing. Large numbers of older people are assuming responsibility for bringing up orphans and vulnerable children. What challenges do they face, and how can these be overcome? This report by HelpAge International and the International HIV/AIDS Alliance draws on evidence collected from programme experience in Africa and Asia. It presents an overview of the issues, good practice examples from community-based programmes and recommendations for future policies, programmes and research.
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Orphans and vulnerable children

Children are affected by and made vulnerable to HIV and AIDS in many ways. For example, as HIV predominantly infects young adults, AIDS has orphaned millions of children. The following document presents an internationally recognised framework for supporting orphans and vulnerable children.

Gulaid, L.A., 2004, The Framework for the Protection, Care and Support of Orphans and Vulnerable Children Living in a World with HIV and AIDS, UNICEF, New York
Despite the a reinforced focus on HIV/AIDS in development strategies and programmes, global HIV infection rates continue to rise and the number of vulnerable children and orphans continues to grow. Can a broad, collective response involving all stakeholders be implemented to overcome the impact of HIV/AIDS on children? This report, compiled by the United Nations calls for greater coordination and creativity in supporting families and communities as the foundation of an effective, scaled-up response.
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Gender

Approximately half of all people living with HIV are now women, and infection rates in sub-Saharan Africa are far higher for women than men. Women have a greater vulnerability to HIV infection than men for physiological and socio-economic reasons. HIV positive women face discrimination and abuse and women carry a great burden when HIV and AIDS affects their families and communities. Gender inequality also limits women's impact on HIV and AIDS policies.

Amnesty International, 2004, Women, HIV/AIDS and Human Rights, Amnesty International, London
The HIV/AIDS pandemic is increasingly understood as a health, development and human rights issue strongly affected by gender. Can a rights-based approach to the gender-related aspects of HIV/AIDS prevention, treatment and support provide a more effective response to the pandemic? This paper, compiled for Amnesty International, reviews women’s gender-specific susceptibility to the virus, concluding that international guidelines on HIV/AIDS and human rights must be implemented in order to address the discriminatory values that put women at greater risk.
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Eckman, A., Huntley, B. and Bhuyan, A., 2004, How to Integrate Gender into HIV/AIDS Programs: Using Lessons Learnt from USAID and Partner Organisations, Interagency Gender Working Group Task Force Report, USAID, Washington, D.C.
Addressing gender issues is increasingly regarded as central to the success of HIV/AIDS programmes. How effective has gender-informed programming been in reducing vulnerability to HIV infection? Compiled for the Interagency Gender Working Group, the Gender and HIV/AIDS Task Force and the United Stated Agency for International Development (USAID), this report examines the key gender issues in HIV/AIDS programming, outlines promising interventions and suggests how these can be strengthened and extended.
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