UNAIDS Regional Director for East and Southern Africa, Dr Sheila Tlou (left) with the First Lady of Uganda Janet Kataaha Museveni.
Credit: UNAIDS

UNAIDS Regional Director for East and Southern Africa, Dr Sheila Tlou appealed to Uganda’s First Lady Janet Kataaha Museveni to champion the elimination of new HIV infections among children in the country.

The request was made during Dr Tlou’s official visit to Uganda from 8-9 November 2011 aimed at engaging high level political leadership in support of the Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Uganda is one of the 22 countries who participated in the development of the Global Plan and has committed to implement it. 

“We should strive to keep mothers alive so that we do not create more orphans,” said Dr Tlou. “We should also enrol them on antiretroviral therapy as soon as possible so that they can safely continue breastfeeding and ensure that the babies are healthy,” she added.

The Director General of the Uganda AIDS Commission, Dr David Kihumuro Apuuli noted that 150 000 children below 15 years in Uganda are HIV positive, with only 24 000 accessing HIV treatment out of 98 000 who need it. Dr Apuuli also noted that adults, who should be an example to the youths, are the ones contributing to over 50% of new infections mostly because of multiple concurrent partnerships.

The First Lady called on government leaders to ‘re-energize their efforts in HIV prevention. “I think prevention campaigns relaxed and people forgot that HIV is still with us. We need to continue drumming HIV prevention messages, especially regarding the elimination of new HIV infections among children, so that people wake up,” said Ms Museveni. “I have been speaking to the president to talk about HIV. He used to and it worked.”

The First Lady Museveni is the founder of the Uganda Women’s Initiative to Save Orphans, and is the patron for the National Youths Forum plus several youth initiatives in HIV and sexual reproductive health.

Ms Museveni who recognized UNAIDS’ work in Uganda, committed to lead the AIDS response. “My traditional area of work focused on young people. But now I’m scattered. It has really distracted me from my calling but I know we really have a challenge. I’m willing to come back on board,” she said.

During her visit, Dr Tlou was also met with the Minister of Health Dr Christine Andoa, Apuuli, and the head of the AIDS Control Programme in the Ministry Of Health Dr Zainab Akol.

Credit: UNAIDS

The fertile northern region of Uganda was known for many years as one of the granaries of the country, consistently producing surpluses for local and international food markets. But two decades of civil conflict between the Uganda People’s Defense Forces (UPDF) and the Lord’s Resistance Army (LRA) have left the Acholi and Lango sub-regions destitute.

Between 1986 and 2006 an estimated 1.8 million people fled from their villages to the shelter of temporary camps. In Kitgum, Gulu, Pader and Amuru districts an estimated 95% of the population lived in such camps.

The war caused significant setbacks in education, healthcare, food production and infrastructure. It also increased vulnerability, particularly amongst girls and women, as well as gaps in HIV service provision to the internally displaced persons (IDPs).

"They have lost almost everything, their assets, their livelihoods. They have lost their skills. You know, they were used to farming and staying in the camps meant that a whole generation lost out on those skills”, says Winifred Nalyongo, a livelihoods specialist with the United Nations Food and Agriculture Organisation (FAO).

In 2006, internally displaced persons began returning to or near their places of origins following the singing of a Cessation of Hostilities Agreement between the Government of Uganda and the LRA. The UN refugee agency (UNHCR) estimated that more than 70 per cent of all internally displaced persons had returned home or in transition camps in January 2009.

HIV and gender-based violence in early recovery settings

 It is in this early recovery setting that FAO has been working to re-establish the livelihoods of the communities impacted by the conflict through the Farmer Field and Life Schools (FFLS) and Junior Farmer Field and Life Schools (JFFLS) programmes. These involve a group learning process whereby women and men farmers learn valuable agricultural and life skills that allow them to improve their livelihoods and reduce their vulnerability to food insecurity, HIV and gender-based violence, among others.

Conflict and displacement are known to be factors in heightening exposure to HIV. In the Northern Ugandan IDP camps, alcoholism and sexual violence are widespread. FAO representatives indicate that forced in a situation of idleness and unable to feed their families men may become frustrated and turn to alcohol, thus exacerbating existing gender inequalities, making women and children more vulnerable to HIV.

Credit: UNAIDS

The UNAIDS/UNHCR policy brief on HIV and refugees mentions that, as refugees struggle to meet their basic needs such as food, water and shelter, women and girls are often forced to exchange sexual services for money, food or protec­tion. Children living without parental support, wheth­er due to separation from or death of family members, are also particularly vulnerable to sexual and physical violence and exploitation.

A 2005 UNICEF study in one of Northern Uganda’s largest IDP camps found that six out of ten women were physically and sexually assaulted by men.

According to a 2004-2005 Ministry of Health survey, HIV prevalence in the war-affected areas of Northern Uganda is at 8.3% compared to the national average of 6.4%.

Reducing vulnerability

FAO’s Farmer Field and Life Schools place strong emphasis on food security and self-reliance as a means to reduce vulnerability to HIV and gender-based violence. They emphasize farming as a business, encouraging members to generate money from their crops, but also teach valuable life skills such as gender sensitivity, child protection, hygiene, nutrition and HIV awareness. 

People living with HIV are encouraged to join the FFLS where they receive nutrition training, an important component in HIV positive living. They can also learn how to farm less labour intensive crops such as okra or vegetable gardens.

Learning new skills early on

In Dubaju village, FAO’s Junior Farmer Field and Life Schools help orphans and vulnerable children to become more self-sufficient and improve their food security. They also learn about staying healthy and protecting themselves from HIV through classroom-based discussions. For example, children learn how to protect crops from pests or treat diseased crops and draw parallels with how they can take care of their bodies and prevent themselves from becoming infected with HIV.

A version of this story first appeared at www.unfpa.org 

The UNFPA-sponsored football tournament offered a way to get the attention of young people in northern Uganda. Photo: Stijn Aelbers/UNFPA Uganda

Although hostilities in northern Uganda ceased in 2006, the lives of young people, formerly targets for abduction by the Lord’s Resistance Army, have not been easy. During the conflict, which lasted more than 20 years, many children spent their early years confined to camps for displaced persons, while others were subjected to trauma, brutality and suffering as child soldiers.

Prolonged instability also took a toll on health and social support systems: reproductive health indicators in the sub-region are among the lowest in the country, and gender-based violence is common.

While the majority of youth—who comprise 56 % of Uganda’s population—live in poverty with few educational or employment opportunities, football is one thing that they can get excited about and that allows them to forget about their troubles. Florence, age 23, from a squad in Gulu District said, “If we come to play football we forget our problems at home. It is like stress management.”

At the Acholi Football Tournament, which took place in five districts, and was supported by UNFPA, the United Nations Population Fund, the goal was to do more than more than help young people relax. It also aimed to reduce teenage pregnancy and gender-based violence, two of the most serious problems in the area.

Referees, coaches, and team captains attended training sessions on the issues, and then became a resource for information, discussion, and guidance. Subsequent dialogue sessions reached some 1,200 players.

Top local officials awarded the winning teams with uniforms that read, “Say no to GBV (gender-based violence) and teenage pregnancy.” Health care workers were also on hand to answer questions and provide health counseling. Over the course of two days, some 10,000 condoms, most supplied by UNFPA, were distributed by health workers and peer counsellors as well as representatives of the Boda Boda Association, which employs many young men as motorcycle taxis drivers.

More than 800 individuals, mostly young men, took advantage of the free voluntary testing and counselling that was offered to allow them to check their HIV status.

Women were also on the pitch, although many are less experienced than their male counterparts, spectators say the buzz of the women’s matches created were a demonstration of the growing popularity and re-thinking of gender roles

A player from the Lalogi team said she has encountered negative attitudes. (See how these are addressed in a new electronic football game.) However, 21-year-old Rose said her husband was supportive: “He is happy that I play. I think he is here watching today,” she shouted over her shoulder as she ran onto the pitch for kick-off.           

UNAIDS Executive Director Michel Sidibé and Prof. Jeffrey Sachs, Director of the Earth Institute, signing the agreement. 21st September, New York.
Credit: UNAIDS/B.Hamilton

UNAIDS and the Millennium Villages Project signed an agreement in New York to strengthen efforts to eliminate mother-to-child transmission of HIV in Africa. The aim of the partnership is to help local governments create “Mother to child transmission-free zones” in 14 ‘Millennium Villages’ across ten African countries.

The Millennium Villages Project, a partnership between The Earth Institute at Columbia University, Millennium Promise, and UNDP, seeks to end poverty by working in rural areas throughout Africa. The new initiative will use the existing infrastructure, human capacity and technical resources in the villages, to help rapidly expand family- and community-centered heath services with focus on stopping new HIV infections among children.

UNAIDS Executive Director Michel Sidibé and Prof. Jeffrey Sachs, Director of the Earth Institute, signed the agreement in the presence of business and African leaders. The ceremony was held under the auspices of President Yoweri Museveni of Uganda and President Abdoulaye Wade of Senegal.

“I salute this partnership to help protect mothers and their children from HIV. This initiative will mobilize resources and generate political will to save young lives, leading to a generation of African children born free of HIV,” said President Wade.

(L to R): President Abdoulaye Wade of Senegal, UNAIDS Executive Director Michel Sidibé, Prof. Jeffrey Sachs, Director of the Earth Institute and President Yoweri Museveni of Uganda.
Credit: UNAIDS/B.Hamilton

Also speaking at the ceremony were Dr Lydia Mungherera, a Ugandan HIV prevention activist representing the organizations HIV+ and TASO. The Executive Director of UNICEF, Ms Ann M. Veneman, the Minister of State of Mali, Mr. Abou Sow; the South African Minister of Health Dr. Aaron Motsoaledi; and Ambassador Eric Goosby, MD, the United States Global AIDS Coordinator participated in a panel discussion at the event.

Each day 1,200 children under the age of 15 are infected with HIV; 90% of these infections occur in sub-Saharan Africa. According to Mr. Sidibe, “In all of Western Europe there were fewer than 100 mother-to-child transmissions (MTCT) in 2007, whereas in sub-Saharan Africa, there were more than 370,000.”

The top priorities outlined in the memorandum include measures to ensure that women of child bearing age avoid getting infected, those that are infected avoid unwanted pregnancy; increase access to antenatal care services; HIV testing and counselling to expectant mothers; and expanded access to HIV prevention and treatment services for children.

The agreement will bring together the Millennium Village Project’s multi-sectoral and science-based development and primary healthcare strategy with UNAIDS’ expertise in community and family-centred prevention strategies in order to create ‘MTCT-free zones’, whose progress will be monitored by both entities.

Executive Director of UNICEF, Ms Ann M. Veneman, South African Minister of Health, Dr. Aaron Motsoaledi, and UNAIDS Executive Director Michel Sidibé.
Credit: UNAIDS/B.Hamilton

“We hope that the creation of ‘MTCT-free zones’ in the Millennium Villages will serve as a model that can be used throughout Africa whereby communities are engaged, men and young people are active partners, and children are born free from HIV,” Mr Sidibé said.
In 2007, there were 2 million children under 15 years living with HIV, up from 1.6 million in 2001 and less than 15% in need of treatment were getting it. In sub-Saharan Africa, only a third of pregnant HIV-positive women received the antiretroviral treatment (ART) to prevent transmitting the infection to their infants, compared with nearly 100% in Western Europe.

Operating in 14 sites in 10 sub-Saharan African countries, the Millennium Villages project has been working with local governments to introduce a model primary health system which will cover approximately 500,000 people.

The Villages work on a model primary health system and include education, nutrition and economic development. The primary health systems include; free services at the point of care; trained professional community health workers; a network of adequately staffed primary clinics; access to a mobile communication network and emergency transport services to facilitate referrals; and a local referral hospital to support second-tier care. The system houses a monitoring and evaluation platform that can readily assess the adequacy, uptake and impact of HIV testing and counselling and family centered HIV prevention services.

Vincent was one of the 3,316 DART participants and is also one of the main characters of The DART Story, a newly launched documentary film. Credit: Medical Research Council

Having 12 children and a very old mother to support, Vincent, middle-aged Ugandan single father living with HIV, knows that his death would spell disaster for the whole family. “If I had died, where would these people go?” said VincentN perched on a stool with his legs outstretched

Fortunately, Vincent has survived. He said it is DART that has saved his life. DART, the Development of Antiretroviral therapy in Africa, is the largest HIV treatment trial ever carried out on the world’s second most-populous continent.

The DART trial has recently reached a remarkable finding in HIV treatment: that taking HIV treatment does not have to be accompanied by regular laboratory tests, at least for the first two years.

James Hakim, professor of the University of Zimbabwe Medical School and co-principal investigator of DART, said the health economists in the DART team who have analyzed the trial data have concluded that a third more people could be successfully treated for HIV in Africa if expensive lab tests weren’t used routinely. “The challenge now is for policy-makers to widen availability of ART,” said the professor.

Before, it was believed that a person on HIV treatment should have regular tests, including CD 4 cell counts, a measure of how well the body’s immune system, which is damaged by HIV, is working.

The DART results show that 87% of people receiving HIV treatment without routine blood test monitoring were still alive and well after five years, only 3 percentage points less than in the group that had routine blood test monitoring. This finding suggests that many more people living with HIV in Africa could receive treatment for the same amount of money that is currently spent on routine lab tests used to monitor the effects of antiretroviral therapy.

It could also lead to antiretroviral therapy being delivered safely and effectively by trained and supervised health workers in remote communities where routine laboratory tests are not available due to high costs or poor resources.

Professor Peter Mugyenyi of the Joint Clinical Research Centre in Uganda, also a DART co-principal investigator, agreed that governments now have evidence that expensive blood tests aren’t needed routinely for HIV treatment to be successful and safe. “It also means that treatment could be delivered locally as long as health care workers have the right training, support and supervision,” said Peter, “This could make a huge difference to people who live in remote areas that are many days walk from the nearest hospital or laboratory.”

According to UNAIDS estimates HIV treatment only reached a third of the 9.7 million people in need at the end of 2007. In Africa alone, around 4 million people urgently need antiretroviral therapy but the resources are limited.

The DART Story

Aiming at finding a safe, simple and more economical way of carrying out HIV treatment, the DART trial began six years ago when treatment for people living with HIV was just starting to become more widely available in Uganda and Zimbabwe.

Vincent was one of the 3,316 DART participants that had severe or advanced HIV infection while not having previously had any antiretroviral therapy. He is also one of the main characters of The DART Story, a newly launched documentary film narrated by Annie Katuregye. The narrator herself, whose husband died of AIDS-related illnesses seventeen years ago at the age of 34, joined the DART trial in Uganda in 2003.

Annie Katuregye joined the DART trial in Uganda in 2003 and is the narrator of the film The DART Story. Credit: Medical Research Council

Like all the other DART participants, Annie and Vincent
randomly allocated to one of two groups. People in the first group received antiretroviral therapy and their doctor was given the results of blood tests done every three months to check for drug side-effects and measure their CD4 cell count. People in the second group had the same antiretroviral treatment and the same blood tests done, but their doctors did not see CD4 count results and only saw the results of safety tests if they were seriously abnormal. People in both groups received free medical care and free diagnostic tests for episodes of illness throughout the trial.

Besides the only 3-percentage-point difference in survival, 78% of the people who survived in the first group had developed no new AIDS-related illnesses, compared with 72% in the second group. No difference in the occurrence of side effects caused by antiretroviral treatment was found between the two groups.

Moreover, irrespective of group, the survival rate in the DART trial is amongst the best reported from any trial, antiretroviral therapy programme or study in Africa. Historical comparisons, based on data from follow-up of similar patients in Uganda who did not have access to antiretroviral treatment make it clear that few of the DART participants would have been alive after five years without treatment.

Sponsored and funded by the UK Medical Research Council, the DART trial was collaboratively carried out by scientists and health care workers from Africa and the United Kingdom. With an original purpose of finding out whether the lab-based strategies used to deliver antiretroviral therapy to people with HIV infection in resource rich countries were essential in Africa, DART has hit its target.

Credit: The World Bank

Transport corridors in sub-Saharan Africa, as elsewhere, enable movement of people and goods, increasing economic activity and spreading wealth. But they also facilitate the spread of HIV. In response, the Africa Transport Sector of the World Bank has published a practical new booklet on how to implement HIV prevention activities as part of road construction projects.

The booklet, The route to good living: An overview of roles and responsibilities for HIV prevention strategies in transport sector projects, shows just why this matters. Numerous studies find relatively high HIV prevalence in this sector, especially among long-distance truck drivers. Several have shown that truckers in Kenya, Rwanda and Uganda were more than twice as likely to be living with HIV as the general population.

Many transport workers spend weeks or months away from their families, and often have multiple sexual partners, which can facilitate the spread of HIV. In Nigeria, for example, one study documented each driver having more than six sexual partners at various stops along his route. This means that people living in and around major transport hubs also have increased vulnerability. In Kenya, along the Trans-Africa Highway, high risk behaviour has been reported among boys and girls visiting truck stops and incidence of sexually transmitted infections was documented in 50 percent of the girls and 30 percent of the boys.

Credit: The World Bank

The route to good living highlights practical steps that can be taken to prevent new infections among transport workers and roadside communities, with special emphasis on road construction works. It summarizes ‘do and don’ts’ for transport ministries, World Bank teams, contractors, consultants, country project units, donors and NGOs when designing and implementing such projects. An overview of the roles and responsibilities of each set of actors within the project cycle is provided: from identification to preparation to implementation and, finally, completion. An HIV prevention strategy should be not an afterthought but an integral part of the undertaking.

The booklet is the latest addition to the information and tools available on the World Bank Africa Transport Sector's AIDS web site.

Promoting HIV prevention in the transport sector is a key component of the overall AIDS response
Credit: The World Bank

It is the result of the sub-Saharan Africa Transport Policy Programme (SSATP) encouraging discussions and collaboration among a range of partners, including the Bank, to provide concrete support in dealing with HIV. The SSATP, a unique partnership of 35 countries, eight regional economic communities, three African institutions (including the African Union/New Partnership for Africa's Development) and international partners recognizes the importance of the transport sector in achieving its goals of reducing poverty and promoting economic growth and regional integration.

In order for the transport sector to fulfill its pivotal role, the potentially devastating effects of the AIDS epidemic must be effectively challenged. The route to good living provides a concrete guide to help achieve this goal

The aim of the campaign, also known as
the “faces” campaign, was to remove the
stigma associated with HIV by showing
pictures together with testimonies of
Ugandans who live positively with HIV.
Credits: UNAIDS/J.Ewen

HIV has often been associated with behaviours that may be considered socially or morally unacceptable by many people such as sex work, sex outside marriage or with multiple partners, sex between men and injecting drugs. This single fact, fueled by high levels of ignorance, denial, fear and intolerance, has widely stigmatized HIV infection.

In order to reverse the preconceptions about people living with HIV and at the same time raise awareness around different AIDS-related issues, UNAIDS in partnership with the Uganda Red Cross, developed a campaign entitled “The Truth is Not Written on Your Face”.

The aim of the campaign, also known as the “faces” campaign, was to remove the stigma associated with HIV by showing pictures together with testimonies of Ugandans who live positively with HIV. At the same time, the campaign highlighted that the HIV status of a person it is not shown on their face. As a result, it reinforced the need for effective and efficient prevention tools and behaviours, such as limiting the number of sexual partners and the consistent use of condoms, to prevent the transmission of HIV.

“Despite a long history with the epidemic, there is often still an assumption in Uganda that it is ‘someone else’ who has HIV, or there are strong moral undertones which suggest it must be sex workers, etc. who are affected by it”, said Malayah Harper, UNAIDS Country Coordinator. This has lead to complacency and much of the positive behaviour change from the 1990s is being eroded. “The ‘faces’ campaign proved these assumptions wrong while at the same time highlighting the importance of preventing HIV”, she added.

Experience teaches that a strong movement
of people living with HIV that affords mutual
support and a voice at local and national
levels is particularly effective in tackling
stigma. Credits: UNAIDS/J.Ewen

Stigma and discrimination are violations of human rights and undermine public health efforts to tackle the HIV epidemic. People living with HIV are frequently subject to discrimination. Many have been thrown out of jobs and homes, rejected by family and friends, and some have been killed because of their HIV status.

Together, stigma and discrimination constitute one of the greatest barriers to dealing effectively with the epidemic. They can discourage governments from acknowledging or taking timely action against AIDS. They can deter individuals from finding out about their HIV status and they inhibit those who know they are infected from sharing their diagnosis and from seeking treatment and care for themselves.

Experience teaches that a strong movement of people living with HIV that affords mutual support and a voice at local and national levels is particularly effective in tackling stigma.

His Excellency the President of the
Republic of Uganda, Yoweri Kaguta
Museveni (left) greeting UNAIDS Executive
Director Dr Peter Piot (center) and Dr
Michel Kazatchkine, Executive Director of
the Global Fund (right).
Photo credit: UNAIDS/M.Mugisha

What is an HIV implementer? Depending on whom you ask at the 2008 Implementers’ Meeting in Kampala, Uganda, which starts today, June 3, you may get varying responses. But one common thread is likely to run throughout – the drive to share lessons learned and best practices on how HIV services are delivered to people affected by the AIDS epidemic.

Over the next five-days, some 1,700 participants – from governments, NGOs, international organizations, including UNAIDS and other UN partners, the private sector and groups of people living with HIV – will exchange ideas and give examples of efforts to overcome obstacles in implementation of HIV treatment, prevention, care and support.

A co-sponsor of the meeting, UNAIDS, together with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Fund, UNICEF, the World Bank, WHO, and the Global Network of People Living with HIV (GNP+), will share examples of its work, and that of its cosponsors and other partners, in supporting countries in HIV programme implementation.

UNAIDS’ senior colleagues and thematic experts will participate in several events, from plenaries and sessions to satellites, focused on: addressing HIV prevention priorities and scaling up local prevention initiatives; HIV coordination and harmonization among implementation partners; communication for social change, particularly on norms about AIDS; and the role of civil society in strengthening the HIV response.

UNAIDS Executive Director Dr Peter Piot
addressing participants during the opening
ceremony of the 2008 Implementers'
meeting. 03 June Kampala, Uganda.
Photo credit: UNAIDS/M.Mugisha

UNAIDS Executive Director Dr Peter Piot will give an address at the opening ceremony together with His Excellency the President of the Republic of Uganda, Yoweri Kaguta Museveni, Ambassador Mark Dybul, the U.S. Global AIDS Coordinator/PEPFAR, Dr Michel Kazatchkine, Executive Director of the Global Fund, and Dr. Kevin Moody, CEO of GNP+.

This is the second HIV Implementers’ Meeting, with the first taking place in 2007 in Kigali, Rwanda.

The HIV/AIDS Implementers' Meeting will take place June 3-7, 2008, in Kampala, Uganda. This year's theme is "Scaling Up Through Partnerships: Overcoming Obstacles to Implementation." The meeting theme recognizes the rapid expansion of HIV programmes worldwide.

Together, implementers will exchange best practices and lessons learned during the implementation of AIDS programmes, with a focus on building the capacity of local prevention, treatment, and care programs; maintaining quality control; and coordination among partners.
Visit the official web site

The Global Health Workforce Alliance (GHWA) held the first ever Global Forum on Human Resources for Health in Kampala, Uganda from March 2-7, 2008. The GHWA, hosted and administered by the World Health Organization (WHO), has been created to identify and implement solutions to the health workforce crisis.

UNAIDS Executive Director  Dr Peter Piot gave the following plenary speech on "Partnerships and linking for action".

Download speech as PDF

Plenary speech by Dr Peter Piot, UNAIDS Executive Director

Kampala, Uganda 5 March, 2008.

UNAIDS Executive Director Dr Peter Piot addressing plenary at the Global Forum on Human resources for Health, in Munyonyo, Kampala, 5 March 2008
Credit: UNAIDS/C. Opolot

Thank you Sigrun – and thank you for inviting me here today.

I came to Kampala for three reasons. Firstly, this Forum is one of the most important meetings in public health to take place this year. We are starting to build a coalition to address one of the greatest obstacles to health.

Secondly, I am here to pledge the firm support of UNAIDS to this initiative.

Thirdly, it is time to de-polarize this debate. Whether we invest in the AIDS response or in strengthening health systems. It is not a question of one or the other. Even when it comes to AIDS, it is not simply a question of strengthening health services but also community mobilization. We must not forget about people or health outcomes

The issue of human resources for health is complex. But we all know it’s not a new one. I lived it myself in the mid-70s in rural Zaire. But nor is it limited to Africa. Last week I was in India where this is an enormous maldistribution of human resources for health.

The shortage results from decades of under-investment by governments, donors and international agencies. It has been intensified by globalization, but globalization may also bring some of the solutions. Responsibility for the current situation is shared – between donors, national governments, NGOs, research organization and international organizations among others. We therefore have a shared duty to address it. That’s why this afternoon’s panel, with its focus on partnership, is so vital.

The debate we are having now is long overdue. And a major reason for its happening at all is AIDS!

One of the peculiar characteristics of AIDS is that it exposes injustices. AIDS - more than any other issue - has thrown a spotlight on the urgent need to strengthen human resources for health, for three reasons.  Firstly, AIDS represents a significant burden on health systems. In some countries, half of all hospital beds are occupied with patients with AIDS-related illnesses. Secondly, to expand ART, and to make ART sustainable, we need strong health systems. Thirdly, being a health worker does not protect you from becoming infected. Botswana, for example lost approximately 17% of its healthcare workforce to AIDS between 1999 and 2005.

There have been good examples of how AIDS investment has helped overcome the human resources for health crisis. I remember well going to Malawi in 2004 with Sir Suma Chakrabarti, then Permanent Secretary of the UK’s DFID. AIDS had brought the health workforce literally to its knees. There was no way it could cope. It was an emergency that required exceptional measures. DFID and other donors financing the sector agreed to fund a groundbreaking initiative, the Emergency Human Resources Programme, to top up salaries for nurses and other health care workers as an incentive not to leave the country. This was totally novel: donors usually resist paying salaries, but in this case we managed to break the taboo.  I’m glad to say that the Global Fund to Fight AIDS, Tuberculosis and Malaria is now supporting this programme.

This is just one example of another characteristic of AIDS: it forces us to do things differently. WHO’s “Treat, train, retain” initiative for health-workers with HIV is another new and pragmatic approach. I don’t know of any other programme that starts by addressing the health of the workers involved. It provides wins all round – to the health workers themselves, to the people who need their services, and to the health sector as a whole. So, when we are talking about strengthening health systems, let’s first make sure that people stay alive! But good partnerships require more than processes. There are too many partnerships that are not enough about results and outcomes.

AIDS funding and programming enhanced essential infrastructure for health facilities. Where HIV services have been integrated into existing service delivery sites, AIDS money helped renovate health facilities, upgraded clinics and laboratories and provided training opportunities for health care workers.

AIDS has also helped promote “task shifting”, an old concept/idea in public health – moving responsibility for certain tasks to other health-workers and community members to free up doctors and nurses to take care of other patients and to deliver other essential health services. Here in Uganda, there is an increasing trend for people living with HIV to take on tasks such as counseling for testing, adherence support, treatment literacy and to produce good quality outcomes.  In Kenya, several organizations have been implementing prevention, treatment literacy and home based care programmes, which are led by people living with HIV at the community level.  Women Fighting AIDS in Kenya, supported by UNICEF in Kisumu and Port Reitz General Hospitals, trained PLWHAs who were then used as PMTCT champions to provide counseling to ante-natal mothers and their partners.

We also see, particularly here in Africa that faith-based organizations play a major in the fight against AIDS providing vital HIV care and treatment services. For example, Christian hospitals and health centers are providing about 40% of HIV care and treatment services in Lesotho and almost a third in Zambia. In other countries, the formal and informal private sector is also very important.

AIDS has brought in new resources, to benefit not only HIV programmes but health systems more widely. Take for example the Haitian “accompagnateurs” – community workers who have been brought into the health workforce through the AIDS programmme. Or in Rwanda, HIV treatment and care was integrated with regular health services, resulting in better coverage for maternal and child health according to a study by Family Health International (FHI) presented at last year’s PEPFAR Implementers Meeting in Kigali.  Les Mutuelles de Santé is another example of financing scheme to mobilize resources for health services.

So I have serious issues with the current wave of statements like “There’s too much money going to AIDS” or “Donors should prioritize health system strengthening”. They completely ignore the growing body of evidence that AIDS expenditure strengthens the health sector and contributes to broader development programmes, besides the fact that AIDS programmes are having measurable results, saving millions of lives. Indeed, AIDS has been an advocate for health systems strengthening.

They also seem to assume that dealing with HIV is mostly about treatment. It isn’t! For every one person we put on antiretroviral therapy, another four or five become infected with HIV. If we don’t radically enhance HIV prevention, demands for treatment will just keep on growing, placing an even greater burden on health systems in the future.

And prevention – except for PMTCT – is far more than a health issue. Prevention is a community based action. Effective HIV prevention derives from a range of multi-sectoral interventions (governments, nongovernmental organizations, faith-based organizations, the education sector, media, the private sector and trade unions and people living with HIV).

A lot of the recent surge of funding started as a direct consequence of the AIDS epidemic. AIDS advocacy did not only succeed in mobilizing money, but it also highlighted the profound disparities in health services that separated the developing countries from the developed world. It is however true that  there are examples where AIDS related activities and AIDS funding are taking away health workers from other tasks. AIDS funding created new and more interesting job opportunities for doctors and nurses with NGOs and foreign aid agencies and thus can be a drain on the public sector. We have seen it happening in Malawi and in Zambia where focus of disease programmes shifted to HIV. However, and certainly in the heavily affected countries, the AIDS burdens for health services is also a reality. We need to find common solutions and ways of working together.

This brings me to my next point. AIDS has taught us about the critical value of partnerships. Tackling AIDS is one of the toughest challenges the world faces today. Like dealing with climate change, it’s tremendously complex - way beyond the capacity of any single sector or institution. It’s one of those issues that jolts us out of our comfort zone, and forces us to create new alliances with a variety of constituencies – across sectors and at state and non-state level.

UNAIDS itself is a joint programme. We are working with a wide range of constituencies – government, scientists, business, labour, and the media. One of the most important partnerships of all has been our relationship with civil society. It was the activists who kick-started the AIDS movement. Without them, we wouldn’t have achieved anything like the progress we’ve made.  It’s thanks to these partnerships that we have been able to mobilize political momentum around AIDS, to leverage funding to $10 billion per year.

In the twelve years since UNAIDS was created, we’ve learnt a lot about partnerships. We’ve seen the advantages of being able to convene diverse actors from public, private, and non profit sectors – all with different strengths. They have the potential to achieve spectacular results – way beyond anything they could hope to achieve on their own.

But coordination and accountability are still important. That’s why UNAIDS established the Three Ones principles, as a framework for partnerships on AIDS.  Just to remind you, these are: one agreed national action framework, one national coordinating authority and one agreed monitoring and evaluation system.

The lessons we’ve learnt through implementing the Three Ones are salutary – and very relevant to the aims of this Alliance. The Agenda for Action is right to highlight the need for “national responses to be guided by a national leadership that convenes all actors around one agreed national effort”, and to point to the importance of accountability. The challenge is to engage serious commitment at all levels – in-country, in donor capitals and international organization headquarters. This requires time and effort. But it will be time and effort well spent.

I began today by saying that addressing the shortage of human resources for health was a joint responsibility. It is something that no institution can tackle alone. It is complex, cross-sectoral and long-term. And, like AIDS, it is not a quick-fix problem and there is no one solution that fits all. This may be a major reason why so little has been done before. Another reason may be the fact that the current crisis of human resources for health is also a highly political issue and therefore any possible solutions need to have full political support. But coming together in this alliance is in itself a tremendous step forward. There is a lot at stake; therefore our response must address the emergencies of today and to draw up longer-term plans for the future.

The Agenda for Action offers a comprehensive menu of activities, but I want to suggest some very concrete actions where we can all work and benefit together.

The first is that we must build partnerships far beyond the public sector. Partnerships are crucial for the success of any solution. We must also look at the critical role of non-state actors in the provision of services and their role in the training of human resources. In many countries, 40 to 60% of health services are delivered by the private sector. We have to establish more private/public partnerships with greater engagement of the private sector, beyond workplace programmes. Equally, in many countries, particularly here in Africa, many clinics and health centers are run by faith-based organization. We need to bring them all into the policy dialogue of heath services provision.

The second is to engage the full participation of civil society. As I mentioned earlier, civil society has been at the heart of the AIDS response from the very beginning. And its presence there has been vital. Not only does civil society activism mobilize action, but community members are an invaluable source of knowledge about what works and about how to reach people. We must listen and learn from them, and at the same time invest in building their capacity to deliver alongside that of public sector.

The third is for health ministries to make improving human resource management a priority. This is implicit in the Agenda for Action. But I think we need to spell it out more clearly. Today’s crisis has come about for two reasons. Lack of investment and lack of management. There’s a lot to do, but one of the first steps should be to establish incentives for performance and raise health-worker morale.

Fourth, we need to work together to question and challenge our concepts of fiscal space, predict medium term expenditure frameworks and the suitability of salary supplementation. We have to involve ministries of finance in the discussions of solutions. We should also work together with the World Bank and IMF on these constraints.

There is also the need to address the issue of public sector pay and work conditions. To address issues such as poor infrastructure, lack of equipment and drugs, long hours and heavy workloads and lack of career development in addition to poor remuneration. This needs to be combined with putting human resources for health on the agenda of civil service reform and donor willingness support and invest in supplementing health workers’ salaries and training. Donors and countries should consider the lessons learnt from the Malawi experience.

These issues are at the heart of any assessment of countries’ ability to scale up the response and the achievements of the MDGs. They are relevant for all of the health MDGs and need close examination and a common assessment of the risks and opportunities.

Press conference at the close of Global Forum on Human resources for Health, Kampala 5 March, 2008. (From left): Chair of the board Global Health Workforce Alliance, Dr Lincoln Chen; UNAIDS Executive Director, Dr Peter Piot and Representative of Women Living with HIV in Uganda, Beatrice Were.
Credit: UNAIDS/C. Opolot

We can be very ambitious, but need clear targets, goals and a partnership, where put the institutional interest aside. Fight for common good and common goal. We need to re-set the rules and to put into practice what has been discussed globally at country level. Every research programme must include overhead (/indirect costs for strengthening capacity. This is starting to be done among largest investors in heath (GAVI; GF; PEPFAR etc).

We also need to find a practical way to compensate low and middle-income countries that are losing their skilled staff in whose education they have invested.

The final – and most relevant for this afternoon’s session - is to be serious about applying the Three Ones principles, for all parties to come together and align around a single strategic plan for strengthening human resources for health that focuses clearly not just on process but on results.  One National AIDS Coordination authority and one agreed country-level monitoring and evaluation system. Such a framework has been invaluable for a well coordinated AIDS response. We are not there yet, but we have made progress.

If we make progress on action plan, it will be because have worked together. It is through diversity we will success. Pragmatic approach is needed, one step at a time, and strong leadership which will hold us together. I believe we have that leadership.

That may sound ambitious. But if we can come back in a year’s time and say we’ve made progress in these four areas, the world’s health workforce will look a lot more robust than it does today – and its population will be fitter as a result.

We have to act now and “to work together to ensure access to a motivated, skilled, and supported health worker by every person in every village everywhere.” Dr. LEE Jong-wook

Thank you.