Final declaration of commitment on HIV/AIDS adopted — disagreement over strengths and weaknesses persist

Late Friday evening the United Nations (UN) adopted a Political Declaration of Commitment on HIV/AIDS that, after days of intense round-the-clock lobbying by HIV/AIDS advocacy groups, contained substantially stronger language than the earlier versions of the document. However, while the President of the General Assembly, Jan Eliasson, praised the declaration and credited civil society for its unprecedented part in the negotiations, one large coalition of activists put out a statement denouncing the document, saying that “UN Member States refused to commit to hard targets on funding, prevention, care and treatment.”

The Political Declaration drafted in 2001, which can be downloaded here, was an eloquently worded statement that committed the world’s nations to take concrete action to halt and reverse the spread and impact of the HIV/AIDS epidemic. The first such commitment that the UN had made on HIV/AIDS, it paved the way for the establishment of the Global Fund for HIV/AIDS, Tuberculosis and Malaria, and ushered in a new era where access to treatment and care became a real possibility (although far from being universally implemented) in even the most resource-constrained settings.

Civil society came to the 2006 UN high level meeting on HIV/AIDS with the expectation that they could build upon the earlier declaration and encourage delegations to develop an even more progressive blueprint detailing, and committing countries to take, actions required to provide universal access to prevention, treatment and HIV and AIDS care. They had good cause to hope for this, since it was what had been promised by the leaders of the G8 industrial nations at the summit at Gleneagles last July, and earlier this year in Abuja, African leaders had also reached an agreement to push for universal treatment by 2010.

Instead, treatment and prevention advocates found themselves fighting to keep the most conservative country delegations from removing many of the commitments made in 2001 from the new declaration, potentially undermining international support for activities and institutions, such as the Global Fund, which have proven so vital in the fight against AIDS in the developing world.

Some countries wanted to remove all references to human rights, vulnerable groups, generic drugs, or access to condoms, sterile injection equipment and harm reduction efforts related to drug use. In addition, several counties want to strip the document of any reference supporting the empowerment of women — even though it is now well-recognised that the social, political and economic disadvantages faced by women are one of the major drivers of the pandemic.

In the end, lobbying by the activists succeeded in restoring much of what had been deleted from the original declaration, although the language of the new declaration is often more ambiguous and considerably watered down. For example, in the 2001 declaration the term “human rights” is used eleven times, in the new document, human rights are only mentioned once — and only in relation to women, rather than to other vulnerable groups and people living with HIV/AIDS. The original declaration also devoted almost two pages to a discussion on the allocation of resources, which dwindled down to a paragraph or two in the new document.

The UN member states for the most part resisted civil society's call for expanding the declaration of commitment. For example, the activists wanted the specific vulnerable populations most at risk or impacted by HIV/AIDS to be spelling out in the declaration, but aside from one new reference to injecting drug users (IDUs), the document makes little progress in this area. Also, although the declaration does mention access to sterile injecting equipment and harm reduction (both also in the original declaration), it does not call specifically for access to substitution drug treatment (such as methadone), which is not provided in Russia and puts IDUs at continued risk.

“Failing to fully address the needs of these groups, and particularly to counter stigma and discrimination by decriminalising drug use and sexual behaviours, will render them more invisible and ultimately lead to even higher rates of HIV/AIDS” said Raminta Stuikyte of the Central and Eastern European Harm Reduction Network.

In a press conference held several hours prior to the final adoption of the declaration, President Eliasson commented on the advocates frustration. “Vulnerable groups are in there. They are different in different countries. We all know who they are. This was a negotiation. That’s where we ended up.”

“But,” according to the Mr Eliasson, “not least because of international civil society and searching our own minds and governments, I think we came to a substantial and forward looking text... there are always things that you want to add or do more ambitiously, but if you look at this text we have a reaffirmation of everything that was said in 2001 [in paragraph 18] and the need to ensure that everything in it is achieved, and that’s the bottom line.”

“I know that none of you got all that you wanted in this declaration,” he said at the conclusion of the meeting. “That is the nature of negotiations. But I know that thanks in part to the influence brought to bear by civil society, the draft got stronger not weaker in the final hours.”

One of the areas where the activists agree that declaration became much stronger was in its strong recognition of the feminisation of HIV/AIDS (the fact that women and girls are bearing the brunt of the pandemic). “Commitments were made to ensure that women can exercise their right to have control over their sexuality and to the goal of achieving universal access to reproductive health by 2015,” according to the civil society press release. Nevertheless, they noted that governments including Syria, Egypt, Yemen, Iraq, Pakistan and Gabon fought efforts to empower girls and provide them with comprehensive sexuality education.

The activists had also wanted the declaration to set clear targets for universal access to prevention, care and treatment and for the funding to affect it. Although, the document does make references to the issue, it only commits nation states to “pursue... efforts... towards the goal of universal access.” According to Paul Davis of HealthGAP, "even putting one more patient on treatment is moving towards the goal of universal access. It is not a concrete commitment".

In the press conference on the final declaration, Dr Peter Piot, Executive Director of UNAIDS, agreed with President Eliasson that the final draft was a strong document, but conceded that the lack of concrete targets was disappointing. He said that now the main goal should be to encourage individual countries to set their own ambitious targets — however, this could prove more difficult in some countries than others especially in the absence of moral pressure from, and accountability to, other member nations that the declaration could have provided.

There was also disagreement over the strength of the financial commitments made in the final declaration. Dr Piot characterised the language on funding in the original declaration as being weaker than in the current declaration. Yet the earlier declaration specified that the governments would: “Ensure that the resources provided for the global response to address HIV/AIDS are substantial, sustained and... by 2005, through a series of incremental steps, reach an overall target of annual expenditure on the epidemic of between 7 and 10 billion US dollars in low and middle-income countries.”

However, in the new declaration the member states merely “recognise” that an estimated 20 to 23 billion dollars will be needed per annum by 2010 [actually the amount of 23 billion dollars is required by 2008] to support rapidly scaled-up AIDS responses, and therefore commit to take measures to ensure that new and additional resources are made available from donor countries and also from national budgets and other national sources.”

Technically, the new declaration does not commit countries to provide all of the funds, while the old language left little room for vacillation.

“At this stage in the pandemic, we expected government commitment to close the global funding gap,” said Kieran Daly of the International Council of AIDS Service Organisations. “Instead they have tried to let themselves off the hook.”

In fact, whether the final declaration is in the end strong or weak could be beside the point. What perhaps was the most disheartening is the intense backroom manoeuvring from countries including the United States to weaken the declaration and to avoid making firm financial commitments. This would seem to indicate a decreased commitment on the part of the most affluent funding country. According to Eric Sawyer, a veteran of ACT UP-NY, “Hour after hour, my government fought for its own selfish interests rather than for the lives of millions dying needlessly around the globe.”

As if to prove his point, at the end of the meeting and at the final adoption of the document, the United States, was alone in qualifying its vote, saying that their support of the declaration was based upon its own narrow definitions of the some of the drafted language.

According to the spokesman for the US delegation, “The United States understands that reference to the international conference on populations and development and the phrase “reproductive health” do not create any “rights” and cannot be interpreted to constitute support, endorsement or promotion of abortion. Furthermore, the US understands all references in this document to “responsible sexual behaviour” to denote abstinence and fidelity,” (pointedly leaving out any reference to condoms).

However, while this statement is clearly a concession to the religious right in the US, it may also have been necessary for the US delegation to take this public stance in order to secure any support for the declaration of commitment back home. Like it or not, the religious right wields considerable influence in the US government at the moment, just as the forces of oppression are strong in other countries around the world. (It is telling when the US is siding with countries like Syria and Saudi Arabia on women’s issues). The declaration probably represents the best result that civil society could have achieved under these circumstances.

“We must not allow the best to be the enemy of the good.” said President Eliasson. “...An alternative would be to write something very lofty to which no one paid attention.”

There are limits to what can be achieved in such a forum as the UN at present, without a better chance of changing things back home. The real work, as Dr Piot suggested, must now be on the national front. And that is where the activists must learn to fight more effectively.