Care and support for people living with HIV/AIDS

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National responses to the epidemic: factors that make a differenceCommunity mobilization against HIV/AIDS is taking place successfully all over theworld. The activities carried out in community projects are as diverse as the peoplesand cultures that make up these communities. Some are entirely “home-grown” andself-sufficient, while others have benefited from external advice and funding. Someare based in religious centres, others in medical institutions, and still others in neighbourhoodmeeting places. Many concentrate on public education, others on providingcare, and still others on prevention and other goals.6. Social policy reform to reduce vulnerabilityHIV transmission is associated with specific risk-taking behaviours. These behavioursare influenced by personal and societal factors that determine people’s vulnerabilityto infection. To be effective, risk-reduction programmes must be designed and implementedin synergy with other programmes, which, in the short and long term,increase the capacity and autonomy of those people particularly vulnerable to HIVinfection. Therefore, the question is how to address directly the societal forces whichdetermine, more than anything else, vulnerability to HIV/AIDS. Issues such as genderimbalance and the inability of women to negotiate when, how and with whom theyhave sex is a social policy issue. The chronic and acute poverty of urban householdsthat leads to their eventual breakdown and the migration of children to the street isnot an issue that can be easily addressed at a household or community level alone.Addressing the societal forces which determine vulnerability to HIV requires engagementat the policy level and political will and resources. Effective social policy reformis a long-term agenda, but even small-scale and incremental steps can send importantmessages about political commitment to reducing the vulnerability of individualsand communities to infection.7. Longer-term and sustained responseEven a comprehensive response to HIV/AIDS does not yield immediate results.Measurable impact may take four to five years to develop. Therefore, a long-termapproach must be taken, which involves building societal resistance to HIV.Beginning with the youngest generation, the reinforcement of safer attitudes andbehaviour will gradually fortify a generation against the spread of AIDS, and in timehave a significant impact on incidence.Effective programmes are characterized by focused action and steadily expandingcoverage. To begin with, using existing resources, it makes strategic sense to focuson important vulnerable populations and geographic areas where rapid HIV spreadtakes on the characteristics of an emergency. Planners must nevertheless take intoaccount the need to reach many different populations, including those who willbecome exposed tomorrow: individual risk and vulnerability change over the lifecycle as children mature into adolescence and adulthood.111
Report on the global HIV/AIDS epidemic – June 2000There is also evidence that continued vigilance is critical even when behaviourchange appears to have become established. The use of condoms among a newlysexually active generation of men who have sex with men for example cannot beassumed, just because an older generation changed its behaviour.Gradually, without losing focus, action must expand steadily until complete countrycoverage is achieved.8. Learning from experienceThe last 15 years of HIV prevention and care have led to the development of a richbody of experience and expertise. While it is essential that individual countries“own” their response there is a great deal of evidence that some policies, strategiesand technologies are particularly effective: that which UNAIDS calls “best practice”.Drawing on best practice and adapting it to local circumstances is valuable both atthe outset, and as the response matures. Learning within a national context is alsoimportant.District bureaucracies provide the critical link between local and national activities.The district level is well placed in many countries to analyse, document and disseminatewhat they learn from the local responses. They can then press for, andnegotiate with, the national authorities the changes and reforms needed in key sectorsto sustain local responses. There are multiple examples of good HIV “projects”– successful interventions that have identified the recipe for success in a given environment.They can provide valuable insights to national programmes.Similarly, national programmes are in a strong position to scale up local responsesto the national level by incorporating local lessons into their strategic planning andreform processes. For example, governments can effectively adopt policy changesand programme approaches that have “passed the test” at the local level.Box 21. International support for national responsesDonor assistance to HIV/AIDS has increased substantially over time. In 1998, 14 ofthe largest donors in the OECD Development Assistance Committee providedUS$ 300 million for HIV/AIDS activities. In 1987 – soon after it was first recognizedthat HIV had spread massively in many developing countries – levels of official developmentassistance (ODA) funding to AIDS were only at 20% of the levels seen adecade later. This increase has occurred at the same time that overall ODA contributionsto developing countries have steadily declined.Unfortunately, as spectacular as this increase appears, it has not kept pace with thespread of the epidemic – or even the most basic requirements for HIV programmesof the most-affected countries. During the same period, the number of infections hasrisen from 4 million to over 34 million, a figure that continues to grow given the more–––>112
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Care and support for people living with HIV/AIDS

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