Report of the UNAIDS Leadership Transition Working Group UNAIDS Leadership Transition Working Group

UNAIDS

Chairs Members Program Coordinator Ruth Levine Joanne Csete Danielle Kuczynski Ngaire Woods Siddharth Dube Tim Evans Senior Researcher Jacob Gayle Devi Sridhar Geeta Rao Gupta Jim Kim Michael Merson Lillian Mworeko Nandini Oomman Nana Poku Asia Russell Todd Summers Alan Whiteside Anandi Yuvaraj

Th is report was draft ed by Ruth Levine, Ngaire Woods, Danielle Kuczynski and Devi Sridhar, with the input of working group members. Members of the working group participated in a personal capacity and on a voluntary basis. Th e report refl ects a broad consensus among the members as individuals, though not all members necessarily agree with every word in the report. Th is text does not necessarily represent, and should not be portrayed as representing, the views of any single working group member, the organizations with which the working group members are affi liated, Oxford University, the Global Economic Governance Programme or its funders, the Center for Global Development, or the Center’s funders and board of directors.

Center for Global Development 1776 Massachusetts Avenue, NW Washington, D.C. 20036 Tel: 202 416 0700 Web: www.cgdev.org

Support for this project was generously provided by the Bill & Melinda Gates Foundation as part of the HIV/AIDS Monitor Program of the Center for Global Development

Cover photo: UN Photo/Mark Garten

Editing and typesetting by Communications Development Incorporated, Washington, D.C. Table of contents

Preface iv

Acknowledgments v

Summary 1

About this report 4 Box 1 What is UNAIDS? 4

Evolution of the AIDS epidemic and UNAIDS 7

Continuing an exceptional response: Key roles for UNAIDS 11

Recommendations for the Secretariat’s Executive Director and the Board 14 Figure 1 Organizational structure of UNAIDS in Geneva 22

Moving forward 23

Annex A Working group biographies 24

Annex B Participants in background interviews 30

Annex C Summary of consultations for UNAIDS working group and participants 32

Annex D Methodology 38

Annex E Further reading 40

References 44

UNAIDS: PREPARING FOR THE FUTURE i Preface

When leaders change, so can institutions. At the and bring a diversity of perspectives—from Center for Global Development we have taken those focused on protecting human rights to the opportunity of leadership change at major those engaged in the intricacies of UN reform, global institutions to ask questions about their from epidemiologists concerned about the in- mandates, resources, and governance and to pro- tegrity of health data to civic activists who see pose (or not) changes and reforms. Our series the global response to HIV/AIDS as too slow has included the World Bank (June 2005), the and too limited. Given the breadth of stakehold- InterAmerican Development Bank (January ers involved directly and indirectly in the work 2006), the African Development Bank (August of UNAIDS, members tried hard to recognize 2006), and the Global Fund to Fight AIDS, a range of points of view, both from members of Tuberculosis and Malaria (October 2006). the working group as well as from participants Now, with the departure of Dr. Peter Piot as at three consultations. Executive Director of the Joint United Nations I am hopeful that the recommendations in Programme on HIV/AIDS (UNAIDS), Ruth this report help UNAIDS consolidate the suc- Levine, who leads our global health policy pro- cesses of the past decade and focus squarely on gram, has collaborated with Ngaire Woods, areas in which it has unique and needed con- Professor of International Political Economy tributions to make in the future: giving voice and Director of University College for Oxford to the voiceless, pushing for a more eff ective University’s Global Economic Governance Pro- response within the UN system, building and gramme, to lead a distinguished working group disseminating evidence for better policies and asking how that unique body should evolve to programs, and bolstering the capacity for action meet future needs. at the country level. Th ose of us on the outside In the course of this project the working will be watching with interest. group members found how deeply held the views about UNAIDS are and how expansive Nancy Birdsall the hopes for its contributions in the future. Its President defenders and challengers alike are passionate Center for Global Development

ii UNAIDS: PREPARING FOR THE FUTURE Acknowledgments

Many individuals helped to shape this report. paper. We would also like to thank Nancy Bird- First, we would like to thank the members of sall for her thoughtful comments on the report the UNAIDS Leadership Transition Work- and Lawrence MacDonald, John Osterman, ing Group, who gave their time, intellect, and and the communications team for their ideas patience over the months that it took to pull and ongoing support. the report together. Th eir expertise and sharp Th e success of the second consultation is observations brought clarity, humanity, and owed to the team at the Global Economic Gov- depth to the fi nal recommendations. We thank ernance Programme, particularly Reija Fanous them for their invaluable contributions. and Edward Joy. Th is meeting provided a great Th e report draws on a series of interviews turning point for the project, helping to focus and global consultations (see annexes B and C the discussion that emerged from the Washing- for lists). We thank the interviewees we con- ton consultation. sulted throughout this project who provided Particular thanks go to the team at the unique insights into the workings of UNAIDS. Health and Economics Research Division We would also like to thank the participants in (HEARD) at the University of KwaZulu-Natal the three global consultations held in Washing- in Durban, South Africa, and Alan Whiteside ton, D.C., Oxford, and Durban. Th e partici- for hosting our third consultation. Th is meeting pants at these meetings provided valuable and refl ected a valuable country-level perspective. broad-reaching insights and ideas that spanned Special thanks go to Andy Gibbs at HEARD— from Capitol Hill to the front lines of the pan- Andy’s careful collaboration from the start of demic in sub-Saharan Africa. We hope that the the project and work in pulling together the diverse views presented are refl ected in this fi nal consultation were invaluable. product. Th e content of this report signifi cantly ben- We also thank the team at the Center for efi ted from a review by Lindsay Knight, whose Global Development for their contributions. expertise with UNAIDS introduced extra pre- Acknowledgment goes to Heather Haines for cision and refi nement. her assistance with the Washington consulta- Finally, we would like to thank Todd Sum- tion and Kristie Latulippe for her substantial mers for intellectual contributions and the eff orts in planning the fi rst consultation and for Bill & Melinda Gates Foundation for the grant her intellectual contributions to the background that facilitated this work.

UNAIDS: PREPARING FOR THE FUTURE iii

Summary

Established in 1996, the Joint United Nations Programme on HIV/AIDS (UNAIDS) brings several United Nations agencies together around a joint mandate to lead, strengthen, and support an expanded and multisectoral response to the AIDS epidemic.

With many accomplishments to its credit, informed by academic research, interviews, and UNAIDS stands as a unique example of a consultations in Washington, D.C., Oxford, cosponsored UN body. It has been a visible and Durban. player over the past decade, as the AIDS epi- Sparked by the question do we need demic has achieved global prominence as a UNAIDS?, the working group agreed that there political and social cause. Since its inception, are important reasons for UNAIDS to con- UNAIDS has been led by its founding Execu- tinue. First, the nature of HIV/AIDS—its relative Director, Dr. Peter Piot, with whom the tionship to issues of human rights and political program became closely identifi ed. With his marginalization and its profound and multisec- departure in December 2008 and the selec- toral determinants and consequences—calls tion of Michel Sidibé as his successor comes for a response above and beyond many past an opportunity to refl ect on both the strengths responses to health conditions. Second, the and shortcomings of UNAIDS. In the United commitments at national and global levels States and elsewhere calls for expanded com- to support the response to HIV and AIDS mitments to global health—with an Institute must be fulfi lled, and UNAIDS is uniquely of Medicine committee recently recommend- positioned—as a special part of the United ing that the United States increase offi cial Nations—to ensure this. Th ird, given its en- development assistance for global health to gagement with both UN member states and $15 billion over four years1—and the prolif- civil society, UNAIDS can promote preven- eration of actors working on HIV and AIDS tion, care, and treatment approaches based on make this a particularly timely moment to both scientifi c evidence and respect for human question the role of UNAIDS in responding rights. to the pandemic. While the rationale for UNAIDS is strong, The UNAIDS Leadership Transition working group members and many of those Working Group was convened in July 2008 by who contributed ideas and information to the the Center for Global Development and Oxford working group process see signifi cant room University’s Global Economic Governance Pro- for strengthening the program. Th e working gramme as an independent ad hoc panel with group believes that, to be most eff ective, the the mandate to formulate a set of recommen- core mission of UNAIDS should be to use its dations for the next executive director and the status and strategic connections as a UN en- governing Programme Coordinating Board of tity to press governments to uphold their ex- UNAIDS. Working group deliberations were isting commitments and to take on new ones that refl ect approaches to containing and treat- 1. See Institute of Medicine 2009. ing the AIDS epidemic that are grounded in

UNAIDS: PREPARING FOR THE FUTURE 1 both scientifi c evidence and human rights. To prevention, care, and treatment approaches; achieve this mission, UNAIDS should focus and the potential resource requirements, on seven areas. fi nancial and otherwise. UNAIDS has been a leader in the fi eld of HIV and human 1. Track government commitments rights—for example, in 1996 and 2006 the and drive a long-term, strategic UNAIDS Secretariat and the UN Offi ce of agenda on HIV/AIDS that includes the High Commissioner for Human Rights strengthening health systems and jointly published a seminal compendium, the building national self-sufﬁ ciency International Guidelines on HIV/AIDS and UNAIDS should continue to play a key role in Human Rights.2 Still, it has recently been crit- holding both donor and other country govern- icized for buckling under political pressure on ments accountable by tracking commitments some important issues. Maintaining its lead in that have been openly made and forging deeper this area will require vigilant insulation from commitments for a long-term response to the the pressure of politics (on topics such as sex pandemic. To date, this has been an area of work and injecting drug use) and a willingness strength for UNAIDS. Still, UNAIDS should to underline to governments why they must reinforce its ability to track funding levels work harder for marginalized at-risk groups, and uses at the country level, using transpar- however politically diffi cult this may be. Th e ent dissemination of credible information as working group stresses that the activities of the main means of promoting fulfi llment of UNAIDS must be guided by evidence rather commitments. than politicking. Th e working group suggests innovative areas of focus for the next phase of commitments to 3. Promote comprehensive care in HIV/AIDS: prevention, treatment, and support, • Using the intensity and international vis- particularly in underpromoted ibility characterizing the recent nature of intervention areas the response to AIDS to strengthen health In part due to political diffi culties in scal- systems in ways that have broad spillover ing up, and in part due to a donor and advo- benefi ts to other health problems. cacy focus on treatment objectives, prevention • Promoting a sustained response that fos- interventions have received less attention than ters greater country-level fi nancial commit- treatment interventions. Although prevention ments to health. and treatment are counterparts, prevention— • Fostering consensus and support for human particularly among populations with high rates rights–centered policies and approaches for of infection such as prisoners, injecting drug eff ective HIV prevention and treatment, users, sex workers, and men who have sex with recognizing the needs of marginalized and men—is an area where evidence-based policies criminalized populations. and fi nancial commitments have been sorely • Developing benchmarks for the cost, qual- lacking and where UNAIDS can make a sig- ity, and eff ectiveness of key interventions. nifi cant contribution.

2. Take a ﬁ rm stand to promote policy 4. Focus on creating more opportunities guidance that is based on evidence for marginalized voices in national and centered on human rights policymaking UNAIDS has an important role to play UNAIDS should continue to expand its work as a clearinghouse for credible scientific in supporting national responses through links evidence—defi ned broadly as social, behav- to country governments, national AIDS coun- ioral, and biomedical data and analyses— cils (NACs), and local civil society, particularly about the magnitude, nature, and causes of the pandemic; the eff ectiveness of diff erent 2. OHCHR/UNAIDS 2006.

2 UNAIDS: PREPARING FOR THE FUTURE groups of people living with HIV. UNAIDS 6. Enhance coordination within the UN has a special role to play in creating opportuni- family and with other donors, and use ties for marginalized and criminalized popula- clear milestones to track progress tions aff ected by HIV to actively participate in UNAIDS has contributed to coordination the design and monitoring of policies and the through initiatives like the “Th ree Ones” and to allocation of resources. monitoring progress in expanding access to HIV treatment, but coordination remains a key chal- 5. Reduce wasteful capacity-building lenge. UNAIDS should work with cosponsors to efforts by brokering higher-quality, assess whether current mechanisms, such as the long-term, locally demanded Committee of Cosponsoring Organizations, are technical support serving their purposes. UNAIDS should carefully UNAIDS builds capacity for national examine how it can align with the “One UN” responses by linking governments, NACs, and reform. Milestones toward better coordination civil society to fi nancial resources and high- should be created and used to track progress. quality technical support. Governments need assistance with improving capacity for policy 7. Examine the structure, management, development, program design, and implemen- and operations of UNAIDS tation. Key civil society groups, particularly Th e working group suggests that an in-depth those that represent marginalized populations, organizational assessment occur with four aims need assistance with coalition development, by January 2010: advocacy, budget tracking, and other activi- • Making the governing board more transpar- ties, and they oft en need established organiza- ent and representative of those most aff ected. tions to recognize their legitimacy. UNAIDS • Improving the coordination framework has several mechanisms to do this, including for joint funding, priority setting, and the recently created Coordinated AIDS Tech- implementation. nical Support database. However, the roles • Instituting robust mechanisms for indepen- of existing support entities are unclear, and dent, scientifi c, and technical review and quality varies. UNAIDS should immediately oversight. address issues related to quality of technical • Aligning the staffi ng in Geneva and within assistance. countries with the institutional mission.

UNAIDS: PREPARING FOR THE FUTURE 3 About this report

In January 2009 Michel Sidibé assumed leadership of the Secretariat of the Joint United Nations Programme on HIV/AIDS (UNAIDS) from its founding Execu- tive Director, Dr. Peter Piot. With this transition comes an opportunity—and an imperative—to re-examine the role of the organization so that UNAIDS can most eff ectively contribute to the global response to HIV and AIDS.

Launched in 1996, UNAIDS is a unique drives epidemics of multiple etiologies,3 and we umbrella program that brings together 10 have seen the introduction of new, better, and UN agencies around a joint mandate to lead, more accessible interventions for prevention, strengthen, and support an expanded response treatment, and palliative care. Unprecedented to the AIDS epidemic (see box 1). fi nancial resources have been mobilized for UNAIDS has changed signifi cantly since HIV and AIDS while international public and its inception. Th e Secretariat has grown in staff private organizations dealing with the epidemic and budget—now with about 900 employees have proliferated. And, as AIDS has grown in and more than 80 country offi ces. It has had prominence on the international agenda and an eff ect well beyond the UN system as an ad- as a part of donor aid fl ows, the calls for tak- vocate for increased funding and attention to ing a systemic approach, for “harmonizing,” for the AIDS epidemic. Interpreting its mandate “delivering results,” and for fostering “country broadly, it has undertaken a range of initiatives ownership,” also have grown louder throughout to generate and share information and to mobi- the domain of development assistance. lize political and fi nancial support. With the transition in leadership, the mo- During the past 12 years UNAIDS has also ment is opportune to ask whether and how frequently been the object of criticism. Some UNAIDS should change to meet the dynamic have charged that UNAIDS has failed to stand needs of responding to the epidemic in the fu- up to conservative political pressures and in ture. To answer this question, Ruth Levine at turn failed to protect the rights of marginal- the Center for Global Development (CGD) and ized populations, such as sex workers and men Ngaire Woods of Oxford University’s Global who have sex with men—people who are also Economic Governance Programme (GEG) criminalized in many countries. Many also crit- convened the UNAIDS Leadership Transition icize UNAIDS for not working eff ectively with Working Group.4 Th e working group includes civil society. And others have pointed out wide 15 senior experts on global health and HIV variations in the capacity of UNAIDS staff to and AIDS from the donor, academic, civil so- provide high-quality technical support at the ciety, and offi cial government communities (see country level.

Th e world’s understanding of HIV and 3. Whiteside 2008. AIDS and the responses within the broader dy- 4. Support for this project was generously provided by the namics of development policy have also changed Bill & Melinda Gates Foundation as part of the HIV/AIDS dramatically. We know more today about what Monitor Program of the Center for Global Development.

4 UNAIDS: PREPARING FOR THE FUTURE Box 1 What is UNAIDS?

Mission: As the main advocate for global action on HIV and AIDS, Unlike the cosponsoring agencies, each with a specifi c man- UNAIDS leads, strengthens, and supports an expanded response date, the cosponsored program does not itself have a mandate but aimed at preventing transmission of HIV, providing care and sup- is intended to coordinate the work of the United Nations on the port, reducing the vulnerability of individuals and communities to AIDS epidemic and to reach beyond the organization to all sectors HIV, and alleviating the epidemic’s impact. of global society to forge a global agenda on HIV and AIDS. UNAIDS does not play a direct role in disbursing funds. 2008/09 Biannual budget: $469 million. The program is served by a Secretariat based in Geneva, with Scope: More than 80 countries worldwide. more than 80 regional and country offi ces; it has a staff of more than 900 people in Geneva and in regions and countries. Leadership (as of January 2009): Michel Sidibé, Executive Director of the UNAIDS Secretariat, Under Secretary-General of the United Governance: UNECOSOC (Economic and Social Council of the Nations. United Nations) has formal governance responsibility over UNAIDS. Within the Joint Programme governance occurs through the Pro- Program structure and organization: UNAIDS is a joint unifi ed programme Coordinating Board (PCB) with membership from 22 coun- gram of the United Nations. The program became operational on try governments, the cosponsoring organizations, and civil society. January 1, 1996, and started with six “cosponsors”—UN organiza- The PCB reviews activities and programs of the Executive Director, tions that contribute efforts and resources to the AIDS response— as well as the UNAIDS Secretariat and the cosponsors. (United Nations Children’s Organization, United Nations Develop- There is also a Committee of Cosponsoring Organizations ment Programme, United Nations Population Fund, United Nations (CCO) comprised of the executive head or designated representa- Educational, Scientifi c, and Cultural Organization, World Health Or- tive of each cosponsoring organization. The CCO meets twice a year ganization, and the World Bank). There are now four more: United to consider matters concerning UNAIDS and to provide inputs into Nations High Commissioner for Refugees, United Nations World the policies and strategies of UNAIDS. Food Programme, United Nations Offi ce on Drugs and Crimes, and The UNECOSOC resolution 1994/24, which defi ned the program, International Labour Organization. Activities of the 10 cosponsors are explains, “The Cosponsors will share responsibility for the develop- laid out in the Joint Programme around seven principal outcomes. ment of the programme, contribute equally to its strategic direction, Principal outcomes: These outcomes refl ect the anticipated impact and receive from it policy and technical guidance relating to the imple- of activities across the cosponsors through the Joint Programme in mentation of their HIV/AIDS activities. In this way, the program will the 2008–09 biennium: also serve to harmonize the HIV/AIDS activities of the Cosponsors.”1 • Leadership and resource mobilization. • Planning, fi nancing, technical assistance, and coordination. Note • Strengthened evidence base and accountability. 1. This report mainly focuses on the work of the Secretariat, not the spe- • Human resources and systems capacities. cifi c activities of each cosponsor on HIV and AIDS. The termUNAIDS is • Human rights, gender, stigma, and discrimination. used throughout, as is common usage to mean the Secretariat (including • Most-at-risk populations. country and regional offi ces) and sometimes the Joint Programme. • Women and girls, young people, children, and populations of humanitarian concern. Source: See UNAIDS 2002a, b; 2008a; UNECOSOC 1994. working group member bios in annex A). Mem- country health ministers and senior offi cials bers generously served as individuals and in a to discuss priorities and challenges in global volunteer capacity. health governance.6 In this tradition the UN- Th e working group approach is based on AIDS Leadership Transition Working Group earlier experiences. CGD formed working was convened to off er strategic recommenda- groups in the past to develop recommendations tions for the new Executive Director of the during leadership transitions at the Global Secretariat—who was appointed during this Fund to Fight AIDS, Tuberculosis and Malaria document’s production—and its Board. Th us, and at major development banks, including the this report, while independent, unoffi cial, and World Bank and regional development banks.5 unsolicited, has a particular audience. In 2008 the Global Economic Governance Programme convened a group of developing 6. Global Economic Governance Programme 2008. See www.globaleconomicgovernance.org/wp-content/uploads/ 5. CGD 2005, 2006a, b. Working%20Group%20Report%20May%202008.pdf.

UNAIDS: PREPARING FOR THE FUTURE 5 Working group discussions were supported the fi ndings and recommendations are based on by background work: approximately 50 semi- a combination of available factual information structured interviews targeting knowledge- and independent views. We recognize that in able individuals (see annex B for the list of some cases progress in particular areas depends interviewees), a comprehensive academic and on more in-depth analysis, and we propose next media review (see reference list), and consulta- steps toward that end. tion in Washington, D.C., Oxford, and Dur- Th is report touches briefl y on the evolution ban. Each of these consultations sought input of UNAIDS and presents key challenges for from informed individuals about the compara- Mr. Sidibé and UNAIDS senior management. tive advantage of UNAIDS and the features Th ese are followed by a set of recommendations required to fulfi ll core functions (see annex C agreed on by working group members and tar- for summary of consultations and annex D for geted at the UNAIDS Secretariat and the Pro- a description of the methodology). gramme Coordinating Board of UNAIDS. Th is report presents a synthesis of what was Th e recommendations are not radical ones, and learned. It refl ects the judgments of working in some cases they reinforce initiatives already group members, the consultation discussions, under way in UNAIDS. But in the context of a perceptions of knowledgeable individuals, and multistakeholder UN organization that is part background research. It does not, however, at- of the larger UN governance system, serious and tempt to comprehensively evaluate the work eff ective leadership will be needed to fulfi ll the of the UNAIDS Secretariat or the cosponsors’ recommendations while shaping organizational work on AIDS. Given the nature of this exercise, culture and engaging key constituencies.

6 UNAIDS: PREPARING FOR THE FUTURE Evolution of the AIDS epidemic and UNAIDS

In June 1981 the Weekly Morbidity and Mortality Report of the Centers for Disease Control and Prevention (CDC) described what would be recognized as the fi rst re- ported cases of HIV in the United States, some rare pneumonias seen in fi ve gay men.7 Doctors in Belgium and Paris had been seeing similar conditions in patients since the mid-1970s, mainly in Africans from the equatorial region or Europeans who had visited this area.8 Doctors in several African countries were also treating patients with similar symptoms; by 1983, AIDS cases had been identifi ed in Congo, Rwanda, Tan- zania, Zaire, and Zambia.9 Signs of a global epidemic were emerging, but for some years in both developed and developing countries funding for activities to prevent HIV transmission and to care for people living with HIV were not major priorities— mainly because many such people came from marginalized and stigmatized groups such as injecting drug users and men who have sex with men. Some politicians denied the existence of local epidemics; others insisted on compulsory HIV testing for people entering their countries and refused entry to those who were HIV positive.10

78109In the West gay rights activists mobilized for fi nancial and other barriers to obtain quality action on prevention, both within their own treatment, rather than toward prevention. community and the domain of public policy.11 As the epidemic exploded in many countries, Th e development of Highly Active Antiretro- particularly in sub-Saharan Africa, most govern- viral Th erapy (HAART)12 in 1996 brought a ments were slow to explicitly recognize the mag- highly sought clinical advance; antiretrovi- nitude and nature of the problem. When they ral drugs could signifi cantly delay the onset did, it oft en emerged from personal reasons. In of AIDS, though at that time many people in 1989, President Kaunda of Kenya, for example, the developed world could not aff ord them, was one of the fi rst African leaders to speak out let alone the many thousands in need in devel- about the need to fi ght the AIDS epidemic aft er oping countries. Th e arrival of these drugs, to losing his son to AIDS. Only as governments in some extent, turned people toward overcoming rich and poor countries alike began to recognize and come to grips with the scope and impact of the global epidemic—including threats the 7. CDC 1981; Behrman 2004, 5. disease posed to economic and social develop- 8. Iliff e 2007. ment progress in high-prevalence countries— 9. Knight 2008. did AIDS move higher up the policy agenda. 10. Knight 2008; Caldwell 1994. Since then, the institutional capacity to re- 11. Piot, Russell, and Larson 2007. spond to this complex disease has expanded, 12. National Institutes of Health 1998. with growing numbers of organizations working

UNAIDS: PREPARING FOR THE FUTURE 7 on HIV and AIDS. Th e epidemiological un- for the United Nation’s work on the epidemic, derstanding of this disease has also deepened, even if it oft en failed to meet it. With the publi- and epidemics of multiple etiologies have been cation of the landmark “Global Strategy for the characterized.13 While progress is still needed, Prevention and Control of AIDS”17 and with people living with HIV/AIDS are gaining voice eventual support from WHO Director-General in policy discourse and playing a major role in Dr. Halfdan Mahler and early contributions mobilization, advocacy, implementation, and from the United States and many European governance. countries, between 1987 and 1989 the budget Biomedical science, which made eff ective had reached $90 million, and GPA staff num- AIDS treatment a reality, continues to play bered near 400.18 an important role, though it is now clear that In 1990, when Mann resigned in the face hoped-for breakthroughs such as vaccines and of tension with WHO’s Director-General Dr. microbicides are unlikely to be available for Hiroshi Nakajima, WHO’s response to the many years.14 epidemic was in peril. At the time, a WHO Th e United Nations response to the AIDS staff member said: “It’s not a question of how epidemic has also evolved in important ways well the program will do aft er Jon Mann, but since leaders fi rst started to recognize the global whether there will be a program worth talking magnitude and nature of the problem and to un- about.”19 derstand the importance of an all-out eff ort to Dr. Michael Merson became head of GPA mitigate its potential impact. Initially defi ned in 1990, amid growing concern from the en- as an emerging health threat, the epidemic was gaged donor community about the ability of placed under the purview of the World Health WHO to manage the program and the now- Organization (WHO). In 1986 the WHO es- apparent need—in light of the relationship be- tablished the Control Programme on AIDS tween the epidemic and a range of sectors other (CPA) under the leadership of Dr. Jonathan than health—to coordinate related activities Mann, a leading expert on AIDS. In 1987 the across UN agencies. An external review of GPA CPA was re-named the Special Programme on led to the decision to replace the program with AIDS (SPA). Slightly more than a year later, in a new body that would coordinate the work of January 1988, the SPA became the Global Pro- the United Nations on AIDS. Th e external re- gramme on AIDS (GPA)—in recognition of the view concluded that “no single agency is capable fact that the epidemic was neither temporary of responding to the totality of the problems nor short term.15 Support from international posed by AIDS; and as never before, a coopera- donors was slow to come and modest. At the tive eff ort, which is broadly based but guided outset GPA had few staff and a budget of about by a shared sense of purpose, is essential.”20 In $5 million, funded with donor contributions 1994 it was agreed that a joint and cosponsored raised through Mann’s personal outreach. program would be established. Th e original six Early on, the global response to AIDS was cosponsors were the United Nations Children’s met by many with discrimination and fear, but Fund (UNICEF), United Nations Develop- Mann felt otherwise: “If we do not protect the ment Programme (UNDP), United Nations human rights of those who are infected, we will Population Fund (UNFPA), United Nations endanger the success of our eff orts, national and Educational, Scientifi c, and Cultural Orga- international, to control AIDS.”16 Mann’s em- nization (UNESCO), and the World Bank— phasis on human rights set the target early on because at the time they were members of the

13. Whiteside 2008. 14. See www.iavi.org and www.mtnstopshiv.org for more 17. WHO World Health Assembly 1987; Mann 1987. information. 18. Behrman 2004. 15. Knight 2008. 19. Hilts 1990. 16. WHO–GPA 1992. 20. GPA Management Committee 1992.

8 UNAIDS: PREPARING FOR THE FUTURE GPA Management Committee. Although the opposition from some of the UN agencies that full story of the origins of UNAIDS is a compli- eventually became cosponsors of UNAIDS. cated one, and diff erent participants and observ- Th is was fueled by a lack of clarity about the ers emphasize distinct aspects of the program’s role of the Secretariat relative to that of the co- creation, several reasons have been cited for the sponsors. Opposition continued and made the establishment of the Joint Programme:21 lives of UNAIDS Secretariat staff very diffi cult • Dissatisfaction among donors with the over- at times, including at the country level. Even all WHO management—encompassing, in to this day, wrangling over culturally sensitive part, criticism that WHO could not coordi- areas, such as services for sex workers and men nate rival UN agencies. who have sex with men, in the fi ne details of • An interest by Organization for Economic policy documents is not unusual at meetings of Cooperation and Development (OECD) Secretariat staff and cosponsors. donors in having more direct control over Under the UNECOSOC resolution multilateral aid mechanisms, as well as the 1994/24, the primary objective of establishing recognition that due to the multisectoral UNAIDS was to lead an expanded, multisec- nature of AIDS, agencies with sector-spe- toral, broad-based response to the AIDS epi- cifi c mandates or those directly responsive demic.22 Th e focus of the organization was to to individual governments of member states were poorly positioned to respond. achieve and promote global consensus • An impetus toward UN reform, with on policy and programmatic approaches; UNAIDS seen as an opportunity to dem- strengthen the capacity of the United onstrate the potential of the UN as a whole Nations system to monitor trends and with a joint work plan, funding responsibili- lessons learned and to ensure that appro- ties, and shared budget among the cospon- priate and eff ective policies and strategies soring agencies. are put into operation at country-level; • A growing understanding in the epidemic re- strengthen the capacity of governments sponse, driven in part by eff ective advocacy of to draw up comprehensive national strat- civil society organizations, that because of the egies, and to coordinate and implement nature and etiology of the disease, responses eff ective HIV/AIDS activities at coun- to HIV and AIDS require dealing with sex— try level; promote broad-based political heterosexual and homosexual—with use of and social mobilization to prevent and illicit drugs, and with all the social, cultural, control HIV/AIDS within countries, and legal ramifi cations they carry. Concen- ensuring that national responses involve trated attention to issues of marginalization, a wide range of sectors and institutions; violation of human rights, and criminaliza- and advocate greater political commit- tion of the most aff ected populations is part ment in responding to HIV/AIDS epi- of this challenge. It was felt that UNAIDS demics at global and country levels, in- as an entity independent of cosponsor man- cluding the mobilization and allocation dates would have more latitude than WHO of adequate resources for HIV/AIDS- to work across sectors and to talk candidly related activities.23 about the many sensitive issues related to guiding a range of rights-based programs. Th e fi rst UNAIDS Executive Director, Dr. But from the complicated and painful Peter Piot, was appointed in 1995. Since then, birth of UNAIDS it is important to note that the UNAIDS Secretariat has grown: its an- the push for the new program came from the nual budget is now $469 million, and staff have donors (supported by AIDS activists) and that from the start there were varying degrees of 22. UNECOSOC 1994. 23. World Health Assembly Executive Board 93rd Session 21. UNAIDS 2002a. 1993.

UNAIDS: PREPARING FOR THE FUTURE 9 increased to some 289 workers at the Secretar- Fight AIDS, Tuberculosis and Malaria); sought iat’s Geneva headquarters and by an additional to widen the reach of indigenous eff orts (such 611 in regional and country offi ces (see box 1 for as with Th e AIDS Support Organization in current overview of UNAIDS). Uganda, now the largest provider of HIV and Since its creation, UNAIDS has played a AIDS services in Africa);25 and engaged with major part in infl uencing the global response new partners (such as with key private sector to HIV. It has focused on raising the visibility programs like that of Merck’s African Com- of the epidemic, in particular by advocating prehensive HIV/AIDS Program).26 Several of greater funding, political commitment, and these actors have greater fi nancial clout than leadership. In an increasingly crowded fi eld the Secretariat—but UNAIDS has not become of global health actors the Secretariat has at- obsolete. As a UN organization, it still has a tempted to help cosponsors improve their HIV unique legitimacy and role in the response to eff orts (such as with the World Bank’s Multi- HIV and AIDS. country AIDS Programs in Africa and the In a changed landscape, what should the fu- Caribbean);24 aimed to collaborate beyond the ture role be for UNAIDS? UN family (such as with the Global Fund to 25. For more on TASO, see http://www.tasouganda.org/. 24. Görgens-Albino et al. 2007. 26. Business Action for Africa 2006.

10 UNAIDS: PREPARING FOR THE FUTURE Continuing an exceptional response: Key roles for UNAIDS

In considering the future of UNAIDS, some challenges deserve mention:

• Th e AIDS epidemic has received the larg- to HIV positively or negatively aff ects the est international, institutional, and fi nan- delivery of or demand for other health ser- cial response of any health condition rela- vices.30 Th us, linking eff orts to treat and tive to its contribution to the global burden prevent HIV to eff orts to strengthen health of disease.27 In large measure, the relatively systems more broadly, as well as to food and successful mobilization of resources to date nutrition policies and to investments in edu- has resulted from advocacy that has framed cation and development, will continue to be the disease as exceptional—especially when crucial—and will continue to form part of compared with other infectious and chronic the agenda that UNAIDS must tackle.31 health problems: it kills adults in the prime • In the future other topics may overtake of their lives, it is spread by sex and illicit health and the AIDS epidemic for fund- drugs, it aff ects those who are largely mar- ing and attention. Although development ginalized and oft en criminalized, and it is assistance for health increased from 4.6% hyperendemic in Southern Africa, where of offi cial development assistance (ODA) so many are aff ected by poverty and coun- in 1990 to close to 13% in 2005 and such tries are burdened by weak health systems. institutions as the World Bank, the Global Despite these factors, whether the disease Fund, Global Alliance for Vaccines and should in fact be seen as exceptional has Immunization (GAVI), and many other been contested by some commentators,28 health-oriented institutions have brought bringing to question whether it warrants a unprecedented attention to health as a part stand-alone UN organization with a single- of the development agenda, other priorities disease focus. such as climate change are gaining ground.32 • Increasingly, global and country-level policy- While new monies are justifi ed in a num- makers are calling for recognition of syner- ber of areas, and a credible case can be made gies and complementarities between services that all development sectors merit large infor HIV and other health conditions compet- creases in aid fl ows, there also are fears that ing for attention and resources. Slower than the global fi nancial and economic crisis will expected progress toward other health pri- lead to less assistance from traditional donor orities, including child and maternal health nations. Heads of state in the United States, goals, has fueled debates about whether United Kingdom, and other countries have funding for HIV is crowding them out.29 In recently reaffi rmed their commitment to in- program implementation there is relatively crease funding for global health and HIV little evidence on whether or how attention 30. Oomman, Bernstein, and Rosensweig 2008; WHO 2008. 31. Loevinsohn and Gillespie 2003; Sperling 2009. 27. Sridhar and Batniji 2008. 32. World Bank 2007. For example, in May 2008 the World 28. Cheng 2008; England 2008. Bank launched its Strategic Framework for Development and 29. Shiff man 2007; Morris, Cogill, and Uauy 2008. Climate Change.

UNAIDS: PREPARING FOR THE FUTURE 11 and AIDS programs.33 Still, worries persist national health plan.36 For UNAIDS this that spending may contract. UNAIDS pro- means that coordination of UN agencies is motion of a sustained, adequately fi nanced happening in the midst of an increasingly response remains needed. complex environment, in which even the • In the rapidly expanding fi eld of global identity of an organization with a mandate health the mechanisms for delivering devel- for coordination is subject to dispute. opment assistance are fragmented and over- The UNAIDS Leadership Transition lapping. While UNAIDS has contributed Working Group deliberations started by refl ect- to coordination eff orts through the “Th ree ing on whether UNAIDS is still needed, and if Ones” and Universal Access consultations,34 so, whether its objectives and structure require many actors outside the direct purview of important modifi cations. eTh working group UNAIDS play prominent and novel roles concluded that UNAIDS does have a unique in fundraising, policy advice, and program and crucial role to play and that terminating or development. To name only a few: the U.S. phasing out UNAIDS would send a devastat- President’s Emergency Plan for AIDS Re- ing signal about the commitment and attention lief (PEPFAR), the Global Fund, UNI- span of the international community. Working TAID, and the Clinton HIV/AIDS Initia- group members articulated three reasons why tive (CHAI). New initiatives rooted in the UNAIDS is still needed. principles of the 2005 Paris and 2008 Accra First, the AIDS epidemic is exceptional in Declarations on aid eff ectiveness35 have been the magnitude of its impact on development in developed to address coordination prob- many countries, especially because of its eff ect lems, at least in selected countries. Exam- on working adults; its association with politi- ples include the One UN reform initiative, cally sensitive topics (sex and drugs) and stigma- which seeks to harmonize programs among tized groups (sex workers, injecting drug users, UN actors at the country level, and the In- and others); and its ambitious response (univer- ternational Health Partnership+ (IHP+), sal access to state-of-the-art treatment and pre- which brings together leading donors and vention interventions). Addressing HIV and mobilizes additional funding within com- AIDS is not confi ned to the health sector. pacts with selected countries around a Second, at a time when a long-term, sustained commitment is required, UNAIDS is

33. Wintour 2008; U.S. President George W. Bush, October needed to keep HIV and AIDS on the global 21, 2008, speech at the White House Summit on Interna- development agenda and to support countries tional Development. and civil society by emphasizing existing na- 34. Th e “Th ree Ones” are one AIDS action framework, tional and international commitments and one national AIDS coordinating authority, and one agreed forging new ones. country-level monitoring and evaluation system. For more Th ird, UNAIDS has a key role to play in information on Three Ones see www.unaids.org/en/ CountryResponses/MakingTh eMoneyWork/Th reeOnes. For providing policy guidance on such imperatives more information on Universal Access see www.unaids.org/ as eff ective HIV prevention and universal access en/PolicyAndPractice/TowardsUniversalAccess/default.asp. to treatment. Among the many actors working 35. Th e 2005 Paris Declaration (www.oecd.org/document/ on HIV and AIDS, only UNAIDS has the back- 18/0,2340,en_2649_3236398_35401554_1_1_1_1,00 ing of all UN member states to provide global .html) builds on the following declarations and commit- leadership on AIDS, which now more than ever ments: Rome 2003 (see www.aidharmonization.org/ah-wh/ secondary-pages/why-RomeDeclaration), Marrakech 2004 includes the challenging task of building con- (see www.mfdr.org/1About.html), and links to Monterrey sensus around the human rights–centered ap- 2002 (see www.un.org/esa/ff d/monterrey/MonterreyCon- proaches that are vital to making headway on sensus.pdf). It is focused on harmonization and alignment HIV prevention and treatment.37 for managing aid. Th e Accra Agenda for Action 2008 further affi rms these principles (see siteresources.worldbank. org/ACCRAEXT/Resources/4700790-1217425866038/ 36. See UNDP 2007; IHP+ 2008. ACCRA_4_SEPTEMBER_FINAL_16h00.pdf). 37. Mann 1995; Open Society Institute 2007.

12 UNAIDS: PREPARING FOR THE FUTURE Nonetheless, changes are warranted. as a one-stop shop for policy, programmatic as- UNAIDS needs to refi ne and reshape its mis- sistance, and epidemic tracking. Many see the sion and identity in substantial and fundamen- UNAIDS Secretariat as oversized and opaque tal ways, to address new challenges. Th e fi rst fi ve- and in need of clear priorities that defi ne a dis- year review of the organization in 2002 alluded tinct niche among other organizations working to confusion over what UNAIDS was meant to on HIV. Clarity on some of these points may be: a sum of all UN activities on HIV/AIDS emerge from the second fi ve-year evaluation of or of the parts of its cosponsors? Or a Geneva- UNAIDS, which will be available at the end of based Secretariat with regional and country 2009. However, following this important lead- outposts, all under the loose rubric of multisec- ership transition, the working group off ers a toralism and an expanded response?38 To some set of recommendations to Mr. Sidibé for the extent, clarity is still lacking, and as mentioned, UNAIDS Secretariat and its regional and coun- issues exist that divide or cause friction between try outposts.39 cosponsors and the Secretariat. Background interviews voiced a clear percep- 39. From this point forward, the term UNAIDS will refer to tion that UNAIDS is overstretched—serving the Secretariat and its regional and country outposts, not to the activities of cosponsors, except where explicit distinctions 38. UNAIDS 2002a. are made.

UNAIDS: PREPARING FOR THE FUTURE 13 Recommendations for the Secretariat’s Executive Director and the Board

Fundamentally, the working group recommends that Mr. Sidibé and the Board refi ne the mission and mandate of UNAIDS. Th e UNAIDS Secretariat has become many things to many constituencies, and the incoming leadership should seize the opportunity to make a clear statement about the primary roles that the UNAIDS Secretariat can and should play. Th e UNAIDS Secretariat’s unique “inside-outside” status—part of the UN system but outside any single agency—means it has the potential to function eff ectively as the engine of the Joint Programme and the wider global response. In turn, the working group believes that the core mission of UNAIDS should be to use its status and strategic connections as a UN entity to press governments to uphold their existing commitments and to take on new ones that refl ect approaches to containing and treating the AIDS epidemic that are grounded in both scientifi c evidence and human rights. Toward this end, UNAIDS should engage in respectful collaboration and capacity building with those most aff ected by HIV/AIDS and drive a coordinated, long-term response informed by government and civil society perspectives.

1. Track government commitments particular, at tracking funding levels and uses at and drive a long-term, strategic the country level.41 agenda on HIV/AIDS that includes In setting commitments UNAIDS could be strengthening health systems and innovative and bold in four ways: fi rst, in look- building national self-sufﬁ ciency ing at how to extend the commitment agenda to UNAIDS can never be an enforcement agency. intensify responses to HIV/AIDS and to bring But it does and should continue to hold both a results focus to other health areas and broader donor and other governments accountable by health systems strengthening; second, in pro- tracking commitments that have been made moting a sustained response that fosters greater openly. UNAIDS also needs to forge deeper country-level fi nancial commitments to health, commitments for a long-term response to the without letting donors off the hook; third, in pandemic, particularly given global commit- driving consensus and support for the human ments made at the United Nations General rights–centered policies and approaches that are Assembly Special Session (UNGASS) and vital to eff ective HIV prevention and treatment reports to the UN General Assembly that countries are asked to make on an annual basis.40 UNAIDS has been doing relatively well at 41. For more information see www.ua2010.org/en/ UNGASS/UNGASS-2008; for joint statement on trans- this; but it needs to do more and do better—in parency to UNAIDS see www.ua2010.org/en/UA2010/ Universal-Access/Civil-Society-Papers/Shadow 40. United Nations 2008. -Reports-2006/Transparency-Joint-Statement-UNAIDS.

14 UNAIDS: PREPARING FOR THE FUTURE and that recognize the needs of marginalized reneged on—such as for universal access and oft en criminalized populations; and fourth, and for fi nancial commitments at the global in developing benchmarking for the cost, qual- level (the Gleneagles G-8 meeting) and ity, and eff ectiveness of key interventions. among and within aff ected countries (the Sustained political will and strong leadership Abuja Declaration).43 It also means taking are crucial to increase funding and reduce the a long-term perspective complementary to number of new infections.42 Although some civil initiatives like aids2031,44 by helping to set society organizations and academics “name and a commitment agenda that promotes na- shame,” currently no offi cial organization holds tional self-suffi ciency and projects future others to account or serves as a clearinghouse for responsibilities of donors and recipient information that permits interested parties to governments. track commitments. Th is is a diffi cult task, espe- • Generate credible projections as a tool to cially for an organization funded by those that it set commitments for future resource needs needs to hold to account, but it is a role that a UN for health system strengthening and scaling organization, with authority jointly conferred by up prevention, sustaining and expanding UN member states, is uniquely placed to play. care and treatment, and driving a long-term Th e working group suggests that to better response to HIV and AIDS predicated on drive the commitment agenda in the ways sug- human rights. For instance, the life-saving gested, UNAIDS should employ the following provision of antiretrovirals (ARVs) has es- strategies: tablished a long-term imperative for recipi- • Publicly record and monitor global and na- ents that must be fulfi lled.45 UNAIDS could tional commitments and declarations, to transparently project those implicit commit- encourage transparency and accountability. ments based on state-of-the-art knowledge To do so, UNAIDS can establish a clearing- about life expectancy, costs of second-line house for information on HIV-related pol- drugs, and costs of eff ective delivery and icy commitments by donor organizations meanwhile estimate the resources required and UN member states. Th is would include, for greatly enhanced prevention strategies. for example, government policy commit- It is important that UNAIDS recognize ments on access to prevention, treatment, and disseminate information on the synergies and other services, including for marginal- that scaling up and maintaining resource fl ows ized people such as sex workers and refugees, for HIV and AIDS can, and should, have for as well as government policy on discrimi- other disease areas and health system strength- nation on the basis of sexual orientation ening, which ultimately contribute to national or against criminals and HIV-positive mi- self-suffi ciency. Th is is essential to develop pro- grants. Simply making available such infor- jections that show the full costs of the pandemic mation creates the conditions for the estab- beyond those of interventions such as training lishment of international benchmarks and health workers, higher remuneration, and im- standards and makes it possible for other proved working conditions. actors to keep up pressure on politicians. • Develop and disseminate information in a 2. Take a ﬁ rm stand to promote policy fully transparent form about what commit- guidance that is based on evidence ments—fi nancial and otherwise—should and centered on human rights be made by all relevant stakeholders to ac- UNAIDS has an important role to play as a cred- celerate progress in fi ghting the epidemic. ible scientifi c clearinghouse for HIV/AIDS, with Th is means looking at what commitments have been made, which commitments have 43. Kaisernetwork.org 2007; Govender, McIntyre, and Loew- been fulfi lled, and what is at risk of being en son 2008. 44. For more information see www.aids2031.org. 42. Piot, Russell, and Larson 2007. 45. Over 2008.

UNAIDS: PREPARING FOR THE FUTURE 15 science defi ned broadly to include social, behav- not alone in its approach, UNAIDS has not ad- ioral, and biomedical fi elds. Although UNAIDS equately prioritized matching the response to a has developed a large number of policy papers, country’s epidemic (that is, whether it is concen- position documents, and advocacy tools and trated in specifi c groups such as injecting drug provided much epidemiological information, users or dispersed throughout the general popu- the organization has been criticized for failing lation) as key to eff ective prevention. at times to fully ground its advocacy in the best Th e recent report of the independent Com- available evidence and for lacking the courage to mission on AIDS in Asia takes the fi rst step take a stand on hard issues.46 UNAIDS should away from political infl uence of the kind that not shirk from sharing unpopular information can dilute the evidence base of policy and pro- with the policy community about the behaviors gram actions. Th e Commission, convened by, that contribute to the spread of the disease, the though independent of, UNAIDS, recognized magnitude of resources required, the need to that many epidemics in Asia are driven by sex work respectfully with groups that face social work, injecting drug use, and sex between men, disdain, and the chances for success or failure of and the Commission has urged UNAIDS and various public health strategies. national governments to fi nd ways of work- In its early years of operation UNAIDS ing respectfully with sex workers, their clients, successfully integrated human rights and pub- men who have sex with men, and people who lic health imperatives, as well as on-the-ground inject drugs to ensure that their experiences evidence of what works best, in framing policies inform program solutions, however politi- and guidance on HIV prevention.47 For example, cally diffi cult this may be.51 Th e Commission’s unique guidelines were produced for legislators report illustrates the range of evidence- and and parliamentarians on protecting the rights of rights-based policy and programmatic guid- disenfranchised populations vulnerable to HIV ance that UNAIDS—the Secretariat and the and on best practice programs for educating sex cosponsors—should be providing. It calls for workers and their clients on prevention. wide-ranging prevention, treatment, and care But in more recent years some critics have services for all who are living with and vulner- noted cases where UNAIDS abandoned evi- able to HIV, including the marginalized groups dence to appear more politically neutral. For that are most aff ected. At the same time, the example, UNAIDS was criticized for deempha- Commission points to the fact that, though ca- sizing empowerment and overemphasizing al- sual sex among young people remains a minor ternative livelihoods for sex workers in a 2007 factor in Asia’s HIV epidemics, signifi cant re- guidance note, a position inconsistent with pre- sources for prevention have been aimed at this vious UN statements on the rights of sex work- group, instead of those most at risk. ers.48 In one example UNAIDS was asked by key stakeholders to drop references in their policies 3. Promote comprehensive care in to needle exchange programs, despite the neces- prevention, treatment, and support, sity of such programs in preventing HIV wher- particularly in underpromoted ever injection drug use is prevalent.49 UNAIDS intervention areas has also been criticized for failing to emphasize Prevention and treatment of HIV are essen- the practice of having concurrent sexual partners tial in reducing infection rates and deaths, but as a driver of the epidemic in Africa.50 Although until fairly recently, insuffi cient resources were spent on prevention,52 and in many places prevention interventions have not been as well 46. Gordon 2008; Epstein 2007. supported as have treatment interventions. A 47. Dube and Csete 2008. 48. Canadian HIV/AIDS Legal Network 2007. 51. Commission on AIDS in Asia 2008; Dube and Csete 49. Th e New York Times 2005. 2008. 50. Epstein 2007. 52. Global HIV Prevention Working Group 2007.

16 UNAIDS: PREPARING FOR THE FUTURE recent Lancet editorial decried, “Th e absolute (CCMs), and local civil society groups, amount of preventive practice and science has UNAIDS can help involve all people living simply been too little. Th e mix of interventions with and vulnerable to HIV, including margin- has been wrong. Leadership and management alized groups, in country responses to the epi- of programs to deliver these interventions have demic. During consultations this was returned been weak. It is fair to say that, despite greatly to as a fundamental need and an area to which increased resources, the state of the response to UNAIDS should continue to commit itself— AIDS is currently at a vulnerable moment.”53 but with more intensity and focus than in the While groups that are left out of prevention are past. oft en also left out of treatment, programs like Th e role of civil society can be unique and PEPFAR have established a treatment impera- complementary to government, particularly in tive that has had a further debilitating eff ect by work on HIV and AIDS where politicians can drawing attention away from prevention inter- be pressured into responding to the needs of ventions, despite their narrowly focused invest- populations that might otherwise be invisible. ments in prevention.54 Globally, HIV preven- Civil society groups can be eff ective in hold- tion services reach fewer than 1 in 5 sex workers ing governments accountable for national and and fewer than 1 in 10 injection drug users and global commitments. And civil society plays a men who have sex with men.55 Th is represents critical role in working for increased expressions an international failure to mitigate the inexo- of demand for quality services to national gov- rable growth in the number of cases and the ernments and bilateral and multilateral donors consequent burden on individuals, households, such as the Global Fund. Such African organi- communities, and governments. zations as Uganda’s Th e AIDS Support Orga- Prevention, particularly in relation to pop- nization (TASO) and South Africa’s Treatment ulations with high rates of infection, such as Action Campaign (TAC) use community-based prisoners, sex workers, injecting drug users, action and legal tactics to motivate appropriate and men who have sex with men, is an area in government responses.56 Indigenous grassroots which evidence-based policies are sorely lack- civil society with leadership that includes people ing. UNAIDS has an important contribution living with HIV and people from marginalized to make in driving a prevention agenda that populations is needed to: avoids harmful polarization against treatment. • Ensure high-quality, equitable treatment Populations excluded from prevention are also and prevention programs. systematically excluded from antiretroviral • Create strong accountability systems. therapy in many countries, to the detriment of • Strengthen political will at the country level eff ectiveness of national responses. UNAIDS to fi ght AIDS and increase investments in should also do more to push for removal of these health. barriers to treatment and to support all forms of • Increase the quality of interactions with na- care, including palliative care where needed. tional and global funders. • Move faster to reach the targets countries 4. Focus on creating more opportunities have already committed to. for marginalized voices in national And UNAIDS should play a stronger role in policymaking supporting and calling for such civil society By building close relationships to member leadership and in helping strengthen those orga- country governments, national AIDS councils nizations to serve more eff ectively. (NACs), Country Coordinating Mechanisms UNAIDS should help build grassroots capacity to advocate and increase UNAIDS linkages to other organizations and political venues. 53. Horton and Das 2008, 421. For instance, some working group members 54. Over 2008. 55. Dube and Csete 2008. 56. Piot, Russell, and Larson 2007.

UNAIDS: PREPARING FOR THE FUTURE 17 noted that UNAIDS needs to expand its work the role of UNAIDS as a broker and imple- with faith-based organizations. Capacity build- menter of technical assistance became con- ing would mean working eff ectively with all af- fused. In addition, there were reports of variable fected people—which means in many countries quality in some of the Technical Support Facili- especially with organizations for sex workers, ties (TSFs)—the pools of consultants managed injecting drug users, men who have sex with through UNAIDS—and in some cases a lack men, and other marginalized populations (such of knowledge of the roles of other entities, such as adolescent girls, migrants, and refugees)—to as the Global Implementation Support Team gain voice and address the structural, legal, and (GIST) and the AIDS Strategy and Action Plan societal barriers that may face them. UNAIDS Service (ASAP),58 two additional technical as- has helped build capacity in the past, for exam- sistance facilities. Th e new Coordinating AIDS ple, in Malawi where it assisted in mobilizing an Technical Support database (CoATS), estab- early grassroots response.57 lished in October 2008, aims to provide timely information on the type, quality, and origin of 5. Reduce wasteful capacity-building expertise delivered in country. Th e impact of efforts by brokering higher-quality, this initiative has yet to be assessed.59 long-term locally demanded UNAIDS should ensure that support is technical support making a positive impact. To do so, the Secre- UNAIDS has responded to the gaps in coun- tariat should foster feedback mechanisms that try-level planning, program design, and imple- are transparent and clearly communicate to mentation capacity by linking governments, end users how technical support entities com- NACs, and civil society to fi nancial resources plement each other. In delivering or brokering and technical support, including for the prepa- technical support, UNAIDS should ensure that ration of proposals for submission to the Global the support is sustainable and available over Fund and other funding sources. Governments the long term. To the maximum extent possi- need help to improve capacity for policy devel- ble, technical support should come from local opment, program design, and implementation; sources. To reduce unfair competition and help key civil society groups, particularly those that build local capacity, only where local support is represent marginalized populations, need sup- not available should UNAIDS turn to resources port with coalition development, advocacy, outside the given country or region. budget tracking, and other activities and may need an established body to recognize their 6. Enhance coordination within the UN legitimacy. At times UNAIDS has demon- family and with other donors, and use strated that it can play an important role in clear milestones to track progress supporting governments and regional bod- Although UNAIDS has contributed to coor- ies through capacity-building activities such dination through such initiatives as the “Th ree as with the Southern African Development Ones” and to monitoring the progress in expand- Community, with which UNAIDS assists in ing access to treatment, it can do more and the development of regional research agendas and epidemic update reports. 58. UNAIDS 2008c. For more on technical assistance see Th e working group believes that UNAIDS www.unaids.org/en/CountryResponses/TechnicalSupport/ should continue to focus on supporting country- default.asp. level capacity, and in doing so, it should strive 59. CoATS is a shared database with up-to-date information for uniformly high-quality technical support, on technical support activities. It is anticipated that major restricting its role to “matchmaker” or broker. partners will input data on planned and ongoing technical Anecdotes off ered by individuals throughout support activities. Th e database will provide information on providers, funders, and recipients of such support. For more consultations highlighted instances of where information see www.unaids.org/en/KnowledgeCentre/ Resources/FeatureStories/archive/2008/20080310_ 57. Knight 2008. CoATS.asp.

18 UNAIDS: PREPARING FOR THE FUTURE better to coordinate the programs of cosponsors that UNAIDS examine mechanisms for clari- and to collaborate with other actors. fying division of labor between the UNAIDS At present, the policies and practices of co- Secretariat and the cosponsors in a way that sponsors are coordinated through mechanisms recognizes the unique contributions of the or- like the Committee of Cosponsoring Organi- ganizations involved. Suggestions for further zations (CCO); the Programme Coordinating improvements in this area are made in a later Board (PCB), the primary governance structure section. of UNAIDS where cosponsors have seats, but In addition, the working group recommends no votes; and the Unifi ed Budget and Workplan that UNAIDS explore more ways to build in- (UBW), which specifi es the division of labor country capacity to help countries “corral the among cosponsors. At the regional and country donors” so they provide complementary support level they are coordinated through the Regional for the national priorities and plans developed Coordinators, Regional Support Teams, theme with genuine civil society involvement. Th is groups, the Resident Coordinator system, and might, in part, be realized through the “Deliv- the UN Joint Teams on AIDS and, where the ering as One” UN reform initiative, which in individuals are strong and active, through the eight countries is testing principles of how the UNAIDS Country Coordinator (UCC). UN family can be better coordinated at the Although UNAIDS has helped to raise HIV country level.64 Th ese eff orts are in their early on cosponsors’ agendas, division of labor and stages; Tanzania, however, has documented program management under the CCO have been progress in aligning UN and government fi nan- deemed ineff ective in past reviews.60 In the view cial and planning cycles. At the same time, the of many individuals consulted at both global Tanzania experience has revealed challenges in and national levels, inadequate leadership by shift ing a project-based UN system to a unifi ed, UNAIDS has resulted in power struggles among policy advisory role.65 UNAIDS should partici- the various UN bodies and a joint work plan that pate actively in this process and analyze and dis- does not adequately delineate responsibility. Th is seminate lessons about what is occurring at the causes some issues to have multiple owners—for country level, including how this process is af- example, prevention of mother-to-child transmis- fecting its operations and interactions with civil sion (MTCT), which falls under the mandate society and governments. Moreover, UNAIDS of a number of cosponsors. Th e result has been can develop, promote, and apply performance duplication of eff ort, unhealthy competition for evaluation methods related to coordination for funding, and gaps in some areas.61 its staff and staff of other UN entities. A 2007 review of UN progress toward meet- Outside UNAIDS unique contributions ing Millennium Development Goal (MDG) 6, have been made by major donors, such as the target 7 (to have contained the spread of HIV Global Fund and U.S. PEPFAR. While coun- by 2015), recommends that UNECOSOC re- tries have the ultimate authority—though oft en view and strengthen the UNAIDS mandate, in- not the capacity—to coordinate their own AIDS cluding enhancing Secretariat authority to lead responses, fragmentation can be addressed, and ensure accountability among cosponsors.62 in part, by developing more concrete arrange- Th is might include examining further the de- ments between institutions in a way that rec- lineation of responsibility in the UBW, a docu- ognizes complementarities. Th e recent Memo- ment in which ownership for nearly every out- randum of Understanding between UNAIDS put is joint.63 Th e working group recommends and the Global Fund, for instance, recognizes

60. UNAIDS 2002a, b. 64. United Nations 2006. Th ese countries include Albania, Cape Verde, Mozambique, Pakistan, Rwanda, Tanzania, 61. Yussuf 2007. Uruguay, and Vietnam. 62. Yussuf 2007. 65. Offi ce of the United Nations Resident Coordinator in 63. UNAIDS 2008a. Tanzania 2008.

UNAIDS: PREPARING FOR THE FUTURE 19 the unique fi nancial resource strengths of the provide a tool for the UNAIDS Secretariat and Fund and UNAIDS advocacy and capacity- the PCB to achieve recommendations that have building linkages on the ground. It sets out a already been outlined in this report. mutual intent to collaborate on a number of • Make the governing board more transparent overarching objectives that include universal and representative of those most aff ected. access, inclusive national leadership and owner- Th e PCB is arguably one of the most in- ship, improved aid eff ectiveness, advocacy, and novative governance mechanisms in the UN partnerships.66 system due to its wide-ranging membership, Even with redoubled eff orts, it is likely that notably from organizations of people living making progress on promoting coordination with HIV and other nongovernmental or- within the UN system, and among external ganizations (NGOs).67 But it should assess partners, will remain diffi cult. Each agency its current transparency by ensuring that in- has a strong incentive to follow its own narrow formation about staffi ng numbers and roles mandate and to show success in its own targets, is in the public domain. At a minimum, the without necessarily contributing to broader col- Secretariat and program could match the lective goals. Th e result is that individual agen- disclosure policies of other international cies jealously guard their own turf and spawn organizations such as the Global Fund. their own new initiatives. Staff are rewarded for Th e PCB should also examine how it promulgating narrow agency goals but not for might align more eff ectively with the gov- contributing to the broader collaborative goals. erning bodies of cosponsors, by taking a In light of this, the working group believes careful look at the CCO and alternative that the UNAIDS Secretariat must constantly options for coordination. One proposal highlight the agreed overall collective goals was for the Secretariat to include employees and remind cosponsors and other collaborat- from the cosponsoring agencies, rather than ing partners of them and should establish clear employees only of a separate entity. milestones and performance criteria to track the Th ere are also several ways to enhance contributions of individual agencies and their representation on the PCB. One is to allow staff ’s progress toward these goals. isTh role permanent seats for hyperendemic coun- would be consistent with broader UN reforms tries that wish to join. A second is to bet- toward “One UN.” ter support civil society organizations in interactions with the PCB, for example, 7. Examine the structure, management, through pre-briefi ngs. A third, discussed at and operations of UNAIDS the December 2008 PCB meeting, might If UNAIDS is to fully succeed in encouraging be to include members of civil society in na- accountability, fostering coordination, provid- tional delegations to the PCB, in addition ing a trusted source of evidence-based policy to the current representation of NGOs on guidance, and supporting capacity building the board.68 for voice and action, then a careful look at the structure, management, and operations of UNAIDS is needed. Criticism and suggestions 67. Th e PCB comprises representatives of 22 governments from all geographic regions, the UNAIDS Cosponsors, for improvement were heard during interviews and five representatives of nongovernmental organiza- and consultations across the four areas high- tions, including associations of people living with HIV; lighted below. Th e working group suggests civil society representatives do not have voting rights. For that a more in-depth organizational assessment composition of the PCB see http://data.unaids.org/pub/ occur across these areas in Mr. Sidibé’s fi rst year InformationNote/2009/pcb_members_updated_en.pdf; for full Modus Operandi for PCB and TOR for CCO see http:// of offi ce (by January 2010). Th is assessment will data.unaids.org/Governance/PCB01/mojune99rev_en.pdf. 68. See resolutions from 23rd PCB at http://data.unaids. 66. UNAIDS and Global Fund to Fight AIDS, Tuberculosis org/pub/InformationNote/2008/20081208_pcb_23_ and Malaria 2008. decisions_en.pdf.

20 UNAIDS: PREPARING FOR THE FUTURE • Improve the coordination framework • Institute robust mechanisms for further infor joint funding, priority setting, and dependent, scientifi c technical review and implementation. oversight. UNAIDS Unifi ed Budget and Work- While UNAIDS already hosts workplan (UBW) is a unique planning tool for ing groups and reference groups,73 it might activities across the cosponsors and Sec- be able to leverage the use of independent retariat.69 But having made few real gains scientifi c councils or research advisory on coordination, the UBW appears to be boards, as was done in other areas with insufficient.70 While it applies mecha- the formation of the Inter-Governmental nisms such as Results-Based Management Panel on Climate Change (IPCC) and (RBM) in principle, it was noted that the Strategic Advisory Group of Experts there are no documented examples where (SAGE) of the WHO Vaccines and Bio- funds have been withheld from under- logicals program. performing agencies. Th is violates some It was also suggested during the con- of the well established preconditions for sultation process that UNAIDS needs to success of an RBM approach.71 Th e UBW be more responsive to local epidemics and should pay more attention to clear metrics, research agendas driven by local research- milestones, divisions of responsibility, and ers working at the country level. One sug- consequences. gestion was to create regional research hubs UNAIDS might move toward fund- and strengthen relationships with under- ing by core contributions so that the infl u- used WHO Collaborating Centres. For ence of donors would be muted preventing instance, the relationship with HEARD, politicking on such controversial issues as at the University of KwaZulu-Natal, is un- needle exchange and rights of sex workers. derused. Information collected at these re- UNAIDS could also explore alternative gional hubs could then be integrated at the fi nancial opportunities and consider mov- global level. ing to longer-term planning. Th e PCB is • Align the staffi ng in Geneva and in country moving to a four-year planning cycle.72 Th is with the institutional mission. would create alignment with the current One of the most consistent suggestions planning cycles of 7 of 10 cosponsors and heard throughout consultations was the allow UNAIDS to plan for commitments need for the UNAIDS Secretariat to be over a longer time frame, strengthening the “right-sized.” Th e organization is perceived core functions discussed above. by some observers as larger than is needed to fulfi ll core functions, with particular con- 69. Th e UBW combines the work of the 10 cosponsors of cerns about the number of staff working at UNAIDS and the Secretariat in a biennial budget and work- the Geneva headquarters (see fi gure 1 for plan. Its aim is to maximize the coherence, coordination, and current organizational structure as well as impact of the UN’s response to AIDS. In theory, the UBW ensures unifi ed and coordinated action around joint priorities staff numbers). Reduction or other changes and results delivered in a framework for joint implementa- in size and reorientation of expertise may tion. For more information see UNAIDS 2008a. be needed at headquarters and regional 70. Yussuf 2007. and country levels so that the structure of 71. UNDG 2009. UNAIDS meets its focused priorities and 72. See meeting notes from 22nd PCB (http://data.unaids. functions. org/pub/InformationNote/2008/20080216_item_7_ ubw_cycle_fi nal_en.pdf); information note on 2007–2011 73. For example, see UNAIDS/WHO Working Group on Strategic Framework (http://data.unaids.org/pub/ Global HIV/AIDS and STI surveillance at www.unaids. InformationNote/2008/20081031_strategicframework_ org/en/KnowledgeCentre/HIVData/Epidemiology/epi- fi nal_en.pdf); and draft resolutions from 23rd PCB (http:// workinggrp.asp. For membership of the UNAIDS Refer- data.unaids.org/pub/InformationNote/2008/20081208_ ence Group see www.unaids.org/en/KnowledgeCentre/ pcb_23_decisions_en.pdf). HIVData/Epidemiology/.

UNAIDS: PREPARING FOR THE FUTURE 21 Based on issues raised during interviews require only limited support, and yet another and consultations, this alignment might exam- may require no UNAIDS presence at all. It was ine appropriate skill mix, epidemic knowledge, also suggested that staff may undertake cross- and UN staff designation commensurate to re- agency secondments (starting at one agency and sponsibilities and need in both the Secretariat rotating between UN agencies before eventu- and the cosponsors. Th is would include a criti- ally returning to where one began), to facilitate cal examination of how staffi ng can be tailored greater institutional harmonization, to harbor a in country and a sense of realism about how better sense of a “One UN” perspective, and to one country may require robust support and build a career path that enables greater levels of the presence of UNAIDS while another may professional options.

Figure 1 Organizational structure of UNAIDS in Geneva

UNAIDS total staff: 900

Executive Director

Executive staff: 14 Deputy Deputy Executive Director, Internal Executive Director, Management and oversight Program External Relations

Staff: 116 Staff: 71 Staff: 4 Staff: 84

Evidence, Strategic Technical and Partnerships Global Coalition Resources monitoring, country operational and external on Women and AIDS management and policy intelligence support relations Gender

Office of Chief Aid effectiveness Partnerships Planning and financial Scientific Advisor Country coordination Civil society partnership resources management and global financing Advocacy and campaigns Planning performance mechanisms Corporate and private sector Finance Programmatic Resource mobilization Administration priorities and support Liaison and Geneva Prevention, care, Technical support total staff: 289 and support National capacity support Communications and Human resources Humanitarian response Implementation and knowledge sharing management programming support Communications and media Staffing and recruitment Content management Compensation and benefits Monitoring and evaluation Web management People development Monitoring operation Program oversight Research and evaluation and support Country monitoring systems Field support workplan Board and Information management Technical reports Performance monitoring UN relations and technology Information management and architecture Epidemiology and analysis Liaison offices Field information technology services Epidemic and impact monitoring New York Network and infrastructure management Epidemiology and evidence Washington, D.C. Systems integration and development dissemination Brussels Global service desk

AIDS ﬁnancing and economics Resource tracking, needs, and costing Economic development analysis

Asia Caribbean East and Europe Latin Middle East and West and Country offices Pacific Southern Africa America North Africa Central Africa and regional support teams total staff: 611 Country offices (81)

Staffing numbers are approximate and take into account all fixed-term and short-term staff working for UNAIDS, including staff through WHO and UNDP contracts, interns, staff on leave, and replacement staff. UN volunteers, consultants, and cosponsor staff are excluded as recruited on different terms and conditions. WHO provides administrative and financial services for UNAIDS. UNAIDS staffing budget: 10% of staff funded from extrabudgetary resources, approximately 35% at headquarters and regional support team level, including Junior Professional Officers, and 55% at country level. The total full- time equivalent staff working on HIV/AIDS in the UN system represents a 64% increase over the previous two years.

22 UNAIDS: PREPARING FOR THE FUTURE Moving forward

Leadership transitions are volatile periods, signaling uncertainties for staff and partners. At UNAIDS managing the transition will require Michel Sidibé to balance continued daily operations in the Secretariat and work with cosponsors with bold, decisive changes across the organization. Following the fi rst Executive Director of UNAIDS will be diffi cult. But Mr. Sidibé’s eight years of insider experience make him a formidable fi gure at the Secretariat. His experience gives him knowledge of the organization’s internal workings that can contribute to an eff ective reshaping of the UNAIDS mission and includes a nuanced understanding of the limits to addressing organizational and governance issues more broadly symptomatic of the UN system. Sidibé will need to contribute to a debate on the process of UN reform and refl ect on how that may impinge on the work of UNAIDS. Th e United Nations reform is grounded in the principles of harmonization outlined in the Paris and Ac- cra Declarations. Th is reform will likely aff ect UNAIDS, requiring an assessment of how the organization interacts with those in the United Nations and with a fragmented group of external global health actors who work on HIV. In this context it is even more vital to clarify the precise mission and purpose of UNAIDS.

Th e working group believes that the core mission and AIDS; in ensuring well coordinated global of UNAIDS should be to use its status and stra- eff orts; and in embedding responses in a long- tegic connections as a UN entity to press gov- term strategy informed by national government ernments to uphold their existing commitments and civil society perspectives. and to take on new ones that refl ect approaches Th e recommendations in this report pro- to containing and treating the AIDS epidemic vide guidance on how UNAIDS might bet- that are at once grounded in scientifi c evidence ter achieve this mission, while recognizing the and human rights. It should lead by example— undiminished importance of this unique joint in working with those most aff ected by HIV program.

UNAIDS: PREPARING FOR THE FUTURE 23 ANNEX A Working group biographies

Joanne Csete is assistant professor of health and Dube was born in Calcutta in 1961. He human rights at Columbia University Mailman studied at Tuft s University, the University of School of Public Health and director of the Pol- Minnesota’s School of Journalism, and the icy and Law Program of the Department of Pop- Harvard School of Public Health, where he ulation and Family Health. She was previously completed his MS in 1991. He has since been the director of programs and interim executive scholar-in-residence at Yale University’s center director at the Firelight Foundation, respon- for interdisciplinary research on AIDS and a sible for managing Grantmaking, Monitor- long-term visiting fellow at the Centre for the ing, Evaluation and Technical Assistance, and Study of Developing Societies, Delhi. He has Advocacy Programs. Before that Csete was the been awarded research grants by the Ford Foun- Executive Director of the Canadian HIV/AIDS dation and the U.S. Institute of Peace. Legal Network, one of the world’s leading orga- Dube has worked and consulted for the nizations working on legal and human rights World Bank, UNICEF, WHO, and other inter- issues related to HIV/AIDS. She founded and national organizations, most recently as senior directed the HIV/AIDS and Human Rights advisor to the executive director of UNAIDS. Program at Human Rights Watch in New York, In 2006 Dube, the writer Vikram Seth, and where she oversaw research and advocacy on a the historian Saleem Kidwai initiated a cam- wide range of human rights violations related paign by prominent Indians to decrim inal ize to the AIDS epidemic, including abuses suf- same-sex relations. In 2003 he helped organize fered by children aff ected by HIV/AIDS. She the fi rst-ever conference on the UN system’s re- also worked for UNICEF for more than seven sponsibilities for protecting the rights of sexual years, including as Chief of Policy and Programs minorities. at the UNICEF Regional Offi ce for Eastern and Southern Africa. Dr. Tim Evans, of Canada, is the Assistant Csete lived in sub-Saharan Africa for more Director-General for Information, Evidence, than 10 years, working on a range of health and and Research. Previously, Evans was the Assis- nutrition programs for children and women. tant Director-General for Evidence and Infor- She was also on the faculties of International mation for Policy. He has a bachelor of social Development Studies and Nutritional Sciences sciences from the University of Ottawa and a at the University of Wisconsin–Madison for doctor of philosophy in agricultural economics fi ve years. from the University of Oxford, as well as a doctor of medicine from McMaster University in Siddharth Dube is a senior fellow at the World Canada. Policy Institute. A writer and commentator on Evans trained in internal medicine at the poverty, public health, and development, Dube’s Brigham and Women’s Hospital at Harvard books include In the Land of Poverty: Memoirs University. He was an assistant professor of in- of an Impoverished Indian Family, 1947–1997 ternational health economics at the Harvard and Sex, Lies and AIDS. He is currently work- School of Public Health. From 1997–2003 ing on a historical account of AIDS in India, to Evans was Director of Health Equity at the be published in 2010. Rockefeller Foundation.

24 UNAIDS: PREPARING FOR THE FUTURE Jacob Gayle began working with the Ford Human Rights; and chair of the Department of Foundation in 2005, as deputy vice president, Global Health and Social Medicine at Harvard to serve as a focal point for the Foundation’s Medical School. Kim is currently leading a new Global HIV/AIDS Initiative. He also maintains Harvard University–based initiative in Global adjunct associate professor status at the Emory Health Delivery designed to discover and share University Rollins School of Public Health. knowledge about the eff ective implementa- During his 16-year career through the U.S. Cen- tion of health programs in poor countries. Kim ters for Disease Control and Prevention (CDC) returned to Harvard in December 2005 aft er a prior to arrival at Ford, Gayle served as Special three-year leave of absence at the World Health Assistant to the Director/HIV for matters Organization (WHO), where he was director of pertaining to United States racial and ethnic the WHO’s HIV/AIDS department and advi- minority populations and for HIV-related social sor to the WHO director-general. and behavioral interventions (1989–91). At the Kim has 20 years of experience in improving direct request of former U.S. President Jimmy health in developing countries and trained du- Carter, Gayle served as Health Secretariat ally as a physician and medical anthropologist. for Th e Atlanta Project at the Carter Center He received his MD and PhD from Harvard (1991–92). Th ereaft er, as a CDC senior public University. Kim has been recognized on nu- health offi cer in global health, Gayle completed merous occasions as a global leader and distin- interagency assignments at the U.S. Agency for guished professional, including being awarded International Development (USAID), Joint a MacArthur “Genius” Fellowship in 2003; United Nations Programme on HIV/AIDS being named one of America’s 25 best leaders (UNAIDS), United Nations Development by US News & World Report in 2005; and being Program (UNDP), and World Bank and was named one of the 100 most infl uential people in assigned to U.S. embassies and missions in Bar- the world by Time magazine in 2006. bados, South Africa, Switzerland, and Trinidad and Tobago. He has authored several refereed Danielle Kuczynski (program coordinator) publications within the fi eld of public health joined the Center for Global Development in and HIV/AIDS throughout his professional September 2007. Prior to joining the Center, career and continues to receive awards and rec- Kuczynski worked in Tanzania with the Uni- ognition for his service in global health and versity of Toronto’s HIV/AIDS Initiative– more specifi cally, HIV/AIDS. Following his Africa as a Knowledge Network Offi cer. In BS at Oberlin College (Psychobiology) in 1979, addition to other overseas experience, her work Gayle completed an MS in preventive medicine, in the public sector includes a 2006 Policy Ana- an MA in health education/community health, lyst post with the Ontario Ministry of Health and a PhD in community and international Promotion. In 2005 Kuczynski completed an health, all from Ohio State University, before MS in international health policy at the Lon- becoming an Associate Professor in community don School of Economics and Political Science and international health at Kent State Univer- where she wrote her dissertation on examining sity (1985–89). perceived barriers to antiretroviral adherence in South Africa. Additionally, she holds a BS in Jim Yong Kim, MD, PhD, holds appointments honors psychology from the University of West- as François Xavier Bagnoud Professor of Health ern Ontario. and Human Rights at the Harvard School of Public Health and Professor of Medicine and Ruth Levine (chair), vice president for programs Social Medicine at Harvard Medical School. and operations and senior fellow at the Center for He is chief of the Division of Global Health Global Development, is a health economist with Equity at Brigham and Women’s Hospital, a more than 15 years of experience designing and major Harvard teaching hospital; director of the assessing the eff ects of social sector programs in François Xavier Bagnoud Center for Health and Latin America, Eastern Africa, the Middle East,

UNAIDS: PREPARING FOR THE FUTURE 25 and South Asia. Before joining CGD, Levine Merson has authored more than 175 ar- designed, supervised, and evaluated loans at the ticles, primarily in the area of disease preven- World Bank and the Inter-American Develop- tion. He currently serves in advisory capacities ment Bank. Between 1997 and 1999, she served for UNAIDS; the Global Fund to Fight AIDS, as the advisor on the social sectors in the offi ce Tuberculosis and Malaria; the World Bank; of the executive vice president of the Inter-Amer- and the Doris Duke Foundation. He is a mem- ican Development Bank. ber of the Bill & Melinda Gates Foundation’s Levine has a doctoral degree in economic Global HIV Prevention Working Group and demography from Johns Hopkins University has served on several NIH review panels and and is the co-author of the books Th e Health advisory committees. of Women in Latin America and the Caribbean (World Bank 2001) and Millions Saved: Proven Lillian Mworeko, a Ugandan HIV-positive Successes in Global Health (CGD 2004), which woman, currently working with the Interna- has been updated with a new edition as Cases tional Community of Women living with HIV in Global Health: Millions Saved (Jones and (ICW, East Africa), has worked with many net- Bartlett 2007). She has also authored major re- works at the national level. She has been involved ports, including A Risky Business: Saving Money at international, national, and regional levels in and Improving Global Health through Better advocacy for the rights of people living with Demand Forecasting (CGD 2007), When Will HIV and AIDS and is a human rights activist. We Ever Learn: Improving Lives through Impact Evaluation (CGD 2006), and Making Markets Nandini Oomman joined CGD in March for Vaccines: Ideas to Action (CGD 2005). 2006 as the director of the HIV/AIDS Moni- tor, which tracks the eff ectiveness of the three Michael H. Merson is the founding director main aid responses to the epidemic: the Global of the Duke Global Health Institute, Wolfgang Fund, the HIV/AIDS Africa MAP program of Joklik Professor of Global Health, and Profes- the World Bank, and the U.S. President’s Emer- sor of Medicine, Community and Family Medi- gency Plan for AIDS Relief. Oomman manages cine, and Public Policy at Duke University. He the initiative and oversees much of the research joined the Duke faculty in November, 2006. program that underpins it. She has more than Merson also served as the fi rst Dean of Public 15 years of public health research, program, and Health at Yale University School of Medicine policy experience, with emphasis on population, from 1995–2004, and in 2001 he was named reproductive health, and HIV/AIDS. as the Anna M. R. Lauder Professor of Public Before receiving her doctorate from the Johns Health in the Yale University School of Medi- Hopkins University School of Public Health, cine. From 1999–2006 he also served as Direc- Oomman managed an urban HIV/AIDS pre- tor of the Center for Interdisciplinary Research vention program for commercial sex workers on AIDS at Yale University. and college youth in Mumbai, India, and led In 1978 he joined the World Health Orga- the technical development of an HIV/AIDS nization (WHO) as a Medical Offi cer in the mass media campaign in the same city. In 1996 Diarrheal Diseases Control Program. He served a post-doctoral fellowship took her to the Rock- as director of that program from January 1980 efeller Foundation where she managed techni- until May 1990. In August 1987 he was also ap- cal assistance for a research grants program on pointed Director of the WHO Acute Respira- improving reproductive health service delivery tory Infections Control Program. In May 1990 in Asia and sub-Saharan Africa. From 2002–04 he was appointed Director of the WHO Global Oomman worked as a specialist in population, Program on AIDS. Th is program was opera- reproductive health, and HIV/AIDS issues tional worldwide and responsible for mobiliz- at the World Bank. Just before joining CGD, ing and coordinating the global response to the she consulted with private foundations in the HIV/AIDS pandemic. United States as an independent researcher.

26 UNAIDS: PREPARING FOR THE FUTURE She has published widely on issues concerning UNAIDS Global Coalition on Women and reproductive and women’s health. AIDS. Gupta was the recipient of the 2007 Washington Business Journal’s “Women Who Nana K. Poku is a John Ferguson Professor Mean Business” award and is frequently recog- of African Studies at the University of Brad- nized for her commitment to quality research ford. He joined the University’s Peace Studies and dedication to the protection and fulfi ll- Department in 2006 from the United Nations ment of women’s human rights. where he held the posts of Senior Policy Advi- Gupta is regularly sought out by the devel- sor to the Executive Secretary of the Economic opment community and media and has been Commission for Africa (ECA) and Director quoted by Th e Washington Post, Th e New York of Research for the United Nation’s Secretary Times, and USA Today, as well as other national General’s Commission on HIV/AIDS and Gov- and international news sources. ernance in Africa (UN-CHGA). He currently serves as a Special Advisor to the Government Asia Russell has worked extensively as part of of Ghana on Poverty Reduction Strategy Papers the U.S. and international AIDS activist move- and health issues and has led 14 appraisal mis- ments over the last 12 years, focusing on treat- sions in 11 countries in Africa. He has also been ment access, particularly among low-income an advisor to the European Union, the World people and other marginalized groups. She is Bank, the OECD, the World Health Organiza- currently the director of International Policy tion, and the United Nations Development Pro- for Health GAP, a U.S.-based activist NGO gram, among other international agencies. founded in 1999 to close the gap in access to Before joining the United Nations, Poku aff ordable AIDS medicines between devel- taught and researched on the impact of oping and developed countries. Health GAP HIV/AIDS and human security issues in Africa campaigns for the resources necessary to sustain at Southampton University, UK. His research access to AIDS treatment for all, with a focus interests include the links between health and on the role of U.S. policies in obstructing sus- political instability, poverty and vulnerability, tainable access to lowest-cost AIDS treatment. globalization and inequality, and confl ict and Since 1995 Russell has also been an orga- children in Africa. On these issues, he has au- nizer and member of ACT UP Philadelphia, the thored and coauthored more than 50 scholarly largest grassroots AIDS activist organization in articles in refereed journals and has written and the United States. Russell has coordinated the edited 12 books. eff orts of successful ACT UP campaigns on issues ranging from national AIDS drug pricing Geeta Rao Gupta has been president of the policies to health care justice for U.S. prisoners International Center for Research on Women and detainees with AIDS or hepatitis C. Rus- (ICRW) since 1997. Prior to becoming presi- sell also serves as a board member represent- dent, she held a number of positions with ing northern NGOs to the board of the Global ICRW, including consultant, researcher, and Fund to Fight AIDS, Tuberculosis and Malaria offi cer. She is frequently consulted on issues and on the Global Fund’s Policy and Strategy related to AIDS prevention and women’s vul- Committee. nerability to HIV and is a dynamic advocate for women’s economic and social empowerment to Devi Sridhar (senior researcher) is a post- fi ght disease, poverty, and hunger. doctoral fellow in politics at All Souls Col- Gupta served as co-chair of the UN Sec- lege, Oxford. She also directs the GEG’s Global retary General’s High Level Panel on Youth Health Project and is a Senior Research Associ- Employment and co-chaired the UN Millen- ate at Oxford’s Centre for International Studies. nium Project’s Task Force on Promoting Gen- She has worked with a number of UN agencies, der Equality and Empowering Women from civil society organizations, and ministries of 2002–05. She also serves as an advisor to the health in emerging and developing countries.

UNAIDS: PREPARING FOR THE FUTURE 27 Sridhar is the author of Th e Battle Against Health Economics and HIV/AIDS Research Hunger: Choice, Circumstance and the World Division (HEARD) at KwaZulu-Natal Uni- Bank (2008, foreword by Amartya Sen) and versity, where he is now Professor of Health editor of Inside Organisations: South Asian Economics and the Director of this division. Case Studies (2008). She holds a PhD and MPh For 10 years (1983–94) he worked as Research from Oxford and a BS from the University of Fellow/Senior Research Fellow for the Eco- Miami. nomic Research Unit, University of Natal (now University of KwaZulu-Natal). Before that, he Todd Summers is a Senior Program Offi cer worked as an Economist for the Overseas Devel- for Global Health at the Bill & Melinda Gates opment Institute in the Ministry of Finance and Foundation. His primary responsibility is lead- Development in Gaborone, Botswana. He is the ing the foundation’s advocacy eff orts on HIV, author of numerous articles and books, most including work on supporting the Global HIV recently HIV/AIDS: A Very Short Introduction Vaccine Enterprise and the Global Fund to (2008). He was a Commissioner on the UN Fight AIDS, Tuberculosis and Malaria. Commission on HIV/AIDS and Governance in Before joining the staff in February 2005, Africa and is the elected treasurer of the Inter- Summers was president of Progressive Health national AIDS Society Governing Council. Partners, a D.C.-based consulting firm he He is also a Governor of Waterford Kamhlabe founded in 2000, specializing in public health United World College in Swaziland. policy. Principal clients included the Bill & Melinda Gates Foundation, the Kaiser Family Ngaire Woods (chair) is Professor of Interna- Foundation, and the University of California, tional Political Economy and Director of the San Francisco. Global Economic Governance Programme at From 1997 to 2000 Summers was the Oxford University. She was educated at Auck- deputy director of the White House Offi ce of land University (BA in economics, LLB Hons National AIDS Policy. While there, he helped in law). She studied at Balliol College, Oxford, coordinate the nation’s HIV/AIDS programs as a New Zealand Rhodes Scholar, completing among the many federal agencies involved and a MPh in International Relations (with distinc- served as principal liaison to President Clin- tion) and a DPhil. She won a Junior Research ton’s Advisory Council on HIV/AIDS. He also Fellowship at New College, Oxford (1990–92) worked closely with the Offi ce of Management and subsequently taught at Harvard University and Budget to support increased funding for (Government Department) before taking up HIV prevention and care. her Fellowship at University College, Oxford. Before coming to Washington, Summers In 2003 she founded a research program inves- was the executive director of AIDS Hous- tigating how global institutions could better ing Corporation, a nonprofi t organization he respond to the needs of developing countries— helped found in 1990 to develop supported the Global Economic Governance Programme. housing programs for people living with HIV. Her recent books include Th e Politics of Global Summers has also held senior positions in the Regulation (with Walter Mattli, 2009), Th e aff ordable housing and commercial real estate Globalizers: the IMF, the World Bank and development fi elds. He has a BA cum laude in their Borrowers (2006), Exporting Good Gover- Religion from Middlebury College in Middle- nance: Temptations and Challenges in Canada’s bury, Vermont. Aid Program (with Jennifer Welsh, 2007), and Making Self-Regulation Eff ective in Developing Alan Whiteside was born in Kenya and grew Countries (with Dana Brown, 2007). up in Swaziland. In 1980 he obtained an MA in Development Economics from the University Anandi Yuvaraj is the Asia Pacifi c Regional of East Anglia, and in 2003 a DEcon from the Coordinator of the International Community University of Natal. In 1998 he established the of Women Living with HIV/AIDS (ICW),

28 UNAIDS: PREPARING FOR THE FUTURE based in Bangkok. Before joining the ICW, Since testing HIV-positive in 1997, she has Yuvaraj worked as Program Manager for HIV played a vital role in broadening political and and Sexual Reproductive Health at PATH’s social responses to the epidemic in India. She India offi ce, where she managed an advocacy began her work by establishing a local orga- project of the Global Campaign for Microbi- nization to support fellow people living with cides (GCM) in India. She was also employed by HIV in her community, which continues to be the International HIV/AIDS Alliance in India a strong and eff ective program. She has been in- as Senior Programme Offi cer for more than fi ve strumental in mobilizing communities aff ected years. During this tenure she got involved with by HIV/AIDS to raise their voices, needs, and the Global Fund to Fight AIDS, Tuberculosis concerns to build supportive environments. Yu- and Malaria as the Board Representative of the varaj has played a crucial role in mobilizing the Communities Delegation (2004–06). civil society in India to infl uence the NACP-III She is also a member of the national advi- through national level consultations. sory board of the Indian chapter of the Interna- Yuvaraj obtained a masters in zoology from tional AIDS Vaccine Initiative. In addition, she Madras University in Tamil NADU, India, served as a steering committee member, advising with a specialization in fi shery biology. She the development of national strategies for phase completed her thesis from the same university III of the National AIDS Control Programme for a masters in philosophy. She has gained (NACP) in India. Yuvaraj serves on the board of strong experience in the policy, advocacy, and the International Partnership on Microbicides program and fi nancial management of HIV and (IPM) as well. AIDS programs at various levels.

UNAIDS: PREPARING FOR THE FUTURE 29 ANNEX B Participants in background interviews

Alanna Armitage, UNFPA Country Repre- Jim Kim, Harvard University sentative for Brazil Rose Kumwenda-Ng’oma, Christian Health Stefano Bertozzi, Mexico National Institute of Association of Malawi Public Health Stephen Lewis, AIDS-Free World Agnes Binagwaho, Permanent Secretary for Margaret Lidstone, Offi ce of the U.S. Global Health in Rwanda AIDS Coordinator Pierre Blais, Permanent Mission of Canada to Collin McIff , Offi ce of the U.S. Global AIDS the UN, Geneva Coordinator Jonathan Brown, World Bank Jeff rey Mecaskey, Save the Children UK Pedro Chequer, UNAIDS Country Coordi- Michael Merson, Duke University nator, Brazil Lazeena Muna, UNAIDS Bangladesh Alex de Waal, Harvard University Leonard Okello, ActionAid Siddharth Dube, World Policy Institute Nandini Oomman, Center for Global Simone ellisOluoch-Olunya, UNAIDS Darfur Development Roger England, Health Systems Workshop, Jeff O’Malley, UNDP Grenada Mead Over, Center for Global Development Helen Epstein, Author Elizabeth Pisani, Author Helene Gayle, CARE USA Beth Plowman, Independent Consultant Jacob Gayle, Ford Foundation Miriam Rabkin, Rockefeller Foundation/ Adrienne Germain, International Women’s Columbia University Health Coalition (written correspondence) Geeta Rao Gupta, International Center for Joana Godinho, World Bank Research on Women (ICRW) Daniel Halperin, Harvard School of Public Jaime Sepulveda, Bill & Melinda Gates Health Foundation Robert Hecht, Results for Development Jeremy Shiff man, Syracuse University Maxwell Carrie Hessler-Radelet, John Snow School of Public Policy International Francisco Songane, WHO Maternal/Perinatal Omokhudu Idogho, ActionAID Partnerships Andrew Jack, Financial Times Anil Soni, Clinton Foundation Jennifer Kates, Kaiser Family Foundation John Stover, Futures Institute

30 UNAIDS: PREPARING FOR THE FUTURE Todd Summers, Bill & Melinda Gates Gill Walt, London School of Hygiene and Foundation Tropical Medicine Keizo Takemi, Harvard School of Public Health Alan Whiteside, University of KwaZulu-Natal Abel Víquez, Joint Commission Against Desmond Whyms, HLSP AIDS, Costa Rica Roy Widdus, Global Health Futures Derek von Wissell, NERCHA, Swaziland Paul Zeitz, Global AIDS Alliance

UNAIDS: PREPARING FOR THE FUTURE 31 Summary of consultations for UNAIDS

ANNEX C working group and participants

Th e following section summarizes the discus- a de-emphasis on prevention and most at- sions and recommendations that emerged over risk populations. the course of the three consultation meetings in • Build appropriate technical capacity and Washington, D.C. (Center for Global Devel- leadership within the program at the coun- opment), Oxford (Global Economic Gover- try level. nance Programme), and Durban (University of • Engage with leading funders (Global Fund, KwaZulu-Natal). PEPFAR). • Engage with and build civil society capac- Washington consultation ity; an important measure of success will be summary, October 15, 2008 how eff ectively it can do this across diff erent groups and in diff erent country contexts. Th is section summarizes general themes, key • Be leaner and meaner: overall, the organiza- points, and ongoing considerations emerg- tion should become more effi cient and eff ec- ing from discussions held October 15, 2008, tive and critically assess how it can refocus in Washington, D.C. at a meeting convened its current functions. by the Center for Global Development to bring together experts on HIV/AIDS, global Ongoing considerations health, and governance to discuss the future For UNAIDS. of UNAIDS and in particular the functions • History has played a part in driving the for- and areas the next Executive Director should mation of the program, and UNAIDS needs address. to be mindful that this is in part why the organization exists today in its current form. General themes • UNAIDS should clarify the meaning and A number of key points were raised during the role of advocacy with respect to how it func- consultation meeting in Washington, D.C. tions. Are its reporting functions in confl ict Th e discussion focused generally on some of with its advocacy role in keeping HIV/AIDS the roles that UNAIDS should both assume a high global health priority? and retain as well as on drawing out questions • Moving forward, UNAIDS needs to clarify that need to be considered if the organization what its role is at the country level. were to re-evaluate its purpose in the future. • Performance indicators: on what basis Some of these considerations relate to issues should success of the organization be that UNAIDS will be unable to address on its judged? own: they refl ect larger debates that should be • Governance and alternative structures: how addressed by the global health and HIV/AIDS could these better facilitate the necessary communities at large. functions of the program?

Key roles for UNAIDS For UNAIDS and other actors. • Improve evidence base and policy response • Adopt a principle that activities should not to prevention in an environment that has have a negative impact on other priority been focused as of late on treatment, causing health topics. Logical fallacies with respect

32 UNAIDS: PREPARING FOR THE FUTURE to HIV/AIDS crowding out other global Eric Leif, Henry L. Stimson Center health funding should be avoided. Noelle Lusane, Offi ce of Congressman Payne • Support an international response to ensure William McGreevey, Constella Group, LLC; commitment to people on treatment. Georgetown University • Avoid pitting a public health versus human rights response. Michael Merson, Duke University • Consider the current context of the fi nan- Nadeem Mohammad, World Bank cial crisis and what this will mean for devel- Stephen Morrison, Center for Strategic Inter- opment overall and health specifi cally. national Studies Nandini Oomman, Center for Global Participants Development Olusoji Adeyi, World Bank Mead Over, Center for Global Development Smita Baruah, Global Health Council Geeta Rao Gupta, International Center for Carol Bergman, Global AIDS Alliance Research on Women Stefano Bertozzi, Mexico National Institute of Jessica Raper, Georgetown University Public Health Asia Russell, Health GAP (Global Access Natasha Bilimoria, Friends of the Global Fight Project) Gillian Buckley, Johns Hopkins School of Jeremy Shiff man, Syracuse University Public Health Andrew Small, US Council of Catholic Bishops Dennis Cherian, World Vision Shannon Smith, Offi ce of Senator Richard Joanne Csete, Independent Durbin (D-IL) Paul Davis, Health GAP (Global Access Devi Sridhar, Global Economic Governance Project) Programme, Oxford University Robert Eiss, National Institutes of Health Carl Stecker, Catholic Relief Services Roger England, Health Systems Workshop, Michele Sumilas, House Subcommittee on Grenada State, Foreign Operations and Related Jacob Gayle, Ford Foundation Programs Andrew Gibbs, University of KwaZulu-Natal Todd Summers, Bill & Melinda Gates David Gootnick, U.S. Government Account- Foundation ability Offi ce Christos Tsentas, Offi ce of Congresswoman Ester Gwan, World Relief Barbara Lee Daniel Halperin, Harvard University University College, Oxford, Dale Hanson Bourke, the Center for Infec- consultation summary, tious Disease Research in Zambia October 27–29, 2008 Foundation Robert Hecht, Results for Development Th is section summarizes general themes emerg- Jennifer Kates, Kaiser Family Foundation ing from discussions held October 27–29, 2008, Jim Yong Kim, Harvard University; Partners at University College–Oxford at a meeting In Health convened by the Global Economic Governance Programme and the Center for Global Develop- Steve Kraus, UNFPA ment to bring together experts on HIV/AIDS, Danielle Kuczynski, Center for Global global health, and governance to discuss the Development future of UNAIDS and in particular the func- Kristie Latulippe, Center for Global tions and areas the next Executive Director Development should address.

UNAIDS: PREPARING FOR THE FUTURE 33 General themes the expertise of each on HIV/AIDS. Th e co- Four general points emerged from the discus- sponsors should produce research and im- sion. First, UNAIDS is just one of many UN plement programs relevant to HIV/AIDS, bodies in need of reform. Th us, while the and thus UNAIDS should ensure that UNAIDS consultation delved into the particu- cosponsors are in continual dialogue with lar reforms the next Executive Director and the each other. Th e idea was raised of UNAIDS PCB could make, there was general awareness being given the authority to also coordinate that UNAIDS is working within an existing other key actors such as the Global Fund, dysfunctional UN system and chaotic health the Gates Foundation, and PEPFAR. architecture. A second point underscored by While this may not be an offi cial relation, discussions was the key role of individuals UNAIDS could use its scientifi c authority and their leadership in this area, both within on HIV/AIDS (see next point) to monitor the UNAIDS Secretariat staff in Geneva and and ensure compliance. Given this new and in-country and within the cosponsors. A third focused role, one suggestion was put forward point was the importance of enforcing commit- to close down all country offi ces and move ments made by donors in the 2005 Paris Dec- to regional representation. A variant on this laration and 2008 Accra Declaration and the would be to have country offi ces only in hy- need to take developing countries’ voices into perendemic countries or those with diffi cult account, especially on issues of coordination political situations for most at risk groups. and priority-setting. Fourth, it is vital that the Another suggestion was put forward for UNAIDS Secretariat and cosponsor staff tai- demand-driven presence of country offi ces. lor their approach and adapt it to the country No consensus was reached on this point, context. and further discussion is needed. • Show leadership and scientifi c expertise. All UNAIDS core functions participants agreed that UNAIDS needs to Consensus was reached that UNAIDS should become the scientifi c expert on HIV/AIDS focus on creating and enforcing global com- prevention and treatment, demonstrate best mitments and standards rather than opera- practices in country on what does and does tions. First, UNAIDS must hold governments not work, and show real leadership on syn- accountable for global commitments already thesizing evidence in an independent and undertaken, such as for universal access com- rigorous manner. UNAIDS should use its mitments. Second, UNAIDS has an equally position and legitimacy as a UN agency to vital role to play in forging new global standards: say things, backed by evidence, that govern- UNAIDS should be the gold standard in terms ments and politicians fi nd diffi cult to say. of technical and policy guidance (see next sec- Attention was drawn to the terms “science” tion). Participants noted that UNAIDS should and “evidence” to indicate that it should not use its legitimacy conferred by UN status to just be biomedical evidence but also social, show leadership on HIV/AIDS and strengthen behavioral, and political evidence. In terms its role as a focal point in the HIV/AIDS of the epidemiology and surveillance roles, response. participants felt that this could be given back to the WHO. UNAIDS activities to achieve • Use evidence for advocacy. UNAIDS should core functions not only be a scientifi c clearinghouse but To achieve its core functions, participants listed also make sure that the evidence is used to UNAIDS core activities. inform policies by cosponsors, governments, • Coordinate cosponsors and other key actors. and nonstate actors. Th is should be under- Participants noted that UNAIDS should pinned by a strong human rights frame- not be an agency. It should focus on coor- work. UNAIDS should provide clear guid- dinating the cosponsors in order to leverage ance to governments and use the evidence to

34 UNAIDS: PREPARING FOR THE FUTURE advocate on behalf of those most aff ected by should work toward a high percentage of the epidemic. core contributions, rather than a reliance • Focus on high-risk groups. Th roughout the on voluntary funds. Th is was seen as crucial consultation, participants continually noted to ensure that UNAIDS can be a strong sci- that UNAIDS must focus on the most high- entifi c clearinghouse and play an advocacy risk groups aff ected by HIV/AIDS. Th ese role, especially when advocating for more include prisoners, injection drug users, men attention to high-risk groups. who have sex with men, indigenous commu- • Transparency. In addition to transparency on nities, and sex workers. Th e activities as a sci- staffi ng, there was consensus that UNAIDS entifi c clearinghouse, use of evidence to advo- must make available in a publicly accessible cate, and the focus on high-risk groups were and useful manner its fi nancial record and seen as interlinked and central to the future other internal reports, at least to a level simi- role of UNAIDS. In particular, the next ex- lar to the Bretton Woods institutions. ecutive director of UNAIDS should work to In terms of next steps, suggestions were forge agreements on the following neglected given on how best to carry the process further areas: naming groups most at risk, decrimi- at the consultation in Durban at the University nalization, supportive social and legal envi- of KwaZulu-Natal with Professor Alan White- ronments, prisoners, and illicit drug users. side. It was felt that there needs to be more input from developing country government offi cials, Whom must UNAIDS hold to account? specifi cally from those involved in the day-to- UNAIDS was seen as needing to play a stronger day management of HIV/AIDS, as well as more and more central role in holding various actors discussion on whether country offi ces are neces- to account. Th ese included donor governments, sary, and why. multilaterals, the new programs, and cosponsors. However, to be able to do this, certain Participants organizational changes are necessary to build a Rajaie Batniji, Global Economic Governance strong UNAIDS secretariat. Programme, Oxford Kate Brennan, Global Economic Governance What must change in order to fulﬁ ll core Programme, Oxford functions? Joanne Csete, Independent • Staffi ng. Th ere was general agreement that the UNAIDS Secretariat in Geneva should Siddharth Dube, World Policy Institute become leaner and more focused. One Jacob Gayle, Ford Foundation suggestion was to cut the Geneva staff to Harold Jaff e, Division of Public Health and Pri- around 40 technically skilled senior staff . mary Health Care, Oxford More transparency and attention should be Edward Joy, New College, Oxford given to criteria for staff recruitment, pro- Mogha Kamalyanni, Oxfam Great Britain portionate compensation, and subsequent performance measurement to ensure there Danielle Kuczynski, Center for Global is a “strong brain” in Geneva. It was felt that Development there needs to be more auditing of staff lead- Dave McCoy, University College, London ership and technical ability, especially in Justin Parkhurst, London School of Hygiene high-priority areas, with clear benchmarks and Tropical Medicine that must be met. Th e need for country Asia Russell, HealthGap representation was also pointed to as needing further discussion. Ed Scott, Ed Scott Ventures • Funding. Given that the UNAIDS Secre- Francisco Songane, World Health Organization tariat staff numbers, and thus annual bud- Devi Sridhar, Global Economic Governance get required, would be reduced, UNAIDS Programme, Oxford

UNAIDS: PREPARING FOR THE FUTURE 35 Alan Whiteside, Health and Economics and Regional role HIV/AIDS Research Division (HEARD) • Be a neutral broker “with muscle” (at the re- Ngaire Woods, Global Economic Governance gional and country level). Programme, Oxford • Facilitate sharing of local experience between countries. Anandi Yuvaraj, International Community of • Enhance links to regional mechanisms. Women Living with HIV/AIDS (ICW) • Strengthen regional bodies and civil society. • Act as an entry point for policy messages. Durban, South Africa, consultation • Harmonize regional research hubs. summary, November 16–18, 2008 • Coordinate meaningfully with other offi - cial collaborating centers and regional ac- Th is brief overview summarizes areas of conver- tors and agencies. gence that emerged at the Durban consultation. • Have a research agenda driven by local It is broken down by themes that were discussed epidemics. over the course of the meeting as well as specifi c • Facilitate information exchange; link to areas of potential focus for UNAIDS. global level.

General themes Country role • Know your epidemic and its changing • Determine role of UNAIDS by local epidemic, nature. capacity, and level of national response. • Recognize that there are multiple • Coordinate UN actors at the country level epidemics—not just epidemiological but based on recognized capacity. social and economic. • UNAIDS Country Coordinators: choose • Remember that HIV/AIDS is exceptional staff for management and leadership capa- in sub-Saharan Africa. bilities based on local needs; increase status • Support civil society. level of in-country leadership to support • Use local governments to lead. their role as a facilitator of multiple actors. • Take a long-term view. • Bring the “legitimacy” of the United • Consider the fi nancial crisis in planning. Nations. • Advocate for scaling up resources. Role of UNAIDS • Facilitate learning from success and failure. Aft er 25 years of few measurable successes, there • Coordinate beyond the UN system. is a need to “re-tool” the strategy. UNAIDS needs the following: Role in technical support • A leaner, more streamlined secretariat in • Ensure that technical support facility con- Geneva. sultants are high quality and that country • Increased legitimacy to coordinate activities feedback meaningfully informs selection; and open discussion between international consider Southern African Development actors. Community (SADC) as a potential broker. • Articulation of a role to hold donors ac- • Play a role in linking researchers and key accountable to commitments. tors and sharing information. • To be an advocate for resource mobilization. • Be a linker, broker, and capacity builder, • An improved role as a repository for evi- but not a competitor to local implementing dence-based policy/practice/advocacy fed organizations. by local research and priorities of regions hardest hit by the epidemic. Role in structure • Information about the epidemics that goes • Form to follow function. beyond epidemiology to include social and • Refocus Geneva and scale up to refl ect economic impacts. worst-hit regions/countries (vertical).

36 UNAIDS: PREPARING FOR THE FUTURE • Shift resources to epidemic countries/regions, Ben Chirwa, National AIDS Council, Zambia proportional to epidemic (horizontal). Paul Dover, Swedish International • Provide stronger regional and country re- Development Agency (SIDA) sources: resources to match scale. Alan Whiteside, Health and Economics and HIV/AIDS Research Division (HEARD) Role in governance • Increase transparency in selection of PCB Tim Quinlan, Health and Economics and (Programme Coordinating Board). HIV/AIDS Research Division (HEARD) • Consider giving SADC/regional bodies po- Phillip Mokoena, Treatment Action tential observer status (PCB). Campaign (TAC) • Strengthen representation of aff ected coun- Valda Lucas, Sex Worker Education and tries; more permanent seats. Advocacy Task Force (SWEAT) • Give civil society better support in their in- Omokhudu Idogho, ActionAid teractions with PCB: prebriefi ngs and so Wasai Jacob Nanjakululu, Oxfam forth. • Increase voice while recognizing UN Jono Gunthorp, Health and Economics and constraints. HIV/AIDS Research Division (HEARD) • Better prepare regional representatives and Rose Kumwenda-Ng’oma, Christian Health hold them responsible (SADC). Association of Malawi Danielle Kuczynski, Center for Global Participants Development Salim Karim, University of KwaZulu-Natal Andy Gibbs, Health and Economics and Antonica Hembe, SADC HIV Secretariat HIV/AIDS Research Division Leonard Okello, ActionAid (HEARD) Derek von Wissell, National Emergency Rochelle Burgess, Health and Economics and Re sponse Council on HIV/AIDS HIV/AIDS Research Division (NERCHA) Swaziland (HEARD)

Summary of points of consensus

Washington, D.C./Oxford Durban

Consider a refocused option Refocus in Geneva but increase presence at regional level with resources shifted according to need in hyperepidemic countries

Increase technical capacity of the organization Increase technical knowledge of UNAIDS staff and ensure position of individual is commensurate with their role at the country level; facilitate access to technical capacity in countries and support technical capacity building at regional and national levels

Be an evidenced-based champion: focus on prevention Increase focus on prevention, recognizing that in SSA, and high-risk groups HIV/AIDS is exceptional and generalized

Be an independent, credible, scientiﬁ c clearinghouse Be a scientiﬁ c clearinghouse at the global level, that is fed by national and regional research priorities

Strengthen role in coordination Strengthen role in coordination at global, regional, and national levels; including to ensure that civil society has access to these spaces

Strengthen role in upholding commitments to HIV/AIDS Support civil society in upholding national commitments at global and regional/national level

UNAIDS: PREPARING FOR THE FUTURE 37 ANNEX D Methodology

Background work for this report occurred from and resolutions related to the establishment of July 15, 2008, to December 8, 2008, and con- UNAIDS. sisted of a broad literature review, several semistructured interviews, and three consultations. Semistructured interviews A full list of interviewees is in annex B of this and comments report; notes from the consultations can be found in annex C. Interviews were conducted from August 1, 2008, to December 8, 2008. Th e intervie- Broad literature review wees included working group members as well as additional individuals collected through A web-based literature review was conducted snowball sampling. Th e initial interviewees in July 2008 through a targeted search using and the working group members were iden- the search terms “UNAIDS” from 1996 until tifi ed by the researchers on the basis of their today. Material included peer-reviewed journal experience and unique perspective from both articles, grey literature, and internal and exter- individual and institutional standpoints. Th is nal UNAIDS evaluations and publications. Th e list of interviewees then grew based on recom- journals covered Lancet; British Medical Jour- mendations from others, particularly aft er the nal; New England Journal of Medicine; Ameri- background paper was posted. Twenty-nine can Journal of Public Health; Canadian Journal interviewees contributed their perspectives of Public Health; European Journal of Public to the fi rst paper; the number of interviewees Health; World Development, Social Science and consulted in preparation of this document now Medicine; Global Governance; International totals 50. Th e background interviews helped Organization; New Political Economy; Review of to provide additional depth and nuance to the International Political Economy; Critical Public recommendations distilled from the consulta- Health Development in Practice; Annual Review tion process. of Public Health; Health Aff airs; Journal of Bio- Th e original background paper was also social Science; Journal of Health, Population and posted online to solicit confi dential comments Nutrition; World Bank Observer; UN Chroni- from readers. A total of seven individuals re- cle; Journal of Public Health Policy; Anthropol- sponded through this mechanism; a number of ogy Today; Medical Anthropology Quarterly; other individuals submitted comments directly Foreign Aff airs; World Politics; International to the authors. Th ese comments were taken into Studies Quarterly; Global Health Governance; consideration in this fi nal report. Where neces- and International Security. sary, individuals were followed up with formal In addition, a media review was conducted interviews; these are listed in annex B. in August 2008 on the search term “UNAIDS” Th e authors acknowledge that the set of in- from 1996 until today, using LexusNexus. Fur- dividuals interviewed for this report may not be ther materials were reviewed as they were iden- fully representative of all aff ected populations tifi ed throughout the consultation process. or involved groups; the group was not intended Th ese included additional articles and media re- to be exhaustive in scope. We accept responsi- leases, published books, and offi cial documents bility for any shortcomings this may create.

38 UNAIDS: PREPARING FOR THE FUTURE Consultations group members were invited to participate in all consultation meetings but were strongly en- Th ree global consultations were also organized couraged to attend the Oxford meeting as an in Washington, D.C. (October 15); Oxford, opportunity to bring members together once U.K. (October 27–29); and Durban, South over the month in which all three meetings oc- Africa (November 16–18). Th ese consulta- curred. Two group teleconferences and written tions aimed to stimulate open and public dis- feedback received between the Durban consul- cussions about the future of UNAIDS, with tation and mid-January 2009 provided oppor- each focused respectively on stimulating a tunities for working group members to ensure broad discourse on roles and responsibilities of that the fi nal product refl ected their views. UNAIDS; bringing academic as well as Euro- It is acknowledged that recommendations pean perspectives with a focus on governance; made at the country level throughout this re- and a perspective on the role of UNAIDS at port are biased by a sub-Saharan African per- the country level. spective; the role that UNAIDS is best suited Th e recommendations of this report took to fi ll will vary between countries and regions shape over the course of this process. Working based on a number of factors.

UNAIDS: PREPARING FOR THE FUTURE 39 ANNEX E Further reading

Afr ica News. 2005. “North Africa; UNAIDS Cohen, Deborah. 2004. “Offi cial Resigns from Tries to ‘Break the Silence’.” February 2. UNAIDS to ‘Tell the Truth’.” British Medi- AIDS Policy and Law. 2001. “UNAIDS Addi- cal Journal 329(July): 67. tion.” November 26. Coovadia, Hoosen M. et al. 2007. “Mother-to- AIDS Policy and Law. 2006. “WHO, UNAIDS Child Transmission of HIV-1 Infection Set Course for HIV Testing.” December 29. during Exclusive Breastfeeding in the First AIDS Weekly. 2003. “AIDS Prevention: UN, 6 Months of Life: An Intervention Co- Sex Workers Hold First-Ever Talks to Find hort Study.” Th e Lancet 368(9567, March/ Ways to Halt Spread of HIV/AIDS.” Feb- April): 1007. ruary 10. Crowe, David. 1999. “UNAIDS Working on Ageing and Elder Health Week. 2006. “UNAIDS, Faulty Defi nition.” Calgary Herald, No- GENEVA; Eff ective Partnerships for HIV vember 30. Prevention Trials Needed between Re- Deblonde, Jessika et al. 2007. “Antenatal HIV searchers and Civil Society.” June 18. Screening in Europe: A Review of Policies.” Ageing and Elder Health Week. 2006. “UNAIDS, European Journal of Public Health 17(Oc- CHINA; United Nations Supports and tober): 414. Strengthens the Response to AIDS in Dickey. 1997. “Interview: We Are Losing a Lot China.” March 26. of Time.” Newsweek, December 8. Balochistan Times. 2005. “Anisa Stresses HIV & Donnely, John. 2004. “Health Specialists Urge AIDS Awareness through Media.” May 12. Rethinking AIDS Fight UNAIDS Report Bass, Emily. 2006. “WHO and UNAIDS Set Cites Lack of Consensus Amongst Major Controversial Course for HIV testing.” Players.” Th e Boston Globe, December 1. Th e Lancet Infectious Diseases 6(December Drug Week. 2003. “Policy: UNAIDS Welcomes 12): 760. Canada’s Move to Implement WTO Pact Becker, Michael L. B. 2008. “Global Warning.” on Generic Medicines.” December 5. Village Voice, Letters, February 8. Dubois Arber, Françoise et al. 2001. “HIV/ Blagov, Sergei. 1998. “Five Young People In- AIDS Institutional Discrimination in fected with HIV Every Minute, Report Switzerland.” Social Science and Medicine Says.” Telegraph Herald (Dubuque, Iowa), 52(10, May): 1525. April 24. Dugger, Celia W. 2008. “Progress Has Been Boseley, Sarah. “AIDS Conference Told of Made in Fight against AIDS, but Not Lack of Resources to Halt Pandemic.” Th e Enough, U.N. Report Says.” Th e New York Guardian, July 13. Times, June 3. Business Recorder. 2005. “UNESCO and Dummet, Henry. 2002. “UNAIDS Slams Nepal UNAIDS sign MOU.” May 21. for Lack of HIV Focus.” World Market’s Chicago Tribune. 2007. “Focusing the Fight on Analysis, July 8. AIDS.” December 1. Dummet, Henry. 2003. “UNAIDS Calls for Chin, James. 2006. “UN Cries Wolf about Faster ARV Drug Delivery.” World Market’s AIDS.” Th e Monitor (Uganda), October 15. Analysis, January 13.

40 UNAIDS: PREPARING FOR THE FUTURE Th e Economist. 2006. “Good in Parts; AIDS.” Harman, Sophie. 2007. “Th e World Bank: Fail- November 22. ing the Multi-Country AIDS Program, Emerging Markets Datafi le. 1999. “Funding Failing HIV/AIDS.” Global Governance of AIDS Eff orts Not Keeping Pace with 13(4): 485. Epidemic.” Emerging Markets Datafile, Hindustan Times. 2005. “Cricket Can Reduce April 23. Stigma Attached to HIV/AIDS Patients: Emerging Markets Datafi le. 1999. “UNAIDS UNAIDS.” 22 December. Again Calls on Private Sector to Ad- Hindustan Times. 2007. “WHO, UNAIDS dress AIDS in the Developing World.” Issue New Guidance on HIV Testing and October 11. Counseling.” October 13. Esguerra, Christian. 2006. “Church, Govern- Karim, Quarraisha Abdool. 2007. “Prevention ment Team Up in Fight v. AIDS, Finally.” of HIV by Male Circumcision.” Th e British Philippine Daily Inquirer, February 9. Medical Journal 335(July): 4. Fiji Times. 2004. “UNAIDS Offi cer Fears Wipe- Khwankhom, Arthit. 2004. “AIDS Special: out.” March 31. UNAIDS Predicts Severe Lack of Fund- Fletcher. 1996. “Birth Control: UNAIDS, Hon- ing.” Th e Nation (Th ailand), July 13. duras and Russia.” Reuters, December 5. Kitahata, Mari M. et al. 2002. “Comprehensive Galvão, Jane. 2005. “Brazil and Access to Health Care for People Infected with HIV HIV/AIDS Drugs: A Question of Human in Developing Countries.” Th e British Med- Rights and Public Health.” American Jour- ical Journal 325(October): 954. nal of Public Health 95(July): 1110. Kmietowicz, Zosia. 2007. “Former UN Envoy Gatherer, Alex et al. 2005. “Th e World Health Attacks UNAIDS for Its ‘Catatonic Pas- Organization European Health in Prisons sivity’.” British Medical Journal 335(De- Project aft er 10 Years: Persistent Barriers cember): 1111. and Achievements.” American Journal of Lab Business Week. 2004. “International Partner- Public Health 95(October): 1696. ship for Microbicides; Microbicide Producer Ginwalla, G. H., A. D. Grant, J. H. Day, T. W. Comments on the UNAIDS/WHO 2004 Dlova, S. Macintyre, R. Baggaley, and AIDS Epidemic Update.” December 26. G. J. Churchyard. 2002. “Use of UNAIDS Lab Business Week. 2007. “HIV/AIDS; Tools to Evaluate HIV Voluntary Coun- UNIFEM, UNAIDS and Johnson & John- seling and Testing Services for Minework- son Announce Grants for Combined Strat- ers in South Africa.” Review of Interna- egies to End Violence against Women and tional Political Economy 14(5 January): Prevent HIV and AIDS.” March 25. 707–26. Latham, Michael C. et al. 2000. “Appropriate Golub, E.L. 2000. “Th e Female Condom: Tool Feeding Methods for Infants of HIV In- for Women’s Empowerment.” American fected Mothers in Sub-Saharan Africa.” Th e Journal of Public Health 90(September): British Medical Journal 320(June): 1656. 1377. Lewis, Steven. 2008. “Stop Bargaining with Gutierrez, Juan Pablo, Benjamin Johns, Taghreed Human Life.” Th e Ottawa Citizen, Febru- Adam, Stefano M. Bertozzi, Tessa Tan-Tor- ary 4. res Edejer, Robert Greener, Catherine Han- Liquid Afr ica. 2005. “UNAIDS Head Con- kins, and David B. Evans. 2004. “Achieving demns Vitamin ‘Charlatans’.” May 25. the WHO UNAIDS Antiretroviral Treat- McNeil, Donald Jr. 2000. “AIDS Is Moving into ment Goal: What Will It Cost?” Th e Lan- Rural Areas, UN Study Says.” Th e New York cet 364(9428, July): 63. Times, June 23. Hargreaves, Sally. 2007. “Increase Funding to Merson, Michael H. 2006. “Th e HIV-AIDS Ensure Universal Access, Warns UNAIDS.” Pandemic at 25: Th e Global Response.” Th e Lancet Infectious Diseases 7(11, Novem- The New England Journal of Medicine ber): 705. 352(June): 2414.

UNAIDS: PREPARING FOR THE FUTURE 41 Moismanteotsile, B. et al. 2003. “Value of Chest Reuters. 1996. “UNAIDS Will Stay in Geneva.” Radiography in a Tuberculosis Prevention June 13. Programme for HIV-Infected People, Bo- Reuters. 1997. “UNAIDS Leader Warns Col- tswana.” Th e Lancet 362(9395, November): leagues about Inaction.” April 8. 1551. Reuters. 1997. “UNAIDS Sponsors Panel At Th e Nation. 2007. “Mongkol to Chair Board of Southern Africa Economic Summit.” May UNAIDS from Next Month.” May 21. 22. Newman, Loren. 2007. “UNAIDS Director Reuters. 1998. “UNAIDS Calls for Vertical HIV Gives Grim AIDS Appraisal During Stan- Intervention Programs.” March 26. ford Talk.” University Wire, May 10. Reuters. 1999. “UNAIDS Launches Youth Okie, Susan. 2006. “Sex, Drugs, Prisons, and Awareness Campaign.” February 26. HIV.” Th e New England Journal of Medi- Reuters. 2000. “Canada Enters into New Col- cine 356(January): 105. laboration with UNAIDS.” November 12. Osborne, Kevin. 2004. “Beyond the Summit: Reuters. 2001. “Coca-Cola Africa Foundation Prevention Will Be Key to Tackling Epi- Joins UNAIDS in Battle Against AIDS.” demic Aft er Th ailand.” Manchester Guard- May 10. ian Weekly, July 9. Reuters. 2001. “UNAIDS Calls for New Deal Panafr ican News Agency (PANA) Daily News- between Pharmaceutical Industry and So- wire. 2004. “New Concepts Needed to ciety.” February 15. Combat HIV/AIDS-UNAIDS Report.” Reuters. 2001. “UNAIDS Meets with AIDS July 7. Experts to Discuss Global Response to the Parker, Melissa. 2000. “HIV/AIDS and In- Epidemic.” May 10. fant Feeding. (World Health Organiza- Reynolds, Steven J. et al. 2003. “Antiretroviral tion Joint United Nations Programme on Th erapy Where Resources Are Limited.” HIV/AIDS UNAIDS and United Nations Th e Lancet 348(May): 1806. Children’s Fund 1998).” Journal of Biosocial Troy, J. Edward. 2007. “Letters: Policy of Science 32(2, January): 286. UNAIDS Has Been a Failure.” Th e Telegraph- Pharma Investments, Ventures, & Law Weekly. Journal (New Brunswick), October 30. 2004. “UNAIDS Responds to Kenyan UN Integrated Regional Information Net- Charges of HIV Prevalence Overestima- work. 2001. “Congo Kinshasa; UNAIDS tion.” February 8. Launches Congo-Oubagui-Chari River Pharma Marketletter. 2003. “UNAIDS Wel- Initiative.” Afr ica News, September 10. comes Bush HIV/AIDS Plan.” February 3. Walker, Neff et al. 2004. “Estimating the Global Pisek, Betsey. 2005. “UNAIDS Chief Kept.” Th e Burden of HIV/AIDS: What Do We Re- Washington Times, January 31. ally Know About the HIV Pandemic?” Th e Potts, Malcolm et al. 2006. “Parachute Ap- Lancet 363(9427, June): 2180. proach to Evidence Based Medicine.” Th e Weidle, Paul J. et al. 2002. “Assessment of a Pilot British Medical Journal 333(September): Antiretroviral Drug Th erapy Programme in 701. Uganda: Patients’ Response, Survival, and PR Week . 2004. “Healthcare: Awareness Cam- Drug Resistance.” Th e Lancet 360(9326, paign Close-up—UNAIDS embarks on July): 34. global push.” Brief Article, November 26. Westport. 1999. “Collaboration Expanding Th e Press Trust of India, LTD. 2006. “Naomi Between UNAIDS and Female Condom Watts Appointed as UNAIDS Ambassa- Maker.” Reuters, April 9. dor.” May 16. WHO Press. 2000. “WHO/UNAIDS Hail Ramsay, Sarah. 1999. “UNAIDS to Publish Consensus on Use of Cotrimoxazole for HIV-Vaccine-Trial Ethics Guidance.” Th e Prevention of HIV-Related Infections in Lancet 354(9182, November): 923. Africa.” April 5.

42 UNAIDS: PREPARING FOR THE FUTURE Wilkinson, David et al. 1999. “Short Course Zaracostas, John. 2008. “Anitretrovirals Reach Antiretroviral Regimens to Reduce More People in Poor Countries but Many Maternal Transmission of HIV.” Th e Brit- Still Lack Access, UNAIDS Says.” Th e Brit- ish Medical Journal 318(February): 479. ish Medical Journal 336(June): 1270. Leu Siew Ying. 2004. “Offi cers Need AIDS Training, Says UN Agency.” South China Morning Post, May 29.

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