What next for UNAIDS?

Abstract

At the end of this year Peter Piot will step down as head of UNAIDS. After 11 years leading the UN's joint programme on HIV/AIDS, what will his legacy be? And with a new Executive Director appointed, what will the future hold for UNAIDS? Pam Das and Udani Samarasekera report.On Jan 1, 1996, a unique UN agency was launched to tackle a disease that 20 million people were living with and 4 million people had died from worldwide. The UN's Joint Programme on HIV/AIDS (UNAIDS) had a complex mandate: to put HIV/AIDS on the political agenda and to coordinate a global, multisectoral response to the pandemic. At that time there was little collaboration between the several UN agencies that had HIV/AIDS programmes. And advocacy and fundraising for the disease was poor. As Devi Sridhar, a politics fellow at Oxford University, UK, who is coordinating a working group on UNAIDS' transition for the Global Economic Governance Programme at Oxford University and the Center for Global Development, notes, “when UNAIDS launched in 1996, funding for HIV/AIDS barely reached US$250 million, the disease was of low priority to donor governments, and countries affected by HIV/AIDS suffered a lack of unified institutional response”.Now the story is very different. HIV/AIDS receives unprecedented resources and political commitment, so much so that some are even asking whether there is still a need for UNAIDS? Although most experts would say that the answer to this question is “yes”, for now, many believe that with a new leader at the helm (see panel), UNAIDS must evolve and adapt to the current global-health architecture to survive. Others think that UNAIDS should be shut down and rolled back into WHO—where coordination of the global response to HIV/AIDS initially began.PanelUNAIDS' new Executive DirectorOn Dec 1, 2008, the UN Secretary-General Ban Ki-moon appointed Michel Sidibé the next Executive Director of UNAIDS.Sidibé, a citizen of Mali, has worked for the UN for over 20 years, joining UNAIDS in 2001. He has been Deputy Executive Director of Programmes since 2007, where he manages over 70% of UNAIDS' financial and human resources, and leads UNAIDS' support to countries via its regional teams and country offices.Sidebé's UN career began in 1987, when UNICEF recruited him to work in the Democratic Republic of the Congo. He later served at the agency's Headquarters in New York. Here, Sidibé, a fluent English and French speaker, and speaker of several African languages, oversaw programmes across 10 francophone countries in Africa. He also managed large programmes to support marginalised and vulnerable populations, as well as HIV programmes for the prevention of mother-to-child transmission, civil society empowerment, and the protection of human rights.In his application for Executive Director he listed that his top priority would be the realignment of UNAIDS' support to countries, to make sure all are making consistent progress towards universal access to HIV prevention, treatment, care and support. Sidebé pledged to ensure that HIV prevention would be high on UNAIDS' agenda. He also promised to “promote and protect human rights, particularly for women”, and “enhance the meaningful involvement of persons infected with and affected by HIV, particularly marginalised and at-risk populations”.Upon his election he said: “The AIDS epidemic is not over in any part of the world. We have to ensure that there is strong and long term leadership and financial commitment to respond to AIDS that is grounded in evidence and human rights.”Sidibé will take up his new position on Jan 1, 2009.From WHO to UNAIDSWHO launched its Special Programme on AIDS (later the Global Programme on AIDS; GPA) in 1987, with Jonathan Mann, one of the world's leading experts on the epidemic, as director. Under his leadership, the programme worked hard to dispel the many myths that existed about HIV/AIDS and to promote a human rights approach to the pandemic. GPA helped developing countries to establish national HIV/AIDS programmes and it raised global awareness of the condition, working closely with non-governmental organisations and people affected by HIV/AIDS.But, despite these achievements, a few years in, cracks started to appear in the programme. “Around the early 1990s there was unhappiness about the performance of WHO, especially in sub-Saharan Africa”, explains Michael Merson, director of the Global Health Institute at Duke University, Durham, NC, USA, who was head of the GPA from 1990–95. Around the same time the UN and its Member States became interested in broadening the global response to the pandemic. “People felt that the way to deal with HIV was not just through the health sector or one UN agency, and UNAIDS was the mechanism that was recommended. It would include many different UN agencies to give a broader, multisectoral response.” But the creation of UNAIDS was somewhat of an experiment, admits Merson. “There were no existing models for the agency, there was no precedent. This was at a time when we didn't know where the pandemic was going.”In July, 1994, the UN's Economic and Social Council endorsed the experiment and UNAIDS was born. The organisation was initially formed from six UN agencies or co-sponsors: the UN Development Programme, UNICEF, the UN Population Fund, WHO, the UN Educational, Scientific and Cultural Organization, and the World Bank. The programme had several key objectives: to provide global leadership in response to HIV/AIDS; promote global consensus on policies; monitor trends; strengthen the capacity of national governments to develop comprehensive national strategies; promote broad-based political and social mobilisation to prevent and respond to HIV/AIDS within countries, involving a wide range of sectors and institutions; and advocate for greater political commitment to, and adequate resources for, tackling the disease.At the end of 1994, the then UN Secretary General Butros Butros-Ghali selected Peter Piot, an internationally respected Belgium academic, to head UNAIDS. Piot was one of the first scientists to work on HIV/AIDS in Africa and had been the Director of the GPA's Division on Research and Intervention Development since 1992.The new director would report into a governing body (Programme Coordinating Board), with representation from 22 countries from all regions of the world and, uniquely for a UN agency, members from non-governmental organisations—something Piot fought hard to gain.HIV activists in South Africa campaign for lower priced antiretrovirals, July, 2000View Large Image Copyright © 2008 Getty ImagesTeething problemsOn Dec 31, 1995, the WHO GPA programme shut down and UNAIDS opened for business on Jan 1, 1996, with 91 staff in the Secretariat, based at WHO headquarters in Geneva, and 10 employees in various regions. Supported mainly by voluntary contributions from countries, the agency's budget was around $130 million for 1996–97.The fledgling agency ran into several difficulties early on. By 1988, the WHO programme was providing direct financial support to more than 130 states. But UNAIDS had a different mandate. Its role was to coordinate funds for HIV/AIDS activities rather than directly distribute them—a change which inadvertently left many country programmes in a precarious financial situation after GPA closed down. With its new multisectoral mandate, UNAIDS also struggled to provide technical support and advice to countries. Getting the co-sponsors to work together also proved difficult, says Merson. UNAIDS was designed to coordinate a multisectoral response to HIV/AIDS at country level and the co-sponsors were meant to integrate HIV/AIDS into all their relevant programmes. But, as Merson says, “people didn't always cooperate. So UNAIDS had country-based and global challenges in the early days.”On top of these teething problems, donor governments reduced their funding of the UN system. “They also didn't maintain their oversight and diligence at the time”, says Merson. “All these factors made things difficult for UNAIDS in the beginning and right at the time when the pandemic was peaking and expanding dramatically.”Praise for UNAIDSBut the agency did eventually find its feet. The size, budget, and reach of UNAIDS has swelled over the past decade. It now has 280 staff in its Secretariat in Geneva, plus 621 staff in seven regional teams and 81 country offices. Four additional UN bodies have joined UNAIDS since 1996—the World Food Programme, the Office of the UN High Commissioner for Refugees, the International Labour Organization, and the UN Office on Drugs and Crime—making a total of ten co-sponsors altogether. The agency's budget was $469 million in 2008–09.What have the agency's key achievements been? UNAIDS has been praised for making non-governmental organisations part of its governing body and for working with civil society groups to lower the prices of antiretrovirals. The organisation has also achieved some major developments within the UN system. As Sridhar says, “it has brought HIV/AIDS into the security realm, resulting in UN Security Council Resolution 1308, as well as General Assembly Special Sessions (UNGASS) on HIV/AIDS”. Many also praise UNAIDS for its initial epidemiological surveillance of HIV/AIDS. UNAIDS was “a reliable source on the extent of the pandemic”, says Merson. He adds, that to its credit, UNAIDS did get UN agencies to work in better harmony.But most would agree that true to its core mandate, UNAIDS' greatest achievement has been as an advocate, promoting and arguing for a strong global response to HIV/AIDS and increasing spending for the disease to $10 billion in 2007.LeadershipPiot has been crucial to this achievement. As Elisabeth Pisani, HIV epidemiologist and journalist, who worked for UNAIDS in the late 1990s, says, “UNAIDS dramatically raised the profile of the epidemic, and I think it can take most of the credit for dramatically raising the funding available for prevention and treatment. A lot of that is because of Peter. His commitment is unquestionable, and that commands respect. Politicians treat him as a peer, and he has I think been quite bold in demanding political leadership on HIV.”Jim Kim, from the Harvard School of Public Health, who was WHO's director of HIV/AIDS from 2004–06, also praises the agency for its advocacy role. “I think that the most important thing that UNAIDS did was to elevate HIV on the overall global development agenda.” Kim puts this down to Piot's hard work plus that of the initial communications team at UNAIDS, who he says, turned Piot from a shy academic into a “rock star”. He believes this move “was critical in raising awareness of HIV”. But some think Piot's rock star persona hindered as well as helped UNAIDS. Sridhar says: “Piot has done a brilliant job with advocacy, fundraising, media attention, political awareness. Very few questions are asked about his dedication to the cause. But it's made it difficult to differentiate UNAIDS from him.”Others agree that Piot's legacy will be mixed, but for different reasons. The case for AIDS exceptionalism—prioritising HIV/AIDS over other health problems—has been Piot's key argument, which has won him both praise and criticism. And, although he has been an effective advocate for the fight against the disease, some say that he has not been political enough during his tenure. Joanne Csete, founding director of the HIV/AIDS Programme at Human Rights Watch, says: “Under his leadership UNAIDS has helped at times to keep some important AIDS issues on the global agenda but has inadequately confronted the issues that are politically the most challenging and are the reasons why AIDS thrives in so many places.”What the critics sayAlthough UNAIDS has consistently opposed ideologically-driven responses as articulated in their policy documents, experts have criticised UNAIDS for being too passive in challenging the potential damage of programmes and policies that were driven by ideology rather than evidence, and for not addressing the rights of high-risk groups. These include, the criminalisation of homosexuality, the exclusion of illicit drug users and sex workers from health services, that a substantial percentage of funds be devoted to abstinence only, and the reinstatement of the global gag rule related to abortion, which has made it more difficult to integrate HIV/AIDS into reproductive health services. Csetse says, “UNAIDS has not adequately provided analysis or criticism, at least not in public forums on any of these issues.”Most of the weaknesses of UNAIDS comes from its ill-conceived structure. “It is beholden to its co-sponsors”, says Pisani. “It has failed to co-ordinate its co-sponsors because they have no desire to be coordinated. Nor has it been able to hold them to account. They all compete with one another for funding, attention, and kudos and UNAIDS is obliged to kowtow to them. Consequently, UNAIDS lacks independence.”Over the years, many experts have questioned the scientific basis of UNAIDS' annual epidemiological estimates, complaining that the burden of HIV/AIDS globally was overstated. But UNAIDS have always insisted, “our estimates are just that—estimates. They are based on available data and the known ways to interpret them. Our work is based on a collective wisdom. We have been bold to make revisions when the methodology and data quality improved—and we will continue to do so.”However, others were convinced that the numbers were intentionally inflated to keep HIV/AIDS high on the political agenda thereby perpetuating Piot's exceptionalism argument further. One expert told The Lancet, “AIDS is an existential threat in one subregion—southern Africa. Elsewhere, AIDS exceptionalism can no longer be sustained and damages the credibility of AIDS in the eyes of objective public-health specialists.”Helen Epstein, an independent consultant on public health, says that by overblowing the prospects for a global heterosexual epidemic, the agency also missed the opportunity to launch a much more focused response for east and southern Africa, where the epidemic is especially serious.FailuresPerhaps the biggest failure in the response to HIV/AIDS has been HIV prevention. Piot admits he should have pushed prevention efforts sooner. But he adds, “in the early days thousands of deaths a day were so overwhelming and needed immediate action that treatment had to take precedence”.Today, global prevention efforts still remain slow. For example, Daniel Halperin, a senior research scientist, Harvard University School of Public Health, points out that UNAIDS and WHO took too long to acknowledge and discuss the potential importance of male circumcision in HIV prevention despite the epidemiological evidence, and as a result countries have delayed uptake. “Now, suddenly, UNAIDS and WHO have fully endorsed circumcision for prevention, but unfortunately this very sudden turn-around has understandably left many African Ministries of Health feeling confused, and mistrustful. If UNAIDS had showed technical leadership on this issue years ago, then programmes/service delivery might be currently occurring at a much faster rate”, Halperin explains.Similarly, Epstein points out that UNAIDS delayed acknowledging the importance of long-term concurrent or overlapping long-term relationships, as opposed to casual sex, in driving the African epidemic, and even slower to recognise that because condoms are seldom used in long-term relationships, programmes to promote their use would have little impact without parallel efforts to promote partner reduction, especially among adults.Some experts think that UNAIDS has paid little attention to the epidemic in men who have sex with men (MSM). Until very recently, this group had not been included in UNAIDS surveillance programmes nor had the UNAIDS' transmission model analysis included Africa, where an emerging epidemic in MSMs is a current concern.Michel SidibéView Large Image Copyright © 2008 CorbisUN headquarters, New York, on World AIDS Day, 2006View Large Image Copyright © 2008 UNAIDSOne AIDS researcher, who asked to remain anonymous, points out that the increased focus on the feminisation of HIV/AIDS has detracted attention from elsewhere. “There is only one region in the world where the majority of infections are in women and that is Africa, and furthermore, we see this only in certain age ranges, so if you are looking at issues like feminisation then clearly you are going to miss an epidemic in MSMs”, he explains.Shut down UNAIDS?Last year, in the British Medical Journal, Roger England, chairman of the think-tank Health Systems Workshop, argued that UNAIDS be shut down, that it is “out of touch with reality and its single issue advocacy is harming health systems and diverting resources from more effective interventions against other diseases”.In support of UNAIDS, Lisa Schechtman from the Global AIDS Alliance, argues that HIV/AIDS is still one of the primary health and development concerns in the world and it is essential that it still be treated as a discrete issue. “Ultimately, while we have made headway on the pandemic, we are not there yet, and morphing AIDS into the broader global health and development community risks setting us back—particularly when we have so many programmes and policies in place that are working and, given more time and resources, can increase their impact.”But while others have questioned the value of having both a full HIV/AIDS unit at WHO and a separate UN institution on the same street, many feel that the responsibility for estimates and surveillance should be given to WHO or a wholly independent and objective scientific committee not appointed by UNAIDS. One expert told The Lancet that UNAIDS' estimates and surveillance are not subject to the natural checks and balances of epidemiologists working in multi-disease environments, who question figures closely. “Their staff do not interact with advocates of other diseases and become increasingly narrow and sectarian, viewing exponents of other views as dissidents. If, for example, estimates had stayed with WHO, they would have been reviewed and challenged by experts and champions of other diseases, who would have alerted them to basic errors”, he said. But Merson thinks that, “we need to have a better option if there isn't going to be a UNAIDS. Going back to WHO is not the solution. We don't want those difficulties of the past, pre-UNAIDS, to happen again. There shouldn't be change for change sake.”Future directionIn the past few years new players like the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President's Emergency Plan for AIDS Relief, the Bill & Melinda Gates Foundation, and other large non-governmental organisations have all joined the fight against HIV/AIDS. “The global health landscape of 2008 is radically different to back then, and in line with this change, UNAIDS needs to evolve to stay relevant”, says Sridhar. Most would agree that the UNAIDS of today should be different from the UNAIDS of 1996. Indeed, The Lancet has learned that the solid collaboration, especially in countries, between UNAIDS and the Global Fund has created an unprecedented positive spirit to harmonise their work together. One senior UNAIDS source said that fusion of the two should be considered at some point. “The current rapprochement may lead to some premarital construction (and why not with GAVI as well..)”, he added.More immediately, many feel UNAIDS needs a major overhaul—that it needs to be smaller, leaner, far better managed, and more open to uncertainty and debate. One expert told The Lancet, “there is a widespread perception that previous appointments and promotions were due largely to perceived individual loyalty to the outgoing Executive Director”. He suggests that all major positions should be re-competed on merit, with an open selection process and an emphasis on recruiting the best, most qualified, most objective scientific specialists.“UNAIDS needs to be a scientific clearing house that shows real leadership on synthesising evidence in an independent and rigorous manner and ensures that the evidence is used to inform policies by co-sponsors, governments and non-state actors”, says Sridhar. It must assume a stronger coordinating role and hold various actors to account on the various pledges and universal access targets for 2010 and beyond, she adds.The key challenges for the new Executive Director, Michele Sidibé, will be to sustain the visibility, money, and the leadership on AIDS, says Piot. “That will require a very skilful combination of politics and not making any compromises on the scientific evidence and the human rights components”, he adds. Equally important for the next phase is to establish linkages between the HIV/AIDS response and health system strengthening, which will be key for treatment sustainability over the next decades.Piot would like to see UNAIDS champion HIV prevention as he does not see any other organisation taking up that challenge given the complex issues that need to be tackled, as described in The Lancet's recent HIV prevention series. Establishing closer ties between the HIV/AIDS response and the health workforce, sexual and reproductive health, social policies, and other public health and development goals will also be important, he feels.Piot is confident that Sidibé has got what it takes to address these challenges but adds, “he is one person though and there is only 24 h in a day. The real key to success will be to surround himself with the best people from the field in the world”. At the end of this year Peter Piot will step down as head of UNAIDS. After 11 years leading the UN's joint programme on HIV/AIDS, what will his legacy be? And with a new Executive Director appointed, what will the future hold for UNAIDS? Pam Das and Udani Samarasekera report. On Jan 1, 1996, a unique UN agency was launched to tackle a disease that 20 million people were living with and 4 million people had died from worldwide. The UN's Joint Programme on HIV/AIDS (UNAIDS) had a complex mandate: to put HIV/AIDS on the political agenda and to coordinate a global, multisectoral response to the pandemic. At that time there was little collaboration between the several UN agencies that had HIV/AIDS programmes. And advocacy and fundraising for the disease was poor. As Devi Sridhar, a politics fellow at Oxford University, UK, who is coordinating a working group on UNAIDS' transition for the Global Economic Governance Programme at Oxford University and the Center for Global Development, notes, “when UNAIDS launched in 1996, funding for HIV/AIDS barely reached US$250 million, the disease was of low priority to donor governments, and countries affected by HIV/AIDS suffered a lack of unified institutional response”. Now the story is very different. HIV/AIDS receives unprecedented resources and political commitment, so much so that some are even asking whether there is still a need for UNAIDS? Although most experts would say that the answer to this question is “yes”, for now, many believe that with a new leader at the helm (see panel), UNAIDS must evolve and adapt to the current global-health architecture to survive. Others think that UNAIDS should be shut down and rolled back into WHO—where coordination of the global response to HIV/AIDS initially began. On Dec 1, 2008, the UN Secretary-General Ban Ki-moon appointed Michel Sidibé the next Executive Director of UNAIDS.Sidibé, a citizen of Mali, has worked for the UN for over 20 years, joining UNAIDS in 2001. He has been Deputy Executive Director of Programmes since 2007, where he manages over 70% of UNAIDS' financial and human resources, and leads UNAIDS' support to countries via its regional teams and country offices.Sidebé's UN career began in 1987, when UNICEF recruited him to work in the Democratic Republic of the Congo. He later served at the agency's Headquarters in New York. Here, Sidibé, a fluent English and French speaker, and speaker of several African languages, oversaw programmes across 10 francophone countries in Africa. He also managed large programmes to support marginalised and vulnerable populations, as well as HIV programmes for the prevention of mother-to-child transmission, civil society empowerment, and the protection of human rights.In his application for Executive Director he listed that his top priority would be the realignment of UNAIDS' support to countries, to make sure all are making consistent progress towards universal access to HIV prevention, treatment, care and support. Sidebé pledged to ensure that HIV prevention would be high on UNAIDS' agenda. He also promised to “promote and protect human rights, particularly for women”, and “enhance the meaningful involvement of persons infected with and affected by HIV, particularly marginalised and at-risk populations”.Upon his election he said: “The AIDS epidemic is not over in any part of the world. We have to ensure that there is strong and long term leadership and financial commitment to respond to AIDS that is grounded in evidence and human rights.”Sidibé will take up his new position on Jan 1, 2009. On Dec 1, 2008, the UN Secretary-General Ban Ki-moon appointed Michel Sidibé the next Executive Director of UNAIDS. Sidibé, a citizen of Mali, has worked for the UN for over 20 years, joining UNAIDS in 2001. He has been Deputy Executive Director of Programmes since 2007, where he manages over 70% of UNAIDS' financial and human resources, and leads UNAIDS' support to countries via its regional teams and country offices. Sidebé's UN career began in 1987, when UNICEF recruited him to work in the Democratic Republic of the Congo. He later served at the agency's Headquarters in New York. Here, Sidibé, a fluent English and French speaker, and speaker of several African languages, oversaw programmes across 10 francophone countries in Africa. He also managed large programmes to support marginalised and vulnerable populations, as well as HIV programmes for the prevention of mother-to-child transmission, civil society empowerment, and the protection of human rights. In his application for Executive Director he listed that his top priority would be the realignment of UNAIDS' support to countries, to make sure all are making consistent progress towards universal access to HIV prevention, treatment, care and support. Sidebé pledged to ensure that HIV prevention would be high on UNAIDS' agenda. He also promised to “promote and protect human rights, particularly for women”, and “enhance the meaningful involvement of persons infected with and affected by HIV, particularly marginalised and at-risk populations”. Upon his election he said: “The AIDS epidemic is not over in any part of the world. We have to ensure that there is strong and long term leadership and financial commitment to respond to AIDS that is grounded in evidence and human rights.” Sidibé will take up his new position on Jan 1, 2009. From WHO to UNAIDSWHO launched its Special Programme on AIDS (later the Global Programme on AIDS; GPA) in 1987, with Jonathan Mann, one of the world's leading experts on the epidemic, as director. Under his leadership, the programme worked hard to dispel the many myths that existed about HIV/AIDS and to promote a human rights approach to the pandemic. GPA helped developing countries to establish national HIV/AIDS programmes and it raised global awareness of the condition, working closely with non-governmental organisations and people affected by HIV/AIDS.But, despite these achievements, a few years in, cracks started to appear in the programme. “Around the early 1990s there was unhappiness about the performance of WHO, especially in sub-Saharan Africa”, explains Michael Merson, director of the Global Health Institute at Duke University, Durham, NC, USA, who was head of the GPA from 1990–95. Around the same time the UN and its Member States became interested in broadening the global response to the pandemic. “People felt that the way to deal with HIV was not just through the health sector or one UN agency, and UNAIDS was the mechanism that was recommended. It would include many different UN agencies to give a broader, multisectoral response.” But the creation of UNAIDS was somewhat of an experiment, admits Merson. “There were no existing models for the agency, there was no precedent. This was at a time when we didn't know where the pandemic was going.”In July, 1994, the UN's Economic and Social Council endorsed the experiment and UNAIDS was born. The organisation was initially formed from six UN agencies or co-sponsors: the UN Development Programme, UNICEF, the UN Population Fund, WHO, the UN Educational, Scientific and Cultural Organization, and the World Bank. The programme had several key objectives: to provide global leadership in response to HIV/AIDS; promote global consensus on policies; monitor trends; strengthen the capacity of national governments to develop comprehensive national strategies; promote broad-based political and social mobilisation to prevent and respond to HIV/AIDS within countries, involving a wide range of sectors and institutions; and advocate for greater political commitment to, and adequate resources for, tackling the disease.At the end of 1994, the then UN Secretary General Butros Butros-Ghali selected Peter Piot, an internationally respected Belgium academic, to head UNAIDS. Piot was one of the first scientists to work on HIV/AIDS in