United Nations General Assembly Special Session Research Articles

Can the Success of HIV Scale-Up Advance the Global Chronic NCD Agenda?

Noncommunicable diseases (NCD) are the leading causes of death and disability worldwide but have received suboptimal attention and funding from the global health community. Although the first United Nations General Assembly Special Session (UNGASS) for NCD in 2011 aimed to stimulate donor funding and political action, only 1.3% of official development assistance for health was allocated to NCD in 2015, even less than in 2011. In stark contrast, the UNGASS on human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) in 2001 sparked billions of dollars in funding for HIV and enabled millions of HIV-infected individuals to access antiretroviral treatment. Using an existing analytic framework, we compare the global responses to the HIV and NCD epidemics and distill lessons from the HIV response that might be utilized to enhance the global NCD response. These include: 1) further educating and empowering communities and patients to increase demand for NCD services and to hold national governments accountable for establishing and achieving NCD targets; and 2) evidence to support the feasibility and effectiveness of large-scale NCD screening and treatment programs in low-resource settings. We conclude with a case study from Swaziland, a country that is making progress in confronting both HIV and NCD.

Evaluating the systems used to monitor HIV populations accessing therapy and care in low-income and lower-middle-income countries

The scale-up of delivery of antiretroviral therapy (ART) in low-income and middle-income countries has been coupled with the collection of data aimed at monitoring the welfare of the HIV-positive and treated populations in those countries. We aimed to compare the data items collected and reported and the degree of harmonization achieved following the publication of WHO tools for collection and reporting of these data in 2006, and of two United Nations General Assembly Special Session (UNGASS) indicators relating to the health of patients on ART in 2008. Retrospective examination of monitoring tools used in four countries in 2008 and 2010. We examined and compared the type of information collected and reported from treatment and care programmes in Malawi, Uganda, Tanzania and Ukraine. We also assessed the effect of the publication of the WHO-recommended data capture and reporting tools and the UNGASS-recommended indicators on harmonizing data in these four countries 2 years following the publication of each of these tools and indicators. : Although the majority of WHO-recommended data items were included in patient record cards, clinic ART registers and in reports submitted to the ministries of health in the countries by 2010, there remains little concordance between the four countries examined on the specific items included in patient records and monitoring reports. Furthermore, numerous additional items, which differ by country, and which are not included in WHO recommendations, are still recorded and reported. The differences and diversity of data reported across countries continues to challenge our ability to make international comparisons and to assess programme performance.

Impact evaluation of a sexually transmitted disease preventive intervention among female sex workers in Hohhot, China

The aim of this study was to evaluate the impact of HIV and sexually transmitted disease (STD) prevention interventions among female sex workers (FSWs) in the city of Hohhot in northern China. Three serial cross-sectional surveys were conducted in 2006, 2007, and 2008 among FSWs. A questionnaire was administered to the FSWs, and HIV and syphilis tests were performed for all participants. Intervention activities including condom promotion and provision, increased condom availability and accessibility, and voluntary HIV counseling and testing (VCT) were carried out among FSWs. There were 624 participants in the 2006 survey, 444 in the 2007 survey, and 451 in the 2008 survey. The United Nations General Assembly Special Session (UNGASS) indicators for FSWs increased from 13.9% in 2006 to 37.7% in 2008 (p<0.001). The average rate of consistent condom use with commercial clients in the month preceding the interview increased significantly from 39.8% in 2006 to 59.6% in 2008 (p<0.001). Not a single HIV-positive case was found among the FSWs over these 3 years, and the prevalence of syphilis decreased remarkably from 9.5% in 2006 to 1.3% in 2008. Logistic regression analysis showed that sauna or hair salon work venues, receiving services from intervention programs, and accepting HIV tests were factors associated with consistent condom use. The findings suggest that consistent condom use and awareness of HIV/AIDS prevention-related knowledge among FSWs have been improved by the intervention. Further prioritized and combined prevention programs aimed at FSWs are needed in order to prevent the HIV/AIDS epidemic spreading in the general population in China.

A United Nations General Assembly Special Session for Mental, Neurological, and Substance Use Disorders: The Time Has Come

Mental, neurological, and substance use (MNS) disorders are leading causes of the global burden of disease and profoundly impact the social and economic well-being of individuals and communities. The majority of people affected by MNS disorders globally do not have access to evidence-based interventions and many experience discrimination and abuses of their human rights. A United Nations General Assembly Special Session (UNGASS) is needed to focus global attention on MNS disorders as a core development issue requiring commitments to improve access to care, promote human rights, and strengthen the evidence on effective prevention and treatment.

Monitoring trends in HIV prevalence among young people, aged 15 to 24 years, in Manicaland, Zimbabwe

BackgroundIn June 2001, the United Nations General Assembly Special Session (UNGASS) set a target of reducing HIV prevalence among young women and men, aged 15 to 24 years, by 25% in the worst-affected countries by 2005, and by 25% globally by 2010. We assessed progress toward this target in Manicaland, Zimbabwe, using repeated household-based population serosurvey data. We also validated the representativeness of surveillance data from young pregnant women, aged 15 to 24 years, attending antenatal care (ANC) clinics, which UNAIDS recommends for monitoring population HIV prevalence trends in this age group. Changes in socio-demographic characteristics and reported sexual behaviour are investigated.MethodsProgress towards the UNGASS target was measured by calculating the proportional change in HIV prevalence among youth and young ANC attendees over three survey periods (round 1: 1998-2000; round 2: 2001-2003; and round 3: 2003-2005). The Z-score test was used to compare differences in trends between the two data sources. Characteristics of participants and trends in sexual risk behaviour were analyzed using Student's and two-tailed Z-score tests.ResultsHIV prevalence among youth in the general population declined by 50.7% (from 12.2% to 6.0%) from round 1 to 3. Intermediary trends showed a large decline from round 1 to 2 of 60.9% (from 12.2% to 4.8%), offset by an increase from round 2 to 3 of 26.0% (from 4.8% to 6.0%). Among young ANC attendees, the proportional decline in prevalence of 43.5% (from 17.9% to 10.1%) was similar to that in the population (test for differences in trend: p value = 0.488) although ANC data significantly underestimated the population prevalence decline from round 1 to 2 (test for difference in trend: p value = 0.003) and underestimated the increase from round 2 to 3 (test for difference in trend: p value = 0.012). Reductions in risk behaviour between rounds 1 and 2 may have been responsible for general population prevalence declines.ConclusionsIn Manicaland, Zimbabwe, the 2005 UNGASS target to reduce HIV prevalence by 25% was achieved. However, most prevention gains occurred before 2003. ANC surveillance trends overall were an adequate indicator of trends in the population, although lags were observed. Behaviour data and socio-demographic characteristics of participants are needed to interpret ANC trends.

HIV bio-behavioural survey among men who have sex with men in Barcelona, Bratislava, Bucharest, Ljubljana, Prague and Verona, 2008-2009

Data from 23 European countries show that the annual number of HIV diagnoses in men who have sex with men (MSM) increased by 86% between 2000 and 2006. This paper reports the main preliminary results of a bio-behavioural survey in MSM with a specific focus on HIV prevalence and use of United Nations General Assembly Special Session (UNGASS) indicators in six cities in Southern and Eastern Europe. Time-location sampling (TLS) was used. A total number of 2,356 questionnaires and 2,241 oral fluid samples were collected (invalid samples 4.1%). The data show different socio-demographic patterns across countries regarding age, level of education, living conditions, living area and self-identity. Southern European cities had the highest percentage of people who had tested for HIV and collected the result. More than 50% of respondents in the sample from Barcelona reported having used a condom last time they had anal sex (57.2%), whilst in all other cities this proportion was below 50%. The cities with the highest HIV prevalence in MSM were Barcelona (17.0%) and Verona (11.8%) whilst lower percentages were reported in Bratislava (6.1%), Bucharest (4.6%), Ljubljana (5.1%) and Prague (2.6%). The low prevalence in Eastern European cities is encouraging. However, with the level of high-risk sexual behaviour documented and the lower frequency of HIV test seeking behaviour, there is a clear risk of an increase in HIV transmission.

XVII International AIDS Conference: From Evidence to Action ‐ AIDS 2008 and the global response to AIDS

The impact of the XVII International AIDS Conference (AIDS 2008) was reflected in a number of commitments from political and business leaders, who announced initiatives ranging from implementing comprehensive sexual education for young people in Latin America to reducing regulatory barriers and the price of drugs in the host country. The unprecedented media coverage brought attention and public awareness to the epidemic in Latin America.Several meetings and sessions at AIDS 2008 also addressed the potential for the International AIDS Conference to play an even stronger role in tracking progress towards universal access and in improving accountability in the global response to AIDS, particularly given some of the inherent weaknesses in the United Nations General Assembly Special Session (UNGASS) review process. The impact of AIDS 2008 was strongest in Mexico, the host country, and in Latin America. Highlights included the policy changes announced by President Calderon on pharmaceutical manufacturing to the focus on sex workers and gay and other MSM in marches, activism and the conference programme.The next two years will determine whether the successes reported in Mexico are sustained and whether there is progress in addressing the barriers that continue to hamper an evidence-based response to HIV/AIDS. The next International AIDS Conference is scheduled for the universal address deadline of 2010.

News and Notes

News and Notes

Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals

In 1998 the United Nations General Assembly Special Session resolved that governments would reduce drug production and consumption greatly within 10 years. With that period now elapsed, there is an interest in reviewing how successful this was and considering how drug policy could be improved. The demand for drugs in the world has stabilized mainly as a result of the interaction of epidemic forces, culture and economic development. Supply has become more concentrated and the menu of drugs has changed surprisingly slowly. Drug policy is shifting to a more explicitly tolerant configuration in Europe and a few other countries, but retains its ferocity in most of the world. The most prominent innovations under discussion have limited potential effects (heroin maintenance), have as yet been unproductive of policy interventions ('addiction is a brain disease') or have no political appeal (legalization). The option with the most scope is increased effort at diverting arrested drug users out of criminal justice systems. No prevention, treatment or enforcement strategies have demonstrated an ability to substantially affect the extent of drug use and addiction. The best that government interventions can do is to reduce the damaging consequences of drug use and drug control. More attention should be given to reductions in the intensity of drug enforcement, which has many unintended adverse consequences and yields few of the claimed gains.

Making Markets for Merit Goods: The Political Economy of Antiretrovirals

This paper examines the role of policy entrepreneurs and global activists in shaping the international market for antiretroviral drugs to combat HIV/AIDS. When ARVs first came on the market in the 1990s they were exceedingly expensive; the cost of treatment was upwards of $10,000 per year. These drugs were thus accessible only to those patients who had high incomes. But in 2006, the “international community,” meeting at a United Nations General Assembly Special Session (UNGASS), made an astonishing pledge to those who were infected with HIV. It proclaimed that there should be universal access to ARV treatment. This UNGASS, following up on an earlier historic UN special session devoted entirely to AIDS in 2001, marked the first time in history that the international community pledged itself to chronic care for the ill, which in this case includes the approximately 30 million people around the world estimated to be HIV positive. How do we explain the transformation of ARVs from private goods, which only a few could afford, into merit goods that were (at least declaratively) to be made available to everyone? In other words, how does a norm of “universal access to treatment” - that no person should be denied these life-extending drugs - become the ethical basis for global public policy with respect to pharmaceutical allocation? What are the lessons of the ARV story for other global issues? These are the primary questions we explore in this paper. Briefly, we argue that the policy entrepreneurs and activists who promoted the creation of a universal access to treatment regime - of the transformation of ARVs into global merit goods - relied on a combination of moral arguments and ideas with favorable material circumstances. From the ethical perspective, the task of these entrepreneurs was to convince the “international community” that access to ARVs was a “human right,” or conversely to convince decision-makers that it was morally wrong to allocate these life-enhancing drugs solely on the basis of ability to pay. But from a material standpoint, these arguments were greatly facilitated by the lowering prices of ARVs caused by a combination of differential pricing (that is, lower prices for drugs in the developing world than in the advanced welfare states) and competition from generics producers, coupled with increases in foreign aid spending devoted to HIV/AIDS and other diseases.

Accountability in the global response to HIV: measuring progress, driving change

Accountability implies that institutions and individuals are answerable for their commitments and responsibilities. The concept of accountability is highly relevant in the global response to HIV/AIDS because governments, donors and other actors have often failed to keep their commitments to expand funding and service delivery levels. Many governments have not been held accountable for failing to address the HIV-related needs of their populations adequately. Accountability is about more than passing judgement. Effective accountability mechanisms can be powerful tools to improve service delivery by providing constructive assessments and motivating decision makers to avoid negative external critiques. An impressive variety of HIV-related accountability projects have emerged over the past few years, the most prominent being the ongoing monitoring of government compliance with the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment. Other accountability efforts are essential in order to capture perspectives and priorities outside of governments and aid agencies. Many civil society-based accountability projects are now tracking HIV policy, service delivery and funding levels. We make several suggestions to increase the impact of accountability efforts, including connecting accountability to sustained advocacy, holding multiple actors accountable, continually assessing what measures of success will be most powerful in driving improved outcomes, and supporting and building the capacity of civil society monitoring efforts. We also suggest exploring how the International AIDS Conferences could serve as an expanded platform for accountability.

Resposta brasileira à epidemia de HIV/Aids, 2001-2005

The document from the United Nations General Assembly Special Session (UNGASS) on HIV/ AIDS forms a fundamental reference point for everyone working in this field. It encompasses a wide variety of perspectives from the formulation of public policies within the national continental and global spheres to the provision of clinical care and implementation of preventive strategies by governments and civil society and last but not least it relates to continuing dialogue with community leaders and the people who are living with HIV and AIDS. Thanks to an initiative coordinated by the Brazilian Institute of Health with support from the non-governmental organizations Gestos-PE and Gapa-SP the Ford Foundation and the National STD/AIDS Program of the Ministry of Health it was possible to quickly bring together a variety of researchers activists and managers of public programs for the prevention and treatment of HIV/AIDS for a meeting on November 21 and 22 2005 at the State of Sao Paulo Department of Health in the city of Sao Paulo. Given the importance of the topic and the quality of the contributions from the different authors it was decided to publish the communications presented: not in their original format which was very preliminary but fully incorporating the critiques and ideas arising from the discussions that followed the presentation of each text at the time of holding the seminar. It was decided in our view correctly to review each contribution in detail starting by designating editors who would be in charge of three thematic blocks related to their respective fields of activity. (excerpt)

Drugs in the UN system: the unwritten history of the 1998 United Nations General Assembly Special Session on drugs

The “international community” presented an apparent unanimity in its endorsement of prohibitive drug control at the United Nations General Assembly Special Session (UNGASS) on drugs in 1998. The reality is that there is a longstanding conflict within the UN system between nations wanting to maintain the prohibition regime and those hoping for a more pragmatic approach. The depth and course of this conflict can be traced through a myriad of documents and records of meetings published by the UN, revealing a previously unwritten history of events leading to the 1998 UNGASS meeting. These show the extent to which the hardliners have gone to maintain the status quo through rhetoric, denial, manipulation, selective presentation, misrepresentation and suppression of evidence, selective use of experts, threats to funding, and purging “defeatists” from the UN system. The UN has committed itself to a drug free world by 2008, even though the problem is worsening faster than its favoured remedy can be applied to solve it. However, some reformers and pragmatists have been challenging the system in their domestic policies. This may encourage a more realistic approach to illicit drugs and help to introduce more rational functioning to the UN system's drug control organisations.

Cannabis control: the model of the WHO tobacco control treaty

There is a growing acceptance of the so-called harm or risk reduction approach. Accessible care primarily directed at drug user’s physical and social functioning, without requiring abstinence (or at least not immediately), persuading users to quit, including needle exchange programmes and the prescription of methadone and other substitute drugs, has increasingly become a realistic modality in the provision of care for drug users. And it has positive results. The Council of Health Ministers of the European Union (EU) adopted in December 2002 specific Recommendations encouraging this risk reduction approach. (Council of the European Union, in press). Whichever way you look at it, the acceptance of this pragmatic approach is contrary to the slogan ‘A Drug Free World*/We Can Do It’ adopted for the United Nations General Assembly Special Session (UNGASS) 1998. Obviously the seriousness of the actual problems in the EU is stronger than the doctrine.

Battle over Children's rights at the United Nations Special Session on Children

The 10-year review of the 1990 World Summit for Children was held at United Nations (UN) headquarters in New York, May 8 to 10, 2002. The two objectives of the UN General Assembly Special Session on Children were to review the progress made in the welfare of children since the 1990 World Summit, and to review the progress made in child welfare since the adoption of the UN Convention on the Rights of the Child in 1989. More than 60 heads of state and governments, 250 parliamentarians, 700 nongovernmental organizations, and hundreds of children came together to chart a course for the future well-being of children, including adolescents. Deputy Prime Minister John Manley led the Canadian delegation. To be sure, there were many successes. To begin with, the level of youth participation was unprecedented. For the first time, young people — more than 350 of them — attended a UN conference as participating delegates. Children and youth were everywhere throughout the Session — chairing meetings, questioning their leaders, and speaking loudly and clearly about the realities of their lives. The Special Session resulted in an outcome document, A World fit for Children (1), which sets the direction for international policy with respect to children for the next decade. This document is quite strong around several issues, including child protection, indigenous rights, education, disability and the sexual exploitation of children. References to the importance of youth participation in the final outcome document were also a step forward. Senator Landon Pearson states about the final document, “most of the text…is positive, forward-looking and useful” (1).