HIV/AIDS In Africa: Political, Policy, Program, Health And Legal Responses

Invited Presentation by Dr. Chinua Akukwe

George Washington University School of Public Health, DC
At the American Bar Association, International Law, Spring Meeting in Washington, DC, April, 2005


The Perspective
Atlanta, Georgia
April 25, 2005

I thank the leadership of the American Bar Association (ABA), the Section on International Law and Practice and the organizers of this conference for convening a discussion on Health and International Trade Law. Since the establishment of the World Trade Organization (WTO), the issue of international trade laws and access to healthcare goods and services has become an important global concern, especially in developing regions of the World. The 2001 WTO conference in Doha, Qatar ended with a series of declarations on international trade, intellectual property rights, patents, public health emergencies and the role of national governments in protecting the health of their citizens.

My discussion will focus on how African governments deal with the political, policy, health and legal dimensions of the epidemic. Since other presenters have discussed the trade law issues critical to effective HIV/AIDS remedial efforts, I will not dwell extensively on the burgeoning role of the WTO on access to public health goods and services.

Regarding the political response to HIV/AIDS, every African government, in my view, is clearly aware of the harsh political realities of HIV/AIDS. These harsh political realities include the potential decimation of emerging middle class; the erosion of hard-won national economic gains; the potential restiveness in Military high commands if popular officers contract HIV and do not have access to lifesaving medicines; the destructive effects of runaway infection on each country’s bureaucracy, and; the possible electoral repercussions if a central government is deemed insensitive to HIV/AIDS.

The 2004 South Africa elections in my view marked a watershed HIV/AIDS political moment in Africa. The ruling party, African National Congress (ANC) and the highly favored Mbeki administration found themselves on the defensive regarding national policies on HIV/AIDS. The ruling government campaigned vigorously on its future AIDS policies rather than on current or past policies. It is no secret that the Mbeki administration is one of the most powerful and effective governments in Africa. Yet, the government had to make sure that South Africans who still have great affection for the ANC did not perceive the government as indifferent to HIV/AIDS issues.

Another effective role of strong HIV/AIDS response is emerging in Uganda. Today, Uganda’s president, Yoweri Museveni is almost an icon in the West because of his courageous and highly effective anti-HIV/AIDS credentials. Consequently, very few Western governments wish to be on record regarding concerns about the future of political transition in Uganda in 2006. The political intentions of President Museveni after 20 years in power remain murky. The political temperature in Uganda is heating up regarding concerns about orderly transition when President Museveni constitutionally mandated two-term in office ends in 2006. .

The policy response of African nations to HIV/AIDS is heavily influenced by multilateral and bilateral agencies that finance HIV/AIDS remedial efforts in the continent. UNAIDS is a very influential player on how African nations develop HIV/AIDS policies. UNAIDS has the capacity to deploy a vast arsenal of technical resources to assist African nations. Other multilateral agencies such as the World Health Organization, the World Bank, the UNICEF and the United Nations Development Program also have leverage over national HIV/AIDS policies by virtue of their vast financial and technical resources compared to resources available to recipient African nations.

Another feature of AIDS policies in Africa is the tight control over implementation issues by central governments. This command-and-control policy making machinery create concerns regarding the participation of national and local stakeholders in the design, implementation, monitoring and evaluation of national HIV/AIDS policies in Africa. To what extent are national AIDS policies in Africa reflective of the knowledge, attitude and perceptions of Africans affected or infected by HIV? Do national AIDS priorities in African nations represent the felt need of target communities? These concerns remain potent despite elaborate “stakeholder forums” or “consultations” that are common in national AIDS policy making in Africa.

Additionally, it is still curious that African nations are yet to take advantage of the explicit provisions in the DOHA Declaration that allow impoverished countries to declare public health emergencies and consequently seek quality lifesaving therapies at the cheapest possible price. HIV/AIDS is already a public health emergency in many Southern African countries, yet current national strategies favor labor intensive and time consuming negotiations with research pharmaceutical companies that manufacture anti-retroviral drugs.

Another major policy issue is the lack of a continent-wide, coordinated policy on HIV/AIDS remedial efforts. Today, in Africa, any organization (public, private or non government) can initiate the implementation of its own version of HIV/AIDS remedial efforts as long as it can deploy financial resources. Many African governments are too poor and lack intellectual depth to engage multilateral and bilateral doors in serious discussions regarding national HIV/AIDS priorities. With the exception of the government of South Africa, and possibly, Nigeria, it would be difficult to name other African countries with significant HIV/AIDS prevalence or incidence that have the clout to bend donor intentions to fit national HIV/AIDS policies.

Lack of money and trained manpower are major drawbacks to effective HIV/AIDS programming in Africa. Basic healthcare infrastructure remains a challenge. Limited logistical capacities represent additional impediments in Africa. For example, lack of portable water and basic sanitation in medical facilities or residential homes can have powerful influence on the ability of caregivers to provide quality care and support to individuals living with AIDS. Limited electricity supply can scuttle the best laid down supply chain strategy for delivering anti-retroviral drugs. Despite these concerns, the gravest challenge to HIV/AIDS in Africa is also difficult to understand.

The gravest challenge to HIV/AIDS programming in Africa, in my view, is the extraordinary disconnect between the frenzy of international HIV/AIDS remedial initiatives and the needs of individuals and families infected or affected by HIV/AIDS in Africa.

Today in Africa, a typical family batting HIV/AIDS is unlikely to receive any support or assistance from current national or international HIV/AIDS remedial programs in Africa despite high decibel media pronouncements. Less than two percent of individuals clinically qualified to receive anti-retroviral therapy in Africa receive these medications.
Another HIV/AIDS programming shortfall is the continued operationalization of remedial efforts as a health sector issue. The concept of a multi-sectoral response to HIV/AIDS is yet to materialize in many parts of Africa although the multidimensional implications of the epidemic are not in question.

The lack of capacity to scale up successful HIV/AIDS programs in Africa represents another significant impediment. National governments in Africa continue to struggle financially and technically to support viable community-based HIV/AIDS programs. Non-government community organizations and secular organizations active in rural parts of Africa often have difficulties attracting sustainable national or international support for HIV/AIDS remedial programs.

In addition, African countries battling HIV/AIDS, to the best of my knowledge, are yet to mobilize their nationals living in the West to join the fight against HIV/AIDS. Countries with alarming physician-to-population ratios such as Ethiopia, Malawi, Zambia and Kenya cannot afford to ignore the potential role of their citizens working as health professionals in the West. Countries such as Nigeria, South Africa and Ghana with huge numbers of professionals living in the West have a ready resource that could play important roles in HIV/AIDS remedial efforts in their native countries.

Early onset of AIDS is often spent in hospital wards in Africa. As the condition worsens, most individuals living with AIDS go home to die. Hospital services in many Southern Africa nations remain over-burdened by the huge influx of individuals living with AIDS. The rising co-infection with Tuberculosis among individuals living with HIV/AIDS is putting additional pressure on Africa’s health systems. Lack of access to anti-retroviral drugs by individuals living with HIV/AIDS is effectively turning hospitals in Africa into mere “consulting clinics” where patients do not benefit from the expertise and knowledge of available medical expertise.

Another critical issue is the state of healthcare infrastructure in Africa. Healthcare infrastructures in many parts of Africa require urgent repairs or expansion to accommodate growing need. Financial support for these infrastructure improvements are often beyond the capacity of African governments. Unfortunately, infrastructure support is not always a priority of external donors.

In addition, the backbone of health systems in Africa, the community-based primary health care program, continues to deteriorate from lack of national and international support, exodus of trained staff and inability to maintain diagnostic and operational equipment. Community-based outreach programs with focus on information, education and communication campaigns also remain fragile as the budget for community health workers do not reflect unmet need.

The American Bar Association has an important role in assisting their counterparts in Africa to remove all vestiges of human rights violation and discrimination against individuals living with HIV/AIDS. The UNAIDS estimates that at least 50% of all African countries do not have laws protecting citizens living with HIV/AIDS from human rights violations or discrimination. In many African countries, the right to privacy of medical records is hardly enforced, and consequently, the idea of voluntary testing and counseling remains challenging.

Another critical issue is the need for legal reforms to end gender inequities in Africa. The inability of African women, especially widows, to own property in some parts of Africa, according to the UNAIDS, is a major contributor to the growing rates of HIV among the female population. Widows with small children have minimal cultural rights to own property or inherit the joint savings accumulated with their late husbands. Legal sanctions against rape and sexual coercion need to be strengthened as part of comprehensive HIV/AIDS remedial efforts.

The American Bar Association can do specific things to assist individuals living with HIV/AIDS in Africa.
First, the ABA can liaise with their counterparts in Africa to strengthen laws against human rights violation or discrimination against individuals living with HIV/AIDS. The ABA can send volunteers to work with national bar associations in Africa.

Second, the ABA leadership should encourage interested members to volunteer for short term technical assignments in specific African countries to meet specific legal needs. A major focus of this technical assistance could ABA volunteers and their African counterparts working closely with African parliaments in various countries to end human rights violation or discrimination against individuals living with HIV/AIDS. In another example, ABA members with expertise in human rights and trade law can provide technical assistance to African nations seeking to improve timely access to quality anti-retroviral drugs for their citizens.

These volunteer lawyers can also provide technical assistance to African nations engaged in negotiations with the often well-legally resourced pharmaceutical companies. They can also assist countries weighing their international legal options regarding generic drug manufacturing, drug re-importation issues, and declaration of public health emergencies.

Third, the ABA can organize training programs for their trade law colleagues in Africa and help link them, electronically, to top international and trade law libraries and databases. Interested junior lawyers can also volunteer to provide electronic legal research assistance to their African counterparts from their base in the United States.

Fourth, the American Bar Association can become a powerful advocacy voice for individuals living with HIV/AIDS in Africa. Today, barring unprecedented global and continental action in the next few years, the vast majority of more than 25 million Africans living with HIV/AIDS will die without access to available lifesaving, anti-retroviral therapy.
In the 21st century, millions of individual may die of a manageable disease solely on the basis of geographical location, even when drugs that can prolong their lives are available. The ABA can play a powerful advocacy role with the US Congress and the White House to ensure that geography is not the ultimate predictor of highly avoidable deaths from AIDS. Today in the United States and Europe, HIV/AIDS is a chronic manageable disease and individuals living with the condition continue to be productive members of the society.
The ABA can also exert a powerful advocacy role in Africa by coming to the aid of individuals who are being persecuted because of their sexual orientation, political beliefs on AIDS remedial efforts or mobilization of target population for better access to health products and goods.

Fifth, the ABA can provide financial and technical assistance to non-government legal organizations in Africa active in HIV/AIDS remedial efforts. These organizations are active on human rights issues, gender inequity issues, representation of individuals living with HIV/AIDS in courts and work place discrimination against HIV/AIDS.

The key to an effective ABA role in international remedial efforts is the need to embrace the concept of multi-sectoral response to HIV/AIDS. I had co-written a document on the need for an HIV/AIDS International Volunteer Services Corps in Africa with multi-sectoral technical teams from the West providing technical services to specific countries and on specific HIV/AIDS remedial issues ( Depending on the specific needs of a country, ABA volunteers may be working closely with their counterparts from the US-based National Medical Association, the Association of Scientists and Physicians of African Descent or other Western-based professional groups already providing volunteer services in Africa.

The intellectual depth of the ABA, the experience of its members in policy development, the fiscal reach of the organization and the deep pockets of some of its members could be deployed to effective use in international HIV/AIDS remedial efforts. The famed Pro Bono legal obligation for ABA members can be implemented in Africa as part of HIV/AIDS remedial efforts.

Thank You So Much For This Opportunity.

Dr. Chinua Akukwe is a former Vice Chairman of the National Council for International Health (NCIH) now known as the Global Health Council, DC, the largest voluntary global health organization in the world.