Governance Can Accelerate the End of the AIDS Epidemic

Mahesh Shukla

Senior Technical Advisor for Public Sector Governance

Under the auspice of Sustainable Development Goal 3, world leaders have set an ambitious target to end the AIDS epidemic by 2030, and the United Nations General Assembly, by consensus, has resolved to accelerate the fight against HIV by adopting the Political Declaration on HIV and AIDS in June 2016. This declaration called for intensifying efforts to realize universal access to comprehensive prevention, treatment, care, and support. As a result, member states have embraced a set of targets to fast-track progress over the next five years to end the epidemic as a public health threat by 2030.

There are many barriers to transform these noble intentions and aspirations into a reality, but three have proven particularly intractable: discrimination, stigma, and criminalization of people living with HIV and people at increased risk of HIV; disempowerment of young people and especially young women; and weak health systems particularly in the countries where the epidemic remains out of control.

Discrimination, Stigma, and Criminalization

The stigma against HIV remains deeply ingrained among many people, and it manifests itself through discrimination against key populations and other marginalized populations, such as migrants and prisoners. Similarly, regulations that criminalize key populations remain widespread, further limiting access to HIV prevention, treatment, care, and support.

According to the United Nations, nearly 60 percent of countries in 2012 had reported regulatory barriers to access, and countries that lacked legal protections for sex workers, men who have sex with men, people who inject drugs, and transgender people vastly outnumbered those with legal protections. Meanwhile, the International Lesbian, Gay, Bisexual, Trans and Intersex Association reported that 75 countries continue to treat homosexuality as a crime.

Ignoring the fact that certain populations are at a higher risk of HIV transmission or criminalizing these populations will not end but extend the epidemic.

Disempowered Youth

For too long, young people have remained in the blind spot of the fight to end the AIDS epidemic and particularly young women.

Young women are eight times more likely to acquire HIV than young men—often because of unequal power dynamics in sexual relationship or intimate partner violence that prevent women from protecting themselves against HIV.

When young women do seek HIV testing and treatment, they instead face stigma, discrimination, and gender-based violence.

Weak Health Systems

If people living with HIV are strong enough to triumph over discrimination or criminalization, then weak health systems do not help.

Weak health systems are perennially short of skilled health workers, HIV testing kits, or antiretroviral (ARV) stocks. Even if the skilled health worker is available, a testing kit or ARV may not be available. Similarly, public health facilities often remain under-financed, under-resourced, and unable to provide prevention, treatment, and care of a reasonable quality on a consistent basis.

The LMG Project's Governance Guides and Handbooks can help improve health services and strengthen health systems.
Tools and tactics for peer-to-peer sharing were the Share Fair's main focus. (Photo: Wycliffe Omanya)

As a result, communities—and key populations—remain disenchanted and disengaged.

The Governance Response

These are the three areas where governance can make most impact. If the leaders who govern a nation have made ending the AIDS epidemic a political priority, they must consider taking at the very least three steps:

  1. Take the discriminatory laws off the books and instead enact and enforce legislation to protect people living with HIV from discrimination even if this means leaders risk spending their political capital.
  2. Invest in the education of girls and establish policies to set young men and women to succeed.
  3. Mobilize resources so that the health facilities are able to deliver services that include HIV prevention, treatment, care, and support to the people living with HIV.

However, these changes may not work or begin solely from top down; they need reinforcement from the bottom up. It is vital that the affected communities, health workers, young people, and women get organized, voice their concerns, and shape political priorities of their political leaders.

This blog post is the first in a series of three blog posts around the 4th Governance for Health Roundtable that was held in Washington, DC, on September 29, 2016.