The Impact of Change: Shifting Global Architecture and HIV
Altman, Dennis, Harvard International Review
AIDS has now been with us for a quarter of a century, and there are people still alive who were among the first people to be diagnosed with HTV after the retrovirus was discovered and named in 1983. Think back to the world of that time: Ronald Reagan was President of the United States, and still locked in what seemed to be a permanent state of hostility with the USSR, whose collapse at the end of the decade was almost entirely unexpected. The greatest economic challenge to the United States was thought then to be Japan, and very few people anticipated the rapid rise of China.
AIDS had almost certainly existed in parts of Africa long before it appeared and was named in the United States, but it remains an epidemic particularly marked by its US history. The stigma that developed around its association with male homosexuals and drug users would be widely disseminated, and remains even today. US initiatives, including the development of a People with Aids (PWA) movement, AIDS activism, major progress in biomedical research and funding for international responses through die President's Emergency Plan for AIDS Relief (PEPFAR), the Gates Foundation, and so forth continues to frame much of the global response, although other countries have often been far more progressive than the United States in their policies. This is true of Brazil's early development of widespread treatment access, and of several countries' policies towards homosexual men, drug users, and prisoners. In its policies for injectors within prisom, Iran is ironically more progressive than the United States, although deeply repressive of sexual behaviour outside marriage.
In the first decade or so the United States was not a major presence internationally in the fight against AIDS, although the founding director of the World Health Organization (WHO) Global Program on AIDS, Jonathan Mann, was an American. Mann established the connection between health and human rights as a dominant paradigm for the international approach to the epidemic, one of the most significant moves in recent public health. The decision of the United Nations in the early 1990s to establish UNAIDS, as a unique hybrid body that is intended to coordinate and lead the efforts of all UN agencies in their responses to was led by others, and its founding director, Peter Piot, was Belgian.
US attention increased during the Clinton Administration, which played a significant role in putting HTV and AIDS on the agenda of the Security Council, with its first ever debate on a health issue in January 2000. That debate was followed a year later by a special meeting of the UN General Assembly, where the United States under the new president adopted a cautious position on both prevention and treatment access. Indeed, the final statement released by a coalition of most civil society representatives in New York signalled out the Bush Administration for criticism: "The United States was particularly damaging to the prospects for a strong declaration. Throughout the negotiations they moved time and again to weaken language on HIV prevention, low-cost drugs, and trade agreements and to eliminate commitments on targets for funding and treatment. It's death by diplomacy," said Eric Sawyer, veteran activist and 25-year survivor of HIV/AIDS, as highlighted in Global Network 2006. Specifically, the United States joined with conservative Islamic nations in refusing to name sex workers, men who have sex with men, and drug users as particularly at risk.
The establishment of the Global Fund to Fight MDS, Tuberculosis, and Malaria owed a great deal to advocacy by US academic experts in public health and development, especially Jeffrey Sachs, but it was the UN secretary-general, not the president of the United States, who took the political lead in its establishment, nor was the United States particularly generous in its initial pledges. However, over the next few years, President Bush greatly increased bilateral assistance for AIDS programs, and total US public and private expenditure on AIDS programs and research now amounts to over half of all global spending on the epidemic. …