HIV/AIDS Global Trust Fund:
Need for an Equitable and Efficient Governance Structure

By Chinua Akukwe and Melvin Foote, Constituency for Africa

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The international community appears poised to intervene to end the devastating effects of the HIV/AIDS epidemic, especially in Africa where, according to the United Nations Agency for HIV/AIDS (UNAIDS), more than 25 million Africans live with the virus or are dying of AIDS. Few infected Africans have access to life saving anti-HIV/AIDS medicines that have transformed the disease from a feared to a manageable chronic infection in the West. Through a combination of street protests, sophisticated policy reviews, media exposes, and powerful commentaries in the print and electronic media, AIDS activists have forced the issue of access to HIV/AIDS care in developing nations.

A major vehicle for the proposed intervention is the HIV/AIDS Global Trust Fund. The June 2001 United Nations Special Assembly Session on HIV/AIDS in New York and the July 2001 G-8 nations summit in Genoa, Italy could lead to a firm resolution and action to stop AIDS in Africa and other hard hit regions of the world.

UN Secretary-General Kofi Annan, speaking at the April 2001 HIV/AIDS Summit in Nigeria, identified five critical issues that should be addressed by the Trust Fund: prevention of new infections, ending maternal-to-child transmissions, providing affordable and accessible treatment, accelerating scientific breakthroughs, and providing social support to those infected and affected by the epidemic (especially AIDS orphans). Annan called for an annual expenditure of $7-10 billion dollars to support the Trust Fund's work. This recommended expenditure represents the equivalent of a little more than one percent of the world's annual military spending. The UN proposal builds upon other global response initiatives such as the Global AIDS and Tuberculosis Relief Act of 2000 of the U.S. Congress (Public Law 106-264) that established the World Bank Global Trust Fund.

A major obstacle to a massive response to the AIDS epidemic in Africa and other developing regions has been the paucity of funds to provide effective treatment and prevention programs. In the keynote address to the May 2001 World Health Assembly, Annan indicated that the current expenditure on AIDS prevention and care in low- and middle-income countries amounts to only 20% of what is minimally needed. In Africa, the epicenter of the epidemic, annual expenditures are even lower—about 10 percent.

The economic costs of a massive treatment program remain a daunting challenge. The lack of basic healthcare infrastructure in Africa and other developing regions pose a major logistical obstacle to accessible HIV/AIDS treatment program. In addition, the lack of other basic infrastructure such as roads, water, electricity, and sanitation in Africa is a major handicap. Less than one in five Africans have access to electricity, and less than 50% have access to drinking water or basic sanitation. The situation is even worse in the rural areas of Africa where more than 70% of the population live.

Limited Response and Many Conditions

The campaign to raise billions of dollars to address the AIDS epidemic is facing serious shortfalls. The U.S. government promised an "initial" allocation of $200 million, while France and the United Kingdom are contributing a combined $234 million to the Trust Fund. The foundation world has been largely silent, except for the $100 million donation announced by the Gates Foundation. The private sector's response came from the $1 million donation from the Credit Suisse Bank.

Despite such limited responses, donors are attaching numerous conditions to their donations. President Bush in announcing the U.S. contribution of $200 million stated that the Fund should respect intellectual property rights and provide incentives for pharmaceutical research. Andrew Nastios, the newly appointed head of the US Agency for International Development (USAID) has come under attack from AIDS activists and researchers for advocating preventive rather than treatment programs, arguing that Africans in the rural areas do not use watches and thus are unfit for complex anti-retroviral treatment programs. The EU's development commissioner, Poul Nielson suggested that EU will back the Trust Fund only if other donated funds are indeed new funds (not recycled prior commitments), the pharmaceutical firms commit themselves to providing cheaper drugs to developing countries, and the Trust Fund addresses other diseases besides AIDS. The Gates foundation donation is earmarked for "innovative HIV/AIDS preventive efforts."

The role of beneficiary nations in the governance of the Trust Fund has not yet been determined. Kofi Annan's envisions a structure that includes both donor and recipient nations in its decision-making apparatus. But tough talk by donor nations suggests that recipient nations may be forced to settle for a less than equitable role in the operations of the fund. Unfortunately, the recipient nations themselves have yet to articulate their views on the architecture of the Trust Fund. The World Bank in the March 2001 report of its analysis of foreign aid programs in ten selected African countries concluded that donor -imposed conditions are doomed to fail without the active participation of the recipient nations in the design and implementation of such programs.

Western nations led by the U.S. should help establish a Global Trust Fund that is based on an equitable and respectful relationship with potential recipient nations. The current move toward a master-servant relationship between donor and recipient nations regarding the Trust Fund is a recipe for disaster. As the Western nations attempt to craft a common approach, the Trust Fund must face the moral, economic, and logistic issues surrounding the lack of access to pharmaceutical goods by the vast majority of individuals living with HIV/AIDS.

Need for a Common Approach

As a way forward, the Global Trust Fund should operate under the following principles:

• No individual should be denied access to available HIV/AIDS clinical management and social support on the basis of geographical location, race, income level, market forces, or national origin.
• Every individual in the recipient countries should have access to culturally appropriate risk reduction messages.
• The governance of the Trust Fund should reflect the viewpoints of the various stakeholders, especially the donor and recipient nations, civil society organizations, and persons living with HIV or AIDS.
• The Trust Fund should operate on the basis of transparency, accountability, and effectiveness.

As a fundamental strategy, the Trust Fund must seek to democratize access to HIV/AIDS lifesaving medicines so that it not only becomes affordable but also available to needy populations. Any false dichotomy between treatment and prevention programs must be avoided since high-risk behaving individuals are unlikely to come forward for testing and counseling unless treatment programs become available. It is also essential that the Trust Fund support comprehensive information, education and communication campaigns that respect cultural and religious norms that do not propagate HIV transmission, promote risk reduction activities, and permit contextual analysis of the factors that influence risky behaviors.

The major infrastructure targets of the Trust Fund should include the primary care networks and the tuberculosis control programs of the recipient nations. Also as part of its strategic approach, the Trust Fund's governors should work closely with recipient nations to ensure that chosen projects reflect the wishes of the target populations, and that intended relief activities reach the at-risk population. The ultimate measure of the Trust Fund should be the number of number of individuals saved from contracting new infections or meeting untimely death from HIV/AIDS and other chosen health conditions in defined communities. Other important targets of the Trust Fund should include the establishment of linkages with other players, the support of poverty reduction initiatives in target communities, and collaboration with public and private partners to accelerate HIV vaccine development and distribution.

Kofi Annan's recommendation for a small secretariat made up of dedicated men and women that will work with other players in the field of development to implement the programs of the Fund should be respected. The Director-General/CEO of the Global Trust Fund should be an expert (preferably African) on both HIV/AIDS and development.

There is no need for the creation of new structures in the recipient nations. The Trust Fund leadership should work with the UN Country teams, the host governments, the civil society and the private sector to implement delivery channels that meet the needs of the target population. In Africa, the TB infrastructure in various countries could become the backbone of the Trust Fund's delivery mechanism. Malawi's successful TB control apparatus, for example, could become the pathway for the phased introduction of antiretroviral treatment program. The Malawi government has identified five critical issues that must be resolved in a national program to introduce antiretroviral treatment programs through an existing TB network: 1) government commitment, 2) case detection of HIV seropositive individuals, 3) administration of standardized triple antiretroviral therapy to symptomatic patients, 4) maintaining a regular and secure supply of antiretroviral drugs, and 5) establishing and maintaining a monitoring system.

The primary care network of developing nations with the cadres of professional and paraprofessional staff could become another delivery mechanism for the Trust Fund. The primary care network often includes a health post, a health clinic, a health center, and a cottage hospital that handle general medical procedures and surgeries. The cottage hospitals often have linkages to more specialized medical centers in the urban centers, and occasionally, serve as training posts for medical students in the teaching hospitals.

The Trust Fund should establish working technical relationships with various specialized UN agencies. These agencies include the UNAIDS, the World Health Organization, the UNICEF, International Labor Organization, the United Nations Development Program, United Nations Fund for Population Activities (gender issues), the Food and Agricultural Organization, and the World Food Program, and the Economic Commission for Africa. The Trust Fund should also enter into technical relationships with think tanks, the private sector, and civil society organizations that have well defined agendas and the appropriate skills.

To avoid becoming an isolated and elitist institution, the leadership of the Trust Fund should conduct regular consultations and briefings with stakeholders. It should offer regular briefings for the civil society organizations, the private sector, persons living with HIV/AIDS, the print and electronic media, students and young people, the academia, and policymakers in donor and recipient nations.

The Next Move

As the world's developed nations ponder their next moves regarding the Global Trust Fund, they should look back to the difficult days in Europe at the end of the Second World War. George Marshall, then-U.S. Secretary of State, in a commencement address to the graduating Harvard Class of 1947, called on America to "do whatever it is able to do to assist in the return of normal economic health in the world, without which there can be no political stability and no assured peace." Furthermore, "It would be neither fitting nor efficacious for this government to draw up unilaterally a program designed to place Europe on its feet economically. This is the business of the Europeans."

Today, the Marshall Plan's sponsoring nation and the plan's beneficiaries are world's most developed and powerful nations, all enjoying unprecedented prosperity. We look forward to the day when Africa and other developing regions of the world would become self-sufficient and prosperous. The HIV/AIDS Global Trust Fund could become the impetus to redefine relationships between the donor and recipient nations.

Faced with limited donations and as donor conditions expand, the Trust Fund stands in danger of being stillborn. That would a shame with woeful consequences. It must be remembered that every 25 seconds an African contracts HIV, and every day 6700 families bury a loved one who died of AIDS.

Chinua Akukwe <cakukwe@att.net> is a board member of Constituency for Africa, and Adjunct Professor at George Washington University School of Public Health. Melvin Foote is President/CEO of the Constituency for Africa (CFA), a Washington, DC advocacy organization. CFA is promoting an AIDS Marshall Plan for Africa.