Are we accountable against our promises?

If Durban 2000 was a wake up call, Barcelona 2002 is likely to be the "yes, but?…" Conference, with the biggest cautionary being accountability. Or as UNAIDS Executive Director Peter Piot says, "will promises be kept?"

It took 20 years from the first knowledge of HIV to political commitment - 180 countries signing the United Nations General Assembly Special Session (UNGASS) Declaration on HIV/AIDS last year. How long will it take for accountability to kick in? For commitment to become visible action? Life-preserving drugs are dramatically cheaper, but very few yet have access to them - only 30,000 of the 28.5m infected people in Africa, as an example, compared to 500,000 of 950,000 North Americans, according to UNAIDS.

"Durban was a wake-up call," says Piot, speaking in Barcelona ahead of the opening of the Conference. "It was depressing, beginning with the opening session and President Mbeki?…" Piot raises his hands and shakes his head. "But in the last two years the speeches and words have come right. UNGASS saw political endorsement from all member states and the recognition that treatment, care and support were integral."

A UNAIDS report on the Global HIV/AIDS epidemic, released last week, noted: "Effective responses are possible only when they are politically backed and full-scale." Piot says that this was why the New Economic Partnership for African Development (NEPAD) - a blueprint for socio-economic development drafted by African leaders - received a lukewarm response from the G8 a fortnight ago. "NEPAD is the first comprehensive plan for African development, and yet, although HIV, with armed conflict, is the greatest challenge in Africa, there is not a significant approach to dealing with HIV/AIDS in that development plan.

"AIDS is a global political issue, and accountability is shifting to the top leadership of the world. It is important that we get out of a public health straitjacket - AIDS should be a bigger part of NEPAD. In Eastern Europe it should be an issue for [Russian Federation President Vladimir] Putin and not just a Deputy Minister of Health. It should be top of the political agenda."

But it is not merely countries of high infection that are showing political inertia in coming to terms with an epidemic that is claiming 8,500 lives and 14,000 new infections each day. At the recent G8 summit in Canada, appeals for agricultural subsidies to be removed, to allow produce from developing nations onto world markets were ignored.

Yet the UNAIDS 2002 Report notes: "Greater access to high-income countries' markets, debt relief and more development aid will go a long way toward enabling countries to reduce poverty. High-income countries spent more than US$300bn in 2001 on agricultural subsidies - roughly equivalent to the combined gross domestic product of all of sub-Saharan Africa." This is an area that the Food and Agricultural Organisation reported a month ago has 12 million people living in famine.

Piot observes that the G8 communique confined AIDS to a single paragraph: "It said something to the effect that without combating AIDS, African development would be a pipedream, but then we saw no action, no commitment from the G8 to increase resources."

The UN Secretary General, Kofi Annan, has sent a questionnaire to all UNGASS signatory governments to map progress toward 2003 and 2005 UNGASS targets. By 2003, as an example, signatory nations have pledged to have in place strategies, policies and programmes that identify and begin to address those factors that make individuals particularly vulnerable to HIV infection, including underdevelopment, economic insecurity, poverty, lack of empowerment of women, lack of education, social exclusion, illiteracy, discrimination, lack of information and/or commodities for self protection, all types of sexual exploitation of women, girls and boys, including for commercial reasons.

The UN will do independent surveys to crosscheck government claims, Piot says. The chief of the UNAIDS partnership team, Bai Bagasao, concedes that this process is less than ideal and will not reach all of civil society for their views about progress, particularly in countries of highest infection. "We are hoping different groups will come together at Barcelona to come up with a coherent plan of action," he says

Some have suggested that there should be a barometer of good governance, and rewards, in terms of increased aid, as an example, for those that score high on such a graph. Piot comments that he believes "good governance should be rewarded, but I don't know whether this will encourage more good governance. It is better to bypass a government that is not doing what it should and give funding direct to non-governmental organizations."

Similarly Piot is critical of recent reports that it would be best to focus on prevention, rather than extend anti-retroviral treatment. "The only effective treatment at present is anti-retrovirals. However, inadequate media attention has been given to the importance of good nutrition. Other treatments and prophylaxis especially, have been neglected. It doesn't make a headline, it is not a sexy story.

"Let's get the debates about cost-effectiveness and the need for treatment out of the way. I'm upset that it is coming up again. I've worked in enough countries to know that health care is not a total mess in all. Access to treatment can be done fairly quickly, around 40% of urban dwellers can quickly get decent treatment - things become more difficult with rural areas. Health services exist. The dire straits of many health services in Africa are used as an excuse for doing nothing. When one is faced with a complex problem, you either become paralysed or you can address it, bit by bit."

Last week China denied recent UNAIDS claims that it was not doing enough to face a catastrophe with a developing HIV/AIDS crisis. "Our work depends on governments, it puts us in a delicate situation. But I feel strongly that it is our job to speak the truth, we have to confront governments with the facts as we see them, and too, work constructively with governments."

UNAIDS Executive Director Peter Piot outlined a brief list of what he would like each government leader to do:

o Make HIV/AIDS your personal priority;
o Make it a Cabinet issue and ensure every single Minister creates a budget line on AIDS and reports on it;
o Ensure that there are enough resources;
o Regularly appear in public with a person living with HIV and talk about the issue;
o Make sure that the $10 billion a year for the Global Fund is met - without it nothing is going to happen.

AIDS2002 Conference Barcelona, July 7-12, 2002