AIDS response caught in a debt trap

Shobha Shukla *

25th International AIDS Conference or AIDS 2024

When countries are unable to repay debts, domestic financing for health, education or social protection gets slashed which disproportionately affects the already impoverished and marginalised communities in the Global South. Richer nations and financial institutions of the Global North have relentlessly imposed neoliberal policies that force Global South countries to prioritise debt repayment over human rights (or risk debt default) through a mix of regressive anti-people taxation, privatisation of public services, deregulation and cuts on public spending that undermine essential services guaranteed under international and national laws.

“African countries like Angola, Kenya, Malawi, Rwanda, Uganda, and Zambia, are paying the interest on their debts which exceeds 50% of government revenues. Half of the countries in Sub-Saharan Africa are either in debt distress or at high risk of it, as they are spending on an average, three times more to repay the interest on their debts than they do on health,” said UNAIDS Executive Director Winnie Byanyima. "Sierra Leone spends 15 times more on servicing its public debt than on the health of its people."

It is critical to ensure that debt restructuring happens quickly and must have human rights and people’s wellbeing in the centre.

Countries need to have enough money to put in health and development responses for the people.

Debt trap diplomacy has caused countries choke on debt

Archbishop Dr Thabo Makgoba of South Africa called for dropping the debt. “Debt is choking the countries of the Global South and denying us what we need for health and education. Please let us breathe.”

This is why UN Secretary General Antonio Guterres calls out for a restructuring of debt to free the countries for investing in the health of their people.

Debt trap is not new, but its impact has become more lethal for those who are likely to be left behind. “Loan interest rates suddenly rose by three-four times when the war in Ukraine broke out. Countries-in-debt are nowhere (geographically) close to where the war is being fought and yet reeling under debt which has grown manifold. When the low-and middle-income countries go to the market to borrow, they do not borrow at the same rate as a richer nation would. A poor country has to borrow at four times higher rate than a country like Germany would from the same market. There are inequalities even in the financial architecture,” explained Winnie Byanyima.

This is the reason why UN head Antonio also called upon reforming the whole financial architecture to level the ground for developing countries.

US$ 500 billion spent on war in Ukraine but AIDS response has US$ 9.5 billion funding gap

One of the health financings that has taken a major blow due to debt trap, skewed financial architecture and spending priorities, is of the global HIV response. US$ 9.5 billion is the funding gap globally – this money is holding back the HIV response as per the plans for delivering on 2025 targets and goals.

Even development aid from richer nations is fast shrinking. “But over US$ 500 billion have been spent by warring parties in one war in Ukraine,” said Winnie. “The cost of not ending AIDS would be exponentially higher than the cost of ending AIDS by 2030. That is why we must ensure that governments fully fund the global AIDS response.”

Compared to 2022, global HIV financing did not increase in 2023 but instead dropped by 5%. The decline in domestic resourcing for HIV was even higher (6%) in 2023 (compared to 2022). It is important to note that almost two-thirds of HIV financing comes from domestic resources within a country (59%) – which is being severely constrained by the debt crisis.

The latest UNAIDS report 2024 “The Urgency of Now: AIDS at a Crossroads” which was launched last month at the world's largest AIDS conference (25th International AIDS Conference or AIDS 2024) shows that in countries and regions where HIV financing has declined significantly – such as in Eastern Europe and Central Asia, Latin America and the Middle East and North Africa – the HIV epidemic is growing. Around half of the total resources needed by 2025, and 93% of the current HIV funding gap, are outside of Sub-Saharan Africa.

“The UNAIDS report 2024 demonstrates that the actions that leaders will take this year will determine whether the world succeeds in ensuring that we reach the end of AIDS by 2030 - or we fail,” said Winnie.

Path to end AIDS is not a mystery – it is a political and a financial choice

With restructuring of debt and financial architecture where human rights and people’s wellbeing are central, governments need to ensure that domestic financing for health (and HIV) is sustained and increases to optimal levels. International development aid should not decline too.

“I am HIV positive myself. I am a gay man. I am in a very lucky position because I live in a country (Germany) where (HIV) treatment is available and where there is no discrimination,” said Peter Wiessner of Action Against AIDS Germany. “This is a lucky position to be in because I know there are certain countries where I would be put in jail… This is what inequality is all about - and this is not right."

Peter is right. Nearly a quarter of people living with HIV worldwide, are not receiving lifesaving treatment - and over half of them are in Africa. As a consequence, a person dies from AIDS-related causes every minute.

1 in 8 people who died due to AIDS in 2023 was a child

Because treatment is inaccessible, almost half of those facing AIDS-related death are children born with HIV – most in Sub-Saharan Africa. Over 76000 children died of AIDS-related causes in 2023 – “All of them could have been saved,” rightly said Winnie. “We cannot accept this (AIDS-related deaths) because we have all the tools for prevention, testing, and treatment and care.”

World leaders pledged to reduce annual new HIV infections to below 370,000 by 2025, but new HIV infections are still more than three times higher than that (1.3 million in 2023). And now cuts in resourcing and a rising anti-rights push are endangering the progress that has been made.

“We need to understand why a backlash is there (against HIV, gender equality, democracy and human rights). Progressive forces have made a difference over the years – with feminists fighting for gender equality and embracing other struggles too – such as for LGBTQIAP+ struggles for rights. They have started to be more intersectional and moved away from the rigid lens of gender binary. They accepted that gender is fluid and worked together with gender diverse communities and anti-racist forces – they understood how racism affects us all. The more powerful progressive and feminist forces become, the stronger is the challenge they pose to the 'monopoly of (patriarchal) power' to which men cling,” said Winnie Byanyima. May be, this growing people-power is what scared those who may wrongly think they are more privileged and entitled than a majority of others – “which made them use the lens of religion or culture to justify and control power.”

“We must keep challenging traditional hierarchies. We have to challenge the laws which exclude people for who they are, or laws which discriminate or criminalise people. My solutions are always about building power of the people,” Winnie added.

Remove obstacles to end AIDS in a rights-based manner

It is not just HIV-related stigma and discrimination, but a range of other forms of stigma associated with sex work, gender diversity or people who use drugs for instance, that compound the challenge. Another major obstacle that jolts the HIV response is laws that criminalise people and behaviours.

“We must tackle the discrimination and stigma that is pushing most marginalised people away from lifesaving services. There is a surge in anti-gender and anti-democracy laws and policies in many countries - this is generating fear amongst marginalised communities most-in-need of HIV prevention, testing and treatment. This is also causing fear amongst those heroic people who serve them. When governments announced that they are going to hunt for LGBTQIAP+ people as criminal - simply for who they love or who they say they are – it is not surprising that those people are afraid to enter a clinic and get the help they need to save lives. Governments must decriminalise same sex relations, decriminalise sex work, and must not use a punitive or criminal approach to drug control. They must end the discrimination faced by girls and women which is driving the HIV pandemic especially in Sub-Saharan Africa - girls are three times more vulnerable than boys of the same age to HIV. It is also harmful social norms and inequality in access to education that aggravate the challenge for girls,” said Winnie.

Agrees Archbishop Dr Thabo Makgoba of South Africa: “Discriminatory and harmful laws - like the one recently passed in Uganda that attacks people who are different - push them away from lifesaving healthcare, and thus these laws kill.”

Apartheid in accessing medicines is unacceptable

“We all are interdependent as latest UNAIDS report shows,” said Archbishop Dr Thabo Makgoba of South Africa. “We cannot end AIDS in some places or for some people. We can only end AIDS by ending AIDS everywhere for everyone. So, I call upon the world leaders to take five urgent steps:

1) Do not cut health financing, rather boost it,
2) Drop the debt,
3) Make medicines accessible and available to all because we cannot accept an apartheid when it comes to access to medicines – human lives of those in Global South are not regarded as having the same value as those in the Global North,
4) Support communities as they know best, and
5) Reject hate and choose love."

Affordable and accessible health choices for everyone

Study results in June 2024 showed that a new long-acting medicine called Lenacapavir helps protect young girls and women from HIV 100% (when used as a Pre-Exposure Prophylaxis or PrEP – and taken twice yearly - one injection every six months). But the price of this medicine is over US$ 40,000 per person per year.

However, generic manufacturers may be able to make Lenacapavir for less than US$ 100 per person per year, shares Winnie. “GILEAD and other patent holders of long-acting treatments and PrEP HIV prevention tools need to grant generic licensing using the UN-backed Medicine Patents Pool and make those generics available for all people in Africa, Asia Pacific, and Latin America,” said Winnie.

“Many technical innovations are only transformative if they are available for those who need them,” she added.

We can make AIDS a history: But will we do so?

“Latest UNAIDS report proves that all of us can make history (by making right decisions to progress towards ending AIDS by 2030),” said Dr Nittaya Phanuphak, Executive Director of Institute of HIV Research and Innovation (IHRI) in Thailand.

“I am saying this because now we have the tools to do so. We have a range of HIV combination prevention options including PrEP, testing, treatment and care. But we have to make the right choices – such as, choose to bring down the price of long-acting Cabotegravir or soon-to-come Lenacapavir which can play a crucial role in enhancing prevention and treatment uptake.”

Let communities lead

“We need a commitment from world leaders to support the community leadership - to bring these science- and evidence-based tools (for HIV prevention, testing, treatment and care) to the people who are so much in need of them. We must also get rid of all punitive laws that severely impede HIV responses,” said Dr Nittaya.

Thailand was the first country in Asia Pacific region to be validated for the elimination of vertical transmission (vertical transmission refers to parent to child transmission of HIV) in 2016. “We are on track for reaching the 2030 targets for HIV testing and treatment. We are also the first country in the world to pilot the community-led same day test and treat, and PrEP services. As of last year we had more than 82% of PrEP users in our country receiving PrEP from these community-led PrEP services,” she added.

“Two decades of our research at IHRI has proved that we can only be successful in ending AIDS if we let the communities lead. UNAIDS 2024 report proves this as well. But sometimes our leaders can take a wrong turn.”

Despite demonstrated stellar evidence from Thailand that community-led interventions are successful in reaching the HIV key populations manifold with quality services, there were a few decisions by Thai government in the end of 2023 which resulted in not-allowing community-led clinics to dispense PrEP and other services. Even doctors associated with non-profits like IHRI were barred from prescribing PrEP.

Dr Nittaya calls for integrated services. “Integrated community-led services go beyond HIV testing and treatment, and include services for STIs, viral hepatitis, sexual and reproductive health, mental health, stigma and discrimination reduction, and addressing other forms of human rights violations.”

Winnie Byanyima sums up well: "The fraying of solidarity between and within countries is putting progress in danger, but the path that ends AIDS is a path that has been proven, and is a path that leaders have promised to take. Whether leaders fulfill their pledge to end AIDS is a political and financial choice. The time to choose the right path is now."