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• W2023984734 abstract "In a recent press release the UNAIDS Executive Director stated that ‘60 million Africans have been touched by AIDS in the most immediate way’ (UNAIDS 2003). The consequences to sub-Saharan African societies are devastating – many social and family systems have already been destroyed beyond repair. Although the prevalence is declining in some areas, the epidemic grows largely unabated in most countries. Still, control efforts remain limited in both quality and scale. Something needs to change! Are things done in the most effective way? Solid practical evidence for Africa is difficult to come by, but theoretical analysis raises some doubt. Much of the focus is on interventions, which, in their present form, because of poor adaptability to local contexts, may not have a major effect on the course of the epidemic, but do help individuals and are likely to reduce stigma, such as prevention of mother-to-child transmission (Msamanga & Swartzendruber 2003) and even HAART treatment. Other interventions, which are likely to be more effective (long-term), such as activation of the community, which seems to have succeeded in Uganda (Stoneburner & Low-Beer 2000), remain limited in other countries. Sex education in schools often stays in the planning stage in ministries of education or is progressing slowly. Condom use in rural areas is very low and social stigma a major obstacle. Political leaders still seem reluctant to tackle the problem forcefully in spite of having committed themselves to do so (African Union Summit 2003). The importance of the deep roots of culture and traditions for the formation of social norms in African societies and the importance of context for sexual behaviour has not been fully recognized and the issue thus not explicitly addressed (UNICEF 2003). The focus has been on individual behaviour change and human rights – not on public health (De Cock et al. 2002) and change of social norms. There is still a need to find local solutions and reconsider what should best be done in a specific country's situation. As the role of AIDS in poverty reduction was recognized, it moved to the top of the general development agenda with all the advantages and drawbacks this implies. It means that AIDS control will be governed by major government policies, which may improve possibilities for funding. However, as such policies largely reflect those of the international organizations and agencies, they may lead to adoption of directives poorly adjusted to local resource limitations – heavy donor dependence leaves sub-Saharan countries without much choice. Donor policies presently favour a mainstreaming, sector-wide approach and budget support, and also reducing their own administrative and technical staff, leaving little room for specifically directed categorical inputs through project support. This has led to a shortage of funding and support for small community-based projects, which are crucial for AIDS control in Africa. Further, the internationally formulated multi-sector approach to AIDS control may delay activities in key sectors of health and education. Broad, often poorly adapted policies dominate and operational aspects are being pushed aside. Governmental systems in many afflicted countries are inefficient. Already weak before the epidemic, they have been further crippled by it, and cannot be expected to fully take on the task of AIDS prevention unless considerably strengthened. Existing support systems often fail to function well: drugs, condoms and information do not always reach people in the villages. NGOs working in the communities, even if they do a good job, are too few, under financed and insufficiently supported. Current policies do not reflect this situation and partly for this reason do not address it effectively. Change through reforms and capacity building is a slow, gradual process, and for many countries means changes to both structures and remuneration systems – politically difficult measures (Hanson 2000). In short, AIDS control often still lingers under political hesitancy, directed by often poorly adapted policies that delay effective implementation of interventions, and is further hampered by a shortage of management skills and qualified staff. International pledges of more money will not help much in the short term (Hanson 2002), as there is a limited capacity to absorb additional funds and use them effectively. On the contrary, rather than offering a solution, too much money poured in too quickly will distort the balance between human and financial resources and indirectly contribute to lower service outputs and fewer prevention activities. What is needed is a way to rapidly increase the absorption capacity. When countries in the horn of Africa and in the south of the continent suffer from serious famine (UNAIDS & WHO 2002), their leaders call out for help, and there are established international organizations to address these emergencies. AIDS and tuberculosis are also causing emergencies – albeit ones which take effect more slowly. The heads of states should acknowledge the great difficulties in combating AIDS they are facing and ask for assistance – assistance to establish functional operational systems before even more irreparable damage is caused to social systems. There is no time to be lost. Small, temporary operational structures and effective parallel nationally directed systems could be established to channel resources into disadvantaged governmental systems and make selected parts of them work better. NGOs could receive support to operate more effectively in the communities. The issue of changing social norms could be more efficiently addressed through synergetic interaction. Condom and drug supplies to the periphery could be ensured and logistics generally improved. It would even be possible to set up reasonably large systems for treatment with anti-retroviral drugs. A system for capacity building could be established. Without these additional structures it will not be possible to absorb large sums of money and transform it into effective action and the existing systems will deteriorate even further. There is no alternative to decisive and effective action to address this developing catastrophe! The leaders of sub-Saharan states must act now, and the international community must be prepared to respond effectively to save these societies from further destruction. The international response would have to include a revision of current policies in the light of experiences gained. We need a mixed approach: support for both for ‘sustainable’ strengthening of the whole system in line with health sector reforms and non-sustainable project support for specifically directed temporary efforts in line with the thinking behind the establishment of the Global Fund to fight AIDS, tuberculosis and malaria. We owe this to the suffering people in these countries. We also owe it to taxpayers in industrialized countries who are both willing to pay and have a genuine desire to help." @default.
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• W2023984734 date "2003-09-01" @default.
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• W2023984734 title "Editorial: How to bridge the gap between policies and implementation - is effective AIDS control presently possible in sub-Saharan Africa?" @default.
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• W2023984734 doi "https://doi.org/10.1046/j.1365-3156.2003.01104.x" @default.
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