Tunisia

UNAIDS Executive Director Michel Sidibé commended Tunisia for its leadership role in the AIDS response in the Middle East and North Africa region during his meeting with President Moncef Marzouki on 20 June in Tunis, Tunisia. Mr Sidibé also congratulated the country for its selection to host the 18th International Conference on HIV/AIDS and STI’s in Africa (ICASA) in 2015.

President Marzouki placed Tunisia among the pioneer countries to ratify the Arab Convention on HIV Prevention and Protection of the Rights of People Living with HIV—adopted in March 2012 by the Arab Parliament—and promised to push for AIDS to remain on the post-2015 development agenda. At the end of the meeting, President Marzouki signed the Protect the Goal ball, pledging his commitment to raise global awareness of HIV.

During his three-day visit to the country, Mr Sidibe also met with representatives of civil society and affected communities, the Vice-President of the National Constituent Assembly, Mehersia Labadi, the Minister of Health, Mohamed Salah Ben Ammar, the Minister of Finance, Hakim Ben Hamouda, and Donald Kaberuka, President of the African Development Bank.

In discussions with community leaders, Mr Sidibé stressed the important role of civil society in advocating for a rights-based approach in the AIDS response and the need for governments to engage them more in the political dialogue. He also emphasized the urgent need for legislative reform and a public health approach towards people who use drugs, to avoid criminalization and ensure access to HIV services.

Mr Sidibé also reiterated the importance of domestic funding to ensure a sustainable response to the epidemic, while stressing the need to establish a concrete investment plan that focuses resources where they are most needed.

Participants at the Youth and UNAIDS event held in Hammamet, Tunisia from the 20-22 of May. Credit: UNAIDS

AIDS activism has radically changed since the beginning of the epidemic. New modes of communication are amplifying people’s voices, creating cross-national webs of solidarity opening up new opportunities for progressive social change.

Young activists in countries around the world are increasingly demanding HIV services to be tailored to their needs and claiming their seat at the decision-making table.

While the HIV prevalence has fallen by nearly 27% among young people aged 15-24 globally between 2001 and 2011, young people still account for 40% of all new HIV infections among adults. In 2011, there were some 4.6 million young people living with HIV.

Against this backdrop, UNAIDS brought together 12 global and regional youth organizations working on HIV, sexual and reproductive health and rights, and lesbian, gay and transgender rights  with the 16 community, country and regional youth activists that constitute the recently established UNAIDS Youth Advisory Forum. The aim was to strategize on a clear direction to move the AIDS response forward for young people.   

“Many small organizations lack the time, resources, and strategic space to reflect on their work and forge new alliances,” said Pablo Aguilera, director of the HIV Young Leaders Fund and member of the UNAIDS Youth Advisory Forum. “We called for this meeting to ensure the movement is responsive to the needs of young people most affected by HIV.”

To deliver results for young people on the ground, a decentralized, connected global youth movement—that thinks globally but acts locally is needed to initiate a new wave of activism in the AIDS response.

The meeting, called the Youth and UNAIDS: A pact for social transformation took place in Hammamet, Tunisia from the 20-22 of May. The main outcome of the consultation was a pact outlining five key themes that cut across individual organizational agendas where youth organizations can make tangible impact towards the goals set in the 2011 United Nations General Assembly Political Declaration on HIV and AIDS.

The five themes include: Integrating HIV services into sexual and reproductive health services, with a focus on government accountability and sexuality education; enabling legal environments and removing punitive laws that impede access to services for young key populations at higher risk; scaling up treatment and disaggregating data for evidence informed advocacy; using resources effectively; and ensuring that HIV remains a priority in the Post-2015 development framework through strategic lobbying of national delegations.

“This new commitment to collaborate around specific priorities is a radical departure from business as usual in the youth AIDS response. Through strengthening collective action that goes beyond organizational agendas, we hope the movement can achieve concrete change for young people affected by HIV,” said Caitlin Chandler, community representative who co-facilitated the meeting together with Beth Goodey from the youth-led development agency Restless Development.

Supporting increased collaboration and strategic direction of the youth movement in the AIDS response is a key priority for the new UNAIDS youth programme, which aims to increase youth leadership, ownership, and mobilization in the AIDS response at the country, regional, and global level by 2015 and beyond.

“We want to work closer with organizations of young people living with HIV and young key populations at higher risk to create broad alliances,” said Mariangela Simao, UNAIDS Director of Gender, Human Rights and Community Mobilization Department. “It’s an effective strategy to ensure national ownership for progressive social change—because the demand for change will come from within,” she added.

Panellists at a conference session on 4 July focused on African innovation. (Left to right): UNAIDS Executive Director Michel Sidibé; Hon. Tim Thahane, Minister of Minerals, Energy and Water Affairs, Lesotho; Mr. Claude Sekabaraga, Senior Health Systems Strengthening and Results Based Financing Specialist, World Bank; Hon. Kebede Worku, State Minister of Health, Ethiopia; Ms Kampeta Sayinzoga, Permanent Secretary, Ministry of Finance, Rwanda.

Addressing 60 Ministers of Finance and Health at a conference in Tunis on 4 July, UNAIDS Executive Director Michel Sidibé praised African leaders for their increased engagement and partnership in HIV responses across the region.

“AIDS investments have fuelled progress across the health and development spectrum,” said Mr Sidibé, who participated in a conference session focused on African innovation.

Strategic HIV investments in Africa have yielded multiple returns. In 22 countries of sub-Saharan Africa, the rate of new HIV infections dropped by more than 25% between 2001 and 2009. More than 5 million Africans are now receiving antiretroviral treatment—up from just 50 000 a decade ago.

However, these gains are fragile. Every day, 3500 Africans die of AIDS. An estimated 5 million Africans who need HIV treatment are still not accessing it. About 300 000 children in Africa continue to be born with HIV every year.

In the current economic downturn, scarce resources must be used with greater efficiency, transparency and accountability, said the UNAIDS Executive Director, in a presentation entitled African solutions to achieve greater value for money. He highlighted cost-effective policies and programmes that have delivered sustainable results on the ground.

In South Africa, for example, unit costs of HIV drugs have been significantly reduced as more people access treatment—from US $500 to $200 per person. Other countries have reduced programme costs by eliminating parallel structures and stand-alone health services.

Investing in innovation

African leaders can accelerate progress by investing in innovation, said Mr Sidibé. Through partnerships with emerging and industrialized economies, they should facilitate the transfer of technologies for medicines and commodities. By focusing resources on HIV research and development, they could build Africa’s knowledge-based economy, he added.

Mr Sidibé encouraged ministers attending the conference to reduce Africa’s dependency on imported HIV medicines through the local production of antiretroviral drugs. He said that a single drug regulatory authority in Africa could ensure the faster roll out of quality-assured medicines.

A new paradigm

Africa is poised to transcend the outdated donor-recipient paradigm, said the UNAIDS Executive Director. Leaders are beginning to embrace a new global compact for shared responsibility and national ownership, he said.

Organized by Harmonization for Health in Africa and hosted by the African Development Bank, the two-day conference in Tunis brought together ministers, parliamentarians and high-level representatives from international organizations, civil society and the private sector.

UNAIDS Executive Director Michel Sidibé met on 3 July with the President of Tunisia, Moncef Marzouki (right) and other high-level government officials.

Meeting on 2-3 July with top officials of Tunisia’s new tripartite coalition government, UNAIDS Executive Director Michel Sidibé praised the country’s leadership for its strong commitment to reducing stigma and discrimination—a key barrier to progress in HIV responses across the region.

While Tunisia has a relatively low HIV prevalence, at about 0.06% of the national population, evidence has shown pockets of high HIV prevalence among key populations, including injecting drug users, sex workers and men having sex with men. These populations often face stigma and discrimination which can hamper access to health services and nurture the HIV epidemic.

In his discussions with the President of the Republic, Moncef Marzouki, Head of Government, Hammadi Jebali, and Vice-President of the National Constituent Assembly, Meherzia Laabidi—three leaders who recently came to power in the country’s first democratic elections—Mr Sidibé noted that youth were the engine of the revolution that brought political change to Tunisia.

“Investing in young people and responding to their aspirations for a more just and equitable society will be critical to the future advancement of this country,” said Mr Sidibé. “Youth can play an important role in accelerating Tunisia’s response to HIV and other health challenges,” he added.

Increasing local production of HIV medicines

Speaking with Mr Sidibé at the Presidential Palace on 3 July, President Marzouki expressed his strong commitment to strengthening the national HIV response. He said that Tunisia would strive to achieve the vision of “three zeroes”—zero new HIV infections, zero discrimination, zero AIDS-related deaths—and highlighted three priority areas for action: improving public health, ensuring human rights and addressing the socio-economic drivers of HIV.

The President noted that Tunisia could help reduce Africa’s dependency on external aid by producing antiretroviral medicines. He pledged to advocate for greater local production of medicines at the next meeting of the New Partnership for Africa’s Development (NEPAD) in Addis Ababa. Currently, a majority of drugs dispensed in Tunisia—and across the African continent—are imported.

Reducing dependency on external aid

In a meeting with Mr Sidibé later that day in La Kasbah Palace, Tunisia’s Head of Government echoed the President’s remarks on local drug production. “I support the idea of Tunisia producing antiretroviral medicines to reduce its dependency on external aid,” said Mr Jebali. “The production of antiretrovirals presents not just an economic opportunity, but also a humanitarian opportunity,” he added.

There was mutual agreement between Mr Jebali and Mr Sidibé that Tunisia should assume greater ownership of HIV prevention programmes that support key affected populations; currently, such programmes are funded exclusively through international sources.

Acknowledging high-risk behaviours

It is time for Tunisia to face the facts on HIV, said the country’s Vice-President, Meherzia Laabidi, in a separate meeting with Mr Sidibé at the Palace of the Assembly. “We must move beyond official political denial. Just closing our eyes won’t stop the fire,” she added.

UNAIDS Executive Director Michel Sidibé (left) with the Tunisian Head of Government, Hammadi Jebali.

In her discussions with Mr Sidibé, the Vice-President recognized that ensuring a socially inclusive society is the responsibility of political leaders. She said that neglecting key populations at high risk of HIV infection puts everyone in danger. “We need to recognize the existence of high-risk behaviours in our societies, such as injecting drug use, sex between men and commercial sex,” she said.

Noting that access to basic health services is a human right, Ms Laabidi underscored the importance of including the “right to health” in the new Tunisian constitution, currently under development.

During his two-day mission in Tunisia, the UNAIDS Executive Director met with several other government officials, including the Minister of Health, Dr Abdellatif El Mekki, and the Minister of Human Rights and Transitional Justice, Samir Dilou. He also engaged with people living with HIV, representatives from key affected communities and the United Nations country team.

The concept of ‘positive prevention’ provides an opportunity to highlight the prevention needs of people who know their positive serostatus.

Ever since HIV testing was developed in the early days of the epidemic, the role of people living with HIV in HIV prevention has been an important aspect of the AIDS response. Following the advent of combination antiretroviral treatment which significantly prolongs life and improves quality of life for people living with HIV, there have been increasing calls to incorporate what is known as ‘positive prevention’ in the continuum of prevention and care programmes and services.

The concept of ‘positive prevention’ provides an opportunity to highlight the prevention needs of people who know their positive serostatus, and is a useful lens through which to understand the important linkages between prevention, treatment, care and support.

However, despite increasing funding directed towards positive prevention, there is a lack of clear understanding globally and regionally of the concept, objectives and programmatic features of ‘positive prevention’, either within the community and representatives of people living with HIV, or between civil society and other partners.

As a direct consequence, the Global Network of People living with HIV (GNP+) and UNAIDS are convening a technical consultation on 27-28 April 2009 in Tunisia on the subject to help develop a common understanding of ‘positive prevention’, as well as guidelines and action plans to inform policies and programmes.

The term ‘positive prevention’ itself will be discussed during the technical consultation as, even though it is the most commonly used term, other terms are also used by different organizations and programmes such as ‘Prevention and Care for People Living with HIV/AIDS’ or ‘prevention with HIV-positive people’.

Participants at the consultation will represent civil society, government agencies, UNAIDS Cosponsors and Secretariat and international development agencies. A majority of the participants will be people living with HIV as the conversation around positive prevention has too often occurred without the involvement of people living with HIV at the design stage and has led to significant shortcomings in most current approaches.

The technical consultation follows the significant Positive Leadership Summit held in Mexico in 2008 and is part of an ongoing process to ensure that positive prevention efforts are based on a solid consensus among positive people. To that end, experts will identify strategies to gather experiences and knowledge of stakeholders, in particular people living with HIV at regional, national and local levels.

If the prevention needs of positive people are to be adequately addressed, people who know they are living with HIV must be involved in defining and developing programmes.

It is expected that the meeting will facilitate the development of a set of principles that will guide the work of and partnerships between multilateral, bilateral, governmental and civil society organizations in designing positive prevention programmes. Participants will also develop recommendations on the scaling up of programmes and policies, informed by the local context.

“Positive prevention” programmes

Many HIV programmes worldwide seek to include people living with HIV in their prevention efforts. Diverse programmatic activities are undertaken, including support for self-help groups and community empowerment, counselling in the context of HIV testing or of family planning, engagement of positive people in education programming (e.g. in delivering personal testimonies), and behaviour change programming directed at HIV-positive people or discordant partners. The aims of these programming efforts vary widely, and are not always explicit or consistent. Quite often, positive prevention programmes have focused on HIV testing and so are seen as irrelevant to people who already know their serostatus. Most existing interventions focus almost entirely on preventing the onward transmission of HIV, which may be counter-productive to programmes intended to address prevention, care and support for HIV positive people in a holistic manner.

If the prevention needs of positive people are to be adequately addressed, people who know they are living with HIV must be involved in defining and developing programmes. A human rights approach combating stigma and discrimination is essential to the success of positive prevention. Positive prevention requires addressing social vulnerabilities such as poverty, gender-based violence, xenophobia and homophobia. It is also inextricably linked with access to treatment, care and support.

While most agree that among the measures of success of positive prevention is the reduction of HIV transmission, it is also widely felt that positive prevention should not be exclusively about preventing onward transmission of HIV. The discussion about positive prevention needs to explore the efforts of people who know they are living with HIV to learn and practice ways to promote their own health and prevent disease.