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Declaration of commitment on HIV/AIDS and the political declaration on HIV/AIDS
United Nations General Assembly (UNGASS)
September 17, 2008

Note by the President of the General Assembly

Summary

The present document reflects the summary of the high-level meeting of the General Assembly on the comprehensive review of the progress achieved in realizing the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS, which was held in New York from 10 to 12 June 2008.

Introduction

• The 2008 high-level meeting on HIV/AIDS was convened to review progress achieved in realizing the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS (General Assembly resolution 60/262, annex). Millennium Development Goal 6 commits the world to halt and reverse the global AIDS epidemic by 2015. Building on the time-bound targets established in the 2001 Declaration of Commitment on HIV/AIDS (General Assembly resolution S-26/2), the 2006 Political Declaration called on all countries to work towards universal access to HIV prevention, treatment, care and support by 2010.
• The 2008 high-level meeting included plenary sessions in the General Assembly with statements from 158 delegations (including 152 Member States and six observers). The opening session was addressed by the President of the General Assembly, the Secretary-General of the United Nations, the Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), a person openly living with HIV and an eminent person actively engaged in the international response.

Five panel discussions addressed the following topics:

1. How do we build on results achieved and speed up progress towards universal access by 2010 — moving on to reach the MDGs by 2015?
2. The challenge of providing leadership and political support in countries with concentrated epidemics;
3. Making the response to AIDS work for women and girls: gender equality and AIDS;
4. AIDS: a multigenerational challenge — providing a robust and long-term response;
5. Resources and universal access: opportunities and limitations.
6. In addition, an interactive hearing with civil society focused on the theme "Action for universal access: myths and realities".

The report of the Secretary-General (A/62/780) entitled "Declaration of Commitment on HIV/AIDS and Political Declaration on HIV/AIDS: Midway to the Millennium Development Goals" provided the basis for deliberations at the high-level meeting.

A number of side-events were organized around this high-level meeting, addressing topics including HIV prevention for young people, prevention of mother-to-child HIV transmission, the role of parliamentarians in strengthening the response to the epidemic, and private sector engagement in the global response. On the eve of the high-level meeting, the first HIV/TB Global Leaders' Forum was held at the United Nations in New York.

The meeting attracted extensive high-level participation from Member States, underscoring the high priority of the global AIDS response. Participants included five Heads of State, two Heads of Government and one Deputy Prime Minister, over 90 ministers and vice-ministers, four First Ladies, 10 national AIDS ambassadors, and more than 140 parliamentarians from over 50 countries.

In recognition of the central role of civil society in an effective AIDS response, the meeting included participation by civil society representatives. Approximately 500 civil society representatives participated in the meeting as members of non-governmental organizations in consultative status with the Economic and Social Council or as specially accredited delegates. Many more attended as members of national delegations. All panel discussions included civil society speakers and participants.

The Heads of the United Nations Office on Drug s and Crime and the World Health Organization (WHO), as well as the Executive Directors of the United Nations Development Fund for Women (UNIFEM) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, participated in the panel discussions.

The organizational arrangements of the high-level meeting were made in accordance with General Assembly resolution 62/178, which, inter alia, requested the President of the General Assembly, with support from UNAIDS and in consultation with Member States, to finalize arrangements for the meeting. In addition, the President was supported by co-facilitators, the Permanent Representatives of Botswana and Estonia, the Civil Society Task Force and the United Nations Secretariat.

Review of progress and challenges

The President of the General Assembly, Srgjan Kerim, highlighted the links between AIDS and other critical challenges facing the global community, including sustainable development, climate change, extreme poverty and hunger. He emphasized that the meeting provided an opportunity to take stock of implementation of international commitments on AIDS and to identify areas where the global community may be falling short. Although substantial progress has been made in scaling up essential AIDS services in low- and middle-income countries, the epidemic continues to outpace the response. In 2007 for every two people receiving antiretroviral therapy, five new HIV infections occurred. He stressed the importance of leadership at all levels to make universal access to HIV prevention, treatment, care and support a reality.

The United Nations Secretary-General, Ban Ki-moon, emphasized the need to build on recent successes to bridge gaps in the global AIDS response. In particular, he cited the unacceptably high rate of AIDS deaths — more than 2 million in 2007 alone — and the lack of access to antiretrovirals faced by millions of people. He also stressed that "halting and reversing the spread of AIDS is not only a goal in itself; it is a prerequisite for reaching almost all the others".

Observing that 2008 marks the sixtieth anniversary of the Universal Declaration of Human Rights, the Secretary-General said the continued discrimination against people living with HIV and groups at high risk represents an unacceptable reality. Particular gratitude was expressed to Dr. Peter Piot, who leaves UNAIDS as its Executive Director at the end of 2008 and whose leadership has "shaped UNAIDS into a living example of UN reform in the best and truest sense of the word".

The Executive Director of UNAIDS, Peter Piot, noted that despite recent progress in almost every region, at the current pace, we will not achieve universal access in most low- and middle-income countries by 2010. AIDS is the leading cause of death in Africa and the seventh highest cause of mortality worldwide. He noted that unless efforts to prevent new HIV infections are strengthened, treatment queues will lengthen, dooming efforts to achieve universal access to antiretroviral therapy.

Dr. Piot said that the AIDS response must move to a new phase, which involves both an immediate response and the development of a longer-term strategy. In particular, he cautioned against complacency resulting from recent successes in the response to the epidemic. In addition to strengthened HIV prevention, he said that key steps are needed with respect to treatment, including strengthening health systems, improving the affordability of medications, investing in new drugs for the future, and integrating HIV prevention and treatment in tuberculosis, maternal and child health, and sexual and reproductive health programmes. He stressed that long-term success in the AIDS response requires improved HIV prevention for young people, effective action to address gender inequality and other human rights violations, and substantial increases in funding.

Ratri Suksma, Programme Officer of the Coordination of Action Research on AIDS and Mobility Asia (CARAM), addressed the meeting as a person openly living with HIV. She said that marriage represents the greatest HIV risk factor for many women in the Asia and Pacific region. She said that stigmatizing attitudes, such as those reflected in national policies that exclude the entry of foreigners living with HIV, will undermine, rather than contribute to, universal access to HIV prevention, treatment, care and support. She stressed the importance of accountability in national AIDS responses, including in countries with concentrated epidemics, where infections are clustered among marginalized groups, such as drug users, sex workers, and men who have sex with men.

Highlighting the need for partnerships in the AIDS response between Governments and civil society, she called upon Governments to implement a range of policies, including the decriminalization of behaviours associated with HIV transmission, the abolition of mandatory HIV testing, and laws to facilitate access to essential HIV prevention services.

Dr. Anthony S. Fauci, Director of the National Institute of Allergy and Infectious Diseases (United States of America), was invited to address the high-level meeting as an eminent person engaged in the AIDS response. Dr. Fauci noted that in the past few years, programmes such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the United States President's Emergency Plan for AIDS Relief, as well as individual Governments, non-governmental organizations, philanthropies, and many others, have performed heroic work in making AIDS drugs available to those who need them. He emphasized the urgency of narrowing the "implementation gap" by ensuring the delivery of biomedical research discoveries to those in need and by strengthening health systems.

Dr. Fauci said the goal of universal access represents both an overriding public health priority and a moral imperative. He emphasized that although proven HIV prevention strategies exist, most people currently are unaware of them or lack access. He stressed that research remains urgently needed to develop microbicidal gels or creams, as well as a preventive vaccine, which remains the best hope for halting the epidemic. Although 2007 resulted in disappointing clinical trial results on the most promising vaccine candidate, he urged perseverance in the vaccine field.

Plenary sessions, panel discussions and civil society hearing

Several points emerged during the General Assembly plenary sessions, panel discussions and the informal interactive civil society hearing, among which are those set out below.

HIV as both a public health and development issue

The AIDS epidemic continues to be recognized as one of the world's leading development challenges, and several countries stressed that their AIDS strategy had been integrated in broader development planning processes. Countries from all regions renewed their strong commitment to attain the Millennium Development Goals. In addition to Goal 6, which aims to have halted and begun to reverse the spread of HIV/AIDS by 2015, several participants emphasized that the AIDS response has a direct impact on several other of the Goals, including Goal 1 (poverty and hunger), Goal 2 (a universal primary education), Goal 3 (gender equality and empowerment of women), Goal 4 (reducing child mortality), and Goal 5 (improving maternal health).

Participants emphasized the importance of achieving the targets for universal access to HIV prevention, treatment, care and support and for the Millennium Development Goals. To support the attainment of both targets, high-income countries were encouraged to implement their commitment to 0.7 per cent of their gross national product as official development assistance.

Participants reported that the global push towards universal access to HIV prevention, treatment, care and support has aided countries in accelerating national efforts to respond to the epidemic. Some delegations reported that they had either already achieved universal access or were on track to meet their targets by 2010. However, several delegations also stated that their countries were unlikely to achieve universal access without a substantial strengthening of effort and additional resources. Obstacles to universal access include systems constraints, insufficient resources, and stigma and discrimination against people living with HIV and groups most at risk of HIV infection.

Scaling up and increasing access to prevention, treatment, care and support services

For the first time in the history of the epidemic, progress towards universal access to HIV prevention, treatment, care and support services by 2010 has been reported in nearly all regions. At the end of 2007, an estimated 3 million people in low- and middle-income countries were receiving antiretroviral drugs, a 42 per cent increase in coverage over 2006. Major strides have also been made in expanding access to services to prevent mother-to-child transmission of HIV, with coverage more than doubling between 2005 and 2007.

Despite the progress in expanding access to HIV treatment, more than two out of three people in low- and middle-income countries who needed antiretroviral medications in 2007 did not receive them. Participants identified obstacles to increased access to treatment programmes, including continued stigmatization of the disease, which limits access to and use of services; unique barriers faced by marginalized groups, such as sexual minorities, sex workers, injecting drug users, indigenous peoples and women and young girls; and sub-optimal coverage for children living with HIV. Participants also said the cost of drugs remains a barrier to universal access in many countries. It was emphasized that intellectual property laws should not prevent countries from obtaining effective and affordable drugs needed for the treatment of HIV infection.

Although tuberculosis (TB) remains the leading cause of death for people living with HIV infection, fewer than one in three individuals living with both HIV and TB disease received both antiretroviral and anti-TB drugs in 2007. Participants said that scaling up integrated services for HIV and TB entails efforts to reduce stigma and discrimination, enhanced support for treatment, increased health education, adherence to treatment and proper infection control practices to address transmission in health-care settings. Participants also emphasized the importance of early detection, diagnosis and treatment of TB, especially multi-drug-resistant TB.

Several countries reported that scaling up access to antiretroviral drugs helps to strengthen national health-care systems, although limited health-sector capacity remains an obstacle. Many low-income countries are experiencing the loss of health professionals trained and employed by the public sector to higher-paying jobs in the private sector or to other countries. It was reported that there was a global shortage of 4.3 million doctors, nurses and midwives in 2006. Some high-income countries committed to increase support for health systems in developing countries. Delegations emphasized, however, that support for health systems should not come at the expense of the resources required to scale up AIDS programmes or services.

Participants said that greater success in prevention of new HIV infections is critical to sustaining an effective response. It was suggested that educational programmes focused on young people, who often lack basic knowledge about HIV, should be strengthened. Youth leadership should be supported to encourage greater HIV awareness and prevention. While global progress in expanding services to prevent mother-to-child transmission is evident, several countries reported that national coverage of such services remains far too limited to have a serious impact.

Several d elegations said that a shortage of strategic information is impeding efforts to expand HIV prevention services. Participants noted that countries should "know their epidemic" to ensure evidence-informed planning, implementation and expansion of HIV services. It was also recommended that as HIV treatment is scaled up, countries should make efforts to capture the potential synergies between prevention and treatment.

Participants identified policies and practices that impede access to services for populations most at risk, including injecting drug users, men who have sex with men, and sex workers. It was observed that national laws may hinder access to, and utilization of, HIV services by most at risk and affected groups. For example, some countries prohibit syringe and needle exchange, methadone maintenance, and other evidence-informed strategies to reduce HIV transmission through drug use. Similarly, several participants said that legal recognition of the rights of men who have sex with men and of transgender individuals would enhance HIV prevention efforts.

Participants noted with concern the low coverage of services to support orphans and other children affected by the epidemic. According to surveys in 11 high-prevalence countries, only about 15 per cent of orphans in 2007 lived in households receiving some form of assistance. It was noted that social protection helps to mitigate the social and economic impacts of the epidemic on households and communities.

Countries emerging from conflict situations are often especially vulnerable to the rapid spread of HIV. It was noted that the disruptions and competing priorities associated with conflict and post-conflict situations often make it even more difficult to ensure a robust AIDS response.

Human rights and gender as core components of an effective response

Respect for human rights is key for an effective response to the HIV epidemic. Countries that have recorded the greatest s uccess in addressing their national epidemic have implemented a strong human rights-based approach, including working actively to eradicate stigma and discrimination against people living with HIV and those populations most at risk.

Participants reported that one third of all countries still lack legal protections against HIV-based discrimination. Some countries maintain travel restrictions for people living with HIV. Many participants called for the abolition of such travel restrictions. It was suggested that reviews of national legislation and policies would support efforts to prevent or eliminate stigma and discrimination.

Gender inequality often makes it difficult for women to protect themselves from exposure to HIV. Violence, or the threat of violence, frequently precludes women's ability to abstain from sex or to insist on the use of a condom. Such fears, often coupled with existing stigma and discrimination towards people living with HIV, discourage women from learning or disclosing their HIV serostatus. Women bear most of responsibility for caring for people affected by AIDS and may face destitution or be ostracized if they are widowed.

Participants emphasized that national responses should prioritize initiatives to advance the status of women. Some delegations said that it is a critical priority to raise the educational level of women and girls as a measure to eliminate gender-based violence. Participants noted that in order to ensure that women have life-saving information, as well as the autonomy and power to make decisions affecting their own bodies, Governments and donors should prioritize access to comprehensive sexual and reproductive health services. Economic empowerment, social support initiatives and legal reform to protect property and inheritance rights were identified as effective strategies to reduce the vulnerability of women.

As a problem that touches on all aspects of human development, HIV requires a multisectoral and incl usive response. Several participants emphasized the importance of involving the private sector as part of an effective AIDS response, while others noted the leadership displayed by many faith-based organizations in national and international efforts. It was noted that families and communities play an important role, both in terms of encouraging behavioural change to reduce HIV transmission and in caring for people living with HIV.

National mechanisms and processes have been established in many countries to ensure meaningful involvement of civil society in the AIDS response. However, civil society participants said that groups representing populations most at risk remain marginalized in some countries. Civil society participants emphasized that vulnerable groups and populations most at risk should be regarded not merely as a focus of programmatic initiatives, but as critical partners in the development, implementation and monitoring of national AIDS programmes and policies.

Several delegations stressed that people living with HIV have a vital role in national AIDS efforts, although many networks of people living with HIV lack sufficient capacity and have difficulty obtaining the necessary financial and technical support. It was recommended that donors increase assistance to civil society organizations, including organizations and networks of people living with HIV.

Mobilizing and sustaining sufficient resources

Although financing for HIV programmes in low- and middle-income countries has significantly increased, more resources will be required to achieve and sustain universal access to HIV prevention, treatment, care and support. Delegations noted that the need for additional resources is particularly acute in countries where the health sector is weak. External sources of funding will be required in the foreseeable future to enable low-income countries to achieve universal access. Some middle-income countries also require additional resources. I t was recommended that the Global Fund and other donors develop sufficient flexibility to enable middle-income countries to access these sources of funding. A number of countries indicated that resources currently provided by high-income countries through loans would be better provided as grants and, where appropriate, ought to be linked to debt relief without conditionalities.

As AIDS is a multigenerational challenge, sustaining a robust response for the long term requires unprecedented resources and political commitment. In particular, delegations emphasized the urgent need to develop sustainable financing mechanisms. Participants reported that the lack of predictable and sustainable financing is already influencing some national authorities to reduce their targets for HIV services. The Global Fund to Fight AIDS, Tuberculosis and Malaria has been an important impetus for scaling up in many countries, and several delegations said that sufficient, long-term contributions to the Global Fund by donors is essential to mobilizing needed resources for a sustainable AIDS response.

To ensure a robust AIDS response for the long term, contributions will be needed from both domestic and external sources. Participants recommended that donors increase HIV-specific contributions and also adhere to long-standing commitments to allocate at least 0.7 per cent of gross national income towards official development assistance. Low- and middle-income countries also have a role to play in closing the projected resource gap for HIV. For instance, to date few African countries have attained the 2001 Abuja Declaration target of 15 per cent of annual national expenditures on health services.

Several delegations emphasized that donors and other stakeholders should also take steps to improve harmonization, coordination and alignment of efforts with national strategies. Delegations recognized the important leadership role that UNAIDS has played in helping countries to achieve recent successes. A number of delegations emphasized the need for better coordinated and integrated responses among some of the United Nations system agencies, international donors, local government and non-governmental organizations.

Leadership and accountability

The high-level attendance at the meeting from Governments and civil society reflected the continued commitment of participants to an effective response to the pandemic. This commitment is also illustrated by several steps taken by the international community in recent years including with regard to the target of universal access to HIV prevention, treatment, care and support; the dramatic increase in financial resources for HIV programmes; and increase in access to critical HIV services.

Yet as the epidemic continues to outpace the response, a stronger and more broad-based leadership across all sectors of society will be required to halt and begin to reverse the global AIDS epidemic by 2015. As participants in one panel discussion emphasized, national leadership can be particularly challenging in countries with concentrated epidemics, where high infection rates in marginalized groups are often masked by low overall HIV prevalence in the general population. Participants said that protecting and promoting the rights of populations most at risk and other vulnerable groups is essential for an effective response.

Several delegations emphasized the critical need to continue investment in HIV research despite recent setbacks in trials on microbicides and vaccine candidates. Reference was also made to the possible impact research findings on male circumcision may have on public health policy.

Participants stressed the need for greater accountability in the AIDS response. More than 40 countries failed to submit progress reports in 2008 on implementation of the 2001 Declaration of Commitment. In particular, civil society participants emphasized the need to ensure full engagement of civil society in national efforts to monitor progress.

Towards universal access: key findings and recommendations

The following are some key findings and recommendations that emerged at the high-level meeting:

• Accelerating progress towards universal access. The push towards universal access to HIV prevention, treatment, care and support by 2010 represents an important step on the road to achievement of the Millennium Development Goals by 2015. Although some countries reported having achieved some of their universal targets, most have indicated that they do not have the human and financial resources to achieve these targets by 2010. Efforts should be redoubled to expedite progress in moving towards universal access and should recognize civil society as an essential partner in this regard. UNAIDS should continue monitoring progress of national AIDS responses.
• Scaling up critical HIV services. With 70 per cent of those who need antiretroviral medications still not receiving them — and with comparable gaps in access to key HIV prevention services — stakeholders at all levels must strengthen efforts to scale up HIV prevention, treatment, care and support. Scaling up HIV prevention is essential to reverse the epidemic, as the continuing and unacceptably high rate of new HIV infections threatens the future viability of treatment programmes. UNAIDS should continue to strengthen its technical support to countries to expedite the scaling up of essential HIV services and should take steps to integrate these efforts with the activities of donors, local governments and non-governmental organizations.
• Strengthening and integrating health systems. Increases in international assistance are required both for HIV-specific programmes and for strengthening of health systems and social sectors in countries. HIV prevention and treatment should be integrated with TB and other relevant health and social services.
• A human rights-based appr oach to the AIDS response. National responses should prioritize the implementation, monitoring and enforcement of policies and programmes to protect and promote human rights. Furthermore, the human rights of vulnerable populations — migrants, youth, prisoners, indigenous peoples — and most at risk populations — sex workers, men who have sex with men, and injecting drug users — should be recognized by law and implemented in practice. Travel restrictions for people living with HIV should be lifted by countries that have such restrictions in place.
• Promoting gender equality and women's empowerment. Countries should give priority to programmes aimed at promoting gender equality, economic empowerment of women, education for all, and legal reform to recognize, promote and protect women's property rights. Donors should recognize initiatives to promote gender equality as essential components of national responses and provide countries with sufficient financial and technical support to implement such efforts.
• Engaging multiple sectors in the AIDS response. National responses should be inclusive, and recognize the role that civil society, the private sector, faith-based groups, community groups and families and a broad array of sectors and stakeholders must play in developing, implementing and monitoring efforts to respond effectively to the epidemic. In particular, national responses must ensure that people living with HIV are full and active participants, including providing organizations and networks of people living with HIV with sufficient resources.
• Mobilizing sufficient financial resources for the AIDS response. Resource shortfalls are apparent in both low- and middle-income countries, and both groups should have access to the resources needed to address their national epidemics. To ensure a robust AIDS response for the long term, greater contributions will be needed from both domestic and external sources. Also, stakeholders should collaborate on the development of strong and sustainable financing mechanisms. As one strategy to increase international resources, donor countries should honour their commitments to devote 0.7 per cent of their gross domestic product for official development assistance.
• There should be flexibility to enable middle-income countries to access funding from the Global Fund and other donors. Developing countries should also increase their domestic expenditures for scaling up HIV prevention, treatment, care and support services. Maximum flexibility should be applied to the interpretation of intellectual property laws to ensure countries' access to effective and affordable drugs.
• Meeting the epidemic's multigenerational challenge. Given the multigenerational challenge of the epidemic, governments, international donors, the United Nations system and other stakeholders must ensure that their support to national responses are sustainable. Achieving national universal access targets at the country level will establish the foundation for such a sustainable and long-term response.
• Mobilizing greater leadership, commitment and accountability. Dedicated and dynamic leadership will ensure that recent momentum in the global response is maintained. Successes must be built upon to ensure sustained progress towards full achievement of the international HIV/AIDS goals. Continued commitment and accountability are critical at the global, regional, national and local levels of leadership.

*A webcast of the high-level meeting is accessible at: http://www.un.org/webcast/aidsmeeting2008/index.asp.

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