8. Conclusion: Emergency, Sustainability and Success

On the 20th anniversary of the World Bank Report 1993, Investing in Health, an independent commission of 25 renowned economist and public health experts re-evaluated and proposed a new investment architecture for global health. The commission’s report Global Health 2035: A World Converging in a Generation was published in The Lancet on December 2013.

An early sign of this can be seen in Peter Piot’s 2006 article in the Lancet which outlines reasons why the international system should maintain the exceptionality of AIDS as a core feature of international development. One of his arguments was about the potential disappearance of direct funding for the existing AIDS system and its work, if the new global system changes its focus. A similar concern has also been expressed by Ellen E. Foley and Anne Hendrixson (2011) in an article questioning the crisis model of policy making in this field.

In a response to their interlocutors on their Comment piece in the Lancet special issue, Sidibé and Buse point out that ‘The aim of our Comment was twofold: to advocate the inclusion of key AIDS governance innovations, principles, and practices in the post-2015 development agenda, and to ignite debate on the future of global health governance’ (2013b:1018).

As in the politics described by Rancière (2010).

Even though the language of human rights and AIDS is used more and more as a means of channelling resources, it is unclear whether this approach will also allow people to politically engage and challenge the Global AIDS system. If they can, then what are the mechanisms for this, how can people participate in debates to influence change, and what are the implications of this for resource relations within the Global AIDS system?

The wellbeing of people with HIV has always been a concern for many and in particular for the thousands of civil society activists who have engaged various political systems throughout 1980s, and 1990s. Nonetheless, the introduction of antiretroviral medication and its impact made the long-term wellbeing of HIV positive people in their everyday lives a major challenge for a global AIDS system that emerged out of this earlier activism and was based on the politics of emergency.

This kind of political agency provided the grounds from which, as I discussed earlier, 1980s AIDS activism emerged. That experience clearly demonstrates the need to consider people as political actors rather as being part of a global system that incorporates them due to their HIV status and then allocates resources to them as it sees it necessary for dealing with HIV.

United Nations General Assembly High-Level Meeting on Ending AIDS, which took place from 8 to 10 June 2016 in New York.

Relevant considerations to do with the Global AIDS system include: who participates in what and how, how does categorical risk identification drive policy targets, what are the policy priorities that underwrite major resource allocation negotiations, and what are the system’s primary funding relations?

This analysis is rather curious, in the way in which the article considers WHO versus UNAIDS as if these organizations are set apart. WHO was a founding co-sponsor of UNAIDS and remains a part of UNAIDS.

Sen’s work initiated an in-depth debate and literature on capabilities which I am not going to rehearse here (Seckinelgin 2004).

Molina et al. point out that ‘assessing adherence to sexual activity-dependent preexposure prophylaxis is challenging and represents another limitation of our study’ (2015: 2244). The challenge here is about the way in which people consider sex and also their own sexual subjectivity in relation to a product, which evidently aims in some manner to regulate it. This will also be more complicated in certain contexts. It is further argued that ‘MSM who are at risk for acquiring HIV who elect to use PrEP need prevention counselling strategies to teach them to take PrEP on a daily and consistent basis’ (Wade Taylor et al. 2014:2).

Hankins et al. provide a nuanced understanding of these functional relations ‘[D]ecision-makers considering the introduction of PrEP in their countries are faced with competing priorities and the need to address key economic, regulatory, distributive justice and access issues. Unless these processes are informed by inputs relative to their own specific context, it will be difficult to realize the full potential of effective and acceptable PrEP implementation’ (2015:5).

For example, a study based in the US South presented in the 2015 Conference on Retroviruses and Opportunistic Infections (CRIO) in Seattle highlights how such interventions are implemented within existing social contexts and how these contextual factors impact outcomes: ‘The investigators conclude that disparities at various steps in the PrEP care continuum, particularly access to health care, could lead to racial disparities in those achieving protection via PrEP’ (Buchbinder and Liu 2015:18). Another similarly context sensitive analysis can be found in a report of a PrEP trial in Botswana. Although the authors articulate the issue as an ‘adherence problem’, their concerns highlight how adherence is about a dynamic interactive relationship between persons and their contexts (Kebaaetswee et al. 2015).