Crisis, Opportunity and Transformation: AIDS Response at A Crossroads

mr_sidibeUNAIDS Executive Director, Mr. Michel Sidibé delivered a speech to the 24th meeting of the UNAIDS Programme Coordinating Board on Tuesday, 23 June 2009 in Geneva. In this speech, he shared the organizational vision, expressed the good progress UNAIDS has made and outlined the great amount of hard work that is ahead of UNAIDS.

Honourable Chair, members of the Board, Cosponsors, governments, civil society, Observers.

Today we meet at a crossroads: in this time of crisis, opportunities beckon, but transformation is called for.

Two weeks ago, when Dr Margaret Chan, the Director-General of the World Health Organization (WHO), raised the influenza pandemic alert to Phase 6, an image came to mind. I saw the H1N1 virus escaping from Pandora’s box into a world already replete with crises: economic crisis, rising food prices, global warming, war. And all this against the backdrop of the AIDS pandemic that continues to kill two million people per year.

Friends, sometimes it’s hard not to despair. But then I remembered: in the Greek myth, when Pandora closed her box again, the only thing left inside it was hope.

Hope, and the conviction it inspires, is what has enabled millions of people living with HIV to keep fighting, against all odds, to change the world. It is this hope that has driven UNAIDS.

Wind blows in our face. But we must catch the stronger wind at our back. It is the wind that links the AIDS response with the movement for the Millennium Development Goals (MDGs).

Let me pause to give a few words of thanks.

First, I would like to acknowledge the outstanding leadership and historic contribution of Peter Piot as the founding Executive Director of UNAIDS. I am honoured and humbled to follow as his successor.

Next, I would like to thank the many governments and partners who have welcomed me in the past months. Special thanks to the Government of Norway for allowing me to work so closely with Ambassador Sigrun Mogedal. Sigrun led the process of consultations that has informed the direction UNAIDS is taking.

Special thanks to developing countries and donors for their critical support and confidence.

Thanks also to our Cosponsors. I am here today representing all of us—as one joint United Nations (UN) programme. Together we are UNAIDS.

Thanks to the many groups and individuals who, in recent months, have provided valuable recommendations to strengthen and improve UNAIDS.

And a special thank you to Secretary-General Ban Ki-moon for his confidence. I recognize his outstanding leadership and the work of his Special Envoys.

I extend my sincere gratitude to all who have so generously advised me over the past six months. My apologies to all I haven’t named.

Entering the new era of the AIDS response

We have entered a new era of the AIDS response.

Over 25 years ago, when I began working for the United Nations Children’s Fund (UNICEF), the world was also at a crossroads. The world faced a crisis of increasing poverty and inequality. My mentor, James Grant, seized the crisis as an opportunity for transformation. He challenged the global status quo, launching Structural Adjustment with a Human Face.

We can do no less today.

We are experiencing the worst economic crisis of our generation.

My friend Josette Sheeran, Executive Director of the World Food Programme, said recently that the world now faces a “human catastrophe”. The crisis could leave 80% of the world’s population without a safety net. The crisis is a direct threat to progress in health and development and to our fragile gains in the AIDS response.

It makes worry about some of the amazing people I have met—like Thobani in South Africa. HIV treatment restored his hope and dignity. Now he is raising his son, but I worry what will happen if the crisis drags on.

Almost US$ 14 billion was spent on AIDS last year. While calling for full funding to reach universal access, it is my view that the world can no longer afford to keep AIDS in isolation.

Today we need to look to the future: aids2031 is challenging us to act now in order to change the course of the epidemic for future generations.

We must reposition UNAIDS in a crowded global health landscape. We must ensure that our future leaders stay focused on AIDS—not fatigued by it.

In the midst of this crisis, what is the best role for UNAIDS? Certainly not the same as it was in 1995.

The challenge of this era is not only how UNAIDS can do more with less, but how we can leverage existing resources and partnerships to produce more measureable results.

In recent months, UNAIDS has been the subject of several reviews, including the ongoing Second Independent Evaluation. In this period we have also met with hundreds of people—our partners, our critics and, most importantly, the people we serve. These reviews and consultations revealed many strengths and areas where we need to improve.

But the clearest message I have received is that now—more than ever—the world is looking to UNAIDS for leadership. Our partners, countries, donors and beneficiaries are demanding that we produce results.

Today I commit UNAIDS to act on three fronts, seeking:
•    First, to increase results and their impact.
•    Second, to optimize and expand partnerships.
•    Third, to transform UNAIDS into a more efficient and effective organization.

Increasing results and their impact

The new Outcome Framework provides a starting point to strengthen our focus and to improve the way we work. An example of UN reform in action, this Outcome Framework optimizes the partnerships between the UNAIDS Secretariat and the Cosponsors in order to guide future investments. The Framework also holds UNAIDS accountable for making the resources of the UN work for results.

For the first time, we have the support of all Cosponsors to focus on achieving results in a few key priority areas: areas where progress is lagging, areas where UNAIDS must accelerate progress towards universal access.

Allow me to share with you some of the key objectives of the Outcome Framework.

Treatment in jeopardy 

Today, we know that antiretroviral treatment programmes are in jeopardy. This could easily become a further crisis for the nearly four million people who have started treatment.

The Outcome Framework commits UNAIDS to stand by people living with HIV and to enhance progress to ensure that people receive treatment.

The Outcome Framework will push all of us to revise the treatment guidelines on an urgent basis.

The Outcome Framework will enable UNAIDS to lead the integration of HIV and tuberculosis services. Pursuing this priority will help to eliminate 500 000 unnecessary deaths from tuberculosis/HIV coinfection and will provide life-saving nutritional support for those who need it most.

The Framework advocates for ending the two-tiered system of global AIDS treatment. This means stopping the practice of using outmoded drugs for people in developing countries. Some 3.2 million people are on treatment in Africa, but only an estimated 3% are on second-line treatment and beyond.

In partnership with my friend Pascal Lamy of the World Trade Organization, WHO and the World Intellectual Property Organization, UNAIDS will explore ways to further exploit the flexibilities of the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPs Agreement). This is urgently needed in order to ensure affordable treatment today and less expensive second- and third-line therapies tomorrow.

HIV prevention now

Another key objective of the Outcome Framework is to break the trajectory of the epidemic by putting our focus back on HIV prevention.

Prevention has been systematically underinvested.

The days of ‘one size fits all’ prevention programmes are over. The Outcome Framework emphasizes combination HIV prevention to help us reach universal access as the foundation for the achievement of the MDGs.

There is a massive dividend to be achieved by wiser, targeted investments in prevention.

For example, HIV among people who inject drugs remains a devastating mode of transmission—outside sub-Saharan Africa it accounts for nearly a third of all HIV cases.

We have evidence that effective programmes for harm reduction and substitution therapy can save billions of dollars. During this crisis, UNAIDS will champion these and other evidenceinformed prevention programmes as smart investments for saving money, saving lives and restoring health and dignity to people.

In fact, five of the priorities in the Outcome Framework are focused, directly or indirectly, on HIV prevention. But I fear that even these new priorities may not be enough. The goals we have set demand that we take more decisive action on sexual transmission of HIV, which still represents the majority of new infections.

For this reason, today I am proposing to add an additional, ninth, priority area, on reducing sexual transmission of HIV. Especially in generalized epidemics in sub-Saharan Africa, halting sexual transmission must be a priority for UNAIDS.

We will ensure that prevention programmes deliver results. We will fast-track an accurate measure of incidence. We will allocate resources to prevention programmes that focus on the people most at risk of becoming infected with HIV.

And we will ensure that we share information more systematically about the lessons learned from prevention programmes in real time, so that countries and partners can learn from others’ failures as well as their successes.

I salute the leadership of and our work with GNP+. Together with UNAIDS, GNP+ is forging a new movement for positive health, dignity and prevention. The movement will transform the four million people on treatment into agents for HIV prevention, treatment, care and support.

In the coming months, I will use my office to engage, country by country, in proactive prevention diplomacy. This is our race against time to ensure universal access to evidence-informed prevention services.

Human rights

Let me address one further imperative.

Punitive laws that discriminate against men who have sex with men, sex workers, injecting drug users, migrants and people living with HIV must be removed from the statute books, country by country.

We see progress being made on this front. In March I met with the President of Senegal to discuss the eight-year sentences given to nine men accused of having sex with men. The following week, Senegal applied its respect for human rights and released them, and thus demonstrated leadership in the region. We have been advocating to governments from Burundi to Norway to the Czech Republic to refrain from punitive laws that criminalize people for who they are.

We have urged the Prime Minister of Thailand to revisit national policies on injecting drug use and on migrants. I was pleased to address the Donor Conference on Harm Reduction, hosted by the Netherlands.

The Secretary-General has showed leadership on AIDS and advocated that the Republic of Korea, as a UN Member State, should rescind travel restrictions against people with HIV.

These developments give us hope that momentum is building. In order to accelerate progress, UNAIDS will establish, under the leadership of the United Nations Development Programme (UNDP), a high-level task team to drive action on the decriminalization of HIV transmission.

AIDS vaccine and science

We should not lose sight of the big picture: the need to end the epidemic. It is not enough to provide treatment to everyone who becomes infected with HIV. If that is our strategy, we will be struggling against HIV forever, and coping with unsustainable costs. Instead, we must strive to defeat HIV decisively. That means giving renewed support for the development of a cure, a vaccine, or both.

If we can help to change this situation, through a vaccine, a cure, or both, imagine the lives we will save. That would be a fantastic return on the investment.

Optimizing and expanding partnerships

I identified three fronts for moving forward. The second front is to optimize and expand our partnerships.

In recent months, during one of the most intensive consultations I could ever imagine, UNAIDS has met with most of the civil society constituencies in this room. They offered their suggestions and critiques on how UNAIDS can do more and do it better.

Today I request our allies in the movements of people living with HIV, women and girls, faithbased organizations and sex workers to further strengthen our partnerships. Help us to plan, mobilize and deliver optimal results at the country level. I am also committed to forging similar partnerships with men who have sex with men, people who use drugs, youth, migrants and other civil society constituencies. We can only succeed with your guidance and vigilance.

Let me provide an example of UNAIDS’ evolving partnership with the women’s movement. In March I addressed the Commission on the Status of Women, where I committed UNAIDS to ensure support for country programmes to promote concrete actions to achieve gender equality and to protect the rights of girls and women.

We need to move the agenda forward, in collaboration with all stakeholders, in particular by listening to the women who are infected and affected by HIV.

I have taken up this issue personally. I am pleased that in March we released new guidance on sex work, which was so long overdue.

There is another opportunity before us—tomorrow we have on our agenda the UNAIDS Action Framework: Addressing Women, Girls, Gender Equality and HIV. I look forward to your views on how to make sure that this Framework embodies these commitments, in order that we can we move to implement it in a strategic and coordinated manner.

This epidemic chiefly affects individuals, families and communities whose stories compel our humility and admiration. When Oran was infected by the plague, the hero in the story by the French philosopher Camus says: “The disease does not interest me; only people interest me. This epidemic compels me to be modest, it teaches me nothing except that I want to face it and fight it by your side”.

Inspired by this, I hereby reiterate my commitment to make UNAIDS the partnership it was always supposed to be—a partnership between agencies of the UN system, a partnership with Member States, civil society and, most important of all, people living with HIV.

This partnership should also inform the relationship between men and women, urban and rural areas and, especially, between this generation and the next, for the sake of a better, HIV-free world and the sake of development. Yet awareness of the pandemic is diminishing among younger generations. In some parts of the world, this generation no longer comprehends the impacts of AIDS that are the abiding memory of my generation.

I hereby commit myself to, and launch an appeal for, new and ever-more innovative partnerships with the new generation of health and development programmes. nnovative financing initiatives such as UNITAID are an invaluable source of additional financial support, especially in the current crisis. The role of UNAIDS is to ensure that such mechanisms work together, avoiding competition and remaining focused on their target populations.

Collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria

In the area of institutional partnerships, the relationship between UNAIDS and the Global Fund is of paramount importance. Now the time has come for UNAIDS to transform our memorandum of understanding with the Global Fund into practical results at the country level.

First, I will ensure that UNAIDS serves as a reliable and impartial partner at the country level, taking a lead role in guiding partners in indentifying the problem and framing an effective response.

Second, the National Strategy Application is a welcome move, and UNAIDS will ensure that these applications are based on credible national strategic plans, and not vice versa.

Third, UNAIDS will take responsibility for developing country-specific gap analysis to inform the deployment of technical support by partners.

Fourth, we will hold each other accountable. Our performance will be measured by a few key indicators: the success rate of grant proposals and national strategic applications, the speed of grant negotiations and the quality of support for grant implementation.

What I am talking about is already being done in western Africa and in the Asia–Pacific region, with great success. This should urgently become the norm across all regions.

US President’s Emergency Plan for AIDS Relief

The US Government has provided UNAIDS with three great opportunities that we must seize. First, the leadership of President Obama’s administration on AIDS and global health. Second, the reauthorization of the US President’s Emergency Plan for AIDS Relief (PEPFAR)—the largest programme for AIDS and health in the world. Third, the confirmation of my friend and colleague Eric Goosby as the new US Global AIDS Coordinator, who will be joining us in the room later.

AIDS and the MDGs

Another pivotal partnership for UNAIDS is our role as the bridge between the AIDS movement and the other global movements for health, human rights, women and development. If we keep AIDS in isolation, we will fail to link HIV to the broader international health and development agenda, as represented by the MDGs. Promoting such a comprehensive approach and leveraging these partnerships will be essential to sustain and accelerate progress in the next phase of the global response to AIDS. This is what I call the AIDS+MDG movement.

Last month, the Secretary-General agreed to support UNAIDS in promoting the AIDS+MDG movement across the UN system. During the World Health Assembly, I received assurances from more than 70 ministers of health to help reposition the AIDS response in support of this movement. We are working with civil society to leverage the strength of our AIDS movement to energize and help transform the broader health and development agenda.

We welcome Sweden’s forthcoming Presidency of the European Union. This will be a great opportunity to further advance the AIDS+MDG agenda.

We are like runners in a pack; the fastest sets the pace and motivates and helps others to perform better than they would do in isolation. The AIDS response can set the pace to help all the MDGs reach the finishing line faster. But to maintain the pace, we must have the courage to transform ourselves.

Transforming UNAIDS into a more efficient and effective organization

The third and final front is to transform UNAIDS into a more efficient and effective organization.

I am privileged to lead an organization with a strong global reputation and a unique convening power. That said, there are areas for improvement that we clearly need to address.

First, UNAIDS needs to focus on a limited set of priorities that we can link to concrete objectives to reaffirm our mandate.

Second, concerns have been raised around the lack of efficiency. This applies to the UNAIDS Secretariat, which some point out as too large. We need to better clarify priorities, roles and links between Headquarters, the regional support teams and our country offices under the principle that the country offices represent the core of our organization.

Third, there are concerns around accountability. We need to define clearer objectives and metrics and strengthen monitoring and reporting to improve our ability to demonstrate impact.

We are already initiating a number of measures at the UNAIDS Secretariat to make us more effective and efficient.

We are looking at innovations in business practices, resource management and information and communication tools, as well as at making the best possible use of UNAIDS staff.

Against the background of the current economic crisis, I have decided to make the following changes within the Secretariat to strengthen accountability and country support and to improve effectiveness and efficiency.

First, we are establishing a Department of Budget, Finance and Administration, headed by a Director who will serve as the Comptroller and Chief Financial Officer of UNAIDS.

Second, we have created an Ethics and Organizational Performance Unit in the Executive Office.

The next step in rationalizing the UNAIDS Secretariat structure will take place over the next few months, in parallel with the completion of the Second Independent Evaluation.

We are currently reviewing the allocation of human and financial resources at the regional and country levels, and the optimal structure, functions and deployment of Secretariat staff—our most valued resource.

UNAIDS is also challenged by the dual systems for administration of Secretariat staff, divided between WHO in Geneva and UNDP in the field. This is causing inequities and a loss of efficiency. I am working to find a solution for this as quickly as possible.

At the country level, ‘delivering as one on AIDS’ is the litmus test for our organization that calls itself ‘UN reform in action’. UNAIDS will not wait to implement the results of UN reform in pilot countries. When Helen Clark, the new UNDP Administrator, assumes her role as the Chair of the Committee of Cosponsoring Organizations in the coming weeks, I will work with her to spearhead UN reform by strengthening UNAIDS country presence. I will ensure UNAIDS at the country level reports directly to the UN Resident Coordinator, and thus becomes an integral part of the Resident Coordinator system and accountability framework.

Particularly in this time of crisis, we also need to strengthen UNAIDS as an employer of choice. We are working with the UNAIDS Staff Association to improve professional development, conditions of service and the overall human resources policy framework.

We have introduced new policies to enable our staff to have more choices based on their lifestyles to attain a better work/life balance by offering more flexible working arrangements.

UNAIDS cares deeply about eradicating stigma and discrimination. This also applies to our internal policies and practices, and hence we recently launched a new policy on diversity and inclusion. We are also pushing for a greater recognition by the UN system of same sex and domestic partnerships.

Let me take a few moments to recognize the work of UN+, which inspired the Secretary-General to focus on AIDS as a priority and helped remind me that UNAIDS can be the world’s conscience on AIDS only if we also ensure support for people living with HIV in our midst.

Governance and Programme Coodinating Board

Recent evaluations highlight potential areas in which to strengthen the authority and functioning of the Programme Coordinating Board (PCB).

I appreciate the comments of the Chair, who expressed concern that the number of issues arising from the PCB is leading to micromanagement of processes, which reduces the efficiency and effectiveness of the Secretariat and makes the Executive Director less focused on strategic issues.

I am working with the Chair to ensure that the PCB will lighten its procedures and remain a high-impact decision-making body. We are further exploring the establishment of a subcommittee to examine these issues in detail.

Unified Budget and Workplan

In this time of financial crisis, accountability and budget rationalization is foremost in my mind. After wide consultation, I have proposed to maintain the next Unified Budget and Workplan (UBW) at its present level. We have been able to increase the UBW allocations of all Cosponsors (by US$ 16 million in total), to enable them to participate fully in the Joint Programme.

Since the establishment of UNAIDS, contributions from donors have consistently exceeded the budget approved by the PCB, and I would like to thank all donors for their strong support to UNAIDS.

I will be monitoring these funds to ensure that our working capital stays at an appropriate level. I will look for ways for UNAIDS to operate in a manner that would require a smaller fund balance and will keep the PCB informed of our financial situation.

I am also mindful, however, that we need to keep the UBW flexible, to respond to the analyses under way and the new priorities.

I have also reduced the resources allocated to the Secretariat, because we can do more with less. We can identify efficiency savings and will use resources more strategically. I pledge to reduce the cost of meetings and travel funded by the UNAIDS Secretariat by 25% in 2010–2011. This includes reducing the number of regional meetings. UNAIDS will also accelerate the use of videoconferencing and new technologies for online collaboration to reduce travel costs and our carbon footprint.

We will also reduce the number of UNAIDS publications, several hundred in the last biennium, to a core series of key publications. I am also committed to shift UNAIDS towards electronic production and dissemination, to ensure that by 2012 UNAIDS Headquarters becomes a paperless office.

I believe that communications offers the key to our transformation. My aim is to be cutting edge in how we share information, using all technologies to better reach people with the information they need.

This is already happening internally. Within UNAIDS we are building an online community for networking and virtual collaboration. On the external side, we will launch more innovations in the coming months.

On the UNAIDS website today we have launched new interactive maps showing the latest universal access targets and data for 111 countries.

And this is just a start.

By leveraging every opportunity to improve ourselves, I am confident that UNAIDS will emerge from this transformation more fit for purpose. We need to transform if we are to play a more dynamic normative, oversight and coordinating role in the AIDS response.

The hope dividend

The transformation of the Secretariat and of UNAIDS is, of course, merely a means to an end. Let me share one particular end with you.

I propose that we come together around an all-out effort to virtually eliminate mother-to-child transmission of HIV by the year 2015. Vertical transmission has been reduced nearly to zero in Europe and North America. Yesterday, in the People on the Move Thematic Segment, Mme Emiliane Jayet, an HIV-positive migrant woman, spoke movingly about giving birth in Geneva to a healthy, HIV-negative child. The world cannot accept that every year 300 000 newborn children are infected with HIV through vertical transmission in Africa.

The virtual elimination of vertical transmission will be one of the concrete outcomes of the AIDS+MDG initiative and our Trojan Horse for strengthening primary health care. It will require a major push to strengthen maternal and child health and services for sexual and reproductive rights. It would help us to balance our emphasis on treatment and prevention.

I believe that we can reach the year 2015 with virtually no more babies born with HIV. We have already started to explore a new compact between WHO, the United Nations Population Fund and UNICEF to make this a reality.

I want my tenure as Executive Director of UNAIDS to be judged by the achievement of this and other ambitious goals.

New developments in South Africa comfort me in my conviction that change is possible: I am thrilled to learn that President Zuma has made clear his goal of accelerating the AIDS response by cutting new infections in half and scaling-up treatment to 80% of those in need by 2011. As the leader of the country with the world’s largest AIDS epidemic, President Zuma must be congratulated.


First, I would like to welcome Eric Goosby, the new US Global AIDS Coordinator, to the room. I know what it took for him to be with us today. Thank you for making your first official appearance at UNAIDS. I know that we share the same agenda—to ensure country ownership, make every dollar work and build synergies between services for AIDS and health.

In my view, if the history of the AIDS response has taught us one thing, it is this: the most enduring solutions will come from people affected.

Together with the Chair of our Board, I saw bottom-up problem-solving at work in Tigray, Ethiopia. There I was privileged to witness an extraordinary community conversation. People from all walks of life, including people living with HIV, were tackling the difficult problems that fuel the AIDS epidemic. It is the success of such approaches that has led me to call for the democratization of problem-solving.

I want to lead UNAIDS by asking: are we making a difference in the lives of the people we serve?

To do so, we need to stand by people affected so as to restore their dignity and hope. We must use our privilege to give voice to the voiceless. The principles of equity and solidarity with people living with HIV must remain the cornerstone of the response.

Above all, UNAIDS must provide the moral compass. We must speak out against AIDS fatigue and against punitive laws that undermine the response.

Our principles must be matched by practical action and measured by concrete results.

Every day I work in the company of a courageous and inspirational staff. Thanks to each of you.

And every day, I think about the millions of people like Thobani I met in South Africa. People whose lives and hope depend on the action we take today.

Thank you.

Michel Sidibé
Executive Director

Green One UN House, 304 Kim Ma, Ba Dinh, Ha Noi, Viet Nam