There is incontrovertible evidence in Africa and elsewhere that advocacy, when properly targeted and packaged, is effective in reversing wrong HIV/AIDS policy. Advocacy works best when it is planned, continuous and implemented in a milieu of concentric contingencies, where practitioners anticipate change and rise up to them without derailing the campaign. Essentially, those at the fore-front of the campaign must be conscious of the proverbial rules of the gambler: know when to show; know when to fold; know when to walk away. Advocacy usually fails when there is a disconnect between evidence and argumentation. This disconnect crucially and negatively affects the construction of goodwill.

Essentially, for the purpose of HIV/AIDS treatment scale-up, advocacy is “a continuous and adaptive process of gathering, organizing and formulating information into argument to be communicated through interpersonal and media channel” to raise resources, gain political or social leadership and prepare society for its acceptance, according to McKee Neill in Involving People, Evolving Behaviour. In South Africa, among other examples, advocacy campaign built on equity and emergency, effectively put governments and pharmaceuticals on the defensive, opening up the field for efficacious generics and getting more people under treatment.

Elements

A few elements of advocacy/strategic communication become useful in campaigning for a scaled-up response to HIV/AIDS treatment in African countries:

1. A relentless and refreshed information acquisition regarding the status of HIV treatment (ARV access, drug resistance, determinants of adherence to treatments, etc).  civil society organisations (CSOs) must increase their thirst for cutting edge information with a unidirectional objective: getting more people under treatment with better first line drugs. Since the field is very dynamic, dedicated persons should be assigned to harmonize data, check facts and renew evidence needed to strengthen argumentation.

2. Burst myths surrounding treatment: Two most common of such myths are that anti-retroviral therapies cannot be sustained in resource-poor settings or amongst high-risk groups; and that first line single dose treatment of AIDS infected pregnant Africans with nevirapine, which would be considered unethical in some Western countries, was best for African countries because of resource constraints. Nemes et al in Antiretroviral Adherence in Brazil, AIDS 18 have shown that patients in low income countries adhere to ART equally, or even better than patients in high-income countries.

3. Push Universal Access, the African position which encapsulates the spirit of the Brazzaville Commitment. The African position contains sufficient targets for an effective advocacy.

Push for increased demonstrable political commitment:

There is a need to operationalize the various commitments to fighting HIV/AIDS made by African leaders at various forums. Often this has not been done because of the clash of national priorities on a platform of scarce resources. CSO should not get drawn into the debate on which priority government should address first. It is a useless exercise which will not increase HIV treatment. Instead, push for on-the-spot assessments at the highest political level. Priorities often change when leadership gets involved in HIV treatment. That was the case with Sofala, Mozambique, (pop 1.5 million) with one of the highest HIV prevalence in Mozambique (26 per cent).

Mozambique: scaling up with increased political commitment

In 2005, of the 50,000 people in need of treatment; only 3,000 were being treated in six centers. Although voluntary counseling and testing (VCT) was available in almost every district, there was only one laboratory in the Province for CD4 counts. The CD4 equipment does not automatically produce CD4 counts: the lab usually did CD4 from White blood cells count, which could not be easily stored in the computer due to personnel shortages. Accordingly, patients, who usually traveled up to 17 kilometers to learn about their results and to begin treatment were often told to return at a later date. Many never bothered to return.

In 2006, the government of Mozambique embarked on a series of programmes beginning from February with Presidential assessment visits to HIV/AIDS endemic areas, the first national meeting of STI/HIV/AIDS, the nomination of Provincial Coordinators, directive to commence early initiation of ART in HIV/AIDS patients also infected by TB, nomination of senior staff of Ministry of Health to provide technical support to each Province and the announcement by the Prime Minister to expand HIV treatment sites to

every district by March 2007.

The initiative worked beyond Sofala. By December 2006, Mozambique had more than 150 sites offering ART. Treatment was provided in 105 of its125 districts and the number of patients on ARVs increased drastically to 44,100 from about 10,000 in April 2005. By changing the nomenclature from VCT which is closely associated with HIV/AIDS into ATS (Sites for Assisting and Testing for Health), Mozambique also drastically reduced AIDS-related stigma and increased the number of those testing for HIV. ATS focuses on testing and counseling for all chronic diseases.

Fulfilling past commitments

One instrument that has not been effectively used for HIV treatment advocacy is the African Peer Review Mechanism (APRM) process. Yet, it is a powerful and formidable tool. APRM addresses HIV/AIDS in two ways: It assesses how the country under review is addressing the pandemic and assesses the country in the framework of Goal 6 of the MDGs.

African heads of state specifically mention HIV/AIDS in three APRM documents. In the Declaration on Democracy, Political, Economic and Corporate Governance, they undertook to work towards the enhancement of Africa’s human resources…and “better health care, with priority attention to addressing HIV/AIDS and other pandemic diseases.” In the Objectives, Standard, Criteria and Indicators for the African Peer Review Mechanism, one of the key objectives cited is the strengthening of “policies, delivery mechanisms and outputs in key social development areas (including education for all, combating of HIV/AIDS and other communicable disease).Lastly, in the APRM Self-Assessment Questionnaire, African leaders made extensive references to the protection of vulnerable groups, including people living with HIV/AIDS (PLWHA) and children orphaned by HIV/AIDS, and the inclusion of HIV/AIDS on the list of socio-economic development indicators. CSOs can influence this process on two fronts: by monitoring when a country is up for the APRM and push authorities and reviewers to give serious and thorough consideration to the issue of HIV/AIDS; and preparing advocacy materials to either validate or question official position on HIV/AIDS.

Since less than half of Africa has signed up for APRM, CSOs will find another instrument, The African Common Position on HIV/AIDS, which encapsulates the Brazzaville Commitment to Universal Access. Led by the African Union Commission, the Brazzaville Commitment was concluded in March 2006 after national consultations in 41 African countries. These consultations involved more than 5,000 stakeholders, including national governments, UN organizations, community-based organizations, civil society groups, and PLWHA. Notwithstanding the hiccups suffered by the Common Position during the last UNGASS in New York, it remains the African position and leaders can be held accountable to it.

Fundamentally, the African Position calls for, among other measures, the development of national account systems to monitor expenditure and resource allocations to accelerate the achievement of the existing target by African leaders to allocate 15% of total budget for health, including HIV and AIDS; the setting up of regional and national bulk purchasing, technology transfer, south-south collaboration and sub-regional production of HIV-related medicines and commodities; the development of Africa’s capacity to use the World Trade Organization global trade rules, such as TRIPS; and the strengthening of relevant laws, jurisdictions and policies, to reduce stigma and discrimination and empower PLWHA.

Conclusion

The future of an accelerated ARV treatment in Africa will depend on intense advocacy by stakeholders in NGOs and CSOs who are best suited to hold leaders to account. They will be successful only to the extent that they effectively use information. CSOs should also forge crucial broad partnerships beyond their traditional allies in pursuit of a new regional agenda to offer HIV/AIDS services to everyone who needs them.

By Yinka Adeyemi

Communication Officer at The Economic Commission for Africa, Addis Ababa.

Published with kind permission from AfCSF 2007