UNAIDS: The First 10 Years

Chapter 3Prevention: the crucial issue63The prevention of mother-to-child transmission was an essential intervention for UNAIDS topromote, but achieving this presented real difficulties. First, women in low-income countriescould not afford to buy the expensive drugs required. Second, the breastfeeding issue wasmost controversial. For years, UNICEF and WHO had promoted breastfeeding because itwas undoubtedly healthier for newborn babies, but now they were confronted with the factthat HIV could be transmitted through the mother’s breast milk. Michael Merson, formerDirector of GPA, recalled a meeting with Jim Grant, then Director of UNICEF: “I said ‘Jim,let me show you the data on breastfeeding [and HIV transmission]’ and he almost fell off hischair. It was too painful for him to accept”. Merson’s arguments with UNICEF in the early1990s were to be played out again with UNAIDS from 1996 onwards.UNAIDS was working on prevention in general with experts such as Tarantola, who hadmoved to Harvard to work with Mann. There was an increasing recognition of the need fora better understanding of people’s vulnerability to HIV infections – not simply the interventionsnecessary to reduce risky behaviour (e.g. information education and communicationto maintain or promote ‘safer sex behaviours’) but also the need to address the ‘contextual,socioeconomic factors that determine the vulnerability of people’. A major factor 13 wasthe ‘poverty spiral’: the impact of the epidemic on national development and of developmenton the epidemic. ‘This is producing a negative spiral with the epidemic underminingdevelopment efforts, and the lack of progress in development, in turn, further increasing thevulnerability of the population to the epidemic’. An example of such effects would be themassive migration of men to work on a road-building project (or the mines in South Africa)where, living in poor conditions apart from partners and families, they have unprotected sexwith sex workers attracted to such projects because of the money available.Bunmi Makinwa from Nigeria joined UNAIDS department of Policy, Strategy and Research in1997, as a Prevention Adviser, after some years spent working for Family Health Internationalin Washington, DC, and Nairobi. He recalled an era of denial and relativism. In one countryhe visited, he was told that more people were dying from car accidents than from AIDS. “Wehad to tell them, ‘that may be the case today but if you look at ten years to come, it will bevery, very different’”.Makinwa’s travels involved identifying the best and most appropriate strategies in thevarious areas of prevention. “We worked with organizations that were leading in condomprogramming, condom manufacturing and distribution, condom social marketing; who arelooking at sex work and coming up with … the best practices”. These strategies were oftendocumented in UNAIDS’ series of Best Practice publications on a wide range of issues, andcountries found them very useful in providing guidance and direction. Over 10 years later,13UNAIDS (1997).