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In many parts of sub-Saharan Africa, declaratory commitment to sexual and reproductive health rights faces very considerable policy-making conundrums which are reviewed in this chapter. These are most visible in the tensions emerging between the impetus for Universal Health Coverage and the ongoing struggle against HIV and AIDS. The opportunities being developed through African regional bodies are then considered, after which the challenges, progress and prospects for sexual and reproductive health rights in sub-Saharan Africa are reviewed in thematic form.

This chapter begins with a consideration of the strongly relational character of human health by outlining the centrality of gender. The following sub-sections present conceptual understandings of both sexual and reproductive health, followed by definitions of the terms that enjoy a broad consensus. The first section ends with a consideration of sexual and reproductive health as a configuration of closely inter-related issues—including but not limited to HIV and AIDS. The second half of the chapter offers a rationale for the sub-Saharan focus of the study and introduces political, normative and socio-legal perspectives that will inform subsequent chapters.

Since the start of the HIV epidemic, community responses have been at the forefront of the response. Following the extraordinary expansion of global resources, the funding of community responses rose to reach at least US$690 million per year in the period 2005–2009. Since then, many civil society organisations (CSOs) have reported a drop in funding. Yet, the need for strong community responses is even more urgent, as shown by their role in reaching the Joint United Nations Programme on HIV/AIDS (UNAIDS) Fast-Track targets. In the case of antiretroviral treatment, interventions need to be adopted by most people at risk of HIV in order to have a substantial effect on the prevention of HIV at the population level. This paper reviews the published literature on community responses, funding and effectiveness. Additional funding is certainly needed to increase the coverage of community-based interventions (CBIs), but current evidence on their effectiveness is extremely mixed, which does not provide clear guidance to policy makers. This is especially an issue for adolescent girls and young women in Eastern and Southern Africa, who face extremely high infection risk, but the biomedical prevention tools that have been proven effective for the general population still remain pilot projects for this group. Research is especially needed to isolate the factors affecting the likelihood that interventions targeting this group are consistently successful. Such work could be focused on the community organisations that are currently involved in delivering gender-sensitive interventions.Keywords: fast track, health and development agenda, HIV prevention response, costs, community

(2016). Fast-tracking HIV prevention: scientific advances and implementation challenges. African Journal of AIDS Research: Vol. 15, Fast-tracking HIV prevention: scientific advances and implementation challenges, pp. iii-viii.

There is no viable substitute for re-energizing, funding and supporting culturally attuned, locally staffed HIV advocacy and prevention programmes, especially in resource poor settings. The evidence that such interventions are effective remains compelling; and although the cost implications are not negligible, the medium to long-term outcomes must be regarded not as complementary, but as integral, to biomedical interventions. The success of the anti-retroviral drugs upscale has enabled a noticeable improvement in AIDS related morbidity and mortality in the recent years; yet the underlying dynamics of the epidemic remains undetermined by the rate at which new infections are taking place in relation to the number of AIDS deaths. While the rate of new HIV infections is stabilising in some of the hardest hit countries, it remains far too high and the future cost of maintaining an ever-expanding pool of people reliant on daily drugs for survival is unsustainable. Countries must exercise caution in continuing to focus on treatment as a ‘quick fix’ to end AIDS as a public health concern. HIV is a socially culturally induced crisis and, as such, a variety of measures are needed simultaneously to appeal to different people, groups and circumstances.

The drive for universal health coverage (UHC) now has a great deal of normative impetus, and in combination with the inauguration of the sustainable development goals, has come to be regarded as a means of ensuring the financial basis for the struggle against HIV and AIDS. The argument of this paper is that such thinking is a case of 'the right thing at the wrong time': it seriously underestimates the scale of the work against HIV and AIDS, and the speed with which we need to undertake it, if we are to consolidate the gains we have made to date, let alone reduce it to manageable proportions. The looming 'fiscal crunch' makes the challenges all the more daunting; even in the best circumstances, the time required to establish UHCs capable of providing both essential health services and a very rapid scale-up of the fight against HIV and AIDS is insufficient when set against the urgency of ensuring that AIDS does not eventuate as a global health catastrophe.

This volume provides a critical and comprehensive assessment of the relationship between gender, inequality and vulnerability to HIV infection and AIDS. It brings together contributions from scholars and practitioners from across the world to explore the relevance of these core concepts to their understanding of the AIDS crisis and the politics of effective response. The chapters in Gender and HIV/AIDS examine current thinking about sexuality, masculinity, gender roles, and culture in relation to HIV/AIDS and global politics of intervention and regulation. In doing so, the volume maps the intellectual and empirical dimensions of a global debate concerning the gendered contours of an epidemic imbedded in the social relations and material realities of societies at large. The normative aspiration of the volume is to stress the enormity and complexity of the relationship between gender inequalities, sexuality and HIV and AIDS, and the impact this has on the lives of affected and infected people, as well as on our work as development practitioners, academics, and activists. We believe that taking gender into account in our response to HIV/AIDS will not only help our understanding of the character and persistence of the epidemic, but has the potential of contributing to both improved policy and to the genuine transformation of gender relations in wider society. The epidemiological statistics show that today women are more vulnerable to HIV than men for a variety of biological and social reasons that will be discussed in this introduction and throughout the book. Policy-makers have recognized this phenomenon as the “feminization of AIDS” (CHGA n.d.; Global Coalition on Women and AIDS 2004; Germain and Kidwell 2005; Piot 2007). This awareness of women’s vulnerability has stepped up prevention work with women, and focused attention on HIV and gender. While this is a necessary development, it is not without controversy. Arguably, the focus on women reinforces patterns of stigma and blame directed at women, portraying them as either vectors or victims of the epidemic (AWID and Kinoti 2008; Busza, this volume). This is partly the result of how “gender” is often addressed in development policy, practice and scholarship, equating gender all too often with women. As a result of the tremendous difficulty of changing entrenched social relationships, policy rarely looks beyond “women’s inclusion,” overlooking the beliefs, norms and values that underpin inequality in

The 2030 Agenda for Sustainable Development was adopted by the United Nations general assembly in September 2015. The agenda encompasses internationally agreed development aspirations – the Sustainable Development Goals (SDGs). The health targets of the SDGs are not merely ambitious in themselves; they are configured with a very considerable range of other, hugely expensive global issues: 17 goals and 169 targets covering nearly every important aspect of human well-being, both physical and relational. Within the health sphere, by the end of the SDGs in 2030, the ambition is that the AIDS epidemic and other communicable diseases should have been ended, child and infant mortality should be significantly reduced, and universal health coverage with financial protection should be in place for all. But the Joint United Nations Programme on HIV/AIDS (UNAIDS) 5-year ‘Fast Track’ plan for front-loading resources in order to build on progress against the HIV/AIDS pandemic is already faltering – surely evidence of the squeeze being exerted by the most urgent non-health issues (eg, SDG 13: climate action), together with an unpropitious political climate for Official Development Assistance generally. Whatever political embarrassment it might provoke, we must confront the inescapable conclusion that the SDGs are aspirational rather than a compulsory commitment to a programme: the hard choices will become larger in number and more anguished. …

Donor country initiatives for the prevention and mitigation of HIV/AIDS are not a matter of simple burden sharing. Instead, they have brought in their wake many of the complexities and unforeseen effects that have long been associated with more general overseas development assistance. In the case of funding directed toward HIV/AIDS, these effects are by no means either secondary or easily calculable. It is widely acknowledged that there is no consensus framework on how these impacts may be defined, no framework/toolkit for the evaluation of impacts and no longitudinally significant data that could provide the substance for those evaluations. The subject of this study focuses not on the health outcomes of funding but on how donor-recipient relations could be better deliberated, negotiated and coordinated. We argue that effective leadership and governance of developing country health systems for HIV/AIDS work requires a reconfiguration of how donor-recipient relations are conceived and contracted, and for this purpose, we propose an adaptation of the Organisation for Economic Co-operation and Development Paris Declaration principles of aid effectiveness.

AIDS-related morbidity and mortality not only affects individuals and their families, but is rapidly undermining African states' capacity to develop. Stemming the impacts of the pandemic has therefore become a major concern. This calls for meeting the needs for care and support of those affected, and increasing the access of persons living with HIV/AIDS to effective treatment. Provision of such complex medication in resource-limited settings is a fairly recent phenomenon. In this context, the article builds on emerging experiences from the field in identifying issues and challenges that need to be addressed in order to facilitate the scaling-up of HIV/AIDS treatment in Africa.

To mark the 25th anniversary of the discovery of the HIV virus, this special issue brings together a collection of articles from leading scholars engaged in, or concerned with, the challenges posed by the HIV/AIDS epidemic. Collectively, the articles address the power relations driving HIV/AIDS, frustrating the possibility of alleviation, care and recovery and operating to relegate entire regions to a vulnerable and bleak future.

There is no doubt that increasing amounts of funding are needed to provide a full package of HIV/AIDS prevention, treatment and mitigation interventions to Africa. However, even the existing funding flows are posing considerable challenges at a national level. In the quest for rapid results, donors have too often chosen to alleviate the lack of local capacity by bringing in foreign technical assistance or building parallel systems for delivering commodities such as drugs that may not be sustainable over the long term once external assistance stops. Even when such interventions may be relevant, they do not address the biggest challenge, namely how to build up the capacity and the systems needed for large-scale implementation of the AIDS response. This article argues that to attain the needed efficacy in HIV/AIDS mitigation programmes, further sustainable increase in external financing is certainly required (particularly for treatment programmes), but even more important is the need to implement them.

although the proximate cause of africa’s aids crisis is hiv, the underlining societal causes are much broader and familiar. across the continent, poverty structures not only the contours of the pandemic but also the outcome once an individual is infected with hiv. thus, until poverty is reduced there will be little progress with either reducing transmission of the virus or creating an enhanced capacity to cope with its socioeconomic consequences. it follows that sustained human development is an essential precondition for any effective response to the pandemic in africa.

As Africa enters its third decade of structural adjustment pressures, the promised advantages of economic restructuring—as hailed by the various lending bodies— have not been forthcoming. The indelible picture emanating from the continent is one of a people relegated to a position of extreme poverty as state managers and the international community either fail to, or seem unable to, pursue policies that will secure the basic needs of its citizens. To compound matters, HIV and AIDS are threatening to erode the continent's already fragile development capacity. Predicated on the continent's limited economic capabilities, this article charts the relationship between poverty, debt relief and the politics of effective response to HIV/AIDS in Africa. The article begins with an assessment of the societal causes and consequences of the epidemic, moving on to contextualize the case for debts cancellation. It concludes by examining the crucial relationship between debt relief and the successful implementation of effective strategies against the pandemic in Africa.

The Global Fund to Fight AIDS offers great promise as an instrument of global action to address the devastating effects of the disease. Yet the enormity of its promise also speaks to the scope of its mission: to facilitate the financing by governments, corporations, philanthropical bodies and individuals of a massive effort to address the epidemic that has to date outpaced previous efforts at effective control. A key challenge is to devise a governance structure that makes effective action likely, satisfies donors, responds efficiently, and produces observable results. By examining recent developments, this paper seeks to outline facets of the governance challenge facing the Global AIDS Fund.

The 13th International Conference on AIDS held in Durban, South Africa, highlighted the social catastrophe unfolding on the African continent. The meeting took place in the country with the largest number of people infected by HIV - the virus that causes AIDS - on the continent that is home to 70% of the world's HIV-infected population. The cruel irony of the unfolding human tragedy is that Africa is also the least equipped region in the world to deal with the multiplicity of challenges posed by the HIV virus. Drawn from ongoing research in southern Africa, this article charts the relationship between poverty, HIV prevalence and the politics of global response.

The causes of human insecurity and suffering in the contemporary world are a major concern of this volume. If security is concerned with the achievement of basic human needs (CHS 2003), then HIV/AIDS poses the foremost challenge to the attainment of security in Africa. Though the exact mechanisms through which the epidemic is unfolding are not fully mapped and understood, it has a non-linear impact on state-society relations. As such, it serves to aggravate existing weaknesses by curtailing the range of options open to policymakers for expanding economies and achieving stated development goals sufficient to arrest underdevelopment on the continent. In the most heavily affected countries the ramifications of HIV/AIDS are evident in the deterioration in social welfare indicators, such as life expectancy, literacy and primary school enrolment that had been improving for several decades. HIV/AIDS is reducing the capacity in all social and economic sectors, as a result of the mortality and morbidity of highly skilled and experienced people who cannot be replaced quickly or easily, but only after long periods of training and skill acquisition. General levels of education fall as enrolments decline among children who lose parents as a result of HIV/AIDS. In some hard hit communities, the epidemic is leading to a retreat into subsistence production in agriculture as a result of reductions in the economically active population. In turn, these declines in economic activity are reducing levels of tax revenue, which lowers the capacity of the public sector to undertake its functions at a time of dramatically increased demand for public services in health, education and training. The net effect of the proceeding processes is the systematic erosion of the ability of all affected societies to safeguard the stock and flow of vital human capacity needed to sustain socio-economic development and political stability. The ability of nations, therefore, to improve the well-being of their citizens, build strong and stable societies, and expand opportunities for all is threatened by the HIV/AIDS. The situation is complicated because many high HIV prevalence countries (especially in Africa) were performing poorly before HIV/AIDS gained a foothold. The issue as to how HIV/AIDS affects society and in the process undermines its ability to sustain the vital human capital needed for sustained human development in Africa is the core preoccupation of this chapter. Using a human security framework (16.2), the chapter charts the rise of the HIV epidemic (16.3), explores the impacts of AIDS (16.4) and, based on primary research, postulates the possible ramifications on sustained human development in the years to come (16.4).