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The former United Nations special envoy for AIDS in Africa has issued a scathing condemnation of UNAIDS (the joint UN and World Health Organization programme on HIV and AIDS) for its “catatonic passivity” in the face of the epidemic. He has also delivered a blistering criticism of the agency's latest report on prevalence.
Stephen Lewis, who worked for the UN for more than two decades, holding the post of special envoy between 2001 and 2006, attacked UNAIDS for “delaying and dithering” in producing revised figures on the prevalence of HIV and AIDS. He said the resulting report, the 2007 AIDS Epidemic Update, had served to divert the world's attention away from the “continuing apocalypse for sub-Saharan Africa” by focusing instead on the mathematical models and reasons for the adjusted figures.
The report, which was released last week (bmj.com, 24 Nov, News Extra doi: 10.1136/bmj.39406.611273.DB), showed that UNAIDS had overestimated the scale of the epidemic in 2007 and that the number of people with HIV or AIDS was 33 million rather than the 40 million it had previously given.
UNAIDS was “stubborn and sloppy” in the way it had compiled the figures, said Mr Lewis, who is currently codirector of the campaigning group AIDS-Free World and professor of global heath at McMaster University, Hamilton, Ontario. For many years it had ignored calls from “knowledgeable epidemiologists” to revise the prevalence estimates, he said.
“It doesn't take a Nobel prize statistician to guess that prevalence rates based on urban antenatal clinics should not be extrapolated to the entire country and presented as holy writ,” Mr Lewis said at a briefing in London ahead of world AIDS day on 1 December. “That became compellingly clear when the spate of population based household surveys, country after country, invariably showed lower prevalence. But the UN chose a course of delay and dithering.”
The slow response had undermined public confidence in the figures and led to “unnecessary levels of doubt, contention. and confusion,” he said.
“Where HIV/AIDS is concerned there is no room for the jolting of confidence. The new estimates confirm a continuing apocalypse for sub-Saharan Africa: 22.5 million infections, 61% of them [in] women, 68% of worldwide infections, 76% of all deaths, 11.4 million orphans . . . This is where the focus must be [and] not a report cluttered by mathematical adjustments so that virtually every story that's written begins with the news of a statistical about-turn,” he said.
The report should not have been authorised for publication, Mr Lewis said, littered as it was with inconsistencies and replete with tables but missing some vital opportunities for clarity.
The report states that 70% of the difference between 2006 and 2007 in the prevalence figure is due to changes in six countries: Angola, India, Kenya, Mozambique, Nigeria, and Zimbabwe—a conclusion that left Mr Lewis “stumped.” While he could understand how prevalence may have been overestimated in India, Kenya, Nigeria, and Zimbabwe, he said, more puzzling was the inclusion of Angola, which has a low prevalence of HIV and AIDS.
Data on Mozambique were also “a mystery.” On four other occasions the report says that the country had seen no decrease in HIV prevalence and indeed that there was evidence of an increase, contradicting the assertion that Mozambique had contributed to the reduced estimate.
Mr Lewis said, “For me the 2007 epidemic update is simply a symbol—a symbol of insufficient leadership within the United Nations—against the pandemic of AIDS. The time has come for the new secretary general to throw the full weight of his office behind a campaign to subdue the pandemic, with a particular consuming focus on Africa.”
He called on the UN secretary general, Ban Ki-moon, to correct the UN's “lamentable record on women” by adopting a proposal from a high level panel on UN reform put forward in November 2006 to set up an international agency for women.
“No one pretends that the women's agency is the sole answer [to the AIDS pandemic], but you can bet that things would not be so excruciatingly horrendous if women had an international vehicle to draw upon, with resources and voice,” he said.
To tackle the HIV epidemic the UN needed to focus on prevention strategies in high risk groups, including the roll out of male circumcision, “which should have been pursued vigorously much more quickly” but which “got caught up in the overweaning proclivity for excessive scientific inquiry when the case is already clear.” Better access to treatment and better resourcing were also vital, he said.
Mr Lewis accused UNAIDS and its 10 cosponsors, which include Unicef, WHO, and the World Bank, of passivity in the face of the HIV and AIDS epidemic.
“More than 25 years into the pandemic we have an epidemic update that is horrifying in its implications. Whether it's 40 million or 33 million, this plague continues to ravage humankind. I simply do not believe that the UN has done everything it can possibly do to turn the tide. And I don't mean the member states, I mean the secretariat,” he said.
“I'm a multilateralist to the core of my being. But that doesn't mean that the UN is above criticism. And it most emphatically doesn't mean acting as an apologist for those who are chosen to lead and who have failed to lead.”