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Can We End AIDS In Africa


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While much has been done to end AIDS in Africa, more work by governments is necessary to move forward, particularly in SA.

It is true to say that the extraordinary shift in the global response to the HIV epidemic in sub-Saharan Africa over the past 15 years has been one of humanity's shining achievements in recent times. The enormity of the scale of the implementation of treatment, care and prevention across the continent has undoubtedly contributed to better health globally.

The roll-out of antiretroviral therapy (ART), surely one of the greatest scientific developments in recent history, has saved an estimated nine million life-years in sub-Saharan Africa.

According to the 2012 Joint United Nations Programme on HIV and AIDS (UNAIDS) global report on the AIDS epidemic, 56% of eligible people on the African continent were receiving ART in 2011. This is higher than the global average of 54%, and, yes, is still nowhere near where we'd want it to be.

But if we recall what pending disaster we were facing at the beginning of the 2000s, one simply has to acknowledge that the transformation of the epidemic and the health infrastructure and systems in many countries resemble a revolution of sorts. Botswana, Namibia, Rwanda, Swaziland and Zambia have all achieved universal access to ART, in other words, more than 80% of those eligible for it have access to ART.

The Human Sciences Research Council's (HSRC) National HIV Prevalence, Incidence and Behaviour Survey that was released recently has confirmed that ART access in South Africa doubled in the country between 2008 and 2012, with South Africa now having the largest public sector ART programme in the world.

ART has dramatically driven down both new HIV infections and AIDS-related deaths. According to UNAIDS, new HIV infections declined by 50% in the past decade and AIDS deaths by 25% between 2005 to 2011. This trend started in the mid-2000s, in large part because of the availability of antiretroviral drugs.

The HSRC report has, however, revealed a worrying trend in South Africa. While the country's new HIV infection rate, or HIV incidence rate, declined among female youths, it remains at unacceptably high levels. In the older population the incidence did not show signs of slowing down. The number of new HIV infections is the highest in the world.

The number of HIV infected pregnant women in Africa who receive preventative ART that significantly reduces their chances of infecting their babies during pregnancy, labour or breastfeeding, has dramatically increased. In countries such as South Africa and Botswana, access is close to 100%. The HSRC report has shown the infection among children under the age of 12 months has declined since 2008, confirming the success of mother-to-child transmission programmes in South Africa.

This is all good news, but looking ahead we need to couch our speech about what remains to be done. We are less than a year away from a pivotal time in the HIV and AIDS response, when consideration of the 2015 Millennium Development Goals, and those "targets" that will succeed them, will take up much of the space of the global health agenda.

We are, make no mistake, at a critical juncture in sub-Saharan Africa's AIDS epidemic. It is clear that substantial barriers remain to ending the epidemic and it is in everyone's interests that they are addressed in the conversations about a post-2015 scenario.

In a nutshell: sub-Saharan Africa, despite all the impressive gains listed above, still shoulders a vastly disproportionate burden of the epidemic. According to the 2012 UNAIDS report, the continent accounted for 71% of all new infections globally in 2011, more than 90% of children infected with HIV and 70% of AIDS-related deaths.

One needs to be mindful when generalising statistics. The "good news" about declining new HIV infections and AIDS deaths is not shared evenly across regions or countries. HIV incidence is, for instance, still on the rise in Guinea-Bissau and is only stable in countries like Tanzania, Uganda, Nigeria, Lesotho, Gambia, Democratic Republic of Congo, Benin and Angola, according to the UNAIDS.

ART coverage reveals a similarly uneven pattern. Universal ART coverage in Botswana, Namibia, Rwanda, Swaziland and Zambia has taken an extraordinary step forward. But the UNAIDS report notes that 12-million people on the continent, a third of the global number of people living with HIV, are still unable to access ART. This is an extraordinary impediment to ending AIDS in Africa.  

Underdeveloped health systems, mismanagement and corruption, political turmoil and the lack of accessibility to remote areas all play their part to prevent wider ART coverage. It is vital that African governments and organisations such as the Global Fund to Fight AIDS, TB and Malaria keep working towards the international commitment of universal coverage by 2015. The key to success will be maintaining this high level of ART coverage, which requires a gradual switch from international funding to sustainable domestic funding.

Even in situations where people have been accessing treatment, retention rates have sometimes become barriers in themselves. According to the UNAIDS report, nearly half of all people in Malawi and 40% in Kenya who started ART in the mid-2000s were no longer on treatment five years thereafter.

But getting people on treatment and on to care is only half the solution: prevention plays a key part in HIV management.

There is now also an urgent need for a discussion among academics, health professionals, activists and bureaucrats around the post-2015 scenarios if the response to HIV is to continue in the right direction. While so much has changed, too much has stayed the same.

Gender inequality continues to see women share the burden of the epidemic – 58% of people with HIV in sub-Saharan Africa are female, according to UNAIDS. The HSRC report has revealed that the HIV incidence rate among South African females aged 15 to 24 is four times higher than the incidence rate found in males in this group. Among the teenage population, the difference between the HIV prevalence between girls and boys is even higher – girls have eight times the infection rate of their male counterparts. The risk factors for females – physiological vulnerability, social and economic inequities, unequal access to education and employment, gender violence, difficulty negotiating sex and condom use, and age-disparate relationships where one sexual partner is more than five years older than the other all fuel the epidemic.

Stigma and discrimination, as they do in so many countries with HIV epidemics, continue to hinder the implementation of science on the ground. And unfortunately much of the problem, if we are frank with ourselves, has been driven by the behaviour of some governments, or at least condoned by decision-makers.

In recent years, much has been made of the punitive anti-homosexuality laws that exist in 35 African countries, and the more recent severe amendments made to them in countries such as Uganda and Nigeria. According to prominent epidemiologists, we have major HIV epidemics among men who have sex with men and in transgender communities. Yet in many sub-Saharan African countries, we are powerless to intervene in any meaningful way because of the fear of reprisal by these governments.

The same could be said to apply to the injecting drug user community. Research studies have confirmed that we have alarming HIV infection rates among injecting drug users, yet it is telling that, even in some international forums, the issue around drug use and HIV doesn't feature prominently on agendas.

The past three decades of HIV and AIDS have taught us that the virus doesn't discriminate, but that people and governments do. A renewed engagement with African decision-makers on human rights issues has to take place if we are to move towards ending AIDS in sub-Saharan Africa and build on the huge gains we've made over the past 15 years.


A Report Card for the US-Africa Leaders Summit


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President Obama closed the first ever US-Africa Leaders’ Summit on August 7, 2014, by declaring it had been an “extraordinary event” and citing the accomplishments of the summit in terms of trade and investment, security cooperation, including a commitment to peacekeeping, and emphasizing the need to address corruption and bad governance on the continent. There is little doubt that the event was historic, with as many as 45 African Heads of State present, including some royalty. Never before has an American administration engaged such a senior Africa leadership group at such a high level. The question, though, is did the conference really break any new ground and accomplish concrete goals? On the surface, the answer seems to be a disappointing, “sort of.” Let’s examine some of the commitments that were announced, and what did and didn’t happen.


On trade and investment, the summit resulted in some serious and significant commitments, but very little that was new from the US Government (USG) side. Most initiatives announced by Obama were updates of existing ones such as Power Africa, Feed the Future, Trade Africa, and Doing Business in Africa. The USG’s new commitments to such initiatives, however, were unimpressive.

For instance, Obama announced that US$26 billion has been “mobilized” for Power Africa, but the USG is committing only US$300 million a year to that effort, with the rest coming from private sources. The USG added another US$7 billion to Feed the Future, the government’s global hunger and food security initiative. A number of agencies like Exim Bank, OPIC, Millennium Challenge Corporation, the US Trade and Development Agency, Department of Agriculture’s Commodity Credit Corporation and Department of State added another US$8 billion or so in credits and new financing for the program. However, the real impetus came from the private side. Obama announced that the New Alliance for Food Security and Nutrition, Feed the Future’s global network of stakeholders in sustainable agriculture, “mobilized” US$10 billion from the private sector and noted that new pledges of US$14 billion had been made at the separate US-Africa Business Forum. By my count, that comes to approximately US$50 billion from the business community and only US$15 billion from the government contributions.  While private sector engagement in economic development is welcomed, it does not represent a major change in policy direction or magnitude as far as government is concerned.

The most welcomed trend here is the realization by the American business and risk capital investment communities of the potential that Africa holds.  It is, after all, the private sector that will have to drive sustainable development.  Government, through aid or partnership, can only do so much.


On the security and peacekeeping side, the analysis is much the same. Obama announced the Security Governance Initiative (SGI) and committed US$65 million to support it. It will include six select partner countries – Ghana, Kenya, Mali, Niger, Nigeria, and Tunisia – and will focus on building institutions of good governance through increasing the capacities of their security sectors, including civilian ministries, police and military departments, depending on the needs of each country.  It mandates close consultation and cooperation with the host governments.

On peacekeeping, the President announced the African Peacekeeping Rapid Response Partnership (APRRP) and committed $110 million per year for 3-5 years to build the capacity of African militaries to rapidly deploy peacekeepers in response to emerging conflict. This effort will be in partnership with the following countries – Senegal, Ghana, Ethiopia, Rwanda, Tanzania, and Uganda. While this is a laudable effort true to the partnership commitment, both initiatives are somewhat limited in scope and the respective US$65 million for SGI and US$550 million for APRRP seem to be a pretty minimal investment if the USG is serious about addressing security issues in Africa.


The final item that Obama emphasized as a success at the conference was, in fact, the least impressive.  Rightly underlining corruption and bad governance as key stumbling blocks to development and economic progress, there seems to be no headway made in that regard, at least not directly. The only commitment was a very vague one to convene “our experts and develop an action plan to promote the transparency that is essential to economic growth.” This is where the choice to not meet head-to-head with problematic leaders was unwise. Obama’s remarks in the session devoted to this issue were eloquent and incisive, points he repeated in his final remarks and press conference. However, they were as effective as the speech in Ghana during his first term, as far as changing the way in which leaders think about their perceived enemies, the constitutional frameworks in which they exist, or the imperatives of establishing reconciliation, trust and communication in a post-conflict context that must precede sustainable peace and successful democracy.

However, much of the value in a summit like this comes from the conversations held on the side, and those did happen.  Chairman of the Foreign Affairs Committee in the House and the Head of the Africa Subcommittee, had very frank and useful private meetings with several Heads of State, including Kabila of the DRC and Salva Kiir of South Sudan, in which they pressed hard on ongoing conflict situations in those countries. They also saw Presidents Johnson of Nigeria and Zuma of South Africa to talk about their troubled situations. At the same time, the US Secretary of State had a private meeting with all the South Sudanese delegation for a frank and open discussion in which he pulled no punches as for the need to bring solution to this conflict.


While there are several disappointments, we should not forget how important it is that the US-Africa Leaders’ Summit was convened in the first place. Africans remain cynical about US motives and commitments, understandably so. The more recent focus of US policy on security, since the introduction of AFRICOM in 2007 and heightened since the growth of serious radical Islam across the Maghreb, has convinced many that the US is only looking for support in our “War on Terror,” and are not really dedicated to Africa’s progress and development. This undertaking and the huge turnout of senior officials and top business and civil society representatives, plus a ceremonial atmosphere at the White House dinner, goes a long way to underpinning relations and establishing bonds that will serve the US well in the future.

Maybe the most important outcome, one that was feared would not happen, is a commitment by the President to make this a regular consultation.  In his closing remarks, Obama said,

“Summits like this can be a critical part of our work together going forward, a forcing mechanism for decisions and action.  So we agreed that the US-Africa Leaders’ Summit will be a recurring event to hold ourselves accountable for our commitments and to sustain our momentum.  And I’ll strongly encourage my successor to carry on this work, because Africa must know that they will always have a strong and reliable partner in the United States of America.” 

Key to this is the last point, to make sure his successor holds to this commitment.  An on-going consultation at the highest levels of US and African governments – as the Japanese, Chinese, EU, and India have been doing for years – will be the best way to address these issues and develop understanding and true cooperation.


Lessons For Doing Business With BoP Markets


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A recent online chat asked how business can best operate in base of the pyramid markets and what could be learnt from the success and failures of those businesses already serving the lowest income communities. Here are 10 key findings:


One of the biggest errors companies can make is to treat base of the pyramid (BoP) projects differently from their core business, according to Cornell's Eric Simanis. Operating in very low income populations presents enormous challenges from high operating costs and poor economies of scale to sceptical consumers, "so if these projects aren't being driven as rigorously and as laser-focused on meeting the numbers as companies would with "traditional markets", they simply won't have a shot at profitability."

A focus purely on social impact won't work - companies need to see social impact as a byproduct of doing good business. In many cases the impact will come through the product itself, Simanis added, this means a focus on good quality products. "I think a lot of the pulling back by companies from the BoP space happened because projects were being run like CSR ventures but were expected to perform on the profits/revenue side."

Business Call to Action's Tatiana Bessarabova agreed that using core business was key. "Whereas CSR typically takes place in the community investment sphere, 'pro-poor' business stems from the core of the business where the company's expertise lies".



Simanis pointed to a difference between scalable and replicable. Every business model is replicable, he said, given time and money. Scalable, however, means it must hit a target return on investment within a certain time frame. "So a break-even business isn't scalable; a single business unit that is profitable may not even be scalable ... the profits have to be high enough and fast enough at the business unit level for a project to be scalable." This is not an easy task and businesses need a huge amount of patience and the willingness to look beyond traditional short term metrics.


3. It's vital to understand the needs, demands and constraints of the target market

Understanding what BoP customers need and want requires a significant time investment. Bessarabova advised working closely with communities, adjusting the business model to the local context and understanding the financial needs of customers. Introducing the idea of paying for a product those prospective BoP customers may not be familiar with means a lot of work on tailoring a company's marketing, distribution and financial approaches.

Havard's Jane Nelson agreed that companies trying to serve the BoP market must take a comprehensive approach to understanding the range of constraints that low-income producers or consumers face. Companies should also think about partnering with others to strengthen their understanding of systems within which low-income producers and consumers are operating.


4. Work should be grounded in country offices

The major challenge BoP units face is where they are based. Projects should be grounded in country, said Eric Simanis. "You can't run a business in Kenya out of the Paris office and have a standalone cell in the field (one of the greatest values of being inside a corporation are the economies of scale of leveraging operations). But if you run projects that are aiming to make less than the target return or are diluting margins, the country office will have no interest in it."

Construction company Lafarge and brewing and beverage company SABMiller were given as good examples of companies working within country offices to drive business which fits with their overall objectives. Kayser praised the Lafarge "toolkit" which has allowed country offices to design an approach appropriate to the local context while leveraging global best practice and experience.


5. There is a significant role for the public and development sector

Nelson referred to the Department for International Development's (DFID) role in providing some initial funding support to Safricom/Vodafone's CSR team to market and business model test the initiative that eventually became M-PESA - the mobile phone based money service - which was then successfully scaled up.Simanis agreed that there was a clear role for the public and development sectors, especially in providing working capital during early stage piloting of business projects. But it's important, he warned, that this capital is not contingent upon business working with local NGOs or addressing certain impacts as this will see the initiative slide into the CSR realm.


6. Businesses need to constantly adapt their products

Businesses that most successfully serve BoP markets constantly adapt their products to meet consumer preferences, said Ashton's Emily Haves. She referred to Barefoot Power which found that customers were much more receptive to their solar products if the cords were white, not black. "It's key to respect everyone as a customer, even if their purchasing power is low." Kayser sounded a note of caution against variety, however, which he said can lead to complexity in terms of training the salesforce, ordering and supply chain. He advised that pilots be kept as small as possible


7. BoP business doesn't mean exploiting the poorest communities

Serving low income populations, when it's about creating viable livelihood opportunities - by incorporating them as consumers, suppliers or distributors - is not exploitative. Haves said that in the energy sector, most have concluded that for energy access products to be sustainable - they need to be delivered through market-based mechanisms. "Experience has shown that when products are given away there is no feedback mechanism for the donor to understand the end-users' priorities, which means the products don't evolve to be truly useful and desirable."Simanis agreed: "Yes it's about selling stuff to poor people ... [but] ... we have to give these consumers the freedom and respect to make their own purchasing decisions." Dictating what people should and shouldn't buy is a tricky road with ethical implications. He advised that companies bring their values into this market - that they believe in the product they're offering and treat customers with respect.


8. It's not just about selling products

There are many different ways business can engage with BoP markets through the value chain. Bessarabova spoke about the waste company employing ex-waste pickers in India to serve households as doorstop collectors. She also referred to the Japanese company aiming to improve the livelihood of Indian farmers by scaling up its production of organically produced cotton.


9. Take the risk away from the customer

De-risking investment for BoP customers is key, said Haves. For example, trust in solar can be low, especially when people have bad experiences. She referred to a company which decided to sell solar as a service rather than a product, so the customer could stop paying if the system stopped working. Kayser added the example of another company, which tied monthly loan repayments to the visits of the maintenance technician to reassure customers that repairs would be carried out and reassure the company that payments would be made.


10. There are good examples of business models working well in BoP markets

Bessarabova offered the example of L'Occitane, which entered the shea-rich Burkina Faso market in 2006. It has worked to support female shea butter pickers and processors and to improve their working conditions, including through literacy programs, microcredit loans and training to support income-generating activities.For Hayes, Greenway Grameen, the Indian social enterprise selling cookstoves, stands out for improving health, saving people money and providing a product customers really want and need. The initiative went through multiple iterations of the cookstove - using feedback from focus groups - to create a product that worked and was desirable, as well as having positive social and environmental impacts.Simanis forwarded BASF's India country team, a business-to-business company which has been targeting opportunities in the value chain of its customers which are serving BoP consumers. He also referenced SC Johnson's work in Ghana on combatting malaria through insecticides and insect repellent.