The annual U.N. General Assembly meeting kicks off this week with a full agenda on global concerns ranging from climate change to nuclear weapons to coronavirus vaccines to economic recovery from the pandemic.
One issue that has long had consensus within the U.N. is the need to address the HIV/AIDS epidemic. But at a June UNGA high-level meeting on HIV/AIDS, Russia refused to support a consensus political declaration on ending the epidemic, forcing the first contested vote on this topic.
What does this swerve toward greater politicization mean for the future of HIV/AIDS and international politics? And are there take-aways on how to address other health crises? Here’s what you need to know.
Russia upended U.N. precedent
Around 80 percent of UNGA resolutions are adopted by consensus rather than by vote. Consensus requires all parties to consider all viewpoints and promotes negotiation and compromise. On global health issues, in particular, the U.N. system has a long tradition of consensus decision-making.
By forcing a contested vote in the June meeting, Russia and three other countries — Belarus, Nicaragua and Syria — broke precedent for negotiating HIV/AIDS policy. The move also diverged more generally from how the U.N. tries to address concerns.
After two months of negotiations, Russia took delegations by surprise in June when it proposed last-minute changes to the final political declaration — after its 73 other objections had already been accommodated.
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The sticking point for Russia was the inclusion of “rights-based” responses to HIV/AIDS, including language committing countries to “eliminating HIV-related stigma and discrimination” and “reviewing and reforming” restrictive laws and policies that criminalize or discriminate against people living with or at risk of HIV. Such laws include those that impose criminal penalties for same-sex relationships, sex work and drug use.
Russia also objected to the political declaration’s support for harm reduction programs — access to sterile needles and replacing illegal opiates with prescribed medicine, for instance — and assistance for key at-risk populations, steps that Russia and its allies described as an affront to cultural and family values.
38 million people are living with HIV
The special session on HIV marked four decades since the first known cases of HIV/AIDS were reported. To date, an estimated 33 million people have died of AIDS-related illnesses and another 38 million are living with HIV.
When the U.N. General Assembly held its first special session on HIV/AIDS in 2001, the overwhelming challenge was the lack of access to lifesaving HIV medications in developing countries. Scientific advances, robust advocacy and massive levels of donor funding delivered through new institutions like the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President’s Emergency Plan for AIDS Relief have gone a long way toward closing this gap.
Over 80 percent of people living with HIV know their HIV status and more than two-thirds are on treatment. But this progress falls short of the UNGA global goals for 2020.
The biggest challenge now is that progress fighting HIV/AIDS has been unequal. Millions of people in key populations — men who have sex with men, sex workers, transgender people, people who inject drugs and people in prison and other closed settings — have been left behind. Women, girls and youths more generally have also faced obstacles. Individuals in these groups are more likely to be exposed to HIV and to face violence, stigma, discrimination and laws that limit their access to health services. Reaching the U.N. goal of ending AIDS as a public health threat by 2030 will require addressing these inequalities, analysts argue.
UNAIDS strategy embraces both science and policy
Policymakers and health advocates working on AIDS issues tend to focus on medical interventions that stem the spread of infection and make treatment available to those that need it. But social and political factors also affect disease transmission and treatment access.
Our research shows that countries that criminalize same-sex relationships, sex work and drug use have worse HIV outcomes. In contrast, countries with laws and policies that protect people from discrimination and gender-based violence are making better progress toward ending AIDS.
The U.N. Joint Program on HIV/AIDS (UNAIDS) has the new Global AIDS Strategy 2021-2026, which lays out a set of policy-focused “social enabler” targets. These aim to reduce the number of countries with punitive laws or policies and reduce stigma, discrimination and violence alongside the medically focused targets for HIV testing and treatment levels. UNAIDS estimates that achieving these social enabler targets will prevent 2.5 million HIV infections and 1.7 million AIDS-related deaths by 2030.
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Will including social policies lead to further political fights?
Russia and its allies objected to the UNAIDS expansion of focus to social policy. These objections may have less to do with the specific policies under discussion than with the idea of a “rights-based approach” in general, which Russia and its allies presented as a cultural imposition.
Data from the HIV Policy Lab at Georgetown University shows that Russia, Belarus, Nicaragua and Syria have already adopted at least some of the laws or policies they opposed, including measures included in the political declaration. The contested UNGA vote suggests that ratcheting up the focus on social policy can also ratchet up political disagreements.
So what are we to make of the vote, and what does this mean for other health threats going forward? Russia and its three allies were not the only countries to object to portions of the political declaration on HIV/AIDS — many other countries took issue with the content of the final text. However, after Russia forced a vote, only four of 193 countries voted “No.” A weak “coalition” may discourage similar gambits in the future.
More importantly, as global strategies to address HIV/AIDS move beyond medical science and health systems to address the socioeconomic and political determinants of disease, we should expect to see more international disagreements about how to move forward. This dynamic also applies to other health problems ranging from noncommunicable diseases to pandemics, and it has been particularly visible in the fraught disagreements over policies to address covid-19.
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Renu Singh (@Renu_Singh_) is a research assistant professor of public policy and an Institute for Advanced Study junior fellow at the Hong Kong University of Science and Technology. She is also a scholar at the O’Neill Institute for National and Global Health Law at Georgetown University.
Mara Pillinger (@mplngr) is a senior associate at the O’Neill Institute for National and Global Health Law at Georgetown University.