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IDJ English – IDJ Report

Unresolved AIDS problems in developing countries

Bilateral support for fighting infectious diseases should be strengthened

Acquired Immune Deficiency Syndrome (AIDS) is a public health problem throughout the world, and was widely regarded as an incurable disease in the 1990s and 2000s. Active measures against AIDS have been promoted at the global level since the early 2000s. However, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS), more than 60% of human immunodeficiency virus (HIV)-positive patients in the Middle East and North Africa do not have access to proper treatment. What role should Japan play in addressing this situation?


UNAIDS’ 90-90-90 Goals

It has been many years since AIDS became a worldwide public health issue. The virus that causes AIDS, is transmitted by a variety of routes, including sexual activity, intravenous drug use and the sharing of needles, and intrauterine transmission. The condition has spread worldwide since the first case was reported in the United States in 1981. By 1997, new HIV infections reached 2.9 million per year. The situation in developing countries is particularly serious, and in Southern Africa in the early 2000s, more than 20% of people aged 15 to 49 were infected with HIV.

In response to the global spread of AIDS, the international community, including international organizations, has been making efforts to stem the tide of the disease. Focusing on the past 20 years, Japan announced the Okinawa Infectious Diseases Initiative at the Kyushu–Okinawa G8 Summit in 2000 and pledged funding for AIDS control. At the same time, the establishment of a global funding system was agreed among the participating countries, which led to the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria, in 2002. With the establishment of the Global Fund, developing countries that want to tackle the problem of AIDS were able to make use of the ample resources of the Global Fund to implement domestic AIDS countermeasures. In 2003, the World Health Organization (WHO) and UNAIDS proposed the 3 by 5 Initiative, which aimed to provide treatment to 3 million people by 2005.

In 2015, UNAIDS set what it dubbed the “90-90-90” goals in response to the adoption of the Sustainable Development Goals (SDGs) at the UN Summit. The goals are: 1) to diagnose 90% of all HIV-positive people, 2) connect 90% of all people diagnosed with an HIV infection to treatment, and 3) realize viral suppression to below detectable levels in 90% of all people receiving therapy for AIDS. Through these efforts, UNAIDS hopes to end AIDS by 2030, the deadline for the SDGs.


“There is a risk that support will be cut off”

The above-mentioned efforts have been successful over time. Among the world’s 37.9 million HIV-positive people as of 2018, 23.3 million have access to treatment. From a macro perspective, the situation has improved. However, there are still people who find it difficult to obtain medical care, especially in Africa, the Middle East, Eastern Europe, and Central Asia.

Masami Fujita, director of the Global Networking Division of the Bureau of International Health Cooperation of the National Center for Global Health and Medicine (NCGM), has been working on AIDS programs for the WHO, mainly in Asian countries. He said, “in the Asian region, ‘key populations’ such as sex workers, drug users, and men who have sex with men (MSM), transgender people, and their sexual partners are predominantly infected, accounting for 75% of new HIV infections.” A recent trend is that the number of HIV-positive MSM is increasing in the Philippines, especially among the younger generations.

In response to this situation, non-governmental organizations (NGOs) have been implementing AIDS countermeasures such as prevention, testing, and treatment for key populations in Asian countries, supported by funding from the Global Fund and donor countries. However, as economic growth has led to the reduction of support from donors and each country implements its own AIDS countermeasures with its own budget, Fujita said, “the domestic system for funding NGOs is not sufficient in many Asian countries. As a result, there are possibilities of cutting off the support to key populations.”

By contrast, the situation in sub-Saharan Africa remains serious. Since the 2000s, the region, where HIV spread extensively throughout the 1990s, has been actively involved in AIDS treatment, prevention, and social inclusion of HIV-positive people and affected communities for more than a decade. However, the region has not reached the stage where we can say that it has “overcome AIDS.”

Masaki Inaba, Program Director for Global Health of the Africa–Japan Forum (AJF), ​​regularly makes policy recommendations on AIDS in Africa. He has noted that, “although Africa’s access to treatment has improved dramatically, continuous access to treatment remains difficult especially in rural areas, urban poor areas, and conflict-affected areas. There are also problems such as the spread of drug-resistant HIV and combined infections of tuberculosis and AIDS. It is far from the end of AIDS.”


Japan’s bilateral support is disappearing

What about support from Japan and its implementing agency, the Japan International Cooperation Agency (JICA), regarding HIV/AIDS countermeasures in the world? In fact, Japan has made great contributions to the Global Fund. As of April 2019, Japan’s contributions totaled roughly $3.5 million, the fifth-largest contribution after the U.S., France, the United Kingdom, and Germany.

However, looking at bilateral support, “Currently, JICA is sending volunteers specializing in infectious disease and AIDS countermeasures via the Japan Overseas Cooperation Volunteers project, but other than that, it has hardly done any AIDS projects.” Shinichi Takenaka, who was in charge of a wide range of AIDS projects in sub-Saharan Africa in the 2000s at JICA, is now a technical advisor to the Stop TB Partnership, which is leading tuberculosis control around the world. He said, “based upon the Okinawa Infectious Diseases Initiative, a number of AIDS projects, including technical cooperation and grant aid, were formed in African countries where JICA has offices. However, as Japan’s policy shifts to universal health coverage (UHC) in the latter half of the 2000s, there are no projects specializing in infectious diseases, and in line with that, there are almost no AIDS projects.”

These policy moves are in great contrast to trends in the U.S. and Europe. As a part of bilateral support for developing countries, the U.S. contributes funds through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The UK, France, and Germany promote bilateral support to complement the Global Fund by funding projects by local NGOs in developing countries.

Based on the above, what role should Japan play in the future? First of all, as a prerequisite, contributions to the Global Fund and efforts toward the realization of UHC, which Japan has set forth, should be continued. Regarding the latter, if health care services are enhanced in developing countries, many lives will be saved.

In addition to the above, another area that deserves consideration is the strengthening of bilateral support focused on infectious diseases. As for AIDS countermeasures, technical cooperation, such as the establishment of inspection facilities to provide high-quality inspection services and counseling support related to inspections, will continue to be necessary. If such technical cooperation is to be provided, it will be necessary to train Japanese experts who can provide instruction in the field.

If JICA cannot provide its own assistance, it should consider offering direct assistance to local NGOs, much like that provided by Western donors. Or, Japan could help to create a system that allocates HIV countermeasure funding to local NGOs in developing countries.

Of course, AIDS is one of the many infectious diseases that is widespread worldwide, and there are other concerns, such as tuberculosis and malaria, that should also be dealt with. However, this is not a situation in which AIDS issue is inferior to other issues. The people involved in aid programs should re-think what to do to bring about the end of AIDS (Keitaro Fukushima).

International Development Journal  2020 August edition















WHOでアジア諸国を中心にエイズプログラムに取り組んできた(国研)国立国際医療研究センター国際医療協力局の藤田雅美連携推進課長によると、「アジア地域では未だにセックスワーカー、ドラッグユーザー、男性間性交渉者(MSM)、トランスジェンダーとその人たちのセクシュアル・パートナーズなど、『キーポピュレーション』と呼ばれる特定のグループで感染が多く見られ、HIV新規感染者数の7 5 % を占めている」と指摘する。近年の傾向としては、「特にフィリピンにおいて、若い世代を中心にMSMのHIV陽性者が増加している」とのことだ。こうした状況を受け、アジア諸国ではグローバルファンドやドナー国からの支援金を原資に、NGOが中心となって、キーポピュレーションに対する予防、検査、治療といったエイズ対策を実施してきた。しかしながら、経済成長に伴い、ドナーからの支援が減って、各国が自前の予算で国内のエイズ対策を実施するようになる中、藤田氏は「NGOに資金を拠出する国内制度が未だに不十分な国が多く、結果としてキーポピュレーションに対する支援が真っ先に切られる恐れがある」と危機感を募らせる。





しかしながら、二国間支援に目を向けると、「現在、JICAは海外協力隊事業で感染症・エイズ対策隊員を送ってはいるが、それ以外ではエイズ案件をほぼ行っていない」。こう語るのは2000年代にJICAの広域企画調査員として、サブサハラアフリカ地域のエイズ案件を幅広く担当し、現在は世界各地で結核対策を主導するStop TB Partnershipでテクニカル・アドバイザーを務める竹中伸一氏だ。同氏によると、「沖縄感染症対策イニシアティブを受け、JICAが事務所を置くアフリカ諸国で技術協力や無償資金協力を含む数多くのエイズ案件が形成された。だが、2000年代後半に日本の政策がユニバーサル・ヘルス・カバレッジ(UHC)に移っていく中で、感染症に特化した案件がなくなり、それに伴ってエイズ案件もほぼなくなった」と指摘する。二国間支援の一環で「米国大統領エイズ救済緊急計画」(PEPFAR)を通して資金拠出する米国や、途上国のNGOに資金拠出をするなどグローバルファンド案件を補完する二国間支援を独自に展開する英仏独の動きとは対照的である。




もちろん、あくまでもエイズは世界的に蔓延する数ある感染症の一つで、他にも結核やマラリアなど対処すべき感染症は存在する。しかし、「他の課題があるから劣後する」という類いの話ではない。エイズを終わらせるために何をすべきか、援助関係者には改めて考えてもらいたい。(本誌編集部:福島 勁太郎)



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