The present state of thinking on HIV/AIDS often lacks a coherent and consistent understanding of the issues, in particular of the systemic impact of AIDS on development. The simplistic behaviour-change models concentrate on the individual instead of focusing on the role of community and group values and norms in sexual and drug-use behaviours. Similarly, responses to the impact of AIDS on society and economy usually fail to reflect the complex interactions. Therefore, reconceptualising the epidemic as a development issue – focusing on the interdependence of social and economic relationships at country, community and family levels – is a key step toward relevant and effective policies and programmes.

Strengthening commitment

Although increasing numbers of countries are engaged in designing multisectoral programmes, real commitment to comprehensive approaches to HIV/AIDS remains low. Even with widespread morbidity and mortality affecting all social classes, stakeholders are still able both in their personal and professional lives to turn a blind eye to HIV/AIDS. The lack of commitment by many governments may be partly due to the presentation of HIV/AIDS as a health problem, but also due to the lack of making a case for concerted action, while convincing arguments are there:

• HIV/AIDS is a threat to public health, being a deadly infectious disease that can spread rapidly among the general population, and put enormous pressure on public health resources.
• HIV/AIDS is a threat to social and economic development, which will over time reduce the potential for improving living standards for the population as a whole.
• There is a moral case for action, as those infected and affected by HIV are all entitled to access to public resources to help them cope with the effects of HIV/AIDS.

Supporting those affected by HIV/AIDS

At the core of a multisectoral response to HIV/AIDS are policies and programmes for and by those infected or affected. In many countries, people living with HIV/AIDS (PLWHA) are now seen as part of the solution and are increasingly being involved in policies and programmes. An effective response is one from which everyone gains and no one loses:

1. Individuals and families gain from effective support programmes, such as access to basic health care, economic support for affected families, nutritional supplements and psycho-social support. This way, PLWHA will remain productive for longer; families gain from the fact that income from work will continue; and children gain as they continue to receive economic and social support through their own family.
2. The State gains, because people continue to work, pay taxes, support their families and do not draw down state support services. In addition, production is not disrupted in key sectors and key services such as education and health are also sustained.
3. The private sector gains because work continuity is sustained and skills continue to be available to the company, meaning less absenteeism and disruption of work, lower retraining costs, and higher productivity.

Creating an enabling environment

Effective prevention and care are not feasible without enabling environments. This requires services to support those infected and affected, as well as a legal framework to protect their rights. Central to an effective response is the mobilisation of civil society, as locally based resources for many types of support are just more effective. In the area of prevention, an enabling environment entails social and cultural norms supportive of protective behaviours and measures. Enabling environments are also critical for non-prevention elements of an effective response to HIV. For example, given the increasing availability and reduction in costs of antiretroviral drugs (ARVs), it now makes good economic sense to make ARVs available. However, it needs to be recognised that ARV therapy is not the solution to the HIV epidemic. The solution continues to lie with changing the structural conditions that lead to HIV transmission and exacerbate the social, political and economic impact.

Strengthening capacity

As HIV is concentrated among the core of the working population who also have important social roles – particularly the support and socialisation of children – many human resources are lost that are critical for capacity development and for maintaining households as productive enterprises. Sustaining this human capital is an important issue; hence, capacity development should be integral to all projects and programmes. Capacity development does not only mean staff training or the creation of new organisations, but requires an enabling environment to ensure that people are used effectively, retained within organisations, and motivated to perform their tasks. This also requires donors to avoid actions that lower national capacity, such as recruitment of key staff away from national uses and the distortion of national pay scales through excessive payment.

Moving  forward, learning from experience

Bearing in mind the fact that there is not one epidemic, but many, and that both the scale of the epidemic and the capacity to address it differ widely between countries, countries need to ensure that what they do is relevant to their particular circumstances and is based on the reality of the problems they face. Processes need to be inclusive and participatory, and allow rapidly learning from experience of what works and what does not. Four key elements of an expanded multisectoral response can be discerned:

1. It is essential that countries have a strategic plan that maps out the key areas and strategic objectives of the national response, thereby constituting a mechanism for the mobilisation of internal and external resources. It is not a detailed map of what to do and how to do it. The plan needs to be the outcome of participatory discussions at all levels, involving all key stakeholders. Needs, capacity and resources should be balanced with the plan's processes and strategic objectives.
2. It is crucial to identify and clarify the roles and responsibilities of government and civil society – as well as the limits of their responsibility. Clearly defined roles facilitate multisectoral collaboration and synergy. A key function of the state is to ensure that an overall policy and legal framework is in place that is supportive of an effective multisectoral response, as well as the institutional structure for their enforcement. Accepting the limitations of the state is a recognition of the need to actively involve civil society.
3. Resources urgently need to be re-distributed to those who can use them effectively. At present, external resources are often concentrated on central government institutions, while far too few end up where they are most needed, i.e., groups and institutions who are closer to the problems. This is most evident in areas of care and support where the effectiveness of state provision is wholly inadequate. One of the puzzling factors in many countries is the absence of commitment and leadership. While there is clearly a need to target those in leadership positions, the existing culture of workshops that are in general unproductive and wasteful of resources, needs to be curtailed. Rather, programmes should build on local initiatives and provide support to those most in need.
4. Programmes should be effective and relevant, reflecting the reality of the situation. Many policies and programmes reflect a very inadequate level of understanding of the complex issues that are involved, especially of the impact of the epidemic on social and economic structures and performance. Hence, applied research is needed to generate the data needed for policy and programme development. This includes systematic monitoring and evaluation to allow learning from experience and ensuring that lessons learned are fed back into policy and programme development.

What stands out is the cost for affected populations of the relative neglect of HIV/AIDS globally, and the failure to shift the response from one that focuses on health to one that is genuinely multisectoral. There is a real possibility that access to ARV therapies will be seen as the solution to the problem, but this would be a mistake. The causes of the epidemic have their origins in structural factors such as poverty and gender, and patterns of development. Unless these are addressed, the epidemic will thrive. There is now a good deal of experience of what can make a difference. The challenge is to take what is known and to transfer it, suitably adjusted to local conditions, but always ensuring that processes for policy and programme development are genuinely participative and inclusive.