A critical look at the UNGASS indicators
Using the mandates of the UN General Assembly Declaration of Commitment on HIV/AIDS in 2001, the UNAIDS Secretariat and Cosponsors collaboratively developed a series of global/regional and national indicators to measure the global community’s progress in reaching the Declaration’s targets in line with the Millennium Development Goals. ICW decided to look closely at how well they measure positive change for HIV positive women.
The indicators are divided into two subgroups: ‘global indicators’ and ‘national indicators’. The ‘global indicators’ comprise a combination of five indicators that provide information on levels and trends in international commitment to HIV/AIDS control. UNAIDS and its partners are responsible for calculating the global-level indicators.
The ‘national indicators’ are further subdivided into three categories:
- Indicators of national commitment and action. These indicators focus on policy, strategic and financial inputs for the prevention of the spread of HIV infection, to provide care and support for those who are infected, and to mitigate the social and economic consequences of high morbidity and mortality;
- Indicators of national programme and behaviour. These indicators focus primarily on programme outputs, coverage and outcomes (e.g., increased knowledge about HIV/AIDS or altered behaviour);
- Indicators of national-level programme impact. These indicators measure the extent to which programme activities have succeeded in reducing rates of HIV infection.
The main problem with the indicators is that they do not in any way capture the dynamics of what causes HIV transmission as it is already assumed that it is non-condom use and non-practice of fidelity and abstinence. More to the point they do not capture gender inequalities that lead to vulnerability or that lead to barriers in accessing care, treatment, and support. In fact care and support are not dealt with adequately as the emphasis of the indicators on treatment focus on medical drugs. Customary practices that increase girls’ and women’s vulnerabilities are not touched on at all. Different questions need to be asked, which are gender sensitive, and qualitative data as well as quantitative data needs to be obtained to fully understand the dynamics of the HIV/AIDS epidemic and strategies are needed to promote change.
Furthermore, although it is recommended in the UNAIDS document ‘Monitoring the Declaration of Commitment on HIV/AIDS: Guidelines on Construction of Core Indicators (2002) that HIV positive people should be involved, involving HIV positive people and specifically HIV positive women is not included as an indicator, despite the recognition by the UN that there is a positive correlation between HIV prevalence and involvement of HIV positive people at all levels of policy making and programming. In fact the guidelines only recommend that HIV positive people are consulted. There is no mention of women’s groups and gender advocates. On a more positive note the UN recommends that data is disaggregated by age group and gender.
We will now take a close look at each indicator measuring national level action and commitment.
National commitment and action
1. Amount of national funds spent by the government on HIV/AIDS.
Allocated national funds comprise expenditure on the following four categories: STD control activities, HIV prevention, HIV/AIDS clinical care and treatment, HIV/AIDS impact mitigation. This indicator is too broad to measure how or where the money is spent and who benefits from it. In a recent ICW workshop in Lesotho looking at government commitments participants said that most money allocated by government for HIV/AIDS is spent on glossy prevention campaign materials and on the people who work in the ministries.
2. National Composite Policy Index
This indicator is to access progress in the development of national-level HIV/AIDS policies and strategies and covers four broad areas of strategic plan, prevention, human rights, care and support. In particular:
- Country has a policy or strategy promoting reproductive and sexual health education for young people.
- Country has a policy or strategy to reduce mother-to-child HIV transmission.
Under human rights:
- Country has laws and regulations that protect against discrimination of people living with HIV/AIDS.
- Country has laws and regulations that protect against discrimination groups of people identified as being especially vulnerable to HIV/AIDS.
- Country has a policy to ensure equal access for men and women to prevention and care, with emphasis on vulnerable populations.
- Country has a policy to ensure that HIV/AIDS research protocols involving human subjects are reviewed and approved by an ethics committee.
Under care and support:
- Country has a policy or strategy to promote comprehensive HIV/AIDS care and support, with emphasis on vulnerable groups.
- Country has a policy or strategy to ensure or improve access to HIV/AIDS-related medicines, with emphasis on vulnerable groups.
These indicators do not capture implementation, or gender barriers to implementation. It is stated that a separate AIDS Programme Effort Survey will be conducted in selected countries to access the effectiveness of national policies and strategies. It seems sensible although maybe not financial viable to conduct such surveys in all countries.
National programme and behaviour indicators
1. Percentage of schools with teachers who have been trained in life-skills-based HIV/AIDS education and who taught it during the last academic year
UNAIDS recognise that this does not cover quality or education for out of school youths. However, we would point out that nor does it cover issues of equity/gender issues either in the content of the HIV/AIDS education or regarding who is able to relate to and use the education obtained.
The indicators also do not reflect the need for greater community wide education, through for example the media, or working with community leaders. Yet our members have reported considerable discrimination within communities and often highlight stigma and discrimination as the most pressing issues faced by HIV positive women.
2. Percentage of large enterprises/companies that have HIV/AIDS workplace policies and programmes
This indicator covers stigma and discrimination of PLWHA, VCT, and access treatment among other issues. However, there is no acknowledgement that gender discrimination often constrains women from accessing ‘good’ jobs in the formal sector in the first place. A factor that works even more severely against women living with HIV as gender discrimination, ill-health and stigma around their HIV status reduce yet further their ability to find and maintain economic opportunities.
The focus is also on large companies in the formal sector that leaves out a vast number of women and men employed in the informal sector and in small businesses. UNAIDS recognise this but feel that these areas are less likely to be reached by workplace HIV/AIDS programming. It is worth thinking about how workplace HIV/AIDS programming can reach the informal sector.
It should also be stated clearly in guidelines to monitoring commitment that employees as well as employers need to be questioned. It is likely that the answers would vary greatly.
3. Percentage of patients with STIs at health-care facilities who are appropriately diagnosed, treated and counseled
The importance of disaggregated statistics by gender and by age (over 20 and under 20) is stated in the guidelines. Appropriate diagnosis, treatment and counselling procedures are considered however once again the barriers to access are not captured, including cost (this is recognized by UNAIDS). Is should, however, be pointed out that a ‘health care facility’ is defined as any setting where health-care services are provided by one or more medically qualified personnel. This wider definition will reflect services at more informal facilities that are likely to be accessed more by women.
4. Percentage of HIV-infected pregnant women receiving a complete course of antiretroviral prophylaxis to reduce the risk of MTCT
This does not capture levels of care and support provided nor does it capture discrimination that a number of our members have reported facing within health care services (this is also true for indicator 3). However, the guidelines do emphasise the need for voluntary counseling and testing.
This indicator is obtained by comparing the number of pregnant women with HIV/AIDS with the number receiving a course of ARVs. However, as most statistics about levels of HIV/AIDS are obtained from ANCs the true extent of the number of pregnant HIV positive women not accessing services (ANC/ARVs etc) will probably not be reflected. It will be the number of women accessing ANC services that have access to ARVs (or not) within these services that will be captured.
This indicator also does not reflect the quality and accuracy of information given to women about PMTCT, which should go further than purely providing ARVs. Our members have spoken about receiving conflicting information or advice around PMTCT, especially breast feeding.
5. Percentage of people with advanced HIV infection receiving antiretroviral combination therapy
Again barriers to access and the provision of care and support, as well as the quality of treatment are not captured by this statistic. As the ICW Global Advocacy Officer on ACTS has pointed out numbers are not enough. They may hide the fact that often men deny their illness and so do not choose to access treatment, while women who want to access ARVs are unable to, due to such factors as cost, confidentiality, or distance of facilities.
At the recent ICW workshops in Lesotho and Swaziland considerable concern was expressed over the availability of accurate information and fear over side effects and adherence. Women not on ARVS felt they were pressured by those not on ARVs and health workers to go on to ARVs despite not feeling psychologically ready (in the absence of accurate information and reliable services). One woman was clearly not responding to treatment despite having been on it for 2 and a half years. Her doctor expressed no desire to change her combination. Women at the Lesotho workshop spoke about a trial programme where women have to use contraceptives (the coil and injections) in order to access ARVs.
6. Percentage of Injecting Drug Users who have adopted behaviours that reduce transmission of HIV
Respondents are asked ‘whether they have injected drugs at anytime in the past month?’ and if yes ‘have they shared equipment?’. They are also asked ‘whether they have had sexual intercourse within the last month?’ and if yes to this question or the first they are asked ‘did they use a condom when they last had sex?’ Statistics should be disaggregated by gender. This indicator is only recommended by the UN for countries where injecting drug use is a significant mode of transmission. However, now Nigeria, Kenya and South Africa are all countries that have increasing numbers of HIV transmission through injecting drug use,, yet they are not traditionally associated with such a mode of transmission.
7. Percentage of young people aged 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (Target: 90% by 2005; 95% by 2010)
It is well acknowledged that knowledge does not reflect practice. Young women often find it difficult to negotiate condom use or they may want to show they ‘trust’ their sexual partner. This may be particularly the case with older sexual partners or when some sort of transaction is involved. Young men may face similar issues although it has been reported that young men often expect their female sexual partners to be faithful and are likely to take more risks with their health, including their sexual health. ICW is also concerned that young women fear showing too much knowledge about sexual health incase they are branded "promiscuous". Therefore we need an indicator that focuses on an enabling environment for accessing and using sexual health information.
8. Percentage of young people aged 15–24 reporting the use of a condom during sexual intercourse with a non-regular sexual partner
There are a considerable amount of young women and men who are infected despite only having had one sexual partner. This statistic is in danger of perpetuating the myth that faithfulness keeps you safe. There are also increasing numbers of young people who have been infected with HIV at birth or through breastfeeding, who may still be well and who have never had sex. More importantly is a young people’s ability to negotiate condom use as well as other aspects of their sexual and reproductive lives. The UNAIDS’ guidelines accept the ‘rightness’ of the ABC approach and do not in any way explore why ABC often fails girls and women and indeed boys and men.
Participants of the Swaziland workshop were worried that a focus on condoms only perpetuates male control of safer sex. It was also felt that the reference to condom in this indicator referred only to the male condom and without a specific mention of female-controlled methods these would be ignored.
9. Ratio of current school attendance among orphans to that among non-orphans, aged 10–14
More qualitative data is needed to capture why boys and girls do or do not attend school and the quality of the education they receive.
Percentage of young people aged 15–24 who are HIV-infected (Target: 25% reduction? in most affected countries by 2005, 25% reduction globally by 2010)
Measured by testing young women at ANCs because it gives the best indicator of changes in the epidemic. This takes no notice of the psychological impact on young women of being diagnosed HIV positive when they are pregnant. It treats them as vectors of disease rather than as individual young pregnant people.
Percentage of HIV-infected infants born to HIV-infected mothers (Target: 20% reduction by 2005; 50% reduction by 2010)
This focuses on the provision of ARVs rather than the actual number of HIV negative children born to HIV positive women. It also ignores the effect of breast-feeding on MTCT of HIV.
The indicators as a whole also do not allow for the exploration of mitigating the gendered impact of HIV/AIDS such as burden of care, diversion of household resources to care for the sick, children being taken out of school, the effects of stigma and discrimination on children and women (other than workplace policies), the impact of widowhood on women and men or indeed the impact of HIV/AIDS at all on a household or community.