聯合國愛滋病規劃署的退出導致中東和北非地區領導層出現真空

捐款者捐款的減少迫使聯合國愛滋病規劃署關閉了其在中東和北非的辦事處，導致人們擔心該地區愛滋病毒/愛滋病重要性的宣傳工作已經結束。

http://www.thelancet.com/hiv Vol 10 October 2023

2023 年 6 月，聯合國愛滋病規劃署關閉了位於埃及開羅的中東和北非 (MENA) 區域辦事處。此前，吉布地國家辦事處於去年關閉。這意味著聯合國愛滋病規劃署在中東和北非地區的存在僅限於五個國家辦事處。人們普遍擔心愛滋病防治活動將受到不利影響。 2010-22 年，中東和北非地區新興愛滋病毒感染人數增加了 61%。它的愛滋病毒治療覆蓋率是世界上最低的，監測工作參差不齊，同性性關係被廣泛定為犯罪。該地區包括伊拉克、黎巴嫩、利比亞、蘇丹和敘利亞等陷入困境的國家。聯合國愛滋病規劃署本身表示，「『中東和北非地區』需要採取一致行動，扭轉當前的流行趨勢，避免愛滋病毒爆發並實現預防和治療目標」。

馬蒂諾 (Tim Martineau) 是聯合國愛滋病規劃署（瑞士日內瓦）的管理主任。他告訴《刺胳針愛滋病毒》雜誌，關閉中東和北非地區辦事處並不是聯合國愛滋病規劃署掉以輕心的事。捐助者捐款的前幾次削減已經迫使該組織在過去幾年中節省了價值 1000 萬美元的資金。馬蒂諾表示：「我們在每個地區都進行了裁員，我們在東部和南部非洲的工作削減了約 500 萬美元，我們在日內瓦的業務也減少了一半」。因此，當愛滋病規劃署面臨進一步的捐贈削減以及去年歐元貶值（導致其歐洲捐款價值下降）時，幾乎沒有迴旋餘地。中東和北非地區是愛滋病毒整體感染率最低的地區，這可能影響了關閉其辦公室的決定。「考慮到我們的財務狀況，我們沒有太多選擇」，馬蒂諾說。

聯合國愛滋病規劃署亞太、東歐和中亞區域支持小組主任伊蒙‧墨菲指出，聯合國愛滋病規劃署的資金來源是自願捐款。「我們不是一個巨大的實施者。當我們受到裁員的打擊時，我們唯一能真正節省開支的地方就是員工」，他說。「聯合國愛滋病規劃署繼續與潛在捐助者和夥伴國家對話，以調動維持其運作水平所需的資源」。

卡達威爾康乃爾醫學院（卡達多哈）人口健康科學教授萊斯.阿布–拉達德 (Laith Abu-Raddad) 認為，中東和北非地區政府可能不願意提供大量資源。「說服該地區的政策制定者投資愛滋病毒/愛滋病是非常困難的。他說，這種流行病集中在受到高度污名化的人群中。「國際投資至關重要。在過去的二十年裡，我們看到摩洛哥等成功實施愛滋病防治計畫的國家之所以能取得成功，是因為國際社會的大力參與」。聯合國愛滋病規劃署強調，關閉中東和北非地區辦事處並不代表退出該地區。儘管如此，阿布–拉達德擔心，這項決定將顯示愛滋病毒/愛滋病不再是一個重要問題，這可能會進一步邊緣化性工作者、注射毒品者和男男性行為者等人群。阿布–拉達德表示：「關閉發出了錯誤的信息，這可能意味著領導層的真空」。「根據我自己的經驗，我知道讓聯合國愛滋病規劃署參與研究計畫可以更容易地獲得資金並使計畫富有成效」。

阿爾及利亞、摩洛哥和突尼斯國家辦事處現由西部和中部非洲區域辦事處（加納達喀爾）提供服務，而埃及和蘇丹辦事處則由東部和南部非洲區域辦事處（南非約翰內斯堡）提供服務。阿布–拉達德說：「中東和北非國家將向流行病學、挑戰和文化截然不同的地方進行報告」。「撒哈拉以南非洲地區的優先事項及其流行病的規模與中東和北非地區無法相提並論。如果沒有自己的區域辦事處，中東和北非地區的愛滋病毒/愛滋病就有可能被忽視」。

Elie Aaraj 是中東和北非減害協會的首席執行官，該協會是世界衛生組織和聯合國愛滋病規劃署於2007 年成立的非政府組織。「聯合國愛滋病規劃署在該地區發揮了非常重要的作用」，他說。「他們組織了許多會議並鼓勵各國加強監視活動。他們支持策略規劃並促進民間組織參與決策。我擔心所有這些努力現在都將結束」。

Aaraj 認為中東和北非地區的知名度將會受到影響。他敦促聯合國愛滋病規劃署至少在日內瓦中央辦公室任命一名負責人可以作為該地區的焦點。阿拉吉強調，「中東和北非地區存在著多種嚴重問題：衝突、難民危機、貧窮、經濟動盪以及對抗愛滋病毒/愛滋病的政治承諾非常薄弱」。「我們需要強有力的外部支持來繼續鬥爭和倡導。聯合國愛滋病規劃署曾提供過這種支持，但現在看來我們已經失去了這種支持。”

塔拉.布里

UNAIDS departure leaves vacuum in leadership in MENA

A cut in donor contributions has forced UNAIDS to close its office in the Middle East and North Africa, leading to fears that advocacy for the importance of HIV/AIDS in the region is at an end.

http://www.thelancet.com/hiv Vol 10 October 2023

In June 2023, UNAIDS shuttered its regional office for the Middle East and North Africa (MENA) in Cairo, Egypt. The move follows last year’s closure of the country office for Djibouti. It means that UNAIDS presence in MENA is restricted to five country offices. There is widespread concern that HIV/AIDS prevention and control activities will be adversely affected. MENA saw a 61% increase in new HIV infections from 2010–22. It has the lowest rate of HIV treatment coverage in the world, surveillance efforts are patchy, and same-sex sexual relations are widely criminalised. The region includes troubled nations such as Iraq, Lebanon, Libya, Sudan, and Syria. According to UNAIDS itself, “concerted action is needed [in MENA] to reverse current epidemic trends, avert HIV outbreaks and reach prevention and treatment targets”.

Tim Martineau is Director for Management at UNAIDS (Geneva, Switzerland). He told The Lancet HIV that closing the MENA regional office was not something UNAIDS took lightly. A previous tranche of cuts in donor contributions had already forced the organisation to make US$10 million worth of savings over the past few years. “We made staff reductions in every region, we cut around $5 million from our work in eastern and southern Africa, and we halved our presence in Geneva”, said Martineau. UNAIDS therefore had little room to manoeuvre when it was faced with a further set of donor cuts coupled with a fall in the euro last year, which reduced the value of its European contributions. MENA is the region with the lowest overall HIV prevalence, which probably influenced the decision to close its office. “Given our financial situation, we did not have a lot of options left to us”, said Martineau.

Eamonn Murphy, Director of the UNAIDS Regional Support Team for Asia and the Pacific as well as for Eastern Europe and Central Asia, pointed out that UNAIDS is financed by voluntary contributions. “We are not a huge implementer. When we are hit by a cut, the only place we can make real savings is on staff”, he said. “UNAIDS continues its dialogue with potential donors and partner countries to mobilise the resources needed to maintain its operational levels.”

Laith Abu-Raddad, Professor of Population Health Sciences at Weill Cornell Medical College-Qatar (Doha, Qatar), believes that governments in MENA are likely to prove reluctant to provide much in the way of resources. “It is very difficult to persuade policy makers in this region to invest in HIV/AIDS. The epidemic is concentrated in populations who are highly stigmatised”, he said. “International investment has been crucial. We have seen over the past two decades that the countries who have had successful AIDS programmes, such as Morocco, have managed to do so because of heavy involvement from the international community.” UNAIDS has emphasised that the closure of the MENA regional office does not represent a withdrawal from the region. Nonetheless, Abu-Raddad worries that the decision will be taken to signify that HIV/AIDS is no longer an issue of importance, which could further marginalise populations such as sex workers, people who inject drugs, and men who have sex with men. “The closure sends the wrong message, and it is likely to mean a vacuum of leadership”, said Abu-Raddad. “I know from my own experience that having UNAIDS involved in research projects made it much easier to get funding and for the projects to be productive.”

The country offices for Algeria, Morocco and Tunisia are now served by the regional office for Western and Central Africa (Dakar, Ghana) while the offices for Egypt and Sudan are served by the regional office for Eastern and Southern Africa (Johannesburg, South Africa). “The MENA countries are going to be reporting to places with very different epidemiologies, challenges, and cultures”, said Abu-Raddad. “The priorities in subSaharan Africa and the size of their epidemics are not comparable to those in MENA. There is a risk that, without its own regional office, HIV/AIDS in MENA will be overlooked.”

Elie Aaraj is chief executive officer of The Middle East and North Africa Harm Reduction Association, a nongovernmental organisation set up by WHO and UNAIDS in 2007. “UNAIDS has played a really important role in the region”, he said. “They have organised many meetings and encouraged countries to step up surveillance activities. They have supported strategic planning and facilitated the involvement of civil society organisations in decisionmaking. I am worried that all these efforts will now come to an end.”

Aaraj believes the visibility of MENA will suffer. He urged UNAIDS at least to appoint someone in the central offices in Geneva who can act as a focal point for the region. “There are multiple, serious problems in MENA: conflicts, refugee crises, poverty, economic turmoil and very weak political commitment to combating HIV/AIDS”, stressed Aaraj. “We need strong external support to continue fighting and advocating. UNAIDS had provided this support, and now it looks like we have lost it.”

Talha Buri