Who should lead UNAIDS?

[Republished from The Lancet]

Richard Horton, Editor-in-Chief of The Lancet, examines the issues around the pending appointment of a new executive director for UNAIDS, as well as the candidates for the post, following the May resignation of executive director Michel Sidibé. The selection process has fueled questions about who may now be best positioned to lead UNAIDS following a sexual harassment scandal that cast a shadow over the agency and its leadership – with some critics questioning whether it should continue as a separate institution altogether. Horton has led The Lancet since 1995, and has established the journal as a leading voice on cutting-edge health policy issues, ranging from antimicrobial resistance (AMR) to obesity and climate change. He is a recent recipient of the Roux Prize.

Richard Horton, Editor-in-Chief, The Lancet. Photo: ILO/A.Lwin

Who is best qualified to lead an organisation—UNAIDS—that has not only suffered severe reputational loss, but also faces threats to its continuing existence? UNAIDS is a jointly sponsored UN programme that has, in its own words, “led and inspired global, regional, national, and local leadership, innovation, and partnership to ultimately consign HIV to history”. But some observers believe this glorious history is just that—history. Rob Yates was recently appointed head of Chatham House’s Centre on Global Health Security. He wrote on Twitter last week that a new Executive Director of UNAIDS should have the “courage and ability to wind up the organisation and integrate it into @WHO”. Kul Gautam, a former Deputy Executive Director of UNICEF, argued that “now it’s time to question [UNAIDS] continuation”. Anthony Costello, most recently a Director at WHO, commented, “No one questions the need for a strong and distinct body for the HIV response. It’s whether UNAIDS would function better under the democratic accountability of the World Health Assembly which might have prevented its shameful recent history”. Laurie Garrett, a Pulitzer-Prize winning writer on global health, noted that those selecting the next Executive Director “MUST define clearly why the world needs UNAIDS & how it should fit in the global health landscape.” Is it time to choose a leader who will close down UNAIDS? Maybe one day. But not now. Predictions about the end of AIDS have been badly misjudged. According to the Global Burden of Disease Study, there were almost 1 million deaths from AIDS in 2017. Those deaths occur throughout the lifecourse, but the toll is especially severe among 15–49-year-olds (676 100 deaths). There are almost 37 million people worldwide living with HIV. And the incidence remains shockingly high—1·9 million people newly infected every year. Although the number of AIDS-related deaths is projected to fall, even by 2040 those deaths will still be unacceptably high (742 million, with a worst-case scenario of 2·3 million deaths). The AIDS epidemic is at a critical moment. Decelerating the political response by extinguishing UNAIDS now would be a catastrophic error.

Photo: UNAIDS/Sydelle Willow Smith

There are five candidates: Salim Abdool Karim (an infectious diseases epidemiologist and Director of the Centre for the AIDS Programme of Research in South Africa); Sani Aliyu (physician, infectious diseases expert, and Director-General of Nigeria’s National Agency for the Control of AIDS); Chris Beyrer (physician, HIV specialist, former President of the International AIDS Society, and Professor of Public Health and Human Rights at Johns Hopkins Bloomberg School of Public Health); Winnie Byanyima (engineer, politician, diplomat, and now Executive Director of Oxfam International); and Bernard Haufiku (physician and Namibia’s former Minister of Health and Social Services). Each candidate has strengths. Aliyu spearheaded Nigeria’s AIDS response under difficult political circumstances. Haufiku has ministerial experience. Byanyima knows how to run a complex global organisation. Karim is a highly respected HIV scientist whose work has transformed clinical practice. And Beyrer, whose partner died of AIDS in 1991, successfully uses human-rights approaches to protect and advance the health of marginalised communities in Asia, Africa, Latin America, Russia, and the US. There are disappointments. Only one woman? No forum for public debate and scrutiny? Appointment not election?

The next Executive Director of UNAIDS must fulfil five criteria. First, s/he must have the personal integrity to restore trust and credibility to a damaged organisation—and to give governments confidence to invest in the AIDS response. Second, s/he must have proven scientific understanding of the AIDS epidemic in order to be able to use evidence as a platform for political advocacy. Third, s/he must have demonstrable ability to represent and engage with civil society. Fourth, s/he must be able to point to their commitment to key vulnerable populations. And finally, s/he must be able to show transformational leadership of a large organisation. The Programme Coordinating Board of UNAIDS met in Geneva last week and “commended the strong competencies of all short-listed candidates”. After interviews, a Committee of Cosponsoring Organisations will deliver no more than three names to the UN Secretary-General, António Guterres. It is no exaggeration to say that his choice may determine the future fate of the AIDS epidemic.

Salim Abdool Karim, Director of the Centre for the AIDS Programme of Research in South Africa. Photo: Rajesh Jantilal/AFP/Getty Images
Sani Aliyu, Director-General of Nigeria’s National Agency for the Control of AIDS. Photo: Sani Aliyu
Chris Beyrer, Professor of Public Health and Human Rights at Johns Hopkins Bloomberg School of Public Health. Photo: Rajesh Jantilal/AFP/Getty Images
Winnie Byanyima, Executive Director of Oxfam International. Photo: Franke Tsang/South China Morning Post/Getty Images
Bernard Haufiku, Namibia’s former Minister of Health and Social Services. Photo: UN Photo/Rick Bajornas

 

 

 

 

 

 

 

 

 

Republished with permission from The Lancet: https://doi.org/10.1016/S0140-6736(19)31563-6. Click here, for more information about Richard Horton and The Lancet.

Image Credits: UNAIDS/Sydelle Willow Smith, ILO/A.Lwin, Rajesh Jantilal/AFP/Getty Images, Sani Aliyu, Franke Tsang/South China Morning Post/Getty Images, UN Photo/Rick Bajornas.

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