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INTRODUCTION
HIV/AIDS has been one of the most discussed issues in sub-Saharan Africa (SSA) in recent years, not only from a medical perspective, but also in terms of its effects on development. How the international aid system has reacted to the emergence of HIV/AIDS within the context of the global health agenda is a relevant and contentious issue. More than two decades after the beginning of the epidemic in SSA, the latest available figures show that today this is the world's most affected region. Exceptionally high rates of prevalence of the virus and its high rates of mortality mean that the disease has become the main cause of death in SSA. This has led to unprecedented falls in life expectancy in a number of SSA countries.1
As a result, the approach to HIV/AIDS in SSA countries has shifted from seeing it principally as a health problem to seeing it as an obstacle to development. It has significant socio-economic effects on households and on a number of economic sectors, as well as on the supply of and demand for basic public services. A particularly disturbing feature is that as many as 61% of the infected population are women.2 Consequently, the global financial response to HIV/AIDS in Africa, particularly Southern Africa, has been massive, leading to a complete reconfiguration of the aid industry in the region. Myriad well-funded new actors and international initiatives, including The Global Fund, have proliferated to deal specifically with HIV/AIDS.3 This expansion in the number of actors involved in HIV/AIDS policies in Southern Africa, together with other features of the global response such as its top-down approach to policies, and its preference for vertical targeting on just one disease or a handful of them, to some extent contradict the Paris Agenda, one of the foundations of the new aid architecture.
The Paris Agenda, set up in 2005 and reinforced in 2008 with the Accra Agenda of Action, establishes four operating principles designed to achieve greater effectiveness in aid delivery: ownership, alignment, harmonisation and mutual accountability.4 However, serious shortcomings appear in applying its principles to global health issues. Development agendas of recipient countries are highly influenced by donors, and instead of prioritising a...