Dr Sophie Harman is a lecturer in International Politics at City University London.

As well as teaching courses on the Global Politics of Health, Disease and Global Governance, Sophie has conducted extensive research into the politics of HIV/AIDS in East Africa. A GLOBAL PROBLEM Of the 40 million people living with HIV/AIDS around the world, 25 million live in sub-Saharan Africa. Many people living with HIV are able to live healthy and productive lives: they can look after their children, go to work, and have healthy relationships with other people. The problem is, this lifestyle is not available to many of those living with the disease in sub-Saharan Africa HIV/AIDS is an epidemic driven by poverty. Lack of education and employment, whether you are born a girl or a boy, or live in a rural or urban community can all enhance an individuals exposure to HIV infection. If the socio-economic factors are combined with poor health systems fragmented after years of bad financial advice from international organisations, war and state corruption, and the creation of new infrastructures, then you have the mother of all international headaches. So how do you begin to think about tackling such a problem? The good news is that many people have become committed to tackling HIV/AIDS. Disease is not limited to one country with increased global interaction, migration, security concerns, and changing approaches to development, HIV/AIDS has come to affect all of us. Decision makers Over US$10billion is channelled to fighting HIV/AIDS every year. This money comes from international organisations such as the World Bank, bilateral donors such as the US government, international non-governmental organisations such as Care International, philanthropic foundations, and government budgets within sub-Saharan Africa. The money goes towards a range of activities and structures from individuals supporting a group of orphans in a rural village, to drug dispensaries in urban healthcare centres, and the establishment of AIDS-specific agencies within government structures. Such is the level of aid being channelled to combat the disease, new structures and institutions to enhance the involvement of people living with HIV/AIDS in local communities have been established. The aim of new institutions such as the Global Fund to fight AIDS, TB and Malaria, is to include those infected and affected by the epidemic in global decisionmaking. These types of decisions focus on how money to combat the epidemic should be spent and what issues need to be tackled. However, the

key question government, policy-makers, public health and development experts should ask is do these structures and financial contributions work? Put simply, it is hard to tell. The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organisation are responsible for gathering a global database on how many people are living with HIV and AIDS, how many deaths have occurred and the rate of new infection. These statistics are available via their websites and published annually on World AIDS Day 1 st December. Over recent years, indicators from sub-Saharan Africa suggest progress has been made against the epidemic, as numbers of people infected with the disease have gone down in many countries. This is not necessarily a result of global interventions working, but could be that many people died in that year, or that previous estimates were incorrect. Reliable data is hard to come by, especially in rural areas where many people do not visit health centres. The large number of actors, such as the World Bank, United Nations and domestic governments, involved in the AIDS response makes it impossible to accurately pinpoint or measure what has or has not worked, and who is or is not responsible. This is where research into international politics comes in. Improving matters Students and scholars of international politics approach the relative success or failings of global interventions by asking the following types of questions: where is the power, how is it expressed, who holds it, and what are its implications? In asking these questions a different picture emerges as to the relative success in fighting the disease, than the statistics indicate. Research suggests that what has come to constitute the governance of HIV/AIDS is every bit a headache as the social and economic determinants that drive high rates of infection. The large amount of money and people involved in combating HIV/AIDS has led to confusion as to where the money goes, who is responsible for what, a lack of direction, and a fudging of institutional structures all factors which prevent money from reaching people in need. Confusion and problems with the structure of these new organisations limits the ability of people living with HIV/AIDS and affected by the epidemic to express their opinion. Whilst they have a say in theory, this does not translate to practice where, agendasetting is conducted at the global level, often in Geneva, New York City and Washington DC. The result is the application of the same blueprint policies, prescribed at a global level, to communities throughout sub-Saharan Africa. Community actors and governments then become accountable for these global decisions and implement them at the local level. The system is highly problematic for scholars of international politics as the actors involved in global decision-making have the power and influence to communicate how the HIV/AIDS problem should be addressed. Those affected by HIV/AIDS do not. There are no checks or balances to make sure the right people have this power and influence, as global actors such as the World

Bank are not held to account for their role in combating HIV/AIDS. The World Bank, for example, is able to devolve responsibility for its decisions to states in sub-Saharan Africa, who in turn implement these strategies and work with community groups. Global ideas are then translated into national programmes that are applied in the community. The chance for communities to participate in politics is therefore limited. Where it exists it is structured in such a way as to maintain the power of global decision-making. This type of top-down power is the norm in international politics and in the past has led to the fragmentation and collapse of state-provided social services such as free healthcare and free education two factors that are now driving infection rates and limiting the ability of states to address the epidemic. What we see is HIV/AIDS, poverty and international politics in a cycle which continues to combat this global crisis in the short term, leaving serious repercussions for the long term ability of states and communities to fully address their countries health concerns. Through the study of international politics we are trying to understand how international systems of governance work and establish how they can be improved. This, it is hoped, will help to improve funding structures for health projects such as those combating HIV and AIDS globally.