A portrait of Achmat, 7 January 2002. Dawid Roux / Media 24 / Gallo Images via Getty

In January 2001 Audrey headed to New York to start her new position at the United Nations Population Fund (UNPF). Achmat joined her that August. Bitter Fruit due for release in South Africa later in the year, was in its last phase of editing. It would be short-listed for the International IMPAC Dublin Literary Award in 2003 and the Booker prize in 2004. During this time, Achmat also worked on short stories, some of which were published in Strange Pilgrimages (2013) and another in Nobody Ever Said AIDS: Poems and Stories from Southern Africa (2007). A few of Achmat’s short stories were translated into Dutch and Spanish and published abroad. He also started on Dikeledi: Child of Tears, No More (2017). To learn more about Achmat’s writing in this period click below:

In New York Achmat managed to balance work, writing and exploring his new home. In 2002 he recalled:

“The most immediate influence is physical. New York is an immense, noisy, rowdy but wonderful place and I am so distracted by the novelty. I do consultancy work on HIV/AIDS two days a week and I am able to write three days a week. But there are many distractions, so many cultural distractions — things that I never had time to do, like going to museums and art exhibitions, and going to listen to people read poetry. The other distraction is that New York is such an enormously noisy place. We live in an apartment just off Park Avenue and 34^th which is like a major crossroad across Manhattan. You hear cars and noise all the time.”

On 11 September 2001 Audrey was at work and Achmat was at Kinko’s exchanging emails with Annari van der Merwe of Kwela Books about a date for the launch of Bitter Fruit. He recalled:

“Tuesday 11, September 2001, just after nine a.m. I was in an e-mail service called Kinko’s (yes, for real!), negotiating a book-launch date with my publisher in South Africa. I heard a noise, louder than the usual heavy-duty vehicle hitting what the New York roads department poetically calls a “raised plow” but continued working on the computer. After all, this was New York and noise was a cultural pre-requisite. Through the window I saw people walking into the middle of busy Madison Avenue and stare up at the sky. All around me Kinko’s diehard cyber patrons were abandoning their pay-by-the minute workstations and rushing out into the street. Soon I was the only one left inside. Sirens were going off everywhere, but that too is a feature of this city, a symbol of how safe and efficient it had become: the emergency services responding to emergencies.”

When he finally found out what had happened, Achmat was anxious about not being able to reach Audrey so he made his way to her office in the UNFPA office building on 42nd Street near Grand Central Station. Meanwhile, Audrey was heading to their apartment on 34th Street just off Park Avenue South, “virtually at the epicentre of the symbolic targets that security officials had identified.” Achmat wrote:

“I could not reach her by phone; my cheap, pre-paid cell phone service had simply abandoned ‘non-contract’ customers. Another lesson: the axiom that you get what you pay for was painfully accurate. Eventually Audrey and I encountered each other, literally, among the many thousands who now crammed the streets. She was walking home and I was going to her office, one of those unlikely coincidences that film directors usually cut from the script.”

There were no taxis, and the subway had stopped functioning. Having decided to donate blood, Audrey and Achmat had to walk to the closest “collection point” on 67th Street, about 30 blocks from their home. When they got there “a sign outside the ‘blood station’ said they had ‘reached capacity and closed.” Achmat described the scene as they walked home:

“It is past midnight and New York is uncannily quiet; the whole city seems to have been swallowed by silence. There must be thousands of people who are unable to sleep tonight, perhaps because they too miss the continuous buzz of traffic, the unnecessary honk-honk of taxis, voices rising from the streets below. Tomorrow the recriminations will start, whole nations will be vilified because of the fanatical deeds of a few; analysis of the most spectacular failure of security management that Americans have suffered since Pearl Harbour will inevitably follow. Hopefully they will find the perpetrators, before they do it again. Of equal importance, find them before this carnage leads to the psychological roundup of the usual mid-eastern suspects and so help to entrench the bitter ‘us’ (the West and its allies) and ‘them’ (the Muslim world) divide.”

As he feared, the 9/11 attacks fuelled hate crimes, racism, and xenophobia against Muslims and people perceived to be Muslim. Achmat described writing “in an atmosphere of superpatriotism, xenophobia and a renewed interest in Islam”. Annari van der Merwe remembers him asking that his first name be excluded from addresses sent by post:

“Then later on [after 9/11], because a lot of manuscripts we sent by mail, Achmat said to me, ‘Please don’t put my name on the envelope. Just put ‘Dangor’ because the feeling is so heightened in New York, that if anybody sees his name as Achmat, that it would just cause problems for him. And he also said to me that he never thought of himself as Muslim, consciously, until that whole back-lash in America.”

Achmat also wrote a 9/11 poem called “Just Yesterday” visit books by decade 2000s to read

Not long after the couple had settled in New York, Achmat joined Synergos (Greek for “working together”) as a Senior Fellow. Synergos, founded by Peggy Dulany in 1986 was based on “the novel premise that tackling the problems of poverty and inequity required collaboration among all stakeholders – and that for collaboration to take place, mindsets needed to shift so that all available insights, experiences, and resources are brought to the table when addressing social challenges”.

Through a three-year fellowship, “Fellows … (were) afforded the opportunity to exchange innovative ideas, models, and tools in the development field, which Synergos distribute(d) to a wider audience”.

In 2000, Synergos entered a partnership with the Abrinq Foundation, established in 1990, after Brazil passed legislation to promote children’s rights. In 2002, Abrinq and Synergos held a series of workshops. Among the Senior Fellows involved was Achmat, described by Synergos as “a specialist in setting up funds, who ran a workshop on endowment building”.

In September 2002, Abrinq, Synergos and the International Youth Foundation sponsored an international seminar in São Paulo on Evaluation, Systematization and Dissemination of Social Projects at which Achmat gave the keynote address. The audience comprised 350 representatives of the nonprofit sector including grassroots organisations, associations and foundations, government agencies and private companies, primarily from Brazil, with some attendees from elsewhere in Latin America.

The Senior Fellowship was not a full-time position nor was it remunerated. However, Audrey recalled, Achmat travelled “to quite amazing places such as the Galápagos, in Ecuador, and the Skeleton Coast in Namibia, amongst others”. He also met a range of people, including social justice activists and people involved in HIV/AIDS work including the Executive Director of UNAIDS.

Achmat continued in the Senior Fellowship Programme until 2003. He was also, at that time, recruited by Peter Piot as a consultant to UNAIDS and as Interim Manager of the World AIDS Campaign. Piot, recalling their first meeting said:

“I met Achmat when he was in New York, working for Synergos, and I had for a long time, friends who were from the Anti-Apartheid Movement and so in New York one said, you know to meet this guy and I ended up in his apartment and talked and talked and I was very impressed by the fact that he was, in Europe you would say a ‘Renaissance Man’, an artist, but also politically very astute. I was fascinated by him and thought he was a very nice man. At some point I was looking for a director for, what we called ‘external relations.’ It was during the time when AIDS was put on the agenda of the UN Security Council, of the UN General Assembly, we had a specialist session and he was very helpful. We also went for Achmat’s advice, because these were the years that President Thabo Mbeki and Minister of Health, Manto Tshabalala Msimang had funny ideas about HIV.”

Achmat himself observed that:

“HIV prevalence rates began to reach their ‘tipping point’ in the late 1980s and the early 1990s, just as the country began to grapple with the more visibly burning issue of political transformation. When the latter reached its summation in 1994 and the impetus behind civil society organisation began to diminish, AIDS was already being driven into the background by stigma and discrimination. As the structured ‘community conversations’ that characterised communal life fell into a lull, the AIDS taboo became a truly unspeakable subject. Only activist organisations kept it ‘on the agenda’.”

A shift was taking place towards a global commitment to fight HIV/AIDS, largely because of the work of international organisations such as UNAIDS, established in 1996, and civil society groups such as the AIDS Coalition to Unleash Power (ACT UP) in the United States (1987) and the Treatment Action Campaign (TAC) in South Africa (1998), amongst many others. The United Nations General Assembly Special Session (UNGASS) of HIV/AIDS was convened a few weeks before Achmat arrived in New York.

The UNGASS took place between 25–27 June 2001. UNAIDS staff had consulted with the many civil society representatives that had applied to attend over the draft “Declaration of Commitment”, which subsequently became a benchmark for global action. Knight notes that “for the first time ever, there were time-bound targets on HIV prevention, resource mobilization and other aspects of the global AIDS response, serving to make governments clearly accountable”. Member States also agreed that gender equality and women’s empowerment were fundamental to an effective response to AIDS.  

Other significant moments that were to impact on Achmat’s work in the years to come, included the establishment of the Global Fund (January 2002), the launch of the Multi-Country HIV/AIDS Programme for Africa (MAP) and the “3 by 5” initiative. It was apparent that AIDS, TB and malaria were all preventable and treatable but combatting these conditions, Knight explains, required “the commitment not only of world leaders and decision-makers, but also of those working on the ground to support the men, women and children living with these diseases.” The Global Fund, Knight elaborates “was a financing mechanism, not an implementing or technically oriented body. It would raise and transfer funding to programmes in countries but it would not design, set up or run the programmes.”

Additional resources became available for antiretroviral treatment (ART) came in March 2002 when the Directors of the World Bank endorsed the Multi-Country HIV/AIDS Programme for Africa (MAP) funding for antiretroviral procurement. Additional finance for HIV/AIDS in Africa was secured from the Organisation for Economic Co-operation and Development (OECD) donors. By November 2002, international resources targeted at HIV/AIDS in Africa amounted to approximately US$1 billion.

Around the beginning of 2002, the lead responsibility for HIV/AIDS treatment within UNAIDS moved from the UNAIDS Secretariat to WHO. WHO published the first edition of its treatment guidelines and declared a “3 by 5” target to treat three million people with antiretrovirals by the end of 2005.

In July 2002, the 14^th International AIDS Conference was held in Barcelona with the theme “Knowledge and Commitment for All”, prioritising access to treatment. Achmat and Audrey attended the conference. At the opening ceremony, Peter Piot announced that treatment was now technically feasible everywhere in the world. He then presented a road map of what was required to keep the promises made at UNGASS the year before: “Let’s bring forward today world leaders who keep their promises on AIDS, are rewarded with our trust, and those who don’t, lose their jobs to those who will”.

At the closing ceremony, former presidents Bill Clinton and Nelson Mandela urged world leaders to “exert stronger leadership” in the fight against HIV/AIDS. Mandela declared “AIDS is a war against humanity” and called for the provision of ART for the millions of people without access. Clinton suggested the US underwrite the cost of AIDS prevention and treatment for countries that could not afford them and that low- and middle-income countries “pool together” the resources they could afford and “send the rest of us the bill for the difference.”

A snippet from the event appears on “The Mandela Diaries: 12 July 2002 Nelson Mandela addresses the 14th International AIDS Conference in Barcelona, Spain”,

Clinton and business strategy consultant Ira Magaziner co-founded the Clinton HIV/AIDS Initiative (later the Clinton Health Access Initiative or CHAI) shortly after the conference apparently “with Mandela’s words in mind.” It was around this time that CHAI appointed Achmat as consultant. CHAI was built on the “principle that it was morally unacceptable that millions of people died each year of AIDS in Africa, Asia, and the Caribbean while those in wealthier countries were treated.”

The Clinton HIV/AIDS Initiative programmes aimed at scaling up HIV/AIDS care and treatment began in Africa and the Caribbean in 2002/2003. Its website estimates that “800 000 people were treated in these countries in the five years as a result of this work, up from a total of 2000 when the work began.” In the early 2000s, treating HIV cost over US$10,000 per person annually. Clinton recalled how the costliness of HIV treatment was addressed: “Generic ARV makers agreed to work with us to shift from a high-cost, low-volume, uncertain payment business to a low-cost, high-volume, certain payment one. Soon the prices began to drop dramatically.”

He acknowledged that they were able to make this kind of progress “because of the essential support of the governments, multilateral organisations, individual donors, and amazingly dedicated NGOs”, the Global Fund and the US President’s Emergency Plan for AIDS Relief (PEPFAR).

President George W Bush announced PEPFAR in his State of the Union address at the beginning of 2003. For Piot, this was a crucial moment in the history of the epidemic: “[when] the most powerful person in the world puts 15 billion dollars on the table, it completely changes the landscape”. Other leaders followed. British Prime Minister Tony Blair, Knight notes, pledged £1.5 billion (approximately US$3 billion) over three years in July 2003.

UNAIDS used its network of Country Coordinators to facilitate PEPFAR’s work. Michael Iskowitz, Director of the US Office of UNAIDS, commented:

“Despite a sometimes contentious relationship between the US Administration and the UN overall, there has been a very solid working relationship between UNAIDS and this administration. UNAIDS has contributed to the implementation of PEPFAR with some very tangible results, particularly in the area of coordination”.

Audrey recalled that Achmat “used to spend hours looking up news about South Africa as those were the days before high-speed internet”. One event he did not need to look up was TAC’s civil disobedience campaign waged to get the government to organise access to ART, and in particular Nevirapine for HIV-positive pregnant women.

In April 2001, the South African government had successfully used the Medicines and Related Substances Control Act to allow the domestic production of cheaper, generic medicines against a lawsuit filed by transnational pharmaceutical companies. However, government provision of ARVs through public health structures remained remarkably low. In 2002, the South African High Court ordered the government to make Nevirapine available to HIV-positive pregnant women. Still, despite the order, no mass-scale provision of Nevirapine occurred.

In February 2003, the TAC led a march of thousands of people on Parliament to protest the lack of universally accessible ARVs and, a month later a global civil disobedience campaign was launched. The TAC circulated a flyer, which read in part:

“Every day more than 600 people in South Africa die of HIV/AIDS-related illnesses. Many lives could have been saved had our government shown urgency and commitment. We still have a chance to save millions of lives. Regrettably, the Minister of Health continues to equivocate. After four years of negotiations, petitions, marches, litigation and appeals, the Treatment Action Campaign (TAC) has decided to begin a peaceful campaign of civil disobedience on 21 March 2003. TAC requests your support in this campaign. We are mobilising 600 people across the country who will volunteer to get arrested in our civil disobedience campaign. … it is still possible to save lives and restore hope. – Zackie Achmat, Treatment Action Campaign, South Africa.”

The campaign was supported in some African countries and elsewhere in the world and reached the streets of New York, supported by the AIDS Coalition to Unleash Power (ACT UP). In August 2003, the South African Cabinet finally approved universal ARV treatment. The programme began in March 2004 in Gauteng and was then expanded to other provinces. By March 2005, the target of the 2003 plan had been met. At least one service point for AIDS related care and treatment in each of the country’s 53 districts had been set up. However, the number of people actually receiving ARV treatment remained far below the stated objective. The Minister of Health continued to speak out against the effectiveness of ARVs, promoting herbal “remedies” as an alternative. Zackie Achmat of TAC recalled it as “war without bullets — the government had declared civil war on its own people.”

Around 2003, Achmat was appointed Interim Manager of the World AIDS Campaign, which had been established in 1997 by UNAIDS and its Co-sponsors to sustain year-round campaigns and advocacy work. Each year had a specific theme linked to World AIDS Day on 1 December which the WHO had declared in 1988 as day for people around the world unite and show support for people living with and affected by HIV and to remember those who lost their lives to AIDS. The theme of the first World AIDS Campaign was ‘Children living in a World with AIDS’. In the following years, themes included “Men make a Difference” (2000–2002); “Stigma and Discrimination” (2003) and “Women, Girls, HIV and AIDS” (2004). In 2005, responsibility for running the Campaign was handed to an independent organisation, the World AIDS Campaign based in Amsterdam. A Global Steering Committee set the strategic direction.

In addition to contributing to the conceptualisation, co-ordination and planning of global campaigns, Achmat was also invited to attend meetings, workshops and conferences. On 22 and 23 March 2004, for example he was a speaker at the Open Forum on AIDS Action in Europe in Brussels organised by AIDS Action Europe, the Pan European NGO Partnership on HIV and AIDS and the regional branch of the International Council of AIDS Service Organisations (ICASO). There were about 100 participants from Western, Central and Eastern Europe and Central Asia, including representatives from community-based organisations, AIDS activists, funding organisations and international organisations such as WHO, UNAIDS and the European Commission.

Achmat spoke on a panel titled “Setting the Agenda for AIDS Action in Europe”, which was chaired by Pedro Silvéro Marques, Director Abraco with fellow panellists: Richard Burzynski, Executive Director of ICASO; Julian Hows, Representative ENP+ (European Network of People with HIV/AIDS); and Jerry Kelliher, Desk Office Balkans and CIS Desk, Development Cooperation Ireland. Other UNAIDS attendees were Kathleen Cravero, Deputy Executive Director and Henning Mikkelsen, UNAIDS’ Europe Regional Coordinator.

The notes from the conference include a summary of key points made by Achmat.

“Mr Dangor gave an overview of the history of the World AIDS Campaign, the global context and the status of the involvement civil society. The World AIDS Campaign strategies include stimulation of growth of national/regional networks, support campaigns in countries most affected, facilitate joint action, promote greater harmony around messages, initiate/support targeted policy efforts, promote dialogue and consensus, and sharpen the political approach to campaigning. The vision of the World AIDS Campaign is to create a global movement of civil society campaigns, ensure that resources are available on a scale equal to the disease, and match resources with sustained action. The ultimate goal is that the response to AIDS is integrated into the ongoing planning of nations everywhere.”

Audrey recalled that Achmat started with “UNAIDS in 2004 formally and then because they were based and head-quartered in Geneva, we left New York and move to Geneva at the end of 2004.” Peter Piot recalled:

Achmat is a wise man and also, he completely disagreed with the President (of South Africa) then and also connected me with Madiba for a number of things. At some point I was determined that he would work with me directly and he was open to it, to leave New York, to be closer to South Africa, but also closer to his wife’s family. Achmat moved to Geneva and we worked together for about five years.”

According to Achmat’s “summary CV”, he was appointed as the Director of Advocacy, Leadership and Resource Mobilization from April 2004 to December 2006, and “(r)efined and implemented a global advocacy strategy to respond to changing dynamics and encourage longer term, sustainable responses to AIDS within key regions of the world, among donors and multilateral organisations.”

By the time he was appointed to this position, UNAIDS was a key player. Funding to combat HIV/AIDS continued to increase dramatically. By 2004 there had been a huge increase in funding for tackling AIDS. From around US$ 300 million a decade earlier, global resources for AIDS in 2005 were estimated to be US$ 8.3 billion. The bulk of funds, Knight notes, came through PEPFAR, the Global Fund and the World Bank’s Multi-Country HIV/AIDS Programme in Africa (MAP) launched in 2002. UNAIDS’ advocacy work contributed to the increase in funding.

It was during trips together for UNAIDS that Peter and Achmat came to know each other better. According to Peter:

“Achmat prepared the trip and the visit and that’s where his political astuteness and skills were very important. He was always pushing me: What are we trying to achieve, who to see and [ensuring we] connect the people living with HIV / AIDS. He prepared a lot of that and sometimes I just did what he suggested.”

Piot recalled that Achmat

“could be very annoyed and upset when things would not go well and if there was too much injustice and of course we came across that all over”. Their “biggest fight,” Piot suggested, “was to reduce the price of the anti-retroviral therapy, which was way too high and we needed to work with industry, with big Pharma to convince them. It was quite difficult in the sense that activists thought we were too close to big Pharma.”

Mahesh Mahalingam, Director of Communications and Global Advocacy, UNAIDS in 2020, noted of Achmat that:

“he was an activist who brought together leaders from all walks of life to make a difference for people—for women, children, the marginalised and people living with HIV. He combined human rights, compassion and kindness to make a unique impression on the AIDS response.”

As the Director of Advocacy, Leadership and Resource Mobilization, Achmat was a member of the Senior Management Team comprising: Peter Piot, Executive Director and Under Secretary-General of the United Nations; Deborah Landey Deputy Executive Director; Paul De Lay, Director of Monitoring and Evaluation; Kari Egge, Director of the Programme Support Group; Ben Plumley, Director of the UNAIDS Executive Office; and Michel Sidibe, Director of Country and Regional Support. Sidibe was appointed as the second Executive Director of UNAIDS, serving from January 2009 until May 2019.

Achmat and the directorate contributed to several UNAIDS reports, which often required ongoing research, such as the annual “AIDS Epidemic Update” reports. UNAIDS also prepared “Global Reports on AIDS”, published a month before every biennial International Conference on AIDS, managed by the International AIDS Society (IAS) established in 1988.

UNAIDS was one of the organisers of the AIDS 2004, 15^th International AIDS Conference which took place in Bangkok, Thailand, from 11 to 16 July 2004. The Conference Theme was: “Access for All” and leaders were invited to report on their country’s progress since the UNGASS Declaration of Commitment in 2001. Fifty-four UNAIDS staff, including Achmat were selected to represent UNAIDS.

According to the conference report, 19 843 delegates from over 160 countries attended, including 2 710 media representatives. Key stakeholders included: health workers; researchers; social and community workers; delegates belonging to government and non-governmental agencies; representatives of the pharmaceutical industry and other businesses; educators; policy makers and leaders; delegates from faith-based communities; the United Nations Family and people living with HIV. Celebrities including famous movie actor Richard Gere and Miss Universe were also in attendance.

Eleven thousand delegates from over 160 countries attended the Opening Ceremony at which Co-Chair and President of the IAS, Dr Joep Lange, expounded on the theme of Access for All:

“It’s about much more than access to medications; it also means access to unbiased information and education about HIV/AIDS; access to effective prevention tools; access to comprehensive medical care; access to resources; access to all those things that will mitigate the impact that HIV/AIDS has on human lives”.

For the first time, the UN Secretary General, Kofi Annan, addressed the International AIDS Conference delegates emphasising that: “We need leaders everywhere to demonstrate that speaking up about AIDS is a point of pride, not a source of shame”.

The conference was held just before his 86^th birthday and Nelson Mandela said that the best birthday present he could receive was a renewed commitment by leaders from all sectors of society to take real and urgent action against HIV/AIDS. Graça Machel, Patron of the Leadership Programme and Mandela’s wife of 6 years, stressed accountability. She acknowledged that “We have not done enough to protect people against HIV/AIDS … Bangkok has to be an end to promises made and promises broken”.

Achmat recalled that there was an argument between Mandela and Tshabalala Msimang after she accused Achmat of “poisoning” Mandela’s mind:

“Madiba was one of the main speakers together with Bill Clinton. South Africa’s Health Minister Manto Tshabalala Msimang, who at the time was against the use of ARVs for HIV and promoted natural remedies instead, asked to see Madiba before he made his speech. Before she went in, she looked into the room where Madiba was and said to me, ‘You! You are you trying to poison Madiba’s mind.’ She went in and I could see through the window that they are arguing. And Madiba gets up: he opened the door and called me: ‘Come in here.’

I remember him telling me, ‘This lady says I can’t think for myself and you put things into my head. Does she think I’m stupid? I know nothing about anything at all?’ She gets up and Madiba says to her, ‘Don’t go and make a fool of our country.’ She bowed to him and said, ‘Goodbye’. She went into the exhibition hall and set up her display of natural remedies and left the conference.”

The conference ended with an urgent call for a move beyond institutional rivalry and ideological barriers from Piot:

“There is no time to be divided by institutional agendas… we all have the same goals, and we must work together, each playing to our individual strengths … let us not forget that all the tools to change the course of this epidemic are in our hands. But are we really willing to change our institutional behaviours as much as our personal behaviours? Are we ready to radically take on these challenges, to leave behind our flags? Every person in this room will provide part of that answer. But what I know is if we are not willing, we will massively fail”.

The realisation was dawning that if the available funding failed to produce positive results in scaling up prevention and treatment, it would be difficult to convince donors to continue making donations. UNAIDS coined the phrase ‘making the money work’ and reviewed disbursement processes and programmes in place at country level. Many did not have the capacity to use the funds because of limited staff and expertise and there was a lack of coordination (or ‘harmonization’, the term more often used in development circles). Piot explained:

“There was really a chaotic situation in Africa. Donors used separate reporting standards, different coordination committees, advisory groups and so on. This is not just a question of bureaucracy gone awry; such chaos impedes attempts to save lives, to plan prevention programmes and reach more people with antiretroviral treatment”.

UNAIDS appointed a team to consult and develop a set of guiding principles to enable better coordination. After reading the report, Piot proposed what he dubbed the “Three Ones” to be applied at country level: one agreed HIV/AIDS action framework or strategic plan to be applied at national level plan which would provide the basis for coordinating the work of all partners and ensuring national ownership of the plan and its implementation; one national AIDS coordinating authority (such as a National AIDS Council) with a broad-based, multisectoral mandate; and one agreed country-level monitoring and evaluation system. Donor and host countries, bilateral and multilateral institutions and international nongovernmental organisations endorsed these principles at the Consultation on Harmonization of International AIDS Funding on 25 April 2004 in Washington, DC.

In March 2005, a meeting took place in London called “Making the money work: the ‘Three Ones’ in action”. For some months before the meeting, a reference group of experts, brought together by the UNAIDS Secretariat, worked on two models. Knight quotes Achmat:

“one model described the funding that would be needed to achieve the level of coverage required by the UNGASS goals – ‘the aspirational goal which is the maximum amount of money available with few constraints’. The second model described what resources could realistically be spent, taking into account low-income countries’ limited ability to implement programmes.”

The proposed models were circulated to the three donor co-hosts of the meeting and the co -sponsors and then at the “Making the Money Work” meeting to representatives of governments, donors and international organisations. Achmat observed: “The miracle is that we were still able to extract one vital thing, and that was a mandate to pursue country-level harmonization, because it gave birth to the Global Task Team.”

The “Global Task Team on Improving Coordination among Multilateral Institutions and International Donors”, co-chaired by Sidibe and the Swedish AIDS Ambassador, Lennarth Hjelmaker was composed of senior representatives from 24 low-income and “developed” countries, civil society groups, regional bodies, the Global Fund and UN organisations. Along with Achmat and his directorate’s advocacy work, it helped facilitate the adoption of the “Three Ones”.

Knight notes that between the end of 2005 and early 2007, there was a clear improvement. Most countries had achieved the “First One”, (a National Strategic Plan). By the end of 2005, 85 per cent of countries reported having established the “Second One”, (a single national coordinating authority for the AIDS response). In many countries, there was also improvement in setting up the “Third One”, (monitoring and evaluation). A number of new commitments and initiatives came from the Global Task Team including the AIDS Strategy and Action Plan service, the Global Implementation Support Team and the Country Harmonization and Alignment Tool.

UNAIDS had placed prevention as a priority on its agenda from the beginning, but it did not have an official strategy or policy in place. Over the years, prevention strategies were sidelined because treatment was more urgent. Between 2004–2005, UNAIDS began co-designing with civil society organisations and communities a strategy in which ‘Prevention for all’ was emphasised.

The UNAIDS Secretariat collaborated with the Bill & Melinda Gates Foundation Working Group on drafting a major policy document concerning prevention. Secretariat staff worked with Cosponsors and the Programme Coordinating Board (PCB) on the final draft. PCB members acted as advocates in their own countries, negotiating informally with various groups. Achmat explained that UNAIDS was the facilitator, bringing people together and “agreeing to act on what they feel comfortable with”.

The draft paper was presented to the 17^th PCB in June 2005. After fierce debate, it was endorsed. “This is a true milestone in the response to AIDS”, Piot remarked, “UNAIDS was clearly fulfilling its role as the world’s reference point in AIDS policy”.

In early 2005, the BBC reported on progress in the development of a microbicide gel called PRO2000 to reduce the transmission of HIV and quoted Professor Janet Darbyshire, Director of the Medical Research Council’s (MRC) Clinical Trials Unit who explained: “microbicides work in one of three ways – by killing the virus before it enters the body by preventing it from taking hold once inside the body or by creating a barrier to stop it from entering the body in the first place.”

Achmat was quoted as saying: “microbicides were one of the most promising new prevention options on the horizon. The development of an effective microbicide would be a breakthrough in giving women a real choice when it comes to protecting themselves from HIV and prevent the further spread of the AIDS.”

By 2004, the “feminisation” of the epidemic could no longer be ignored. In 1997, 48% of adults (15+) living with HIV were women; by 2004, nearly half of all adults (15+) living with HIV between 15 and 49 years of age were women – in Africa, the figure rose to 59%. Globally, in 2004, about 5000 women were infected every day. UNAIDS had recognised women as vulnerable early on. At the 2001 UNGASS, as has been mentioned, it had been acknowledged that gender equality and women’s empowerment were fundamental to ensuring an effective response to AIDS. However, despite some progress, women’s “concerns were too often sidelined or just ignored by those working on AIDS.”

In a 2005 interview conducted by Africa Review, Achmat called for an addition to the ABC prevention acronym:

“We have ABC … Abstain, be faithful or use a Condom. If I could add another letter, it would be ‘W’ for women, because we will never defeat AIDS in Africa until we empower the women. These things must become embedded in every activity of government at every level.”

In May 2006, the Global Coalition on Women and AIDS, launched by UNAIDS in 2004 published an agenda for action titled “Keeping the Promise”.

By the late 1990s, triple combination therapy for HIV had been approved and had changed the lives of People Living with HIV (PLHIV) radically. But treatment, according to the People’s Health Movement, had been way beyond the means of almost all people in low- and middle-income countries (LMICs). The competition from generic alternatives in these countries played a major role in the fall of the price of ARVs, which made them affordable for individuals, governments and international funding agencies. In 2001, Cipla an Indian generic manufacturer offered treatment at less than a dollar a day — a 97 per cent reduction. Indian generic medicines became the lifeline for patients in most LMICs.

In 2005, India set about amending its patent law to comply with the World Trade Organisation’s (WTO) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), which required that 20-year product patents on medicines would be granted, which would give patent holders exclusive rights over the manufacture, sale, use, and import of the patented medicine. This development led to significant concern from public interest groups, the United Nations and UNAIDS.

About a month before the Indian Parliament was to debate the legislation, Achmat, as Director of Advocacy, Communication and Leadership, UNAIDS and other UN and WHO representatives sent letters to the Indian lawmakers urging legislators to utilise all possible “flexibilities” in the TRIPS Agreement to limit the scope of patent protection.

Neha Dewan and Shakti Shankar quote an extract from Achmat’s appeal to Kamal Nath, India’s Minister of Commerce and Industry in their 2015 article published by The Dollar Business “Trouble with Indian pharma – has Indian pharma lost its path?”

“Affordable HIV medications from India have so far saved thousands of lives, yet more than 8,000 people around the world continue to die every day because they have no access to treatment. Despite concerted efforts across the world, only about one in ten people in urgent need of HIV antiretroviral treatment in low and middle-income countries has access to existing medicines. Current legislative proposals intended to take the 1970 Indian Patents Act beyond the commitments agreed in the World Trade Organisation’s Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) threaten to undermine India’s leadership in providing affordable medicines.”

After intense debates, on March 23, 2005, the Indian Parliament passed the bill to amend The Patents Act, 1970, to make it WTO-compliant adhering to TRIPS requirements that pharmaceutical products should be patentable and added sufficient provisions to limit the extent of what fell under patent protection by restricting what could be said to constitute an “invention”.

“Given the difficult circumstances in Zimbabwe,” Achmat said in an interview with Michael Fleshman for Africa Renewal, a UN digital magazine, “we were sceptical at first.” In 2005, it was communicated to Achmat’s directorate that new infection rates in Zimbabwe had declined. UNAIDS commissioned the Imperial College in London to review data from a wide variety of sources.  It turned out that the figures were correct. They were announced in a press statement on 10 October 2005: infection rates among pregnant women declined from 24.6 per cent in 2002 to 21.3 per cent in 2004. Achmat added that infection rates among young people, another high-risk group, had dropped even further, from about 25 to 20 per cent. However, he cautioned: “this is no reason for complacency. Zimbabwe still has one of the highest HIV prevalence rates in the world. The challenge now is to build on those gains.”

Achmat discounted increased mortality rates as the only explanation for declining numbers of infections:

“All reviews tell us that mortality does play a role [in prevalence rates], but that level of decline cannot be accounted for by outward migration or mortality. The death rate would have had to quadruple, in fact to be the sole cause of the decline.”

When asked for reasons, Achmat said: “it is an indication that education and prevention programmes launched during the 1990s are beginning to show results. For us that is very significant.” Achmat pointed out that Zimbabwe’s strong education system, its emphasis on district and community management of AIDS programmes and improvements in the status of women since independence in 1980 could be factors.

He suggested that factors such as: early analysis; behavioural change; young people waiting longer before becoming sexually active; fewer casual sex partners and the increased use of condoms, were also part of the explanation.

He pointed out that neighbouring Zambia received $187 in aid for every HIV-positive citizen in 2004, whereas Zimbabwe’s strained relations with some donors meant that it received only $4 per person, according to the World Bank. Achmat said that offered an important lesson:

“You do not have to wait for a massive amount of external funding to contain the spread of HIV. As vital as resources for prevention, care and treatment are what is even more important is that countries own both the problem and the solution, instead of the targets and the programmes coming from outside.”

According to Knight, it was clear well before the end-date of 2005 that the objective of the “3 by 5” campaign launched in September 2003 would not be reached. But, there were improvements. By December 2005, data from 18 countries indicated they had met the “3 by 5” target of providing treatment to at least half of those who needed it. Without the funding from PEPFAR, the Global Fund and the World Bank, the number of people receiving treatment by the end of 2005 would have been considerably lower. The “3 by 5” initiative also brought together a wide range of stakeholders and more than 200 organisations were involved in the initiative, which “had an important catalysing effect at global level.”

In July 2005, in Gleneagles, Scotland, leaders of the G8 announced their intention to “work with WHO, UNAIDS and other international bodies to develop and implement a package for HIV prevention, treatment and care, with the aim of as close as possible to universal access to treatment for all those who need it by 2010”. This goal was subsequently endorsed by all UN Member States at the High-Level Plenary Meeting of the 60th Session of the UN General Assembly in September 2005.

The 2006 Report on the Global AIDS Epidemic, was a special edition to celebrate ten years of UNAIDS. In the foreword, Piot noted that “since the world’s leaders committed themselves, at the 2001 UN General Assembly Special Session on HIV/AIDS, to mount an urgent response to AIDS, there has been real progress on key fronts. Goals that appeared impossible to achieve just five years ago have now been realised. There is robust political commitment today.”

He urged though that long term strategic planning was vital:

“Because this pandemic and its toll cannot be reversed in the short term, we need to sustain a full-scale response for the next decades … We must make this conceptual leap in our planning and actions—and move from the reactive to the active and strategic. To get us to the point where future generations are free from AIDS will require that every aspect of the response be sustained over the longer term—leadership commitment, activism, financial resources, innovation in developing new medicines and preventive technologies, and, not least, real action to tackle the fundamental drivers of this pandemic, particularly gender inequality, poverty and discrimination. In this 25th year of AIDS, success is in sight—but securing it will require an unprecedented response from the world for the next decades. We cannot afford to rest until then.”

Although positive developments were noted, the report stressed that there was much to be done in South Africa:

“South Africa’s AIDS epidemic—one of the worst in the world—shows no evidence of a decline. Based on its extensive antenatal clinic surveillance system, as well as national surveys with HIV testing and mortality data from its civil registration system, an estimated 5.5 million [4.9 million–6.1 million] people were living with HIV in 2005 … While South Africa’s HIV prevention efforts have not made notable inroads against the epidemic, there has been significant progress on the treatment front. With approximately 190 000 people receiving antiretroviral treatment by the end of 2005, South Africa accounts for a large share of the treatment scale-up in sub-Saharan Africa overall this decade (WHO/UNAIDS,2006). However, this still means that less than 20% of the almost one million South Africans in need of antiretroviral treatment were receiving it in 2005.”

The 16^th International AIDS Conference managed by the IAS and co-organised by the Global Network of People Living with HIV/AIDS (GNP+), the International Community of Women Living with HIV/AIDS (ICW), the International Council of AIDS Service Organisations (ICASO), UNAIDS and the Canadian AIDS Society was held in Toronto, Ontario, Canada during the week of 13 – 18 August, 2006. The largest conference to date, it attracted over 21 000  participants representing 187 countries, including scientists, healthcare providers, political, community and business leaders, journalists, government, non-governmental and intergovernmental representatives, and people living with HIV. A record 13 112 scientific abstracts were submitted. Governor General Michaëlle Jean; Bill Clinton; Stephen Lewis, the United Nations special envoy for HIV/AIDS in Africa; Bill and Melinda Gates; and celebrities Richard Gere and Alicia Keys amongst others attended.

Helene Gayle and Mark A Wainberg of the IAS, in 2007 paper published in Journal of the International AIDS Society, note that it was the first time in recent years that the conference was held in a “developed” country and there were no “major demonstrations by activist groups in protest against the actions of pharmaceutical companies and their booths in the exhibit areas of the conference”. Key lectures at the opening and closing ceremonies, together with many of the oral sessions, focused on treatment access. The South African Minister of Health, Gayle and Wainberg report, stated at the start of the conference that “lemon juice, beetroot, and garlic were effective means of combating the HIV epidemic”. “(N)umerous speakers mocked [her] comments” throughout the proceedings. Other speakers at the conference, according to activist Simon Collins writing for HIV Treatment Bulletin, “highlighted again and again, that we have everything we need to stop HIV and to treat people already living with the virus; what we lack is political will for change, and in this we are all responsible for positions taken by our own governments.”

Stephen Lewis gave his last speech as UN Ambassador for AIDS in Africa. He spoke in the closing session and received a standing ovation, Collins writes, “for broadening his talk to clear political and social concerns: the disproportionate [impact] of HIV on women, their own abysmal track record of equitable inclusion of women within the UN system, and political leadership most particularly from South Africa”.

After AIDS2006, the 16^th International AIDS Conference, South Africa’s Cabinet signed off on the new “National Strategic Plan for HIV & AIDS and STIs, 2007 – 2011” (NSP), prepared by the South African National AIDS Council (SANAC) in what academics Simelela and Venter describe as a “laborious, politically charged but widely consultative process”. The NSP committed the government to providing ARVs to 80% of “eligible” HIV+ people. By December 2007, an estimated 424 009 patients were receiving ARVs. By 2007, drawing on information generated in a national survey, TAC activist Mark Heywood noted that approximately 5.4 million people in South Africa were infected with HIV and by 2008, only an estimated half a million people were receiving ARV therapy. The number of annual AIDS-related deaths was between 300 000 and 400 000 – nearly a thousand deaths a day. Mandela turned to Achmat who relayed this moment in his contribution to Vimla Naidoo and Sahm Venter’s edited collection I Remember Nelson Mandela:

“I remember getting a call from Jakes Gerwel and being told, ‘The old man wants to speak to you and it’s important that you listen very very carefully because you also have to give back to your country. And then Madiba came on and asked me if I enjoyed my stay at UNAIDS because it’s time to come home to fight that HIV battle here. I wanted to say to him, ‘But Madiba you know I’ve just settled in’. I’d just been there for two years from 2004 and Zachary our son was just born. I remember Madiba being so persuasive that I said, ‘OK I’ll send confirmation to Jakes.’ He yelled, ‘Jakes! The man says yes!’”

The UNAIDS Secretariat had its own headquarters in Geneva in a new building shared with the WHO made possible with support from the Swiss Confederation. The inauguration of the new building took place in November 2006. It was also a time of reflection for Achmat and UNAIDS. During Achmat’s tenure, UNAIDS had achieved much. Through its advocacy and in partnership with others, it had positioned AIDS high on the political agenda of global, regional and national leaders and powerful organisations such as the G8, the World Economic Forum and other such bodies. More than 200 international companies are members of the Global Business Coalition on AIDS and many trade unions worldwide are actively engaged in the struggle. Promises made at the UNGASS of 2001 were honoured.

Of Achmat’s tenure and contribution to UNAIDS Peter Piot recalled:

“What he brought was a new narrative about HIV/AIDS – one that was more humane. A combination of people’s stories and hard economics and security. I learned a lot from him. He was also very instrumental in developing and promoting stronger African ownership of the whole issue. Not so easy, because it was seen as something that came from outside, homosexual men were blamed and there were all kinds of difficult stories. He brought in a human rights dimension particularly from a perspective of those who are the most vulnerable, the poorest and so on. He was able to develop the narrative in a very powerful way.”

At the end of 2006, Achmat left UNAIDS to lead the Nelson Mandela Foundation (NMF), but it was not the end of his activism in the AIDS arena. As CEO of the NMF, he continued with HIV/AIDS work. Nor did the move home sever his relationship with UNAIDS. Achmat was part of a consortium collectively known as aids2031 established by UNAIDS as an independent forum “to take a critical look at the global HIV/AIDS response”. Work commenced in 2007 and the findings were published in a book titled Aids: Taking a Long-Term View in 2010. 

Achmat’s sister, Jessie, recalled Achmat’s work in the AIDS field at the 2020 memorial:

“He was the most fearless man I knew. He had courage beyond anything and I remember with the HIV and AIDS crisis in our country, he did not stand back. He stood up against what he thought was a policy that would take us down a path of ruin and he intentionally made sure that everybody understood, that the only way to go, was through not going with the ignorance that was abound at the time, but helping people to understand this virus, this disease and what it would do to people and that people here needed help and they needed funding and he wasn’t afraid to ask for that funding from various organisations.”