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Institutional Complexity as a Challenge for a Coherent HIV Control Policy: Brussels.

Author(s) Christoph Schweikardt1, Yves Coppieters2.
Affiliation(s) 1School of Public Health, Université Libre de Bruxelles, Brussels, Belgium, 2School of Public Health, Université Libre de Bruxelles, Brussels, Belgium.
Country - ies of focus Belgium
Relevant to the conference tracks Infectious Diseases
Summary The Brussels Region is an example of the challenges in implementing global principles in the fight against HIV/AIDS locally. This is due to divided legal competencies between the Federal and the Federate (Communities, Regions) level resulting a complex legal and administrative structure and multiple coordination processes between governments. Growing Federal government commitment led to the preparation of a national plan HIV/AIDS which provides an opportunity to pass from confirmatory legislation to a new agreed HIV/AIDS action framework.
Background According to the Belgian Scientific Institute for Public Health (WIV-ISP), more than one third of HIV positive persons in Belgium, of whom the residence was known at the time of diagnosis, reside in the Brussels Region. In April 2004, the "Consultation on Harmonization of International AIDS Funding" recommended three general principles in the fight against HIV/AIDS. The first is an agreed AIDS action framework that provides the basis for coordinating the work of all partners, the second a national AIDS coordinating authority, with a broad-based multisectoral mandate; and thirdly an agreed country-level monitoring and evaluation system. The implementation of these principles poses serious challenges to countries with a complex distribution of legal competencies in health care such as Belgium. In Belgium, health care competencies are divided between the Federal level (treatment) and the sub-national Federate entities, the Regions and the Communities (prevention, health promotion). The Flemish and the French Communities exercise their legal competences concurrently in the Brussels Region, thereby increasing institutional complexity in Brussels. Furthermore, Federal legislation cannot overrule the legislation of the Communities and the Regions in their respective areas of competence.
Objectives The aim of this study is to describe the consequences of institutional complexity with regard to the different governments which are influential within the territory of the Brussels Region in the fight against HIV/AIDS and the role of Federal government as a key actor in this regard.
Methodology In order to elicit the cooperation between the different governments and the role of the Federal government, government publications and documents relating to HIV/AIDS prevention and control, such as policy statements and reports (Federal, Communities, Regions), the documentation of parliamentary debates and published personal statements of representatives were assessed, complemented by participation in the sub-workgroup "Test and treat" of the Belgian National Plan HIV/AIDS and also subsequent informal conversations with experts were carried out.
Results The legal competence of the Communities in the field of prevention led to cooperation arrangements with different parts of the Brussels government according to their competence of the Dutch- and French-language institutions, respectively. Federal government commitment increased since 2006 by:(1) taking over the financing of free and anonymous HIV testing from Doctors Without Borders (Médecins Sans Frontières, MSF) in Brussels after their decision to withdraw. This resulted in a Federal pilot programme of anonymous and free testing for the three Regions (Flanders, Wallonia, Brussels) in 2006 and subsequent legislation with the royal decree of December 28, 2006 as the initiating key document.

(2) taking the initiative for the National Plan HIV/AIDS by negotiating support from the Federate entities in the inter-ministerial conference in 2012 and chairing its preparation until the following year. Experts and workers in the field from all Regions were appointed to workgroups / sub-workgroups on prevention, screening, and care of HIV-infected persons in order to work out recommendations by June 2013. These were taken up by the Federal government in order to negotiate potential future actions with the Federate entities before publishing the plan.

Conclusion The experience of the Brussels governments indicates that institutional complexity is unlikely to be reduced in the short run.  The limits of civil society engagement concerning HIV testing in Brussels prompted Federal government into action. The National Plan HIV/AIDS provides an opportunity for a new agreed AIDS action framework and for passing from confirmatory to pro-active legislation. In this regard, the strong point of the approach of Federal government was that it chose a step by step approach that involved decision-making bodies and practitioners in order to obtain as high a commitment as possible. The process shows how a government can exploit its scope of action notwithstanding legislative limitations and institutional complexity.