Chapter three HIVIAIDS confronting a killer Today HIV/AIDS is a major global health emergency, affecting all regions of the world, causing millions of deaths and suf- fering to millions more. But access to effective prevention and treatment varies widely. This chapter examines what can and must be done to narrow this gap, and to combat the disease in even the poorest countries. It suggests an aggressive strat egy for global action against the HIv/AIdS pandemic that unites the efforts of WHO and its partners from many sectors and effectively combines prevention and care
HIV/AIDS: confronting a killer 41 Chapter Three HIV/AIDS: confronting a killer Today HIV/AIDS is a major global health emergency, affecting all regions of the world, causing millions of deaths and suffering to millions more. But access to effective prevention and treatment varies widely. This chapter examines what can and must be done to narrow this gap, and to combat the disease in even the poorest countries. It suggests an aggressive strategy for global action against the HIV/AIDS pandemic that unites the efforts of WHO and its partners from many sectors and effectively combines prevention and care
HIVIAIDS confronting a killer Acquired immunodeficiency syndrome(AIDS)is the leading infectious cause of adult death in the world. Untreated disease caused by the human immunodeficiency virus(Hiv) has a case fatality rate that approaches 100%. Not since the bubonic plague of the 14th century has a single pathogen wreaked such havoc. AIDS has torn apart families and caused untold suf- fering in the most heavily burdened regions. In hard-hit areas, including some of the poorest parts of the world, HIV has reversed gains in life expectancy registered in the last three dee ades of the 20th century. HIVIAIDS is a major global health emergency. HIV infection also fuels other epidemics of global concern- most notably tuberculosis, which has become a leading cause of death not only among people living with HiV, but also among their HIV-negative family members and contacts. But AIDS is not the same everywhere. Ac cess to effective prevention and treatment, and consequently the fates suffered by individual infected with HIV, vary widely. People living with HIV but benefiting from the latest medical developments can hope to lead normal lives in many respects: the use of combination chemo- therapy with antiretroviral agents(ARvs)renders AIDS a chronic and treatable disease more Ike diabetes than other serious viral diseases for which there are no effective therapies(see Figure 3. 1). In Australia, Europe, Japan and the United States of America, many people with advanced AIDS have resumed their normal lives In poorer countries, however, and among the poor living in wealthy societies, HIV remains a death sentence. Over the past decade, the outcome gap"the different fates of rich and poor- has widened considerably (1) Why has there been a failure to contain HIVIAIDS? Why have the fruits of modern medicine, including ARVs, not been delivered to those most in need? The answer to these two questions is essentially the same: AIDS is a disease whose impact is much greater where there is poverty and social inequality, including gender inequality. It is not easily managed in settings in which weakened health systems fail to perform, especially for minorities and those living in poverty. HIVIAIDS thus raises urgent human rights issues, especially concerning the right to health care(see Table 3.1) For all these reasons, HIVIAIDS serves as a report card on current global health status: rising incidence and a growing death toll are rebukes to optimism. It is vital that the global health community makes a bold effort against HIV/AIDS, guided by a commitment to equity in This chapter reviews important trends in the Hiv epidemic and the ways in which effective partnerships can attack both the pandemic and its root causes. It examines successes and failures in the struggle against the worlds most devastating infectious disease, before
HIV/AIDS: confronting a killer 43 3 HIV/AIDS: confronting a killer Acquired immunodeficiency syndrome (AIDS) is the leading infectious cause of adult death in the world. Untreated disease caused by the human immunodeficiency virus (HIV) has a case fatality rate that approaches 100%. Not since the bubonic plague of the 14th century has a single pathogen wreaked such havoc. AIDS has torn apart families and caused untold suffering in the most heavily burdened regions. In hard-hit areas, including some of the poorest parts of the world, HIV has reversed gains in life expectancy registered in the last three decades of the 20th century. HIV/AIDS is a major global health emergency. HIV infection also fuels other epidemics of global concern – most notably tuberculosis, which has become a leading cause of death not only among people living with HIV, but also among their HIV-negative family members and contacts. But AIDS is not the same everywhere. Access to effective prevention and treatment, and consequently the fates suffered by individuals infected with HIV, vary widely. People living with HIV but benefiting from the latest medical developments can hope to lead normal lives in many respects: the use of combination chemotherapy with antiretroviral agents (ARVs) renders AIDS a chronic and treatable disease more like diabetes than other serious viral diseases for which there are no effective therapies (see Figure 3.1). In Australia, Europe, Japan and the United States of America, many people with advanced AIDS have resumed their normal lives. In poorer countries, however, and among the poor living in wealthy societies, HIV remains a death sentence. Over the past decade, the “outcome gap” – the different fates of rich and poor – has widened considerably (1). Why has there been a failure to contain HIV/AIDS? Why have the fruits of modern medicine, including ARVs, not been delivered to those most in need? The answer to these two questions is essentially the same: AIDS is a disease whose impact is much greater where there is poverty and social inequality, including gender inequality. It is not easily managed in settings in which weakened health systems fail to perform, especially for minorities and those living in poverty. HIV/AIDS thus raises urgent human rights issues, especially concerning the right to health care (see Table 3.1). For all these reasons, HIV/AIDS serves as a report card on current global health status: rising incidence and a growing death toll are rebukes to optimism. It is vital that the global health community makes a bold effort against HIV/AIDS, guided by a commitment to equity in prevention and care. This chapter reviews important trends in the HIV epidemic and the ways in which effective partnerships can attack both the pandemic and its root causes. It examines successes and failures in the struggle against the world’s most devastating infectious disease, before
The World Health Report 2003 Figure 3. 1 Trends in age-adjusteda rate of death from HIV infection, USA, 1987-2000 8642 88 自 6420 1987198819891991991199219931994199519961997199819992000b Year b Using the year 2000 US standard populat Source: Centers for Disease Control and Prevention discussing goals for the coming years. These include narrowing the AIDS outcome gap by providing three million people in developing countries with combination ARV therapy by the end of 2005(known as the 3 by 5" target). Throughout this discussion, HIV/AIDS care is understood to include treatment with ARVs. Although robust HIV prevention and care con stitute a complex health intervention, such interventions are not only feasible in resource- poor settings, but are precisely what is needed. The HIvAIDS epidemic: a brief overview A new disease emerges AIDS was first described in 1981, when previously healthy young adults-mainly men living in urban areas of the United States-began falling ill with opportunistic infections previously unknown among this age group. Similar infections were soon described in Africa, the Carib bean and Europe; AIDS was clearly an epidemic disease. Most of these young people died and a host of discrepant hypotheses emerged, but a bloodborne viral pathogen was suspected early on. In 1983, this suspicion was confirmed when Professor Luc Montagnier and others discovered a novel pathogen: a retrovirus tropic for the CD4 cells that orchestrate cell-medi ated immunity and protect humans from a broad range of viral, mycobacterial, and fungal Where effective screening was available, transfusion-associated transmission was eliminated, but HiV was not easily stopped. Condoms were shown to be effective in preventing sexual transmission of hiv, but it was not long before those who studied AIDS concluded that male condoms alone would not be enough in settings in which poverty and gender inequality rendered poor women especially vulnerable to HIV infection(2). Women in turn transmit ted Hiv to their unborn children or to breastfeeding infants. Injecting drug use introduced HiV to previously untouched regions of the former Soviet Union and to parts of Asia. Poor quality health care-including the reuse of syringes, needles, and other medical parapherna lia-also contributed to the entrenchment of this new epidemic
44 The World Health Report 2003 discussing goals for the coming years. These include narrowing the AIDS outcome gap by providing three million people in developing countries with combination ARV therapy by the end of 2005 (known as the “3 by 5” target). Throughout this discussion, HIV/AIDS care is understood to include treatment with ARVs. Although robust HIV prevention and care constitute a complex health intervention, such interventions are not only feasible in resourcepoor settings, but are precisely what is needed. The HIV/AIDS epidemic: a brief overview A new disease emerges AIDS was first described in 1981, when previously healthy young adults – mainly men living in urban areas of the United States – began falling ill with opportunistic infections previously unknown among this age group. Similar infections were soon described in Africa, the Caribbean and Europe; AIDS was clearly an epidemic disease. Most of these young people died, and a host of discrepant hypotheses emerged, but a bloodborne viral pathogen was suspected early on. In 1983, this suspicion was confirmed when Professor Luc Montagnier and others discovered a novel pathogen: a retrovirus tropic for the CD4 cells that orchestrate cell-mediated immunity and protect humans from a broad range of viral, mycobacterial, and fungal pathogens. Where effective screening was available, transfusion-associated transmission was eliminated, but HIV was not easily stopped. Condoms were shown to be effective in preventing sexual transmission of HIV, but it was not long before those who studied AIDS concluded that male condoms alone would not be enough in settings in which poverty and gender inequality rendered poor women especially vulnerable to HIV infection (2). Women in turn transmitted HIV to their unborn children or to breastfeeding infants. Injecting drug use introduced HIV to previously untouched regions of the former Soviet Union and to parts of Asia. Poorquality health care – including the reuse of syringes, needles, and other medical paraphernalia – also contributed to the entrenchment of this new epidemic. 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000b Deaths per 100 000 population 18 16 14 12 10 8 6 4 2 0 Figure 3.1 Trends in age-adjusteda rate of death from HIV infection, USA, 1987–2000 a Using the year 2000 US standard population. b Preliminary mortality data for 2000. Year Source: Centers for Disease Control and Prevention
HIV/AIDS: confronting a killer The current situation Table 3.1 Coverage of adults in developing countries with How well has the international community antiretroviral therapy, by WHO region, December 2002 coped with this new threat to global health?Region Estimated Coverage In spite of remarkable scientific achieve ments-the development of inexpensive Africa diagnostics by the mid-1980s, theAmericas 196000 370000 sequencing of the entire HIV genome less Europe 7000 80000 % than 15 years later, and the development Eastern Mediterranean 3000 29% of effective antiretroviral therapy by 1995 South-East Asia the virus has continued to spread(see All WHO regions 300000 5500 Figure 3. 2). It is estimated that during the course of 2002 some 5 million people be- came infected with HIV, and almost 3 million people died of AIDS Everywhere in the world, HIV is transmitted through a fairly limited number of mecha HIV is a bloodborne retrovirus and is transmitted through sexual contact, contami blood transfusions, injecting drug use, failure to observe what are now termed in medical circles"universal precautions", and from mother to infant during pregnancy, delivery and breastfeeding The most heavily burdened continent is Africa, where the spread of the pandemic has been accelerated by a variety of factors, including widespread poverty, gender inequality, and health systems weakened by pressures such as the large external debt loads of states. Africa is home to more than 70% of those currently infected with Hiv. Of all aIdS deaths worldwide-28 million at the end of 2002-the majority have also occurred on this continent(3). HIV infec tion has fanned epidemics of TB in some African countries, increasing the risks to the whole population, regardless of serostatus. Across sub-Saharan Africa, rates of TB have more than trebled, and many conclude that the disease cannot be controlled without aggressive treat ment of AIDS(4). Debates about the relative importance of different modes of HIv transmission in sub-Saha ran Africa persist, but the evidence indicates that Hiv in this region is primarily a sexually transmitted pathogen(5). Nonetheless, the difficulties involved in following universal pre- cautions in overburdened and under-resourced health care facilities may lie at the root of many AIDS deaths in Africa(6 ). In many regions, unsafe blood transfusions continue, under scoring the importance of blood safety as a component of effective HIV/AIDS control. The immensity and rapidity of the spread of Hiv have reversed gains in life expectancy in many African countries(see Chapter 1). But the worst may be yet to come. The poorer re ions of Asia, including densely populated southern Asia, are the latest areas to be affected by the emerging AIDS epidemic. There has been an alarming HIV/AIDS cases in Asia over the past two decades; the burden of disease and death in the region will be enormous if current epidemiological trends are not slowed or reversed. Developed countries are also afflicted. The Russian Federation and Ukraine, along with other countries in eastern Europe and countries in central Asia, have the most rapidly expanding HIV epidemics. Here the disease is more closely tied to injecting drug use, which itself is linked to a rapid rise in indices of social inequality(3). Although the absolute number of AIDS cases in the former Soviet Union remains relatively small, the epidemic is expanding rapidly in the Russian Federation and other countries in the region(see Box 3.1). Prison- seated epidemics of TB, including drug-resistant strains, will be further fanned by the rapid rise in HIV incidence already documented among Russian prisoners. Only aggressive
HIV/AIDS: confronting a killer 45 The current situation How well has the international community coped with this new threat to global health? In spite of remarkable scientific achievements – the development of inexpensive diagnostics by the mid-1980s, the sequencing of the entire HIV genome less than 15 years later, and the development of effective antiretroviral therapy by 1995 – the virus has continued to spread (see Figure 3.2). It is estimated that during the course of 2002 some 5 million people became infected with HIV, and almost 3 million people died of AIDS. Everywhere in the world, HIV is transmitted through a fairly limited number of mechanisms. HIV is a bloodborne retrovirus and is transmitted through sexual contact, contaminated blood transfusions, injecting drug use, failure to observe what are now termed in medical circles “universal precautions”, and from mother to infant during pregnancy, delivery and breastfeeding. The most heavily burdened continent is Africa, where the spread of the pandemic has been accelerated by a variety of factors, including widespread poverty, gender inequality, and health systems weakened by pressures such as the large external debt loads of states. Africa is home to more than 70% of those currently infected with HIV. Of all AIDS deaths worldwide – 28 million at the end of 2002 – the majority have also occurred on this continent (3). HIV infection has fanned epidemics of TB in some African countries, increasing the risks to the whole population, regardless of serostatus. Across sub-Saharan Africa, rates of TB have more than trebled, and many conclude that the disease cannot be controlled without aggressive treatment of AIDS (4). Debates about the relative importance of different modes of HIV transmission in sub-Saharan Africa persist, but the evidence indicates that HIV in this region is primarily a sexually transmitted pathogen (5). Nonetheless, the difficulties involved in following universal precautions in overburdened and under-resourced health care facilities may lie at the root of many AIDS deaths in Africa (6). In many regions, unsafe blood transfusions continue, underscoring the importance of blood safety as a component of effective HIV/AIDS control. The immensity and rapidity of the spread of HIV have reversed gains in life expectancy in many African countries (see Chapter 1). But the worst may be yet to come. The poorer regions of Asia, including densely populated southern Asia, are the latest areas to be affected by the emerging AIDS epidemic. There has been an alarming rise in HIV/AIDS cases in Asia over the past two decades; the burden of disease and death in the region will be enormous if current epidemiological trends are not slowed or reversed. Developed countries are also afflicted. The Russian Federation and Ukraine, along with other countries in eastern Europe and countries in central Asia, have the most rapidly expanding HIV epidemics. Here the disease is more closely tied to injecting drug use, which itself is linked to a rapid rise in indices of social inequality (3). Although the absolute number of AIDS cases in the former Soviet Union remains relatively small, the epidemic is expanding rapidly in the Russian Federation and other countries in the region (see Box 3.1). Prisonseated epidemics of TB, including drug-resistant strains, will be further fanned by the rapid rise in HIV incidence already documented among Russian prisoners. Only aggressive Table 3.1 Coverage of adults in developing countries with antiretroviral therapy, by WHO region, December 2002 Region Number of Estimated Coverage people need Africa 50 000 4 100 000 1% Americas 196 000 370 000 53% Europe 7 000 80 000 9% Eastern Mediterranean 3 000 9 000 29% South-East Asia and Western Pacific 43 000 1 000 000 4% All WHO regions 300 000 5 500 000 5%
The World Health Report 2003 harm-reduction efforts and improved therapy for TB can stem what is a peculiarly modern epidemic of two linked diseases that are now colliding within countries reaching from west ern Europe to the Pacific Ocean(7). The true toll of hiviaids The epidemiology of HIV, including the dynamics of risk, is instructive. But epidemiology tells only part of the story. a disease that has so adversely affected life expectancy will also take a great d societies, above and beyond its terrible cost in immediate human suffering. To take two examples, AIDS has orphaned an estimated 14 million African children and will decimate the corps of teachers, health care workers and civil servants in the hardest-hit countries(8 These social disruptions are manifest in direct economic effects. A recent World Bank stud predicts that South Africa will face" complete economic collapse. within three generations if the country does not take effective measures to combat AIDS (9). But there is much more to the story than can be measured by economists. Other social scientists are broadening the analysis to look at the impact of the disease on an array of events and processes. What, for example, are the social consequences of having millions of AIDS orphans? How does the disappearance of so many parents contribute to the spread of armed conflict and the social pathologies that accompany urban migration and attendant unemployment? What is the cost of the"burnout"registered among health professionals across Africa and in other set ings where AIDS therapy is not available to those who need it most(10)? Science is only beginning to understand the social and economic toll of HIV/AIDS, which is heaviest in precisely those settings least prepared for a new threat to health and well-being igure 3.2 HIVIAIDS: episodes in an evolving epidemic etroviral therapy 2En352 First treatment developed to reduce HN vaccine starts in Thailand oved in USA ing of blood donations starts First dedine in HIV UN Secretary-General Kofi Annan 28时490道tmd 8E2 198019811982198319841985198619871988198919901991199199319941995199619971998 0120022003 Year Source: WHOYUNAIDS
46 The World Health Report 2003 harm-reduction efforts and improved therapy for TB can stem what is a peculiarly modern epidemic of two linked diseases that are now colliding within countries reaching from western Europe to the Pacific Ocean (7). The true toll of HIV/AIDS The epidemiology of HIV, including the dynamics of risk, is instructive. But epidemiology tells only part of the story. A disease that has so adversely affected life expectancy will also take a great toll on the social fabric of heavily burdened societies, above and beyond its terrible cost in immediate human suffering. To take two examples, AIDS has orphaned an estimated 14 million African children and will decimate the corps of teachers, health care workers and civil servants in the hardest-hit countries (8). These social disruptions are manifest in direct economic effects. A recent World Bank study predicts that South Africa will face “complete economic collapse … within three generations” if the country does not take effective measures to combat AIDS (9). But there is much more to the story than can be measured by economists. Other social scientists are broadening the analysis to look at the impact of the disease on an array of events and processes. What, for example, are the social consequences of having millions of AIDS orphans? How does the disappearance of so many parents contribute to the spread of armed conflict and the social pathologies that accompany urban migration and attendant unemployment? What is the cost of the “burnout” registered among health professionals across Africa and in other settings where AIDS therapy is not available to those who need it most (10)? Science is only beginning to understand the social and economic toll of HIV/AIDS, which is heaviest in precisely those settings least prepared for a new threat to health and well-being. Figure 3.2 HIV/AIDS: episodes in an evolving epidemic 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year Number of people living with HIV/AIDS (millions) 45 40 35 30 25 20 15 10 5 0 Source: WHO/UNAIDS First efficacy trial of a potential HIV vaccine starts in Thailand UN Security Council holds its first discussion of HIV/AIDS UN Secretary-General Kofi Annan calls for creation of a global fund on AIDS and health UN General Assembly adopts HIV/AIDS Declaration of Commitment Launch of Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) WHO backs "3 by 5" target of ARV treatment for 3 million people by 2005 WHO declares ARV treatment gap a global health emergency Brazil provides antiretroviral therapy through its public health system UNAIDS created Highly Active Antiretroviral Therapy (HAART) first discussed Outbreak in eastern Europe detected among injecting drug users First treatment developed to reduce mother-to-child transmission First decline in HIV prevalence begins among pregnant women in Uganda Azidothymidine (AZT) approved for use in USA WHO launches Special Programme on AIDS Cases of HIV/AIDS now reported in all world regions First HIV antibody test approved in USA. HIV screening of blood donations starts African heterosexual AIDS epidemic revealed Human Immunodeficiency Virus (HIV) identified as cause of AIDS Acquired Immunodeficiency Syndrome (AIDS) first defined First cases of unusual immune deficiency identified among gay men in USA
HIV/AIDS: confronting a killer Responding to HIVAIDS lessons from the past 20 years The first two decades of Hiv have disclosed a great deal about how best to prevent and at tenuate HIV-related suffering. There are large and small successes to report, but also well- documented defeats with important lessons. There are emerging trends. There are important local variations which render broad generalizations about the global AIDS pandemic ex- tremely hazardous. What can be documented now are a series of interconnected subepidemics". Each calls for a different set of interventions. Fortunately, the experience gained over the past 20 years offers guidance for those seeking to reverse the trends One of the most important lessons of recent years is the need for integrated AIDS prevention and care. Equity in AIDS prevention requires that correct and culturally appropriate infor mation be imparted, along with existing prevention tools, to those most at risk of Hiv infec tion, wherever they live. WHO considers inclusive and equitable prevention a fundamental part of its AIDS work. While there are studies emphasizing the need for constant efforts to promote safer sex and good medical practice, there are no data to support the claim that increased access to AIDS care hampers prevention efforts in the resource-poor settings in which HIV takes its greatest toll On the contrary, emerging evidence from ARV programmes in resource-poor settings such as central Haiti and Khayelitsha, South Africa, suggests that improving care will serve directly to strengthen prevention in a number of ways. These in- clude: increasing demand for voluntary counselling and testing; reducing stigma and pro moting greater openness in discussions of HIV/AIDS in the community; and helping to keep families intact and economically stable, thus slowing the growth of at-risk populations such as orphans and sex workers(11-15) What accounts for the often stark division between AIDS prevention and care, which in the developing world has meant that, for most people living with HIV, there is simply no decent medical care available at all? That it took 15 years to develop effective antiretroviral therapy for AIDS is regarded as a success by some; for the tens of millions who have died of AIDS, any victory has come too late. But the fact that much was known about HIV and its modes of transmission well before effective therapy became available contributed, in both rich and poor countries, to a separation of Hiv prevention and care. In Australia, Europe and the United States, HiV prevention and care are different enterprises conducted by different groups of people(16). Hiv prevention does not usually take place in AIDS clinics in wealthy Box 3.1 HIV/AIDS in the European Region The European Region is experiencing the fastest growing HIV epidemic The HIVAIDS epidemic has changed dramatically since its onset in in the world, and significant further growth is likely. Between 1995 and the 1980s Sustainable, long-term, comprehensive and massive response 2003, the number of newly reported HIV infections in western Europe in western Europe, with extensive funding and political support for pre- doubled to almost 170 000, and in central and eastern Europe grew vention, treatment and care limited the spread of the epidemic. Wide- from 27 000 to 320 000. It is now estimated that at least 1.7 million spread prevention measures contributed to stabilizing and decreasing people in Europe are already infected with HIV. transmission rates, while antiretroviral treatment was also made widely An epidemic of injecting drug use is fuelling the HIV epidemic In available. In spite of such measures, the HIv/AiDS epidemic remains a the former Soviet Union, where two-thirds of all Europeans infected serious and ongoing challenge in western Europe. In eastern Europe, with HIV live, 84% of all HIV cases with a known transmission route are limited political commitment and funding, low coverage by prevention attributable to injecting drug use. In western Europe, sexual transmis. services, severely limited access to treatment and care and high levels of sion is the dominant route, with the largest number of infections among stigmatization of groups at risk are the main reasons for a continuousl men who have sex with men and among immigrant populations from worsening HIV epidemic high prevalence countries
HIV/AIDS: confronting a killer 47 Responding to HIV/AIDS: lessons from the past 20 years The first two decades of HIV have disclosed a great deal about how best to prevent and attenuate HIV-related suffering. There are large and small successes to report, but also welldocumented defeats with important lessons. There are emerging trends. There are important local variations which render broad generalizations about the global AIDS pandemic extremely hazardous. What can be documented now are a series of interconnected “subepidemics”. Each calls for a different set of interventions. Fortunately, the experience gained over the past 20 years offers guidance for those seeking to reverse the trends. One of the most important lessons of recent years is the need for integrated AIDS prevention and care. Equity in AIDS prevention requires that correct and culturally appropriate information be imparted, along with existing prevention tools, to those most at risk of HIV infection, wherever they live. WHO considers inclusive and equitable prevention a fundamental part of its AIDS work. While there are studies emphasizing the need for constant efforts to promote safer sex and good medical practice, there are no data to support the claim that increased access to AIDS care hampers prevention efforts in the resource-poor settings in which HIV takes its greatest toll. On the contrary, emerging evidence from ARV programmes in resource-poor settings such as central Haiti and Khayelitsha, South Africa, suggests that improving care will serve directly to strengthen prevention in a number of ways. These include: increasing demand for voluntary counselling and testing; reducing stigma and promoting greater openness in discussions of HIV/AIDS in the community; and helping to keep families intact and economically stable, thus slowing the growth of at-risk populations such as orphans and sex workers (11–15). What accounts for the often stark division between AIDS prevention and care, which in the developing world has meant that, for most people living with HIV, there is simply no decent medical care available at all? That it took 15 years to develop effective antiretroviral therapy for AIDS is regarded as a success by some; for the tens of millions who have died of AIDS, any victory has come too late. But the fact that much was known about HIV and its modes of transmission well before effective therapy became available contributed, in both rich and poor countries, to a separation of HIV prevention and care. In Australia, Europe and the United States, HIV prevention and care are different enterprises conducted by different groups of people (16). HIV prevention does not usually take place in AIDS clinics in wealthy Box 3.1 HIV/AIDS in the European Region The European Region is experiencing the fastest growing HIV epidemic in the world, and significant further growth is likely. Between 1995 and 2003, the number of newly reported HIV infections in western Europe doubled to almost 170 000, and in central and eastern Europe grew from 27 000 to 320 000. It is now estimated that at least 1.7 million people in Europe are already infected with HIV. An epidemic of injecting drug use is fuelling the HIV epidemic. In the former Soviet Union, where two-thirds of all Europeans infected with HIV live, 84% of all HIV cases with a known transmission route are attributable to injecting drug use. In western Europe, sexual transmission is the dominant route, with the largest number of infections among men who have sex with men and among immigrant populations from high prevalence countries. The HIV/AIDS epidemic has changed dramatically since its onset in the 1980s. Sustainable, long-term, comprehensive and massive response in western Europe, with extensive funding and political support for prevention, treatment and care limited the spread of the epidemic. Widespread prevention measures contributed to stabilizing and decreasing transmission rates, while antiretroviral treatment was also made widely available. In spite of such measures, the HIV/AIDS epidemic remains a serious and ongoing challenge in western Europe. In eastern Europe, limited political commitment and funding, low coverage by prevention services, severely limited access to treatment and care and high levels of stigmatization of groups at risk are the main reasons for a continuously worsening HIV epidemic
The World Health Report 2003 countries. In many poor countries, however, HiV prevention does take place in clinics, al- though Hiv care often does not take place at all. The results of this separation have been adverse. Although there have been some significant victories, their benefits have been unevenly distributed. Despite striking declines in mortality rates adjusted for age among some people living with AIDS, affluent countries still face ongo- ing or growing subepidemics. As elsewhere, rates of HIV transmission vary by social stand ing. In the southern United States, for example, HIV continues disproportionately to affect ethnic minorities in urban conglomerations. Increasingly, poor black people living in rural areas connected by major routes of commerce are also affected. Research conducted in rural North Carolina suggests that the incidence of sexually transmitted infections(STIs)is closely linked to the presence of an interstate highway (17). Similar patterns have also been docu mented in rural parts of Africa and Asia. Even when local epidemiology differs, social in- equalities remain part of the equation for both risk of infection and access to care. In urban areas of the Russian Federation and Ukraine, in contrast to rural southern areas of the United States, a rapidly emerging epidemic is attributable to injecting drug use; among those most affected are the unemployed and, again, members of ethnic minorities Integrating HIV prevention and care Prevention activities need to be designed with the local epidemiology of the disease in mind In settings in which HIV is largely sexually transmitted, information and education cam- paigns can save lives. In Thailand, for example, it is estimated that aggressive condom pro motion targeting military personnel and sex workers has resulted in significantly fewer new infections than had been predicted (18). In settings in which HIV transmission is linked more closely to injecting drug use, harm-reduction strategies(for example, the provision of clean injecting equipment as well as adequate therapy for drug dependence) have proved to be effective(19). But in every setting studied, the distinction between prevention and care most marked in the poorest countries, where few of those in need of Iv care ever receive it has crippled effective response to the disease and also heightened social stigma. The integration of Hiv prevention and care is a recurrent and unifying theme of wHo ef- forts, in spite of the great diversity of subepidemics In settings where HIV/AIDS is seen not as a private problem but as a public one, good public policy can prevent new infections, as well as avert death among those already living with HIv. Of course, there is far too much work at hand for there to be no division of labour in prevention and care Clinicians must ensure that their distinctive skills are used optimally to benefit patients. Activists and com- munity members will make their most important contributions to prevention, support, edu cation and avoca It is difficult categorically to class on-the-ground activities as contributing either to"preven tion""care"exclusively. For example, most people would class the prevention of mother to-child transmission(pMTCT) of Hiv as a prevention activity But implementing such programmes has often called for improved prenatal care: MTCT-Plus"initiatives follow up the initial preventive intervention with ARV treatment for HIV-positive mothers, when clini- cally indicated, allowing women not only to give birth to healthy babies but also to live to raise them(20). Similarly, improving HIV care helps to destigmatize AIDS. Decreased stigma is associated with increased interest in voluntary counselling and testing, which is a corner- stone of effective Hiv prevention and care(13). Some recent studies have begun to catalogue the mechanisms by which increased access to quality Hiv care can strengthen prevention fforts (15)
48 The World Health Report 2003 countries. In many poor countries, however, HIV prevention does take place in clinics, although HIV care often does not take place at all. The results of this separation have been adverse. Although there have been some significant victories, their benefits have been unevenly distributed. Despite striking declines in mortality rates adjusted for age among some people living with AIDS, affluent countries still face ongoing or growing subepidemics. As elsewhere, rates of HIV transmission vary by social standing. In the southern United States, for example, HIV continues disproportionately to affect ethnic minorities in urban conglomerations. Increasingly, poor black people living in rural areas connected by major routes of commerce are also affected. Research conducted in rural North Carolina suggests that the incidence of sexually transmitted infections (STIs) is closely linked to the presence of an interstate highway (17). Similar patterns have also been documented in rural parts of Africa and Asia. Even when local epidemiology differs, social inequalities remain part of the equation for both risk of infection and access to care. In urban areas of the Russian Federation and Ukraine, in contrast to rural southern areas of the United States, a rapidly emerging epidemic is attributable to injecting drug use; among those most affected are the unemployed and, again, members of ethnic minorities. Integrating HIV prevention and care Prevention activities need to be designed with the local epidemiology of the disease in mind. In settings in which HIV is largely sexually transmitted, information and education campaigns can save lives. In Thailand, for example, it is estimated that aggressive condom promotion targeting military personnel and sex workers has resulted in significantly fewer new infections than had been predicted (18). In settings in which HIV transmission is linked more closely to injecting drug use, harm-reduction strategies (for example, the provision of clean injecting equipment as well as adequate therapy for drug dependence) have proved to be effective (19). But in every setting studied, the distinction between prevention and care – most marked in the poorest countries, where few of those in need of HIV care ever receive it – has crippled effective response to the disease and also heightened social stigma. The integration of HIV prevention and care is a recurrent and unifying theme of WHO efforts, in spite of the great diversity of subepidemics. In settings where HIV/AIDS is seen not as a private problem but as a public one, good public policy can prevent new infections, as well as avert death among those already living with HIV. Of course, there is far too much work at hand for there to be no division of labour in prevention and care. Clinicians must ensure that their distinctive skills are used optimally to benefit patients. Activists and community members will make their most important contributions to prevention, support, education and advocacy. It is difficult categorically to class on-the-ground activities as contributing either to “prevention” or “care” exclusively. For example, most people would class the prevention of motherto-child transmission (pMTCT) of HIV as a prevention activity. But implementing such programmes has often called for improved prenatal care: “MTCT-Plus” initiatives follow up the initial preventive intervention with ARV treatment for HIV-positive mothers, when clinically indicated, allowing women not only to give birth to healthy babies but also to live to raise them (20). Similarly, improving HIV care helps to destigmatize AIDS. Decreased stigma is associated with increased interest in voluntary counselling and testing, which is a cornerstone of effective HIV prevention and care (13). Some recent studies have begun to catalogue the mechanisms by which increased access to quality HIV care can strengthen prevention efforts (15)
HIV/AIDS: confronting a killer Integrated prevention and care: success stories Only a few countries have introduced legislation to protect the rights of those living wi HIV, including the right to effective therapy. Brazil is one country that has done so success fully. Although social inequalities exist in Brazil, it became one of the first countries in the world to mandate universal and free access to HIV care. In this way, aIDS was transformed from a private problem, one affecting individuals and their families, to a public one By intro ducing innovative legislation, Brazil was able to build up Latin America's largest and best functioning AIDS programme. Widespread access to ARVs may have helped to destigmatize the disease in Brazil and thereby improve demand for voluntary counselling and testing Although causality is hard to prove, projections made over a decade ago, when it was pre dicted that Brazil would have a rapidly expanding epidemic, have not come to pass. HIV incidence has declined in recent years now that ARVs are widely available: only 7361 new cases of HIV infection were registered in the first nine months of 2001, compared with 17 504 cases registered in 2000 (21). The Ministry of Health of Brazil estimates that cost savings for reduced hospital admissions and treatment of opportunistic infections between 1997 and 2001 were close to USS 2.1 billion. The Brazilian experience is not unique. In 2003, Mexico passed legislation similar to Brazils and may reasonably hope for similar successes( 22). Policy can therefore have an indisputable therapeutic effect on HIV/AIDS Countries far poorer than Brazil or Mexico have been forced to focus their efforts elsewhere but can still achieve positive results In Haiti, the most impoverished country in the Ameri- has introduce ed culturally appropriate Hiv prevention and state-of-the-art HIV care to a population living in dire poverty. One project in Haiti's Central Plateau is a small but mature integrated prevention and care project that first incorporated community-based ARV use in 1998. Because rural Haiti is a setting in which there are very few physicians or nurses, the"HIV Equity Initiative"relies on community health workers called accompagnateurs who pay daily visits to patients in their home villages. The accompagnateurs(some of whom are themselves living with HIV) are not so much providing directly observed therapy as taking care of their neighbours(see Box 3. 2) The Haiti project has been notable for its clinical and social success -lowered mortality and decreased stigma -but also for its low costs. with the advent of generic ARVs, the HIv equity Initiative is now being scaled up throughout the forbidding terrain of central Haiti, which is without electricity or paved roads(23). Seroprevalence studies suggest that the Haitian HIV Box 3.2 Accompagnateurs: an example of AIDS care in resource-poor settings The existence of effective therapy for AIdS has dramatically altered the community health workers. In some settings, a number of people, in- outcome of HIv infection in certain parts of the world, but such ad- cluding traditional healers, have expressed an interest in being trained vances are rarely used in precisely those settings most heavily burdened to"accompany"their neighbours living with AIDS. The involvement of with AIDS. Most HIV-related deaths in the developing world today occur these and other community-based workers as accompagnateurs will be among those who have never received combination chemotherapy with critical if even modest treatment goals are to be met in the coming antiretrovirals(ARVs). Reasons offered for this failure have been many, years. There is an important precedent in the community-based man- but two are usually given: the high cost of ARVs and the lack of infra- agement of a chronic infectious disease Tuberculosis programmes re- structure required for their use. The first of these objections is under porting the highest cure rates are often those relying on accompagnateurs review as generic ARVs become available and as the price of branded or other community-based providers. The amount of training required is pharmaceuticals dr minimal; supervision of accompagnateurs may be offered by clinic-based The question of missing infrastructure remains. Experience in Haiti nurses and physicians. If the accompagnateur model is adopted widely and elsewhere suggests that this may be largely a question of personnel patients afflicted with other chronic diseases may hope for high-quality rather than laboratory or medical infrastructure. In settings with few medical care even where there is no doctor(23) physicians and nurses there often exists a large number of underutilized
HIV/AIDS: confronting a killer 49 Integrated prevention and care: success stories Only a few countries have introduced legislation to protect the rights of those living with HIV, including the right to effective therapy. Brazil is one country that has done so successfully. Although social inequalities exist in Brazil, it became one of the first countries in the world to mandate universal and free access to HIV care. In this way, AIDS was transformed from a private problem, one affecting individuals and their families, to a public one. By introducing innovative legislation, Brazil was able to build up Latin America’s largest and bestfunctioning AIDS programme. Widespread access to ARVs may have helped to destigmatize the disease in Brazil and thereby improve demand for voluntary counselling and testing. Although causality is hard to prove, projections made over a decade ago, when it was predicted that Brazil would have a rapidly expanding epidemic, have not come to pass. HIV incidence has declined in recent years now that ARVs are widely available: only 7361 new cases of HIV infection were registered in the first nine months of 2001, compared with 17 504 cases registered in 2000 (21). The Ministry of Health of Brazil estimates that cost savings for reduced hospital admissions and treatment of opportunistic infections between 1997 and 2001 were close to US$ 2.1 billion. The Brazilian experience is not unique. In 2003, Mexico passed legislation similar to Brazil’s and may reasonably hope for similar successes (22). Policy can therefore have an indisputable therapeutic effect on HIV/AIDS. Countries far poorer than Brazil or Mexico have been forced to focus their efforts elsewhere, but can still achieve positive results. In Haiti, the most impoverished country in the Americas, a public–private partnership has introduced culturally appropriate HIV prevention and state-of-the-art HIV care to a population living in dire poverty. One project in Haiti’s Central Plateau is a small but mature integrated prevention and care project that first incorporated community-based ARV use in 1998. Because rural Haiti is a setting in which there are very few physicians or nurses, the “HIV Equity Initiative” relies on community health workers called accompagnateurs who pay daily visits to patients in their home villages. The accompagnateurs (some of whom are themselves living with HIV) are not so much providing directly observed therapy as taking care of their neighbours (see Box 3.2). The Haiti project has been notable for its clinical and social success – lowered mortality and decreased stigma – but also for its low costs. With the advent of generic ARVs, the HIV Equity Initiative is now being scaled up throughout the forbidding terrain of central Haiti, which is without electricity or paved roads (23). Seroprevalence studies suggest that the Haitian HIV Box 3.2 Accompagnateurs: an example of AIDS care in resource-poor settings The existence of effective therapy for AIDS has dramatically altered the outcome of HIV infection in certain parts of the world, but such advances are rarely used in precisely those settings most heavily burdened with AIDS. Most HIV-related deaths in the developing world today occur among those who have never received combination chemotherapy with antiretrovirals (ARVs). Reasons offered for this failure have been many, but two are usually given: the high cost of ARVs and the lack of infrastructure required for their use. The first of these objections is under review as generic ARVs become available and as the price of branded pharmaceuticals drops. The question of missing infrastructure remains. Experience in Haiti and elsewhere suggests that this may be largely a question of personnel rather than laboratory or medical infrastructure. In settings with few physicians and nurses there often exists a large number of underutilized community health workers. In some settings, a number of people, including traditional healers, have expressed an interest in being trained to “accompany” their neighbours living with AIDS. The involvement of these and other community-based workers as accompagnateurs will be critical if even modest treatment goals are to be met in the coming years. There is an important precedent in the community-based management of a chronic infectious disease. Tuberculosis programmes reporting the highest cure rates are often those relying on accompagnateurs or other community-based providers. The amount of training required is minimal; supervision of accompagnateurs may be offered by clinic-based nurses and physicians. If the accompagnateur model is adopted widely, patients afflicted with other chronic diseases may hope for high-quality medical care even where there is no doctor (23)
The World Health Report 2003 pidemic is contracting rather than growing(24), although the precise impact of HIv/AIDS programmes on the spread of the disease remains to be measured. Uganda is another extremely poor country that has known declining HIV infection rates Some have claimed that declining prevalence is the result of an aggressive government cam- paign to advance prevention messages. The "ABC campaign"is a social marketing effort to promote abstinence, monogamy ("be faithful"is the B in the acronym)and condom use(25) owever, declining HiV prevalence in Uganda involves far more than high-level political will and forceful condom promotion, important as these factors are. Developments in Uganda reflect a complex biosocial pattern that includes war, death, migration, and many other events and processes(including, in Kampala and beyond, increased access to ARVs)not necessarily included under the rubric"ABC campaign"(see Figure 3.3). The empowerment of women appears to have been a key factor in enabling safer patterns of sexual behaviour. Civil society groups such as The AIDS Service Organization(TASO)have played a major role. It is also important to note that post-war Uganda, with help from the European Community and other funders, has made significant investments in rebuilding its health care infrastructure(26). Setting a new agenda On the basis of the rationale for integrating prevention and care, outlined above, this report suggests an aggressive strategy for global action against the hiviaIDS pandemic This agenda will unite the efforts of partners from many sectors A human rights approach Although some people may have become wary of expressions such as"adopting a human rights approach to HIVIAIDS highly pragmatic steps can be taken to do just that, and these interventions will have a salutary effect on AIDS prevention and care. Social and economic rights, including the right to health care, are central to a future in which Hiv will play a less Figure 3.3 Trends in the cost of ARV drugs and the number of people on treatment Uganda,1997-2002 2000 1997 1999 Price of first-line regimen in USS per year Number of people on treatment
50 The World Health Report 2003 epidemic is contracting rather than growing (24), although the precise impact of HIV/AIDS programmes on the spread of the disease remains to be measured. Uganda is another extremely poor country that has known declining HIV infection rates. Some have claimed that declining prevalence is the result of an aggressive government campaign to advance prevention messages. The “ABC campaign” is a social marketing effort to promote abstinence, monogamy (“be faithful” is the B in the acronym) and condom use (25). However, declining HIV prevalence in Uganda involves far more than high-level political will and forceful condom promotion, important as these factors are. Developments in Uganda reflect a complex biosocial pattern that includes war, death, migration, and many other events and processes (including, in Kampala and beyond, increased access to ARVs) not necessarily included under the rubric “ABC campaign” (see Figure 3.3). The empowerment of women appears to have been a key factor in enabling safer patterns of sexual behaviour. Civil society groups such as The AIDS Service Organization (TASO) have played a major role. It is also important to note that post-war Uganda, with help from the European Community and other funders, has made significant investments in rebuilding its health care infrastructure (26). Setting a new agenda On the basis of the rationale for integrating prevention and care, outlined above, this report suggests an aggressive strategy for global action against the HIV/AIDS pandemic. This agenda will unite the efforts of partners from many sectors. A human rights approach Although some people may have become wary of expressions such as “adopting a human rights approach to HIV/AIDS”, highly pragmatic steps can be taken to do just that, and these interventions will have a salutary effect on AIDS prevention and care. Social and economic rights, including the right to health care, are central to a future in which HIV will play a less 0 2 000 4 000 6 000 8 000 10 000 12 000 1997 1998 1999 2000 2001 2002 Price of first-line regimen in US$ per year Number of people on treatment Figure 3.3 Trends in the cost of ARV drugs and the number of people on treatment, Uganda, 1997–2002 Year
HIV/AIDS: confronting a killer destructive role in people's lives. Governments should take the lead in promoting a human rights model of AIDS prevention and care Promotion of the human rights approach to AIDS cannot remain solely the charge of the nation-state,however, especially as poor and beleaguered governments are exhorted to do more and more with less and less Civil society organizations, including groups of people living with HIV/AIDS, will continue to yy a cruc ial role in advancing a human-rights-based HIVIAIDS agenda at global,na tional and local levels. Such groups have been at the forefront of HIv/AIDS prevention, edu cation,and advocacy- not only in wealthy countries, but also in Brazil, Haiti, South Africa Thailand, Uganda and elsewhere. It is important to ensure that some of the new funding now flowing to HIVIAIDS work through mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria(GFATM)and bilateral initiatives is channelled to civil society groups, especially community-based organizations run by and for people living with HIV/AIDS Dimensions of good HIV/AIDS control Although equity is the only acceptable end goal, it is nevertheless true that setting priorities is a key step in the crafting of sound policy. It is possible to identify a number of highly impor tant considerations in implementing projects and national aIdS programmes in resoure poor settings Haiti, one of the worlds poorest countries, provides insights. Spiralling, entwined epi- demics of TB and HIV and the worst poverty in the Americas did not stop Haiti from putting together a successful application to the GFATm. The proposal submitted to the gFatm called for expanding integrated HIV prevention and care and was linked to the existing national AIDS control plan(27). The Haitian model proposes a stepwise implementation, beginnin with improved voluntary counselling and testing and prevention of mother-to-child trans- mission and then unfolding progressively in several dimensions. The first dimension includes a complete range of prevention services and practices to reduce HIV transmission in all set tings. Prevention activities are integrated with improved HIV care for people already infected. Prevention measures include culturally appropriate, community-based HIV education, con dom distribution, and voluntary counselling and testing. This component also embraces blood Ifety and the observance of universal precautions, including safe injection practices The second dimension is improved women's health, including access to family planning and safe childbirth. Prevention of hiv transmission from mother to infant will have. as a"wind- fall benefit the improvement of womens health in a broader sense. Indeed, it will be easie to meet Millennium Development Goals related to maternal mortality by improving capa ity to scale up pilot programmes for the prevention of mother-to-child transmission The third dimension of integrated HIV prevention and care is improved TB case-finding and care. This is important in communities heavily burdened by both diseases, since in these settings-most of southern Africa is a case in point-TB is the leading serious opportunistic infection among people living with HIV. Finally, the fourth component of this model is the diagnosis and treatment, preferably through algorithms reflecting local epidemiology, of all STIs. Numerous studies have shown that improving care for STIs will diminish the risk of acquiring HIV (28-30) Local variation has always been a central factor in the hiviaidS story, so the relevance of any pilot projects should be scrutinized Can such programmes be scaled up district-wide or nationally? Can they be replicated in other heavily burdened and resource-constrained areas?
HIV/AIDS: confronting a killer 51 destructive role in people’s lives. Governments should take the lead in promoting a human rights model of AIDS prevention and care. Promotion of the human rights approach to AIDS cannot remain solely the charge of the nation-state, however, especially as poor and beleaguered governments are exhorted to do more and more with less and less. Civil society organizations, including groups of people living with HIV/AIDS, will continue to play a crucial role in advancing a human-rights-based HIV/AIDS agenda at global, national and local levels. Such groups have been at the forefront of HIV/AIDS prevention, education, and advocacy – not only in wealthy countries, but also in Brazil, Haiti, South Africa, Thailand, Uganda and elsewhere. It is important to ensure that some of the new funding now flowing to HIV/AIDS work through mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and bilateral initiatives is channelled to civil society groups, especially community-based organizations run by and for people living with HIV/AIDS. Dimensions of good HIV/AIDS control Although equity is the only acceptable end goal, it is nevertheless true that setting priorities is a key step in the crafting of sound policy. It is possible to identify a number of highly important considerations in implementing projects and national AIDS programmes in resourcepoor settings. Haiti, one of the world’s poorest countries, again provides insights. Spiralling, entwined epidemics of TB and HIV and the worst poverty in the Americas did not stop Haiti from putting together a successful application to the GFATM. The proposal submitted to the GFATM called for expanding integrated HIV prevention and care and was linked to the existing national AIDS control plan (27). The Haitian model proposes a stepwise implementation, beginning with improved voluntary counselling and testing and prevention of mother-to-child transmission and then unfolding progressively in several dimensions. The first dimension includes a complete range of prevention services and practices to reduce HIV transmission in all settings. Prevention activities are integrated with improved HIV care for people already infected. Prevention measures include culturally appropriate, community-based HIV education, condom distribution, and voluntary counselling and testing. This component also embraces blood safety and the observance of universal precautions, including safe injection practices. The second dimension is improved women’s health, including access to family planning and safe childbirth. Prevention of HIV transmission from mother to infant will have, as a “windfall benefit”, the improvement of women’s health in a broader sense. Indeed, it will be easier to meet Millennium Development Goals related to maternal mortality by improving capacity to scale up pilot programmes for the prevention of mother-to-child transmission. The third dimension of integrated HIV prevention and care is improved TB case-finding and care. This is important in communities heavily burdened by both diseases, since in these settings – most of southern Africa is a case in point – TB is the leading serious opportunistic infection among people living with HIV. Finally, the fourth component of this model is the diagnosis and treatment, preferably through algorithms reflecting local epidemiology, of all STIs. Numerous studies have shown that improving care for STIs will diminish the risk of acquiring HIV (28–30). Local variation has always been a central factor in the HIV/AIDS story, so the relevance of any pilot projects should be scrutinized. Can such programmes be scaled up district-wide or nationally? Can they be replicated in other heavily burdened and resource-constrained areas?
