This is a critical moment in the history of HIV/AIDS. There is more money, more political will and more attention being paid to this killer disease than ever before. And yet, more people than ever are dying of AIDS and becoming infected with HIV. By using HIV treatment programs to strengthen existing prevention programs and improve health systems, the international community has a unique opportunity to change the course of history, says The World Health Report 2004 - Changing History .
WHO, UNAIDS and partners are implementing a comprehensive HIV/AIDS strategy which links prevention, treatment, care and support for people living with the virus. Until now, treatment has been the most neglected element in most developing countries. Yet among all possible HIV- related interventions, the report says it is treatment that can most effectively boost prevention efforts and in turn drive the strengthening of health systems and enable poor countries to protect people from a wide range of health threats.
"At long last, global investment in health - and particularly in the fight against HIV/AIDS - is on the rise. It brings a welcome and long overdue improvement in the prospects for controlling the worst global epidemic in several centuries. The challenge now is to coordinate all our efforts and to ensure that this money benefits the people who need it most," said LEE Jong-wook, Director-General of the World Health Organization (WHO).
Vital resources have now been pledged, including more than US$ 20 billion from donor countries and through multilateral funding agencies, including the Global Fund to fight AIDS, Tuberculosis and Malaria, the United States President's Emergency Plan for HIV/AIDS Relief and the World Bank1 . These funds must now be used swiftly and in a coordinated way to prolong the lives of millions of children, women and men who will otherwise soon die. Adequate technical support for HIV/AIDS programmes must be mobilized to ensure that the new investments have the greatest possible long-term impact on the health of people in poor countries.
"We must invest these additional resources in strengthening comprehensive prevention and care strategies that build on twenty years experience of what we know works," said Dr Peter Piot, UNAIDS Executive Director. "Scaling up effective HIV treatment and prevention programmes is the best strategy to save lives and keep future generations HIV-free."
The report says the delivery of AIDS treatment and prevention also offers the chance to build up health systems in the poorest countries, providing health benefits for all. "Future generations will judge our era in large part by our response to the AIDS pandemic," said Dr Lee. "By tackling it decisively we will also be building health systems that can meet the health needs of today and tomorrow. This is an historic opportunity we cannot afford to miss."
Already, AIDS has killed more than 20 million people and is now the leading cause of death and lost years of productive life for adults aged 15-59 years worldwide. Today, an estimated 34-46 million people are living with HIV/AIDS. Without treatment, all of them will die a premature and in most cases painful death. In 2003, three million people died and five million became infected. Almost six million people in developing countries will die in the near future if they do not receive treatment - but only about 400 000 of them were receiving it by the end of 2003.
The long-term economic and social costs of HIV/AIDS have been seriously underestimated in many countries, the report says. Projections now suggest that some countries in sub-Saharan Africa will face economic collapse unless they bring their epidemics under control, mainly because HIV/AIDS weakens and kills adults in their prime - depriving communities of doctors, teachers and lawyers, as well as farmers, miners and police officers, and depriving children of their parents.
Hope through treatment
In September 2003, WHO, UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria declared lack of access to treatment with antiretroviral medicines a global health emergency. In response, these organizations and their partners launched an effort to provide three million people in developing countries with antiretroviral therapy by the end of 2005 - the "3 by 5" initiative.
By March 2004, 48 of the countries with the highest burden of HIV/AIDS had expressed their commitment to rapid treatment expansion and requested technical cooperation in designing and implementing scale-up programmes.
"As money is finally beginning to flow through the Global Fund and others towards treatment programmes in developing countries, we see that countries need advice, information about best practices and technical assistance in order to execute the rapid scale-up," says Professor Richard Feachem, Executive Director of The Global Fund to Fight AIDS, Tuberculosis and Malaria. "WHO will play a crucial role in the years to come to ensure that increased resources are turned into lives saved."
WHO is working closely with all partners, including national health officials, treatment providers, community organizations, people living with HIV/AIDS and other stakeholders to design national treatment scale-up plans and begin their implementation. Political commitment and national ownership of programmes are essential. The streamlined funding mechanisms developed by the Global Fund are enabling many countries to access funding and expand AIDS treatment and prevention programmes faster than ever before.
Prevention and treatment go together
Scaling up treatment can support and strengthen prevention programmes. Where treatment has been made available, this has led to overwhelming demands for testing and counselling. Good counselling and HIV education lead to more effective prevention in those who are uninfected, and significantly reduces the potential for infection transmission in those who have HIV.
Scaling up testing and counselling in health services for people with TB, for pregnant women and for vulnerable populations including youth, sex workers and injecting drug users, leads to greater engagement of those who may be vulnerable - again strengthening opportunities for prevention. Motivating communities to learn their HIV status in a context of access to antiretroviral treatment is altering community responses to HIV, encouraging greater openness and helping to reduce the stigma and denial that has enabled the virus to spread so disastrously.
Action in Countries
As new funding flows in, technical resources and trained staff must be ready to ensure its effective use. Countries often need technical assistance in implementing programmes on the ground, and have requested clear guidance on treatment delivery and programme management. WHO makes a fundamental contribution by providing such guidance.
To help accelerate the treatment initiative, WHO has developed a simplified set of antiretroviral drug regimens, testing and treatment guidelines that are consistent with the highest standards of quality of care. The guidelines are intended to be used at all levels of the health system, as well as in the community to monitor and promote adherence to treatment. Because these regimens make it possible for even the poorest areas to start treating those who need it, they ensure that rollout of treatment programs can be done equitably.
WHO has also designed streamlined guidelines for training health workers in a wide range of skills, from HIV counselling and testing and recruitment of patients to treatment delivery, clinical management of patients and the monitoring of drug resistance.
In partnership with UNICEF and the World Bank, WHO has established the AIDS Medicines and Diagnostics Service to ensure that developing countries have access to quality antiretrovirals and diagnostic tools at the best prices. The service aims to help countries to buy, forecast and manage the supply and delivery of products necessary for treatment and monitoring. It will also provide information to manufacturers to enable them to forecast demand, thus ensuring that quantities produced reflect real needs at affordable prices.
As policy and technical support work at country level intensifies, WHO, UNAIDS and partners will continue advocating globally for adequate resources to support countries. New resources available through the Global Fund and other partners will be critical to success. On request, WHO is providing countries with technical assistance in the preparation of applications to the Global Fund and other potential donors.
Towards Health for All
The report says that the global HIV/AIDS treatment gap reflects wider patterns of inequality in health and is a test of the international community's commitment to tackle these inequalities. Beyond working to save millions of lives under immediate threat, WHO and its partners are confronting a broad range of health problems that afflict poor communities and keep them poor, viewing HIV/AIDS treatment expansion and the Millennium Development Goals as steps on the road to Health for All.
The report makes it clear that the treatment initiative will not end in 2005. Ahead lie the challenges of extending treatment to many more millions of people and maintaining it for the rest of their lives, while simultaneously building and sustaining the health infrastructures to make that huge task possible. "The ultimate aim is nothing less than to reduce health inequalities by building up effective, equitable health systems for all," the report says.
The World Health Report 2004 - Changing History is published on May 11, price Swiss francs 30.00. The price for developing countries is Swiss francs 10.00. The report is available on the WHO web site, at www.who.int/whr .
1 Major pledges include: US$ 15 billion by 2008 through the United States President's Emergency Plan for HIV/AIDS Relief; US$ 5.5 billion has been pledged to the Global Fund to fight AIDS, Tuberculosis and Malaria; more than US$ 1 billion had been made available through the World Bank Multi-Country HIV/AIDS Program (MAP)