The world health report

Chapter 3: HIV/AIDS: confronting a killer

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.

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).

Figure 3.1
Figure 3.1

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 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 resource-poor settings, but are precisely what is needed.

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