Chapter 1. A global emergency: a combined response
This chapter describes the current epidemiological state of HIV/AIDS epidemics around the world and examines the daunting challenges that lie ahead. It shows that the world is far from ready for what is to come: it provides evidence that the social and economic consequences of unchecked HIV/AIDS epidemics will be catastrophic for many communities and countries.
Although it has seemed a familiar enemy for much of the last 20 years, the global HIV/AIDS pandemic is only now beginning to be seen for what it is: a unique threat to human society, whose impact will be felt by future generations. The most explosive growth of the pandemic occurred during the middle of the 1990s, especially in sub-Saharan Africa. Today, an estimated 34–46 million people are living with HIV/AIDS. Two-thirds of the total live in Africa, where about one in 12 adults is infected, and one-fifth in Asia. Globally, unprotected sexual intercourse between men and women is the predominant mode of transmission of the virus.
The chapter explains why WHO, along with its partners, believes an emergency global and comprehensive response is essential and must embrace prevention, treatment and long-term care. Prevention is essential to protect the many millions of young adults and children who are most at risk but who are not yet affected. Treatment is the difference between life and death for the millions of people who are HIV-positive but are currently denied access to antiretroviral medications. Long-term care is also essential. Almost 6 million people need treatment now – only about 400 000 received it in 2003. The chapter argues that a treatment gap of such dimensions is indefensible, and that narrowing it is a public health necessity.
Together, prevention, treatment and long-term care and support can reverse the seemingly inexorable progress of the HIV/AIDS epidemics, offering the worst-affected countries and populations their best hope of survival.
Chapter 2. The treatment initiative
This chapter stresses the need for a comprehensive strategy that links prevention, treatment, research, and long-term care and support for people living with HIV/AIDS. But it points out that until now, treatment has been the most neglected component of this approach in much of the developing world. To accelerate prevention while limiting the social devastation now unfolding, rapid expansion of HIV/AIDS treatment with antiretroviral medicines in the countries hardest hit by the pandemic is needed immediately.
Despite mounting evidence that this treatment works in resource-poor settings, by late 2003 less than 7% of people in developing countries in urgent need were receiving it. The chapter examines public health arguments and economic and social arguments for scaling up antiretroviral therapy. It then presents WHO’s strategy for working with countries and partners to reach the treatment target and provides an estimate of the global investment required. It explains the five pillars that support the strategy. These are: global leadership, strong partnership and advocacy; urgent, sustained country support; simplified, standardized tools for delivering antiretroviral therapy; effective, reliable supply of medicines and diagnostics; and rapid identification and reapplication of new knowledge and successes.
The opportunities and challenges facing selected countries are explored, highlighting the need to ensure that treatment scale-up reaches the poorest people. Finally, the chapter considers the wider importance of expanded treatment as a new way of working across the global health community for improved health outcomes and equity.
Chapter 3. Community participation: advocacy and action
The participation of communities and civil society groups, particularly groups of people living with HIV/AIDS, is crucial to treatment scale-up and comprehensive HIV/AIDS control. This participation will include both advocacy and the involvement of community members in delivering services and support to patients. Community involvement is essential to prevention, treatment, care, support and research.
This chapter describes the background of community participation as a dimension of public health work and recalls key achievements of civil society HIV/AIDS activism. It then considers the roles that civil society groups and community members will play in scaling up antiretroviral therapy in resource-poor settings.
State leadership will be indispensable to successful scale-up, and civil society cannot replace the public sector. But a key task of effective government leadership will be creating partnerships with civil society organizations and mechanisms to make use of the skills available within communities. The commitment to community participation links the treatment strategy with the Health-for-All vision and an equity-based agenda in global public health. The values of human rights, health equity and social justice embraced by many civil society AIDS activist groups are closely related to WHO’s constitutional objective: “the attainment by all peoples of the highest possible level of health”. This chapter shows that these values provide a basis for ongoing collaboration and partnerships between communities, civil society groups, national governments and international organizations, including WHO.
Such collaboration will be crucial to future health progress. The role of the 3 by 5 initiative in catalysing innovative partnerships is part of how it is changing ways of thinking and working in global health. For example, communities educated and mobilized around HIV/AIDS control will be better able to take part in health promotion, disease control and treatment efforts regarding health problems related to other Millennium Development Goals: to combat malaria and other diseases, maternal and child mortality, and the growing burden of chronic adult diseases in low-income and middle-income countries.
Chapter 4. Health systems: finding new strength
Health sector interventions against HIV/AIDS – especially the treatment initiative – are dependent on well-functioning health systems. In countries with a high burden of HIV/AIDS, systems are often degraded and dysfunctional because of a combination of underfunding and weak governance. HIV/AIDS places additional burdens on these weakened health systems.
The 3 by 5 initiative has the potential to strengthen health systems in a number of ways, by, for example, attracting resources to the health system in addition to those required for HIV/AIDS, stimulating investment in physical infrastructure, developing procurement and distribution systems of generic application, and fostering interaction with communities which can benefit a wide range of health interventions. It is important that any potentially adverse effects on the wider health system are anticipated and minimized.
The chapter continues with a consideration of the health systems context in resource-poor settings, taking note of the participation of both public and private providers. It then considers how health systems can be strengthened, so that they can implement the expanded treatment initiative while continuing to improve and expand many other health interventions. The conceptual framework of the four main functions of health systems is used: leadership, service delivery, resource provision, and financing. In the medium term, the financing gap will have to be closed mainly by external donors, because national governments and economies are incapable of generating much more than they do already, whereas donors, aware of their past pledges, can be enouraged to do more.
Chapter 5. Sharing research and knowledge
This chapter records that, since scientists first identified the human immunodeficiency virus as the cause of AIDS in 1983, there have been many remarkable research achievements related to the disease and many people have benefited. Twenty years ago there was little effective treatment; today there is a range of antiretroviral drugs that dramatically improve patients’ quality of life and chances of survival.
Despite significant advances, however, including the design and testing of more than 30 candidate HIV vaccines, it will be several more years at least before a safe and effective vaccine becomes widely available. In examining that continuing quest, the chapter also reviews research into other important areas of HIV/AIDS prevention, treatment and care.
There are four broad categories of challenges facing researchers.
- Prevention research – slowing down the growth and geographical expansion of the epidemic: a challenge for epidemiology and sociobehavioural aspects of prevention.
- Vaccine research – designing a safe and effective preventive vaccine, the best hope for the long-term prevention and control of HIV/AIDS.
- Treatment research – generating new antiretroviral drugs and designing new therapeutic strategies that would be active on “wild” and resistant strains of viruses, easy to take and better tolerated than currently available drugs: a challenge for basic and clinical research.
- Delivery system (operational) research – making care and antiretroviral treatment available to all of those who need it worldwide: a multidisciplinary undertaking.
The chapter examines important matters such as the prevention of HIV transmission from mother to child; the development and use of microbicides; the need to sustain long-term adherence to treatment; toxicities; drug resistance; joint approaches to HIV/AIDS and tuberculosis; economic issues; health policy analysis; equity issues; and international collaboration. The chapter leads on to the report’s brief concluding section, which contains an optimistic view of the future. It emphasizes that a crucial moment has been reached in the history of HIV/AIDS, and that there is now an unprecedented opportunity to alter its course. Ahead lies the challenge of extending lifelong treatment to many more millions of people, while simultaneously building and sustaining the health infrastructures to make that huge task possible. The outcome can be better health for generations to come.