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Africa: AIDS, New World Health Plan
AfricaFocus Bulletin
Dec 1, 2003 (031201)
(Reposted from sources cited below)
Editor's Note
"I feel angry, I feel distressed, I feel helpless ... to live in a
world where we have the means, we have the resources, to be able to
help all these patients - what is lacking is the political will.
... It does indicate a certain incredible callousness that one
would not have expected in the 21st century." - United Nations
Secretary General Kofi Annan.
This issue of AfricaFocus Bulletin contains excerpts from the press
release announcing a new World Health Organization initiative to
bring AIDS treatment to three million people - half of those who
need it - by the end of 2005. Yet even this commitment - still
awaiting full funding from the world's rich countries - would leave
the other half to die. Meanwhile the U.S. Senate adjourned without
final approval of the spending bills that would approve $2.4
billion for the first year of President Bush's AIDS initiative -
$400 million more than the President's request, but still short of
the $3 billion a year he promised early this year.
Another AfricaFocus Bulletin distributed today cites stronger
voices in Africa speaking for immediate action and some signs of
progress on several fronts. World AIDS Day 2003 marks a sharp
increase in the number of statements, events, and media specials
across the globe. But it will take even greater efforts to force
U.S. and other rich country politicians to match rhetoric with
resources.
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World Health Organization and UNAIDS Unveil Plan to Get 3 Million
AIDS Patients on Treatment by 2005
Nov 30, 2003
Excerpted from press release; for full text and more information
see: http://www.who.int/hiv]
Geneva - The World Health Organization (WHO) and UNAIDS today
release a detailed and concrete plan to reach the 3 by 5 target of
providing antiretroviral treatment to three million people living
with AIDS in developing countries and those in transition by the
end of 2005. This is a vital step towards the ultimate goal of
providing universal access to AIDS treatment to all those who need
it. ...
"Preventing and treating AIDS may be the toughest health assignment
the world has ever faced, but it is also the most urgent," said Dr
LEE Jong-wook, Director-General of the World Health Organization.
"The lives of millions of people are at stake. This strategy
demands massive and unconventional efforts to make sure they stay
alive."
UNAIDS announced last week that 40 million people around the world
are infected with HIV, and that the global AIDS epidemic shows no
signs of abating. Five million people became infected with HIV
worldwide and 3 million died this year alone - that's 8,000 people
every day. WHO estimates that six million people worldwide are in
immediate need of AIDS treatment. This strategy outlines the steps
needed to deliver treatment to half of them within two years.
The strategy is a key element in a combined programme of
accelerating HIV/AIDS prevention and treatment. Much has already
been done by countries, by UNAIDS, the World Bank, foundations, WHO
and many other groups. After twenty years of fighting the epidemic,
it is now clear that a comprehensive approach to HIV/AIDS must
include prevention, treatment and care. ...
Evidence and experience shows that rapidly increasing the
availability of antiretroviral treatment in line with 3 by 5
targets can lead to more people knowing their HIV status and more
openness about AIDS. Individuals on effective treatment are also
likely to be less infectious and less able to spread the virus.
Good treatment programmes will make more people come forward for
testing HIV/AIDS status. Treatment can therefore contribute to the
rapid acceleration of prevention.
Building on work done by UNAIDS, developing and donor countries,
NGOs and other multilateral agencies, WHO and UNAIDS are taking
another big step forward in the global movement to increase access
to prevention and treatment services.
"The lack of HIV treatment is without a doubt a global emergency,"
said Dr. Peter Piot, UNAIDS Executive Director. "We firmly believe
that we stand no chance of halting this epidemic unless we
dramatically scale up access to HIV care. Treatment and prevention
are the two pillars of a truly effective comprehensive AIDS
strategy."
3 by 5 Strategy
To reach the 3 by 5 target, WHO and UNAIDS will focus on five
critical areas:
* Simplified, standardised tools to deliver antiretroviral therapy
* A new service to ensure an effective, reliable supply of
medicines and diagnostics
* Rapid identification, dissemination and application of new
knowledge and successful strategies
* Urgent, sustained support for countries
* Global leadership, strong partnership and advocacy
Simplified Treatment Recommended
The strategy has greatly simplified the recommendations for AIDS
treatment regimens. The number of such WHO-recommended regimens has
been cut to four from 35. All four are equally effective. The
selection of an individual regimen for a patient will be based on
a combination of individual needs, together with the availability
and suitability of a particular regimen in a country. The strategy
also recommends the use of quality-assured "fixed dose
combinations" or easy-to-use blister packs of medicine whenever
they are available. The aim is to ensure that all people living
with AIDS, even in the poorest settings, have access to treatment
through this simplified approach.
The strategy also includes the global AIDS Medicines and
Diagnostics Service (AMDS), which will ensure that poor countries
have access to quality medicines and diagnostic tools at the best
prices. The service, which will be operated by WHO, UNICEF and
other partners, will help countries to forecast and manage supply
and delivery of necessary products for the treatment and monitoring
of AIDS. ...
Another key element is the simplification of monitoring, so that
easy-to-use tests such as body weight and colour-scale blood tests
are used where more complicated and expensive tests for viral load
and white cell (CD4) count are not yet available. The simpler
tests, combined with clinical evaluations by adequately trained
health workers, can be effective in monitoring the progress of
AIDS, the effectiveness of treatment and its side effects.
Treatment Action in Countries Already Under Way
Antiretroviral therapy programmes can only be expanded if there is
coordinated, scaled-up action in countries, particularly those
hardest-hit by AIDS. Countries are at the heart of the 3 by 5
strategy and will be the focus of all efforts to meet the 3 by 5
target. Many countries have already demonstrated their commitment
to this target. Immediately following the declaration of a global
AIDS treatment emergency, more than 20 countries requested
collaboration and input from WHO, UNAIDS and other partners. ...
Training of health workers is an urgent need in all countries
involved. Many of the countries with the highest numbers of people
living with HIV/AIDS have very few doctors or other trained health
staff. Many of these health workers have died as a result of
untreated AIDS; others have moved to seek better pay and job
security in wealthier countries.
Thousands of community workers to be trained
One of the most innovative aspects of the 3 by 5 strategy is a
method for urgently training tens of thousands of community health
workers to support the delivery and monitoring of HIV/AIDS
treatment. An intensive training programme would enable these
health workers to evaluate and monitor patients, and make sure they
receive and are taking their medicines.
The strategy acknowledges that the involvement of communities and
community workers is essential to the success of this initiative.
Significant evidence and experience shows that without strong
community support, people may have a more difficult time adhering
to their medical regimens. Also, community involvement is a
critical element of any successful HIV prevention strategy.
There is also good evidence that treatment can have an accelerating
effect on prevention efforts. "We know from experience that the
availability of treatment encourages people to learn their HIV
status and receive counselling," said Dr Paulo Teixeira, Director
of the HIV/AIDS Department at WHO. "We also know that the
availability of treatment reduces stigma for people living with
AIDS. People living with AIDS have a right to treatment and we must
find a way to deliver." ...
Funding
Reaching the 3 by 5 target will require substantial new funding for
AIDS treatment from all sources - countries, donor governments and
multilateral funding agencies. WHO has estimated that the funding
required amounts to approximately $5.5 billion over the next two
years.
"We know what to do but what we urgently need now are the resources
to do it," said Dr Lee. We must waste no time in building strong
alliances immediately to implement this strategy. Three million
people are counting on it."
For further information contact: Melanie Zipperer, Communications
Officer, HIV Department, Tel: +41 22 791 1344; Mobile: +41 79 475
1722; E-mail: zippererm@who.int or Iain Simpson, Communications
Officer, WHO Director-General's Office, Tel: +41 22 791 3215,
Mobile: +41 79 475 5534, email: simpsoni@who.int
Or please check the WHO HIV web site on http://www.who.int/hiv or
write to threebyfive@who.int.
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AIDS epidemic update: December 2003, Sub-Saharan Africa
[Excerpted from full report at http://www.unaids.org]
High levels of new HIV infections are persisting and are now
matched by high levels of AIDS mortality.
Sub-Saharan Africa remains by far the region worst-affected by the
HIV/AIDS epidemic. In 2003, an estimated 26.6 million people in
this region were living with HIV, including the 3.2 million who
became infected during the past year. AIDS killed approximately 2.3
million people in 2003.
Unlike women in other regions in the world, African women are
considerably more likely-at least 1.2 times-to be infected with HIV
than men. Among young people aged 15-24, this ratio is highest:
women were found to be two-and-a-half times as likely to be
HIV-infected as their male counterparts, according to six recent
national surveys. These discrepancies have been attributed to
several factors. They include the biological fact that HIV
generally is more easily transmitted from men to women (than vice
versa). As well, sexual activity tends to start earlier for women,
and young women tend to have sex with much older partners.
HIV prevalence varies considerably across the continent-ranging
from less than 1% in Mauritania to almost 40% in Botswana and
Swaziland. More than one in five pregnant women are HIV-infected in
most countries in Southern Africa, while elsewhere in sub-Saharan
Africa median HIV prevalence1 in antenatal clinics exceeded 10% in
a few countries. And while sustained prevention efforts in a few
countries in West and East Africa (principally Senegal and Uganda)
continue to demonstrate that HIV/AIDS can be checked with human
intervention, signs that similar inroads might be building in
Southern Africa remain tenuous, at best.
A trend analysis of antenatal clinic sites in eight countries
(between 1997 and 2002) shows HIV prevalence among pregnant women
levelling off at almost 40% in Gaborone (Botswana) and Manzini
(Swaziland), and at almost 16% in Blantyre (Malawi) and 20% in
Lusaka (Zambia). Prevalence exceeded 30% in South Africa's mainly
urban Gauteng province (which includes Johannesburg), while median
HIV prevalence in Maputo (Mozambique) was 18% in 2002. (Note that
HIV prevalence among pregnant women in rural areas of Southern
Africa is, on the whole, significantly lower than among their urban
counterparts. The subregion, though, is the most urbanized on the
continent, with more than 40% of the population living in urban
areas.)
Southern Africa is home to about 30% of people living with HIV/AIDS
worldwide, yet this region has less than 2% of the world's
population. As elsewhere on the continent, prevention (and,
increasingly, treatment and care) programmes have been stepped up
in this subregion. Even when effective, such efforts can take
several years to manifest in declining HIV prevalence trends. At
the moment, there is scant evidence of such a decline in Southern
Africa. However, there has been a trend of falling HIV prevalence
among young women attending antenatal care in Lilongwe (Malawi),
where prevalence among young women (aged 15-24) was almost 23% in
1996 and dropped to 15% in 2001. Whether this is an aberration or
is associated with safer sexual behaviour remains to be seen.
In South Africa, 2002 surveillance data show that, countrywide, the
average rate of HIV prevalence in pregnant women attending
antenatal clinics has remained roughly at the same high levels
since 1998-ranging between 22% and 23% in 1998-1999 and then
shifting even higher to around 25% in 2000-2002. ... In five of the
country's nine provinces-including the most populous ones-at least
25% of pregnant women are now HIV-positive. The epidemic varies
within South Africa, however. At almost 37%, HIV prevalence among
antenatal clinic attendees in KwaZulu-Natal is about three times
higher than in the Western Cape-the province with the lowest
prevalence. Based on the country's latest national round of
antenatal clinic-based surveillance, it is estimated that 5.3
million South Africans were living with HIV at the end of 2002.
Because of South Africa's relatively recent epidemic, and given
current trends, AIDS deaths will continue to increase rapidly over
the next five years at least; in short, the worst still lies ahead.
A speedily-realized national antiretroviral programme could
significantly cushion the country against the impact.
In four neighbouring countries-Botswana, Lesotho, Namibia and
Swaziland-the epidemic has assumed devastating proportions. There,
HIV prevalence has reached extremely high levels without signs of
levelling off. In 2002, national HIV prevalence in Swaziland
matched that found in Botswana: almost 39%. Just a decade earlier,
it had stood at 4%. Neither Botswana nor Swaziland presents signs
of incipient decline in HIV prevalence among young pregnant women
aged 15-24. HIV prevalence in antenatal sites in Namibia rose to
over 23% in 2002, while Lesotho's most recent data (collected in
2003) show median HIV prevalence among antenatal clinic attendees
climbing to 30%.
Figures released in Zimbabwe this year have been interpreted to
suggest that national adult HIV prevalence has dropped from the
end-2001 estimate of 34% to 25% and that the country is turning its
epidemic around. Unfortunately, there appears to be no basis for
this view. The new figure represents a statistical correction of
the 2001 estimate, which had relied on antenatal data that included
a significant proportion of testing irregularities. (In addition,
new data have become available for some rural areas, and the latest
census has indicated that Zimbabwe has a smaller total population
than previously assumed.) ...
There are signs that the epidemic has levelled off in Zambia, where
national HIV prevalence has remained stable since the mid-1990s. A
national population-based survey in 2001-2002 found that almost 16%
of 15-49-year-olds who agreed to be tested were HIV-positive. The
findings of the survey were consistent with the antenatal
clinic-based surveillance data for 2001.
In Mozambique, median HIV prevalence varied from 8% among pregnant
women in the north, to 15% and 17%, respectively, in the centre and
south. ...
Angola gives cause for concern despite the comparatively low HIV
levels detected to date. After almost four decades of war, huge
population movements are under way. Millions of people have been
able to leave the cities and towns they had been trapped in,
internal and cross-border trading movements are resuming, and an
estimated 450,000 refugees are returning (many from neighbouring
countries with high HIV prevalence rates). Such conditions could
prime a sudden eruption of the epidemic. ...While too little
accurate information is available on the epidemic's advance
elsewhere in Angola, there is no doubt that the country's HIV/AIDS
response leaves much room for improvement. ...
A distinct picture emerges in East Africa and parts of Central
Africa. HIV prevalence continues to recede in Uganda, where it fell
to 8% in Kampala in 2002-a remarkable feat, considering that HIV
prevalence among pregnant women in two urban antenatal clinics in
the city stood at 30% a decade ago. Similar declines echo this
accomplishment across Uganda, where double-digit prevalence rates
have now become rare.
To date, no other country has matched this achievement-at least,
not nationally. But the proportion of pregnant women found to be
HIV-positive in antenatal clinic sites has fallen to 13% in the
Rwandan capital, Kigali (from a high of almost 35% in 1993).
However, given the massive population movements after the 1994
genocide, comparisons over time in Rwanda should be drawn with
caution. In Addis Ababa, among 15-24-year-old pregnant women, HIV
prevalence has dropped almost as sharply-down to about 11% in 2003
after having peaked at approximately 24% in 1995. This could mark
a significant development, given that the country's epidemic is
largely concentrated in its cities (with HIV prevalence at less
than 2% in Ethiopia's rural pregnant women). ...
HIV prevalence in pregnant women has remained at low levels in
Kinshasa (Democratic Republic of the Congo). More recent data from
other urban and rural sites from the government-controlled parts of
the Democratic Republic of the Congo suggest that HIV prevalence in
2003 may, in fact, be at 5% or less across large parts of the
Republic, with the exception of Katanga province in the south-east,
which shares a border with Zambia and where there is a prevalence
of 6%, and possibly the eastern parts of the country where
surveillance activities were delayed in 2003.
In West Africa, diverse epidemics are under way. Still paying off
is Senegal's decision early in its epidemic to invest massively in
HIV-prevention-and-awareness programmes in the 1980s (when HIV
infection rates were still very low). Sustained programme efforts
have stabilized HIV prevalence levels among pregnant women at
around 1% since 1990, with these levels holding fast through 2002,
but HIV prevalence among sex workers has increased slowly over the
past decade. ... Population-based and other surveys suggest that
adult HIV prevalence levels remain relatively low in other
countries of the Sahel-around 2% in Mali, and 1% or lower in
Gambia, Mauritania and Niger. Like Burkina Faso, Ghana shows stable
trends. In the latter case, median HIV prevalence among pregnant
women attending antenatal clinics has fluctuated between 2% and
just over 3% since 1994 (and barely exceeding 4% in the capital,
Accra, in 2002).
The situation is graver in Cote d'Ivoire, which is still saddled
with the highest HIV prevalence in West Africa. More than 1 in 10
pregnant women have HIV infections in some of the country's
regions, although, in 2002, HIV prevalence among pregnant women in
Abidjan dropped to its lowest level (7%) for a decade. Nigeria's
most recent surveillance data (2001) suggest an anomaly, with the
country's major cities having a lower HIV prevalence (below 5%, in
fact) than several smaller cities classified as rural-most
noticeably in the south.
Despite widespread improvements across Africa in recent years, the
coverage of HIV surveillance systems in a few countries remains too
sparse to provide data that capture the epidemic's actual spread
and trends. ... [the] apparent `levelling off' of HIV prevalence
has been interpreted by some observers as an indication that the
HIV/AIDS epidemic might have reached a turning point in sub-Saharan
Africa. Unfortunately, available evidence does not offer grounds
for such conclusions. ...
AfricaFocus Bulletin is a free independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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