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