The world has reached a crucial moment in the history of HIV/AIDS, and The World Health Report 2004 the chance to change the history of health for generations urgent public health challenge. Unknown barely a quarter of a century ag milion peaple have died from it and an estimated 34-46 million others are changing history The World Health Report 2004-Changing Histor published by the Wor evention, treatment, care and long-term support Until now, treatment has developing countries almost 6 million aapl in these countries will die in the near future if they do not receive tre WHO and its partners have declared the treatment gap a global emergency an ealth projects ever concaved. This report shows how it can be done. It goes rther, looking beyond 2005 to explain how international organizations, national governments, the private sector and communities can combine their strengths and simultaneously fortify health systems for the enduring benefit of all. by the global pandemic, The Wordd Health Report 2004 makes essential reading world Health Organization a political, professional or personal interest in health. 灵好
changing history The World Health Report 2004 World Health Organization c h a n ging history The World H e alth R e p ort 2 0 0 4 WHO The world has reached a crucial moment in the history of HIV/AIDS, and now has an unprecedented opportunity to alter its course. The most important message of the latest World Health Report is that, today, the international community has the chance to change the history of health for generations to come and open the door to better health for all. Tackling HIV/AIDS is the world’s most urgent public health challenge. Unknown barely a quarter of a century ago, it is now the leading cause of death for young adults worldwide. More than 20 million people have died from it and an estimated 34–46 million others are now infected with the virus. There is as yet no vaccine and no cure. The World Health Report 2004 – Changing History, published by the World Health Organization, calls for a comprehensive HIV/AIDS strategy that links prevention, treatment, care and long-term support. Until now, treatment has been the most neglected element in most developing countries: almost 6 million people in these countries will die in the near future if they do not receive treatment – but only about 400 000 of them were receiving it in 2003. WHO and its partners have declared the treatment gap a global emergency and have launched a drive to provide 3 million people in developing countries with antiretroviral therapy by the end of 2005 – one of the most ambitious public health projects ever conceived. This report shows how it can be done. It goes further, looking beyond 2005 to explain how international organizations, national governments, the private sector and communities can combine their strengths and simultaneously fortify health systems for the enduring benefi t of all. Illustrated with photographs of people whose lives have been deeply affected by the global pandemic, The World Health Report 2004 makes essential reading for everyone with a political, professional or personal interest in health. ISBN 92 4 156265 X
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changing history The World Health Report 2004 World Health Organization changing history The World Health Report 2004 World Health Organization
WHO Lbrary Cataloguno-in-Putlcabon Data contents mans cresent angrgomate barber ines fr wich trere may net爬b not mentored Errors and omissions excepted, the names of proprietary proaucts are deangushed by initia Message from the Director-General maned in ths publication is complete Overview red trom boskordersewha nt mergency: a combined response ra(Director, HI/AIDS). The uneven spread of Hv The des trentment on durng health
ii iii Message from the Director-General ix Overview xi A chance to change history xii Why treatment must be scaled up xiii Expanding treatment access xiii Towards Health for All xiv Chapter summaries xv Chapter 1 A global emergency: a combined response 1 The global situation 1 The uneven spread of HIV 3 Rises in mortality, reductions in life expectancy 4 The deadly interaction: HIV/AIDS and other diseases 7 The AIDS treatment gap 7 The human, social and economic consequences 8 Women: unequally at risk 8 The underestimated economic threat 9 The threat of institutional collapse 10 Prevention, care and support: strategies for change 11 Preventing the sexual transmission of HIV 12 Breaking the link with other sexually transmitted infections 13 Preventing infection in infants and children 13 Injecting drug use – reducing the harm 15 Preventing transmission during health care 15 Testing and counselling 15 contents WHO Library Cataloguing-in-Publication Data World Health Organization. The World health report : 2004 : changing history. 1.World health - trends 2.HIV infections - therapy 3.Acquired immunodefi ciency syndrome - therapy 4.Acquired immunodefi ciency syndrome - therapy 5.Anti-retroviral agents - supply and distribution 6.Delivery of health care - organization and administration 7.World Health Organization I.Title II.Title: Changing history. ISBN 92 4 156265 X (NLM Classifi cation: WA 540.1) ISSN 1020-3311 © World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who.int Copies of this publication can be ordered from: bookorders@who.int Design: Reda Sadki Layout: Steve Ewart, Sue Hobbs and Reda Sadki Printing coordination: Keith Wynn Printed in France 2004/15763 – Sadag – 20000 This report was produced under the overall direction of Tim Evans (Assistant Director-General), Robert Beaglehole (Editor-in-Chief), Jim Kim (Special Adviser to the Director-General) and Paulo Teixeira (Director, HIV/AIDS). The principal authors were Robert Beaglehole, Alec Irwin and Thomson Prentice. The other main contributors to chapters were: Chapter One: Ties Boerma, Jean-Paul Moatti, Alex de Waal and Tony Waddell. Chapter Two: Jhoney Barcarolo, Alex Capron, Charles Gilks, Alaka Singh and Marco Vitoria. Chapter Three: Hedwig Goede, Ian Grubb and Stephanie Nixon. Chapter Four: David Evans, Neelam Sekhri, Phyllida Travis and Mark Wheeler. Chapter Five: Don Berwick, Michel Kazatchkine and Yves Souteyrand. Other contributors to the report were: Christopher Bailey, Michel Beusenberg, Boakye Boatin, Andrew Boulle, Guy Carrin, David Coetzee, François Dabis, Betina Durovni, Dominique Egger, Paula Fujiwara, Claudia Garcia-Moreno, Eric Goemaere, Peter Graaf, Raj Gupta, Kate Hankins, Kei Kawabata, Wayne Koff, Michael Lederman, Ying-Ru Lo, Naisiadet Mason, Kedar Mate, J.P. Narain, Carla Obermeyer, Amolo Okero, Catherine Orrell, Andreas Reis, Peter Reiss, Alan Stone, Tessa Tantorres, Kate Taylor, Roger Teck and David Walton. Contributors to statistical tables were: Carla Abou-Zahr, Prerna Banati, Steve Begg, Christina Bernard, Ana Betran, Maureen Birmingham, Daniel Bleed, Monika Blössner, Anthony Burton, Laurent Chenet, Christopher Dye, Charu Garg, Peter Ghys, Patricia Hernández, Mehran Hosseini, Jose Hueb, Chandika Indikadahena, Mie Inoue, Peter Jackson, Doris Ma Fat, Colin Mathers, Sumi Mehta, John Miller, Bernard Nahlen, Mercedes de Onis, Richard Poe, Leonel Pontes, Jean-Pierre Poullier, Nathalie Proust, Eva Rehfuess, Kenji Shibuya, Karen Stanecki, Michel Thieren, Niels Tomijima, Nathalie Van de Maele, Catherine Watt and Hongyi Xu. Valuable input was received from Assistant Directors-General, policy advisers to the Director-General at WHO headquarters, and many technical staff. Additional help and advice were kindly provided by Regional Directors and members of their staff. The report was edited by Barbara Campanini and Leo Vita-Finzi. Translation coordination and other administrative and production support was provided by Shelagh Probst. The web site version and other electronic media were provided by Gael Kernen. The photographs and media kit were coordinated by Gary Walker. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle
Chapter 2 ne treatment initiative research C+knowledge The 3 by 5 strategy Preventing transmission from mother to child ical new approach hien 3 by 5 staining long-term adherence Ethical poicies for treatmen 3445538345788 Equity issues munity participation: advocacy eaction Conclusion society responds to the ADs tragedy Basic indicators for all wHO Member States Community health workers and treatment Community empowerment and pubic health shaping the tuture Deaths by cause, sex and mortality stratum in WHO regions ealth systems: finding new strength urden of disease in DALYs by cause, sex and mortality str Annex table 4 Healthy lite expectancy (HALE) n all wHO Member states, ees 'or 2002 national heath accounts ind cators measured levels of expenditure on health, 1997-2001 136 Meeting the challenge: hope for the future Milennium Dewelopment Goals: selected health indcators n all WHO Member states, 2000 (unless specified) List of Member states by wHO region and mortality stratum
Chapter 5 Sharing research knowledge 73 Prevention research 74 Linking prevention and access to treatment 74 Preventing transmission from mother to child 76 Protecting women with microbicides 77 Vaccine research 77 Treatment research 78 Sustaining long-term adherence 78 Coping with toxicities 79 Preventing drug resistance 79 Developing new drugs and strategies 80 Tackling tuberculosis and HIV/AIDS together 80 Operational research 81 Economic issues 82 Health policy analysis 83 Equity issues 84 International collaboration 84 Sharing knowledge 86 Conclusion 91 Statistical annex 9 3 Explanatory notes 93 Annex Table 1 Basic indicators for all WHO Member States 112 Annex Table 2 Deaths by cause, sex and mortality stratum in WHO regions, estimates for 2002 120 Annex Table 3 Burden of disease in DALYs by cause, sex and mortality stratum in WHO regions, estimates for 2002 126 Annex Table 4 Healthy life expectancy (HALE) in all WHO Member States, estimates for 2002 132 Annex Table 5 Selected national health accounts indicators: measured levels of expenditure on health, 1997–2001 136 Annex Table 6 Selected national health accounts indicators: measured levels of per capita expenditure on health, 1997–2001 144 Annex Table 7 Millennium Development Goals: selected health indicators in all WHO Member States, 2000 (unless specifi ed) 148 List of Member States by WHO region and mortality stratum 156 Chapter 2 The treatment initiative 21 Treatment scale-up: public health arguments 23 Treatment scale-up: economic and social arguments 24 The 3 by 5 strategy 25 Partnerships: vital for success 26 Delivering treatment: a practical new approach 27 Antiretroviral drug resistance: acting now to prevent a major problem 29 The costs of achieving 3 by 5 30 The front lines: working in countries 32 China 32 India 33 Kenya 34 Thailand 34 Zambia 35 Ethical policies for treatment 35 Making 3 by 5 work for the poor and marginalized 36 Beyond 2005 38 Chapter 3 Community participation: advocacy action 43 Community participation in public health 44 Civil society responds to the AIDS tragedy 45 The power of a human rights approach 47 Civil society and treatment expansion 48 From advocacy to service implementation 48 Community health workers and treatment 50 Community empowerment and public health: shaping the future 52 Chapter 4 Health systems: fi nding new strength 57 Investing in change 58 Beyond the public sector 59 The business sector contribution 59 Leadership for change 61 Health information systems 61 Monitoring 3 by 5 62 Service delivery 62 Health system resources 64 The human resource crisis 64 Systemic solutions to the workforce crisis 64 Financing issues 66 Meeting the challenge: hope for the future 69 iv v
Index 803.2 Figures 803.4 2 Applying the expertise af people liing wah HIWA DS: Helens s ory 52 Antiretroviral therapy in the Westem Cape Province, South Africa expectancy in sub-Saharan Africa and selected countries. 1970-2010 Lite expectancy in Africa, with and without HIV/AIDS, 2002 Universal access to an retroviral herapy in Brazil treatment, end 2003 of the 3 by 5 initiative 80x5.1 cotal: UsS.5 bilion), 2004-2005 Learning by doing-the operational research agenda hs tram HIV/AIDS among health workers in Mala, 1990-2000 64 Boxes The impact of H/AIDS on the Millennium Development Goal estimates and population-based surveys 351 Prevertion and treatment in Brail and the Bahama Cambodia and Thailand-successes and challen The Global Fund to Fight AIDs, Tuberculosis and malaria 3478 Free antiretroviral t HoW Asian drugs help African and men B027 Reaching the poor in Ro de Janeiro The Society for Women and AIDs in Ark
vi vii Box 3.2 The role of faith-based organizations 46 Box 3.3 A successful community effort in Suriname 48 Box 3.4 Partnerships for treatment in Uganda 50 Box 3.5 Applying the expertise of people living with HIV/AIDS: Hellen’s story 52 Box 4.1 Antiretroviral therapy in the Western Cape Province, South Africa 59 Box 4.2 Incentives to health workers in Malawi 65 Box 4.3 Universal access to antiretroviral therapy in Brazil 66 Box 4.4 New international sources of fi nance 67 Box 4.5 Health fi nancing reform in Kenya 68 Box 5.1 Learning by doing – the operational research agenda 81 Box 5.2 Building partnerships in the fi ght against disease 85 Index 159 Figures Figure 1.1 Estimated number of adults infected with HIV, by WHO region, 1980–2003 2 Figure 1.2 HIV prevalence among pregnant women attending antenatal clinics in areas of sub-Saharan Africa, 1997–2002 4 Figure 1.3 Trends in life expectancy in sub-Saharan Africa and selected countries, 1970–2010 6 Figure 1.4 Life expectancy in Africa, with and without HIV/AIDS, 2002 7 Figure 2.1 Estimated worldwide coverage with antiretroviral treatment, end 2003 22 Figure 2.2 Projected costs of the 3 by 5 initiative (total: US$ 5.5 billion), 2004–2005 30 Figure 4.1 Deaths from HIV/AIDS among health workers in Malawi, 1990–2000 64 Boxes Box 1.1 The impact of HIV/AIDS on the Millennium Development Goals 3 Box 1.2 HIV estimates and population-based surveys 5 Box 1.3 Prevention and treatment in Brazil and the Bahamas 11 Box 1.4 Cambodia and Thailand – successes and challenges 12 Box 2.1 Checking the spread of HIV/AIDS in Brazil 23 Box 2.2 Ensuring the supply of medicines to the developing world 24 Box 2.3 The Global Fund to Fight AIDS, Tuberculosis and Malaria 27 Box 2.4 Free antiretroviral therapy in Barbados 28 Box 2.5 How Asian drugs help African patients 33 Box 2.6 Ensuring equal access for women and men 37 Box 2.7 Reaching the poor in Rio de Janeiro 38 Box 3.1 The Society for Women and AIDS in Africa 45