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Introduction
The HIV/AIDS Pandemic
The HIV/AIDS pandemic has become a human,social and economic disaster, with far-reaching implications for individuals, communities and countries. No other disease has so dramatically
highlighted the current disparities and inequities in health-care access, economic opportunity and the protection of basic human rights.
By the end of 2002 42 million people were estimated to be infected with HIV. During 2002,the AIDS epidemic claimed more than 3 million lives and 5 million people became infected with
HIV. Each day there are some 14,000 new HIV infections, with more than half of these occurring among young people under 25 years of age. Over 3 million children are HIV infected.
Globally, the major mode of HIV transmission is through sexual intercourse. HIV is also spread through injecting drug use, sexual intercourse between men, mother-to-child transmission and
through contaminated blood in health care settings. The relative importance of the different modes of transmission varies between and within regions of the world.
Sub-Saharan Africa has been most severely affected by the epidemic with almost 9% of its adult population infected in 2002 and an estimated 29.4 million people living with HIV. Life expectancy
has fallen to levels below 50 years. Nearly 10% of child mortality is HIV-associated, erasing progress in child survival during the past decades. In Asia/Pacific there are now more than 7 million
infected people, and further spread could lead to millions more becoming infected in the next decade. The epidemic in Latin America and the Caribbean is well established with nearly 2 million people
infected, and rapid growth has been observed in recent years in Eastern Europe and Central Asia.
Other Sexually Transmitted Infections (STIs)
Other sexually transmitted infections are of concern because they can increase the risk of transmission or acquisition of HIV. Rates of sexually transmitted infections are very high. In 1999 it was estimated
that the annual global incidences of the four most common STIs among adults were: syphilis 12 million; gonorrhoea 62 million; chlamydial infections 92 million; and trichomoniasis 174 million, giving a combined total of
340 million new infections annually.
Impact on Security and Economic Development
In many countries, HIV/AIDS pushes people deeper into poverty as households lose their breadwinners, livelihoods are compromised and savings are consumed by the cost of health care. The pandemic also adds to the strain on national
institutions and resources, and undermines the social systems that help people to cope with adversity. In the most severely affected settings there is already evidence that HIV/AIDS is eroding human security and productivity,
undermining economic development, and threatening social cohesion.
Educational systems and education standards too are being affected as more young people are forced to leave school to take care of sick parents and look after siblings. More than 11 million African children have lost one or both parents to AIDS.
The spread of HIV and the impact of AIDS are disproportionately affecting young people, and therefore the future of the global community itself.
Imbalance in Treatment Access
In many developed countries, the availability of combination antiretroviral treatment has meant dramatic reductions in HIV/AIDS-related mortality and morbidity. As a result, more people with HIV are able to enjoy better health and lead productive lives.
This is in stark contrast to the developing world, where there is little treatment access and HIV/AIDS related illness and death are commonplace.
Complacency Threatens Progress
HIV infection rates and AIDS-related deaths are on the rise again in some countries where real progress was previously being made in containing the pandemic. Complacency and “AIDS fatigue” at government, donor, community and individual
levels are contributing to this situation. In some settings, HIV prevention and care initiatives and services have been allowed to run down, while other countries have not modified their prevention and care programmes in the face of new
complexities.
In particular, failure to maintain a balance between treatment and prevention has weakened efforts to combat HIV/AIDS in some countries. For example, some developed countries have not maintaineda strong enough focus on prevention following
the advent of combination antiretroviral treatment from 1995 onwards. Also, the effects of wider access to antiretroviral treatment on prevention programmes and client support are not always fully considered. This is contributing to increasing
rates of unsafe behaviours, rising HIV-infection rates and substantial problems with antiretroviral resistance and cross-resistance in a number of developed countries. Developing countries now have a unique opportunity to learn from these
experiences by maintaining strong prevention efforts even as access to antiretroviral treatment is scaled-up.
Impact on the Health Sector
The health sector is facing severe shortages of human and financial resources, especially in the worst-affected countries. Many health-sector services and facilities are struggling to cope with the growing impact of HIV/AIDS. This is clearly
demonstrated in sub-Saharan Africa, where people with HIV-related illnesses occupy more than 50% of hospital beds, and where organizations andfacilities providing care and support are simply being overwhelmed by the demand.
At the same time as demand for health services increases, more health-care personnel in sub-Saharan Africa are themselves dying or unable to work as a result of AIDS. To compensate for these losses and to meet growing service demands, more
doctors and nurses will need to be trained and new categories of health professions established (e.g. medical assistants, nurse practitioners, and counsellors). The situation in sub-Saharan Africa may well arise in other regions unless strategies
are put in place now to strengthen the human and financial capacity of the health sector.
Variable Support for Health Ministries
Health ministries have decades of experience in leading health-sector responses to serious health challenges. Yet in the case of HIV/AIDS, some health ministries are experiencing difficulties in stewarding such responses. Furthermore, their
central role in providing the technical input needed to guide overall national planning for HIV/ AIDS is not always recognized or fully utilized.
Lack of resources, too many competing demands, and lack of influence within government decisionmaking are demoralizing some health ministries. Many national HIV/AIDS strategic planning and decision-making structures are cumbersome and
have unintentionally confused rather than assisted responses. Some of these structures have also unintentionally marginalized health ministries or fragmented their efforts with the result that their experience and other comparative advantages
are not being fully utilized, thereby hindering the overall national response to the pandemic.
Opportunities in Adversity – Applying the Lessons Learned
This overview of the HIV/AIDS pandemic clearly indicates that even after 20 years of effort there are still many challenges to be met. Yet this is also a time of hope and much possibility. Remarkable progress is being made wherever political leadership
is supporting the health sector in working with other sectors and the wider community in combating HIV/AIDS. Opportunities are being created through global determination to increase human and financial resources; to expand prevention efforts; to
scale-up antiretroviral treatment access in developing countries; and to support research into prevention and treatment approaches. There is now an important opportunity not only to provide better care for people living with HIV/AIDS but to improve health
systems and the provision of health care for all.
Hope can also be derived from the wealth of knowledge and experience amassed over 20 years of global effort in responding to HIV/AIDS. We have learned much about HIV itself and the disease process. We know a great deal about how to prevent
HIV infection, and about the factors that fuel its spread. We also know which kinds of treatment and care interventions are effective and have learned important lessons including:
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strong government leadership generates the most effective national responses to HIV/AIDS;
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investing in prevention, treatment and care now avoids far heavier human and financial costs in the future;
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wide-ranging public-information campaigns (which include frank discussion of sexual behaviour and drug use) help counter denial and lead to reduced levels of HIV infection;
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making condoms, sterile injecting equipment and other commodities widely available reduces risk and results in lower infection rates;
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strong control programmes for STIs result in fewer HIV infections;
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rational and effective use of antiretrovirals and other HIV-related treatments produces striking reductions in HIV/AIDS-related mortality and morbidity;
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national HIV/AIDS strategic plans help generate effective national and multisectoral responses and optimize the use of human and financial resources;
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different models can be used to provide a strategic framework for responding to HIV/AIDS, but placing health ministries at the centre of strategic
planning helps to maximize health sector expertise in supporting effective national outcomes;
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meaningful partnerships between governments,health professions, people living withHIV/AIDS, vulnerable groups, local communities and nongovernmental
organizations result in strong national and local responses;
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epidemiological and behavioural data are required to inform development and monitoring of national strategic plans for HIV/AIDS;
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laws and policies that counter stigma and discrimination against people living with HIV/AIDS and vulnerable populations reduce
the negative impact of the pandemic and enhance prevention, health-promotion, treatment and care efforts.
The cost of learning these lessons has been considerable, both in terms of individual human suffering, societal impact and financial costs. It is
therefore imperative that the opportunities available now are acted upon. In support of this, barriers such as lack of education, inaccessibility
of treatments, gender inequality, negative cultural attitudes, stigma and discrimination all need to be strongly countered.
Creating a Framework for Partnership and Action – the Global Health-Sector Strategy for HIV/AIDS (2003–2007)
The foundations for generating action to meet the daunting challenges posed by HIV/AIDS are clear policies, effective strategic planning and sound
decision-making processes. These foundations help to create strong partnerships, to make the best use of human and financial resources, and to
generate positive outcomes. However, many countries are struggling to create a truly effective strategic approach to HIV/AIDS.
Conscious of the need to define and strengthen the role of the health sector within a broad multisectoral response to HIV/AIDS, the World
Health Assembly adopted a resolution in May 2000 (WHA53.14) requesting the Director General of WHO to develop a strategy for addressing
HIV/AIDS as part of the United Nations systemwide effort to combat the pandemic. The resulting Global Health-Sector Strategy (GHSS) for HIV/
AIDS described in this document is only one of a number of important initiatives that have emerged since the United Nations Special Session on
HIV/AIDS in 2001, and has been developed by WHO in a spirit of renewed determination. The global community in general and the health sector
in particular now have an exceptional opportunity to redouble their efforts against a devastating global pandemic and to show what can be
achieved through bold leadership and concerted action.
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