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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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AfricaFocus Bulletin is an independent publication that is not subsidized by any government, foundation, or organization. Subscriptions are free, but you are encouraged to make a voluntary subscription payment to help support this ongoing service.

Visit http://www.africafocus.org to make your payment or find out other ways to provide support. At this new website you will also find a searchable archive of AfricaFocus Bulletin, customized news feeds from AllAfrica.com and BBC Africa, and more.

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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.

*************************************************************

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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