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Science,
Vol 304, Issue 5679, 1909-1910 , 25 June 2004
PUBLIC HEALTH: Peter Piot [HN21], Richard G. A. Feachem [HN22],* Lee Jong-wook [HN23], James D. Wolfensohn [HN24] Every 2 years, the scientific community working on AIDS is joined by activists, health officials, and government leaders to take stock of the AIDS epidemic and to share the latest findings. Since the last International AIDS Conference [HN1] in Barcelona, some 10 million people have been infected with HIV and just under 6 million people have died from AIDS [HN2]. Projections now suggest that some countries in sub-Saharan Africa will face economic collapse unless they bring their epidemics under control [HN3]. AIDS weakens and kills adults in their prime. AIDS-impacted countries are losing teachers, nurses, and civil servants at a faster rate than they can educate new ones. An estimated 14 million children have lost one or both parents, stretching the capacities of families and local communities. In 2002 alone, there were 1 million new infections in the Asia Pacific region [HN4]. Asia has provided the world with models for tackling the AIDS epidemic, from Thailand, Cambodia [HN5], and elsewhere. We've seen striking leadership emerge in China. But the window of opportunity is closing. Inequity, poverty, unequal status of women, stigma against people living with HIV, and cultural myths about sex contribute to an explosive epidemic. The risk of the epidemic's spreading in India raises grave concerns [HN6]. Already 10% of the world's HIV-positive population lives in India--more than 4 million people. In 6 years, 10 million Chinese could be living with HIV unless infection rates are slowed [HN7]. Eastern Europe and Central Asia [HN8] are also at the center of rapidly expanding AIDS epidemics that affect more than 1 million people, compared with only 30,000 in 1990. In Eastern Europe, young people make up 40% of the population and are at particular risk. Globally, women make up nearly half of all people infected with HIV. Yet, they lack prevention, care, and support services [HN9].
The State of the Global Response Yet there is room for optimism. Over the past 2 years, we have seen a number of positive developments. The campaign for access to treatment for all who need it is driving a much wider and deeper understanding of the AIDS epidemic in many countries. This, together with a better realization of the economic and social impact of the epidemic, has pushed up development assistance for fighting HIV/AIDS. Substantial progress has been made in understanding the relation between prevention and treatment [HN10], as well as how important reduction of stigma [HN11] is to make people willing to be tested and to seek treatment. To help accelerate its "3-by-5" treatment initiative [HN12] (to put 3 million people on treatment by 2005), the World Health Organization (WHO) has developed a simplified set of antiretroviral drug regimens, testing, and treatment guidelines (1) [HN13] that are consistent with the highest standards of quality of care. The guidelines are intended to be used at all levels of the health system, including the community, to monitor and promote adherence to treatment. Because these regimens make it possible for even the poorest areas to start treating those who need them, they ensure that rollout of treatment programs can be done equitably. A growing number of countries have shown that increasing access to treatment is both possible and effective. Brazil has the most advanced national HIV/AIDS treatment program in the developing world [HN14]--it is estimated that between 1994 and 2002, almost 100,000 deaths have been averted (a 50% drop in mortality) through the introduction of antiretroviral therapy (ART). As a result of the program, hospital admissions have declined significantly, and cost savings in reduced hospital admissions and opportunistic infections are estimated at more than US$1 billion (2). The program has also been effective in reducing the rates of tuberculosis and other opportunistic infections. Access to drugs is a central element in any effective strategy to fight HIV-AIDS. In affirming that the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) should be interpreted and implemented so as to protect public health and to promote access to medicines, the Doha Declaration on the TRIPS Agreement and Public Health (3) [HN15] has ensured that international trade rules and intellectual property rights protection support the efforts of developing countries to secure such access. It is crucial to ensure that all countries adhere to the Doha Declaration as TRIPS comes into effect in 2005. To provide treatment to those who need it safely and effectively, we need to develop simplified drug treatments, based on fixed-dose combinations and copackaging. We have affordable and effective first-line drugs to treat AIDS, but second-line drugs are still too expensive and out of reach for most countries. Affordable second-line regimens are needed. To treat AIDS in children, effective pediatric formulations are desperately needed.
A Strengthened Approach We are working to ensure that the resources are spent wisely to help countries mount sustainable and effective AIDS strategies. We recognize the importance of streamlining and focusing our work in every country. This is why we and other governments and donors, including the United States and the United Kingdom, are jointly promoting the principle of the "Three Ones" (4) [HN19]: one agreed-upon HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority, with a broad-based mandate; and one agreed-upon country-level monitoring and evaluation system. To that end, the Global Fund, the World Bank, WHO, UNAIDS, and other partners have agreed on a monitoring and evaluation toolkit (5) [HN20], for use by all partners and governments. This is based on global consensus, and we are working with partners such as the U.S. President's Emergency Plan for AIDS Relief to harmonize indicators, data collection, and technical support.
Key Challenges Increasing human capacity and global funding. As drug prices fall and resources become increasingly available, lack of human resources will become the main brake on a scale-up of HIV/AIDS interventions, in particular for a roll-out of treatment. In Africa alone, WHO estimates that around 100,000 health workers are missing, because they have died from the disease, have emigrated, or have left for better-paid work. Essential work to tackle personnel crisis ranges from giving health workers priority in receiving ART to continue helping others to compensating for extensive brain-drain created by rich countries' demand for doctors and nurses. Involvement of communities is also essential to the success of integrated prevention and treatment programs. Motivating communities to know their HIV status in a context of access to ART is encouraging greater openness and helping a community-based response to reduce the stigma and denial that have enabled the virus to spread so disastrously. Substantial new financial resources are becoming available to fight HIV/AIDS. Even so, we are still far from the level of $20 billion, which will be needed every year by 2007. This is a challenge both to donor countries and developing countries. Domestic expenditure needs to increase substantially, and it could do so in a number of middle-income countries. It is unrealistic for the majority of developing countries to be able to cover all or even most of the funding needed to counter the spread of HIV/AIDS with domestic resources over the coming 10 or 15 years. We must acknowledge that some countries will need the support of the international community for decades. Ensuring prevention and treatment. We can now leave simplistic discussions of prevention versus treatment behind. Growing scientific evidence supports common sense in arguing that new HIV infections will only be substantially reduced when broad access to treatment is combined with strengthened prevention efforts. To reach those in need, we must develop much more effective systems to offer routine testing universally without losing the important principles of free choice and support through counseling and, increasingly, offers of treatment. Scaling-up testing and counseling is a lynchpin of prevention, particularly for high-risk and vulnerable groups, including youth, sex workers, and injecting drug users, as well as for people with tuberculosis and pregnant women. Nonetheless, we must not underestimate the challenge posed by the stigma and discrimination faced by people living with HIV (6). Combatting them has to be central to any prevention and treatment strategy. The debate has also matured to a level where we now should be able to agree that national prevention strategies need to be based on a combination of universal access to tools that enable individuals to protect themselves from infection and individual and collective behavior change. The tools include condoms, clean needles, and effective blood screening, as well as factual, uninhibited knowledge about how people can reduce risk of HIV transmission. Behavior change should focus not only on abstinence and a reduction in the number of sexual partners, but also on economic and social practices that promote the spread of HIV, such as labor structures that split families for extended periods of time and violence against women. We must intensify research in new technologies, particularly those that will help women, such as microbicides. National preparedness and ownership. At the heart of every national success story against HIV/AIDS is strong and visible national commitment and leadership. Direction from the top is essential to break public taboos and to forge a genuinely multisector response both within government and in the broader society. Governments must engage health service deliverers that function outside the public heath system. In several developing countries, NGOs, faith-based organizations, and private commercial entities provide well over half of all health services. These sectors need to be mobilized in a coordinated and unified manner, within a coherent national strategy of open stewardship. National leadership is also needed to set priorities. It is essential that donors respect and adhere to guidelines and requirements set out by the national authorities, in particular relating to treatment protocols. It is also crucial that countries receive the newest data and best possible technical advice to enable them to make these decisions. The Global Fund is designed specifically to respond to a country-driven process, and it is adjusting its practices to better serve its grantees. This is a model that should also guide other donor programs. The flip-side of this process is a focus on results. Donors have a right to expect that their funding leads to measurable, long-term impact. To achieve this, programs need to be drawn up against specific targets, and future funding should be contingent on showing realistic progress toward these targets through simple, widely shared monitoring and evaluation systems. The international community can and must support local efforts by providing funding, guidance, and technical support to governments and partners and by encouraging involvement by civil society. Ultimately, the most critical element of a sustained global response to AIDS is the willingness and ability of nations to take ownership of the problem. We are gaining experience of what works. Although no one size fits all, we cannot wait for the perfect solution. We must learn by doing and ensure better coordination and use of resources. References and Notes
P. Piot is the executive director of the Joint United Nations Programme on HIV/AIDS. R. G. A. Feachem is the executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. J. Lee is the director-general of the World Health Organization. J. D. Wolfensohn is president of the World Bank Group, Washington, DC, USA. *Author for correspondence. E-mail: jon.liden@theglobalfund.org
HyperNotes General Hypernotes Dictionaries and Glossaries The On-line Medical Dictionary is provided by CancerWeb. A glossary of HIV/AIDS-related terms is provided by AIDSinfo. Web Collections, References, and Resource Lists The Yahoo Directory provides HIV/AIDS Internet links, as well as news coverage related to AIDS. MedlinePlus from the National Library of Medicine (NLM) offers links to AIDS Internet resources and news. NLM's Specialized Information Services Web page provides a collection of links to HIV/AIDS information resources. The library of the Karolinska Institutet, Stockholm, Sweden, provides links to Internet resources on HIV/AIDS. Online Texts and Lecture Notes Internet resources relating to international HIV and AIDS issues include those provided by UNAIDS (the Joint United Nations Programme on HIV/AIDS), the CDC's Global AIDS Program, the World Health Organization (WHO), the WHO Department of HIV/AIDS, the United Nations Development Programme, the World Bank, the Pan American Health Organization, the U.S. Agency for International Development (USAID), and the Global Fund to Fight AIDS, Tuberculosis and Malaria. HIV InSite is a gateway to AIDS information from the University of California School of Medicine. A section on countries and regions is included. AIDSinfo is a service of the U.S. Department of Health and Human Services. Links to other U.S. government resources are provided. Other Internet resources focusing on AIDS research, prevention and treatment, and news include USAID's Synergy Project, the Johns Hopkins AIDS Service, the Harvard AIDS Institute, the AIDS Education Global Information System (AEGIS), AVERT, The Body, the Population Reference Bureau, the Kaiser Family Foundation, and the Bill & Melinda Gates Foundation. P. Bugl, Department of Mathematics, University of Hartford, offers lecture notes for a course on epidemics and AIDS. General Reports and Articles AIDS Epidemic Update: December 2003 is provided in PDF format by WHO (also available as a UNAIDS publication). Science presents a series of special news reports on HIV/AIDS in Asia: Southeast Asia (19 September 2003 issue), India (23 April 2004), and China (4 June 2004). See also the editorial and articles in this issue (25 June 2004). The 29 November 2002 issue of Science had an Enhanced Viewpoint article by R. C. Gallo and L. Montagnier titled "Prospects for the future." The Population Reference Bureau makes available (in PDF format) a September 2002 article by P. Lamptey, M. Wigley, D. Carr, and Y. Collymore titled "Facing the HIV/AIDS pandemic." A 2001 report titled Beyond 2000: Responding to HIV/AIDS in the New Millennium is made available in PDF format by the WHO South East Asia Regional Office. Access to HIV Prevention: Closing the Gap is a 2003 report (available in PDF format) from the Bill & Melinda Gates Foundation. Confronting AIDS: Public Priorities in a Global Epidemic is a 1997 report made available with related resources by the World Bank AIDS Economics Web site. The AIDS Pandemic in the 21st Century is a 2002 report (PDF format) made available by the International Programs Center of the U.S. Census Bureau. USAID's Global Health Web site provides a collection of HIV/AIDS success stories in PDF format Numbered Hypernotes
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