UNAIDS, June 2000 "Report on the Global HIV/AIDS Epidemic"
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Dear Colleagues,
On June 27th, 2000, UNAIDS has released the second "Report on the
Global HIV/AIDS Epidemic"
Many of you may have already accessed the report and might hence skip
this message. For those of you who have not yet had a chance to read
the report and would like to have an overview, I am forwarding with
this message the UNAIDS Geneva press release and an additional sum-
mary of some of the key issues covered by the report.
The full report is available via the UNAIDS WebPages:
http://www.unaids.org/epidemic_update/report/Epi_report.pdf
in HTML and .PDF file format (size 2,177 kb) in English and .PDF for-
mat in French and Spanish. In case you have at your location only ac-
cess to e-mail, the full report can be forwarded to you, depending on
the capacity of your mailbox. The UNAIDS report will likely be the
basis for important discussions at the XIIIth International AIDS Con-
ference in Durban, South Africa from the 9th to the 14th of July,
2000).
Sincerely,
Hans ML Spiegel, MD
Pediatrics, Pediatric Infectious Diseases,
Elizabeth Glaser Pediatric AIDS Foundation Scholar
The Aaron Diamond AIDS Research Center
Rockefeller University
455 1st Ave, 7th FL
New York, NY 10016, USA
Tel: +1-212-448-5011
Fax: +1-212-725-1126
mailto:hspiegel@adarc.org
[From the Moderator: The UNAIDS Geneva press release has been pub-
lished via AFRO-NETS on 27 June already; we therefore include only
the additional summary of key issues. DN Mod.]
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Additional Details from the UNAIDS Report June 27th, 2000
(The citations and summaries span several paragraphs; for access of
graphs, tables and to find the context, please refer to the page num-
bers).
On Orphaned Children:
So far, the AIDS epidemic has left behind 13.2 million orphans -
children who, before the age of 15, lost either their mother or both
parents to AIDS. Studies in Uganda have shown that following the
death of one or both parents, the chance of orphans going to school
is halved and those who do go to school spend less time there than
they did formerly. According to a report published jointly in 1999 by
UNICEF and the UNAIDS Secretariat, AIDS orphans are at greater risk
of malnutrition, illness, abuse and sexual exploitation than children
orphaned by other causes.
There is a consensus that help for orphans should be targeted at sup-
porting families and improving their capacity to cope, rather than
setting up institutions for the children. Orphanages may not be rele-
vant to a long-term solution. Moreover, in a subsistence economy,
children sent away from their village may lose their rights to their
parents' land and other property as well as their sense of belonging
to a family. In Malawi, the Government decided early on to support
community-based programs and has had a National Orphan Care Task
Force since 1991. Across the country, community-based organizations
are setting up child-care centers to improve the care of children and
increase their learning opportunities. In Zambia, which has the sec-
ond largest proportion of AIDS orphans in the world after Uganda,
non-governmental organizations are working hard to fill gaps by pro-
viding food, clothing and school fees to orphans and their families.
In Zimbabwe, where 7% of all children under 15 are orphaned by AIDS,
a National Policy on the Care and Protection of Orphans has been de-
veloped, which advocates that orphans should be placed in institu-
tions only as a last resort and be cared for by the community when-
ever possible.
Uganda Women's Effort to Save Orphans (UWESO) was started in 1986 by
Janet Museveni, wife of President Yoweri Museveni, in the aftermath
of the country's lengthy civil war, functioning as a relief agency to
assist orphans in resettlement camps and return them to their ex-
tended families. As the country became increasingly affected by the
AIDS epidemic, UWESO shifted its emphasis to support for AIDS or-
phans; the organization, with its 35 branches countrywide, helps fund
education and training for the children and runs a micro-finance
scheme to help the caretakers - typically, female relatives of the
children - to start up small businesses and trading activities.
(UNAIDS Report 2000, pages 27-28)
On the Toll of the AIDS Epidemic on Education:
Skilled teachers are a precious commodity in all countries, but in
some parts of the world, they are becoming too sick to work or dying
of HIV-related illness long before retirement. The Central African
Republic, where around one in every seven adults is estimated to be
infected with HIV, already has a third fewer primary school teachers
than it needs. It is commonly assumed that children drop out of
school when their parents die, whether of AIDS or another cause. In-
formation collected in large household surveys representative of the
general population confirms the general assumption that children
whose parents have both died are less likely to be in school than
children who are living with one or both parents. The impact of pa-
rental AIDS is not necessarily a direct one or seen only in children
who have already been orphaned. A child's schooling may be temporar-
ily interrupted by a shortage of cash occasioned by spending on a
parent's ill-health or by periods of work in the home to help sick
parents. By the time children are actually orphaned, they are likely
to be over-age for their class, even if they are still in school.
This was the case in both the Zimbabwean and Kenyan studies cited
here. Being older than their classmates was in turn associated with a
higher rate of dropping out of school for a number of other reasons,
including pregnancy and the need to take paying work. Many of the
marriages that led to drop-out were arranged, so it is quite possible
that relatives or sick parents themselves saw marrying a girl off as
a relatively painless way of ensuring that she would be cared for af-
ter their death (UNAIDS Report 2000, pages 29-30).
On HIV Prevention Programs at the Workplace:
A study in 40 Zimbabwean factories demonstrated that strengthened
prevention efforts in the workplace can reduce HIV transmission when
compared with workplaces that have weaker prevention programs. In
factories with peer educators the rise in HIV incidence was 34% lower
than in factories without. This substantial reduction was achieved at
a cost of around US$ 6 per employee (UNAIDS Report 2000, page 35).
What makes People Vulnerable?
Many factors in vulnerability can best be understood within the uni-
versal principles of human rights. Vulnerability to AIDS is often en-
gendered by a lack of respect for the rights of women and children,
the right to information and education, freedom of expression and as-
sociation, the rights to liberty and security, freedom from inhuman
or degrading treatment, and the right to privacy and confidentiality.
Promoting human rights and tolerance is thus important in fighting
AIDS as well as in its own right (UNAIDS Report 2000, page 37).
On Breaking the Silence:
A clarion call for greater openness had already been sounded by South
African President Thabo Mbeki. "For too long we have closed our eyes
as a nation, hoping the truth was not so real," the then Deputy
President Mbeki told South Africans in 1998. "For many years, we have
allowed the HIV virus to spread... [and now] we face the danger that
half of our youth will not reach adulthood. Their education will be
wasted. The economy will shrink. There will be a large number of sick
people whom the healthy will not be able to maintain. Our dreams as a
people will be shattered." (UNAIDS Report 2000, pages 38-39)
Secretary-General of the United Nations, Kofi Annan, told the United
Nations Security Council that the "impact of AIDS is no less destruc-
tive than that of warfare itself, and by some measures, far worse.
(Council's meeting in January 2000, UNAIDS Report 2000, page 39).
On the Impact of Education on the HIV Prevention Effort:
In an attempt to draw correlations between sexual behavior and educa-
tion, UNAIDS analyzed the results of studies conducted mostly among
15-19-year-olds in 17 African and 4 Latin American countries. The
analysis showed that as the level of education increases, some kinds
of risky behavior increase in frequency while other kinds decrease.
Better-educated girls tend to start having sex later: the proportion
of girls who were sexually experienced by the age of 18 was 24% lower
among those with a secondary education than among those who had been
only to primary school. However, the reverse was true of boys in many
countries. A further risk pattern, seen in both sexes, was that bet-
ter-educated individuals were generally more likely to have casual
partners. Education and information are fundamental human rights.
When children and young people are denied the basic information, edu-
cation and skills to deal with HIV, whether because of religious val-
ues, social mores or cultural preferences, they are that much less
empowered to reduce their own risk of infection (UNAIDS Report 2000,
pages 43-44).
On Violence against Women:
Violence directed against girls and women - in a sense, the most
egregious sign of male domination - makes them vulnerable to HIV in-
fection in a number of direct and indirect ways. According to a large
number of studies in many countries and on all continents, between a
third and a half of married women say they have been beaten or other-
wise physically assaulted by their partners. Like domestic violence,
sexual violence directed against women is depressingly common all
over the world, although accurate statistics are few and far between.
In one study some 30% of women aged over 18 said they had been sexu-
ally abused, as had one-fifth of teenage girls, but the vast majority
took no action. (UNAIDS Report 2000, pages 49-51).
On the Success of Existing Prevention Strategies:
There is now plenty of evidence about how well various options work.
The report covers a wide range of prevention efforts, with detailed
analysis of country specific patterns of transmission and the impact
of different interventions over time. Discussed in detail are: How
many young people manage to delay first sex? How many stay abstinent
before marriage? Sex before marriage: the HIV risks? What about fi-
delity between regular partners? Condom use: rising, but still not
enough. The female condom. Men who have sex with men. Men who have
sex with men and women. Male circumcision and HIV infection. HIV and
other sexually transmitted infections: an opportunity to strengthen
prevention. Reducing HIV transmission among drug users: interventions
are effective but not politically popular. Needed: an AIDS vaccine
(UNAIDS Report 2000, pages 55-77).
On Prevention of Mother-to-Child Transmission of HIV:
Since the start of the HIV epidemic, it is estimated that 3.8 million
children have died of AIDS before their 15th birthday, nearly 0.5
million of them in 1999 alone. Another 1.3 million children are cur-
rently living with HIV, and most will die before they reach their
teens. The vast majority of these children were born to HIV-infected
mothers: they acquired the virus in the womb, around the time of
childbirth or during breast-feeding. In the late 1990s, it was found
that around half of all these infections occur during breast- feed-
ing. Higher rates of HIV and of childbearing [for women in developing
countries] mean that prevention programs have to reach a much larger
number of women. Secondly, there are fewer HIV counseling and testing
facilities available. Thirdly, breast-feeding is almost universal,
and safe alternatives to breast milk are harder to come by.
Studies in Thailand in early 1998 showed that a relatively simple
drug regimen - a short one-month course of the anti-retroviral drug
zidovudine (AZT) - given to HIV-infected mothers late in pregnancy
could halve the rate of HIV transmission to their infants so long as
the women also avoided breast-feeding. In late 1999, a study in
Uganda showed that similar results could be achieved by giving nevi-
rapine to the mother at the onset of labor and then to the infant af-
ter delivery. This regimen costs about US$ 4 per HIV-infected woman -
less than a tenth of the cost of a one-month course of AZT. As a re-
sult, nevirapine has been included in the WHO Model List of Essential
Drugs as a drug for decreasing mother-to-child transmission of HIV.
The willingness to be tested increased in parallel with the awareness
within the general population that HIV infection in infants can be
prevented. A randomized controlled trial in Kenya, which followed the
children of HIV-infected women until the age of two years, reported a
lower mortality rate among those who had received replacement feed-
ing, a difference due mainly to the higher HIV infection rates among
the breast-fed infants. The biggest challenge of all will be to ex-
pand coverage beyond the pilot projects to reach all HIV-infected
pregnant women and their families. As part of planning ahead for this
expansion, health systems will have to rise to the considerable chal-
lenge of improving infrastructure, training, motivation and retaining
the necessary health staff, and improving distribution systems so
that HIV test kits, drugs and infant formula are consistently avail-
able to those who need them (UNAIDS Report 2000, pages 81-84).
On Care and Support for People Living with HIV/AIDS:
As example for the challenge to provide antiretroviral drug coverage
in a high income country, a study in the drug using population is
presented, where half of the people who met the criteria for treat-
ment under the national guidelines were receiving no antiretroviral
therapy at all, and just 14% were on the more expensive three-drug
combinations. In another high- income country in the same patient
population 60% were not receiving any antiretrovirals nearly a year
after becoming medically eligible for this therapy and women were
more than twice as likely as men to be untreated. In some countries,
there is also less social support available for injecting drug users.
(UNAIDS Report 2000, page 86).
On the Importance to Involve the Community:
In retrospect, our thinking about how to tackle the epidemic was
revolutionized by the community-based groups, non-governmental or-
ganizations and associations of people living with HIV that took up
part or all of the challenge of care and support, and often the chal-
lenge of prevention too (Greater involvement of people living with
HIV/AIDS - the GIPA principle). If anything, the involvement of HIV-
positive people has become even more visible and credible since 1995.
This is when the community stepped up pressure to increase access to
highly active antiretroviral therapy - in memory of those who had not
survived long enough to benefit from it and out of solidarity with
the millions who still could not afford it. Attempts to formulate
community standards for care and support have been as well completed
with some success in Burkina Faso, the Central African Republic, Ma-
lawi and in Phayao Province in northern Thailand. Formulating commu-
nity standards makes it possible to identify the resources for care
already available in the community and to determine how they could be
used to better effect through support from the formal health system
(UNAIDS Report 2000, pages 87-88).
Health Care: Where are the Gaps?
In the poorer developing countries, local health centers and small
hospitals lack adequate facilities to diagnose the opportunistic dis-
eases of people with HIV. They repeatedly run out of supplies of es-
sential drugs, including the ones needed to alleviate distressing
symptoms and to manage opportunistic infections. The high costs of
antiretroviral drugs, and the sophisticated medical facilities re-
quired to track patients' progress and monitor side-effects, have
been major stumbling blocks to access for the vast majority of people
with HIV in the developing world. Enormous variations in access to
antiretrovirals exist in middle-income countries. In most of Asia,
people with HIV have limited access. Argentina, Brazil, Colombia,
Costa Rica and Uruguay provide a legal right to some form of antiret-
roviral therapy, though the application of the law is somewhat
patchy. Experience in Brazil shows that the costs of such therapy,
although high, are offset to some extent by savings on treatment for
opportunistic infections and on hospital stays Nevertheless, some
concern has been voiced over the risk that HIV prevention activities
may suffer if too much effort and money is devoted to providing
treatment (UNAIDS Report 2000, pages 89-90).
On Comprehensive care and support strategy needed:
UNAIDS proposes to target action along five strategic axes:
1. creating political will and mobilizing resources;
2. increasing access to voluntary HIV counseling and testing;
3. increasing access to psychosocial support and impact alleviation
4. improving health service delivery;
5. increasing access to drugs of special interest to people living
with HIV infection. (UNAIDS Report 2000, page 92).
On Psychological and Social Support and other Measures to alleviate
the Impact of HIV/AIDS:
An important goal of social support is inclusion - enabling affected
people to live without fear and to continue functioning as normal
members of society. [Peer support groups] help members cope with dis-
crimination and stigma. One such group, at an antenatal clinic in
South Africa, was described by the women members as the only place
where they could relax and be themselves.
However, support groups are generally unable to meet one of the most
important challenges facing people in developing countries: lack of
income. Most people with HIV or AIDS are or become unemployed, and
the stark reality is that unless they can rely on broader support
from government and society there is little a community group can do
to alleviate this impact. Micro-credit, also known as micro-finance,
is an effective poverty-alleviation instrument promoted by the United
Nations Development Program (UNDP). UNDP estimates that micro-finance
at present covers only 1% of the potential market, affording great
potential for expansion. (UNAIDS Report 2000, pages 93-95).
On Improvement of Health Service Delivery:
AIDS increases the demand on the health sector and at the same time
reduces the human resources available to it by causing illness and
death in the sector's workforce. The desirable response would be to
increase the number of health care workers so as to maintain the sec-
tor's ability to deliver services. This requires decisions about the
kinds and numbers of health care workers that will be needed, and a
clear idea of how the cost of the mitigation efforts will be shoul-
dered.
The following are examples of care and support packages, according to
resources availability:
The essential package
1. voluntary HIV counseling and testing;
2. psychosocial support for HIV-positive people and their families;
3. palliative care and treatment for pneumonia, oral thrush, vaginal
candidiasis and pulmonary tuberculosis (DOTS);
4. prevention of infections with cotrimoxazole prophylaxis for symp-
tomatic HIV-positive people;
5. official recognition and facilitation of community activities that
reduce the impact of HIV infection.
The intermediate package
All of the above PLUS one or more of the following:
1. active case-finding (and treatment) of tuberculosis among HIV-
positive people;
2. preventive therapy for tuberculosis for HIV-positive people;
3. systemic antifungals for systemic fungal infections (such as
cryptococcosis);
4. treatment of Kaposi sarcoma with essential drugs;
5. surgical treatment of cervical cancer;
6. treatment of extensive herpes with acyclovir;
7. funding for community activities that reduce the impact of HIV in-
fection.
The advanced package
All of the above PLUS:
1. triple antiretroviral therapy;
2. diagnosis and treatment of opportunistic infections that are dif-
ficult to diagnose and/or expensive to treat, such as atypical my-
cobacterial infections, cytomegalovirus;
3. infection, multiresistant tuberculosis, toxoplasmosis, and HIV-
associated cancers;
4. specific public services that reduce the economic and social im-
pacts of HIV, to supplement community efforts that reduce the im-
pact of HIV infection.
(UNAIDS Report 2000, pages 96-98)
On Improvement of Access to Pharmacotherapy:
Through collaboration between the UNAIDS Secretariat, WHO and UNICEF,
some of the obstacles to essential drug access are being tackled.
First, beginning in 1997, 15 new drugs of interest to people with HIV
were included in the WHO Model List of Essential Drugs. Working with
WHO and UNICEF, the Secretariat identified manufacturers and prices
for 44 essential drugs whose procurement was being hampered by insuf-
ficient information on cost and availability.
Discussed are here:
1 The experience in Brazil with generic alternatives to proprietary
antiretrovirals, The Government decided to start local manufacture of
drugs that were not patent-protected, and for which it had the know
how and infrastructure.
2 The experience with the TRIPS agreement, which guarantees patent
protection for Member States of the World Trade Organization (WTO)
for a minimum period of 20 years, but grants governments the right to
produce and sell a patented product under circumstances of national
emergencies. Reference to campaigns of Medecins Sans Frontieres and
other humanitarian groups.
3 The experience with the UNAIDS Drug Access Initiative in Cote
d'Ivoire and Uganda where end-user prices of antiretroviral drugs de-
creased after negotiation with the pharmaceutical companies holding
the patents on those drugs (UNAIDS Report 2000, pages 99-104).
On Better Prospects for Preventing Infections in Those with HIV:
The bulk of evidence now suggests that a few relatively inexpensive
drugs could help ward off severe illness and add months, if not
years, to the lives of HIV-positive people in even the poorest devel-
oping countries:
One drug is isoniazid, which has been shown to be effective in ward-
ing off 60% of active tuberculosis episodes in people with HIV. A
simple regimen costs on average just a few cents a day for both the
medicine and the health services involved. This is why UNAIDS and WHO
have recommended since 1998 that a simple and inexpensive regimen for
preventing tuberculosis should be part of the essential care package
for people with HIV.
Cotrimoxazole - widely used for prophylaxis and treatment of PCP in
high-income countries, was tested for its preventive impact in C�te
d'Ivoire. In one study in Abidjan, where the drug costs of a 12-month
regimen were just US$ 17.50, cotrimoxazole prophylaxis resulted in
significantly fewer severe infections (as measured by hospital admis-
sions). A consultative workshop in Harare, Zimbabwe, March 2000, at-
tended by UNAIDS, WHO, clinicians, public health specialists, na-
tional AIDS program managers, people living with HIV/AIDS, donors and
AIDS activists recommended for people who have already developed
symptoms of HIV infection, that cotrimoxazole prophylaxis should be
part of their essential care and support package.
Isoniazid and cotrimoxazole prophylaxis - which can only be offered
to people with proven HIV infection, may further increase the inter-
est and willingness of people to be tested for HIV (UNAIDS Report
2000, pages 105-106).
On Common Features of Effective National Responses:
1. Political will and leadership;
2. Societal openness and determination to fight against stigma;
3. A strategic response; A single, powerful national AIDS plan. Be-
ginning with the analysis of the national HIV/AIDS situation, risk
behaviors and vulnerability factors, Effective strategy development,
drawing on evidence-based methods of HIV/AIDS prevention, care and
impact alleviation ("best practices"). Many programs have yet to be-
come comprehensive in either geographical coverage or content. A
sound strategic plan based on epidemiological evidence and best prac-
tices will at least ensure basic coverage;
4. Multisectoral and multilevel action;
5. Community-based responses; The eventual outcome of the AIDS epi-
demic is decided within the community;
6. Social policy reform. Reduce vulnerability. The question is how to
address directly the societal forces, which determine, more than any-
thing else, vulnerability to HIV/AIDS. This requires engagement at
the policy level, political will and resources;
7. Longer-term and sustained response;
8. Learning from experience;
9. Adequate resources.
If the action needed for risk-reduction and vulnerability-reduction
becomes part of the mainstream of national life, direct costs will be
less, the benefits will have many spin-offs, and programs are more
likely to be sustainable.
Debt relief: Some 95% of HIV-infected people live in developing coun-
tries, most of them in sub-Saharan Africa. And of the 39 so-called
heavily indebted poor countries identified by the World Bank, 32 are
in Africa. Together they owe more than US$ 2.2 trillion in debt. Lack
of funds for an expanded response to AIDS has been worsened by these
high levels of foreign indebtedness. Across Africa, national govern-
ments pay out four times more in debt service than they spend on
health and education. In order to mount effective national AIDS pre-
vention programs, countries in Africa will need to spend at least US$
1-2 billion a year, far more than is currently being invested.
Sources that might be tapped for these additional resources include
increased donations from the private sector and foundations, expan-
sion and redirection of development assistance, and reallocations
within countries' own public budgets. Relieving countries' debt bur-
den is one of the more promising new approaches that could increase
the funds flowing into programs to roll back the AIDS epidemic in Af-
rica. By relieving debt in the poorest countries - which, often, are
the ones with the highest HIV and AIDS figures - money now exported
to service debt could be reinvested into AIDS prevention and care.
(UNAIDS Report 2000, pages 108-115).
Conclusion
Two decades of action against the epidemic have generated important
insights into an effective response. While international political,
financial and technical support are important, lowering incidence and
mitigating the epidemic's impacts must be a nationally driven agenda.
To be effective and credible, national responses require the persis-
tent engagement of the highest levels of government. Countries that
have adopted forward-looking strategies to fight the epidemic are
reaping the rewards in falling incidence. Other countries are yet to
see the fruits of their efforts, and in the absence of rapid and
visible results, sustaining a response becomes more difficult.
However, evidence shows that the combination of approaches described
in this chapter have brought about a lowering of incidence in some
countries. At present, and until the arrival of a vaccine, these ap-
proaches are the strongest weapons in our fight back against HIV/AIDS
(UNAIDS Report 2000, page 115).
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