Kevin De Cock; Ian Grubb1
World Health Organization, 1211 Geneva 27, Switzerland
June 2006 marks the 25th anniversary of a report of five cases of Pneumocystis carinii (now jirovecii) pneumonia in men who have sex with men, heralding the acquired immunodeficiency syndrome (AIDS).1 Over 65 million infections with the causative agent, human immunodeficiency virus (HIV), have now caused at least 25 million deaths.
Following recognition at the XI International Conference on AIDS in 1996, that combination antiretroviral therapy (ART) dramatically improves survival, various initiatives have helped to bring treatment to people with HIV/AIDS in developing countries. Although the target of treating 3 m people by the end of 2005 (WHO's "3 by 5" initiative) was not reached, about 1.3 m people now receive ART in low- and middle-income countries. Major lessons from the initiative include the utility of country-owned targets in mobilizing efforts and promoting accountability, the need for extensive partnerships to scale up activities, the importance of identifying and resolving health systems constraints, the challenges of ensuring equity, and the synergy between treatment initiatives and a simultaneous scaling-up of HIV prevention.2
In 2005, G8 leaders made a commitment to "working with WHO, UNAIDS and other international bodies to develop and implement a package of HIV prevention, treatment and care, with the aim of coming as close as possible to universal access to treatment for all those who need it by 2010".3 As the lead agency for the health sector response to HIV/AIDS, WHO has consulted widely with others to define its contribution, drawing on the "3 by 5" experience and the UNAIDS technical support division of labour.4 The following five strategic priorities will require a refocusing of WHO's efforts and the mobilization of new resources.
The first strategic direction recognizes that wider access to HIV testing and counselling is essential: data from recent surveys in heavily affected countries show that fewer than 10% of HIV-infected persons know whether or not they are infected.5 There has been a move towards offering HIV testing more routinely in health care settings, as well as a re-evaluation of the intensity of pre-test counselling. WHO will be consulting with partners to develop guidance on HIV testing in clinical settings. Particularly lacking at the moment is guidance on the testing of children.
The second major priority is the delivery of prevention in health care settings. In particular, the requirements of people living with HIV and their families for prevention services have gone largely unaddressed. Also, the prevention of HIV transmission from HIV-infected mothers to their children requires more attention. In developing countries, fewer than 10% of HIV-infected women are being reached with preventive interventions,6 and programmes are handicapped by the weakness of maternal health care and the challenge of HIV transmission through prolonged breastfeeding. Measures to prevent HIV transmission in the healthcare setting are essential, as are partnerships to ensure that prevention-related health services reach populations at high risk of contracting HIV, including drug users, sex workers and men who have sex with men. In addition to assembling the evidence base for emerging biomedical preventive interventions such as male circumcision, WHO will guide implementation of available measures.
Thirdly, achieving universal access requires not only continued efforts to scale up ART treatment, but also improved prevention and management of opportunistic infections, care (including nutrition and palliation) and a focus on treatment and care for neglected populations such as drug users and children.
WHO's fourth strategic direction calls for vigorous efforts to tackle health system challenges brought to light by the "3 by 5" initiative. These include inadequacies in human resources, laboratory and other infrastructure, systems to procure and supply drugs and other commodities, and overall administrative and management capacity. Unless these challenges are given priority, it will be difficult to ensure transition from the emergency mode of "3 by 5" to sustainable, long-term programmes.
WHO's final priority will be the gathering, analysis, interpretation and dissemination of strategic information about the scaling-up of HIV/AIDS programmes in the health sector. Information concerning access to and coverage and impact of health sector interventions will be essential in order to assess progress towards universal access. Data will also need to include treatment outcomes such as rates of adherence to therapy, drug toxicity and patient survival, including HIV-free survival for infants of infected mothers.
The WHO response to HIV/AIDS over the next five years comprises an evidence-based health sector approach that emphasizes prevention, treatment and care at the same time as reinforcing health systems. Universal access cannot be a mere slogan. The task ahead is helping WHO Member States to provide quality HIV/AIDS services to everyone who needs them.
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