T h The world has reached a crucial moment in the history of HIV/AIDS, and now e The World Health Report 2004 has an unprecedented opportunity to alter its course. The most important mes- W o r l sage of the latest World Health Report is that, today, the international community d H has the chance to change the history of health for generations to come and e a l t open the door to better health for all. Tackling HIV/AIDS is the world’s most h R urgent public health challenge. Unknown barely a quarter of a century ago, e p o it is now the leading cause of death for young adults worldwide. More than rt 2 20 million people have died from it and an estimated 34–46 million others are 0 0 now infected with the virus. There is as yet no vaccine and no cure. 4 changing history The World Health Report 2004 – Changing History, published by the World Health Organization, calls for a comprehensive HIV/AIDS strategy that links prevention, treatment, care and long-term support. Until now, treatment has been the most neglected element in most developing countries: almost 6 million people in these countries will die in the near future if they do not receive treat- c h ment – but only about 400 000 of them were receiving it in 2003. a n WHO and its partners have declared the treatment gap a global emergency and g i n have launched a drive to provide 3 million people in developing countries with g h i antiretroviral therapy by the end of 2005 – one of the most ambitious public s t o health projects ever conceived. This report shows how it can be done. It goes ry further, looking beyond 2005 to explain how international organizations, national governments, the private sector and communities can combine their strengths and simultaneously fortify health systems for the enduring benefi t of all. Illustrated with photographs of people whose lives have been deeply affected World Health Organization by the global pandemic, The World Health Report 2004 makes essential reading for everyone with a political, professional or personal interest in health. WHO ISBN 92 4 156265 X The World Health Reportrt 2004 changing historyry WorldWorld HealthHealth OrganizationOrganization ii iii WHO Library Cataloguing-in-Publication Data World Health Organization. contents The World health report : 2004 : changing history. 1.World health - trends 2.HIV infections - therapy 3.Acquired immunodefi ciency syndrome - therapy 4.Acquired immunodefi ciency syndrome - therapy 5.Anti-retroviral agents - supply and distribution 6.Delivery of health care - organization and administration 7.World Health Organization I.Title II.Title: Changing history. ISBN 92 4 156265 X (NLM Classifi cation: WA 540.1) ISSN 1020-3311 © World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dis- semination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to Publications, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specifi c companies or of certain manufacturers’ products does not imply that they are en- dorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial Message from the Director-General ix capital letters. The World Health Organization does not warrant that the information contained in this publication is complete Overview xi and correct and shall not be liable for any damages incurred as a result of its use. A chance to change history xii Information concerning this publication can be obtained from: Why treatment must be scaled up xiii World Health Report Expanding treatment access xiii World Health Organization Towards Health for All xiv 1211 Geneva 27, Switzerland E-mail: [email protected] Chapter summaries xv Copies of this publication can be ordered from: [email protected] Chapter 1 A global emergency: a combined response 1 This report was produced under the overall direction of Tim Evans (Assistant Director-General), Robert Beaglehole (Editor-in-Chief), Jim Kim The global situation 1 (Special Adviser to the Director-General) and Paulo Teixeira (Director, HIV/AIDS). The principal authors were Robert Beaglehole, Alec Irwin and Thomson Prentice. The uneven spread of HIV 3 The other main contributors to chapters were: Chapter One: Ties Boerma, Jean-Paul Moatti, Alex de Waal and Tony Waddell. Chapter Two: Jhoney Rises in mortality, reductions in life expectancy 4 Barcarolo, Alex Capron, Charles Gilks, Alaka Singh and Marco Vitoria. Chapter Three: Hedwig Goede, Ian Grubb and Stephanie Nixon. Chapter Four: The deadly interaction: HIV/AIDS and other diseases 7 David Evans, Neelam Sekhri, Phyllida Travis and Mark Wheeler. Chapter Five: Don Berwick, Michel Kazatchkine and Yves Souteyrand. Other contributors to the report were: Christopher Bailey, Michel Beusenberg, Boakye Boatin, Andrew Boulle, Guy Carrin, David Coetzee, The AIDS treatment gap 7 François Dabis, Betina Durovni, Dominique Egger, Paula Fujiwara, Claudia Garcia-Moreno, Eric Goemaere, Peter Graaf, Raj Gupta, Kate Hankins, The human, social and economic consequences 8 Kei Kawabata, Wayne Koff, Michael Lederman, Ying-Ru Lo, Naisiadet Mason, Kedar Mate, J.P. Narain, Carla Obermeyer, Amolo Okero, Catherine Women: unequally at risk 8 Orrell, Andreas Reis, Peter Reiss, Alan Stone, Tessa Tantorres, Kate Taylor, Roger Teck and David Walton. Contributors to statistical tables were: Carla Abou-Zahr, Prerna Banati, Steve Begg, Christina Bernard, Ana Betran, Maureen Birmingham, Daniel The underestimated economic threat 9 Bleed, Monika Blössner, Anthony Burton, Laurent Chenet, Christopher Dye, Charu Garg, Peter Ghys, Patricia Hernández, Mehran Hosseini, Jose The threat of institutional collapse 10 Hueb, Chandika Indikadahena, Mie Inoue, Peter Jackson, Doris Ma Fat, Colin Mathers, Sumi Mehta, John Miller, Bernard Nahlen, Mercedes de Onis, Prevention, care and support: strategies for change 11 Richard Poe, Leonel Pontes, Jean-Pierre Poullier, Nathalie Proust, Eva Rehfuess, Kenji Shibuya, Karen Stanecki, Michel Thieren, Niels Tomijima, Nathalie Van de Maele, Catherine Watt and Hongyi Xu. Preventing the sexual transmission of HIV 12 Valuable input was received from Assistant Directors-General, policy advisers to the Director-General at WHO headquarters, and many technical Breaking the link with other sexually transmitted infections 13 staff. Additional help and advice were kindly provided by Regional Directors and members of their staff. Preventing infection in infants and children 13 The report was edited by Barbara Campanini and Leo Vita-Finzi. Translation coordination and other administrative and production support was provided by Shelagh Probst. The web site version and other electronic media were provided by Gael Kernen. The photographs and media kit were Injecting drug use – reducing the harm 15 coordinated by Gary Walker. Proofreading was by Marie Fitzsimmons. The index was prepared by Kathleen Lyle. Preventing transmission during health care 15 Testing and counselling 15 Design: Reda Sadki Layout: Steve Ewart, Sue Hobbs and Reda Sadki Printing coordination: Keith Wynn Printed in France 2004/15763 – Sadag – 20000 iv v Chapter 2 Chapter 5 The treatment initiative 21 Sharing research knowledge 73 Treatment scale-up: public health arguments 23 Prevention research 74 Treatment scale-up: economic and social arguments 24 Linking prevention and access to treatment 74 The 3 by 5 strategy 25 Preventing transmission from mother to child 76 Partnerships: vital for success 26 Protecting women with microbicides 77 Delivering treatment: a practical new approach 27 Vaccine research 77 Antiretroviral drug resistance: acting now to prevent a major problem 29 Treatment research 78 The costs of achieving 3 by 5 30 Sustaining long-term adherence 78 The front lines: working in countries 32 Coping with toxicities 79 China 32 Preventing drug resistance 79 India 33 Developing new drugs and strategies 80 Kenya 34 Tackling tuberculosis and HIV/AIDS together 80 Thailand 34 Operational research 81 Zambia 35 Economic issues 82 Ethical policies for treatment 35 Health policy analysis 83 Making 3 by 5 work for the poor and marginalized 36 Equity issues 84 Beyond 2005 38 International collaboration 84 Sharing knowledge 86 Chapter 3 Community participation: advocacy action 43 Conclusion 91 Community participation in public health 44 Civil society responds to the AIDS tragedy 45 Statistical annex 93 The power of a human rights approach 47 Explanatory notes 93 Civil society and treatment expansion 48 Annex Table 1 From advocacy to service implementation 48 Basic indicators for all WHO Member States 112 Community health workers and treatment 50 Annex Table 2 Community empowerment and public health: shaping the future 52 Deaths by cause, sex