Investing in a comprehensive health sector response to HIV/AIDS: scaling-up treatment and accelerating prevention (January 2004 - to December 2005)

WORLD HEALTH ORGANIZATION

ORGANISATION MONDIALE DE LA SANTE

REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL OU PACIFIQUE OCCIDENTAL

REGIONAL COMMITTEE Fifty-fifth session Shanghai, China 13-17 September 2004 Provisional agenda item 13

WPRJRCSSIINF.DOC./2 10 August 2004 ORIGINAL: ENGLISH

INVESTING IN A COMPREHENSIVE HEALTH SECTOR RESPONSE TO HIV/AIDS: SCALING-UP TREATMENT AND ACCELERATING PREVENTION (JANUARY 2004 TO DECEMBER 2005).

This document was prepared by the WHO Secretariat and presents the strategic and resource framework for WHO, HIV/AIDS programme and WHO's support to countries as they scale up their national plans. Only recently finalized, it was distributed at the 15th International AIDS Conference in Bangkok, Thailand, in July 2004. Copies .of the full document will be available at the fifty-fifth session of the Regional Committee, together with: 25 profiles of countries with a high burden of HIV/AIDS (including Cambodia, China and VietNam from the Region); seven advocacy sheets (accelerating prevention, '3 by 5' questions and answers, '3 by 5' closing the treatment gap - changing the story, treatment works, testing and counselling, the AIDS Medicines and Diagnostics Service and WHO prequalification); and an interview with Dr Jim Kim, Director of the HIV/AIDS department at WHO Headquarters. documents will be available in English only. These

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EXECUTIVE SUMMARY

During 2003, an estimated 4.1 million people 15-49 years old became infected with HIV, with an additional 630 000 children becoming infected. HIV/AIDS killed about 3 million people in the same year. This occurred despite the existence of proven interventions that can prevent transmission and of life-saving antiretroviral therapy. However, of the 5.5 million people in developing and transitional countries (other than Canada, the United States of America, countries in western Europe, Australia, New Zealand and Japan) estimated to need antiretroviral therapy, only 440 000 had access to it by 30 June 2004, representing an increase of only 40 000 people in the first six months of 2004. WHO's HIV/AIDS programme focuses on assisting governments and other stakeholders in implementing a coordinated and comprehensive health-sector response to HIV/ AIDS. Consistent with the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS and the Global Health-Sector Strategy for HIV/AIDS 2003-2007, this response incorporates a spectrum of HIV I AIDS and related services, including prevention, treatment, care and support. It also must include appropriate health systems standards, skills mix, supportive policies and partnerships that enable effective multisectoral approaches. As in the past, prevention efforts remain a high priority for WHO, especially among vulnerable populations and in clinical settings. However, until now, treatment is the element that a majonty of developing countries have neglected most in their comprehensive national response to HIV/AIDS. The lack of treatment has helped to perpetuate stigma and discrimination and greatly reduced the impact of prevention and care efforts, including uptake ofHIV testing and counselling. A significant new component of WHO's HIV/AIDS programme in 2004-2005 therefore includes activities to support Member States in scaling up treatment and in realizing the global target of having 3 million people in developing countries receiving antiretroviral therapy by the end of 2005. With significant new resources now available to scale up national HIV/AIDS programmes, countries face particular challenges in ensuring that they and their partners effectively manage, coordinate and monitor their efforts at the national level, contribute to overall health systems development and address pressing social challenges such as promoting greater involvement of people living with HIV/AIDS and affected communities, elevating the social status of women and girls and promoting equitable access to services. WHO's HIV/AIDS programme is designed to contribute to attaining these broad social goals.

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The WHO HIV/AIDS Plan for January 2004-December 2005 presents the strategiC and resource framework for WHO's HIV/AIDS programme. It describes the work of WHO in providing suppon to countries as they develop and implement their national scale-up plans. It includes an introductory epidemiological situation analysis and the most recent estimates of antiretroviral therapy coverage by region. The WHO HIV/AIDS Plan is not a detailed work schedule; it provides a framework for developing detailed work plans, with specific time-bound activities and responsibilities necessary to bring the WHO HIV/AIDS Plan to fruition at all levels of WHO. In addition, detailed joint plans are being developed with UNAIDS Cosponsors to coordinate, align and integrate work at country level. The WHO HIV/AIDS Plan for January 2004-December 2005 is designed to draw on the comparative advantage of the WHO as the specialized agency on health within the United Nations system. It seeks to strengthen WHO's role in supporting the coordination of national responses in the health sector, convening stakeholders and stimulating new partnerships. These partnerships will not only include those with and between the United Nations organizations and the governments of Member States but will also involve technical agencies, donors, civil society groups, organizations of people living with HIV/AIDS and the private sector. Consistent with the WHO programme budget for 2004-2005, the HIV/AIDS programme encompasses activities in five functional areas: • • • • • strategic information advocacy and policy technical and normative guidance country capacity-building operations research and knowledge management.

These functional areas focus on scaling up treatment, care and suppon and accelerating HIV IAIDS prevention through action in the health sector. In determining its programme objectives in 2004-2005 for HIV/AIDS as well as in other areas

of work, WHO will focus a greater proportion of its human and financial resources at the regional and country level. To specifically improve the support provided to Member States in scaling up HIV treatment and accelerating prevention, "3 by 5" teams will be in place in focus countries by the third quarter of 2004. More intensive and comprehensive country profiling systems now being

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implemented will enable technical support needs to be assessed more effectively and responses tailored appropriately to meet country needs. The proportion of the total HIY/AIDS budget dedicated to the regional and country levels is increasing from 66% in 2002-2003 to 87% in 2004-2005, with the African Region of WHO receiving 55% of total funds. WHO will also be strategic about where and how it provides technical assistance. Although it will continue to respond to requests from all Member States, WHO will concentrate its resources in countries where the burden of disease is most acute and where positive impact is antic1pated to be greatest. WHO will focus on technical areas in which it has a comparative advantage. A new Strategic and Technical Advisory Committee will be established to provide guidance to the WHO HIY/AIDS programme, and regular reports covering "3 by 5" milestones and expected results will be published. The WHO HIY/AIDS Plan for January 2004-December 2005 sets out anticipated resource requirements of US$ 218.1 million for WHO's HIY/ AIDS programme across all levels of the Organization during 2004-2005, of which US$ 62 million remained unfunded as of 1 July 2004. Additional financial support to close this funding gap is needed if the full programme of work described in the WHO HIY IAIDS Plan is to be implemented.

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WHO's HIV/AIDS strategy under the spotlight Dr Jim Yang Kim, Director of WHO's HIV/AIDS Department, talks to the Bulletin about "3 by 5"- the global strategy which aims to provide three million people in developing countries with antiretroviral treatment by 2005 not important but HIV/AJDS is clearly of people within a population using the disease that could define our generastandardized regimens and simple treattion. It is killing a particular portion of ment algorithms. the population which is the most impor"WH 0 has been saying for years tant for social viability: young men and that we need to invest more in health women in the prime of their lives, people and in some ways, we have been sucwho are key to a community's social and cessful- the world is investing more economic structure. It is an enormously in health but almost all of the new serious problem, as the World Bank investment is for HIV. The world has points out, when a country loses people voted- presidents and prime ministers in whom so much has already been have voted- to put their money into invested and who must in turn invest the fight against HIV/AJDS. For WHO in the next generation, if societies are to turn its back on HIV/AJDS would to be sustained. therefore be tantamount to a dereliction ''By choosing w focus on the HIV/ -of-dury.-It's--an-opporruniry-we-cannor-AIDS treatment gap, WHO's Directorafford to miss. WHO must therefore General, Dr LEE Jong-wook, recoghelp the world achieve its goals but at nized that WHO has an important role the same time make sure that those to play in combating this epidemic. This goals contribute to broader social is because scaling-up treatment for HIV development." in developing countries requires a public health approach. Until now, the only Bulletin: Is there more to ':3 by 5" than way HIV could be treated was in a very treatment? clinical, hospital-based, first-world type ]K: "Yes. In providing HIV treatment, approach, where physicians were the only we can achieve many other things at the ones who could treat HIV patients. same time. For example, by increasing In order to quickly and equitably roll access to ART, we have learnt that we can out HIV treatment in resource-poor reduce the stigma associated with HIV settings, we could not take a one doctor, one patient approach. We had to deinfection. In the first world, the availvelop ways of treating many thousands ability of ART- which can dramatically

About "3 by 5": Since its introduction in 1996, highly active antiretroviral therapy (ART) has enabled people with HIV/AJDS in industrialized countries to live healthier, longer lives and to continue to contribute to the social and economic well-being of their families and societies. However, although 95% of the world's 40 million HIV-positive people are living in developing countries, only about 400 000 of the six million people requiring treatment actually received it in 2003. To address this treatment gap, at the UN General Assembly Special Session on HN/AJDS in 2001, UN Member States unanimously committed to scaling up ART within their national HIV I AlDS programmes. In late 2003, WHO and UNAIDS declared the inequity in access to HN/AJDS treatment a global public health emergency and launched the initiative, dubbed "3 by 5", which aims to treat three million people living with HN in developing countries by the end of2005. In a special interview with the Bulletin, WHO's Director ofHIV/ AlDS explains the principles behind the strategy, describes the challenges to its success and recounts the progress made towards achieving the target to date.

Bulletin: Why has WHO chosen HIVI AIDS for the signature initiative ofthe current Director-Generalship? ]K: "There are many reasons. One of the reasons is that for certain areas of the world the threat ofHIV/AIDS is more severe than almost any other disease that we've seen for many hundreds of years. This is not to say that other diseases are

Dr Jim Yang Kim, Director of WHO's HIV/AIDS Department

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transform dying people back into healthy, productive individuals- was a critical factor in reducing the stigma associated with HIV and in enabling people to resume their lives. "Secondly, providing HIV treatment also strengthens prevention. For example, when effective HIV treatment was offered in the first world, resistance to being tested dropped fairly quickly. One of the most powerful ways to prevent HIV is by quickly expanding the number of people who know their status so that they can protect themselves and others. "Thirdly, by providing HIV treatment we can also strengthen health systems. To deliver HIV treatment, countries need systems that can provide chronic care and follow a patient throughout their life. The system must also, at least at a basic level, provide for their general health-care needs. I believe that WHO should intervene in countries in a way that can help ensure the long term development of health-care systems that will function not only for HIV but also for other chronic illnesses, such as diabetes and hypertension." Bulletin: So '3 bJ' 5" isn't just tmother "vertical" programme?

Bulletin: What can WHO do to facilitate treatment scale-up? ]K: "Lots of things, including establishing technical norms and guidelines and providing direct technical support to ministries of health at the country level. We can also help ensure that national efforts are coordinated - that partners are working together on the ground." Bulletin: WHO estimates that it will cost US$ 5.5 billion to reach the '3 by 5" target over the next two years. Is this funding in place?

Strengthening health systems means strengthening the policy and regulatory capacity of governments in relation to the whole range of health-care providers." Bulletin: WHO has committed to getting three million people on ART by 2005 and to keeping them on treatment for the rest oftheir lives. Is this target achievable?

]K: "The target is achievable but it depends on how much political will, money and resolve the world is willing to invest. Many people tell me that it's not achievable, but since very few have really tried to scale-up ART treatment, how could they possibly know with such certainty that it is impossible? I'm not interested in defeatist conclusions at the outset. We should be discussing the obstacles to achieving this target and working to develop ways of overcoming them, instead of citing reasons why it can't be done." Bulletin: WHO has been accused ofdouble standards because it has recommended drugs for developing countries that have not been approved by national drug regulrztory authorities for we in developed countries such as the EU, Japan and the US What is the justification for this?

]K: "No, not right now. Bur there are many possibilities for increasing funding to get more people on treatment. First, the cost of antiretrovirals continues to go down. Secondly, redirecting some of the funds from the first three rounds of grants by the Global Fund to Fight AIDS, TB and Malaria could lead to more money available for treatment. Also, the World Bank is now moving much more quickly to fund treatment in the countries in which they are working. In addition, the US Government is now playing a major role and contributing resources. Canada has also made a substantial contribution to the "3 by 5" initiative. With all these possibilities, WHO can play an important role at the country level to help ensure the funds are spent sufficiently." Bulletin: What is the US$ 5.5 billion for?

]K: "We have to make sure that it doesn't become one. There are so many aspects of caring for an HIV patient that we clearly need to integrate HIV care into a broader primary health-care system. That is what was done in Thailand and in Haiti. Unless HIV treatment is integrated into the overall health-care system, I think it will fail in the long run." Bulletin: Who is responsible for achieving '3 by5"?

JK: "The reason they are not approved in those specific countries is that selling generic medicines would breach national patents in those rich countries. Recent developments at the World Trade Organization have allowed poor countries - in the event of a pandemic like HIV/AlDS- to import generic drugs made under compulsory licensing, if they are unable to manufacture the medicines themselves. Several countries are doing this now. Bur how do those countries which may not have good drug regulatory authorities evaluate the quality of these imported generic drugs? The EU, Canada, Australia and rhe US have highly respected drug regulatory authorities but it is difficult for rhem to test these generic drugs for a number of reasons including the enforcement of parents. "So we have a situation where the drugs are available, poor countries want them and they want them with quality assurance bur they themselves may not have the regulatory capacity to give that kind of assurance. WHO, therefore, has developed its pre-qualification system which utilizes drug regulators from countries like Switzerland, 475

]K: "It is for the many aspects of treatment and prevention scale-up - training health workers, paying for ART, providing medicines for opportunistic infections and all the different aspects of a comprehensive treatment programme that must be in place." Bulletin: How will countries persuade their private health sectors to implement the pillars of'3 by 5"?

]K: "It is important to understand that "3 by 5" is not a WHO project. WHO cannot and never claimed to be able to do this by itself We don't have money for drugs, we are not a funding agency and we are not even going to be the primary implementing agency on the ground. WHO has chosen to hold itself accountable to the "3 by 5" target because we feel it is the most concrete, transforming and appropriate goal around which to organize our activities at d1is point in d1e epidemic. Whether or not the world can achieve "3 by 5" will depend on many other actors. In proclaiming our commitment to the target, we are saying that we will do everything in our power to help countries reach their aspirations in treating their HIV-positive citizens."

]K: "The private sector is already a major provider of HIV treatment in many countries. Our experience has been that the private sector is also looking for guidance on how to treat HIV patients because there are many choices. But governments need to play a stronger regulatory role and WHO is working to provide them with a framework by which they can establish procedures, rules and regulations ro guide the treatment activities of not only the private sector but also of nongovernmental and faith-based organizations.

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I News Canada, Australia, France and 16 other countries w assess the quality of the drugs. This allows the UN system and poor countries to import them with confidence." Bulletin: How will WHO advise countries on how to make difficult ethical decisions such llS who to begin treating first?

]K: "We are preparing very practical guidelines to help countries make these choices. Bur there is no way round the question of who to treat first. The goal is universal access but you have to start somewhere. Triage is part of every medical imervention and triage has always presemed an ethical problem. But the situation in which we are living now- where a minute percentage of those who need treatment in Africa are receiving it -has much more serious ethical implications. Who to treat first is a far better ethical problem to deal with than not treatinp; at all. Some people have suggested that launching "3 by 5" created an ethical problem but I see it very differently. The "3 by 5" initiative and the push for universal access will help us pull ourselves out of the gravest of ethical problems and organizations like Medecins Sans Frontieres are showing how communities can successfully make these decisions for themselves." Bulletin: How will WHO help countries address the issue ofpatient confidentiality?

then that is another issue. A major question is: how serious do the side effects need to be before a change in therapy is required? I would personally argue that in first world coumries, drug regimens are often changed too quickly. We really have to work to develop a better understanding of the appropriate time to change regimens, especially when there is a limited pool of drugs." Bulletin: Many argue that supervised therapy is necessary to prevent the emergence ofdrug resistant HIV strains. Does WHO recommend supervised therapy to countries scaling up treatment?

]K: 'This is a big challenge. There is no question that the cost is much higher. One of the top priorities of WHO's AIDS Medicines and Diagnostics Service is to look into this issue and try to bring these costs down to the level of firstline regimens in a very short period of time. I am hopeful that this issue can be resolved fairly quickly." Bulletin: Countries have to become TRIPS (trade-related aspects ofintellectual property rights) compliant by 2005. Is this going to drive up the cost ofART and how will this a./feet countries' abilities to provide treannent for "3 by 5 "?

]K: "My personal view is that we should recommend supervised therapy. However, there are all kinds of issues involved relating to human rights, logistics, availability of resources and so on. So it is a difficult issue and it needs to be properly studied. I think in the end, we will conclude, as Partners In Health (my former organization) in Haiti did, that having treatmem support workers to help people take their drugs is very cost effective and that it can help prevent drug resistance and improve patiem outcomes overall. "Currently, WHO strongly recommends countries to provide patients with treatment supporters where possible. Our responsibility is to work with countries and donors to conduct operational studies which will confirm the importance of treatment supervision in prevenrine; rhe emere;ence of rlmr; resistance. But one point I would stress is that WHO definitely does not suggest that countries should delay the initiation of therapy if a treatment support worker system cannot be established. Many programmes that don't use them have done extremely well and in fact, compliance rates have been quite high in these programmes. "WHO, together with its partners, is building a monitoring and surveillance system called HIV Resner through which we will be monitoring the emergence of drug resistance, through studies over time. "Resistance is a challenge we need to anticipate but it is never used as an excuse not to provide treatment in rich countries and shouldn't be in poor ones." Bulletin: The cost ofsecond-line drug regimens are monumental by comparison to fiw-line regimens. How will countries care for patients who have foiled to respond to first-line regimens?

]K: 'TRIPS compliance doesn't necessarily mean that the cost of ART will go up. If drug prices were to rise, I think that the HIV community including different civil society actors would respond by re-affirming the spirit of Doha and its relationship to public health. TRIPS Donfirmu tho importanoo of tra.d.o a.nd. intellectual property but it also says that these issues are not more important than public health disasters like HIV/AIDS. In 2005, we may have to negotiate again but we think and hope that the conclusion will be the same. Protecting public health in the face of emergencies and other disasters like HIV/AIDS must take priority." Bulletin: What has been achieved since the launch of"3 by 5"?

JK: "Protecting patient confidemialiry i~ a prouk:rn that exists in all health-car.: systems including those in developed countries. The way to look at "3 by 5" is as an opportunity to improve the ability of developing country health systems to protect patient confidentiality. If it can be done for HIV then it can be done for other health problems. It won't be easy bur since we have to do it anyway, why not use the political will behind HIV treatment to make a real effort to solve the problem?" Bulletin: Are there systems in place for the monitoring and evaluation ofpatients on treatment, in particular for any potential side efficts resulting from ART which may require a change in drug regimen?

JK: "WHO has sf'nt tf'am.s to '\7 rnuntries and we now have a much better idea of what is and is not happening at the country level. As a result of that, we have been able to develop a clear and focused business plan and to define the specifics ofWHO's role. We now know that WHO has more to offer in some areas but not in others and we know what has already been done by the countries themselves and by other partners. WHO is learning every day how to be a better partner. "We have produced some very good tools: clinical guidelines, monitoring standards, training materials that are currently being used in countries. We need to do more, and we will. Right now, we are doing everything we can to help bring all the players together because the whole world needs to rally around this incredible challenge if we are going to reach "3 by 5"." • Sarah Jane Marshall, Bulletin

]K: "Yes, there have to be systems in place to monitor and evaluate patients on treatmem. Some patients will be monitored in rural areas mostly under the supervision of nurses and health workers but if they have serious side effects that require changing therapy, 476

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December 2003 through

3 by 5

PROGRESS REPORT June 2004

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Contents Foreword ............................................................... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 5 Introduction ............................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 7 Key findings ............................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 9 Providing treatment to the people in need . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Leadership, partnership and advocacy ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 9 Urgent, sustained country support ........... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Simplified standardized tools and technical guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 An effective and reliable supply of medicines and diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 13 Achieving targets for scaling up treatment: overcoming challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Annex 1. Reporting of results versus objectives: June 2004. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 19 Annex 2. Discussion of results and interventions planned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 21

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Foreword I believe that our collective response to the HIV/AIDS pandemic is the benchmark by which our generation will be judged. We cannot shirk this historic responsibility, nor can we afford to fail. Increasing the availability of HIV/AIDS treatment, prevention and care has been and must continue to be a central priority for the World Health Organization, UNAIDS and their partners. For nearly a decade, a number of bilateral donors, NGOs, foundations, the private sector, people living with HIV/AIDS, faith based organizations, multilateral agencies and national governments have been engaged in advocacy, planning, research, capacity development and programming to enable the scale up of HIV treatment and care. This effort did not begin and does not end with "3 by 5". The immense work of activists to push us to where we are today cannot be underestimated. The UNAIDS secretariat and cosponsors have all contributed political and technical support along the way. Not least of all, the Global Fund to Fight AIDS, TB and Malaria, the U.S. President's Emergency Plan for AIDS Relief, the World Bank, the European Commission, the governments of Australia, Belgium, Canada, France, Germany, Ireland, Italy, Japan, the Netherlands, Norway, Spain, Sweden, the United Kingdom, other bilateral donors, nongovernmental organizations, the Gates and other Foundations, as well as the private sector, have all contributed resources and expertise. We recognize and commend their efforts through which new hope has been created that millions of lives can be saved. In order to help move scale-up forward more quickly, in 2003 I joined with UNAIDS to declare the lack of HIV/AIDS treatment to be a global public health emergency. This move was precipitated by the recognition that with reduced drug prices and the demonstrated feasibility of delivering treatment even in resourceconstrained settings, the continued lack of treatment for so many people who need it was unacceptable. On World AIDS Day 2003 we announced a strategy to facilitate reaching “3 by 5”– 3 million people in developing and transitional countries receiving antiretroviral therapy by the end of 2005. If countries and the international community continue to intensify their efforts, we will reach this target, and that will set us on the road towards our ultimate goal of universal access to treatment for all those who need it. Since we published the “3 by 5” strategy, we have been working to help break through obstacles and ensure that the people in need of treatment can get it. We have established the AIDS Medicines and Diagnostics Service to assist countries with the information and technical assistance they need to purchase highquality AIDS medicines and diagnostic tools. WHO has strengthened the antiretroviral prequalification project to assess the quality of medicines against rigorous international criteria. We have sent staff to more than 20 countries to respond to specific requests for help. We have worked to build a network of partners who have joined us in committing to the goal of delivering treatment to people where and when they need it. We believe that the building blocks, supported by many partners, are now in place to rapidly increase the availability of antiretroviral therapy on a large scale. Countries were quick to respond to the promise of “3 by 5”. Forty requested technical support almost immediately, and many more followed. However, the funding needed to implement WHO’s contribution to the strategy did not become available as quickly as we had expected. We therefore reviewed our options and focused on using the staff and other resources already available within WHO as effectively as possible. More funding has recently been made available, particularly from the Government of Canada, which made a generous pledge of CAD 100 million to fund the “3 by 5” initiative, and from the Governments of the United Kingdom and Sweden. The combination of this new funding and the political will needed to increase the availability of treatment, prevention and care strongly improves prospects for controlling the worst global epidemic the world has ever faced. I am well aware that we and our partners have set an ambitious goal. That is just what we needed: a difficult, time-limited undertaking that would force us to change the way we work at WHO. "3 by 5" is the best way to challenge ourselves to make the contribution we should be making to the global effort against HIV/AIDS. We will continue to measure ourselves against specific targets to assess the progress we are making.

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This progress report highlights the achievements of the first six months of the initiative to expand the availability of HIV/AIDS treatment as well as the many challenges that remain. This is based on a series of milestones included in the WHO “3 by 5” strategy. Considering the slow growth in the availability of treatment in developing countries, the actions of many partners over the past year – and especially the past six months – offer hope that we may at last turn the tide against this terrible pandemic.

LEE Jong-wook Director-General World Health Organization

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Introduction Changing contexts and responses The “3 by 5” target builds upon the years of work of governments and civil society in many countries, supported by their bilateral and multilateral partners, to expand access to HIV treatment. People living with HIV in low and middle income countries have been pressing their demands for antiretroviral treatment since the mid 1990s, when it became clear that treatment was dramatically reducing AIDS mortality and morbidity in the high income countries where it was accessible. As early as 1997, UNAIDS and WHO launched the Drug Access Initiative in Cote d’Ivoire and Uganda, the first public sector pilot projects demonstrating that antiretrovirals could be delivered safely and effectively in resource-limited settings. Despite the subsequent successes of one after another small-scale pilot project, few countries have managed to deliver HIV treatment to all, or even the majority, of those in need. In the late 1990s and in 2000-2001, additional initiatives such as the International Therapeutic Solidarity Fund, the African Comprehensive HIV/AIDS Partnerships (ACHAP) in Botswana, and the work of Médecins Sans Frontières, U.S. Centers for Disease Control and Prevention, and many donor funded efforts, to name a few, added much knowledge to implementing HIV/AIDS treatment programs. Excluding Brazil, which accounts for about one-third of all people on antiretroviral therapy in developing and transitional countries, access to antiretroviral medicines in 2002 increased by 50 percent globally, and by about two-thirds in sub-Saharan Africa. Whereas the initial base of numbers of persons treated was small, the pace of increased access to treatment has begun to grow. For example, Barbados, Cuba and Costa Rica provide free antiretroviral access to all those in need, while the Bahamas, Guyana, Senegal and Thailand have been making significant progress toward universal treatment access. Despite the increasing political attention paid to HIV/AIDS, more than 8000 people are still dying every day from a disease that can be treated and prevented. However, some important progress is being made. Significant new resources are flowing to support the scaling up of antiretroviral therapy and are not simply being diverted from core prevention activities. More and more countries accept the need to provide antiretroviral therapy to the people who need it, and international and national partners across a diverse range of groups and agencies are coming together to support scale-up in accordance with “3 by 5” targets. The unprecedented momentum for access to treatment poses challenges for many countries. Coordination around a common set of goals and objectives at the national level is critical. Accordingly, UNAIDS developed the “three ones” principles to highlight the need for one national programme, one coordinating body and one monitoring and evaluation framework. Partnerships have been an increasing focus of work for WHO, as “3 by 5” is increasingly embraced as a global target owned by everyone. “3 by 5” clearly cannot be the project of one or even several agencies; the task is far too large and complex. The “3 by 5” target has been widely discussed and sometimes misinterpreted. A time-limited target is a proven method for mobilizing action and resources. Some people remain uncomfortable with the ambitious agenda of having 3 million people receiving treatment in the next 18 months. But WHO and UNAIDS believe that the target is achievable and are committed to supporting all Member States to achieve it. Anything less falls short of an appropriate response to the greatest global public health challenge of our times. Beyond 2005, the ultimate goal of providing treatment to everyone who needs it as a human right has not been questioned.

e WHO response to helping countries In the past six months, WHO has worked strenuously to respond to the overwhelming demand from countries for urgent assistance. The original intention was to recruit “3 by 5” country officers and “3 by 5” country teams as soon as possible for each of the WHO-identified focus countries. Given the initial shortfall of funds to recruit new staff for these key positions, WHO instead focused on sending its existing staff to countries to provide interim support. Twenty-four teams from WHO headquarters and regional offices were sent in response to requests from countries. These missions mapped the local situation, identified key partners and technical assistance needs, prompted and reinforced political commitment and supported the process of developing national scaleup plans. In addition, 37 staff members from headquarters and regional offices were sent for 4 to 8 weeks to

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countries that had requested urgent support, especially those preparing applications for Round Four funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Deployed staff also helped countries to identify obstacles to expanding access to the entire range of HIV/AIDS prevention, treatment and care services and, in some cases, began to develop initial plans for scaling up treatment. Much of this work has led to the creation of detailed country profiles developed with national counterparts and partners in each country. These profiles will be a practical tool to help guide countries in their scale-up efforts, to monitor progress and to clarify roles and responsibilities among the various actors at the country level. Meanwhile, at WHO headquarters, at WHO regional offices and in consultation with partners, other key elements of the strategy were taking shape. The AIDS Medicines and Diagnostics Service (AMDS) was established as a multi-agency network linking WHO and the UNAIDS Secretariat more closely with other UNAIDS cosponsors the United Nations Children’s Fund (UNICEF), the World Bank and the United Nations Population Fund (UNFPA), and now, the United Nations Development Programme (UNDP). Twenty-nine countries have already procured antiretroviral medicines through a combination of existing and new services under the AMDS umbrella. Member States have broadly endorsed WHO’s prequalification process, which assesses the quality, safety and efficacy of drugs submitted by participating manufacturers. Further, WHO’s Expert Committee on the Selection and Use of Essential Medicines has strongly recommended the use of fixed-dose combinations (fixed amounts of two or more active ingredients in one tablet or capsule), which simplify procurement and treatment and improve adherence.1 Finally, the country-by-country availability of drugs and the related supply chain management issues are currently being mapped to identify specific gaps and technical assistance needs. Technical and policy tools and guidelines were developed with unprecedented speed to help countries, donors and other partners in scaling up antiretroviral therapy within the context of a comprehensive health system response. Simplified and standardized approaches have facilitated the development of basic antiretroviral therapy training materials, and training packages and modules for health care and community workers have been under accelerated development. Key stakeholders have also agreed on a harmonized set of measures and tools to monitor progress on the implementation of antiretroviral therapy scale-up. Extensive work has also been undertaken to establish, broaden and engage more extensively a broad network of partners including donors, United Nations organizations, business and trade unions, pharmaceutical manufacturers, faith-based organizations, people living with HIV/AIDS, nongovernmental organizations and treatment activists supporting “3 by 5”. Three major international meetings have been held during which a wide range of partners have committed to working towards the “3 by 5” target and the ultimate goal of universal access to HIV/AIDS treatment for everyone who needs it. The roles of UNAIDS Cosponsors have been clearly delineated. However, many of these partnerships have not yet been formalized but are based on a mutual commitment to the goal of increasing the access of people living with HIV/AIDS to treatment, support and care services. Although this work has successfully built on the initial commitment of countries, donors and international organizations to the goal of increasing access to antiretroviral therapy, it has not yet led to a sharp rise in the number of people living with HIV/AIDS receiving treatment. This is disappointing but not a reason to hesitate. Increased resources combined with progress in addressing the barriers to scaling up identified during the past six months auger well for this number to rise significantly over the next six months. There are many reasons for optimism: a rapid increase in the number of countries developing and refining their national HIV/AIDS treatment plans, coupled with increased resource flows, is accelerating progress on access. For the first time, specific plans are now in place to strengthen WHO country offices in focus countries with dedicated “3 by 5” country officers, national programme officers, administrative staff and appropriate activity budgets. Negotiations underway should lead to further cuts in the price of antiretroviral medicines. Training courses have been designed, health workers are being trained and the certification of health workers competent to deliver and monitor antiretroviral therapy has been agreed upon. Nevertheless, the modest increase in the number of people being treated over the past year clearly shows that progress is not rapid enough. To this end, WHO is taking steps to improve the documentation and reapplication of knowledge and best practices in accelerating the scaling up of antiretroviral therapy. A system for information and knowledge management to support antiretroviral therapy scale-up will begin in Uganda in 2004. The scope of this work includes collecting data about the people receiving antiretroviral therapy, collecting qualitative information about treatment and health systems performance and implementing processes to share information and learning across multiple treatment sites using collaborative quality improvement techniques. In September 2004, a team of experts will visit countries such as Brazil and Thailand that have successfully scaled up to document key lessons from their experience. The members of this team will then provide direct and immediate assistance in reapplying these approaches to several countries ready to scale up nationally.

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1 For more information on the WHO Prequalification Project, please visit the website. http://mednet3.who.int/prequal/

“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Key findings The key findings relate to progress against the key milestones included in the “3 by 5” strategy2 launched in December 2003. The 15 specific milestones are grouped into categories that follow, and Annexes 1 and 2 more fully describe the relevant figures (the actual results versus objectives as of June 2004).

Providing treatment to the people in need • Number of men, women and children with advanced HIV infection receiving antiretroviral therapy

As of 30 June 2004, 440 000 people with HIV/AIDS were receiving antiretroviral therapy in developing and transitional countries. This is 60 000 less than the target for the initial six months of the “3 by 5” Initiative. Although this is disappointing, the absolute increase of 40 000 people in a few months does indicate that country and international efforts to scale up HIV/AIDS treatment are resulting in progress. National and international efforts related to “3 by 5” have advanced national planning for antiretroviral therapy, reduced drug prices and increased political will. Following intense work over the past six months, many of the building blocks are now in place to facilitate a rapid increase in the number of people on treatment over the next 18 months.

Leadership, partnership and advocacy Building political commitment • • Amount of additional financial resources allocated to support WHO’s contribution to “3 by 5” Number of countries appealing to WHO for support for “3 by 5”

The “3 by 5” Initiative has helped to generate significant additional momentum and political commitment for expanded access to antiretroviral therapy over the past six months. A major accomplishment has been to increase the pressure on countries and all concerned partners to rapidly scale up treatment. Key examples include the following. • Individual government and health ministry responses. These have been extremely positive. So far, 56 countries have appealed to WHO for help in increasing access to treatment. Further, several countries have recently improved national HIV/AIDS policies that encourage large-scale testing and counselling, address stigma and discrimination and, in some cases, significantly improve access by making antiretroviral drugs free of charge. International endorsement. At the WHO Executive Board Meeting in January 2004 and the World Health Assembly in May 2004, Member States strongly endorsed the “3 by 5” timetable and approved the expanded HIV/AIDS programme budget. Member States reaffirmed their commitment to HIV/ AIDS prevention, treatment, care and support and further urged the Director-General to improve the access of developing countries to antiretroviral medicines and other products used in the diagnosis, treatment and care of HIV/AIDS, including by strengthening the WHO prequalification project. The “three ones” . In April 2004, donors, developing countries and United Nations agencies broadly endorsed the UNAIDS “three ones” principles, which call for one national plan, one coordinating mechanism and one set of measures to monitor progress in scaling up antiretroviral therapy at the country level. The implementation of this concept is vital to ensure the coordination of national efforts. Significant financial contributions to WHO. Canada, Sweden and the United Kingdom have given WHO significant funding for “3 by 5” activities. This will enable WHO to move forward with a substantial part of its work in this biennium. Broad-based financial support to combat HIV/AIDS. WHO recognizes the significant contributions from many bilateral donors, along with the Global Fund to Fight HIV/AIDS, TB and Malaria, the World Bank, and foundations. Their contributions to date are presented in the UNAIDS Global Resource Tracking Consortium report “Financing the Expanded Response to AIDS”, July 2004 (in press) and is available on the UNAIDS website www.unaids.org

•

•

• •

2 Treating 3 million by 2005 – making it happen. The WHO strategy. Geneva, World Health Organization, 2003 (http://www.who.int/ 3by5/about/strategy/en/index.html, accessed 25 June 2004).

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Building effective partnerships and involving communities • • Number of partner organizations whose role in “3 by 5” is agreed and published Number of partnerships between formal antiretroviral therapy service outlets and communitybased groups

Significant progress has been made during the past six months in building partnerships with a variety of organizations to strengthen and harmonize collective action towards achieving “3 by 5”. These include other United Nations organizations, donors, governments and related organizations such as national AIDS commissions, nongovernmental organizations, faith-based organizations, community-based organizations, treatment activists, pharmaceutical manufacturers and the private sector. In some cases the nature of these relationships is well understood and has been documented. In many other cases, although there is a general sense of alignment and a desire for cooperation and mutual support, more clarity is required to clearly identify the respective roles and responsibilities of the organizations involved. Consistent with the “three ones” principles, WHO wants to ensure that each country has one plan, one coordinating mechanism and one set of measures to monitor progress. Partners have a collective responsibility to ensure that all necessary roles are filled in countries with a minimum of redundancy. Highlights of progress include the following. • • The “3 by 5” Global Partners Group. Two meetings have been held, the most recent of which included more than 90 individuals and organizations expressing support for scaling up treatment and accelerating prevention. United Nations agencies commit to cohesive, country-level “3 by 5” action. The Committee of Cosponsoring Organizations of UNAIDS has agreed on the roles and responsibilities of the UNAIDS Secretariat and Cosponsors in scaling up antiretroviral therapy and their respective contributions to realizing the “3 by 5” target. Technical partnerships. Several important technical partnerships have been established. For example, WHO is collaborating with UNICEF, the World Bank, UNDP and nongovernmental organizations in purchasing drugs and diagnostics (see the discussion of AMDS below) and with UNAIDS, the United States President’s Emergency Plan for AIDS Relief and other partners to harmonize the monitoring and evaluation indicators required for increasing access to antiretroviral therapy. Support for treatment preparedness. Along with UNDP, the World Bank and the UNAIDS Secretariat, WHO has sponsored a number of interactions with and between various organizations of people living with HIV/AIDS and treatment activist groups with a view to encouraging and supporting the active involvement of community-based organizations in scaling up treatment. Specifically, in June 2004 WHO committed US$ 1 million towards building capacity for treatment preparedness and treatment literacy among organizations of people living with HIV/AIDS to support their role in scaling up treatment. Private-sector engagement . WHO is working with the private sector to determine what forms of collaboration will be most productive, especially in broad-based programme communication to promote treatment awareness, testing and counselling.

•

•

•

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004 Urgent, sustained country support Strengthening national planning for scale-up • • • Number of additional WHO staff deployed and/or realigned to WHO country offices for “3 by 5” Number of countries establishing antiretroviral therapy targets in accordance with “3 by 5” Number of countries with a national plan for implementing scale-up in accordance with the “3 by 5” target

Strengthening the capacity of countries to establish ambitious treatment targets and to develop and implement plans to achieve them is a critically important aspect of the overall “3 by 5” strategy. Although some important progress has been made in this area, objectives are not currently being realized to the degree required. This area will be an extremely important focus for WHO and many other partners in the coming six months. • Twelve countries have now officially established treatment targets for the end of 2005 equal to or greater than the “3 by 5” target of providing treatment to 50% of those in need, but many other countries have significant targets that fall somewhat short of this. • Three countries have completed national scale-up plans that, once implemented, will allow at least 50% of those in need to receive antiretroviral therapy. • UNAIDS Cosponsors will be collaborating at the country level to support countries in implementing the “three ones” principles. • The serious lack of funds for “3 by 5” from January to May 2004 restricted WHO from strengthening country and regional offices as planned. Only a small proportion of the incremental staffing planned was realized. • However, WHO staff conducted 24 missions to countries at the request of governments to map the HIV/AIDS situation and to identify the support needed for scaling up antiretroviral therapy. In addition, 37 staff were deployed to countries for 4–8 weeks to assist in developing funding proposals for the Global Fund to Fight AIDS, Tuberculosis and Malaria and national scale-up plans. During the next six months, country and regional offices will be strengthened. These changes will better equip WHO country offices to support national governments in developing and implementing scale-up plans. • Based on recently approved Round 4 grants by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the success rate was 50% for HIV/AIDS proposals in which WHO assisted the countries versus 30% for those without WHO assistance. Further, when both WHO and UNAIDS provided assistance, the success rate improved to 75%.

Strengthening national capacity • • • • Number of countries that have introduced training using WHO-supported certification of competence Number of health providers and community treatment supporters trained to deliver antiretroviral therapy services in accordance with national standards Number of service outlets providing antiretroviral therapy services according to national standards Number of public and nongovernmental organization service outlets providing testing and counselling services

Significant progress has been made during the past six months in building the capacity of countries to support a comprehensive health system response to HIV/AIDS. Numerous training programmes have been developed and successfully adapted for local use in a number of countries. To support this training and to ensure a consistent level of competence, WHO and its partners are developing standards and processes for certifying in-country health care workers. Encouragingly, WHO data indicate that the development of key infrastructure for antiretroviral therapy service delivery is progressing at a pace that could eventually support 3 million people on antiretroviral therapy by the end of 2005. Specifically, the number of health and community care workers trained in delivering and monitoring antiretroviral therapy, the number of sites providing antiretroviral

11

therapy and the number of sites providing testing and counselling are at or above the target level as of June 2004. Although a great deal more needs to be done, WHO estimates that about 15% of the staff trained in antiretroviral therapy, 5% of antiretroviral therapy delivery outlets and 24% of testing and counselling sites required to support the “3 by 5” target are now in place. Specific highlights are the following. • Training package. A training package for health workers at first-level facilities has been developed based on the WHO Integrated Management of Adult and Adolescent Illness (IMAI) format, including a basic clinical training course in antiretroviral therapy, a short course on opportunistic infections, and accompanying aids such as a patient education flipchart. Eight countries have adapted and rolled out IMAI-based training. Technical resource networks and knowledge hubs. A series of regional technical resource networks and subregional knowledge hubs for capacity-building were created, including knowledge hubs for HIV/AIDS treatment and care in Burkina Faso, Sudan, Uganda and Ukraine. Patient monitoring guidelines. Simplified patient monitoring guidelines were developed and agreed upon, outlining a unified data collection system for individual patient management and for clinic, district and national monitoring. A corresponding patient card was developed and integrated into IMAI guidelines and training materials. Service outlets. In developing countries: o 15 000 health care and community treatment supporters have been trained in delivering and monitoring antiretroviral therapy; o 500 centres are now providing antiretroviral therapy; and o 4880 sites are providing testing and counselling services.

• •

•

Simplified, standardized tools and technical guidance Equipping countries with the technical guidance and simplified approaches needed for scaling up • Number of standard training packages and other key guidance documents published

Clear, standard and simplified technical guidelines and training materials are crucial in enabling antiretroviral therapy to be rapidly scaled up in resource-constrained settings. Simplification enables antiretroviral therapy to be implemented on a broad scale by allowing health care and community workers to play a more significant role and by simplifying the purchasing and supply chain management of drugs and diagnostics. Simplified and standardized approaches have also facilitated the development of basic antiretroviral therapy training materials, treatment guidelines and technical and operational guidelines for scaling up care and treatment. Here the partnership between WHO and UNDP is addressing social and community concerns. Technical and policy tools and guidelines have been developed with unprecedented speed to help countries, donors and other partners with the building blocks to scale up antiretroviral therapy within the context of a comprehensive health-sector response. A harmonized set of measures and tools to track progress on implementing antiretroviral therapy scale-up agreed by WHO, UNAIDS, the United States President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis and Malaria and other partners has simplified country level monitoring and reporting requirements. Highlights include the following. • • • • • • Treatment guidelines. Simplified treatment guidelines have been published that recommend four first-line and accompanying second-line regimens. Technical and operational recommendations. A set of technical and operational recommendations for scaling up antiretroviral therapy has been published covering topics including the essential package of care and prevention needed to support antiretroviral therapy delivery. Testing and counselling. Guidelines on HIV testing and counselling and the use of rapid HIV tests have been updated. Monitoring and evaluation. Monitoring and evaluation measures that have been harmonized with all key partners have been developed. Care manuals. Manuals on palliative, chronic and acute care have been developed. Other guidelines. Several other guidelines have been published outlining targeted interventions for vulnerable populations, including sex workers and injecting drug users.

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004 An effective and reliable supply of medicines and diagnostics Improving the supply and reducing the cost of necessary drugs and diagnostics • • Average price per person per year for the first-line treatment regimen Number of countries using AMDS for procurement and/or distribution of drugs and/or diagnostics

The timely and uninterrupted supply at reasonable cost of the required medicines and diagnostics including antiretroviral drugs, laboratory equipment and reagents, HIV test kits and antibacterial agents to treat opportunistic infections is clearly essential for scaling up antiretroviral therapy. In addition to logistical challenges, the costs involved in procurement and supply management are considerable and may represent up to 65% of the total cost of scaling up treatment. Significant progress has been made in a variety of areas. The price of first-line treatment with fixed-dose combination formulations continues to decrease, with benchmark pricing now about US$ 150 per person per year (a decrease of about US$ 150 in less than 12 months). However, not all countries have adopted these low-cost regimens as their standard. Furthermore, generic antiretroviral drugs have not yet been registered in many countries. Thus, despite good progress on a number of fronts, the average price for firstline treatment remains above target. Finally, the cost of second-line treatments remains high. WHO has improved its ability to offer normative and technical support both through AMDS and in its prequalification project. The highlights are the following. • • • • WHO has joined in partnership with the UNAIDS Secretariat, UNICEF, the World Bank, UNFPA and UNDP to create AMDS, a technical network to support the availability of high-quality and safe antiretroviral drugs and diagnostics for countries. Countries are increasingly requesting and receiving technical support through AMDS. Assistance is being provided in close cooperation with UNICEF and will soon include joint activities with other partners including Management Sciences for Health, John Snow Inc. and Médecins Sans Frontières. Countries are increasingly requesting and receiving procurement support through AMDS. UNICEF procures most of the antiretroviral drugs for United Nations agencies. Fixed-dose combinations of triple combination antiretroviral drugs have been prequalified by WHO’s prequalification project. A database is being constructed that brings together in one place the necessary market information to enable decision-makers to procure high-quality products at a competitive price. UNICEF is creating a physical inventory of selected antiretroviral drugs to serve both emergency demand (avoiding stock-outs resulting from planning problems) and small customers. Over the next six months, WHO, UNICEF, Management Sciences for Health, John Snow Inc., Médecins Sans Frontières and other partners will create systems to facilitate demand forecasting at the institutional and national levels. Aggregating this information at a global level will help manufacturers in planning their production capacity. WHO is developing an electronic procurement system for diagnostics to facilitate a rapid procurement cycle for the products prequalified for its bulk procurement scheme.

• •

•

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Achieving targets for scaling up treatment: overcoming challenges Progressive scaling up. Achieving targets for scaling up treatment involves building the required political commitment, health system and resource base to allow for rapid expansion. The number of people being treated rises more slowly in the beginning, with more rapid growth in the later phases of scaling up. Work to date has successfully built on the initial commitment and earlier work of countries, donors and international organizations. However, much needs to be done to realize the desired steep rise in the number of people on treatment. “3 by 5” is helping to mobilize global, national, and community action. This report emphasizes, however, that success in increasing treatment access to reach the stated targets will heavily depend on country and community action. Looking ahead to 2005, a number of countries and their partners are heavily engaged in supporting the scaling up of treatment and prevention. Their leadership and action are critical to achieving the “3 by 5” target. The 34 countries with the highest burden of people living with HIV needing access to treatment have an estimated total treatment need of 4 677 000 by the end of 2005. Of these 34 countries, 24 have already declared a cumulative target of 1 061 900 people on treatment by the end of 2005. Countries rely on their own resources as well as external resources to achieve these targets. Table 1 indicates the types of commitments that some partners have made to provide people with treatment. Although there may be some duplication among partners in individual countries, the net result of the commitments offers reason to be optimistic about achieving “3 by 5”.

Table 1. Commitments made by partners towards scaling up antiretroviral therapy Source of support Government of the United States of America Other bilateral partners World Bank multi-country HIV/AIDS programmes Comments The goal is to treat 2 million people by 2008. Several donors are supporting countries in scaling up treatment through their bilateral programming. Over US $1.7 billion has been committed through grants, loans and credits for HIV/AIDS worldwide, most of which has come through the Multi-Country HIV/AIDS Program for Africa and the Caribbean Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending. These funds can be used to increase access to antiretroviral therapy. In addition, health infrastructure commitments can help strengthen health service delivery. This is a new three-year project (US$ 60 million) to support expansion of treatment access in Burkina Faso, Ghana and Mozambique. The Global Fund has reported that the recently completed Round 4 grant cycle will support antiretroviral therapy for 932 000 over five years. In addition, the Global Fund projects that grants from Rounds 1–3 will support 692 000 (Round 1: 232 000, Round 2: 283 000, Round 3: 177 000) people on antiretroviral therapy. This would yield a total support for more than 1.6 million people on antiretroviral therapy over the next five years.

World Bank Treatment Acceleration Program

Countries supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria

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Private sector

The Accelerating Access Initiative reports that it is covering 150 000 people with antiretroviral therapy now and could increase coverage. The Accelerating Access Initiative is driven by the research-based pharmaceutical industry. In addition, several corporations and businesses in affected countries are actively engaged in providing antiretroviral therapy to their employees and additional beneficiaries. The large reach of faith-based organizations in delivering health services represents major potential to expand antiretroviral therapy to people in need. Nongovernmental organizations such as Médecins Sans Frontières, Family Health International and others have contributed and will continue to contribute to delivering antiretroviral therapy. Médecins Sans Frontières estimates that it is currently providing treatment to 13 000 people in 19 countries.

Faith-based organizations

Nongovernmental organizations

Availability of resources. Globally, increased political commitment to treatment access, often promoted by civil society, results in increased focus on preventing and treating HIV/AIDS among governments, bilateral and multilateral donors as well as the United Nations system. Allocations from national budgets and debt relief funds are also increasing. The roll-out of treatment in South Africa will rely largely on domestic funding, and Cameroon is using millions of dollars in debt relief to support care and treatment programmes. In June 2004, the World Bank Board of Directors approved US$ 60 million for a new Treatment Acceleration Program to scale up treatment in Burkina Faso, Ghana and Mozambique. This funding is in addition to the US$ 1 billion being provided by the World Bank Multi-Country AIDS Program for Africa and the US $155 million under the Caribbean Multi-Country HIV/AIDS Prevention and Control Adaptable Program Lending. The money for the new Treatment Acceleration Program is largely in the form of grants and can be used flexibly for procurement, strengthening health system infrastructure, training and community preparedness. The Global Fund to Fight AIDS, Tuberculosis and Malaria has approved HIV-related grants that will support access to antiretroviral therapy for 1.6 million people. The United States President’s Emergency Plan for AIDS Relief is expected to provide treatment for 2 million people in priority countries. Affordability of AIDS medicines and diagnostics. The prices of some antiretroviral drugs have continued to drop in low-income countries. In October 2003, the William J. Clinton Foundation announced that it had obtained prices from several generic manufacturers, under certain conditions, as low as US$ 140 per person per year for a WHO-recommended first-line regimen. The prices of some proprietary antiretroviral drugs have also continued to fall slightly, although they remain higher than the generic versions for most drugs. Some governments have begun to utilize the flexibility in international trade agreements to make medicines more affordable and accessible. In May 2004, Malaysia and Mozambique announced that their national authorities had issued compulsory licences for certain antiretroviral drugs, and Canada reformed its patent legislation to allow its generic pharmaceutical producers to export under World Trade Organization rules to countries without adequate manufacturing capacity. More and more developing and transitional countries are exploring the possibility of producing HIV-related medicines locally, and a group of developing and industrialized countries agreed to support technology transfer in this area at the WHO Executive Board meeting in January 2004. Engaging communities and civil society. In many countries, civil society – faith-based organizations and national and international nongovernmental organizations – continues to provide a major share of HIV/AIDS services. The reach of health care services is illustrated by the Catholic Church’s claim that it provides more than one quarter of health care globally. As of April 2004, Médecins Sans Frontières was providing antiretroviral therapy to about 13 000 people in 19 countries in Africa, Asia and Latin America. Organizations such as The AIDS Support Organization in Uganda, Zanmi Lasanté (Partners in Health) in Haiti and small community-based organizations such as The Centre in Zimbabwe (a self-help drop-in, counselling, support, research and training project for people living with HIV/AIDS) continue to expand and improve their treatment programmes.

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004 Remaining challenges. Much still needs to be done. Recognizing the key challenges allows the world community to redouble its energy and commitment to overcoming them. They include: • • • • • • • • continuing momentum and avoiding complacency enhancing national planning improving data and surveillance building innovative partnerships accelerating prevention and care reinforcing health systems ensuring that drugs and diagnostics are affordable and available ensuring equity in coverage.

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Annex 1. Reporting of results versus objectives: June 2004 Status of country scale-up measures for June 2004 Published milestones for June 2004 Input 1. Amount of additional financial resources allocated to “3 by 5” a) within WHO overall b) at WHO country offices 2. Number of additional WHO staff deployed and/or realigned to WHO country offices for “3 by 5” 3. Number of standard training packages and other key guidance documents published (not including revisions of documents) 4. Number of partner organizations whose role in “3 by 5” is agreed and published Process 5. Number of countries appealing to WHO for support for “3 by 5” 6. Number of countries establishing antiretroviral therapy targets in accordance with “3 by 5” 7. Number of countries with a national plan for implementing scale-up in accordance with the “3 by 5” target 40 35 25 US$ 100–350 20 30 56 12 3 US$ 484 29 0 US$ 86 million US$ 54 million 200 15 90 US$ 39 million US$ 25 million 58 33 15

Result as of June 2004

8. Average price per person per year for the first-line treatment regimen 9. Number of countries using AMDS for procurement and/or distribution of drugs and/or diagnostics 10. Number of countries that have introduced training using WHOsupported certification of competence Output 11. Number of health providers and community treatment supporters trained to deliver antiretroviral therapy services in accordance with national standards 12. Number of service outlets providing antiretroviral therapy services according to national standards 13. Number of partnerships between formal antiretroviral therapy service outlets and community-based groups 14. Number of public and nongovernmental organization service outlets providing testing and counselling services Outcome 15. Number of men, women and children with advanced HIV infection receiving antiretroviral therapy a

10 000

15 000

500 1 500 1 000

500 not available a 4 880

500 000

440 000

This could not be measured as initially stated. New qualitative measures for community involvement in scaling up antiretroviral therapy are being developed. on track milestone not achieved but solid progress being made significantly off track and intervention required

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004

Annex 2. Discussion of results and interventions planned 1. Additional financial resources allocated to “3 by 5” a) within WHO overall and b) at WHO country offices

In late 2003, the funding target for WHO’s HIV/AIDS activities in the 2004–2005 biennium was initially established at US$ 400 million, with US$ 350 million for scaling up antiretroviral therapy and US$ 50 million for prevention and other work. In January 2004, the WHO Executive Board revised the US$ 400 million to US$ 218 million given that partner organizations were expected to increase their contribution to scaling up treatment in the form of both human and financial resources. Actual WHO spending on HIV/AIDS work during the 2002–2003 biennium was US$ 59 million. Thus, the revised target for additional overall funding for WHO’s HIV/AIDS work by the end of 2005 is US$ 159 million ($218 million minus US$ 59 million), of which 65% (US$ 103 million) is expected to be spent at the country level. Revised spending targets for the first six-month period in total and at the country level would therefore be US$ 40 million and US$ 26 million respectively. These have basically been met. In the current biennium 2004–2005, WHO has received commitments for HIV/AIDS funding totalling US$ 156 million, the main components of which are regular budget (US$ 18 million), Unified Budget and Workplan allocations from UNAIDS (US$ 16 million) and donations (US$ 122 million – notably including US$ 72 million from the Government of Canada). Since most of the pledged donations were not received during the December 2003 to June 2004 period, actual total funds available to be spent during the first six months amounted to US$ 54 million. This represents an incremental US$ 39 million (US$ 54 million minus one quarter of the US$ 59 million spent in 2002–2003) in additional financial resources versus the previous biennium. An additional US$ 62 million is required to enable WHO to fulfil its role as described in the WHO HIV/AIDS Plan for 2004–2005.3

2.

Number of additional WHO staff deployed and/or realigned to WHO country offices for “3 by 5”

The reported number of 58 comprises the recruitment of the first 21 “3 by 5” country officers in focus countries by the end of June 2004 plus the 37 staff from headquarters and regional offices deployed to country offices for 4–8 weeks during April–May 2004. This is well below the target of 200 staff dedicated to “3 by 5” implementation. The below-target progress in increasing WHO staff at the country level is directly attributable to the substantial shortfall in funding during much of the period from December 2003 to June 2004. Recently committed funds will now enable WHO to accelerate its efforts to recruit at country and regional offices during the second half of 2004.

3.

Number of standard training packages and other key guidance documents published

Key guidance documents have been developed with unprecedented speed to help countries and partners with the building blocks to scale up antiretroviral therapy and accelerate prevention within the context of a comprehensive response to HIV/AIDS. The following list of documents published from December 2003 to June 2004 shows that the target of 15 packages and documents published has been exceeded. 3

Investing in a comprehensive health-sector response to HIV/AIDS: scaling up treatment and accelerating prevention. WHO HIV/ AIDS Plan for January 2004–December 2005. Geneva, World Health Organization, 2004.

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1. 2. 3. 4. 5.

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

26. 27. 28. 29. 30. 31. 32. 33.

Palliative care: symptom management and end-of-life care (IMAI) General principles of good chronic care (IMAI) Chronic HIV care with ARV therapy (IMAI) Acute care (IMAI) Emergency scale-up of antiretroviral therapy in resource-limited settings: technical and operational recommendations to achieve 3 by 5. Report of the WHO/UNAIDS International Consensus Meeting on Technical and Operational Recommendations for Emergency Scaling-up of Antiretroviral Therapy in Resource-limited Settings, 18–21 November 2003, Lusaka, Zambia National AIDS programmes. A guide to monitoring and evaluating HIV/AIDS care and support Evidence for action: effectiveness of community-based outreach in preventing HIV/AIDS among injecting drug users Interim policy on collaborative TB/HIV activities A public health approach for scaling up antiretroviral (ARV) treatment. A toolkit for programme managers Training guide for HIV prevention outreach to injecting drug users. Workshop manual Guidelines for effective use of data from HIV surveillance systems (UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance) Technical briefs on various topics (12) (http://www.who.int/3by5/publications/en) Guidelines for conducting HIV sentinel serosurveys among pregnant women and other groups (UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance) Human capacity-building plan for scaling up HIV/AIDS treatment The Lighthouse: a centre for comprehensive HIV/AIDS treatment and care in Malawi. Case study (in press). Approaches to the management of HIV/AIDS in Cuba. Case study (in press). Antiretroviral therapy in primary health care: experience of the Chiradzulu programme in Malawi Antiretroviral drugs and the prevention of mother-to-child transmission of HIV infection in resourcelimited settings HIV/AIDS and sex work toolkit HIV testing and counselling toolkit HIV-related care, treatment and support for HIV-infected women and their children: summary of recommendations Recommendations for HIV diagnosis in children born to HIV-infected women Rapid HIV tests: guidelines for use in testing and counselling services in resource-constrained settings Prevention of mother-to-child transmission of HIV generic training curriculum Evidence for action: four policy briefs Provision of sterile injecting equipment to reduce HIV transmission Reduction of HIV transmission in prisons Reduction of HIV transmission through drug-dependence treatment Reduction of HIV transmission through outreach Guidelines on ethical issues in second generation surveillance Guide to monitoring and evaluating national HIV/AIDS prevention programmes for young people Advocacy guide: HIV/AIDS prevention among injecting drug users Integrating prevention and care services for HIV-positive drug dependents in the Americas (Pan American Health Organization) HIV/AIDS treatment and care guide for implementation (WHO Regional Office for the Western Pacific) Basic start up training modules for HIV/AIDS care and treatment (WHO Regional Office for the Western Pacific) HIV/AIDS clinical management training modules (WHO Regional Office for the Western Pacific) Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004 4. Number of partner organizations whose role in “3 by 5” is agreed and published

Partnerships, which WHO and UNAIDS identified and embraced early in the development of the “3 by 5” strategy, are indispensable for reaching the target. In November 2003, a meeting of the “3 by 5” Global Partners Group attended by some 30 organizations, institutions, donors, nongovernmental organizations, advocates and people living with HIV/AIDS was held to build support for the “3 by 5” target and to solicit and receive partner input to the draft “3 by 5” strategy. Six months later, more than 90 individuals and groups participated in the second meeting of the “3 by 5” Global Partners Group. In December 2003, no formal agreements were in place to document the nature of the relationships and accompanying expectations. As of 1 June 2004, some 15 specific partnerships were defined by letters or memoranda of understanding. This is below the target of 90. WHO has improved outreach to the faith-based community, with more than 20 organizations now identified as potential partners. In addition to infrastructure, financial resources and technical expertise, faith-based organizations also offer a vast corps of volunteers and communities of caregivers. Although clearly documenting the respective roles and responsibilities WHO and its partners will assume in scaling up antiretroviral therapy will continue to be desirable, acknowledging what such partnerships are providing will also be important in the future. Thus, in future progress reports, in addition to documenting the partnerships that have been clearly agreed in writing, WHO will also report what various partner organizations are doing, and – as country-level experience becomes clearer – define more focused measures of the impact of these partnerships.

5.

Number of countries appealing to WHO for support for “3 by 5”

Since 1 December 2003, 56 countries have appealed to WHO for support in scaling up national antiretroviral therapy programmes. This is well above the target of 40. The actual expressed demand reflects the considerable need for technical assistance countries require. WHO will be placing priority on strengthening WHO country offices to provide direct assistance, emphasizing developing and implementing plans for scaling up treatment.

6.

Number of countries establishing antiretroviral therapy targets in accordance with “3 by 5”

One of the compelling reasons for setting a time-limited and ambitious target for the number of people accessing antiretroviral therapy by the end of 2005 was to challenge countries and the donor community to address global treatment needs. The most visible manifestation of any new approach would be the speed with which countries faced up to their own treatment needs and committed to addressing them by adopting antiretroviral therapy targets in accordance with “3 by 5”. WHO predicted that 35 countries would commit to treatment targets in accordance with “3 by 5” by June 2004 – slightly less than those appealing for support for scale-up activities. So far, only 12 countries have antiretroviral therapy targets equal to or greater than the “3 by 5” target. Some countries are in the process of setting national targets; others remain conservative and will need appropriate national success models for inspiration. WHO will continue to vigorously advocate that national governments adopt targets that would allow 50% of the people in need to receive treatment by the end of 2005.

7.

Number of countries with a plan for implementing scale-up in accordance with the “3 by 5” target

National implementation plans for scaling up antiretroviral therapy, which outline how national programmes and proposals for the Global Fund to Fight AIDS, Tuberculosis and Malaria will actually be put into operation, are a prerequisite for achieving “3 by 5”. In establishing process milestones for activities for scaling up antiretroviral therapy within countries, it was assumed that action planning would usually follow on after a commitment had been made for national targets in line with “3 by 5”. Based on 40 countries appealing for help in scaling up antiretroviral therapy, and 35 countries having targets in line with “3 by 5”, WHO expected that slightly more than half would have national plans for implementation by June 2004. Such predictions of national preparedness have been too optimistic, and so far only three countries have published these plans.

23

More encouragingly, as of 30 June 2004, WHO was aware of 20 additional countries currently in the process of developing their national plans for scaling up antiretroviral therapy. WHO is now giving priority assistance for the development of national scale-up plans to many of these countries that have already adopted or are planning to adopt ambitious targets for scaling up.

8.

Average price per person per year for the first-line treatment regimen

In April 2004, the lowest price of quality-assured first-line treatment in low-income developing countries that includes fixed-dose combinations of antiretroviral drugs where possible ranged from US$ 285 (for generically sourced stavudine + lamivudine + nevirapine) to US$ 675 (for (zidovudine + lamivudine) and nevirapine, sourced from the research-based pharmaceutical industry).4 The average price was US$ 484, which is above the target of US$ 100–350.

Regimen (Stavudine 30 mg + lamivudine + nevirapine) Stavudine 30 mg + lamivudine + nevirapine (Stavudine 30 mg + lamivudine) + efavirenz (Zidovudine + lamivudine) + nevirapine (Zidovudine + lamivudine) + nevirapine (Zidovudine + lamivudine) + efavirenz (Zidovudine + lamivudine) + efavirenz Total average

Sourced from Ranbaxy Laboratories Limited Bristol-Myers Squibb Company + GlaxoSmithKline + Boehringer Ingelheim Ranbaxy Laboratories Limited + Merck & Co., Inc. (Ranbaxy Laboratories Limited or Hetero Drugs Limited) + Hetero Drugs Limited (GlaxoSmithKline) + Boehringer Ingelheim (Ranbaxy Laboratories Limited or Hetero Drugs Limited) + Merck & Co., Inc. (GlaxoSmithKline) + Merck & Co., Inc.

Lowest price (US dollars) 285 555

Average price (US dollars) 420

472 287

472 481

675 544 564

584 484

The price of first-line treatment with the fixed-dose combination formulation stavudine + lamivudine + nevirapine, sourced from the generic pharmaceutical industry, continues to decline, with the mass media often quoting benchmark prices of US$ 140–168 per person per year. Nevertheless, the reality is that many countries cannot or do not use this combination or pay more for it. In addition, many people cannot use this combination, either because they need concomitant treatment for tuberculosis (TB) or because they develop side-effects from the drugs contained in it. Consequently, representing these benchmarks as the average price for first-line antiretroviral therapy would not be accurate. Based on experience from Uganda, the average cost of first-line treatment was calculated assuming that 25% of the people eligible for treatment would use each of the four WHO-recommended first-line treatment regimens. This brings the average price of first-line treatment, weighted for the share of different treatment regimens, to US$ 484 per person per year. Reaching the December 2005 target of US$ 50–200 per person per year will require substantial effort to reduce the cost of efavirenz and brand-name nevirapine.

4

Untangling the web of price reductions: a pricing guide for the purchase of ARVs for developing countries. 6th ed. Geneva, Campaign for Access to Essential Medicines, Médecins Sans Frontières, 19 April 2004 (http://www.accessmed-msf.org/prod/ publications.asp?scntid=22420041625454&contenttype=PARA&, accessed 28 June 2004).

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004 The benchmark of US$ 140, announced by the William J. Clinton Foundation, requires countries or programmers to provide significant guarantees that are difficult to provide given the relatively small size of their antiretroviral therapy programmes and uncertainty about long-term funding. Consequently, to the best of WHO’s knowledge, only a few small transactions of antiretroviral drugs have taken place at this price so far. The other benchmark of US$ 168 per person per year is a recent one. Prequalified fixed-dose combinations of stavudine + lamivudine + nevirapine were sold at this price to programmes in April 2004 and were publicly offered to WHO at the meeting of the “3 by 5” Global Partners Group in May 2004 by a consultant speaking for Cipla Ltd. Before April 2004, most countries that used generic fixed-dose combinations paid more – between US$ 200 and US$ 300 per person per year. Even in programmes that begin with stavudine + lamivudine + nevirapine as their preferred first-line treatment, about 20% of the people receiving therapy experience severe adverse events and treatmentlimiting toxicity related to some components of the regimen. Further, in programmes that enrol significant numbers of TB patients, nevirapine cannot be used because of interactions with the TB drug rifampicin. The most reasonable way to report on the average cost of first-line treatment is therefore to calculate the value of the basket of drugs needed, weighted for their relative share in the basket. Finally, the benchmarks for stavudine + lamivudine + nevirapine are for generic antiretroviral drugs only. In many countries, generic antiretroviral drugs are either not registered or cannot or will not be used for fear of litigation as a consequence of potential patent infringement. Consequently, the average price of antiretroviral drugs needs to take into account the proportion of first-line drugs originating from the research-based pharmaceutical industry. Reaching the December 2005 target will require further price reduction among all antiretroviral drugs included in first-line treatment regimens. The various options available include reducing the prices of the drugs that are currently most expensive. However, the most powerful tool for lowering prices is competition. WHO will continue to develop normative and policy guidance to enable countries to buy antiretroviral drugs from an increasing number of manufacturers. Countries can ensure the presence of an enabling legal environment for competition, for example, by changing their patent laws so that they can use the flexibility of the TRIPS (TradeRelated Aspects of Intellectual Property Rights) Agreement, and some could invest in the local production of antiretroviral drugs so that more competitors enter the market. AMDS will also assist countries in pooling demand for antiretroviral drugs for large tenders to drive down prices by leveraging collective scale.

9.

Number of countries using AMDS for procurement and/or distribution of drugs and/or diagnostics

AMDS is a network of units and departments in the United Nations and technical partner organizations that work together to improve access to antiretroviral drugs and HIV diagnostics. Although new procurement partners might join the AMDS network, UNICEF is currently the main procurement partner in AMDS. As of June 2004, 50 projects in 29 countries had used UNICEF supply services for procuring antiretroviral drugs. In addition, one country procured antiretroviral drugs through the WHO supply service for its national programme. This is above the target of 20 countries. At present the volume in each of these supply transactions is small, but it is growing rapidly. In future, the AMDS secretariat will provide a comprehensive clearing house for information on access to antiretroviral therapy and HIV diagnostics, with information at the global, regional and national levels and easy access to guidance on how to procure and manage these commodities. It will also provide access to an expanding network of partner organizations (such as UNICEF, the World Bank, UNDP, Management Sciences for Health, John Snow Inc., Médecins Sans Frontières and the International Development Association) that already provide technical assistance in procurement and supply management and will broker between these providers and the programmes that need technical assistance. With its partners, AMDS will also create new services. Among these is creating a strategic stockpile of antiretroviral drugs that country programmes can use to overcome stock-outs or to place small start-up orders. This initiative is in urgent need of funding. In addition, AMDS will support the creation of an emergency funding mechanism to deal with short-term cash flow problems in treatment programmes.

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10.

Number of countries that have introduced training using WHO-supported certification of competence

In June 2004, WHO convened an International Consultation on Antiretroviral Therapy Training and Certification, bringing together partners from more than 46 organizations representing 17 countries. Recommendations will be published soon on establishing in-country certification for health workers involved in antiretroviral therapy. Once these are published, countries will be able to begin using WHO-supported certification of competence. Delays in establishing a formal framework for certification at the international level and in many countries reflect a situation in which scarce resources have been channelled into meeting urgent training needs at the expense of investing in the development of more formal regulatory mechanisms (see below for an assessment of training activities). However, the positive response to the WHO Consultation suggests that countries and organizations that have been occupied with rapidly introducing the training of programmers are now keen to consolidate their training efforts and to start developing certification and quality control mechanisms. A significant number of countries are expected to investigate the WHO-supported certification of competence in the next six months.

11.

Number of health care providers and community treatment supporters trained to deliver antiretroviral therapy services in accordance with national standards

By June 2004, reports submitted to WHO indicated that more than 15 000 health care workers from 32 focus countries had been trained in antiretroviral therapy since early 2001.5 At least 3000 of these people were trained in the first half of 2004, indicating that training efforts are gaining momentum. The number of 15 000 trainees may be somewhat understated, as reports from countries are incomplete. More than one third of the people trained were physicians, followed by nurses and counsellors. Smaller numbers of community treatment supporters and other people involved in antiretroviral therapy delivery – such as laboratory technicians and pharmacy staff – were also trained. The clear emphasis on training physicians mirrors the fact that the initial models of antiretroviral therapy service delivery have been largely physician-driven. However, this is unlikely to be sustainable, and newer models of antiretroviral therapy provision need to emphasize the necessity of shifting tasks towards nurses, health care workers and community treatment supporters. Progress in training now depends critically on countries’ ability to closely link existing training efforts with coordinated scale-up and human resources plans and to expand training towards the health workers who are carrying the bulk of the treatment burden at first-level facilities. UNDP’s assistance in addressing social and community issues will also be important.

12.

Number of service outlets providing antiretroviral therapy services according to national standards

When the WHO “3 by 5” strategy was published in December 2003, some service outlets were already providing antiretroviral therapy in countries targeted by the strategy. However, the number of these outlets was nowhere near sufficient to achieve the global “3 by 5” target, and most were not operating under standardized national frameworks. Since December 2003, WHO and key partners have supported the development of both international and national standards for antiretroviral therapy provision and provided the technical support necessary to scale up the number of health outlets providing antiretroviral therapy services. At the end of May 2004, the total number of antiretroviral therapy outlets in 20 countries for which these data were available was 498. It is therefore reasonable to assume that the total number of antiretroviral therapy sites existing in June 2004 is likely to be more than the 500 set as a target. The reported figure does not include private outlets in most cases. In many countries, private providers are thought to account for a sizeable proportion of the sites where antiretroviral therapy can be obtained. 5 Reports included information provided by national AIDS coordination mechanisms, WHO country offices and WHO mission reports and reports provided by training institutions. Reporting on training prior to 2001 was excluded since many people who were trained never had the opportunity to apply these skills because antiretroviral drugs were not available.

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“3 by 5” PROGRESS REPORT

December 2003 through June 2004 13. Number of partnerships between formal antiretroviral therapy service outlets and community-based groups

From the outset, the “3 by 5” Initiative assumed that effective partnerships between local community-based groups and the providers of antiretroviral therapy services, usually a government-supported entity, were essential to the successful scaling up of antiretroviral therapy. An appropriate measure of the uptake of antiretroviral therapy was considered to be a simple count of such partnerships between organizations of people living with HIV/AIDS and local service outlets. Experience has demonstrated that this approach is not currently generating useful data. More important are the potentially multiple actions and interactions that enable an entire community to participate in and accept the scaling up of antiretroviral therapy. WHO has already convened community-based groups, including organizations of people living with HIV/ AIDS, treatment activists and others dedicated to improving treatment access, and will continue to do so from July to December 2004. The objective of these sessions is to assist in developing appropriate measures and guidelines for community involvement in areas such as programme communication, treatment preparedness and the training of community health workers and other adherence supporters. Clearer qualitative and quantitative measures will be developed to replace the initial indicator that can better measure and monitor the effective involvement of communities in scaling up antiretroviral therapy.

14.

Number of public and nongovernmental organization service outlets providing testing and counselling services

The data on service outlets providing testing and counselling are from 18 countries and suggest important preliminary conclusions. • • Many of the countries in which antiretroviral therapy scale-up is planned already have a substantial number of sites for testing and counselling. This information has not previously been consolidated, so it remains unclear how many testing and counselling services currently operate in all focus countries and where they are sited: for example, are they integrated within clinical in- and outpatient settings or antenatal care services? What proportion are operated by government? What proportion are nongovernmental organization services? Are they located in areas where the need is greatest? Because the “3 by 5” milestone activity constitutes a baseline assessment in many of the countries from which data were requested, the proportion of these services implemented since “3 by 5” was declared as a global target cannot be determined yet. Based on the figures available for this review, at least 173 of the sites were specifically identified as new since December 2003.

•

Identifying 3 million people needing treatment requires identifying 20 million people living with HIV, assuming that 15% need treatment at any one time. If the overall HIV prevalence across the focus countries is 10%, 200 million people would need to be tested to identify the 20 million with HIV. However, this number could be very substantially reduced and most likely halved if services targeted the settings in which people living with HIV/AIDS and related diseases are more likely to present. The target of 20 000 testing and counselling service outlets was based on the assumption that reaching sufficient numbers to enable the “3 by 5” target to be achieved would require each site to see an average of 20 people daily and to provide testing and counselling for 5000 people by 31 December 2005. As part of planning for “3 by 5”, WHO advocates integrating decentralized testing and counselling services in all clinical settings where people at greater risk of HIV infection are likely to present, such as sites for services for tuberculosis, sexually transmitted infections, injecting drug users and other sites, including those linked to family planning and antenatal care services.

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15.

Number of children, women and men with advanced HIV infection receiving antiretroviral therapy

Since December 2003, the number of people receiving antiretroviral therapy in developing and transitional countries has increased from 400 000 to 440 000. Although the number of people receiving antiretroviral therapy is below the original target for June 2004, important groundwork has been laid during the first six months of the “3 by 5” process. Countries with a high burden of HIV/AIDS are working to establish the foundation and crucial mechanisms to prepare an enabling environment for scaling up antiretroviral therapy, including improving technical capacity, drug supply logistics, financial viability and monitoring and evaluation schemes as well as monitoring drug resistance and strengthening health systems overall. With increased funding for scaling up treatment now becoming available, many countries will start scaling up antiretroviral therapy programmes on a wide scale during the next six months. As political commitment and leadership strengthens at the country level and all partners strongly commit to unified action, the likelihood of achieving the target set for December 2004 – 700 000 people with advanced HIV infection receiving antiretroviral therapy – increases daily. For the future, WHO technical guidance requests countries to disaggregate their monitoring and evaluation by gender and age to obtain more detailed information about the people receiving treatment. This is critical to understanding the gender equity dimensions of treatment access efforts.

Note on methods The Department of HIV/AIDS of WHO has been collecting data in the past six months from countries on their estimates of the number of people receiving antiretroviral therapy. This has been done through surveys of key country specialists and informants, reports by national authorities and WHO and UNAIDS staff in the countries, including recently deployed WHO staff. The numbers obtained mostly include estimates for the public health sector and, in some cases, private-sector provision of antiretroviral therapy. After the data were collected, the country-specific estimates were made and rounded to accommodate potential underestimation of those receiving treatment in the private sector. Regional totals were generated from country data when available and by extrapolation when no data were available to give regional estimates of people being treated and antiretroviral therapy coverage. An external consultant’s report was used in these extrapolations, and this process provided an additional source for estimating the antiretroviral therapy coverage. These estimates were compared with those derived from the approach of the Department of HIV/AIDS. In almost all cases, the numbers were essentially the same. In a few cases, substantial differences were found and additional data were sought to resolve the inconsistencies. When the difference could not be resolved, the average of the two estimates was used.

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INVESTING IN A COMPREHENSIVE HEALTH SECTOR RESPONSE TO HIV/AIDS Scaling up Treatment and Accelerating Prevention

WHO HIV/AIDS PLAN January 2004 – December 2005

WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

© World Health Organization 2004 All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). 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; email: permissions@who.int). The designations employed and the presentation of the material in this publication and the boundaries and names shown on these maps 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 specific companies or of certain manufacturers’ products does not imply that they are endorsed 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 capital letters. The World Health Organization does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention

Contents Acronyms and abbreviations .......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Foreword ............................................................... ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 5 Executive summary .............................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 1. 1.1 1.2 1.3 1.4 2. 2.1 2.2 2.3 2.4 2.5 2.6 3. 3.1 3.2 4. 4.1 4.2 4.3 4.4 4.5 4.6 5. 5.1 5.2 5.3 6. 6.1 6.2 6.3 Background ................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Purpose of this document......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . 9 Situation analysis ........................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A comprehensive strategic framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Challenges for country-level action ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 WHO HIV/AIDS programme, 2004–2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 19 Introduction .................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Comparative advantages .......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 HIV/AIDS Area of Work for 2004–2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Scaling up antiretroviral therapy ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Scaling up care and support .................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Accelerating prevention ............................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Structure of WHO and model for service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 43 Structure......................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Matching support with country needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Implementation through partnership: working together to make it happen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 The “3 by 5” Global Partners Group .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 United Nations system partners ............ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Technical partnerships ............................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 50 Country-level partners ............................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 50 Donors ............................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 51 Civil society, faith-based and private-sector groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 WHO programme budget and resource requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 53 Overview of the programme budget .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Staffing ............................................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Resource needs........................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Technical and managerial oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Strategic and Technical Advisory Committee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . 59 Annual meeting of the “3 by 5” Global Partners Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Monitoring and reporting on progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

Annex 1. HIV prevalence, HIV mortality, antiretroviral therapy treatment needs and targets for the 49 “3 by 5” focus countries .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Annex 2. Resolution WHA57.14 of the World Health Assembly, 22 May 2004: Scaling up treatment and care within a coordinated and comprehensive response to HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Annex 3. WHO Constitution, Article 2 .............. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Annex 4. Roles and responsibilities of UNAIDS Cosponsors and the UNAIDS Secretariat in the “3 by 5” Initiative ........................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

Acronyms and abbreviations AIDS AMDS HIV MTCT-Plus TB “3 by 5” UNAIDS UNICEF WHO acquired immunodeficiency syndrome AIDS Medicines and Diagnostics Service human immunodeficiency virus programmes intended to provide lifelong care and treatment to women living with HIV/ AIDS identified through programmes for the prevention of mother-to-child transmission and to their families tuberculosis the target of having 3 million people in developing countries on antiretroviral therapy by the end of 2005 Joint United Nations Programme on HIV/AIDS United Nations Children’s Fund World Health Organization

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention

Foreword The HIV/AIDS epidemic is the single most important challenge facing the global public health community. A comprehensive response to HIV/AIDS is needed to expand evidence-based prevention interventions and to ensure that the people in need receive effective care, treatment and support. Great progress has been made over the past few years in making antiretroviral therapy an affordable and realistic option for even the most resource-constrained countries. Ways to ensure that treatment and care effectively support prevention efforts are becoming increasingly clear. The challenge now is to translate these opportunities into action. I have always believed that time-limited targets promote accountability, mobilize action and focus efforts in the face of major challenges. HIV/AIDS is no exception. Although the “3 by 5” target is ambitious, a lack of ambition now will condemn many people to a preventable death and make the task of controlling HIV/AIDS even more difficult in the years ahead. In places where no comprehensive programme has previously been in place, mounting a rapid response to HIV/AIDS that includes antiretroviral therapy and more robust prevention efforts will inevitably involve complexity and uncertainty. Many partners need to be involved. They need to be clear about what they can contribute, what it will cost and what they aim to achieve. I am therefore very pleased to present the WHO HIV/AIDS Plan for 2004–2005, which outlines how WHO proposes to help countries in mounting a comprehensive response to HIV/AIDS during 2004 and 2005 and what this will cost. Several donors have already made substantial contributions to WHO to enable us to support treatment scale-up and move towards realizing the “3 by 5” target. The progress and achievements made since WHO and UNAIDS launched the “3 by 5” Initiative in December 2003 are outlined in the enclosed “3 by 5” Progress Report. However, the full WHO HIV/AIDS Plan requires additional funding of US$ 62 million for full implementation. These resources are needed urgently, and WHO encourages additional partners to commit to and support this effort.

LEE Jong-wook Director-General World Health Organization

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention

Executive summary During 2003, an estimated 4.1 million people 15–49 years old became infected with HIV, with an additional 630 000 children becoming infected. HIV/AIDS killed about 3 million people in the same year. This occurred despite the existence of proven interventions that can prevent transmission and of life-saving antiretroviral therapy. However, of the 5.5 million people in developing and transitional countries (other than Canada, the United States of America, countries in western Europe, Australia, New Zealand and Japan) estimated to need antiretroviral therapy, only 440 000 had access to it by 30 June 2004, representing an increase of only 40 000 people in the first six months of 2004. WHO’s HIV/AIDS programme focuses on assisting governments and other stakeholders in implementing a coordinated and comprehensive health-sector response to HIV/AIDS. Consistent with the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS and the Global HealthSector Strategy for HIV/AIDS 2003–2007, this response incorporates a spectrum of HIV/AIDS and related services, including prevention, treatment, care and support. It also must include appropriate health systems standards, skills mix, supportive policies and partnerships that enable effective multisectoral approaches. As in the past, prevention efforts remain a high priority for WHO, especially among vulnerable populations and in clinical settings. However, until now, treatment is the element that a majority of developing countries have neglected most in their comprehensive national response to HIV/AIDS. The lack of treatment has helped to perpetuate stigma and discrimination and greatly reduced the impact of prevention and care efforts, including uptake of HIV testing and counselling. A significant new component of WHO’s HIV/AIDS programme in 2004–2005 therefore includes activities to support Member States in scaling up treatment and in realizing the global target of having 3 million people in developing countries receiving antiretroviral therapy by the end of 2005. With significant new resources now available to scale up national HIV/AIDS programmes, countries face particular challenges in ensuring that they and their partners effectively manage, coordinate and monitor their efforts at the national level, contribute to overall health systems development and address pressing social challenges such as promoting greater involvement of people living with HIV/AIDS and affected communities, elevating the social status of women and girls and promoting equitable access to services. WHO’s HIV/AIDS programme is designed to contribute to attaining these broad social goals. The WHO HIV/AIDS Plan for January 2004–December 2005 presents the strategic and resource framework for WHO’s HIV/AIDS programme. It describes the work of WHO in providing support to countries as they develop and implement their national scale-up plans. It includes an introductory epidemiological situation analysis and the most recent estimates of antiretroviral therapy coverage by region. The WHO HIV/AIDS Plan is not a detailed work schedule; it provides a framework for developing detailed work plans, with specific time-bound activities and responsibilities necessary to bring the WHO HIV/AIDS Plan to fruition at all levels of WHO. In addition, detailed joint plans are being developed with UNAIDS Cosponsors to coordinate, align and integrate work at country level. The WHO HIV/AIDS Plan for January 2004–December 2005 is designed to draw on the comparative advantage of the WHO as the specialized agency on health within the United Nations system. It seeks to strengthen WHO’s role in supporting the coordination of national responses in the health sector, convening stakeholders and stimulating new partnerships. These partnerships will not only include those with and between the United Nations organizations and the governments of Member States but will also involve technical agencies, donors, civil society groups, organizations of people living with HIV/AIDS and the private sector. Consistent with the WHO programme budget for 2004–2005, the HIV/AIDS programme encompasses activities in five functional areas: • • • • • strategic information advocacy and policy technical and normative guidance country capacity-building operations research and knowledge management.

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

These functional areas focus on scaling up treatment, care and support and accelerating HIV/AIDS prevention through action in the health sector. In determining its programme objectives in 2004–2005 for HIV/AIDS as well as in other areas of work, WHO will focus a greater proportion of its human and financial resources at the regional and country level. To specifically improve the support provided to Member States in scaling up HIV treatment and accelerating prevention, “3 by 5” teams will be in place in focus countries by the third quarter of 2004. More intensive and comprehensive country profiling systems now being implemented will enable technical support needs to be assessed more effectively and responses tailored appropriately to meet country needs. The proportion of the total HIV/AIDS budget dedicated to the regional and country levels is increasing from 66% in 2002–2003 to 87% in 2004–2005, with the African Region of WHO receiving 55% of total funds. WHO will also be strategic about where and how it provides technical assistance. Although it will continue to respond to requests from all Member States, WHO will concentrate its resources in countries where the burden of disease is most acute and where positive impact is anticipated to be greatest. WHO will focus on technical areas in which it has a comparative advantage. A new Strategic and Technical Advisory Committee will be established to provide guidance to the WHO HIV/ AIDS programme, and regular reports covering “3 by 5” milestones and expected results will be published. The WHO HIV/AIDS Plan for January 2004–December 2005 sets out anticipated resource requirements of US$ 218.1 million for WHO’s HIV/AIDS programme across all levels of the Organization during 2004–2005, of which US$ 62 million remained unfunded as of 1 July 2004. Additional financial support to close this funding gap is needed if the full programme of work described in the WHO HIV/AIDS Plan is to be implemented.

Key documents related to the WHO HIV/AIDS Plan Document Investing in a comprehensive health-sector response to HIV/AIDS. Scaling up treatment and accelerating prevention. WHO HIV/AIDS Plan for January 2004–December 2005, July 2004 Country profiles, first edition (26 countries), July 2004 Purpose Describes the strategic and resource framework specifically for WHO in the HIV/AIDS area of work during 2004–2005 and lays out WHO’s role in scaling up treatment and care and accelerating prevention. Describes the roles of each level of the WHO structure and the financial and human resources allocated to each. Practical tool for use at the country level to guide countries in scaling up their response to HIV/AIDS, monitor progress and clarify roles among partners. Will be updated frequently as the situation develops in each country. Reports on global progress by all countries towards achieving the target of having 3 million people in developing countries receiving antiretroviral therapy by the end of 2005. It also reports the status of the June 2004 key milestones for 15 global monitoring indicators outlined in the “3 by 5” strategy document Treating 3 million by 2005 – making it happen. To be issued every six months. Describes the work WHO will carry out during 2004–2005 to deliver the agreed programme budget outcomes. Details will include activities, responsibility, cost and timing at the country, regional and headquarters levels. Work plans are typically not formally published but can be made available on request. Describes for each country the roles and responsibilities of all UNAIDS Cosponsors and other United Nations organizations at the country level in supporting countries’ response to “3 by 5”. It will detail specific tasks, responsibilities, budgets and timing.

“3 by 5” Progress Report: December 2003– June 2004, July 2004

WHO HIV/AIDS work plan, September 2004

Joint United Nations HIV/AIDS country-level response on “3 by 5”, October 2004

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention

1. Background 1.1 Purpose of this document This document discusses the context for the work being undertaken in WHO’s HIV/AIDS programme. It analyses the epidemiological situation and includes the most recent estimates of antiretroviral coverage, the global strategic framework and current challenges to translating this into results at the country level (Section 1 – Background). Section 2 describes the comparative advantages offered by WHO, the functional areas of activity within the HIV/AIDS area of work for 2004–2005 and the specific focus of the programme on scaling up antiretroviral therapy and accelerating HIV prevention. Section 3 describes how WHO is structured and how resources and capacity are being reoriented to support country-level action. Section 4 illustrates how WHO works within the United Nations system and with other partners. Section 5 outlines the resources required in 2004–2005 for WHO to accomplish its stated contribution to HIV/AIDS. Section 6 describes the mechanisms for technical and managerial oversight of the HIV/AIDS programme. The WHO HIV/AIDS Plan is not a detailed work plan. Rather, it provides an overall framework to guide the departments responsible for HIV/AIDS in preparing such work plans at the country, regional and headquarters levels of WHO. These work plans are now being developed and will define the specific tasks and activities required to bring the WHO HIV/AIDS Plan to fruition, together with timelines and resource requirements. Joint planning sessions between headquarters, regional and country offices integrate the work of the three levels to ensure that all priority needs are addressed and that gaps in resources are identified.

1.2

Situation analysis

1.2.1 Global overview UNAIDS and WHO have estimated that the number of people living with HIV/AIDS at the end of 2003 was 37.8 million (34–42 million). This includes 2.1 million (1.9–2.6 million) children younger than 15 years of age. During 2003, an estimated 4.1 million (3.6–5.6 million) people 15–49 years old were newly infected, with an additional 630 000 (570 000–740 000) incident infections in children. The estimated number of people who died during 2003 from illness related to HIV/AIDS is 2.9 million (2.6–3.3 million). Most of these deaths (2.2 million) occurred in sub-Saharan Africa, where coverage of antiretroviral therapy remains low. Sub-Saharan Africa, which has an estimated 25.0 million (23.1–27.9 million) people living with HIV/AIDS, is the region with the highest burden, constituting almost 70% of people living with HIV/AIDS worldwide. South, South-East and East Asia follow with 7.4 million (4.6–11.1 million), with 2.0 million (1.4–2.8 million) occurring in Latin America and the Caribbean, 1.9 million (1.3–2.6 million) in Europe and central Asia, 1.0 million (0.5–1.6 million) in North America and 0.5 million (0.2–1.4 million) in northern Africa and the Middle East. Of the 37.8 million people living with HIV/AIDS worldwide, 2.1 million are children under the age of 15. Again, the great majority, 1.9 million (1.7–2.2 million) are living in sub-Saharan Africa and were infected as a result of mother-to-child transmission. Given the high prevalence of people already infected and despite the large numbers of people dying every year, the number of people living with HIV/AIDS continues to increase by about 1.5 million per year. In the mid-1990s, when the growth in the global HIV epidemic peaked, that growth was almost entirely driven by the epidemics in sub-Saharan Africa and South and South-East Asia. The picture is now much more diverse. In 2002–2003 the western Pacific and eastern Europe contributed substantially to global growth.

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

In 2003, the estimated worldwide number of people needing antiretroviral therapy in developing and transitional countries was nearly 6 million. This figure was based on mortality estimates. Such estimates have to be interpreted with some caution, as they can vary in countries that use different criteria for starting antiretroviral therapy. In addition, the uncertainty ranges for the number of people living with HIV/AIDS (34–42 million) and for the number of people who need antiretroviral therapy (4–8 million) are wide. The most important uncertainty is around the size and trend of the epidemic in some countries. The global HIV treatment needs over time will increase as more people develop AIDS each year and the people who are accessing antiretroviral therapy and surviving will need to keep taking medication. Tuberculosis (TB) remains a major killer of people with HIV/AIDS. WHO figures show that TB accounts for up to 13% of AIDS deaths worldwide. In Africa, HIV is the single most important factor determining the increased incidence of TB in the past 10 years. Antiretroviral therapy has been shown to reduce susceptibility to TB disease by 80–90% in both industrialized and developing countries.

1.2.2 Overview of the “3 by 5” focus countries Annex 1 presents a list of 49 countries identified by WHO for initial, intensified technical support and dedicated resources to scale up antiretroviral therapy and accelerate HIV/AIDS prevention. The list comprises a combination of global and regional priorities. On a global basis, WHO identified the 34 countries with the highest unmet treatment need for focused attention. These 34 countries account for 85% of the unmet treatment need globally. In addition, several WHO regions identified groupings of countries (such as the central Asian republics) having specific regional strategic significance (such as a rapidly spreading epidemic) that were also felt to require focused and urgent attention. WHO will continue to support Member States not appearing on this list of countries. Section 3.2 outlines the HIV/AIDS support provided to all Member States. In total, these 49 countries account for 73% of the global people living with HIV/AIDS, 78% of the mortality from HIV/AIDS in developing and transitional countries and 86% of the people needing treatment in developing and transitional countries; nevertheless, their estimated coverage for antiretroviral therapy is only 4.0%. Six countries comprise a full 50% of the global treatment needs: South Africa, India, Nigeria, Zimbabwe, the United Republic of Tanzania and Kenya.

1.2.3 Estimates of global and regional coverage In 2001, a group of partners including the United States Agency for International Development, UNAIDS and WHO carried out a survey of HIV/AIDS treatment coverage in health services. The survey estimated that about 300 000 people in developing countries were receiving antiretroviral therapy at that time, representing 2% of the total estimated need. In December 2003 when the “3 by 5” target was established, an estimate was made that about 400 000 people were receiving antiretroviral therapy. Using a variety of direct country-level information sources, WHO now estimates that 440 000 people had started receiving antiretroviral therapy by June 2004, representing 8% of the total estimated needs (Table 1 presents the overall results). Although this increase is substantial compared with the 2001 estimates, the gap between needs and coverage remains large. Antiretroviral therapy coverage is lowest in the African Region of WHO, where the burden is highest. Only an estimated 150 000 people were receiving treatment in the African Region by June 2004; the estimated coverage of 4% nearly doubles the coverage estimated in December 2003. These coverage estimates are somewhat uncertain because many countries have not yet fully implemented monitoring systems for antiretroviral therapy and may not have included everyone in care in the private sector. Treatment in the private sector has been available for some time, although high prices for care, laboratory support, and medication may have limited access through these services.

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention Table 1. Estimated antiretroviral therapy coverage and overall antiretroviral therapy needs in developing and transitional countriesa according to regions of WHO WHO region Estimated number of people on antiretroviral therapy, June 2004 150 000 220 000 11 000 4 000 40 000 15 000 440 000 Estimated antiretroviral therapy need, 2004–2005 b 3 840 000 410 000 120 000 100 000 860 000 170 000 5 500 000 Antiretroviral therapy coverage

African Region Region of the Americas European Region Eastern Mediterranean Region South-East Asia Region Western Pacific Region Total a b

4% 54% 9% 4% 5% 9% 8%

All countries except those in western Europe, the United States, Canada, Australia, New Zealand and Japan. This includes people already receiving antiretroviral therapy at the beginning of 2004 plus an estimate of those who will need to start antiretroviral therapy during 2004 and 2005.

1.3

A comprehensive strategic framework

1.3.1 Declaration of Commitment on HIV/AIDS At the United Nations General Assembly Special Session on HIV/AIDS in 2001, United Nations Member States unanimously committed to scaling up the global effort against HIV/AIDS through a comprehensive response that includes prevention, treatment, care, support, impact mitigation and promoting and protecting human rights.

1.3.2 e Global Health-Sector Strategy for HIV/AIDS 2003–2007 Following the United Nations General Assembly Special Session on HIV/AIDS, the World Health Assembly requested the Director-General of WHO to develop a strategy that would further elaborate on the contribution of the health sector to realizing the targets and objectives of the Special Session’s Declaration of Commitment. The resulting Global Health-Sector Strategy for HIV/AIDS 2003–2007, adopted by the World Health Assembly in 2003 (resolution WHA56.30), aims: • • • • • to help the health sector to meet the goals contained in the Declaration of Commitment on HIV/ AIDS; to advise health ministries and other stakeholders on the core components of an effective healthsector response to HIV/AIDS; to support health ministries in developing policy, planning, priority-setting, implementation and monitoring frameworks needed to generate such a response as part of overall national strategic plans; to enhance and promote the comparative advantages, expertise and experience that health ministries and other stakeholders can contribute to national strategic planning for HIV/AIDS; and to describe the specific actions to be undertaken by ministries of health and WHO to strengthen the health-sector response to the HIV/AIDS epidemic.

The Global Health-Sector Strategy for HIV/AIDS 2003–2007 is based on the premise that the goals set

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out in the Declaration of Commitment on HIV/AIDS can only be achieved if the health sector acts firmly and provides the necessary leadership in its areas of responsibility and expertise, within the context of a multisectoral response. Consistent with the Global Health-Sector Strategy for HIV/AIDS 2003–2007, WHO’s work on HIV/AIDS focuses specifically on assisting governments and other stakeholders in implementing a coordinated and comprehensive health-sector response to HIV/AIDS incorporating a continuum of HIV/ AIDS and related services, including prevention, treatment, care and support. Such a response also needs to include appropriate health system standards, skills mix, supportive policies and enabling partnerships.

1.3.3 WHO’s mission and objective The Declaration of Commitment on HIV/AIDS describes HIV/AIDS prevention as “the mainstay of the response”, and prevention remains central to WHO’s programme of activities. The focus of work is on the interventions for which the health sector is clearly responsible and that act to create synergy with treatment, care and support and strengthen the health-sector response overall, such as HIV testing and counselling and preventing HIV infection among women and infants. In addition, WHO’s prevention efforts focus on targeting vulnerable populations for interventions and expanding the continuum of care for people living with HIV/AIDS to meet their prevention needs as well. Since September 2003, WHO has accelerated HIV/AIDS activities at all levels of the Organization and in countries in scaling up antiretroviral therapy. Although much important normative work continues to be done, WHO’s strong new country focus in HIV/AIDS has resulted in a new mission statement for its work in the area of HIV/AIDS. WHO’s mission in HIV/AIDS is: to achieve the highest attainable standard of health for all people by reducing the impact of HIV/AIDS on their lives. We do this by: • • • supporting the health-sector response of our Member States working in partnership with all actors and partners in this field defining and developing effective technical norms and guidance.

WHO’s objective in HIV/AIDS is: to rapidly scale up access to HIV/AIDS treatment and care while accelerating prevention and strengthening health systems to enable a more effective and comprehensive health-sector response.

1.3.4 e “3 by 5” Initiative Treatment has been the most neglected element within a comprehensive health-sector response to the HIV/AIDS epidemic. Increased global funding to support rolling out antiretroviral therapy, together with considerably reduced prices for antiretroviral drugs, growing political commitment and numerous successful pilot initiatives, offer unprecedented opportunities for countries to expand antiretroviral therapy programmes to a national scale. WHO has therefore made a significant effort to increase the human and financial resources available within its overall HIV/AIDS programme to provide the leadership and technical assistance its Member States need to scale up access to HIV treatment and care. “3 by 5” – treating 3 million people living with HIV/AIDS in developing countries by the end of 2005 – is a target that drives this aspect of WHO’s work, rather than a specific programme or unit within the Organization. The “3 by 5” target was based on the analytical work of several scientists before the United Nations General Assembly Special Session on HIV/AIDS. This showed that, with an all-out effort, 50% of those in need of treatment could be reached by the end of 2005.1 WHO adopted the target in the belief that only by working towards a measurable, time-limited target of this kind would the Organization and the global community act with the urgency necessary for millions of lives to be saved. WHO is encouraged by the commitment of the UNAIDS Secretariat and Cosponsors and of many other organizations to realizing “3 by 5”. The “3 by 5” strategy document,2 launched in December 2003, provides an initial strategic framework to show what WHO proposed to do to help realize the “3 by 5” target. WHO activities were grouped under five strategic pillars: • global leadership, strong partnership and advocacy 1 2

Schwartländer B et al. Resource needs for HIV/AIDS. Science, 2001, 292:2434–2436. Treating 3 million by 2005 – making it happen. The WHO strategy. Geneva, World Health Organization, 2003 (http://www.who.int/ 3by5/about/strategy/en/index.html, accessed 25 June 2004).

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Scaling up treatment and accelerating prevention • • • • urgent, sustained country support simplified, standardized tools and regimens effective, reliable supplies of medicines and diagnostics rapidly identifying and reapplying new knowledge and successes.

WHO’s programme of work to scale up access to antiretroviral therapy has continued to evolve with input from partners and lessons from work being undertaken in countries. In addition to WHO’s efforts, 3 million people will be treated in developing countries by the end of 2005 only through concerted, sustained action and unprecedented collaboration by many other individuals and organizations. WHO’s contributions to scaling up antiretroviral therapy as described in Treating 3 million by 2005 – making it happen were endorsed by WHO Member States at the World Health Assembly in May 2004 (see Annex 2, World Health Assembly Resolution WHA57.14, in which WHO Member States acknowledge and affirm the importance of treatment and care within a coordinated and comprehensive response to HIV/AIDS that contributes to overall strengthening of health systems).

1.4

Challenges for country-level action

The remainder of this section outlines several challenges WHO Member States now face in translating the global strategic framework described in Section 1.3 into effective responses to HIV/AIDS at the country level.

1.4.1 e “three ones” principles New resources now available have given rise to an increasing number of partners and actors working in HIV/AIDS at the country level. The United Nations system, donors, technical agencies and governments in developing and transitional countries are increasingly concerned to ensure that their efforts are coordinated and are based on a common strategy, avoid multiple reporting mechanisms and minimize duplication and fragmentation of effort. The “three ones” concept for country-level responses to HIV/AIDS provides a valuable framework for ensuring that resources and effort are harmonized, sustainable and results-based. The principles are: • • • one agreed HIV/AIDS action framework that drives the alignment of all partners; one national HIV/AIDS coordinating authority with a broadly based multisectoral mandate; and one agreed monitoring and evaluation system at the country level.

The “three ones” approach is broad in nature and needs to be applied to a specific country’s institutions and responses. Donors, international agencies and governments broadly agree that a significant proportion of international efforts – including the technical expertise and convening mechanisms of the United Nations system at the country level – need to ensure that national efforts to scale up antiretroviral therapy and accelerate prevention align with a “three ones” approach and serve as effective vehicles for multisectoral coordination and partnership. Applying these principles will also contribute to broader strengthening of health systems and facilitate more effective links between development partners.

1.4.2 Strengthening health systems The recognition that HIV/AIDS can be managed as a chronic disease even in developing countries and that prevention efforts can be even more successful in the presence of robust treatment and care programmes represents a profound shift in the battle against AIDS. Although the opportunities and challenges for effectively responding to HIV/AIDS have never been greater, it is antiretroviral therapy – of all the possible HIV-related interventions – that can most effectively drive the overall strengthening of health systems, and in particular, chronic health care. An increasing number of countries now have national plans for scaling up antiretroviral therapy and are reflecting HIV/AIDS needs in poverty reduction and other development strategies. Functioning health systems are fundamental to successful, equitable and sustainable delivery of a continuum

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of HIV/AIDS prevention, treatment, care, and support. The challenges of scaling up antiretroviral therapy highlight the persistent fragility of health systems overall, attributable both to the impact of the HIV/AIDS epidemic itself and the result of chronic inadequate funding and weak management. This fragility is manifest in weak infrastructure, poorly integrated services and a shortage of personnel fuelled by the ongoing exodus of health workers in many countries from the public to the private health sector and to other countries. Providing antiretroviral therapy, prevention and other health services along the continuum necessary for a comprehensive health-sector response to HIV/AIDS requires that all levels of the health system are functioning and are working together. In addition to “3 by 5” and the United Nations General Assembly Special Session on HIV/AIDS, broader health objectives – such as the Millennium Development Goals and health for all – can be supported by improving the quality and coverage of HIV/AIDS services. Obtaining greater access to better services requires strengthening human resources planning and management, drug procurement and supply chain systems, financing mechanisms, health facility planning, patient tracking, social and political analysis and community and private sector involvement. HIV/AIDS interventions also need to build on existing health services, infrastructure and experience, such as the extensive national TB control programmes now in place in many countries as well as sexual, reproductive and children’s health services. Feedback WHO has received from countries indicates the need for broad technical support to strengthen health systems in addition to assistance specifically to accelerate prevention and to scale up antiretroviral therapy, for example, through the WHO country cooperation strategy process. Underpinning the work of WHO is the belief that developing health systems and a comprehensive response to HIV/AIDS require close collaboration between disease areas and development partners, and that scaling up the response to HIV/AIDS – including antiretroviral therapy – is itself a bold effort that can strengthen health systems (Box 1).

Box 1.

e HIV/AIDS and Health Systems Platform

A core principle of the “3 by 5” strategy is that scaling up antiretroviral therapy must contribute to the broader strengthening of health systems. In addition, any rapid expansion of services places major demands on existing health systems. The “3 by 5” strategy already addresses several issues related to health systems, but other challenges remain. WHO is therefore establishing an HIV/AIDS and Health Systems Platform to complement the other intense efforts to improve HIV/AIDS prevention, treatment, care and support. A plan will be developed in consultation with partners by September 2004. Its work will be designed to assist people living with HIV/AIDS, providers, programme managers and policy-makers in overcoming major health system obstacles to improved HIV care and to anticipate, detect and respond to the implications focused activities have for the rest of the health system. In addition to being designed as a critical complement to the short-term target of “3 by 5”, the Platform foresees its work extending well beyond 2005.

1. Individuals and households Antiretroviral therapy is life-long, and efforts to rapidly expand coverage mean that novel delivery approaches are being used. The Platform will help to ensure that attention is maintained on care provided to marginalized groups. It will work to ensure a focus on patient safety, help to develop policies to ensure that having access to antiretroviral therapy does not place individuals and households at financial risk and monitor trends in catastrophic levels of health care spending by households.

2. Provider organizations and services Little is known about how to scale up health services rapidly on a nationwide, equitable and sustained basis, especially when existing services are limited and of low quality. Drawing on the experience of other priority interventions, the Platform will examine the lessons learned from different approaches to enhancing service delivery. Antiretroviral therapy will be expanded in facilities in the context of increased resources, and this will place huge demands on management and administrative capacity. The Platform will examine innovative ways to strengthen facility and district management, and in collaboration with the International Alliance on Patient Safety, will support the development of patient safety strategies and monitoring systems that are feasible in resource-limited settings.

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Scaling up treatment and accelerating prevention

3. Policy options for human resources and health financing The Platform will support countries in developing financing and human resource strategies for scaling up care for HIV/AIDS while thinking through the implications for the rest of the health system. It will develop or harmonize tools that a) track overall and disease-specific national and external expenditure; b) estimate the costs of scaling up and of including HIV treatment in benefit packages; and c) assess, project and plan workforce needs for HIV/AIDS within a setting of overall development of the health workforce. It will synthesize evidence on: how well various forms of financing protect people from the financial risks of illness and ensure access to services, including antiretroviral therapy; how to ensure sustainable financing; and how to address workforce imbalances, migration, motivation and the effects of political and macroeconomic influences on human resource policies.

4. Scaling up HIV/AIDS care: the implications for the rest of the health system Governments need a strategic overview of trends in health and health services across the whole system to reconcile competing demands for resources, protect vulnerable people and ensure accountability. This is a particular challenge when private providers are a major source of care. The Platform will contribute to efforts to strengthen country health information systems by: • • • developing a core set of indicators or health system metrics that can be used to monitor the strength and performance of health systems; helping countries to link the monitoring of HIV/AIDS scale-up with national processes of monitoring progress towards achieving Millennium Development Goals and to integrate equity concerns into monitoring systems; and evaluating the system-wide effects of scaling up, to better understand both what worked and why.

1.4.3 Addressing social challenges Several persistent social challenges need to be tackled in scaling up HIV/AIDS interventions at the country level. These challenges need to be addressed by many actors, in numerous ways and on many fronts, most especially through more vigorous and sustained political commitment at the country level to realizing the rights to health, to information and to freedom from discrimination. This section briefly describes some of those challenges and WHO’s contributions to addressing them.

Stigma and discrimination The Declaration of Commitment on HIV/AIDS provides that, by 2003, all countries will have enacted, strengthened or enforced legislation to prevent discrimination against people living with HIV/AIDS and against vulnerable populations. Nevertheless, by mid-2003, only 62% of United Nations Member States had laws and policies in place to protect people living with or affected by HIV/AIDS against discrimination.3 Substantially fewer (38%) had policies that prohibit discrimination against vulnerable populations. The stigma associated with HIV/AIDS continues to impede effective national responses to the epidemic, underscoring the importance of immediate action by countries to enact and enforce the anti-discrimination policies provided for in the Declaration of Commitment on HIV/AIDS. Although wider access to antiretroviral therapy will itself help to significantly reduce stigma and discrimination, additional efforts are required to ensure uptake of testing and treatment, for example, by further mobilizing communities, improving the knowledge and attitudes of health care providers and undertaking broadbased communication initiatives as part of national scale-up plans. WHO will increasingly emphasize these approaches through policy guidance and education material,4 initiatives for training health providers and communication efforts related to HIV/AIDS. 3 4 General Assembly of the United Nations. Progress towards implementation of the Declaration of Commitment on HIV/AIDS. New York, United Nations, 2003 (Report of the Secretary-General, A/58/184). Understanding and responding to HIV/AIDS-related discrimination in the health sector. Washington, DC, Pan American Health Organization, 2003 (http://www.paho.org/English/AD/FCH/AI/stigma.htm, accessed 25 June 2004). HIV/AIDS: stand up for human rights! Geneva, World Health Organization, 2003 (http://www.who.int/hhr/news/en/cartoon_%20complet.pdf, accessed 25 June

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Involving communities and people living with HIV/AIDS In the Declaration of the 1994 Paris AIDS Summit, countries committed to increasing the involvement of people living with or affected by HIV/AIDS in national responses. WHO ensures that organizations of people living with HIV/AIDS and representatives of affected communities are represented on its partnership forums and other bodies. Models of care and prevention at the country level promoted by WHO highlight the importance of delivering treatment and care for HIV/AIDS through primary health care approaches, taking account of the important role of people living with HIV/AIDS and communities in advocacy, treatment preparedness and literacy and planning and delivering antiretroviral therapy programmes (for example, as expert patients) and in monitoring and evaluating services. Finally, WHO is reviewing health insurance and workplace issues to address the needs of people living with HIV/AIDS in the WHO workforce.

Ethics and equity The fact that HIV/AIDS does not affect everyone equally and the fact that the need for treatment and care often exceeds the current ability to deliver it means that some people will receive treatment and others will not. Such a situation poses serious ethical issues for governments, international agencies, nongovernmental organizations, groups of people living with HIV/AIDS, institutions and health care workers. The most compelling of these ethical dilemmas involve choices that will affect the life and death of millions of people. This set of circumstances imposes powerful ethical obligations to deliver treatment in ways that are as fair, beneficial, and sustainable as possible. Some of the questions that arise include the following. Should some population groups be given priority in access? To what extent should considerations of fairness constrain another objective of public health intervention: maximizing the benefits produced? How can fair processes (such as ones that are transparent, participatory and revisable) in making these difficult decisions be assured? To support the countries in making the difficult decisions involved, WHO is preparing guidance on the ethical and equitable scaling up of treatment and care for HIV/AIDS. In January 2004, a WHO/UNAIDS Consultation on Equitable Access to Care for HIV/AIDS took place at WHO headquarters in Geneva, involving a wide range of stakeholders including human rights experts, people living with HIV/AIDS, philosophers, communitybased organizations and programme managers from all WHO regions. The report of the consultation as well as three background papers provide an overview of the issues.5 The interim guidance document is intended to be useful for government officials, programme administrators at the district and local levels, communitybased and nongovernmental organizations, groups of people living with HIV/AIDS and international and donor agencies. It will be revised periodically in light of emerging evidence. Training materials are also being developed and case studies of best practices collected. These illustrate both the ethics and equity norms for antiretroviral therapy programmes and fair processes for the development of policies within countries. Indicators to measure outcomes and fair decision-making processes are also being developed. Finally, WHO is working with its partners to identify how country-level monitoring of antiretroviral therapy programmes can most effectively measure equitable outcomes, for example by disaggregating data on gender, age, socioeconomic status and marginalization.

Gender Women and girls now account for 50% of people living with HIV/AIDS globally and 58% of people living with HIV/AIDS in sub-Saharan Africa. These trends are most pronounced among young people. Women and girls are becoming increasingly vulnerable to HIV infection and bear the overwhelming burden of AIDS care, both informally in their families and communities and through the formal care sector. Programmes need to recognize and respond to the variety of ways in which gender inequity exposes women and girls to the risk of HIV infection, undermines women’s access to services and programmes and entrenches the inequitable situation of women. A gendered approach to addressing this inequity needs to involve men and women and advocacy for a legislative and policy environment that promotes the rights of women.6 5 World Health Organization and UNAIDS. Consultation on Equitable Access to Treatment and Care for HIV/AIDS, 26–27 January 2004. Summary of issues and discussion. Geneva, World Health Organization (in press). Macklin R. Ethics and equity in access to HIV/AIDS treatment. Geneva, World Health Organization (in press). Daniels N. How to achieve fair distribution of ARTs in “3 by 5”: fair process and legitimacy in patient selection. Geneva, World Health Organization (in press). “3 by 5”, priority in treatment, and the poor. Geneva, World Health Organization (in press). Draft Code of Good Practice for NGOs responding to HIV/AIDS, International Federation of Red Cross and Red Crescent Societies, 2004 (http://www.ifrc.org/what/health/hivaids/code, accessed 25 June 2004).

6

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Scaling up treatment and accelerating prevention The development of national responses needs to closely address gender issues – including attention to the roles and responsibilities of men and measures to empower women and girls, to improve their socioeconomic status, to reduce stigma and discrimination and to enhance their access to HIV/AIDS prevention, treatment, care and support. A growing body of evidence shows that community-driven interventions help to improve access by women and girls to health care and psychosocial support. The collective stock of knowledge about the gender-related determinants of risk, vulnerability and barriers to service utilization by women and girls has grown over the past decade, but putting that knowledge to practice remains a formidable challenge for policy-makers and implementers across all sectors. WHO is committed to contributing through its HIV/AIDS programme to improving the health and social outcomes for women and girls and to working with all necessary partners – such as women living with HIV/AIDS, nongovernmental organizations, the United Nations–sponsored Global Coalition on Women and AIDS and national governments 7 – to further this objective. Specifically, WHO will work to ensure that programmatic entry points to treatment appropriate for women and girls are strengthened, such that HIV testing and counselling with links to treatment programmes are established in settings such as reproductive health, including family planning and maternal and child health services, and in home care programmes that might serve women. WHO will strongly advocate with all governments, donors and partners that the global target for the numbers of women receiving antiretroviral therapy should be in accordance with the epidemiological profile of the disease and will assist individual countries in setting appropriate targets for both women and children. Accordingly, WHO’s monitoring and evaluation tools and support to countries will continue to be designed to ensure that countries collect information that allows them to understand the nature of their epidemic according to gender, age, geography and risk group and to use these variables to predict treatment needs and monitor the progress of their treatment, care and prevention programmes.

7

Integrating gender into HIV/AIDS programmes: report of an expert consultation, 3–5 June 2002, Geneva, Switzerland. Geneva, World Health Organization, 2002 (http://www.who.int/hiv/pub/prev_care/gen/en, accessed 25 June 2004).

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Scaling up treatment and accelerating prevention

2. WHO HIV/AIDS programme, 2004–2005 2.1 Introduction This section describes the WHO HIV/AIDS programme for the 2004-2005 biennium. It begins by describing the comparative advantages on which the functional activities are based. The five functional areas of the WHO programme budget for 2004–2005 are then described (Section 2.3), including key outcomes and indicators, together with illustrative examples of the priority activities to be undertaken in each functional area. Sections 2.4, 2.5, and 2.6 focus on the three areas that provide the specific content for: scaling up antiretroviral therapy, scaling up care and support and accelerating HIV/AIDS prevention.

2.2

Comparative advantages

Article 2 of WHO’s Constitution specifies the Organization’s mandate to serve as the “directing and coordinating authority on international health work” and in so doing, to assist governments and to provide technical assistance (Annex 3). World Health Assembly resolutions WHA55.12, WHA56.30 and WHA57.14 define the scope of WHO’s HIV/AIDS work. WHO works within the family of UNAIDS Cosponsors to facilitate multisectoral efforts within the United Nations system. As part of its broad health-sector mandate in HIV/AIDS, it specifically serves as the convening agency within the United Nations system for HIV/AIDS treatment, care and support as well as for preventing the mother-to-child transmission of HIV. WHO works closely with the UNAIDS Secretariat and Cosponsors at the global level and in countries with cosponsoring agencies through the United Nations country theme groups on HIV/AIDS. The roles WHO will perform as described here are consistent with WHO’s overall mandate and the expectations expressed by the Organization’s partners at a meeting in Geneva, Switzerland in May 2004.

Support and advisory role with health ministries and national governments WHO has a close relationship supporting and advising health ministries in Member States at their request. WHO’s relationships with ministries and other parts of government allow it to raise and negotiate a broad range of technical and policy issues. This is especially important given the changes implied by the paradigm shift of scaling up antiretroviral therapy, which presents new challenges to the health sector.

Convening and coordinating partner efforts in scaling up treatment, care and prevention Country-level experience indicates that WHO could be well positioned to coordinate action and inputs from many stakeholders and to ensure that such inputs are organized into a cohesive scale-up of health-sector responses. In countries, this includes active involvement in the United Nations country theme groups on HIV/ AIDS and close cooperation with the UNAIDS Secretariat, UNAIDS cosponsors and other United Nations agencies to help coordinate United Nations action at the country level.

Technical expertise WHO’s expertise in technical guidance covers the array of health system issues related to scaling up antiretroviral therapy and accelerating prevention. This includes simplified treatment regimens, testing and counselling, capacity-building (tools and training), models for scaling up antiretroviral therapy, laboratory requirements, drug procurement and supply chain management, human resource planning and management, surveillance, monitoring and evaluation, outreach to vulnerable populations, programme communication, operations research and the general development of health systems. WHO continues to receive many requests for technical assistance from Member States in all these areas. WHO also plays a valuable role in providing policy guidance in a variety of related areas such as ethics, community involvement and strengthening and financing health systems.

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

Planning WHO assists governments and other stakeholders in developing national implementation plans for healthsector interventions, including scaling up antiretroviral therapy, in accordance with the “three ones”.

Strategic information management and reporting WHO has long undertaken the role of identifying, collecting and synthesizing information in many areas of health. This information includes epidemiological data, information on the type and availability of health services (which is geographically mapped) and information on health systems. WHO is working to align key partner organizations in supporting a standard set of HIV/AIDS monitoring and evaluation measures to be collected at the country level to eliminate redundant effort and optimize the use of resources.

Global support for high-quality drugs and diagnostics WHO can make a range of contributions in supporting efficient processes of global and national drug procurement and supply chain management. The unique WHO prequalification process allows manufacturers to have their products certified by an independent panel of experts following an internationally endorsed process. This enables countries to source these products for use while being assured of drug quality. The new AIDS Medicines and Diagnostics Service (AMDS) – a joint initiative of WHO, the United Nations Children’s Fund (UNICEF), the World Bank, the United Nations Development Programme, the UNAIDS Secretariat and other partners 8 – will synergize the delivery of an array of additional services to improve access to HIV drugs and diagnostics at the country level. When fully operational, AMDS will be an indispensable resource to countries, acting as a clearing house for information such as drug prices and the regulatory and patent status of all medicines related to antiretroviral therapy. AMDS will provide direct technical support to all countries and will assist in developing detailed supply management plans in 40 countries by the end of 2005. AMDS will work to reduce antiretroviral and diagnostic prices by standardizing treatment, by assisting in price negotiations and by helping countries to pool demand and leverage their collective scale.

Operations research and learning through experience WHO’s knowledge of health-sector responses and health systems performance allows it to guide and inform operations research and the design and implementation of surveillance, monitoring and evaluation systems. WHO will work with countries to collect and analyse data on key operational questions, such as integrating antiretroviral therapy into existing health services and providing preventive and therapeutic interventions along a continuum of care. Lessons learned from scaling up will be rapidly and widely disseminated.

Assisting countries in mobilizing resources WHO has knowledge and expertise in mobilizing funds at the country, regional and global levels, including developing proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria and other major foundations and developing project plans for World Bank support. Special efforts will continue to be made to assist countries in developing proposals in all three disease areas supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. For example, in Round 4, WHO assisted 22 countries in developing proposals to support scaling up antiretroviral therapy. WHO can also assist both countries and granting agencies in expediting the distribution and implementation of resources.

Advocating for a comprehensive response to HIV/AIDS Given its close relationship with Member States, WHO can work with governments to ensure that appropriate political will and commitment to HIV/AIDS programmes are sustained.

Leveraging WHO’s organizational capability WHO’s global, regional and country presence, as well as its technical and human resources, represent a major resource pool for countries. Finding ways to better leverage total organizational capability at its various levels to fight HIV/AIDS represents a major opportunity for WHO as a whole to modernize, integrate and be more responsive to country needs. 8 AMDS will be a network hub model helping to coordinate the many ongoing efforts to improve procurement and supply chain management. With a coordinating secretariat based at WHO, the technical work of AMDS will be mainly carried out in collaboration with UNAIDS Cosponsors and other partners. AMDS is strongly linked to the Interagency Pharmaceutical Coordination Group (a partnership between WHO, UNICEF, the World Bank, the United States Agency for International Development and the United Nations Population Fund).

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Scaling up treatment and accelerating prevention HIV/AIDS technical staff work collaboratively with those in many other parts of WHO. New ways to leverage existing capabilities are being explored, such as using WHO staff working in polio or TB at the country level to accelerate the scaling up of antiretroviral therapy.

Identifying gaps and seeking solutions As health-sector interventions are scaled up at the national level, new challenges will emerge and gaps in the response will need to be filled by developing new tools, partnerships and policies. Although WHO will not necessarily lead activities in all cases, it plays a valuable role in monitoring these gaps and in identifying solutions and working with others – especially UNAIDS Cosponsors – to develop them.

2.3

HIV/AIDS Area of Work for 2004–2005

The HIV/AIDS area of work contained in the 2004–2005 programme budget for WHO identifies a set of five expected results. Consistent with the 2004–2005 programme budget framework, HIV/AIDS activities are grouped into five functional areas: strategic information; advocacy and policy; technical and normative guidance; country capacity-building; and operations research and knowledge management.

2.3.1 Strategic information Comprehensive HIV/AIDS responses, including scaling up efforts for treatment and prevention, require accurate and timely information. WHO is regarded as an important source of global surveillance information, for example, in developing, implementing and operating second-generation surveillance systems, which include HIV/AIDS, sexually transmitted infections and behavioural data. WHO also focuses on developing tools and guidelines for mapping, monitoring and evaluating health-sector interventions and building capacity for monitoring and evaluation. This area of work requires close collaboration with international partners and the guidance of the WHO representative in each country, who helps to ensure that data are consistent across the health sector, are nationally owned and reflect country needs.

Expected results • Comprehensive and reliable national and global mechanisms for HIV monitoring and evaluation, including surveillance, formulated or in place o Indicators: (1) number of targeted countries that conduct systematic, standardized surveillance in identified priority populations, including surveillance of behaviour and patterns of antiretroviral drug resistance; (2) number of evidence-based reviews to support strategies

•

Comprehensive and reliable information available to support the country-level procurement of drugs and diagnostics o Indicator: number of country procurement and supply management profiles developed

•

Comprehensive and reliable information on country-level activities for scaling up antiretroviral therapy o Indicator: number of “3 by 5” country profiles developed

Illustrative activities • Providing leadership and harmonization of technical tools and guidance and capacity-building related to monitoring and evaluation, including HIV/AIDS, sexually transmitted infections and behavioural surveillance Mapping HIV/AIDS service coverage, delivery points and programme scale-up, including priority factors as needed, such as programme impact, equity and antiretroviral therapy adherence Conducting surveillance and monitoring of HIV drug resistance, including acting as the secretariat for HIVResNet, a global network of HIV drug resistance scientists that is the primary partner in

• •

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

developing global standards, guidelines, definitions and reports relating to antiretroviral drug resistance (Box 2) • Establishing a data clearing house on antiretroviral drugs and diagnostics, including acting as the secretariat for AMDS, which will develop country-specific information on drugs and diagnostics (such as sources of technical assistance, prices, patents, suppliers, warehousing and distributors), collect global-level information on patents and the regulatory status of antiretroviral therapy and diagnostics and disseminate models and methods for procurement and supply chain management.

Box 2.

WHO’s strategy for minimizing HIV drug resistance through good practices, surveillance, and monitoring

Because HIV has a very high mutation rate, and because antiretroviral therapy should be continued for life once it has begun, HIV drug resistance will emerge to some degree among people in treatment even if appropriate antiretroviral therapy is provided and adherence is supported. However, wellfunctioning antiretroviral therapy programmes can minimize the emergence of HIV drug resistance and its transmission. WHO seeks to promote practices to minimize the emergence and transmission of HIV drug resistance and to reduce its public health consequences. The public health principles for minimizing HIV drug resistance are: • • • • ensuring appropriate antiretroviral drug access, prescribing and use promoting adherence supporting the prevention of HIV transmission taking appropriate action based on monitoring and surveillance.

WHO is the secretariat for HIVResNet, a global network of laboratory technicians, clinicians and epidemiologists. HIVResNet was formed to support and implement standardized methods for HIV resistance surveillance and monitoring. Current plans include the implementation of an international laboratory quality assurance system to support regional networks and international partnerships for genotyping HIV drug resistance. In-country databases for HIV drug resistance surveillance and monitoring, which could contribute data to a global database housed at WHO, are also being developed. WHO’s plan for HIV drug resistance surveillance and monitoring has three elements: • • • monitoring antiretroviral therapy programmes for appropriate prescribing practices, support of adherence, clinical outcomes, drug supply and prevention measures; estimating transmitted HIV drug resistance by testing specimens from HIV serosurveys or diagnostic centres through HIV drug resistance threshold surveys and representative sampling; and monitoring patterns of HIV drug resistance emerging at 12 and 24 months among cohorts of people starting their initial antiretroviral therapy regimen.

Information will be used to monitor the continuing utility of standard regimens used within the country and to guide public health action to support the minimization of HIV drug resistance. With HIVResNet and other international partners and sufficient funding, WHO plans to collaborate with up to 20 countries to begin monitoring and surveillance of HIV drug resistance in the coming year. Draft guidelines have been published (http://www.who.int/3by5/publications/documents/hivdrugsurveillance/en, accessed 25 June 2005) and will be updated regularly.

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Scaling up treatment and accelerating prevention 2.3.2 Advocacy and policy Scaling up a comprehensive health-sector response to HIV/AIDS including antiretroviral therapy and accelerating prevention efforts requires health system leadership, coordination, innovation and partnership. Several issues related to advocacy, health policy and systems development must be addressed to advise and guide decision-makers on the best approaches to scaling up.

Expected results • Countries will be supported in developing and implementing national plans for scaling up and implementing antiretroviral therapy in accordance with the “3 by 5” target o • Indicators: (1) number of countries with national plans for scaling up; (2) number of countries with national plans for scaling up in accordance with “3 by 5” targets

HIV/AIDS advocacy and strategic planning enhanced by promoting and developing multisectoral partnerships o Indicators: (1) number of countries incorporating recommendations and core health-sector interventions from the Global Health-Sector Strategy for HIV/AIDS 2003–2007 into national plans; (2) number of strategic collaborations and partnerships supported by WHO

•

Countries supported in developing and implementing successful funding proposals o Indicator: annual increase in the success rate of WHO-supported funding proposals

•

Countries supported in strengthening health systems through technical support for physical infrastructure planning, upgrading laboratory services, transport, information technology and clinics and through accreditation of service delivery points o Indicators: (1) number of countries with comprehensive physical infrastructure plans; (2) number of countries that have introduced WHO-supported accreditation of service delivery points

Illustrative activities • Developing and implementing strategic advocacy and communication products for targeted outreach, including donors, nongovernmental organizations and mass media: communicating messages through events, news updates, web sites, video, photographs, information materials and publications Undertaking advocacy and providing global policy guidance in key areas, including planning, financing, service delivery, ethical issues, equity, human resources, health systems development, HIV/AIDS in emergency settings, models for scaling up, outreach to vulnerable populations, private sector and community participation, drug pricing (including second-line regimens), and working with countries to adapt these to national settings

•

2.3.3 Technical and normative guidance Normative work will continue in key thematic areas, building on the rapidly evolving knowledge base and addressing issues critical for effectively designing and implementing programmes.

Expected results • Technical and normative guidance developed and provided to countries to enhance essential HIV prevention, treatment, care and support services and interventions

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

o

Indicator: number of targeted countries using and/or adapting WHO tools on the management of HIV and related conditions, including tuberculosis and sexually transmitted infections, and on the procurement, manufacture, regulation and appropriate use of HIV-related drugs and diagnostics

Illustrative activities • Developing technical and operational guidelines in priority areas, such as: o o The clinical use of antiretroviral therapy, with further attention to mother-to-child transmission and special groups such as women, children and injecting drug users Integrating testing and counselling and antiretroviral therapy in various health care settings (including TB care, inpatient and outpatient health care, antenatal care, child health, services for sexually transmitted infections, harm reduction services for injecting drug users and scaling up antiretroviral therapy in district and primary health care services) HIV diagnosis among infants and young children and related family-based counselling Use of rapid HIV tests and related counselling Counselling and support for people on antiretroviral therapy, including adherence and prevention Integrating communication initiatives into HIV/AIDS testing, prevention, care and treatment programmes Surveillance, monitoring and evaluation

o o o o o •

Prequalifying HIV-related drugs and diagnostics, maintaining a Model List of Essential Medicines and providing technical guidance on drugs and diagnostics procurement and supply management through AMDS

2.3.4 Country capacity-building Programmes are only sustainable in countries if resources are invested in long-term capacity-building. WHO’s focus is on linking the activities and technical assistance of each of its organizational levels to country needs. WHO will actively support putting the “three ones” framework into operation. Of the five functional areas in this section, the largest proportion of the WHO budget is dedicated to country capacitybuilding activities (shown in Table 7 later in the document).

Expected results • Countries will be supported in building national capabilities and technical expertise for improving health system responses to HIV/AIDS, including planning and setting priorities; allocating and managing resources; and delivering and evaluating services and interventions o • Indicator: number of targeted countries building competencies in HIV/AIDS in the health sector, including uptake of WHO normative tools and resources

The involvement of communities in delivering HIV prevention, care, support and treatment will be enhanced o Indicator: number of strategic collaborations and partnerships supported that involve civil society organizations and people living with HIV/AIDS

•

Human resources to deliver HIV services will be strengthened in countries by developing and implementing training, certification and strategies for rapidly disseminating knowledge o Indicators: (1) number of countries that have introduced training using WHO-supported certification of competence; (2) number of health providers and community treatment providers trained in delivering antiretroviral therapy services

•

Supply chain management and procurement of diagnostics and antiretroviral drugs will be improved o Indicator: number of countries using support from AMDS for procurement, manufacturing and supply management of antiretroviral drugs and diagnostics

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention Illustrative activities Technical support • Providing technical support to countries for policy development, strategic planning and adaptation of technical and operational guidelines in all key programme areas

National capacity-building • • Strengthening WHO country offices to provide improved country support, consistent with the WHO country cooperation strategy in each country, including recruiting dedicated HIV/AIDS staff Strengthening WHO’s participation in in-country mechanisms, such as United Nations country theme groups on HIV/AIDS and country coordinating mechanisms, to support coordination, planning and the mobilization of resources Supporting national health-sector planning on HIV/AIDS, including scaling up antiretroviral therapy Supporting national institution-building, such as national HIV/AIDS resource centres or knowledge hubs and regional networks Strengthening the capacity of countries to conduct research and monitoring and evaluation, including monitoring and evaluating the quality, coverage and effectiveness of the scaling up of antiretroviral therapy and the impact of scaling up on the development of health systems Supporting initiatives to mobilize communities and to increase preparedness for treatment

• • •

•

Human resources development From a country perspective, major bottlenecks in successfully responding to human resource challenges in the health sector include (1) the absence of a concerted human resource strategy to recruit, train and retain the workforce necessary to deliver antiretroviral therapy; (2) the use of multiple training materials; (3) weak training capacity; (4) insufficient quality control and certification systems in the training sector; (5) lack of financial resources for training; and (6) poor coordination and segmented approaches to training. The WHO capacity-building plan aims to support countries in overcoming these barriers to ensure both the emergency expansion of the HIV/AIDS workforce and the long-term sustainability of human resources in the health sector (Table 2).

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Table 2. Elements of the WHO plan for human resource capacity-building Countries Human resources planning Support the development of one country human resource and training plan Regions Technical resource networks and regional guidance for human resource assessment and planning Global Shared understanding of tools and guidelines for human resources planning among key technical, donor and academic institutions; development of core guidance Partner consensus on training packages, outlining core competencies, curricula and annotated training material for different types of health workers, with a focus on facility-based interventions

Developing training materials

Training material appropriate to a national scalingup approach for all key staff involved in scaling up antiretroviral therapy, with a focus on facility-level training based on the WHO Integrated Management of Adult and Adolescent Illness module Appropriate pre- and in-service training capacity with a focus on district and firstlevel training

Technical assistance in developing national training materials through regional technical resource networks and knowledge hubs, including technical networks related to the WHO Integrated Management of Adult and Adolescent Illness Providing opportunities for training trainers and providing in-country support to build capacity among training providers based on training packages (including training based on the WHO Integrated Management of Adult and Adolescent Illness approach) through resource networks and knowledge hubs Technical assistance in establishing certification systems through technical resource networks

Capacity of training providers

Developing partnerships to support the development of technical resource networks at the regional level

Certification and quality control

National systems for certification of health workers involved in scaling up antiretroviral therapy

Recommendations and partner consensus on the criteria for process, content and outcome verification for developing national certification systems Facilitation of access to global funding through guidance notes and case-by-case assistance

Financial resources

Training and human resource needs appropriately reflected in funding plans and proposals

Regional back-up to the development of national funding plans and proposals

2.3.5 Operations research and knowledge management 26

INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention Learning by doing is critical to rapidly scaling up HIV/AIDS programmes. WHO can play a role in helping to identify priorities in operations research and in integrating operations research into service delivery. WHO can also be actively involved in an innovative process of information and knowledge management to rapidly improve practices and interventions, for example, by improving information systems and promoting best practices accessible at the country level.

Expected results • A dynamic and relevant global agenda and innovative partnerships will be stimulated for research, including operations research on scaling up treatment and accelerating prevention and research on drug resistance, vaccine and microbicide development o Indicator: number of research initiatives strengthened through WHO mechanisms or participation

Illustrative activities • Formulating a global operations research agenda and identifying the key partnerships needed to implement it, with possible priority areas including: o o o o Integrating antiretroviral therapy into existing infrastructure and programmes, including links with maternal and child health, reproductive and sexual health, TB control programmes and services for drug users Comparing models of prevention, treatment, care and support, including innovative models of supporting adherence and programmes to reach out to vulnerable populations Maximizing synergy between preventive and therapeutic interventions Optimizing the contributions of the private sector, communities and people living with HIV/ AIDS to service delivery, including the role of people on antiretroviral therapy as expert patient trainers, treatment supporters and clinic staff; quality assurance; equity of access to services; adherence and its impact on transmission; and the social and systemic impact of programmes The use and acceptability of rapid HIV testing, especially among marginalized groups

o • •

Knowledge management systems, especially for data on country scale-up: linking countries engaged in scaling up through an information network that shares innovations and insights from the field in real time, including progress against standard indicators Identifying and reapplying learning by disseminating best practices in programme design and delivery

2.4

Scaling up antiretroviral therapy

2.4.1 Overview Through its intelligence-gathering efforts, WHO is building significant knowledge on scaling up antiretroviral therapy at the country level – both current and planned. The exact roles that WHO will play in each country in supporting scale-up will be based on a thorough analysis of the situation at the country level, in collaboration with governments and partners. Partners with specific expertise or comparative advantages may fill some roles better, in which case WHO is prepared to play a strong brokering or convening role. Scaling up should be understood in the broadest sense to include not only the logistics of procuring and supplying drugs but also core related activities such as financing, training of health providers, developing enabling policies and regulations and developing appropriate health infrastructure. This section describes in general terms the major barriers identified in efforts to scale up antiretroviral therapy at the country level, together with the contribution WHO will make to addressing them. It also outlines how WHO’s country assessment and data-gathering processes will guide the development of detailed country work plans.

2.4.2 Overcoming barriers to scaling up 27

WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

Country contexts and barriers and opportunities for rapidly and sustainably scaling up antiretroviral therapy are increasingly well understood as a result of improved country mapping, staff deployment and interaction with partners. Experience to date indicates that countries are currently struggling with several obstacles and challenges that serve as roadblocks to progress in scaling up national responses. However, numerous opportunities also exist to move ahead. This section highlights these obstacles and opportunities and outlines what WHO will do to help address them.

National political commitment and an enabling policy environment • • • • • • • • • • • • Some countries have inadequate overall political commitment. Competing government structures and stakeholders result in poor national coordination. Some countries have no national antiretroviral therapy policy or strategy or antiretroviral therapy component in the national HIV/AIDS strategy. Antiretroviral therapy guidelines and protocols are inadequate or need updating. Policies on the choice of antiretroviral therapy regimen or drugs (fixed-dose combinations – proprietary or generic) need to be developed. Regulations restrict the type of health care workers and/or services that can provide treatment follow-up and drug prescription (such as limited to AIDS treatment centres). Antiretroviral therapy provided through the private sector is regulated poorly or not at all. Access to antiretroviral therapy is inequitable among women, children, poor people, vulnerable groups, health workers and displaced people and in remote areas and emergency settings. Policies limit access to effective drug dependence treatment (such as the availability of methadone). Some confusion exists on targets for scaling up antiretroviral therapy (aligning national, WHO and donor targets). Legal, social and systemic barriers prevent access to services by marginalized populations such as drug users, sex workers, prisoners, displaced people and undocumented people, and community and political support for providing services to such populations is often lacking. Stigma and discrimination continue to dissuade people from seeking testing and/or treatment.

WHO will: intensify advocacy efforts to encourage high-level political support in countries; encourage national leadership and ownership; continue advocacy among global partners to encourage broad support for the “3 by 5” target and scaling up antiretroviral therapy; adapt tools and guidelines to country needs; undertake advocacy and provide technical support for the development of enabling legislation; engage partners to ensure efforts to reduce stigma and discrimination, including training of health care providers and greater use of expert patient trainers; provide technical guidance to support improved programme communication and outreach; and support monitoring and evaluation to improve programme quality, acceptability and accessibility.

Funding • • • • • • • Funding gaps exist for drug supply and technical assistance at the country level. More resources are needed at the country level to support the procurement and distribution of drugs and diagnostics. Resources could potentially be diverted from other programmes. Existing resources are used inefficiently and efforts are duplicated. Funding, financing and donor agencies coordinate and cooperate poorly with technical support agencies. Investment in sustainable responses is lacking, such as national institution-building. In many cases, funds granted to date have not been distributed.

WHO will: work with countries to develop integrated strategies for mobilizing resources that raise funds for scaling up at the global, regional and country levels; provide technical support to countries to enable them to plan, reallocate internal resources and mobilize external resources; map country input to facilitate donor coordination; develop costing tools and assist with country-specific financial analysis; and work with funding organizations to expedite the flow of granted funds to countries.

Supply of drugs and diagnostics

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Scaling up treatment and accelerating prevention • • • • • The prices of drugs and diagnostics remain high in some countries, often as a result of intellectual property issues. Drug regulation, procurement mechanisms and supply chains are weak in some countries. Storage and security of commodities needs to be improved. Concerns persist about drug quality. Laboratory facilities are weak or nonexistent.

WHO will: engage with governments and industry to promote lower drug prices; work through multilateral trade agreements to find solutions to intellectual property and trade-related issues; ensure that qualityassured, fixed-dose combination drugs have regulatory approval in all key countries; provide technical support through AMDS, including an information clearing house and country mapping and capacitybuilding.

Development of health systems • • • • • • • • Human resources and capacity-building need to be strengthened to overcome a lack of comprehensive strategies and policies on human resources, insufficient skills and personnel and a lack of training materials. Staffing regulations are inadequate: for example, due to recruitment limitations. Staff are not retained because of factors such as illness, burnout, low pay and more attractive conditions in other countries or sectors. Capacity-building activities at the national level are weakly coordinated (such as an absence of a training strategy and plan). The numbers and skills of trainers of staff are inadequate. The skills of laboratory personnel are inadequate. The quality of tools and support materials for antiretroviral therapy training is poor. There is no process of certifying trained staff.

WHO will: support countries in identifying major gaps in health-sector capacity and devise strategies to address them; promote community involvement and empowerment; provide technical support for developing capacity for managing procurement and the supply chain; develop training tools for health care providers and treatment supporters, in particular for training health workers at first- and secondlevel facilities based on the WHO Integrated Management of Adult and Adolescent Illness approach (Box 3); develop recommendations on national training certification guidelines and accreditation of health care facilities; and provide technical guidance on scaling up testing and counselling services.

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Box 3.

Preparing front-line workers: a WHO antiretroviral therapy training package for health workers at first-level facilities

Recognizing the urgency of integrating HIV/AIDS treatment into health services at first- and second-level facilities, WHO and partners have developed a clinical HIV care training package based on the WHO Integrated Management of Adult and Adolescent Illness approach. The package is based on several simplified, operational guidelines covering Acute care, Chronic HIV care with antiretroviral therapy, General principles of good chronic care and Palliative care (http://www.who.int/ 3by5/publications/documents/imai/en, accessed 25 June 2004). These guidelines will support the shift of key tasks from physicians to nurses and health care workers and encourage the involvement of lay providers and the community. The WHO Integrated Management of Adult and Adolescent Illness guidelines have been translated into several readily adaptable training courses for health workers in firstlevel facilities. • Basic antiretroviral therapy clinical training course. This course prepares nurses, clinical officers or medical assistants to perform a clinical review, undertake clinical staging, provide prophylaxis, prepare patients for adherence, initiate a fixed-dose first-line antiretroviral regimen among people without complications under supervision, consult or refer to district medical officers, respond to side effects, monitor and support adherence, collect data based on a simple treatment card and effectively integrate HIV care and prevention. This course requires 4.5 days of training. Antiretroviral therapy aide training course. This course addresses HIV basics, including the continuum of care and progression of disease; available treatments; patient education and support; adherence preparation, monitoring and support; communication skills; group education and support; and reception and triage. This course also requires 4.5 days. It can be used with lay providers or staff with limited clinical background. Short course on opportunistic infection management. This course focuses on the emergency quick check, cough or difficult breathing (pneumonia, TB, and other causes of severe illness), mouth and skin problems, headache and meningitis and peripheral neuropathy. Emphasis is placed on when to suspect HIV infection or TB disease and how to manage less severe opportunistic infections, allowing many people with WHO Stage III and IV HIV disease to be treated prior to antiretroviral therapy without referral to the district.

•

•

All materials based on the WHO Integrated Management of Adult and Adolescent Illness approach were developed over time through expert consultation and field application. Effective, rapid processes of country adaptation are recognized to be key for their relevance to countries. For example, Uganda’s Ministry of Health has adapted guidelines and training materials based on the WHO Integrated Management of Adult and Adolescent Illness approach. WHO helped to train a national core group of 40 facilitators and 30 expert-patient trainers who are now rolling out training based on the WHO Integrated Management of Adult and Adolescent Illness approach at the district level. WHO regional offices and headquarters are now setting up regional pools of experts who can provide support to countries in developing and rolling out antiretroviral therapy training all the way to first-level facilities. WHO will continue to learn from in-country application and improve and expand the range of tools available to implementers. WHO has already developed patient education flipcharts and patient treatment cards for each first-line regimen and is developing additional training aids such as videos. Additional materials, such as training courses based on the WHO Integrated Management of Adult and Adolescent Illness approach for district medical officers, are in production. Training packages based on the WHO Integrated Management of Adult and Adolescent Illness approach are complemented by simplified patient monitoring guidelines that were agreed upon during an international meeting in March 2004. These are based on agreed minimal or essential data elements to be collected during clinical chronic HIV care and antiretroviral therapy to support direct care needs and drug supply monitoring at the facility level and to meet the reporting needs of district and national programmes in accordance with the overall WHO/UNAIDS recommendations.

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention Coordination of national responses • In some cases, national leadership and ownership is weak, resulting in poor coordination at the national and regional levels: for example, weak coordination mechanisms and overlapping responsibilities of units in health ministries, country coordinating mechanisms, “3 by 5” technical working groups, task forces and United Nations country theme groups on HIV/AIDS. It is not clear who is responsible or accountable for planning, managing and monitoring the scaling up of antiretroviral therapy programmes. Care and antiretroviral therapy units and teams are not yet in place at the national and regional levels. Conflicts exist between various government bodies such as the national AIDS control programme and the national AIDS commission. There are few best practices in this area. Stronger partnership and coordination are needed.

• • • • •

WHO will: support country-led coordination processes; provide technical leadership on the health-sector response; contribute to quickly demonstrating successful scale-up models in countries (Box 4); and develop measures for monitoring progress in coordination.

Box 4.

Developing national models for scaling up antiretroviral therapy

Country by country, the numbers of people receiving antiretroviral therapy need to be expanded dramatically. On average, coverage in the 34 countries with the highest burden of disease needs to increase 13 times to achieve the “3 by 5” target, but some countries must scale up by a factor of 20 to 100 in less than two years. The United Republic of Tanzania, for example, needs to increase the number of people being treated from 1650 to 130 000 – a factor of 79. Each country’s national scale-up plan will need to translate that challenge into local terms, describing the current and planned infrastructures, the structure of the care system, the nature and structure of informal systems of care, drug needs, human resource requirements, training needs and so on. To date, many countries have begun to consider what needs to be done to scale up treatment so rapidly, but few have determined how such scale up can occur in such a compressed period of time. Although WHO knows well that the details vary, often dramatically, among local settings, WHO – with assistance from the Institute for Healthcare Improvement – has developed one such process for rapidly scaling up the provision of antiretroviral therapy in countries. A separate WHO publication, entitled An approach to rapid scale-up using HIV/AIDS treatment and care as an example (in press), provides details of this potential approach. This approach to scaling up has two major elements: • • a multiplicative model for involving care and treatment sites in successive expansion waves; and a real-time interactive operations research method, linked to a collaborative improvement model (called the breakthrough series model by the Institute for Healthcare Improvement), through which all the sites, along with the national team, learn and grow together in their ability and capacity.

It is hoped that publication of this potential approach to exponential scale-up of antiretroviral therapy will provoke thinking throughout the HIV/AIDS community about the need for and application of such a model. WHO is not advocating any particular approach but is simply signalling the need for exceptional thought and action to reach so many people in need of treatment in such a short period of time.

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Planning for scaling up • • • National operational plans have not yet been developed or the necessary input from all stakeholders and partners has not been obtained. More work is needed in programming and implementing scale-up: agreeing on common targets, testing and counselling services and mobilizing the public and communities. There is uncertainty about how to avoid antiretroviral therapy becoming a stand-alone programme and how to ensure that it leads to overall strengthening of health systems and a continuum of care: for example, in countries with high rates of TB and HIV coinfection, further collaboration with TB control programmes is desirable (Box 5).

WHO will: ensure that scaling up makes use of existing infrastructure and delivery mechanisms (especially TB, general medical and antenatal); promote referral models between primary, secondary and tertiary care; integrate HIV/AIDS training into overall human resource strategy; and promote policy collaboration between HIV/AIDS, development partners and health systems specialists.

Box 5.

HIV and TB: two diseases, one person

Over the past 50 years, TB workers have developed a delivery system for the drug management of TB that is now sufficiently robust to reach into many low-income, low-infrastructure settings. Known as DOTS (directly observed therapy, short course), it also includes a simple diagnostic process, supervised treatment – at least in the initial phase – and recording and reporting the outcome of each case. Each year 3 million cases are treated using the DOTS approach. TB is such a major killer of people with HIV/AIDS that TB needs to be seen as more than just another opportunistic infection and more than just an entry point. Delivery of TB treatment offers many lessons and potential synergy with efforts to scale up access to antiretroviral therapy. The same person often has TB and needs HIV treatment. Existing TB delivery services offer ready opportunities for both treating and preventing HIV. Similarly, emerging delivery services for antiretroviral therapy need to identify people with TB and refer them for sputum testing. Most TB work is done by general health workers in general health services. The same applies to HIV/ AIDS. Significant resources can be saved by ensuring that training for health workers, supervision of smaller health facilities by district hospitals and monitoring and evaluation address both diseases. The fixed-dose combination drugs required for both TB and HIV come from similar, if not always identical, pharmaceutical companies and are intended for the same people. Procurement, purchasing and supply chain management of drugs for both conditions can be streamlined in many cases. The diseases, however, are clinically different and require different technical approaches and different treatments. Each country needs a central unit of experienced professionals responsible for ensuring that a universal standard of care is achieved for each disease, but the scaling up of antiretroviral therapy need not reinvent the wheel at every turn.

TB programme collaboration in scaling up antiretroviral therapy – the experience of Malawi Malawi was one of the first countries to begin scaling up antiretroviral therapy nationally. The implementation of collaborative TB/HIV activities9 has progressed well, with 15 of 44 hospitals in 11 of 28 districts now providing routine HIV testing and counselling and cotrimoxazole preventive therapy for TB patients, with a plan to expand to the rest of Malawi by the end of 2005. Effective collaboration between TB and voluntary counselling and testing clinics has resulted in rates of acceptance of HIV testing among TB patients of over 70%. Lay counsellors function effectively along with nurse counsellors in the hospital, compensating for an acute shortage of nurse counsellors.

9

Collaborative TB/HIV activities in Malawi build on the foundations of the ProTEST project of WHO and partners, which showed how district-level TB and HIV collaboration could work and the benefits that could be derived. They are supported by the United Kingdom Department for International Development, the KNCV Tuberculosis Foundation, the Norwegian Agency for Development Cooperation and WHO. For more information, see Interim policy on collaborative TB/HIV activities (http://www.who.int/hiv/pub/ prev_care/tbhiv/en, accessed 25 June 2004).

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Scaling up treatment and accelerating prevention

Beginning this year, collaboration between TB and voluntary counselling and testing clinics will be further enhanced through the use of a standardized voluntary counselling and testing register. The HIV/AIDS unit in the Ministry of Health developed the register in collaboration with other stakeholders, including the national TB programme. All clients accessing voluntary counselling and testing will be asked whether they have been referred from care services, including TB. After post-test counselling, clients who admit having a cough for more than three weeks will be referred to TB services. All these will be documented in the voluntary counselling and testing register, making it easy to capture data about how many people with TB are accessing voluntary HIV counselling and testing and how many people accessing voluntary HIV counselling and testing are subsequently referred to TB services. The HIV Unit of Malawi’s Ministry of Health, working within the Department of Clinical Services, designed the Malawi plan for scaling up antiretroviral therapy and took it forward after a wide consultative process that included the national TB programme as one of the key stakeholders. This 2–year (2004–2005) plan includes rapidly scaling up antiretroviral therapy nationwide that builds on many of the components of the DOTS strategy and the experience of the national TB programme in implementing collaborative TB/HIV activities. The goal of the plan is to provide antiretroviral therapy for 80 000 eligible people by the end of 2005, which exceeds the expected “3 by 5” target (65 000). Further, the plan foresees collaboration with the national TB programme at all levels to develop the systems and modalities for supervising, monitoring and evaluating the delivery of antiretroviral therapy. National guidelines – both for the use of antiretroviral therapy and for the management of HIV-related diseases – have been developed, along with a curriculum to train health workers in antiretroviral therapy and in managing HIV-related opportunistic infections. These guidelines and curriculum include a) the eligibility of people living with HIV/AIDS for antiretroviral therapy, b) intensified TB case detection, rapid investigation and early treatment of diagnosed TB and c) TB preventive therapy for people living with HIV/AIDS among whom active TB has been excluded. Collaboration between the national TB and HIV/AIDS programmes will be further strengthened with the agreement that the TB programme will use its existing regional staff and infrastructure to monitor antiretroviral therapy services in Malawi. Antiretroviral roll-out begins in September 2004 in close collaboration with the national TB programme and as an integral component of collaborative TB/HIV activities. Nationwide coverage is expected within two years, making Malawi a leader in delivering antiretroviral therapy in Africa.

2.4.3 Country-level gathering of information and data WHO is uniquely placed at the global and regional levels to collect, monitor, synthesize and report on relevant country-level intelligence in the scaling up of HIV/AIDS treatment and care. A system to routinely collect information related to the status of HIV/AIDS treatment and care has been established and will be used to analyse information and provide advice and guidance to WHO staff, country counterparts and other partners.

Key data sources and collection methods Multiple data collection methods and data sources will be used to ensure the greatest efficiency and relevance of country intelligence-gathering. These include existing data sources, country missions and deployments, country surveys and the “3 by 5” Incident Room and Help Desk. Existing data sources. Sources of data include country assessment reports and research articles, key country strategy documents, country and partner surveys, consultations in-house and with partners, proposals and work plans of the Global Fund to Fight AIDS, Tuberculosis and Malaria, World Bank assessment and project documents and documents from UNAIDS Cosponsors, major bilateral partners and donors and nongovernmental organization initiatives.

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Country missions and deployments. WHO staff and consultants have been deployed to a number of countries for scoping missions and longer-term periods to provide direct technical assistance for country scale-up. A structured checklist has been used to guide intelligence-gathering on these missions and deployments. “3 by 5” country teams use a template for regular reporting on progress in implementing antiretroviral therapy. Country surveys. Where necessary, surveys and other data collection instruments are used to gather specific data from countries related to scaling up antiretroviral therapy. For example, regular surveys of progress toward reaching the “3 by 5” target have been designed to gather country information for reporting on the “3 by 5” milestones. The resulting database includes: key information on progress from each country; capacity development situation and needs (including human resources and training); and HIV testing and counselling services. “3 by 5” Incident Room and Help Desk. The “3 by 5” Incident Room is one of the key contact points in WHO headquarters for regular “3 by 5” communication with countries and regional offices, including deployed WHO staff, “3 by 5” country teams and partners. It facilitates communication between country and regional staff and headquarters counterparts. The “3 by 5” Incident Room manages all country support databases and provides country progress reports. Based in the “3 by 5” Incident Room, “3 by 5” Help Desk staff and country support analysts track incoming country information on scaling up antiretroviral therapy and provide a rapid response to all country requests, questions and issues requiring immediate resolution.

Major products Major products include a “3 by 5” Country Support Database and country profiles for HIV/AIDS treatment scale-up. The “3 by 5” Country Support Database collects and makes available relevant global and regional information and information for each focus country. The database synthesizes data obtained by reviewing existing materials, country missions and deployments, country surveys and information collected by the “3 by 5” Incident Room. Detailed country profiles for HIV/AIDS treatment scale-up are developed for all focus countries participating in scaling up. These profiles are updated regularly as new information is made available. The profiles are developed jointly with the respective national government counterparts and partners in each country. The data are drawn from the “3 by 5” Country Support Database. For each country the profiles include information on basic demographic and HIV/AIDS indicators; situation analysis; country policies, structures and programmes for HIV/AIDS treatment; data on antiretroviral therapy coverage; resource requirements and funds committed for scaling up antiretroviral therapy; the role of various implementation partners involved in scaling up antiretroviral therapy; progress in implementing the “three ones” principles; and information on WHO support in the country so far and priorities for further WHO support. The profile aims to be a practical tool to help guide countries in their scaling-up efforts, to monitor progress and to clarify roles and responsibilities across different partners. The profiles are targeted for in-country use and can be made available from WHO to interested parties on request. Based on the full country profiles, summary country profiles are produced for public distribution. These single-sheet profiles are updated regularly to ensure that they provide current and relevant information on the situation of scaling up antiretroviral therapy in “3 by 5” focus countries.

2.5

Scaling up care and support

Antiretroviral therapy can only be effective if provided as part of a continuum of HIV/AIDS care and support interventions and services that address the broad range of needs of people living with HIV/AIDS, including those that are not purely biomedical. Comprehensive care and support require a multidisciplinary and multisectoral approach involving many different community elements for effective delivery. This requires developing innovative partnerships with existing services and structures and, in some cases, developing new systems and processes to ensure the adequate and sustained delivery of comprehensive care and support. This section describes several of the key elements of that continuum and the contribution WHO will make to scaling them up in parallel with the expansion of antiretroviral therapy.

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Scaling up treatment and accelerating prevention 2.5.1 Home and community-based care Chronic care over the course of a lifetime is best provided as close as possible to where people live. For people living far from treatment and care facilities who do not have access to transport or whose mobility is otherwise restricted, providing care in the home and community is critically important. This requires community organization and support. Capacity-building, including training of home-based care providers – such as nurses, community health workers, other people living with HIV/AIDS, friends and family members – is required to ensure that services are adequately delivered and used and that the quality of care is maintained. However, shifting work to communities has to be synchronized with shifting of resources to communities and requires investment in systems of monitoring and support for communitybased treatment supporters and care providers. WHO will: develop policy and strategies for incorporating home-based care into overall national health systems; develop core training competencies and curricula for community health workers and treatment supporters; and endorse national guidelines for home care services, including basic palliative care by family members and community volunteers.

2.5.2 Palliative care Palliative care includes the management of physical symptoms such as pain, cough, skin rashes, fever and diarrhoea as well as dealing with psychosocial elements of disease, including depression, suicidal thoughts and other mental health problems. It also comprises spiritual support and bereavement counselling and is inclusive of the client and his or her environment. Palliative care often requires a multidisciplinary approach. WHO will: develop a policy statement on palliative care in HIV/AIDS; develop guidelines on HIV/AIDS and palliative care and advocate for including palliative care in national scale-up plans and HIV/AIDS guidelines in hospital, clinical, community-based and home settings; incorporate palliative care in HIV/AIDS training materials and approaches (based on the WHO Integrated Management of Adult and Adolescent Illness approach and other appropriate standards); support the inclusion of palliative care in curricula for health care providers; and develop policy on morphine use and availability, including who will be permitted to administer narcotics.

2.5.3 Nutritional support Nutrition plays an important role in maintaining immune function. Good nutrition increases resistance to infection and disease, improves energy, maintains strength and enhances productivity. People with HIV/ AIDS are more at risk for malnutrition for reasons such as reduced food intake, poor absorption, changes in metabolism, chronic infections and illnesses, anorexia, diarrhoea, fever, nausea, oral and oesophageal infections and anaemia. Managing these conditions and providing nutritional support are effective interventions that are fundamental to other HIV/AIDS care activities. Antiretroviral drugs should often be taken together with food, making access to adequate food important to effective treatment. WHO will: integrate nutritional support into policy and technical guidance on treatment and care; assess related education and training needs; identify partners to determine the need for and to provide direct food assistance; and incorporate nutrition into policy and technical guidance on home-based care programmes.

2.5.4 Psychosocial support Psychosocial support is important to everyone with chronic disease, including people living with HIV/AIDS. Counselling, spiritual support, support to enable disclosure, risk reduction and adherence to treatment, are all important at different stages of disease progression and the continuum of care, including the end of life. In addition, mental health issues have long been neglected in policies and guidance on HIV/AIDS care and must be addressed to ensure appropriate care and support for people living with HIV/AIDS and their families. WHO will: integrate psychosocial support into policy and technical guidance on treatment and care,

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including the special needs of vulnerable populations; advocate including psychosocial support in national scale-up plans, training initiatives, curricula and HIV/AIDS guidelines in hospital, clinical, community-based and home settings; map mental health services and identify gaps; and hold a consensus meeting on the mental health needs of people living with HIV/AIDS in resource-limited settings to identify programme priorities and operations research needs.

2.6

Accelerating prevention

2.6.1 Overview Prevention remains central to a comprehensive public health response to HIV/AIDS. To reduce the growth and size of HIV epidemics at a population level, prevention efforts must intervene effectively in lowprevalence settings and in situations where the potential for transmission is greatest, and they must reach sufficient scale. WHO’s interventions in prevention focus on these key areas: • • • testing and counselling as the entry point to both treatment and prevention; comprehensive programmes to prevent HIV infection among women, infants and young children; and targeted interventions for vulnerable populations, including injecting drug users, sex workers, young people and people living with HIV/AIDS.

Similar to scaling up antiretroviral therapy, WHO’s specific contribution in these areas of prevention work includes normative, technical and operational guidelines, capacity-building and technical support to countries. This contribution will be provided through broad technical partnerships. WHO is especially concerned with reducing HIV infection in women, who are increasingly vulnerable to HIV infection. Renewed efforts are required to develop and expand effective interventions that alter the factors at the individual, household and community levels that determine women’s vulnerability to HIV infection. These factors include mobility, poverty, violence, the social constructions of masculinity, HIV risk behaviour among men and biological characteristics. Increased access to antiretroviral therapy creates new opportunities for accelerating prevention. Some benefit may derive directly from the provision of treatment, such as the biological effects of treatment that may influence infectiousness. Other opportunities for accelerating prevention will result from enhanced health care access related to the scaling up of antiretroviral therapy, such as improved access to the diagnosis and treatment of sexually transmitted infections. More broadly, the wider availability of treatment will result in a fundamental shift in public health and societal perceptions and responses to the epidemic. In most settings where treatment has been made available, this has resulted in a large-scale increase in the number of people who know their HIV status and receive counselling and has increased community awareness about HIV/AIDS. However, treatment can potentially dilute prevention efforts. A concerted effort must therefore be made to target interventions where risk remains high, such as among young people, and to link prevention with treatment along a continuum of services.

2.6.2 Testing and counselling Recent studies indicate that overall coverage of testing and counselling is extremely poor in countries with the highest HIV burden. Worldwide, only 5% of people with HIV are estimated to be aware of their status. Dramatically scaling up access to testing and counselling is therefore key for successfully implementing antiretroviral therapy. HIV status must be known before treatment can commence or before decisions can be taken about future prevention needs, such as in preventing mother-to-child transmission. WHO advocates offering HIV testing and counselling widely in health care settings to everyone who might benefit from knowing their HIV status. Knowing one’s status enables people to initiate or maintain behaviour to prevent the acquisition or further transmission of HIV. WHO will: map and report on the coverage of testing and counselling in high-priority countries; publish core curricula for training the counselling and support staff at sites where testing and counselling are offered; publish standard operating procedures for integrating testing and counselling into clinical care sites, including in- and outpatient, TB, sexually transmitted infections, antenatal and family planning services and services targeting injecting drug users and sex workers; provide technical assistance to strengthen testing

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Scaling up treatment and accelerating prevention and counselling capacity at the country level; develop and publish indicators of testing and counselling quality to be applied at the programme level; develop and publish training curricula for the use of rapid HIV tests; develop communication campaigns aimed at lowering stigma, normalizing HIV testing and learning one’s HIV status; support operations research to assess the optimal integration of testing and counselling into clinics; and develop operational protocols for psychosocial care and support of people living with HIV/ AIDS in resource-constrained settings.

2.6.3 HIV prevention and care for women and children Of the estimated 4.1 million people 15–49 years old who became infected with HIV in 2003, about half were women, and this proportion is increasing. In addition, an estimated 630 000 children became newly infected with HIV, mostly associated with mother-to-child transmission. It is important to make the most of existing opportunities to reach women with key HIV prevention and care interventions through existing reproductive and sexual health services, such as family planning, maternal and child health and care services for reproductive tract infections and sexually transmitted infections. To improve overall maternal and child health outcomes, services for preventing mother-to-child transmission must be comprehensive and integrated into reproductive, maternal and child health services. The HIV/AIDS and maternal and child health agendas have now converged, and programmes to prevent HIV among women, infants and children are seen as a rallying point for enhanced care for women and children and as an opportunity to strengthen related health systems. WHO and its partners promote a comprehensive public health approach to preventing HIV infection among infants and young children consisting of four elements: • • • • primary prevention of HIV infection with a particular emphasis on reaching women of childbearing age and their partners with relevant services; prevention of unintended pregnancies among HIV-infected women; prevention of HIV transmission from HIV-infected women to their infants by providing specific interventions, including antiretroviral prophylaxis, safer delivery practices and infant feeding counselling and support; and the provision of treatment, care and support for women living with HIV/AIDS and their children and families.

WHO’s area of work in research and programme development in reproductive health is also heavily engaged in prevention activities for women and children: in particular, research and development around linking reproductive health, preventing mother-to-child transmission, antiretroviral therapy and HIV prevention and providing technical guidance on interventions for the prevention and care of sexually transmitted infections. WHO will: provide policy and technical guidance in implementing key interventions for preventing HIV transmission to women, infants and young children and for the care and support of those already infected or exposed as an integral component of essential services for reproductive and sexual health and for maternal and child health; provide operational guidance to strengthen links between preventing motherto-child transmission and care, treatment and support services for HIV-infected women and their families; and provide, in partnership with other United Nations agencies and other key partners, technical support to countries for implementing and scaling up comprehensive and integrated prevention and care programmes for women and children and for building human capacity for preventing mother-to-child transmission and for related treatment, care and support.

2.6.4 Community-based interventions Poverty, gender inequality, population displacement and instability are important structural factors that increase vulnerability to HIV infection, especially for women. Stigma and fear of HIV/AIDS are widespread. A range of strategies for communication and service delivery are needed at the community level to help to create more enabling environments for prevention, in addition to removing barriers that keep people from accessing HIV testing and counselling, prevention and treatment services.

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Young people (10–24 years) remain at the centre of the HIV/AIDS pandemic in terms of transmission, impact and potential for change. Over 2 million young people continue to become infected with HIV every year. WHO has a specific mandate for health-sector interventions, which includes support for the prevention of HIV among young people, as well as treatment and care. WHO’s Department of HIV/AIDS focuses on the most vulnerable categories of young people: young women and men in sex work, young people who use drugs and HIV orphans. WHO’s Department of Child and Adolescent Health and Development is also engaged in prevention and reducing vulnerability among young people, including developing training materials and programmes in focus countries, operations research and programme guidance on strategic information and supportive evidence-based policies. WHO will: support and coordinate prevention activities targeted at young people within WHO and with the United Nations Population Fund, UNAIDS and other United Nations partners; develop guidance and tools for health ministries to include young people in prevention activities; and develop capacity and provide technical support to countries for early implementation and scale-up of rapid assessment responses and other interventions targeting young people.

2.6.5 Programme communication Information and education about HIV/AIDS, especially for vulnerable populations, including women, is an essential component of prevention as well as interventions to scale up testing and counselling and treatment. WHO supports an integrated approach to communication emphasizing combating stigma through community-based programming. This includes leading and supporting communication campaigns for normalizing testing and counselling. In particular, WHO is focused on working with partners as implementers of strategic communication work at the country level. WHO will: develop a network of communication specialists to share experiences and best practice; provide technical support to countries for developing communication strategies with a focus on participatory methods; develop and publish technical guidelines on the effective integration of communication related to prevention and treatment; undertake capacity-building programmes in regions and countries; and support treatment awareness within communities.

2.6.6 Targeted interventions for vulnerable populations Injecting drug users Injecting drug use is driving the most rapidly growing HIV/AIDS epidemics in the world. About 10% of new HIV infections worldwide – and as high as 80% in some countries – are attributable to injecting drug use. HIV can spread rapidly in injecting drug-using populations and then stabilize at very high levels. For example, HIV infection among injecting drug users in Ukraine rose from virtually zero in 1994 to 31–57% in less than two years. In many countries, injecting drug users have limited access to HIV/AIDS prevention and care services. Users of illicit drugs are often marginalized and threatened by sanctions if they seek institutional treatment and other services. However, criminalizing drug use can increase rather than reduce the spread of HIV by forcing injecting drug users underground and thereby further reducing their access to services. To combat the spread of HIV among injecting drug users and their sex and drug use partners, WHO supports harm reduction activities, beginning with peer-based outreach. Rather than waiting for injecting drug users to enter health institutions, more services need to be provided in places where drug users are and where they use drugs. Successful efforts to reduce drug-related harm – including crime and other health conditions in addition to HIV/AIDS – build on three main complementary strategies: • • • supporting drug users who are ready to stop using drugs: for example, through drug treatment services, including drug substitution treatment such as methadone for heroin users; reducing injecting among those who continue using drugs: for example, through communication and counselling programmes that provide information on ways to prevent or minimize the risk of HIV infection; and reducing the sharing of injection equipment among injecting drug users: for example, by providing sterile injecting equipment in needle and syringe programmes.

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Scaling up treatment and accelerating prevention Comprehensive HIV prevention and treatment activities for injecting drug users need to use innovative peer-driven approaches. Policies and legislation that support HIV prevention and treatment programmes for injecting drug users also need to be developed in many countries. WHO will: establish an evidence base for effective HIV/AIDS prevention and treatment among drug users; promote methods for rapid assessment and response among drug-using populations; provide technical guidance and advocacy on scaling up outreach to injecting drug users; provide technical support and guidance on peer interventions; support harm reduction and promote access to drug dependence treatment programmes and to antiretroviral therapy; and mobilize harm reduction networks to implement effective HIV/ AIDS prevention and treatment interventions.

Sex work More than 80% of new HIV infections occurs through heterosexual contact. Factors that increase the rate and efficiency of heterosexual HIV transmission include high rates of changing sex partners and the presence of other sexually transmitted infections. Both these factors can be addressed through proven interventions – peer outreach, condom programmes and efforts to control sexually transmitted infections – that focus on networks of sex workers. WHO will: provide technical guidance and programme support to countries on how to scale up prevention interventions for male and female sex workers and their clients, including screening and treatment and care services for sexually transmitted infections.

Other especially vulnerable populations Migrant and refugee populations, seasonal workers, men who have sex with men and incarcerated people in closed settings are especially vulnerable and need specific prevention interventions. Especially vulnerable populations are often difficult to reach. WHO will: synthesize an evidence base for effective HIV/AIDS prevention and treatment interventions among vulnerable populations; promote rapid assessment methods; support the mobilization of communitybased organizations reaching out to such groups; and provide policy guidance. WHO will work in close collaboration with appropriate lead agencies, such as the Office of the United Nations High Commissioner for Refugees and the International Organization for Migration, as well as with national authorities, including justice ministries, to promote interventions for these groups.

2.6.7 Safer clinical settings Interventions promoted by WHO include injection and blood safety measures as well as policies, supplies and training to eliminate transmission in health care settings. In addition, postexposure prophylaxis must be available in case of accidental exposure. Particular emphasis must be focused on facilities in hightransmission areas. WHO will: carry out situation analyses and mapping; develop technical guidelines and training curricula; monitor and evaluate programmes; and provide technical support for the planning and evaluation of national programmes.

2.6.8 Prevention for people living with HIV/AIDS People living with HIV/AIDS are a logical but neglected focus for prevention programmes. Effective prevention interventions among people living with HIV/AIDS can significantly affect the spread of the epidemic (Box 6). Providing knowledge and skills related to prevention helps to reduce transmission to uninfected partners. Experience indicates that people receiving treatment will take steps to adopt safer behaviour if they understand the issues and are supported with ongoing counselling. WHO therefore supports an integrated approach that strengthens prevention interventions linked to treatment services. Clinic-based prevention services should be reinforced and integrated into the regular schedule of consultations.

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WHO will: provide technical guidance and programme support to enable a full package of interventions to prevent HIV infection, including sexual and reproductive health counselling and support; promote education and risk-reduction counselling for people living with HIV/AIDS; promote beneficial disclosure and partner referral for testing and counselling; and promote education on and supply of condoms, harm reduction services, treatment of sexually transmitted infections and counselling for couples to reduce the risk of transmission between partners.

Box 6.

e essential package of care and prevention services necessary to support antiretroviral therapy

In November 2003, in Lusaka, Zambia, WHO and UNAIDS hosted an International Consensus Meeting on Technical and Operational Recommendations for Emergency Scaling-Up of Antiretroviral Therapy in Resource-Limited Settings. This meeting brought together more than 100 experts, including people living with HIV/AIDS, treatment advocates, United Nations agencies, policy-makers, donors and nongovernmental organizations involved in providing HIV/AIDS treatment, care and support. Meeting participants acknowledged that scaling up antiretroviral therapy needs to form part of a continuum of services and that many services currently provided solely at the central and district level need to be quickly expanded to health centres and, for many of the routine elements of patient management, into community settings in which expertise already exists and can be rapidly built upon with appropriate resources and training. The meeting resulted in a number of consensus recommendations for rapidly scaling up antiretroviral therapy at various levels of the health system in the following categories: • • • • • people living with HIV/AIDS and communities as leaders in antiretroviral therapy; the essential package of care and prevention services necessary to support antiretroviral therapy; service delivery, human resources and training; management of commodities and supplies; and strategic information.

The meeting participants made the following recommendations on the essential package of care and prevention services necessary to support antiretroviral therapy. Recommendation 1A. Antiretroviral therapy should be initiated in facilities at all levels of the formal health care system as soon as the following minimum conditions are available: • • • • HIV testing and counselling; personnel trained and certified to prescribe antiretroviral therapy and follow up recipients clinically; an uninterrupted supply of antiretroviral drugs; and a secure and confidential patient record system.

Recommendation 1B. The following must be made available at all levels of the health system concurrent with (and following) the introduction of antiretroviral therapy: • • adherence support; and community mobilization and education on antiretroviral therapy.

Recommendation 2. People with symptomatic WHO Stage III and IV conditions who have tested HIVpositive and received post-test counselling should be offered antiretroviral therapy immediately. Recommendation 3. Stavudine + lamivudine + nevirapine should be the preferred first-line regimen for the immediate implementation of large-scale antiretroviral therapy programmes in resource-limited

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Scaling up treatment and accelerating prevention

settings. Fixed dose combinations should be used as soon as formulations of proven quality and bioequivalence are available and provide programmatic advantages.10 Recommendation 4. Chronic HIV/AIDS care capacity should be developed in health facilities concurrently with – and not as a prerequisite for – the introduction of antiretroviral therapy. Recommendation 5. Laboratory tests should be used according to the 2003 WHO treatment guidelines.11 Recommendation 6. HIV testing and counselling should be available in health-sector facilities at all levels of the health system and should be included in the service package of programmes that target vulnerable and difficult-to-reach populations. Recommendation 7. Simple, rapid, finger-prick tests should be the tests of choice in scaling up testing and counselling services. Recommendation 8. Strengthen existing HIV prevention services while antiretroviral therapy is being introduced. [This includes scaling up of outreach to vulnerable populations with a particular focus on poor people, sex workers, men who have sex with men and injecting drug users. Services should emphasize HIV testing and counselling, treatment of sexually transmitted infections, promotion of safer sex, condom distribution and harm reduction services.] Recommendation 9. Ensure that people living with HIV/AIDS receive key prevention services and commodities. Source: adapted from Emergency scale-up of antiretroviral therapy in resource-limited settings: technical and operational recommendations to achieve 3 by 5. Report of a WHO consultation. Geneva, World Health Organization, 2003 (http://www.who.int/ 3by5/publications/documents/zambia/en, accessed 25 June 2004).

10 Following the Lusaka meeting, on 1 December 2003, WHO prequalified the first triple fixed-dose combinations of the above preferred first-line regimen. WHO-prequalified products are listed at http://mednet3.who.int/prequal (accessed 25 June 2004). 11 Scaling up antiretroviral therapy in resource-limited settings: treatment guidelines for a public health approach – 2003 revision. Geneva, World Health Organization, 2003 (http://www.who.int/3by5/publications/documents/arv_guidelines/en, accessed 25 June 2004).

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Scaling up treatment and accelerating prevention

3. Structure of WHO and model for service delivery 3.1 Structure 3.1.1 Overview WHO is structured to provide a mechanism by which international knowledge can be translated into good practice in health at the global, regional and country levels. The roles of the three different levels of WHO in supporting the response to HIV/AIDS are described below. In addition to clarifying and reinforcing the respective roles of each level of the Organization, WHO is committed to allocating the majority of its spending to the regional and country office levels. In 2002–2003, 66% of total WHO spending on HIV/AIDS occurred at the regional and country levels. As Fig. 1 shows, WHO aims to spend 87% of its HIV/AIDS budget in the 2004–2005 biennium at the regional and country levels. Section 5 covers financial and staffing details.

������������������������������������� Fig. 1. WHO HIV/AIDS Budget Allocation 2004–2005 ��������� �������� ������������������������������� ����������� ������������ ���

Fig. 2 shows how the various levels of WHO are linked together to deliver HIV/AIDS services to people living in WHO Member States in need of health services and to the governments of the Member States. Fig. 2 illustrates that people in need of health services are the most important concern. Within WHO, the inverted pyramid demonstrates how each level of the organization acts to assist and enable those above it in providing the required services to Member States and their citizens.

Fig. 2 e WHO model for service delivery

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The following subsections briefly outline the scope of responsibility of each of the three levels of the WHO structure. As discussed in subsection 1.1, each country office, regional office and headquarters department is responsible for developing detailed work plans laying out the specific activities to be accomplished and describing the resource requirements and timelines based on the overall guidance provided by key organizational strategies and the WHO HIV/AIDS Plan. These work plans are integrated through joint planning sessions managed by programme management resources at regional offices and headquarters.

3.1.2 Country and liaison offices (65% of total WHO spending) The country level of WHO is paramount, as the millions of people in need of HIV/AIDS services live at the country level. WHO country offices play a unique role in providing support and advice to health ministries and other health partners on a broad range of health issues. They also play an important convening and coordination role, bringing government and other partners together to develop and implement appropriate national responses to HIV/AIDS. The WHO representative or liaison officer coordinates WHO activities in the country. The WHO representative is considered the chief external or technical adviser to the government on health matters. WHO Country offices sometimes have dedicated staff working on general or specific programmes. These may be international staff or local staff employed as national programme officers. In the case of HIV/AIDS, WHO plans to staff the offices of focus countries with one “3 by 5” HIV/AIDS country officer who, in conjunction with the WHO representative or liaison officer and working closely with all other partners acting at the country level, will plan WHO’s overall response in the country. The country officer will be supported by an appropriate number of additional resources, including a substantial activity budget plus other international staff, national programme officers and administrative staff. These teams are expected to be largely established by the fourth quarter of 2004. They will work with the national AIDS coordinating body and other partners to develop a comprehensive response in each country. Although WHO is prepared to provide a wide range of support at the country level if requested, subsection 2.2 describes the areas in which WHO feels it is best equipped to add value. This shifting of incremental resources in the HIV/AIDS area of work to the country level is closely aligned with the WHO decentralization policy and process underway that strives to strengthen WHO country offices through the WHO country cooperation strategy in each country (Box 7). The enhanced performance of WHO country offices should ensure better technical support for countries in developing integrated responses to HIV/AIDS and more effective participation by stakeholders, including people living with HIV/AIDS, nongovernmental organizations and other civil society groups.

Box 7.

e WHO country cooperation strategy

The WHO country cooperation strategy uses a process through which WHO reflects and defines its strategic vision for the medium term in a specific country. The process emphasizes consultation and strategic dialogue with stakeholders at the country level and inside WHO. It is led by the WHO representative, and most of the responsibility for the process lies with the country office, with inputs from the regional office and WHO headquarters. The timing and justification for formulating a country cooperation strategy depend on the country context. In the context of “3 by 5”, specific country cooperation strategies will be updated to include the new efforts to increase access to antiretroviral therapy. WHO’s work to scale up antiretroviral therapy needs to take place through existing national processes and coordination mechanisms to ensure that the scaling-up effort forms part of national policies and programmes. The country cooperation strategy therefore provides a framework for examining critical challenges facing health systems at the country level. The country cooperation strategy also relates to other processes in the country: the national poverty reduction strategy paper, sector-wide approaches and others, and activities led by the Common Country Assessment/United Nations Development Assistance Framework as well as activities led by other agencies. It also allows WHO to examine how it can work better as part of the United Nations country team and overall health development partners. The country cooperation strategy also provides a framework for the country level to determine workforce

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Scaling up treatment and accelerating prevention needs to realize the work plan of the country office.

3.1.3 Regional offices (22% of total WHO spending) The overall responsibility of each of the six WHO regional offices is to support the countries in its region. The regional offices do this in a variety of ways, including: • • • • • • • translating global norms, standards and knowledge into regional contexts; developing technical standards unique to the region; building the competencies and capacities of country offices; providing financial and human resources support to country offices; providing the first level of response to country requests for technical assistance; identifying areas in which headquarters support is required and coordinating the provision of such assistance; and coordinating and integrating individual country needs into an overall regional programme budget for HIV/AIDS.

While there are variations in the way Regional Offices are structured and how the Regional HIV/AIDS Programmes are positioned in each Office, in all cases HIV/AIDS work at Regional Offices is coordinated by Regional Advisors (RA) for HIV/AIDS. These Advisors provide a critical linkage in both directions with HIV/AIDS staff at country and headquarters level. They also coordinate HIV/AIDS activities with other programmes at the Region Office level. Similar to country offices, WHO is also strengthening the HIV/AIDS presence at the regional office level. Regional offices will be equipped with appropriate numbers of staff and activity budgets to enable them to provide the necessary support to countries effectively and efficiently (see Section 5).

3.1.4 Headquarters (13% of total WHO spending) Staff of the Department of HIV/AIDS at WHO headquarters perform two main functions. They support WHO regional and country offices in the effective delivery of HIV/AIDS health services at the country level. This is largely accomplished by working closely with colleagues in regional and country offices and providing technical support in a variety ways, including missions to countries to address specific needs. They also take leadership in a variety of areas, including overall advocacy and policy for HIV/AIDS issues, broad-based HIV/AIDS research, development of technical norms and standards and collaborating with other technical departments performing HIV/AIDS work in their respective fields of health. Examples of this collaboration between the Department of HIV/AIDS and other departments include: • • • • • • • the Interim Policy on Collaborative TB/HIV Activities (with Stop TB/Partnership Secretariat); guidance on ethical and equitable access to antiretroviral therapy (with Ethics, Trade, Human Rights and Health Law); health systems policy, including financial analysis and human resource needs for scaling up antiretroviral therapy (with Evidence and Information for Policy and Strategic Planning and Innovation); drug prequalification and essential medicines (with Essential Drugs and Medicines Policy); links between HIV/AIDS and sexual and reproductive health (with Reproductive Health and Research) and HIV/AIDS prevention for young people (with Child and Adolescent Health and Development); analysis of opportunities and constraints to health systems posed by scaling up efforts (with Strategic Planning and Innovation); and development of an operations research and knowledge management agenda (with the Special Programme for Research and Training in Tropical Diseases).

The Department of HIV/AIDS at WHO headquarters manages several interdepartmental working groups that assemble staff from across the Organization to focus on specific activities and expected results. Similarly, the Assistant Director-General for HIV/AIDS, Tuberculosis and Malaria chairs an Organization-wide task force composed of all Assistant Directors-General to enhance communication and coordination, identify

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and solve problems and provide high-level political commitment to HIV/AIDS work.

3.2

Matching support with country needs

The set of services, activities and anticipated results WHO offers varies from country to country, depending on the level of action (country, regional or global), the other partners involved and the ability of WHO to respond (Table 3). The following principles underlie the WHO response: • • • • WHO will focus its efforts and resources in countries where positive impact is anticipated to be greatest. WHO will provide different levels of support to different countries according to need. WHO will focus on a specific number of technical areas in which it has comparative advantage and the greatest impact can be achieved. WHO will work closely with partners and build on already existing and planned initiatives.

More effective mapping of country-level activity through real-time information networks and a regular country profiling process will enable more accurate assessment of both the needs of specific countries and the capacity of WHO and other partners to respond.

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Scaling up treatment and accelerating prevention Table 3. Types of technical support WHO provides Provided to All Member States

Type of technical support WHO provides Responsive technical support WHO provides responsive technical support according to the requests and identified needs of all Member States. Primary responsibility for technical support rests with the WHO country office, with support from the regional office. The Department of HIV/AIDS at WHO headquarters provides support by: • • • • ensuring that WHO country and liaison offices possess the core competencies required to respond to country requests, either by providing direct technical assistance or by referring to other WHO units or other agencies; enabling Member States to readily access strategic, policy and normative information and key tools and guidelines; strengthening regional technical networks and institutions that can act as resources for countries in implementing national programmes; and providing direct technical assistance to Member States where specific needs have been identified or crisis situations emerge.

Proactive technical support WHO provides proactive technical support to “3 by 5” focus countries, which have the greatest HIV/AIDS treatment needs or have been identified as regionally strategic. Support involves a partnership across WHO headquarters, regional offices and country offices. In addition to the support described above for all Member States, technical support focuses specifically on scaling up antiretroviral therapy, including: • • • • • strengthening WHO country offices with dedicated HIV/AIDS teams and health systems specialists; providing direct technical support in developing and implementing national HIV/AIDS health-sector plans, with a specific component of treatment and care, including antiretroviral therapy; integrating WHO tools and guidelines into national institutions and programmes; supporting national strategic capacity-building; strengthening key national HIV/AIDS institutions, health systems and resource centres, especially clinical services, laboratory facilities, drug procurement and management systems, testing and counselling, monitoring and evaluation, human resource development and referral systems; facilitating the establishment of partnerships at the national and district levels and coordinating with other major initiatives, especially those focusing on scaling up antiretroviral therapy; ensuring the technical soundness of interventions; guiding the development of an operations research agenda addressing key questions relevant to programmatic areas and health systems development; helping to document experience and disseminate tools that would inform other countries; assisting in mobilizing and managing resources; and supporting countries in designing scale-up plans that are ethically sound and equitable.

“3 by 5” focus countries (Annex 1)

• • • • • •

Several countries (such as China, Ethiopia, India, Nigeria, the Russia Federation and South Africa) play a pivotal role in determining the future of the HIV/AIDS pandemic. These are countries with large populations and/or geographical size where the current or potential spread of HIV/AIDS will have major regional or global impact. In addition to the assistance described above, incremental decentralized support will be provided.

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Scaling up treatment and accelerating prevention

4. Implementation through partnership: working together to make it happen WHO is only one of many organizations working to scale up antiretroviral therapy, accelerate prevention and contribute to the overall response to HIV/AIDS. The focus of much work is at the country level, where people live, where HIV is transmitted and where treatment must be offered. Partners involved in the global response include United Nations and multilateral agencies, foundations, nongovernmental, faith-based and community organizations, the private sector and labour unions and, importantly, representatives of the community of people living with HIV/AIDS. To achieve the “3 by 5” target, the Millennium Development Goals and the goals of the Declaration of Commitment on HIV/AIDS, every individual and organization must play their part. Activities across the WHO HIV/AIDS programme are undertaken in concert with a variety of stakeholder-specific working groups and technical collaborations, including the “3 by 5” Global Partners Group, United Nations system partners, technical partnerships, country-level partners, donors and civil society, faith-based and private-sector groups.

4.1

e “3 by 5” Global Partners Group

The “3 by 5” Global Partners Group comprises a wide range of major international organizations encompassing all stakeholder groups. The purpose of the “3 by 5” Global Partners Group is to ensure regular opportunities for information exchange and advocacy between stakeholders in the global movement to scale up the response to HIV/AIDS.

4.2

United Nations system partners

The UNAIDS family of organizations has committed its full support to scaling up treatment and accelerating prevention. In addition to WHO, several provide support to health ministries: • • • • • the United Nations Population Fund for links between reproductive health services and HIV; UNICEF for its focus on mother-to-child transmission of HIV, adolescent and child welfare and procurement of antiretroviral drugs and treatments for opportunistic infections; the United Nations Development Programme for its focus on involving people living with HIV in developing policy and designing programmes; the International Labour Organization for workplace health policy; and the World Bank as the largest donor of funds for health infrastructure development and planning.

Stronger relationships are also being developed with the newest UNAIDS cosponsors, the World Food Programme, for food security and nutritional support as part of HIV/AIDS treatment and programmes for preventing the mother-to-child transmission of HIV, and the Office of the United Nations High Commissioner for Refugees, for HIV/AIDS interventions in emergencies, including among refugees and other displaced and emergency-affected populations. The executive heads of the UNAIDS Cosponsors have agreed to the respective roles of these agencies in scaling up HIV/AIDS treatment and their contributions to realizing the “3 by 5” target. This is described in more detail in Annex 4. The UNAIDS Secretariat and its UNAIDS country coordinators in country coordinate the multisectoral response on behalf of the United Nations system. This coordination is implemented through the United Nations country theme groups on HIV/AIDS, with the UNAIDS country coordinators acting as the secretariat at the country level. Other examples include participation in interagency coordination mechanisms within the United Nations (for example, at the global level, WHO is the convening agency within the United Nations system for HIV/AIDS

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treatment, care and support as well as for preventing the mother-to-child transmission of HIV) and involvement in other interagency mechanisms such as the Interagency Task Team on Injecting Drug Use convened by the United Nations Office on Drugs and Crime. Similar interagency coordination mechanisms exist at the regional and subregional levels.

4.3

Technical partnerships

WHO is heavily engaged in technical partnerships with other technical agencies, international nongovernmental organizations and community networks on specific issues. Examples include: • cooperation with the Global AIDS Program of the United States Centers for Disease Control and Prevention and the United States Agency for International Development on HIV testing and counselling and activities for preventing the mother-to-child transmission of HIV and, in the WHO Western Pacific Region, work related to injecting drug users. partnership with Médecins Sans Frontières on various aspects of scaling up treatment and related capacity-building; working with the French project ESTHER (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau) on capacity-building, training and strengthening the decentralization of services; collaboration with Family Health International, the AIDS Foundation East-West, the Open Society Institute and international and regional harm reduction networks on harm reduction and treatment access for injecting drug users; a partnership with UNAIDS, UNICEF, the World Bank and leading nongovernmental organizations involved in drug procurement to establish AMDS, aimed at supporting countries in strengthening their procurement of commodities and consistency in distribution systems; cooperating with training institutions and other stakeholders to establish standard competencies for a range of types of health worker, to ensure that training programmes related to antiretroviral therapy meet global norms; working with the Global Fund to Fight AIDS, Tuberculosis and Malaria to ensure that countries can develop fundable proposals and implement effective programmes to scale up antiretroviral therapy as part of a comprehensive approach to HIV/AIDS; cooperating with the All Africa Conference of Churches and Islamic medical associations (as a model for other faith-based organizations) to enhance existing pharmaceutical distribution networks for effective and reliable access to and distribution of pharmaceuticals and diagnostic supplies; collaboration with UNAIDS and the United States President’s Emergency Plan for AIDS Relief to harmonize monitoring and evaluation indicators related to antiretroviral therapy; cooperation with the World Bank Treatment Acceleration Program (including nongovernmental organizations, associations and the private sector) on scaling up antiretroviral therapy; and working with the World Food Programme on information systems linking food insecurity and HIV/ AIDS prevalence.

• • • • • • • • • •

4.4

Country-level partners

Ultimately, treatment scale-up, improved prevention efforts and the implementation of a comprehensive response to AIDS require action by partners at the country level. WHO has worked and will continue to work with a wide array of partners to provide assistance and enable joint efforts. At the country level, WHO’s key traditional partner is the health ministry, the arm of government tasked with implementing health-sector activities for HIV/AIDS within the supportive strategic HIV/AIDS framework and as part of the overall national strategy. WHO also contributes to strengthening mechanisms for partnership at the country level, including United Nations expanded theme groups on HIV/AIDS, country coordinating mechanisms and national AIDS commissions to ensure multi-stakeholder involvement and input to governments implementing antiretroviral therapy programmes. Other traditional partners with which WHO will need to continue working include national and regional academic and research institutions in developing evidence-based, normative standards, guidelines and tools, either as WHO collaborative centres or as partners on specific projects.

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention 4.5 Donors

WHO works closely with a large number of bilateral partners that provide significant levels of technical and financial assistance to countries in mounting a comprehensive HIV/AIDS response. They include the Governments of Australia, Belgium, Canada, Denmark, France, Germany, Ireland, Italy, Japan, the Netherlands, Norway, Sweden, Switzerland, the United Kingdom, the United States of America and many others plus the European Union. Collaboration includes aligning their in-country support for activities with the technical and policy contributions of WHO to support country efforts. In addition to the development agencies of these countries, organizations providing technical assistance, private foundations and academic institutions are valued partners. WHO also collaborates closely with the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank.

4.6

Civil society, faith-based and private-sector groups

Civil society, faith-based and private-sector groups have an important role to play in the response to HIV/ AIDS. For example, with faith-based organizations performing up to 40% of AIDS care in Africa, fostering these relationships is critical to the success of “3 by 5”. Other partners in civil society include associations of people living with HIV/AIDS; business and occupational health service providers; labour organizations; and national and international nongovernmental organizations with longstanding experience in community mobilization, such as the International Federation of Red Cross and Red Crescent Societies and Planned Parenthood International. WHO has dedicated new resources and personnel to building relationships with these communities and organizations.

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention

5. WHO programme budget and resource requirements 5.1 Overview of the programme budget The 2004–2005 WHO programme budget as approved by the Executive Board in January 2004 identifies the budget requirements for the HIV/AIDS area of work for the biennium as US$ 218.1 million. The US$ 218.1 million total represents a dramatic 269% increase in HIV/AIDS spending compared with the actual spending of US$ 59 million during the 2002–2003 biennium. In formulating this programme budget, WHO addressed three important questions. • • • What is the appropriate geographical distribution of spending? How much of the budget should be allocated to country, region and headquarters activities? What proportion of investment should be made in treatment and care as part of a comprehensive response to HIV/AIDS and prevention, which continues to be the mainstay of the response? How should effort and funding be distributed across the functional areas of WHO’s work?

5.1.1 Geographic distribution of funds and activities WHO will dramatically increase the percentage of its budget spent at the country and region levels compared with headquarters activities. Specifically, the proportion of total spending at the country and regional levels will increase from 66% in 2002–2003 to 87% in 2004–2005. WHO will also ensure that funds are allocated in proportion to the geographical burden of disease. As a result, the African Region of WHO will receive 55% of total funds during the 2004–2005 biennium. Table 4 vividly demonstrates the commitment WHO has made to significantly increase the proportion of its spending at the country and regional levels by showing the actual and projected spending over five bienniums.

Table 4. Biennium

WHO spending on HIV/AIDS (in millions of US dollars), 1996–2005 Budget or actual Total WHO HIV/ AIDS spending Increase in spending compared with the previous biennium Percentage spent at the headquarters level Increase in headquarters’ share of spending compared with the previous biennium NA +21% +31% –11% –62%

1996–1997 1998–1999 2000–2001 2002–2003 2004–2005

Actual Actual Actual Actual Budget

28 39 50 59 218

NA +39% +28% +18% +269%

24 29 38 34 13

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

Table 5 provides further details of the budget according to WHO region.

Table 5. e 2004–2005 WHO HIV/AIDS budget (in thousands of US dollars) according to geographical level Geographical level Total budget a (% of total)

Headquarters Region of WHO Regular budget 5 073 Other sources 23 000 Subtotal

Regional Regular budget Other sources Subtotal

Country Regular budget Other sources Subtotal

Headquarters African Region Region of the Americas South-East Asia Region European Region Eastern Mediterranean Region Western Pacific Region Total Percentage by geographical level

28 073

28 073 (13%) 2 945 23 000 25 945 2 994 92 000 94 994 120 939 (55%) 12 602 (6%) 20 669 (10%) 11 319 (5%) 11 349 (5%) 13 165 (6%) 218 116 (100%)

104

4 000

4 104

498

8 000

8 498

1 966

5 000

6 966

703

13 000

13 703

200

3 000

3 200

1 119

7 000

8 119

786

3 000

3 786

563

7 000

7 563

504

3 000

3 504

661

9 000

9 661

5 073

23 000

28 073

6 505

41 000

47 505

6 538

136 000

142 538

13%

22%

65%

100%

a

Excludes about US$ 6 million allocated to other WHO departments from the UNAIDS Unified Budget and Workplan).

5.1.2 Proportion of spending on treatment and prevention activities In order to incorporate a major set of activities to scale up HIV/AIDS treatment and care, WHO will dramatically increase the spending in terms of both total dollars and the percentage of the budget allocated to treatmentrelated activities. Treatment-specific spending will increase from about US$ 5.9 million (10% of the programme budget) in 2002–2003 to US$ 109.0 million (50% of the programme budget) in 2004–2005. At the same time, WHO will continue to accelerate its efforts and associated spending in support of prevention-related activities. Spending on prevention-specific activities will increase from about US$ 35.4 million (60% of the programme budget) in 2002–2003 to US$ 54.5 million (25% of the programme budget) in 2004–2005. Attempting to identify resources allocated to treatment and prevention is complicated by the fact many activities are cross-cutting and support both of these important priorities. For example, many of the normative and country capacity-building interventions in key technical areas required for ensuring a comprehensive response to HIV/AIDS cut across both prevention and treatment. These include HIV testing and counselling, developing entry points, links with malaria and TB control activities, advocacy, programme communication and work on strategic information, including surveillance, and monitoring and evaluation.

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Scaling up treatment and accelerating prevention Some activities can be designated as specific to treatment or prevention. For example, harm reduction, preventing mother-to-child transmission and targeted interventions for vulnerable populations may be considered prevention interventions. MTCT-Plus, antiretroviral therapy for children, adherence support, postexposure prophylaxis and other clinical care activities may be designated as specific to treatment. Using these criteria, Table 6 estimates the spending allocated to treatment, cross-cutting and prevention activities during 2002–2003 and 2004–2005.

Table 6. WHO spending (millions of US dollars) on HIV/AIDS treatment and prevention, 2002–2005 Biennium Treatment % of budget Spending (index versus previous biennium, 2002–2003 = 100) 5.9 (100) 109.0 (1847) Cross-cutting % of budget Spending (index versus previous biennium, 2002–2003 = 100) 17.7 (100) 54.5 (308) Prevention % of budget Spending (index versus previous biennium, 2002–2003 = 100) 35.4 (100) 54.5 (154) Total Spending (index versus previous biennium, 2002–2003 = 100) 59.0 (100) 218.1 (369)

2002–2003 2004–2005

10 50

30 25

60 25

5.1.3 Allocation of spending across activity areas WHO will continue to deliver expected results across its five key functional areas (strategic information, advocacy and policy, technical and normative guidance, country capacity-building, and operations research and knowledge management) in 2004–2005. However, country-level activity will be preferred wherever possible. Further, WHO will ensure that the right work is being done at the most appropriate level of the Organization. Table 7 summarizes planned spending across the five functional areas, with the addition of programme management. A full 36% of total spending will be applied towards building capacity at the country level. Spending is reasonably consistent across the three organizational levels, with two exceptions. Country offices spend more on capacity-building and less on normative guidance than WHO headquarters. This pattern is very consistent with the expectations of the roles of the different levels as described in Section 3.

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Table 7. WHO 2004–2005 HIV/AIDS budget according to the amount (in millions of US dollars) and percentage allocated to each functional area Level Functional area Countries Amount Strategic information Advocacy and policy Technical and normative guidance Country capacitybuilding Operations research and knowledge management Programme management Total 17.1 22.8 11.4 57.0 7.1 % 12 16 8 40 5 Regions Amount 5.7 5.7 4.8 14.7 2.4 % 12 12 10 31 5 Headquarters Amount 3.7 3.4 6.7 7.0 2.5 % 13 12 24 25 9 Total WHO Amount 26.5 31.9 22.9 78.7 12.0 % 12 14 11 36 6

27.1 142.5

19 100

14.2 47.5

30 100

4.8 28.1

17 100

46.1 218.1

21 100

5.2

Staffing

WHO’s ability to undertake the activities described in this document – including activities to support realization of the “3 by 5” target – requires a dedicated team of professionals appropriately dispersed across the three levels of the organization and experienced in HIV/AIDS, antiretroviral therapy, health planning, public health and partnership development. Assuming that funding is provided to support the total programme budget of US$ 218.1 million, WHO projects a total HIV/AIDS staffing across the organization of 415. This total, as shown in Table 8, comprises a combination of international professional staff (249), national programme officers (76) and administrative support staff (90). About 53% of the planned staff will be based in WHO country offices, 28% at regional offices and 19% at WHO headquarters. However, the country and regional offices will be equipped with substantial activity budgets totalling US$ 116.2 million, which can also be used to hire additional required staff on a short-term or contractual basis. In a typical “3 by 5” focus country for scaling up antiretroviral therapy, WHO projects placing teams of 4–20 staff members, comprising a “3 by 5” country officer, reporting to the WHO country representative or liaison officer and responsible for leading the HIV/AIDS team on the ground. The team will be supported by several international professional staff and nationally recruited technical staff along with an appropriate complement of administrative support staff. The international and national professional staff will bring a variety of technical skills to the team such as expertise in antiretroviral therapy, laboratories, drug supply chain management, health systems, capacity-building, training and monitoring and evaluation. The specific number and mix of skills will be determined on a country-by-country basis by the WHO representative and the “3 by 5” country officer in consultation with the government and partner organizations present, based on a thorough understanding of the national scale-up plan. Regional office WHO HIV/AIDS teams will also be strengthened so that they can provide necessary technical backstopping and support to the country-based staff and maintain direct support to non-focus countries that need occasional guidance but that do not require full-time dedicated HIV/AIDS staff. HIV/AIDS staffing at headquarters will be reduced from current levels and will focus on the tasks that are best performed at a global level, such as normative guidance, global data and information management, policy issues and coordination with partners at a global level.

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Scaling up treatment and accelerating prevention Table 8. Staffing distribution and costs and activity spending (in millions of US dollars) based on the 2004–2005 WHO programme budget for HIV/AIDS International professional staff Country offices Regional offices Headquarters Total Staff costs Total budget 106 83 60 249 87.0 National programme officers 76 0 0 76 6.0 Administrative support staff 38 32 20 90 4.0 Total staff Activity budget 98.7 17.5 4.9 121.1

220 115 80 415 97.0

218.1

5.3

Resource needs

Putting the 2004–2005 WHO programme budget into perspective leads to a recognition that an investment of slightly more than 1% of the total estimated US$ 20 billion needed to deliver a comprehensive response to HIV/AIDS over the same two-year period12 will enable WHO to provide leadership, guidance and technical assistance to countries so that these resources are most effectively turned into results. Importantly, of the US$ 218.1 million 2004–2005 programme budget, only US$ 18.1 million comes from WHO’s regular budget. This means that US$ 200 million must be raised from other sources. As of July 2004, WHO had secured US$ 156 million of the required US$ 218 million, leaving a funding gap of US$ 62 million. Funds secured so far include the generous pledge of CAD 100 million (US$ 72 million) by the Government of Canada, announced on 10 May 2004, as well as contributions from Sweden and the United Kingdom. There is an immediate need to front-load the remainder of this investment in WHO given the urgency of moving ahead in countries now so that the “3 by 5” target can be met on schedule. In other words, although donations arriving late in the biennium will be gratefully received, they will not help the organization deliver the “3 by 5” target. Countries and other funding organizations considering a donation are respectfully asked to do so now. As this funding gap is met and activity scaled up, WHO will be called upon to do more and may submit additional appeals for funding beyond the US$ 218.1 million on a country-by-country basis as specific needs are further defined and better understood. In 2004–2005, WHO is receiving US$ 21.5 million from the UNAIDS Unified Budget and Workplan funded by a number of bilateral donors. Of this amount, about US$ 6 million is directed to other WHO clusters and departments to do important HIV/AIDS work in a variety of fields including child and reproductive health, blood safety and microbicide and vaccine research. The remainder of the US$ 21.5 million is included in the total of US$ 156 million secured so far. As a result of the previous WHO policy of mainstreaming HIV/AIDS activities throughout the Organization, in addition to the US$ 218.1 million for staffing and activities led by the Department of HIV/AIDS at WHO headquarters and regional and country office HIV/AIDS budget items, additional clusters and departments at WHO headquarters support HIV/AIDS activities that require additional funding requirements not presented here. WHO is currently reviewing and consolidating this work under the overall coordination of the Department of HIV/AIDS. 12 Schwartländer B et al. Resource needs for HIV/AIDS. Science, 2001, 292:2434–2436.

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Scaling up treatment and accelerating prevention

6. Technical and managerial oversight This section describes the steps WHO is taking to measure global progress in scaling up a comprehensive response to HIV/AIDS, report on activity in its own areas of work and ensure accountability to its Member States, donors and the international community.

6.1

Strategic and Technical Advisory Committee

A Strategic and Technical Advisory Committee is being created at WHO headquarters to independently evaluate scientific and technical aspects of the HIV/AIDS area of work. The Strategic and Technical Advisory Committee will review, from a scientific and technical viewpoint, WHO collaboration with and support to countries’ efforts to respond to the HIV/AIDS epidemic, including providing guidance on policies, strategies and technical support. It will also advise on priorities among the possible areas of activity related to HIV/AIDS in the context of a) the WHO mandate and corporate strategy, b) the programmes of UNAIDS and its cosponsors, c) trends in the HIV/AIDS epidemic and d) the health-sector response to the epidemic. The Strategic and Technical Advisory Committee will consist of 20–25 members to be appointed by the WHO Director-General, taking into consideration diversity and balance of professional background, gender, geographical representation, international standing and affiliations. Members will include representatives of nongovernmental, communitybased and faith-based organizations and organizations of people living with HIV/AIDS.

6.2

Annual meeting of the “3 by 5” Global Partners Group

WHO held meetings of the “3 by 5” Global Partners Group in November 2003 and May 2004 specifically to discuss scaling up antiretroviral therapy and to plan the joint action needed to realize the “3 by 5” target. The Group will meet at least annually to share information and update partners on WHO’s plans, activities and progress related to HIV/AIDS.

6.3

Monitoring and reporting on progress

6.3.1 “3 by 5” milestones The “3 by 5” strategy document lists 15 milestones representing key indicators of progress in scaling up global treatment, with baselines (where available) at December 2003. WHO will report on progress against these milestones every six months, beginning in July 2004 for the period January 2004–December 2005.

6.3.2 Progress reporting by country Progress in scaling up antiretroviral therapy and accelerating prevention by country will be regularly and periodically reviewed and maintained on the WHO web site using selected country measures consistent with the globally agreed “3 by 5” monitoring and evaluation indicators. These reviews will enable a group of partners and peers to assess overall progress for each country, to identify opportunities for improvement and to refine national scale-up plans. Country progress reporting will be supported by ongoing maintenance and improvement of the country profiles.

6.3.3 Programme budget reconciliation WHO will report its total spending on HIV/AIDS every six months comparing global, regional and countrylevel activity with the WHO HIV/AIDS Plan and the programme budget.

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6.3.4 Monitoring and evaluation Tracking and reporting of key indicators that measure the degree the WHO HIV/AIDS Plan for 2004–2005 has been achieved will include: • • • • • • funding; staffing at country and regional offices; activity budgets at country and regional offices; number of countries that have put the “three ones” principles into operation for treatment scaleup; number of requests for technical assistance supported; and selected indicators of health systems performance.

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Scaling up treatment and accelerating prevention

Annex 1 HIV prevalence, HIV mortality, antiretroviral therapy needs and targets for the 49 “3 by 5” focus countries Region WHO focus country Estimated number of people living with HIV/AIDS (0–49 years), end 2003 a Estimated adult prevalence of HIV/AIDS (15–49 years), end 2003 a Estimated annual deaths from AIDS (0–49 years), 2003 a Estimated total number needing antiretroviral therapy in 2005 b “3 by 5” treatment target (50% of estimated need) Antiretroviral therapy target declared by country for end 2005 Estimated number of people receiving antiretroviral therapy (15–49 years), June 2004 700 18 000 2 000 2 186 3 389 8 660 1 000 7 400 2 025 2 500 4 500 716 2 740 500 1 370 21 000 11 000 1 000 3 760 2 840 200 400 17 000 1 800 2 140 20 000 400 3 200 20 000 170 1 650 1 000 8 500 6 000 179 746 Antiretroviral therapy coverage

AFR AFR AFR AFR WPR AFR AFR WPR AFR AFR AFR AFR AMR AFR AMR SEAR AFR AFR AFR AFR SEAR AFR AFR EUR AFR AFR EMR AFR AFR EUR AFR WPR AFR AFR Subtotal

Angola Botswana Burkina Faso Burundi Cambodia c Cameroon Central African Republic China Côte d’Ivoire Democratic Republic of the Congo Ethiopia Ghana Guatemala Guinea Haiti India d , e Kenya Lesotho Malawi Mozambique Myanmar Namibia Nigeria Russian Federation f Rwanda South Africa Sudan Swaziland Uganda Ukraine g United Republic of Tanzania Viet Nam Zambia Zimbabwe High-burden countries

240 000 350 000 300 000 250 000 170 000 560 000 260 000 840 000 570 000 1 100 000 1 500 000 350 000 78 000 140 000 280 000 NA 1 200 000 320 000 900 000 1 300 000 330 000 210 000 3 600 000 860 000 250 000 5 300 000 400 000 220 000 530 000 360 000 1 600 000 220 000 920 000 1 800 000 27 308 000

3.9% 37.3% 4.2% 6.0% 2.6% 6.9% 13.5% 0.1% 7.0% 4.2% 4.4% 3.1% 1.1% 3.2% 5.6% NA 6.7% 28.9% 14.2% 12.2% 1.2% 21.3% 5.4% 1.1% 5.1% 21.5% 2.3% 38.8% 4.1% 1.4% 8.8% 0.4% 16.5% 24.6%

21 000 33 000 29 000 25 000 15 000 49 000 23 000 44 000 47 000 100 000 120 000 30 000 5 800 9 000 24 000 NA 150 000 29 000 84 000 110 000 20 000 16 000 310 000 NA 22 000 370 000 23 000 17 000 78 000 20 000 160 000 9 000 89 000 170 000 2 251 800

32 000 60 000 43 000 38 000 28 000 85 000 39 000 100 000 78 000 160 000 200 000 52 000 12 000 16 000 40 000 710 000 220 000 54 000 130 000 190 000 42 000 29 000 520 000 71 000 36 000 750 000 43 000 32 000 110 000 45 000 260 000 22 000 140 000 290 000 4 677 000

16 000 30 000 21 500 19 000 14 000 42 500 19 500 50 000 39 000 80 000 100 000 26 000 6 000 8 000 20 000 355 000 110 000 27 000 65 000 95 000 21 000 14 500 260 000 35 500 18 000 375 000 21 500 16 000 55 000 22 500 130 000 11 000 70 000 145 000 2 338 500

5 500 55 000 20 000 12 500 12 800 not declared not declared 30 000–50 000 not declared not declared 93 000 30 000 not declared 20 000 5 000–10 000 (end 2004) 100 000 95 000 28 000 not declared 21 000 10 000 not declared 15 000 not declared not declared not declared 20 000 12 000 60 000 2 100 220 000 15 000 100 000 55 000 1 061 900

2.2% 30.0% 4.7% 5.8% 12.1% 10.2% 2.6% 7.4% 2.6% 1.6% 2.3% 1.4% 22.8% 3.1% 3.4% 3.0% 5.0% 1.9% 2.9% 1.5% 0.5% 1.4% 3.3% 2.5% 5.9% 2.7% 0.9% 10.0% 18.2% 0.4% 0.6% 4.5% 6.1% 2.1% 3.8%

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Region

WHO focus country

Estimated number of people living with HIV/AIDS (0–49 years), end 2003 a

Estimated adult prevalence of HIV/AIDS (15–49 years), end 2003 a

Estimated annual deaths from AIDS (0–49 years), 2003 a

Estimated total number needing antiretroviral therapy in 2005 b

“3 by 5” treatment target (50% of estimated need)

Antiretroviral therapy target declared by country for end 2005

Estimated number of people receiving antiretroviral therapy (15–49 years), June 2004 29 1 654 94 1 212 251 1 421 1 500 49 0 19 1 530 0 0 0 0 7 759 187 505 h 440 000

Antiretroviral therapy coverage

AMR AMR EMR AMR AMR AMR SEAR EUR EUR AMR AMR EMR EUR EUR EMR Subtotal TOTAL

Belize Costa Rica Djibouti El Salvador Guyana Honduras Indonesia Kazakhstan Kyrgyzstan Nicaragua Panama Somalia Tajikistan Uzbekistan Yemen Regionally strategic countries Estimated total for 49 focus countries Estimated total for all countries except those in western Europe, the United States, Canada, Australia, New Zealand and Japan

3 600 12 000 9 100 29 000 11 000 63 000 110 000 16 500 3 900 6 400 16 000 NA <200 11 000 12 000 303 700 27 611 700

2.4% 0.6% 2.9% 0.7% 2.5% 1.8% 0.1% 0.2% 0.1% 0.2% 0.9% NA <0.1% 0.1% 0.1%

<200 900 770 2 200 1 100 4 100 2 400 <200 <200 <500 <500 NA NA <500 NA 13 570 2 265 370

440 2 500 1 200 4 700 2 000 7 400 7 100 460 48 930 2 200 NA NA 770 NA 29 748 4 706 748 5 500 000

220 1 250 600 2 350 1 000 3 700 3 550 230 24 465 1 100 NA NA 385 NA 14 874 2 353 374 3 000 000

not declared not declared 1 370 not declared not declared not declared 10 000 not declared not declared not declared not declared not declared not declared not declared not declared 11 370 1 073 270

6.6% 66.2% 7.8% 25.8% 12.6% 19.2% 21.1% 10.7% 0.0% 2.0% 69.5% NA NA 0.0% NA 26.1% 4.0% 8.0%

AFR: African Region; WPR: Western Pacific Region; AMR: Region of the Americas; SEAR: South-East Asia Region; EUR: European Region; EMR: Eastern Mediterranean Region. NA: not available. a

b

c

d

e

f

g h

The WHO/UNAIDS Working Group on Surveillance and Estimates generates estimates for number of people living with HIV/AIDS, adult prevalence rate and annual deaths from AIDS using Spectrum software. The estimated total number needing antiretroviral therapy is based on the estimated two-year mortality plus 80% of those currently receiving treatment. Cambodia has estimated the number of people living with HIV/AIDS as 157 500 and antiretroviral therapy need as 22 000 based on calculations by the National Center for HIV/AIDS, Dermatology and STD (NCHADS). For India, the current number of people on antiretroviral therapy need is an average between an independent coverage survey and the country profile data. For India, the declared antiretroviral therapy target refers to the country’s commitment to begin treatment in April 2004 but not to a specific target date of the end of 2005. The Russian Federation has estimated the need for antiretroviral therapy to be 139 000 based on calculations made by their Federal AIDS Center. Ukraine’s country-declared target is for March 2005. The difference between the 187 505 people receiving antiretroviral therapy in the 49 focus countries and the global number of 440 000 people receiving therapy is accounted for by approximately 250 000 people on treatment in about 120 other developing countries and countries in transition. Of these approximately 120 countries, the following have relatively large estimated numbers of people on antiretroviral therapy: Brazil (140 000), Argentina (25 131), Mexico ( 21 498), Thailand (13,000), Colombia (12 000), Venezuela (9 525), Romania (5 500), Chile ( 4 032), Malaysia (2 700), Peru (1 900), Bahamas (1 884), Poland (1 800), Senegal (1 600), Cuba (1 293).

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Scaling up treatment and accelerating prevention

Annex 2 Resolution WHA57.14 of the World Health Assembly, 22 May 2004 Scaling up treatment and care within a coordinated and comprehensive response to HIV/AIDS The Fifty-seventh World Health Assembly, Having considered the report on HIV/AIDS;13 Noting with great concern that by the end of 2003 about 40 million people were living with HIV/AIDS, the pandemic had claimed an estimated 3 million lives in 2003, and that HIV/AIDS affects women and children with particular severity; Also concerned that, although about 6 million people in developing countries need antiretroviral treatment, only 440 000 currently receive it; Noting with concern that other health conditions also cause high morbidity and mortality in developing countries; Acknowledging that antiretroviral therapy has reduced mortality and prolonged healthy lives and that the feasibility of delivering antiretroviral treatment has been demonstrated in several resource-constrained settings; Recognizing that treatment and access to medication for those infected and affected by HIV/AIDS, as well as prevention, care and support are inseparable elements of a comprehensive health-sector response at the national level, and require adequate financial support from States and other donors; Recognizing that social stigma, discrimination, lack of affordability of antiretroviral medicines, economic constraints, limitations in health care capacity and human resources are some of the major impediments to access to treatment and care and social support for people living with HIV/AIDS; Also recognizing the need to further reduce the costs of antiretroviral medicines; Recalling the Declaration of Commitment on HIV/AIDS adopted at the United Nations General Assembly special session on HIV/AIDS (27 June 2001), which acknowledges that prevention of HIV infection must be the mainstay of national, regional and international responses to the epidemic and calls for significant progress, by 2005, in implementing comprehensive care strategies, including for access to antiretroviral drugs; Recalling also resolution WHA55.12 on the contribution of WHO to the follow-up of the United Nations General Assembly special session on HIV/AIDS, resolution WHA55.14 on ensuring accessibility of essential medicines, resolution WHA56.27 on intellectual property rights, innovation and public health, and resolution WHA56.30 on the global health-sector strategy for HIV/AIDS; Recalling and recognizing the Programme of Action adopted at the International Conference on Population and Development (Cairo, 1994), commitments made at the World Summit for Social Development 13 Document A57/4 submitted to the Fifty-seventh World Health Assembly.

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(Copenhagen, 1995) and the World Summit for Children (New York, 1990), the Beijing Declaration and Platform for Action (1995), the Declaration on the Elimination of Violence against Women (1993), and the Millennium Declaration (2000), their recommendations and respective follow-ups and reports; Noting with satisfaction the agreement of 25 April 2004 among development partners to improve coordination and harmonization in the response to HIV/AIDS at the country level, through the “Three Ones” principle, namely, one agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority, with a broad-based multisectoral mandate; and one agreed country-level monitoring and evaluation system; Recognizing the central role of the health sector in the response to HIV/AIDS and the need to strengthen health systems and human capacity development so that countries and communities may contribute fully to realization of the global targets set out in the Declaration of Commitment on HIV/AIDS and to develop public health systems with a view to minimizing the emergence of drug resistance; Underlining the importance of WHO’s work, including through the WHO-initiated procurement, quality and sourcing project, to facilitate access by developing countries to safe, effective and affordable antiretroviral drugs and diagnostics at the best price; Recalling the Declaration on the TRIPS Agreement and Public Health adopted at the WTO Ministerial Conference (Doha, November 2001), and welcoming the decision taken by the General Council of WTO on 30 August 2003 on the implementation of paragraph 6 in that Declaration;14 Acknowledging WHO’s special role within the United Nations system to combat and mitigate the effects of HIV/AIDS, its responsibility in the follow-up of the Declaration of Commitment on HIV/AIDS and, as a cosponsor of UNAIDS, in leading United Nations efforts in relation to treatment and care for HIV/AIDS and playing a strong role in prevention; Welcoming the progress made by many Member States in beginning to scale up treatment for HIV/AIDS in their countries; Welcoming also the increased support of Member States for programmes to combat HIV/AIDS; 1. WELCOMES the Director-General’s “3 by 5” strategy to support developing countries, as part of WHO’s follow-up to the comprehensive global health-sector strategy for HIV/AIDS, in securing access to antiretroviral treatment for 3 million people living with HIV/AIDS by the end of 2005, and notes the importance of mobilizing financial resources from States and other donors for WHO to achieve this target; URGES Member States, as a matter of priority: (1) to establish or strengthen national health and social infrastructure and health systems, with the assistance of the international community as necessary, in order to assure their capacity to deliver effectively HIV/AIDS prevention, treatment, care and support services; (2) to strengthen national planning, monitoring and evaluation systems in order to deliver HIV/AIDS prevention, treatment, care and support services within the context of the overall national health strategy, ensuring an appropriate balance between services for HIV/AIDS and all other essential health services; (3) to pursue policies and practices that promote: (a) sufficient and adequately trained human resources with the appropriate skillmix to invoke a scaled-up response; (b) human rights, equity, and gender equality in access to treatment and care; (c) affordability and availability, in sufficient quantities, of pharmaceutical products of good quality, including antiretroviral medicines and medical technologies used to treat, diagnose and manage HIV/AIDS; (d) accessible and affordable treatment, testing and counselling with informed consent, prevention and care services for all, without discrimination, including the most vulnerable or socially disadvantaged groups of the population; (e) good quality and scientific and medical appropriateness of pharmaceutical products or medical technologies for treatment and management of HIV/AIDS, irrespective of

2.

14 Document WT/L/540, available at http://docsonline.wto.org.

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention their sources and countries of origin, inter alia by making the best use of WHO’s list of prequalified drugs that meet international quality standards; (f) further investments in medicines, including microbicides, diagnostics and vaccine research, in social science and health systems research, and in traditional medicines and possible interactions with other medicines, in order to improve effective interventions; (g) development of health systems designed to promote access to antiretroviral medicines and to facilitate adherence to treatment regimens with a view to minimizing drug resistance as well as protection of patients against counterfeit medicines; (h) integration of nutrition into a comprehensive response to HIV/AIDS; (i) promotion of breastfeeding in the light of the United Nations Framework for Priority Action on HIV and Infant Feeding and the new WHO/UNICEF Guidelines for PolicyMakers and Health-Care Managers; (4) to consider, whenever necessary, adapting national legislation in order to use to the full the flexibilities contained in the Agreement on Trade-Related Aspects of Intellectual Property Rights; (5) to apply the “Three Ones” principle with a view to improving coordination and harmonization in the response to HIV/AIDS; (6) to encourage that bilateral trade agreements take into account the flexibilities contained in the WTO TRIPS Agreement and recognized by the Doha Ministerial Declaration on the TRIPS Agreement and Public Health; REQUESTS the Director-General: (1) to strengthen the key role of WHO in providing technical leadership, direction and support to health systems’ response to HIV/AIDS, within the United Nations system-wide response, as a cosponsor of UNAIDS; (2) to take action within the framework of the “Three Ones” principle: (a) to provide support to countries in order to maximize opportunities for the delivery of all relevant interventions for prevention, care, support and treatment of HIV/AIDS and related conditions, including tuberculosis; (b) to support, mobilize and facilitate efforts of developing countries to scale up antiretroviral treatment in a manner that focuses on poverty, gender equality, and the most vulnerable groups, within the context of strengthening national health systems while maintaining a proper balance of investment between prevention, care and treatment; (c) to provide guidance on accelerating prevention in the context of scaled-up treatment, in line with the global health-sector strategy for HIV/AIDS; (3) to take measures to improve access of developing countries to pharmaceutical and diagnostic products to diagnose, treat and manage HIV/AIDS, including by strengthening WHO’s prequalification project; (4) to ensure that the prequalification review process and the results of inspection and assessment reports of the listed products, aside from proprietary and confidential information, are made publicly available; (5) to support developing countries in improving management of the supply chain and procurement of good-quality AIDS medicines and diagnostics; (6) to provide support to countries to embed the scale-up of the response to HIV/AIDS into a broad effort to strengthen national health systems, with special reference to human resources development and health infrastructure, health system financing and health information; (7) to provide a progress report on implementation of this resolution to the Fifty-eighth World Health Assembly, through the Executive Board.

3.

Eighth plenary meeting, 22 May 2004 A57/VR/8

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Scaling up treatment and accelerating prevention

Annex 3 WHO Constitution, Article 2 In order to achieve its objective, the functions of the Organization shall be: (a) (b) (c) (d) (e) f) g) (h) (i) (j) (k) (l) (m) (n) (o) (p) (q) (r) (s) (t) (u) (v) to act as the directing and coordinating authority on international health work; to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate; to assist Governments, upon request, in strengthening health services; to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments; to provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories; to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services; to stimulate and advance work to eradicate epidemic, endemic and other diseases; to promote, in cooperation with other specialized agencies where necessary, the prevention of accidental injuries; to promote, in cooperation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; to promote cooperation among scientific and professional groups which contribute to the advancement of health; to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective; to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment; to foster activities in the field of mental health, especially those affecting the harmony of human relations; to promote and conduct research in the field of health; to promote improved standards of teaching and training in the health, medical and related professions; to study and report on, in cooperation with other specialized agencies where necessary, administrative and social techniques affecting public health and medical care from preventive and curative points of view, including hospital services and social security; to provide information, counsel and assistance in the field of health; to assist in developing an informed public opinion among all peoples on matters of health; to establish and revise as necessary international nomenclatures of diseases, of causes of death and of public health practices; to standardize diagnostic procedures as necessary; to develop, establish and promote international standards with respect to food, biological, pharmaceutical and similar products; generally to take all necessary action to attain the objective of the Organization.

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Scaling up treatment and accelerating prevention

Annex 4 Roles and responsibilities of UNAIDS Cosponsors and the UNAIDS Secretariat in the “3 by 5” Initiative 15

The Committee of Cosponsoring Organizations of the Joint United Nations Programme on HIV/AIDS (UNAIDS) has agreed upon the roles and responsibilities of the UNAIDS Secretariat and Cosponsors in scaling up antiretroviral therapy and their respective contributions to realizing the “3 by 5” target. Although these are not intended to be mutually exclusive and certain activities may be undertaken by more than one agency, they offer guidance to agency staff and the international community based on the agencies’ respective mandates and areas of expertise.

International Labour Organization (ILO) • • • • • • • • Advocating treatment by mobilizing its tripartite constituency: governments, employers and workers Promoting direct access to HIV treatment in the workplace, with integration of prevention, through dissemination of the Code of Practice on HIV/AIDS and the World of Work Expanding access to HIV care, treatment and support through occupational health services and community outreach programmes Advocating and promoting the extension of social protection to improve access to HIV/AIDS care and treatment Identifying and implementing innovative health and life insurance schemes to sustain access to HIV/AIDS care and treatment Supporting training and capacity-building in countries through its network of field offices Identifying and promoting innovative strategies to address the needs in the informal economy and small and medium-sized enterprises Promoting public and private partnerships to extend workplace programmes to communities through co-investment.

UNAIDS Secretariat • Participating in planning and developing the “3 by 5” Initiative, including at executive level, and participating through staff in the “3 by 5” core team, working groups, costing activities, meetings with WHO regional office and country staff, technical and operational guideline development, and joint “3 by 5” events for World AIDS Day Supporting the “3 by 5” Initiative through the core functions of leadership and advocacy, strategic information, tracking, monitoring and evaluation, engaging civil society and mobilizing partners, and mobilizing resources Mobilizing country-based support and coordination through United Nations country theme groups on HIV/AIDS and United Nations country coordinators, including facilitating entry and undertaking WHO emergency team missions in countries, mobilizing other partners within United Nations expanded country theme groups on HIV/AIDS such as civil society, donors and the private sector and promoting effective communication and coordination at the country level.

• •

15 The Office of the United Nations High Commissioner for Refugees became a Cosponsor of UNAIDS on 25 June 2004. The Committee of Cosponsoring Organizations will therefore update this list in July, 2004.

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

United Nations Children’s Fund (UNICEF) • • • • • • • • Procuring and delivering antiretroviral drugs, including global pharmaceutical supply networks, diagnostic equipment and supplies Strengthening the capacity of health services, including providing technical assistance to countries, advising on overall health system reform, providing competitive cost estimates for antiretroviral drugs, drug forecasting, procurement, supply management and distribution systems Advocating at the global and country levels for increased access to care and treatment of women, children and young people identified through MTCT-Plus and adolescent-friendly health services Supporting the scaling up of MTCT-Plus programmes and establishing links with care and treatment programmes Promoting voluntary testing and counselling linked to MTCT-Plus and adolescent-friendly health services Supporting links between orphans and care and treatment programmes Modelling paediatric care and treatment programmes Supporting effective communication on treatment literacy

United Nations Development Programme (UNDP) • • • • • • Developing capacity, including enhancing skills needed for the performance of health care professionals, civil society actors, private sector professionals and community health workers Promoting community mobilization and ownership of the “3 by 5” Initiative to favour decisionmaking at the community level Advocating at the global and country levels and identifying ways in which the requirements for treatment are adequately reflected in the work of the United Nations Development Programme on development planning and governance Collaborating on the facilities set up for drugs (AMDS), especially in the area of developing the capacity of countries to ensure the availability of drugs in the context of intellectual property rights and the World Trade Organization TRIPS Agreement Identifying ways in which assessments include different dimensions of making a large-scale programme work – governance challenges, institutional effectiveness and strengthening systems Promoting the strengthening of capacity among local and regional organizations and cooperation within and between developing countries

United Nations Educational, Scientific and Cultural Organization (UNESCO) • • • • • • Providing assistance and capacity-building for the development of comprehensive plans in response to the pandemic by ministries of education that include information about and access to treatment both in and out of school settings Promoting laws, policies and programmes that combat stigma and discrimination against AIDSaffected and HIV-infected students and teachers Advocating treatment, including through culturally sensitive education and communication messages and through its extensive networks of journalists Linking prevention and treatment and integrating treatment information in prevention education Promoting treatment access as part of comprehensive AIDS programming among teachers and in school settings Promoting a rights-based approach to prevention and treatment for all young people, including those not enrolled in school

United Nations Office on Drugs and Crime (UNODC) • • • • • Advocating treatment, especially HIV treatment, as part of overall treatment and rehabilitation for injecting drug users Strengthening the capacity of drug dependence treatment personnel in antiretroviral therapy Strengthening the capacity of prison health services in antiretroviral therapy Advocating the inclusion of the victims of trafficking in persons, especially women and young girls, in antiretroviral therapy Supporting the inclusion of HIV treatment education and literacy as part of drug dependence prevention and treatment programming

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INVESTING IN A COMPREHENSIVE HEALTH-SECTOR RESPONSE TO HIV/AIDS

Scaling up treatment and accelerating prevention United Nations Population Fund (UNFPA) • • • • Advocating on the prevention, treatment and care continuum, including the essential role of prevention within the “3 by 5” Initiative Promoting equitable access to treatment, emphasizing young people and women, priority access for HIV-positive pregnant women, and meeting the special sexual and reproductive health needs of HIV-positive women Building capacity on HIV prevention as a component of antiretroviral therapy delivery Utilizing infrastructure for the delivery of reproductive health services, such as those related to maternal and child health, preventing mother-to-child transmission, adolescent-friendly services, sites for services for sexually transmitted infections and for family planning, as entry points for voluntary HIV counselling and testing and antiretroviral drug delivery or as conduits for referral to antiretroviral drug delivery points Promoting voluntary HIV counselling and testing, especially in reproductive health service settings Promoting male and female condoms for preventing HIV and sexually transmitted infections as an integral part of delivering antiretroviral therapy services Providing procurement services for preventive commodities (male and female condoms, HIV test kits, drugs for treating sexually transmitted infections and safe delivery kits) and technical expertise and related tools in forecasting and procurement

• • •

World Bank • • • • • • • Providing funding through the Multi-Country HIV/AIDS Program for Africa and Treatment Acceleration Program for comprehensive AIDS programming, including treatment, through both governments and nongovernmental organizations Mobilizing indigenous communities through individual grants Engaging WHO and United Nations system country-based staff in the Multi-Country HIV/AIDS Program for Africa programming and including “3 by 5” in Bank country missions Mobilizing all sectors in countries in “3 by 5” activities Sharing experience through expertise in and guidelines on procurement Promoting allocating debt relief savings towards health system and AIDS programming, including treatment Promoting access to treatment under a rights-based approach

World Food Programme (WFP) • • • • • Advocating treatment, especially HIV/AIDS treatment, to alleviate the impact of HIV/AIDS on food insecurity in high-prevalence countries and in poor populations Providing nutritional support as part of preventing mother-to-child transmission and MTCT-Plus programmes for food-insecure populations Supporting HIV/AIDS treatment programmes by providing food to food-insecure people living with HIV and their families Supporting HIV/AIDS treatment programmes for children living with HIV/AIDS Supporting HIV/AIDS treatment programmes with logistics and other transport and storage capacity and expertise

World Health Organization (WHO) • • • • • Providing overall leadership and advocacy for “3 by 5” within the United Nations system Supporting national authorities in effectively coordinating “3 by 5” activities in countries Coordinating normative guidance and developing standardized procedures and tools for delivering antiretroviral therapy Developing standardized tools for tracking the performance of antiretroviral therapy programmes and for the surveillance of antiretroviral drug resistance Supporting countries in strengthening the capacity of the health sector to effectively deliver antiretroviral therapy

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WHO HIV/AIDS PLAN FOR JANUARY 2004–DECEMBER 2005

• • • • • •

Supporting the development of human resource capacity at the country level Providing technical support to countries in developing national “3 by 5” targets, strategies and implementation plans Supporting countries in mobilizing sufficient resources to implement national “3 by 5” strategies Establishing and maintaining AMDS Coordinating operations research on models for antiretroviral therapy delivery Tracking overall progress towards “3 by 5”

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ANGOLA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 32 000 Antiretroviral therapy target declared by country: 5 500 by 2005

Matadi Mbanza Congo

Kananga Mbuji− Mayi

Democratic Republic of the Congo Kahemba

Latest available year for 2001− 2003 Percent seropositive Less than 1

HIV sentinel surveillance in pregnant women

Uige Lucapa

35 200

treat Million by

Luanda

Caxito Ndalatando

1 − 4.9 5 − 9.9 10 −14.9 15 −19.9

Malange

Saurimo

20 −29.9 Ngunza Luena Benguela Kuito Huambo

30 and more

Angola

Main roads

Population density (pers./sq.Km) Less than 10

Lubango Namibe

Menongue

Zambia Mongu

10 − 49

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Onjiva

750 and more

0

80

160

320 Kilometers

Namibia

Botswana

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 14.1 35.3 39.9 700 5.5 31 0.377 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS WHO/ UNAIDS Ministry of Health WHO WHO/ UNAIDS WHO 2003 1.6 – 9.4% 2003 2003 June 2004 2003 2004 97 000 – 600 000 12 576 700 32 000 12 not available 25.9% WHO

3. Situation analysis • Epidemic level and trend and gender data. The first case of AIDS in Angola was diagnosed in 1985. Until recently, national efforts to conduct sentinel surveillance were hindered by the ongoing armed conflict that has consumed the country since independence. As a result, information about the HIV prevalence among pregnant women attending antenatal clinics is scarce. According to government sources, 12 576 AIDS cases had been reported by the end of 2003, corresponding to about 10% of the estimated AIDS cases in Angola. This underreporting may result from inadequate perception of the magnitude of the infection and low levels of knowledge. According to UNAIDS, about 320 000 people 15–49 years of age were living with HIV/AIDS in 2001, and the adult prevalence was estimated to be 5.5%. This high magnitude of the epidemic is probably due to a lack of perception about risk combined with weak knowledge about prevention. In Luanda, where about 25% of the population resides, the estimated prevalence rate in 2001 was 8.6%. According to other studies conducted by WHO and other partners, the prevalence among sex workers in Luanda increased from 20% in 1999 to 33% in 2001. • Major vulnerable and affected groups. Based on data collected and AIDS case reporting, the primary route of HIV transmission is heterosexual, with a male-female ratio of 1:1. Not only heterosexual transmission is responsible for the spread of HIV in the country. Based on cumulative data (1985 to March 2004), 15% of AIDS cases were caused by mother-to-child transmission of HIV, 16% by needles and other medical devices and 18% by blood transfusions. The distribution of people living with AIDS (also cumulative) demonstrates that about 60% are 20–39 years old, the age group with

the greatest contribution to economic productivity in Angola. Women 15–39 years old have a high burden of cases and women 40–59 years old a lower burden. This situation could be attributed to the advent of early and frequent sexual activity among women, to the imbalance in gender power and to the increase in sex work among young women because of high levels of poverty. According to Angola’s national strategic plan on HIV/AIDS for 2003–2008, vulnerable groups are those that are potentially exposed, individually and collectively, because of structural, institutional, political and cultural variation that makes them susceptible to infection with HIV/AIDS. Using these criteria, the following vulnerable groups were identified: sex workers, truck drivers, mineworkers, military personnel, youth, street children, pregnant women, dislocated people, refugees and resettled populations, prisoners, drug users, blood transfusion recipients, traditional healers and traditional birth attendants, health workers and children infected and affected by HIV, including orphans. • Policy on HIV testing and treatment. National guidelines on integrated care for people living with HIV/AIDS need to be developed, and the tools for delivering antiretroviral therapy need to be simplified and standardized as much as possible. There are limitations in the government’s ability to develop health policies tailored to needs in accordance with the resources available. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Zidovudine + lamivudine + nevirapine (US$ 172) plus nelfinavir (US$ 358), total US$ 530. • Assessment of overall health sector response and capacity. According to official data, about 65% of the health units were destroyed during the war. Factors

1 © World Health Organization 2004

S U M M A R Y C O U N T R Y P RO F I L E F O R H I V / A I D S T R E AT M E N T S C A L E - U P

Cities and towns

ANGOLA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

such as the massive destruction of the health network, the deterioration of the socioeconomic fabric, the great population movement and the diseases related to HIV/AIDS are all at the root of the worsening health status of the people in Angola. Some of these factors further explain the poor capacity of the services to detect and treat other chronic diseases, including leprosy and trypanosomiasis. The proportions of staff posts in government health services are: physicians: 10–15%; registered nurses: about 40%; and others: 50%. Angola has a lack of professional resources capable of resolving matters within the health system, mainly at the primary level. Only 30% of the population has access to health services. • Critical issues and major challenges. In the post-war context, Angola is facing various challenges in combating poverty and famine, reconstructing economic and social infrastructure, socially reintegrating demobilized military personnel and promoting national economic development. The institutional capacity of the National HIV/AIDS Programme and human resource capacity across the health sector as a whole urgently need to be strengthened. Additional support is needed in management, human resource planning, planning for the development of antiretroviral therapy capacity, procurement and national supply chain management and community preparedness and understanding.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Supporting the development of proposals to the fourth round of funding of the Global Fund to Fight AIDS, Tuberculosis and Malaria with key partners, including UNDP and UNAIDS • Providing technical assistance to support “3 by 5” efforts in planning, care and treatment, voluntary counselling and testing and partners’ involvement • Through the WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa, supporting the strengthening of the capacity of health systems in establishing a sentinel surveillance system for HIV/AIDS as well as improving case management of sexually transmitted infections and voluntary counselling and testing services, and improving laboratory capability in testing for HIV and sexually transmitted infections

Key areas for WHO support in the future • Establishing a “3 by 5” country team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Supporting the development of a national operational plan for scaling up antiretroviral therapy • Assisting in developing a plan for procurement and supply management of antiretrovirals and HIV/AIDS diagnostics • Assisting in training physicians, nurses and community health leaders in testing and counselling as well as care and support • Providing technical support for provincial supervision in capacity-building for scaling up antiretroviral therapy

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 WHO estimates that the total funding required to support scaling up antiretroviral therapy in Angola over 2004–2005 to meet the WHO “3 by 5” treatment target of 16 000 people is between US$ 27 million and US$ 40 million. Of this amount, government commitments to scaling up antiretroviral therapy are estimated to be about US$ 7 million. Bilateral funding over the same period is expected to provide about US$ 2.7 million. Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Angola to reach 16 000 people by the end of 2005 is about US$ 18–31 million.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently planned. • Additional staffing needs identified include international medical officers with background in antiretroviral therapy and HIV to assist the Ministry of Health in training physicians, nurses and community health leaders; and an international logistician to work on procuring, distributing and monitoring antiretroviral drugs and other supplies related to scaling up antiretroviral therapy, working with the Ministry of Health to strengthen the supply subsystem.

5. Antiretroviral therapy coverage In 2003, WHO and UNAIDS estimated Angola’s total antiretroviral therapy need for 2005 to be about 32 000 people, and the WHO “3 by 5” treatment target for 2005 is 16 000 people (based on 50% of need). The government has declared a national treatment target of 5500 for 2005. The government plans to support the delivery of antiretroviral drugs for 2000 people in 2004, with plans for an additional 1000 people in 2005.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health provides leadership in implementation coordination, national plan development, national human resource planning and programme evaluation with support from WHO. UNDP contributes to financial management activities, and the United States Centers for Disease Control and Prevention contributes to determining the cost of scaling up and raising funds to achieve this. • Antiretroviral therapy service delivery. The Ministry of Health manages and leads all activities related to delivering antiretroviral therapy services with assistance from WHO in supply chain management, capacity-building, training, developing guidelines and testing and counselling. UNICEF contributes to capacity-building activities. Organizations supporting the implementation of voluntary counselling and testing centres include: the Portuguese Institute for Preventive Medicine; Population Services International; the United States Centers for Disease Control and Prevention; GOAL (a nongovernmental organization based in Ireland); CAJ-JIRO (Centro de Apoio aos Juvens, or youth support centre); Marie Stopes International; Divine Providence Hospital; the Sisters of Teresa; and national nongovernmental organizations. Additional partners in this effort include British Petroleum, Esso, the Rufford Foundation and the Spanish Agency for International Cooperation (AECI). • Community mobilization. The Ministry of Health leads activities related to adherence and psychosocial support as well as material support, including nutrition. Additional assistance is needed in building capacity among people living with HIV/AIDS and in programme communication. • Strategic information. The Ministry of Health provides leadership in all areas related to strategic information, including monitoring and evaluation, antiretroviral resistance and operational research and is supported by the United States Centers for Disease Control and Prevention in these efforts. WHO and the United States Centers for Disease Control and Prevention provide support to the Ministry in surveillance.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Angola and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

BOTSWANA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 60 000 Antiretroviral therapy target declared by country: 55 000 by 2005

Angola

Kasane

Zambia

Livingstone

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1

Latest available year for 2001− 2003

35 200

treat Million by

Zimbabwe Maun

Gweru

1 − 4.9 5 − 9.9 10 −14.9 15 −19.9

Bulawayo

Francistown

20 −29.9

Namibia Gobabis

Ghanzi

30 and more

Main roads

Population density (pers./sq.Km) Less than 10 MolepololeMochudi Gaborone Kanye Lobatse

10 − 49

50 − 99

100 −249

South Africa Tsabong

250 −499

500 −749

Pretoria

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Johannesburg

750 and more

0

62.5

125

250 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 1.8 51.3 40.4 2 872 7.6 190 0.614 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 35.5 – 39.1% Source WHO/ UNAIDS

330 000 – WHO/ 380 000 UNAIDS 10 178 18 000 60 000 not available not available 79% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. In 2001, the median HIV prevalence among antenatal clinic attendees tested in 22 health districts was 36.3%. HIV prevalence among antenatal clinic attendees increased rapidly from 18.1% in 1992 to 32.4% in 1995 and 38.5% in 2000 and declined slightly in 2001. Major urban areas in Botswana include Gabarone, Francistown and Selebi-Phikwe. The HIV prevalence increased from 14.9% in 1992 to 39.1% in 2001 in Gabarone and from 23.7% in 1992 to 44.9% in 2001 in Francistown. Sites outside the major urban areas are also experiencing increasing HIV infection trends. In 2001, median HIV prevalence in areas outside the major urban areas was 38.6%. • Major vulnerable and affected groups. People 15–19 and 20–24 years old exhibit high and increasing HIV infection trends. HIV prevalence at all sites increased from 16.4% in 1992 to 24.1% in 2001 among those 15–19 years old and from 20.5% in 1992 to 39.5% in 2001 among those 20–24 years old. HIV prevalence rates peaked among the 25- to 29-year-old antenatal clinic attendees at 50.4% in 2000 and declined to 48.4% in 2001. • Policy on HIV testing and treatment. Routine HIV testing started in early 2004. Sixteen voluntary counselling and testing centres have been established countrywide in collaboration with BOTUSA (a collaboration between the government and the United States Centers for Disease Control and Prevention). Botswana was one of the first countries in Africa to establish a national antiretroviral therapy programme. The implementation of antiretroviral therapy started in one centre in 2001 and has since been expanded to eight sites. The provision of antiretroviral therapy free of charge positively influenced the demand for voluntary counselling and testing.

• Antiretroviral therapy: first-line drug regimen, cost per person per year. The starting regimen for adult men, women with no reasonable risk of pregnancy and children older than five years is: zidovudine + lamivudine + efavirenz. The starting regimen for pregnant women or women likely to become pregnant and for children younger than five years is zidovudine + lamivudine + nevirapine. The government is currently funding the procurement of antiretroviral drugs. Antiretroviral therapy is provided free of charge in the public sector. • Assessment of overall health sector response and capacity. There is a high level of political commitment. Botswana is among the 19 African countries that have established a National AIDS Council chaired by the head of state to take charge of a multisectoral response to AIDS. Various factors are identified as obstacles to an effective health sector response to rapid scaling up and decentralization of antiretroviral therapy, particularly. the fragmentation of HIV/AIDS programmes and interventions. • Critical issues and major challenges. A lack of human resources has been identified as the most significant constraint to scaling up antiretroviral therapy. Issues affecting staffing levels include a government freeze on creating new posts to prevent future budget deficits. Other major challenges to scaling up antiretroviral therapy include policy-related issues such as whether nurses should be authorized to initiate treatment, the use of generic drugs, strengthening public-private partnerships, ensuring fairness and equity in providing antiretroviral therapy services and reducing sociocultural effects and stigma.

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Botswana

Serowe

Cities and towns

BOTSWANA 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Community mobilization. Over the years, civil society involvement in HIV/AIDS in Botswana has focused on prevention and on basic care for affected and infected victims. Several nongovernmental organizations operate in Botswana together with faith-based organizations. The most common community-based organizations involved in HIV/AIDS work are church organizations and women’s groups. Village health committees are also reported to be very active in HIV/AIDS in many areas. The First Coping Center for People Living with HIV/AIDS, which began in Gaborone as a private initiative, has been expanded to six centres operating countrywide. The main challenge faced by nongovernmental organizations and community-based organizations is the scarcity of available funding. • Strategic information. The Ministry of Health provides leadership and coordination in monitoring and evaluation, surveillance, patient tracking, operational research and information management activities. Supporting agencies include the Ministry of Local Government, the Botswana–Harvard Partnership and WHO.

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 30 000 by the end of 2005 is between US$ 97 million and US$ 101 million. • The national antiretroviral therapy programme is funded by the government in collaboration with the African Comprehensive HIV/AIDS Partnerships (ACHAP) and a few other development partners. ACHAP is funded by the Bill & Melinda Gates Foundation with a US$ 50 million contribution over a five-year period, to be matched by pharmaceutical manufacturer Merck & Co., Inc. and The Merck Company Foundation, whose contributions will include antiretroviral medicines. • Botswana submitted a successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria with two-year approved funding of US$ 18.6 million focused on training, strengthening treatment, care and support activities, scaling up prevention programmes and reducing stigma and discrimination. An estimated US$ 3.2 million of this is expected to be available for scaling up antiretroviral therapy. • The United States President’s Emergency Plan for AIDS Relief is expected to contribute about US$ 36 million for scaling up antiretroviral therapy in Botswana. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Botswana to reach 30 000 people by the end of 2005 is between US$ 38 million and US$ 42 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a WHO scoping mission to Botswana in March 2004 to assess the situation and identify opportunities and challenges for scaling up antiretroviral therapy and areas for WHO support • Supporting the development of a national operational plan for scaling up antiretroviral therapy • Assessing the human resource situation for scaling up antiretroviral therapy

5. Antiretroviral therapy coverage • Botswana’s total treatment need for 2005 is estimated to be 60 000 people, and the WHO “3 by 5” treatment target is 30 000 for the end of 2005 (based on 50% of need). • The government has declared a national treatment target of 55 000 by 2005. • An estimated 18 000 people are currently receiving therapy; 12 000 are enrolled in public health facilities (under MASA – the national antiretroviral therapy programme) and about 6000 through the private health sector.

Key areas for WHO support in the future • Establishing a subregional “3 by 5” team for Botswana, Lesotho and Swaziland • Supporting the strengthening of Ministry of Health planning and coordination mechanisms • Supporting the review and update of regulations and policies on the role of nurses and midwives in delivering antiretroviral therapy • Supporting the review and update of policies and legislation on issues related to the TRIPS Agreement and generic antiretroviral drugs • Supporting the strengthening of the monitoring and evaluation system in accordance with scaling up antiretroviral therapy, including work on indicators for tuberculosis, HIV/AIDS care, preventing mother-to-child transmission and testing and counselling • Supporting the development of treatment literacy to ensure community involvement

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The National AIDS Council coordinates the multisectoral response to HIV/AIDS. The secretariat of the National AIDS Council is the National AIDS Coordinating Agency. The National AIDS Council has representatives from 17 sectors including civil society, the private sector and the public sector. Other coordinating mechanisms include the National HIV/AIDS Partnership Forum, chaired by the National AIDS Coordinating Agency; and the HIV/AIDS Donor Coordination Forum, chaired by the Ministry of Finance and Development Planning. The government has also established HIV/AIDS sector committees in all ministries aimed at mainstreaming HIV/AIDS into sector plans and programmes. The Ministry of Local Government coordinates the district response centrally. The AIDS Department of the Ministry of Health plays the role of sector leadership, formulating policy, strategic planning, developing programmes, technical support and implementation in selected areas. WHO supports the AIDS Department in coordinating and harmonizing the work of all stakeholders. • Antiretroviral therapy service delivery. The Government introduced highly active antiretroviral therapy on a nationwide scale in 2001. The implementation started in one centre, Princess Marina Hospital, and has since expanded to eight additional sites. The African Comprehensive HIV/AIDS Partnerships (ACHAP), funded by the Bill & Melinda Gates Foundation, Merck & Co., Inc. and The Merck Company Foundation, has been responsible for coordinating and financially supporting the antiretroviral therapy programme since inception. It has provided critical human resources and facilitated and supported the development of needed space in a number of treatment sites. It has also supported the development of information, education and communication activities for antiretroviral therapy, a system for tracking patients on treatment and monitoring of the programme. It has also provided support for logistics, medicines and other supplies. Other major partners supporting the antiretroviral therapy programme in Botswana include the United States President’s Emergency Plan for AIDS Relief and the United States Centers for Disease Control and Prevention. The Baylor Center of Excellence is promoting comprehensive HIV/AIDS family care and support. The Botswana–Baylor partnership includes work on antiretroviral therapy for children and women and family care in general. The Botswana–Harvard Partnership provides assistance in laboratory services. BOTUSA is contributing to HIV testing and counselling activities. WHO is supporting activities related to assessment and planning for human resources for scaling up.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS. Recruitment of a subregional “3 by 5” officer (for Botswana, Lesotho and Swaziland) is currently underway. • Additional staffing needs identified include one National Programme Officer and one medical officer for antiretroviral therapy.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Botswana and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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BURKINA FASO Mauritania

July 2004

WHO estimate of number of people requiring treatment – end 2005: 43 000 Antiretroviral therapy target declared by country: 20 000 by 2005

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1

Latest available year for 2001− 2003

Mopti

Mali Ouahigouya

Gorom Gorom Djibo Dori

35 200

treat Million by

Niger Niamey

1 − 4.9 5 − 9.9 10 −14.9 15 −19.9

Tougan Nouna Dedougou

Yako

Burkina Faso Kaya Bogande

Boulsa Ziniare Ouagadougou Reo Zorgo Koudougou Koupela Kombissiri Manga Tenkodogo

20 −29.9 Fada Ngourma Diapaga

30 and more

Sikasso Orodara

Cities and towns Bobo Dioulasso Diebougou Leo Po Bolgatanga Gaoua Wa Natitingou

Main roads

Banfora

Population density (pers./sq.Km) Less than 10

Benin Ghana Togo Sotouboua Parakou

10 − 49

50 − 99

Korhogo Bouna

100 −249

250 −499

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Côte d Ivoire Dabakala 100

500 −749

Katiola 0 50

200 Kilometers

Bondoukou

Nigeria

750 and more

Tanda

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 13.4 17.6 41.7 190 8.1 6 0.33 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 2.7 – 6.5% 2003 2001 June 2004 2003

190 000 – WHO/ 470 000 UNAIDS 18 144 2 000 43 000 not available not available 29.4% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Burkina Faso is one of the most severely affected countries in Africa, characterized by a generalized epidemic. About 75% of people living with HIV/AIDS are 15–40 years old. Prevalence is high among pregnant women, estimated to be 6% in 2001. • Major vulnerable and affected groups. Vulnerable groups include female sex workers (with an estimated prevalence of 59% in Ouagadougou), truck drivers (estimated prevalence of 13% in Ouagadougou) and prisoners. Burkina Faso is also burdened by a high rate of tuberculosis and HIV coinfection. • Policy on HIV testing and treatment. Testing in Burkina Faso is voluntary and confidential and is mostly carried out by community-based organizations. The number of voluntary counselling and testing sites is limited, and existing sites are concentrated in urban areas. The National Strategic Framework for HIV/AIDS for 2001–2005 includes the provision of antiretroviral drugs and the treatment of opportunistic infections. Care and treatment protocols were revised in December 2003 in accordance with WHO recommendations. Treatment is not provided free of charge in Burkina Faso but at a subsidized rate. A CD4 count is mandatory before initiating antiretroviral therapy. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Stavudine (or zidovudine) + lamivudine + nevirapine (or efavirenz). The average annual cost per person is about US$ 912, but public subsidies reduce the user charge to US$ 120 per year. • Assessment of overall health sector response and capacity. Burkina Faso has a high level of political commitment to scale up care and treatment for HIV/AIDS. The health sector response, outlined in the National Strategic Framework for HIV/ AIDS for 2001–2005, is multisectoral and decentralized and covers prevention, surveillance, care and treatment and partnership-building activities. Financial management systems are well developed. The human resource capacity of the health sector is limited, both in terms of numbers and skills. • Critical issues and major challenges. One of the major challenges to scaling up antiretroviral therapy is the shortage of skilled human resources. A comprehensive human resource plan needs to be developed, taking into account providing adequate incentives for health workers in the public sector. Training tools also need to be developed and training organized for health workers providing care and treatment. Procurement mechanisms are well organized, but clear criteria need to be established for distributing antiretroviral drugs and forecasting the requirements. A limited number of sites provide treatment, concentrated in hospitals in urban areas. Mechanisms for monitoring and evaluation and surveillance of drug resistance need to be strengthened. Testing and counselling facilities need further development. The cost of antiretroviral drugs makes them inaccessible to the vast majority of the population, which constitutes a major barrier to scaling up antiretroviral therapy.

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BURKINA FASO 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Strategic information. The Ministry of Health and the CNLS are responsible for monitoring and evaluation and surveillance. A national multisectoral monitoring system is being developed under the leadership of the CNLS to monitor all health sector information related to the care and treatment of people living with HIV/AIDS.

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 21 500 people by the end of 2005 is between US$ 22.5 million and US$ 33 million. • Since 1987, the government has significantly increased its financial commitment to the fight against HIV/AIDS. It is estimated that the government will commit about US$ 3.2 million to scaling up antiretroviral therapy during 2004–2005. • Burkina Faso submitted a successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria focused on meeting the gaps in implementing the National Strategic Framework for HIV/AIDS for 2001–2005, including expanding treatment and strengthening health systems. An estimated US$ 4.2 million will be available from the Global Fund money to support scaling up antiretroviral therapy in 2004–2005. • In May 2004, Burkina Faso submitted a proposal to the Treatment Acceleration Program of the World Bank, with a focus on capacity-building, monitoring and evaluation and community mobilization for scaling up antiretroviral therapy. • The United Nations System provides funds through UNAIDS, the World Bank, UNDP, UNICEF, WHO, UNFPA and WFP. An estimated US$ 1.6 million will be available from multilateral sources to support scaling up antiretroviral therapy in 2004–2005. • Nongovernmental organizations such as Médecins Sans Frontières, the Red Cross and others have also committed funds to scaling up antiretroviral therapy at different levels. • Bilateral sources of funding for HIV/AIDS include Belgium, China, Denmark, France, Italy and the Netherlands. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Burkina Faso to reach 21 500 people by the end of 2005 is between US$ 13.1 million and US$ 23.5 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Carrying out a WHO scoping mission to Burkina Faso in November 2003 in collaboration with the Ministry of Health, CNLS and other partners to review the status of implementation of antiretroviral therapy, to identify opportunities and challenges for scaling up antiretroviral therapy, to map available and potential resources and to identify areas for WHO support • Supporting national adaptation of guidelines and training manuals for various categories of health workers • Supporting the standardization of care and treatment tools • Supporting the development of tools for monitoring and evaluating the national HIV/AIDS care and support programme • Supporting the development of a national operational plan for scaling up antiretroviral therapy, including reinforcing the health system • Supporting the strengthening of procurement and drug management and distribution systems • As part of the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting a project coordinated by the CNLS that is increasing access to care and treatment in four districts (Dori, Kossodo, Bobo Dioulasso and Banfora); expanding and strengthening second-generation surveillance in eight districts; providing information, education and communication for reinforcing sexual behaviour change among young people recruited in military services in two districts (Ouagadougou and Bobo Dioulasso); and building institutional capacity for monitoring the fight against HIV/AIDS • As part of the WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa, supporting improving blood safety, strengthening activities to prevent the mother-to-child transmission of HIV, testing and counselling in antenatal clinics and maternal and child health services

5. Antiretroviral therapy coverage • In 2003, WHO and UNAIDS estimated Burkina Faso’s total treatment need for 2005 to be 43 000 people, and the WHO “3 by 5” treatment target is 21 500 people by the end of 2005 (based on 50% of need). • The country-declared antiretroviral therapy target is 20 000 people by 2005 • An estimated 2000 people were receiving antiretroviral drugs through various initiatives at the end of 2003. • The World Bank Multi-Country HIV/AIDS Program for Africa provides antiretroviral drugs to 850 people living with HIV/AIDS, and the World Bank Treatment Acceleration Program plans to provide treatment to an estimated 18 000 people living with HIV/AIDS in Burkina Faso. • The WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa is providing treatment to an estimated 140 people in collaboration with the French project ESTHER (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau) and local partner organizations. Other key organizations providing treatment include the Red Cross and Médecins Sans Frontières. • It is estimated that the funds committed to date to scaling up antiretroviral therapy, including funds available from the successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, will enable treatment for an estimated 6000 people living with HIV/AIDS.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Supporting the Ministry of Health and the CNLS in implementing the national operational plan for scaling up antiretroviral therapy • Harmonizing monitoring and evaluation tools in the context of a national monitoring and evaluation system and strengthening the surveillance of drug resistance • Promoting operational research • Finalizing the national training plan and supporting the organization of training activities for health personnel, laboratory technicians and community workers and the training of trainers • Supporting the National Therapeutic Committee in developing national policy and strategies for expanding care and treatment for people living with HIV/AIDS

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health and the National AIDS Council (CNLS) provide leadership in coordinating the health sector response to HIV/AIDS. Burkina Faso is in the process of developing a national action plan that integrates all care-related interventions by collaborating partners under the same umbrella. The Ministry of Health takes the lead in national planning of human resources and in strengthening the health system. • Antiretroviral therapy service delivery. The Ministry of Health provides leadership in delivering antiretroviral therapy services, assisted by the CNLS. The National Central Medical Store coordinates procurement of antiretroviral drugs and supply chain management. WHO supports the development of national guidelines and, along with GTZ, supports training activities. Several international partners support the delivery of antiretroviral drugs, including the World Bank, the Red Cross, Médecins Sans Frontières and the French project ESTHER (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau). • Community mobilization. Many nongovernmental organizations work in collaboration with the Ministry of Health to mobilize communities and support people living with HIV/ AIDS. PAMAC, a network of community-based organizations and associations of people living with HIV/AIDS, actively provides community-based care and strongly advocates for prevention, treatment literacy and adherence, and voluntary testing and counselling.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway. • Under the World Bank Treatment Acceleration Program, the recruitment of one international staff member, two United Nations Volunteers and one administrative support staff member is planned.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Burkina Faso and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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BURUNDI

July 2004

WHO estimate of number of people requiring treatment – end 2005: 38 000 Antiretroviral therapy target declared by country: 12 500 by 2005 HIV sentinel surveillance in pregnant women Kibungo

Kigali Kibuye Gitarama

Latest available year for 2001− 2003 Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

Rwanda Cyangugu Gikongoro Butare

35 200

treat Million by

Kayanza

Muyinga Ngozi

15 −19.9 20 −29.9

Bubanza

Karusi Cankuzo Muramvya

30 and more

Bujumbura

Burundi Gitega

Ruyigi

Main roads

Population density

Democratic Republic of the Congo Bururi Rutana

(pers./sq.Km) Less than 10 10 − 49

United Republic of Tanzania

50 − 99 100 −249 250 −499 500 −749 750 and more

Makamba

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

0

15

30

60 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 7.1 9.8 40.8 103 8.1 4 0.337 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 4.1 – 8.8% 2003 2001 June 2004 2003

170 000 – WHO/ 370 000 UNAIDS 25 361 2 186 38 000 not available not available 35.2% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. The first AIDS case in Burundi was diagnosed in 1983. Since then, the epidemic has reached alarming proportions, making the disease one of the major causes of mortality. Burundi is facing a generalized epidemic with adult prevalence rates in the range of 4.1% – 8.8% with a higher proportion in urban areas than rural. Prevalence rates appear to have stabilized in urban areas but are continuing to rise in rural areas. • Major vulnerable and affected groups. After more than 10 years of internal conflict, major vulnerable and affected groups include all armed forces (soldiers, customs agents, police officers, security forces and rebel groups), sex workers, youth (especially school dropouts) and people at risk of sexual violence, specifically internally displaced people and refugees. • Policy on HIV testing and treatment. In 2000, the government implemented a national policy on antiretroviral therapy to improve access to treatment. The government promotes the use of generic antiretroviral drugs and has implemented a policy that guarantees anonymous testing and counselling free of user charges. The policy on simplified antiretroviral therapy regimens has been finalized and validated nationally, based on WHO protocols. The government is committed to a policy of providing antiretroviral therapy free of user charges. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The government removed import duties from pharmaceutical products as of January 2000 and negotiated with major pharmaceutical companies to achieve lower prices. A national therapeutic solidarity fund was established with an initial contribution from

the government of US$ 200 000, which also contributes to lowering antiretroviral therapy prices. The annual cost of treatment was US$ 3600 in 2001 and has dropped US$ 360 per patient in 2004. The first-line drug regimen is zidovudine (or stavudine) + lamivudine + etavirenz (or nevirapine). • Assessment of overall health sector response and capacity. Because the Ministry of Public Health has limited capacity, the Ministry of HIV/AIDS was created in the President’s office to lead a multisectoral effort. This initiative is intended to reinforce the public system and support the decentralization of antiretroviral therapy delivery and the training of nurses to deliver antiretroviral therapy. About 115 physicians and 37 nurses have received antiretroviral therapy training. There are more than 80 voluntary testing and counselling centres, but the quality of services varies. Voluntary counselling and testing centres perform rapid HIV tests, but only two sites in Bujumbura (the capital) perform CD4 cell counts and viral load. The tuberculosis programme has started to test for HIV in several sites. Nine sites provide antiretroviral therapy, most of which are in Bujumbura. The effects of the war substantially weakened health services infrastructure and human resource capacity, and efforts are currently underway to rehabilitate hospitals and health centres and strengthen operational capacity. • Critical issues and major challenges. There is a strong political commitment to scaling up antiretroviral therapy. National systems to fight HIV are in place, but strengthening is necessary, especially in human resources and capacity-building at all levels as well as the coordination and overall management of the effort to scale up antiretroviral therapy. Decentralization will be crucial to reach people who cannot access the provincial hospitals.

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Cities and towns

BURUNDI 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Supporting the Ministry of Public Health in a home-based care programme for assisting people living with HIV/AIDS through a number of nongovernmental organizations • Reviewing existing treatment regimens and protocols and providing technical assistance to finalize them based on WHO simplified treatment protocols • Providing support for developing a Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria • Supporting training through WHO Integrated Management of Adult and Adolescent Illness training • Providing assistance to reinforce partnerships at all levels • Supporting the development of a national operational plan for scaling up antiretroviral therapy for 2004 and 2005 • Through the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting the improvement of the geographical coverage of voluntary counselling and testing by creating three new sites; supporting the improvement of home-based care by providing access to care and treatment among people living with HIV/AIDS in Rutana and Makamba; and building the institutional capacity of the CNLS to improve the coordination and monitoring of activities to fight HIV/AIDS.

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 19 000 people in 2005 is between US$ 32 million and US$ 41 million. The main sources of funding are the government, which has committed about US$ 180 000 per year; the Round 1 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria, which is anticipated to provide US$ 4.1 million during 2004–2005 for treatment; multilateral partners, which have committed about US$ 1.9 million and nongovernmental organizations, which are expected to provide about US$ 400 000 during 2004–2005. The World Bank, through its Multi-Country HIV/AIDS Program for Africa, is in the final process of accepting to purchase antiretroviral drugs for several years. • Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Burundi to reach 19 000 people by the end of 2005 is between US$ 25 million and US$ 35 million.

5. Antiretroviral therapy coverage • Burundi’s total antiretroviral therapy need for 2005 is estimated to be 38 000 people, and the WHO “3 by 5” treatment target was set at 19 000 people (based on 50% of estimated need). In its National Strategic Plan for 2004–2006, the government declared national antiretroviral therapy targets of 5000 people in 2004, 12 500 in 2005 and 25 000 in 2006. • However, only 2186 people were estimated to be receiving antiretroviral therapy at the end of 2003, mostly through nongovernmental organization services and private practitioners. • Burundi’s Round 1 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria was recently revised to increase the number of people living with HIV/AIDS receiving antiretroviral therapy.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Providing technical support for developing human resources and training • Supporting the government by supplying normative guidance such as accreditation of training, of voluntary counselling and testing and of treatment sites • Supporting the development of criteria on which the quality of the work performed by the providers of antiretroviral therapy can be evaluated • Conducting a mission to provide technical assistance on procuring antiretroviral drugs and diagnostics and supply chain management • Technical support for the development of an HIV/AIDS reference centre

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of HIV/AIDS is responsible for coordinating the multisectoral aspects related to the fight against HIV/AIDS through the National AIDS Committee (CNLS). The Ministry of Public Health provides leadership in all technical areas related to the health aspects of HIV. With antiretroviral therapy being scaled up, several issues are being raised such as coordination, training, accreditation of sites and the logistics of antiretroviral therapy. The key United Nations agencies involved in supporting HIV at government level are WHO, UNAIDS and UNICEF (focused on preventing mother-to-child transmission and on youth). • Antiretroviral therapy service delivery. As a central, autonomous body attached to the Ministry of Public Health, the Centrale d’Achat de Médicaments Essentiels du Burundi leads supply chain management. The CNLS provides leadership in building capacity, developing guidelines and accelerating prevention. Nongovernmental organizations are very active in delivering antiretroviral therapy, providing treatment through a range of HIV/AIDS centres, mainly in Bujumbura. They also provide HIV testing and counselling and home-based care. Extension to various provinces has started. The Ministry of Public Health has started to deliver antiretroviral therapy in several hospitals. WHO provides normative support for developing treatment guidelines and training material. • Community mobilization. The Ministry of HIV/AIDS and the Ministry of Public Health lead and manage communication activities related to HIV/AIDS programmes. Several nongovernmental organizations, local and international, as well as United Nations agencies and bilateral partners support programmes aimed at mobilizing communities to support people living with HIV/AIDS. Nongovernmental organizations support information, education and communication initiatives, HIV/AIDS counselling, psychosocial and material support and health care assistance to people living with HIV/AIDS and their families. • Strategic information. The CNLS provides leadership in monitoring and surveillance activities and collects information for partners involved in scaling up antiretroviral therapy. It is developing a standardized monitoring system that will be used by both the private and the public sector. There are discussions about creating a HIV/AIDS reference centre.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently planned. • An additional HIV/AIDS National Programme Officer is in place under the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Burundi and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

CAMBODIA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 28 000 Antiretroviral therapy target declared by country: 12 800 by 2005

Sisaket Nakhon Ratchasima Buriram Surin

Thailand

Lao People s Democratic Republic

Champasak

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1

Latest available year 2001 −2003

35 200

treat Million by

1 − 4.9 Phnum Tbeng Meanchey Stoeng Treng Siemreab Batdambang Lumphat

5 − 9.9 10 −14.9 15 −19.9 20 −29.9

Chanthaburi Trat

Kracheh

Senmonorom

Kampong Chnang Kampong Cham

Cities and towns

Population density (pers./sq.Km) Less than 10

Krong Kaoh Kong

Phnom Penh Prey Veng Kampong Spoe Tay Ninh Svay Rieng Thu Dau MotBien Hoa Ho Chi Minh City Kampot

Viet Nam

10 − 49 50 − 99 100 −249 250 −499

Takev

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Cao Lanh Long Xuyen My Tho Vinh Long Truc Giang 0 40 80 160 Kilometers

Tan An

500 −749

750 and more

Rach Gia

Can Tho

Tra Vinh

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 14.5 18.3 54.6 253 16 30 0.556 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) Estimate Source WHO/ UNAIDS NCHADS WHO/UNAIDS

2003 1.5 – 4.4% 2004 2003 2001 April 2004 2003 2004 2002 2003 157 500 170 0001 9 318 3 389 28 0002 58 51 613 11%

WHO/ UNAIDS WHO WHO/ UNAIDS NCHADS NCHADS Cambodia National Tuberculosis Centre

3. Situation analysis • Epidemic level and trend and gender data. Cambodia has a generalized epidemic and one of the highest prevalence rates in Asia, estimated to be 2.6% in 2002 (HIV sentinel survey). Whereas the increase in the prevalence rate seems to be slowing, the number of people with AIDS needing antiretroviral therapy is increasing. In 2002, an estimated 3% of men and 2% of women were living with HIV. • Major vulnerable and affected groups. Major vulnerable and affected groups include sex workers, male police officers, garment factory workers, mobile populations (cross-border and road construction workers), clients of sex workers and the clients’ partners, and men who have sex with men. Estimates indicate that 28.8% of sex workers have HIV. One of the most exposed groups is children born to infected mothers. Injecting drug users are an emerging vulnerable group. • Policy on HIV testing and treatment. The Ministry of Health regards voluntary and confidential counselling and testing as an important intervention to reduce HIV risk behaviour and an integral part of ongoing prevention and care strategies. The Ministry of Health published a document on policy, strategy and guidelines in December 2002, and Cambodia’s National Center for HIV/AIDS, Dermatology and STD (NCHADS) provided an updated implementation guide in January 2004. The strategy is based on anonymous, confidential services for counselling and testing. In the national health sector, the strategy tends to promote institutionalized voluntary and confidential counselling and testing rather than stand-alone services. New voluntary and confidential counselling and testing centres are linked and integrated into public health services within the continuum of care strategy. By the

end of 2004, 70 government voluntary and confidential counselling and testing centres will be operating throughout Cambodia. The government target is to have a voluntary and confidential counselling and testing centre linked to each of the 67 referral hospitals and some former district hospitals by the end of 2005. A few centres in private clinics will also be part of the NCHADS programme for expanding voluntary and confidential counselling and testing. Meanwhile, many private sites provide testing but are not presently licensed. The quality control system for HIV testing and quality assurance for HIV counselling need to be developed further. The scaling up of antiretroviral therapy is included in the Operational Framework for the Continuum of Care for People Living with HIV/AIDS. The approach is phased-in and physician-led. The NCHADS has produced and updated national guidelines for the use of antiretroviral therapy in adults and adolescents. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Stavudine + lamivudine + nevirapine: US$ 240; stavudine + lamivudine + efavirenz: US$ 465. • Assessment of overall health sector response and capacity. The Ministry of Health and the NCHADS have a strong political commitment, actively planning, mobilizing and coordinating partners for scaling up HIV/AIDS treatment. The Operational Framework for the Continuum of Care for People Living with HIV/AIDS, which will provide the basis for scaling up antiretroviral therapy in Cambodia, is a core component of the Strategic Plan for HIV/AIDS and STD Prevention and Care developed by the NCHADS. The Operational Framework was reviewed recently and updated to cover the period 2004–2007 and falls within the health service delivery core strategy of

1 1 2

WHO/UNAIDS estimate that the number of people living with HIV/AIDS (0–49 years) is between 100 000 and 290 000 (2003). NCHADS (the National Center for HIV/AIDS, Dermatology and STD) estimated that the antiretroviral therapy need for 2002 was 22 000.

© World Health Organization 2004

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Pouthisat

Cambodia

30 and more

CAMBODIA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP Stores of the Ministry of Health coordinate procurement and supply chain management supported by UNICEF, the French project ESTHER (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau), Médecins Sans Frontières and the World Bank. The National Public Health Institute, NCHADS and the Ministry of Health coordinate strengthening laboratory services, supported by Institut Pasteur, ESTHER and Médecins Sans Frontières. WHO provides support to the NCHADS in capacity-building, including developing curricula and guidelines and site-level training. NCHADS coordinates testing and counselling activities with support from UNICEF, the United Kingdom Department for International Development, World Vision, Family Health International and the Reproductive Health Association of Cambodia. Private sites also provide some testing and counselling services. • Community mobilization. More than 80 international and national nongovernmental organizations work with the NCHADS on HIV/AIDS. The National AIDS Authority coordinates the activities of civil society partners in collaboration with NCHADS. Groups of people living with HIV/AIDS, such as the Khmer HIV/AIDS NGO Alliance and the Cambodia People Living with HIV/AIDS Network, are very active and provide adherence and psychosocial support together with other community-based groups such as Cambodian HIV/AIDS Education and Care. • Strategic information. The National AIDS Authority coordinates monitoring and evaluation activities. There is a high level of commitment to realize a unified monitoring and evaluation system, bringing together various partners. The United States Centers for Disease Control and Prevention, the United States Agency for International Development and UNAIDS support the National AIDS Authority and the NCHADS in developing a multisectoral approach to monitoring systems. Family Health International and the United States Centers for Disease Control and Prevention provide support for surveillance activities, including drug resistance surveillance. Médecins Sans Frontières, the Sihanouk Hospital Center of HOPE, the Institute of Tropical Medicine (Antwerp, Belgium), the University of New South Wales and the University of California at San Francisco support the operations research unit of the NCHADS.

the Ministry of Health Strategic Plan for 2003–2007. The comprehensive continuum of care framework provides a strategy for the care of people living with HIV/AIDS and builds a basis for antiretroviral therapy with a comprehensive and integrated approach. Prevention activities, services for treating sexually transmitted infections, blood safety programmes and services for preventing mother-to-child transmission are developed. A training programme for physicians has been established and curricula developed for nurses and auxiliary health workers. • Critical issues and major challenges. The capacity of Cambodia’s health sector to respond to the foreseen expansion of antiretroviral therapy depends on the availability of funds and the capacity for procurement. Systems for drug procurement and supply chain management will need strengthening, and the distribution of antiretroviral drugs in the private sector will require specific regulation. The capacity of the provincial and district health departments to lead and coordinate the scale-up process will need reinforcement as will human resource capacity. Community involvement, including the involvement of people living with HIV/AIDS, in scaling up care and treatment should also be strengthened.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the government-declared target of 12 800, which is in accordance with the WHO “3 by 5” treatment target of 14 000 people for the end of 2005, is between US$ 12 million and US$ 28 million. • The government has committed an estimated US$ 1 million for scaling up antiretroviral therapy during 2004–2005. • Bilateral partners including the United States Centers for Disease Control and Prevention, the United Kingdom Department for International Development and the Asian Development Bank have committed an estimated US$ 1 million for scaling up treatment during the same period. • Cambodia submitted successful Round 1 and 2 proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria, focused on reducing the burden of HIV/AIDS among vulnerable populations and providing care and treatment for people living with HIV/AIDS, including limited antiretroviral therapy. An estimated US$ 6 million is anticipated to be available from these rounds for scaling up antiretroviral therapy. • The Country Coordinating Mechanism has submitted a Round 4 proposal to the Global Fund, with a focus on providing care and treatment for people living with HIV/AIDS and reducing the percentage of HIV-infected infants born to HIV-infected mothers. • Nongovernmental organizations and charity foundations, including Médecins Sans Frontières, the French project ESTHER (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau), Center of Hope, CARE, Douleurs Sans Frontières and Family Health International have committed an additional estimated US$ 10.3 million to scaling up antiretroviral therapy in Cambodia during 2004–2005. • Taking into account the funds committed to date, WHO estimates that the total funding gap for Cambodia to reach 14 000 people by the end of 2005 is up to US$ 9.8 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a scoping mission in January 2004 to assess the situation of antiretroviral therapy in Cambodia and to identify opportunities and challenges for scaling up antiretroviral therapy and areas for WHO support • Supporting the NCHADS in developing a national operational plan for scaling up antiretroviral therapy • Supporting NCHADS in developing systems for monitoring people receiving antiretroviral therapy and for monitoring antiretroviral therapy programmes • Supporting the strengthening of voluntary testing and counselling services

Key areas for WHO support in the future • Establishing an HIV/AIDS country team to support the government and all partners in scaling up antiretroviral therapy • Supporting the NCHADS in developing and implementing a national system for procuring, supplying and distributing antiretroviral drugs linked to monitoring of people receiving antiretroviral therapy • Supporting the NCHADS in building capacity • Supporting strengthening health systems

5. Antiretroviral therapy coverage • NCHADS estimates that the antiretroviral therapy need for 2002 was 22 000. • It is estimated that Cambodia’s total treatment need for 2005 is 28 000 people. • The national target of treating 12 800 people by 2005 is in accordance with the WHO “3 by 5” treatment target of 14 000 by 2005 (based on 50% of estimated need). • NCHADS estimates that 3389 people are receiving treatment as of April 2004, mainly supported by nongovernmental organizations. In the public sector, 11 centres in four provinces have started offering antiretroviral therapy.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO country office staff for HIV/AIDS and sexually transmitted infections include one Medical Officer for HIV/AIDS, and the recruitment of an international Country Officer for treatment scale-up is underway. • Additional staffing needs identified include one international staff member to support the NCHADS on HIV/AIDS care and treatment, one administrative staff member and one support staff member.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The National AIDS Authority, created in 1999 and composed of 26 ministries, 24 provinces and representatives of civil society, coordinates the multisectoral response to the epidemic, provides the legal and policy framework and strengthens partnerships among all stakeholders. It is chaired by the Secretary of State for Health. The Ministry of Health and the NCHADS provide leadership for the health sector response to HIV/AIDS. The United Kingdom Department for International Development, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States Centers for Disease Control and Prevention, the Asian Development Bank, the World Bank and a consortium led by the University of New South Wales are supporting the NCHADS Strategic Plan for HIV/AIDS and STD Prevention and Care. WHO provides technical assistance in planning, programme evaluation and strengthening health systems. • Antiretroviral therapy service delivery. The NCHADS provides leadership in delivering antiretroviral therapy services. The NCHADS and the Central Medical

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Cambodia and the WHO Regional Office for the Western Pacific.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

CHINA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 100 000 Antiretroviral therapy target declared by country: 10 000 – 15 000 by 2004 and 30 000 – 50 000 by 2005

HIV sentinel surveillance in injecting drug users

Latest available year for 1998 −2000 Percent seropositive Less than 1

35 200

treat Million by

Qiqihar Harbin Urumqi BaotouHuhot Beijing Yinchuan ChangchunJilin Shenyang Anshan Tianjin Dalian Qingdao

1 − 4.9

5 − 9.9 10 −24.9 25 −39.9 40 and more

Kashi

China Lhasa

Xining Lanzhou Xi’an

Taiyuan ShijiazhuangJinan Luoyang Zhengzhou

Chengdu Chongqing Guiyang Kunming

Hefei Wuhan Nanjing Hangzhou Changsha Fuzhou

Cities and towns

Population density (pers./sq.Km) Less than 10

Nanning Macau Fangcheng Gang VictoriaKowloon

10 − 49

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau. Map production: WHO

750 and more

0

387.5

775

1,550 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 1 313 38.2 71.1 902 10.2 49 0.721 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 0.1 – 0.2% 2003 2001 June 2004 2003 2004

430 000 – WHO/ 1 500 000 UNAIDS 1 111 7 400 100 000 79 not available 0.7% WHO WHO/ UNAIDS WHO WHO/ UNAIDS Ministry of Health

3. Situation analysis • Epidemic level and trend and gender data. China has a low prevalence overall but localized high prevalence in certain populations and regions. Although the adult prevalence rate is 0.1–0.2%, reported HIV/AIDS infections have increased by 30% in recent years, and the epidemic has spread to 31 of China’s 34 provinces and other administrative units. Women are increasingly at risk of becoming infected with HIV; 36% of reported cases in 2003 were women. • Major vulnerable and affected groups. Injecting drug users are the largest vulnerable population group (about 4 million), with HIV infection rates up to 80% in some areas. Data from sentinel surveillance also indicate that infection rates among sex workers and men who have sex with men are increasing. Former paid plasma donors, mostly concentrated in central China, had prevalence rates as high as 65%. Although the epidemic is still concentrated among a few high-risk groups, the conditions exist for HIV to spread into the general population. • Policy on HIV testing and treatment. A new policy to provide free HIV testing and counselling, including rapid testing, is currently being reviewed. The government plans to grant subsidies to cover costs and to improve access to voluntary testing and counselling. Efforts are also underway to address confidentiality issues. In December 2003, the government made five commitments to enhance its efforts to prevent and control HIV/ AIDS: to clarify targets, identify responsibilities and improve evaluation and supervision; to provide free antiretroviral drugs to low-income people; to improve laws and regulations and launch public awareness campaigns; to protect the legitimate rights of people living with HIV/AIDS and oppose social discrimination against them; and to increase international cooperation on HIV/AIDS. The government also committed to the “Four Frees and One Care” – free antiretroviral drugs for poor people in urban and rural areas, free testing in heavily affected areas, free treatment and counselling for pregnant women, free schooling for children orphaned by HIV/AIDS and financial aid to people living with HIV/AIDS living in poverty. This policy of voluntary testing and counselling free of charge has not been fully implemented yet, and cost is a limiting factor. Technical documents on HIV testing are currently being reviewed, and the use of rapid testing is foreseen in revisions. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Since 2003, domestic antiretroviral therapy has been available at an average annual cost of between US$ 600 and US$ 900. The current first-line regimen consists of zidovudine or stavudine, didanosine and nevirapine. Limited amounts of Combivir® (zidovudine + lamivudine) and efavirenz are available for free within the National Free Antiretroviral Therapy Programme in case of severe side effects. Domestically produced indinavir is now available to provide more options, and lamivudine will be placed in the first line soon. Prophylaxis to prevent mother-to-child transmission consists of a single dose of nevirapine for the mother and infant free of charge. No paediatric formulation is yet available in China. The Government is making efforts to increase access to antiretroviral drugs. • Assessment of overall health sector response and capacity. Investment in public health and HIV/AIDS has increased significantly since the outbreak of severe acute respiratory syndrome in 2003. The China AIDS Response (CARES) Project, a comprehensive care pilot

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CHINA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Antiretroviral therapy service delivery. The Ministry of Health procures medicines and manages the supply chain supported by NCAIDS, the State Food and Drug Administration, WHO and the Clinton Foundation. WHO supports the prequalification of medicines. WHO also supports capacity development and the development of training guidelines. NCAIDS and the Chinese Medical Association coordinate site-level training activities in collaboration with CDC, the Clinton Foundation and Médecins Sans Frontières. NCAIDS and the Chinese Medical Association undertake testing and counselling activities in collaboration with CDC and local hospitals. The Ministry of Health, NCAIDS and the Chinese Medical Association also take the lead in accelerating prevention activities, supported by other ministries and WHO. • Community mobilization. Community involvement in programmes to accelerate treatment is limited in China. Some pilot projects involving people living with HIV/AIDS exist but on a very small scale. International nongovernmental organizations involved in AIDS awareness programmes include PATH, Save the Children UK, Marie Stopes International, World Vision and the Ford Foundation. NCAIDS and the Chinese Medical Association take the lead in programme communication, capacity-building activities for people living with HIV/AIDS and adherence and psychosocial support supported by CDC and the American Foundation for AIDS Research. • Strategic information. NCAIDS and the Ministry of Health provide leadership in surveillance, monitoring and evaluation. NCAIDS conducts surveillance of antiretroviral resistance with support from WHO and CDC. Designated hospitals and local centres for disease control and prevention are coordinating the tracking of people receiving antiretroviral therapy with support from WHO, CDC, the Clinton Foundation and Médecins Sans Frontières. WHO provides technical guidance on developing monitoring and evaluation capacity.

project including antiretroviral therapy, was initiated in 2002 and includes 127 counties in provinces with high prevalence rates. Health care staff are being trained, and central health authorities are preparing guidelines for HIV/AIDS treatment and care. The HIV/AIDS surveillance system currently includes 194 national and about 400 provincial surveillance sites, monitoring a number of risk groups. A 100% condom use programme is operating in 10 provinces, and harm reduction pilot projects are underway in at least five provinces. Several laws and regulations have been designed and promulgated to enhance the security of blood supply since 1995. However, the local capacity of the public health sector to treat HIV/AIDS remains limited, and the CARES project is constrained by several factors including limited human resource capacity, limited availability of laboratory support and insufficient community support mechanisms for counselling and adherence. • Critical issues and major challenges. Many of the marginalized and vulnerable populations are difficult to reach. People are often unaware of their HIV status, and access to voluntary testing and counselling is limited. Capacity to deliver antiretroviral therapy is severely lacking, due to both a scarcity of trained health care staff and infrastructure shortages. Procurement mechanisms for antiretroviral drugs need to be strengthened. Planning for scaling up antiretroviral therapy is multisectoral, but coordination among national or international partners and initiatives needs to be strengthened. HIV/AIDS treatment services need to be linked with drug dependence treatment services and outreach programmes for vulnerable populations. Community participation also needs to be built into efforts to scale up antiretroviral therapy and to reduce social stigma and discrimination.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 50 000 people by the end of 2005 is between US$ 471 million and US$ 496 million. • The government has committed an estimated US$ 27 million in 2004 and US$ 33 million in 2005 to scaling up antiretroviral therapy. • China submitted a successful Round 3 proposal on comprehensive care, treatment and support to the Global Fund to Fight AIDS, Tuberculosis and Malaria (US$ 97 million for HIV/AIDS over a period of five years), with a focus on increasing awareness, prevention and care. Of this amount, an estimated US$ 16 million will be available to support scaling up antiretroviral therapy in 2004–2005. • The Country Coordinating Mechanism has submitted a Round 4 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria focusing on vulnerable populations, including injecting drug users and sex workers. • Multilateral agencies providing support for prevention and care activities include the World Bank, UNDP, UNAIDS, the Australian Agency for International Development, the United States Centers for Disease Control and Prevention (CDC), the United Kingdom Department for International Development and the European Union. • WHO estimates that nongovernmental organizations, charities and foundations have committed about US$ 2 million to scaling up antiretroviral therapy during 2004–2005. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for China to reach 50 000 people by the end of 2005 is between US$ 395 million and US$ 420 million.

7. WHO support for scaling up antiretroviral therapy WHO's response so far • Conducting a joint WHO–UNAIDS scoping mission to China from 26 February to 5 March 2004 to review the status of antiretroviral therapy implementation and to identify opportunities and challenges for scale-up and areas for WHO support • Reviewing technical protocols included in the 14 State Council action points for the national meeting in April 2004, including voluntary counselling and testing, management of antiretroviral therapy, management of opportunistic infections, compensation for health workers, a training plan and support to orphans • Supporting the Country Coordinating Mechanism in developing the Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria with a focus on antiretroviral therapy and care • Providing technical assistance to the Ministry of Health in developing a comprehensive national plan for care and treatment • Reviewing national guidelines on antiretroviral therapy

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and other partners in scaling up antiretroviral therapy • Reviewing the experience of pilot sites established within the CARES Project and documenting lessons learned for scaling up antiretroviral therapy • Reviewing and updating policy and guidelines for testing and counselling • Building capacity, including adapting training modules • Strengthening surveillance and monitoring and evaluation systems • Mobilizing partners, including nongovernmental organizations and people living with HIV/AIDS • Expanding interventions targeting marginalized groups of the population such as injecting drug users and sex workers

5. Antiretroviral therapy coverage • China’s total treatment need for 2005 is estimated to be 100 000 people, and the WHO “3 by 5” treatment target is 50 000 people by the end of 2005 (based on 50% of need). • The government is committed to providing treatment to 10 000–15 000 people by 2004 and 30 000–50 000 people by the end of 2005. • At the end of 2003, an estimated 7400 people were receiving treatment, most through the public sector. • The CARES Project is currently providing first-line treatment free of charge in 9 provinces and 74 counties, with the ultimate goal of scaling up access to antiretroviral therapy free of charge for anyone in rural or urban areas not covered by basic medical insurance.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway. • Recruitment of one senior policy adviser and one technical officer for second-generation surveillance and injecting drug use is currently underway with the support of the Swedish International Development Cooperation Agency. • Additional Country Office staffing needs identified include a planning adviser for planning and technical support on monitoring and evaluation; a human resources and health For further systems adviser; a capacity-building information, adviser; a communication officer; and three National Programme Officers. please contact:

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. China is operating within the framework of the China Plan of Action for Containment and Control of HIV/AIDS 2001–2005, a multisectoral plan coordinated by the State Council. The Ministry of Health and the National Centre for AIDS Prevention and Control (NCAIDS) are developing a national plan for scaling up antiretroviral therapy with support from WHO, CDC and the Clinton Foundation. In April 2004, the government established the State Council Working Group on HIV/AIDS, a multisectoral body headed by the Vice-Premier and the Health Minister and including 22 vice-ministers and 7 provincial vice-governors. This State Council is taking the lead in formulating national HIV/AIDS policy, supported by WHO. The Ministry of Health and NCAIDS are coordinating national human resources planning and strengthening of the health system with support from the United Nations Theme Group on HIV/AIDS in China and the United Kingdom Department for International Development.

World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for China and the WHO Regional Office for the Western Pacific.

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DJIBOUTI

July 2004

WHO estimate of number of people requiring treatment – end 2005: 1 200 Antiretroviral therapy target declared by country: 1 370 by 2005

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1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 0.7 83.4 49.6 835 13.7 58 0.462 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS WHO/ UNAIDS WHO/ UNAIDS WHO WHO/ UNAIDS Ministry of Health 2003 0.7 – 7.5% 2003 2001 June 2004 2003 2003 2 300 – 24 000 1 783 94 1 200 8 not available 23% Ministry of Health

3. Situation analysis • Epidemic level and trend and gender data. Djibouti faces a generalized epidemic. According to Ministry of Health sources, a survey conducted in 2002 showed that the HIV prevalence in Djibouti was about 2.9%. The prevalence was estimated to be 3.3% in Djibouti City and 1.1% in other districts, including Obock, Tadjourah, Ali-Sabieh and Dikhil. The same survey indicated that women are more affected than men; in Djibouti City, the prevalence is estimated to be 3.6% among women and 3.1% among men. In other districts, the HIV prevalence was estimated to be 1.7% among women and 0.3% among men. People 20–29 years old have a higher prevalence rate of about 6%. • Major vulnerable and affected groups. In Djibouti, in addition to the vulnerability of youth and women, the major vulnerable groups are men in uniform, sex workers, dockworkers and truck drivers. • Policy on HIV testing and treatment. The policy on testing encourages people to undergo testing voluntarily. Before testing, pretest counselling is offered, and post-test counselling takes into account HIV status. A national antiretroviral therapy protocol has been developed and is being revised in accordance with WHO simplified treatment guidelines. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The firstline drug regimen for people without tuberculosis is zidovudine + lamivudine + efavirenz (for men), zidovudine + lamivudine + abacavir (for women), zidovudine + lamivudine + nevirapine (for pregnant women or children younger than 3 years) and zidovudine + lamivudine + efavirenz or zidovudine + lamivudine + nevirapine (for children 3 years or older). For people with tuberculosis, the first-line drug regimen is zidovudine + lamivudine + abacavir. The average cost per person per year is estimated to be US$ 1680. • Assessment of overall health sector response and capacity. Djibouti’s health system is weak. Health services need to be strengthened to provide a more vigorous response to the HIV/AIDS epidemic and to support scaling up antiretroviral therapy. Eight sites have been identified as antiretroviral therapy centres. For outpatients, they are: Centre Yonis Toussaint, Health Centre of Einguela, Organisme de Protection Sociale, Health Centre for the Ministry of Defence and Health Centre for the Police. For inpatients, they are: Peltier General Hospital, Tuberculosis Centre (Paul Faure) and French military hospital (Bouffard). All these antiretroviral treatment sites are located in Djibouti City. Testing and counselling activities are fully functional but presently carried out only in the following antiretroviral therapy treatment sites: Centre Yonis Toussaint, Health Centre of Einguela, Health Centre for the Ministry of Defence and Health Centre for the Police. • Critical issues and major challenges. The major constraints to scaling up antiretroviral therapy are the lack of human resources capacity and management skills. Drug procurement logistics systems are weak, and parallel procurement systems are run by various parties. The current system’s capacity for procurement and stocking is very weak.

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DJIBOUTI 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a scoping mission to assess the situation of antiretroviral therapy in Djibouti and to identify opportunities and challenges for scaling up antiretroviral therapy provision and areas for WHO support • Reviewing and revising national antiretroviral therapy protocols and guidelines in accordance with WHO guidelines • Developing a Round 4 proposal submitted to the Global Fund to Fight AIDS, Tuberculosis and Malaria with special focus on scaling up antiretroviral therapy • Supporting the development of an operational plan for scaling up antiretroviral therapy for 2004–2007

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the “3 by 5” treatment target of 600 people by the end of 2005 is between US$ 2.2 million and US$ 3.3 million. About US$ 226 000 is anticipated to be available from multilateral sources to fund scaling up antiretroviral therapy during 2004–2005. Taking into account the funds committed to date, WHO estimates that the total funding gap for Djibouti to scale up antiretroviral therapy to 600 people by the end of 2005 is between US$ 2.0 million and US$ 3.1 million. • Djibouti has been involved in a major process of health sector reform with financial support from the World Bank, which has committed US$ 15 million over a period of five years. The United States Agency for International Development is also committing US$ 12 million. Other major supporters of the Ministry of Health include the French Cooperation, the African Development Bank, the Governments of Italy and Morocco and the Islamic Development Bank.

Key areas for WHO support in the future • Establishing a “3 by 5” team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy. The team is also expected to provide support to other Horn of Africa countries, including Somalia and Yemen • Developing a national human resource plan for scaling up antiretroviral therapy • Developing a monitoring and evaluation system • Supporting operational research including drug resistance, economic impact and adherence to therapy • Supporting training of all levels of service providers

5. Antiretroviral therapy coverage • Djibouti’s total treatment need for 2005 is estimated to be 1200 people, and the government has declared a national antiretroviral therapy target of 1370 people by the end of 2005. • Currently, an estimated 94 people are receiving antiretroviral therapy.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Executive Secretariat of the Intersectoral Committee against AIDS, Tuberculosis and Malaria coordinates all AIDS-related activities. More than 11 ministerial departments and several nongovernmental organizations carry out AIDS control activities. In 2002, the Government developed a national strategy for preventing and controlling HIV/AIDS that serves as a reference for all partners who would like to contribute to the national response against HIV/ AIDS. The Ministry of Justice is involved in legal and policy-related issues. The Ministry of Finance is responsible for human resource planning. Other ministries play major roles such as the Ministries of Youth and Sports, Promotion of Women, Education, Interior, Labour, Information and Defence. United Nations agencies also support various components of the programme. • Antiretroviral therapy service delivery. The Ministry of Health in collaboration with other sectors is responsible for overall coordination and management of the national antiretroviral therapy programme, health system strengthening, laboratory services and capacity-building. The French Cooperation is especially involved in providing antiretroviral therapy services in hospitals, laboratory services and treating opportunistic infections. • Community mobilization. A community support unit has been established as part of the Executive Secretariat. Currently, key nongovernmental organizations are being identified to support the antiretroviral therapy programme. • Strategic information. The Ministry of Health coordinates the activities related to monitoring and evaluation with support from WHO.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Recruitment of a subregional “3 by 5” officer (Djibouti, Somalia and Yemen) is planned.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Djibouti and the WHO Regional Office for the Eastern Mediterranean.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

ETHIOPIA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 200 000 Antiretroviral therapy target declared by country: 93 000 by 2005

Asmara

Hajjah San’a Al Hudaydah Dhamar Ibb

Marib

HIV sentinel surveillance in pregnant women ’Ataq

Eritrea Mek’ele

Yemen Al Bayda

Latest available year for 2001− 2003 Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

35 200

treat Million by

Ta’izz Lahij Aden

Sudan

Gonder

Djibouti Obock Dese Debre Markos Hargeysa Tadjoura Dikhil Djibouti Ali Sabieh Ceerigaabo

15 −19.9

20 −29.9

Nek’emte

Addis Ababa

Harar

Somalia Laascaanood

30 and more

Gore Jima

Ethiopia Asela Awasa Goba

Cities and towns

Main roads

Population density Gaalkacyo

(pers./sq.Km) Less than 10

Arba Minch Dhuusa Mareeb

10 − 49

50 − 99

Beledweyne Xuddur

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Uganda

Moroto

Kenya 0 85

Garbahaarey Baydhabo Jawhar 170 340 Kilometers

750 and more

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 72.4 15.5 48 93 4.9 3 0.359 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 2.8 – 6.7% 2003 2001 June 2004 2003

950 000 – WHO/ 2 300 000 UNAIDS 100 353 4 500 200 000 not available not available 29.1% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. In 2003, Ethiopia had an estimated 950 000 - 2.3 million people living with HIV/AIDS. The average prevalence rate of HIV infection in the adult population is estimated to be in the range of 2.8 - 6.7% with a much higher proportion in urban areas compared to rural. Morbidity and mortality associated with HIV/AIDS strongly impact the health sector and are among the major impediments to delivering quality care to its full capacity. The bed occupancy rate from AIDS may well exceed 40% of total beds. • Major vulnerable and affected groups. HIV transmission occurs mainly through heterosexual contact, with the highest prevalence being among people 15–24 years (12%). • Policy on HIV testing and treatment. The current model for delivering antiretroviral therapy is physician-led and hospital-based, whereas health centres can provide antiretroviral drugs for preventing mother-to-child transmission only. Antiretroviral drugs are distributed by licensed pharmacists at authorized outlets. The service is provided only for those who can afford to pay for the drugs and laboratory costs. The Council of Ministers approved a national policy for supply and use of antiretroviral drugs in July 2002. The policy provides a tax exemption for antiretroviral drugs and related supplies and defines the modalities of delivering antiretroviral therapy. Clinical guidelines on the use of antiretroviral drugs were developed in February 2003. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Several antiretroviral drugs of different classes have been identified and included in the List of Drugs in Ethiopia. However, to date only the following products are available for distribution: zidovudine, lamivudine, stavudine, efavirenz, nevirapine, nelfinavir and a fixed combination of zidovudine + lamivudine (Lamuzid® or Combivir®). The average cost of the WHO-recommended first-line regimen is US$ 360 per person per year. • Assessment of overall health sector response and capacity. Ethiopia has 119 hospitals and 412 health centres. Although they have inadequate resources, they represent a consistent infrastructure with potential to provide antiretroviral therapy services to a large proportion of people in need of treatment. • Critical issues and major challenges. HIV/AIDS is one of the major challenges for overall national development. It is linked to a seven-year loss in life expectancy, an estimated 1.2 million orphans and a loss of productivity and income at the workplace with severe effects at the household and community levels. There is a substantial shortage of health workers of all types to serve the health needs of a rapidly expanding population. This shortage is aggravated by high turnover among health workers, especially physicians and counsellors, throughout Ethiopia. Antiretroviral therapy is currently provided only at referral and provincial hospitals. Scaling up antiretroviral therapy services would require an extension within the health system to include more peripheral facilities. Surveillance and monitoring and evaluation systems need to be strengthened.

1 © World Health Organization 2004

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ETHIOPIA 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Assessing the overall antiretroviral therapy situation in accordance with “3 by 5” and identifying opportunities for scaling up • Assisting in developing the Country Coordinating Mechanism Round 4 proposal submitted to the Global Fund to Fight AIDS, Tuberculosis and Malaria addressing specific antiretroviral therapy needs • Assessing the human resource situation for scaling up antiretroviral therapy • Reviewing the model for delivering antiretroviral therapy and assessing its potential for rapid scale-up (involving intermediate- and lower-level health workers) • Reviewing the national policies, guidelines and strategies on antiretroviral therapy • Adapting the WHO Integrated Management of Adult and Adolescent Illness guidelines for chronic HIV disease care, including training national facilitators • Through the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS: establishing two voluntary counselling and testing sites (Harari and Kombolcha districts), strengthening the management of opportunistic infections at three sites (Kombolcha, Bahrdar and Gambella); strengthening syndromic management of sexually transmitted infections at four sites (Harari, Bahrdar, Oromiya and Gambella); strengthening youth-friendly health services at two sites (Oromiya and Bahrdar); and building institutional capacity within the Ministry of Health for improving the coordination and monitoring of HIV/ AIDS activities

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 100 000 people by the end of 2005 is between US$ 223 million and US$ 263 million. • Ethiopia submitted a successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, focusing on a large range of HIV activities including voluntary counselling and testing, clinical management of HIV, home-based care, capacity-building, surveillance and monitoring and evaluation. Funding of US$ 55 million was approved for 2004–2005. Of this amount, it is estimated that about US$ 11.3 million may be available to support scaling up antiretroviral therapy in 2004–2005. Ethiopia has also submitted a Round 4 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria. • An estimated US$ 81.5 million may become available from the United States President’s Emergency Plan for AIDS Relief to support scaling up antiretroviral therapy during 2004–2005. • Other bilateral partners are estimated to have committed about US$ 15 million for scaling up antiretroviral therapy during 2004–2005. • A World Bank loan of US$ 59 million for the Ethiopian Multi-sectoral AIDS Project provides support for diagnostic capacity-building, including procuring equipment and consumables and training personnel. Under this Project, 12 referral laboratories will be equipped with devices for determining viral load and CD4 cell counting. • Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Ethiopia to reach 100 000 people by the end of 2005 is between US$ 111 million and US$ 151 million.

5. Antiretroviral therapy coverage • Ethiopia’s total treatment need for 2005 is estimated to be 200 000 people, and the WHO “3 by 5” treatment target is 100 000 people by the end of 2005 (based on 50% of need). The government has declared a national treatment target of 93 000 people by the end of 2005. To date, an estimated 4500 people have access to antiretroviral therapy, mostly through 14 hospitals in seven regions. • Armed Forces hospitals and a site supported by Médecins Sans Frontières provide some treatment to military personnel and their spouses. Médecins Sans Frontières is willing to support the delivery of antiretroviral drugs free of charge to as many as 1500 people living with HIV/AIDS, including marginalized groups such as sex workers. Private companies have expressed keen interest in providing antiretroviral therapy to their employees. • Ethiopia is among the countries receiving assistance from the United States President’s Emergency Plan for AIDS Relief, which has indicated a target of 210 000 people receiving antiretroviral therapy by 2008.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Assisting in overall coordination of the antiretroviral therapy programme and harmonizing it with various partner initiatives • Supporting the development of a national operational plan for scaling up antiretroviral therapy • Developing a human resource strategy and national plan for developing capacity for scaling up antiretroviral therapy • Supporting the roll-out of training of health service providers

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for general HIV activities and another to coordinate activities funded by the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS. Recruitment of an international “3 by 5” Country Officer is currently underway. • Additional staffing needs identified include five National Programme Officers to be based at the Ministry of Health, 11 National Programme Officers to be based in the regions, an administrative officer, a finance officer and a clerk.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The HIV/AIDS Prevention and Control Office, chaired by the Ministry of Health, is officially designated as the national coordinating authority for AIDS. It is supported by the United States Centers for Disease Control and Prevention and the Drug Administration and Control Authority. • Antiretroviral therapy service delivery. The Ministry of Health coordinates activities related to delivering antiretroviral therapy services. The Pharmaceuticals and Supplies Service supports procurement of drugs. The Global Fund to Fight AIDS, Tuberculosis and Malaria is supporting the HIV/AIDS Prevention and Control Office and the Ministry of Health in strengthening disbursement systems. WHO provides support in developing antiretroviral therapy guidelines and capacity-building. The United States Centers for Disease Control and Prevention has a cooperative agreement with the WHO Regional Office for Africa to support the implementation of an essential package for HIV/AIDS prevention and care, including the secondment of staff to Ethiopia. • Community mobilization. The private sector, nongovernmental organizations and faith-based organizations have expressed great interest in participating in scaling up antiretroviral therapy in Ethiopia. International nongovernmental organizations such as Médecins Sans Frontières provide antiretroviral therapy. • Strategic information. The HIV/AIDS Prevention and Control Office coordinates the national monitoring and evaluation framework. The Ethiopian Health and Nutrition Research Institute supports drug resistance surveillance. The United States Centers for Disease Control and Prevention supports surveillance activities.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Ethiopia and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

GHANA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 52 000 Antiretroviral therapy target declared by country: 30 000 by 2005

Bobo Dioulasso Orodara Banfora Gaoua Wa Diebougou

Leo

Po Bolgatanga

Latest available year for 2001− 2003 Natitingou

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1 1 − 4.9

35 200

treat Million by

Bouna

Tamale

Benin Bassar

5 − 9.9 10 −14.9

Parakou

15 −19.9

Dabakala Bondoukou

Cities and towns Sunyani

Mbahiakro Daoukro Dimbokro Bongouanou Agnibilekrou

Main roads Abomey Kpalime

Population density (pers./sq.Km)

Abengourou

Kumasi

Ho

Lokossa Porto Novo Cotonou

Less than 10

10 − 49

Tiassale

Adzope Agboville

Koforidua

Lome

50 − 99

100 −249 Aboisso Accra

250 −499

Abidjan

500 −749 Cape Coast Sekondi

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more

0

45

90

180 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 21.4 45.1 57.6 265 8.6 12 0.567 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 1.9 – 5.0% 2003 2001 June 2004 2003

210 000 – WHO/ 560 000 UNAIDS 47 444 716 52 000 not available not available 15.7% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Current surveys show an increase in adult prevalence rates from 2.3% in 2000 to 3.4% in 2002. Prevalence is highest in the Eastern region and lowest in the Northern region. The female-male ratio was 6:1 in 1987 and was estimated to be 2:1 in 2001. • Major vulnerable and affected groups. The most severely affected group is those aged 25–34 years, accounting for nearly 42% of all AIDS cases reported in 2002. People 15–24 years old are increasingly vulnerable, with a prevalence rate of 3%. HIV seroprevalence rates among sex workers increased from 2% in 1986 to nearly 40% in 1991. By 1997–1998, the HIV prevalence in Accra and Tema had reached 74.2% among “seated” (home-based) sex workers and 27.2% among “roaming” sex workers. In 1999, sex workers in Kumasi had an HIV prevalence rate of 82%. The HIV prevalence among people attending sexually transmitted infection clinics in Accra increased from 2% in 1988 to nearly 9% in 1991. In 1998, HIV infection among women attending sexually transmitted infection clinics tested in Adabraka, Greater Accra region, had reached 27%. In the Southern region, the HIV prevalence is 24.0% among people attending sexually transmitted infection clinics and 3.0% among blood donors. • Policy on HIV testing and treatment. The draft National HIV/AIDS Policy states that voluntary testing should be provided in a non-stigmatizing environment. It aims to encourage vulnerable groups to undergo regular voluntary testing and seek early diagnosis and treatment for sexually transmitted infections. The policy states that, except in the case of blood donors and people showing symptoms suggestive of AIDS, there should be no routine testing for HIV/AIDS and testing should not be done without the knowledge of the individual.

• Antiretroviral therapy: first-line drug regimen, cost per person per year. The first-line drug regimen is zidovudine + lamivudine + nevirapine or efavirenz; or stavudine + lamivudine + nevirapine or efavirenz. The cost per person per year is about US$ 600 for drugs and other services, including investigations, with user charges of 10%. • Assessment of overall health sector response and capacity. The Ghana AIDS Commission was established in 2001 and is fully operational, and is chaired by the President. The National AIDS Control Programme is in the process of developing an implementation plan to guide the provision of antiretroviral therapy in Ghana, within the framework of the National Strategic Framework on HIV/AIDS (2001–2005). Every region has an HIV/AIDS coordinator, and multisectoral AIDS committees have been established at the regional and district levels. A national monitoring and evaluation framework has been developed through a broad participatory process, and monitoring and evaluation focal points have been appointed in all 110 districts. All districts have district hospitals, and services provided include antenatal care. Public laboratory facilities are available at the regional level. High-level political commitment is evident up to the presidential level. Ghana’s health system is highly decentralized, and a sectorwide approach to health sector financing is in place. • Critical issues and major challenges. Human resource capacity is the major bottleneck for scaling up treatment, both in terms of the numbers of health care workers and technical capacity. Ghana suffers from high turnover of highly skilled personnel, as the emigration rate is high. Domestically, there are significant capacity gaps in addressing treatment, support and care; legal and ethical policy, including legal protection for people living with HIV/AIDS; and the establishment of links, networking and referral systems between the public sector and civil society.

1

© World Health Organization 2004

S U M M A R Y C O U N T R Y P RO F I L E F O R H I V / A I D S T R E AT M E N T S C A L E - U P

Côte d Ivoire

Ghana

Togo

Sotouboua

20 −29.9

30 and more

GHANA 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a situation analysis to assess opportunities and challenges for scaling up antiretroviral therapy and areas for WHO support • Supporting the development of a proposal for the World Bank Treatment Acceleration Program with a focus on scaling up antiretroviral therapy • Supporting the development of national guidelines and protocols for antiretroviral therapy, opportunistic infections, preventing mother-to-child transmission, voluntary counselling and testing and nutrition and infant feeding • Supporting the development of a national human resources plan

• Following the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS in 2001, the government directed that 15% of Ghana’s health budget will be committed to HIV/AIDS activities and encouraged all ministries to create an HIV/AIDS budget line. Through the Ghana AIDS Commission, the World Bank Multi-Country HIV/AIDS Program for Africa and the Ghana AIDS Partnership Programme funded by the United Kingdom Department for International Development have become important mechanisms for channelling funds to civil society and ministries, departments and agencies. • WHO estimates that the total funding required for scaling up antiretroviral therapy to reach the “3 by 5” treatment target of 26 000 in 2005 is between US$ 31.2 and US$ 39.7 million. • Ghana’s Round 1 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria was approved for voluntary testing and counselling activities as well as treatment at three public hospitals and one mission hospital. Total funding approved was US$ 14.1 million, including US$ 4.9 million in the first two years, and focused on accelerating prevention and care for vulnerable groups. Ghana has submitted a proposal to the Treatment Acceleration Program of the World Bank focusing on improving access to antiretroviral therapy through public-private partnerships. • The funding available to support scaling up is anticipated to include about US$ 6.7 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria, about US$ 12 million from multilateral partners, including the World Bank, and about US$ 8.1 million from bilateral partners. • Taking into account funds already committed by the government, multilateral partners, bilateral partners and nongovernmental organizations, WHO estimates the funding gap for 2004–2005 to be between US$ 5.1 million and US$ 12.8 million.

Key areas for WHO support in the future • Establishing a “3 by 5” country team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Finalizing the national HIV/AIDS policy • Supporting the accreditation of centres providing antiretroviral therapy • Developing quality assurance mechanisms for drug procurement • Developing a national training plan for scaling up antiretroviral therapy at the district level • Adapting WHO Integrated Management of Adult and Adolescent Illness guidelines and training modules on HIV/AIDS care • Developing a national communication strategy to reduce stigma and to mobilize community-based groups for treatment • Harmonizing and integrating the monitoring and evaluation system of the World Bank Treatment Acceleration Program into the national monitoring and evaluation framework • Developing guidelines for resistance monitoring as part of the international global surveillance system developed by WHO

5. Antiretroviral therapy coverage • Ghana’s total antiretroviral therapy need for 2005 is estimated to be 52 000 people, and the WHO “3 by 5” treatment target is 26 000 for the end of 2005 (based on 50% of need). The government has declared a national antiretroviral therapy target of 30 000 people by the end of 2005. • The government supported the provision of antiretroviral therapy to an estimated 716 people in 2003. • Funding committed by the government for 2004–2005 includes the purchase of antiretroviral drugs for about 4000 people.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include a National Programme Officer as a technical officer and another for HIV/AIDS. The recruitment of an international “3 by 5” Country Officer is currently planned. • The recruitment of an international staff member is also planned under the World Bank Treatment Acceleration Program.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health and the Ghana AIDS Commission provide leadership in developing national plans, coordinating national response and managing financing. Within the health sector, implementation is managed by the Ministry of Health and the Ghana Health Service, and the National AIDS Control Programme is responsible for developing and supervising clinical policy. The multisectoral National Strategic Framework on HIV/AIDS (2001–2005) guides national response and alignment of partners. WHO provides support to the Ministry of Health and the Ghana AIDS Commission in national efforts to build human resources capacity. • Antiretroviral therapy service delivery. The Ministry of Health and the Ghana Health Service provide leadership in delivering antiretroviral therapy services and began treatment in four government hospitals in 2003. Other organizations contributing to developing guidelines and managing the drug supply chain include WHO, Family Health International and UNICEF. Family Health International, nongovernmental organizations and WHO are developing a capacity-building plan. The private sector and civil society, especially nongovernmental organizations, are increasingly involved in prevention activities and providing care and support services. A limited number of private hospitals, clinics and laboratories provide voluntary counselling and testing services. • Community mobilization. The Ghana AIDS Commission, the Ministry of Local Government and Rural Development, WHO, other United Nations agencies, nongovernmental organizations and the central government all contribute to psychosocial support activities and building the capacity of people living with HIV/AIDS. The United Kingdom Department for International Development supports the social marketing of condoms and capacity-building efforts. • Strategic information. The Ghana AIDS Commission provides leadership in issues of monitoring and evaluation. The Ministry of Local Government and Rural Development, WHO, nongovernmental organizations and universities work alongside the government in developing monitoring systems, information and research systems and patient-tracking systems. The United States Agency for International Development supports monitoring and evaluation activities as well as efforts related to prevention, care and support and institutional development.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Ghana and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

GUINEA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 16 000 Antiretroviral therapy target declared by country: 20 000 by 2005

Gambia Kolda Farim

Basse Santa Su

HIV sentinel surveillance in pregnant women

Senegal Koundara Gabu Mali Gaoual Labe Pita Boke Telimele Dalaba Fria Boffa Kindia Mamou Faranah Tongue Dinguiraye

Mali Bamako

Latest available year for 2001− 2003

Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

35 200

treat Million by

Guinea− Bissau Fulacunda

Siguiri

Catio

15 −19.9

Guinea Dabola

Kouroussa Kankan

20 −29.9

30 and more

Cities and towns Conakry

Forecariah Kissidougou Makeni Kerouane

Odienne

Main roads

Population density (pers./sq.Km) Less than 10

Freetown

Sierra Leone Bo Kenema

Gueckedou Macenta Voinjama

Beyla Touba

10 − 49

50 − 99

100 −249 Nzerekore Yomou Sanniquellie Biankouma

250 −499

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Liberia Robertsport 0 45 90 180 Kilometers

Côte d Ivoire Danane Bangolo Duekoue Guiglo

500 −749

750 and more

Gbarnga

Kakata

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 8.6 34.5 52.3 362 11.3 13 0.425 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS WHO/ UNAIDS WHO/ UNAIDS WHO WHO/ UNAIDS 2003 1.2 – 8.2% 2003 2001 June 2004 2003 51 000 – 360 000 8 448 500 16 000 not available not available 8.6% WHO

3. Situation analysis • Epidemic level and trend and gender data. The spread of the HIV/AIDS epidemic in Guinea is attributed to several critical factors such as its proximity to high-prevalence countries, a large refugee population from neighbouring countries, large numbers of internally displaced people and general subregional instability. HIV prevalence in the adult population is 1.2–8.2%. The HIV prevalence among pregnant women increased from 1.5% in 1995 to 2.8% in 2001. AIDS cases comprise 52% men, 45% women and 3% children. • Major vulnerable and affected groups. The most highly affected groups include sex workers, truck drivers, armed forces personnel, mining industry workers and people with tuberculosis. • Policy on HIV testing and treatment. The National AIDS Control Policy was signed into law in 1998, which outlined the institutional framework of the national response. A new policy on both testing and treatment is currently being developed with the support of the United States Agency for International Development and Family Health International. National guidelines on treatment and monitoring procedures for antiretroviral therapy have been developed, based on WHO guidelines, and validated by all partners. However, adherence protocols have yet to be developed. • Antiretroviral therapy: first-line drug regimen, cost per person per year. All first-line drugs are on the official list of essential medicines. The drugs and prices are as follows: zidovudine + lamivudine + nevirapine (US$ 780 per year); zidovudine + lamivudine + efavirenz (US$ 1400 per year); stavudine + lamivudine + nevirapine (US$ 780 per year); and stavudine + lamivudine + efavirenz (US$ 1200 per year). No subsidies are in place for purchasing drugs, and the Pharmacie Centrale de Guinée has difficulty in supporting the direct and indirect costs of antiretroviral therapy.

• Assessment of overall health sector response and capacity. The strengths of the national response include decentralized implementation, multisectoral involvement and high political commitment, as evidenced by the location of the National AIDS Committee within the Prime Minister’s office. There is an agreed HIV/AIDS action framework based on the National Health Development Plan, the national strategic framework to combat HIV/AIDS and a strategic framework for care and treatment including antiretroviral therapy. However, the capacity of the health sector needs to be strengthened to meet the growing domestic need for scaling up antiretroviral therapy. Access to HIV testing and counselling is very limited, with only three centres operating. These centres are integrated into health facilities located in Conakry, Mamou and Guékédou. Efforts to expand voluntary counselling and testing services began recently through a partner funded by the United States Agency for International Development in collaboration with the Ministry of Health. Access to well-organized post-test services (psychosocial support, HIV-related care and treatment including antiretroviral therapy) is also very limited and has resulted in poor uptake of HIV testing and counselling services. Antiretroviral therapy is currently offered in one central hospital in Conakry and in one regional hospital in Mamou. • Critical issues and major challenges. The national response to the epidemic remains in its early stages and has been weakened by inadequate resources. Critical limitations include: inadequate human, material and financial resources; a lack of cross-sectoral collaboration; poor collaboration among implementing agencies; and a lack of a monitoring and evaluation system. No HIV sentinel surveillance programme has been conducted in Guinea since 1996. There are no

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GUINEA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP and evaluation systems. The Ministry of Planning supervises epidemiological research. WHO is working to strengthen surveillance and antiretroviral drug resistance monitoring as well as other information management activities. The United States Agency for International Development and UNICEF are supporting operational research activities in collaboration with the national university.

systems for demand forecasting or procurement logistics. Management systems for finances, human resource planning and drugs therefore require strengthening and support for scaling up antiretroviral therapy. Limited access to HIV testing and counselling services and the high cost of antiretroviral drugs remain major barriers to scaling up.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total cost to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 8000 people by the end of 2005 is between US$ 28 million and US$ 36 million. • Funds anticipated to be available to support scaling up antiretroviral therapy during 2004–2005 include about US$ 6.7 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria and about US$ 3.4 million from bilateral partners. • The World Bank Multi-Country HIV/AIDS Program for Africa provides financial support to scaling up antiretroviral therapy, and additional support is anticipated from the German development agency GTZ, the United States Agency for International Development, Médecins Sans Frontières, UNICEF, the French Cooperation and PRISM, a collaborative project between Management Sciences for Health and the United States Agency for International Development (Pour Renforcer les Interventions en Santé reproductive et MST/SIDA). Guinea currently benefits from the HIPC (Heavily Indebted Poor Countries) Initiative, in which its debt reduction must be reoriented towards financing priority health and social sectors, including HIV/AIDS. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Guinea to reach 8000 people by the end of 2005 will be between US$ 18 million and US$ 26 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a scoping mission to assess the situation of antiretroviral therapy in Djibouti and to identify opportunities and challenges for scaling up antiretroviral therapy provision and areas for WHO support • Assisting the government in developing key normative documents, including existing treatment regimens and guidelines

Key areas for WHO support in the future • Establishing a ‘‘3 by 5’’ country team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Supporting the development of the national operational plan for scaling up antiretroviral therapy • Advocating for equitable access to antiretroviral therapy • Strengthening the national capacity to absorb the resources provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank Multi-Country HIV/AIDS Program for Africa • Assisting in establishing systems for programme management and monitoring and evaluation

5. Antiretroviral therapy coverage • Guinea’s total treatment need for 2005 is estimated to be 16 000 people, and the WHO “3 by 5” treatment target is 8000 people by the end of 2005 (based on 50% of need). • The government has declared a national target of providing treatment to 20 000 people by 2005. • In 2003, an estimated 500 people, all adults, benefited from antiretroviral therapy, mostly at their own expense and at high cost.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Recruitment of an international “3 by 5” Country Officer is planned. • Additional staffing needs identified include a National Programme Officer to focus on community mobilization activities for scaling up antiretroviral therapy.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health leads national plan development, financial management and coordination of HIV/AIDS activities through the National Program for the Care, Support and Prevention of STIs and HIV/AIDS. Agencies supporting these activities include WHO, the World Bank, the United States Agency for International Development, French Cooperation, UNICEF and the United Nations Theme Group on HIV/AIDS in Guinea. The United Nations Theme Group on HIV/AIDS in Guinea has been instrumental in strengthening coordination between partners and their overall commitment to antiretroviral treatment scale-up. The CNLS (Comité National de Lutte contre le Sida) has a leading role in policy development, fundraising and programme evaluation activities. • Antiretroviral therapy service delivery. The National Program for the Care, Support and Prevention of STIs and HIV/AIDS currently manages all clinical elements of the government’s response to the epidemic, including testing, counselling, laboratories, capacity-building, developing guidelines and providing support for people living with HIV/AIDS. UNICEF provides leadership in procurement and supply chain management activities working alongside the Pharmacie Centrale de Guinée. WHO, UNICEF, the United States Agency for International Development, the World Bank, GTZ and UNFPA support activities to build capacity, promote training and accelerate prevention. • Community mobilization. The National Program for the Care, Support and Prevention of STIs and HIV/AIDS provides leadership in all elements of community mobilization. The Ministry of Communication plays an active role in communication and sensitization related to behaviour change, supported by UNICEF and the United States Agency for International Development. Several nongovernmental organizations and associations of people living with HIV/AIDS are actively involved in community mobilization activities related to antiretroviral therapy at all levels. • Strategic information. The Ministry of Health, through the National Program for the Care, Support and Prevention of STIs and HIV/AIDS, coordinates and manages activities related to monitoring and evaluation, antiretroviral drug resistance, patienttracking systems, operational research and information management. The CNLS is mandated to coordinate multisectoral activities, including country-level monitoring

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Guinea and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

HAITI

July 2004

WHO estimate of number of people requiring treatment – end 2005: 40 000 Antiretroviral therapy target declared by country: 5 000 – 10 000 by the end of 2004

HIV sentinel surveillance in pregnant women

Cuba Port− De− Paix Monte Cristi Cap− Haitien Liberte Fort− Dajabon Gonaives

Latest available year for 2001 −2003 Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9 15 −19.9 20 −29.9

35 200

treat Million by

Hinche

30 and more

Haiti Jeremie au− Prince Port−

Cities and towns Elias Pina

Main roads

Population density (pers./sq.Km) Jimani

Less than 10

10 − 49

50 − 99 Les Cayes Jacmel

100 −249

250 −499 Pedernales

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more 0 20 40 80 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 8.4 37.2 50.1 431 14.1 22 0.467 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 2.5 – 11.9% Source WHO/ UNAIDS

120 000 – WHO/ 600 000 UNAIDS 8 902 1 370 40 000 not available not available 28% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Haiti, with a population of 8 million, has the highest HIV prevalence rates in Latin America and the Caribbean. It faces the worst AIDS epidemic outside Africa. Haiti is confronting a generalized epidemic fuelled by endemic poverty with high illiteracy rates, inadequate health and social services that are further weakened by chronic political instability such as the social and political events of 2003–2004, high internal migration rates and a high prevalence of sexually transmitted infections. HIV infection rates may no longer be rising and may potentially be declining in some areas; however, strong caution should be exercised in interpreting these data because the available information is limited. • Major vulnerable and affected groups. The epidemic began in the late 1970s and has spread widely throughout Haiti. The most common mode of transmission is heterosexual contact, with women comprising half the people living with HIV/ AIDS. An estimated 4000 cases of mother-to-child transmission occurred during 2003. AIDS is the leading cause of death among adult women and has orphaned more than 200 000 children. Young people and people living in urban areas are particularly affected. The rate in some regions may be three times the national rate. • Policy on HIV testing and treatment. Among the strategies for the comprehensive management of people living with HIV/AIDS, the HIV/AIDS National Strategic Plan for 2002–2006 emphasizes care and treatment as critical strategies as well as rapidly scaling up voluntary counselling and testing.

• Antiretroviral therapy: first-line drug regimen, cost per person per year. National norms and guidelines are currently being developed. Highly active antiretroviral therapy is available from two nongovernmental organizations (the Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO) and Zanmi Lasanté), in coordination with the Ministry of Public Health and Population. Various first-line regimens are in use: zidovudine + lamivudine + efavirenz or zidovudine + lamivudine + nevirapine and stavudine + lamivudine + nevirapine. UNAIDS estimates that the annual cost per person is about US$ 720 for first-line regimens and from US$ 900 to US$ 1920 for second-line regimens. Generic drugs are available, but access to generics is limited by weaknesses in the global supply management system. • Assessment of overall health sector response and capacity. To date, only 6% of the estimated number of people living with HIV/AIDS who need treatment are receiving highly active antiretroviral therapy. The social and political events of 2003–2004 worsened the existing inadequacy of health sector response and capacity. Strengthening the health sector is thus critical for scaling up antiretroviral therapy. • Critical issues and major challenges. Treatment is incompletely integrated into the existing health system and services, especially in tuberculosis and antenatal settings. The various initiatives and activities related to care need to be coordinated better. Tools, treatment protocols and models of service delivery are not standardized. Access to voluntary counselling and testing services is limited, especially among pregnant women and youth in high-prevalence areas. HIV/AIDS care and management has insufficient qualified human resources. The comprehensive supply management of drugs and diagnostics is fragmented. Monitoring and evaluation systems urgently need to be strengthened.

1

© World Health Organization 2004

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HAITI 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Providing assistance in developing the HIV/AIDS National Strategic Plan for 2002–2006 and supporting activities related to strengthening the health system and developing guidelines • Supporting capacity-building among people living with HIV/AIDS, developing a nutrition project, developing monitoring and surveillance systems and strengthening in-country information management activities.

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 20 000 people in 2005 is between US$ 58 million and US$ 62 million. • Commitments from the Global Fund to Fight AIDS, Tuberculosis and Malaria are expected to provide about US$ 4 million for scaling up antiretroviral therapy for 2004–2005. Haiti is also receiving strong support from the United States President’s Emergency Plan for AIDS Relief, with estimated commitments of more than US$ 41.6 million to fund treatment during 2004–2005. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Haiti to reach 20 000 people by 2005 is between US$ 9 million and US$ 13.4 million.

Key areas for WHO support in the future • Establishing a “3 by 5” Country Officer in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Providing support to projects among the population infected or affected by HIV/AIDS to generate financial resources and strengthen community participation • Supporting five administrative health units with antiretroviral therapy and coordinating and facilitating activities for sharing lessons learned

5. Antiretroviral therapy coverage • Haiti’s total antiretroviral therapy need in 2005 is estimated to be 40 000 people, and the WHO “3 by 5” treatment target is 20 000 people by the end of 2005 (based on 50% of need). The government has declared a national treatment target of 5000–10 000 people by the end of 2004, and the United States President’s Emergency Plan for AIDS Relief plans to treat 25 000 people by the end of 2007. • Total antiretroviral therapy provision during 2003 was estimated to be 1370, primarily through private sector involvement. Haiti’s Round 1 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria is expected to provide antiretroviral therapy to more than 1200 people living with HIV/AIDS and is expected to extend highly active antiretroviral therapy coverage to 30% of the need by 2007.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer. The recruitment of an international “3 by 5” Country Officer is currently underway. • Additional staffing needs identified include both an international expert and a national expert with backgrounds in HIV/AIDS to support the Ministry of Public Health and Population.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Public Health and Population provides leadership, and the UCC (Unité de coordination centrale) under the Ministry takes technical responsibility. The UCC also provides leadership in policy, implementation and coordination. Political instability is weakening national leadership, but the Ministry of Public Health and Population receives growing support from the United States Agency for International Development. The United States President’s Emergency Plan for AIDS Relief and the United States Centers for Disease Control and Prevention support financial management. The Ministry along with WHO provides leadership in activities to strengthen the health system, but these activities suffer from a lack of coordination. • Antiretroviral therapy service delivery. Several nongovernmental organizations play an important role in reaching to vulnerable populations. The United States Agency for International Development facilitates all activities conducted by United States partners through the United States President’s Emergency Plan for AIDS Relief. Family Health International provides clinical training. Nongovernmental organizations supporting scaling up antiretroviral therapy include GHESKIO and Médecins du Monde, which are active in preventing mother-to-child transmission. Additionally, several bilateral partners (including France and Canada) support activities relevant to scaling up antiretroviral therapy. UNICEF also works in antenatal settings. In 1998, Partners in Health began providing highly active antiretroviral therapy to a small number of its patients with advanced AIDS under directly observed therapy. The Red Cross is contributing to expanding access to safe blood and blood products. • Community mobilization. UNAIDS and WHO provide leadership in capacity-building for people living with HIV/AIDS, supported by a number of nongovernmental organizations including Concern Worldwide, GHESKIO and the Clinton Foundation. Other nongovernmental organizations including Population Services International and PLAN International provide leadership in programme communication activities, with support from UNICEF and WHO. Partners in Health has been working in Haiti for 15 years on tuberculosis and AIDS and has been providing HIV education in Haiti since 1986. Population Services International has been active in Haiti for 12 years in social marketing of condoms and contraceptives and in communication on behaviour change. CARE has managed mitigation programmes for several years in the southern part of Haiti, including community care and support for people living with HIV/AIDS and their families. • Strategic information. The UCC, the United States Centers for Disease Control and Prevention and WHO provide leadership in monitoring systems, but systems have not yet been standardized. Information management activities are generally led by GHESKIO, the United States Centers for Disease Control and Prevention, UCC and WHO.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Haiti and the WHO Regional Office for the Americas.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

INDIA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 710 000 Antiretroviral therapy target declared by country: 100 000, starting on 1 April 2004

35 200

treat Million by

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 1 081 28.2 61 471 3.1 24 0.590 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 0.4 – 1.3% 2003 2001 June 2004 2003

2 200 000 – WHO/ 7 600 000 UNAIDS 8 438 21 000 710 000 not available not available 4.6% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Annual national surveillance rounds show that the prevalence of HIV among adults is increasing in all 25 states. Of these, six states (four southern: Tamil Nadu, Maharashtra, Karnataka and Andhra Pradesh; and two north-eastern: Nagaland and Manipur) have generalized epidemics with a high intensity of transmission. In the four southern states, the predominant mode of transmission is sexual, whereas the predominant mode in the two north-eastern states is injecting drug use. In addition, eight states (Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh, Chattisgarh, Jharkhand, Uttaranchal and Orissa) are especially vulnerable, as reflected by low economic performance indicators, low health status, high mobility, the presence of tribal communities with limited access to health services and, for Uttar Pradesh and Bihar, very large populations. Together these 14 states account for 89% of all reported AIDS cases and 70% of the country’s population. Three states (Goa, Pondicherry and Gujarat) have concentrated epidemics, and the remaining states are experiencing low-level epidemics. The proportion of women among reported AIDS cases is increasing in all states, reflecting the greater vulnerability of women to HIV/AIDS, especially in rural areas. In the six high-prevalence states, the HIV prevalence among pregnant women exceeds 1%. • Major vulnerable and affected groups. Vulnerable groups include injecting drug users, female sex workers, men who have sex with men, migrants and other mobile groups such as truck drivers. The epidemic is spreading from “high-risk” groups to the general population and from urban to rural areas. Factors contributing to this increase include increasing migration to high-prevalence areas for employment opportunities, high rates of sexually transmitted infections, low levels of awareness in rural areas, low condom use and rising levels of unsafe sex among young people.

• Policy on HIV testing and treatment. The government has issued a comprehensive HIV testing policy indicating that no individual should undergo mandatory testing for HIV; that mandatory HIV testing should not be imposed as a precondition for employment or for providing health care facilities during employment; that adequate voluntary testing facilities with pretest and post-test counselling should be made available throughout India in a phased manner; and that each district should have at least one HIV testing centre with proper counselling facilities. Any person who wishes to know his or her HIV status should have access to all necessary facilities, and the results should be kept confidential. In marriage, if one of the partners insists on a test to check the HIV status of the other partner, such tests should be carried out by the contracting party to the satisfaction of the person concerned. For HIV testing facilities in private sector hospitals, clinics, nursing homes and diagnostic centres, the state governments should adopt legislative and other measures to ensure that these testing centres conform to the national policy and guidelines related to HIV testing. In December 2003, the government announced a strong policy and programme commitment to provide antiretroviral treatment to 100 000 people living with HIV/AIDS, free of charge, with implementation starting on 1 April 2004. The main target subgroups of this programme are seropositive mothers who have participated in the programme for the prevention of motherto-child transmission; seropositive children under 15 years; and people with AIDS who seek treatment at the designated hospitals. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Recommended firstline antiretroviral regimens for adults and adolescents include stavudine + lamivudine + nevirapine or zidovudine + lamivudine + nevirapine or stavudine + lamivudine + efavirenz or zidovudine + lamivudine + efavirenz. The stavudine + lamivudine + nevirapine combination costs US$ 160 per person per year.

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INDIA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

• Assessment of overall health sector response and capacity. The National AIDS Control Organization (NACO) is responsible for coordinating the overall health sector response to HIV/AIDS, supported by the state AIDS control societies at the state level. The National AIDS Control Programme, first launched in 1987, is now in its second phase (1999–2004). Its objective is to reduce the transmission of HIV through a decentralized and comprehensive programme of generating awareness, changing behaviour, targeting vulnerable groups with intervention and conducting research. In December 2003, the government also committed to expanding access to treatment for people living with HIV/AIDS. India has a sizeable pool of physicians and other health professionals and well-developed health service infrastructure. Training in HIV care is now part of all medical and nursing curricula, and national guidelines on antiretroviral therapy are in the process of being finalized. India also has the advantage of an established domestic drug manufacturing base. • Critical issues and major challenges. Key issues include ensuring the quality and safety of antiretroviral therapy, strengthening systems to procure medicines and diagnostics and to supply them to treatment centres and increasing access to and the quality of voluntary counselling and testing services. Equally important is engaging private sector providers in scaling up access to antiretroviral therapy and strengthening the integration of services with other prevention, care and support interventions as well as public health programmes such as programmes for sexually transmitted infections and tuberculosis. National systems for monitoring and evaluation and surveillance of drug resistance need to be strengthened. Women and vulnerable populations must be empowered to increase access to and use of antiretroviral therapy.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The NACO coordinates all prevention and control activities related to HIV/AIDS. Various ministries and departments, private sector organizations and nongovernmental organizations implement HIV/AIDS programmes in collaboration with the NACO. WHO and UNAIDS provide support in developing national plans, coordinating implementation and making policy. A joint Programme Committee consisting of senior representatives of the NACO, the consortium of nongovernmental organizations and co-opted experts has been set up to ensure that the efforts undertaken by partners are harmonized. At the state level, activities will be coordinated by the State Antiretroviral Therapy Programme Implementation Committee, under the leadership of the state AIDS control societies. • Antiretroviral therapy service delivery. The NACO provides leadership in delivering antiretroviral therapy services, including procurement and supply chain management, developing guidelines, building capacity and laboratories and diagnostics. WHO, UNAIDS, UNICEF and the United States Centers for Disease Control and Prevention support activities. • Community mobilization. More than 800 nongovernmental organizations are involved in prevention, care and support interventions across India. A consortium of nongovernmental organizations was created recently to manage subgrants to community-level nongovernmental organizations. People living with HIV/AIDS are also extensively involved in national prevention and treatment programmes. They refer people for antiretroviral therapy, provide support and peer counselling to people on antiretroviral therapy, help maintain high rates of adherence and provide psychosocial support to the families and friends of people living with HIV/AIDS. The private sector also works in partnership with the public health system and nongovernmental organizations to support workplace interventions. • Strategic information. The NACO coordinates monitoring and evaluation of HIV/AIDS programmes, supported by WHO, the United States Centers for Disease Control and Prevention and the Indian Council for Medical Research. The NACO has developed monitoring tools for scaling up antiretroviral therapy in consultation with various stakeholders, including United Nations and bilateral agencies. The tools have been fieldtested and are being used by implementing institutions. The Indian Council for Medical Research conducts drug resistance surveillance.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 355 000 people by the end of 2005 is between US$ 234 million and US$ 300 million. • National budgetary allocations for HIV/AIDS programmes have increased over the years. The five-year budget of the National AIDS Control Programme has increased from US$ 100 million for the first phase (1992–1997) to US$ 300 million in the second phase (1999-2004). • In 1999, a loan of US$ 191 million was signed with the World Bank for implementing the second phase of the National AIDS Control Programme. • The Global Fund to Fight AIDS, Tuberculosis and Malaria granted US$ 26.1 million over two years in Round 2 with a focus on preventing mother-to-child transmission, implementing a comprehensive care package for mothers living with HIV/AIDS and their infants and partners and enhancing access to antiretroviral therapy through publicprivate partnerships. • India submitted a successful Round 3 proposal to the Global Fund to address HIV and tuberculosis coinfection, with two-year approved grant funding of US$ 2.6 million. • The Country Coordinating Mechanism has submitted a proposal to the Global Fund for US$ 165 million over five years in Round 4, with a focus (80% of the total budget) on launching a large-scale, phased initiative on antiretroviral therapy access closely linked to expanded prevention and support and on increasing the engagement of the private sector and the civil society sector, including people living with HIV/AIDS. • Other key bilateral and multilateral sources of funding for activities related to HIV/AIDS include the United Kingdom Department for International Development, the United States Agency for International Development, UNDP, UNICEF, the Australian Agency for International Development and the Bill & Melinda Gates Foundation. • Taking into account all funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for India to reach 355 000 people by the end of 2005 is between US$ 19 million and US$ 72 million.

7. WHO support for scaling up antiretroviral therapy WHO's response so far • Conducting a WHO scoping mission in December 2003 in collaboration with UNICEF, UNAIDS and national partners to identify opportunities and challenges for scaling up antiretroviral therapy and to identify areas for WHO support • Providing support to the NACO to develop the Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria • Providing technical assistance to review and finalize national antiretroviral therapy guidelines and the national operational plan for scaling up antiretroviral therapy

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Providing technical assistance to the NACO to finalize antiretroviral therapy training modules • Providing technical assistance to the NACO to strengthen programme monitoring and evaluation and drug resistance surveillance • Providing technical assistance in developing communication on programmes for scaling up antiretroviral therapy

5. Antiretroviral therapy coverage • India’s total treatment need for 2005 is estimated to be 710 000 people, and the WHO “3 by 5” treatment target is 355 000 people by the end of 2005 (based on 50% of need). • As of June 2004, an estimated 21 000 people were receiving treatment, mostly through the private sector. • The Round 2 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria is expected to provide antiretroviral therapy to nearly 4500 women and their partners and children. The objective of the Global Fund Round 4 proposal is to provide 180 000 people with antiretroviral therapy in the public sector and 200 000 people with antiretroviral therapy in the private sector by the fifth year. • The government is committed to providing treatment to 100 000 people living with HIV/AIDS, starting on 1 April 2004. • Some treatment is provided through the private not-for-profit and the corporate sectors. The Employees State Insurance Scheme in the public sector and the Central Government Health Scheme also provide antiretroviral therapy services to employees.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway. • Additional staffing needs identified include a National Programme Officer, a technical officer and national consultants.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for India and the WHO Regional Office for South-East Asia.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

INDONESIA ������� ����� � ������

July 2004

WHO estimate of number of people requiring treatment – end 2005: 7 100 Antiretroviral therapy target declared by country: 10 000 by 2005

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Map data sources: Ministry of Health, Indonesia; WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

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1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2002 2002 2001 2001 2001 2001 Estimate 222.6 44.9 66.4 678 3 16 0.682 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2003 2003 2003 June 2004 2003 2004 Estimate <0.2% 53 000 – 180 000 1 371 1 500 7 1001 25 not available not available Source WHO/ UNAIDS WHO/ UNAIDS WHO WHO WHO/ UNAIDS Ministry of Health

3. Situation analysis • Epidemic level and trend and gender data. HIV transmission was initially related to sexual transmission, but transmission among injecting drug users has increased eight-fold since 1998. HIV prevalence and epidemic dynamics vary greatly across Indonesia. Six provinces are most heavily burdened: Bali, East Java, Jakarta, Papua, Riau and West Java. Injecting drug users represent most new HIV cases reported nationally, with concentrated HIV epidemics among male injecting drug users in several provinces. Heterosexual transmission dominates in Papua, with concentrated epidemics among female sex workers. Because of limitations in the national HIV/AIDS surveillance system, few cases are identified and reported at the national level. As of December 2003, a total of 2720 HIV-positive cases, 1371 AIDS cases and 479 AIDS-related deaths had been reported to the Ministry of Health. Among the AIDS cases, 78% were men; and heterosexual transmission accounted for 51%, injecting drug use for 26% and men who have sex with men for 9%. Major vulnerable and affected groups. Seroprevalence among highly affected populations of injecting drug users has reached as high as 48% in Jakarta, 53% in Denpasar, Bali, and 24% in West Java. Merauke Papua has the highest prevalence rate among female sex workers (26.5%). The 2002 national estimates indicated that the HIV prevalence ranges from 19.2–34.4% among injecting drug users and 2.0–5.2% among sex workers. Other groups highly affected were Waria (transsexuals) (9.3–27%) and prisoners (8.6–22%). The HIV prevalence among men who have sex with men was estimated to be 0.4–1.3%. Policy on HIV testing and treatment. HIV testing and counselling services are based on principles promoted by WHO. The Ministry of Health is finalizing national guidelines for HIV testing and counselling, and training modules and materials have been developed. The availability and user cost of testing and counselling services varies between provinces. Access is limited, and stigmatization remains an obstacle to use. Physicians mostly refer symptomatic people for HIV testing and counselling. The practices are not standardized; HIV testing and counselling services in sexually transmitted infections, tuberculosis, antenatal and drug dependence services do not exist or are not well developed. Antiretroviral therapy: first-line drug regimen, cost per person per year. The Ministry of Health has developed national guidelines for antiretroviral therapy and case management, along with

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training curricula. The recommended first-line regimen is zidovudine + lamivudine + nevirapine. Most antiretroviral drugs have been registered in Indonesia but are not widely available, especially not outside Jakarta. Efavirenz is not yet registered, although it can be made available through an exemption scheme. Few generic antiretroviral drugs are registered. The envisaged supply system will rely on the local production of these three antiretroviral drugs by Kimia Farma, already approved by the Food and Drugs Control. The cost of the triple regimen is about US$ 564 per person per year. The Ministry of Health has committed to subsidizing the treatment of 4000 people in 2004 so that they only have to pay US$ 300 per person per year. The commitment of provinces to provide additional subsidies varies. Assessment of overall health sector response and capacity. Indonesia’s health system is highly decentralized; provincial and district health services have significant autonomy to determine policies, priorities and financing. Local initiatives for antiretroviral therapy have been launched throughout Indonesia, under the commitment of local authorities and of physicians taking care of people living with HIV/AIDS. Treatment models including adherence counselling have been developed at the central level, taking into account experiences from local initiatives. A total of 25 hospitals in the 13 priority provinces have been identified as ART service delivery points. Critical issues and major challenges. The current national capacity to respond to scaling up (including HIV testing and counselling, case management, adherence counselling, laboratory monitoring and treatment support) is inadequate to achieve the national target for antiretroviral therapy. A systematic approach to building institutional and human resources capacity will have to be developed across the health sector for this purpose. The coverage of HIV/AIDS programmes targeting injecting drug users and sex workers is extremely low. Promising small-scale programmes exist for injecting drug users, including methadone maintenance, peer outreach, risk reduction counselling, HIV testing and counselling, condom distribution to drug users and support groups for people living with HIV/AIDS, but coverage is inadequate to affect the overall epidemic. Stigma, discrimination and cultural norms create difficulty in reaching the most vulnerable populations and in implementing effective prevention and treatment interventions.

1 1

The Ministry of Health estimates the total number needing antiretroviral therapy in 2005 is 9 200 (2003).

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INDONESIA 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • • • •

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP memorandum of understanding with the National Narcotic Board providing opportunities for scaling up effective HIV/AIDS prevention and care programmes for injecting drug users. Strategic information. Activities have mainly focused on HIV surveillance. Since 1993, an updated HIV sentinel surveillance system has been operating under the centres for disease control of the Ministry of Health, which mainly target female sex workers. Thirteen of 30 provinces are reporting surveillance data. In some provinces, unlinked anonymous surveys are also conducted among prisoners and pregnant women attending antenatal clinics. Ad hoc surveys are conducted for injecting drug users, clients of sex workers, men who have sex with men and attendees of sexually transmitted infections clinics, mainly with the support of Family Health International and the Australian Agency for International Development. A standard monitoring system for HIV testing and counselling and antiretroviral therapy is not in place, and the local monitoring is not coordinated between various services. WHO, UNAIDS, international donors and the Global Fund are supporting the National AIDS Commission and the Ministry of Health in establishing a comprehensive monitoring and evaluation system.

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WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 3550 people by the end of 2005 is between US$ 41.5 million and US$ 52 million. The Ministry of Health has identified US$ 1.2 million for 2004 to subsidize the cost of antiretroviral drugs. Provincial governments are identifying additional resources to varying degrees. Subsidies for related services, such as voluntary counselling and testing, drugs for opportunistic infections and laboratory services, will highly depend on commitment and allocations from local governments, and other donors. Indonesia has requested a total of US$ 15.9 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria and has approved two-year funding of US$ 6.9 million for HIV/AIDS of which a small fraction is allocated for antiretroviral therapy (for 200 people). Several bilateral donors are supporting activities related to HIV/AIDS, but these do not include antiretroviral therapy. Several nongovernmental organizations support treatment and care, of which only Médecins Sans Frontières directly funds antiretroviral therapy. Indonesia’s Round 4 proposal to the Global Fund has a subcomponent on HIV/AIDS treatment and care and includes antiretroviral therapy for 20 000 people by the fifth year. Of US$ 65 million requested over five years for prevention and treatment, US$ 25.4 million is for drugs (antiretroviral drugs and drugs for prophylaxis and treating opportunistic infections), including US$ 4.2 million in the first year. Taking into account the funds committed to date, WHO estimates that the total funding gap for Indonesia to reach 3550 people by the end of 2005 is between US$ 30.3 million and US$ 40.8 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • • • • • • Conducting a comprehensive “3 by 5” scoping mission in January 2004 and preparing a set of recommendations for country action and WHO support Supporting a workshop in Indonesia in December 2003 on HIV/AIDS prevention and treatment among injecting drug users that addressed issues related to scaling up harm reduction and linking HIV/AIDS treatment and care with services for drug users Funding two pilot methadone programmes in Bali and Jakarta as HIV/AIDS prevention programmes and funding for delivering antiretroviral therapy to drug users Providing assistance to the Ministry of Health in developing a national plan for scaling up antiretroviral therapy, guidelines on antiretroviral therapy and a monitoring and evaluation plan Providing technical assistance in procuring drugs and managing supply Providing technical support for the Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria, with a particular focus on the HIV/AIDS treatment and care subcomponent

5. Antiretroviral therapy coverage • • • National estimates indicate that Indonesia’s total treatment need for 2005 is 9 200 people, and the WHO “3 by 5” treatment target is 3550 people for the end of 2005 (based on 50% of WHO estimated need). The country-declared national treatment target is 5000 people by the end of 2004 and 10 000 people by the end of 2005. As of June 2004, an estimated 1500 people have started antiretroviral therapy through government services; 90% are paying the full cost of treatment and care. No data are available on antiretroviral therapy prescribed in the private sector, but proprietary antiretroviral drugs are seldom available in private pharmacies and mostly limited to Jakarta.

Key areas for WHO support in the future • • • • • • • • Establishing a “3 by 5” country team to provide technical assistance to the government and partners in scaling up antiretroviral therapy Providing technical support to the recently established National HIV/AIDS Treatment and Care Advisory Committee and the coordination unit at the central and provincial levels Providing technical assistance in developing the strategic and operational plan for scaling up antiretroviral therapy, including building human resources capacity and determining costs Providing assistance to the government in establishing a communication strategy for promoting the “3 by 5” Initiative, including fact sheets, posters and information leaflets for people living with HIV/AIDS Providing technical assistance in establishing testing and counselling services for all entry points, hospital or community-based Providing technical assistance in reviewing and implementing (including training) national guidelines on HIV testing and counselling, antiretroviral therapy and case management Providing assistance for adapting and translating WHO tools and guidelines relating to scaling up antiretroviral therapy (toolkit) Providing technical assistance for strengthening laboratory services, including training laboratory technicians in HIV testing methods, CD4 count technology and laboratory monitoring of antiretroviral therapy, setting standards and implementing quality assurance practices in 25 hospitals Providing assistance for adapting and translating WHO tools and guidelines for HIV/AIDS prevention, treatment and care for vulnerable populations, including toolkits on injecting drug use, drug substitution therapy, condom promotions, sex work and men who have sex with men Providing advice on international pricing, drug procurement and prequalified antiretroviral drugs, opportunistic infection drugs and diagnostics Providing technical assistance for developing a national monitoring and evaluation plan for scaling up antiretroviral therapy and a surveillance system for antiretroviral drug resistance Supporting the development of operational research on antiretroviral therapy adherence, especially among vulnerable populations

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health is taking the lead in developing a plan for HIV/AIDS treatment and care (including antiretroviral therapy) as a core element of the comprehensive national HIV/AIDS response. Various Ministry of Health directorates and other units are actively involved, such as centres for disease control, medical services, pharmaceutical services, community health services and laboratory services. Since 2001, a decentralized process has transferred budget to the districts and municipal administrations. A National AIDS Commission was established in 1994 and is coordinated by the Ministry of Social Welfare. AIDS commissions were then established in every province (headed by the vice-governor) and districts. Not all are fully functioning, especially in districts. The National HIV/AIDS Strategy for 2003–2007 identified seven programme priorities: HIV/AIDS prevention, care and treatment; support for people living with HIV/AIDS; surveillance of HIV/AIDS and sexually transmitted infections; operational studies and research; enabling environments; coordination of multiple stakeholders; and a sustainable response. The Coordinating Minister for People’s Welfare convened a meeting in January 2004 with six other ministers represented on the National AIDS Commission and governors of the six most affected provinces. The meeting produced the Sentani Commitment, which endorses scaling up antiretroviral therapy to at least 5000 people by the end of 2004, reducing harm and promoting condoms. The government is finalizing a national policy for antiretroviral therapy with the support of WHO. Antiretroviral therapy service delivery. The Ministry of Health provides overall leadership in delivering antiretroviral therapy services. Family Health International has conducted training for counsellors in 10 provinces, but the counselling is still seldom available. A pilot project for preventing mother-to-child transmission has been implemented in two sites. In Jakarta, Pellita Ilmu supports the project, and in Merauke District in Papua Province, the District Public Office Project targets four health centres and traditional birth attendants. WHO is assisting the government in integrating services for HIV/AIDS and tuberculosis. The Working Group on AIDS from the Faculty of Medicine has conducted training in HIV testing and counselling, antiretroviral therapy management for physicians and nurses and HIV/AIDS care and support for treatment supporters. Community-based and nongovernmental organizations are providing most services for vulnerable populations, depending greatly on external funding from international donors, including the Australian Agency for International Development and Family Health International. The Working Group on AIDS from the Faculty of Medicine supports the ad hoc system for supplying unregistered generic antiretroviral drugs, which are imported using a special access permit. Kimia Farma has a nationwide distribution system that will supply the hospitals designated for providing antiretroviral therapy. Community mobilization. Throughout the country, many promising but small-scale projects target vulnerable populations, especially injecting drug users and sex workers. Most projects focus on preventing HIV/AIDS with a limited emphasis on treatment and care, but many community-based and nongovernmental organizations are very well placed to monitor and support people living with HIV/AIDS on treatment through such mechanisms as case management, adherence monitoring, buddy systems, home visits and home-based care. Referral systems between community-based and nongovernmental organizations and government facilities are less than optimal. The National AIDS Commission recently signed a

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Staffing input for scaling up antiretroviral therapy and accelerating prevention • The WHO Country Office has one international HIV/AIDS Medical Officer (with a focus on HIV/AIDS prevention) and an HIV/AIDS National Professional Officer. An international “3 by 5” Country Officer is in the process of being recruited to provide overall coordination and management of WHO support in Indonesia. Additional staff needs identified include nine National Programme Officers: one as a treatment liaison officer, one as a monitoring and evaluation officer, one to support For further procurement and capacity-building and one for each of the six priority provinces to support information, scaling up antiretroviral therapy. please contact:

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World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Indonesia and the WHO Regional Office for the South-East Asia.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

KENYA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 220 000 Antiretroviral therapy target declared by country: 95 000 by 2005

Sudan

Ethiopia Garbahaarey

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

Latest available year for 2001− 2003

35 200

treat Million by

Moroto

Uganda Mbale

Wajir

Somalia Bu’aale

15 −19.9

20 −29.9

Kampala

Jinja

Kakamega Kisumu Nakuru

Nyeri

Embu

Kismaayo

Cities and towns

Main roads

Nairobi Musoma

Population density (pers./sq.Km) Less than 10

10 − 49 Mwanza

50 − 99

100 −249

United Republic of Tanzania Shinyanga

Moshi

250 −499

Arusha Mombasa

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more

Singida

0

60

120

240 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 32.4 38.8 50.9 367 6.2 29 0.489 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) Estimate Source WHO/ UNAIDS 2003 4.7 – 9.6% 2003 2001 June 2004 2003 2003 2003 2002

820 000 – WHO/ 1 700 000 UNAIDS 81 492 11 000 220 000 304 123 060 51.4% WHO/ UNAIDS WHO WHO/ UNAIDS Ministry of Health Ministry of Health WHO

3. Situation analysis • Epidemic level and trend and gender data. In 1999, Kenya declared HIV/AIDS a national disaster and public health emergency as a result of the following disturbing statistics. An estimated 820 000 to 1.7 million people are living with HIV/AIDS in Kenya. An estimated 1.5 million people have died from AIDS since 1984. More than 1.2 million children younger than 15 years (3.7% of the total population) have been orphaned through the death of their mother. At least 180 000 people die from AIDS annually. • Major vulnerable and affected groups. Vulnerable groups include AIDS orphans, pregnant women and rural populations living in areas with a high burden of disease. Women 15–24 years of age are more than twice as likely to be infected as men this age. The prevalence of HIV is higher in urban areas: about 15.3% among pregnant women. • Policy on HIV testing and treatment. The government established the National AIDS Control Council in November 1999 to oversee all HIV/AIDS matters. The Council has in place the Kenya National HIV/AIDS Strategic Plan 2000–2005, whose overriding theme is social change to reduce HIV/AIDS and poverty. Other supportive policies include the Sessional Paper No. 4 of 1997, providing a policy framework to guide all partners in Kenya’s response to the challenges of HIV/AIDS. Other indications of political commitment include a condom policy, national guidelines on voluntary counselling and testing, guidelines on national home-based care programmes and services, guidelines on blood safety, guidelines on antiretroviral therapy and guidelines on preventing mother-to-child transmission. A new policy on diagnostic testing and counselling is expected to be finalized by July 2004.

• Antiretroviral therapy: first-line drug regimen, cost per person per year. The first-line drug regimen consists of a generic form of the fixed-dose combination stavudine + lamivudine + nevirapine and costs US$ 240 per person per year. First-line therapy also substitutes efavirenz for nevirapine for two months for people in the initiation stage of tuberculosis treatment and switches drugs in case of complications (to stavudine + lamivudine + efavirenz or zidovudine + lamivudine + efavirenz). The average cost per person per year of this treatment course is US$ 284. The national authorities have approved all first-line drugs. • Assessment of overall health sector response and capacity. Kenya’s response to HIV/AIDS is addressed primarily through the National AIDS Control Council and the National AIDS and STDs Control Programme (NASCOP). Kenya has made significant progress in preparing for institutionalizing care and treatment and has advanced plans to open 30 comprehensive care centres, including all provincial hospitals, 15 highvolume district hospitals and support to six mission hospitals. • Critical issues and major challenges. Health facilities are understaffed; an additional 2100 staff are estimated to be required to support scaling up antiretroviral therapy. Several areas need to be developed further, including aligning and coordinating partners around scaling up, developing a national human resources plan to support scaling up, improving capacity to develop operational research for antiretroviral therapy and further developing protocols on antiretroviral therapy and adherence. Treatment literacy is very low, which is associated with very high levels of stigma among health workers and general population. Although an estimated 11 000 people are receiving antiretroviral therapy, systematic monitoring and evaluation is lacking.

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Kenya

30 and more

KENYA 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Supporting the training of health workers in the rational use of antiretroviral drugs in 15 health centres • Supporting the development of proposals for the Global Fund to Fight AIDS, Tuberculosis and Malaria and planning for implementation • Under the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, providing support for: expanding and promoting voluntary counselling and testing services; expanding and promoting services for preventing mother-to-child transmission; building institutional capacity (Ministry of Health) to identify and document best practices in voluntary counselling and testing and preventing mother-to-child transmission; and building the capacity of the WHO Country Office and the Ministry of Health by financially supporting one National Programme Officer and a project coordinator based in the NASCOP

• WHO estimates that the total funding required to scale up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 110 000 people in 2005 is between US$ 286.3 million and US$ 336.5 million. Of this amount, government resources are expected to fund US$ 79.7 million. Kenya receives substantial support from the United States President’s Emergency Plan for AIDS Relief, with expected commitments of US$ 143.85 million for 2004–2005 and support from other bilateral partners of about US$ 17.2 million over the same period. • Kenya submitted a successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria and was granted US$ 36.7 million for the HIV/AIDS component. A portion of the funding from Round 2 is proposed to be reallocated to HIV/AIDS care and, specifically, to antiretroviral therapy. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Kenya to reach 110 000 people by the end of 2005 is between US$ 39.6 million and US$ 60.7 million.

Key areas for WHO support in the future • Establishing a “3 by 5” country team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Supporting finalization of Kenya’s operational plan for scaling up antiretroviral therapy • Supporting monitoring and evaluation activities, including designing and implementing a national system for patient tracking and monitoring and evaluation • Addressing WHO certification of fixed-dose combinations • Supporting strengthening laboratory services, including the National Public Health Laboratory, for quality assurance for antiretroviral drugs, including staff, guidelines and standards • Assisting in developing and implementing a plan for reviewing programmes • Providing technical assistance to formally assess Kenya’s emerging capacity for manufacturing medicine

5. Antiretroviral therapy coverage • Kenya’s total treatment need in 2005 is estimated to be 220 000 people, and the WHO “3 by 5” treatment target is 110 000 people (based on 50% of need). Kenya’s declared national treatment target for 2005 is to reach 95 000 people. • During 2003, the government provided an estimated 1000 people with antiretroviral therapy; other sectors covered an additional 10 000 people. • Kenya’s successful Round 2 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria is expected to provide antiretroviral therapy to 4000 people over two years and will fund the training of 1800 health workers. • Looking forward, the United States President’s Emergency Plan for AIDS Relief aims to provide 45 000 people with antiretroviral therapy by the end of 2005, and other sources are expected to support an additional 7000 people.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The NASCOP provides leadership in policy, programming and national human resources planning and, along with the Ministry of Health, jointly leads in coordinating implementation and strengthening the health system. Various bilateral partners including the United States Agency for International Development, the United States President’s Emergency Plan for AIDS Relief, the United States Centers for Disease Control and Prevention (CDC), the United Kingdom Department for International Development and nongovernmental organizations contribute to strengthening the health system. The United States Agency for International Development and the United States President’s Emergency Plan for AIDS Relief provide strong support for national human resources planning. • Antiretroviral therapy service delivery. The NASCOP provides leadership in supply chain management, laboratories, capacity-building, training, development of guidelines, testing and counselling, accelerating prevention and the processes of entering antiretroviral therapy. The Ministry of Health and the national procurement agency (KEMSA) provide leadership in procurement issues, supported by an international consortium for procurement established with the international procurement agencies of Crown Agents, GTZ and John Snow Inc. (JSI). Building the capacity of KEMSA is a key objective of the consortium. Policy on managing the supply chain and guidelines for antiretroviral drugs have been developed by the Logistical Management and Information Unit based at KEMSA in conjunction with NASCOP. CDC and the United Kingdom Department for International Development support site-level training and, along with WHO, capacity-building. The United States President’s Emergency Plan for AIDS Relief and CDC, among other agencies, support testing and counselling. WHO provides normative support for developing tools and guidelines, and a range of agencies support the processes of entering antiretroviral therapy, including bilateral partners, nongovernmental organizations and others. • Community mobilization. The NASCOP leads communication activities related to programmes with support from UNAIDS, CDC, the United States Agency for International Development and the United Kingdom Department for International Development. A communication strategy for antiretroviral therapy is under development. The National AIDS Control Council provides leadership in building the capacity of people living with HIV/AIDS with support from the NASCOP. • Strategic information. The NASCOP provides leadership in the areas of monitoring and evaluation, surveillance, antiretroviral drug resistance, information management and operational research. The areas of monitoring and evaluation and tracking people receiving antiretroviral therapy are also supported by CDC, Médecins Sans Frontières, Family Health International, JSI Research and Training Institute and private companies. CDC also supports information management and antiretroviral drug resistance activities.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer in the position of Focal Point Coordinator in East Africa for the WHO study on the use of highly active antiretroviral therapy to prevent mother-to-child transmission and one National Programme Officer on HIV/AIDS. The recruitment of an international “3 by 5” Country Officer is currently underway. • Under the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, one National Programme Officer is in place and the recruitment of another is planned.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Kenya and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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LESOTHO

July 2004

WHO estimate of number of people requiring treatment – end 2005: 54 000 Antiretroviral therapy target declared by country: 28 000 by 2005

HIV sentinel surveillance in pregnant women Butha− Buthe Hlotse

Latest available year for 2001− 2003 Percent seropositive Less than 1 1 − 4.9 5 − 9.9

35 200

treat Million by

Teyateyaneng Mokhotlong

10 −14.9 15 −19.9 20 −29.9

Maseru

Lesotho Mafeteng

30 and more

Cities and towns

Main roads

Population density (pers./sq.Km) Less than 10 Mohales Hoek Qacha’s Nek

10 − 49

50 − 99

100 −249 Moyeni

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

South Africa 0 15 30 60 Kilometers

750 and more

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 1.8 17.9 35.7 419 12 23 0.510 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 26.3 – 31.7% Source WHO/ UNAIDS

290 000 – WHO/ 360 000 UNAIDS 14 640 1 000 54 000 not available not available 72.9% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Lesotho faces a serious and worsening HIV/ AIDS problem. One in three people 15–49 years old in Lesotho is HIV positive, among the highest rates in the world. Generalized poverty and social dislocation because of migratory labour are the two main factors driving the HIV epidemic. The epidemic has a mature pattern, with a high case–fatality ratio, large numbers of orphans and vulnerable children, increasing mother-to-child transmission, decreasing life expectancy, declining productivity affecting the national economy and very high demands on the health care system. Not only are the numbers of people with AIDS increasing drastically, the number of new HIV infections is very high with no indication that the epidemic is stabilizing. • Major vulnerable and affected groups. Recent studies indicate that the people mostly affected include young people, and especially teenage girls and people 20–29 years old; people with sexually transmitted infections; former miners; migrant labourers; factory workers; unemployed people; and female sex workers. Data from five major sentinel surveillance sites show a steady upward trend in the proportion of pregnant women 20–24 years old testing HIV positive. HIV prevalence among people attending antenatal care and care services for sexually transmitted infections has increased over time. The prevalence among people attending services for sexually transmitted infections increased from 4.8–7.1% in 1991 to 35–63% in 2000. The prevalence among people attending antenatal care increased from 0.7–5.5% in 1991 to 15.8–42.2% in 2000. • Policy on HIV testing and treatment. HIV testing and counselling guidelines were recently updated in accordance with WHO recommendations. Nongovernmental organizations, people living with HIV/AIDS, bilateral and multilateral partners and community-based organizations have all worked closely with the government to develop the Policy

Framework on HIV/AIDS Prevention, Control and Management and the National HIV/AIDS Strategic Plan (2002–2005). Under the Round 2 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria, a national policy on the use of antiretroviral drugs is scheduled to be developed and disseminated. WHO guidelines on the use of antiretroviral therapy in resource-constrained settings and on the clinical management of HIV/AIDS are also scheduled to be reviewed and adapted for use in Lesotho. In March 2004, the government initiated a policy of universal voluntary counselling and testing. • Antiretroviral therapy: first-line drug regimen, cost per person per year. In 2001. the first antiretroviral therapy programme was started at Maluti Hospital, which belongs to the Christian Health Association of Lesotho. Under this programme, the user meets the cost of the antiretroviral drugs, laboratory assessment and monitoring. First-line regimen: lamivudine + zidovudine + nevirapine or efavirenz at a cost of US$ 1600 per person per year. • Assessment of overall health sector response and capacity. The government has established structures and frameworks in response to the HIV/AIDS epidemic, including the United Nations Theme Group on HIV/AIDS in Lesotho and bilateral agencies, the Lesotho AIDS Programme Coordinating Authority, district AIDS task forces and a national multisectoral task force. Health sector reforms launched in 2000 have focused on building system capacity both through the public and private sector. A national programme for preventing mother-to-child HIV transmission has been developed and implemented, and antiretroviral therapy pilot programmes are being carried out in three districts. Additional capacity-building is needed in preventing transmission and promoting health, in community organization and in building partnerships.

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LESOTHO

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

• Critical issues and major challenges. Critical barriers for scaling up antiretroviral therapy include limited essential drugs, lack of voluntary counselling and testing services, lack of services for preventing mother-to-child transmission, an inadequate communication strategy on HIV/AIDS and inadequate clinical management of people living with HIV/AIDS. Despite clear strategies proposed in the National HIV/AIDS Strategic Plan, inadequate skills and financial resources have compromised the translation of the strategies into concrete plans for implementation. Health care workers urgently need training. Laboratory capacity to diagnose and monitor people on antiretroviral therapy needs to be strengthened.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting situation analysis for scaling up antiretroviral therapy • Convening a discussion of partners on scaling up antiretroviral therapy and on identifying the partners’ roles • Supporting the development of a national operational plan for scaling up antiretroviral therapy • Supporting the development of training materials for HIV testing and counselling and for training trainers • Reprogramming the Round 2 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria • Developing testing and counselling training materials and training trainers

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 27 000 people in 2005 is between US$ 36 million and US$ 44 million. The Global Fund to Fight AIDS, Tuberculosis and Malaria and bilateral sources are anticipated to commit US$ 9 million for scaling up antiretroviral therapy in 2004–2005. • Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Lesotho to reach 27 000 people by the end of 2005 is between US$ 27 million and US$ 35 million.

Key areas for WHO support in the future • Providing support through a subregional “3 by 5” team to assist the government and its partners in scaling up antiretroviral therapy • Providing support for implementing the Round 2 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria in accordance with national plans for scaling up antiretroviral therapy

5. Antiretroviral therapy coverage • Lesotho’s total treatment need for 2005 is estimated to be 54 000 people, and the WHO “3 by 5” treatment target for the end of 2005 is 27 000 people (based on 50% of estimated need). • The Round 2 proposal for the Global Fund aims to provide treatment to 10 000 clinically eligible people by the third year of the programme. • The government has set a national treatment target of 28 000 people for 2005. • During 2003, an estimated 1000 people received antiretroviral therapy.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Recruitment of a subregional “3 by 5” officer (for Botswana, Lesotho and Swaziland) is currently underway. • Additional staffing needs identified include a National Programme Officer for HIV/ AIDS, a National Programme Officer for HIV and tuberculosis and a Home-based Care Coordinator.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health is responsible for implementing the national antiretroviral therapy programme with support from various partners. The Ministry of Local Government and the Ministry of Labour support activities related to human resource planning. The Ministry of Justice is responsible for the legal and policy framework and for supporting people living with HIV/AIDS. UNAIDS supports the coordination process, monitoring and evaluation, acceleration of prevention and supports people living with HIV/AIDS. The World Bank contributes to managerial and financial processes along with the United Kingdom Department for International Development and Development Cooperation Ireland, which also support management and financial processes including determining the cost of scaling up and raising funds to achieve this. • Antiretroviral therapy service delivery. The involvement of partners in delivering and scaling up antiretroviral therapy is still at an early stage. Discussions are currently ongoing to identify the specific roles and contributions of partners in supporting the scaling up of antiretroviral therapy. The National Drug Stockpile and Control Authority provides support to the services and activities related to antiretroviral drugs. The World Food Programme provides support for increasing the capacity of laboratory services and management of the drug supply chain. • Community mobilization. UNICEF supports activities related to programme communication; the United Nations Theme Group on HIV/AIDS in Lesotho and the World Food Programme provide support for programme communication and material and nutrition support. • Strategic information. In association with the Ministry of Health, WHO provides support for implementing operational planning, patient tracking, antiretroviral drug resistance, operational research, laboratory services, capacity-building, testing and management of the drug supply chain.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Lesotho and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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MOZAMBIQUE Mansa Lumumbashi Solwezi Ndola

July 2004

WHO estimate of number of people requiring treatment – end 2005: 190 000 Antiretroviral therapy target declared by country: 21 000 by 2005

Kasama

Lindi

Zambia

United Republic of Tanzania Mzuzu

HIV sentinel surveillance in pregnant women

Comoros Lichinga Pemba

Latest available year for 2001− 2003 Percent seropositive Less than 1 1 − 4.9 5 − 9.9

Chipata Kabwe Lusaka

Malawi

Mayotte

35 200

treat Million by

Lilongwe

Nampula Mocambique Blantyre Tete

10 −14.9

15 −19.9

20 −29.9 Livingstone Harare

Mozambique Mutare Chimoio Beira

30 and more

Gweru

Cities and towns

Bulawayo Francistown Masvingo

Main roads

Madagascar

Population density (pers./sq.Km)

Botswana Serowe Toliara Inhambane Mochudi Gaborone Lobatse

Less than 10

10 − 49

50 − 99

100 −249

South Africa Pretoria Johannesburg

Xai− Xai Piggs Peak Mbabne Maputo Hlatikulu

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more

Swaziland

0

110

220

440 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 19.2 35 42.6 189 18.9 11 0.356 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 9.4 – 15.7% Source WHO/ UNAIDS

980 000 – WHO/ 1 700 000 UNAIDS 25 024 2 840 190 000 not available not available 47.3% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Mozambique faces a major HIV epidemic, given the high average prevalence level coupled with structural factors such as poverty, gender inequality, cultural conditions and high levels of labour mobility. With an estimated HIV prevalence among adults (15–49 years) of 13% in 2001, Mozambique is one of the most affected countries. An estimated 500 people are infected every day. An estimated 57% of all adults affected are women. The national HIV prevalence masks considerable regional differences, with estimated adult prevalence rates being 13.2% in the south, 16.5% in the centre and 5.7% in the north. • Major vulnerable and affected groups. The high prevalence in the central region is attributed to a number of factors, including the return to Mozambique, after the peace agreement in 1992, of an estimated 2 million refugees from neighbouring countries with high rates of HIV prevalence. The mobility of the population along the transport corridors that link Mozambique and the port of Beira to Zimbabwe and Malawi also contribute to the high prevalence. In the southern region, the highest adult prevalence rates are in the province of Gaza, in which many men work as migrant labour in mines in South Africa. • Policy on HIV testing and treatment. Mozambique has no official policy on HIV testing. Testing for the general population is largely “opt-in”, whereas “opt-out” is the standard approach for preventing mother-to-child transmission and for inpatient services. There is strong political commitment to scaling up antiretroviral therapy. The National Health Sector Strategic Plan to Combat Sexually Transmitted Infections and HIV/AIDS, 2004–2008 plans for scaling up highly active antiretroviral therapy to 132 000 people by the end of 2008. The Ministry of Health has established

clear treatment criteria that are in line with WHO recommendations. Guidelines on antiretroviral therapy are being reviewed. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The national guidelines on antiretroviral therapy are currently being revised to incorporate changes in treatment regimens in accordance with international standards. However, the backbone first-line regimen will continue to be lamivudine + stavudine + nevirapine, procured at a price of US$ 140 per person per year. All first-line drugs have regulatory approval. • Assessment of overall health sector response and capacity. The overall health sector response to HIV/AIDS has been limited, both geographically and programmatically. The largest share of resources invested has been concentrated in the province of Maputo, and activities restricted to epidemiological surveillance, certain preventive interventions (such as modest campaigns to promote condoms) and sporadic provision of treatment for opportunistic infections. The national health system is constrained by a lack of resources. The multisectoral National AIDS Council, established in 2000 and chaired by the Prime Minister, has provided significant support in planning, coordinating and streamlining the multisectoral response to HIV/AIDS. Mozambique has developed a specific plan for building human resource capacity to fight HIV/AIDS, planning to train 2000 intermediate-level health care professionals. A new national drug management and logistics system is being developed in anticipation of a massive increase in antiretroviral therapy coverage. Under this system, drugs, instead of being sent to Maputo (the capital), will be sent directly to the five provincial hospitals (Maputo, Beira, Nampula, Zambézia and Manika).

1 © World Health Organization 2004

S U M M A R Y C O U N T R Y P RO F I L E F O R H I V / A I D S T R E AT M E N T S C A L E - U P

Zimbabwe

MOZAMBIQUE

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Strategic information. The Department of Planning and Cooperation of the Ministry of Health provides leadership in monitoring and evaluation with support from the United States Centers for Disease Control and Prevention. The Epidemiology Section of the National Health Department is responsible for surveillance.

• Critical issues and major challenges. Mozambique lacks trained human resources and requires considerable investment in health care infrastructure to increase geographical coverage and facilitate access in remote areas. Drug procurement and management systems are complex, and fear of stock-outs is widespread. Policies and strategies to address such issues as care for and protection of orphans and other children affected by HIV/AIDS, advocacy against stigma and discrimination and cross-border migration of vulnerable groups need to be strengthened. Coordination also needs to be strengthened between the National AIDS Council, the Ministry of Health and other partners, including nongovernmental organizations.

7. WHO support for scaling up antiretroviral therapy WHO's response so far • Conducting an assessment mission in April–May 2004 to identify opportunities for scaling up HIV/AIDS treatment and care • Supporting the development of the World Bank Treatment Acceleration Program proposal with a focus on scaling up HIV/AIDS treatment and care • As part of the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting the prevention of mother-to-child transmission by implementing a comprehensive package of antenatal, obstetric, postnatal and infant care interventions in two provinces (Manica and Sofala), including expanding access to voluntary HIV counselling and testing among pregnant women; ensuring access to care and treatment for HIV-positive women and their children and partners; and increasing access to psychosocial support services for pregnant and postpartum women living with HIV/AIDS in seven districts • As part of the WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa, providing technical support for developing policies and guidelines on preventing mother-to-child transmission and for the clinical management of HIV, including antiretroviral therapy; and providing essential services in three districts in the province of Sofala regarding blood safety, clinical management of opportunistic infections and home-based care.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 95 000 people by the end of 2005 is between US$ 117 million and US$ 132 million. • Mozambique has recently transformed its international aid management system from project-based assistance to a sector-wide approach. • Of funds available from Round 2 grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria, an estimated US$ 10 million is expected to be available for scaling up antiretroviral therapy over the period 2004-2005. • An estimated US$ 50 million may become available from the United States President’s Emergency Plan for AIDS Relief to support scaling up antiretroviral therapy during 2004–2005. • In 2003, Mozambique received a five-year grant of US$ 55 million as part of the World Bank Multi-Country HIV/AIDS Program for Africa, to focus on building the capacity of civil society organizations and strengthening the capacity of health services. • Other key organizations contributing to scaling up antiretroviral therapy include United Nations agencies and the Clinton Foundation. • In April 2004, Mozambique submitted a proposal to the Treatment Acceleration Program of the World Bank. The proposal includes components on voluntary counselling and testing, antiretroviral therapy, preventing mother-to-child transmission and MTCT-Plus, opportunistic infections and home-based care. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Mozambique to reach 95 000 people by the end of 2005 is between US$ 39 million and US$ 54 million.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Supporting the Ministry of Health in finalizing and updating policies and standard guidelines for HIV treatment and care • Supporting the National AIDS Council, the Ministry of Health and the Ministry of Education in reviewing the current HIV/AIDS curriculum and developing standard training programmes for physicians, pharmacists, clinical officers and nurses in institutions of intermediate and higher education • Supporting the Ministry of Health in technically supervising antiretroviral therapy prescription at the province and district levels • Supporting the Ministry of Health in strengthening mechanisms for procuring, distributing and ensuring stock control of drugs and laboratory kits • Providing technical assistance in developing a monitoring and evaluation framework, including surveillance of drug resistance • Collaborating with the World Food Programme to ensure adequate food aid and nutritional support for people receiving antiretroviral therapy

5. Antiretroviral therapy coverage • Mozambique’s total treatment need for 2005 is estimated to be 190 000 people, and the WHO “3 by 5” treatment target is 95 000 people by the end of 2005 (based on 50% of need). • As of April 2004, an estimated 2840 people were receiving antiretroviral drugs in Mozambique. An estimated 20 sites offer antiretroviral therapy in the public sector through collaboration between the government and nongovernmental organizations such as the Community of Sant’Egidio and Médecins Sans Frontières. • The National Health Sector Strategic Plan to Combat Sexually Transmitted Infections and HIV/AIDS, 2004–2008 plans to provide treatment to 21 000 people living with HIV/AIDS by the end of 2005 and 132 000 people by the end of 2008, with the support of bilateral and multilateral agencies. • In order to reach these targets, the Plan foresees opening and operationalizing 129 integrated networks of preventive and curative services, including voluntary testing and counselling, across Mozambique.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway. • The WHO/OPEC Fund Multi-country Initiative on HIV/AIDS supports one National Programme Officer. • Additional staffing needs identified include: two international medical officers for secondment to the Ministry of Health; one pharmacist to support the National Health Department; one technical officer to support the development of the national operational plan for scaling up antiretroviral therapy for 2005; and one consultant to review the current HIV/AIDS curriculum for physicians, nurses and clinical officers in institutions of higher and intermediate-level education.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health provides leadership on all technical and policy-related issues, including developing national plans, coordinating implementation and financial management. The National AIDS Council takes the lead in coordinating the multisectoral response to HIV/AIDS. • Antiretroviral therapy service delivery. The Medical Care Unit within the National Health Department of the Ministry of Health coordinates procurement and supplychain management of antiretroviral drugs, supported by the National Centre for Medical Supplies and the parastatal procurement agency MEDIMOC. The National Health Department and the Human Resource Department in the Ministry of Health coordinate training and capacity-building activities. The National Health Department also provides leadership in testing and counselling activities. • Community mobilization. The National AIDS Council leads the multisectoral dialogue with national and international nongovernmental organizations. International nongovernmental organizations such as the Community of Sant’Egidio and Médecins Sans Frontières are implementing successful projects on highly active antiretroviral therapy.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Mozambique and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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NIGERIA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 520 000 Antiretroviral therapy target declared by country: 15 000 by 2005

Tahoua

HIV sentinel surveillance in pregnant women

Niamey

Niger Maradi Dosso Sokoto Birnin Kebbi Katsina

Zinder Diffa

Chad

Latest available year for 2001− 2003

Bol

Percent seropositive Less than 1 1 − 4.9

35 200

treat Million by

Burkina Faso Kaduna

Kano

Ndjamena

Dutse

Damaturu

Maiduguri

5 − 9.9

10 −14.9

15 −19.9 Maroua Bauchi Jos Minna Parakou

Benin

20 −29.9

Ilorin Oshogbo Ibadan Abeokuta Porto Novo Cotonou Lagos

Cities and towns

Main roads Lokoja Makurdi Ngaoundere

Population density (pers./sq.Km)

Akure

Less than 10 Enugu Benin City AsabaAwka Bamenda Owerri Umuahia Uyo Calabar Port Harcourt Bafoussam

10 − 49

Cameroon Bertoua Yaounde

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Buea Douala Malabo 0 75 150 300 Kilometers

750 and more

Equatorial Guinea

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 127.1 46.2 48.8 435 1.9 15 0.463 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 3.6 – 8.0% 2003 2001 June 2004 2003

2 400 000 – WHO/ 5 400 000 UNAIDS 60 564 17 000 520 000 not available not available 27% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Nigeria has one of the largest HIV/AIDS epidemics in the world, characterized by an adult prevalence rate in the range of 3.6–8.0%. The epidemic is growing rapidly, and national estimates indicate that the prevalence rate has risen steadily since 1991. Women are more affected than men, with a female-male ratio of 1.38:1. • Major vulnerable and affected groups. Young people, especially women 20–24 years old, are increasingly vulnerable. Other affected groups include sex workers and people with tuberculosis. Low levels of condom use, especially among mobile populations, a high prevalence of untreated sexually transmitted infections, poverty, stigma and discrimination contribute to the rapid spread of the epidemic. • Policy on HIV testing and treatment. The government is committed to establishing a network of voluntary and confidential counselling and testing services to provide access to affordable and accessible high-quality testing and counselling. All screening facilities must apply the prescribed national protocol for HIV testing provided by the Federal Ministry of Health and be certified by the government according to Federal Ministry of Health protocols. The government is committed to offering testing and counselling services at all antenatal clinics. In 2001, the government announced a programme to provide antiretroviral treatment to 10 000 adults and 5000 children living with HIV/AIDS at subsidized rates, within the context of the National HIV/AIDS Emergency Action Plan and the National Health Sector Plan for HIV/AIDS, which is still being developed. Under the Health Sector Plan, the government will commit to ensuring that everyone has access to quality health care and adequate treatment or management of their conditions, including

the provision of antiretroviral therapy. Antiretroviral therapy must be medically supervised and governed by established effective guidelines that are regularly updated with findings from research. Cost-effective drug lists will be developed and incorporated into Nigeria’s Essential Drugs List. Antiretroviral drugs must be sold under strict medical supervision. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The firstline drugs include lamivudine, stavudine and nevirapine. Under the government programme, the average annual cost of drugs is US$ 368, and users pay a subsidized rate of US$ 86 per person per year. • Assessment of overall health sector response and capacity. The national and state levels have a high level of political commitment to scaling up HIV/AIDS care and treatment. The government programme to provide antiretroviral treatment began in 2002 with the purchase of drugs and test kits for 10 000 people. Treatment was first started in 25 tertiary institutions. Preventing mother-to-child transmission started in 2001 with six model centres jointly managed by the Federal Ministry of Health and UNICEF: there are now 11 model and 22 satellite centres. Many treatment centres have exceeded treatment quotas, and about 17 000 people are currently receiving antiretroviral therapy. The overall national response to HIV/AIDS is decentralized and multisectoral and has focused on increasing awareness about the epidemic, promoting behaviour change, providing care and support for people living with HIV/AIDS and establishing an effective surveillance system. A National Health Sector Plan for HIV/AIDS is in the process of being developed.

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S U M M A R Y C O U N T R Y P RO F I L E F O R H I V / A I D S T R E AT M E N T S C A L E - U P

Abuja

Nigeria Jalingo

Yola

Garoua

30 and more

NIGERIA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Community mobilization. A wide range of nongovernmental organizations and networks of people living with HIV/AIDS are involved in community-related work. UNDP has collaborated with the United Kingdom Department of International Development to spearhead the formation of support groups through the Ambassadors of Hope. UNDP focuses on human rights issues and on generating income through microcredits to empower people living with HIV/AIDS. UNODC operates the Partnership against Drug Abuse and HIV/AIDS, both at the national level and in West Africa as a whole. • Strategic information. The Federal Ministry of Health is responsible for overall monitoring and evaluation of programmes and for operational research. The United States Centers for Disease Control and Prevention has supported the National Surveillance Survey and is committed to training, infrastructural development, capacity-building and blood safety issues. The Centre for Right to Health provides voluntary counselling and testing services and is establishing networks for monitoring and data collection through the state AIDS programme coordinators.

• Critical issues and major challenges. A major challenge to treatment scale-up is the low availability of and delays in the delivery of antiretroviral drugs. High user charges for laboratory tests constitute another barrier to treatment access. Coordination of the many stakeholders involved in supporting and delivering antiretroviral therapy is lacking.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 260 000 people by the end of 2005 is between US$ 370 million and US$ 416 million. • The government is expected to commit about US$ 19 million by 2005 for scaling up antiretroviral therapy. • Nigeria submitted a successful Round 1 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, of which an estimated US$ 4.44 million is anticipated to be available for scaling up antiretroviral therapy. • Nigeria is also a beneficiary of the United States President’s Emergency Plan for AIDS Relief and is expected to receive an estimated US$ 112 million for scaling up antiretroviral therapy in 2004–2005. • Nigeria is a beneficiary of the World Bank Multi-Country HIV/AIDS Program for Africa, with funding of US$ 90.3 million over five years (2002–2007). • Several other bilateral and multilateral partners have committed about US$ 15 million for scaling up antiretroviral therapy over 2004–2005. • Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Nigeria to reach 260 000 people by the end of 2005 is between US$ 218 million and US$ 265 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a scoping mission in January 2004 to assess the status of antiretroviral therapy implementation and to identify opportunities and challenges for scaling up and areas for WHO support • Providing technical assistance to the WHO Country Office and the government to begin planning for scaling up antiretroviral therapy • Providing technical assistance to begin coordinating the process of developing the Health Sector Plan for HIV/AIDS

5. Antiretroviral therapy coverage • Nigeria’s total treatment need for 2005 is estimated to be 520 000 people, and the WHO “3 by 5” treatment target is 260 000 by the end of 2005 (based on 50% of need). • The government has declared a national treatment target of reaching 15 000 people by the end of 2005. • An estimated 17 000 people are receiving antiretroviral therapy, of which about 11 435 receive treatment through the government-subsidized programme. Some treatment is also provided by private pharmaceutical companies such as Ranbaxy, which is supplying 3000 person–years of treatment outside the government programme.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Supporting the Federal Ministry of Health in reprogramming the Round 1 funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria in order to redirect some funds to monitoring and evaluating antiretroviral therapy within the National AIDS and STD Control Programme, and to develop a plan for procuring antiretroviral drugs • Supporting a review of guidelines on antiretroviral therapy and designing a monitoring system for the federal antiretroviral therapy programme

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. Nigeria has strong political commitment to address HIV/AIDS and expand antiretroviral therapy provision. Government provision of antiretroviral therapy resulted from a Presidential Directive in 2001. The National AIDS Council is responsible for overall multisectoral coordination of the response to HIV/AIDS in Nigeria. The Federal Ministry of Health provides national leadership in implementing antiretroviral therapy programmes, including developing treatment policies and guidelines, allocating resources and providing technical support to states and implementers. Partners providing support for developing the National Health Sector Plan for HIV/AIDS include WHO, UNDP, UNICEF, the United States Agency for International Development, the Society for Family Health, Pathfinder International, the United Kingdom Department for International Development, the Network of People Living with HIV/AIDS, the World Bank, the Civil Society Consultative Group and Médecins Sans Frontières. • Antiretroviral therapy service delivery. The government is the main provider of antiretroviral therapy services. About 27 tertiary government health facilities were identified at the federal level to begin providing antiretroviral therapy. The Centre for Specialist Studies provides antiretroviral drugs free of charge on a monthly basis to people at two centres, in Sagamu and Ife, including treatment for children. The Christian Health Association of Nigeria, which has a network of more than 4000 health facilities of different levels of care across the country, is also involved in providing antiretroviral therapy. The AIDS Prevention Initiative in Nigeria, a project of the Harvard School of Public Health with funding from the Bill & Melinda Gates Foundation, supports preventing mother-to-child transmission, diagnosing HIV/ AIDS and monitoring clients on antiretroviral therapy at three sites. WHO provides normative technical assistance in developing treatment policies, guidelines and strategies. UNICEF’s technical role in scaling up antiretroviral therapy includes support for procurement and assisting in obtaining the highest-quality antiretroviral drugs at the best prices.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Nigeria and the WHO Regional Office for Africa.

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RUSSIAN FEDERATION

July 2004

WHO estimate of number of people requiring treatment – end 2005: 71 000 Antiretroviral therapy target declared by country: no declared target

��������������������������� ����������������

35 200

treat Million by

����������������� ������������������� � ��� ��� ���� ��� ���� ����

Map data source: Federal AIDS Center, Russian Federation Map production: WHO

����� ���� ����� ���� ��������

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 142.4 73.3 64.8 2 139 10.7 115 0.779 Source United Nations United Nations WHO UNECE WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) •

Estimate

Source WHO/ UNAIDS

2003 0.6 – 1.9% 2003 March 2004 June 2004 2003

420 000 – WHO/ 1 400 000 UNAIDS 1 009 1 800 71 0001 not available not available Federal AIDS Center

WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. The Russian Federation has a concentrated epidemic among injecting drug users. It has one of the most rapidly growing HIV epidemics globally, with significant spread occurring from 1996. Of the 89 regions, 88 have reported HIV cases. The epidemic is relatively young, with most individuals infected between 1999 and 2002. The relative number of people living with HIV/AIDS needing treatment is therefore still low but will increase dramatically over the next five years. Although the epidemic has been driven by male injecting drug users, increasing heterosexual transmission is being reported, with heterosexual transmission accounting for 4.7% of new cases in 2001 and increasing to 17.0% of new cases in 2003, resulting in increasing numbers of women being infected. The adult prevalence of HIV is estimated to be approaching or have exceeded 1%. Major vulnerable and affected groups. The epidemic is largely concentrated among injecting drug users (more than 80% of reported HIV cases for which the mode of transmission is reported). HIV prevalence rates among injecting drug users in some cities approach 65%. There are an estimated 1.5 to 3.5 million injecting drug users in the country. A significant proportion of drug users are involved in sex work, acting as a bridging population for spreading HIV into the general community. An estimated 5–15% of sex workers are infected with HIV, increasing to 48% for the sex workers who inject. HIV seroprevalence among prisoners is estimated at about 2–4%. Policy on HIV testing and treatment. The 1995 Russian Federal Law on HIV/AIDS includes a wide range of legal guarantees and social protection related to HIV/AIDS. Under this law, the Russian Federation state guarantees anonymous and confidential HIV testing; pre- and post-test counselling; and free access to health care and social welfare services for individuals infected with HIV. Voluntary counselling and testing, although available on a large scale, is often compromised by inadequate quality of counselling and a lack of informed consent in the health care system. Despite a policy of universal access to antiretroviral therapy, coverage is estimated at less than 5% (2004).

2002

5.1%

WHO

•

•

•

•

Antiretroviral therapy: first-line drug regimen, cost per person per year. As of May 2004, antiretroviral therapy is only available through a limited number of federal and regional AIDS centres. National antiretroviral therapy guidelines are being developed based on WHO guidelines. The use of single and dual antiretroviral therapy has been common practice. Fourteen antiretroviral drugs are registered. Tenofovir is not on the list of registred drugs (applied for registration in 2004) to cover antiretroviral drug needs in accordance with WHO antiretroviral therapy guidelines. No generic antiretroviral drugs are registered. Prices paid at the end of March 2004: first-line US$ 7800–8800; second-line US$ 12 000–15 000. Assessment of overall health sector response and capacity. The Russian Federation has a well-developed government HIV/AIDS health service infrastructure including the Federal AIDS Center (responsible for federal HIV/AIDS guidelines, normative direction and epidemiology), 7 okrug (interregional) AIDS centres, 89 regional AIDS centres and 20 municipal AIDS centres. Each AIDS centre provides HIV/AIDS prevention, testing and counselling, treatment, surveillance and laboratory monitoring and has at least 50 staff representing a broad mix of professions, skills and experience. In addition to the estimated 7000 dedicated HIV/AIDS government staff at these centres (of which about 300 are HIV/AIDS specialist physicians), about 1000 laboratories conduct routine serological surveillance for HIV infection, and about 100 infectious disease hospitals and infectious diseases units in about 300 hospitals can provide inpatient care for people living with HIV/AIDS. About 9000 infectious disease physicians are working in these hospitals or units that could be trained in HIV/AIDS treatment and care. Nongovernmental organizations are providing HIV/AIDS services in over 40 regions. Critical issues and major challenges. Most people needing treatment are marginalized and difficult to reach (drug users and sex workers), requiring strategies for outreach, reducing stigma and supporting adherence. Drug dependence treatment and

1 © World Health Organization 2004

1

The Federal AIDS Center estimates that the total number needing antiretroviral therapy at the end of 2005 is 139 000.

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RUSSIAN FEDERATION

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP Examples of nongovernmental organizations supporting the scaling up of antiretroviral therapy include AIDS Foundation East-West (preventing mother-to-child transmission and providing care and support for people living with HIV/AIDS); Open Health Institute (harm reduction, including treatment for drug users); Population Services International (HIV educational materials for vulnerable populations); and AIDS infoshare (advocacy for people living with HIV/AIDS). A range of bilateral donors support activities relevant to antiretroviral therapy, including the United States Agency for International Development, the European Union, the United Kingdom Department for International Development, the Swedish International Development Cooperation Agency, Canada and Finland. Community mobilization. A range of nongovernmental organizations (such as AIDS infoshare and the Humanitarian Action Foundation), United Nations agencies (such as WHO, UNDP and UNODC) and bilateral donors (such as Canada and the United States Agency for International Development) work alongside the government in mobilizing communities and supporting people living with HIV/AIDS. Strategic information. The Federal AIDS Center and the Federal Surveillance Service provide leadership in surveillance, monitoring and evaluation, including surveillance of antiretroviral drug resistance. WHO plays an important role in providing technical guidance. Various universities from North America and western Europe support research activities related to HIV/AIDS treatment and care.

tuberculosis services need to be better coordinated and linked with HIV/AIDS services. Antiretroviral therapy guidelines need to be finalized and implemented to address inappropriate and ineffective treatment regimens. Antiretroviral drug prices are still too high. Generic drugs have not been registered. Drug procurement and supply management is decentralized and poorly coordinated. Although a large workforce exists, retraining is needed.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • • Of the 56 000 people the Ministry of Health and Social Development estimates needed antiretroviral therapy at the end of 2003, only about 1800 were receiving therapy (essentially all within public health care). The successful Round 3 applicant to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the NGO Consortium Russia plans to spend about 5% of their funding of US$ 89 million over 5 years to provide antiretroviral therapy for 2500 people living with HIV/AIDS and for an additional 2000 HIV-infected women under their MTCT-Plus project in a maximum of 10 regions. The recent five-year World Bank loan project of US$ 47 million, which includes a key component for HIV/AIDS, includes limited funding for antiretroviral therapy solely for MTCT-Plus and programmes for children. Of the US$ 4 million annual HIV/AIDS budget of the Ministry of Health and Social Development, 70% is devoted to purchasing antiretroviral drugs, and additional government funds provide treatment for opportunistic infections. In addition, richer regions purchase their own antiretroviral drugs. In 2003, the City of Moscow spent US$ 6 million on antiretroviral drugs, allowing 880 people to be treated. AIDS centres in about 80 of the 89 regions lack the resources to purchase any antiretroviral drugs and must depend on receiving supplies from the annual Ministry of Health and Social Development allotment. In the absence of universal access to antiretroviral therapy, all regions (including Moscow) provide limited or no access to treatment for individuals from marginalized and vulnerable groups. The Russian Federation Country Coordinating Mechanism has submitted a Round 4 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria focusing on scaling up antiretroviral therapy for vulnerable populations, including injecting drug users, and aims to provide antiretroviral therapy for about 74 000 people over 5 years. WHO estimates that between US$ 668 million and US$ 685 million is required to support scaling up of antiretroviral therapy to reach the WHO “3 by 5” treatment target of 35 500 people by the end of 2005. Taking into account the funds committed to date, WHO estimates that the total funding gap for the Russian Federation to reach 35 500 people by the end of 2005 is between US$ 656 million and US$ 673 million.

•

•

• • •

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • • Developing models for HIV/AIDS and sexually transmitted infection outreach to vulnerable populations, including injecting drug users, sex workers and men who have sex with men Reviewing existing HIV/AIDS treatment regimens and protocols and providing technical assistance for developing national HIV/AIDS treatment guidelines based on WHO HIV/AIDS treatment protocols developed for Commonwealth of Independent States countries Assisting the Country Coordinating Mechanism in developing a Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria with a focus on HIV/AIDS treatment and care Preparing a strategy paper to outline options for achieving lower antiretroviral drug prices

• •

• •

• •

Key areas for WHO support in the future • • Establishing a “3 by 5” country team at the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy Assisting the government in developing key normative documents, including a National Strategy on HIV/AIDS, a National HIV/AIDS Treatment Plan and standards of HIV/AIDS treatment and care for different levels of the health care system (primary, secondary and tertiary). Guidelines on treatment will be finalized to be consistent with evidence-based recommendations from the WHO. Developing and supporting a strategic approach to reducing antiretroviral drug prices, including accelerating generic registration and negotiating prices with pharmaceutical companies Assisting in developing a plan for the procurement and supply management of antiretroviral drugs and HIV/AIDS diagnostics Providing technical support for establishing regional centres of excellence in building capacity for scaling up antiretroviral therapy Assisting in developing models of HIV testing and counselling and antiretroviral therapy delivery for vulnerable populations, including drug users, sex workers and prisoners

5. Antiretroviral therapy coverage • • • • In 2003, WHO and UNAIDS estimated the Russian Federation’s total antiretroviral therapy need for 2005 to be about 71 000 people, and the WHO “3 by 5” treatment target for 2005 is 35 500 people (based on 50% of need). The Federal AIDS Center (2004) estimated the total antiretroviral therapy need to be 56 000 in 2003, increasing to 93 000 by the end of 2004 and 139 000 by the end of 2005 (based on initiating antiretroviral therapy when CD4 ≤ 300 cells/mm2). The government has not declared an antiretroviral therapy target, although it has an overall goal of universal access to antiretroviral therapy for everyone who needs it. Of the estimated 1800 people living with HIV/AIDS receiving antiretroviral therapy as of June 2004, the vast majority were being treated through the public sector, with funding provided through federal and regional budgets. • • • •

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health and Social Development provides leadership in policy and programming within the public sector. The Ministry of Health and Social Development was reorganized recently, and the responsibility for HIV/AIDS treatment and care needs to be clarified. No national HIV/AIDS authority exists, although the Advisory Council to Fight HIV/AIDS, consisting of 25 government and nongovernmental organization members, was established in 2003, with United Nations agencies invited to participate. The Federal AIDS Center provides policy advice and normative guidance. National planning involves other key ministries, including the Ministry of Justice, Ministry of Education and Science and Ministry of Economic Development and Trade. Key United Nations agencies involved in policy support include WHO, UNAIDS, UNODC (especially in relation to prisons and drug users) and UNICEF (young people and preventing mother-to-child transmission). Antiretroviral therapy service delivery. The Ministry of Health and Social Development provides leadership in antiretroviral therapy service delivery, primarily through the okrug and regional AIDS centres. WHO provides normative support for tools and guidelines development (such as antiretroviral therapy guidelines, HIV testing and counselling and laboratory services). UNICEF supports drug procurement. Several nongovernmental organizations provide services that support scaling up antiretroviral therapy, including HIV testing and counselling, reaching out to vulnerable populations, training health care workers and directly providing treatment and care services.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • • The WHO Country Office has one National Programme Officer addressing HIV/AIDS issues and another specifically focusing on a United Nations Foundation project targeting vulnerable populations. An international “3 by 5” Country Officer is being recruited to coordinate WHO’s support for scaling up antiretroviral therapy, which will include establishing an in-country “3 by 5” team.

•

For further information, please contact: World Health Organization Department of HIV/AIDS

“3 by 5” Help Desk This country profile was developed in collaboration with national authorities, the WHO Country Office for the Russian Federation and the WHO Regional Office for Europe. E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

SUDAN

July 2004

WHO estimate of number of people requiring treatment – end 2005: 43 000 Antiretroviral therapy target declared by country: 20 000 by 2005

Libyan Arab Jamahiriya

Egypt Wadi Halfa

Saudi Arabia Port Sudan

HIV sentinel surveillance in pregnant women Percent seropositive

Latest available year for 1998 −2000

35 200

treat Million by

Dongola

Less than 1 1 − 4.9 5 − 9.9 10 −14.9

Faya

Chad Biltine Abeche El Fasher

Omdurman

Khartoum

Eritrea Asmara Mek’ele Gonder

15 −19.9

20 −29.9

Sudan El Obeid

30 and more

Cities and towns

Main roads Am Timan Birao Malakal Nek’emte Ndele Gore Wau Jima Dese Debre Markos

Population density (pers./sq.Km) Less than 10

Ethiopia Asela Awasa Goba

10 − 49

50 − 99

Central African Republic Bria Bambari Sibut Obo

100 −249

Arba Minch

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Bangassou Mobaye

750 and more

Democratic Republic of the Congo 0 137.5 275 550 Kilometers

Arua

Uganda

Kenya

Somalia

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 34.3 38.4 57.1 390 4.6 14 0.503 Source United Nations United Nations WHO CNS/BOS/ MOF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 0.7 – 7.2% 2003 2001 June 2004 2003

120 000 – WHO/ 1 300 000 UNAIDS 4 004 400 43 000 not available not available 13.8% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level, trend and gender data. According to national sources, at the end of December 2003, 10 959 cases of HIV/AIDS had been reported to the Sudanese National AIDS Control Programme since the beginning of the epidemic. A total of 1437 were reported in 2003, representing an increase of about 13% in the cumulative total. According to WHO/UNAIDS estimates, adult prevalence is in the range of 0.7–7.2%, and the main mode of transmission is heterosexual. The overall HIV prevalence in southern Sudan is difficult to estimate, as the civil strife of the past 50 years has led to the collapse of infrastructure, creating pockets of relatively isolated areas along with widespread poverty and illiteracy. • Major vulnerable and affected groups. According to national estimates, prevalence among vulnerable groups is estimated to be 1% among antenatal care attendees, 10% among tea sellers in the southern district of Juba, 2% among prisoners, 1% among truck drivers, 1.3% among street children, 4.3% among sex workers and 4% among refugees. These figures represent data from government-controlled states. The existing data from southern Sudan show varying HIV prevalence rates: 0.9% in the general population in Rumbek (2003), 0.3% in a group of people with tuberculosis in Upper Nile (2001), 7.2% in the general population in Yambio (2000) and 2.7% in the general population in Yei County on the border (2003) with Uganda. The southern states are hardest hit with HIV/AIDS because of the lack of health services and health awareness, in addition to their proximity to highprevalence neighbouring countries. • Policy on HIV testing and treatment. There is no clear policy on testing and counselling,

but the Ministry of Health is committed to strengthening access to voluntary testing and counselling services. The Health Secretariat of the Sudan People’s Liberation Army drafted an HIV/AIDS policy in 2001 for the south that was endorsed by the leadership of that movement. In 2002, the New Sudan National AIDS Council was created to monitor and evaluate the implementation of the policy. A national treatment plan is being developed. Treatment guidelines are available but need to be updated. Although political commitment is high in Sudan, resources are scarce. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The current cost of a first-line treatment regimen is US$ 516 per person per year, using zidovudine + lamivudine + nevirapine. • Assessment of overall health sector response and capacity. The Sudanese National AIDS Control Programme was established in 1987 and has been significantly strengthened in recent years. With strong political commitment from the highest levels, the Sudanese National AIDS Control Programme has developed a National Strategic Plan for 2003–2007 emphasizing multisectoral collaboration and community mobilization for a coordinated national response. In close collaboration with civil society, four parallel health service delivery systems work towards reducing the morbidity and mortality related to HIV/AIDS: the public health system (primary health care structure, with 300 rural hospitals and referral structures at state level); the health services of the police (including access to all 43 state prisons); the Armed Forces health services, (also treating civilians); and the health services of nongovernmental organizations, working with many of the 4 million internally displaced people.

1 © World Health Organization 2004

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SUDAN

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

• Critical issues and major challenges. In general, Sudan’s health system suffers from a weak infrastructure in terms of human resources, health service coverage and funds. It is characterized by major disparities in the distribution of services and resources between and within states, between rural and urban areas and in states affected by conflict. Major bottlenecks for scaling up treatment and care include stigma and discrimination, a lack of entry points (services for voluntary testing and counselling), poor health care services and lack of human capacity in the public system and civil society. Blood-banking facilities and regulations for blood testing do not exist in the south, which also suffers from a serious lack of health care personnel trained in antiretroviral therapy. The delay in finalizing the peace process is an additional challenge to reaching those in need. An estimated 3.5 million refugees are expected to return once the peace agreement is signed.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a series of missions over the past 12 months to assess the HIV/AIDS situation and to support the development of a training course and materials on HIV/AIDS programme management • Providing technical assistance for establishing a knowledge hub in Khartoum to support regional HIV/AIDS capacity-building with the support of WHO and GTZ • Recruiting a National Programme Officer to assist the Ministry of Health in monitoring drug resistance related to HIV, tuberculosis and malaria

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 21 500 people by the end of 2005 is between US$ 41.5 million and US$ 64.6 million. • Sudan submitted a successful Round 3 proposal to the Global Fund to Fight AIDS, Tuberculosis and malaria focusing on prevention and advocacy in the context of a multisectoral national response to HIV/AIDS. A corresponding national plan of action has been developed. However, this proposal does not cover the need to scale up antiretroviral therapy, except for US$ 400 000 per year for treating 400 people at the price of US$ 1000 per person per year. This proposal further envisages the establishment of 12 voluntary counselling and testing centres. Total funding anticipated to be available to support scaling up antiretroviral therapy from the Global Fund grant is estimated to be US$ 2.3 million during 2004–2005. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Sudan to reach 21 500 people by the end of 2005 is between US$ 39.2 million and US$ 62.2 million.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and other partners in scaling up antiretroviral therapy • Developing national standards for HIV/AIDS treatment and care for different levels of the health care system, including national guidelines on antiretroviral therapy • Developing a national operational plan for scaling up antiretroviral therapy, with clear roles for the partners • Developing training courses for state-level HIV/AIDS managers • Establishing a knowledge hub in Khartoum to support the development and implementation of capacity-building activities related to antiretroviral therapy

Staffing input for scaling up antiretroviral therapy and accelerating prevention • One National Programme Officer was recruited recently through funding from the Norwegian Agency for Development Cooperation to coordinate activities related to drug resistance monitoring for HIV, tuberculosis and malaria. Recruitment of an international “3 by 5” Country Officer is currently underway. • Additional Country Office staffing needs identified include one National Programme Officer and one general support staff.

5. Antiretroviral therapy coverage • Sudan’s total treatment need for 2005 is estimated to be 43 000, and the WHO “3 by 5” treatment target is 21 500 people by the end of 2005 (based on 50% of need). • The government is committed to providing treatment to 20 000 people by the end of 2005 and 40 000 people by the end of 2009. • It is estimated that about 400 people are currently receiving antiretroviral therapy, mostly through the non-public sector.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health and the Sudanese National AIDS Control Programme coordinate and manage the overall HIV/AIDS programme, including the provision of antiretroviral therapy. The Ministry of Health also coordinates the legal and policy framework, programme evaluation and planning of human resources. WHO, UNICEF and nongovernmental organizations contribute to the process of strengthening the heath system. • Antiretroviral therapy service delivery. The Ministry of Health provides leadership in delivering antiretroviral therapy services. The Ministry of Defence and the Ministry of the Interior collaborate closely with the Ministry of Health in providing testing and counselling and management of people living with HIV/AIDS at entry points. The Ministry of Health and partner nongovernmental organizations take the lead in planning and implementing activities related to capacity-building and site-level training. WHO and GTZ will assist in establishing a knowledge hub in Khartoum to support capacity-building activities at the national and state levels. • Community mobilization. Civil society groups increasingly collaborate with the Ministry of Health and the Sudanese National AIDS Control Programme in activities related to programme communication, capacity-building for people living with HIV/AIDS and treatment adherence and psychosocial support. • Strategic information. The Ministry of Health, in partnership with WHO, supports systems for monitoring antiretroviral drug resistance, patient tracking and operational research.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Sudan and the WHO Regional Office for the Eastern Mediterranean.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

SWAZILAND

July 2004

WHO estimate of number of people requiring treatment – end 2005: 32 000 Antiretroviral therapy target declared by country: 12 000 by 2005

South Africa Piggs Peak

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9 Mbabne

Latest available year for 2001 −2003

35 200

treat Million by

Mozambique Siteki Manzini

15 −19.9 20 −29.9

30 and more

Cities and towns

Main roads

Population density (pers./sq.Km) Less than 10

10 − 49 Hlatikulu

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more

0

12.5

25

50 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 1.1 23.5 38.8 1 244 7.5 41 0.547 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2003 2002 2003 2003 2001 June 2004 2003 Estimate 37.2 – 40.4% Source WHO/ UNAIDS

210 000 – WHO/ 230 000 UNAIDS 4 787 3 200 32 000 not available 12 000 75.1% Ministry of Health WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Swaziland is considered to be one of the most HIV-affected countries in the world, with about one in three adults infected. Swaziland is experiencing a generalized HIV/AIDS epidemic. The prevalence of HIV infection has increased sharply, from 3.0% in 1992 to between 37.2% and 40.4% in 2003. About 200 000 people are living with HIV/AIDS, and more than 12 000 adults and children have already died from AIDS. About 75% of the people with tuberculosis are coinfected with HIV. • Major vulnerable and affected groups. The population most affected by HIV/AIDS is women 20–24 years old. No information is available on the HIV prevalence among sex workers. Men and women with sexually transmitted infections have high HIV prevalence rates. • Policy on HIV testing and treatment. HIV testing is available as part of testing and counselling services linked to health services (tuberculosis clinics, sexually transmitted infections, preventing mother-to-child transmission and others) or through stand-alone voluntary counselling and testing clinics. HIV testing is always voluntary. In September 2003, the Ministry of Health and Social Welfare developed an Emergency Care and Treatment Implementation Plan to initiate scaling up of antiretroviral therapy through a phased approach. This Plan identifies seven treatment centres (including regional hospitals, two private clinics and two company clinics) to be considered for the first phase of the scaling-up process. Under the Plan, the government has already started to provide antiretroviral drugs free of charge to people living with HIV/AIDS. The Plan also includes strategies for strengthening human

resource capacity for scaling up antiretroviral therapy, ensuring adequate supplies of safe, approved and affordable antiretroviral drugs, promoting the accessibility of antiretroviral drugs to children and at the workplace, establishing a community-based antiretroviral therapy support system and ensuring a conducive policy environment to facilitate scaling up antiretroviral therapy services. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The most commonly used combination is stavudine + lamivudine + nevirapine (66%), followed by stavudine + lamivudine + efavirenz (12%), zidovudine + lamivudine + nevirapine (7%) and zidovudine + lamivudine + efavirenz (4%). The recently negotiated price for a triple combination regimen is US$ 175 per person per year. • Assessment of overall health sector response and capacity. Swaziland has made enormous progress towards providing antiretroviral therapy guided by the Health Sector Response Plan for HIV/AIDS 2003–2005 and the Emergency Care and Treatment Implementation Plan. Voluntary testing and counselling services are being scaled up to expand coverage, and laboratories are being strengthened to support the delivery of antiretroviral therapy services. Swaziland has good infrastructure (roads, electricity and water) and community networks that can be used to support treatment scale-up. • Critical issues and major challenges. Lack of human resources capacity is a major challenge to scaling up antiretroviral therapy in Swaziland. The recruitment and retention of staff is constrained by poor working conditions, few incentives and low pay. A system to ensure continuous supply and distribution of AIDS medicines and diagnostics needs to be strengthened. The various agencies

1 © World Health Organization 2004

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Swaziland

SWAZILAND

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP supporting treatment. The Swaziland AIDS Support Organization is an umbrella body for people living with HIV/AIDS and is involved in treatment literacy among people living with HIV/AIDS and the general public. Other nongovernmental organizations include The AIDS Support Centre, Swazis for Positive Living and Swaziland Youth United against HIV/AIDS. UNICEF and UNDP provide technical support for mobilizing communities and building capacity. • Strategic information. The Ministry of Health and the private sector have developed a computerized patient-tracking system. The Swaziland National HIV/AIDS Programme and the National Emergency Response Committee on HIV/AIDS undertake other aspects of monitoring and evaluation, supported by the World Bank. WHO and UNAIDS provide technical support in HIV surveillance, monitoring drug resistance and operational research.

involved in procurement, storage and supply of drugs need to harmonize their efforts, including the Government Tender Board, the Central Medical Stores and the care centres. Laboratory capacity is being strengthened at the central level; the same needs to be done at the regional level. A major challenge is strengthening the Swaziland National HIV/AIDS Programme in the Ministry of Health and Social Welfare to be able to adequately scale up care and treatment.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 16 000 people by the end of 2005 is between US$ 27 million and US$ 30 million. • The major sources of funding for antiretroviral therapy are the government budget, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the private sector. • The government has allocated US$ 2 million in 2003 and US$ 2.5 million in 2004 for purchasing antiretroviral drugs. • Swaziland submitted a successful Round 2 proposal to the Global Fund for AIDS, Tuberculosis and Malaria, for US$ 29.6 million over two years for HIV/AIDS, focusing on preventing mother-to-child transmission, expanding voluntary counselling and testing, providing HIV treatment and providing social support to orphaned children. Of this amount, it is estimated that about US$ 8 million will be available to support scaling up antiretroviral therapy during 2004–2005. • The Country Coordinating Mechanism has submitted a Round 4 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria for US$ 48 million over five years, with a focus on reducing the incidence of HIV/AIDS in Swaziland and mitigating the impact on the infected and affected individuals, families and communities, including palliative care. • Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Swaziland to reach 16 000 people by the end of 2005 is between US$ 19 million and US$ 22 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a WHO scoping mission in January 2004 in collaboration with the Ministry of Health and Social Welfare and UNAIDS to assess the status of antiretroviral therapy implementation and to identify opportunities and challenges for scaling up antiretroviral therapy and areas of WHO support • Providing technical assistance to the Ministry of Health and Social Welfare in finalizing the national framework for scaling up antiretroviral therapy • Supporting the Ministry of Health and Social Welfare in analysing human resources in depth to provide a basis for expanding an antiretroviral therapy programme • Supporting the development of training materials for various categories of health care providers • Supporting the strengthening of systems for procuring, storing, distributing and managing drugs, including the regulation and quality control of medicine • As part of the WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa, providing support in two districts (Mbabane and Mankayane) for improving access to and the quality of voluntary testing and counselling services, strengthening the National Blood Service by developing a quality management system and strengthening the continuum of care in managing and monitoring people living with HIV/AIDS • Supporting the Country Coordinating Mechanism in developing the Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria

5. Antiretroviral therapy coverage • Swaziland’s total treatment need for 2005 is estimated to be 32 000 people, and the WHO “3 by 5” treatment target is 16 000 people by the end of 2005 (based on 50% of need). • WHO estimates that about 3200 people were receiving antiretroviral therapy in June 2004. • The government is committed to providing antiretroviral therapy to 12 000 people by the end of 2005. • The public sector started providing antiretroviral therapy in 2001 at Mbabane Hospital, and antiretroviral drugs have been offered free of charge since November 2003. About 500 people are being treated at that site. • The government has also supported an antiretroviral therapy programme initiated by people living with HIV/AIDS through the Swaziland AIDS Support Organization; 620 people benefit from this service. • The private sector is providing antiretroviral drugs to about 700 people through a medical-aid scheme. In addition, private companies have organized specific programmes to provide antiretroviral drugs to their employees. • Round 2 funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria are intended to provide treatment for 10 000 people by the end of 2005. The Round 4 proposal aims to provide treatment to an additional 3000 people by the end of 2005.

Key areas for WHO support in the future • Providing continuing support in identifying strategies to address human resource constraints in the health sector response to HIV/AIDS • Providing continuing support in strengthening mechanisms for procuring and supplying drugs • Supporting the revision of national treatment protocols in accordance with WHO guidelines • Supporting the development and implementation of a countrywide information, education and communication strategy, targeting the general public and specific groups, including health workers, people living with HIV/AIDS, teenagers, schoolchildren and the mass media • Providing technical advice to help to develop a simplified and viable monitoring and evaluation system for antiretroviral therapy, especially for tracking antiretroviral drug resistance

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health and Social Welfare and the National Emergency Response Committee on HIV/AIDS, which is attached to the Prime Minister’s Office, provide leadership in treatment scale-up. The Ministry of Health and Social Welfare is responsible for developing policies, strategies and guidelines for implementing antiretroviral therapy programmes. UNAIDS provides support to the Ministry of Health and Social Welfare in strengthening coordination mechanisms. • Antiretroviral therapy service delivery. The Ministry of Health and Social Welfare takes the lead in implementing antiretroviral therapy scale-up. It sets standards and guidelines for antiretroviral therapy and provides supervision and technical support to both public and private providers. Others involved in providing antiretroviral therapy include private providers and mission hospitals. WHO provides normative technical support. Several partners provide support to the government in delivering antiretroviral therapy services. The Japan International Cooperation Agency and the Italian Cooperation support drug procurement. The United Kingdom Department for International Development and the European Union support activities related to voluntary testing and counselling. • Community mobilization. Several nongovernmental organizations are involved in efforts to mobilize community involvement in providing antiretroviral therapy and

Staffing input for scaling up antiretroviral therapy and accelerating prevention • The current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections includes one technical officer for HIV/AIDS, and recruitment of a subregional “3 by 5” officer (Botswana, Lesotho and Swaziland) is currently underway.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Swaziland and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

UNITED REPUBLIC OF TANZANIA WHO estimate of number of people requiring treatment – end 2005: 260 000 Antiretroviral therapy target declared by country: 220 000 by 2005 Buluko Mbarara Byumba

July 2004

Uganda Bukoba Musoma

Embu Nairobi

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1 1 − 4.9 5 − 9.9 Mombasa

Gisenyi Kibuye

Latest available year for 2001 −2003

Kibungo Cyangugu Butare Gikongoro Ngozi Bubanza Karusi Cankuzo

Rwanda

Kenya Mwanza

35 200

treat Million by

Burundi

Arusha Moshi Shinyanga

Bururi Rutana Makamba Kigoma Tabora Singida

10 −14.9 15 −19.9

Tanga Wete Mkoani Mkokotoni ZanzibarKoani Morogoro Kibaha Dar es Salaam

20 −29.9

Cities and towns

Main roads Sumbawanga Iringa

Population density (pers./sq.Km) Less than 10

Mbeya

10 − 49

50 − 99 Lindi

100 −249 Mtwara

Zambia Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO Mansa 0 80 160

250 −499

Songea

500 −749

Malawi 320 Kilometers

750 and more

Mzuzu

Mozambique

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 37.7 34.9 46.5 263 12.1 12 0.400 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 6.4 – 11.9% Source WHO/ UNAIDS

1 200 000 – WHO/ 2 300 000 UNAIDS 132 606 1 650 260 000 not available not available 33.8% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. The United Republic of Tanzania is a highburden, low-income country facing one of the largest HIV pandemics on the globe. The country is experiencing a mature, generalized HIV epidemic, which is still growing. The first cases of HIV/AIDS were reported in 1983. By 1985, the United Republic of Tanzania had an estimated 140 000 people living with HIV/AIDS (1.3% prevalence) and by 1990, about 900 000 (7.2% prevalence). Since the National AIDS Control Programme was established in 1985, the progression of the epidemic has been monitored through unlinked, anonymous testing of blood from pregnant women attending antenatal clinics for the first time in selected sentinel sites. Best estimates of prevalence suggest that the rural prevalence is about 2% lower than the national average and roughly half the urban prevalence. The overall prevalence of HIV infection among blood donors during 2002 was 9.7%, with women having a higher prevalence (12.3%) than men (9.1%). Based on the prevalence among blood donors and the 2002 census data, an estimated 1 894 160 people aged 15 years and above were living with HIV/AIDS in the United Republic of Tanzania in 2002. • Major vulnerable and affected groups. The major groups include: 1) women 15–24 years old; 2) orphans and vulnerable children 0–18 years old; 3) men 25–34 years old; 4) sex workers; 5) people in the transport sector, mines, police force, military, prisons and prisoners; 6) refugees; and 7) elderly people forced into new roles as caregivers without support themselves. • Policy on HIV testing and treatment. The national policy on HIV/AIDS specifies that all linked HIV testing must be voluntary, with pre- and post-test counselling, and all

testing for other health conditions must conform to ethical principles, that is, informed consent. In March 2003, the Ministry of Health developed the Health Sector HIV/AIDS Strategy for 2003–2008, on which the National Care and Treatment Plan for HIV/AIDS for 2003–2008 was developed, in collaboration with country partners. The Cabinet has approved the National Care and Treatment Plan for HIV/AIDS, and all care and treatment projects and programmes in the country will be incorporated into the Plan. • Antiretroviral therapy: first-line drug regimen, cost per person per year. First-line antiretroviral therapy regimens for adults are: a) stavudine + lamivudine + nevirapine; b) stavudine + lamivudine + efavirenz; c) zidovudine + lamivudine + efavirenz; and d) zidovudine + lamivudine + nevirapine. First-line antiretroviral therapy regimens for children are: zidovudine + lamivudine + nevirapine and zidovudine + lamivudine + efavirenz. The cost of basic highly active antiretroviral therapy dropped to US$ 360 per person per year in February 2003 (Dar es Salaam) and is expected to continue to fall rapidly. • Assessment of overall health sector response and capacity. The overall health sector response capacity is rated as high compared with other countries in Africa with a similar level of development. By 1999 there were 4961 health facilities, of which the government owned 3035 and nongovernmental organizations, parastatal organizations, voluntary agencies and the private sector owned 1926. Community- and home-based care initiatives are being introduced in some areas. There are an estimated 250 voluntary counselling and testing sites nationwide, of which the government runs 180. Less than 5% of the population has accessed voluntary counselling and testing services because of stigma and costs, although the Ministry of Health has committed to testing health

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United Republic of Tanzania

30 and more

UNITED REPUBLIC OF TANZANIA SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP workers, youth and poor people free of charge in the Health Sector HIV/AIDS Strategy for 2003–2008. The government is strongly committed to the fight against HIV/AIDS and that commitment continues to expand. The Tanzania Commission for HIV/AIDS (TACAIDS), created in 2000, leads the national response to HIV/AIDS. • Critical issues and major challenges. The constraints in the existing public health sector infrastructure are recognized as a major bottleneck to the implementation of the National Care and Treatment Plan for HIV/AIDS for 2003–2008. No legal instrument is in place to overrule the requirements of intellectual property rights regulations and allow the import of generic drugs and the local manufacture of drugs covered by patents. Access to voluntary counselling and testing varies greatly, and the price of voluntary counselling and testing has constituted a financial access barrier. The human resource shortage in the health sector is a major constraint to scaling up antiretroviral therapy. • Strategic information. The Ministry of Health leads and manages surveillance, monitoring and evaluation, information management and operational research activities. WHO plays an important role in providing technical guidance. The United States Centers for Disease Control and Prevention, UNAIDS and TACAIDS provide support for surveillance activities. Monitoring antiretroviral drug resistance, tracking patients and information management activities require additional strengthening and support. The government and its international partners signed a memorandum of understanding recently, articulating the desire by all partners to coordinate their efforts in planning, implementing monitoring and evaluation and mobilizing resources for the National Multi-sectoral Framework on HIV/AIDS. In this context, implementing partners have different roles, which TACAIDS is monitoring and coordinating.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 130 000 people in 2005 is between US$ 185 million and US$ 314 million. • Of this, the government has committed about US$ 8.9 million to support scaling up antiretroviral therapy for 2004 - 2005, and the United States President’s Emergency Plan for AIDS Relief is expected to commit substantial support of US$ 89.6 million over the same period. Other bilateral partners are expected to provide additional support of about US$ 13.9 million. • The Global Fund to Fight AIDS, Tuberculosis and Malaria provided a grant of US$ 87 million in Round 3 for tuberculosis and HIV collaborative activities, including care and treatment. The Global Fund Round 4 proposal requested US$ 288 million, of which US$ 207 million is allocated for care and treatment for two years. The Global Fund Round 3 grant is anticipated to provide an estimated US$ 4.2 million for scaling up antiretroviral therapy during 2004–2005. • Other funding to support scaling up antiretroviral therapy will be available starting in 2004 through the World Bank Multi-Country HIV/AIDS Program for Africa. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap to reach 130 000 people by the end of 2005 will be between US$ 68 million and US$ 197 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Supporting the development of the Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria • Conducting a “3 by 5” scoping mission in December 2003 to identify opportunities and challenges for scaling up antiretroviral therapy • Under the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting the strengthening of voluntary counselling and testing services and improved access to home-based care in Iringa, Dodoma and Zanzibar; promoting institutional capacity-building in each of the districts; improving the capacity of the WHO Country Office by financially supporting one national project officer; and supporting a project coordinator at the Ministry of Health, National Aids Control Programme.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Supporting the health sector review • Providing technical assistance in human resource planning and capacity-building • Providing technical assistance in developing a plan for voluntary testing and counselling • Providing technical assistance in facilitating the disbursement of Round 3 funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria • Providing technical assistance on procurement issues • Supporting the strengthening of the human resources capacity of the National AIDS Control Programme in laboratory services, organization of HIV/AIDS clinical services, monitoring and evaluation and community mobilization.

5. Antiretroviral therapy coverage The total treatment need for 2005 is estimated to be 260 000 people, and the WHO “3 by 5” treatment target for 2005 is 130 000 people (based on 50% of estimated need). The government has declared a national antiretroviral therapy target for 2005 of 220 000 people, and the current estimate of antiretroviral therapy coverage is 1650 people.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer, and recruitment of an international “3 by 5” Country Officer is currently underway. • Under the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, an additional National Programme Officer is in place and two additional WHO National Programme Officers are scheduled for immediate deployment.

6. Implementation partners involved in scaling up antiretroviral therapy • Management and leadership. In 2000, the government established TACAIDS under the auspices of the Prime Minister’s Office to lead the multisectoral response to the epidemic. The role of TACAIDS is to intensify the national response through strategic leadership, policy guidance and coordinating public, voluntary, private and community efforts. The Ministry of Health provides leadership in policy and programming within the public sector, with the TACAIDS supporting the national planning process, fundraising and programme evaluation. National human resources planning provides the greatest challenge, and studies to inform the planning process are ongoing with support from the President’s Office for Regional Administration and Local Government and the Ministry of Finance. • Antiretroviral therapy service delivery. The Ministry of Health leads and manages most delivery of antiretroviral therapy services. WHO provides normative support for developing tools and guidelines along with the United States Centers for Disease Control and Prevention and nongovernmental organizations. The Medical Stores Department provides leadership in procurement and supply chain management, with the United States Agency for International Development, WHO, the United States Centers for Disease Control and Prevention and a range of nongovernmental organizations providing support, also in capacity-building, site-level training, strengthening laboratories and accelerating prevention. • Community mobilization. The Ministry of Health provides leadership in programme communication, capacity-building among people living with HIV/ AIDS and adherence and psychosocial support. WHO, the President’s Office for Regional Administration and Local Government and a range of nongovernmental organizations work alongside the government in mobilizing communities.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for the United Republic of Tanzania and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

UGANDA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 110 000 Antiretroviral therapy target declared by country: 60 000 by 2005

Sudan

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1

Latest available year for 2001− 2003

35 200

treat Million by

Arua

1 − 4.9 Gulu Moroto

Democratic Republic of the Congo

5 − 9.9 10 −14.9 15 −19.9 20 −29.9

30 and more Mbale

Cities and towns

Main roads Fort Portal Bombo Kampala Jinja Kakamega

Population density (pers./sq.Km) Less than 10

Kenya Kisumu Masaka Mbarara

10 − 49

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more Ruhengeri Gisenyi

Rwanda

United Republic of Tanzania 0

Musoma 40

80

160 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 26.7 12.2 49.3 242 16.4 14 0.489 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 2.8 – 6.6% 2003 2001 June 2004 2003 2003

350 000 – WHO/ 880 000 UNAIDS 55 861 20 000 110 000 43 not available 24% WHO WHO/ UNAIDS WHO WHO/ UNAIDS Ministry of Health

3. Situation analysis • Epidemic level and trend and gender data. Uganda has a generalized heterosexual HIV epidemic that is showing declining trends. HIV prevalence in the adult population (15–49 years old) is currently estimated to be between 2.8% and 6.6%. The 2003 surveillance report of the National AIDS Control Programme states that the HIV prevalence of a Medical Research Council and Uganda Virus Research Institute cohort declined from 5.8% in 2000 to 5.0% in 2002. The prevalence rate among women was 5.5% versus 4.5% among men. Uganda AIDS Information Centre data on voluntary counselling and testing also show higher prevalence rates among women versus men 15–24 years old, although the rates are declining in both groups. The prevalence rate declined from 29% in 1992 to 10.3% in 2002 among women and from 11% in 1992 to 2.8% in 2002 among men. The total number of adults and children living with HIV/AIDS in Uganda is estimated to be between 350 000 and 880 000. • Major vulnerable and affected groups. Major vulnerable groups include women, pregnant women, young people and children. • Policy on HIV testing and treatment. HIV testing is provided within the context of voluntary counselling and testing and diagnostic testing for care and treatment. The country’s National Strategic Framework for Expansion of HIV/AIDS Care and Support (2001–2002 to 2005–2006) focuses on scaling up access to comprehensive care, including treatment for opportunistic infections, community- and home-based care and support and antiretroviral therapy. Uganda has developed national guidelines on antiretroviral therapy in accordance with the WHO treatment guidelines. In June 2004, the government announced an initiative to provide free antiretroviral drugs to all people who are clinically eligible. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The first-line

regimen options are zidovudine (or stavudine) + lamivudine + nevirapine (or efavirenz). The average cost of the first-line regimen was US$ 400 per person per year in March 2003 including the cost of drugs, laboratory tests and training. • Assessment of overall health sector response and capacity. Uganda has a very high level of political commitment and awareness at all levels and a strong and comprehensive health sector response to HIV/AIDS that has become a model for many countries. The Uganda AIDS Commission was established in 1992 and has coordinated the multisectoral approach through joint planning, joint monitoring and evaluation and information sharing. Major interventions have included programmes focused on communication to increase awareness and change behaviour, strengthening laboratory and blood transfusion services to ensure blood safety, managing sexually transmitted infections and establishing a continuum of comprehensive care that includes HIV testing and counselling, providing drugs for treating opportunistic infections and providing antiretroviral drugs. In 1997, the HIV Drug Access Initiative was launched with the support of UNAIDS to improve access to HIV care, including antiretroviral therapy. In 2000, the Ministry of Health established a National Committee on Access to Antiretroviral Therapy. As a result of the very comprehensive HIV/AIDS response, Uganda’s HIV prevalence rate has declined, especially among people 15–24 years old. • Critical issues and major challenges. The shortage of human resources is a major constraint to scaling up antiretroviral therapy. This has been compounded by low salaries, lack of incentives and the ban on hiring in the public sector. The capacity for scaling up is also weak at the district and subdistrict levels. Uganda has the capacity to rapidly scale up antiretroviral therapy if adequate financial resources are made available.

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Uganda

UGANDA 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Community mobilization. A wide range of nongovernmental organizations are involved in community-related work. The Uganda National AIDS Support Organizations coordinate activities. Key national nongovernmental organizations involved in community mobilization include The AIDS Support Organization, Uganda AIDS Information Centre and Reach Out Mbuya, among many others. • Strategic information. The Ministry of Health together with the Uganda AIDS Commission is responsible for monitoring and evaluation activities. It also coordinates operational research activities. Other agencies involved in generating strategic information include the Academic Alliance, Joint Clinical Research Centre, The AIDS Support Organization and Uganda AIDS Information Centre. Organizations providing support in this area include the United States Centers for Disease Control and Prevention and WHO.

• WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 55 000 people by the end of 2005 is between US$ 66 million and US$ 131 million. • The government has committed an estimated US$ 3 million to scaling up antiretroviral therapy for 2004. • Uganda submitted a successful Round 1 proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria, with a comprehensive approach to prevention, care and treatment of HIV/AIDS (two-year approved funding of US$ 36 million). Uganda also submitted a Round 3 proposal to the Global Fund with two-year funding approved of US$ 70.4 million for scaling up antiretroviral therapy and interventions for orphans and other vulnerable children. Total funding anticipated to be available to fund treatment scale-up from Global Fund grants is about US$ 35.1 million for 2004–2005. • The United States President’s Emergency Plan for AIDS Relief has committed more than US$ 90 million for the year 2004 to assist Uganda in preventing and treating AIDS. Of these funds, national estimates indicate that about US$ 12.6 million is anticipated to be committed to scaling up antiretroviral therapy during 2004–2005. • Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Uganda to reach 55 000 people by 2005 is up to US$ 57.6 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Supporting the Ministry of Health in developing a comprehensive national plan for scaling up antiretroviral therapy • Supporting the Ministry of Health in national adaptation of WHO Integrated Management of Adult and Adolescent Illness guidelines • As part of the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting expanding voluntary counselling and testing facilities in 11 districts; increasing the number of health subdistricts implementing home-based care; establishing a model for scaling up the prevention of mother-to-child transmission at the health subdistrict level; and building institutional capacity at the district level in collecting, analysing and utilizing HIV/AIDS data and information • As part of the WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa, supporting the strengthening of integrated community-based HIV/AIDS prevention and care interventions (HIV surveillance, home-based care, preventing mother-to-child transmission and DOTS) in Uganda

5. Antiretroviral therapy coverage • Uganda’s total treatment need for 2005 is estimated to be 110 000 people, and the WHO “3 by 5” treatment target is 55 000 people by the end of 2005 (based on 50% of need). • The HIV Drug Access Initiative was launched in 1997 with five accredited centres in the region around Kampala. By the end of its pilot phase in 2000, the HIV Drug Access Initiative had provided treatment to an estimated 1000 people. • In the expansion phase, the number of accredited health facilities has increased to 25, and 23 of these are providing antiretroviral therapy. • In June 2004, an estimated 20 000 people living with HIV/AIDS had access to antiretroviral therapy, most through research programmes and nongovernmental organizations such as the Joint Clinical Research Centre; Uganda AIDS Information Centre; The AIDS Support Organization, the Medical Research Council and the Mildmay Uganda Centre. The Joint Clinical Research Centre is providing an estimated 12 500 people, mostly in Kampala, with generic antiretroviral drugs at cost. Other nongovernmental providers include Reach Out Mbuya, a community-based HIV/AIDS project in Mbuya on the outskirts of Kampala that administers antiretroviral therapy; and the Uganda Cares Programme in Masaka, an integrated community-based and -driven antiretroviral therapy centre. Bilateral and multilateral partners support many of these organizations. • Faith-based organizations also provide treatment. Kamwokya Christian Caring Community, a faith-based organization in Kampala, plans to provide antiretroviral therapy coverage to up to 500 people with financial support from the United States President’s Emergency Plan for AIDS Relief. • The private sector provides some antiretroviral therapy for employees. Since 2002, the Bank of Uganda has offered antiretroviral therapy at subsidized rates to its employees. • Uganda has declared a treatment target for the end of 2005 of 60 000 people. The recently announced government initiative to provide free antiretroviral drugs to everyone will reach 2700 people in 2004 through regional referral hospitals, other accredited district hospitals, level IV health centres (small hospitals) and some missionary hospitals.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and other partners in scaling up antiretroviral therapy • Providing technical assistance in setting up systems for tracking patients and monitoring and evaluation programmes • Providing technical assistance in capacity-building • Providing technical support in communication • Providing technical support in developing systems for monitoring drug resistance • Collaborating with the World Food Programme to ensure adequate food aid and nutritional support for people receiving antiretroviral treatment

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and recruitment of an international “3 by 5” Country Officer is currently underway. • Additional staffing needs identified include two National Programme Officers for the WHO Country Office, three National Programme Officers to strengthen the National AIDS Programme of the Ministry of Health, one international communication officer and one international staff member for monitoring and evaluation activities.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Uganda AIDS Commission is responsible for overall multisectoral coordination of the national response. The National AIDS Programme of the Ministry of Health is the lead agency in scaling up antiretroviral therapy. It develops policies, plans, strategies and guidelines for providing antiretroviral therapy and coordinates with other implementing partners. WHO and UNAIDS provide support in planning and coordinating implementation. A national human resources plan is being finalized with support from WHO and the Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia. A national task force of all stakeholders has been set up to harmonize human resource planning for the national scale-up plan. • Antiretroviral therapy service delivery. The Ministry of Health leads and coordinates antiretroviral therapy service delivery by public, private, and nongovernmental organizations. The Joint Medical Stores and WHO support drug procurement and supply chain management. The Ministry of Health coordinates capacity-building and training activities, with support from WHO and the Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia. WHO also supports the development of guidelines.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Uganda and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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UKRAINE

July 2004

WHO estimate of number of people requiring treatment – end 2005: 45 000 Antiretroviral therapy target declared by country: 2 100 by 2005

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1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 48.2 67.2 67.2 771 7.6 33 0.766 Source United Nations United Nations WHO UNECE WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 0.7 – 2.3% 2003 June 2004 June 2004 2003 2003

180 000 – WHO/ 590 000 UNAIDS 7 465 170 45 000 127 not available 5.7% WHO Ministry of Health WHO WHO/ UNAIDS Ministry of Health

3. Situation analysis • Epidemic level and trend and gender data. There is a concentrated epidemic among injecting drug users, who comprise 73% of all reported cases since 1986 and 59% of all newly reported HIV infections in 2003. There is considerable regional variation, with the eastern and southern regions most affected, including Odessa, Mikolaev, Dniepropetrovsk, Donetsk, Crimea and Sevastopol. The most rapid spread took place between 1995 and 1997 among networks of injecting drug users. Since then there has been increasing heterosexual transmission, especially to the female sexual partners of injecting drug users and related to sex work. • Major vulnerable and affected groups. HIV prevalence rates among injecting drug users are as high as 59% in the most severely affected cities. HIV prevalence rates among sex workers are much higher than in western Europe (6–32%), especially among sex workers who inject drugs (33–83%). Female sex partners of injecting drug users and children of female drug users are especially vulnerable. • Policy on HIV testing and treatment. Increasing HIV infection rates have been masked by a decrease in testing among injecting drug users because of a law adopted in March 1998 that codified the principle of voluntary HIV testing in Ukraine. The law also stipulates that HIV/AIDS treatment should be free, including antiretroviral therapy, although limited resources have restricted universal access to antiretroviral therapy. • Antiretroviral therapy: first-line drug regimen, cost per person per year. National HIV/AIDS treatment guidelines, including first- and second-line regimens, have been developed with the assistance of WHO. First-line regimens include: efavirenz + zidovudine + lamivudine; nevirapine + zidovudine + lamivudine; and nelfinavir

+ zidovudine + lamivudine. Second-line regimens include: nelfinavir + stavudine + lamivudine; efavirenz + stavudine + didanosine; and lopinavir with a low-dose ritonavir boost + stavudine + lamivudine. Zidovudine and lamivudine are procured in a fixeddose combination. The Ministry of Health tender for 2000–2002 resulted in an average antiretroviral therapy cost of US$ 10 000 per person per year. Because generic products rapidly penetrated the market, first-line regimens range in price from US$ 494 to US$ 3711 per person per year and second-line regimens from US$ 1090 to US$ 5722. • Assessment of overall health sector response and capacity. The overall capacity of the health sector to provide antiretroviral therapy is very limited. Antiretroviral therapy is provided in three government hospitals and through one small programme run by Médecins Sans Frontières. The Round 1 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria will support scaling up antiretroviral therapy, including establishing antiretroviral therapy by trained personnel in seven regions with cascade training to follow. • Critical issues and major challenges. Marginalization of and discrimination against drug users remains a major obstacle to identifying individuals needing treatment, encouraging them to seek treatment services and providing quality care. Coordination and links between drug dependence treatment services, outreach programmes, tuberculosis services and HIV/AIDS prevention and treatment services need to be strengthened to ensure the comprehensive management of people living with HIV/ AIDS. Although clinicians have been trained in readiness for scaling up antiretroviral therapy, procurement of antiretroviral drugs still depends on the availability of donor funds and strengthening systems for drug procurement and supply management.

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UKRAINE 4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Community mobilization. The Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank support significant community mobilization activities. The International HIV/AIDS Alliance, other international nongovernmental organizations, UNAIDS and the European Union support the building of capacity among people living with HIV/AIDS and community organizations. A range of nongovernmental and community-based organizations represent the interests of affected and vulnerable populations, including people living with HIV/AIDS and drug users. • Strategic information. The National AIDS Prevention Center is involved in operational research and tracking patients. UNAIDS has supported the Ministry of Health in developing the national HIV/AIDS monitoring and evaluation system. WHO is providing technical assistance for monitoring antiretroviral drug resistance.

• Ukraine was successful in its Round 1 application to the Global Fund to Fight AIDS, Tuberculosis and Malaria, with a total of US$ 92 million requested over five years and US$ 17.35 million approved for the first two years. The treatment and care component of the proposal is budgeted at about US$ 62 million, with the Ministry of Health proposed as principal recipient for the component. About US$ 7 million had been disbursed by May 2004. In January 2004 the grant was reprogrammed, and the International HIV/AIDS Alliance was appointed interim principal recipient. It is proposed that the grant cover antiretroviral therapy for 2100 people from 2004 to March 2005. The number of people to be covered for 2005 has not yet been agreed. • The World Bank has provided a US$ 60 million loan to Ukraine for implementing the US$ 72 million Ukraine Tuberculosis and AIDS Epidemic Control Project. This Project includes developing treatment protocols, treating pregnant women to prevent mother-to-child transmission, treating opportunistic infections, training staff, strengthening laboratories and conducting a small antiretroviral therapy pilot project. Total funding for HIV/AIDS treatment is US$ 4 million. • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the “3 by 5” treatment target of 22 500 is between US$ 242 million and US$ 246 million. It is anticipated that funding available for scaling up antiretroviral therapy during 2004–2005 could include about US$ 27.4 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria grant and about US$ 1 million from bilateral partners. Taking into account the funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Ukraine to reach 22 500 people by the end of 2005 is between US$ 214 and US$ 218 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Providing technical and financial assistance for developing HIV/AIDS treatment protocols for Ukraine • Supporting the development of a National HIV/AIDS Treatment and Care Plan as part of the overall national HIV/AIDS plan • Providing technical assistance for drug procurement and supply management • Providing technical assistance in developing national standards for HIV testing and counselling • Supporting the establishment of a pilot project on HIV and tuberculosis in Donetsk • In collaboration with GTZ, establishing the Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia (in Kiev) to support regional capacity-building, including: adapting HIV/AIDS treatment and care tools and guidelines locally and regionally; developing training curricula and materials; providing training for trainers and HIV/AIDS care providers; and establishing a subregional network of HIV/AIDS treatment and care experts and institutions • Providing technical support for planning for the implementation of the Global Fund to Fight AIDS, Tuberculosis and Malaria grant and the Ukraine Tuberculosis and AIDS Epidemic Control Project supported through the World Bank loan

5. Antiretroviral therapy coverage • Ukraine’s total treatment need for 2005 is estimated to be 45 000 people, and the WHO “3 by 5” treatment target is 22 500 by 2005. The government has declared a national treatment target of providing antiretroviral therapy to 2 100 people by the end of 2005. • As of June 2004, an estimated 170 people were receiving therapy. • As of June 2004, the Ministry of Health is providing antiretroviral therapy for 137 people and is relying on donor funds to significantly expand the programme. An additional 10–15 people are being treated through regional health budgets in Kiev and Odessa. Médecins Sans Frontières supports a small treatment programme in Odessa covering antiretroviral therapy for about 42 people, including children.

Key areas for WHO support in the future • Establishing a “3 by 5” country team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Assisting the government in finalizing the National HIV/AIDS Treatment and Care Plan, including an operational plan for scaling up antiretroviral therapy • Strengthening the capacity of the Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia to expand training, with a focus on HIV/AIDS clinicians • Continuing to provide technical assistance for strengthening systems for procuring drugs and supply chain management

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health has overall responsibility for national HIV/AIDS policy, programming and management. The Ministry of Health led a strategic planning process that resulted in the development of the National AIDS Programme for 2004–2008. The Country Coordinating Mechanism provides a mechanism for coordinating the activities of partners. The Vice-Prime Minister is co-chair of the Country Coordinating Mechanism and Head of the Government Commission on HIV/AIDS. The Expanded United Nations Theme Group on HIV/AIDS in Ukraine complements the coordination efforts of the Country Coordinating Mechanism. The International HIV/AIDS Alliance, as the interim principal recipient for the Global Fund to Fight AIDS, Tuberculosis and Malaria grant, is responsible for managing the grant and facilitating the coordination of implementation. WHO and UNAIDS play important roles in providing technical assistance for developing national plans and guiding policy. • Antiretroviral therapy service delivery. The Ministry of Health provides overall leadership in delivering antiretroviral therapy services, primarily through government AIDS centres. WHO provides technical assistance to the Ministry of Health in procuring drugs, and the International HIV/AIDS Alliance, as principal recipient, is managing procurement related to the Global Fund to Fight AIDS, Tuberculosis and Malaria grant. WHO provides normative guidance for activities related to scaling up antiretroviral therapy, including antiretroviral therapy guidelines, HIV testing and counselling, laboratory services, drug dependence treatment and outreach to drug users. Capacity-building is supported through the World Bank loan and the Knowledge Hub for the Care and Treatment of HIV/AIDS in Eurasia (based in Kiev). The United States Agency for International Development, WHO and UNFPA support testing and counselling activities.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway. • Additional staff needs identified include: one international medical officer and one National Programme Officer to focus on delivering antiretroviral therapy; one National Programme Officer to support community mobilization efforts; and one National Programme Officer to support monitoring and evaluation and strategic information management.

For further information, please contact: World Health Organization Department of HIV/AIDS

“3 by 5” Help Desk This country profile was developed in collaboration with national authorities, the WHO Country Office for Ukraine and the WHO Regional Office for Europe. E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

VIET NAM

July 2004

WHO estimate of number of people requiring treatment – end 2005: 22 000 Antiretroviral therapy target declared by country: 15 000 by 2005

China Myanmar

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

Latest available year for 2001 −2003

35 200

treat Million by

Lao People s Democratic Republic Vientiane

15 −19.9

20 −29.9

30 and more

Thailand Bangkok

Cities and towns

Population density (pers./sq.Km)

Cambodia Phnom Penh

Less than 10

10 − 49

50 − 99

Viet Nam Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

100 −249

250 −499

500 −749

750 and more

0

115

230

460 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 82.5 25.5 69.6 415 6.1 21 0.688 Source United Nations United Nations WHO United Nations WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 Estimate Source WHO/ UNAIDS 2003 0.2 – 0.8% 2003 2001 June 2004 2003

110 000 – WHO/ 360 000 UNAIDS 5 332 1 000 22 000 not available not available 1.8% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Viet Nam is facing a rapidly growing HIV epidemic that is beginning to extend beyond initial concentrations in networks of injecting drug users and sex workers. The first case of HIV infection was detected in 1990. By 2002, more than 10 000 people were becoming infected per year, and the epidemic had expanded to all 61 provinces of Viet Nam, with HIV detected in 93% of districts and 49% of communes. Viet Nam is still in a concentrated epidemic stage, but there is clear spread to the general population, with sentinel surveillance showing HIV seroprevalence of more than 1% among antenatal women in four provinces. • Major vulnerable and affected groups. Viet Nam’s HIV/AIDS epidemic affects mainly young people: 63% of those infected at the end of 2002 were 20–29 years old. It is largely concentrated among injecting drug users and their partners and sex workers and their clients. Fifty to sixty per cent of the total reported people living with HIV/AIDS are injecting drug users. The national average HIV prevalence among injecting drug users increased from 9.4% in 1996 to 29.3% in 2002; in some provinces, the HIV prevalence among injecting drug users has reached 60–70%. • Policy on HIV testing and treatment. Viet Nam is strongly committed to ensuring a vigorous response to the HIV/AIDS epidemic, and political involvement is evident at the highest level. In February 2003, the Prime Minister signed a directive on strengthening HIV/AIDS prevention and control that includes prevention, care and treatment in a multisectoral framework. The Prime Minister approved the National Strategy on HIV/AIDS for 2004–2010 with a Vision to 2020. The National Strategy allows for the first time the provision for harm reduction activities among injecting

drug users and female sex workers and also refers to comprehensive antiretroviral therapy and care services for people living with HIV/AIDS among its priorities. The notion of voluntary counselling was only recently introduced in Viet Nam, with the development of counselling centres all over the country. Guidelines on antiretroviral therapy developed a few years ago recommended the use of only two drugs, but these guidelines are now being revised and will follow WHO recommended guidelines. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Antiretroviral therapy is not currently available beyond a few small pilot projects. Antiretroviral therapy is only accessible to a small number of people who can afford to pay the high cost of treatment, estimated to be US$ 700–900 per year for the locally produced two-drug combination lamivudine + zidovudine. • Assessment of overall health sector response and capacity. Overall health indicators in Viet Nam are quite good given its low gross domestic product per capita. Viet Nam has demonstrated its capacity to manage several infectious diseases, including severe acute respiratory syndrome. Viet Nam has the advantage of having an extensive network for health care and myriad community-based organizations. However, the capacity of the various levels of the governmental structures administering and leading HIV/AIDS work in Viet Nam needs to be built to keep pace with the implementation of scaling up antiretroviral therapy. Capacitybuilding for scaling up antiretroviral therapy in both managerial and technical areas will require the support and coordination of many different in-country partners.

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VIET NAM

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP

• Critical issues and major challenges. The main barrier to scaling up is the cost of the antiretroviral drugs. With financing from the Global Fund to Fight AIDS, Tuberculosis and Malaria to purchase drugs, capacity and stigma issues can be tackled, as Viet Nam now has strong political commitment to ensuring equity of access. Regulatory barriers also need to be overcome. The patent status of the main drugs recommended for first- and second-line treatment is not clear, which limits procurement options. If patents restrict the import of generic antiretroviral drugs, the prices will have to be negotiated with patent drug manufacturers, likely leading to higher costs.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Assessing the national antiretroviral therapy programme in the context of the “3 by 5” strategy, especially identifying opportunities and gaps • Assisting in procuring antiretroviral drugs, especially as related to patent issues • Developing a national operational plan for scaling up antiretroviral therapy focusing on the role of partners • Assessing needs with regard to harm reduction interventions, including antiretroviral therapy for injecting drug users • Conducting final selection with the Ministry of Health of 15 sites for antiretroviral therapy services in 2004, site-focused operational planning meetings to define resource needs and timelines, operational planning with partners to define the support they can provide (or are providing) at each site and elaborating essential operational research agenda to be carried out in these first-phase sites

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 11 000 people by 2005 is between US$ 50 million and US$ 56 million. • The government has committed about US$ 2.7 million to fund activities for scaling up antiretroviral therapy during 2004–2005. Round 1 funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria was recently made available to Viet Nam and will permit immediate start-up of activities that will lay the basis for scaling up, including initially procuring antiretroviral drugs and establishing services in 15 antiretroviral therapy sites linked to prevention services in five highly affected provinces. It is estimated that the Global Fund grants will provide about US$ 6 million for scaling up antiretroviral therapy during 2004–2005. • Taking into account funds committed to date to support scaling up antiretroviral therapy, WHO estimates that the total funding gap for Viet Nam to reach 11 000 people by the end of 2005 is between US$ 42 million and US$ 47.6 million.

Key areas for WHO support in the future • Establishing a “3 by 5” team in the WHO Country Office to support the government and other partners in scaling up antiretroviral therapy • Providing continued support for procuring antiretroviral drugs, including capacity-building in price negotiation, prequalification, how to procure antiretroviral drugs at reasonable prices now (with Round 1 funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria) and planning for longerterm procurement or local production (prequalification) • Developing national standards for HIV/AIDS treatment and care for different levels of the health care system, including national guidelines on antiretroviral therapy • Planning for capacity-building • Developing a harm reduction plan (overlapping antiretroviral therapy issues) • Supporting the development of communication and advocacy strategies • Supporting the strengthening of laboratory services • Developing a national monitoring and evaluation system for the antiretroviral therapy programme, including patient tracking • Developing community-based approaches that will integrate harm reduction, drug dependence treatment and antiretroviral therapy • Drafting a detailed “3 by 5” operational plan for 2004, including a framework for scaling up in 2005

5. Antiretroviral therapy coverage • Viet Nam’s total treatment need for 2005 is estimated to be 22 000 people, and the WHO “3 by 5” treatment target was set at 11 000 people (based on 50% of estimated need). In 2003, the government supported the provision of antiretroviral therapy to about 1000 people. • With technical assistance from WHO, the Ford Foundation and others, Viet Nam has declared a national target of providing 15 000 people with antiretroviral therapy by the end of 2005. At least 15 sites are expected to begin providing antiretroviral therapy during an initial implementation phase in 2004. • Viet Nam was recently added as the 15th focus country of the United States President’s Emergency Plan for AIDS Relief. The Emergency Plan interventions in Viet Nam through non-governmental organizations could provide treatment for an estimated 13 000 people living with HIV/AIDS.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer in the position of technical officer as well as one full-time medical officer. Recruitment of an international “3 by 5” Country Officer is currently underway.

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The Ministry of Health (with support from United Nations agencies and the Ministry of Labour, Invalids and Social Affairs) is responsible for the overall coordination and management of the national antiretroviral therapy programme, including the legal and policy framework, determining the costs of scaling up and raising the funds to achieve this, human resource planning, strengthening the health system, delivering antiretroviral therapy services and strategic information. • Antiretroviral therapy service delivery. Under the leadership and coordination of the Ministry of Health, the Clinton Foundation and United Nations agencies provide support for procuring antiretroviral drugs. The United States Centers for Disease Control and Prevention and the French project ESTHER (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau) support overall capacity-building activities, in-service training of service providers, the development of normative guidelines and testing and counselling activities. ESTHER is also beginning smallscale antiretroviral therapy in Hanoi, Ho Chi Minh City and Haiphong. • Community mobilization. Community-based organizations lead work related to building the capacity of groups of people living with HIV/AIDS and to promoting adherence and psychosocial support with contributions from international nongovernmental organizations. The Ministry of Health provides leadership for programme communication and advocacy at the community level as well as material (that is, nutrition) support. • Strategic information. WHO supports the Ministry of Health in implementing activities related to monitoring, antiretroviral drug resistance, tracking patients, operational research and information management.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Viet Nam and the WHO Regional Office for the Western Pacific.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

2 © World Health Organization 2004

ZAMBIA

July 2004

WHO estimate of number of people requiring treatment – end 2005: 140 000 Antiretroviral therapy target declared by country: 100 000 by 2005

Sumbawanga

United Republic of Tanzania Mbeya

HIV sentinel surveillance in pregnant women Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

Latest available year for 2001 −2003

Democratic Republic of the Congo Kasama

35 200

treat Million by

Mansa Lumumbashi Mzuzu

15 −19.9

Angola

Solwezi

Malawi Ndola Chipata Lilongwe

20 −29.9

30 and more

Cities and towns

Main roads

Zambia Mongu

Kabwe

Population density (pers./sq.Km)

Lusaka

Mozambique Tete

Less than 10

10 − 49

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

Namibia Botswana

Kasane Livingstone

Zimbabwe 320 Kilometers

Harare

750 and more

0

80

160

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 10.9 35.8 39.7 342 13.5 19 0.386 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 13.5 – 20.0% Source WHO/ UNAIDS

730 000 – WHO/ 1 100 000 UNAIDS 44 942 8 500 140 000 not available not available 62.2% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level, trend and gender data. Zambia has a generalized HIV/AIDS epidemic that appears to be stabilizing. The Zambia Demographic Health Survey, 2001–2002 estimates that the national HIV seroprevalence among people 15–49 years old is about 16%. It is considerably higher among women (18%) than among men (13%) and higher in urban populations (25–35%) than in rural populations (8–16%). Zambia has an estimated 1 million people living with HIV/AIDS. The HIV/AIDS epidemic is estimated to have resulted in at least 600 000 orphans. HIV/ AIDS morbidity and mortality also results in an estimated 50% of general hospital admissions and more than 70% of specialized medical hospital admissions. • Major vulnerable and affected groups. Women are one of the major vulnerable groups. According to the Zambia Demographic Health Survey, 2001–2002, women account for 54% of all people living with HIV/AIDS. HIV infection is also high among both men and women 15–49 years old, the most economically productive age. The HIV prevalence among girls 14–19 years old is six times that of boys in the same age group. Women 20–29 years old are also vulnerable, as are orphans and other vulnerable children. Other vulnerable groups are military personnel, sex workers, truckers, fisheries workers and fishmongers. • HIV testing and treatment policy. The HIV testing policy requires full pretest counselling. The government has recently decided that diagnostic testing and counselling should be offered to sick people as part of a comprehensive HIV/AIDS care package. It is also considering putting in place a policy of opt-out HIV testing to further expand access to HIV testing. In 2002, the government decided to make antiretroviral therapy widely available to everyone needing treatment and allocated US$ 3 million to purchase

antiretroviral drugs for 10 000 people, to be provided through the public health service. • Antiretroviral therapy: first-line drug regimen, cost per person per year. The main firstline antiretroviral drug regimen is stavudine + lamivudine + nevirapine in accordance with WHO recommendations, with a fixed-dose combination being widely used. The regimen comprising zidovudine + lamivudine + nevirapine is also a recognized first-line regimen but less commonly used. The cost of the main regimen averages US$ 480 per person per year but is subsidized by the government. • Assessment of overall health sector response and capacity. The government is highly politically committed to addressing HIV/AIDS. Several national support structures have been put in place, including a high-level Cabinet Committee on HIV/AIDS, which provides policy direction and regularly reports to the Cabinet on HIV/AIDS issues. The National HIV/AIDS/STI/TB Council (NAC), established in December 2002, coordinates the national multisectoral response, one component of which is the health sector response. Zambia has also developed policies, planning frameworks, guidelines and protocols to guide the national response. A national HIV/AIDS policy is being finalized. A national strategic plan for intervention in HIV/AIDS and sexually transmitted infections has been developed and the costs determined, and it includes a component on scaling up care and treatment. Zambia has been scaling up the health sector response to HIV/AIDS through several initiatives, including the Poverty Reduction Strategy Programme, the Highly Indebted Poor Country Initiative, the Zambia Social Investment Fund, the Zambia National Response to HIV/AIDS Project (funded through the World Bank Multi-Country HIV/AIDS Program for Africa) and

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ZAMBIA

SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Antiretroviral therapy service delivery. The Central Board of Health is the lead agency in delivering antiretroviral therapy services. It supervises and provides technical support to a network of government and health facilities and district health services. The Churches Health Association of Zambia coordinates the programmes of faith-based hospitals. Numerous private practitioners provide antiretroviral therapy. WHO provides normative support for developing tools and guidelines (such as guidelines on antiretroviral therapy; HIV testing and counselling; and laboratory services). WHO and the United States Centers for Disease Control and Prevention support capacity-building activities. UNICEF supports procurement and capacity-building for supply management. • Community mobilization. Care-related activities performed by nongovernmental organizations and community-based organizations include home-based care, voluntary counselling and testing and psychosocial support. The Network of Zambian People Living with HIV/AIDS has branches in all districts. The International HIV/AIDS Alliance provides technical support to community groups in antiretroviral therapy support and strengthening community- and home-based care programmes. WHO and UNICEF are supporting the development of a communication strategy for antiretroviral therapy. • Strategic information. The Central Board of Health coordinates efforts in surveillance, monitoring and evaluation of antiretroviral therapy services. Other key institutions include the University Teaching Hospital and the Tropical Diseases Research Centre. WHO, UNAIDS and the United States Centers for Disease Control and Prevention provide technical guidance.

the Global Fund to Fight AIDS, Tuberculosis and Malaria grant from Round 1. This response includes voluntary counselling and testing, providing antiretroviral therapy, developing home-based care, managing opportunistic infections, strengthening laboratory capacity, ensuring blood safety, managing sexually transmitted infections and encouraging multisectoral behaviour change. • Issues and challenges. The major challenge to scaling up antiretroviral therapy in Zambia is to guarantee continued funding for drugs and supplies. A crucial challenge to the programme of scaling up treatment is the low rate of disbursement of pledged funds. Another significant challenge is the lack of human resources. Much stigma is still associated with HIV/AIDS, limiting the number of people who seek HIV testing and care.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 70 000 people by the end of 2005 is between US$ 228 million and US$ 248 million. • In 2003, the government allocated US$ 3 million from the national budget to purchase antiretroviral drugs. The same amount is committed to scaling up antiretroviral therapy in both 2004 and 2005. • Preliminary estimates indicate that the United States President’s Emergency Plan for AIDS Relief may commit up to US$ 125 million for 2004–2005. • The Global Fund to Fight AIDS, Tuberculosis and Malaria granted Zambia US$ 92 million over five years for HIV/AIDS in Round 1. It is estimated that about US$ 13.5 million of this amount will be committed to scaling up antiretroviral therapy during 2004–2005. There are plans to reprogramme the grant to match current needs. • The Country Coordinating Mechanism has submitted a proposal for US$ 253 million over five years to the Global Fund to Fight AIDS, Tuberculosis and Malaria for Round 4 with a focus on scaling up access to treatment. • The World Bank granted Zambia US$ 42 million under the second Multi-Country HIV/AIDS Program for Africa (MAP2). The grant includes an antiretroviral therapy component in the context of MTCT-Plus through which both mothers and fathers will have access to treatment. • Other sources of support include the Japan International Cooperation Agency, the United States Centers for Disease Control and Prevention, nongovernmental organizations and United Nations agencies. • Taking into account funds committed to date for scaling up antiretroviral therapy, WHO estimates that the total funding gap for Zambia to reach 70 000 people by the end of 2005 is between US$ 63 and US$ 83 million.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a WHO scoping mission in October 2003 to assess the situation of antiretroviral therapy implementation and to identify opportunities for rapidly scaling up antiretroviral therapy programmes and areas for WHO support • Providing technical assistance to the Central Board of Health, the National AIDS Council and other partners in developing a comprehensive national plan for scaling up antiretroviral therapy • Providing technical assistance to the Country Coordinating Mechanism for developing a Round 4 proposal for the Global Fund to Fight AIDS, Tuberculosis and Malaria with a focus on HIV/AIDS treatment and care and to accelerate the disbursement and implementation of the Round 1 grant • As part of the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting the strengthening of community- and home-based care for people living with HIV/AIDS in five districts (Kasama, Mansa, Chipata, Mazabuka and Mongu) and supporting building institutional capacity at the central and district levels to coordinate and monitor activities

5. Antiretroviral therapy coverage • Zambia’s total treatment need for 2005 is estimated to be 140 000 people, and the WHO “3 by 5” treatment target is 70 000 people (based on 50% of estimated need). • The government declared a national treatment target of 100 000 by 2005. The government’s national antiretroviral therapy programme began in 2002 with two pilot sites at the University Teaching Hospital and Ndola Central Hospital. It has since expanded to all provincial hospitals and 33 district hospitals. As of June 2004, an estimated 5000 people were accessing antiretroviral therapy through the public sector, and another 3500 people were estimated to be accessing antiretroviral therapy through the private sector. • National estimates project an additional antiretroviral therapy coverage to 4000 people per year through the MTCT-Plus project funded by the World Bank Multi-Country HIV/AIDS Program (MAP2) and to 20 000 people per year with funds from a Round 1 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. • The Global Fund to Fight AIDS, Tuberculosis and Malaria Round 4 proposal includes the provision of antiretroviral therapy for 25 000 people in the first year and 105 000 people by the fifth year.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Providing technical assistance for streamlining the procurement and supply management of antiretroviral drugs and diagnostics • Providing technical assistance in approaches to increasing the use of antiretroviral therapy and addressing issues of equity of access to treatment • Providing technical assistance to the government in reviewing policies and normative documents and standards on HIV/AIDS treatment and care for different levels of the health care system (primary, secondary and tertiary) • Collaborating with the World Food Programme to ensure adequate food aid and nutritional support for people receiving antiretroviral therapy • Providing technical assistance to develop a communication strategy for antiretroviral therapy • Providing technical assistance to develop a national plan for building human resources capacity

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. The NAC coordinates the national multisectoral response to HIV/AIDS. The Ministry of Health sets health policy related to HIV/AIDS, and the Central Board of Health is contracted to implement the health sector response to HIV/AIDS. The NAC has established national technical working groups, which include the Implementation of Care and Treatment Technical Working Group. This is composed of technical experts in care and treatment from various stakeholder organizations, including the public, nongovernmental organizations, faith-based organizations and the private sector, and provides technical guidance to the national coordinating bodies, including the NAC and the Central Board of Health. WHO is supporting the development of a national operational plan for scaling up antiretroviral therapy. The United Kingdom Department for International Development, the United States Centers for Disease Control and Prevention, the European Commission and other bilateral partners support the strengthening of the health system.

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of For further an international “3 by 5” Country Officer is information, currently underway. please contact: • Additional staffing needs identified include three National Programme Officers to be World Health Organization seconded to the Central Board of Health Department of HIV/AIDS to support scale-up activities. This country profile was developed in collaboration with national authorities, the WHO Country Office for Zambia and the WHO Regional Office for Africa.

“3 by 5” Help Desk

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E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

ZIMBABWE

July 2004

WHO estimate of number of people requiring treatment – end 2005: 290 000 Antiretroviral therapy target declared by country: 55 000 by 2005

Lusaka

HIV sentinel surveillance in pregnant women

Mozambique Zambia

Latest available year for 2001 −2003 Percent seropositive Less than 1 1 − 4.9 5 − 9.9 10 −14.9

35 200

treat Million by

Namibia Kasane

Livingstone

Harare

15 −19.9

20 −29.9

Gweru

Cities and towns

Main roads

Population density Bulawayo

(pers./sq.Km) Less than 10

10 − 49

Botswana

Masvingo Francistown

50 − 99

100 −249

250 −499

500 −749

Map data sources: WHO/UNAIDS Epidemiological Fact Sheets and the United States Census Bureau Map production: WHO

750 and more Serowe

South Africa

0

55

110

220 Kilometers

1. Demographic and socioeconomic data Date Total population (millions) Population in urban areas (%) Life expectancy at birth (years) Gross domestic product per capita (US$ ) Government budget spent on health care (%) Per capita expenditure on health (US$) Human Development Index 2004 2003 2002 2001 2001 2001 2001 Estimate 12.9 34.7 37.9 719 8 45 0.496 Source United Nations United Nations WHO IMF WHO WHO UNDP

2. HIV indicators Date Adult prevalence of HIV/AIDS (15–49 years) Estimated number of people living with HIV/AIDS (0–49 years) Cumulative number of reported AIDS cases Reported number of people receiving antiretroviral therapy (15–49 years) Estimated total number needing antiretroviral therapy in 2005 HIV testing and counselling sites: number of sites HIV testing and counselling sites: number of people tested at all sites Prevalence of HIV among adults with tuberculosis (15–49 years) 2002 2003 2003 2001 June 2004 2003 Estimate 21.7 – 27.8% Source WHO/ UNAIDS

1 500 000 – WHO/ 2 000 000 UNAIDS 74 782 6 000 290 000 not available not available 75.3% WHO WHO/ UNAIDS WHO WHO/ UNAIDS

3. Situation analysis • Epidemic level and trend and gender data. Zimbabwe is experiencing a generalized HIV epidemic. Each day an estimated 564 adults and children become infected with HIV. The prevalence of HIV in the adult population (15–49 years) is currently estimated to be about 24.6%. The total number of adults and children living with HIV/AIDS is about 1.8 million. About 50% of the people living with HIV/AIDS are infected during adolescence and young adulthood. The number of children who have been made orphans by HIV/AIDS is currently estimated to be 761 000, and this figure is projected to reach 1 million by 2005. • Major vulnerable and affected groups. Women are disproportionately affected by HIV/AIDS, constituting 51% of the population and 53% of people living with HIV/AIDS in 2003. The estimated number of women living with HIV/AIDS has been higher than that for men since 1989, and the numbers of new infections among women have exceed those among men since 1989. The prevalence of HIV infection also varies with place of residence. The most affected areas (with average HIV prevalence of about 34.9%) are large-scale commercial farms, administrative centres, high-growth areas outside cities and towns, state lands and mines. Urban areas have an average HIV prevalence of 28.1% versus about 20.9% in rural areas. Other groups severely affected by HIV/AIDS include women who engage in sex work, uniformed personnel and orphaned children. • Policy on HIV testing and treatment. HIV testing is provided within the context of voluntary testing and counselling, diagnostic testing (preventing mother-to-child transmission, opportunistic infections and antiretroviral therapy) and blood safety.

Rapid tests are most frequently used, and other tests are used for quality assurance. There is no mandatory HIV testing. The country has a comprehensive response to HIV, especially for care and treatment, which includes treatment for opportunistic infections; community and home-based care and support; and antiretroviral treatment. In 2002, the government declared HIV/AIDS and the lack of antiretroviral therapy to be an emergency. The government intends to provide access to treatment to all people in need. However, because of resource constraints, a phased approach has to be adopted for scaling up antiretroviral therapy. • Antiretroviral therapy: first-line drug regimen, cost per person per year. Zimbabwe follows WHO-recommended treatment guidelines for antiretroviral therapy. The first-line regimen is stavudine + lamivudine + nevirapine. The average cost is about US$ 222 per person per year. There are currently two local manufacturers of generic antiretroviral drugs. All first-line and alternative generic drugs for antiretroviral therapy have been registered with the Medicines Control Authority of Zimbabwe. • Assessment of overall health sector response and capacity. Zimbabwe has an organized health system with reasonable infrastructure. A strong network of health facilities in both urban and rural areas serves as a ready platform for expansion. Tuberculosis clinics are already operating at all hospitals in the country. Special opportunistic infection services are being set up at major health facilities. Services for the prevention of mother-to-child transmission are delivered at 174 sites throughout the country. Laboratory support is available, with two laboratories (Harare and Mpilo) capable of performing CD4 counts. Most hospitals can already

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S U M M A R Y C O U N T R Y P RO F I L E F O R H I V / A I D S T R E AT M E N T S C A L E - U P

Zimbabwe

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SUMMARY COUNTRY PROFILE FOR HIV/AIDS TREATMENT SCALE-UP • Strategic information. The Ministry of Health and Child Welfare is responsible for overall monitoring and evaluation of the programme and for operations research. Other agencies involved in generating strategic information include WHO, the United States Centers for Disease Control and Prevention and the University of Zimbabwe.

carry out rapid HIV tests as well as full blood counts and chemistry. However, additional laboratory support (especially with regard to equipment and reagents) is still required. The National Microbiology Reference Laboratory at Harare Hospital is now equipped to perform viral load tests and plays a vital role in ensuring the quality control of supplies and reagents related to HIV/AIDS. • Critical issues and major challenges. The impact of HIV/AIDS, the prevailing harsh economic conditions and reduced donor support have all combined to severely strain the delivery of health services. The shortage of human resources is one of the major constraints, as trained health personnel continue to emigrate to other countries, and a growing number of other health workers succumb to HIV/AIDS. Shortage of drugs and supplies is another major constraint that is essentially due to high and rising costs and inadequate availability of foreign currency.

7. WHO support for scaling up antiretroviral therapy WHO’s response so far • Conducting a scoping mission to Zimbabwe in February 2004 in collaboration with UNAIDS and the Ministry of Health and Child Welfare to assess the current status of antiretroviral therapy implementation and the opportunities for scaling up access to treatment and to identify areas for WHO support • Supporting the AIDS and Tuberculosis Unit of the Ministry of Health and Child Welfare and other partners in developing a comprehensive national plan for scaling up antiretroviral therapy • Supporting the Country Coordinating Mechanism in accelerating disbursement and implementation of the Round 1 funding from the Global Fund for AIDS, Tuberculosis and Malaria • As part of the WHO/OPEC Fund Multi-country Initiative on HIV/AIDS, supporting the strengthening of community and home-based care and health services delivery systems for people living with HIV/AIDS in five districts (Kasama, Mansa, Chipata, Mazabuka and Mongu) and building institutional capacity at the central and district level to coordinate and monitor activities (project coordinated by the National AIDS Council) • As part of the WHO/Italian Initiative on HIV/AIDS in Sub-Saharan Africa, supporting the improvement of access to information on HIV prevention, sexual and reproductive health and infant feeding in the context of preventing mother-to-child transmission; making HIV counselling and voluntary testing available for couples, pregnant women and women contemplating pregnancy; and providing access to antiretroviral drug prophylaxis for the mother-to-child transmission of HIV and access to follow-up programmes for infants exposed to HIV transmission.

4. Resource requirements and funds committed for scaling up antiretroviral therapy in 2004–2005 • WHO estimates that the total funding required to support scaling up antiretroviral therapy to reach the WHO “3 by 5” treatment target of 145 000 people by the end of 2005 is between US$ 319.5 million and US$ 380.5 million. • The government has committed an estimated US$ 4 million for the purchase of antiretroviral drugs. • Of the US$ 10.3 million (for 2 years) approved in Round 1 by the Global Fund to Fight AIDS, Tuberculosis and Malaria, about US$ 1.9 million is expected to support treatment scale-up for 2004–2005. • WHO estimates that the total funding gap for Zimbabwe to reach 145 000 people by the end of 2005 is between US$ 308 million and US$ 369 million.

5. Antiretroviral therapy coverage • Zimbabwe’s total treatment need for 2005 is estimated to be 290 000 people, and the WHO “3 by 5” treatment target is 145 000 (based on 50% of need). • The government’s declared national treatment target is 55 000 people by the end of 2005. • As of June 2004, an estimated 6000 people have access to treatment, of which most are catered for by private practitioners and largely via their own means. • Of this number, an estimated 760 people are catered for by operations research projects such as Development of Antiretroviral Therapy in Africa and the Zimbabwe AIDS Prevention Programme. Both are concentrated in urban areas. A rural faith-based organization also provides some treatment in Mutoko.

Key areas for WHO support in the future • Establishing a “3 by 5” country team to support the government and all partners in scaling up antiretroviral therapy • Providing technical assistance in setting up systems for patient tracking and monitoring and evaluating programmes • Assisting the government in reviewing policies and normative documents and standards on HIV/AIDS treatment and care for different levels of the health care system (primary, secondary and tertiary) • Providing technical support in developing systems for monitoring drug resistance

6. Implementation partners involved in scaling up antiretroviral therapy • Leadership and management. There is strong political commitment to address HIV/AIDS and expand antiretroviral therapy provision in Zimbabwe. A special tax for HIV/AIDS (the National HIV/AIDS Levy) has been in existence since 1999. From funds generated by this tax, the government has been able to buy antiretroviral drugs worth about US$ 3 million. The National AIDS Council was created by Parliament and charged with the responsibility for overall multisectoral coordination of the response to HIV/AIDS in Zimbabwe. The National AIDS Council is also responsible for allocating resources for HIV/AIDS. It manages funds from the National HIV/AIDS Levy and is the principal recipient of the grant for HIV/AIDS of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The AIDS and Tuberculosis Unit of the Ministry of Health and Child Welfare is the lead agency in scaling up antiretroviral therapy. It develops policies, plans, strategies and guidelines for providing antiretroviral therapy as well as coordinating with other implementing partners. • Antiretroviral therapy service delivery. Over 70 hospitals of different sizes operated by the government, nongovernmental organizations and the private sector have been identified for delivery of antiretroviral therapy. The Zimbabwe office of the United States Centers for Disease Control and Prevention provides technical support for a range of areas including reinforcing laboratory capacity, management capacity, surveillance and research. WHO provides normative guidance in developing treatment guidelines and other tools for delivering antiretroviral therapy. UNICEF is currently supporting the procurement of antiretroviral drugs, and the National Pharmaceutical Company is responsible for drug storage and distribution. The Medicines Control Authority of Zimbabwe is the drug regulatory authority. • Community mobilization. Several nongovernmental organizations are involved in community-related work. The nongovernmental organizations operate under the umbrella organizations Zimbabwe AIDS Network and the Zimbabwe National Network of People Living with HIV/AIDS. Other institutions involved in community mobilization include the Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS).

Staffing input for scaling up antiretroviral therapy and accelerating prevention • Current WHO Country Office staff responsible for HIV/AIDS and sexually transmitted infections include one National Programme Officer for HIV/AIDS, and the recruitment of an international “3 by 5” Country Officer is currently underway. • The WHO/OPEC Fund Multi-country Initiative on HIV/AIDS supports one National Programme Officer. • Additional staffing needs identified include two National Programme Officers, one Administrative Assistant, one Finance Officer, one Logistics Officer and one Secretary.

For further information, please contact: World Health Organization Department of HIV/AIDS This country profile was developed in collaboration with national authorities, the WHO Country Office for Zimbabwe and the WHO Regional Office for Africa.

“3 by 5” Help Desk E-mail: 3by5help@who.int Tel.: +41 22 791 1565 Fax: +41 22 791 1575 www.who.int/3by5

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