WHO News.

774 Bulletin of the World Health Organization | October 2006, 84 (10) WHO News Q: Should health workers offer free HIV testing even if antiretroviral treatment is unavailable or unaffordable? A. Strong arguments can be made for free universal access to prevention, diagnosis and treatment, since user fees impede access to these services and adherence to treatment. The absence of antiretroviral therapy (ART) should not be an absolute impediment to the routine recommend dation of HIV testing by healthdcare providers because it is clear that a great deal can be done — even without ART — in terms of providing lifedprolongd ing care. Providerdinitiated testing and counselling must, however, be scaled up in the context of national plans to expand access to treatment and care. Q: Is there a shift from voluntary HIV testing and counselling (VCT) to provider- initiated testing? A. WHO believes that a diverse range of approaches is needed, including both voluntary HIV testing and counselling and providerdinitiated testing and cound selling. Providerdinitiated testing and counselling refers to testing of patients who visit healthdcare facilities or are visited by health workers. The process must remain voluntary and emphasize consent, confidentiality, counselling and information. A key aspect of providerd initiated testing and counselling is to ensure informed consent by providing D for diagnosis and E for everything else New technologies to fight HIV/AIDS — male circumcision, pre-exposure prophylaxis, microbicides and vaccines — came under the spotlight at the Toronto AIDS conference in August. Dr Kevin De Cock talks to the Bulletin about these as well as the ethical issues that must be addressed as HIV testing is rolled out in developing countries. In this interview, he calls for better coordination of donor funds, given the new global target of universal access to prevention and treatment services by 2010. Dr Kevin M. De Cock, a Belgian-born citizen of the United States, received his Bachelor of Medicine and Bachelor of Surgery from Bristol University in the United Kingdom in 1974, and a Tropical Medicine and Hygiene diploma from the Liverpool University School of Tropical Medicine in 1979. De Cock is an infectious disease specialist with expertise in HIV/AIDS, tuberculosis, liver disease and tropical diseases. He has served in senior public health posts, most recently as Director of the US Centers for Disease Control and Prevention (CDC) Division of HIV/AIDS Prevention from 1997 to 2000 and Director of CDC’s activities in Kenya from 2000 to 2006. De Cock has served on numerous professional committees and editorial boards. He co-edited the supplement to the journal AIDS, entitled AIDS in Africa, Second Edition. He was appointed Director of WHO’s Department of HIV/AIDS in 2006. W HO Dr Kevin M De Cock the patient with an opportunity to ded cline testing. WHO and UNAIDS also continue to strongly support clientdinitid ated VCT, which occurs mainly outside healthdcare settings for people who want to know their serostatus. Q: When will WHO issue revised testing guidelines for HIV? A. The guidelines being discussed cond sider only providerdinitiated testing in healthdcare settings, a narrow focus. Fold lowing an international consultation in early July 2006, codsponsored by WHO and UNAIDS, a further draft of the guidelines is being developed for public comment. WHO and UNAIDS plan to issue the guidelines later this year. Q: Is it ethical to encourage self-testing in countries where counselling and treatment are not available? A: Selfdtesting is largely unexplored. The traditional view is that testing should not be done without counselling, but some of what is said about counseld ling is not evidence based. With much more experience with testing, one has to ask whether the negative attitudes towards selfd and homedtesting will not, in future, seem paternalistic and inappropriate. If we believe in selfdemd powerment and rights of the individual, why should selfdtesting not be allowed, when selfdtesting (diabetes, pregnancy) or selfdexamination (breast and testicular cancer) are actively promoted for other conditions? However, more work and reflection are required before offering specific advice, and some form of patient information and education will always be important. Q: How will testing be free and widely available in countries where HIV/AIDS prevalence is high? A: There has been a tremendous scaledup of HIV testing in developing countries, especially in Africa, mostly through VCT programmes. There is increasing emphasis, for example in Botswana, Kenya and Malawi, on the additional approach of providerdinitiated testing and counselling in healthdcare settings. In many settings testing is free, through the support of donor initiatives. Q: If home-testing were widely available in developing countries, how would you counsel people on the implications of a positive or negative result? A: Selfdtesting would obviously need to be carefully handled and protocols and standardized information will need to be developed and evaluated. Selfdtesting is not likely to become the dominant form of testing. We need to ask ourselves, however, whether universal knowledge of HIV serostatus in heavily affected countries is not a requirement if we are 775Bulletin of the World Health Organization | October 2006, 84 (10) WHO News to achieve universal access to HIV/AIDS prevention, treatment and care. Q: Is WHO disappointed that the “3 by 5” campaign failed to achieve its stated goals? A: “3 by 5” was about more than a numeric target. This campaign fundad mentally changed the landscape of how the world is addressing HIV/AIDS. Treatment and prevention are insepad rable parts of the response and both are needed.Concerning treatment scaledup, we have learned many lessons as a result of “3 by 5”, for example, about health systems weaknesses, and that more focus is needed on previously underdserved populations, such as children and injectd ing drug users. Q: South Africa attracted considerable criticism in Toronto. How do you view the situation? A: Clearly, there is much dissatisfaction with the official response to HIV/AIDS in South Africa. In my view, this has resulted in at least three important missed opportunities. Firstly, South Africa, with its political and economic authority, could have been a leader in the fight against AIDS for the rest of the continent. Secondly, enormous international support, financial and technical assistance, and goodwill could have been mobilized if the unorthodox discussions and controversy had been avoided. Thirdly, treatment and prevend tion scaledup could have occurred much faster and gone further. As it is, South Africa is not among the 20 or so lowd and middledincome countries that have achieved 50% HIV/AIDS treatment coverage of those in need. Q: There is more donor money to fight HIV/AIDS than ever before, but is the money being spent in a coordinated way on evidence-based interventions? A: Coordination can always be improved and this is certainly necessary in the struggle against HIV/AIDS. WHO and its partners are working to improve how we work together, for example through implementation of the recomd mendations of the Global Task Team on Improving Coordination among Muld tilateral Institutions and International Donors. We do also need to do better in the use of evidence in the design of public health interventions; for example, on policies and practices concerning male circumcision, isoniazid preventive therapy (for tuberculosis), postdexposure prophylaxis, and abstinence. It is part of WHO’s role to synthesize existing knowledge, support operational red search and disseminate the evidence in support of different interventions and approaches. But decisiondmaking will never be simply about evidence alone. Political choices obviously influence practice, such as restrictions on needle and syringe exchange in many cound tries. An emphasis on human rights also represents more of a value or moral judgement than an evidencedbased one, but this judgement is essential. Q: Do some donors attach conditions to the use of funds for HIV/AIDS regarding sex workers, injecting-drug users and condoms, ignoring the scientific evidence? A: I assume you mean PEPFAR (US President’s Emergency Plan for AIDS Relief ) policies on ABC (abstinence, be faithful, condoms). The furious political debate around this, which is polarizing and often impedes genuine discussion, has generally been brought in by politid cians or individuals with vested interests on both sides of the political spectrum, including in heavily affected African countries. I hope we can move beyond the ABC debate — there will not be a single magic bullet for HIV prevention, it is more complicated than fixating on the alphabet, and we also need D and E. D for diagnosis (HIV testing) and E for everything else! Q: Can such funds still be used in a con- structive way? A: If certain programmes indeed impede or do not fund certain initiatives, needle exchange, condoms, or whatever, there is nothing to stop other donors stepping in and filling the gap, or coordinating assistance. Why is this not done more? This again represents missed opportunid ties for collaboration and coordination. Q: The Bill and Melinda Gates Founda- tions is one of public health’s biggest spon- sors, but one could argue that it is focusing on hi-tech solutions while the technology to prevent, treat and control HIV/AIDS is known and available but needs to be rolled out universally? A: I think the Gates Foundation is under some criticism for excessive emphasis on technologies and underdemphasizing basic programmatic work required to improve global health. This was rather evident in Toronto with the great attention given to technological interventions such as pred exposure prophylaxis. Understandably, the Foundation does not want to take on “entitlement programmes” without an end in sight. I think Foundation staff recognize the predicament and that it is the subject of intense discussion. Whether we have the knowledge and technold ogy we need is an interesting question. Most of the world faces HIV epidemics concentrated in specific groups: men who have sex with men, sex workers, injecting drug users, sex partners of such persons, and their children. We have the knowledge and interventions to control these epidemics, and in some settings this has been done effectively. At the other extreme, we have generalized epidemics with very high rates of HIV infection in the general population, for example in southern Africa. Targeted interventions cannot control such situations, and we have not had the difficult discussions about what additional technological and social interventions are needed to turn such situations around. We have basically applied similar approaches to very differd ent epidemiologic contexts and should not be surprised this is not successful. Q: There are technological developments that are keenly awaited. When will the world see these widely available? A: It is dangerous to predict how fast things will happen. In terms of new techd nologies, I think the likely order of more expanded use will be (i) male circumcid sion; (ii) predexposure prophylaxis with ART; (iii) microbicides; (iv) vaccines. Q: How would you define universal access to antiretroviral treatment? When will this happen? A: In the speech Dr LEE (Jongdwook) was to make to the 2006 World Health Assembly on the day he died, he wrote that universal access means that “no one should die because they can’t get drugs or there aren’t clinics”. He called for “a relentless push to make sure people know how to prevent HIV infection”. WHO and UNAIDS are working with countries to convert a political and aspirational tard get into countrydowned, specific targets that can be linked to programmatic work. Irrespective of targets, WHO is respond sible for setting standards and norms and needs to provide guidance on what constitute acceptable levels of availability, coverage and impact. O 776 Bulletin of the World Health Organization | October 2006, 84 (10) WHO News Recent news from WHO • Dr Howard Zucker, Assistant Director-General for WHO’s Health Technology and Pharmaceuticals cluster of departments, was appointed Representative of the Director-General for Intellectual Property, Innovation and Public Health on 18 September. • Nearly thirty years after phasing out the widespread use of indoor spraying with DDT and other insecticides to control malaria, WHO announced on 15 September that this intervention should once again play a major role in disease control efforts. • WHO welcomed the Republic of Montenegro (formerly part of Serbia and Montenegro) as its 193rd Member State. • WHO Member States have proposed 13 candidates for the post of WHO Director-General, WHO announced on 6 September. The candidates are: Candidate Proposed by Candidate Proposed by Dr Kazem Behbehani Kuwait Dr Pascoal Manuel Mocumbi Mozambique Dr Margaret Chan China Dr Shigeru Omi Japan Dr Julio Frenk Mexico Dr Alfredo Palacio González Ecuador Mr David A. Gunnarsson Iceland Professor Pekka Puska Finland Dr Nay Htun Myanmar Ms Elena Salgado Méndez Spain Dr Karam Karam Syrian Arab Republic Professor Dr Tomris Türmen Turkey Dr Bernard Kouchner France The WHO Secretariat will provide translations of the proposals and the curriculum vitae of each of the 13 candidates into the six official languages of the United Nations: Arabic, Chinese, English, French, Russian and Spanish. WHO’s 193 Member States will receive this by 5 October ahead of an Executive Board meeting in Geneva on 6–8 November to decide on a short-list of candidates, interview them, and then vote to nominate a candidate to the World Health Assembly. In a special one-day session on 9 November, the WHA will consider the Executive Board’s nomination and appoint a director-general. For more details about the process of electing a new director-general please see: http://www.who.int/mediacentre/selection_faq/en/index.html • A quarter of health facilities in parts of Lebanon affected by the recent conflict are not functioning, due to physical damage, access restrictions and lack of staff, while water and fuel shortages remain a serious problem, according to an assessment of more than 400 health facilities by Lebanon’s Ministry of Health and WHO released on 6 September. • The world is in danger of missing the Millennium Development Goal targets for providing clean water and sanitation to people in developing countries, WHO said on 7 September. According to a new report by WHO and UNICEF, MDG Drinking Water and Sanitation Target – The Urban and Rural Challenge of the Decade, the situation is becoming acute in urban areas due to rapid population growth. Read the report here: http://www.who.int/water_sanitation_health/monitoring/jmpfinal.pdf • WHO Goodwill Ambassador for Maternal, Newborn and Child Health and fashion model Liya Kebede highlighted the plight of millions of women and girls living with obstetric fistula on 1 September when she launched the WHO manual: Obstetric Fistula: Guiding Principles for Clinical Management and Programme Development. • WHO said on 25 August that it is intensifying efforts to support governments, particularly in developing countries, to increase helmet use for motorcyclists through a new publication: Helmets: a road safety manual for decision-makers and practitioners. Read the manual here: http://www.who.int/roadsafety/projects/manuals/helmet_manual/en/ WHO news from Toronto AIDS conference 13–18 August 2006 • WHO reported that in low- and middle-income countries just over 1.6 million people were receiving antiretroviral therapy at the end of June 2006, a 24% increase over the 1.3 million who had access to the drugs in December 2005, and four times the 400 000 people receiving treatment in these countries in December 2003. • WHO, the International Labour Organization and the International Organization for Migration launched a coordinated global plan called Treat, Train, Retain to address a major and often overlooked barrier to preventing and treating HIV/AIDS: the severe shortage of health workers, particularly in developing nations. • For the first time the effectiveness of different types of HIV prevention campaigns for young people done through schools, health services, media, communities for young people have been reviewed and graded for their usefulness. A new WHO publication, Steady, Ready, GO! identifies what should be done to prevent HIV infection in young people. http://www.who.int/child-adolescent- health/publications/ADH/ISBN_92_4_120938_0.htm • WHO presented the findings of a WHO/UNAIDS consultation held in July 2006 confirmed that caring for sexually transmitted infections can reduce HIV transmission. • HIV Director Dr Kevin De Cock and TB/HIV Coordinator Dr Paul Nunn, both from WHO, joined by Dr Helene Gayle, the International AIDS Society President, called on the global HIV community to step up collaboration on tuberculosis control.