WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONDIALE DE LA SANTE
REGIONAL COMMITTEE Forty-sixth session Manila 11-15 September 1995
WPRlRC4617 16 June 1995 ORIGINAL: ENGLISH
Provisional agenda item 10.1
ANNUAL REPORT ON AIDS, INCLUDING SEXUALLY TRANSMITTED DISEASES
At the forty-fifth session of the Regional Committee in 1994, the Regional Director was requested to collaborate with Member States on technical aspects of regional and country management of sexually transmitted diseases as a strategy for HlV/AIDS prevention and control. The predominant mode of transmission of human immunodeficiency virus (HlV) is the same as for other sexually transmitted diseases - sexual contact. Many of the measures for preventing transmission of HIV and sexually transmitted diseases are the same, as are the target audiences for these interventions. Additionally, the presence of sexually transmitted diseases increases the rate of transmission of HIV. Because of these links between HlV and other sexually transmitted diseases, WHO recommends that HlV/AIDS and sexually transmitted disease programmes should be integrated. Regional activities have been integrated in support of health promotion and HlV/AIDS programme development, and strengthening case management of other sexually transmitted diseases. Continuing this approach will require very detailed collaboration between the new Joint United Nations Programme on AIDS, the Regional Office and national programmes. Strong political commitment will be required to enable development of public health policies to reduce the impact of HlV/AIDS and sexually transmitted diseases in the Region. The Regional Committee is requested to discuss the report and its implications and recommend appropriate interventions for the Region.
WPRlRC46/7 page 2
1. HIV AND AIDS
1.1
Regional situation and trends As at 15 June 1995, a total of 43 500 HIV infections and 8370 AIDS cases have been reported
from the 36 countries and areas in the Western Pacific Region. A breakdown for each country is provided in Table I, on pages 11-12. Three groups of countries and areas can be identified within the Western Pacific Region. The first group includes Australia and New Zealand. Currently, 74% of the total AIDS cases and 45% of the total HIV infections are accounted for by these two countries. The annual reported number of new HIV infections from these countries seems to have reached its peak and has been gradually decreasing over the last decade, as demonstrated in Figure 1. The reasons for this decline are difficult to determine exactly. However, there is no doubt that good surveillance systems have given
-
information to policy-makers and health and community workers, enabling development and implementation of targeted interventions and education. These have included development of
outreach programmes for injecting drug users, education and peer education of different at-risk groups, education programmes for commercial sex workers, and education and training of health care workers. The second group is the countries and areas that have reported no HIV infections, or very few. American Samoa, Cook Islands, Mongolia, Nauru, Niue, Tokelau, Tuvalu and Vanuatu have yet to report any HIV infections or AIDS cases; Kiribati and Solomon Islands have reported HIV _
infection:; but no AIDS cases. Seven other countries and areas have reported a total of ten or fewer HIV infections to date. Several variables may contribute to the complete absence, or lower number of reported HIV infections. Such variables may relate to lower mobility of people resulting from
geographic isolation of the country or area, the knowledge of health care workers, cultural reasons, the availability ofHIV testing, or to an inadequate surveillance system.
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Figure 1. Annually reported HIV infections in Australia and New Zealand, 1986-1994
AUSTRALIA
3~r--------------------------------------------. 2500 2~
! z
1500
----------_
..
_------------_
..
- - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -,.. .. """"""--..6 500
o~--_+----~----~---+----+_--~----~---~
1986
1987
1988
1989
1990 Year
1991
1992
1993
1994
NEW ZEALAND 130r--------------------------------------------, 120 110
} Z
E :0
100 90
----------------- ---- ---------------------
._~-=....c:."
80 70~----~----~--~----~----_+----_+----~----~
1986
1987
1988
1989
1990 Year
1991
1992
1993
1994
WPRlRC4617 page 4
The third group includes a number of countries and areas, such as Cambodia, Malaysia and Viet Nam, where the number ofHIV infections is increasing. For many of these countries and areas, the increase has occurred mainly over the last two to four years. Because there is a delay between testing positive for HIV and developing AIDS, the number of AIDS cases in most of these countries and areas has only very recently started to increase. In the short term, the annual reported number of HIV infections in this group of countries and areas is likely to continue to increase. This increase will partly be due to better surveillance systems within each country or area, and an increasing awareness by health care workers of the possibility of HIV infection, as well as improved access to laboratories for diagnosing HIV. The emerging pattern for some of the countries and areas in this group is demonstrated in Figure 2.
in the Western Pacific Region, 1986-1994
Figure 2. Annually reported HIV infections in selected countries
4OO0r------------______________________________- . 3500 3000
~
.. •
2500 2000
" 1500 z 1000
500
1987 1988 1989 1990 1991 1992 1993 1994
o --~C --_Q .....:::::::::::~:c~=-:.=-=-::c~-=-=-=-=-~:ci_::;6:c~.~==:.=-!::.=-_~ 1986
L-.._ _ _ _ _ _ _ _ _ _ _ _ _ _
In this third group, it should be noted that HIV infections are mostly seen in either the heterosexual population or in injecting drug users, depending on the country or area. Interventions therefore need to be targeted at the sex industry and injecting drug users. The point at which the annual HIV infections in each of these countries and areas reaches a peak and begins to decline is dependent on a number of variables: the success of the programmes now being put in place; the
WPRlRC4617 pageS
quality of surveillance; the political will to continue to support and to improve access to testing; education programmes for both specific vulnerable groups and health professionals; and targeted programmes for reduction of risk behaviour. Of these, one of the most important is surveillance. Good surveillance makes it possible to understand the size and nature of the HIV/AIDS problem in different parts of each country or area so that appropriate action can be planned and implemented.
1.2
Improving surveillance An improved regional surveillance system for HIV/AIDS was introduced in 1993 and is being
refined further to meet the increasing need for accurate information described above. Analysing the surveillance data enables the Regional Office to discuss problems with countries and areas as the problems start to emerge at a national level. WHO has collaborated with a number of countries and areas to develop or improve HIV/AIDS surveillance systems depending on the needs of the country or area and on the situation. The Regional Office provided materials such as test kits for laboratories, and technical support, including training laboratory technicians and health care workers in a number of countries and areas. Information exchange is an important aspect of recognizing problems and trends. Every six months the AIDS surveillance report for the Western Pacific Region is published and distributed globally, free of charge. Five issues have been produced to date.
2. THE RESPONSE TO HIV/AIDS IN THE WESTERN PACIFIC REGION
2.1
Priority programme approaches In an analysis of interventions in countries that are successfully reducing the incidence of
HIV infection and countries that have kept HIV infection very low, the following are priorities for the interruption of transmission: control of sexually transmitted diseases; and activities to influence changes in behaviour to avoid risk, with targeted health promotion, education, and training programmes. These approaches are interlinked and are most effective when implemented in
conjunction with each other. Successful approaches have included peer education, and the provision of accessible quality primary health care services to target populations. WHO has been providing information to sex workers and people who have multiple partners, so that they can reduce the risk of HIV infection by
WPRfRC4617 page 6
avoiding penetrative sex or by using latex condoms consistently and correctly during intercourse. Condom promotion, in conjunction with the other programme efforts, increases the proper and consistent use of condoms in the prevention of sexually transmitted diseases and AIDS. WHO has strongly recommended the use of "syndromic case management" of sexually transmitted diseases wherever resources are limited. Syndromic case management is based on taking a brief history of the symptoms from the patient and making a very simple examination for abnormal signs. Treatment is given for all the infectious organisms which, in that particular geographic area, are known to cause that collection of signs and symptoms - or syndrome. This avoids the need for expensive laboratory support in identifying specific etiological agents. Such support is rarely -
consistently available. Syndromic case management can be performed by non-specialist health care workers and allows effective, routine sexually transmitted disease care to be delivered promptly in the general health care system and not just in special sexually transmitted disease clinics.
2.2
Programme activities Proilramme management Programme management is crucial to the proper implementation of the priority approaches in
countries. WHO has provided technical collaboration to strengthen programme management in the following countries: Cambodia, China, the Lao People's Democratic Republic, the Philippines and VietNam. In 1995, 12 countries and areas reviewed their AIDS medium-term plans and formulated second medium-term plans. This involved all appropriate sectors of government, United Nations agencies and the donor community, providing a truly multisectoral approach to HIV/AIDS prevention and control. The medium-term plans will provide a platform for further development by the Joint United Nations Programme on AIDS. In order to allocate resources appropriately, prevention indicators have been prepared for all programme components so that countries can define appropriate targets. Methodologies have also been developed for countries for measuring progress towards these targets. The prevention indicators cover five areas: knowledge about HIV/AIDS, condom availability, sexual risk behaviour, the
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treatment and prevention of sexually transmitted diseases, and the incidence of HIV infection and sexually transmitted diseases.
WPRlRC46n page 7
In March 1995, an intercountry workshop on prevention indicators was conducted in Hanoi, Viet Nam, attended by national AIDS programme staff members or managers, epidemiologists, population survey specialists and planners from six countries. Each country that was represented developed an appropriate workplan to strengthen activities utilizing prevention indicators. Sexually transmitted diseases HIV infection is essentially a sexually transmitted disease. The Regional Office has
supported seven countries in developing their sexually transmitted disease programmes with training
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courses for health personnel. A survey of the sexually transmitted disease situation in the Region has been started. The resulting information will ensure appropriately focused support. As part of the survey, a
questionnaire was completed by 31 out of 35 countries and areas. The answers to the questionnaire clearly identified the importance of the services delivered by the private sector. One of the major weaknesses identified by the survey was in the reporting of sexually transmitted disease cases. To encourage reporting, a simple combined patient encounter sheet has been designed and is being field-tested. Condom promotion There has been collaboration with many countries to promote condom use as an intervention
--
strategy for HIV I AIDS.
Some US$150 000 worth of condoms were provided to countries from
October 1994 to September 1995. Health promotion education and training WHO has collaborated with countries and areas in the Region to promote and facilitate education and training programmes in support of national AIDS programme objectives. This includes curricular development for health care workers, development of outreach programmes, peer education workshops and training courses to implement the syndromic case management of sexually transmitted diseases. HIV/AIDS as part of the new health curricula of secondary schools has been introduced in Papua New Guinea and Viet Nam. In the Philippines, HIV/AIDS has also been introduced in the
WPRlRC4617 page 8
revised secondary school curriculum. In a small number of other countries, HIV/AIDS has been part of the health curriculum for a number of years. A growing number of countries are actively planning the inclusion ofHIV/AIDS in the national school curriculum. There are currently six modules in the HIVIAIDS reference library for nurses. A training manual on syndromic case management of sexually transmitted diseases has been developed and tested. These modules have been distributed to provide technical support to facilitate education
programmes for all health care workers. Two new sets of modules are being developed. These are Teaching modules for basic
education in human sexuality and Teaching modules for continuing education in human sexuality. The first set of modules is being developed in collaboration with the maternal and child health programme. The United Nations Population Fund (South Pacific) will be using both sets of modules in support of its training programme for midwives. These health care workers are in a good position to educate women to protect themselves against sexually transmitted diseases, including HIV infection. A series of training programmes, seminars and workshops for laboratory technicians was formulated.
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It includes serodiagnosis of HIV, blood safety, and methods and principles of
HIV-screening assays. The National AIDS Committee of Cambodia was provided with technical support to analyse the laboratory facilities and capability in ten provinces. To carry out this analysis, supplies such as test kits, pipettes and gloves were provided. Successful outreach programmes targeted at sex workers and injecting drug users have been established. The provision of education and counselling for all those associated with the "sex
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industry" has been promoted and the need to offer services, condoms, information and education to sex workers' clients emphasized. These outreach programmes vary in content depending on the social and cultural traditions of each country. For example, a government will support a nongovernmental organization in the
distribution of condoms either free, or at a low cost to groups of sex workers. Government agencies and nongovernmental organizations are also providing access to clean needles and syringes for injecting drug users by subsidizing them and/or selling them at cost. Changes in public policies have also been effective in reducing risk activity.
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Many countries are in the early stages of developing outreach programmes or models, based on experience in other countries. The Regional Office is collaborating with these countries and supporting technology transfer from the countries which have successful programmes. To promote the use of syndromic case management of sexually transmitted diseases in the countries and areas of the Region, a manual was developed and field-tested in four Pacific island countries, in the Philippines and in the Lao People's Democratic Republic. Appropriate
modifications have been made. Its use will lead to the training of basic health care workers and the capability for provision of routine sexually transmitted disease service delivery throughout general health care systems as recommended by WHO .
.3. CONCLUSION
In many countries and areas of the Region, the increase in HIV infections has been slow compared with other parts of the world. Although some countries remain virtually free of HIV infections, a small number are experiencing a rapid increase. In two countries, a consistent reduction has been seen over the last few years. Good surveillance systems, sustained political commitment, and development and
implementation of education and targeted interventions have been important elements in achieving this reduction in the notified annual number of new HIV infections. Epidemiological studies in the Region show that HIV transmission is now primarily related to commercial sex activity and injecting drug use. It is also known that sexually transmitted diseases are a major factor in the transmission ofHIV.
It is essential to be able to analyse the trend and patterns of the transmission in order to direct prevention activities appropriately. For this, effective surveillance systems are required, backed by constant and reliable HIV laboratory support. All governments need to implement the public health package for sexually transmitted disease care and prevention, recommended by WHO, which includes: • promotion of safer sexual behaviour, including condom use;
WPRlRC4617 page 10
• • •
provision of comprehensive case management at community-level clinics; promotion of appropriate health care-seeking behaviour; integration or close coordination of AIDS and sexually transmitted disease programmes. All countries, but particularly those which are experiencing a rapid increase in new
infections, must also increase their commitment to the following interventions which have been shown to be successful: • • • • outreach programmes for injecting drug users; education programmes for sex workers; peer education and other health promotion activities for identified at-risk groups; education and training of health care workers; Response to the HIV challenge must be supported by all sectors of society and governments. The response must be based on policies that balance the needs of society and the concern for the individual. The importance of individual responsibility in protection against infection must be
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highlighted. Information should enable individuals to make rational decisions appropriate to their needs and expectations, as well as to the society in which they live. HIV infection and sexually transmitted diseases will continue to be significant public health problems and future technical collaboration with the health sectors of governments should be intensified. -
.'
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Table 1. HIV/AIDS trends by year of diagnosis, Western Pacific Region (using data available as at 15 June 1995)
Country I Area
<1988 or unknown AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV
1988 0 0 531 1731 1 1 0 0 0 7 0 0
1989 0 0 603 1626 0 0 0
1990 0 0 654 1412 2 3 0
1991 0 0 773 1413 0
1992 0 0 730 1293 0 1 0 91 5 261 0 0 1 3 3 8 2 10 14 71 90 493 0
1993 0 0 782 1050 1 69 0 201 23 274 0
1994 0 0 787 984 0 82 9 642 29 531 0
1995 0 0
Cumulative
TOTALS
American Samoa Australia
0 0 877 9273 • (1) 2
0 0 5737 18782 3 158 13 1225 65 1774 0 0 7 28 45 144 30 70 142 544 889 4122 0 2 10 59 8 93 200 11375 6 10 2 8 2 2 0
.......
Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hon9 Kong Japan Kiribati Lao People's Democratic Republic Macao Malaysia Mariana Islands, Northern Marshall Islands Micronesia, Federated States of Mongolia
0 0 3 3 216 0 0 1 4 5 19 3 13 15 60 82 238 0 2 1 8 1 4 14 1686 1 2 0 0 0
... 4 288
0 0 3 16 0 0 • (1) 4 7 39 4 7 9 106 54 2209 0 0 1 0 0 1 1 8 2 3 2 6 0 0 0 0
0 0 170 0 0 1 1
0 2 299 0 0 2 2 9 22 3 13 12 34 189 97 0 0 0 0 0 1 12 662 0 1 0 0 1 1 0 0
...
0 1 5 9 12 5 11 19 79 147 424 0 0 4 18 2 40 40 2538 0 1 0 1
0 2
0 0 4 18 1 6 7 28 31 51 0 0 0 0 0 0 4 23 1 1 0 0 0 0 0 0
5 3 9 11 9 38 104 204 523 0 0 4 17 2 33
0 4
5 17 1 1 16 38 92 87 0 0 0 1 1 1 6 183 0 1 0 0 1 1 0 0
...
12 24
0 0 11 2 13 40 2417 0 0 0 0 0
0 0 0 4 ...
72 3544 2 1 0 1
11 314
0 0
0 0
0 0 0 0
0 0
0 0
0 0
0 0
0
0
... ...
0
HIV totals include AIDS cases . ... No preliminary 1995 data has yet been received . • Indicates the extent to which the sum of the annual totals reported exceeds the cumulative total reported.
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Country I Area
<1988 or unknown AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV AIDS HIV
1988
1989
1990
1991
1992
1993
1994
1996
Cumulative
TOTALS
Nauru New Caledonia New Zealand Niue Palau Papua New Guinea Philippines Republic 01 Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu Viet Nam Wallis and Futuna TOTALS
a a 6 17
a a 6 11 38 96
a a 2 13 60 108
a a 2 9 73 104
a a 3 16 67 111
a a 9 11 56 106
a a 6 18 52 90
a a 7 21 41 89 ...
a a 2 7
a a 43 123 473 997
86 293
a a a a
a a a a
a a a a
a a a a
a a a a
a a a a
a a
19 15 31 79 1 14
• (1 ) 4 19
a
9 12 14 35 3 22 6 15
a a
5 15 8 39 1 37 5 10
13 32 16 68 2 54
a a
13 35 13 79 1 42 12 42
8 29 17
1 1 8 17
a a
69 2 76 18 55
a a 0
1 1 8 40 32 100 6 78 22 64
a a a a
...
a a a a 11 31 5 43
a a
16 69 56 118 11 90
a a
a a
a
a a a a a • (1) a a 0 0 • (16) • (75)
a a
a a a a a a a a 0 a a a a
a a a a 2 2
AIDS HIV
1089 12034
0 656 2057
a a a a a a a a 809 2351
a a a a a a a a a a a
1 0 0 1001 2833
a a a a a a a a a a a a a
a 1 2
a a a a 0 a a 86
a a a a a a a a 1 1
48 86
a a a a a a a a 1 2 ... ...
1 15 20 0 1
1 1 91 247 198 618 32 456 1 1 138 328
-
a 1 5 6
a a
a a a a a a 228 2325 1 1 8370 43500
126 1124
0 1008 3993
0 1 998 5107
a
118 1147 1 1462 8107
a a a 42 0 60 779
0 1287 6239
a
a
-.