WORLD HEALTH ORGANIZATION EXECUTIVE BOARD 111th Session Provisional agenda item 5.2 EB111/4 9 December 2002
Contribution of WHO to the follow up of the United Nations General Assembly special session on HIV/AIDS Report by the Secretariat
1. HIV/AIDS continues to place unprecedented demands on the health sector in nearly all affected countries. Although many countries have now drawn up multisectoral HIV/AIDS strategies and have committed themselves to expand their national responses in order to meet the Millennium Development Goals and the targets set out in the Declaration of Commitment of the United Nations General Assembly special session on HIV/AIDS (June 2001), obstacles to funding and effectively implementing these frameworks persist. Furthermore, the health sector has often not well articulated its contribution to an expanded response, despite its central role in providing prevention, treatment and care, mobilizing resources and coordinating action in other sectors.
A GLOBAL HIV/AIDS STRATEGY FOR THE HEALTH SECTOR 2. Conscious of the need to define and strengthen the health sector’s role within a multisectoral response, the Fifty-third World Health Assembly adopted resolution WHA53.14 in May 2000 requesting the Director-General, inter alia, to develop a global health-sector strategy for responding to the HIV/AIDS epidemic as part of the United Nations system’s strategic plan for HIV/AIDS for 2001-2005. This initiative signalled WHO’s commitment to increasing its overall involvement, as a cosponsor of UNAIDS, in the United Nations system-wide effort to combat the epidemic. 3. Progress in framing the global health-sector strategy was reviewed by the Executive Board and the Health Assembly during 20011 and 20022. During this period, global approaches to tackling HIV/AIDS underwent a fundamental change, with prevention and care no longer viewed as separate and competing interventions but as complementary and mutually reinforcing elements of a comprehensive response. At the United Nations General Assembly special session on HIV/AIDS, the first ever devoted to a health issue, the global community manifested significantly increased political will. Major reductions in the prices of antiretroviral drugs were made in several developing countries. At the same time, important new resources to support expansion of country programmes became available through mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and 1 2
Documents EB107/29 and A54/15, respectively. Documents EB109/36 and A55/9, respectively.
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the World Bank’s Multicountry HIV/AIDS Program. Broad-based consultations on a global healthsector strategy indicated clearly that countries need guidance to take advantage of these new opportunities while simultaneously building on and improving existing activities. 4. The extensive consultations on the strategy involved WHO regional and country offices, cosponsors of UNAIDS, ministries of health, national AIDS commissions, other governmental bodies, nongovernmental organizations, people living with HIV/AIDS, and other partners. The process was guided by an external reference group, consisting of experienced programme managers, representatives of governments of affected countries, nongovernmental organizations and bilateral aid agencies, academics, and people living with HIV/AIDS. A common theme that emerged was that the goals set out in the General Assembly special session’s Declaration of Commitment on HIV/AIDS can be achieved only if the health sector acts firmly in its areas of responsibility and contributes strongly to the overall effort. Accordingly, the draft global health-sector strategy (an executive summary of which is annexed) reflects the targets and timelines contained in the Declaration, and emphasizes those goals of direct concern to the health sector. The objectives of the strategy should therefore assist the United Nations system as a whole in monitoring implementation of the Declaration of Commitment and other complementary strategies, and progress towards attaining the Millennium Development Goals. 5. The strategy aims to provide support to governments and health-sector policy-makers in assessing and strengthening the role of the health sector within current national responses to HIV/AIDS. Drawing on lessons learned during 20 years of the epidemic, it sets out the essentials of a health-sector response, including mobilization of stakeholders, sound strategic frameworks, mechanisms to ensure accountability and multisectoral involvement. It also recommends major healthsector interventions that constitute a comprehensive national response and that have been shown to be effective in curbing the epidemic in different settings. 6. Although some countries are further advanced than others in implementing HIV/AIDS strategies and scaling up programmes, the strategy deals with several critical tasks facing the health sector almost universally. These include: prioritization, given competing demands; resource mobilization; financial management; coping with weak health infrastructures; enhancing and sustaining human resources; ensuring quality of services; and strengthening research within national programmes. Detailed action points in each section of the strategy emphasize its practical orientation. 7. The strategy affirms the stewardship role that the health sector should play in national responses, but it also acknowledges the critical roles for other parts of government. It promotes a coherent national response, by supporting Member States in defining areas of leadership for both the health sector and other areas of government. Moreover, it affirms the crucial role of nongovernmental and community-based organizations in national and local responses and suggests ways in which the health sector can best support their efforts. In addition, it highlights the need for new, broad-based partnerships with, for instance, donors, foundations, bilateral agencies and the private sector. It is expected that all stakeholders will be guided by the strategy and involved in its implementation. 8. The strategy will be put into effect in the context of strengthened country action to expand HIV/AIDS programmes. Accordingly, it promotes greater accountability and synergy between Member States and other stakeholders, including WHO, clearly articulating the Organization’s complementary action to facilitate implementation. This support includes building country capabilities in order to fill gaps in expertise in, for example, strategic planning, programme management, design and use of evidence-based normative tools, strengthening epidemiological and behavioural surveillance systems, and mobilizing and managing new resources so that they are deployed for maximum impact. 2
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9. WHO will periodically evaluate progress in implementing the strategy, including an interim review in 2005 and a full review in 2007, in order to ensure that support responds to needs and developments.
BUILDING ON OPPORTUNITIES FOR A STRONGER RESPONSE 10. WHO’s contribution to follow up to the Declaration of Commitment of the United Nations General Assembly special session on HIV/AIDS is also evident in the way HIV/AIDS activities have been brought into the mainstream of WHO’s work, throughout the Organization. The department of HIV/AIDS at headquarters has primary responsibility in the areas of strategic information, normative guidance and approaches to HIV/AIDS prevention, treatment, care and support. 11. WHO is continuing to provide technical support to the secretariat of the Global Fund to Fight AIDS, Tuberculosis and Malaria in assessing funding applications, and working through country and regional offices to initiate proposals to funders and to facilitate implementation of successful applications. These activities are strongly supported by WHO’s work on strengthening surveillance systems and the collection of strategic information at country level, including data collection in populations most at risk. This work also supports improved monitoring of responses, evaluation of interventions and operational research. 12. As HIV is not transmitted at random, WHO’s prevention strategies focus on targeting interventions to where they will yield the most benefit, including high-transmission contexts such as certain geographical locations, among vulnerable groups or other situations where risk and vulnerability converge. For example, prevention programmes may need to prioritize some industrial communities or urban slums where clusters of high HIV incidence stem from the intersection of sexual networks, commercial exchanges, and alcohol and drug use, and whence HIV spreads to other groups, often fuelled by sexually transmitted infections. Unsafe sex is a common risk factor and actions are needed to reduce risk and vulnerability and to strengthen protective factors. WHO therefore promotes sexual and reproductive health strategies including safer sex, use of male and female condoms, prompt and effective case management of sexually transmitted infections and extension of interventions to reduce transmission of HIV to infants as core elements in containing the HIV epidemic. HIV prevention services based on harm-reduction principles and drug-dependence treatment continue to be emphasized in programmes related to substance use. Among the highest priorities for WHO is working to ensure that information and services for young people, who now account for about half of all new infections, are available, accessible and appropriate. 13. With up to 5% of new HIV infections globally attributable to poor injection practices by health workers, the safe and rational use of injections and good management of sharps waste remain top priorities, together with WHO’s work with governments to ensure the safety, quality and adequacy of blood and blood products. The Organization is also contributing to international research on prevention technologies, such as microbicides and vaccines. 14. Within this broad programme of work, WHO gives high priority to increasing access to and affordability of HIV/AIDS treatment, because not only does the health sector have a fundamental responsibility to provide the highest possible level of care but improving access to treatment will create new opportunities to broaden and make more effective the health-sector response. For example, better access to treatment is likely to boost the morale of health-sector staff significantly and reduce demand for inpatient services. It will provide a major incentive for people to come forward for HIV testing, thereby providing new entry points to the health system for those who are infected – including
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opportunities to support them, their partners and families to prevent further transmission – as well as those who are not infected with HIV. Improved access requires engagement with the community and links between existing services (e.g. maternal care and those for people with tuberculosis or sexually transmitted infections), thus strengthening the health sector as a whole. Most important, the possibility of being treated will help diminish the fear, stigmatization and discrimination associated with HIV/AIDS, enabling a more open, humane and effective response. However, without a strong commitment to prevention, countries risk being faced with the agonizing paradox – seen in cities throughout the industrialized world – of the benefits of reduced morbidity and mortality among people living with HIV/AIDS due to antiretroviral therapy being undermined by rising HIV incidence rates. 15. WHO made significant progress in 2002 in promoting access to antiretroviral treatment: guidelines were issued on the use of antiretroviral therapy in resource-poor settings; 10 antiretroviral drugs were added to the WHO Model List of Essential Drugs; and the first-ever Model Formulary, which provides information on the recommended use, dosage, adverse effects, contraindications and warnings for all 325 medicines on the Model List, was launched. This progress will be consolidated in 2003 through an extensive programme on essential drugs and medicines policy and related technical support to countries; by building on new frameworks such as that to reduce the burden of HIV and tuberculosis;1 establishing new models of HIV testing and counselling; provision of guidance on the procurement and use of HIV-related diagnostics; and innovative approaches to integrating HIV interventions into existing programmes such as family planning and maternal and child health, including care for HIV-positive mothers and prevention of transmission of HIV to infants. WHO is working with an international coalition of partners to draft and implement a plan of action for extending access to antiretroviral treatments to three million people by 2005. The plan will include technical support and information sharing to guide countries in implementing national treatment programmes. 16. Experience shows that even in the hardest hit and most resource-constrained settings, improved responses to the epidemic are possible. WHO is fully committed to supporting governments and partners in order to take advantage of new and existing opportunities for a more effective response, including the further elaboration and implementation of the global health-sector strategy for HIV/AIDS.
ACTION BY THE EXECUTIVE BOARD 17. The Board is invited to consider the following draft resolution: The Executive Board, Having considered the draft global health-sector strategy for HIV/AIDS,2 RECOMMENDS to the Fifty-sixth World Health Assembly the adoption of the following resolution: The Fifty-sixth World Health Assembly, Having considered the draft global health-sector strategy for HIV/AIDS; 1 2
A strategic framework to decrease the burden of TB/HIV, document WHO/CDS/TB/2002.296. Document WHO/HIV/2002.25.
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Mindful of WHO’s role, as a cosponsor of UNAIDS, in ensuring that the Declaration of Commitment on HIV/AIDS of the United Nations General Assembly special session on HIV/AIDS (June 2001) is followed up; Deeply concerned about the unprecedented burden the HIV/AIDS epidemic is placing on the health sector, and acknowledging the central role of that sector in providing an expanded, multisectoral response; Conscious of the opportunities and challenges presented by the availability of new resources to Member States through mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and from the World Bank, bilateral agencies, foundations and other donors; Acutely aware of the need to strengthen health-sector capacity in order: (a) to absorb and manage resources; (b) to improve planning, prioritization, development of human resources, programme management, integration and implementation of key interventions, mobilization of nongovernmental organizations, and assurance of service quality; and (c) to support research as part of national responses; Equally conscious of the need simultaneously to expand activities in prevention, treatment, care, support, surveillance, monitoring and evaluation, as essential and mutually supportive elements of a strengthened overall response to the HIV/AIDS epidemic; Aware of the corresponding increase in demand by Member States for technical support, normative guidance and strategic information in order to make optimal use of resources and to maximize the impact of interventions; Recalling that resolution WHA53.14 requested the Director-General, inter alia, to develop a global health-sector strategy for HIV/AIDS and sexually transmitted infections, 1. 2. ENDORSES the global health-sector strategy for HIV/AIDS; URGES Member States, as a matter of urgency: (1) to adopt and implement the strategy as appropriate to national circumstances as part of national, multisectoral responses to the HIV/AIDS epidemic; (2) to strengthen existing, or to establish new, structures, and to mobilize and to engage all concerned parties, within and beyond the health sector, to implement the strategy through the health and other concerned sectors, and for monitoring and evaluating its effectiveness; (3) to take all necessary steps to fulfil their obligations under the Declaration of Commitment on HIV/AIDS of the United Nations General Assembly special session on HIV/AIDS; 3. in REQUESTS the Director-General to provide support to Member States, on request, implementing the strategy and evaluating its impact and effectiveness.
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ANNEX A GLOBAL HEALTH-SECTOR STRATEGY FOR HIV/AIDS 2003-2007 Providing a framework for partnership and action Executive summary1 BACKGROUND 1. The HIV/AIDS pandemic has become a human, social and economic disaster, with far-reaching implications for individuals, communities and countries. No other disease has so dramatically highlighted the current disparities and inequities in access to health care, economic opportunity and the protection of basic human rights. More than 40 million people worldwide are infected with HIV. Each day there are some 14 000 new HIV infections, with more than half in people under 24 years of age. 2. HIV incidence and AIDS-related death rates are again rising in some countries where real progress had previously been made in stemming the epidemic. In some settings, HIV prevention and care initiatives and services have been allowed to run down, whereas other countries have not kept a sharp enough focus on prevention following the advent of combination antiretroviral treatment. Developing countries now have a unique opportunity to learn from these experiences by maintaining strong prevention efforts even as access to antiretroviral treatment is expanded. 3. The health sector is facing severe shortages of human and financial resources, especially in the worst affected countries. Health-care workers themselves are directly affected by HIV/AIDS, and organizations and facilities providing care and support are simply being overwhelmed by the demand.
AIMS AND TARGET AUDIENCE 4. The aim of the global health-sector strategy is to define and strengthen the response of the health sector to the HIV/AIDS epidemic within the overall multisectoral response. 5. The strategy’s specific objectives are: • to advise health ministries on the essential interventions needed for an effective health-sector response to HIV/AIDS; • to support health ministries in creating the frameworks of policy and for planning, prioritysetting, implementation and monitoring necessary to support such a response; • to enhance and promote the strengths, expertise and experience that health ministries can contribute to national strategic planning for HIV/AIDS;
1 The global health-sector strategy for HIV/AIDS (document WHO/HIV/2002.25) will be available in the Executive Board room.
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• to help the health sector to attain the goals contained in the United Nations General Assembly Declaration of Commitment on HIV/AIDS. 6. While the primary target audience comprises ministers of health, and policy-makers and other decision-makers in the health sector, the strategy is also intended for other health-sector stakeholders including: international agencies; public and private health services; nongovernmental organizations; community groups; professional associations; and institutions with direct inputs into the health-care system. Many other government departments and agencies, with responsibilities ranging from finance to foreign affairs, can all contribute substantially to a comprehensive response to HIV/AIDS; the strategy will help to identify areas of leadership in the response to HIV/AIDS for the health sector, and for other areas of government with support and technical advice from health ministries. Opportunities for managing diversity and maximizing synergies can be created through partnerships and linkages with the public and private sectors and donors.
GOALS, GUIDING PRINCIPLES AND CORE COMPONENTS 7. In the Declaration of Commitment on HIV/AIDS adopted at the United Nations General Assembly special session on HIV/AIDS in June 2001, the global community committed itself to a range of actions at the local, national, regional and international levels.1 The global health-sector strategy reflects the aspirations and actions contained in the Declaration since many of its targets can only be met through a strong, broad contribution of the health sector. The goals of current efforts to combat HIV/AIDS can be summarized as follows: (i) to prevent transmission of HIV; (ii) to reduce the morbidity and mortality related to HIV/AIDS; and (iii) to minimize the personal and societal impact of HIV/AIDS. 8. The following guiding principles that have emerged from the broad consultative process for formulating the strategy and the various relevant United Nations system documents2 are prerequisites for effective and sustained prevention, health promotion, treatment and care for HIV/AIDS. (a) It is the role of government, working with civil society, to provide the leadership, means and coordination for an effective response to HIV/AIDS at national and community levels. (b) It is a fundamental responsibility of the health sector to provide the highest possible levels of care, even in resource-constrained settings. (c) Prevention, treatment and care are indivisible elements of effective responses. Although prevention of HIV infection forms the mainstay of the health-sector response, it cannot be separated from the treatment and care of those living with HIV/AIDS. (d) Health ministries and the health sector have a responsibility to use the best available evidence to inform planning and decision-making for HIV/AIDS.
United Nations General Assembly twenty-sixth special session, Declaration of Commitment on HIV/AIDS, 27 June 2001, resolution S-26/2. 2 UNAIDS, Global Strategy Framework on HIV/AIDS, Geneva, UNAIDS, 2001; United Nations system strategic plan for HIV/AIDS for 2001-2005, Geneva, UNAIDS, 2001 (document UNAIDS/PCB(11)/01.3).
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(e) People have a right to know their HIV status, and testing and counselling should be widely accessible through ethical, practical and, where appropriate, innovative models of delivery. (f) Prevention methods, treatment and the applications of results of scientific breakthroughs need to be equitably and affordably available to all, with priority given to the vulnerable. (g) A successful response depends on the active engagement of people living with and affected by HIV/AIDS. (h) Programming should take cognizance of the gender inequalities that fuel the pandemic.
(i) Both broad-based and targeted interventions are required – broad-based interventions are essential for generating wide awareness of HIV/AIDS in populations and targeted interventions complement such approaches. (j) Bringing HIV/AIDS services and programmes into the mainstream of health systems delivers effective, cost-efficient outcomes. Existing reproductive-health programmes in particular offer entry points for HIV/AIDS interventions. (k) HIV infection in medical settings must be prevented.
9. Even the most resource-limited settings have engendered success stories of slowing the rate of new infections and providing high-quality care for those affected. Based on these experiences and the wealth of knowledge gained globally from two decades of responses to HIV/AIDS, WHO has compiled several core components (see Appendix) of a comprehensive health-sector response to HIV/AIDS. Many of these components will depend on, and in turn benefit, other public health programmes. In particular, access to information and services for maternal and child health, sexual and reproductive health, and the control of tuberculosis and sexually transmitted infections together provide an essential foundation upon which to build sound HIV/AIDS programmes.
IMPLEMENTING AN EFFECTIVE HEALTH-SECTOR STRATEGY FOR HIV/AIDS 10. The translation of the core components of a health-sector response into fully operating programmes, services and policies needs: strong leadership, to mobilize government and the nongovernmental sector; a strategic framework, to support implementation; systems for the identification and allocation of resources; means for setting priorities; and mechanisms for evaluation. 11. To implement an effective health-sector strategy, governments will need to undertake the following, provided that government action is complemented by the participation of civil society and the business and private sectors: (a) to provide strong political leadership, within and outside the health sector. Within that sector, health ministries are the major force for leadership and mobilization, with a responsibility to advocate the inclusion of all health-sector stakeholders in national planning and decision-making. Leadership is needed outside the health sector, too. Many countries have broadened leadership and responsibility for responding to HIV/AIDS and have established HIV/AIDS commissions or similar bodies to help to shape and coordinate national efforts, often
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resulting in major benefits, including the resolve to confront cultural and societal barriers to HIV prevention and care, the commitment of resources, and nationwide action; (b) to draw up a national HIV/AIDS strategic plan, including the health-sector response, with the full participation of all stakeholders, and which encourages innovation and carefully considers local factors, such as in-country diversity, potential barriers to access and the availability of resources; (c) to define and allocate roles and responsibilities in order to avoid uncertainty or conflict. Policy and technical advisory committees on HIV/AIDS – with their membership drawn from health professions, researchers, people living with HIV/AIDS, vulnerable communities, nongovernmental organizations and other areas – provide a forum for obtaining informed advice on the practical implications of policy choices and priorities; (d) to promote comprehensive responses to HIV/AIDS bringing in other sectors of government, including departments of finance, justice, education, planning, labour, agriculture, tourism, corrective services, defence and foreign affairs. Health ministries need to be able to assess the impact of policies in non-health sectors, including the business sector and donor agencies, on the responses to HIV/AIDS; (e) to mobilize the nongovernmental sector, as it is neither possible nor desirable for health ministries and other areas of government to attempt to provide all HIV/AIDS-related programmes and services; (f) to optimize use of scarce human and financial resources by including in national strategic plans for HIV/AIDS mechanisms for accountability, monitoring and evaluation; (g) to formulate a detailed plan for funding with, for many countries, innovative strategies to supplement governmental funding allocations for HIV/AIDS. Despite the call in the United Nations Declaration of Commitment on HIV/AIDS for substantially increased national and global funding, resources continue to fall far short of what is needed. Examples of innovative funding approaches include national poverty reduction strategies; use of debt-relief proceeds for impact-reduction activities and preferential access to essential commodities through price or trade concessions; engagement of the business and private sectors; health-sector initiatives such as sector-wide approaches; and the Global Fund to Fight AIDS, Tuberculosis and Malaria; (h) to improve management, accountability and transparency in health ministries and the health sector, and to consider how to sustain responses to HIV/AIDS over the long term; (i) given that the demands placed on any HIV/AIDS initiatives in most settings are likely far to outstrip the available resources, to provide leadership and technical expertise in prioritysetting, with the application of ethical principles and technical criteria, including: • basing interventions on sound evidence of effectiveness; • applying lessons drawn from national and global experience; • using epidemiological and behavioural information to inform priority-setting;
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• taking into account the impact on access, vulnerability, equity, human rights and discrimination; • participation of major stakeholders in each step of setting priorities; • fully justifying limitations on access to prevention, treatment and care; • an open and transparent priority-setting process.
REALIZING OUTCOMES 12. Three further determinants for the successful implementation of a health-sector strategy have been identified: human resources and capabilities; quality assurance; and research. To this end, health ministries and other parts of the health sector will need: • to ensure a sufficient number of qualified and skilled health-sector personnel through training about not just technical skills in delivering prevention, health promotion, treatment and care but also advocacy, leadership, management and strategic planning, as well as fostering interpersonal skills and eliminating prejudice, with the aim of ensuring sensitive, compassionate attitudes towards clients; • to set clear national quality standards for HIV-related programmes, services and commodities, with allowance for innovation (especially when accompanied by research and evaluation); • at a minimum, to establish an epidemiological and behavioural surveillance system in order to inform planning and priority-setting. Operational, biomedical, clinical, epidemiological and social research provides invaluable information to help the health sector to respond to HIV/AIDS. Research also contributes to promoting quality standards in clinical care, prevention programmes and other interventions. Even in resource-limited settings, HIV research findings can lead to innovative, cost-effective approaches, and provide data on outcomes of local interventions. International cooperation in research between countries can inform programmatic and policy responses.
CONCLUSION 13. As the first step to putting this global health-sector strategy into practice health ministries, with the active participation of their health-sector partners, should examine health-sector planning for HIV/AIDS and consider adjusting this to reflect the principles, framework and interventions proposed. WHO is committed to matching the effort being asked of Member States. WHO will carefully examine its own capacity for supporting this strategy, and will strengthen that capacity where needed.
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APPENDIX CORE COMPONENTS OF A HEALTH-SECTOR RESPONSE TO HIV/AIDS
Prevention and health promotion • • • • Framing broad-based programmes to educate the general population about HIV/AIDS Promoting safer and responsible sexual behaviour and practices, particularly use of condoms Targeting interventions where they will yield most benefit, in particular where risk and vulnerability converge through behaviours, locations and group membership Promoting harm reduction among injecting drug users, such as wide access to sterile injecting equipment, and drug-dependence treatment and outreach services to help to reduce frequency of injecting drug use Providing widely accessible HIV testing and counselling Treatment • • • • Implementing programmes to prevent mother-to-child transmission of HIV Increasing access to services to diagnose and treat sexually transmitted infections Strengthening services to diagnose and treat HIV/AIDS and related opportunistic and concurrent infections such as tuberculosis Providing a continuum of care from the home to the health facility supported by a system of client referral Health standards and health systems • • Ensuring the safety of blood and blood products Promoting universal precautions to reduce the risk of occupational HIV infection in health facilities, community settings and the home; and providing post-exposure prophylaxis to health workers accidentally exposed to HIV Setting and promoting national standards for the public, private and community-based delivery of HIV/AIDS prevention, health promotion, treatment and care Increasing access to antiretroviral drugs and other advanced HIV-related treatments Building capacity of health systems, as appropriate, including human resource levels and the mix of available skills Informed policy and strategy development • • Establishing or strengthening epidemiological and behavioural surveillance for HIV and sexually transmitted infections Elaborating plans for funding and generating resources, and strengthening accountability and monitoring systems for both human and financial resources
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Countering discrimination against and stigmatization of people living with HIV/AIDS and vulnerable groups Reviewing policies, laws and regulations to ensure that they support programmes on HIV and other sexually transmitted infections Mobilizing communities, nongovernmental organizations, people living with HIV/AIDS, vulnerable groups, and the business sector
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