V8 final summary ua 2011 en-nov 27.pdf

Progress rePort summary 2011
Foreword
1. Introduction
2. Key findings: Update on the HIV epidemic
3. Key findings: Selected health sector interventions for HIV prevention
4. Key findings: Knowledge of HIV status
5. Key findings: Scaling up treatment and care for people living with HIV
6. Key findings: Scaling up services for key populations at higher risk

of HIV infection
7. Key findings: Scaling up HIV services for women and children:

Towards elimination of mother to child transmission and improving
maternal and child health in the context of HIV
8. Conclusions: Achieving and sustaining universal access
This documents the extraordinary progress achieved over the past decade in the health sector response to HIV. Access to evidence-informed HIV prevention, testing and counselling, treatment and care services in low- and middle-income countries has expanded dramatically. This progress demonstrates how countries can surmount seemingly intractable health and development challenges through commitment, investment and collective action.
The global incidence of HIV infection has stabilized and begun to decline in many countries with generalized epidemics. The number of people receiving antiretroviral therapy continues to increase, with 6.65 million people getting treatment at the end of 2010. Almost 50% of pregnant women living with HIV received effective antiretroviral regimens to prevent mother-to-child transmission, spurring the international community to launch the Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. What would have been viewed as wildly unrealistic only a few years ago is now a very real possibility.
Recent published evidence from clinical trials has confirmed the powerful impact antiretroviral drugs have on the epidemic as part of an effective package of options for HIV prevention. For the first time, the prospect of a microbicide that contains antiretroviral medicine is providing additional hope to the women in sub-Saharan Africa who continue to bear a disproportionate burden of the HIV epidemic in this region.
Despite these advances, still too many people are acquiring HIV infection, too many people are getting sick and too many people are dying. Of particular concerns are trends affecting Eastern Europe and Central Asia, where the numbers of people acquiring HIV infection and dying from HIV-related causes continue to increase. New surveillance data confirm that the epidemic disproportionately affects sex workers, men who have sex with men, transgender people, people who inject drugs, prisoners and migrants in both concentrated and generalized epidemics. Too often national AIDS plans omit these people, who face formidable legal and other structural barriers to accessing HIV services. Globally, more than 50% of the people eligible for treatment do not have access to antiretroviral therapy, including many people living with HIV who are unaware of their HIV status. Children have much poorer access to antiretroviral therapy than do adults, and attrition at each stage in the cascade of care has highlighted the need to strengthen links within HIV services and with other areas of health and community systems.
Nevertheless, several critical developments over the past year have highlighted the capacity of the global response to innovate and learn from scientific and programmatic evidence. The Political Declaration on HIV/AIDS, adopted in June 2011 by the United Nations General Assembly, set ambitious targets aimed at achieving universal access and the health-related Millennium Development Goals by 2015. The WHO Global Health Sector Strategy on HIV/AIDS, 2011–2015, the UNAIDS 2011–2015 Strategy: Getting to Zero, and the UNICEF's strategic and programmatic focus on equity will help to guide national and global efforts to respond to the epidemic and move from an emergency response to a long-term, sustainable model of delivering HIV services. These strategies emphasize the need to better tailor national HIV responses to the local epidemics, to decentralize programmes to bring them closer to people in need and to integrate with other health and community services to achieve the greatest impact. These are important developments aimed at consolidating gains to date and improving the quality, coverage and efficiency of HIV services.
The past decade has seen a historically unprecedented global response to the unique threat the HIV epidemic poses to human development. Networks of people living with and affected by HIV, as well as civil society organizations, 2 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011

have continued to work with other partners, to demand and mobilize political leadership. This has led to increased funding, technical innovation and international collaboration that has saved millions of people's lives and changed the trajectory of the epidemic. As capacity at all levels increases, programmes are becoming more effective and efficient. Nevertheless, financial pressures on both domestic and foreign assistance budgets are threatening the impressive progress to date. Recent data indicating that HIV funding is declining is a deeply troubling trend that must be reversed for the international community to meet its commitments on HIV.
HIV has proven to be a formidable challenge, but the tide is turning. The tools to achieve an AIDS-free generation are in our hands. Let us move forward together on the ambitious goals set for 2015 and bring us closer to realizing our collective vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths.
Director-General Executive Director Executive Director World Health Organization This report reviews progress made until the end in the response to HIV through regular monitoring and of 2010 in scaling up access to health sector reporting. Since 2010 was the deadline established in interventions for HIV prevention, treatment, 2005 for achieving universal access to HIV prevention, care and support in low–and middle-income treatment, care and support, this report also represents countries. It is the fifth in a series of annual progress an important benchmark, an opportunity to take stock reports published since 2006 by the World Health and identify both achievements and outstanding gaps Organization (WHO), United Nations Children's Fund and to take a constructive look forward in the response (UNICEF) and Joint United Nations Programme on HIV/ at this critical point in the response to the HIV epidemic.
AIDS (UNAIDS), in collaboration with national and international partners, to monitor key components of The results of commitment, investment and the health sector response to the HIV epidemic. The collaboration over the past decade have translated report reflects the commitment of United Nations into substantial improvements in access to evidence- Member States, civil society and United Nations informed HIV prevention, diagnosis, treatment, care and agencies to ensure accountability for global progress support interventions in the health sector (Table 1.1).
Table 1.1 Key indicators for the HIV epidemic, 2002–2010
Number of people living with HIV (in millions) Number of people newly infected with HIV (in millions)Number of people dying from AIDS-related causes (in millions)% of pregnant women tested for HIVaNumber of facilities providing antiretroviral therapyaNumber of people receiving antiretroviral therapyaNumber of children receiving antiretroviral therapyaCoverage of antiretroviral medicines for preventing mother-to-child transmission (%)a a In low- and middle-income countries.
b The coverage data includes provision of single-dose nevirapine which is no longer recommended by WHO.
c This data does not include single-dose nevirapine regimen which is no longer recommended by WHO. It should not be compared with the previous years. When including single-dose nevirapine, the coverage in 2010 is 59%.
4 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
• A total of 2.7 million people acquired HIV infection dying in sub-Saharan Africa and the full onslaught of the in 2010, down from 3.1 million in 2001, contributing epidemic would not be felt until 2006, when more than to the total number of 34 million people living with 2.2 million people died each year from AIDS-related HIV in 2010 (see Chapter 2).
causes (2,3). The revolution in HIV treatment brought • Access to HIV testing and counselling is increasing: about by combination antiretroviral therapy in 1996 coverage of HIV testing and counselling among had forever altered the course of disease among those pregnant women rose from 8% in 2005 to 35% in living with HIV in high-income countries but had only 2010. Nevertheless, the majority of people living with reached a fraction of people in low and middle-income HIV in low–and middle-income countries still do not countries, which bore 90% of the global HIV burden (1).
know their serostatus (see Chapter 4).
• The number of health facilities providing antiretroviral At the XIII International AIDS Conference in July therapy, a key indicator of expanded health system 2000 in Durban, South Africa, activists, community capacity to deliver treatment, expanded from 7700 leaders, scientists and health care providers joined in 2007 to 22 400 at the end of 2010, a threefold forces to demand access to treatment and an end to increase (see Chapter 5).
the enormous health inequities between the global • Access to antiretroviral therapy in low–and middle- North and global South. Months later, world leaders income countries increased from 400 000 in established the Millennium Development Goals, a 2003 to 6.65 million in 2010, 47% coverage of series of ambitious, time-bound targets aimed at people eligible to treatment, resulting in substantial achieving progress on several health and development declines in the number of people dying from AIDS- goals over the next 15 years, including Millennium related causes during the past decade (Fig. 1.1). Development Goal 6: combat HIV, malaria and other Mounting scientific evidence suggests that increased diseases (4). In 2001, the United Nations General access to antiretroviral therapy is also contributing Assembly Special Session on HIV/AIDS (UNGASS) substantially to declines in the number of people approved the Declaration of Commitment on HIV/ acquiring HIV infection.
AIDS, with common targets in specific technical areas, • The number of children receiving antiretroviral such as expanding access to antiretroviral therapy, therapy increased from 71 500 at the end of 2005 antiretroviral prophylaxis to prevent the mother- to 456 000 in 2010. Nevertheless, the 23% coverage to-child-transmission of HIV and HIV prevention. of children is a substantial gap to the coverage of The Declaration also committed Member States to establish a dedicated global health fund to finance the • Coverage of pregnant women receiving the HIV response, resulting in the launch of the Global Fund most effective antiretroviral regimens to prevent to Fight AIDS, Tuberculosis and Malaria one year later: mother-to-child transmission of HIV (excluding The Global Fund quickly became a cornerstone in the single-dose nevirapine) is estimated at 48% in global response to HIV, funding country-led responses 2010(see Chapter 7).
through a pioneering, performance-based grant system. In 2003, the United States Government announced the United States President's Emergency Plan for AIDS Building foundations: political commitment,
Relief. At US$ 15 billion over five years, it was the largest investment and technical innovation
single funding commitment for a disease in history. The United States President's Emergency Plan for AIDS At the beginning of the 21st century, the international Relief was reauthorized in 2008 for up to US$ 48 billion community faced formidable health and development to combat AIDS, TB and malaria for 2009–2013.
challenges, none more so than countries in the poorest region of the world: sub-Saharan Africa. Additional innovations in global health funding A rapidly expanding HIV epidemic was already followed. By 2006, Brazil, Chile, France, Norway and dramatically reversing decades of progress on key the United Kingdom had agreed to create UNITAID, an development indicators, such as infant mortality and international drug purchase facility financed through a life expectancy (1). Although the global incidence of modest levy on airline tickets. UNITAID now finances HIV infection had peaked in the mid-1990s, more than and supports strategic interventions in the drugs and 3 million people were being newly infected per year, diagnostics markets in 94 countries (5).
AIDS had become one of the leading causes of adults Fig. 1.1 Number of people with access to antiretroviral
By the middle of the last decade, another benchmark therapy and the number of people dying from AIDS-related
was established when G8 leaders – and later all United causes, low- and middle-income countries, 2000–2010
Nations Member States – endorsed the goal of achieving universal access to a package of HIV prevention, care,  People receiving antiretroviral therapy  People dying from AIDS-related causes treatment and support interventions for everyone who needs them (9). By the end of 2005, the number of people receiving antiretroviral therapy in low- and middle-income countries had jumped to more than 1.4 million. Progress on Millennium Development Goal 6 and UNGASS targets accelerated in the second half of the decade; guidelines on preventing mother-to-child- transmission and on care for children, antiretroviral therapy, provider-initiated testing and counselling and medical male circumcision were released. The 2010 WHO recommendations on antiretroviral therapy (10) reflect clinical evidence that early initiation of antiretroviral therapy (recommended at CD4 cell counts less than 350 per mm3) significantly reduces morbidity and mortality and also has important preventive benefits.
Increased political and financial commitments to the The "3 by 5" target was met in 2007, and by the end HIV response developed in parallel with normative of 2010 the number of people receiving treatment guidance and strategic technical innovations, including in low- and middle-income countries had reached a ground-breaking approach to scaling up treatment 6.65 million, an increase of more than 16-fold in seven access in low- and middle-income countries: the years (see Chapter 5). The trends are similar in access public health approach to antiretroviral therapy (6). Key to antiretroviral medicine for preventing mother-to- elements of the public health approach include using child-transmission, enabling 350 000 infants to avoid standardized treatment protocols and drug regimens, HIV infection since 1995 (see Chapter 7) (Fig. 1.2).
simplified clinical monitoring, maximizing coverage with limited resources, optimizing human resources for health and involving people living with and affected by Fig. 1.2 Coverage of antiretroviral prophylaxis for preventing
HIV in designing and rolling out antiretroviral therapy the mother-to-child-transmission of HIV and the number of
new HIV infections among children, low- and middle-income
countries, 2003–2010
 Number of new HIV infections among children Scaling up the global HIV response
 Coverage of antiretroviral prophylaxis for preventing When WHO and UNAIDS launched the "3 by 5" Initiative on World AIDS Day in 2003, only 400 000 people in low- and middle-income countries had access to antiretroviral therapy (8). The "3 by 5" Initiative, which set a target of obtaining access to antiretroviral therapy for 3 million people by the end of 2005, led a fundamental shift in thinking about the feasibility of funding and delivering antiretroviral medicines and other drugs for people in resource-limited settings. The rapid scale-up of antiretroviral therapy in low- and middle-income countries, especially during the past five years, has significantly reduced the number of people dying from AIDS-related causes (Fig. 1.1).
a Coverage before 2010 include single-dose nevirapine, which is no longer recommended by WHO. Coverage in 2010 does not include single dose nevirapine. 6 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
Uptake of HIV testing and counselling, which is decade: from an estimated 7800 in 2001 to 89 500 in critical to ensuring appropriate referral to prevention 2010 (see Chapter 2) (12).
and treatment services, also increased from about 64 million tests in 2009 to 72 million in 2010 (in 87 Although HIV testing and counselling uptake has reporting countries). In eastern and southern Africa, the improved, many people living with HIV in low- and subregion with the highest number of pregnant women middle-income countries still do not know their living with HIV, testing and counsel ing coverage among HIV status, undercutting efforts to reduce onward pregnant women increased from 14% to 61% between transmission and refer those testing HIV-positive to 2005 and 2010, and the number of facilities providing appropriate care and treatment; an estimated 7.5 million antiretroviral therapy in low- and middle-income people are eligible for treatment but are not accessing countries – a key measure of the capacity of the health antiretroviral therapy because they are unaware of their systems to scale up to meet the demand for treatment HIV serostatus. Although provider-initiated testing and – increased from less than 7700 in 2005 to 22 300 in counselling has led to dramatic increases in the number 2010, a three-fold increase.
of people living with HIV diagnosed in the symptomatic stages of HIV disease, testing based in health facilities Although there has been concern that investment to is unlikely to identify people at earlier, asymptomatic date has not adequately addressed the constraints stages of infection (above 200 CD4 cells per mm3). of health system, a 2009 study (11) indicated that – Novel approaches to community-based testing are on balance – HIV investment has strengthened the therefore urgently needed (see Chapter 4).
capacity of health systems, partly by introducing important innovations in how health services are For children, the situation is even graver, since less funded and delivered. The grant architecture of the than one quarter of the children eligible for treatment Global Fund to Fight AIDS, Tuberculosis and Malaria, are accessing antiretroviral therapy. Attrition rates of for example, has evolved to address structural deficits 20% or more 12 months after people start receiving in health system capacity. The past few years have also antiretroviral therapy in many programmes indicate seen evolution in thinking about how to better integrate the need for intensified efforts and strategies to HIV services with other areas of the health sector, initiate treatment earlier, retain individuals in care (see including maternal, newborn and child health, sexual Chapter 5) and increase the quality of interventions.
and reproductive health, drug dependence treatment and harm reduction (including opioid substitution Women, especially young women, remain therapy), tuberculosis and primary health care. In disproportionately affected in sub-Saharan Africa, addition, approaches to task-shifting or task-sharing in highlighting the need to address gender inequity and countries are contributing to improving the productivity harmful gender norms as a central component of of scarce human resources for health.
the global response to HIV (13). Key populations at higher risk of HIV infection and transmission, including Nevertheless, significant challenges remain. Although people who inject drugs, men who have sex with men, the annual number of people newly infected with HIV transgender people, sex workers, prisoners and migrants has dropped since their peak in the late 1990s, this is continue to be underserved by current HIV services and still occurring at an unacceptably high rate: between often have the highest HIV prevalence in areas with 2.5 and 3 million people annually for the past five years, both generalized and concentrated epidemics (see adding to the global number of people living with HIV Chapter 2) (12). Despite the commitments made in the that reached 34 million [31 600 000–35 200 000] 2001 and 2006 UNGASS declarations to respect the by the end of 2010 (see Chapter 2). Reductions in the human rights of key populations at higher risk, these number of people acquiring HIV infection, especially groups continue to face violence, social stigma and poor people 15–24 years old in the countries in sub-Saharan access to HIV services in many settings, a situation Africa that have a high burden of HIV, have been offset compounded by laws that criminalize homosexuality, by increases in new infections in Eastern Europe and drug use and sex work.
Central Asia, where the primary mode of transmission is among people who inject drugs and their sexual Domestic and international HIV-specific funding has networks and where the number of people dying from decreased from US$15.9 billion in 2009 to US$ 15 billion AIDS-related cause increased 1100% during the past in 2010, well below the estimated US$ 22–24 billion needed in 2015 for a comprehensive, effective global the drive for optimizing and innovating treatment response to HIV (14,15).
in the key areas of drug regimens, point-of-care diagnostics, integrated and decentralized delivery of The past decade has witnessed fundamental changes HIV services (17,18) and mobilizing communities (17). The in the approach to global public health challenges. 2010 WHO recommendations on antiretroviral therapy The results have been demonstrated in both human reflect clinical evidence that initiating antiretroviral and economic terms. A 2011 study (16) indicated that therapy early (recommended at CD4 cell counts investment in antiretroviral therapy programmes to less than 350 mm3) significantly reduces morbidity date is significantly influencing increased economic and mortality and also has significant benefits in activity and labour force productivity in low- and preventing HIV infection and TB (10). Recent scientific middle-income countries, reaching total gains of up breakthroughs have confirmed the significant effects to US$ 34 billion and 18.5 million life-years by 2020, of prevention interventions based on antiretroviral more than offsetting the costs of antiretroviral therapy medicine as part of combination prevention, including programmes. Introducing antiretroviral therapy has oral pre-exposure prophylaxis, topical microbicides averted 2.5 million deaths in low- and middle-income and treatment as prevention (19–21).
countries globally since 1995 (Chapter 2). Nevertheless, at a time when mounting evidence indicates that UNAIDS and WHO have released five-year strategies political and financial commitments in the first decade (2011–2015), aimed at building on the progress to of the 21st century are paying enormous dividends, date and establishing ambitious new targets for 2015: concerns are growing about the sustainability of the zero new infections, zero discrimination and zero response, the continued upward trajectory of costs and AIDS-related deaths (22,23). The Global Health Sector the millions still in need. The data in this report confirm Strategy on HIV/AIDS, 2011–2015 (23), endorsed by all that, although important and substantial progress has WHO Member States in May 2011, guides national HIV been made, only 10 low- and middle-income countries, responses in the health sector and outlines the role of including 3 with generalized epidemics, achieved the WHO and other partners in achieving the 2015 targets. universal access target for antiretroviral therapy (80% The strategy focuses on four strategic directions: coverage) in 2010.
optimizing HIV prevention, diagnosis treatment and care; leveraging broader health outcomes through HIV responses; building strong and sustainable health and The roadmap to 2015
community systems; and reducing vulnerability and removing structural barriers to accessing services. Budgetary constraints in the aftermath of the 2008 Success in scaling up access to antiretroviral therapy recession and the ongoing volatility in the global and antiretroviral prophylaxis to prevent mother- economy are threatening hard-won gains and to-child-transmission of HIV has driven the recent underscore the need to reduce commodity costs and commitment among United Nations Member States, maximize efficiency in how HIV programmes are civil society and United Nations Agencies, co-convened funded and implemented.
by UNICEF and WHO, to establish a global plan aimed at eliminating new HIV infections among children and A new investment framework seeks to ensure a improving maternal health through intensified, country- more strategic funding approach that includes both led action and resource mobilization (24).
the need for additional funding and a fundamentally different approach to designing programmes and The 2011 Political Declaration on HIV/AIDS builds on delivering services, focusing on a core set of basic the enormous progress made during the past decade, programmatic activities, critical enablers and establishing bold and ambitious targets for 2015 (26). developmental synergy. The investment framework The Declaration acknowledges the challenges faced grounds the global HIV response more firmly in by countries in achieving universal access by the evidence-informed interventions that should be original 2010 deadline and commits to intensified universally applied for greatest impact and in local efforts to reach universal access and Millennium epidemiology (Box 1.1) (15). The Treatment 2.0 initiative, Development Goal targets. For the first time in the launched by WHO and UNAIDS in 2010, is continuing more than 30 years since the epidemic emerged, 8 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
Box 1.1
Towards an improved investment approach for an effective global HIV response
At the end of 2010, about US$ 15 billion was available to scale up HIV services worldwide, split almost evenly between international and domestic sources (Fig. 1.3). But international assitance has declined from US$ 8.7 billion in 2009 to US$ 7.6 billion in 2010. More than 70% of international donor government disbursements for HIV programmes were channel ed bilateral y, and the remainder was al ocated primarily through UNITAID and the Global Fund to Fight AIDS, Tuberculosis and Malaria. After years of considerable increases, international funding for HIV programmes actually fell in 2010.
The investment framework promotes setting priorities for the efforts based on a nuanced understanding of country epidemiology and context and calls for evidence-informed activities that directly reduce HIV transmission, morbidity and mortality to be scaled up according to the size of the relevant affected populations.
Annual resource needs to deliver on this optimized approach should peak at US$ 22–24 billion in 2015, when universal access is achieved, and should subsequently decline, along with HIV transmission, morbidity and mortality rates. By 2020, the return on this comprehensive investment framework would be 12 million fewer people newly infected with HIV than would be possible with current funding levels and 7.4 million fewer people dying from AIDS-related causes (Fig. 1.4).
Fig. 1.3 Global resources available for HIV programmes in
Fig. 1.4 Annual number of people newly infected with
low- and middle-income countries, billions of US dollars,
HIV, baseline scenario and optimized investment
 Baseline  Investment framework ted with HIV (millions New infections averted between 2011 and 2020: 12.2 million f people newly inf 0.5 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Source: UNAIDS World AIDS Day report 2011 (25).
the international community can see success on the In an era dominated by economic crises and fiscal horizon. Scientific advances, committed leadership and constraints, the HIV response continues to provide strategic investment will yield a long-term, sustainable examples of how focused and smart investment can response to HIV that also strengthens synergy with reap enormous human, economic and social benefits. other health and development goals. The hard-won Countries and communities enter the fourth decade progress during the past decade has proven what can with HIV at a crossroads. Although the challenges are be achieved through collective action on common goals.
daunting, the road to success is clear.
1. Haacker M, ed. The macroeconomics of HIV/AIDS. Washington, DC, International Monetary Fund, 2004.
2. The world health report 2004: changing history. Geneva, World Health Organization, 2004 (http://www.who.int/whr/2004/en, accessed 15 October 2011).
3. UNAIDS and WHO. AIDS epidemic update 2009. Geneva, UNAIDS, 2009 (http://www.unaids.org/en/dataanalysis/epidemiol ogy/2009aidsepidemicupdate, accessed 15 October 2011).
4. Goal 6: combat HIV/AIDS, malaria and other diseases. New York, United Nations, 2000 (http://www.un.org/millenniumgoals/ aids.shtml, accessed 15 October 2011).
5. How UNITAID came about. Geneva, UNITAID, 2011 (http://www.unitaid.eu/en/about/-background-mainmenu-18/159.html, accessed 15 October 2011).
6. Grubb I, Perriëns J, Schwartländer B. A public health approach to antiretroviral treatment: overcoming constraints. Geneva, World Health Organization, 2003 (http://www.who.int/hiv/pub/prev_care/en/PublicHealthApproach_E_pdf, accessed 15 October 2011).
7. Gilks CF et al. The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings. Lancet, 8. WHO, UNAIDS and UNICEF. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector. Progress report 2009. Geneva, World Health Organization, 2009 (http://www.who.int/hiv/2009progressreport/report/en/index.html, accessed 15 October 2011).
9. Political Declaration on HIV/AIDS – United Nations General Assembly Resolution 60/262. New York, United Nations, 2006.
10. Antiretroviral therapy for HIV infection in adults and adolescent: recommendations for a public health approach (2010 revision). Geneva, World Health Organization, 2010 (http://www.who.int/hiv/pub/arv/adult2010/en/index.html, accessed 15 October 2011).
11. World Health Organization maximizing positive synergies collaborative group. An assessment of interactions between global health initiatives and country health systems. Lancet, 2009;373: 2137–69.
12. UNAIDS Global report on the AIDS epidemic 2010. Geneva, UNAIDS, 2010 (http://www.unaids.org/globalreport, accessed 15 October 2011).
13. Shabazz-El W. Human rights as a conscious achievement [slide presentation with audio]. XVIII International AIDS Conference, Vienna, Austria, 23–27 July 2010 (FRPL0307; http://pag.aids2010.org/flash/?pid=112291, accessed 15 October 2011).
14. AIDS at 30: nations at a crossroads. Geneva, UNAIDS, 2011 (http://www.unaids.org/en/resources/unaidspublications/2011, accessed 15 October 2011).
15. Schwartländer B et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet, 2011, 377:2031– 16. Resch S et al. Economic returns to investment in AIDS treatment in low and middle income countries. PLoS ONE, 2011, 6:e25310.
17. WHO and UNAIDS. The Treatment 2.0 framework for action: catalysing the next phase of treatment, care and support. Geneva, World Health Organization, 2011 (http://www.who.int/hiv/pub/arv/treatment/en/index.html, accessed 15 October 2011).
18. Hirnschall G, Schwartländer B. Treatment 2.0: catalysing the next phase of scale-up. Lancet, 2011, 378:209–211.
19. Karim QA et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science, 2010, 329:1168–1174.
20. Grant RM. Pre-exposure chemoprophylaxis for HIV prevention in men who have sex with men. New England Journal of Medicine, 21. Cohen MS et al. Prevention of HIV-1 infection with early antiretroviral therapy. New England Journal of Medicine, 2011, 365:493– 10 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
22. Getting to zero: 2011–2015 strategy: Joint United Nations Programme on HIV/AIDS. Geneva, UNAIDS, 2010 (http://www.unaids.
23. Global health sector strategy on HIV/AIDS: 2011–2015. Geneva, World Health Organization, 2011 (http://www.who.int/hiv/pub/ hiv_strategy/en/index.html, accessed 15 October 2011).
24. Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive. Geneva, UNAIDS, 25. UNAIDS World AIDS Day report 2011. Geneva, UNAIDS, 2011 (http://www.unaids.org/en/resources/presscentre/ 26. United Nations General Assembly. Political Declaration on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV/AIDS – United Nations General Assembly Resolution 65/277. New York, United Nations, 2011.
2. Update on the HIV epidemic
At the end of 2010, an estimated 34 million Not all regions and countries fit the overall trends, people [31 600 000–35 200 000] were however. The annual number of people newly infected living with HIV globally, including 3.4 with HIV has risen in the Middle East and North Africa million [3 000 000–3 800 000] children from 43 000 [31 000–57 000] in 2001 to 59 000 less than 15. There was 2.7 million [2 400 000- [40 000–73 000] in 2010. After slowing drastically 2 900 000] new HIV infections in 2010, including in the early 2000s, the incidence of HIV infection in 390 000 [340 000–450 000] among children less Eastern Europe and Central Asia has been accelerating again since 2008. Globally, the annual number of people newly infected The trends in AIDS-related deaths also differ. In Eastern with HIV continues to decline, although there is stark Europe and Central Asia, the number of people dying regional variation. In sub-Saharan Africa, where from AIDS-related causes increased more than 10-fold most of the people newly infected with HIV live, an between 2001 and 2010 (from about 7800 [6000– estimated 1.9 million [1 700 000–2 100 000] people 11 000] to 90 000 [74 000–110 000]). In the same became infected in 2010. This was 16% fewer than the period, the number of people dying from AIDS-related estimated 2.2 million [2 100 000–2 400 000] people caused increased by 60% in the Middle East and newly infected with HIV in 2001 and 27% fewer than North Africa (from 22 000 [9700 38 000] to 35 000 the annual number of people newly infected between [25 000–42 000]) and more than doubled in East Asia 1996 and 1998, when the incidence of HIV in sub- (from 24 000 [16 000–45 000] to 56 000 [40 000– Saharan Africa peaked overall.
The annual number of people dying from AIDS-related Introducing antiretroviral therapy has averted 2.5 million causes worldwide is steadily decreasing from a peak deaths in low- and middle-income countries globally of 2.2 million [2 100 000–2 500 000] in 2005 to an since 1995. Sub-Saharan Africa accounts for the vast estimated 1.8 million [1 600 000–1 900 000] in 2010. majority of the averted deaths: about 1.8 million.
The number of people dying from AIDS-related causes began to decline in 2005–2006 in sub-Saharan Africa, Providing antiretroviral prophylaxis to pregnant South and South-East Asia and the Caribbean and has women living with HIV has prevented more than 350 000 children from acquiring HIV infection since 1995. Eighty-six per cent of the children who avoided In 2010, an estimated 250 000 [220 000–290 000] infection live in sub-Saharan Africa, the region with the children less than 15 died from AIDS-related causes, highest prevalence of HIV infection among women of 20% fewer than in 2005.
reproductive age.
12 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
3. Selected health sector interventions for HIV
More than 550,000 males were The global burden of sexually transmitted infections circumcised for HIV prevention in the remains high in most regions of the world. Early priority countries of sub-Saharan Africa identification and treatment of sexually transmitted by the end of 2010. However, progress infections are important elements in a comprehensive towards the target of expanding coverage of male and effective HIV response. New rapid syphilis tests circumcision to 80% of men 15–49 years old is still very provide an opportunity to scale up syphilis screening in limited in most countries. many settings in which traditional tests were unavailable. The availability and safety of blood and blood products In 2010 and 2011, landmark studies were published for transfusion remain a concern. In 40 countries, less strengthening the evidence base on the preventive than 25% of the blood supplies comes from voluntary effects of antiretroviral drugs. People living with HIV unpaid blood donors; in low-income countries with receiving antiretroviral therapy are less likely to transmit available data, only 53% of blood donations were HIV, and HIV-negative people who take antiretroviral screened in a quality-assured manner in 2008. pre-exposure prophylaxis orally in tablet form or topically in a vaginal gel reduce their risk of acquiring HIV.
Number of males circumcised for HIV prevention during 2008–2010 and estimated number of male circumcisions needed to
reach 80% coverage among 15–49 year old men in priority countries of eastern and southern Africa
Number of male circumcisions done by calendar year
Estimated number of male circumcisions needed
to reach 80% coverage among males
15–49 years old
Ethiopia (province of Gambella) United Republic of Tanzania 20 855 905
* Kenya's goal is: to increase the proportion of men aged 15–49 years who are circumcised in Kenya from 84 to 94% by 2013; the number of male circumcisions needed to achieve this national goal are in the table. Source: Kenya National Strategy for Voluntary medical Male Circumcision, October 2009, Republic of Kenya Ministry of Public health and Sanitation. Data sources: PEPFAR Male Circumcision Technical Working Group (unpublished data) unless otherwise indicated.
a National AIDS & STI Control Programme of Kenya. b Ministry of Health of Lesotho.
c Ministry of Health of Malawi.
d National Department of Health of South Africa.
e Ministry of Health of the United Republic of Tanzania.
4. Knowledge of HIV status
The number of facilities providing HIV testing Population-based surveys conducted in selected low- and counselling continued to increase. The income countries in sub-Saharan Africa show that reported number of health facilities providing 1) the proportion of people who report having ever HIV testing and counselling services reached had an HIV test is higher among women than men 131 000 in 2010 (119 countries), from 107 000 in and 2) knowledge of HIV status, although increasing, 2009 (118 countries), 78 000 in 2008 (111 countries) remains broadly inadequate. In six countries with and 30 300 in 2007 (78 countries). In a subset of 104 results from population-based surveys conducted in countries reporting data in both 2009 and in 2010, the 2007–2009, a large proportion of respondents was median number of facilities per 100 000 population not aware of their HIV seropositivity before the survey, increased from 5.7 to 8.2 (44%). from about 30% in Kenya to close to 70% in the Congo. The number of HIV tests increased globally. In a subset Available data indicate that extensive attrition exists of 87 countries providing data in both 2009 and 2010, between HIV testing and counselling and treatment, about 72 million HIV tests were performed, an increase care and support services. Greater attention is needed from the 64 million tests performed in 2009; the to implement service delivery models that reflect median number of tests per 1000 adult population rose local needs and can strengthen links between HIV from 47 to 55, a 17% gain. testing and counselling and other services, including prevention, treatment, care and support interventions. 14 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
5. Scaling up treatment and care for people living
A t the end of 2010, 6 650 000 people were Data on the proportion of people who remain on receiving antiretroviral therapy in low- and antiretroviral therapy over time in low- and middle- middle-income countries, an increase income countries continue to show that most attrition of over 1.4 million people, or 27%, from (discontinuation of antiretroviral therapy) occurs within December 2009. Sub-Saharan Africa had the greatest the first year of starting therapy. The average retention increase in the absolute number of people receiving rate at 12 months after initiating antiretroviral therapy antiretroviral therapy in 2010, from 3 911 000 in was 81% (92 reporting countries), 75% at 24 months December 2009 to about 5 064 000 a year later.
(73 countries) and 67% at 60 months (46 countries).
Overall, the estimated coverage of antiretroviral therapy In low- and middle-income countries outside the among adults and children in low- and middle-income Americas (45 reporting countries), most (97%) adults countries continued to increase and was 47% [44–50%] were receiving first-line regimens and 3% second- of the 14.2 million [13 400 000–15 000 000] people line regimens as of December 2010. In the Region of eligible for treatment at the end of 2010, up from 39% the Americas (21 reporting countries), a substantially [37–42%] observed in December 2009.
higher proportion (28%) of adults received second-line regimens, and 3% received third-line regimens.
As of December 2010, 10 low- and middle-income countries, including 3 countries with generalized Among 93 reporting countries, 88 already recommend epidemics (Botswana, Namibia and Rwanda), had initiating antiretroviral therapy for everyone with CD4 already achieved universal access to antiretroviral counts less than 350 cells per mm3 as of late 2010. therapy, defined as providing antiretroviral therapy Among 87 reporting countries, 84 have also adopted to at least 80% of the people eligible for treatment. international guidelines that recommend shifting away Seven additional countries, including two countries from stavudine-based to zidovudine- or tenofovir- with generalized epidemics (Swaziland and Zambia), based regimens.
had estimated coverage levels between 70% and 79%.
Progress continues to be made in expanding access to The number of children younger than 15 years of age and uptake of HIV testing and counselling for people receiving antiretroviral therapy in low- and middle- with tuberculosis (TB). A total of 2.1 million people with income countries increased by 29% between 2009 and TB were tested for HIV in 2010, equivalent to 34% of 2010. About 456 000 children younger than 15 years all notified cases, versus 28% in 2009 and 3% in 2004.
were receiving antiretroviral therapy at the end of 2010, up from 354 600 in December 2009. However, As of December 2010, 58% of reporting low- and the estimated coverage is much lower among children middle-income countries (69 of 119) indicated that (23%) than among adults (51%).
isoniazid preventive therapy was a part of their package of interventions for people living with HIV; 90% (113 of Among 109 reporting countries, the estimated 125) indicated having policies to promote intensified antiretroviral therapy coverage was higher among case–finding, and 78% (98 of 126) had a policy for women, estimated at 53%, than among men (40%).
TB infection control. Coverage of isoniazid preventive therapy remained low, as only 12% of the reported Moderate levels of transmitted drug resistance have number of people living with HIV newly enrolled into been observed in some countries. Among 11 surveys care received isoniazid preventive therapy in 2010.
conducted in 2009 to monitor transmitted HIV drug resistance, 5 showed moderate (between 5% and 15%) transmitted HIV drug resistance.
Number of people receiving antiretroviral therapy in low- and middle-income countries, by region, 2002–2010
 North Africa and the Middle East Europe and Central Asia  East, South and South-East Asia  Latin America and the Caribbean Sub-Saharan Africa Number of adults and children (combined) receiving and eligible for antiretroviral therapy, and estimated percentage coverage in
low- and middle-income countries by region, December 2009 to December 2010
Number of
Number of
people receiving Estimated number of people
people receiving Estimated number of people
eligible for antiretroviral
coverage
eligible for antiretroviral
coverage
Sub-Saharan Africa [9 700 000–11 000 000] [9 000 000–10 200 000] Eastern and southern [7 100 000–8 000 000] [6 600 000–7 400 000] Western and central [2 600 000–3 100 000] [2 400 000–2 800 000] Latin America and the [710 000–920 000] [670 000–870 000] [620 000–810 000] [590 000–780 000] [91 000–110 000] [84 000–110 000] East, South and South- [2 100 000–2 500 000] [2 000 000–2 400 000] Europe and Central Asia [500 000–650 000] [450 000–600 000] North Africa and the [120 000–190 000] [110 000–180 000] 14 200 000
[13 400 000–15 000 000]
13 300 000
[12 400 000–14 100 000] 39% [37–42%]
16 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
6. Scaling up services for key populations at
higher risk of HIV infection
Coverage of harm reduction programmes for regional basis, availability was generally highest in East, people who inject drugs remained limited South and South-East Asia and was substantially more in 2010. Among 107 reporting countries, limited in North Africa and the Middle East. Although 42 had needle and syringe programmes and sexually transmitted infection management is available 37 offered opioid substitution therapy.
in many countries for people who inject drugs, men who have sex with men, and sex workers, the prevalence of In the subset of 30 countries that provided data on active syphilis in these key populations is still over 15% needle and syringe programmes, the median number in several countries.
of syringes distributed per year per person who injects drugs was 50.7, still below the internationally recommended level of 200 syringes per person who Testing and counselling
injects drugs per year. Three low- and middle-income countries – Bangladesh, India and Slovakia – provided The reported proportions of selected key populations 200 or more syringes per person who inject drugs per at higher risk of HIV infection receiving testing and year, and an additional three – Kazakhstan, Tajikistan counselling in the past 12 months remain limited: and Viet Nam – distributed between 100 and 200 the median percentage receiving HIV testing and syringes per person who inject drugs per year.
counselling was 49% among sex workers, 32% among men who have sex with men and 23% among people Less than 2.5% of people who inject drugs received who inject drugs.
opioid substitution therapy among 32 reporting countries.
In the subset of countries reporting multiple surveys, the median uptake of HIV testing and counselling A total of 113 low- and middle-income countries increased from 39% in 2006–2008 to 52% in 2009– reported information on the availability of programmes 2010 among sex workers, increased from 30% to 35% engaging men who have sex with men. The most among men who have sex with men and from 23% to commonly reported interventions were HIV testing and 25% among people who inject drugs.
counselling, followed by antiretroviral therapy and care. Regionally, the availability of targeted interventions for men who have sex with men was higher in Latin Treatment and care
America and the Caribbean, in Europe and Central Asia and in East, South and South-East Asia.
In Europe and Central Asia, available data reveal continued inequity in the access of people who inject A total of 113 low- and middle-income countries drugs to antiretroviral therapy. In 2010, people who reported information on the existence of programmes inject drugs represented 62% of the cumulative and policies engaging sex workers. The most commonly number of reported HIV cases with a known route available intervention was HIV testing and counselling, of transmission but only 22% of those receiving followed by antiretroviral therapy and care. On a antiretroviral therapy 7. Scaling up HIV services for women and
children: towards elimination of mother to child
transmission and improving maternal and child health in the
context of HIV
National political commitments to expand HIV UNGASS goal of providing antiretrovirals (excluding prevention, treatment and care services for single-dose nevirapine) for preventing mother-to-child women and children intensified in 2010. The transmission to 80% of pregnant women living with global plan to eliminate new HIV infections HIV in need: Botswana, Lesotho, Namibia, South Africa among children and improve the health of mothers and Swaziland.
set ambitious targets for 2015, including reducing the number of children newly infected with HIV by Among the estimated 1.49 million infants born to 90%, reducing the number of women dying from HIV- mothers living with HIV, 42% [38-48%] received associated causes during pregnancy, delivery and post- antiretroviral medicine to prevent HIV transmission partum by 50% and reducing the mother-to-child from their mothers, up from 32% [29–36%] in 2009.
transmission to less than 5%.
The coverage of HIV interventions for infants and In 2010, 35% of pregnant women in low- and middle- children is improving but remains low. Among 65 income countries received HIV testing and counselling, reporting countries, only 28% [24–30%] of infants up from 26% in 2009. In sub-Saharan Africa, the region born to mothers living with HIV received an HIV test with the highest number of pregnant women living within the first two months of life. Only 23% [19–24%] with HIV, coverage increased from 35% to 42%, with of HIV-exposed children in 87 reporting countries especially high rates of increase in countries in eastern received co-trimoxazole prophylaxis within two months and southern Africa (52% to 61%). of birth in 2010. The number of children receiving antiretroviral therapy increased from an estimated In 2010, the coverage of pregnant women receiving the 354 600 in 2009 to 456 000 in 2010, but the coverage most effective regimens to prevent mother-to-child for the estimated 2 020 000 [1 800 000–2 300 000] transmission (excluding single-dose nevirapine) is an children in need is only 23% [20–25%], much lower estimated 48% [44–54%].
than the 51% [48–54%] coverage of antiretroviral therapy among adults.
Among the 22 priority countries for eliminating mother-to-child transmission, 5 reached the 2001 18 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
Estimated percentage of pregnant women who received an HIV test in the past 12 months in low- and middle-income countries by region,
2005 and 2008–2010
 2005  2008  2009  2010 Latin America Latin America Estimated number of women living with HIV receiving the most effective antiretroviral regimens for preventing mother-to-
child transmission and coverages with most effective regimens and with single dose nevirapine, low- and middle-income
countries, by geographical region, 2010
Number of pregnant women
living with HIV receiving the
most effective antiretroviral
Estimated number of
regimens (excluding
pregnant women living with
Estimated coverage with single-dose nevirapine) for HIV who need antiretroviral Estimated coverage with the
single-dose nevirapine preventing mother-to-child
medicine for preventing
most effective regimens, as
only (regimen no longer recommended by WHO
recommended by WHO) Sub-Saharan Africa [1 200 000–1 500 000] Eastern and southern [840 000–1 000 000] Western and central [360 000–470 000] Latin America and the [17 000–33 000] [11 000–25 000] East, South and South- [53 000–95 000] Europe and Central Asia [15 000–22 000] North Africa and the 4% [3–6%]
All low- and middle-
[1 300 000–1 600 000]
Percentage of children living with HIV receiving antiretroviral therapy in low- and middle-income countries, 2005, 2009 and 2010a
 2005  2009  2010 Latin America Latin America a Revision of eligibility criteria for paediatric treatment have substantially increased needs in 2010 and, consequently, have decreased coverages. Percentages in 2010 are not directly comparable with previous years.
The bar indicates the uncertainty range around the estimate.
20 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
8. Conclusions: achieving and sustaining universal
The achievements of the global HIV response A time of opportunities
over the last 10 years have been extraordinary. The incidence of HIV infection declined by Nevertheless, the global HIV response has seldom more than 25% between 2001 and 2009 in been better positioned to address these challenges. 33 countries, and the HIV prevalence among young The year 2011 has brought new political momentum, pregnant women attending antenatal clinics has and important scientific breakthroughs have been declined by 25% or more in 7 countries (1). At the end announced. The recent United Nations General of 2010, more than 6.6 million people were receiving Assembly High Level Meeting on AIDS (2) has antiretroviral therapy in low- and middle-income regalvanized partners, and its final Declaration fully countries, a 16-fold increase from the approximately recognizes the central role of universal access to HIV 400 000 people recorded in December 2003. Forty- prevention, treatment, care and support services in eight low- and middle-income countries now provide achieving the full range of the Millennium Development antiretroviral therapy to more than 50% of adults in Goals. It provides a clear framework to deliver on need, including 10 countries with universal access, ambitious, yet feasible, time-bound goals by 2015, and about 50% of pregnant women received the most including reducing sexual transmission by 50%, cutting effective regimens to prevent the mother-to-child in half the number of people living with HIV dying transmission of HIV in 2010. As a result of these efforts, from TB and providing antiretroviral therapy to at the annual number of AIDS-related deaths worldwide least 15 million people who need it. The international has fallen from the peak of 2.2 million recorded in 2005 community has also developed and endorsed a detailed, to an estimated 1.8 million in 2010.
action-oriented global plan to support the elimination of the mother-to-child transmission of HIV and improve Although much has been accomplished since the 2001 maternal health by 2015 (3).
United Nations General Assembly Special Session on HIV/AIDS, the launch of the "3 by 5" initiative New scientific evidence and innovation have also in December 2003 and the adoption of the 2006 expanded the toolkit of interventions for delivering Political Declaration on HIV/AIDS, this report also on these goals. The old divisions between treatment draws attention to the multiple challenges that must and prevention have been torn down. The landmark be tackled before universal access to HIV prevention, HPTN 052 study has now clearly demonstrated treatment, care and support becomes a global reality. that antiretroviral therapy can dramatically reduce An estimated 2.7 million [2 400 000–2 900 000] HIV transmission. Various studies have similarly people were newly infected with HIV in 2010, including demonstrated the efficacy of pre-exposure prophylaxis 390 000 [340 000–450 000] children, bringing the in reducing the risk of acquiring HIV infection, including total number of people living with HIV to 34 million among men who have sex with men.
[31 600 000–35 200 000]. The coverage, quality and accessibility of many interventions, especially Such breakthroughs have also brought new impetus to among populations at higher risk for HIV infection, are vaccine research and development, and the scientific still insufficient. Most people living with HIV remain community is actively engaged in designing approaches unaware of their serostatus, and late initiation of that may lead to an eventual cure. Essential as this is, antiretroviral therapy is still common in many contexts. however, the importance of innovation goes well beyond Retention levels across the cascade of interventions, scientific discoveries. It is also vital to improve and bring from HIV testing to treatment and care, are inadequate, to scale existing technologies while designing new and many people identified as HIV positive are lost to approaches that can best leverage available resources and optimize outcomes.
Innovation and efficiency: the unfinished
poorer rural communities and key populations at higher risk of HIV infection and transmission, such as men who have sex with men, transgender people, sex workers, An optimized global HIV response driven by more people who inject drugs, migrants and prisoners.
efficient and innovative approaches lies at the core of the WHO global health sector strategy on HIV/ More data have become available on the burden of AIDS 2011–2015 (4) and the new investment framework the epidemic among these populations, including in proposed by UNAIDS and partners. By promoting countries with generalized epidemics in sub-Saharan the scaling up of six core programmatic activities, Africa. However, the responses have lagged considerably according to relevant population needs, investing in behind. For instance, in Eastern Europe and Central critical social and programmatic enablers and seeking Asia, people who inject drugs, one of the most severely synergy with other development sectors, more focused affected key populations, continue to be less likely to investment can result in more than 12 million fewer have access to antiretroviral therapy than people who people infected with HIV and 7.4 million fewer deaths acquired HIV through other routes of transmission. by 2020 as compared to the baseline. Realizing greater Moreover, key populations at higher risk of HIV infection efficiency and impact by developing and scaling up new continue to face high levels of stigma, criminalization and modalities of service delivery is also central to the five harassment, thus impairing their ability and willingness to pillars of the Treatment 2.0 initiative.
seek life-saving prevention, treatment, care and support. Gender-based violence also remains a major source of Although investing available resources more effectively inequity in health services. Addressing these situations is essential, fully implementing this optimized approach requires considerably stronger human rights frameworks requires a further US$ 7 to 9 billion annually, in addition so that these populations can be adequately protected to the US$ 15 billion currently available, to expand the and can freely access, without fear of persecution or coverage of key interventions. The resources available reprisal, services tailored to their needs.
globally to fund the HIV response declined in 2010 despite growing evidence of effectiveness and impact. Greater attention is also needed to ensure that people HIV programmes must be fully funded not only to who are aware of their serostatus are adequately sustain current achievements but also to ensure that followed up so that they can enrol in care or receive interventions reach the scale and intensity needed to antiretroviral therapy. For instance, many pregnant maximize their population-level benefit.
women, even when found to be living with HIV and provided with antiretroviral drugs to prevent the vertical After almost a decade of extraordinary efforts and transmission of HIV, are not retained in care for their results, it has become increasingly clear that achieving own health. Lack of follow-up also negatively affects universal access to HIV prevention, treatment, care their babies, who fail to receive early diagnosis and, if and support requires changing both the demand found to be living with HIV, provided with the necessary for and supply of services. More must be done to treatment. Retention therefore needs to be improved stimulate users to seek out services and ensure they throughout the cascade of interventions by developing can access them, and systems must be adapted and more robust linkage systems and by identifying and strengthened to provide timely, affordable and high- addressing key barriers. Several countries have made progress in developing systems to measuring and reducing patient attrition.
Reach and retain
Adapting services to meet clients' needs
In many contexts, current accomplishments reflect coverage of the most accessible segments of the The experiences of countries that have successfully population, mostly more highly educated city residents achieved universal access for some programme with comparatively greater monetary resources in components, such as Rwanda, clearly demonstrate the closer proximity to health systems (5–7). Greater efforts importance of bringing services closer to communities. and novel strategies are needed to extend service Transport and opportunity costs can powerfully deter provision to harder-to-reach populations, including seeking out health care and associated commodities, 22 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
which is especially important given the lifelong nature ensure the sustainability of programmes. Health of antiretroviral therapy. Decentralizing high-quality workers need to be adequately prepared and supported services to the lowest feasible level of the health to address the needs of increasing numbers of people system can facilitate early diagnosis and retention in who require lifelong care. In Malawi, local programmes care and may ensure that non-urban and often poorer have pioneered innovative approaches with remarkable segments of the population can reach services (8).
results. Procurement and supply management systems must also be improved and expanded, as stock-outs of System structures and pathways must be streamlined antiretroviral drugs are still common in more than one and coordinated so that navigating them becomes less third of reporting low- and middle-income countries. burdensome and time-consuming to users. Multiple This is especially important as new medicines and appointments, scheduled for different days and at interventions become available, such as point-of-care different services, discourage people from attending diagnostics, and are incorporated into health care and being followed up. Moreover, a client-centred supply chains.
approach requires recognizing that individuals often reach health systems with multiple needs that Governance systems must be further strengthened extend beyond those related to HIV. For instance, to ensure inclusive, transparent and accountable a woman may need family planning for herself and leadership. In this respect, communities of people vaccination for her children in addition to antiretroviral living with or affected by HIV must be fully engaged in drugs. Nevertheless, patient needs are still too often designing, implementing and evaluating national HIV perceived and addressed in isolation, and many missed responses. Their continued activism is fundamental in opportunities result in profound detrimental effects on catalysing and sustaining political momentum.
general health outcomes.
Although emergency approaches were instrumental Closer collaboration and integration must be developed in building or strengthening HIV programmes for among services, including those for maternal and child rapid scale-up in most countries, their transition health, harm reduction, sexual and reproductive health to sustainable models of service delivery must be and managing TB, other sexually transmitted infections accelerated. This entails addressing three key issues. and viral hepatitis. Organizational arrangements must First, the capacity of governments, communities consider the local context, including epidemiological and civil society organizations to take leadership of profiles. They may cover a broad spectrum, from national responses must be reinforced. In addition, strengthening referral systems to establishing one-stop HIV responses need to be clearly linked with other clinics that can offer multiple interventions by the same national social and economic goals and frameworks clinical team. Greater coordination between HIV and so that programmes address the epidemic within their noncommunicable disease programmes is also vital to broader health and development contexts. Lastly, as life expand the coverage of interventions that can address expectancy increases and HIV management evolves a host of other critical conditions, including those towards a model of chronic-disease care, greater associated with ageing, poor nutrition and sanitation attention needs to be focused on monitoring the quality and mental disorders.
of the services provided, as this strongly influences long-term adherence, retention in care and outcomes.
Preparing systems for reaching and
The challenges towards universal access are sustaining universal access
considerable, but so are the technical resources, political support and commitment of all partners As HIV programmes continue to be scaled up, involved in the global HIV response. Additional focused health systems must be prepared to provide care investment and building on current achievements to more people, at an earlier stage of HIV infection and applying the lessons learned from implementing and for a longer period of time. In settings facing programmes can enable the efficiency, quality and severe shortages of health care workers, enhanced coverage of interventions to be increased and ultimately task-shifting strategies need to be designed and make universal access to large-scale, high-quality HIV implemented to tackle enrolment bottlenecks and prevention, treatment, care and support a reality.
1. UNAIDS Report on the global AIDS epidemic. Geneva, UNAIDS, 2010 (http://www.unaids.org/globalreport/global_report.htm, accessed 15 October 2011).
2. United Nations General Assembly. Political Declaration on HIV/AIDS: intensifying our efforts to eliminate HIV/AIDS. New York, United Nations, 2011 (http://www.un.org/Docs/journal/asp/ws.asp?m=A/65/L.77, accessed 15 October 2011).
3. Global plan towards the elimination of new HIV infections among children by 2015 and keeping their mother alive – 2011–2015. Geneva, 4. Global health sector strategy on HIV/AIDS 2011–2015. Geneva, World Health Organization, 2011 (http://whqlibdoc.who.int/ publications/2011/9789241501651_eng.pdf, accessed 15 October 2011).
5. Schneider H et al. Urban–rural inequalities in access to ART: results from facility based surveys in South Africa. AIDS 2010 – XVIII International AIDS Conference, Vienna, Austria, 18–23 July 2010 (Abstract TUPE0987; http://www.iasociety.org/Default.aspz?pageid=12&abstracted=200738997).
6. The Zimbabwe health-sector investment case (2010–2012): accelerating progress towards the Millennium Development Goals. Zimbabwe, Ministry of Health and Child Welfare, 2010. 7. USAID Health Policy Initiative. Equity: quantify inequalities in access to health services and health status. Washington, DC, Futures Group, Health Policy Initiative, Task Order 1, 2010 (http://www.healthpolicyinitiative.com/Publications/Documents/1274_1_EQUITY_Quantify_FINAL_Sept_2010_acc.pdf, accessed 15 October 2011).
8. Mekonnen Y et al. Equity and access to ART in Ethiopia. Washington, DC, Futures Group, Health Policy Initiative, Task Order 1, 24 GLOBAL HIV/AIDS RESPONSE – Epidemic update and health sector progress towards Universal Access – Progress Report 2011
For more information, contact:World Health OrganizationDepartment of HIV/AIDSAvenue Appia 201211 Geneva 27SwitzerlandE-mail: [email protected]/hiv

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