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HIV/AIDS

Updated October 2003

Why address HIV/AIDS?
How Does HIV/AIDS Spread?
Can HIV/AIDS be brought under control in developing countries?
What are the effective interventions to prevent HIV/AIDS?
What is targeted prevention?
What about treatment, care and mitigation of HIV/AIDS?
What should be done about HAART?
Choosing Interventions
Lessons Learned
More Information
Resources
Printable PDF Version (English, Russian)

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Logo - UNAIDS


Why address HIV/AIDS?

The HIV/AIDS epidemic has spread with ferocious speed. Virtually unknown 20 years ago, HIV has infected more than 60 million people worldwide. Each day, approximately 14,000 new infections occur, more than half of them among young people below age 25. At the end of 2002, of over 42 million people living with HIV/AIDS (PLWHA), of whom 30 percent were co-infected with tuberculosis (TB). Over 95 percent of PLWHA are in low and middle-income countries. More than 20 million have died from AIDS, 3 million in 2002 alone. AIDS is now the leading cause of death in Sub-Saharan Africa and the fourth-biggest killer globally. The epidemic has cut life expectancy by more than 10 years in several nations.

HIV/AIDS is not just a public health problem. Once generalized, the epidemic has far reaching consequences to all social sectors and to development itself. It can decimate the workforce, create large numbers of orphans, exacerbate poverty and inequality, and put tremendous pressure on health and social services. Annual basic care and treatment for a person with AIDS, even without antiretroviral drugs (ARV), can cost as much as 2-3 times per capita gross domestic product (GDP) in the poorest countries. HIV/AIDS already causes a measurable fall in annual per capita growth in the hardest-hit countries of Sub-Saharan Africa and threatens to reverse their development achievements of the last 50 years.

This fact sheet provides a summary of the issues of and interventions for HIV/AIDS epidemic from the public health perspective.

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How Does HIV/AIDS Spread?

The major modes of transmission are sexual intercourse, unsafe injecting practices, mother-to-child (in utero, during birth or through breastfeeding), and transfusion of contaminated blood or blood products. Heterosexual transmission accounts for more than 70% of all HIV infections worldwide. Certain groups are more likely to contract and spread HIV, such as commercial sex workers (CSWs)
(http://www.unaids.org/publications/documents/care/general/JC-FemSexWork-E.html ) (http://www.worldbank.or.th/social/index.html) and their clients, injecting drug users (IDUs)(7. UNAIDS: Evidence-based Findings...), men who have sex with men (MSM), and highly mobile workers. HIV/AIDS is initially concentrated in these groups who engage in high-risk behavior, and then spills over into the wider population.

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Can HIV/AIDS be brought under control in developing countries?

There are success stories in the fight against HIV/AIDS on a national scale among developing countries. Thanks to prompt, vigorous and large-scale implementation of effective intervention programmes, which are enabled by adequate funding, favorable policy environments, strong political leadership and popular support, countries such as Thailand, Uganda, and Brazil have been able to control the spread of HIV/AIDS. For example, Thailand has reduced annual new HIV infections from 140,000 a decade ago to 30,000 in 2001. This is strong evidence that the epidemic can be subdued in developing countries. The potential exists to prevent extensive new infections despite the severity of the global pandemic, therefore, the international community has set the target of reducing HIV prevalence among 15-24 year-olds by 25% in the most affected countries by 2005 and globally by 2010.

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What are the effective interventions to prevent HIV/AIDSo?

No cure or effective vaccine has yet been developed, but the tools to prevent HIV infection already exist. A core set of prevention interventions have effectively reduced the spread of HIV/AIDS. These include:

  • Promoting behavior change through communication programs, peer education, and voluntary counseling and testing (VCT)
  • Increasing condom use through condom promotion and distribution
  • Diagnosing and treating sexually transmitted infections (STI)
  • Ensuring a safe blood supply
  • Preventing mother-to-child transmission (MTCT) through short courses of ARV and providing infant feeding options
  • Supporting harm reducation among injecting drug users (IDUs), which includes providing clean injecting equipment, counseling, and drug abuse treatment.

Prevention averts suffering and death, but pays vast dividendsin future savings to the health system and the public sector at large. The cost of averting an HIV infection through cost-effective interventions can be a fraction of the cost of treatment and care for an AIDS patient.

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What is targeted prevention?

Evidence strongly suggests that irrespective of the stage of the epidemic, the most efficient method to reduce the spread of HIV (or any STI) in the general population is to reduce its transmission among groups at high risk. This targeted prevention approach, in which well-trained peers (such as former CSWs or IDUs) are used to disseminate information and safer sex supplies, organize skill building sessions and conduct referrals to other HIV/AIDS services, has been proven effective in many settings. For this reason, interventions and resources should be directed more strongly to groups at high risk. Targeted prevention is more effective when combined with programs to change social norms and reduce stigma.

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What about treatment, care and mitigation of HIV/AIDS?

AIDS is a fatal disease, but there are interventions which can prolong and improve life for PLWHA. These include psychosocial support including counseling, clinical management of common opportunistic infections (OIs) (including TB), Highly Active Anti-retroviral Therapy (HAART), and palliative care. Community and home-based care can complement traditional hospital-based care and help ease the pressure on the health system, especially in countries with generalized HIV/AIDS epidemics. A social safety net for poor households affected by AIDS, as well as for AIDS orphans and vulnerable children, can help alleviate their suffering. Treatment and care can be cost-effective and have spillover effects in strengthening commitment to prevention. As HIV infection progresses, the care and treatment interventions for PLWHA need to change. While a basic treatment and care package can be developed to meet the changing needs of PLWHA, the challenge remains to develop services on a scale which will reach the largest numbers of those in need.

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What should be done about HAART?

Although HAART is not a cure and its impact on population transmission still uncertain, it reduces and prevents many opportunistic infection and prolongs life. Because of high cost, treatment complexity and the lack of infrastructure to administer and monitor the therapy, HAART is currently not widely available outside high-income countries. Yet experience from developing countries has shown that rates of adherence to HAART are at least as high (and typically higher) in developing countries. Thanks to discounts and generic manufacturers, the cost of drugs for HAART has been reduced to the range of US$ 500 - 1,000 per patient per year in some developing countries. Although this is a fraction of what it costs in developed countries, many low-income countries are still unable to afford this price.

Currently, five to six million people infected with HIV in the developing world need access to antiretroviral therapy (ART) to survive. Only 300,000 have this access. This failure to deliver ART to millions of people who need them is a medical emergency. Efforts are underway to make HAART more affordable and feasible for low- and middle-income countries with a goal of having 3 million people on treatment by the end of 2005. While continuing to give the highest priority to prevention and the basic package of AIDS treatment and care, where necessary and possible, governments might wish to (i) pepare a HAART strategy, whic includes public and private mechanisms to finance HAART; (ii) evaluate and prepare the capacities of the health system for HAART. Such steps would enable sustained, safe and effective use of HAART in the future.

UNAIDS supports a comprehensive treatment and care approach that includes voluntary counseling and testing, psycho-social support, palliative care, prevention and treatment of opportunistic infections, good nutrition, strengthening of health systems, fair and sustainable financing, and, where possible, access to HAART.

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Choosing interventions

Choosing the right mix of interventions for implementation is very important in a setting with limited resources and implementation capacity. An appropriate balance among prevention, treatment, care and mitigation should be based on:

  • specific epidemiology of HIV/AIDS, including who are at risk and stage of the epidemic
  • cost-effectiveness of interventions 
  • level of public resources available 
  • implementation capacity
  • extent to which intervention is a "public good"

In all cases, the most important interventions are: behavior change promotion, condoms, STI management, blood safety, VCT, and harm minimization among IDUs. Care, treatment, support and MTCT prevention will have least impact in countries of low prevalence (less than 5% in any high-risk group), be more relevant where the epidemic is concentrated (prevalence over 5% in a high-risk group, but less than 1% in the general population) and become increasingly important in countries with generalized epidemic (population prevalence over 1%).

Core InterventionsBenficiaries/
Target Groups 
Indicators 
Prevention activities   

Promote behavior change

  • Promote behavior change at both individual level (eg., through peer education for individuals at high risk) and community/societal level (eg., through communication campaigns to change social norms and attitudes, which would in turn help reinforce safe bahviors at individual levels)
  • Tailor behavior change messages to specific audiences such as groups at high risk, men, women, young people
  • Address stigma
  • Involve motivated PLWHA, members of vulnerable groups in public information efforts
  • Promote HIV/AIDS/STI programs, services and products
Groups at high risk (priority)
G eneral population 
  • Indicators of bahavior change in groups with high-risk behavior and in young people, for example: % of respondents (i) having high risk sex in the last year, (ii) using condoms at last high-risk sex
  • % of respondents with (i) knowledge of HIV prevention methods, (ii) no incorrect belief about HIV/AIDS
  • % of respondents with accepting attitudes towards PLWHA
  • % of formal employers with non-discriminatory practices in recruiitment, benefits and advancement for HIV-positive employees 

Increase condom availability, acceptability and quality

  • Ensure a guaranteed supply of quality male & female condomes and a condom dissemination system
  • Distribute condoms through different approaches (targeted, community-based, outlet-based)
  • Popularize & increase acceptability of condoms through condom promotion & social marketing campaigns
  • Control the quality of condoms through sampling & testing

Groups at high risk (priority)


G eneral population
  • Total number of condoms available for distribution nation-wide
  • % of retail outlets & other service delivery points with condoms in stock
  • % of condoms that meet quality control standards

Establish a comprehensive STI management program

  • Develop a national protocol for STI case management
  • Include STI drugs in the essential drug list
  • Make syndromic management of STI available at first point of contact in the health care system
  • Link STI services to counseling & other HIV/AIDS services
  • Educate people how to avoid STIs, recognize common STI symptoms & seek treatment
Patients with STIs & their sexual contacts
  • % of STI patients who are appropriately diagnised & treated according to national guidelines
  • % of STI patients who are given advice on condom use, partner notification and referred for HIV testing

 

Offer voluntary counseling and testing service

  • Establish/strengthen a highly accessible VCT system which offers anonymous VCT service (testing, pre-test & post-test counseling) to anyone who needs it
  • Publicize the existence of VCT services
  • Ensure the affordability of VCT, especially for high-risk & vulnerable groups
  • Link VCT to other HIV/AIDS and STI services

 

Groups at high risk (priority)


G eneral population
  • % of people aged 15-49 who voluntarily requested testing & received their results
  • % of districts with VCT services
     

Ensure blood safety

  • Exclude paid donors & high-risk donors.  Rely instead on voluntary donors from low-risk populations for blood supply
  • Avoid unnecessary blood transfusions
  • Screen all blood for HIV antibody & other blood-borne infectious agents
General population
  • % of blood units transfused in the last 12 months that were adequately screened for HIV
  • % of districts/regions with access to blood banks which do not pay blood donors 

Prevent mother-to-child transmission (MTCT)

  • Provide VCT service to antenatal clinic attendees
  • Provide HIV-positive pregnant women with short courses of zidovudine or nevirapine where possible.  Counsel them on infant feeding options
  • Improve family planning services & incorporate HIV prevention activities
All pregnant women
H IV-positive pregnant women & their babies
W omen of reproductive age 
  • % of pregnant women counseled & tested from HIV
  • % of HIV-positive women receiving anti-retroviral therapy during pregnancy

Harm minimization amond IDUs

  • Improve access to sterile ijecting equipment & condoms
  • Promote safe injecting practicies as well as safe sex behavior
  • Offer counseling & drug abuse treatment
IDUs & their sexual contacts
  • % of IDUs sharing injecting equipiment at last injection
Treatment, care and mitigation activities   
Core Interventions Benficiaries/
Target Groups 
  Indicators 

Provide treatment of opportunistic infections (OIs) & palliative care

  • Develop a HIV/AIDS treatment & care strategy (including HAART)
  • Develop & implement clinical guildelines for management of ocmmon OIs, including TB
  • Ensure an adequate supply of drugs for OIs treatment & palliative care
  • Strengthen the capacity of the health system to provide treatement & care to HIV-positive patients (e.g, ensure adeuqacy of diagnostic & treatment facilities for common OIs, train medical personnel in treatment & care for HIV-related conditions)
  • Develop linkages between HIV/AIDS, STI and TB programs
People living with HIV/AIDS
  • % of health facilities with the capacity to delivier appropriate care to HIV-infected patients
  • % of PLWHA receiving screening and prophylactic treatment for TB
  • TB program indicators (where there is a dual epidemic of HIV and TB)
  • % of health professionals receiving training in treatment & care of HIV-related conditions 

Provide community-based & hose-based care to complement traditional hospital care

  • Provide funding & training for communities & NGOs to provide care for & support PLWHA
People living with HIV/AIDS & their families
  • % of households with a chronically ill adult (15.49 years) receiving external help to care for the patient or to replace lost income

 

Strengthen the safety net for poor households affected by AIDS, including AIDS orphans

  • Provide assistance to poor households affected by AIDS & to AIDS orphans
Poor people living with HIV/AIDS & their families, poor AIDS ophans
  • % of poor households receiving external help to care for an AIDS orphan
Provide counseling & prevention services for PLWHAs & their familiesPeople living with HIV/AIDS & their families
  • % of clinics offering HIV/AIDS counseling & prevention interventions for PLWHAs & their families
Indicators adapted from:  National AIDS programmes: A Guide to Monitoring and Evaluation.  UNAIDS.  Geneva 2000

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Lessons Learned

  • Act Early No country is insulated from the risk of HIV/AIDS. Governments should intervene as soon as possible because the more widely HIV/AIDS spreads, the more difficult and costly prevention, care and treatment become (http://www.unaids.org/publications/documents/responses/index.html#national) (http://www.worldbank.org/aids-econ/confront/ovrview.htm#Summary) .
  • Increase government commitment, attention, and funding.This is key to success in every country that has made headway against the epidemic. Leaders need to overcome taboos and stigma, speak openly about the disease, and place a multi-sectoral HIV/AIDS program high in their development agendas. To ensure adequate funding for HIV/AIDS, it is necessary for governments to re-examine spending priorities, reallocate accordingly, and mobilize donor support.
  • Create and enabling policy enironment. An enabling environment with regard to logal, social, and gender policies is essential for the success of a national HIV/AIDS program, as it facilitates the participation of key stakeholders and helps reduce risk-taking behaviors, stigma and discrimination.
  • Prevent infection among those most likely to contract and spread HIV.Effective, low-cost prevention interventions for such groups at high risk already exist. However, such groups are often the most marginalized and stigmatized and thus unable to compete for attention and resources themselves. To identify groups at high risk, their social networks and then target them with sustained, effective prevention interventions should be the priority of a national HIV/AIDS program.(http://www.unaids.org/bestpractice/collection/subject/specific/index.html ) (http://www.nap.edu/books/0309071372/html).
  • Prioritize interventions by their proven effectiveness. Prioritizing interventions based on their effectiveness can maximize the number of new HIV infections averted in the presence of resource and capacity constraints. Budget allocation among different components of a national HIV/AIDS program should reflect a strategic choice of effective interventions. (http://www.worldbank.org/aids-econ/papers/ainssilence.pdf)
    (http://www.nap.edu/books/0309071372/html). ( http://www.worldbank.org/aids-econ/thaifund.htm) .
  • Address gender inequality. There are more women getting infected than men in many developing countries. Women now account for 55% of adults living with HIV/AIDS in Sub-Saharan Africa. Gender inequality is a contributing factor to the epidemic and needs to be addressed in the long term through measures such as improving education and labor force participation of women.
  • Use a multi-sectoral approach with active involvement of all relevant sectos, civil society, NGOs, and private entities. This would generate greater commitment, mobilize additional resources, and improve the sustainability of interventions and their chance for success. Different sectors such as education, transport, defense, tourism, etc., can play a role in the fight against HIV/AIDS. Local communities and NGOs are often capable of understanding local cultural and social contexts, mobilizing people, and reaching out to marginalized high-risk groups. They therefore can successfully implement many HIV/AIDS interventions and need to be provided with direct financial and technical support to act t the local level, where the public sector is often less effective.(http://www.unaids.org/bestpractice/collection/subject/responses/index.html#non.
  • Integrate HIV/AIDS in poverty reduction strategies. It is still not clear whether poverty increases the likelihood of HIV infection. However, there is strong evidence that HIV/AIDS causes and worsens poverty. The integration of HIV/AIDS into national antipoverty programs and development instruments such as PRSPs and HIPC would help ensure the priority of HIV/AIDS control in the development agenda and facilitate actions to mitigate the impact of AIDS on the poor.
  • Develop a good monitoring and evaluation (M&E) and surveillance system.  A realistic M&E plan with clearly-defined input, output, outcome and impact indicators helps track the performance of the national AIDS response and evaluate its impact on the epidemic. A Second Generation Surveillance System, recommended by WHO and UNAIDS, monitors trends in the epidemic and in contributing risk behaviors.
    (http: //www.unaids.org/publications/documents/epidemiology/surveillance/JC427-Mon& ;Ev-Full-E.pdf)

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More Information

World Bank: Global - Debrework Zewdie (Dzewdie@worldbank.org)
                        Africa - Keith Hansen (Khansen@worldbank.org)
UNAIDS: James Sherry (Sherryj@unaids.org)

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Key Resources

Available at http://www.unaids.org:

Available at http://www.worldbank.org/aids:

Other:

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Printable PDF Version (English, Russian)

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