From Bangkok to Toronto: The Tough Road Ahead in the Campaign to Combat HIV/AIDS
HIV/AIDS is still a major global emergency, which must remain at the forefront of policy-makers' priorities. That was the over-riding message of the 15th International AIDS Conference in Bangkok, Thailand in July 2004 and it is a message that will be repeated again and again before the next International AIDS Conference in Toronto, Canada in July 2006.
For the World Health Organization, the Bangkok conference was an opportunity to review the progress made, and assess the myriad challenges that remain, particularly when it comes to achieving the goals of the "3 by 5" Initiative – the joint programme with UNAIDS that aims to get 3 million people living with HIV/AIDS in developing and middle-income countries on antiretroviral (ARV) treatment by the end of 2005.
In WHO's Western Pacific Region alone, at least 1.5 million people are living with HIV/AIDS. Of these, 170 000 need antiretroviral treatment at this stage of their disease, according to estimates released in June 2004. However, only 15 000 (a mere 9%) have access to such medication.
"This is clearly unacceptable," said Dr Shigeru Omi, Regional Director of WHO's Western Pacific Region. "There needs to be a renewed push at the regional and individual country level to address this situation on a war footing. WHO and its partners are there to assist in this crucial effort."
Four countries of special concern
Four countries are of special concern to WHO in its Western Pacific Region: Cambodia, China, Papua New Guinea and Viet Nam. Cambodia has the highest HIV/AIDS prevalence rate in the world outside sub-Saharan Africa. While the estimated prevalence rate fell from 2.8% in 2001 to 2.6% in 2002, the country is still grappling with an epidemic that could jeopardize economic gains of recent years. It is estimated that 26 000 people, including children, who are currently infected with HIV could develop full-blown AIDS by 2005. The government of Cambodia recognizes the threat, and is working closely with WHO and other partners to tackle the situation.
China, with an estimated 840 000 HIV/AIDS cases, is still considered a lowprevalence country, given the ratio of cases to the overall population. The Chinese Government, however, is committed to containing the epidemic in the world's most populous nation and is calling for swift action at the central and provincial levels nationwide. An estimated 70% of cases in China are linked to injecting drug users (IDUs). These include female IDUs who may barter sex in exchange for drugs, hence serving as bridge to the general population.
By contrast, heterosexual transmission is the predominant means of HIV infection in Papua New Guinea, which is facing a major HIV/AIDS epidemic, with estimated annual increases of 15%-30% in numbers infected. Parent-to-child transmission is the second most common means of infection. The similarity of sexual behaviour patterns in Papua New Guinea and those in sub-Saharan Africa suggests to many experts that the epidemic there has the potential to reach those of sub-Saharan Africa – with potentially devastating impact for the already impoverished country's economic and societal structures.
In Viet Nam, the official estimate of HIV prevalence in the 15-49 age group was 0.28% in 2002. However, there are an average of 40 to 50 new HIV infections reported every day and it is projected that there will be 197 000 people living with HIV/AIDS by 2005. The situation may be far worse than these figures indicate, since underreporting is a persistent problem and a significant number of those infected do not refer to health services until the disease is well established. As in many other Asian countries, the number of reported cases linked to sexual transmission is still low, but this number is increasing. It is expected that sexual transmission will become the dominant mode of transmission in coming years.
Steps towards reaching the 3 by 5 targets:
Given the vital need for antiretroviral treatment, the Bangkok conference's theme of "access for all" was particularly relevant, especially in light of the "3 by 5" Initiative. "Today, it seems there is a real chance to reach a large part of the '3 by 5' target in time for the next International AIDS Conference," said Dr Bernard Fabre-Teste, a WHO HIV/AIDS expert. "However, many things must come together for this to happen as we move along the road to Toronto."
Dr Fabre-Teste argued that:
· Each country must adopt "The Three Ones":
· There must be a true partnership between government bodies, all relevant government partners (including WHO, UNAIDS and other UN agencies) and representatives of people living with HIV/AIDS (at the institutional and individual levels).
· Implementation of "The Three Ones" must be harmonized with the wideranging partnership described above.
· Adherence to antiretroviral treatment by those with access to such medication must be ensured, in order to avoid the development of resistance to ARVs.
· There must be training, not only of doctors, but of thousands upon thousands of health care workers, community/society leaders and people living with HIV/AIDS themselves so they can participate in the implementation, distribution, follow-up and monitoring of antiretroviral treatment.
· There must be an emphasis on guaranteeing equitable, universal access to care for all who need it, including the most marginalized and vulnerable groups, such as sex workers and injecting drug users.
· More communities and people living with HIV/AIDS must be involved in prevention and care programmes, from their design to their implementation and monitoring phases, to compensate for any weaknesses in health care systems and to reduce stigma and discrimination.
· There must be more operational research into treatment for injecting drug users and for children who require specific pediatric ARV formulations.
· A joint TB/HIV control approach must be reinforced, recognizing the need to tackle the two diseases jointly in many instances.
· There must be an urgent focus on preventing transmission modes that have long been ignored in this Region, such as men having sex with men.
· More intensive prevention programmes for younger people must be developed.
· A continual, ever-vigilant brand of activism at various levels should be encouraged to monitor the promises and agreements made by governments and public health institutions in combating the HIV/AIDS pandemic.
Prevention and care go hand in hand
"We have long said this, but after the Bangkok conference it's more clear than ever before: prevention and care are absolutely complementary," said Dr Shigeru Omi. "In that sense, the '3 by 5' Initiative represents a comprehensive prevention and care approach."
"In the Asia-Pacific region," said Dr Fabre-Teste, "prevention means widespread application of two types of actions. First, condom promotion programmes – acknowledging that the condom is truly the only preventive vaccine when it comes to HIV/AIDS. And second, harm reduction programmes, including possible substitution treatment such as methadone for injecting drug users."
Dr Fabre-Teste noted that the controversy triggered in Bangkok over which types of HIV/AIDS prevention programmes to encourage was needlessly divisive. WHO and its partners, he said, insist that, while abstinence should be an important part of the approach to the epidemic, abstinence alone is not realistic. While a country's preferences will be sociologically and culturally based, Dr Fabre-Teste pointed out, the optimal prevention platform is one that combines the "CNN approach" (Condoms, Needles, Negotiating Skills) with the "ABC approach" (Abstinence, Be Faithful, Condoms).
In the end, however, the long-term success of any prevention and care programme or approach depends on the investment by governments and their partners. This will require a significant long-term financial outlay, combined with long-term commitment on the part of all players.
"Whether it's '3 by 5', or any other initiative," said Dr Omi, "decision-makers, stakeholders and all partners must invest more in HIV/AIDS prevention today if they want to avoid paying significantly more tomorrow. This is true not only for countries in WHO's Western Pacific Region – but across the world."
WHO encourages everyone to get involved in efforts to tackle the global HIV/AIDS pandemic. Much more information on the outcomes of the Bangkok conference of 2004, and the challenges ahead as we move towards Toronto in 2006, can be found at our website http://www.who.int/3by5/en/
For more information, please contact Mr Peter Cordingley, Public Information Officer, at (63 2) 528 9991 to 93, or email: PIO_Unit@wpro.who.int