Health for health

What is the significance of HIV/AIDS? '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, of whom 30 percent were co-infected with tuberculosis. 'Over 95 percent of people living with HIV/AIDS 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, can cost as much as 2-3 times per capita gross domestic product 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.

How much will it cost? Economic analyses show that prevention of mother-to-child-transmission is cost effective, with costs well below US$100 per healthy life year gained. But cost-benefit and cost-effectiveness are highly context-specific and will be influenced by HIV prevalence and distribution, and the rate of uptake of mother-to-child-transmission interventions. Prices of anti-retroviral drugs used to prevent mother-to-child-transmission range from US$ 0-4 for nevirapine and up to US$ 300 for a short course of zidovudine. Costs for replacement feeding range from US$ 50 to US$ 300 for a period of six months depending on the country. Typically, about 90% of total mother-to-child-transmission program cost is in setting up services, including training, and strengthening health infrastructure.

How does HIV/AIDS spread? The major modes of transmission of AIDS are: 'Sexual intercourse. 'Unsafe injecting practices. 'Mother-to-child (in utero, during birth or through breastfeeding). '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; men who have sex with men 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. Can HIV/AIDS be brought under control in developing countries?

Developing countries populations are particularly susceptible to HIV/AIDS because of inadequate funding, unfavourable policy environments and lack of popular support. Despite the high potential of HIV/AIDS in developing countries such as Thailand, Uganda and Brazil, there are some success stories in the fight against HIV/AIDS on national scale among developing countries. 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.

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".

What are the effective interventions to prevent HIV/AIDS? No cure or effective vaccine has yet been developed, but the tools to prevent HIV infection already exist. AIDS is a fatal disease, but modern interventions can prolong and improve the lives of patients afflicted with HIV/AIDS. A core set of interventions can be effective in reducing the spread of HIV/AIDS. These include: 1. Promoting behavior change at both individual and community/social level through communication programs, peer education, and voluntary counselling and testing. 'Tailor behaviour change messages to specific audiences such as groups at high risk, men, women and young people. 'Address stigma associated with HIV/AIDS by involving highly motivated people with HIV/AIDS as members of vulnerable groups in public information dissemination and efforts. 'Promote HIV/AIDS/STI programs, services and products. 2. Increasing condom use, availability and quality through condom promotion and distribution. 'Ensure a guaranteed supply of quality male and female condoms and a condom dissemination system. 'Educate people how to avoid Sexually Transmitted Infections or STI, recognize common STI symptoms and seek and distribute condoms through different approaches (targeted, community-based, outlet-based). 'Popularize and increase acceptability of condoms through condom promotion and social marketing campaigns. 'Control the quality of condoms through regular sampling and testing. 3. Establish comprehensive sexually transmitted infections management programmes. 'Diagnosing and treating sexually transmitted infections. 'Develop a national protocol for sexually transmitted infections case management. 'Include sexually transmitted infections drugs in the essential drug list. 'Make syndromic management of sexually transmitted infections available at first point of contact in the health care system. 'Link sexually transmitted infections services to counseling and other HIV/AIDS services. 4. Establish voluntary counseling and testing service. 'Establish and/or strengthen a highly accessible voluntary counseling and testing system which offers anonymous testing, pre-testing and post-test counseling to anyone who needs it. 'Publicize the existence of voluntary counseling and testing service. 'Ensure the affordability of voluntary counseling and testing service, especially for high-risk and vulnerable groups. 'Link voluntary counseling and testing to other HIV/AIDS and sexually transmitted infectious services. 5. Ensuring a safe blood supply. 'Exclude paid donors and high-risk donors. Utilize voluntary donors from low-risk populations for blood supply. 'Screen all blood for HIV/AIDS antibody and other blood-borne infectious agents. 'Avoid unnecessary blood transfusions. 6. Preventing mother-to-child transmission. 'Develop and implement short courses of antiretroviral drugs and providing infant feeding options. 'Provide voluntary counseling and testing services to antenatal attendees. 'Provide HIV-positive pregnant women with short courses of zidovudine or nevirapine where possible. 'Improve family planning services and incorporate HIV prevention activities. 7. Supporting harm reduction among injecting drug users, which includes providing clean injecting equipment, counseling, and drug abuse treatment. 'Improve access to sterile injecting equipment and condoms 'Promote safe injecting practices as well as safe sex behaviour. 'Offer counseling and drug abuse treatment. 8. Provide treatment of opportunistic infections and palliative care. 'Develop a HIV/AIDS treatment and care strategy including Highly Active Anti-retroviral Therapy or HAART. HAART reduces and prevents many opportunistic infections associated with HIV/AIDS and may serve to prolong 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 developed countries. HAART distribution and scope of treatment can be increased by adopting the following: 'Reducing the cost of drugs for HAART to make them more affordable and feasible for low- and middle-income countries. Some evidence of this has already been implemented and 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. 'Develop and implement clinical guidelines for management of common opportunistic infections including Tuberculosis. 'Ensure an adequate supply of drugs for opportunistic infections, treatment and palliative care. 'Strengthen the capacity of the health system to provide treatment and care to HIV-positive patients (e.g., ensure adequacy of diagnostic and treatment facilities for common opportunistic infections, train medical personnel in treatment and care for HIV-related conditions). 9. Provide community-based and home-based care to complement traditional hospital care. 'Provide funding and training for communities to provide care for and support people living with HIV/AIDS. 10. Strengthen the safety net for poor households affected by AIDS, including AIDS orphans. 'Provide assistance to poor households affected by AIDS and to AIDS orphans. 11. Provide counseling and prevention services for people living with HIV/AIDS and their families. 12. Adopt targeted prevention to reduce the transmission of HIV/AIDS among groups at high risk. This targeted prevention approach involves the use of well-trained peers who disseminate information concerning safer sex and conducts referrals to other HIV/AIDS services. This approach has proven to be successful in many different settings. It is therefore recommended that interventions and resources should be directed more strongly to groups at high risk. Targeted prevention is more effective when combined with programmes to change social norms and reduce stigma. 13. Prompt action. Every country is susceptible to the risk of HIV/AIDS. Leaders and Governments should act promptly and intervene as soon as possible because the more widely HIV/AIDS spreads, the more difficult and costly prevention, care and treatment become. 14. 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. 15. Create and enabling policy environment. An enabling environment with regard to local, 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. 16. 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. 17. 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. 18. Use a multi-sectoral approach with active involvement of all relevant sectors, civil society 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 are often capable of understanding local cultural and social contexts, mobilizing people, and reaching out to marginalized high-risk groups. 19. 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 programmes 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. 20. Develop a good monitoring and evaluation and surveillance system. A realistic monitoring and evaluation 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 World Health Organization and United Nation AIDS Program, monitors trends in the epidemic and in contributing risk behaviors.

'Prevention is better than cure' and should be stressed in all AIDS programs. Prevention averts suffering and death and reduces, prevents and eliminates burden to health care systems. 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.

References Adeyi O et al. AIDS, Poverty Reduction and Debt Relief: A Toolkit for Mainstreaming HIV/AIDS Programmes into Development Instruments, UNAIDS and World Bank, Geneva, 2000. http://www.worldbank.org/aids-econ/confront/ovrview.htm#Summary. http://www.unaids.org/bestpractice/collection/subject/specific/in dex.html. http://www.nap.edu/books/0309071372/html. National AIDS Programmes: A Guide to Monitoring and Evaluation. UNAIDS. Geneva, 2000. UNAIDS, 2002, AIDS Epidemic Update. UNAIDS, 2002, Report on the Global HIV/AIDS Epidemic. World Bank, 1997, Confronting AIDS: Public Priorities in a Global Epidemic World Bank, 1999, Intensifying Action Against HIV/AIDS in Africa: Responding to a Development Crisis. World Bank, 2000, Costs of Scaling HIV Program Activities to a National Level in Sub-Saharan Africa: Methods and Estimate.

About the author: Dr Pattron is a Public Health Scientist in the Ministry of Health, Trinidad.