From Bangkok to Toronto: The Tough Road Ahead in the Campaign to Combat HIV/AIDS

MANILA, Philippines -- 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 program 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 percent) 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 are of special concern to WHO in its Western Pacific Region:

Cambodia, China, Papua New Guinea and Vietnam. Cambodia has the highest HIV/AIDS prevalence rate in the world outside sub-Saharan Africa.  While the estimated prevalence rate fell from 2.8 percent in 2001 to 2.6 percent 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

low-prevalence 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 percent 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 percent to 30 percent in numbers infected.  Parent-to-child transmission is the second most common means of infection.  The similarity of

sexual behavior 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 Vietnam, the official estimate of HIV prevalence in the 15 to 49 age

group was 0.28 percent 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.

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."

Fabre-Teste argued that:

    -- Each country must adopt "The Three Ones":

        One agreed AIDS action framework that provides the basis for

         coordinating the work of all partners;

        One national AIDS coordinating authority with a broad-based

         multisectoral mandate;

        One agreed country level monitoring and evaluation system

         (http://www.unaids.org/)

    -- 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 wide-

       ranging 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 healthcare 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 programs, 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 programs 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.

"We have long said this, but after the Bangkok conference it's more clear

than ever before: prevention and care are absolutely complementary," said

Omi.  "In that sense, the '3 by 5' Initiative represents a

comprehensive prevention and care approach."

"In the Asia-Pacific region," said Fabre-Teste, "prevention means

widespread application of two types of actions.  First, condom promotion

programs -- acknowledging that the condom is truly the only preventive

vaccine when it comes to HIV/AIDS.  And second, harm reduction programs,

including possible substitution treatment such as methadone for injecting drug

users."

Fabre-Teste noted that the controversy triggered in Bangkok over which

types of HIV/AIDS prevention programs 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, 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

program 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 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."

More information on the outcomes of the Bangkok conference can be found at

http://www.who.int/3by5/en .

Source: World Health Organization