foreword In 2009, countries, partners and communities succeeded in scaling up access to HIV prevention, treatment and care.

Transcription

1 For more iformatio, cotact: World Health Orgaizatio Departmet of HIV/AIDS Aveue Appia Geeva 27 Switzerlad S ummary

2

3 foreword This year s report o HIV/AIDS itervetios i the health sector presets strog evidece of progress i the global effort to fight HIV/AIDS, but it also makes clear how much work remais to be doe. I 2009, coutries, parters ad commuities succeeded i scalig up access to HIV prevetio, treatmet ad care. Importat gais have bee made towards the goal of elimiatig mother-to-child trasmissio of HIV by Over half of all pregat wome livig with HIV i low- ad middle-icome coutries received atiretrovirals to prevet HIV from beig trasmitted to their babies, ad more childre livig with HIV are beefitig from treatmet ad care programmes. Commuity-drive, rights-based prevetio programmes have cotributed to lowerig the umber of HIV ifectios. WHO s revised guidelies for atiretroviral therapy ow recommed iitiatio of therapy at a earlier stage of disease ad, oce fully implemeted, these chages will help to further reduce the morbidity ad mortality due to HIV. These advaces are all cause for ecouragemet. Nevertheless, this report also demostrates that, o a global scale, targets for uiversal access to HIV prevetio, treatmet ad care will ot be met by Oly oe third of people i eed have access to atiretroviral therapy, coverage of prevetio itervetios is still isufficiet, ad most people livig with HIV remai uaware of their serostatus. Stigma, discrimiatio ad social margializatio cotiue to be experieced daily by people who are the most affected by HIV ad hardest to reach i may coutries, icludig people livig with HIV, sex workers, ijectig drug users, me who have sex with me, trasgeder people, prisoers ad migrats. At the same time, the fiacial crisis ad resultig ecoomic recessio have prompted some coutries to reassess their commitmets to HIV programmes. Reduced fudig for HIV services ot oly risks udoig the gais of the past years, but also greatly jeopardizes the achievemet of other Milleium Developmet Goals, especially those related to materal ad child health. While the global HIV respose may have exposed the shortcomigs of curret health systems, it has also drive more cocerted actio towards addressig broader systemic issues, icludig huma resource capacity, physical ifrastructure, supply chais, health fiacig ad iformatio systems. As may coutries have show, the ogoig scale-up of HIV programmes ca be successfully leveraged to tackle logstadig systemic bottleecks that have preveted other health outcomes from beig achieved. We must also strategically itegrate HIV/AIDS itervetios ito atioal health services, strategies ad plas, icludig those for sexual, reproductive, materal ad child health, tuberculosis, sexually trasmitted ifectios ad harm reductio. Special approaches remai ecessary to address the particular circumstaces ad eeds of those populatios at greater risk for HIV ifectio. Rights-based atioal strategies must iclude special efforts to reach the poorest ad those who are socially excluded. Programmes must be desiged ad delivered i ways that esure equity i access, icludig for childre ad wome. Oly such a combied commitmet to programme plaig ad delivery, built upo a solid primary healthcare framework, ca fully capture syergies betwee itervetios, esure programmatic sustaiability, ad maximize coverage ad impact. PROGRESS REPORT SUMMARY

4 towards uiversal Although there is cosiderable room for improvemet, HIV programmes have had a positive impact o other disease outcomes ad o social ad ecoomic developmet more broadly. The implicatio for public policy is clear: while the respose to other global health priorities must be further stregtheed, this must happe i additio to, ot istead of, a cotiued ad icreasig commitmet to HIV. Oly by workig together ca we tur the tide of the epidemic. We have the kowledge ad ability to achieve uiversal access ad reverse the epidemic. Let us tur the challeges faced by the global HIV respose ito a opportuity to reew our efforts ad deliver o our collective commitmets. Margaret Cha Michel Sidibe Athoy Lake Director-Geeral Executive Director Executive Director World Health Orgaizatio UNAIDS UNICEF 2 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

5 access Executive Summary The HIV epidemic remais a major global public health challege, with a total of 33.4 millio people livig with HIV worldwide. I 2008 aloe, 2.7 millio people were ewly ifected with HIV. Sice 2006, whe Uited Natios Member States committed to scalig up services ad itervetios towards the goal of uiversal access to HIV prevetio, treatmet, care ad support by 2010, the WHO, UNICEF ad UNAIDS Secretariat has sought to moitor key compoets of the health sector respose to the HIV epidemic worldwide. This report, the fourth aual progress report published sice 2006, assesses the situatio at the ed of 2009, oe year before the uiversal access target. It compiles iformatio from 183 of the 192 Uited Natios Member States, comprisig 144 low- ad middle-icome coutries ad 39 high-icome coutries, o the status of the global health sector respose to HIV, progress made ad remaiig challeges to achievig uiversal access. The year 2009 saw cotiuig progress i expadig access to HIV testig, prevetio, treatmet ad care i low- ad middle-icome coutries. Some coutries have already attaied uiversal access (defied as coverage of at least 80% of the populatio i eed) to atiretroviral therapy ad/or itervetios to prevet mother-to-child trasmissio. For a good umber of coutries, uiversal access is withi clear reach by the ed of Despite these ecouragig fidigs, global targets for HIV prevetio, treatmet, care ad support are ulikely to be achieved i This has importat implicatios for a rage of Milleium Developmet Goals (MDGs) beyod those specifically related to HIV (MDG 6), such as MDGs 4 ad 5, with targets related to child ad materal health. After years of cosiderable icreases i iteratioal assistace, fudig remaied essetially flat over the curret period. I the cotext of a global fiacial crisis, this report uderscores the urgecy of cotiuig to mobilize support by coutries, doors ad global agecies i order to respod to the HIV epidemic ad cotribute to achievig the MDGs. HIV testig ad cousellig I 2009, more coutries adopted policies o provideriitiated testig ad cousellig, ad the umber of facilities providig HIV testig ad cousellig cotiued to icrease. As of December 2009, over two thirds of coutries i sub- Sahara Africa ad Lati America ad the Caribbea had itroduced policies supportig provider-iitiated testig ad cousellig. There was also a icrease i the umber of HIV tests performed globally. Oe hudred coutries reported a total of 67 millio people tested i I the 82 coutries for which comparable data are available for 2008 ad 2009, the media umber of tests performed per 1000 populatio icreased from 41 to 50 respectively. However, kowledge of HIV status remaied iadequate. Accordig to 10 recet atioal populatio-based surveys i sub-sahara Africa, the media percetage of people livig with HIV who kow their HIV status is below 40%. I additio, testig ad cousellig programmes are ot always tailored to local cotexts, ad cosiderable gaps remai betwee testig ad cousellig eeds ad existig practices. Key idicators of progress i low- ad middle-icome coutries i 2008 ad 2009 a December 2008 December 2009 Number of adults ad childre receivig atiretroviral therapy Atiretroviral therapy coverage amog adults ad childre: Based o 2010 WHO guidelies (treatmet iitiatio at CD4 cell cout <350 cells/mm 3 ) 28% [26 31%] 36% [33 39%] Based o 2006 WHO guidelies (treatmet iitiatio at CD4 cell cout <200 cells/mm 3 ) 42% [38 48%] 52% [47 58%] Atiretroviral therapy coverage amog childre less tha 15 years of age 22% [16 34%] 28% [21 43%] Percetage of pregat wome livig with HIV receivig atiretroviral drugs to prevet mother-to-child trasmissio 45% [37 57%] 53% [40 79%] a See box o Updated guidace o atiretroviral therapy ad its implicatios for eeds estimates. PROGRESS REPORT Summary

6 towards uiversal Health sector itervetios for HIV prevetio More low- ad middle-icome coutries reported coductig surveillace for HIV amog selected populatio groups at higher risk for HIV ifectio, such as ijectig drug users, sex workers ad me who have sex with me. Nevertheless, most coutries were still uable to provide data o the coverage of HIV prevetio programmes 1 amog these populatio groups, ad the quality ad represetativeess of the reported data are sometimes limited. I 2009, amog 27 low- ad middle-icome reportig coutries, the media percetage of ijectig drug users reached with HIV prevetio programmes i the 12 moths precedig the surveys was 32%. Of 92 coutries that reported iformatio o harm reductio policies for ijectig drug users, 36 reported havig eedle ad syrige programmes, ad 33 offered opioid substitutio therapy. I all the reportig coutries, the umber of syriges distributed per ijectig drug user per year is below the iteratioally recommeded target of 200 syriges per ijectig drug user per year. Amog 21 reportig coutries, the media percetage of me who have sex with me reached with HIV prevetio programmes i the 12 moths precedig the surveys was 57%. I the case of sex workers, the media percetage was 58% amog 38 reportig coutries. 1 Based o UNGASS idicators; see Tables 3.4 p.30 (ijectig drug users), 3.6 p.34 (me who have sex with me), 3.7 p.36 (sex workers) Updated guidace o atiretroviral therapy ad its implicatios for eeds estimates I 2009 ad 2010, WHO issued revised guidelies ad recommedatios o (i) atiretroviral therapy for adults ad adolescets, icludig pregat wome, (ii) atiretroviral drugs for treatig pregat wome ad prevetig HIV ifectio i ifats, (iii) atiretroviral therapy for HIV ifectio i ifats ad childre, ad (iv) HIV ad ifat-feedig. WHO s updated guidelies o atiretroviral therapy for adults ad adolescets, icludig pregat wome, ow recommed that atiretroviral therapy be iitiated whe CD4 cell couts reach or drop below 350 cells/mm 3, regardless of whether or ot patiets have cliical symptoms (see boxes 4.1 ad 4.2). Although this chage has icreased the umber of people estimated to be i eed of atiretroviral therapy at the ed of 2009 from 10.1 millio to 14.6 millio [ millio], it is expected that, i the medium term, the higher iitial ivestmets required to coform to these guidelies will be fully compesated for by fewer hospitalizatios ad lower morbidity ad mortality rates. As of December 2009, 29 coutries had already icorporated the ew WHO recommedatios o eligibility criterio for iitiatig atiretroviral therapy ito their atioal treatmet guidelies. Multiple legal ad sociocultural barriers cotiue to prevet or discourage ijectig drug users, me who have sex with me, trasgeder people ad sex workers from accessig ad usig health-care services. Addressig these issues requires removig puitive laws that crimialize their behaviours, ad creatig eablig eviromets to reduce stigma ad discrimiatio ad protect huma rights. Some progress was made i developig ad implemetig additioal prevetio tools ad techologies. As of Jauary 2010, over male circumcisios had bee performed i six Sub-Sahara coutries reportig o service delivery. The availability ad safety of blood ad blood products for trasfusio remais a area of cocer i low- ad middle-icome coutries. Oly 48% of blood doatios i low-icome coutries were screeed i a quality-assured maer, compared to 99% ad 85% i high- ad middleicome coutries, respectively. Treatmet ad care for people livig with HIV At the ed of 2009, 5.25 millio people were reported to be receivig atiretroviral therapy i low- ad middle-icome coutries. This represets a icrease of over 1.2 millio people from December 2008, the largest icrease i oe year. Sub-Sahara Africa had the greatest icrease i the absolute umber of people receivig treatmet i 2009, from i December 2008 to a year later. Based o the ew criterio for treatmet iitiatio (CD4 cell cout of or below 350 cells/mm 3 ), atiretroviral therapy coverage icreased from 28% [26 31%] i December 2008 to 36% [33 39%] at the ed of Uder the previous criterio for treatmet iitiatio (CD4 cout of or below 200 cells/mm 3 ), global coverage would have reached 52% [47 58%] i Eight low- ad middle-icome coutries (Botswaa, Cambodia, Croatia, Cuba, Guyaa, Oma, Romaia ad Rwada) had already achieved uiversal access to atiretroviral treatmet by December 2009 (treatmet coverage of at least 80% of patiets i eed). At 39%, atiretroviral therapy coverage was higher amog wome, compared with 31% amog me. Available coutry cohort data o the proportio of patiets retaied o atiretroviral therapy over time show that most patiet attritio occurs withi the first year of treatmet iitiatio ad that retetio rates ted to stabilize thereafter. I 2009, the average retetio rate at 12 moths across low- ad middle-icome coutries was 82%, ad was approximately the same amog me ad wome. Reported 4 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

7 access retetio treds i 2009 were similar to those observed i However, may programmes were still techically ad operatioally uable to provide data o patiet retetio, especially over loger periods. It is essetial that parters ad coutries step up efforts to stregthe patiet ad cohort moitorig systems to capture, process ad use logitudial retetio data. As of mid-2010, 28 coutries had implemeted surveys to classify trasmitted HIV drug resistace. Amog 15 WHO quality-assured surveys, trasmitted HIV drug resistace was estimated at <5% by 13 coutries, ad betwee 5% ad 15% by two. HIV-related tuberculosis (TB) remais a serious challege for the health sector s respose to HIV. I 2008, of the 9.4 millio icidet TB cases worldwide, a estimated 1.4 millio were amog people livig with HIV. Although the rate of HIV testig ad cousellig for TB patiets is icreasig, it remais iadequate. Almost 22% of people with otified TB kew their HIV status i 2008, up from 16% i 2007 ad 3.2% i Atiretroviral therapy coverage amog people livig with HIV ad TB was low, ad implemetatio of the Three I s for TB cotrol itesified TB case fidig amog HIV patiets, isoiazid prevetive therapy ad TB ifectio cotrol remaied isufficiet. Updated guidace o prevetio of motherto-child-trasmissio ad paediatric treatmet The 2010 revised guidelies o prevetio of mother-to-child trasmissio of HIV propose major chages to more effective atiretroviral drug itervetios. This icludes earlier atiretroviral therapy (ART) for a larger group of HIV-positive pregat wome (CD4 350 or stage 3 or 4 disease) to beefit both the health of the mother ad prevet HIV trasmissio to her child durig pregacy ad breastfeedig. For wome who do ot require ART the guidelies recommed two optios for atiretroviral prophylaxis, to be chose at coutry level takig ito accout feasibility ad implemetatio issues (see Box 5.3). I additio, the revised guidelies ow recommed the provisio of atiretroviral drugs to the mother or child to reduce the risk of HIV trasmissio durig breastfeedig i settigs where it is judged to be the safest ifat-feedig optio (see Box 5.3 ad Box 5.4). Updated paediatric atiretroviral therapy guidelies ow advise that all HIV-positive childre less tha 24 moths of age be started o atiretroviral therapy, ad that childre more tha 24 moths of age be iitiated o treatmet depedig o age-specific CD4 cell cout thresholds (see Box 5.6). These revisios should sigificatly lower vertical trasmissio rates, icrease HIV-free survival, ad improve the quality of life ad survival of ifats ad childre livig with HIV. Additioal techical ad fiacial support is eeded, however, to eable coutries to fully implemet the revised recommedatios i a timely ad effective maer. HIV services for wome ad childre Access to services for prevetig mother-to-child trasmissio of HIV expaded further i A estimated 26% of all pregat wome i low- ad middleicome coutries received a HIV test i 2009, up from 21% i However, this figure is still low, largely due to iadequate coverage of HIV testig i East, South ad South-East Asia (17%) where 55% of pregat wome live. A estimated 53% [40 79%] of pregat wome livig with HIV received atiretroviral drugs to reduce the risk of trasmittig HIV to their ifats, up from 45% [37 57%] i I sub-sahara Africa, which has aroud 91% of the 1.4 millio pregat wome i eed of atiretroviral drugs for prevetig mother-to-child trasmissio, the coverage is 54% [40 84%] i The efficacy of atiretroviral drugs i prevetig motherto-child trasmissio of HIV varies with the type of drug combiatio used ad the duratio of the regime. Amog pregat wome who have access to atiretroviral drugs for prevetig mother-to-child trasmissio, the proportio receivig sigle-dose evirapie decreased from 49% to 30% betwee 2007 ad 2009, whereas the percetage of wome receivig more efficacious regimes icreased from 33% to 54% durig the same time period. Approximately 51% of pregat wome who tested positive for HIV were assessed for their eligibility to receive atiretroviral therapy for their ow health, up from 34% i About childre less tha 15 years of age were receivig atiretroviral therapy at the ed of 2009, up from at the ed of 2008, a icrease of 29% i oe year. These childre represeted a estimated 28% [21 43%] of all childre less tha 15 years estimated to eed atiretroviral therapy i low- ad middle-icome coutries, up from 22% [16 34%] i 2008 ad 7% [5 11%] i Overall atiretroviral therapy coverage amog childre i low- ad middle-icome coutries was lower tha that amog adults (37% [35 41%]). Moreover, i 54 reportig coutries, oly 15% [10 28%] of childre bor to HIVpositive mothers received a HIV test withi the two first moths of life. Greater efforts are eeded to scale up early testig of HIV-exposed ifats, reduce the rate of loss to follow up amog them i the postatal period, ad further itegrate HIV itervetios with services for materal, ewbor ad child health. PROGRESS REPORT Summary

8 towards uiversal Despite the limitatios of the available iformatio, there has ever bee so much evidece of the positive ad growig impact of HIV-related ivestmets i reducig ew ifectios, avertig deaths ad esurig that people livig with HIV ejoy healthy lives. Yet, this evidece becomes available at a time whe the global ecoomic crisis of has put the sustaiability of may HIV programmes at risk. It is clear that without cotiued ad stregtheed fiacial ad programmatic commitmets, there is cosiderable dager that these achievemets could be udoe. Addressig the challeges posed by the MDGs pertaiig to HIV requires actio alog four mai strategic directios: (i) expadig ad optimizig the global HIV respose, (ii) catalysig the impact of HIV programmes o other health outcomes, (iii) stregtheig health systems for a sustaiable ad comprehesive respose, ad (iv) tacklig the structural determiats of the respose, icludig huma rights violatios. 6 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

9 access Itroductio This report reviews the progress made i 2009 i scalig up access to selected health sector itervetios for HIV prevetio, treatmet ad care i low- ad middleicome coutries. It is the fourth i a series of aual progress reports published sice 2006 by the World Health Orgaizatio (WHO), Uited Natios Childre s Fud (UNICEF) ad Joit Uited Natios Programme o HIV/ AIDS (UNAIDS) i collaboratio with iteratioal ad atioal parters to moitor key compoets of the health sector respose to the HIV epidemic worldwide is a ladmark year for the global HIV respose. At the 2006 Uited Natios Geeral Assembly High-Level Meetig o AIDS, world leaders committed to scalig up services ad itervetios towards the goal of providig uiversal access to HIV prevetio, treatmet, care ad support by the ed of this year (1). Now, as coutries ad parters prepare to review uiversal access goals ad targets i the moths ahead, assessig progress is critical to idetify areas where itesified actio is eeded to icrease coverage ad impact. This report will support this process i two ways. First, the accurate ad up-to-date strategic iformatio i the report will help coutries to take stock of their achievemets ad idetify programmatic bottleecks, service delivery gaps ad challeges. Secod, the updated global respose will assist the iteratioal commuity i settig policy priorities, defiig targets ad desigig relevat strategies to better support ad ehace coutry resposes. The proximity of 2010 has served to rally ad galvaize parters ivolved i the HIV respose at all levels. Ecouragigly, 2009 witessed reewed commitmet ad resolve towards attaimet of uiversal access ad the Milleium Developmet Goals (MDGs). The lauch of UNAIDS Outcome Framework has helped focus attetio o te programmatic areas ad a rage of cross-cuttig strategies i which progress must be rapidly accelerated (2). At the same time, the iteratioal commuity has also moved decisively towards agreeig to virtual elimiatio of mother-to-child trasmissio of HIV by 2015 (3). A ew global health iitiative, spearheaded by the Uited States Govermet, will support low- ad middle-icome coutries to improve health outcomes ad stregthe health systems, 1 Two other importat joit publicatios, to be released later i 2010, will complemet the health sector-related iformatio preseted ad discussed herei. The AIDS Today :2010 UNAIDS Global Report will discuss the curret status of the epidemic ad the multisectoral respose at the global ad atioal levels, ad the Stocktakig report o childre ad AIDS will preset additioal critical data o the progress made ad challeges i scalig up services for wome, childre ad youg people affected by the epidemic. icludig HIV services. New fiacial allocatios have bee agreed to by the Global Fud to Fight AIDS, Tuberculosis ad Malaria. WHO s guidelies o atiretroviral therapy for adults ad adolescets as well as childre ow recommed iitiatio of therapy at a earlier stage of the disease, which should further reduce HIV-related mortality ad morbidity as well as HIV trasmissio. At the same time, the global HIV respose has bee buffeted by both the global fiacial crisis ad the chagig public health ad developmet priorities at atioal ad iteratioal levels. These evets have highlighted the eed to ehace the impact of curret ivestmets by improvig the efficiecy, effectiveess ad quality of programmes, stregtheig likages betwee programmes ad buildig systems for a sustaiable respose. This report shows that, amog 144 low- ad middle-icome coutries reportig programme data this year, eight had already achieved uiversal access to atiretroviral therapy at the ed of 2009, providig treatmet to at least 80% of patiets i eed. Furthermore, 15 coutries had achieved the 80% target for coverage with atiretroviral prophylaxis to prevet mother-to-child trasmissio of HIV. Although more coutries may reach uiversal access goals by the ed of 2010 as a result of ogoig efforts, global targets for HIV prevetio, treatmet, care ad support are ulikely to be achieved. Importatly, this has implicatios ot oly for the HIV respose, but also for all other MDGs, particularly MDGs 4 ad 5, o child ad materal health. Ideed, as documeted by recet research, a lower burde of HIV/AIDS has bee associated with greater progress towards the achievemet of child mortality ad tuberculosis goals tha ecoomic growth itself (4). I the absece of HIV, materal mortality worldwide would have bee lower by about 6% i 2008 (5) ad a recet academic study (6) has estimated that up to 18% of pregacy-related deaths may be due to HIV. I spite of all the challeges ad costraits, this report demostrates that, with itesified ad accelerated efforts, coutries ca achieve uiversal access. Health-care workers have bee traied, critical ifrastructure has bee upgraded, ad health systems are gradually beig stregtheed. Although much remais to be doe ad improved, millios of ew HIV ifectios have already bee averted ad millios of people are alive today as a result of ivestmets i HIV over the past few years. PROGRESS REPORT Summary

10 towards uiversal Data sources ad methods WHO, UNICEF ad UNAIDS joitly collected data from atioal programmes worldwide through a commo reportig tool to moitor ad report o progress i the health sector respose towards uiversal access. I order to avoid duplicatio ad maximize data cosistecy, all idicators ad the correspodig data collectio processes have bee desiged to build o the moitorig framework of the Declaratio of Commitmet o HIV/AIDS of the Uited Natios Geeral Assembly Special Sessio (UNGASS) o HIV/AIDS (7). However, this report differs from its 2009 versio i two mai aspects. First, this year, coutries were asked to report data o 35 idicators, compared to 46 i 2009 (see Aex 8). Secod, ot all 35 idicators are preseted ad discussed i this report, as a umber of them will be compiled ad published later this year i the AIDS Today: 2010 UNAIDS Global Report. Data used i this report were reported by 39 high-icome ad 144 low- ad middleicome coutries. I additio, estimates of treatmet eeds ad coverage i low- ad middle-icome coutries have bee substatially revised due to chages i the recommeded set of criteria for therapy iitiatio. WHO s 2010 atiretroviral therapy guidelies ow recommed that all adults ad adolescets, icludig pregat wome, with HIV ifectio ad a CD4 cout of or below 350 cells/mm 3 should be started o atiretroviral therapy, regardless of whether or ot they have cliical symptoms. This chage icreased the umber of people estimated to be i eed of atiretroviral therapy at the ed of 2009 from 10.1 millio to 14.6 millio [13.5 millio 15.8 millio] (see Box 4.2). The data collected ecompass the followig programmatic areas: (i) HIV testig ad cousellig, (ii) prevetio of sexual trasmissio of HIV ad prevetio of trasmissio through ijectig drug use, (iii) maagemet of sexually trasmitted ifectios; (iv) coverage of atiretroviral therapy (v) coverage of collaborative HIV/TB services, (vi) stockouts of atiretroviral drugs, ad (vii) HIV itervetios for wome ad childre, icludig prevetio of mother-to-child trasmissio. Policy-related questios were also asked to assess programmatic developmet. Respose rates varied by idicator ad are preseted i the correspodig chapters. This report also relies o data from other sources, icludig special surveys (such as o pricig ad utilizatio of atiretroviral drugs ad other supplies, ad surveillace of HIV drug resistace), populatio-based surveys (such as the Demographic ad Health Surveys) ad recet scietific literature. Additioal data- ad methodology-related otes are icluded i each chapter, as appropriate. 8 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

11 access HIV testig ad cousellig Key fidigs The umber of coutries providig data o HIV testig ad cousellig remaied stable. I 2009, 118 low- ad middle-icome coutries reported data o the availability of HIV testig ad cousellig i health facilities compared to 111 i Oe hudred coutries provided iformatio o the uptake of these services i 2009, up from 98 i More coutries adopted policies o provider-iitiated testig ad cousellig. As of December 2009, over two thirds of coutries i sub-sahara Africa, ad i Lati America ad the Caribbea had itroduced policies supportig provider-iitiated testig ad cousellig. The umber of facilities providig HIV testig ad cousellig cotiued to icrease. The reported umber of health facilities providig HIV testig ad cousellig icreased to i 2009 (118 reportig coutries), up from i 2008 (111 coutries). I 101 low- ad middle-icome coutries reportig data i both 2008 ad 2009, the media umber of facilities per populatio rose by 28% durig this period, from 4.3 to 5.5. The umber of HIV tests performed icreased globally. Oe hudred coutries reported a total of 67 millio people tested i I the 82 coutries for which comparable data are available, the media umber of tests performed per 1000 populatio grew by almost 22% betwee 2008 ad 2009, from 41 to 50. Populatio surveys coducted i low- ad middle-icome coutries show that (i) the proportio of people who report havig ever had a HIV test is higher amog wome tha me, ad (ii) kowledge of HIV status remais iadequate, based o 10 populatio-based surveys coducted i , the media percetage of people livig with HIV who kow their status is estimated at below 40%. Testig ad cousellig programmes eed to be better tailored to the local epidemiological cotexts. A effective respose requires efforts to icrease the uptake of services, especially amog most-at-risk populatios, while respectig huma rights ad 2007 figures may differ from those published i previous Progress Reports due to updates or correctios submitted by coutries. PROGRESS REPORT Summary

12 towards uiversal Health Sector Itervetios for HIV Prevetio Key fidigs I. Prevetig HIV ifectio amog populatios at higher risk for HIV ifectio More coutries reported coductig surveillace for HIV amog selected populatios at higher risk for HIV ifectio. Of 149 low- ad middle-icome coutries surveyed, 42 reported coductig surveillace for HIV amog ijectig drug users versus 41 coutries i The umber of coutries that reported coductig HIV surveillace amog me who have sex with me icreased from 44 to 54, ad amog sex workers from 65 to 74. The media percetage of ijectig drug users reached with HIV prevetio programmes i the 12 moths precedig the surveys was 32% amog 27 coutries reportig data i Coverage of harm reductio programmes remaied limited i Amog 92 reportig coutries, 36 had eedle ad syrige programmes, ad 33 offered opioid substitutio therapy. I coutries reportig eedle ad syrige programmes, the umber of syriges distributed per ijectig drug user per year was still below the iteratioally recommeded level of 200 syriges per ijectig drug user per year. The media percetage of me who have sex with me reached with HIV prevetio programmes i the 12 moths precedig the surveys was 57% amog 21 coutries reportig data i Regioally, media coverage i 2009 was highest at 63% i Europe ad Cetral Asia. The media percetage of sex workers reached with HIV prevetio programmes i the 12 moths precedig the surveys was 58% amog 38 coutries reportig data i The highest media coverage of prevetio programmes was 76%, observed i Lati America ad the Caribbea. II. Selected HIV prevetio itervetios i the health sector Additioal progress has bee made i scalig up male circumcisio programmes i the 13 priority coutries of sub-sahara Africa. As of Jauary 2010, over male circumcisios had bee doe i six coutries providig data o service delivery. The global burde of sexually trasmitted ifectios remais high i most regios of the world. Early idetificatio ad treatmet of sexually trasmitted ifectios is a critical elemet i cotrollig HIV ifectio, especially amog people with multiple sexual parters. The availability ad safety of blood ad blood products for trasfusio cotiues to be a issue of cocer, especially i low-icome coutries. While 99% ad 85% of doatios i high- ad middle-icome coutries, respectively, were screeed i a quality-assured maer i 2009, i low-icome coutries the comparable figure was 48%. 10 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

13 access Treatmet ad Care for people livig with HIV Key fidigs At the ed of 2009, people were receivig atiretroviral therapy i low- ad middle-icome coutries, a icrease of over 1.2 millio people from December This represets a 30% rise from a year earlier ad a 13-fold icrease i six years. Sub-Sahara Africa had the greatest icrease i the absolute umber of people receivig treatmet i 2009, from i December 2008 to about a year later. As of December 2009, eight low- ad middle-icome coutries had already achieved uiversal access to atiretroviral therapy, defied as providig atiretroviral therapy to at least 80% of patiets i eed, ad 21 additioal coutries had coverage rates higher tha 50%. WHO ow recommeds that adults ad adolescets iitiate atiretroviral therapy at a earlier stage of disease. WHO s revised atiretroviral therapy guidelies recommed that all adults ad adolescets, icludig pregat wome, with HIV ifectio ad a CD4 cout of or below 350 cells/mm 3 should be started o atiretroviral therapy, regardless of whether or ot they have cliical symptoms. This chage has icreased the umber of people estimated to be i eed of atiretroviral therapy at the ed of 2009, from 10.1 millio to 14.6 millio [13.5 millio 15.8 millio]. As of December 2009, 45 coutries had already icorporated ito their atioal treatmet guidelies the ew WHO recommedatios o eligibility criteria ad regime choice for adults ad adolescets, ad 33 had already started implemetig stavudie (d4t) phase-out plas. Coverage of atiretroviral therapy i low- ad middle-icome coutries rose further i Based o the ew set of criteria for treatmet iitiatio, coverage icreased from 28% [26 31%] i December 2008 to 36% [33 39%] at the ed of Uder the previous criteria for treatmet iitiatio (CD4 cout at or below 200 cells/mm 3 ), global coverage would have reached 52% [47 58%] i The umber of childre uder 15 years of age receivig atiretroviral therapy icreased by 29% betwee 2008 ad About childre less tha 15 years of age were receivig atiretroviral therapy at the ed of 2009, up from at the ed of Childre represeted 6.8% of people receivig atiretroviral therapy ad 8.7% of people i eed. Amog 95 reportig coutries, atiretroviral therapy coverage was higher amog wome, estimated at 39%, compared to 31% amog me. Data o the proportio of patiets retaied o atiretroviral therapy over time cotiued to show that most patiet attritio occurs withi the first year of iitiatio of therapy ad that retetio rates ted to stabilize thereafter. I 2009, the average retetio rate at 12 moths across low- ad middle-icome coutries was 82%. More evidece is ow available of the positive impact of atiretroviral therapy o HIV trasmissio, ad additioal research is ogoig to idetify ad assess policy ad operatioal implicatios. Twety-eight coutries have completed surveys or are i the process of implemetig them to classify the extet of trasmitted HIV drug resistace. Quality assured results are available for 15 surveys. I 13 of these, trasmitted HIV drug resistace was classified as low (<5%) ad i two it was classified as moderate (betwee 5% ad 15%). PROGRESS REPORT Summary

14 towards uiversal Further, but limited, reductios i the prices of first-lie regimes occurred betwee 2008 ad However, the price of secod-lie regimes remaied cosiderably higher tha that of first-lie regimes. I 2009, the weighted media price of the six most widely used first-lie regimes was US$ 137 per perso per year i low-icome coutries, US$ 141 i lower middle-icome coutries ad US$ 202 i upper middle-icome coutries. For the most commoly used secod-lie regimes the weighted media per perso per year was respectively US$ 853, US$ 1378 ad US$ I low- ad middle-icome coutries outside of the Americas (59 reportig coutries), 97.5% of adult patiets were o first-lie regimes ad 2.4% were receivig a secod-lie regime. I the Americas Regio (17 reportig low- ad middle-icome coutries), 84% of adults were receivig a first-lie regime, 9.7% were beig treated with a secod-lie regime ad 6.3% were o salvage therapy. There has bee progress i expadig HIV testig ad cousellig for tuberculosis (TB) patiets over the past years. Almost 1.4 millio TB patiets kew their HIV status i 2008, accoutig for 22% of otified cases compared to 16% i 2007 ad 3.2% i However, atiretroviral therapy coverage amog people livig with HIV ad TB was low, ad implemetatio of the 3 I s for TB cotrol itesified TB case fidig amog HIV patiets, isoiazid prevetive therapy ad TB ifectio cotrol remaied isufficiet. Number of people receivig atiretroviral therapy i low- ad middle-icome coutries, by regio, North Africa ad the Middle East Europe ad Cetral Asia East, South ad South-East Asia Lati America ad the Caribbea Sub-Sahara Africa Millios Ed 2002 Ed 2003 Ed 2004 Ed 2005 Ed 2006 Ed 2007 Ed 2008 Ed TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

15 access Estimated umber of adults ad childre (combied) receivig ad eedig atiretroviral therapy, ad percetage coverage i low- ad middle-icome coutries by regio, December 2008 to December 2009 a Geographical regio Number of people receivig atiretroviral therapy Sub-Sahara Africa Easter ad Souther Africa Wester ad Cetral Africa Lati America ad the Caribbea Lati America Caribbea East, South ad South-East Asia Europe ad Cetral Asia North Africa ad the Middle East All low- ad middle-icome coutries December 2009 December 2008 Estimated umber of people eedig atiretroviral therapy, based o WHO 2010 guidelies [rage] a [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Estimated atiretroviral therapy coverage, based o WHO 2010 guidelies [rage] b 37% [34 40%] 41% [38 45%] 25% [22 28%] 50% [46 59%] 51% [45 61%] 48% [42 55%] 31% [26 36%] 19% [16 21%] 11% [10 14%] 36% [33 39%] Number of people receivig atiretroviral therapy Estimated umber of people eedig atiretroviral therapy, based o WHO 2010 guidelies [rage] a [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Note: some umbers do ot add up due to roudig. a See Box 4.2 for further iformatio o the methods for estimatig the eed for ad coverage of atiretroviral therapy i 2008 ad b The coverage estimate is based o the urouded estimated umbers of people receivig ad eedig atiretroviral therapy. Estimated atiretroviral therapy coverage, based o WHO 2010 guidelies [rage] b 28% [26 31%] 32% [30 34%] 19% [17 22%] 48% [44 56%] 49% [45 59%] 37% [33 43%] 25% [20 29%] 15% [13 17%] 10% [9 12%] 28% [26 31%] PROGRESS REPORT Summary

16 towards uiversal Scalig up HIV services for wome ad childre Key fidigs The proportio of pregat wome who received a HIV test icreased slightly. A estimated 26% of the estimated 125 millio pregat wome i low- ad middle-icome coutries received a HIV test i 2009, up from 21% i 2008 ad 7% i I the Easter ad Souther Africa regio, the proportio of pregat wome who received a HIV test icreased from 43% i 2008 up to 50% i Approximately 51% of pregat wome testig positive were reported to have bee assessed for eligibility to receive atiretroviral therapy for their ow health. Over half of the 1.4 millio pregat wome livig with HIV are estimated to have received atiretroviral drugs to prevet trasmissio of HIV to their ifats. A estimated 53% [40 79%] of pregat wome livig with HIV received atiretrovirals to reduce the risk of trasmittig HIV to their ifats, up from 45% [37 57%] i 2008 ad 15% [12 18%] i A large proportio cotiued to receive the less efficacious sigle-dose evirapie regime. Slightly more ifats received atiretroviral prophylaxis to prevet acquisitio of HIV from their mothers. Thirty-five per cet [26 53%] of ifats i eed received atiretroviral prophylaxis for prevetio of mother-to-child trasmissio i 2009, up from 32% [26 40%] i Amog ifats ad childre exposed to HIV, access to early testig, care ad treatmet is isufficiet. I 2009, i 54 reportig coutries, oly 15% [10 28%] of childre bor to HIV-positive mothers received a HIV test withi the two first two moths of life. The proportio of childre i eed who received atiretroviral therapy rose further i The umber of childre below the age of 15 years o atiretroviral therapy rose from i 2008 to i This represets a estimated coverage of 28% [21 43%] of childre i eed of atiretroviral therapy, up from 22% [16 34%] i 2008, based o updated treatmet eeds. Estimated umber of pregat wome livig with HIV eedig ad receivig atiretrovirals for prevetig mother-to-child trasmissio of HIV, ad percetage coverage i low- ad middleicome coutries, by regio 2009 Geographical regio Number of pregat wome livig with HIV receivig atiretrovirals for PMTCT Estimated umber of pregat wome livig with HIV i eed of atiretrovirals for PMTCT Estimated coverage a Sub-Sahara Africa [ ] 54% [40% 84%] Easter ad Souther Africa [ ] 68% [53% >95%] Wester ad Cetral Africa [ ] 23% [16% 44%] Lati America ad the Caribbea [ ] 54% [39% 83%] Lati America [ ] 53% [37% 81%] Caribbea [ ] 59% [39% >95%] East, South ad South-East Asia [ ] 32% [22% 52%] Europe ad Cetral Asia [ ] 93% [63% >95%] North Africa ad the Middle East [ ] 3% [2% 6%] All low ad middle icome coutries [ ] 53% [40% 79%] Note: some umbers do ot add up to roudig. a The coverage estimate is based o the urouded estimates of pregat wome receivig ad eedig atiretrovirals for prevetig mother-to-child trasmissio. 14 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector

17 access Beyod 2010 I 2009, low- ad middle-icome coutries cotiued to make cosiderable progress i scalig up access to key health sector itervetios, icludig HIV testig ad cousellig, atiretroviral therapy ad prevetio of mother-to-child trasmissio of HIV. A additioal 1.2 millio people started receivig life-savig atiretroviral therapy i 2009, brigig the total umber of people o atiretroviral therapy i low- ad middle-icome coutries to 5.25 millio. I 2009, 53% of HIV-ifected pregat wome received atiretroviral drugs to reduce the risk of HIV trasmissio to their childre. Importat ew evidece has also emerged o the secodary beefits that atiretroviral therapy has i prevetig HIV trasmissio. The combiatio of prevetio, treatmet ad care itervetios is already beefitig adults ad childre worldwide, as millios of lives have bee saved ad ew ifectios averted. Yet, a large proportio of people i eed still do ot have access to the required itervetios. Although importat progress has bee made i prevetig ew HIV ifectios, 2.7 millio people were ewly ifected i Despite a rapid icrease i the uptake of HIV testig, a majority of people livig with HIV do ot kow their status. As a result, most of them iitiate therapy at a late stage of the disease. Coverage of prevetio itervetios amog groups at higher risk for HIV ifectio remais less tha 50% i may coutries. Less tha three moths away from December 2010, uiversal access is a commitmet ot yet fulfilled i most low- ad middle-icome coutries. Paradoxically, while the global ecoomic crisis of has put the sustaiability of may HIV programmes at risk, there has ever bee so much evidece of the positive ad growig impact of HIV-related ivestmets i cuttig ew ifectios, reducig deaths ad esurig that people livig with HIV ejoy healthy lives. Without sustaied ad stregtheed fiacial ad programmatic commitmets, there is a sigificat dager that these achievemets may be udoe. Addressig these challeges requires actio alog four mai strategic directios: (i) expadig ad optimizig the global HIV respose, (ii) catalysig the impact of HIV programmes o other health outcomes, (iii) stregtheig health systems for a sustaiable ad comprehesive respose, ad (iv) tacklig the structural determiats of the respose, icludig huma rights violatios. Doig more, more strategically First ad foremost, the hard-wo gais of the past decade must be protected ad ehaced. As we cotemplate the road towards 2015, optimizig HIV prevetio, treatmet ad care outcomes must be a key priority. Ehacig the value for moey of the global HIV respose etails improvig the quality of service delivery i order to icrease retetio i care ad i atiretroviral therapy programmes, reduce early death ad loss to follow up, improve adherece ad optimally prolog the use of effective, lower-cost first-lie regimes. It calls for better uderstadig of the epidemic, icludig the behaviours that drive it ad the impact of various prevetio itervetios. It implies stregtheig likages ad referrals betwee programmes. It demads the implemetatio of flexible systems that idetify ad correct implemetatio bottleecks. Doors ad developmet parters also have a vital role to play i this drive towards greater efficiecy ad effectiveess by securig lower trasactio costs, greater harmoizatio of efforts ad aligmet with coutry priorities. At the same time, it is clear that additioal ivestmets are called for i order to expad coverage of essetial itervetios. Low- ad middle-icome coutries must substatially ramp up their domestic budget allocatios to fud HIV services. I 2001, at a coferece coveed by the Orgaizatio of Africa Uity i Abuja, Nigeria, Africa States committed to allocate at least 15% of their aual budgets to the health sector (8). While progress has bee made, atioal allocatios must still grow o average by over 50% i order meet the Abuja targets (9). Cocurretly, high-icome coutries must reaffirm their collective commitmet to uiversal access, as agreed to by leaders of the G8 i Gleeagles i 2005 ad reaffirmed at the Uited Natios Geeral Assembly i 2006 (10). It is importat that bilateral ad multilateral fuders, developmet agecies ad techical support providers be adequately resourced to support coutry HIV scale-up plas. I particular, esurig the successful completio of the third repleishmet of the Global Fud to Fight AIDS, Tuberculosis ad Malaria will be critical to protect ad ehace curret achievemets. Leveragig the global HIV respose for broader health ad developmet gais The sustaiability ad effectiveess of the global HIV respose deped as well o whether ad how it supports PROGRESS REPORT Summary

18 towards uiversal improvemets i other health ad developmet outcomes. As Ba Ki-moo, Uited Natios Secretary-Geeral, recetly stated, uiversal access to HIV prevetio, treatmet, care ad support represets, above all, a essetial bridge towards achievig the full rage of Milleium Developmet Goals (MDGs) (11). Ideed, slowig the rate of ew HIV ifectios ad decreasig HIV-related morbidity ad mortality is vital to advacig almost every global developmet goal. I sub-sahara Africa, for example, HIV ad tuberculosis accout for over 25% of deaths amog wome of reproductive age (12). Providig adequate care ad treatmet is thus vital to the achievemet of MDG 5, o improvig materal health. Esurig that the ext geeratio of childre is bor HIV-free through effective prevetio of mother-to-child trasmissio supports MDG 4, o the reductio of child mortality. As the scale-up of atiretroviral therapy cotiues, its impact o reducig HIV trasmissio amog adults ad childre will icrease accordigly. Atiretroviral therapy has already cotributed to lowerig both the icidece of ad mortality from tuberculosis (see Box 4.14). Successful HIV resposes also eable broader developmet gais. HIV prevetio ad treatmet allow people to live healthy, productive lives, ehacig labour output ad decreasig household vulerability to poverty ad huger. They also prevet childre from becomig orphas, thus protectig their livelihoods ad the geeratioal trasmissio of huma capital. They help maitai a adequate pool of schoolteachers, the backboe of quality primary educatio. They empower wome by highlightig geder iequalities ad promotig sexual ad reproductive health ad rights. Without accelerated efforts, uiversal access to treatmet, prevetio ad care will ot be achieved i most coutries ad this, i tur, will decrease the impact of developmet ivestmets i geeral. Towards itegrated ad stregtheed health systems HIV programmes have helped stregthe atioal health systems by attractig vital ew fiacial resources for health, buildig systemic capacity ad itroducig chroic disease maagemet approaches for the first time i may resource-limited settigs. For example, the itegratio of atiretroviral therapy ito existig public sector materal ad child health cliics i Lusaka, Zambia, has already doubled the proportio of eligible wome iitiatig treatmet (see Box 5.5). However, more must be doe to esure that ivestmets i the HIV respose traslate ito broad-based health systems stregtheig. Itegratig services, strategies ad plas ca improve ot oly equity, access ad coverage, but may also ehace the quality ad efficiecy of care. I order to realize these syergies, HIV programmes must be implemeted withi a primary health-care framework capable of providig itegrated services that address multiple patiet eeds through a cotiuum of care. These iclude services for materal ad child health, harm reductio, ad the maagemet of tuberculosis, sexually trasmitted ifectios ad viral hepatitis. It is ecessary to deepe the ivolvemet of commuities i programme maagemet ad service provisio i order to esure the adequacy of itervetios delivered ad maximize outreach ad uptake. Addressig structural barriers through a rightsbased approach A comprehesive approach, which pursues both equity ad efficacy, demads that all people i eed be capable of accessig prevetio, treatmet ad care, icludig populatios ad groups at higher risk for HIV ifectio, such as sex workers, ijectig drug users, me who have sex with me, trasgeder persos, prisoers ad migrats. Yet, eve i 2010, discrimiatio ad harassmet cotiue to ofte push these groups to live o the margis of society beyod the reach of health services. Greater attetio must be paid to how the iterplay betwee law ad social values may impede access to essetial health services ad compromise the effectiveess of HIV programmes. The crimializatio of HIV trasmissio, same-sex relatios, sex work ad drug use impedes effective itervetios to prevet HIV trasmissio amog these groups ad makes them sigificatly less likely to seek life-savig treatmet ad care. May of these issues are compouded further by poverty ad social margializatio (13). Addressig the eeds of groups at higher risk for HIV ifectio requires strog actios to uphold their huma rights ad protect them from violece ad exclusio. Focused efforts are eeded to remove puitive laws ad create eablig legal eviromets that address the huma rights violatios curretly blockig effective AIDS resposes. The egagemet of affected commuities ad civil society i policy desig, programme maagemet ad service delivery remais a essetial compoet of successful resposes. The ageda of the global HIV respose remais clearly ufiished. Every day, thousads are still beig ifected ad dyig due to lack of access to prevetio, treatmet ad care. Although uiversal access may ot be a global reality by the ed of 2010, ivestmets i the global HIV respose are already payig off. The sooer high-quality services are scaled up, the larger will be the social ad ecoomic gais from fewer ifectios, lower mortality ad havig millios of people live loger ad healthier lives. 16 TOWARDS UNIVERSAL ACCESS: Scalig up priority HIV/AIDS itervetios i the health sector