Please note: This archive was last updated in 2005.

RHO archives : Topics : HIV/AIDS

Overview/Lessons Learned

Introduction

AIDS (acquired immune deficiency syndrome) is a human tragedy. Since the epidemic began in the early 1980s, AIDS has caused more than 30 million deaths and orphaned more than 14 million children worldwide. With no cure in sight, the AIDS-causing virus, human immunodeficiency virus (HIV), continues to spread around the world, causing more than 13,000 new infections each day. By the end of 2003, 38 million people were living with HIV, including 2.1 million children under 15 years old (Idemyor, 2003; UNAIDS 2004). Over 95 percent of these HIV cases occurred in the developing countries of sub-Saharan Africa and South and Southeast Asia. That proportion is set to grow even more as infection rates continue to rise in countries where poverty, poor health systems, and limited resources for prevention and care fuel the spread of HIV. In both China and Vietnam, recent statistics show sharp increases in HIV infection among sex workers and injecting drug users. In several countries of Eastern Europe and Central Asia—including Estonia, the Russian Federation, and Ukraine—HIV prevalence has risen exponentially since the mid-1990s. While sub-Saharan Africa suffers from high and growing rates of HIV prevalence in many countries (including Mozambique, South Africa, and Swaziland), some urban centers in countries such as Ethiopia, Rwanda, and Uganda have registered declining HIV prevalence among pregnant women, a measure of infection rates in the general population (UNAIDS, 2003).

In 2003, approximately 4.8 million new HIV infections and 2.9 million AIDS-related deaths occurred worldwide. Women accounted for approximately 2 million new infections and 1.2 million AIDS deaths. Nearly half of all new HIV infections—6,000 per day—occur in young people aged 15 to 24. Approximately 630,000 new infections occurred among children under 15 years of age, most of whom are thought to have contracted HIV through mother-to-child transmission (also called perinatal or vertical transmission) before or during birth, or through breastfeeding. The rates of mother-to-child HIV transmission are highest in developing countries (such as those in Africa) and range from 25 to 45 percent, compared to 3 percent in some U.S. populations, and 7 percent in Europe. Breastfeeding accounts for up to 50 percent of perinatal HIV transmission in developing countries (UNAIDS 2003; UNAIDS 2004). See the UNAIDS 2004 Report on the Global HIV/AIDS Epidemic for more information on the global HIV/AIDS epidemic.

HIV/AIDS exacts a heavy toll on its victims. People living with HIV/AIDS face tremendous health risks from opportunistic illnesses (such as tuberculosis) that compromise their way of life and dramatically increase their risk of death. In sub-Saharan Africa, average life expectancy has dropped to 47 years, 15 years less than it would have been without AIDS (UNAIDS 2002). In the hardest-hit countries in southern Africa, overall life expectancy is expected to fall to about 30 years of age between 2005 and 2010. Among infants and children, HIV/AIDS is reversing the health gains realized worldwide through years of improved child health and immunization services. In countries like Malawi, Tanzania, Uganda, and Zambia, the estimated infant mortality rates have increased 40 percent as a result of AIDS. Similarly, child mortality rates are projected to increase by as much as 50 to 75 percent in eastern and southern Africa, and 15 to 50 percent in countries like Brazil, Guyana, Haiti, and Thailand.

Tuberculosis is a major opportunistic disease among people living with HIV infection, and tuberculosis incidence and mortality have increased in developing countries in recent years (PATH/Outlook 1999). The dual epidemics of HIV and tuberculosis fuel each epidemic's progress and impact. Because HIV suppresses the body's immune system, persons infected with HIV have both a greater probability of progression from infection to tuberculosis disease and a greater speed of progression. Tuberculosis, on the other hand, adds to the disease burden of HIV-infected persons and hastens their death. Tuberculosis is a leading cause of death among people with HIV infection. Approximately 30 percent of all AIDS deaths result directly from tuberculosis; this figure reaches as high as 40 percent in sub-Saharan Africa and Asia. For more information on tuberculosis, visit the WHO Global Tuberculosis Program website at www.who.int/gtb/.

In addition to health risks, people living with HIV/AIDS face social and cultural barriers, including stigmatization, discrimination, and rejection from health-service providers, friends, and relatives. These barriers, often worsened by the concurrence of the HIV and tuberculosis epidemics, can affect their access to health and medical services, the quality of services they receive, and their daily livelihoods.

The consequences of HIV/AIDS extend beyond its immediate victims, also affecting surviving family members, communities, and societies. It is estimated that for each woman who dies of AIDS in Africa, two children will be orphaned. More than 90 percent of children orphaned by AIDS live in sub-Saharan Africa, and the numbers are increasing daily. In the next decade, the number of orphans is also expected to increase in Asia, the Americas, Central and Eastern Europe, and the countries of in the Newly Independent States (NIS). In developing countries, AIDS orphans face extreme economic uncertainty and are at higher risk of malnutrition, illness, abuse and sexual exploitation than children orphaned by other causes. In addition, these surviving children must face the stigma and discrimination that accompany HIV/AIDS, leaving them socially isolated and often deprived of basic social services such as education (UNAIDS 2001). For more information about the impact of HIV/AIDS on family members, see RHO's Older Women section.

Because HIV/AIDS affects people during their most productive years, when they are responsible for the support and care of others, it carries profound social and economic repercussions for communities and societies. HIV/AIDS is the primary cause of disease burden in developing countries and accounts for about 2.8 percent of the global burden of disease worldwide. It is now the leading overall cause of death in Africa, accounting for more than 6 percent of the disease burden in some cities, and is the fourth greatest cause of death worldwide.

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Role of prevention in reducing HIV/AIDS

Although AIDS is incurable, the transmission of HIV is preventable. Experience worldwide has shown that prevention works. Efforts made over the past 20 years to reduce HIV transmission have shown that effective prevention strategies operate on many levels and reinforce one another. For example, prevention programs can:

  • Increase people's awareness and knowledge of HIV/AIDS and how to protect against it.
  • Create an environment where people can openly discuss safer sexual and drug-injecting practices and ways to adopt them.
  • Provide services such as access to affordable condoms and clean injection equipment, HIV testing, and treatment for reproductive tract infections (RTIs) including sexually transmitted infections (STIs). (Untreated STIs can greatly enhance the risk of HIV acquisition and transmission. See RHO Reproductive Tract Infections for more information.)
  • Help people acquire the skills they need to protect themselves and their partners.
  • Reform laws to protect people's health and expand their access to health services.

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Demand for care and support for people with HIV/AIDS

Worldwide projections suggest that the number of HIV infections and AIDS cases will increase significantly in the coming years. The figures are especially bleak in developing countries. As the number of people with HIV/AIDS increases, demand for care, including antibiotic drugs and prophylactic antiretrovirals, also increases. Resource-poor countries have typically lacked the ability to provide adequate care for those affected by HIV/AIDS. For example, in Ethiopia in 1996, the estimated number of AIDS cases was nearly four times the total number of hospital beds in the country.

HIV/AIDS is increasingly being viewed not as a fatal and acute disease, but as a chronic disease that, while it cannot be cured, can be managed. The progression from HIV infection to AIDS varies considerably among individuals. On average, the time between HIV infection and AIDS (referred to as the incubation period) is about 10 years; the time between AIDS and death is about two years. There is evidence in developed countries that the incubation period of AIDS is lengthening. People with HIV/AIDS are living longer and are suffering fewer opportunistic infections, probably as a result of better patient care and medical advances in new antibiotic treatment and antiretroviral therapies. Unfortunately, despite recently formed plans in several developing countries to offer widespread access to antiretroviral therapy, these drugs remain expensive and require complex administration procedures. The survival time for people with HIV/AIDS in developing countries is generally much shorter than in developed countries.

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Alternative care models: community-based care and support

Worldwide, countries have long been faced with the daunting task of finding cost-effective ways to provide compassionate care to the increasing number of people with HIV/AIDS. Because of the huge demand for care, inadequate facilities, and lack of financial resources and skills, the worst-affected countries often are those least able to provide care to HIV/AIDS patients. As countries searched for ways to cope with the need to care for people with HIV/AIDS, attention shifted from hospital-based care—the most expensive mode of HIV/AIDS care delivery—to lower-cost alternative care models.

Experience with alternative treatment and care options worldwide has shown that community-initiated care programs are more effective and much less expensive than hospital-initiated care programs. For resource-poor countries, community-initiated care has traditionally been the only feasible option for providing care and support for the continually increasing number of people with HIV/AIDS, although the recent plunge in the cost of antiretroviral drugs and initiatives to provide expanded HIV treatment offer hope to greater numbers of people living with the virus. Components of community-based care and support for people with HIV/AIDS vary among programs. In general, the types of services include counseling and testing, clinical care, home-based care, and social support services.

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Linking prevention and treatment

In recent years, AIDS advocates have worked with pharmaceutical companies to achieve an unprecedented drop in the price of antiretroviral drugs to treat HIV infection in developing countries. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have strengthened this opportunity by launching the “3 by 5” program, a global initiative to provide antiretroviral therapy to three million people living with HIV/AIDS in developing countries by the end of 2005.

Although plans to expand antiretroviral availability and treatment remain nascent in many areas, they represent an important opportunity to link treatment to HIV prevention. As millions of people access treatment in health care facilities, providers will have a unique opportunity to present HIV-prevention messages, offer HIV counseling and testing, and provide services to people who are HIV-positive, HIV-negative, and those who are untested. As antiretroviral treatment decreases infection levels, offering hope for people to live longer and healthier lives, prevention will gain viability, and HIV/AIDS-related stigma may ebb (Gayle and Lange, 2004).

Lessons learned

Efforts to prevent HIV/AIDS and provide care and support to people living with the virus have produced the following lessons learned:

HIV/AIDS and Development

HIV prevention efforts combined with care and support for people living with the virus are essential, but may not be sufficient to confront HIV/AIDS in developing countries. The following are equally important factors in the response to HIV epidemics in low-resource areas:

  • Health is dependent on many social components, including education, employment, and civil rights.
  • Efforts to correct gender disparities and fortify women’s rights have a positive impact on women’s disproportionate share of the HIV burden.
  • Societies that foster and require political accountability are more likely to experience governance that deals openly and effectively with HIV/AIDS (Prah Ruger, 2004).

Prevention

  • Knowledge alone is not enough. People need skills, support, and motivation to change their behavior and avoid HIV infection.
  • The same prevention approach will not work in every setting. Risk and vulnerability vary in every society, and it is not always possible to find and work with all vulnerable groups.
  • Although targeting specific groups is important, complementary efforts to reach the general population—especially young people—are equally essential to HIV prevention.
  • Political leadership and support are critical to an effective response to the HIV/AIDS epidemic.
  • Working with young people is key to HIV prevention efforts. Effective approaches include:
    • HIV/AIDS life-skills education;
    • communications programs involving mass media;
    • condom access;
    • voluntary counseling, testing, and referral services;
    • management of STIs;
    • participation of parents and other adults; and
    • strategies to strengthen the social and economic status of young people.

Care and Support

  • Collaboration with local organizations and agencies can help enhance a project's visibility and effectiveness.
  • By allowing more channels for entry to care and support services, integration of services with local institutions and community groups (e.g., religious institutions, hospitals, local health facilities, schools) help maximize use of scarce resources and skills and increase access.
  • Promotion of community- and home-based care as part of a continuum of care is important in efforts to control the AIDS epidemic.
  • Collaboration with hospital-based services can facilitate continuity of home-based care and support services.
  • Involving community members (including people with and affected by HIV/AIDS, local leaders, traditional healers, families members, women's groups) in the planning and implementation of services is integral to a project's success and helps ensure sustainability of services.
  • Community members and volunteers, especially people with HIV/AIDS, can be trained and supported to provide project services and play a vital role in educating their peers and caring for people with HIV/AIDS (Kerrigan 1999).

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