WHO surveys AIDS treatment access, highlights health gap seen by UNAIDS

Julian Meldrum, Julian Meldrum
Published: 26 November 2002

The World Health Organization has issued a report which, for the first time, tries to measure the extent to which people in low- and middle-income countries have access to treatment and medical prevention services for HIV and AIDS. Based on targets set in the Declaration of Commitment of the UN General Assembly Special Session on AIDS in June 2001, it shows there is still a long way to go before those targets can be met.

Speaking at the launch of the latest global AIDS statistics, Dr Peter Piot of UNAIDS estimated that annual spending in low- and middle-income countries needs to rise from its present level of US $3 billion to US $10 billion by 2005, if access to essential prevention and treatment is to be extended wherever this is possible. Mobilising these resources will depend on activism at community level as well as on national leaders, and the response in wealthier countries is as important as in those most severely affected by AIDS.

The WHO survey is limited to health services, while recognising that any successful response to AIDS must go beyond the health sector. Indeed, more than 30 governments in Africa are now reported by UNAIDS to have established National AIDS Committees that report directly to the President or Prime Minister.

In particular, WHO looked at:

  • voluntary counselling and testing, other than testing of hospital patients who are unwell, for diagnostic purposes
  • prevention of mother-to-child transmission
  • antiretroviral therapy with three or more drugs in combination
  • treatment of opportunistic infections
  • prophylaxis (medical prevention) of opportunistic infections using cotrimoxazole or isoniazid
  • screening of blood donations in transfusion services
  • DOTS (directly observed treatment, short course) for tuberculosis

In each case, WHO estimated the number of people who would need the services in each country (excluding wealthy countries such as the USA, Canada, European Union, Japan, Australasia).

For example, the need for ARVs was estimated at twice the number of people who died from AIDS during one year. This was on the basis that people who meet current criteria for treatment would have an average life expectancy of two years if they remained untreated. This would be a conservative estimate, if the number of people dying with AIDS in a country is rising.

It then consulted experts within each country to assess the situation as it stood in 2001, in the level of access provided. To combine these figures on a regional basis, they were weighted according to the relevant populations. The levels of access provided in larger countries such as Brazil or Nigeria would therefore count more heavily in determining the overall figures than access in smaller countries such as Costa Rica or Botswana.

Access to voluntary counselling and testing

WHO estimated the annual need for VCT in each country as twice the estimated national prevalence of HIV, spread over five years.

Overall, WHO estimates that only 12% of the people who need access now have it. Coverage is high in south America, moderate in south east Asia and (eastern) Europe, and generally low in Africa and the western Pacific.

Prevention of mother-to-child transmission

Here the need is based on an estimate of the number of live births, assuming that all should have access to counselling, testing and - where necessary - treatment including ARVs and advice and support on appropriate infant feeding.

The challenges vary between regions, depending on HIV prevalence and current access to antenatal care and trained birth attendants.

In the Americas, coverage is estimated at 35% on average, reflecting the huge commitments made by Brazil and the Caribbean countries to developing services to prevent mother-to-child transmission. Coverage elsewhere ranges from just 1% in Africa to 2% in eastern Europe and south east Asia, and 3% in the western Pacific region. These figures are set to change, as many countries have pilot programmes and plans to scale up their provision in the near future.

Access to antiretrovirals

Of the countries surveyed by WHO, half reported that antiretroviral treatment is not available in the public sector. Another 30% made it available to less than one quarter of the population. Only 11% of countries reported wide availability in 2001.

As with prevention of mother-to-child transmission, most ARV treatment is provided in the American region, where Argentina, Brazil, Chile and Cuba are reported as offering it to all who need it. Since Brazil also has the largest epidemic in the region, this gives rise to a weighted average coverage of 25% for the Americas, compared to 4% for eastern Europe and south east Asia, 2% for the western Pacific, and just 1% for Africa. WHO estimates that 4.4 million people in Africa need ARV treatment out of a global total of 5.4 million in less developed countries.

In 2001, Cameroon provided ARV treatment to 12,780 people with HIV through 16 treatment centres run by NGOs or public authorities. Uganda was treating between 5,000 and 8,000 people, and otherwise only Cote d'Ivoire and Malawi had more than 1,000 people on ARV treatment, in the whole of the African public health sector.

Care and treatment

Describing levels of care and treatment is difficult, since what is needed is complex and varied. WHO has drawn up lists of needs and classified them in packages of 'essential', 'intermediate' and 'advanced' services. They then asked local experts to estimate levels of access to each for the capital city, other urban areas, and for rural areas in each country surveyed.

Brazil and Mexico, two of the largest countries in the Americas, provide high levels of 'advanced' care and treatment for people with HIV. Otherwise, most people with HIV lack even the essential decent minimum levels of medical care and treatment. More than two thirds of people with HIV in Africa and Asia fall into this category.

Prophylaxis against opportunistic infections

WHO estimated the need for this as equal to the need for ARV treatment. It finds that cotrimoxazole and isoniazid are very under-used, especially where the need is greatest. In Africa, only 2% of adults and 1% of children who should be offered prophylaxis were receiving it in 2001. However, in south east Asia, the figure was supposedly closer to 32% for adults, though whether this takes account of reported difficulties people have in adhering to this treatment is unclear.

Blood safety

While more than 90% of donated blood is reportedly screened for HIV, there is still some risk attached to transfusion in many countries. Some transfusions occur on an emergency basis, outside of formal blood services. Sometimes shortages of test kits lead to breakdowns in screening procedures. (And, in countries where incidence is very high, antibody tests would inevitably miss a significant minority of cases of HIV infection among blood donors.) There are still a very few countries in Africa, south east Asia, and even the Americas, which have not implemented universal screening of donated blood.

DOTS treatment for tuberculosis

The one area of treatment in which African provision can sometimes match, or improve on, that offered in other parts of the world, relates to tuberculosis. On average, around 36% of the African population have access to treatment provided according to WHO's recommendations. While this is not good enough to eradicate TB it does point to the potential, greatly to expand access to other forms of HIV treatment and care.

For the future, WHO has committed itself to carrying out more detailed surveys to get a more accurate picture of real levels of access to services. However, what they have done already is invaluable as a reference, a bench-mark and a wake-up call for the global response to AIDS.


WHO Coverage of selected health services for HIV/AIDS prevention and care in less developed countries in 2001. Geneva: World Health Organization, 2002.

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