The need to implement an expanded and comprehensive response (ECR) to the HIV/AIDS pandemic is urgent. Leaders of nations and other stakeholders now recognize this pressing need and are calling for expanded programs for both communities and individuals. The signing of the Declaration of Commitment by governments at the United Nations General Assembly Special Session in June 2001 empowers stakeholders at the global, national and local levels to respond to the pandemic with bold action.
Many countries have begun scaling-up to expand delivery of interventions and programs to more individuals; a special focus has been on the profound numbers of HIV/AIDS orphans and vulnerable children (OVC). ECR strives to ensure quality, improve accountability systems and increase the range of interventions and programs that are delivered to populations not currently served.
Strategies for an Expanded and Comprehensive Response (ECR) to a National HIV/AIDS Epidemic: A Handbook for Designing and Implementing HIV/AIDS Programs is designed to help countries implement an ECR. The Handbook builds on global thinking and consultation on ways to make an impact on the epidemic based on two decades of HIV/AIDS work around the world. The Framework on Global Leadership on HIV/AIDS (UNAIDS, November 2000), through extensive consultation with an array of stakeholders, provides a common strategic approach for significantly reducing infection rates among young people in the most affected countries by 2005. The NGO sector, in work such as Expanding and Strengthening Community Action, Displaced Children and Orphans Fund of USAID (2000), has examined expanding and strengthening community action to mitigate the impact of HIV/AIDS on children and families. And UNAIDS' "Best Practices" document, Expanding the Global Response to HIV/AIDS Through Focused Action, helped the global community understand the programmatic links between risk, vulnerability and impact. This Handbook complements these and other documents to provide practical tools for applying ECR. Experts in HIV/AIDS prevention, care and support, strategic planning, operational issues, capacity development, resource allocation, and monitoring and evaluation all contributed to the Handbook. It offers specific strategies, both operational and technical, for developing an ECR, and it can be adapted to meet the needs of various populations at different levels of the epidemic.
The Handbook is a living document that will change as the epidemic evolves and as we learn more from our responses to it.
The Handbook is divided into eight modules, each with essential information for implementing ECR. The text raises key questions that must be addressed locally, features informative case studies and directs users to reading lists for more in-depth information.
The Handbook is based on the premise that sufficient resources – both local and international – can be mobilized effectively to enable the rapid delivery of an ECR to the global HIV/AIDS pandemic. It is technically and operationally feasible to expand the delivery of HIV/AIDS interventions within countries, and this book defines strategies for doing so. Key challenges to developing an ECR include enhancing absorptive capacity, building infrastructure, increasing technical and operational capacity and designing accountability systems to ensure that resources are used effectively. The Handbook describes strategies to deal with each of these challenges, which require significant investment by countries and the international community.
It is only through the expanded and comprehensive delivery of proven interventions that the global battle against HIV/AIDS can be won. This battle requires the full support and investment of nations and the international community in building and refining the necessary systems and infrastructure.
Background
The global HIV/AIDS pandemic is the worst infectious disease crisis to confront the world since the bubonic plague halved the population of Europe in the five years after its arrival in 1347. To date, 22 million people have died of AIDS worldwide; another 36 million live with HIV/AIDS today.
The situation in Africa is particularly alarming. In 1998, an estimated 200,000 Africans died from war, while 2.2 million Africans died from AIDS. Approximately 5.3 million adults and children in 2000 became infected with HIV. Each day in Africa, there are an estimated 5,500 AIDS deaths and 11,000 new HIV infections.
The massive loss of human life will continue to change the social, economic and political structure in African countries in ways that have not yet been imagined. This loss will forever change relationships at family, community and political levels. One measure of the massive social change still to come is the growing number of orphans, children affected by HIV/AIDS and other children made vulnerable by the pandemic. In 2010, 20 percent to 30 percent of all children under age 15 will be orphaned in 11 sub-Saharan African countries, even if all new infections are prevented and some form of treatment is provided to slow the onset of AIDS in those living with HIV.
HIV/AIDS is increasing dramatically in the Asia and Pacific Region. India leads Asia in absolute numbers of individuals living with HIV/AIDS, estimated to be between three million and five million. China, while not as affected by HIV/AIDS as countries further south, has a growing problem, with seroprevalence rates (now estimated at 0.1 million to 0.4 million) increasing rapidly. The number of people with HIV/AIDS in this region may grow larger than the total in sub-Saharan Africa in absolute numbers before 2010.
HIV also is spreading rapidly in Latin America. Prevalence is high in Brazil and in the Caribbean countries, with the exception of Cuba. Deteriorating health care infrastructures are causing a dramatic rise in HIV in Russia, the Newly Independent States (NIS) and, to a lesser extent, in Eastern Europe (as a result of economic difficulties). After a slow and late start, HIV is spreading rapidly throughout the European part of the NIS beyond the original cohort of injection drug users. An estimated 270,000 people were HIV-positive in 1998, representing a more than five-fold increase from 1997. Although Ukraine has been hardest hit, Russia, Belarus and Moldova have registered major increases. Russian Health Ministry officials predict that the HIV-positive population in Russia alone could reach two million by 2002.
Recognizing the magnitude of this global crisis, leaders from civil society, governments and multinational agencies declare HIV/AIDS the single most critical security and development issue facing the world today. Developing, financing and implementing programs to slow the spread of HIV and reduce the impact of HIV/AIDS are now among the highest priorities for civil societies.
Adequate resources remain a key challenge for success. While a growing number of effective clinical and behavioral interventions are being made available to reduce HIV transmission and improve care and support for those living with HIV, the resources available for countries to effectively implement these interventions is insufficient. Experts estimate that $9 billion (US) is required annually to provide a minimum package of prevention, care, treatment, infrastructure strengthening and capacity building.
Defining an Expanded and Comprehensive HIV/AIDS Response
During the 1980s and 1990s, we identified some appropriate responses, but neither the rate of transmission nor the impact of the pandemic has been reduced sufficiently. Experience has provided lessons and tools that can help develop and implement ECR.
Worldwide, new attention has been devoted to scaling-up HIV prevention activities. It is important to note the difference between scaling-up and ECR. Scaling-up refers to increasing the geographic coverage and number of individuals served by a program. ECR addresses this, but also focuses on increasing coverage to different population types and improving the quality and scope of the services offered and the accountability systems. The ultimate goal is to ensure that a comprehensive range of interventions and programs are delivered to reduce the transmission and impact of HIV on the population.
There are four key expected results of ECR:
- Reduction in HIV transmission
- Reduction in AIDS morbidity and mortality
- Improved quality of life for people living with HIV/AIDS
- Lessening of the impact of the epidemic in affected locations and populations
Many factors must be reviewed when countries consider strategies and options for implementing ECR. They include:
- Financial resources
- Infrastructure
- Absorptive capacity
- Technical and operational capacity
- Financial management systems
- Financial accountability
- Continuing disruption of health, social and economic infrastructures
Because these elements often are underdeveloped, the challenge is to devise strategies to address them. Successful outcomes of ECR can be affected by:
- Mobilization of resources
- Mobilization of civil society, political support and commitment
- Strength and type of leadership from key sectors and organizations
- Technical and organizational capacity in both the public and private sectors
- Level of commitment to inter-sectoral and multi-sectoral expansion
- Resource management systems
- Decentralization of planning, funding and program implementation
- Monitoring and evaluation systems
Chart 1 summarizes the ECR conceptual framework, using the information above.
Chart 2 illustrates the key elements for ECR.
