Speech Delivered By The WHO Regional Director For Africa, Dr Luis Gomes Sambo, At The Opening Of The Second SADC Military Workshop On HIV/AIDS Luanda, 27 September 2011
- Honourable Minister of Defence, General Cândido Van-Dúnem;
- Honourable Ministers and Deputy Ministers;
- Excellency Chief of Defence Staff of Angola;
- Distinguished Members of the Angolan Armed Forces;
- Excellency Chief of the Angolan Armed Forces Health Services and Chairman of the Organizing Committee, Lieutenant-General Dr Aires Africano;
- Distinguished Participants in this Second SADC Military Workshop on HIV/AIDS;
- Military Generals; • Senior Officers;
- Excellency Chairman of the Angolan Association of Medical Doctors;
- Excellency United Nations Resident Coordinator, Mrs Maria do Valle Ribeiro;
- Distinguished Guests;
- Ladies and Gentlemen
I would like, first and foremost, to thank the Minister of Defence for inviting me to this gathering and for giving me the opportunity to address such an important global public health issue that disproportionately affects the African continent. Due to its importance from the political, economic and social standpoints, HIV/AIDS is one of the Millennium Development Goals (MDG6) and a priority in the Strategic Directions for WHO Action for the period 2010-2015. I am therefore pleased to note that HIV/AIDS will be the focus of discussion at this three-day workshop.
About 30 years ago, the US Centers for Disease Control and Prevention (CDC) made an announcement to the entire world about the clinical records of five youths from Los Angeles, aged between 29 and 36 years. That announcement has become, as it were, the beginning of the history of this terrible disease called Acquired Immunodeficiency Syndrome (AIDS). While HIV was considered initially as limited to some risk groups, it soon became obvious through research and epidemiological surveillance that the entire world population is exposed to the risk of infection. All continents, all strata of society and all age groups, without distinction, are affected by AIDS.
Currently, more than 33 million people are affected by HIV worldwide including 20 million people in sub-Saharan Africa. That accounts for 67% of the global burden of HIV infection. Southern Africa is the subregion most affected by the infection.
From the onset of the AIDS epidemic, much importance was attached to surveillance of the disease. Consequently, with the support of the World Health Organization and other international partners, ministers of health established surveillance sites especially in antenatal services with a view to monitoring the trends of the epidemic particularly among pregnant women. Data gathered during the period from 2007–2009 among pregnant women attending antenatal clinics show that SADC countries are the most affected, with prevalence ranging between 2.8% and 39% as opposed to 2%– 7% in countries of East Africa, 0.6%–7% in countries of Central Africa and 0.1%–3.7% in countries of West Africa. Even so, average prevalence of HIV/AIDS among pregnant women visiting antenatal clinics in the African Region increased from 9.5% in 2000 to 3.4% in 2008.
Furthermore, prevalence studies carried out among the general public show that there are intersubregional variations in prevalence trends and that women are more affected than men, hence the emergence of the expression “feminization of HIV/AIDS”. Monitoring of the number of new infections over the years shows that there has been a decrease by 25% in 22 countries of the African Region.
HIV testing and counselling is an entry point to AIDS prevention. Despite the notable progress in this area, with nearly 31 000 health units in the African Region carrying out 31 million HIV tests in 2009, the truth is that about 75% of people aged between 15 and 49 years do not know their HIV serological status. This situation should be improved. It is worth noting that the percentage of health units providing HIV testing and counselling services is highest in Southern Africa compared with other subregions.
From the onset of the AIDS pandemic significant importance has been attached to prevention because “prevention is better that cure”, as the saying goes. Where there is no cure, as is the case of AIDS, then prevention becomes even more important. It became evident much early that abstinence, fidelity between partners, condom use, and dissemination of information on HIV/AIDS and its means of transmission, are the cornerstone of primary prevention. Use of female condoms was added later to the tools of prevention. Despite the difficulty in accurately assessing the percentage of condom users, population and health studies show that condom use is increasing in sub-Saharan Africa. For example, statistics from Botswana show that at least 80% of men in the country use condoms in high-risk sexual intercourse.
Vertical transmission, which has been practically eliminated in developed countries, is a major source of concern in our Region. The truth is that more than 90% of HIV-positive children worldwide are in sub-Saharan Africa and more than 90% of them were infected through vertical transmission. Yet, the percentage of pregnant women who test for HIV is higher in Southern Africa than in the remaining subregions. The same applies to HIV-positive pregnant women receiving antiretroviral treatment for preventing vertical transmission.
Concerning male circumcision, it has been found that in some countries of our Region (e.g. Mali, Mauritania and Senegal) prevalence of the disease is lower in areas where the practice is common than in areas where it is not practised. Subsequently, in 2007 a study in Kenya, South Africa and Uganda showed that male circumcision actually reduces HIV transmission from women to men by nearly 60%. A consultative meeting of the UNAIDS/WHO expert group in March 2007 finally recommended that male circumcision be included in the package of HIV prevention measures. Thirteen countries of the African Region are striving to scale up the use of male circumcision as a preventive measure. The countries are Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe in Southern Africa as well as Kenya, Rwanda and Uganda. In addition to the traditional surgical method of male circumcision, new methods are being developed currently and some of them have proved to be promising. Meanwhile the WHO Advisory Committee on male circumcision has set out the criteria and the steps to follow for prequalification of new methods of male circumcision prior to their use on large scale.
As regards antiretroviral treatment, progress was slow at the beginning. However, thanks to persistent efforts, research has been robust and constant and, as a result, about 30 antiretroviral medicines are currently available. These medicines make it possible: (i) to prolong and improve the quality of life of AIDS patients; (ii) to ensure that people living with HIV have a more productive life; (iii) to reduce AIDS mortality; and (iv) to give HIV-infected parents an opportunity to care for their children for much longer periods. Administration of antiretroviral treatment for people living with HIV is based on criteria set by WHO, namely diagnosis of the disease and CD4 cell count.
Based on the experience gathered over time, WHO, in 2010, reviewed and updated the criteria for the treatment of adults, pregnant women, adolescents and children so that treatment can start as early as possible using safer medicines. The treatment is life-long and should not be interrupted. The average cost of a first-line treatment (only medicines excluding the cost of laboratory tests and other related expenses) is about US$ 137 per person per year.
All countries of the African Region have made substantial progress in antiretroviral treatment and care provision for AIDS patients. This became possible thanks to political commitment, continuing technical support and substantial financial investments from both national and international sources. 3 By the end of 2009, more than 3 912 000 People Living with HIV were receiving antiretroviral treatment, representing a coverage of nearly 37% compared with 800 000 in 2005. Although this undoubtedly represents a major progress, the fact remains that more than two thirds of people in need of treatment have no access to it.
Furthermore, progress has been made in decentralizing the distribution of antiretrovirals and, as a result, they are increasingly accessible to those who need them. For example, the number of treatment centres increased from 2000 in 2005 to over 8278 in 2009. A survey conducted by WHO in 2010 showed that 97% of children and 97% of adults receiving antiretroviral treatment in the African Region started first-line treatment, which is a good option. Unfortunately, for various reasons including management-related problems, there have been stock-outs of medicines in some countries, with attendant interruption of treatment of patients, sometimes resulting in emergence of resistance to first-line medicines or even in death of the patients. Such situations should be avoided at all costs as they involve human lives that are being endangered.
Tuberculosis continues to be the commonest opportunistic infection among People Living with HIV. About 35% of TB cases are HIV-positive while 40% of deaths of People Living with HIV are due to tuberculosis. This underscores the extreme importance of forging closer collaboration between the two programmes for the benefit of patients. As I have already mentioned in connection with antiretroviral therapy, interrupting the treatment of TB cases poses a great danger for it can contribute to the development of drug-resistant TB (MDR-TB and XDR-TB) which is a major public health problem, yet easy to treat. HIV-positive TB patients should therefore be given both treatments systematically and should be properly monitored while avoiding treatment interruption at all costs. Available statistics show that the number of people with TB/HIV co-infection in the SADC subregion is higher than anywhere else in the African Region.
Thirty years after the discovery of AIDS, some progress has been made in AIDS control in Africa. By the end of 2009, HIV incidence had been reduced by 25% in 22 countries of sub-Saharan Africa. In some countries, HIV/AIDS-related deaths have dropped by 11% to 72%. However, much remains to be done. Against this background, Heads of State and Government at a special summit in Abuja in 2006 decided to turn into reality universal access to prevention, treatment and care for HIV/AIDS, malaria and tuberculosis.
With specific regard to HIV/AIDS, the key interventions for achieving the objective of universal access are:
- Public education on the risk factors, namely drug and alcohol abuse, having multiple partners, ignorance, certain cultural practices, etc.
- HIV testing and counselling as an entry point to prevention. This matter of great importance has not been given adequate attention as evidenced by the figures I enumerated earlier. It would be advisable for the military to devote more attention to this matter.
- Primary prevention, through using various methods: abstinence; fidelity and/or reduction of the number of partners; use of condoms (by males and females); early and effective treatment of sexually-transmitted infections; post-exposure prophylaxis by using antiretrovirals; safe blood transfusion and prevention of nosocomial infection.
- Prevention of vertical transmission, which is part of primary prevention, deserves emphasis, given its importance. That can be done through screening pregnant women in antenatal examination and including them in antiretroviral treatment programme.
- Male circumcision, which is also part of primary prevention, must be given emphasis due to its specificity and its growing importance in the Region, suffice it to mention that new methods of circumcision are becoming available on the market.
- Antiretroviral treatment, to be started as early as possible based on new WHO criteria (CD4 cell-count <350 per mm2 ), while ensuring its accessibility to patients in need.
- Control of HIV/TB co-infection.
It is important to note that the only way to make a significant impact on the trends of the epidemic in the African Region is to use the multisectoral approach and a combination of interventions.
Before I end my speech, permit me to address some issues related to other components of MDG6, namely: malaria and some infectious diseases of epidemic potential.
Notwithstanding the progress made by African countries in the past five years, malaria continues to be a major cause of illness and death. The WHO World Malaria Report 2010 indicates that nearly 80% (225 million) of malaria cases and 90% (781 000) of malaria deaths worldwide are in the African Region.
In 2010, 23 countries of the Region recorded a reduction of more than 50% of malaria cases and deaths, which indicates that it is possible to control and even eliminate the disease. For its part, Southern Africa recorded over 50% reduction of malaria cases and deaths in health facilities.
With regard to infectious diseases of epidemic potential, starting with cholera, more than 90% of cases reported to WHO are in the African Region. Every year, 20 countries in our Region report more than 100 000 cases with nearly 3100 deaths. Six SADC countries, namely Angola, Democratic Republic of the Congo (DRC), Malawi, Mozambique, Zambia and Zimbabwe reported outbreaks of cholera epidemic in 2011. This problem is multisectoral and the challenges in controlling cholera are related to access to safe drinking water and basic sanitation in addition to lack of hygiene.
Concerning viral haemorrhagic fevers, it should be recalled that the most lethal fevers are caused by Ebola virus and Marburg virus.
Since the discovery of Ebola in 1976 up to the year 2008, 20 outbreaks of epidemics of Ebola fever have already been recorded. An estimated 2293 cases have been recorded causing 1536 deaths. The lethality rate ranges between 50% and 95%. Congo, DRC, Gabon and Uganda were the countries affected by the Ebola epidemics.
With regard to Marburg virus epidemics, between 1980 and 2007, there have been more than 358 cases with 282 deaths, at an estimated lethality rate of 78%. The affected countries were Angola, DRC, Kenya, South Africa and Uganda.
The epidemiological profile of the African Region is dominated by infectious diseases which alone account for about 65% of mortality. However, there is absolute need to keep an eye on chronic noncommunicable diseases because their incidence is rising at an alarming rate. There is scientific evidence that chronic noncommunicable diseases have four main common risk factors: tobacco use, harmful use of alcohol, lack of exercise and poor dietary habits. It would be highly important, therefore, that the armed forces implement a noncommunicable diseases control programme directed at prevention of the risk factors.
I thank you very much for your attention.
