《卫生经济学》课程参考文献（WHO年度报告）：World Health Report 2004 changing history

l0 The World Health Report 2004 global emergency: a combined response 11 Studies previously misinterpreted the effects of epidemics as being simiar No velopment Goals) b being undermined with ng-term negathe consequences. fering from a lack of healt milady, 邮加应 apital with which to work The result of these misinterpretations and assur he impact of HIN/AIDs on the health sector is often enormous. The severity and tionally and intema ionally to revise economic policies to mplexity of clinical opportunistic conditor ce account of HIAIDS tion rates, inpatient mortaly and increasing treatment costs. In some sub-sahar 3.Ⅲ enditures, with substantial improvements in the quality of life of patients. Chapter 4 deals at ngh wih the key issues linking HI auce human capcal and the abilty totransmit it, and contnbu e to a long-term decline wen the daunting social and economic consequences of the spread of Hv, the n e wery first days of the epidemic n the 1980s. The next section looks at the cun nga of prevention and care strategies in play around the world. PREVENTION CARE AND SUPPORT: STRATEGIES FOR CHANGE ing in Africa, tor exampl, I expectations. The survial and functioning of institutions in a number of alysis of agricultural services, judici sure that those who test positive are lnked to counselling Box 1.3 Prevention and treatment in Brazil and the bahamas reats to regional security caused by attect economic actities such as tourism ( )or il ns and a 38%d who survive. The effort to enrol all chldren in schocl by 2015(one

10 The World Health Report 2004 a global emergency: a combined response 11 Studies previously misinterpreted the effects of epidemics as being similar to those caused by one-off shocks, such as natural disasters or international economic downturns, which many economies can absorb and which are beyond the control of planners. Predictions have also frequently refl ected assumptions that the worst-hit countries in Africa had an excess of labour, and suggested that a contraction in work￾force numbers might lead to more effi cient use of land and capital. The belief was that GDP per capita would actually increase if a fall in GDP were lower than the fall in population. Similarly, it had been thought that the destruction of the labour force and hence the reduction in labour supply caused by HIV/AIDS could result in an increase in the productivity of each remaining worker because each would have more land and capital with which to work. The result of these misinterpretations and assumptions was a widespread failure nationally and internationally to revise economic policies to take account of HIV/AIDS. HIV/AIDS will have long-term and widespread effects that will last for generations, and which do not reveal themselves in many economic studies. Ill-health and prema￾ture death lead to wasted investment in human capital and globally reduce the incen￾tives to invest in building for the future. An inadequate response to HIV/AIDS will allow the disease to continue to destroy education systems and other vital institutions, re￾duce human capital and the ability to transmit it, and contribute to a long-term decline in savings and investment. There will therefore be substantial benefi ts in responding to epidemics – even those of low prevalence. The threat of institutional collapse The implications of reduced life expectancy in adults for societies heavily burdened by HIV/AIDS are becoming clear, though previous poor performance of institutions has sometimes obscured the specifi c impact of HIV/AIDS (35). Institutional malfunction￾ing in Africa, for example, has been concealed by long-running ineffi ciency and low performance expectations. The survival and functioning of institutions in a number of southern African countries are now threatened. Incapacity is critical. Already there are major shortages of qualifi ed personnel in key organizations. Posts are vacant or occupied on an “acting” capacity. Continuity of staff is low because of deaths and the reshuffl es they occasion. Morale is equally low. Numerous studies and anecdotal evi￾dence point to the slowing down and near paralysis of agricultural services, judiciaries, police forces, education systems and health services. Many African businesses have also been severely affected by reduced labour supply, especially the loss of experienced workers in their most productive years, increased absenteeism, reduced profi tability and loss of international competitiveness (36). Threats to regional security caused by the epidemic are another example of indirect impacts that may negatively affect economic activities such as tourism (37) or infl ows of foreign investment (38). Across southern and eastern Africa, the education sector is suffering as the loss of teachers exceeds those being trained (39). This is not only a result of AIDS-related illness and death: some teachers are being hired by the private sector, which is also in need of skilled personnel, while others are migrating. The effects are masked by the fact that fewer children enrol in school because HIV/AIDS-affected families cannot afford school fees or need their children to work at home. The result will be lower edu￾cational achievement, with negative implications for efforts to reduce poverty, improve gender relations and decrease HIV transmission, and for the overall health of those who survive. The effort to enrol all children in school by 2015 (one of the Millennium Development Goals) is being undermined with long-term negative consequences. One of the many tragedies of HIV/AIDS is that it often strikes hardest where health systems are weakest, and deals a double blow. Systems that in any case cannot cope are weakened further by HIV/AIDS deaths and disability among large numbers of health personnel (see Chapter 4). In low-income countries which were already suf￾fering from a lack of health care workers, health care systems are overburdened. In Côte d’Ivoire and Uganda, 50–80% of adult hospital beds are occupied by patients with HIV-related conditions. In Swaziland, the average length of stay in hospital is six days, but in 80% of cases increases to 30 days for patients with tuberculosis associ￾ated with HIV (40). The impact of HIV/AIDS on the health sector is often enormous. The severity and complexity of clinical opportunistic conditions are associated with high hospitaliza￾tion rates, inpatient mortality and increasing treatment costs. In some sub-Saharan countries, the rate of general hospital bed occupation by AIDS patients is frequently higher than 50%. The introduction of antiretroviral therapy, however, has been shown to lead to a sharp reduction in HIV/AIDS-related mortality, morbidity and care ex￾penditures, with substantial improvements in the quality of life of patients. Chapter 4 deals at length with the key issues linking HIV/AIDS, health systems and treatment expansion. Given the daunting social and economic consequences of the spread of HIV, the need for effective and wide-ranging methods of prevention is as clear as it has been since the very fi rst days of the epidemic in the 1980s. The next section looks at the current range of prevention and care strategies in play around the world. PREVENTION, CARE AND SUPPORT: STRATEGIES FOR CHANGE HIV/AIDS may not be curable, but it is certainly preventable and treatable. It has been estimated that almost two-thirds of the new infections projected to occur during the period 2002–2010 can be prevented if the coverage of existing HIV prevention strate￾gies is substantially increased (41). Prevention efforts can and do work to halt the spread of the virus, and real advances in treatment hold out the hope of longer and better lives for those already infected. Scaling up treatment must become a way to support and strengthen prevention programmes. Careful integration of prevention and treatment services will ensure that those who test positive are linked to counselling and treatment, which can lead them to protect others from infection (42). Furthermore, and increasing. In 1999, 62% of men reported condom use at last sexual intercourse, and in 2000 and 2002, 70% did so. Condom use with a paid partner in the previous year increased from 69% in 1999 to 77% in 2002. The impact of prevention interventions was also observed among injecting drug users. The most signifi cant reduction in the index of sexu￾al risk behaviour was found in this group (43). Similarly, in the Bahamas, the introduction of antiretroviral therapy has been accompa￾nied by heightened prevention successes, in addition to significant reductions in deaths The Brazilian experience shows that scaling up antiretroviral treatment enhances, rather than impedes, prevention efforts if they are scaled up simultaneously. Since 1996 (the year Brazil’s universal antiretroviral drug dis￾tribution programme began), sexual behav￾iour, and more recently HIV prevalence, have been monitored among nearly 30 000 male army conscripts. In 1999–2002, over 80% of the conscripts were sexually active and the proportion with multiple partners remained steady; but HIV prevalence among the men was low (0.08%) and condom use was high (56% reduction in deaths from AIDS, includ￾ing an 89% reduction in deaths among chil￾dren). The success of prevention efforts is also evident from the fact that mother-to-child transmission of HIV was reduced from 28% to 3%; there was also a 44.4% reduction in new HIV cases, a 41% decline in HIV prevalence rate among patients being treated for sexually transmitted infections, and a 38% decline in HIV prevalence rate among pregnant women (44). Box 1.3 Prevention and treatment in Brazil and the Bahamas

2 The World Health Report 2004 a global emergency: a combined response 13 eople who might othenwise be afraid to undergo testing are more likely to seek Level ot social and ec transmitted intections and HI/AIDS ey hawe access to treatment(see Box 1.3) Preventing the sexual transmission of HIV populations, as long as they use evidence- y chosen prevention measure requires that people not only have the proper r cients in Africa, Asia and Latin America are effective In Abidjan(Coe d hire) Box 1.4 Cambodia and Thailand-successes and challenges 四 sk-sex nationwide gratin effors iyer mante“m数h地2 transmitted infections-especially those most linked to HIv transmission -in th elevated risk rep 量喜 others appear. Programmes peaple have over the last few years, and that HIV prealence among them has dropped sL in tum that focused p ther sexually transmitted infections 一mc the East. young peopl remans Sexually transmitted infections increa to tive tmes (49). They help drive the spread of HIv. If untreated, they not only increase risks n sex work be as effecte and aggressive In bath countries, the rdde od sex work in Hw lookng at emanding epidemics wth 10-15% wth new evanna pattems of risk 50, 51 Current and projected impact of prevention efforts ntrol sexually transmitted infections have important eftects even in more adanced Preventing infection in infants and children that 5-20% of born to HM-indteced women acquire most effective ways to prevent infection in imants and young children are to sB90999的0的t0 ntected women. It is also possible, I

12 The World Health Report 2004 a global emergency: a combined response 13 people who might otherwise be afraid to undergo testing are more likely to seek services for sexually transmitted infections and HIV/AIDS when they have access to treatment (see Box 1.3). Preventing the sexual transmission of HIV Prevention approaches can work in many populations, as long as they use evidence￾based strategies, carefully tailored to the social and economic settings in which they are implemented and to the state of national HIV/AIDS epidemics. A comprehensive approach that supports social and individual rights, involves communities and is de￾veloped on the basis of their cultural values has been found to be effective when com￾bined with the promotion of consistent condom use, voluntary testing and counselling for HIV, and delayed sexual initiation. Promotion of other strategies, such as abstinence and reduction in number of partners, also needs to be based on fi rm evidence. Level of social and economic development, and cultural factors such as gender in￾equality or access to education and health care, are all known to be obstacles to the successful implementation of prevention initiatives. Interventions that reduce the ef￾fects of such obstacles – by implementing measures that allow girls to stay in school for longer, for example – can have a lasting impact on rates of HIV transmission. The promotion of human rights, combined with behavioural change programmes, also helps (45, 46). Lessons learnt from various settings and communities show that the use of any chosen prevention measure requires that people not only have the proper knowledge but also the ability to apply it. Consistent condom use demands a reliable distribution system to people who live in poverty or in diffi cult-to-reach areas (47). Interventions that have targeted popula￾tions at high risk such as men who have sex with men and female sex workers and their clients in Africa, Asia and Latin America are effective. In Abidjan (Côte d’Ivoire) and Cotonou (Benin), HIV prevalence among sex workers declined during the 1990s and the increased use of condoms contributed signifi cantly to these declines (48, 49); similar changes have been observed in sex workers in Cambodia and Thailand (see Box 1.4). Evidence from a South African mining community showed that interventions among those most at risk increased condom use and greatly reduced rates of sexu￾ally transmitted infections – especially those most linked to HIV transmission – in the community (52). Effective prevention programmes aimed at young people can teach them responsible and safe sexual behaviour, according to some of the latest research. Recent fi ndings from Uganda indicate that young people have changed their behaviour considerably over the last few years, and that HIV prevalence among them has dropped (53). Breaking the link with other sexually transmitted infections Sexually transmitted infections increase the risk of HIV transmission by at least two to fi ve times (49). They help drive the spread of HIV. If untreated, they not only increase the infectivity of HIV-positive individuals but also make those who are HIV negative more susceptible to infection. Early detection and treatment, and related efforts to reduce the prevalence of these infections, should therefore be an integral component of a comprehensive HIV prevention effort. The potential benefi ts are probably greatest in the early stages of a national HIV/AIDS epidemic when the virus spreads as a result of high rates of change of sexual partners, but evidence suggests that measures to control sexually transmitted infections have important effects even in more advanced epidemics. Preventing infection in infants and children Every year an estimated 2.2 million pregnant women infected with HIV give birth, and about 700 000 neonates contract HIV from their mothers. HIV transmission from mother to child may occur during pregnancy, labour and delivery, or during breast￾feeding. In the absence of any intervention, 14–25% of children born to HIV-infected mothers become infected in developed countries, 13–42% in other countries (54). This disparity is mostly a result of different breastfeeding practices. It is estimated that 5–20% of infants born to HIV-infected women acquire infection through breast￾feeding. The most effective ways to prevent infection in infants and young children are to prevent HIV infection in women and to prevent unintended pregnancies among HIV￾infected women. It is also possible, however, to prevent most cases of transmission transmission was realized early on and major nationwide prevention efforts were mounted, working not only with brothel owners and sex workers, but also reaching out to the large cli￾ent populations – almost 20% of adult males in the early 1990s. In response to these pro￾grammes, condom use between sex work￾ers and clients rose to more than 90%, and the number of men visiting sex workers was halved. Using this Asian Epidemic Model, the East￾West Center and its collaborators have ex￾plored the impacts of these prevention efforts. Without aggressive prevention programmes, it is estimated that both countries would now be looking at expanding epidemics with 10–15% HIV infection in Asia remains largely confi ned to those people at higher levels of risk – sex workers, injecting drug users, men who have sex with men – and their sexual partners. Those at elevated risk represent anywhere from 7% to 25% of the adult population, mak￾ing severe epidemics a possibility in all the countries of the region. However, the focused nature of risk means in turn that focused prevention efforts with high coverage can slow or reverse the course of the epidemics. By mounting intensive, well￾funded and extensive efforts to reduce the risks in sex work, Cambodia and Thailand have changed the course of their epidemics. In both countries, the role of sex work in HIV of their adult populations living with HIV/AIDS, instead of the declining epidemics of 2–3% currently seen. But as one avenue of HIV transmission is closed off, others appear. Programmes for injecting drug users, men who have sex with men, and sexually active young people have been weak and ineffective to date. The epi￾demic among injecting drug users in Thailand continues unabated, condom use among young people remains low at around 20%, and there are HIV levels of around 15% in men who have sex with men. If the two countries are to sustain their past successes, they must adapt responses to be as effective and aggressive with new evolving patterns of risk (50, 51). Box 1.4 Cambodia and Thailand – successes and challenges Current and projected impact of prevention efforts Infections prevented 1.2 1.0 0.8 0.6 0.4 0.2 0.0 Number of people infected with HIV (mllions) �������� 86 88 90 92 94 96 98 00 02 04 06 08 10 ���� With intervention No intervention ���� Infections prevented 10 8 6 4 2 0 Number of people infected with HIV (mllions) �������� 86 88 90 92 94 96 98 00 02 04 06 08 10 The ‘no intervention’ curve represents an estimate of HIV infections had behaviours not been changed by prevention efforts

4 The World Health Report 2004 a global emergency: a combined response 15 their infants. Ar rophylaxis in can facilities, to accept counselling and testing, to return for test results and tD adop 的as viral drugs the to include HIv-relted care retroviral regimens, though this reduction is not sustained where feeding practices 删 drug use clusive breasteeding is recommended during the first months of lie To l ore than 110 countnes. In the absence of harm-feauction activities, HV prevalance or more within one to two years ot ble, taking into account local circumstances. the dividual woman's situation d the risks posed by using replacement feeding, including infections other than HIv by sexual transmission among inject- se who want to s op using drugs or, through substitution therapy, to stop inje Caring for HIv-positive infants in Moscow ndude projects that try transmission of 19% per year in cities with such projects (wi Preventing transmission during health care Improper blood-transtusion practices are another important route of parenteral HNv w-risk donors, eliminating unnecessary transfusions, and systematic screening of accep actice and efforts should be increased in all health care settings to reduce the e posure of patients and carers to bloodborne infections. Testing and counselling majonity of people lting with H/AIDS in low-income countries are unaware preventing inection in mothers and infants. I is als

14 The World Health Report 2004 a global emergency: a combined response 15 from HIV-infected pregnant women to their infants. Antiretroviral prophylaxis in com￾bination with other interventions such as elective caesarean section before onset of labour and rupture of membranes, and refraining from breastfeeding, have now almost entirely eliminated HIV infection in infants in the developed world, with transmission rates below 2%. In developing countries where breastfeeding is the norm, the risk of HIV transmission to the newborn child can be more than halved by short-course antiretroviral regimens, though this reduction is not sustained where feeding practices to reduce risk are not adopted. To reduce the risk of postpartum transmission of HIV through breastfeeding, WHO currently recommends that when replacement feeding is acceptable, feasible, afford￾able, sustainable and safe, HIV-infected mothers avoid all breastfeeding. Otherwise, exclusive breastfeeding is recommended during the fi rst months of life. To minimize the risk of postpartum transmission, breastfeeding should be discontinued as soon as is feasible, taking into account local circumstances, the individual woman’s situation and the risks posed by using replacement feeding, including infections other than HIV and malnutrition. Although progress is now being made in the delivery of these low-cost and relatively simple interventions on a large scale in the most-affected countries, it has been slower than anticipated. Women must be encouraged and helped to attend antenatal care facilities, to accept counselling and testing, to return for test results and to adopt safer infant feeding practices, and must be given access to correctly administered antiretroviral drugs. Current challenges include achieving a rapid increase in accept￾ance of HIV testing and counselling, integrating prevention of infection in infants and young children into maternal and child health services, and extending the prevention of mother-to-child transmission to include HIV-related care, treatment and support for HIV-infected mothers, their infants and family. Injecting drug use – reducing the harm There may be as many as 2–3 million past and current injecting drug users living with HIV/AIDS worldwide. There are HIV epidemics associated with such drug use in more than 110 countries. In the absence of harm-reduction activities, HIV prevalence among injecting drug users can rise to 40% or more within one to two years of the introduction of the virus into their communities. HIV transmission through the sharing of non-sterile injection equipment is augmented by sexual transmission among inject￾ing drug users, and between them and their sex partners. Injecting drug users should have access to services that help reduce the related risks of drug use and HIV infection. Drug treatment programmes should be accessible to those who want to stop using drugs or, through substitution therapy, to stop injecting. Harm reduction primarily aims to help injecting drug users to avoid the negative health consequences of injecting and to improve their health and social status. Interventions include projects that try to ensure that those who continue injecting have access to clean injection paraphernalia. One evaluation carried out in 99 cities showed a reduc￾tion in the risk of HIV transmission of 19% per year in cities with such projects (with no concomitant increase in drug use) compared with an 8% increase in cities without them (55). Preventing transmission during health care Improper blood-transfusion practices are another important route of parenteral HIV transmission. Policies and procedures are needed to minimize the risk of transmission through blood transfusion, including the creation of a national blood service, use of low-risk donors, eliminating unnecessary transfusions, and systematic screening of blood for transfusion. Universal precautions in health care settings prevent the transmission of HIV and other bloodborne pathogens, and therefore increased access to safer technologies is needed. A review of published studies has shown that unsafe injections play a minor but signifi cant role in HIV transmission in sub-Saharan Africa (56). Irrespective of the exact contribution to the HIV/AIDS pandemic, unsafe injections are an unacceptable practice and efforts should be increased in all health care settings to reduce the ex￾posure of patients and carers to bloodborne infections. Testing and counselling The vast majority of people living with HIV/AIDS in low-income countries are unaware that they are infected. Testing is an essential means of identifying these people and beginning treatment, and for preventing infection in mothers and infants. It is also a critical component of a comprehensive strategy to prevent sexual transmission. Stud￾ies have shown that people who test positive for HIV tend to reduce risk behaviours (57). Joint counselling and testing sessions with couples may increase condom use. Caring for HIV-positive infants in Moscow In eastern Europe and the former Soviet Union the number of HIV/AIDS cases has increased rapidly during the last decade. Unlike in most other regions, infection here is spread primarily though injecting drug use. Many women who become infected in this way transmit the virus to Ilse Frech/Lookat/Network their babies. These three infants are being cared for at a small clinic in the Orechovo-Zoejevo Hospital, Moscow. The clinic provides a home for HIV-positive children whose mothers have died or are unable to look after them

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