GOAL 6 – Combat HIV/AIDS, malaria and other diseases



[pic] |Department of Economic and Social Affairs

[pic] | |

| Progress towards the Millennium Development Goals,1990-2005 |

GOAL 6 – Combat HIV/AIDS, malaria and other diseases

Goal 6 calls for stopping and reversing the spread of HIV/AIDS, malaria and other major diseases, including tuberculosis. Not surprisingly, all three of these diseases are concentrated in the poorest countries. And they could be largely controlled through education, prevention and, when illness strikes, intervention.

How the indicators are calculated

Target 7 - Have halted by 2015 and begun to reverse the spread of HIV/AIDS

Tracking the AIDS epidemic

|HIV/AIDS indicator |

|The AIDS epidemic is tracked on the basis of estimated |

|prevalence rates in the population aged 15 to 49 years. The|

|prevalence is given by the number of HIV/AIDS cases as a |

|percentage of the population in that age group. |

In 2004 alone, an estimated 3.1 million people died of AIDS (500,000 of them among children under 15). At the end of that year, 39.4 million people were living with HIV, the highest number on record.

The worst affected region is sub-Saharan Africa, home to nearly two thirds of all people living with HIV. An estimated 2.3 (2.1-2.6) million AIDS deaths occurred there in 2004. Prevalence rates among adults in that region have reached 7.2 per cent, rising to over 30 per cent in some settings. Prevalence rates appear to have stabilized in most subregions of sub-Saharan Africa, albeit at very high levels. This does not mean that the epidemic has been controlled, only that new infections are roughly equal to the number of deaths each year. AIDS is an increasingly significant cause of death for children under five in the worst affected countries of southern Africa.

Figure 1. HIV prevalence in adults aged 15 to 49 in sub-Saharan Africa and all developing regions (percentage) and number of AIDS deaths in sub-Saharan Africa (millions), 1990–2004

[pic]

|Chart 1. Countries where more than 10 per cent of|

|the adult population are living with HIV or AIDS,|

|2003 |

|Percentage of population 15-49 living with HIV or|

|AIDS |

|Lesotho |28.9 |

|Zambia |16.5 |

|Malawi |14.2 |

|Central African Republic |13.5 |

|Mozambique |12.2 |

|Source: United Nations Statistics Division, |

|Millennium Indicators Database, available from |

| (accessed June|

|2005); based on data provided by The Joint United|

|Nations Programme on HIV/AIDS (UNAIDS). |

The AIDS epidemic is growing fastest in a number of countries in Eastern Europe (see Table 1).. The driving force behind the epidemic in the region is injecting drug use – an activity that has spread explosively in the years of turbulent change since the demise of the Soviet regime. A striking feature is the low age of those infected. More than 80 per cent of HIV-positive people in the region are under 30 years of age. By contrast, in North America and Western Europe, only 30 per cent of infected people are under age 30. The most serious and firmly established epidemic in the region is in Ukraine, which is experiencing a new surge of reported infections, while the Russian Federation is home to the largest epidemic in the entire region (indeed, in all of Europe).

In Asia, where an estimated 5.4–11.8 million people are living with HIV, relatively low national prevalence rates mask localized epidemics that have the potential to escalate dramatically. The large, populous countries of China, India and Indonesia are of particular concern. General prevalence in these countries is low, but this masks serious epidemics already under way in certain provinces, territories and states.

Even in high-income countries in North America, Western Europe and Australia, rising infection rates among some groups suggest that advances in treatment and care have not been matched by consistent progress in prevention.

Virtually every region, including sub-Saharan Africa, has several countries where the epidemic is still at a low level or at an early enough stage to be held in check by effective action. This calls for programmes that can thwart the spread of HIV among the most vulnerable population groups. But in many countries, inadequate resources and a failure of political will and leadership still bar the way – especially where HIV has established footholds among marginalized and stigmatized groups, such as women engaged in commercial sex, injecting drug users and men who have sex with men. Unless reticence is rapidly replaced with pragmatic and forward-looking approaches, HIV will spread more extensively in many countries that, until now, have escaped with only minor epidemics. In countries that have successfully reversed the spread of HIV, including Thailand and Uganda, strong and outspoken political leadership has been a defining feature of the national response.

|Table 1. HIV prevalence |

|  |Percentage of population aged 15 to 49 living with HIV |

|  |1990 |2001 |2004 |

|  |

The gender dimension

The AIDS epidemic is affecting a growing number of women and girls (see Table 1). Globally, just under half of all people living with HIV are female. But as the epidemic worsens, the share of infected women and girls is increasing. Women and girls make up almost 57 per cent of all people infected with HIV in sub-Saharan Africa. Among Africans aged 15 to 24, the difference between the sexes is even more pronounced. In the worst affected countries, recent national surveys show as many as three young women living with HIV for every young man. In most other regions too, the proportion of women and girls living with HIV has grown in the last five years. These trends point to serious shortcomings in the response to AIDS. Services that can protect women against HIV should be expanded, and education and prevention are needed to counteract the factors that contribute to women’s vulnerability and risk.

Why are women, especially younger women, more vulnerable than men in regions such as sub-Saharan Africa, where heterosexual sex is the primary means of transmission? There is a combination of factors at play, both biological (the female reproductive tract is more susceptible to infection) and social (men tend to have more sexual partners than women, and women may not be able to insist that men use condoms or abstain from sex, which are the only two widely available means to prevent HIV transmission). Paradoxically, marriage and long-term relationships do not protect women from HIV. A recent study in Cambodia found that 13 per cent of men in urban areas and 10 per cent of men in rural areas reported having sex with both their wives and female sex workers. In Thailand, a 1999 study found that 75 per cent of HIV-positive women were likely to have been infected by their husbands. Violence also increases the risk of infection among women, and especially among adolescent girls, since forced sex and consequent abrasions facilitate entry of the virus.[i] The underlying realities of sex and gender must be taken into account in strategies to achieve this MDG target.

The AIDS epidemic has other important gender dimensions. One is that women and girls bear the brunt of caring for sick relatives, which furthers their descent into poverty. UN Secretary-General Kofi Annan described the vicious cycle in his statement for International Women’s Day in 2004: “As AIDS forces girls to drop out of school, whether they are forced to take care of a sick relative, run the household, or help support the family, they fall deeper into poverty. Their own children, in turn, are less likely to attend school and more likely to become infected. Thus, society pays many times over the deadly price of the impact on women of AIDS.” Furthermore, pregnant women may lack the money or the independence within the household to pay for and take the drugs needed to prevent transmission of HIV to their infants.

The impact of AIDS on social and economic development

One way in which AIDS affects social and economic development is its impact on the labour force. Not only does it reduce the supply of skilled and experienced workers, lower productivity and raise labour costs, it also undermines human capital development and growth by depriving new generations of parental guidance, skills transfer, and education both in and out of school. The fact that the primary impact of the epidemic is on the working-age population means that women and men with important economic and social roles are prevented from making their full contribution to development. Together these factors have a negative impact on economic growth by weakening the tax base, lowering demand, and discouraging foreign and domestic investment. As a result of AIDS, the rate of growth of the gross domestic product in several highly affected countries is already measurably lower.

At the level of the family, the epidemic has eroded the savings capacity of households and the profits of informal, household-based enterprises. Households impoverished by the loss of adult labour due to AIDS also face the burden of care for the sick and dying. This task often falls on the young – especially girls – which can disrupt or cut short their schooling. The lack of time and skills leads to lowered food production, which can threaten food security. The epidemic also erodes savings and profits of formal productive enterprises, lowering government revenues to finance public services, including health services, which are in increased demand as a result of AIDS. Education is also under pressure, as the sector loses the staff to plan, train and deliver services. In sub-Saharan Africa, several government ministries are already unable to fill vacancies due to AIDS-related illness and mortality; in the most affected areas, the very process of governance, the quality and range of public services, and the likelihood of sustainable economic and social development are all under threat.

Focusing on young people and groups at high risk

In countries with generalized epidemics, where HIV transmission is established among the general population and occurs mainly through heterosexual contact, HIV prevalence is tracked among those aged 15 to 24. Data is acquired through antenatal clinics in the capital city treating pregnant women in this age group and through national population-based surveys.

|Table 2. HIV prevalence among 15 to 24 years olds from national |

|population-based surveys, 2001/2004 |

| |Percentage living with HIV |

| |Women | |Men |

|Burkina Faso |1.17 | |0.51 |

|Burundi |3.3 | |1.6 |

|Cameroon |4.8 | |1.4 |

|Dominican Republic |0.7 | |0.4 |

|Ghana |1.2 | |0.1 |

|Kenya |5.9 | |1.3 |

|Mali |1.3 | |0.3 |

|Niger |0.8 | |0.3 |

|South Africa |12.0 | |6.1 |

|United Republic of Tanzania |4.0 | |3.0 |

|Zambia |11.2 | |3.0 |

|Zimbabwe |18.0 | |5.0 |

|Source: United Nations Statistics Division, “World and regional trends”, |

|Millennium Indicators Database, available from |

| (accessed June 2005); based on data |

|provided by UNAIDS. |

Data on HIV prevalence among pregnant women in capital cities are currently available for 26 countries in sub-Saharan Africa for the period 2000-2003. Data show HIV prevalence reaching 39 per cent in sites in Swaziland, almost 33 per cent in Botswana, 32 per cent in South Africa, 28 per cent in Lesotho, and 22 per cent in Zambia. Sustained prevention programmes in some countries have demonstrated that the spread of HIV can be controlled. The most notable case is Uganda. Although no other country has so dramatically reversed the epidemic, they have succeeded in reducing rates of infection. Ambitious and sustained prevention efforts are urgently needed in other countries.

The small amount of data available from population-based surveys in countries shows a wide gender gap. In all 12 countries with data, young women are more likely than young men to be infected, and in six countries, young women are more than three times as likely to be infected as men.

In other parts of the world, HIV infections are concentrated among sub-populations that are at particularly high risk. These include injecting drug users, men who have sex with men, commercial sex workers, migrants and other groups. In many countries, HIV prevalence rates among injecting drug users are high and, in several countries of Asia and Eastern Europe, they are on the rise. Although several countries have seen declines in HIV prevalence among commercial sex workers as a result of successful prevention programmes – like the public campaigns on condom use in Thailand – other countries in different regions see rising prevalence rates among sex workers. Most developing countries have insufficient data to be able to assess trends among men who have sex with men.

|Indicators of knowledge and HIV prevention |

|Progress made in educating people about the risk of |

|HIV/AIDS is assessed by tracking the percentage of young |

|people who know the basic facts about HIV/AIDS— that is, |

|the percentage of women and men aged 15 to 24 who correctly|

|identify the two major ways of preventing the sexual |

|transmission of HIV (using condoms and limiting sex to one |

|faithful, uninfected partner); who reject two common local |

|misconceptions; and who know that a healthy looking person |

|can transmit the AIDS virus. Progress in preventing the |

|spread of HIV is tracked on the basis of the percentage of |

|women and men who use condoms during sex to protect |

|themselves from becoming infected. |

Preventing HIV infection

Because there is no cure for AIDS, prevention is paramount. A fundamental aspect of the prevention strategy is educating people about the risks of HIV infection. Still, most young people are unaware of their HIV status. Millions more know too little about how HIV is transmitted to protect themselves against it.

These young people do not know, for example, that healthy looking individuals can have HIV or that consistent condom use can protect them from infection with the virus. Surveys in sub-Saharan Africa found that only 21 percent of young women and only 30 percent of young men aged 15 to 24 had the critical information needed to protect themselves. Only 13 per cent of young women in South-Eastern Asia had this basic level of knowledge, and 7 per cent of young women and men in the Commonwealth of Independent States (CIS).

|Table 3. Young people with a comprehensive and correct knowledge of HIV/AIDS, 1999/2003 |

| |Women aged 15-24 | |Men aged 15-24 |

| |Number of countries |Per cent who have | |Number of countries |Per cent who have |

| |covered by the surveys |comprehensive | |covered by the |comprehensive |

| | |knowledge1/ | |surveys |knowledge1/ |

|Developed regions (Albania only) |1 |0 | |- |- |

|CIS |6 |7 | |2 |7 |

|Sub-Saharan Africa |32 |21 | |14 |30 |

|Latin America and the Caribbean |6 |28 | |1 |24 |

|Eastern Asia (Mongolia only) |1 |32 | |- |- |

|Southern Asia (India only) |1 |21 | |1 |17 |

|South-Eastern Asia |3 |13 | |- |- |

|Source: United Nations Statistics Division, “World and regional trends”, Millennium Indicators Database, available from |

| (accessed June 2005); based on data provided by United Nations Children’s Fund, UNAIDS and the |

|World Health Organization. |

|1/Percentage of young women and men aged 15 to 24 who correctly identified the two major ways of preventing the sexual transmission |

|of HIV (using condoms and limiting sex to one faithful, uninfected partner), who reject two common local misconceptions, and who know|

|that a healthy looking person can transmit the AIDS virus. |

Consistent use of condoms is an effective method to prevent HIV infection, and the percentage of women who know that they can protect themselves in this way is an indication of the extent to which national information and education programmes about HIV have succeeded. Only a limited number of countries have collected data on condom use at the last occurrence of higher-risk sex, and not many countries have had successive surveys to indicate trends. Nevertheless, the data on behaviour that do exist suggest that about 25 percent of women in sub-Saharan Africa used a condom the last time they had sex with a high-risk partner (not their usual partner), and 43 percent of young men used a condom with a high-risk partner (see Table 4). Women within marriage are also at risk of contracting HIV and often lack the power to negotiate condom use with their husbands. Only 5 per cent of married women worldwide report using condoms as a contraceptive method.

|Table 4. Young people using condoms as a protection measure against HIV, 1999/2003 |

| |Women aged 15-24 | |Men aged 15-24 |

| |Number of countries |Per cent who used a | |Number of countries |Per cent who used a |

| |covered by the |condom at last | |covered by the |condom at last |

| |surveys |high-risk sex1/ | |surveys |high-risk sex1/ |

|CIS |1 |32 | |3 |54 |

|Sub-Saharan Africa |23 |25 | |22 |43 |

|Latin America and the Caribbean |5 |24 | |2 |41 |

|Southern Asia (India only) |1 |51 | |1 |59 |

|Source: United Nations Statistics Division, “World and regional trends”, Millennium Indicators Database, available at |

| (accessed June 2005); based on data provided by United Nations Children’s Fund, UNAIDS and the |

|World |

|Health Organization. |

|1/ The percentage of young women and men aged 15 to 24 reporting the use of a condom during sexual intercourse with a non-regular |

|sexual partner in the last 12 months, among those who had such a partner in the last 12 months. |

|Chart 2. Countries where less than 10 per cent of women aged |

|15 to 24 have a comprehensive and correct knowledge1/ of |

|HIV/AIDS, 1999/2003 |

|Percentage of women 15-24 |

|Albania |0 |

|Somalia |0 |

|Tajikistan |1 |

|Azerbaijan |2 |

|Turkmenistan |3 |

|Equatorial Guinea |4 |

|Central African Republic |5 |

|Chad |5 |

|Niger |5 |

|Armenia |7 |

|Indonesia |7 |

|Benin |8 |

|Guinea-Bissau |8 |

|Uzbekistan |8 |

|Mali |9 |

|Source: United Nations Statistics Division, Millennium |

|Indicators Database, available from |

| (accessed June 2005); |

|based on data provided by UNICEF, UNAIDS and WHO. |

|1/ Percentage of young women aged 15 to 24 who correctly |

|identified the two major ways of preventing the sexual |

|transmission of HIV (using condoms and limiting sex to one |

|faithful, uninfected partner), who reject two common local |

|misconceptions, and who know that a healthy looking person |

|can transmit the AIDS virus. |

Condom use is one measure of protection against HIV; delaying sexual intercourse to a later age, reducing the number of non-regular sexual partners, and being faithful to one uninfected partner are equally important. But where abstinence and faithfulness are not options, consistent and correct use of condoms with non-regular sexual partners is especially important for young people. It is this age group that often experiences the highest rates of HIV acquisition because of low prior exposure to infection and relatively high numbers of non-regular sexual partners. Consistent condom use with non-regular sexual partners is important even in countries where HIV prevalence is low since non-regular partners can be among high-risk groups.

Knowledge about HIV/AIDS is slowly improving over time, but is still alarmingly low. It therefore comes as no surprise that the available data on condom use suggest that a majority of young people do not use condoms in high-risk sex. In addition to scaling up prevention efforts aimed at young people, specific prevention services need to be scaled up for groups at high risk of infection.

For the foreseeable future, education will remain the only “vaccine” against HIV – a powerful tool for halting its spread. But education is being undermined by the impact of HIV/AIDS on both the supply as well as the demand for schooling. The epidemic is reducing the supply of education by raising the levels of morbidity and mortality among teachers. It is affecting the demand for education by forcing children to stay at home to care for sick family members or to supplement family income. Breaking this cycle requires action on two fronts – investing in children’s education and increasing access to antiretroviral therapy for parents as well as teachers.[ii]

Growing numbers of children orphaned by AIDS

|Monitoring support programmes for |

|children orphaned by AIDS |

|Since children orphaned by AIDS face discrimination and |

|increased poverty, it is important to monitor to what |

|extent AIDS support programmes are successful in providing |

|educational opportunities to these children. The indicator |

|used for this purpose is the ratio of school attendance of |

|orphans to attendance of non-orphans. |

AIDS has orphaned millions of children, and the number is expected to grow over the next decade as HIV-infected parents become ill and die.[iii] Around 15 million children under 15 had lost one or both parents to AIDS by the end of 2003 in countries in Africa, Asia and Latin America and the Caribbean. That number is projected to nearly double by 2010. Between 1990 and 2003, the number of children in sub-Saharan Africa who lost one or both parents to AIDS increased from less than 1 million to more than 12 million. In 2003, there were over 7 million children in sub-Saharan Africa alone who had lost both parents; 4 million of these children lost parents to AIDS. This social problem without precedent demands an innovative and effective response.

Children affected by HIV/AIDS often lack access to adequate nutrition, health care, housing and clothing. They are likely to drop out of school because of discrimination and emotional distress, because they cannot afford to pay school fees, or because they need to care for parents or caretakers infected with HIV, or for younger siblings. A defining characteristic of children orphaned by AIDS is that they are typically “double” orphans (meaning that both parents have died), because of the fact that HIV is sexually transmitted. This also means that they are doubly disadvantaged. On average, children in sub-Saharan Africa who are have lost both parents are 22 per cent less likely to attend school than children whose parents are both alive and who are living with at least one of those parents (see Table 5). As the number of orphans continues to grow, it will be critical to ensure that these children are not marginalized and that all children have access to education.

|Table 5. School attendance of orphans aged 10-14, 1999/2003 |

| |Number of countries covered by the |Ratio of school attendance of orphans to school |

| |surveys |attendance of non-orphans1/ |

|Sub-Saharan Africa |37 |0.78 |

|Latin America and the Caribbean |6 |0.89 |

|South-Eastern Asia |2 |0.81 |

|Source: United Nations Statistics Division, “World and regional trends”, Millennium Indicators Database, available from |

| (accessed June 2005); based on data provided by United Nations Children’s Fund, UNAIDS and the |

|World Health Organization (UN Population Division, World Population Prospects: 2002 Revision). |

|1/ Ratio of the current school attendance rate of children aged 10 to 14 who have lost both biological parents to the current school|

|attendance rate of children aged 10 to 14 whose two biological parents are still alive and who are currently living with at least |

|one of these parents. |

An agenda for change

At the United Nations General Assembly Special Session on HIV/AIDS in June 2001, heads of state and government committed themselves to meeting a number of key goals to diminish HIV prevalence among people aged 15 to 24. These included reducing the HIV prevalence among young people by 25 per cent in the most affected countries by 2005, and by 25 per cent worldwide by 2010, and ensuring that over 90 per cent of young people have the information, education, services and life skills they need to reduce their vulnerability to HIV. Additional goals address gender discrimination and the problems of young people who are especially vulnerable.

Effective methods to fight HIV/AIDS, including condom use and behaviour change campaigns in communities, schools, workplaces and the mass media, are available, as are simple antiretroviral protocols to reduce mother-to-child transmission and antiretroviral therapy to reduce morbidity and prolong the lives of those already infected with the virus.[iv] Yet, the greatest obstacle to delivery of HIV/AIDS services, especially antiretroviral treatment, is the terrible state of health systems in much of the developing world, particularly the acute shortage of skilled health workers in many countries. Remedying this will required sustained investment in health systems.[v]

When serious, long-term efforts are made to ensure that young people have the means to protect themselves, HIV rates decline. In Thailand, for example, the government carried out a campaign promoting “100 per cent condom use” in brothels, discouraging the demand for commercial sex. The campaign targeted sex workers and their clients, forcing brothel owners to take responsibility for condom use in their establishments. It also provided for the distribution of free condoms and routine health examinations of sex workers for sexually transmitted diseases. The net result was a drop in the number of new infections per year: from 143,000 in 1991 to 19,000 in 2004. Critical factors in Thailand’s success were strong political commitment from top leadership, a strong health care infrastructure, and the large and increasing spending on its AIDS programme.[vi]

Prevention strategies are obviously crucial, but poor and rich countries also need to work together to ensure that people infected with HIV are provided access to the drugs they need, as called for in target 17 of the Millennium Development Goals. Once people are infected, drug treatment can prolong their lives. In pregnant women, it can also decrease, by about one third, the risk of transmitting HIV to their babies. In December 2003, the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS) and other UN partners announced the “3 by 5 Initiative”, challenging countries to get 3 million people, or half those in need, on treatment by the end of 2005. WHO and UNAIDS estimate that, overall, 72 per cent of the un-met need for treatment is in sub-Saharan Africa and 22 per cent in Asia (India, Nigeria and South Africa alone account for 41 per cent of the total). During the second half of 2004, the number of people on antiretroviral therapy in developing regions increased from 440,000 to an estimated 700,000, or about 12 per cent of those needing treatment, thus reaching the 2004 milestone of the 3 by 5 Initiative. Botswana and more than ten countries in Latin America have already reached the 3 by 5 goal of treating 50 per cent or more people needing antiretroviral therapy in their countries.[vii]

The dissemination of patented AIDS drugs is governed by the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement. A recent decision of the Council for TRIPS[viii] clarifies the right of poor countries to import generic copies of key drugs in order to stave off a public emergency. This is crucial since many poor countries do not have a domestic pharmaceutical industry capable of developing such medicines. They also suffer from a lack of specialized human resources like pharmacists and technicians, deficient health infrastructures, weak political will and inadequate donor assistance coupled with lack of donor coordination.[ix]

The existence of generic drugs is key in keeping drug prices affordable, since voluntary price cuts by drug companies cannot provide a comprehensive solution.[x] Brazil’s HIV/AIDS treatment programme, for instance, relies on generic drugs, and it has been able to cut the number of AIDS deaths by half and generate savings, which nearly offset the cost of providing the medicines. Thailand’s capacity to manufacture generic antiretroviral drugs has created the potential to expand the government’s treatment programme significantly at a cost of less than $300 per patient per year.[xi]

Though the price of generic versions has dropped sharply, the cost of these drugs and the challenges of making them available in settings with weak health systems – as well as the limited capacity of health systems to reach those in need – remain the biggest obstacles to treatment. Services for care and treatment need to be further expanded to reach the millions more who could benefit from them.

Target 8 - Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

The heavy toll of malaria

|Indicators on malaria |

|Because young children suffer the largest burden, malaria |

|mortality is tracked among children aged 0 to 4, as the |

|number of deaths per 100,000 children. Progress made in the|

|prevention and treatment of malaria is also tracked among |

|young children, on the basis of the percentage of children |

|aged 0 to 4 who sleep under insecticide-treated mosquito |

|nets and the percentage of those with fever who are treated|

|with antimalarial drugs. |

Malaria is endemic to the poorest countries, mainly those in tropical and subtropical regions of Africa, Asia and the Americas. Malaria is both preventable and curable. Still, an estimated 300 to 500 million clinical malaria cases and more than 1 million malaria deaths occur each year. More than 90 per cent of these deaths occur in sub-Saharan Africa, and almost all of them are among children under 5 years of age.

|Table 6. Malaria mortality rate, 20001/ |

|Region |Number of deaths per|

| |100,000 children |

| |aged 0-4 years |

|Developed regions | 0 |

|Northern Africa | 47 |

|Sub-Saharan Africa | 791 |

|Latin America/Caribbean | 1 |

|Eastern Asia | 0 |

|South-Central Asia | 6 |

|South-Eastern Asia | 2 |

|Western Asia | 26 |

|Oceania | 2 |

|Source: United Nations Statistics Division, “World and|

|regional trends”, Millennium Indicators Database, |

| (accessed June |

|2005); based on data provided by the World Health |

|Organization. |

|1/Mortality estimates for malaria are under revision. |

|Current estimates are not sufficiently reliable to |

|estimate trends. |

Today, over 3 billion people[xii] are at risk of contracting malaria. In many parts of Africa, children experience at least three life-threatening infections by the age of one; those who survive may suffer learning impairments or brain damage.

Pregnant women and their unborn children are also at particular risk of malaria, which can lead to prenatal mortality, low-birthweight babies and maternal anaemia.

As with AIDS, malaria preys on the poor and makes their situation even more perilous. Repeated infections can have a debilitating effect, often removing otherwise healthy adults from the workforce for days and even weeks at a time. Infection rates in rural areas are highest during the rainy season, which is also the time when families most need strong adults to work in the fields.[xiii] A brief episode that delays planting or coincides with harvesting can have catastrophic economic effects and can deepen impoverishment at the household level, especially if antimalarial medicines are purchased out of meagre cash reserves. Research suggests that families affected by malaria do, indeed, harvest fewer crops than non-infected families. This can be devastating to the incomes of the rural poor.

Malaria costs Africa an estimated $12 billion annually and is a major factor in the erosion of development in some of the poorest countries of the world. The disease has slowed economic growth in African countries by an estimated 1.3 per cent per year, the compounded effects of which are a gross domestic product level that is now as much as 32 per cent lower than it would have been had malaria been eliminated as a problem from Africa in 1960.

Lack of comprehensive data makes it difficult to assess whether the incidence of malaria is growing or reversing. Overall, estimates of prevalence are relatively unreliable – and insufficient to estimate trends – but there is little evidence of improvement in the world’s malaria-endemic regions.

Preventing and treating malaria

Much of current monitoring on malaria control focuses on young children in Africa because they are the most severely affected. Although there is sufficient evidence to confirm the effectiveness of the main malaria interventions, such as use of insecticide-treated mosquito nets, these have not been made available to those who need them most. Currently only about 16 per cent of children under five sleep under a bed net, and only 3 per cent sleep under an insecticide-treated net, despite the fact that they are a low-cost and highly effective way of reducing the risk of malaria. By preventing the disease in the first place, insecticide-treated nets reduce the need for drug treatment and other health services, which is particularly important in view of the increase in drug-resistant malaria parasites.

Figure 2: Children under 5 using a mosquito net (light bars) and insecticide-treated nets--ITNs (dark bars), 1998-2000. The dotted line indicates the 2000 Abuja Summit target for coverage[xiv].

Figure 3: Mosquito nets sold or distributed in sub-Saharan Africa, 1999-2003 (millions)

[pic]

Progress in the delivery of mosquito nets and insecticides to malaria-endemic countries in sub-Saharan Africa has been substantial. Distribution of insecticide-treated nets in African countries has increased tenfold in the past 3 years in over 14 African countries. This is the result of targeted, subsidized or free distribution of the treated nets during immunization campaigns and programmes in antenatal clinics. In Malawi, 1 million insecticide-treated mosquito nets were distributed in 2003 alone, boosting coverage from 5 per cent of households in 2000 to 43 per cent by the end of 2003. At the same time, distribution of the nets through the health-care network increased participation in routine preventive services. Other countries are now adopting the same strategy.

Procurement of treated nets by UNICEF has more than doubled, from 2.3 million nets in 2001 to nearly 4.8 million nets worth $13.5 million in 2003; some $3.7 million worth of insecticide was also procured. Specifications for netting materials and insecticides have been produced, and UNICEF strictly follows these specifications. In addition, long-lasting insecticidal nets have been developed in response to the low retreatment rates for conventional nets. Two types of these long-lasting nets have been successfully evaluated by the WHO Pesticide Evaluation Scheme and are now recommended for malaria prevention. Similar progress in the delivery of insecticide-treated mosquito nets has been made by other agencies such as the United States Agency for International Development (USAID) and the United Kingdom’s Department for International Development (DFID). The procurement market still needs wider funding guarantees to enable reliable forecasting and further increases in scale.

In the majority of African countries for which data are available, about 38 per cent of children under five with recent fever are treated with antimalarial drugs. However, these figures do not take into account late treatment, inadequate dosing, poor quality drugs or resistance of the malaria parasite to the drugs. Therefore the coverage rates for effective, life-saving treatment are likely to be significantly lower.

Figure 4. Children under five with fever that were treated with an antimalarial medicine. (The dark blue bars represent chloroquine, the light blue bars represent other medicines.)

[pic]

Due to the rapid emergence and spread of P. falciparum malaria, which is resistant to conventional single treatments, a major policy change is being adopted for treatment. Chloroquine, the cheapest and most widely used antimalarial drug, has lost its clinical effectiveness in most parts of the world. Since 2001, WHO has recommended that countries faced with resistance to single drugs should change to combinations of at least two antimalarial drugs with different mechanisms of action. In particular, artemisinin-based combination therapies, or ACTs, are highly effective for treatment of malaria and should be deployed wherever possible. Over the past few years, many countries have changed their national antimalarial drug policies to require the use of more effective treatments, especially ACTs. Combined with home-based management of malaria and strengthening of public health services, more effective treatment is reaching young children. ACTs are derived from the Artemisia annua plant. Access to this natural substance remains difficult due to the high cost and limited supply. Since the plant has a six- to eight-month growing season, accurate forecasting of demand is a critical factor in maintaining the supply of artemisinin-based combination therapies. Production and financing of ACTs remain the major challenges to meeting the projected needs of 132 million people in 2005. The purchase of ACTs in countries has been financed principally by the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria.

The formidable ability of the malaria parasite to develop rapid resistance to new drugs, and of the mosquitoes to become resistant to new insecticides, means that researching, developing and manufacturing new drugs and insecticides will continue to be of paramount importance. There is also potential for an antimalarial vaccine, although this has proven more complex and is taking longer than expected.[xv]

In areas of stable malaria transmission, WHO recommends intermittent preventive treatment for pregnant women. This involves at least two treatment doses of an effective antimalarial to all pregnant women living in high-risk areas through routine visits to antenatal clinics. Effective delivery of this intermittent treatment results in fewer pregnant women with anaemia and fewer low-birthweight babies.

A number of recent developments suggest that the fight against malaria is moving in the right direction. United Nations agencies and their partners are distributing free, insecticide-treated mosquito nets to people in need. And national drug policies regarding malaria are changing, for the better. Between 2001 and 2004, 40 countries – half of them in Africa – amended their national policies to require the use of ACTs. In addition, 80 countries are benefiting from over $290 million for malaria control, provided through the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria. Still, the funds available fall short of what is needed. WHO estimates that around $3.2 billion each year is required to finance effective malaria control worldwide.[xvi]

Major developments in malaria monitoring

A major development in monitoring progress towards the MDG malaria target was the formation of the Malaria Monitoring and Evaluation Reference Group, known as MERG. The group was established to promote the development of a comprehensive system to track progress towards the MDG and Abuja Summit[xvii] targets. MERG brings together concerned United Nations agencies, including WHO, UNICEF, the World Bank, as well as key bilateral donors, such as USAID, DFID (UK) and the Global Fund, the Roll Back Malaria regional networks and representatives of country level malaria control programmes, and academic and research organizations. It focuses on harmonizing and coordinating all work related to the monitoring of malaria targets, and provides guidance to the Roll Back Malaria partnership on specific technical issues, coordination and collaboration, as well as communication and dissemination of information related to monitoring and evaluation.

Once thought defeated, tuberculosis makes a comeback

|Indicators on tuberculosis |

|Progress in combating TB is assessed on the basis of trends|

|in the prevalence rate (the number of cases of TB per |

|100,000 population) and the number of deaths due to |

|tuberculosis each year per 100,000 population. Progress in |

|the implementation of TB control is assessed on the basis |

|of the proportion of estimated smear-positive cases (those |

|responsible for most transmission) treated under the |

|internationally recommended control strategy known as |

|“DOTS”, and the proportion of these cases that are |

|successfully treated. |

In 2003, there were an estimated 8.8 million new tuberculosis (TB) cases, including 0.67 million in people infected with HIV. That same year, tuberculosis killed 1.7 million people, including 230,000 people with HIV infection. The poor are most at risk for several reasons: among them are lack of treatment, which means that the disease keeps spreading in poor countries, and malnutrition, which compromises people’s ability to fight off the infection. Most of the deaths associated with TB occur during an adult’s most productive years – between the ages of 15 and 54. Detecting and curing TB is, therefore, a key intervention for addressing poverty and inequality.

Tables 7 and 8 present WHO assessments of TB prevalence and incidence rates, respectively, from all forms of TB (excluding people infected with HIV). Global estimates of the incidence of TB (that is, new cases arising each year) are rising slightly (1 per cent in 2002-2003). However, it is estimated that, globally, prevalence rates are falling, as increasing proportions of TB cases are receiving proper treatment under an internationally recommended control strategy known as “DOTS” (Tables 10 and 11).

|Table 7. Tuberculosis prevalence rate, 1990, 2001, 2002, 2003 |

| |Number of tuberculosis cases per 100,000 population 1/ |

| |1990 |2001 |2002 |2003 |

|WORLD |308 |265 |254 |240 |

|Developed regions |36 |22 |20 |20 |

|Commonwealth of Independent States |82 |154 |150 |147 |

|CIS, Europe |77 |159 |155 |147 |

|CIS, Asia |99 |141 |138 |146 |

|Developing regions |386 |320 |307 |288 |

|Africa |286 |397 |397 |409 |

|Northern Africa |125 |53 |52 |52 |

|Sub-Saharan Africa |323 |471 |471 |485 |

|Latin America and the Caribbean |156 |97 |93 |89 |

|Asia |441 |336 |318 |290 |

|Eastern Asia |325 |264 |258 |239 |

|South Asia |493 |374 |350 |306 |

|South-Eastern Asia |726 |505 |466 |446 |

|Western Asia |117 |77 |77 |78 |

|Oceania |569 |415 |353 |369 |

|Source: United Nations Statistics Division, based on country data provided by WHO. See Millennium Indicators Database, |

|“World and regional trends”, , (accessed June 2005). |

|1/ Excluding those infected with HIV. |

Masked by the global averages are steep increases in TB prevalence in sub-Saharan Africa and in the European countries of the Commonwealth of Independent States. These rising trends are associated with the AIDS epidemic and multi-drug resistant TB (in the case of Africa) and with falling living standards and failing public health systems (in the case of the CIS countries).[xviii]

|Table 8. Tuberculosis incidence rate, 1990, 2001, 2002, 2003 |

|  |Number of new cases per 100,000 population 1/ |

| |1990 |2001 |2002 |2003 |

|WORLD |119 |128 |128 |129 |

|Developed regions |29 |19 |18 |17 |

|Commonwealth of Independent States |49 |107 |106 |104 |

|CIS, Europe |46 |107 |104 |100 |

|CIS, Asia |59 |106 |110 |114 |

|Developing regions |145 |151 |152 |153 |

|Northern Africa |59 |51 |50 |50 |

|Sub-Saharan Africa |142 |253 |263 |274 |

|Latin America and the Caribbean |99 |68 |65 |63 |

|Eastern Asia |117 |105 |104 |103 |

|Southern Asia |171 |168 |168 |168 |

|South-Eastern Asia |248 |237 |236 |235 |

|Western Asia |60 |52 |52 |52 |

|Oceania |204 |173 |171 |168 |

|Source: United Nations Statistics Division, based on country data provided by the World Health Organization. See Millennium|

|Indicators Database, “World and regional trends”, , (accessed June 2005). |

|1/Excluding those infected with HIV. |

|Table 9. Tuberculosis mortality rate, 1990, 2001, 2002, 2003 |

| |Number of deaths due to tuberculosis per 100,000 population1/ |

| |1990 |2001 |2002 |2003 |

|WORLD |27 |26 |25 |24 |

|Developed regions |5 |2 |2 |2 |

|Commonwealth of Independent States |8 |17 |17 |17 |

|CIS, Europe |8 |18 |17 |17 |

|CIS, Asia |10 |15 |16 |17 |

|Developing regions |34 |31 |30 |29 |

|Africa |32 |44 |44 |46 |

|Northern Africa |14 |4 |4 |4 |

|Sub-Saharan Africa |36 |53 |53 |54 |

|Latin America and the Caribbean |14 |9 |9 |9 |

|Asia |37 |31 |30 |28 |

|Eastern Asia |25 |19 |19 |18 |

|South Asia |44 |39 |37 |34 |

|South-Eastern Asia |60 |48 |46 |44 |

|Western Asia |12 |8 |8 |9 |

|Oceania |43 |37 |35 |33 |

|Source: United Nations Statistics Division, based on country data provided by WHO. See Millennium Indicators Database, |

|“World and regional trends”, , (accessed June 2005). |

|1/ TB mortality rates exclude deaths from TB among people infected with HIV. |

Sub-Saharan Africa is the worst hit region, with 485 cases per 100,000 population and an additional 40 cases per 100,000 population in people who are infected with HIV. South-Eastern Asia is also badly affected, with a prevalence rate of 446 cases per 100,000 people. Mortality levels are also highest and on the rise in sub-Saharan Africa. And they remain high, although decreasing slightly, in South-Eastern Asia. In terms of incidence, in 2003 there were nearly 9 million new cases, including 674,000 among people with HIV. The emergence of drug-resistant strains of the disease, the increase in the number of people with HIV or AIDS, which reduces resistance, and the growing number of refugees and displaced persons have all contributed to the spread of TB.

An international strategy to overcome tuberculosis

The WHO recommended approach to TB control is via DOTS, a cost-effective strategy that could prevent millions of TB cases and deaths over the coming decade. DOTS is a five-pronged strategy consisting of:

▪ Government commitment to sustained TB control;

▪ Detection of TB cases through sputum smear microscopy among symptomatic people;

▪ Regular and uninterrupted supply of high-quality TB drugs;

▪ 6-8 months of regularly supervised treatment (including direct observation of drug-taking for at least the first two months);

▪ Reporting systems to monitor treatment progress and programme performance.

|Table 10. DOTS detection rate, 1990, 2001, 2002, 2003 |

| |Percentage of estimated smear-positive cases notified to WHO through DOTS |

| |1990 |2001 |2002 |2003 |

|WORLD |28 |32 |37 |45 |

|Developed regions |22 |28 |40 |43 |

|Commonwealth of Independent States |12 |12 |17 |18 |

|CIS, Europe |4 |5 |6 |9 |

|CIS, Asia |37 |34 |47 |42 |

|Developing regions |29 |33 |38 |46 |

|Africa |38 |40 |47 |49 |

|Northern Africa |82 |80 |83 |84 |

|Sub-Saharan Africa |36 |39 |45 |48 |

|Latin America and the Caribbean |42 |41 |45 |48 |

|Asia |25 |30 |34 |44 |

|Eastern Asia |30 |31 |31 |44 |

|South Asia |14 |23 |29 |41 |

|South-Eastern Asia |38 |42 |48 |53 |

|Western Asia |28 |28 |27 |26 |

|Oceania |13 |14 |22 |21 |

|Source: United Nations Statistics Division, based on country data provided by WHO, See Millennium Indicators Database, |

|“World and regional trends”, , (accessed June 2005); based on data provided by WHO. |

The success of DOTS depends on expanding case detection while ensuring high treatment success rates. Many of the 182 national DOTS programmes in existence by the end of 2003 have shown that they can achieve high treatment success rates, close to or exceeding the target of 85 per cent. The global average treatment success rate for DOTS programmes was 82 per cent for the cohort of patients registered in 2002, maintaining the high level achieved for patients treated in 2000. However, cure rates tend to be lower, and death rates higher, where drug resistance is frequent, or HIV prevalence is high.

In 2003, 45 per cent of estimated new smear-positive TB cases were identified under DOTS, up from 28 per cent in 2000. Between 1995 and 2000, the number of smear-positive cases identified under DOTS increased an average of 134,000 cases a year. From 2002 to 2003, the increase was 324,000 cases, reflecting an acceleration in progress. If the improvement in case identification between 2002 and 2003 is maintained, the case detection rate will be 60 per cent in 2005. To reach the 70 per cent coverage target endorsed by the World Health Assembly, DOTS programmes must recruit TB patients from non-participating clinics and hospitals, especially in the private sector in Asia, and from beyond the present limits of public health systems in Africa. To reach the target of 85 per cent treatment success, a special effort must be made to improve cure rates in Africa and Eastern Europe.

Whether the burden of TB can be reduced sufficiently to reach the MDG target by 2015 depends on how rapidly control programmes can be implemented by a diversity of health-care providers, and how effectively they can be adapted to meet the challenges presented by HIV co-infection (especially in Africa) and drug resistance (especially in Eastern Europe).

|Table 11. DOTS treatment success rate, 1990, 2001, 2002, 2003 |

| |Percentage of registered smear-positive cases successfully treated |

| |1990 |2001 |2002 |2003 |

|WORLD |80 |82 |82 |82 |

|Developed regions |76 |74 |75 |76 |

|Commonwealth of Independent States |77 |76 |75 |75 |

|CIS, Europe |65 |68 |67 |66 |

|CIS, Asia |79 |78 |77 |78 |

|Developing regions |81 |82 |82 |82 |

|Africa |71 |74 |72 |74 |

|Northern Africa |87 |88 |84 |88 |

|Sub-Saharan Africa |69 |72 |71 |73 |

|Latin America and the Caribbean |84 |81 |82 |83 |

|Asia |86 |88 |88 |87 |

|Eastern Asia |96 |94 |96 |92 |

|South Asia |82 |83 |85 |86 |

|South-Eastern Asia |79 |86 |86 |86 |

|Western Asia |82 |81 |83 |85 |

|Oceania |75 |76 |76 |64 |

|Source: World Health Organization. |

Notes

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[i] UNAIDS, 2004 Report on the Global AIDS Epidemic (UNAIDS/04.16E, Geneva, June 2004).

[ii] UNDP International Poverty Centre, In Focus, March 2005.

[iii] UNICEF/UNAIDS/USAID, Children on the Brink 2004: A joint report of new orphan estimates and a framework for action. July 2004.

[iv] Global HIV Prevention Working Group. HIV Prevention in the Era of Expanded Treatment Access.

[v] The Lancet 2005, “Emerging Consensus in HIV/AIDS, Malaria, Tuberculosis, and Access to Essential Medicines”.

[vi] UNDP International Poverty Centre, In Focus, March 2005.

[vii] The “3 by 5” target across countries is to treat 50 per cent of those in need, as set in the 2003 WHO/UNAIDS strategy. Some countries have set their own targets, which may be the same, higher or lower than that set by the 3 by 5 Initiative.

[viii] 30 August 2003, Decision of the Council for TRIPS, “Implementation of paragraph 6 of the Doha Declaration on the TRIPS agreement and Public Health”, available at

[ix] UN Millennium Project. Prescription for healthy development: increasing access to medicines. Task Force on HIV/AIDS, Malaria, TB and Access to Essential Medicines 2005; New York.

[x] UNDP, Human Development Report 2003, p.159 (Oxford University Press, New York, 2003).

[xi] UNDP International Poverty Centre, In Focus, March 2005.

[xii] Roll Back Malaria, WHO and UNICEF, 2005 World Malaria report.

[xiii] Global Fund to Fight AIDS, Tuberculosis and Malaria, available at

[xiv] The challenge is to reach the dotted line, which indicates 2000 Abuja Summit Targets for coverage. For more information on the 2000 Abuja Summit Target, visit:

[xv] Roll Back Malaria, WHO and UNICEF, 2005 World Malaria report.

[xvi] Ibid.

[xvii] Abuja Declaration on HIV/AIDS, Tuberculosis and other Related Infectious Diseases, available at: .

[xviii] See WHO, WHO Report 2002: Global Tuberculosis Control (WHO/TB/2002.295, Geneva, 2002).

How the indicators are calculated

Indicators of knowledge and prevention of HIV/AIDS

The agreed indicator on knowledge of HIV/AIDS is defined as the “percentage of population aged 15-24 who correctly identify the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner), who reject the two most common local misconceptions about HIV transmission, and who know that a healthy-looking person can transmit HIV”. However, since there are not sufficient data to calculate the indicator as defined, UNICEF, in collaboration with UNAIDS and WHO produced two proxy indicators that represent two components of the actual indicator. They are defined as follows: “percentage of women and men 15-24 who know that a person can protect her/himself from HIV infection by consistent use of condom”; and “percentage of women and men 15-24 who know that a healthy-looking person can transmit HIV”. These two indicators are currently used to track progress in promoting the knowledge of valid HIV prevention methods and reducing misconceptions relating to the disease. For the current report, only data on women were available.

The first indicator is calculated as follows: the number of women (or men) aged 15-24 who, in response to prompting, correctly identify consistent use of condoms as means of protection against HIV infection, as a percentage of total number of women (or men) respondents aged 15-24. The second indicator is calculated as follows: the number of women (or men) aged 15-24 who, in response to prompting, correctly respond that a person who looks healthy may transmit HIV, as a percentage of total number of women (or men) respondents aged 15-24.

The indicator on prevention, is defined as the number of women respondents ages 15–24 who reported having had a non-regular (non-marital and non-cohabiting) sexual partner in the last 12 months and using a condom the last time they had sex with this partner, as a percentage of the number of women respondents ages 15–24 who reported having had a non-regular sexual partner in the last 12 months.

Indicators on AIDS orphans

The number of children orphaned by HIV/AIDS is defined as the estimated number of children who have lost either their mother, their father, or both parents to AIDS before age. Since orphanhood is often accompanied by stigma, prejudices and increased poverty, it is important to monitor the extent to which AIDS support programmes succeed in securing the educational opportunities of orphaned children. The indicator used for this purpose is the ratio of the current school attendance rate of children aged 10–14 both of whose biological parents have died, to the current school attendance rate of children aged 10–14 whose parents are both still alive and who currently live with at least one biological parent. Although the indicator does not differentiate between children who lost their parents due to HIV/AIDS and those whose parents died of other causes, it does capture the extent to which AIDS support programmes succeed in securing the educational opportunities of orphaned children.

Indicators on tuberculosis

Tuberculosis prevalence and death rates*

Prevalence of tuberculosis (all forms) per 100,000 population and deaths due to tuberculosis per 100,000 population (both prevalence and death rates exclude TB in HIV-infected individuals).

Direct measures of prevalence from surveys are available in only a small number of countries. Similarly, reliable vital registration systems providing data on TB deaths are not widely in place. Country-specific estimates of prevalence and death rates are, in most instances, derived from estimates of incidence, combined with assumptions about the duration of disease (for prevalence) and case fatality rate (for mortality). The duration of disease and the case fatality rate are assumed to vary according to whether the disease is smear-positive or not; whether the individual receives treatment in a DOTS programme or non-DOTS programmes, or is not treated at all; and whether the individual is infected with HIV.

Incidence of TB is rarely measured directly. Estimates of incidence are derived from notifications to WHO (coupled with assumptions about the proportion of incident cases which is notified); from disease prevalence surveys (coupled with assumptions about the duration of disease); or from surveys of the prevalence of infection in children, used to calculate the annual risk of TB infection (ARTI) (coupled with assumptions about the relationship between ARTI and the incidence of disease).

Estimates of HIV prevalence in the general population (from UNAIDS) are combined with assumptions about the relative incidence rate of TB in HIV-infected and HIV-uninfected individuals are used to estimate what proportion of incident TB cases (and hence prevalent cases and deaths) are in HIV-infected individuals. The MDG indicators exclude TB cases and deaths among HIV-infected individuals.

Incidence, prevalence and mortality are all estimated with error. The results of uncertainty analysis (described in Corbett et al.) are available at who.int/gtb/tbestimates. Proportion of tuberculosis cases detected, and proportion cured under DOTS

Reporting annually to WHO is one of the requirements of the DOTS strategy. The proportion of cases detected under DOTS is calculated for each country by dividing the number of smear-positive cases notified to WHO by the estimated number of incident smear-positive cases for the country for that year. Incidence is estimated (with error) as described above. Emphasis is placed on the detection and treatment of smear-positive cases as these cases are most infectious, so treating them has the greatest impact on transmission. Furthermore, smear-positive disease tends to be more severe, and more likely to be fatal.

Monitoring the outcome of TB treatment is another requirement of the DOTS strategy. The treatment success rate is the proportion of new smear-positive patients registered for treatment under DOTS that are cured (with laboratory confirmation) or who complete treatment (without laboratory confirmation of cure). This indicator is monitored routinely by national TB control programmes, and reported annually to WHO.

* The methods used to estimate TB prevalence and death rates are described in detail in: C. Dye, S. Scheele, P. Dolin, V. Pathania and M. C. Raviglione (1999), “Global burden of tuberculosis: estimated incidence, prevalence and mortality by country”, Journal of the American Medical Association 282, p.677-686; E.L. Corbett, C. Watt, N. Walker, D. Maher, M.C. Raviglione, B.G. Williams and C. Dye, “The growing burden of tuberculosis: global trends and interactions with the HIV epidemic” Archives of Internal Medicine 163, p. 1009-1021; World Health Organization. "Global Tuberculosis Control, Surveillance, Planning, Financing. WHO Report 2004". Geneva.

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Figure 5. African countries that, by 2004, had changed their policy on treatment of malaria to one requiring the use of artemisinin-based combination therapy

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