Report on the Global HIV/AIDS epidemic

Care and support for people living with HIV/AIDS

Health care: where are the gaps?
Despite decades of effort by communities and governments to improve access to
health care, and despite the help of WHO and other institutions, the health sector
deficiencies in the developing world appear to be growing instead of shrinking.
Even before the epidemic, the health care system did not get a fair share of the
national budget. Typically, health centres and hospitals were short-staffed, facilities
for diagnosis were inadequate and drug supplies erratic, and training for health care
providers was uneven and often poor. These deficiencies have worsened with the
arrival of the HIV epidemic, which has increased the demands for health care and
simultaneously reduced the health system's capacity to respond (see page 31).
In the poorer developing countries, local health centres and small hospitals lack
adequate facilities to diagnose the opportunistic diseases of people with HIV. They
repeatedly run out of supplies of essential drugs, including the ones needed to alleviate distressing symptoms and to manage opportunistic infections. For example,
oral thrush - a fungal disease which causes pain on swallowing - could be treated
relatively easily, but millions of patients continue to suffer for lack of a simple antifungal drug. Tuberculosis, which can be cured, often goes untreated for the same
reason. In Zambia, for example, where the tuberculosis case-load increased sixfold
between 1992 and 1998, proper treatment became increasingly problematic
because health facilities kept running out of TB drugs.
Even big teaching hospitals affiliated with urban medical schools - supposedly the
best-supplied part of the health system - have serious problems, to judge from a
UNAIDS survey of 22 university teaching hospitals in 19 African and 3 Asian cities
completed in 1997. The hospitals surveyed had suitable diagnostic facilities and the
right drugs to treat three conditions - pneumonia, pulmonary tuberculosis and oral
thrush. These are the only HIV-related conditions that are easy to diagnose and inexpensive to treat. For any other HIV-related illness, diagnostic capacity (X-ray and laboratory facilities) and drug supplies were so inadequate that a patient would have
less than a 50% chance of being correctly diagnosed and treated. This was true, for
instance, of Kaposi sarcoma (a frequent HIV-related cancer), serious fungal infections such as cryptococcal meningitis, and viral infections affecting the brain. Relief
for difficulty in breathing was unavailable in half the hospitals. Strong painkillers were
available in only two-fifths, despite the fact that most people with advanced HIV
infection require pain control at some point.
The high costs of antiretroviral drugs, and the sophisticated medical facilities required
to track patients' progress and monitor side-effects, have been major stumbling
blocks to access for the vast majority of people with HIV in the developing world.
Enormous variations in access to antiretrovirals exist in middle-income countries. In
most of Asia, people with HIV have limited access. In Thailand, for instance, the

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