Department of Economic and Social Affairs
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
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.
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.
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.
1
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
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).
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
http://millenniumindicators.un.org (accessed June
2005); based on data provided by The Joint United
Nations Programme on HIV/AIDS (UNAIDS).
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
2
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
1990
Developed regions
Commonwealth of Independent
States, Europe
Commonwealth of Independent
States, Asia
Northern Africa
Sub-Saharan Africa
Latin America and the Caribbean
Eastern Asia
Southern Asia
South-Eastern Asia
Western Asia
Oceania
Percentage of population aged 15 to 49 living with HIV
2001
2004
Estimated
adult
HIV
prevalence
0.2
Percentage of
adults living with
HIV who are
women
<020
Estimated
adult
HIV
prevalence
0.4
Percentage of
adults living with
HIV who are
women
26
Estimated
adult
HIV
prevalence
0.5
Percentage
of adults
living with
HIV who
are women
29
<0.1
<20
0.8
32
1.2
35
<0.1
<0.1
2.7
0.3
<0.1
0.1
0.1
<0.1
<0.1
<20
<20
54
33
<20
<20
<20
<20
<20
<0.1
<0.1
7.3
0.6
0.1
0.5
0.5
<0.1
0.4
32
<20
57
38
20
27
29
<20
29
0.2
<0.1
7.2
0.7
0.1
0.7
0.5
<0.1
0.6
33
<20
57
39
22
30
30
<20
31
Source: United Nations Statistics Division, “World and regional trends”, Millennium Indicators Database, available at http:/millenniumindicators.un.org (accessed June 2005); based
on data provided by UNAIDS.
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
3
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. 1 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.
4
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.
Table 2. HIV prevalence among 15 to 24 years olds from national
population-based surveys, 2001/2004
The small amount of data
available from population-based
Percentage living with HIV
surveys in countries shows a
Women
Men
wide gender gap. In all 12
Burkina Faso
1.17
0.51
countries with data, young
Burundi
3.3
1.6
women are more likely than
Cameroon
4.8
1.4
young men to be infected, and
Dominican
Republic
0.7
0.4
in six countries, young women
Ghana
1.2
0.1
are more than three times as
Kenya
5.9
1.3
likely to be infected as men.
Mali
1.3
0.3
In other parts of the world, HIV
Niger
0.8
0.3
infections are concentrated
South
Africa
12.0
6.1
among sub-populations that are
United Republic of Tanzania
4.0
3.0
at particularly high risk. These
Zambia
11.2
3.0
include injecting drug users,
men who have sex with men,
Zimbabwe
18.0
5.0
Source: United Nations Statistics Division, “World and regional trends”, Millennium
commercial sex workers,
Indicators Database, available from http://millenniumindicators.un.org (accessed June
migrants and other groups. In
2005); based on data provided by UNAIDS.
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.
Preventing HIV infection
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.
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).
5
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
Per cent who
Number of
Per cent who
countries
have
countries
have
covered by the
comprehensive
covered by the
comprehensive
surveys
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 http://millenniumindicators.un.org
(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
Per cent who
Number of
Per cent who
countries
used a condom
countries
used a condom
covered by the
at last high-risk
covered by the
at last high-risk
surveys
sex1/
surveys
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
http://millenniumindicators.un.org (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.
6
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 nonregular 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.2
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 http://millenniumindicators.un.org
(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.
7
Growing numbers of children orphaned by AIDS
AIDS has orphaned millions of children, and the
Monitoring support programmes for
number is expected to grow over the next
children orphaned by AIDS
decade as HIV-infected parents become ill and
Since children orphaned by AIDS face
3
die. Around 15 million children under 15 had
discrimination and increased poverty, it is important
lost one or both parents to AIDS by the end of
to monitor to what extent AIDS support programmes
2003 in countries in Africa, Asia and Latin
are successful in providing educational opportunities
America and the Caribbean. That number is
to these children. The indicator used for this
projected to nearly double by 2010. Between
purpose is the ratio of school attendance of orphans
1990 and 2003, the number of children in subto attendance of non-orphans.
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
Sub-Saharan Africa
Latin America and the Caribbean
South-Eastern Asia
Number of countries covered
by the surveys
37
6
2
Ratio of school attendance of orphans to
school attendance of non-orphans1/
0.78
0.89
0.81
Source: United Nations Statistics Division, “World and regional trends”, Millennium Indicators Database, available from
http://millenniumindicators.un.org (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.
8
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. 4 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.5
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.6
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. 7
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 8
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.9
The existence of generic drugs is key in keeping drug prices affordable, since voluntary price
cuts by drug companies cannot provide a comprehensive solution. 10 Brazil’s HIV/AIDS
9
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. 11
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
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.
Today, over 3 billion people12 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.
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.
Table 6. Malaria mortality rate, 20001/
Number of
deaths per
100,000 children
aged 0-4 years
Region
0
Developed regions
47
Northern Africa
791
Sub-Saharan Africa
1
Latin America/Caribbean
0
Eastern Asia
6
South-Central Asia
2
South-Eastern Asia
26
Western Asia
2
Oceania
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
Source: United Nations Statistics Division, “World and
regional trends”, Millennium Indicators Database,
most need strong adults to work in the fields. 13 A
http://millenniumindicators.un.org (accessed June 2005);
brief episode that delays planting or coincides with
based on data provided by the World Health Organization.
harvesting can have catastrophic economic effects
1/Mortality estimates for malaria are under revision. Current
and can deepen impoverishment at the household
estimates are not sufficiently reliable to estimate trends.
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.
10
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, insecticidetreated 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 coverage14.
Guinea-Bissau
Sao Tome & Prin.
Gambia
Malaw i
Comoros
Benin
CAR
Madagascar
Chad
Sudan (Northern)
UR Tanzania
Burkina Faso
Niger
Zambia
Somalia
Equatorial Guinea
Senegal
Sierra Leone
Togo
Ghana
Kenya
Eritrea
DR Congo
Cameroon
Angola
Côte d'Ivoire
Gabon
Uganda
Namibia
Nigeria
Rw anda
Zimbabw e
Burundi
Sw aziland
Figure 3: Mosquito nets sold or distributed
in sub-Saharan Africa, 1999-2003 (millions)
ITNs
Any nets
0
20
40
60
Percentage
80
100
11
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.)
CAR
Comoros
Sao Tome & Prin.
Sierra Leone
Ghana
Togo
Benin
Guinea-Bissau
Angola
Côte d'Ivoire
Gambia
UR Tanzania
Zambia
Sudan (Northern)
Cameroon
Niger
Burkina Faso
DR Congo
Equatorial Guinea
Gabon
Mali
Senegal
Nigeria
Chad
Madagascar
Burundi
Sw aziland
Mauritania
Somalia
Namibia
Rw anda
Kenya
Eritrea
Ethiopia
Malaw i
CQ
Any antimalarial
0
20
40
60
80
100
P ercentage
12
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.15
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
Figure 5. African countries that, by 2004, had
moving in the right direction. United
changed their policy on treatment of malaria to
Nations agencies and their partners are
one requiring the use of artemisinin-based
distributing free, insecticide-treated
combination therapy
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.16
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 Summit17 targets. MERG brings together concerned
13
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
In 2003, there were an estimated 8.8 million
new tuberculosis (TB) cases, including 0.67
Progress in combating TB is assessed on the basis
million in people infected with HIV. That same
of trends in the prevalence rate (the number of
year, tuberculosis killed 1.7 million people,
cases of TB per 100,000 population) and the
including 230,000 people with HIV infection.
number of deaths due to tuberculosis each year per
The poor are most at risk for several reasons:
100,000 population. Progress in the implementation
among them are lack of treatment, which
of TB control is assessed on the basis of the
means that the disease keeps spreading in
proportion of estimated smear-positive cases (those
poor countries, and malnutrition, which
responsible for most transmission) treated under the
compromises people’s ability to fight off the
internationally recommended control strategy known
infection. Most of the deaths associated with
as “DOTS”, and the proportion of these cases that
TB occur during an adult’s most productive
are successfully treated.
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
308
265
WORLD
Developed regions
Commonwealth of Independent States
CIS, Europe
CIS, Asia
Developing regions
Africa
Northern Africa
Sub-Saharan Africa
Latin America and the Caribbean
Asia
Eastern Asia
South Asia
South-Eastern Asia
Western Asia
Oceania
36
82
77
99
386
286
125
323
156
441
325
493
726
117
569
22
154
159
141
320
397
53
471
97
336
264
374
505
77
415
2002
254
20
150
155
138
307
397
52
471
93
318
258
350
466
77
353
Source: United Nations Statistics Division, based on country data provided by WHO. See Millennium Indicators Database, “World and regional trends”, http://millenniumindicators.u
1/ Excluding those infected with HIV.
14
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).18
Table 8. Tuberculosis incidence rate, 1990, 2001, 2002, 2003
Number of new cases per 100,000
population 1/
1990
2001
2002
2003
119
128
128
129
29
19
18
17
49
107
106
104
46
107
104
100
59
106
110
114
145
151
152
153
59
51
50
50
142
253
263
274
99
68
65
63
117
105
104
103
171
168
168
168
248
237
236
235
60
52
52
52
204
173
171
168
WORLD
Developed regions
Commonwealth of Independent States
CIS, Europe
CIS, Asia
Developing regions
Northern Africa
Sub-Saharan Africa
Latin America and the Caribbean
Eastern Asia
Southern Asia
South-Eastern Asia
Western Asia
Oceania
Source: United Nations Statistics Division, based on country data provided by the World Health Organization. See Millennium Indicators
Database, “World and regional trends”, http://millenniumindicators.un.org, (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”, http://millenniumindicators.un.org, (accessed June 2005).
1/ TB mortality rates exclude deaths from TB among people infected with HIV.
15
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. SouthEastern 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 fivepronged 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”, http://millenniumindicators.un.org, (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.
16
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 healthcare 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.
17
Notes
UNAIDS, 2004 Report on the Global AIDS Epidemic (UNAIDS/04.16E, Geneva, June 2004).
UNDP International Poverty Centre, In Focus, March 2005.
3 UNICEF/UNAIDS/USAID, Children on the Brink 2004: A joint report of new orphan estimates and a framework
for action. July 2004.
4 Global HIV Prevention Working Group. HIV Prevention in the Era of Expanded Treatment Access.
5 The Lancet 2005, “Emerging Consensus in HIV/AIDS, Malaria, Tuberculosis, and Access to Essential
Medicines”.
6 UNDP International Poverty Centre, In Focus, March 2005.
7 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.
8 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
http://www.wto.org/english/tratop_e/trips_e/implem_para6_e.htm
9 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.
10 UNDP, Human Development Report 2003, p.159 (Oxford University Press, New York, 2003).
11 UNDP International Poverty Centre, In Focus, March 2005.
12
Roll Back Malaria, WHO and UNICEF, 2005 World Malaria report.
1
2
Global Fund to Fight AIDS, Tuberculosis and Malaria, available at
http://www.globalfundatm.org/journalists/infosheets/malaria.html
13
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: http://rbm.who.int/docs/abuja_brf2702.htm
14
15
Roll Back Malaria, WHO and UNICEF, 2005 World Malaria report.
16
Ibid.
Abuja Declaration on HIV/AIDS, Tuberculosis and other Related Infectious Diseases, available at:
http://www.uneca.org/adf2000/Abuja20Declaration.htm .
17
18
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 healthylooking 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-
18
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 www.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
19
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.
20