Comment
trends need to be doubled and intentional investment must reach the poorest with the highest effect of care. In addition to completion of the unfinished business for pneumonia, diarrhoea, malaria, and HIV, a major shift needs to prioritise a healthy start, through quality of care at birth for every woman, and improved care of small and sick newborn babies. The Lancet Every Newborn series8 details the evidence, and the Every Newborn Action Plan is gaining momentum. This healthy start also improves human capital, targeting disability, preterm birth, small for gestational age, and stunting. The next child survival revolution has to go beyond survival alone to counting child development outcomes. The post-2015 framework needs explicit targets for maternal mortality, under-5 mortality, and neonatal mortality, but also for stillbirths and development outcomes. However a gap remains for effective accountability mechanisms and leadership for national change (table). Finally, clever modelling is no panacea for poor input data. Counting births and deaths is not just about a piece of paper, but a shift in norms to show that every birth and every death counts and that millions of newborn and child deaths are not inevitable.8
I am an unpaid member of both the IHME Global Burden of Disease Scientific Review Group and WHO’s Global Statistics Advisory Board. 1
2
3
4 5
6 7
8
9
10
11
12
Joy E Lawn London School Hygiene & Tropical Medicine, London WC1E 7HT, UK [email protected]
13
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. UNICEF. Levels and trends in child mortality. New York: United Nations, 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf (accessed May 24, 2014). Oestergaard MZ, Alkema L, Lawn JE. Millennium Development Goals national targets are moving targets and the results will not be known until well after the deadline of 2015. Int J Epidemiol 2013; 42: 645–47. Byass P. The imperfect world of global health estimates. PLoS Med 2010; 7: e1001006. Lawn JE, Kinney M, Black RE, et al. A decade of change for newborn survival, policy and programmes: a multi-country analysis. Health Policy Plan 2012; 27 (suppl 3): 6–28. Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008; 372: 950–61. Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013; 382: 2027–37. Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, potential beyond survival. Lancet 2014; published online May 19. http:// dx.doi.org/10.1016/S0140-6736(14)60496-7. Kerber KJ, Lawn JE, Johnson LF, et al. South African child deaths 1990–2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4? AIDS 2013; 27: 2637–48. National Institute of Population Studies. Pakistan Demographic and Health Survey 2012–13. Preliminary report. December, 2013. http://dhsprogram. com/publications/publication-FR290-DHS-Final-Reports.cfm (accessed July 7, 2014). Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377: 1863–76. Bryce J, Victora CG, Black RE. The unfinished agenda in child survival. Lancet 2013; 382: 1049–59. Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54.
Counting what counts for maternal mortality More than half a century ago, Dugald Baird1 wrote the public health classic about the application of a preventive outlook to obstetrics. This paper challenged the dominant curative model by acknowledging the broader determinants of pregnancy outcomes, and led to the emergence of social obstetrics. Baird’s message remains very relevant today. A social perspective is clearly relevant to all areas of health care, but it is vulnerable groups who suffer the most from its absence, especially children and women.2 The latest estimates of maternal mortality from Nicholas Kassebaum and colleagues3 published in The Lancet are a reminder of the need to apply a social lens to assessing improvements in health outcomes. The usual metrics of numbers and ratios show decreases since 1990 at global, regional, and national levels, with, for example, a worldwide estimate of 283 maternal deaths www.thelancet.com Vol 384 September 13, 2014
per 100 000 livebirths in 1990 (95% uncertainty interval 259–307), and 209 (186–234) in 2013. However, little is learnt from these figures in terms of the fundamental question of who has benefitted from this progress: have social gradients in the risk of preventable maternal death been narrowed? This question needs to be a focus as the Millennium Development Goal deadline approaches, and as the future world we want is debated.4 Evidence of marked differences in the burden of maternal mortality goes back centuries,5 both for individual-level characteristics, such as age or parity, and for aggregate-level factors, such as regions or rural versus urban areas. Although such a long-term view of differentials is restricted to what are now highincome countries with advanced vital registration systems, evidence of patterns of maternal mortality
See Articles page 980
933
Corbis
Comment
has been accumulating in low-income and middleincome countries, mainly from research, for at least 25 years.6 Kassebaum and colleagues’ study3 represents one of latest contributions, and shows impressive developments, methodologically in terms of grappling with data inadequacies, and collaboratively with regards to data access and sharing. Striking differences in maternal mortality are shown by cause, age, timing of death, and geography. Although we support the investigators’ view that such analysis can help to inform policy debates on acceleration of progress, we argue that the content is necessary but not sufficient. The main omission relates to fundamental drivers of risk of maternal mortality—the social determinants of health.7 Lessons from history and from major policy analyses8 reveal the importance of showing social gradients, both to inform intervention strategies and to judge progress. Should overall decreases in maternal mortality be regarded as progress if large gaps still exist in risk between social groups? Maternal mortality has long been regarded as a major measurement challenge in low-income and middle-income countries, but advances in capture and reporting have arisen, and the amount of data available is substantial, as testified by Kassebaum and colleagues’ study. Key differences are now being reported, albeit with room for improvement, and the rarity of maternal death is no longer being seen as a barrier to disaggregation of findings. Therefore, it is hard to accept that an absence of social gradients for maternal mortality in major global overviews can be attributed solely to poor methods or 934
reporting systems. An alternative explanation relates to missing data for the social circumstances of women because relevant questions are not being asked or, more fundamentally, because the social perspective is not always paramount in thinking and acting. Redress of this problem has important implications, both for future measurement and action. The advanced methods and technical collaboration apparent across global health metrics in general, and women’s and children’s health in particular, should give confidence that measurement solutions can be found for monitoring social gradients in maternal mortality and other health outcomes. For example, lessons should be drawn from the tracking of inequities in the coverage of key interventions by Countdown to 2015, some of which are also used in estimation models for maternal mortality, such as a skilled attendant at birth.9 Other analytical innovations should be sought to enable evidence of social gradients from research studies to be used, including adaptation of indirect estimation approaches.10 Reduction of inequities features strongly in the post-2015 sustainable development goals and universal health coverage,4 and in recent strategic reframing for maternal and newborn health.11,12 Introduction of a strong social perspective has synergies, for example, helping to re-focus attention both on preventive approaches to health improvement, and on preparation of the next generation13 of health-care workers to acknowledge social issues. The emerging epidemiological and obstetric transitions14 necessitate socially informed metrics, and a stronger social perspective also links directly with empowering the most marginalised women and with policies that seek to reduce barriers to care, especially financial ones.15 Just as Baird challenged accepted wisdoms in the early 1950s by highlighting social obstetrics, we add to the calls16 for new paradigms in the post-2015 era. Progress needs be informed and judged by social gradients, by counting what counts. *Wendy J Graham, Sophie Witter School of Medicine and Dentistry, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK [email protected] WJG is a member of the Technical Advisory Group for the Maternal Mortality Estimates Inter-Agency Group. We declare no competing interests.
www.thelancet.com Vol 384 September 13, 2014
Comment
We are grateful for the constructive comments on an earlier draft received from Carla Abou-Zahr, Siladitya Bhattacharya, Oona Campbell, Veronique Filippi, Ruth Lawley, Dileep Mavalankar, and Cesar Victora. 1 2 3
4
5 6 7
8
Baird D. Preventive medicine in obstetrics. N Engl J Med 1952; 246: 561–68. Fathalla MF. When medicine rediscovered its social roots. Bull World Health Organ 2000; 78: 677–78. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 980–1004. UN Secretary General. A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015. Report of the Secretary General. July 26, 2013. New York: United Nations General Assembly, 2013. Loudon I. Death in childbirth. An international study of maternal care and maternal mortality 1800–1950. Oxford: Clarendon Press, 1992. Graham WJ, Airey P. Measuring maternal mortality: sense and sensitivity. Health Policy Plan 1987; 2: 323–33. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008. Ottersen OP, Dasgupta J, Blouin C. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67.
9
10 11
12 13
14 15
16
Barros AJD, Victora CG. Measuring coverage in MNCH: determining and interpreting inequalities in coverage of maternal, newborn, and child health interventions. PLoS Med 2013; 10: e1001390. Graham WJ, Fitzmaurice AE, Bell JS, Cairns JA. The familial technique for linking maternal death with poverty. Lancet 2004; 363: 23–27. Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54. Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923–58. Souza JP, Tuncalp O, Vogel JP, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 2014; 121: 1. Witter S, Boukhalfa C, Filippi V, et al. Cost and impact of policies to remove fees for obstetric care in Benin, Burkina Faso, Mali and Morocco. FEM Health report. March, 2014. http://www.abdn.ac.uk/femhealth/ documents/Deliverables/Overall_cost_and_effects_report_ final_14_04_14.pdf (accessed June 20, 2014). Bustreo F, Say L, Koblinsky M, Pullum TW, Temmerman M, Pablos-Méndez A. Ending preventable maternal deaths: the time is now. Lancet Glob Health 2013; 1: e176–e77.
MDG 6 and beyond: from halting and reversing AIDS to ending the epidemic The global community strongly agrees on the need for coordinated action in the response to AIDS and on the opportunity to increase results by focusing on populations at increased risk of HIV. When the UN member states adopted the Millennium Development Goals (MDGs) in 2000, they identified in MDG 6 one of the goals to be a reversal in the spread of HIV: “Combat HIV, tuberculosis and malaria”. Partners in global health have worked hard to make that goal a reality and have achieved tremendous progress. So much so that this year member states are considering a new bold commitment—to end the epidemics of AIDS, tuberculosis, and malaria by 2030. In The Lancet, Christopher Murray and colleagues1 use results from their Global Burden of Disease (GBD) study 2013 to describe progress made towards reaching MDG 6. We applaud several specific strengths of the GBD 2013 study. First, the analysis shows a remarkable achievement of the global AIDS response: 19·1 million life-years have been saved since 1996, mainly in low-income and middle-income countries, and in a cost-effective manner. Second, the findings provide an opportunity to explore how the burden of different diseases differs across geographical regions and over time. In particular, the relative burden of malaria, tuberculosis, and HIV/AIDS, as highlighted by Murray and colleagues, www.thelancet.com Vol 384 September 13, 2014
is of particular interest for decision makers in countries as well as for international donors, including those who have a funding portfolio for all three of these diseases. Third, the methods of the Institute for Health Metrics and Evaluation (IHME) illustrate the potential value of using data on mortality and AIDS-specific deaths from vital registrations and surveys to inform estimates of HIV prevalence and incidence trends. In fact, past exchanges between the IHME team and UNAIDS on this subject have already resulted in a joint workshop with countries in Latin America that explicitly considered the value of data on AIDS-related mortality. Fourth, compared to IHME’s approach in the 2010 GBD study, the new study offers improvements in the way uncertainty is captured around estimates. Overall, Murray and colleagues echo our concerns that despite breakthrough progress, HIV continues to take a severe toll on health globally.2 We see a massive ongoing burden of deaths from AIDS-related illnesses that could be prevented. We all see places where more can be done. This is an essential message for political leaders and policy makers. No matter what lens you look through, the opportunity to make a transformative difference in HIV lies before us. By producing country-specific estimates of new HIV infections and global estimates of people living
Published Online July 22, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61222-8 See Articles page 1005
935
trends need to be doubled and intentional investment must reach the poorest with the highest effect of care. In addition to completion of the unfinished business for pneumonia, diarrhoea, malaria, and HIV, a major shift needs to prioritise a healthy start, through quality of care at birth for every woman, and improved care of small and sick newborn babies. The Lancet Every Newborn series8 details the evidence, and the Every Newborn Action Plan is gaining momentum. This healthy start also improves human capital, targeting disability, preterm birth, small for gestational age, and stunting. The next child survival revolution has to go beyond survival alone to counting child development outcomes. The post-2015 framework needs explicit targets for maternal mortality, under-5 mortality, and neonatal mortality, but also for stillbirths and development outcomes. However a gap remains for effective accountability mechanisms and leadership for national change (table). Finally, clever modelling is no panacea for poor input data. Counting births and deaths is not just about a piece of paper, but a shift in norms to show that every birth and every death counts and that millions of newborn and child deaths are not inevitable.8
I am an unpaid member of both the IHME Global Burden of Disease Scientific Review Group and WHO’s Global Statistics Advisory Board. 1
2
3
4 5
6 7
8
9
10
11
12
Joy E Lawn London School Hygiene & Tropical Medicine, London WC1E 7HT, UK [email protected]
13
Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. UNICEF. Levels and trends in child mortality. New York: United Nations, 2013. http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf (accessed May 24, 2014). Oestergaard MZ, Alkema L, Lawn JE. Millennium Development Goals national targets are moving targets and the results will not be known until well after the deadline of 2015. Int J Epidemiol 2013; 42: 645–47. Byass P. The imperfect world of global health estimates. PLoS Med 2010; 7: e1001006. Lawn JE, Kinney M, Black RE, et al. A decade of change for newborn survival, policy and programmes: a multi-country analysis. Health Policy Plan 2012; 27 (suppl 3): 6–28. Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet 2008; 372: 950–61. Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013; 382: 2027–37. Lawn JE, Blencowe H, Oza S, et al. Every Newborn: progress, priorities, potential beyond survival. Lancet 2014; published online May 19. http:// dx.doi.org/10.1016/S0140-6736(14)60496-7. Kerber KJ, Lawn JE, Johnson LF, et al. South African child deaths 1990–2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4? AIDS 2013; 27: 2637–48. National Institute of Population Studies. Pakistan Demographic and Health Survey 2012–13. Preliminary report. December, 2013. http://dhsprogram. com/publications/publication-FR290-DHS-Final-Reports.cfm (accessed July 7, 2014). Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Lancet 2011; 377: 1863–76. Bryce J, Victora CG, Black RE. The unfinished agenda in child survival. Lancet 2013; 382: 1049–59. Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54.
Counting what counts for maternal mortality More than half a century ago, Dugald Baird1 wrote the public health classic about the application of a preventive outlook to obstetrics. This paper challenged the dominant curative model by acknowledging the broader determinants of pregnancy outcomes, and led to the emergence of social obstetrics. Baird’s message remains very relevant today. A social perspective is clearly relevant to all areas of health care, but it is vulnerable groups who suffer the most from its absence, especially children and women.2 The latest estimates of maternal mortality from Nicholas Kassebaum and colleagues3 published in The Lancet are a reminder of the need to apply a social lens to assessing improvements in health outcomes. The usual metrics of numbers and ratios show decreases since 1990 at global, regional, and national levels, with, for example, a worldwide estimate of 283 maternal deaths www.thelancet.com Vol 384 September 13, 2014
per 100 000 livebirths in 1990 (95% uncertainty interval 259–307), and 209 (186–234) in 2013. However, little is learnt from these figures in terms of the fundamental question of who has benefitted from this progress: have social gradients in the risk of preventable maternal death been narrowed? This question needs to be a focus as the Millennium Development Goal deadline approaches, and as the future world we want is debated.4 Evidence of marked differences in the burden of maternal mortality goes back centuries,5 both for individual-level characteristics, such as age or parity, and for aggregate-level factors, such as regions or rural versus urban areas. Although such a long-term view of differentials is restricted to what are now highincome countries with advanced vital registration systems, evidence of patterns of maternal mortality
See Articles page 980
933
Corbis
Comment
has been accumulating in low-income and middleincome countries, mainly from research, for at least 25 years.6 Kassebaum and colleagues’ study3 represents one of latest contributions, and shows impressive developments, methodologically in terms of grappling with data inadequacies, and collaboratively with regards to data access and sharing. Striking differences in maternal mortality are shown by cause, age, timing of death, and geography. Although we support the investigators’ view that such analysis can help to inform policy debates on acceleration of progress, we argue that the content is necessary but not sufficient. The main omission relates to fundamental drivers of risk of maternal mortality—the social determinants of health.7 Lessons from history and from major policy analyses8 reveal the importance of showing social gradients, both to inform intervention strategies and to judge progress. Should overall decreases in maternal mortality be regarded as progress if large gaps still exist in risk between social groups? Maternal mortality has long been regarded as a major measurement challenge in low-income and middle-income countries, but advances in capture and reporting have arisen, and the amount of data available is substantial, as testified by Kassebaum and colleagues’ study. Key differences are now being reported, albeit with room for improvement, and the rarity of maternal death is no longer being seen as a barrier to disaggregation of findings. Therefore, it is hard to accept that an absence of social gradients for maternal mortality in major global overviews can be attributed solely to poor methods or 934
reporting systems. An alternative explanation relates to missing data for the social circumstances of women because relevant questions are not being asked or, more fundamentally, because the social perspective is not always paramount in thinking and acting. Redress of this problem has important implications, both for future measurement and action. The advanced methods and technical collaboration apparent across global health metrics in general, and women’s and children’s health in particular, should give confidence that measurement solutions can be found for monitoring social gradients in maternal mortality and other health outcomes. For example, lessons should be drawn from the tracking of inequities in the coverage of key interventions by Countdown to 2015, some of which are also used in estimation models for maternal mortality, such as a skilled attendant at birth.9 Other analytical innovations should be sought to enable evidence of social gradients from research studies to be used, including adaptation of indirect estimation approaches.10 Reduction of inequities features strongly in the post-2015 sustainable development goals and universal health coverage,4 and in recent strategic reframing for maternal and newborn health.11,12 Introduction of a strong social perspective has synergies, for example, helping to re-focus attention both on preventive approaches to health improvement, and on preparation of the next generation13 of health-care workers to acknowledge social issues. The emerging epidemiological and obstetric transitions14 necessitate socially informed metrics, and a stronger social perspective also links directly with empowering the most marginalised women and with policies that seek to reduce barriers to care, especially financial ones.15 Just as Baird challenged accepted wisdoms in the early 1950s by highlighting social obstetrics, we add to the calls16 for new paradigms in the post-2015 era. Progress needs be informed and judged by social gradients, by counting what counts. *Wendy J Graham, Sophie Witter School of Medicine and Dentistry, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK [email protected] WJG is a member of the Technical Advisory Group for the Maternal Mortality Estimates Inter-Agency Group. We declare no competing interests.
www.thelancet.com Vol 384 September 13, 2014
Comment
We are grateful for the constructive comments on an earlier draft received from Carla Abou-Zahr, Siladitya Bhattacharya, Oona Campbell, Veronique Filippi, Ruth Lawley, Dileep Mavalankar, and Cesar Victora. 1 2 3
4
5 6 7
8
Baird D. Preventive medicine in obstetrics. N Engl J Med 1952; 246: 561–68. Fathalla MF. When medicine rediscovered its social roots. Bull World Health Organ 2000; 78: 677–78. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 980–1004. UN Secretary General. A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015. Report of the Secretary General. July 26, 2013. New York: United Nations General Assembly, 2013. Loudon I. Death in childbirth. An international study of maternal care and maternal mortality 1800–1950. Oxford: Clarendon Press, 1992. Graham WJ, Airey P. Measuring maternal mortality: sense and sensitivity. Health Policy Plan 1987; 2: 323–33. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization, 2008. Ottersen OP, Dasgupta J, Blouin C. The political origins of health inequity: prospects for change. Lancet 2014; 383: 630–67.
9
10 11
12 13
14 15
16
Barros AJD, Victora CG. Measuring coverage in MNCH: determining and interpreting inequalities in coverage of maternal, newborn, and child health interventions. PLoS Med 2013; 10: e1001390. Graham WJ, Fitzmaurice AE, Bell JS, Cairns JA. The familial technique for linking maternal death with poverty. Lancet 2004; 363: 23–27. Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in women’s and children’s health: a new Global Investment Framework. Lancet 2014; 383: 1333–54. Langer A, Horton R, Chalamilla G. A manifesto for maternal health post-2015. Lancet 2013; 381: 601–02. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet 2010; 376: 1923–58. Souza JP, Tuncalp O, Vogel JP, et al. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 2014; 121: 1. Witter S, Boukhalfa C, Filippi V, et al. Cost and impact of policies to remove fees for obstetric care in Benin, Burkina Faso, Mali and Morocco. FEM Health report. March, 2014. http://www.abdn.ac.uk/femhealth/ documents/Deliverables/Overall_cost_and_effects_report_ final_14_04_14.pdf (accessed June 20, 2014). Bustreo F, Say L, Koblinsky M, Pullum TW, Temmerman M, Pablos-Méndez A. Ending preventable maternal deaths: the time is now. Lancet Glob Health 2013; 1: e176–e77.
MDG 6 and beyond: from halting and reversing AIDS to ending the epidemic The global community strongly agrees on the need for coordinated action in the response to AIDS and on the opportunity to increase results by focusing on populations at increased risk of HIV. When the UN member states adopted the Millennium Development Goals (MDGs) in 2000, they identified in MDG 6 one of the goals to be a reversal in the spread of HIV: “Combat HIV, tuberculosis and malaria”. Partners in global health have worked hard to make that goal a reality and have achieved tremendous progress. So much so that this year member states are considering a new bold commitment—to end the epidemics of AIDS, tuberculosis, and malaria by 2030. In The Lancet, Christopher Murray and colleagues1 use results from their Global Burden of Disease (GBD) study 2013 to describe progress made towards reaching MDG 6. We applaud several specific strengths of the GBD 2013 study. First, the analysis shows a remarkable achievement of the global AIDS response: 19·1 million life-years have been saved since 1996, mainly in low-income and middle-income countries, and in a cost-effective manner. Second, the findings provide an opportunity to explore how the burden of different diseases differs across geographical regions and over time. In particular, the relative burden of malaria, tuberculosis, and HIV/AIDS, as highlighted by Murray and colleagues, www.thelancet.com Vol 384 September 13, 2014
is of particular interest for decision makers in countries as well as for international donors, including those who have a funding portfolio for all three of these diseases. Third, the methods of the Institute for Health Metrics and Evaluation (IHME) illustrate the potential value of using data on mortality and AIDS-specific deaths from vital registrations and surveys to inform estimates of HIV prevalence and incidence trends. In fact, past exchanges between the IHME team and UNAIDS on this subject have already resulted in a joint workshop with countries in Latin America that explicitly considered the value of data on AIDS-related mortality. Fourth, compared to IHME’s approach in the 2010 GBD study, the new study offers improvements in the way uncertainty is captured around estimates. Overall, Murray and colleagues echo our concerns that despite breakthrough progress, HIV continues to take a severe toll on health globally.2 We see a massive ongoing burden of deaths from AIDS-related illnesses that could be prevented. We all see places where more can be done. This is an essential message for political leaders and policy makers. No matter what lens you look through, the opportunity to make a transformative difference in HIV lies before us. By producing country-specific estimates of new HIV infections and global estimates of people living
Published Online July 22, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61222-8 See Articles page 1005
935
