AIDS is an extraordinary kind of crisis; it is both an emergency and a long-term development issue. Despite increased funding, political commitment and progress in expanding access to HIV treatment, the AIDS epidemic continues to outpace the global response. No region of the world has been spared. The epidemic remains extremely dynamic, growing and changing character as the virus exploits new opportunities for transmission.

Rates of infection are still on the rise in many countries in sub-Saharan Africa. In 2003 alone, an estimated 3 million people in the region became newly infected. New epidemics appear to be advancing unchecked in other places, notably Eastern Europe and Asia -- regions that are experiencing the fastest-growing epidemics in the world.

More than 20 years and 20 million deaths since the first AIDS diagnosis in 1981, almost 38 million people (range 34.6-42.3 million) are living with HIV. Even though the cure is elusive, we have learned crucial lessons about what works best in preventing new infections and improving the quality and care for people living with HIV. There have been some major developments, including antiretroviral medicines.

Despite these signs of progress, there are still huge challenges to turning the tide of this epidemic. Funding has greatly increased but is still only half of what is needed and is not always effectively utilized. Many national leaders remain in denial about the impact of AIDS on their people and societies.

Today we are faced with life and death choices. Without major action, the global epidemic will continue to outstrip the response. But there is an alternative: together we can forge policies grounded in science, not political rhetoric, and embark boldly on the "Next Agenda" -- an agenda for future action based on innovative approaches.

What Are the Major Challenges?

• The female face of the epidemic. Women are increasingly at great risk of infection. As of December 2003, women accounted for nearly 50% of all people living with HIV worldwide and for 57% in sub-Saharan Africa. Women and girls also bear the brunt of the impact of the epidemic; they are most likely to take care of sick people, to lose jobs, income and schooling as a result of illness, and to face stigma and discrimination. There is an urgent need to address the many factors that contribute to women's vulnerability and risk -- gender and cultural inequalities, violence, ignorance.
• Young people -- 15-24 year olds -- account for nearly half of all new HIV infections worldwide. They are the largest youth generation in history and need a protective environment -- regular schooling, access to health and support services -- if they are to play their vital part in combating the epidemic.
• Scaling up treatment programmes providing life-prolonging antiretroviral therapy. Only 7% of the people who need antiretroviral treatment in developing countries have access to ARVs -- 400 000 at the end of 2003. Programmes must be sustainable to prevent the development of drug-resistant strains of the virus.
• Several countries in southern Africa face a growing crisis in delivering vital public services that are crucial to the AIDS response. Reasons for this range from migration of key staff from public to private sectors, migration abroad, to the deadly impact of the AIDS epidemic itself.
• Scaling up prevention programmes that currently reach only one in five people at risk of HIV infection. In low- and middle-income countries in 2003, only one in ten pregnant women was offered services for preventing mother-to-child HIV transmission. In high-income countries, treatment has been a much higher priority than prevention and as a result, there have been rises in HIV transmission for the first time in a decade.
• Tackling stigma and discrimination. They directly hamper the effectiveness of AIDS responses, stop people being tested for HIV, prevent the use of condoms or HIV-positive women breastfeeding to protect their babies against infection, and prevent marginalized groups such as injecting drug users receiving the care and support they need.
• Tackling the neglect of orphans. AIDS has killed one or both parents of an estimated 12 million children in sub-Saharan Africa and far too many of these orphans are not properly cared for.

Global AIDS Funding

In addition to providing up-to-date global, regional and country data, the report releases new estimates on global resources needed to effectively combat the epidemic in the developing world. For the first time, the revised estimates reflect data obtained from 78 countries, many on the frontlines of the AIDS epidemic.

Although global spending on AIDS has increased 15-fold from US$300 million in 1996 to just under US$5 billion in 2003, it is less than half of what will be needed by 2005 in developing countries. According to newly revised costing estimates, an estimated US$12 billion (up from US$10 billion) will be needed by 2005 and US$20 billion by 2007 for prevention and care in low- and middle-income countries.

The estimated US$20 billion would provide antiretroviral therapy to just over six million people (over four million in sub-Saharan Africa), support for 22 million orphans, HIV voluntary counselling and testing for 100 million adults, school-based AIDS education for 900 million students and peer counselling services for 60 million young people not in school. About 43% of these resources will be needed in sub-Saharan Africa, 28% in Asia, 17% in Latin American and the Caribbean, 9% in Eastern Europe, and 1% in North Africa and the Near East.

Fully funding the response to AIDS will require an extraordinary effort, which cannot be met from currently planned regular domestic and international development budgets. It will require extraordinary leadership and will have to use currently untapped resources.