Though hundreds of thousands of poor AIDS patients in the developing world are now on life-saving anti-retroviral drugs, the majority of the 3 million people targeted by the WHO initiative have not yet been reached. With only a year to go for the programme’s deadline, obstacles to the global AIDS treatment effort remain.
Two years ago, in response to the growing global HIV/AIDS pandemic and the huge number of people in the world’s developing or transitional nations who are unable to afford or access anti-retroviral (ARVs) drugs that could be life-saving, the United Nations’ World Health Organisation launched its ambitious ‘3 by 5’ project. Launched on World AIDS Day, December 1, 2003, the project was so named because it aims to provide 3 million of the estimated 6 million people in need, in developing countries, with anti-retroviral therapy (ART) by the year 2005.
By the end of 2004, 700,000 AIDS-infected people in developing countries were receiving anti-retroviral therapy, an increase of 75% over the previous year. This still represents only 12% of the ‘3 by 5’ target. The programme also remains short of US$ 2 billion of the estimated US$ 3.5-3.8 billion required to meet its target.
The WHO’s latest progress report on the initiative, presented on January 26 at the recent World Economic Forum in Davos, Switzerland, says that this funding gap could be bridged by reductions in the cost of drugs or service delivery. The initiative is supported and funded by the WHO, the Joint UN Programme on HIV/AIDS -- UNAIDS, the Global Fund and the US President’s Emergency Plan for AIDS Relief (PEPFAR).
“We salute the countries who have now shown us that treatment is possible and can be scaled up quickly even in the poorest settings,” WHO director-general Lee Jong-Wook said. “AIDS treatment access is expanding every day thanks to the dedicated work of doctors, nurses, health workers and people living with HIV and AIDS who are often working under difficult circumstances to turn the dream of universal treatment into a reality.”
A regional and country-wise breakdown shows that:
- The number of people on treatment doubled over six months, from 150,000 to 310,000 in sub-Saharan Africa , and from 50,000 to 100,000 in Asia.
- In Latin America and the Caribbean , the numbers continue to improve and there are now 275,000 people on treatment there.
- Botswana in Africa and more than 10 Latin American countries are already treating half or more of those in need, while Uganda and Thailand are expected to be treating 50% or more people needing ART in the first half of 2005.
Number of people receiving ARV therapy in developing and transitional countries by region, 2002–2004
However experts noted that in both affected countries and internationally, efforts on the delivery and funding front needed to be stepped up, and fast. With just about a year to go before the programme’s deadline is up, 88% of the target group still needs to be reached.
The WHO and UNAIDS estimate that, overall, 72% of the unmet need for treatment is in sub-Saharan Africa and 22% in Asia . India , Nigeria and South Africa alone account for 41% of the overall need for treatment.
The WHO needs $ 60 million before the end of 2005 to provide the necessary technical assistance to countries to help them reach their targets. “While today’s figures are encouraging, the work so far has been laying the groundwork for a much larger expansion in the months and years to come,” said Richard Feachem, executive-director of the Global Fund to fight AIDS, Tuberculosis and Malaria, a unique public-private partnership created three years ago on United Nations secretary-general Kofi Annan’s initiative to attract additional resources in the battle against the three diseases.
Since July 2004, only 260,000 new patients have benefited from ARV therapy in developing countries. Every day, over 8,000 people die from AIDS, and every year another 5 million new HIV infections are reported.
Estimated number of people receiving ART people needing ARV and percentage coverage in developing and transitional countries by region, December 2004a,b
|Geographical Region||Estimated number of people receiving ARV therapy, December 2004 (low estimate–high estimate) c||Estimated number of people 15–49 years old needing ARV therapy, 2004 d||ARV therapy coverage, December 2004 (%) e||Estimated number of people receiving ARV therapy, June 2004|
|Sub-Saharan Africa||310 000 [270 000–350 000]||4 000 000||8%||150 000|
|Latin America and the Caribbean||275 000 [260 000–290 000]||425 000||65%||220 000|
|East, South and South-East Asia||100 000 [85 000–115 000]||1 200 000||8%||55 000|
|Europe and Central Asia||15 000 [13 000–17000]||150 000||10%||11 000|
|North Africa and the Middle East f||4 000 [2 000–6 000]||55 000||7%||4 000|
|Total||700 000 [630 000–780 000]||5.8 million||12%||440 000|
Note: numbers do not add up due to rounding.
In the light of these figures and the latest report on ‘3 by 5’, Médecins Sans Frontières (MSF), or Doctors Without Borders, which provides ARV treatment to over 25,000 patients in 27 countries has said: “Treatment expansion is moving at a snail’s pace. From the perspective of a medical humanitarian organisation working in resource-poor countries to treat people with AIDS, the global picture is bleak.”
The WHO and its partners have acknowledged that key obstacles to meeting the ‘3 by 5’ target that must be tackled urgently include:
- The high cost of first and, particularly, second-line treatment and diagnostic tests. Due to lack of generic competition, much-needed second-line medicines are already two to 12 times more expensive than the most affordable WHO-recommended first-line generics. The WHO itself describes ARV prices as an “increasingly serious public health hazard”. Thus far, however, the WHO and others are demanding nothing of governments or pharmaceutical companies and offer no practical solutions.
- The lack of affordable and user-friendly AIDS medicines for children. MSF says the fact that there are few adapted and affordable paediatric formulations for the 2.2 million children living with HIV, and few diagnostic and monitoring tools suited to their needs, is a problem that the WHO and Unicef continue to fail to address.
- The need to ensure equitable access to reach the most vulnerable, including sex workers, prisoners and injecting drug-users. And the need to rapidly accelerate and coordinate prevention and treatment services.
MSF says other barriers include trade rules that interfere with generic competition that has brought the prices of AIDS drugs down dramatically and was a prerequisite for getting donors and national governments to commit to treatment. January 2005 marks a new threat to access to medicines.
India , where most of the largest producers of generic ARVs are located, no longer has the right to produce generic versions of new drugs because it is implementing the World Trade Organisation (WTO) Agreement on Trade-related Aspects of Intellectual Property Rights (TRIPS). This will most likely lead to a steep increase in the prices of any new drugs to treat AIDS. If the prices of second-line medicines are any indication, we are in for steep price increases, MSF notes.
The humanitarian agency says the WHO must do much more to strengthen its pre-qualification project, and the US government and pharmaceutical industry (and the private groups they fund) must stop undermining confidence in generic medicines through inaccurate and irresponsible public campaigns.
Finally, lack of investment into research and development (R&D) for new preventive, diagnostic, monitoring and therapeutic tools adapted for use in resource-limited settings is completely off the international political agenda. New tools to diagnose HIV in children under 18 months, to diagnose TB, and detect treatment failure, for example, are urgently needed in the field as are new and adapted drugs, vaccines and microbicides, says MSF.
According to the WHO, whatever treatment is underway is happening because national governments are taking the lead in coordinating efforts with all partners to scale up treatment in rural and urban areas.
The Global Fund, meanwhile, provides flexible funds to governments and projects. PEPFAR funds as well as provides technical assistance and guidance for programme and capacity development to support national strategies. The WHO and UNAIDS provide guidance and technical assistance to help countries turn finance into programmes, and non-governmental organisations (NGOs), faith-based organisations, networks of people living with HIV/AIDS and the private sector are all contributing.
According to MSF, however, the claim that the ‘3 by 5’ partners are working a tandem to achieve this acclaimed success is a myth and that the amount of collaboration is being overstated. PEPFAR projects are often at odds with Global Fund projects and national policies in terms of procurement and distribution of drugs, processes for evaluating the quality, safety and efficacy of medicines, and coherence with national protocols. In fact, because of these policy inconsistencies, PEPFAR has recently been criticised for having a smaller selection of ARVs available for its 15 ‘focus countries’ than other treatment initiatives, and for spending far more money than other initiatives on ARVs.
On January 26, the US Government Accountability Office released a report which found that PEPFAR pays US$ 40-368 more than other AIDS initiatives per patient per year for first-line regimens because it relies only on the FDA (Food and Drug Administration) approved drugs and “does not include some FDCs that are preferred by some of the focus countries”. The report explains that, “for every 100,000 patients on this regimen (d4T+3TC+NVP) for five years, the plan could pay over US$ 170 million more than the other initiatives”. In other words, PEPFAR could be treating thousands more people with the funds it is spending.
Among other problems are the need to increase the number of individuals who know their HIV status, in part through the routine offer of testing and counselling at critical health system entry points, and the continued lack of adequate human resources and trained medical and non-medical health workers in affected communities.
“We know that treatment is more than just access to anti-retrovirals,” UNAIDS executive-director Peter Piot said embracing a wider approach to the AIDS crisis. “People living with HIV need comprehensive services, from testing and counselling to nutritional support. Just as there is an urgent need to increase access to treatment, we must also renew our commitment to preventing new HIV infections.”
The WHO says it needs $ 60 million before the end of 2005 to provide the necessary technical assistance to countries to help them reach their targets. However, MSF maintains that despite its lofty aims the WHO and its partners are not doing enough to tackle the AIDS pandemic where the needs are most urgent.
InfoChange News & Features, February 2005