The "3 by 5" Initiative: Progress and Challenges
Plenary address by Jim Yong Kim, M.D., Ph.D. Director, Department of HIV/AIDS, WHO at the VII International Congress on AIDS in Asia and the Pacific, 4 July 2005, Kobe, Japan,
Friends, Distinguished Guests:
Four years ago, in 2001, just before the landmark United Nations General Assembly meeting on HIV/AIDS, Bernhard Schwartländer and his colleagues at UNAIDS published an article in the journal Science, in which they developed an optimal scenario about what the response to AIDS could look like, four years ahead, in 2005. They projected that a major infusion of new resources would finance an expansion of key prevention interventions, impact mitigation, care, and antiretroviral treatment for 3 million people by 2005 - about half of those in need. With this article, the “3 by 5” target was quietly born. But the scenario assumed that apart from new resources, everything else needed to treat 3 million would also be in place by 2005: treatment protocols would need to be developed, hundreds of thousands of health workers would have to be trained and communities educated; people would need to come forward to be tested for HIV. Most important of all, the political commitment shown at UNGASS would need to be maintained and translated into action.
Even with the strong, public commitment by world leaders at UNGASS, and despite the promising results being shown by a few NGOs and governments running pilot treatment projects in several developing countries, most people argued that scaling up treatment was impossible on a national and global scale. Donors continued to favour prevention even though, as we now know, a response that focuses on prevention alone is neither effective nor just. And, at that time, treatment regimens were more complicated; the drugs themselves were expensive and very few health workers in developing countries knew how to use them.
For two years, while people died for lack of access to life-saving treatment, we debated among ourselves about whether it was cost-effective to save human lives, about whether to back off the target or to move forward and reach for it. Only the activists reminded us that precious time was being lost.
Things had begun to change by mid-2003, when Dr LEE Jong-Wook came to office as Director General of WHO. Drug prices had come down. Global resources for HIV/AIDS had increased significantly. PEPFAR and the Global Fund had been born. But even then, many people advised Dr Lee that embracing the target was an act of political suicide. Some said that people in Africa wouldn’t take their pills on time, because they didn’t have watches. Or they said the pills would melt in the heat. They said that this generation of people living with HIV/AIDS couldn’t be saved, and that our only hope lay in preventing the next generation from becoming infected.
Well, it was clear to Dr Lee and those of us on his staff that he and the organization had two clear choices. His first action as Director General could be to turn his back not only on the target, but on an entire generation. Or, he could take aggressive action - and responsibility - by fully embracing “3 by 5”. As you all know, he chose the latter course, because he knew that his tenure would be defined by how effectively WHO responded to the greatest health crisis of our time. He knew that a response without treatment would be half-hearted and half-baked.
He also knew from his days in polio how effective an ambitious target can be in bringing an end to a circular debate and helping us move from incessantly asking ourselves “if” we can treat people in developing countries, to “how” it can be done quickly and effectively. We knew then that any credible target, any target that was really going to make a difference, had to aim for at least 50% of those needing treatment. So, in the first few months of Dr. Lee's administration, we worked closely with UNAIDS to declare the gap between those in need of treatment and those with access to it, to be a global health emergency. A few months later, in December 2003, WHO and UNAIDS released their “3 by 5” strategy.
Above all, the target has served as a catalyst for WHO itself. It has dramatically mobilized action, resources and coordination on AIDS from our headquarters in Geneva to our six regional offices and of course on to our 145 country offices; it has required us to quickly scale up our HIV/AIDS work in areas where we are seen to have expertise: building consensus on treatment protocols and technical approaches; advising Ministries of Health; monitoring and evaluating programs. The target has also forced us to improve in areas where we were weak: advocacy, building partnerships, working with communities, making a difference at country level.
We were also convinced that all the things that were needed to scale up HIV treatment, could bring about benefits above and beyond treating people with HIV/AIDS. For one thing, it could revitalize the debate on prevention, and make us think seriously about how prevention and treatment must go together. Indeed, I believe that the landmark prevention strategy that was just approved by the board of UNAIDS was at least partly inspired by “3 by 5”. Treatment also forced us to think about how we deliver HIV/AIDS interventions in a way that builds better health systems, and better treatment for other chronic and acute conditions. These were discussions that had never happened before.
And so, once WHO embraced “3 by 5”, we knew what we had to do. Starting two years late, our job was to work feverishly to put in place all the things that Bernhard Schwartländer had told us in 2001 were needed to reach 3 million by 2005. We needed simplified and standardized treatment regimens, so we brought all the experts together and agreed on treatment protocols that made sense for resource-limited settings. We had to be sure that the drugs we recommended were good quality, so we supported and expanded the prequalification program to assess the quality of antiretroviral medicines. In the last 18 months, we’ve worked with dozens of countries on treatment protocols and scale-up plans. We’ve developed standardized training tools and patient tracking systems that will be used in up to 30 countries by the end of this year. We’ve placed staff in nearly 40 countries specifically to work on scaling up HIV treatment and prevention.
"3 by 5" has had a very positive impact on WHO but our work is just one small part of the overall "3 by 5" movement. Many different governments and organizations have made extraordinary efforts to making treatment scale-up happen. Donors such as the Global Fund to Fight AIDS, TB and Malaria, bilateral initiatives such as the US President’s Emergency Plan for AIDS Relief, other UN agencies, NGOs, activists and community organizations, to faith-based groups and the private sector have all made enormous, historic contributions. Most importantly, many governments have established their own “3 by 5” targets and are driving forward with national scale up efforts. After all, it is ultimately governments that are responsible for delivering health care to their citizens but for many of them, “3 by 5” has provided important impetus to take action. As one WHO country representative said to me, once they knew that WHO fully supported treatment scale-up, there was a shift. Governments stopped asking “Should we do it?” and started asking “How do we do it?”
Eighteen months along, progress has been encouraging. Nearly 80 countries have asked WHO for help in scaling up treatment as part of their national AIDS effort. Of the 49 countries that are the special focus of our AIDS program, 40 have now declared national treatment targets, compared to only four in December 2003. Thirty-four of these countries have developed or drafted national treatment scale up plans, up from only three, 18 months ago. Fourteen countries have now achieved their “3 by 5” target of treating half in need, among them, Thailand and soon, we hope, Cambodia. Many countries have committed their own resources to treatment scale-up, or asked for more money from donors so that they can fund treatment as well as prevention.
Although we hoped for faster progress, we’ve seen a steady increase in the numbers every six months since we began. Last week we reported that, beginning from a baseline of 400,000 people on antiretroviral treatment in low and middle-income countries in 2003, approximately 1 million people are now receiving ART. Progress in sub-Saharan Africa, the most heavily-affected region, has been especially encouraging, with more than a three-fold increase in the number of people on treatment in the last 12 months. Scale up in Africa as a whole appears to be accelerating, and many African countries report that demand for treatment is starting to outstrip their capacity to supply it. Compared to 12 months ago, when system constraints seemed insurmountable, African officials now stress their need for increased resources and technical support so that they can keep the momentum going.
- Thailand still leads the way and is working to expand access in all districts. Coverage is now approaching 60% of those in need, and the government is focusing on expanding access in all districts. About 3,000 Thais are enrolling in treatment programs every month.
- Since mid-2003, antiretroviral use in Cambodia has increased ten-fold, reaching more than 30% of people in need. Community-based treatment and care services in Cambodia are a model for the world.
- China has made major political commitments to scale up treatment through its program of Four Frees and One Care. With support from the Global Fund, it is providing antiretrovirals to over 12,000 people, and embarking on a national effort to ensure widespread access. Its recent effort to greatly expand access to methadone maintenance programs is an inspiration to the entire world.
- Indonesia too, is beginning to expand treatment services for injection drug users, including methadone maintenance.
Progress in the Asia Pacific region has also been significant, with a near tripling in the number on treatment in the last year. In the last six months, the number of people on treatment in East, South and South-East Asia has increased by more than 50 per cent, from 100,000 to 155,000 people.
We should acknowledge and celebrate these successes. At the same time, we must also acknowledge that, based on current trends, it is unlikely that the 3 million target will be reached by the end of 2005. In this region alone, another 945,000 people need treatment now. As we heard from J.V.R. Prasada Rao from UNAIDS on Saturday, treatment coverage in most countries in Asia and the Pacific is less than 10 percent, in many cases, much less. In many of the countries in this region, programs are only now starting up, and need to move with a much greater sense of urgency.
As our recent progress report notes, much can be accomplished if we focus global attention and effort on the 20 countries that between them account for 85 per cent of unmet global treatment need. Among these 20 countries, millions of Chinese and Indian lives hang in the balance, and efforts made in these two countries now could determine the course of the global epidemic. There is no doubt that, because of their vast size and populations, they face enormous challenges in translating their political commitments into action and bringing treatment programs to scale.
But we’ve already learned an enormous amount about how such challenges can be tackled. Most importantly, we've learned beyond any doubt that HIV treatment in this region and elsewhere in the developing world - is feasible, effective and increasingly affordable. We’ve also seen in every case, that what underpins success is an essential combination of political, technical and financial support, invested in a way that strengthens overall capacity to deliver health services.
On a technical level, implementing simplified and standardized approaches to treatment is absolutely critical if we are to move forward to universal access in the coming years. Not only have such approaches met with great success in many settings, they are clearly the only way that rapid scale up and broad coverage is going to be achieved. The problem is that not enough countries are using them. Simplified regimens – in particular those that utilize fixed dose combinations - are of course central. But the shift to standardized and simplified approaches also means making the most of available human resources.
There is enormous human capacity in Africa and Asia, for example; we are just not using it to its full advantage. One Minister of Health recently said to me that they have now realized that ARV treatment doesn’t need to be doctor-driven. His country is using clinical officers and nurses to monitor patients and they have even begun to train new high school graduates, among whom a serious unemployment problem exists, to be clinical officers and play a critical role in the delivery of antiretroviral therapy. A simplified and standardized approach to treatment and training which enables health and community workers to manage and monitor patients is surely one of the answers to relieving the human resource crisis and improving the health of poor people. We will continue to strongly advocate for this approach.
Another major lesson of the last six to 12 months is that we have a much clearer idea about the kind of technical support that is needed by countries right now to enable treatment scale up in the longer term. Training health and community workers is obviously a very high priority for countries, and for WHO. But the human resource crisis is not confined to health care providers; we must build basic skills and capacity to improve the administration and management of programmes at both the national and peripheral levels.
For countries, strengthening systems to efficiently manage supplies of drugs and diagnostics is currently another pressing concern. Improved supply management will not only serve people living with HIV/AIDS, but will have significant spin-offs for entire populations through improved access to other essential medicines. Several procurement agencies which collaborate with WHO in the AIDS Medicines and Diagnostics Service – such as UNICEF and the International Dispensary Association – have played a key role in supporting countries with limited procurement capacity.
However, procurement is often done by countries themselves and in many cases their experience is limited and supply systems are weak. WHO’s position is that drug procurement and supply can be strengthened by better coordination of all partners working within a nationally agreed and properly funded Procurement and Supply Management Plan. In addition to describing who should procure what, the plan must define such things as how drugs will be stored, transported, distributed and re-stocked. It also must set out how the capacity to manage drugs supplies will be quickly built up. Training and capacity building are particularly important right now because many of the tools needed to forecast demand for treatment and to manage supply systems down to district level exist, but they aren’t being used. The partners in the AIDS Medicines of Diagnostics Service, including WHO, are trying to fix this problem quickly by helping countries to plan, training program managers and providing technical support when countries run into supply problems. But much more is needed so WHO and UNICEF will soon put forth an aggressive and ambitious plan to vastly expand technical support for drug management in the countries that need it the most.
A number of countries are also asking us to help bring some order to a prevailing sense of chaos that has accompanied the proliferation of new players working at country level. In some cases, different agencies bring with them different treatment protocols, training materials and delivery models. In our rush to get things started, we have developed many small projects with a variety of funders who are all doing their own thing. This approach was critical for building momentum but now we must move from a project approach to a program approach in which the national AIDS authority is in charge of determining what training, treatment, prevention and monitoring and evaluation protocols will be acceptable in the country. Without such standardization, increasing chaos could eventually threaten the very existence of programs.
The third thing that countries constantly tell us is that they need sustainable financing to support treatment over the long term. We are seeing too much hope and ambition stifled by fear on the part of governments that they will be left holding the AIDS treatment baby when donors decide that their priorities have shifted. Such fears are contributing to the retention of user fees for treatment at the point of service delivery in many countries, despite growing evidence that fees of any kind present a huge obstacle to the majority of people who need treatment - especially women. If countries are going to scale up and get rid of user fees, they need assurance that their enormous investment of effort so far will not be abandoned. That means more political commitment and resources from the major donors. By UNAIDS estimates, at least an additional US $18 billion above what is currently pledged will be needed for global HIV/AIDS over the next three years.
Some recent signs are encouraging. WHO warmly welcomes the recent decision of G8 finance ministers to free up up to US $40 billion through debt relief for the poorest countries. Our host country, Japan, has recently made a significant new contribution to the Global Fund an announced a hugely ambitious program to support health and development projects in Africa. But there is no escaping the fact that much more is needed now, and will be in the years ahead.
Countries can also help themselves by continuing to increase their own financial commitments. The 10 “3 by 5” focus countries that are immediately eligible for G8 debt relief are now in a position to make significant new resource allocations to their HIV/AIDS budgets. At least one, Zambia, has said that it intends to do so. As we heard from UNAIDS, this region as a whole can actually afford to fund its own response to HIV/AIDS, but in too many countries, national AIDS expenditure remains inadequate and relies mainly on external funding for their AIDS programs.
Drug prices are, of course, an ongoing challenge. We are still a long way from the original “3 by 5” goal of US $250 per person per year for first line treatment. To reach these prices, countries are utilizing a number of different approaches. WHO has long supported the right of countries to exercise the full flexibilities available to them under international trade agreements so that they can protect the health of their populations. While incentives must be kept in place for research-based companies to develop new ARVs, the public health disaster of HIV requires that we be creative and relentless in continuing to drive down the costs of drugs so that they are affordable for all.
There is no doubt that in the era of treatment, prevention must become a much higher priority, particularly for low-burden countries. In this region as in others, some have argued that treatment has taken resources and effort away from prevention. My response to such claims is always the same. The Global Fund was actually conceived as a treatment fund, but in fact, more than half of its resources have gone to prevention. The possibility of treatment is revitalizing prevention, bringing with it new resources and opportunities to do prevention better. Research has shown that demand for testing and counselling increased a staggering 27-fold in the Masaka district of Uganda when treatment became available. There is every reason to believe that the same is true in Asia, where only about 8 per cent of pregnant woman are currently getting tested. More testing means more opportunities to prevent mother to child transmission, to tell people how they can protect themselves and others, to offer condoms and clean needles. Health care workers can and should be prevention workers, too.
A recent study in the Mekong countries confirms that treatment is one of the best stigma-fighters we have. The incidence of stigma and discrimination has fallen more in Cambodia, where treatment is becoming widely available, than in Laos and Vietnam, where it is not as readily accessible. Furthermore, recent epidemiological modelling shows that expanding treatment and prevention together can dramatically reduce the resource needs for treatment over the long term. So it’s a two-way street. Treatment makes prevention more effective, while prevention makes treatment more affordable. All of which confirms that “3 by 5” is not just about treatment, but is a prevention target, as well.
It is true that, in this region, prevention programs will look different depending on the setting and the populations most affected. For many countries here, treatment and harm reduction must go hand in hand. In the last week, the UN system has strongly affirmed its commitment to harm reduction, firstly at the UNAIDS Program Coordinating Board, and secondly, after an extensive review of the scientific evidence, with the addition of methadone and buprenorphine to the WHO Model List of Essential Medicines. These decisions represent a difficult but extraordinary merger of science, with compassion. Critics of substitution therapy have long argued that it is no use just replacing one drug dependence with another. They have also said that if you hand out clean needles and syringes, you encourage drug use. But the evidence clearly shows that these interventions prevent HIV transmission and don’t increase drug use. Every country will have its own approach, but if we are to be both scientific and compassionate, we have no choice but to tell the world that syringe exchange programs and methadone/buprenorphine treatment programs are essential elements of a comprehensive prevention package.
I am often asked: what happens after 2005? Let me be clear. “3 by 5” wasn’t simply a bureaucratic commitment to an institutional target. We will continue to work night and day to ensure that three million people receive treatment, sooner rather than later, and in months rather than years. WHO's commitment has always been to the 3 million souls waiting for treatment and not to a target. We will never abandon the 2 million more people to whom treatment was promised. Once we reach 3 million we will move on to put all of our energy into reaching universal access.
At the same time, the vision beyond 2005 now has to merge with the broader health and development objectives already in place for the next decade, the most significant of which are the Millennium Development Goals for 2015. The United Kingdom has recently been a leading advocate of universal access to antiretroviral treatment by 2010, and they were instrumental in the endorsement of that goal by G8 finance ministers, just two weeks ago. The British government deserves a lot of credit for pushing us further forward to this most humane and brilliant target. WHO strongly supports the goal of universal access to treatment by 2010, and pledges to play its part.
Achieving universal access to treatment is important because it forces us to think in very different and practical ways. First, it requires us to be quite specific about the package of interventions that ought to be universally available. Many people, myself among them, are of the view that because treatment and prevention are interdependent, we ought to be providing universal access not just to treatment, but to a basic package of HIV/AIDS interventions to everyone who needs it, including prevention. We are now very close to a global consensus about what that minimum package of prevention, care and treatment ought to include.
Secondly, our task in pursuing the goal of universal access will not be simply to count the numbers of people on treatment, as we have with “3 by 5”. Instead, we will have to look very closely at whether and where health services exist at district and community level; whether, for example, long term care and support for people with AIDS and other chronic conditions is available within an acceptable traveling distance, or to certain populations. In short, we will have to look at both coverage and equity, and at building primary health care systems for chronic conditions in general. This is a major advance in our approach.
On this 4th of July, American Independence Day, it is appropriate that I close with a quote from Benjamin Franklin, one of the authors of the US Declaration of Independence, who, in reflecting on his experience with the American Revolution said to us: “Every generation needs a new revolution”. Seth Berkeley will rightly tell us that a vaccine is our best hope for ending the AIDS epidemic in the next generation. For this generation, antiretroviral treatment for all and our commitment to building the systems that will sustain it, is our revolution. The amount of effort it will take to reach universal access is daunting indeed. But reaching 1 million on treatment has taken us past the point of no return.
Our revolution will require that we continue confronting and resolving the most glaring disparities around fundamental human rights. But when Gay Men’s Health Crisis, ACT-UP, Healthgap, TAC and others take to the streets to demand treatment, care and prevention for people in shanty towns in Asia, we know we've already been part of something revolutionary. When so many of us can stand behind injection drug users, even though our leaders condemn them, we take another major step forward. When Sunil Pant is able to bring the silent brutality against gay men and women in Nepal to the world stage, we know that a new solidarity is emerging. But this revolution is just beginning. Bringing it to a conclusion and achieving universal access will test us much more than we can imagine.
Because we must remember: 3 million is just the tip of the iceberg. We must commit ourselves to the task of providing prevention, care and treatment to at least 40 million fellow human beings over the next couple of decades. What kind of world would it be if we were able to reach that seemingly outlandish and utopian goal? It would be a world of simple justice, basic decency and unprecedented solidarity. With the determination of all of us in this room today, it is precisely that kind of world that my five year old son will find waiting for him when he grows up and begins to search for his generation's revolution.
Thank you very much. Domo Arigato Gozaimashta.