“Scaling up access to care in resource constrained settings: What is needed?”

Jim Yong Kim, M.D., Ph.D. Director, Department of HIV/AIDS, WHO

XV International AIDS Conference, Bangkok Plenary Address, 13 July 2004

Distinguished guests, colleagues and friends, Just two years ago in Barcelona, we began to see the building blocks of a truly global response to HIV/AIDS fall into place. Two months earlier, the Global Fund to Fight AIDS, Tuberculosis and Malaria had announced its first round of grants including money to fund HIV treatment, care and prevention in 28 different countries. Today, after three more rounds and billions of dollars in commitments, the Global Fund has become a powerful financial weapon against HIV. Then in 2003, U.S. President George W. Bush signed the Global AIDS Act pledging the unprecedented sum of $15 billion over five years. As I stand before you today, these new resources provide us with real hope that treatment can become a reality for people living with HIV/AIDS in poor countries.

In Barcelona, we also began to talk about something that seemed to be missing from the UNGASS Declaration of Commitment: a target for treatment, not treating thousands, but millions more, 3 million people, in fact, by the end of 2005. At the same time, we witnessed the birth of a global advocacy movement to push us toward that goal, and the growth and power of that movement is abundantly evident in this room today. And - halting and inadequate as these steps have sometimes been - we began to talk for the first time about the kind of public health approach that would be necessary to make this target possible, the strategies, the alliances, the regimens, the diagnostics, the infrastructure, the people and all the other things that would need to come together to reach a target as challenging as "3 by 5".

Since then, we have made real progress – we now have nearly 20 billion dollars pledged for integrated AIDS prevention and care. More and more countries are committing to scale up treatment and care; prevention activities, though inadequate, continue to expand. Drug prices continue to fall – as low as $140 per person per year in the most encouraging scenario. We know what we need to do. We know that prevention and treatment must be accelerated together, and we even have some ideas as to how that might be done. Finally, many of the pieces are falling into place.

But, we also know that, since we last gathered, 6 million more people have died. Ten million more have become infected. The number of people on treatment in developing countries may have doubled, but from such a minimal base that we - all of us with the power and the responsibility to make a difference - can only hang our heads in shame. By these measures of human life, the ones that really matter, we have failed and we have failed miserably to do enough in the precious time that has passed since Barcelona. We are all responsible for that failure. The hope we felt in Barcelona, and the hope that we stubbornly insist on today, is tinged with anger, with frustration, and with grief for those millions of people that we have failed to save.

Some people have said that "3 by 5" is an inflated target, unrealistic, an impossible dream. But I find it difficult to see the value of that sort of speculation. What we do want to hear is what the obstacles are, how these barriers can be overcome, how we can work better, faster and more effectively together to reach our goal. Let’s not dwell on whether it is possible and waste more time; let’s just make it happen.

No one ever said reaching three million people would be easy. But we knew that only a concrete, measurable, time-limited target like "3 by 5" could bring about the change needed to make WHO act with the urgency that this terrible epidemic demands.

And, my friends, we have made progress:

  • Since December, 56 countries have appealed to WHO for technical assistance to rapidly scale up HIV treatment and care.
  • In just 6 months, 12 countries have set targets to treat 50% or more of those people who need treatment by the end of 2005.
  • At WHO, we’ve developed new treatment guidelines that will ensure that all people, no matter the level of infrastructure in the areas in which they live, will have access to high-quality therapy. In attempting to get 3 million people in the developing world onto treatment, simplification of high quality therapy and community-based care will be the only way that we can assure equity in accessing services.
  • We established an AIDS Medicines and Diagnostics Service to try to ensure that procurement and supply chain management of appropriate products will not be barriers to scaling up treatment.
  • We have developed training modules for all levels of health workers. As well, we are developing certification systems so that countries can maintain quality in their training programs.
  • And we have worked with all of our partners on monitoring and evaluation systems to help us track our progress.
  • We continue to expand our excellent drug prequalification program, which provides critical information on drug quality to other UN agencies and all others who chose to use our system.
  • Just two months ago, at the World Health Assembly, the 192 Member States of WHO unanimously endorsed the "3 by 5" target. We must now make sure that all these countries have everything they need to live up to the commitments they have made.

Much of this has been possible because of our capacity to work within a multilateral system. We’re proud to be one of the 10 United Nations agencies that form UNAIDS, and the agency responsible for HIV treatment and care. "3 by 5" is an effort to bring the full capacity of WHO to bear upon the HIV/AIDS epidemic. The entire UNAIDS family has endorsed "3 by 5", and we will soon be undertaking intensive joint activities in countries.

But the movement to expand access to treatment did not begin and will not end with "3 by 5". We have been led above all by the activists. It began with people like Zachie Achmet, Gregg Gonsalves, Noreen Kaleeba, Mark Harrington, Jeanne Gapiya, Millie Katana, Dorothy Anyango, Paysan Suwanawong and many more. It began in pioneering countries like Brazil, Cuba, Haiti, Uganda, Botswana, Gabon, Senegal, and our hosts Thailand.

All of these countries committed themselves early on to treating people with AIDS. It began with NGOs like Médecins sans Frontières, Partners in Health and Pharmaccess, who worked tirelessly to bring essential services and medicines to the poor and the abandoned. It began with ACTUP, with TAC, with SWAA; it continues with PATAM, GNP+, ICW, RedLA, the ITP, the Thai Drug Users Network and with thousands of people living with HIV/AIDS who are doing courageous and extraordinary things in kitchens and lean-tos, persisting in their fight for simple justice with no funding and little support. It began too with governments like France, the first G8 country to note that while AIDS drugs were available in the north, most of the patients lived in the south. France went on to establish a path-breaking treatment solidarity fund soon thereafter.

The European Commission, Canada, Germany, Italy, Japan, the US, the UK and Sweden, the Netherlands and others followed, joining together to lay the foundations of the Global Fund. It continues with UNAIDS, under our leader Peter Piot, who has kept all our eyes focused on this epidemic, even as our efforts faltered. The World Bank for years and the Clinton Foundation more recently have made critical commitments. Faith-based organizations and the business sector, including the pharmaceutical industry, and companies treating their own employees, have played important roles .

Amidst our anger and frustration, let us also remember the leaders who have brought us to where we are today.

We have moved very far from thinking about treatment and prevention as competing priorities. But it is not enough to say that treatment and prevention go together. The opportunity to offer treatment to those denied access represents our best chance yet to accelerate prevention. Already, commitment to treatment scale up has allowed us to refine the joint WHO and UNAIDS policy on testing and counseling. With the possibility of treatment, we feel it is critical to routinely offer testing and counseling in all health care settings. Knowing your HIV status is one of the most powerful forces for behavior change and we have to be ambitious in our efforts to make testing and counseling widely available in every country.

Of course, the more routine offer of HIV testing cannot come at the expense of human rights. It can only work with counseling, consent, confidentiality, community involvement and an aggressive effort to fight stigma and discrimination.

For those who still fear that treatment is taking attention away from prevention, I would point out that the potential for treatment has actually brought more money for HIV prevention. In fact, prevention accounts for 60% of Global Fund grants for AIDS so far.

AIDS treatment programs require lifelong contact between patients and health care services, and so our efforts to scale up antiretroviral therapy must build health systems capable of chronic care in all countries. I believe that the unprecedented political will behind antiretroviral treatment in poor countries will allow us to build health systems that will have benefits far beyond the care and treatment of PLWHA. Our hosts here in Thailand provide us with a model for integrating antiretroviral treatment into existing primary health care services. We should aim to build health systems capable of this kind of comprehensive care everywhere. The international financial institutions have a critical role to play in this regard for the weakening of the public health sector opens a gap that cannot be filled by NGO’s or activists. Integrated HIV prevention and care can strengthen primary health care, and this broader goal is one that we must not abandon.

The possibility of antiretroviral treatment has captured the imagination of political leaders because of its transforming effect on individuals and societies.

Joseph Jeune has asked us to tell you his story. He is one of many who now have a chance to live because of ART. He lives in a rural village in Haiti with very little infrastructure, but has been receiving care thanks to the Global Fund and the tireless efforts of the NGO Zanmi Losante / Partners in Health.

So what is needed to give everyone the chance that Joseph received?

  • A simplified, public health approach that assures equitable access to high quality treatment
  • We must begin moving the drugs
  • Gender equality, attention to children and the needs of the marginalized, young people and injection drug users
  • Partnerships and cooperation at the country level. As Quincy Jones has reminded us, when we enter countries, we need to ‘check our egos at the door’.

One sympathetic donor once asked me about "3 by 5": ‘Dr Kim, why all the urgency?’ It made me think of the experience of Martin Luther King. When he was in the Birmingham jail, he received a letter from a white moderate who was deeply sympathetic to his cause. The letter said:

“All Christians know that the colored people will receive equal rights eventually— eventually—but it is possible that you are in too great a religious hurry. It has taken Christianity almost 2000 years to accomplish what it has. The teachings of Christ take time to come to Earth.” All social movements, it seems, have friends who say, ‘Slow down!’ Dr King replied: “…such an attitude stems from a tragic misconception of time and a strangely irrational notion that there is something in the flow of time that will inevitably cure all ills. “Actually, time itself is neutral. It can be used destructively or constructively. “More and more I feel that the people of ill will have used time much more effectively than the people of good will. We will have to repent in this generation not merely for the hateful words and actions of the bad people, but for the appalling silence of the good people.”

As we have learned from this epidemic, silence cannot be an option. "3 by 5" is our best chance to use time creatively and effectively to fight this epidemic. Those of us with power and responsibility are called to do everything possible over the next 18 months to make a difference, to finally dance with this epidemic at its own pace. For the activists, you must hold all of our collective feet to the hottest possible fire because large organizations and the powerful have a way of finding reasons to not take action. If you don’t continue to push us, we will falter. Bold and ambitious goals for AIDS prevention and care - and action to match – are our only options. Anything less is to miss the warning of Martin Luther King and to be guilty of an appalling and deadly silence. "3 by 5", LETS MAKE IT HAPPEN.