Getting medicine to HIV/AIDS patients - the "3 by 5" initiative

National Institute of Public Health, Tokyo, Japan
23 April 2004

Good afternoon, everyone.

HIV/AIDS is the worst health threat the world has faced for several centuries. I will tell you a little about the current global effort to contain this disease. A central component of it is to make antiretroviral treatment available where it is most urgently needed. Afterwards, I would be happy to hear your views and try to answer any questions you may have.

Japan is a low-prevalence country for HIV/AIDS, and is supporting this effort in developing countries through its contributions to WHO and to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The rationale "3 by 5" is the short name for a United Nations target of getting antiretroviral treatment to 3 million of the people living with HIV/AIDS in developing countries by the end of 2005. Since the 1990s this treatment has proved its ability to restore AIDS patients to strength and a normal life. But the production and distribution of the drugs required have been slow. In addition, the drugs have been unaffordable to patients in poor societies.

Since AIDS was first described in 1981, it has killed over 30 million people. In the worst-hit countries the transmission of HIV is accelerated by poverty, gender inequality and health systems weakened by external debt. At present there are 40 million people in the world who are living with HIV/AIDS. More than 70% of those infected with HIV now live in Africa, and the majority of AIDS deaths have occurred there. In some countries the disease has reversed the trend towards longer life expectancy. It has orphaned an estimated 14 million children. A recent World Bank study predicted that South Africa, to take one example, would face "complete economic collapse" if it did not take effective measures to combat AIDS.

Disease control involves prevention and treatment. The rapid spread of a lethal disease requires the most effective control measures that exist. Until recently, for HIV/AIDS, this meant prevention alone, through blood safety, health information and education, and condoms. Now treatment is also available. It can increase the effectiveness of prevention by encouraging people to seek advice and testing, and by keeping those infected alive and able to work and look after their families.

The figure of 3 million represents half of those who would otherwise die of HIV/AIDS during this year and next. That 8000 people a day should be dying of a disease that is both preventable and treatable is a disaster from every point of view. Morally it is unacceptable; practically it destroys the global society we live in. Universal access to treatment is not an idea or an option but a necessity. The question of how quickly it can be achieved is important, but it can only be answered by doing everything possible now to make the delay as short as possible.

The "3 by 5" initiative is a first step to a practical response to this emergency. At the same time it is a statement that the international community has no alternative but to do everything in its power to stop the devastation that is occurring while it still can be stopped.

The way this is put in WHO’s Constitution is: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” This statement was made just after the Second World War, when the consequences of denying that right had been fully seen and felt in many countries. The only way to make such statements have meaning is to put them into practice.

In September of last year, at the United Nations in New York, I declared current HIV/AIDS situation to be a global emergency. I was speaking on behalf both of the World Health Organization and of the joint United Nations Programme on HIV/AIDS (UNAIDS).

On December 1, we announced our global strategy for achieving "3 by 5" - a comprehensive view of what needs to be done to make treatment available on the scale needed. The strategy covers everything from the global to the local partnerships required, and the action they will take.

UNAIDS is also promoting the principle of "three ones", which we fully support: one national plan, one coordinating body, and one system for tracking progress. This is aimed at consolidating the many kinds of effort that are being made by government, nongovernmental and community organizations, so as to maximize their impact. Above all, it is partnerships that will eventually win the fight against HIV/AIDS, and it takes determination to form and maintain partnerships and harmonize their efforts.

The plan Over 90% of the treatment gap the "3 by 5" target seeks to fill is located in just 34 countries, and two thirds of these countries are in sub-Saharan Africa.

The core of the strategy consists in simplifying and standardizing procedures for treatment to make it accessible to people living where the health services are weak or non-existent. Access in such areas is being achieved only by a very few people in scattered locations around the world, through the efforts of individuals and small groups. The need now is to make the necessary knowledge, skills and resources available on the largest possible scale in the shortest possible time. We are using a public health approach in which a team of health care workers, supervised by a doctor, can start and manage patients on antiretroviral therapy.

We have been working with many partners to harmonize and standardize tools for monitoring and evaluating programme activities, and tracking patients. These partners include the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNAIDS, the World Bank, and the US Centers for Disease Control. They are involved in raising and distributing funds, operational and scientific research, training, and organizing prevention and control activities.

The aim of universal access to antiretroviral therapy is to make HIV infection treatable as a chronic disease, like diabetes, for which sufferers receive lifelong treatment if necessary. This is how it is already seen by some for whom treatment is easily accessible. For the millions who see no hope of access, however, it continues to be a lethal and severely stigmatizing disease.

To deliver lifelong care, a strong health system is needed. The stock of medicines has to be dependable. The carers have to be properly supervised and supported to provide a reliable service of high quality. At present, health systems are run down in many of the countries that are bearing the brunt of the epidemic. They have received little or no investment in recent years. The "3 by 5" initiative therefore has to invest in strengthening and improving weak health systems; otherwise it will be impossible to provide the necessary services. Strengthened health systems will benefit all other users as well, not just those living with HIV/AIDS.

This illustrates an important principle behind all emergency work: while saving lives and meeting the most pressing needs, it must build the systems that will make life possible on a permanent basis.

What has been done Since 1 December, 50 countries have appealed to us for assistance to scale up their capacity to provide treatment for AIDS patients. Within the limits of the resources currently available to WHO, we have sent teams to 28 of them, and plan to do so to a further five. The success of the assessment and planning carried out in countries with these teams has led to high expectations for further support. There is a wide range of immediate needs for further assistance. All this has been done in partnership with the many existing organizations active in countries that are committed to scaling up ART rapidly.

Our aim is to establish "3 by 5" teams in 40 countries selected on the basis of their high burden of HIV/AIDS and the strategic needs of the campaign. These teams will be supporting the Ministry of Health in each country and be based in the WHO office or in some cases in the Ministry of Health.

Our staff will not be implementing ART themselves but supporting countries to do this in a sustainable but urgent fashion, in line as far as possible with the "3 by 5" target for that country. We will be using the "three ones" approach to help countries coordinate the wide array of activities and partners needed to scale up treatment delivery within the framework of one national plan.

So far we have raised additional resources to staff 22 country teams, and the process of recruitment and deployment is going on now. Over 1600 people applied for the international and country team leader posts when we advertised them recently.

While these posts are being filled and the teams are being formed, we have deployed staff from headquarters and the regional offices to help countries to prepare their applications for support from the Global Fund, and to make detailed action plans for scale-up. These activities have identified a wide array of needs for technical assistance.

Expert help is needed in 90% of the countries we are working with for capacity-building and training; in 60% for drug procurement and supply chain management; and in 50% for monitoring and evaluation.

Prospects As much as possible, we will be meeting these needs for technical support with staff from our offices until the "3 by 5" teams are in place. All these countries need assistance at the same time, and there is a quite limited supply globally of individuals who are skilled in these specialist areas of ART. Not all needs will be met immediately, but a focus on training and innovative approaches will reduce the delays.

In the "3 by 5" strategy document there is an appendix which sets out milestones for progress towards achieving the target. The very last line is “Number of men, women and children with advanced HIV infection receiving antiretroviral therapy.” For December 2005 it is 3 000 000.

Our first review of progress towards these targets will be at the international AIDS meeting in Bangkok this July. Thereafter we will be reporting every six months on progress.

Conclusion A very important feature of this whole initiative is “learning by doing”. Constant gathering of data about what works and what does not work is a guide to success and a continually renewed source of energy. As public health professionals and researchers, you will be aware of some of the questions that urgently need answering. I will end by mentioning some of them.

How does treatment specifically affect prevention in practice? How to provide care equitably? How to make the best use possible of available human resources? How to deliver ART cost-effectively? How to reduce stigma? How to contain drug resistance? How to build up an effective primary and chronic care management system?

These are some of the real issues raised by "3 by 5". Tackling them will save lives and strengthen health systems. In this way the initiative will be working as a catalyst for renewal and innovation in the health services.