Chapter 2
The treatment initiative
Chapter 1 showed the magnitude of the threat posed by HIV/AIDS. This chapter describes the magnitude of the task of responding to it and explains how WHO and its partners are supporting countries in one of the most ambitious endeavours in the history of public health. A comprehensive approach to HIV/AIDS links prevention, treatment and long-term care and support. In much of the developing world, however, treatment has until very recently been the most neglected component. It now needs to be rapidly expanded, along with accelerated prevention efforts, in the countries hardest hit by the pandemic.
Since 1996, more than 20 million people in the developing world have died of AIDS. If antiretroviral therapy had been rapidly deployed, most of these people would probably be alive today. Despite mounting political pressure and evidence that AIDS treatment works in resource-poor settings, by late 2003 less than 7% of people in developing countries in urgent need of antiretroviral drugs were receiving them (see Figure 2.1). In September 2003, LEE Jong-wook, Director-General of WHO, joined Peter Piot, Executive Director of UNAIDS, and Richard Feachem, Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, to declare the lack of access to antiretroviral therapy a global health emergency. In response, WHO, UNAIDS and a wide range of partners launched the "Treat 3 million by 2005" initiative - known as 3 by 5. Treating 3 million people by the end of 2005 is a necessary target on the way to the goal of universal access to antiretroviral therapy for everyone who needs it.
To reach this goal, major obstacles must be overcome. With few exceptions, HIV/AIDS has struck hardest in countries whose health systems were already weak. Many countries working to expand HIV/AIDS treatment face significant deficits in areas such as health sector human resources, HIV counselling and testing, drug procurement and supply management, health information systems, and laboratory capacity (including the ability to monitor drug resistance).
Delivering the results called for under 3 by 5 will challenge countries' capacities and test the will of the global health community. But it is an essential task whose implications go far beyond the immediate aim of saving millions of lives in the coming years. It may also be the key to saving some of the world's most fragile health systems from further decline, and thereby offering whole societies a healthier future. Seen in this context, the 3 by 5 initiative is a vital opportunity to ensure that the new global resources flowing into HIV/AIDS are invested in ways that strengthen health systems for the long-term benefit of everyone.
This chapter examines public health, economic and social arguments for scaling up antiretroviral treatment in resource-poor settings. It then presents WHO's strategy for working with countries and partners, and provides an estimate of the global investment required. The opportunities and challenges facing countries are explored, highlighting the need to ensure that antiretroviral treatment reaches the poorest and most marginalized people. Finally, the chapter considers the wider importance of 3 by 5 as a new way of working across the global health community for improved health outcomes and equity.
WHO's commitment to support countries is guided by a broad assessment of resources and needs in global public health. Global investment in health has risen in recent years while many other sectors of international development assistance have stagnated, but the bulk of the new health investment is in HIV/AIDS. As the international agency charged with seeking the highest possible level of health for all people, WHO has the responsibility both to support expanded access to antiretroviral therapy and to work with countries and international partners to ensure that the new resources flowing into HIV/AIDS are invested so as to build sustainable health system capacities. Only an international public health agency can fulfil this technical cooperation and stewardship function. Health systems strengthening is the key both to sustainable provision of antiretroviral treatment and to reaching other public health objectives, including the health-related Millennium Development Goals and containment of the expanding epidemics of chronic diseases in the developing world.