The costs of achieving 3 by 5
The exact cost of reaching the 3 by 5 target will depend on how quickly care is scaled up in participating countries. It is likely to total at least US$ 5.5 billion by the end of 2005 in the set of high-burden countries that together account for 90% of the target (18). This estimate assumes that 25% of the target is reached in 2004 and the remaining 75% the following year. It assumes that the prices of medicines remain at currently lowest available levels reported by the WHO Essential Drugs and Medicines Department (first-line treatment of US$ 304 per person per year). Total programme costs could be significantly reduced if drug prices for all countries approached those negotiated by the William J. Clinton Foundation for the 14 countries it supports (first-line treatment at less than US$ 140 per person per year).
Cost projections are based on the treatment regimens required for three different entry points: tuberculosis patients, antenatal clinics and health facilities. They include at the patient level:
- counselling and condom distribution for the people tested as part of the programme;
- antiretroviral drugs (first-line drugs for all people identified in late-stage disease and second-line drugs for treatment failures);
- antiretroviral drugs to prevent mother-to-child transmission for women testing positive in antenatal care clinics and who are in early clinical stages of disease;
- treatment and prophylaxis of opportunistic infections;
- palliative care;
- laboratory tests for toxicity for those showing signs of toxicity and switches of individual drugs in case of confirmed toxicity.
At the programme level, costs include training for doctors, nurses, clinical officers, community health workers and lay volunteers, supervision and monitoring, increasing the capacity of the medicines distribution and storage system, recruiting community health workers, universal precautions, and post-exposure prophylaxis. They also include purchasing an appropriate number of CD4 machines, automated blood counters and blood chemistry machines in low-income countries, beginning in 2005.
Figure 2.2 shows the breakdown of estimated costs of 3 by 5 over the two-year period 2004-2005. Not surprisingly, antiretroviral drugs account for the greatest proportion, while treatment of opportunistic infections, palliative care and universal precautions are also major contributors.
These estimates include preventive activities required to support the 3 by 5 strategy directly. They also assume that other preventive interventions for HIV/AIDS will continue at the current rate. They do not include major changes to the health system infrastructure, which are not possible given the short time frame of 3 by 5. If other interventions are scaled up at the same time - perhaps for malaria and/or tuberculosis with financing from the Global Fund to Fight AIDS, Tuberculosis and Malaria - short-term constraints might be encountered in terms of shortages of personnel, health facilities or laboratory testing facilities. To achieve the Millennium Development Goals by 2015, including those related to HIV/AIDS, immediate investment in infrastructure and in health systems strengthening will be needed in many of the countries implementing 3 by 5. These issues are discussed further in Chapter 4.
The figure of US$ 5.5 billion concerns the countries with the highest burden from HIV/AIDS. Earlier, higher estimates have been superseded in other ways. For example, the model of care assumed in earlier calculations was more intensive in testing and staff time than that adopted by WHO to confront the AIDS treatment emergency. In addition, drug prices have fallen considerably.