Chapter 2
The front lines: working in countries
Countries are driving the rapid expansion of HIV/AIDS treatment under 3 by 5. Those countries already severely affected by HIV/AIDS and those with small but expanding epidemics have committed themselves to the emergency initiative.
Solving the emergency requires innovation backed by experience and expertise. It implies streamlining or suspending familiar but unsuitable procedures and devising effective new ones at short notice as events unfold. Key elements of the emergency response at country level include:
- adequate political and financial commitment to scaling up treatment;
- high-level national mechanisms for planning, coordinating and leading treatment efforts;
- ensuring continuous availability of drugs and diagnostics;
- moving quickly to build capacity in health services and communities;
- establishing appropriate systems for monitoring and evaluation and operational research as programmes are rolled out.
When a WHO 3 by 5 emergency mission is invited to a country, it can help stimulate work in all the above areas. Within days of the declaration of the global HIV/AIDS treatment emergency, the first WHO country mission was on the ground in Kenya. The mission began work with national health officials and political leaders, community and nongovernmental organization representatives, private-sector health care providers, international agencies, and other stakeholders to build consensus and catalyse action for rapid scale-up of treatment. Similar WHO emergency assessment teams have been sent out as countries request them. By mid-February 2004, 15 emergency planning missions had been completed and several more were planned in response to country requests.
Countries approach the 3 by 5 challenge from very different departure points, and with varying strengths and weaknesses. Yet important areas common to all have emerged. Announcements in late 2003 of national commitment to significant scale-up from China, India, Kenya, Malawi, South Africa, Zambia and others strengthened the growing, shared momentum. Now countries, communities and international partners are working to translate political commitments into action that saves lives. The following case-studies describe the range of situations countries face and some emerging common themes.
China
More than 800 000 people in China are estimated to be living with HIV/AIDS. Injecting drug use has been the predominant mode of transmission, but heterosexual transmission related to sex work is on the increase. With new commitment from its political leaders, China has embraced the 3 by 5 initiative, which means aiming to provide treatment to 100 000 patients by the end of 2005.
Big problems must be tackled quickly. Epidemiological surveillance of HIV/AIDS needs further reinforcement. Implementation mechanisms for treatment are incomplete. Capacities need to be strengthened in many areas of work. Currently, despite provision of free antiretrovirals, patients must pay for HIV testing, symptomatic care, transportation costs and other expenses. These costs are serious obstacles to treatment access and adherence. Fortunately, China's strengths include a burgeoning domestic pharmaceutical industry which is now producing generic antiretroviral drugs. High-level commitment to intensified action on HIV/AIDS was underlined on World AIDS Day 2003, when Premier Wen Jiabao and Vice Premier Madam Wuyi visited people living with HIV/AIDS at Beijing's Youan Hospital.
India
Official estimates in India for 2003 put the number of HIV-positive people at 3.8-4.6 million, with 600 000 in urgent need of treatment. India's national HIV prevalence rate is below 1%, but some regions and population groups are much more heavily affected. For example, more than 50% of commercial sex workers in the state of Goa and the city of Mumbai are HIV-positive. Efforts to scale up treatment will focus initially on six states - Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu - but there are immense difficulties. For example, the city of Mumbai alone has a larger population than Botswana and Zambia combined.
India's health system has significant strengths, including a large pool of skilled doctors and other health professionals. Training in HIV care is now part of all medical and nursing curricula, though few students yet receive adequate practical experience in clinical management. The country has numerous medical centres of excellence and an array of high-level research institutions. Without doubt, antiretroviral procurement and distribution will pose major challenges, but on the other hand successful models of drug supply management do exist, such as that in Delhi State (19). India has a robust domestic pharmaceutical industry, which is also a major source of generic antiretrovirals (Box 2.5).
On the eve of World AIDS Day in December 2003, as WHO released its 3 by 5 strategy, the Government of India announced a commitment to begin providing antiretroviral treatment free of charge to selected groups of patients in April 2004 and to place 100 000 people on treatment within a year. A WHO exploratory mission was invited to India within days of the government's announcement. WHO HIV/AIDS specialists are being deployed to each of the six high-burden states, with other initiatives aimed at supporting the country on issues such as clinical management, drug procurement, laboratory support and monitoring and evaluation.
By mid-February 2004, training of key staff in 16 institutions selected to initiate the treatment programme was advancing under the leadership of the National AIDS Control Organization. WHO worked with this organization on finalizing training curricula and materials, and a capacity-building plan.
Kenya
About 1.8 million Kenyans are living with HIV/AIDS. Of the 280,000 Kenyans who urgently require antiretroviral therapy, about 11,000, or 4%, are currently on treatment. The majority of these patients are treated in the private sector or by nongovernmental and faith-based organizations.
Kenya has shown high-level political commitment to scaling up treatment and care, alongside prevention efforts. State health officials have set the following target: "Progressively deliver effective antiretroviral therapy, reaching 50% (140 000 patients) by 2005 and 75% (200 000 patients) by 2008, so as to increase the quality of life and survival by 10 years; reduce HIV-related hospital admissions by 60% and enhance significantly national prevention efforts". Major obstacles to this objective include a large financing gap, understaffed health facilities and high unemployment among trained health care workers. Treatment literacy - the understanding of what treatment is and how to manage it - is low. This is associated with very high levels of stigma among both health workers and the general population.
The government has declared HIV/AIDS a national disaster and is finalizing the legal provisions to enhance HIV/AIDS control, including provision of care and treatment on an emergency basis. Kenya has already made significant progress in preparation for institutionalization of care and treatment. The Ministry of Health has advanced plans for the phased opening of 30 comprehensive HIV/AIDS care centres, selected on the basis of geographical coverage, HIV prevalence, and the level of preparedness for antiretroviral treatment. Training of health care workers has begun. Legal barriers to the importation and local manufacture of generic antiretrovirals have been removed.
Thailand
Around 100 000 people are currently in need of treatment in Thailand, but there are hopes that the country will reach the 3 by 5 objective of 50 000 patients by the end of 2005. Thailand has had a national, comprehensive HIV/AIDS control programme since the 1990s, integrating prevention, care and treatment (see Box 1.4).
By September 2003 the national antiretroviral treatment programme covered more than 13 000 patients. The government has allocated US$ 25 million to reach the 2004 target. The programme is continuing to strengthen infrastructures and capacity at management and service delivery level. Antiretroviral medicines will soon be covered by the universal health insurance plan. The biggest challenges are ensuring adherence and strengthening programme monitoring as well as drug resistance surveillance.
Zambia
In Zambia, which has an adult HIV prevalence of 16%, about 1 million people are living with HIV/AIDS, and around 200 000 are in urgent need of antiretrovirals. The government has shown firm commitment to scaling up treatment, although progress has been slowed by limited resources and health system capacity. Only about 1000 patients were on antiretrovirals in the public sector at the end of 2003; an unknown number receive private-sector treatment. A national target of 100 000 people on treatment by the end of 2005 was adopted in 2003 after discussions between government health officials and a WHO delegation.
Obstacles to reaching this target are of similar scale and complexity to those encountered in many countries in sub-Saharan Africa. They include lack of funding to cover the projected costs of drugs, a significant health sector human resource shortage, weak laboratory capacity, weak monitoring and evaluation systems, and inadequate dissemination of information among stakeholders and communities. HIV/AIDS remains heavily stigmatized, limiting the number of people who seek testing and care in both the private and public sectors. Poverty and patients' inability to pay for medicines constitute major challenges for national treatment scale-up, given that 73% of Zambians are classified as poor (20).
In his State of the Nation address to Parliament in January 2004, Zambian President Levy Mwanawasa affirmed commitment to 3 by 5. WHO has worked closely with health ministry officials in preparing an implementation plan, which includes an ambitious programme to train thousands of health workers, community workers and volunteers in aspects of treatment provision during 2004-2005. WHO is also providing policy and technical cooperation in Zambia's development of a proposal for funding from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Funding from the United States President's Emergency Plan for AIDS Relief will further accelerate the national response.