The 3 by 5 initiative has set a time-bound target, which is useful for the purposes of motivating performance and measuring results. But the initiative will not end in 2005, partly because people will need to remain on treatment for the rest of their lives. Moroever, beyond the immediate target stands the goal of universal access. The target covers only half the global HIV/AIDS treatment gap. Another 3 million people will remain in urgent need of antiretroviral therapy. Eventually, almost all of the 40 million people now infected with HIV worldwide will require access to therapy. Progress achieved in scaling up access by 2005 must rapidly be extended to people who are still deprived.
The immediate target and the wider goal of universal coverage will challenge communities, countries and global institutions concerned with health. But the challenge must be faced. The expansion of treatment is no longer a question of if, but how. The use of antiretroviral medicines in developing countries will expand rapidly in the coming years. Many people with HIV/AIDS, even very poor people, will find ways to obtain medicines that promise to extend their lives. Will this take place efficiently through rational programmes able to set high standards for drug quality, patient care and support, treatment adherence and monitoring? Will principles of equity and fair access be respected? Or will the inevitable increase in the use of antiretrovirals in resource-poor settings take place in a piecemeal and anarchic way, with access largely determined by geography, social status and the ability to pay? Will this involve only limited support for treatment adherence and scant oversight of drug quality and resistance monitoring?
Without serious commitment to treatment access, the latter scenario is the more likely, and will inevitably result in the exclusion of large numbers of patients in need, poorer outcomes for numerous patients who do obtain some form of treatment, and rapid spread of resistance to drugs. Shared commitment to treatment access across the global health community can ensure that the process of expanding access to antiretroviral therapy unfolds quickly and fairly, maximizing benefits while limiting public health risks.
Such shared commitment will also strengthen partnerships that are vital to the future of global public health. Previous successful global campaigns - including smallpox eradication, the worldwide battle against tuberculosis, massive mobilization against polio and the response to SARS - provide important lessons for treatment scale-up. All of these efforts surmounted great obstacles and most ran into unforeseen difficulties. Yet none of them matches the HIV/AIDS treatment challenge in scope and complexity. The 3 by 5 initiative is catalysing new ways of working within WHO and across the global health community based on results-oriented teamwork among many partners, strong linkages between communities, national authorities and international institutions, and an overarching commitment to health equity.