AIDS Alert International

About 1 million people in developing countries now receive HIV medications

Achievement falls short of WHO’s 3 by 5’

The world’s health community has succeeded in bringing antiretroviral treatment to about 1 million HIV-infected people in developing nations, which highlights both the progress made and challenges to come.

"What we’re seeing is a historically significant scale up of a chronic disease treatment program," says Jim Yong Kim, MD, PhD, director of the HIV/AIDS Department at the World Health Organization (WHO) in Geneva. Kim and other world health officials spoke about the progress in providing HIV treatment worldwide at a teleconference held in June.

"The HIV treatment scale up is surely the most ambitious project in the history of global public health," he says. "However, we don’t believe that progress has been fast enough."

There are an estimated 6.5 million people in developing nations who need antiretroviral treatment, says Ties Boerma, PhD, director of WHO’s department of measurement and health information systems. Boerma also spoke at the teleconference.

The 6.5 million figure includes all people who are in the last two years of their infection, he says.

"So we’ve also estimated that 660,000 children are in need of treatment," Boerma adds.

WHO and UNAIDS set a goal called the "3 by 5" initiative two years ago, in hopes of bringing 3 million people in developing nations into antiretroviral treatment by 2005. With 2 million remaining on the goal at the midyear point, it does not appear the goal will be met, Kim says.

"While we don’t think we’re going to make the target, there are tremendously exciting things happening in many, many countries," he says.

A June report by WHO and UNAIDS, called Progress on Global Access to HIV Antiretroviral Therapy — An Update on "3 by 5," describes these hallmarks of the program’s success:

  • Zambia, which has an epidemic that has resulted in HIV infection among 16% of the population, with women constituting 54% of the people living with HIV/AIDs, now has 600,000 orphans as a result of AIDS deaths. In October 2004, the president of Zambia announced a plan to provide antiretroviral drugs for free at public institutions; and as of March 2005, the government reported distributing antiretroviral therapy to 22,000 people, adding about 1,000 people a month to the treatment list. WHO now estimates that between 26,000 and 30,000 people in Zambia are receiving HIV antiretroviral therapy.
  • Mozambique has more than 1.1 million people living with HIV/AIDS, about 12% of the adult population, and there are estimates the country’s HIV/AIDS toll will grow to 1.8 million by 2007. Despite years of civil conflict and a weak health infrastructure, the nation is scaling up its antiretroviral treatment program.

    "The Minister of Health of Mozambique when he visited us during the World Health Assembly told us that they’ve now been convinced that treatment programs based on clinical officers and nurses who are supervised by physicians are very effective," Kim says. "So they have begun training their high school graduates, among whom they have a terrible unemployment problem."
  • The HIV epidemic in Indonesia, with about 110,000 people infected, has grown rapidly among injecting drug users, reaching a prevalence rate of 53% among IDUs in Bali and 48% among IDUs in Jakarta. The Indonesian government has committed to bringing 10,000 people into treatment by the end of 2005. The government also issued in October 2004 a compulsory license for the production of two antiretroviral drugs, and 25 antiretroviral referral sites were initiated in 13 provinces of Indonesia. The country also has established pilot methadone programs in Jakarata and Bali, including prison methadone programs.

The world health community’s focus on expanding antiretroviral treatment has led to some important changes in prevention and testing.

"There’s an incredible upsurge in the demand for testing, and what’s happened because of these expanded treatment programs is that we’re doing testing in a different way," says Paul De Lay, MD, director of evaluation at UNAIDS.

"We are offering tests to those who are most likely to need them — TB patients, patients with sexually transmitted diseases, people with illnesses that are within the range of an AIDS diagnosis in an outpatient clinic, sick people in an inpatient hospital ward situation," he explains.

UNAIDS estimates the cost of scaling up anti-retroviral treatment in developing countries will reach $22 billion by 2008, a number that includes the cost of refurbishment of health centers and recruiting new health providers , De Lay says.

WHO and UNAIDS officials acknowledge that part of the reason the 3 by 5 goal has not been reached is because of unanticipated challenges, including problems with the drug delivery system.

"What we call procurement and supply chain management is a major issue," Kim says. "I don’t think any of us really thought that it would be as big an issue as it’s become."

These problems often are as simple as a country lacking a warehouse with a lock where the drugs could be safely stored.

Also, many countries are faced with the reality of dealing with a volume of need for antiretrovirals that surpasses any other medical need they’ve handled, Kim notes. "So it’s things like this, the small details that we just got a late start on that didn’t get here."

The majority of developing countries have had difficulty getting their systems up and running, says Bernard Schwartlander, MD, director of strategic information and evaluation for the Global Fund to Fight AIDS, Tuberculosis, and Malaria. However, improvements are being made, he says.

For example, in India there have been major resources from the Global Fund, and there has been a major initiative launched with the Clinton Foundation, Schwartlander reports.

"I think for India, we’re going to have to look at creative and innovative solutions," Kim says. "What we hope to see is vastly improved numbers in terms of physicians and nurses who understand antiretroviral treatment, and that’s through the Clinton Program."

Plans are to train 100,000 people in the next couple of years, he adds.

Another challenge of providing antiretroviral treatment to developing nations is that whether it’s one in six or one in three people in need of drugs who receive the help, there has to be some ethical system for deciding who will receive the treatment, Kim notes.

"We thought very hard about this, and we convened meetings of the top medical ethicists in the world and really asked them this question," he says. "What they said was what we can do as ethicists is offer to countries and even communities a set of three or four different scenarios of how they might go about selecting who gets treatment first."

There are many ways to make this decision, Kim says, including these:

  • "You can look at the severity of the symptomology, how sick people are," he says.
  • "You can look at health workers, for example, is a case that’s been made in some countries, that in order to care for the rest, we need to get the health workers on treatment," Kim says.

Most of the countries have responded to these suggestions by asking for general boundaries, including what the world health community feels is absolutely unethical, and then they’ll think about it and come up with their own approach, he explains.

The result has been that many nations are making decisions based on local criteria, Kim says.

So far it appears that at least with regard to gender issues, the distribution of drugs is encouraging, as early data show that about half of the people on treatment are women, he reports.

"So that should not let us drop our guard because what we’ve also seen is that the enrollment of women is much higher in places where access to care is free at the point of delivery," Kim says. "So we’ve got to keep counting, and we’ve got to give general guidelines, but then it’s really countries, communities, and organizations that will make the final decision."