Access to HIV treatment continues to accelerate in developing countries, but bottlenecks persist, says WHO/UNAIDS report

The number of people receiving combination antiretroviral therapy (ART) for HIV/AIDS in developing countries is increasing significantly – more than doubling from 400 000 in December 2003 to approximately one million in June 2005 – according to a new report released by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). However, access to HIV treatment continues to fall short of the growing need, and overall progress is unlikely to be fast enough to reach the target set by WHO and UNAIDS of treating three million people by the end of 2005.

The WHO/UNAIDS report shows that the number of people receiving ART is increasing in every region of the world, and the rate of scale-up is also accelerating. In sub-Saharan Africa, the region most severely affected by HIV, approximately 500 000 people are currently receiving ART – more than triple the number of people on ART in June 2004, and nearly double the number just six months ago. Similarly, in Asia -- the second most affected region -- the number of people with access to ART has tripled since June 2004 to approximately 155 000 today. More than 50% of this increase occurred in the first six months of this year.

Today's WHO/UNAIDS report identifies the factors that have helped some countries to achieve important advances in access to ART, as well as the bottlenecks that have slowed progress in many areas. The progress made to date has been possible as a result of the concerted efforts of many countries and donors with technical assistance from UNAIDS, WHO and other partners. The report provides a series of recommendations to increase progress in treatment scale-up, including adopting simplified and standardized treatment approaches that can maximize the number of people receiving quality ART, and help strengthen overall health systems capacity.

"The movement to expand HIV treatment access is making substantial progress," said WHO Director-General Dr LEE Jong-wook. "This is the first time that complex therapy for a chronic condition has been introduced at anything approaching this scale in the developing world. The challenges in providing sustainable care in resource-poor settings are enormous, as we expected them to be. But every day demonstrates that this type of care can and must be provided."

"It is imperative that we continue to speed up access to life-saving HIV treatment, not only as a means of treating the millions in need today, but also as a tool to help prevent millions of additional infections," said UNAIDS Executive Director Dr Peter Piot. "One of the key findings of the new report is that the availability of treatment increases the number of people who access key prevention services, such as testing and counseling."

The "3 by 5" target, endorsed by all 192 WHO Member States, was intended as an interim step toward the goal of universal access to HIV treatment for those who need it. The target was based on what could be achieved if countries, donors, and international agencies were fully successful in expanding political will, mobilizing funding resources, and building health infrastructure and systems. Today's report emphasizes that while political, financial, and technical support for ART scale-up have in some cases met or exceeded expectations, in others the prerequisites of a successful response are still not fully in place.

Moving forward to expand treatment access

Progress in scaling up access to ART varies considerably from country to country. To date, 14 low- and middle-income countries have met the "3 by 5" target of providing ART to at least half of the people in need, and several are moving towards providing universal access. The experiences of many of these countries inform the report's recommendations for accelerating progress in all countries.

"In the past 18 months, we've learned a tremendous amount about scaling up access to HIV treatment in even the poorest settings," said Dr Jim Yong Kim, Director of WHO's HIV/AIDS Department. "Major concerns remain including more affordable drug prices and greater access to new drugs through exercising TRIPS flexibilities. But we've learned beyond any doubt that treatment in the developing world is feasible, effective, and increasingly affordable. We've also seen in every case that what underpins success is an essential combination of political, technical, and financial support, invested in a way that strengthens overall capacity to deliver essential health services."

WHO/UNAIDS' recommendations for increasing the pace of ART scale-up in developing countries include the following:

* Political commitment: Of 49 WHO/UNAIDS "focus countries", 40 have established national targets for treatment access, and 34 are developing or have completed implementation plans. These plans are a first step toward rapidly scaling up ART access. The WHO/UNAIDS report calls for countries that do not have concrete plans to put them in place quickly.
* Standardized approaches and increased capacity: The countries making the most significant progress in providing quality ART to the greatest number of people are those that have adopted standardized drug regimens and clinical monitoring procedures. These countries are also addressing bottlenecks in procurement and supply chain management and in human resources capacity – by training non-physician health workers to safely and effectively administer ART. More countries should follow these leads.
* Technical support: WHO and other UN agencies are in the process of increasing technical assistance to countries in scaling up their ART programmes and strengthening their health sectors overall. A key WHO initiative employs new mapping software to help countries pinpoint the greatest unmet needs for a range of health services, in order to best target available resources. Overall, there is a need for technical assistance agencies to better coordinate with each other and with donors. The new UNAIDS Global Task Team is one forum for promoting this kind of improved cooperation.
* Sustainable financing: Donors have committed a total of US$ 27 billion over the next three years for HIV/AIDS treatment, care, and prevention efforts. However, not all of these commitments have been delivered, and the total amount pledged leaves a projected shortfall of at least US$ 18 billion for the period 2005-2007. Donors should accelerate funding disbursements to countries, increase their commitments, and pledge long-term, predictable funding. Developing countries should continue to invest their own resources. The new G-8 debt relief proposal provides an opportunity for several countries to reallocate significant resources to HIV/AIDS.
* Linking treatment and prevention: Evidence is emerging that ART availability leads to an upsurge in demand for HIV testing and counseling and other prevention services. In one district in Uganda, introduction of ART led to a 27-fold increase in demand for HIV testing and counseling. The WHO/UNAIDS report recommends steps for countries to integrate HIV treatment with testing and prevention, including using the same health clinics to offer both treatment and testing, and training health workers who administer ART to also offer prevention.

Toward universal access to treatment and prevention

The "3 by 5" target has been a major catalyst for mobilizing international support and action around the global effort to expand HIV treatment access. The experience gained in providing treatment to an initial one million people has laid the foundation for an accelerated scale-up in the future toward the goal of universal access to treatment by 2010, as called for in the G-8 Finance Ministers' meeting of 10-11 June 2005.

A key challenge in achieving universal access to both treatment and prevention will be the provision of increased financial and technical support to strengthen health and social systems. Priorities need to shift to ensuring that essential packages of prevention, treatment and care services are in place district by district, and community by community. It is also necessary to measure progress and analyse barriers to implementation on a continuous basis in order to inform effective action.

Scaling up HIV treatment presents an opportunity for countries to make lasting improvements in training health workers and establishing effective systems for providing a spectrum of health care to those who need it most. It is also critical to meeting a number of broader health and development goals. The rapid spread of HIV and HIV-related illness and death are directly impeding progress in six of eight key areas addressed by the Millennium Development Goals, which seek to make dramatic gains in improving health and reducing poverty worldwide by the middle of the next decade.

WHO/UNAIDS estimates of treatment access

WHO/UNAIDS ART access estimates reflect a broad range of efforts to provide HIV treatment in developing countries. ART programmes are financed and operated in large part by countries themselves, with the support of a range of bilateral and multinational donors, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund), the U.S. President's Emergency Plan for AIDS Relief, and other donors, with technical support provided by a number of international agencies, including WHO and UNAIDS.

In compiling estimates of ART access, WHO uses the most recent country reports received from the health ministry, the WHO or UNAIDS country office, or another reliable source in the country. These reports are checked against data from major donors, including the Global Fund and the U.S. President's Emergency Plan for AIDS Relief. The reports are also checked against data from the pharmaceutical companies that manufacture ART drugs and ship them to developing countries.

Download report [pdf 1.50Mb], Progress on global access to HIV antiretroviral therapy: an update on "3by5"