A new report by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that the number of people on HIV antiretroviral treatment (ART) in low- and middle-income countries more than tripled to 1.3 million in December 2005 from 400 000 in December 2003. Charting the final progress of the "3 by 5" strategy to expand access to HIV therapy in the developing world, the report also says that the lessons learned in the last two years provide a foundation for global efforts now underway to provide universal access to HIV treatment by 2010.
Progress in treatment scale-up, while substantial, was less than initially hoped. The report notes, however, that treatment access expanded in every region of the world during the “3 by 5” initiative, with approximately 50 000 additional people beginning ART every month in the past year. Sub-Saharan Africa, the region most severely impacted, led the scale-up effort, with the number of people receiving HIV treatment there increasing more than eight-fold to 810 000 from 100 000 in the two-year period. By the end of 2005, more than half of all people receiving HIV treatment in low- and middle-income countries resided in sub-Saharan Africa, up from one-quarter two years earlier.
“Two years ago, political support and resources for the rapid scale-up of HIV treatment were very limited,” said WHO Director-General, Dr LEE Jong-wook. “Today "3 by 5" has helped to mobilize political and financial commitment to achieving much broader access to treatment. This fundamental change in expectations is transforming our hopes of tackling not just HIV/AIDS, but other diseases as well.”
In July 2005, the G8 nations endorsed a goal of working with WHO and UNAIDS to develop an essential package of HIV prevention, treatment and care with the aim of moving as close as possible to universal access to treatment by 2010, a target subsequently endorsed by the United Nations General Assembly in September 2005. The new WHO/UNAIDS report outlines a number of steps that must be taken to continue and expand treatment scale up toward achieving this goal.
Substantial increases in HIV treatment access
Countries in every region of the world made substantial gains during the “3 by 5” period in closing the gap between those in need of treatment and those receiving it. The number of public sector treatment sites in low- and middle-income countries increased from fewer than 500 providing ART to more than 5100 operational treatment sites by the end of 2005. A recent survey showed for example that the number of treatment sites in Malawi increased from three in early 2003 to 60, and in Zambia increased from three to more than 110 facilities in just over two years.
Globally, 18 developing countries met the “3 by 5” target of providing treatment to at least half of those in need by the end of 2005, and are now concentrating their efforts on moving towards universal access to treatment. While other countries fell short of this target, lessons learned in expanding treatment access and overcoming critical weaknesses in health systems are informing new initiatives to further scale-up HIV prevention, treatment and care services. Increased availability of ART averted an estimated 250 000 to 350 000 premature deaths in the developing world in 2005 alone.
Launched by WHO and UNAIDS on World AIDS Day, 1 December 2003, "3 by 5" aimed to provide treatment to three million people in low- and middle-income countries by the end of 2005. This ambitious target was based on a 2001 analysis of what could be accomplished with an optimal combination of funding, technical capacity building, health systems strengthening and political will and cooperation. The initiative confirmed that HIV treatment can be delivered effectively in a wide variety of health systems, including those in poor countries and rural settings, and that large-scale ART access is both achievable and increasingly affordable.
Between 2003 and 2005, global expenditure on AIDS increased from US$ 4.7 billion to an estimated US$ 8.3 billion. Significant proportions of this funding were provided by the US President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, TB and Malaria and the World Bank. During the same period, the price of first-line treatment decreased by between 37% and 53%, depending on the regimen used.
Progress: Treatment access by region
Between end-2003 and 2005, HIV treatment access expanded in every region of the world. Sub-Saharan Africa and East, South and Southeast Asia, the regions most heavily affected by the epidemic, achieved the most rapid and sustained progress.
* More than 810 000 people in sub-Saharan Africa, or 17% of those in need of ART, had accessed treatment by the end of 2005. Well over half the people on ART in the developing world live in this region. This substantial increase in ART availability in sub-Saharan Africa occurred despite considerable regional challenges: the region is home to over 20 of the world’s 25 poorest countries, and suffers a shortage of some one million professional health workers, with an additional 20 000 trained staff lost each year to emigration.
* East, South and Southeast Asia recorded significant gains in ART access from end-2003 (70 000 people) to 2005 (180 000 people), with coverage in the region expanding more than 75% in 2005. Thailand was a major driver of this increase, particularly during 2004 and the first half of 2005.
* Latin America and the Caribbean, with more than 315 000 people on ART (up from 210 000 at the end of 2003), is providing treatment to approximately 68% of its population in need – the highest coverage of any region in the developing world. Thirteen countries in this region provide treatment to more than half of the population in need.
* Despite gains in overall numbers on treatment, ART access in low- and middle-income countries in Eastern Europe, Central Asia, the Middle East and North Africa was lower than in other regions, with just 21 000 people in Eastern Europe and Central Asia and 4000 in the Middle East and North Africa receiving treatment as compared to 15 000 and 1000 respectively at the end of 2003. Virtually all countries in these regions are experiencing low-level epidemics that involve difficult-to-reach populations such as injecting drug users (IDUs) and sex workers.
Reaching women, children and vulnerable populations
While the new report found no systematic bias against women in ART access, rates of coverage for women varied. In some countries, more women receive treatment; in others, more men. One notable area of concern is access to therapy to prevent mother-to-child HIV transmission, which remains unacceptably low. Between 2003 and 2005, fewer than 10% of HIV-positive pregnant women received antiretroviral prophylaxis before or during childbirth. As a result, 1800 infants were born with HIV every day. Each year, over 570 000 children under the age of 15 die of AIDS, most having acquired HIV from their mothers. In 2005, 660 000 children under the age of 15 were in need of immediate ART, representing more than 10% of unmet global need. Nine out of ten children needing treatment live in sub-Saharan Africa.
While an estimated 36 000 injecting drug users (IDUs) were receiving ART by the end of 2005, more than 80% (30 000) of these are in Brazil. The remaining 6000 patients were distributed among 45 other countries. These figures suggest a large unmet need, particularly in Eastern Europe and Central Asia, where IDUs represent 70% of HIV cases but just 24% of patients currently on treatment.
“Misinformation about the disease and stigma against people living with HIV still hamper prevention, care and treatment efforts everywhere,” said Dr Peter Piot, UNAIDS Executive Director. “If we are to get ahead of the AIDS epidemic, we must tackle stigma, ensure that the available funds are spent effectively to scale-up HIV prevention, care and treatment programmes, and mobilize more resources.”
Moving toward universal access
While important advances in HIV treatment access have been achieved in the past two years, the report also acknowledges that, despite the efforts of many partners and significant funding from a number of donors, the "3 by 5" strategy fell short of its ambitions. Obstacles to scaling up HIV treatment and prevention highlighted in the report include poorly harmonized partnerships; constraints on the procurement and supply of drugs, diagnostics and other commodities; strained human resources capacity and other critical weaknesses in health systems; difficulties in ensuring equitable access; and lack of standardized systems for the management of programmes and monitoring progress.
“The past two years have provided a wealth of experience and information on which we must now continue to build,” said Kevin De Cock, Director, HIV/AIDS Department at the World Health Organization. “We intend to utilize this knowledge to focus future efforts on overcoming persistent challenges and obstacles. It is particularly important that scaling-up HIV prevention, treatment and care services contributes to strengthening of health systems overall.”
A number of lessons learned in treatment scale-up efforts and outlined in the new report provide a valuable roadmap for efforts to achieve universal access to treatment. Among these are:
* The positive impact of targets in creating and sustaining momentum for action and in increasing accountability among stakeholders. A key element of the “3 by 5” strategy was developing bold country-level targets that encouraged national governments to expand capacity beyond what was previously considered possible. Moving forward, targets for treatment must be complemented by achievable targets for other elements of a comprehensive response to AIDS, including prevention and mitigating impact.
* The need to strengthen health systems. Building universal access to HIV treatment will require significant ongoing efforts to re-build, reinforce and expand under-staffed and under-funded health care systems that are already severely challenged in many countries.
* Promoting a 'public health approach' to health care delivery that emphasizes service decentralization, community mobilisation and education, team-based approaches and the delegation of routine tasks to trained nurses and health workers. The approach also promotes use of mechanisms to ensure the consistency and quality of supplies of drugs and diagnostics as well as the routine offer of voluntary testing and counselling to increase knowledge of HIV status in settings where there is high HIV prevalence.
* The ongoing need to intensify prevention efforts and to integrate prevention and treatment scale-up, using all effective approaches and paying particular attention to the needs of vulnerable groups. Epidemiological modelling consistently shows that more deaths can be averted with a comprehensive response including both prevention and treatment, than by focusing on treatment or prevention alone.
* The need for substantial increases in resources and sustainable financing. UNAIDS estimates that the gap between available resources and those needed is US$18 billion for the period 2005-2007, and that at least US$22 billion per year will be needed by 2008 to fund comprehensive national HIV prevention, treatment and care programmes.
* Long-term donor commitments are essential to ensuring sustainable treatment scale-up, as placing large numbers of people on ART is impractical for many countries without firm funding. The report encourages the use of innovative financing mechanisms to fund increased resources for AIDS. These include a proposal by France to introduce an airline solidarity contribution and the UK’s International Finance Facility, which aims to “front-load” additional funds leveraged from international capital markets to make them immediately available for sustainable investments that support the achievement of the Millennium Development Goals.
The new report emphasizes that WHO and UNAIDS will continue to build upon these lessons learned, as well as on the priorities, strategies and partnerships of “3 by 5" in accelerating the AIDS response. UNAIDS is currently facilitating the development of nationally agreed plans and targets to move towards universal access to HIV prevention, treatment, care and support. WHO's contribution to realizing the goal of universal access will be based on a set of priority interventions in the following five strategic directions, known to be able to significantly influence the epidemic in different epidemiological contexts:
* enabling people to know their HIV status through HIV testing and counselling;
* accelerating the scale-up of treatment and care;
* maximizing the health sector's contribution to HIV prevention;
* investing in strategic information to guide a more effective response; and
* strengthening and expanding health systems.
Progress on global access to HIV antiretroviral therapy [pdf 2.85Mb]