Year in Review 2005 - The long slow road to '3 by 5'

AFRICA: Year in Review 2005 - The long slow road to '3 by 5'

[ This report does not necessarily reflect the views of the United Nations]

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Nigerian activists pressured the government to provide free treatment

JOHANNESBURG, 20 Jan 2006 (PLUSNEWS) - Almost a month after the deadline, the World Health Organisation's (WHO) campaign to put three million people in the developing world on anti-AIDS drugs by the end of 2005 has failed to meet its target.

When WHO launched the '3 by 5' initiative it was widely acknowledged that the 'aspirational' target represented a significant hurdle, given the state of global funding for AIDS, doubtful political will, drug availability and technical capacity.

But activists acknowledged that it did at least represent a goal to work towards, especially since, in Africa, fewer than 30,000 people were on antiretroviral (ARV) medication in 2001.

Dr Eric Goemaere, head of Medecins Sans Frontieres (MSF) in South Africa noted, "It's good to have an ambitious target. People are under pressure to move - and things are moving, and moving fast."

In 2004 and 2005, African governments cranked up the rollout of ARV drugs to their HIV-positive citizens and about half a million people in sub-Saharan Africa were receiving the life-prolonging medication in June 2005 - a three-fold increase in a period of 12 months.

During an interview with PlusNews last month, WHO's HIV/AIDS director, Dr Jim Yong Kim, pointed out that countries everyone was sure would never be able to scale up treatment had managed to reach their targets.

Many doubted that Botswana would be able to offer free treatment to all who needed it in 2002, but it became the first country in Africa to do so, and now has half the estimated 110,000 people who need them receiving ARVs.

Although it was no surprise when Uganda and Botswana met their targets before the end of 2005, few would have predicted that the tiny kingdom of Swaziland would be providing ARV drugs to 50 percent of its HIV-positive people, he added.

Despite the progress made, activists have been reluctant to label the '3 by 5' campaign an outright success.

According to the International Treatment Preparedness Coalition (ITPC), a global alliance of over 600 treatment activists, '3 by 5' has fallen at least one million people short of the target. The coalition warned that if there were to be any hope of achieving an even more ambitious goal in five years' time, "courageous new leadership from all parties" would be required.

"The status quo will not get us there," ITPC said in a new report.


Inevitably, financial constraints remain a major hurdle, particularly the cost of ARV medicines to countries. In 2005 it was estimated that US $3.8 billion would be required to achieve '3 by 5', but a study released by the international NGO, Action Aid, warned that WHO was facing a $2 billion funding shortfall, which could knock off course its ability to meet those commitments.

Children were neglected by most national treatment programmes, and WHO and UNAIDS concluded that 660,000 children globally should have had access to ARVs in 2005. But "probably less than five percent" of the one million people on treatment in the developing world were children.

Staff shortages continued to inhibit the scaling-up of treatment in many countries: as many as 100,000 trained healthcare workers were needed to handle the growing national programmes, WHO and UNAIDS found.

South Africa, for instance, was faced with a "massive human resource crisis" and was struggling to address the acute nursing shortages, Fatima Hassan, an attorney with South Africa's AIDS Law Project, told PlusNews.

WHO's Kim admitted that the two nations with the biggest HIV caseload on the continent - South Africa and Nigeria - had been a disappointment. "These countries have a lot more infrastructure, but it's been more difficult for a lot of complicated reasons."

Hassan, one of the authors of the ITPC report, was more forthright about South Africa's slow pace in rolling out ARVs, attributing the tardiness to a lack of political will and leadership, "coupled with denialism and a flirtation with pseudoscience".

The report found that health minister Manto Tshabalala-Msimang was responsible for creating a false dichotomy between nutrition and HIV/AIDS, as she continued to issue ambiguous statements about nutrition and ARVs. She also refused to act against false claims by people associated with AIDS denialists, it added.

Some 70,000 South Africans were taking anti-AIDS medication by August 2005, but the estimated number in need of treatment is between 500,000 and 700,000.

"With the necessary political will and leadership, these obstacles can be overcome," Hassan stressed.

In Nigeria, the inequitable distribution of treatment centres meant fewer people had access to the drugs. The rollout has been plagued by delays: in January 2002, the programme was expected to expand from 25 to 100 treatment centres within a year, but failed to reach this goal; paediatric ARVs only became available in early 2005; bottlenecks in the purchasing of new drugs led to ARV shortages and treatment interruption.

But the major barrier for many HIV-positive Nigerians was the cost of the medication.

According to a new study by MSF, the lack of free AIDS treatment was increasing the risk of treatment failure. Research done in Nigeria's economic capital, Lagos, among patients who had to pay for their treatment, revealed that 44 percent had had multiple treatment interruptions or took insufficient dosages due to a lack of money.

Ibrahim Umoru, who is receiving his supply of life-prolonging drugs through MSF, noted: "Most positive persons cannot afford the cost of treatment, which is responsible for their interrupting treatment. The federal government has to provide free access and comprehensive care."

Until last month, beneficiaries on the government's programme were required to pay Naira 1,000 (US $8) a month for ARVs, but after pressure from treatment activists and donors the health ministry announced that it had decided to waive the monthly contribution.

A week later, the government said it planned to double the number of anti-AIDS treatment sites to 66 within three months to meet its new target of 250,000 people receiving the medication. Over 30,000 people were accessing the drugs in November 2005.


According to WHO's Kim, "If these countries take off as they say they are going to, and if they do it in the next year, my hope is that we'll get the three million before the end of 2006. In that case, we'll call it '3 by 5-and-a-half'."

Hassan conceded that the '3 by 5' initiative was a "good starting point, because it put a lot of governments under the spotlight - they are now under moral and social pressure to start being accountable."

"The campaign opened up the way for African countries to start treatment programmes, helped get preferential prices for ARVs, helped make laboratory tests cheaper ... it was not a total failure - it created a lot of momentum," she added.

The challenge now is whether national governments can sustain this momentum, once the hype surrounding the '3 by 5' campaign has died down.


However, Kim called for a shift in momentum towards prevention because although treatment had become more widely available in the past few years, it had also become evident that prevention efforts were being sidelined.

When WHO releases its much-anticipated report on the campaign it will highlight the fact that 750,000 and 1 million Africans were receiving ARVs by the end of 2005. But even more telling is that in 2005, an estimated 3.2 million people in the region became newly infected.

"Yes, there is guarded optimism over the progress that has been made in terms of access to life-prolonging treatment," the UNAIDS regional co-ordinator for East and Southern Africa, Mark Stirling, told PlusNews. "But we could definitely be doing more along the lines of prevention to get ahead of this pandemic."


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