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Almost a decade ago, the development of an effective treatment for the human immunodeficiency virus (HIV) that causes AIDS opened an ugly new gap in the global divide between rich and poor. People in wealthy countries could get the expensive new drugs, known as anti-retrovirals (ARVs), and live. For people in poor countries, there would be no drugs, only the certainty of a slow and agonizing death. And die they did, in the millions.

AIDS activists in South Africa: anti-retroviral medicines now give some hope for the future.

Photo: AFP/Getty Images/Rajesh Jantilal

Declaring the inability of the poor to obtain HIV/AIDS medications "a global health emergency," the director-general of the UN's World Health Organization (WHO), Dr. Lee Jong-wook, launched a global drive to provide life-extending ARVs to 3 million people, including 2 million in Africa, by the end of 2005. It is known as the "3x5" campaign.

About 6 million people worldwide currently require ARVs, which are prescribed only to those in the last stages of the disease. It is also a long-term commitment, since the drugs do not cure the disease and must continue for life. "To deliver anti-retroviral treatment to the millions who need it we must change the way we think and change the way we act," noted Dr. Lee. "Business as usual will not work. Business as usual means watching thousands of people die every single day."

For 30 million HIV-positive people in Africa, it is a matter of life or death. HIV, which attacks the body's natural defences against infection, has had its greatest impact in sub-Saharan Africa, where poverty, weak public health systems, fear of stigmatization and the high cost of testing and treatment have allowed the virus to spread virtually unchecked. The UN estimates that no more than 100,000 of the over 4 million Africans who need ARV medications receive them.

The campaign will be modelled after WHO's emergency response to the SARS epidemic, a highly infectious respiratory illness that was quickly contained by a coordinated global effort last year. WHO technical experts will be dispatched to countries to help local authorities establish testing, distribution and treatment facilities. WHO will also develop standardized and simplified treatment protocols, design training schemes for 100,000 additional health workers and create a central information clearing-house on drug quality, availability and prices.

"It will take a huge effort, an unprecedented effort, by all the stakeholders if we are to go from having 300,000 people in poor countries [on ARVs] to 3 million in just two years.... Our targets are difficult but they are possible."
-- Dr. Paolo Teixeira, 3x5 campaign director

It is a hugely ambitious undertaking, intended to increase the number of people on ARV treatment 10-fold in just two years. It is also a victory for Africa, said Ms. Milly Katana, the lobbying and advocacy director for the non-governmental Health Rights Action Group in Uganda. Speaking from her home in Kampala, Ms. Katana, who also sits on the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, told听Africa Recovery听that "for years we argued with the donors, the multinational drug companies and even some private foundations and non-governmental groups that treatment was possible. And we heard every kind of excuse why it could not be done." Now, the argument is not whether to treat the poor but how. "That is the breakthrough," she said. "The 3x5 campaign is a victory for the efforts and struggles of people in Africa living with HIV/AIDS."

Treatment 'must be possible'

But can it be done? Interviewed by听Africa Recovery听in New York in early February, the 3x5 campaign director, Dr. Paolo Teixeira, readily acknowledged that the technical, financial and political obstacles to success are enormous. "It will take a huge effort, an unprecedented effort, by all the stakeholders if we are to go from having 300,000 people in poor countries [on ARVs] to 3 million in just two years," he said. "Governments, civil society, donors, multilateral agencies, drug companies, non-governmental organizations [NGOs], and even WHO must come together as never before. Our targets are difficult but they are possible," he continued. "They must be possible. Think of the lives that are at stake."

Dr. Teixeira, an architect of Brazil's model national treatment programme before joining WHO, argued that a number of factors make this the right time for a global commitment to treatment access, including:

• Drug prices.听Pressure from people living with HIV/AIDS and competition from low-cost manufacturers of generic copies of patented ARV drugs have seen prices drop in recent years from $12,000 - $15,000 annually to as low as $300 per year in developing countries. A recent agreement between some generics manufacturers and former US President Bill Clinton could bring the price down to $140 a year -- less than 40 cents per day.
• Greater political will.听More political leaders in Africa and other developing regions, after years of denial, have taken leadership of national HIV/AIDS efforts.
• Proven models.听Uganda's success in sharply reducing HIV infection rates with aggressive education and prevention programmes demonstrates that the disease can be halted even in very poor countries. Pilot programmes by M茅decins sans Fronti猫res and other non-governmental groups have proved that HIV/AIDS can be treated in countries without sophisticated health services.
• Improved technology.听The development of a single pill that combines three of the most effective ARV compounds has greatly reduced the cost and complexity of treatment programmes. The new tablet, together with improved testing, monitoring and diagnostic techniques, has eliminated many technical barriers to treatment in developing countries.

"We know what to do, we know how to do it and we know it can be done," Dr. Teixeira said. "Now it is a question of will."

Under existing treatment programmes, WHO expects that the number of people on ARVs in developing countries will grow from 300,000 to 935,000 by the end of 2005. The 3x5 campaign seeks to increase that number by 2 million, Dr. Teixeira noted, and will require at least $5听bn in new money over the next two years. The search for those funds, he added, is only just beginning.

US programme is key

In a detailed survey of global HIV/AIDS funding sources, researcher Jennifer Cates, HIV policy director for the Henry J. Kaiser Family Foundation in the US, found that in 2003 about half of all funding for HIV/AIDS programmes in poor countries came in the form of bilateral official development assistance. Developing countries raised another 25 per cent from domestic sources, with the balance coming from multilateral donors like the Global Fund and the World Bank, private donors and UN agencies (see table below). "Funding from all sources has been rising steadily in recent years and the trend appears set to continue," she noted. "But it remains well below the levels UNAIDS [the Joint UN Programme on HIV/AIDS] estimates is needed -- and that was true even before the 3x5 campaign financing requirements are factored in."

Funding for treatment received a dramatic boost on 23 February, when the US government launched its President's Emergency Programme for AIDS Relief (PEPFAR) in Washington. The plan commits the US to a 5-year, $15听bn effort to provide ARVs for 2 million people in 14 countries in Africa and the Caribbean. Botswana, C么te d'Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia will participate, together with Haiti and Guyana in the Caribbean.

According to analysts, the US will spend about $5听bn on existing bilateral HIV/AIDS programmes in about 100 countries over the next five years and has committed a minimum of $200听mn annually to the Global Fund. PEPFAR therefore represents some $9听bn in additional funding -- an amount that the programme's head, Mr. Randall Tobias, has asserted is "more money than has ever been committed by any nation for any health care initiative." A third of the funding, $5听bn, will be spent to promote sexual abstinence.

Mr. Tobias, a former chief executive of the Eli Lilly pharmaceutical company, also announced that that the first installment of the new funding, $335听mn, would underwrite ARV treatment for 137,000 people over the next 5 years. PEPFAR's $2.4听bn budget for 2004 is nearly equal to total global spending on HIV/AIDS in developing countries in 2002.

Bilateral programmes, global needs

In theory, PEPFAR alone could meet the 3x5 target of 2 million additional people on treatment, although on a longer time frame. WHO officials welcome the initiative as a big step towards the campaign's goals. But many commentators, including the UN Secretary-General's Special Envoy on HIV/AIDS in Africa Stephen Lewis, question the effectiveness of bilateral responses to the global epidemic, calling instead for increased support for the Global Fund.

There is no question that funding for treatment and prevention programmes will continue to flow bilaterally, Mr. Lewis told听Africa Recovery. "And every penny that does . . . is welcome. But there are significant drawbacks to bilateral programmes. For one thing, donor countries pick and choose, so countries that desperately need funds are excluded." Under PEPFAR, he noted, some of the most heavily affected countries, including Swaziland, Lesotho, Malawi and Zimbabwe, are excluded. "That's one of the problems with bilateral funding."

"Very often," he said, "the donor will dictate uses of their funds which are not consistent with the national AIDS policies of recipient governments. The Global Fund speaks to a process which is rooted at the country level, and in which virtually every stakeholder has participated."

Another potential problem is coordination between PEPFAR and the 3x5 campaign on such fundamental issues as drug procurement. The primary ARV medication for the 3x5 campaign, the triple combination tablet, is currently available only from low-cost generic suppliers. Activists fear that the US, which resisted changes in World Trade Organization rules to make generics cheaper and more available, is planning to use only costly patented drugs from US companies.

US officials bristle at the suggestion, noting that PEPFAR guidelines specifically permit both patent holders and generics manufacturers to bid on supply tenders. Critics have responded, however, that language elsewhere in the PEPFAR plan could prohibit the purchase of generic drugs. They note that the US has continued to press for restrictive patent protections in regional and bilateral trade negotiations.

Some US drug manufacturers are also challenging the safety and quality of the triple combination tablet. Although WHO has approved the pill for use, some companies argue that it could speed up resistance to the current generation of anti-retroviral drugs and encourage counterfeiting. A meeting between senior US and WHO officials is set for later this year to coordinate policy.

Finding the resources

Even with PEPFAR, however, overall global spending on HIV/AIDS in developing countries will remain well short of requirements, and the need is rising. According to UNAIDS, a minimum of $8.3听bn is needed for 2004, a number that will rise to $10.7听bn in 2005 and nearly $15听bn in 2007. Because ARV treatment must continue for life, drug access programmes like PEPFAR and the 3x5 campaign will increase demand.

The Global Fund is one potential source of additional resources. Launched in 2001 as a multilateral funding agency to accelerate the international response to HIV/AIDS, malaria and tuberculosis, the Fund reports it has approved $2.1听bn in multi-year grants in 121 countries to date, including about $750听mn for HIV/AIDS programmes in Africa. Dr. Richard Feacham, executive director of the Global Fund, told reporters in September that the facility would be the "principal" funding vehicle for the 3x5 effort.

Another AIDS coffin: Will there be enough funds to stem the epidemic's deadly toll?

Photo: Jake Price

But the Fund has not succeeded in securing the multibillion-dollar pledges needed for a rapid scale-up of treatment programmes. According to Ms. Cates, technical reasons have hampered the disbursement of funds, with just $164听mn reaching approved projects as of December 2003.

Although 60听per cent of Global Fund grants have gone for HIV/AIDS programmes, only a portion of those funds are earmarked for treatment. Without significant increases in contributions, the Global Fund is only expected to underwrite ARV treatment for 240,000 people by the end of 2005 -- about 8 per cent of the 3x5 goal.

The World Bank has also stepped up support for HIV/AIDS prevention and treatment. Since it first began lending for HIV/AIDS projects in 1986, the Bank reports that it has committed $2.2听bn to combat the disease in more than 50 countries. That includes a $1听bn fund for Africa, the Multi-country HIV/AIDS Programme, established in June 2001. To date, $865听mn in concessionary loans and grants have been approved in 24 African countries.

But even the Bank's very low interest loans have to be repaid, and some indebted countries have been reluctant to borrow more for HIV/AIDS programmes. In its estimates of global spending, UNAIDS calculates the difference between the amount provided and the amount to be repaid to arrive at a "grant value equivalent" for such World Bank financing. The adjusted figures totalled $95听mn in 2002 and $120听mn in 2003.

Debt relief through the Heavily Indebted Poor Countries initiative has also released money. The Bank reports that 24 African countries have received some degree of debt relief, permitting some to increase spending on HIV/AIDS programmes. But one activist group, Jubilee USA Network, estimates that even after debt reduction, African governments spend an average of $14听per person annually on debt payments, compared to $5听for health care.

"What should be happening at this moment is that the treasuries of the Western world should be falling open and money should be pouring in," said Mr. Lewis. "But there is a huge gap -- several billions of dollars -- between what governments are prepared to spend and what the requirements really are. On those billions of dollars, millions of lives hang." Failure to mobilize the resources for the 3x5 campaign, he concluded, "would be an incomparable tragedy, a continuing astonishing delinquency on the part of the rich nations of the world."