Universal Access to Antiretroviral Therapy: Are We Moving the Targets?

Abstract

T hree years ago at a United Nations (UN) General Assembly High-Level Meeting on HIV/AIDS, the World Health Organization (WHO) declared the lack of access to HIV treatment a global health emergency. The WHO subsequently launched its ‘‘3 by 5’’ initiative on World AIDS Day 2003, aiming to place 3 million people in the developing world on antiretroviral therapy (ART) by the end of 2005. The Millennium Development Goals Report 2008 stated that, ‘‘by the end of 2007, 3 million of an estimated 9.7 million people in need of AIDS treatment in developing countries were receiving the drugs.’’ This is remarkable progress when compared to the 2003 figures, indicating that 300 000 had access to ART of the 6 million who were clinically eligible. Because the number 1 is infinitesimally greater than 0, this was surely good news for these 3 million people and their families. Progress was achieved through the combined efforts of country programs, the WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and global health initiatives such as the Global Fund to Fight AIDS, Tuberculosis & Malaria; the US President’s Emergency Plan for AIDS Relief (PEPFAR); and the Clinton HIV/AIDS Initiative (CHAI). Global camaraderie against this insidious disease is to be applauded. However, one must also be attentive to the needs of the 6.7 million people who did not gain access to ART and who may be asking, ‘‘Why not us?’’ Is this fair? The world is now focused on achieving universal access to HIV prevention and treatment, including ART, by 2010, as called for at the 2006 UN General Assembly High-Level Meeting on HIV/AIDS. Yet, as we advance this goal, it is important to remember that the world has unfortunately not delivered on many of its other similar promises, the WHOs ‘‘3 by 5’’ initiative being a case in point. One may also remember ‘‘Health for All’’ by 2000, and perhaps other time-delimited goals. As we contemplate the slow pace of progress with respect to achieving Universal Access by 2010, as well as the Millennium Development Goals and the likelihood of not achieving them by 2015, it is important that we spare a thought to the mechanisms by which we set these global goals. First, the elaboration of global goals should effectively involve those who would be responsible for their implementation. These include, but are not limited to, the district health teams, the communities, and the ministries of finance. Second, resources, including capacity, should be provided at the implementation level to ensure that the job is not only done but that similar and related jobs are done in the process and that they are flexible enough to be capable to respond to these needs over time. Finally, the monitoring and evaluation should be done in a transparent and neutral manner to ensure that lessons learned are truly fed back into the process. If done well, we would heed the Confucian dictum: ‘‘When it is obvious that the goals cannot be met, do not change the goals but rather modify the strategies.’’ Our experience in tracking health care reforms at the district level has confirmed that holistic districtbased strategies are most efficient at delivering people-directed initiatives. This would require that the short-term, project-based approach be traded for the more rational long-term development initiatives embraced by the Declaration of Alma-Ata. Five years after making the commitment, I believe that we have the wherewithal to provide ART for all who are in need of its lifesaving and life-enhancing From the University of Buea in Cameroon.