1 10 by 10: Setting Global & National Targets to Achieve Universal Access The international community has committed itself to coming “as close as possible to universal access” to AIDS treatment and prevention by 2010. Achieving that ambitious goal depends upon clearly defining what universal access means and setting specific global and national targets to drive planning, measure progress and promote accountability. We propose, as a global AIDS treatment target, "10 by 10"-- ten million people receiving antiretroviral therapy by 2010. Based on current projections, we estimate that in 2010, the number of people with HIV who will need AIDS treatment globally will grow by between 60 and 70%; that is, to about 10 million people. We suggest the following Declaration language on universal access: “By 2010, ensure that at least 10 million people have access to HIV treatment, through an acceleration of HIV treatment scale-up efforts involving all stakeholders: civil society, people living with HIV/AIDS, member states, donor countries and multilateral institutions. In order to ensure that this target is reached equitably, Member States should develop, in an inclusive manner, specific targets for the coverage of vulnerable populations by national treatment plans, including, for example, active injecting drug users, people co-infected with tuberculosis and HIV, sex workers, children, men who have sex with men, women, and migrant populations.” There should also be specific international treatment targets for certain groups: “By 2010, ensure that 15% of all people on treatment are children living with HIV.” “As the leading preventable cause of death among people with HIV worldwide, all stakeholders must ensure that by 2010 people have universal access to effective tuberculosis diagnostics and treatment, as described in the Global Plan to Stop Tuberculosis. Specifically, that: 22 million people seeking HIV voluntary counseling and testing will be screened for tuberculosis; 2.6 million people living with HIV are given isoniazid preventative therapy; 3.8 million people co-infected with tuberculosis and HIV are in DOTS care; 3.1 million people with tuberculosis are tested for HIV; and 0.3 million HIV positive tuberculosis patients are started on antiretroviral treatment.” There must also be a global MTCT prevention target: “By 2010, ensure that all women living with HIV who are pregnant have access to information, voluntary counseling and testing, ARV therapy and a continuum of necessary care to prevent mother to child transmission.” 2 There must also be a global target for prevention: “By 2010, ensure that the information and means to avoid HIV infection is available to all citizens through an accelerated effort involving civil society, people living with HIV/AIDS, member states, donor countries and multilateral institutions.” 0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 2003 2004 2005 2006 2007 2008 2009 2010 Global Targets: Reaching 10 by 10 Steady Growth Ramping up Two models of interim progress to achieve 10 by 10 In its March 2006 report on AIDS treatment delivery1 the World Health Organization observed of the 3 by 5 initiative that, “establishing a global benchmark… encouraged countries to set ambitious national treatment targets, demonstrating that targets can play a vital role in encouraging national ownership and in mobilizing stakeholders, funds, technical agencies and donors.” Global targets mobilize international institutions, country governments, donors, and advocates. They help countries and international organizations focus on outcomes and plan for steady, incremental progress leading to clear goals. They acknowledge that both countries and international organizations have responsibilities in the universal access effort. The Universal Access report for the UNGASS update does not include specific global interim or final targets and relies on countries to set their own targets. A more strategic, outcomes-oriented global effort -- with clear milestones and assignments of responsibility to international actors as well as national governments -- is necessary to achieve universal access. We call for countries and the global community set clearly defined interim and final targets for universal access to AIDS prevention and treatment. Following is a discussion of national target setting and bullet points on the proposed Declaration language. Setting Country Level Targets Target-setting at the national level is expressly recognized as a key priority in the UNAIDS Universal Access report (“the UA report”) submitted to the UN General Assembly entitled “Towards universal access: UNAIDS assessment on scaling up HIV 1 WHO, Progress on Global Access to HIV Antiretroviral Therapy, March 2006, Geneva 3 prevention, treatment, care and support”.2 One of the report’s six key recommendations provides that: “Every country should set in 2006 ambitious AIDS targets that reflect the urgent need to massively scale up HIV prevention, treatment, care and support and move as close as possible to the goal of universal access by 2010.” The UA report also provides “seven core indicators and four recommended indicators to help countries set targets and measure their progress towards universal access.”3 In addition, implicit in each of the remaining five key recommendations are references to specific targets and indicators. For example, the recommendation that “[no] credible, costed, evidence-informed, inclusive and sustainable national AIDS plan should go unfunded” indicates the need for targets relevant to establishing costs and sustainability needs. Implementation of the key recommendations in the UA report is dependent upon the development of a series of related targets and indicators. Of central importance is the basis upon which such targets and indicators are developed and the process used to develop them. But before considering this, it is helpful to consider additional justifications for the adoption of national targets and indicators: implementation, accountability, monitoring, and leverage. Implementation: The Secretary-General has noted in his reports to the General Assembly that many countries still have incomplete national HIV strategies and financing plans and/or key parts of their strategies are yet to be implemented, despite a commitment to complete national strategies by 2003.4 The development of national targets and indicators will provide increased pressure on national governments to reach this overdue goal. There should be an updated commitment that calls on all countries to complete the development and implementation of multisectoral national strategies and financing plans for combating HIV/AIDS by the end of 2006. . The UN system and donors must play a much more vigorous role in supporting all countries to achieve this commitment. Accountability: Perhaps the most important reason for establishing national targets and indicators is to ensure that all key stakeholders, including governments, donor and international agencies, the private sector and civil society can be held to account.5 As is often mentioned in any discussion on targets and indicators, “What gets measured gets done.” Ensuring accountability requires target setting that deals expressly with the allocation of responsibilities, timeframes and funding. Monitoring & Evaluation: Ineffective monitoring and evaluation remains a major shortcoming in the global response to HIV/AIDS. Monitoring and Evaluation cannot be 2 This is in the context of already agreed-upon targets and indicators in the Millennium Development Goals, which provide a broad framework upon which to build further consensus. 3 It further states that “[t]hese country targets would be used, in turn, to develop regional and global targets.” 4 “By 2003, ensure the development and implementation of multisectoral national strategies and financing plans for combating HIV/AIDS,” para. 37, U.N. Declaration of Commitment on HIV/AIDS. 5 The targets and indicators recommendations in the UA report are listed under the heading “accountability.” 4 strengthened without national targets for reaching universal access. Each country’s national HIV strategy must be supported by strong monitoring and evaluation to give capacity to measure impact and to identify and address changes in the epidemic as they arise, not after the event. Such changes include adjusting programs, priorities and funding to meet new challenges in prevention, support and treatment delivery; initiatives to address systemic problems and changing workforce needs; adjustments to local HIV programs. All this requires an effective, built-in system of monitoring and evaluation plus the capacity for countries to make “real time” adjustment to their strategies, programs, priorities and funding. Practicality: National planning cannot be conducted in a vacuum. A commitment to realizing universal access by 2010 requires a series of interim targets, each being followed by an evaluation that considers whether targets have indeed been met or passed, the implications thereof for adjusting future targets and what changes to the country plan need to be made if the goal of universal access is to be achieved within the designated timeframe. In this way, targets are practical tools for evaluating progress and responding to needs. Leverage: The UA report speaks about “access to predictable and long-term financial resources.” These resources cannot be guaranteed in the absence of coherent planning that quantifies the goal of universal access. UNAIDS has already quantified a resource gap of $22 billion for 2008. Targets – and indicators to measure whether such targets have been met – are indispensable tools for identifying and measuring funding gaps. Countries in need of external financial resources would be unable to exercise any form of leverage in the absence of an defined funding gap, which is itself reliant on the development of targets. Inclusiveness in the target setting process The UA report speaks about the development (or adaptation) of “prioritized and costed AIDS plans” with “full participation of all stakeholders” by December 2006. As already mentioned, it also speaks about “credible … [and] inclusive … national AIDS plan[s].” The report recognizes that national planning processes – including the setting of targets and the identification of indicators – are not simply government processes. The development of targets and indicators, as part of the national planning process, involves more than consultation -- full and meaningful participation of stakeholders is necessary. To be full participants in the process, civil society must be able to access appropriate information and financial resources. All stakeholders must be permitted to identify their own representatives. All parties must agree to a set of guidelines and principles around which the planning process will be structured. Talking points on proposed Declaration language • Without credible but ambitious time-bound numerical targets, the international effort to ensure universal access will not succeed. The commitment to universal access made by the G8 and reaffirmed by the UN Member States requires clear numerical targets that describe the number of people to be reached with HIV treatment that the international community, governments and civil society can achieve. But preparatory efforts related to the Universal Access Initiative have consciously avoided the development of time-bound numerical treatment targets. 5 • Past experience shows that clear numerical targets accelerate action and promote accountability at national, regional and international levels. The risk of failing to reach the target of 10 million people on treatment by 2010 is greatly outweighed by the tremendous benefits associated with an international movement working together to reach that ambitious but attainable goal. • The “3 by 5” initiative showed that mobilization around numerical HIV treatment targets play a critical catalyzing role in treatment scale-up efforts. Although the goal of 3 million people on treatment by 2005 was not reached, the accelerated pace of treatment scale-up between 2003 and 2005 would not have happened without efforts of the international community working to reach the 3 by 5 goal. In addition, the target galvanised pressure on the pharmaceutical industry to reduce prices and forced engagement in treatments access by previously uncommitted donor and recipient countries. • Recommitting to the goal of universal HIV treatment and prevention access without targets sends the wrong message to the international community. Governments and other stakeholders can only conclude that the world is not serious about mobilizing all available resources to reach the goal of universal HIV treatment and prevention access if the goal comes without a time-bound numerical target.