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Missing the Target - Off target for 2010: How to avoid breaking the promise of universal access.
Update to ITPC's AIDS treatment report from the frontlines.
International Treatment Preparedness Coalition (ITPC), 24 May 2006.
EXECUTIVE SUMMARY
Actions by governments and multilateral institutions over the last year helped lay the foundation for gradual expansion of AIDS treatment access. Yet the world is on a trajectory that will fall significantly short of the internationally endorsed universal
access goal for 2010, leaving millions without lifesaving care and hundreds of
thousands of people with HIV/AIDS facing the prospect of imminent death. In
December 2005, the “3 by 5” initiative came to an end, having helped spur
treatment expansion but falling 1.7 million people below its goal. In the wake of this failure the international community has made new promises, developed new plans, and is experimenting with new systems of operating.
Despite these positive developments, no one should be fooled that the current pace or magnitude of the response will come close to achieving the universal access pledge that will be solemnly reaffirmed at the UNGASS Review meeting in May 2006. According to the World Health Organization (WHO), about 600,000 more people gained treatment access in 2005. At that rate fewer than half of those who need AIDS treatment will have access in 2010.
An international alliance of civil society advocates has called for setting a new global AIDS treatment target of “10 by 10” – 10 million people accessing treatment by 2010. But the international community seems to have gone out of its way to avoid setting explicit global treatment targets that would focus attention on specific outcomes, acknowledge the responsibilities of global institutions as well as countries, and drive accountability.
The response to AIDS must be led at the country level, but this does not mean
leaving countries on their own. Countries that sometimes fail in implementation of scale-up must not be abandoned, but instead receive intensive and ongoing international assistance to overcome impediments. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), The Joint United Nations Programme on HIV/AIDS (UNAIDS), WHO, and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) should publicly challenge and call to account national leaders who are not doing enough to lead the fight to end the AIDS epidemic in their countries.
International and bilateral agencies will be judged on their ability to help countries set and achieve ambitious treatment and prevention goals. But major barriers to treatment scale-up remain on the country and international level, including inadequate financing, mismanagement, technical challenges, stigma, and human resources shortages. Are we moving forward or are we slipping backwards in the fight for access to treatment?
In November 2005, the International Treatment Preparedness Coalition (ITPC)
issued Missing the Target: A Report on HIV/AIDS Treatment Access from the
Frontlines. The report detailed specific barriers and potential solutions to AIDS
treatment delivery in six countries heavily affected by the epidemic, and it made recommendations for national governments and multilateral institutions. This bulletin is the first of the semi-annual updates ITPC will make on global and national progress on scale-up of AIDS treatment.
Six months after the publication of Missing the Target, ITPC has found progress on several of the barriers to scale-up identified in November. Still, deficient national leadership, and slow implementation of reforms remain critical roadblocks to treatment delivery and are costing lives every day in each of the six countries reviewed.
In the Dominican Republic, treatment delivery is expanding but people in
some of the poorest areas with the highest rates of HIV have seen little
meaningful increase in treatment access. Government and donor agencies are still are not collaborating efficiently. Scarce resources have been squandered even while there are ongoing concerns about sustainability of funding. Second-line drugs cost 10 to 20 times more than first-line generics.
In India, the number of treatment centers has increased, but hundreds of
thousands of people in need still do not have access to antiretroviral therapy (ART). National guidelines must be reformed and action is needed to reach children and ensure greater equity in care. A clear plan to achieve universal access has yet to be developed.
In Kenya, AIDS treatment services have been undercut by growing food shortages in some areas. Stigma remains a serious issue and there is a critical health care worker shortage. Kenyan government delays in submitting audit reports held up the release of Global Fund monies.
In Nigeria, more treatment centers have opened across the country. However, the Global Fund has suspended two grants because the country failed to meet targets on drug access and demonstrate transparency. This development could jeopardize the government’s ability to meet its pledge to make free treatment more widely available. Also still lacking is improved collaboration among global agencies.
In Russia, government funding has grown but these new resources have yet to translate into significant increases in treatment delivery. There is an
urgent need for services appropriate for injection drug users (IDUs). Other top priorities include better health care worker training, more efficient drug
procurement, and comprehensive anti-stigma efforts. Greater involvement
of people living with HIV and AIDS (PLWHA) is essential.
In South Africa, the number of people on treatment has increased, but scale-up efforts continue to lag due to inadequate national leadership,
government efforts to inhibit civil society participation, pervasive AIDS
denialism, and a virtually non-functional Global Fund Country
Coordinating Mechanism (CCM). Among the greatest needs are improved treatment access for children and men and accelerated preparation for the
implementation of second-line therapy.
The multilateral and bilateral response:
To assess the work of international institutions, ITPC wrote to the Global Fund, UNAIDS, WHO, and PEPFAR to ask what they had done to tackle the challenges outlined in Missing the Target. The agencies’ responses were hopeful in that they outline many of the building blocks of what an effective response would look like: a more coordinated, efficient global effort that is able to meet the needs of countries; build sustainable systems of care; and integrate HIV prevention, tuberculosis, and other services. There is evidence of hard work and noble intentions, but change is coming far too slowly. To move more quickly and effectively, each of these agencies
needs increased and sustained financing from the global community. Other changes
are needed as well:
The Global Fund is providing resources to support treatment for steadily
increasing numbers of people, but its ability to sustain and expand this
work requires greatly increased financial support. The Fund must also
identify new strategies to address failing grants and weak CCMs.
WHO has made progress on providing technical assistance and guidance to countries and is expanding its in-country staff, but now needs to show
tangible outcomes in terms of ambitious and workable national plans and
resolution of barriers in countries. The late Director-General Dr Lee Jongwook's
leadership in spearheading the "3 x 5" initiative put WHO at the forefront of the global treatment response. His successor needs to be a visible advocate for universal access and aggressively seek funding to support WHO's AIDS-related work.
UNAIDS has managed a universal access planning process and is helping
some countries operationalize their national plans. However, the agency
must also show faster progress on UN system collaboration and implement
a true strategic plan for accomplishing universal access.
PEPFAR has expanded the reach of its treatment delivery and has initiated
a variety of activities to build health systems. While continuing these efforts
it must, however, end counterproductive policy prescriptions that undermine
service delivery and do more to build human resources capacity in countries.
There is little evidence that substantial progress has been made on the country or international level at integrating HIV and TB programming—another priority that
will facilitate development of health care system capacity as part of AIDS treatment scale-up.
As an international group of PLWHA and their advocates, ITPC is committed to
closely monitoring the action—and inaction—of governments and multilateral and bilateral institutions. It will continue to offer praise and encouragement, where appropriate, as well as criticism when leaders and organizations shirk their responsibilities to PLWHA. ITPC’s goal is to focus attention on specific barriers to treatment access and to help drive progress on the goal of universal access.
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