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Africa: AIDS Progress Real but Limited
AfricaFocus Bulletin
Jan 28, 2005 (050128)
(Reposted from sources cited below)
Editor's Note
The number of Africans receiving anti-retroviral treatment more
than doubled from 150,000 to 310,000 in the last six months
of 2004, the World Health Organization (WHO) reported this week.
For those on treatment, treatment adherence and survival rates were
comparable to or even better than the rates in developed
countries. But there are still more than ten times that many
Africans who need AIDS treatment now but are not receiving it: 3.7
million people in sub-Saharan Africa alone, out of 5.1 million
worldwide.
The report demonstrates that progress is possible, despite the
difficulties of coordination among multiple programs at the global,
bilateral, and national levels. One additional barrier to progress
was toppled this week when the US Food and Drug Administration
approved a set of generic anti-retroviral drugs produced by the
South African drug manufacturer Aspen, making it possible for
countries to purchase these drugs using funds from the US bilateral
AIDS program.
Many on the frontlines of the war against AIDS, comparing the
numbers with the need rather than with past performance, say these
limited successes are too little and too late. Doctors Without
Borders, which has led the way in AIDS treatment and now provides
treatment to some 25,000 patients, issued a press release saying
treatment expansion is still moving "at a snail's pace," and that
many crucial issues are not being addressed, including treatment
for children (see
http://www.doctorswithoutborders.org/pr/2005/01-27-2005.shtml).
Despite its emphasis on progress, the WHO report also identifies
formidable gaps in both money and capacity needed to provide
treatment this year to 2.3 million more people, to reach WHO's
minimum goal of 3 million. There is still a cash shortfall of
approximately $2 billion, more than half the estimated minimum of
$3.5 billion needed in 2005.
Another critical gap, the report stresses, is the capacity of
health systems, including in personnel and administration.
Strengthening these systems is essential to the goal of increasing
AIDS treatment. It is also required in order to ensure that scaling
up AIDS treatment enhances the delivery of all health services,
rather than diverting scarce resources from other health
priorities.
This AfricaFocus Bulletin contains excerpts from a press release
announcing the reprot, released at the World Economic
Forum in Davos, from a fact sheet accompanying the 64-page report,
and from the executive summary and country case studies included in
the report.
The full report, including graphs, is available at
http://www.who.int/3by5/progressreport05/en
For previous AfricaFocus Bulletins on AIDS and other health issues,
see http://www.africafocus.org/healthexp.php
For ongoing news on African health, visit
http://allafrica.com/health
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Joint Media Release WHO/UNAIDS/Global Fund/US Government
26 January 2005
700,000 People Living with Aids in Developing Countries Now
Receiving Treatment
Partnerships Across All Sectors Are Driving Treatment Scale up
Davos - By the end of 2004, 700 000 people living with AIDS in
developing countries were receiving antiretroviral (ART) treatment
thanks to the efforts of national governments, donors and other
partners. This is an increase of approximately 75% in the total
number receiving treatment from a year ago, and is up from 440 000
in July 2004.
Today, at a joint press conference at the World Economic Forum's
Annual Meeting, Switzerland, the World Health Organization (WHO),
the Joint United Nations Programme on HIV/AIDS (UNAIDS), the United
States Government and the Global Fund to fight AIDS, Tuberculosis
and Malaria revealed the results of their joint efforts to increase
the availability of ART in poor countries. They underlined that
progress has been made thanks to extensive collaboration and unity
of purpose. However all the organizations warned that major,
continued efforts are needed in countries and internationally to
continue working towards the goal of access to treatment for all
who need it.
"We salute the countries who have now shown us that treatment is
possible and can be scaled up quickly even in the poorest settings.
AIDS treatment access is expanding every day thanks to the
dedicated work of doctors, nurses, health workers and people living
with HIV and AIDS, who are often working under difficult
circumstances to turn the dream of universal treatment into a
reality," said Dr Lee Jong-wook, WHO Director-General.
The organizations warned that there are still very real challenges
to reaching the goal of universal access to treatment. In many
countries, the speed of progress has rapidly increased, but to
achieve universal access, the international community and national
governments need to do much more to translate political and
financial commitments into real actions in countries.
"The heart and soul of President Bush's Emergency Plan for AIDS
Relief is to work shoulder to shoulder with host governments and
our other partners in those nations in support of the national
strategy of each country," said Ambassador Randall Tobias, the US
Global AIDS Coordinator. "Although the results are being discussed
today by donors and international organizations, the results were
achieved by the work of talented and dedicated people in-country.
We are dedicated to supporting their efforts, but the true credit
rests with them."
Collaboration across all sectors is making treatment happen.
Treatment is happening because national governments are taking the
lead to coordinate efforts with all partners to scale up treatment
in rural and urban areas. The Global Fund is providing flexible
funds to governments and projects. The United States is funding, as
well as providing technical assistance and guidance for, program
and capacity development to support national strategies. WHO and
UNAIDS are providing guidance and technical assistance to help
countries turn finance into programmes. NGOs, faith-based
organizations, networks of people living with HIV/AIDS and the
private sector are all contributing.
"Collaboration over the past year has shown that several
initiatives can work in tandem to achieve real acceleration. While
today's figures are encouraging, the work so far has been laying
the ground work for a much larger expansion in the months and years
to come," said Dr Richard Feachem, Executive Director of the Global
Fund to fight AIDS, TB and Malaria.
WHO and UNAIDS believe the current figures are the most accurate
estimates to date. They are based on a composite of numbers given
by countries and partners. In the region with the heaviest burden
- sub-Saharan Africa - the number of people on treatment has
doubled over six months from 150 000 to 310 000. In Asia, the
figure has doubled since June from 50 000 to 100 000. In Latin
America and the Caribbean, the numbers continued to improve and
there are now 275 000 people on treatment in this region. Botswana
and more than ten countries in Latin America are already treating
50% or more of those in need in their countries. Building on years
of AIDS awareness and prevention programmes, Uganda and Thailand
are expected to be treating 50% or more people needing ART in the
first half of 2005.
At the beginning of December 2004, 240 000 people were on treatment
as a result of financing by the US government and the Global Fund.
This number is increasing rapidly as newly started treatment
programmes accelerate.
"We know that treatment is more than just access to
antiretrovirals," said Dr Peter Piot, UNAIDS Executive Director.
"People living with HIV need comprehensive services, from testing
and counselling to nutritional support. Just as there is an urgent
need to increase access to treatment, we must also renew our
commitment to preventing new HIV infections."
WHO and UNAIDS estimate that at the end of 2004 around six million
people were in need of treatment in developing countries. In
December 2003 WHO, UNAIDS and UN partners announced the "3 by 5"
target, challenging countries to get three million people or half
of those in need on treatment by the end of 2005. WHO and UNAIDS
estimate that overall 72% of un-met need for treatment is in
Sub-Saharan Africa; 22% is in Asia; India, Nigeria and South Africa
alone account for 41% of the overall need for treatment. The "3 by
5" target can only be reached if major progress is made in the
countries with the greatest unmet need.
WHO and UNAIDS today published the results of global efforts to
increase the availability of ART in poor countries in the second "3
by 5" Progress Report. The total of 700 000 people receiving
treatment reaches the interim target for 2004, as outlined in the
WHO/UNAIDS "3 by 5" strategy.
For further information please contact:
World Health Organization - Iain Simpson, Mobile: +4179 475 5534
Global Fund - Jon Liden, Mobile +4179 244 6006
UNAIDS - Dominique De Santis, Tel: +4122 791 4509, Mobile: +4179
254 6803
US Govt - Elissa Pruett, Mobile: +1202 521 2177
World Economic Forum - Mark Adams, Director of Media, Tel: +41
(0)22 869 1212, Fax: +41 (0)22 869 1394, mark.adams@weforum.org
"3 by 5" Progress Report December 2004
Executive summary
Statistical overview
In the second half of 2004, the number of people on antiretroviral
(ARV) therapy in developing and transitional countries increased
dramatically from 440,000 to an estimated 700,000. This figure
represents about 12% of the approximately 5.8 million people
currently needing treatment in developing and transitional
countries and includes people receiving ARV therapy supported by
the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United
States President's Emergency Plan for AIDS Relief, the World Bank
and other partners.
In sub-Saharan Africa, the number of people on treatment doubled
from 150 000 to 310 000 in just six months. In Botswana, Kenya,
South Africa, Uganda and Zambia the number of people receiving
treatment increased by more than 10 000 in each country. Botswana,
Namibia and Uganda now have an estimated ARV therapy coverage that
exceeds one quarter of all people needing treatment, and 13
countries in the region have exceeded 10% coverage. This region now
has well over 700 sites that can deliver ARV therapy.
In East, South and South-East Asia, 100,000 people were on
treatment by the end of 2004, twice the number reported six months
previously. Thailand is leading the way, expanding treatment access
to all districts with more than 900 ARV therapy facilities and
starting more than 3000 people on treatment every month.
In Latin America and the Caribbean, access to ARV therapy continued
to improve. Brazil has led the way by providing access to ARV
therapy for its entire population, but nine more countries also
have estimated coverage rates exceeding 50%. Progress in Eastern
Europe, Central Asia, North Africa and the Middle East has
generally been much slower.
Initial data show that treatment success rates in developing
countries are just as good as those in affluent industrialized
countries. Adherence to regimens is as high as 90% and treatment
benefi ts to individuals are dramatic, with survival rates
exceeding 90% after one year and 80% after two years of ARV
therapy.
...
During the second half of 2004, an additional 40,000 to 50, 000
people initiated treatment each month worldwide. Nevertheless,
there are enormous barriers to reaching the target in 2005. Many of
the advances have been geographically uneven: critical building
blocks are still missing in far too many areas of highburden
countries.
The success of "3 by 5" will ultimately be determined by the action
taken in countries, by governments, civil society, health care
providers and partner organizations. Political will demonstrated at
the highest possible level in any individual country will be
decisive in determining whether it reaches its target. Governments
can also be encouraged by the flexibility and creativity already
displayed by major donors in making money move to where it is
needed most, but their efforts must now be taken to the next level.
Given present system costs, at least US$ 2 billion in sustained
additional funding from national governments and external funders
will be necessary to provide access to ARV therapy for
approximately 2.3 million people.
The resource gap is only one of many difficult obstacles that
confront us. Cost of ARV medicines to countries and individuals is
an area of particular concern, as is the geographical distribution
of services related to HIV/AIDS and human resources. There is still
a critical need to improve the infrastructure for delivery of care
and treatment. Organizations working in the field of HIV/AIDS must
ensure that their efforts offer real solutions to the very real
problems countries will face. However, progress in 2004 has laid
the foundations for an extraordinary push to reach the "3 by 5"
target by the end of 2005.
Joint Fact Sheet WHO/UNAIDS/283
January 2005
"3 by 5" Progress - December 2004
Progress: key points
- The world has met the 2004 target for "3 by 5"
- WHO/UNAIDS estimate that 700,000 people were on antiretroviral
treatment (ART) in developing countries by the end of 2004. This
reaches the "3 by 5" milestone for December 2004 as set out in the
WHO/UNAIDS strategy.
- 700,000 represents over 12% of the estimated 5.8 million
currently needing ART in developing and transitional countries.
- Botswana and more than ten countries in Latin America have
already reached the "3 by 5" goal of treating 50% or more of people
needing ART in their countries.2
- Thailand and Uganda are expected to reach the "3 by 5" target of
treating 50% or more people needing ART in the first half of 2005.
- Cambodia, Cameroon, Kenya and Zambia have made much progress in
increasing the number of ART sites throughout their countries. All
are treating over 10% of the people in need.
- In the region with the heaviest burden of HIV/AIDS, sub-Saharan
Africa, the number of people on ART has more than doubled over six
months from 150,000 to 310,000.
- In Asia the number have doubled since June from 50,000 to
100,000.
- In Latin America and the Caribbean the figures continued to
improve. There are now 275 000 people on ART in this region.
Brazil has universal access to ART.
- The most successful countries are those that have shown
commitment and leadership, including strategic use of their own
resources and effective engagement of partners. The success of '3
by 5' ultimately depends upon country-level commitment and action.
Treatment works: Adherence rates high
- A growing number of countries have shown that increasing access
to treatment is both possible and effective. Brazil has the most
advanced national HIV/AIDS treatment programme in the developing
world - over a seven-year period, almost 100,000 deaths have been
averted (a 50% drop in mortality) through the introduction of ART.
- Initial results show that adherence to simplified antiretroviral
drug regimens, particularly those using fixed-dose combinations, is
very high (around 90%). An initiative sponsored by the Government
of Senegal has maintained good (80 - 90%) adherence over two to
three years.
- The survival rate of AIDS patients is improving with increased
access to ART. In a trial in Entebbe, Uganda, since January 2003,
90% of participants on ART were alive after 15 months of treatment.
- These figures are comparable or even better than those from
developed countries.
Partnerships: Helping to drive treatment scale-up
- Over the last 12 months, a remarkable international movement has
gathered behind the "3 by 5" target. Partnerships both within
countries and globally, in the public and private sectors, are
helping to drive the effort to increase access to ART.
- 136 partners are now formally involved in reaching the "3 by 5"
target as advocates, donors, advisors, collaborators and providers
of funding, technical and other services.
- Community activists and groups in countries - including people
living with HIV and AIDS - have led the world in advocating for ART
and in delivering medicines to people in need.
- Building on ongoing work in countries, the Global Fund to Fight
AIDS, Tuberculosis and Malaria, the United States President's
Emergency Plan for AIDS Relief and the World Bank have played a
critical role in providing flexible funding.
- Organizations like the Clinton Foundation and M‚decins Sans
FrontiŠres have been instrumental in lowering the price of
first-line antiretroviral medicines.
- Ultimately it is countries that must take the lead. Brazil,
Thailand and Uganda have been successful due to high-level
political commitment, strategic use of their own resources and the
effective engagement of partners, More countries need to follow
their lead if "3 by 5" is to be accomplished.
Challenges: Key obstacles must be tackled urgently
- Another 2.3 million people need to initiate treatment by the end
2005 for the target to be met.
- Overall 72% of un-met need for treatment is in Sub-Saharan
Africa; 22% is in Asia.
- South Africa, India and Nigeria alone account for 41% of the
overall un-met need for treatment.
- The "3 by 5" target can only be reached if much progress is made
in the countries with the greatest unmet need.
- There remain a number of difficult obstacles that need to be
addressed:
- the high cost of first- and particularly second- line treatment
and diagnostic tests;
- the lack of affordable and user-friendly AIDS medicines for
children;
- the need to ensure equitable access to reach the most vulnerable,
including sex workers, prisoners, injecting drug users;
- the need to rapidly accelerate and coordinate prevention and
treatment services, and make better use of critical entry
points such as TB and maternal health services;
- the need to increase the number of individuals who know their HIV
status, in part through the routine offer of testing and
counselling at critical health system entry points;
- the continued lack of adequate human resources, trained medical
and non-medical health workers in affected communities.
Increasing access to treatment must go hand in hand with increased
prevention efforts.
The resources gap: More funds urgently needed
- The flexibility and creativity displayed by major donors is
extremely encouraging. Their support for increasing access to
treatment must continue.
- Of the estimated US$ 3.5-3.8 billion needed to achieve the global
"3 by 5" target, at least an additional US$2 billion is still
needed.
- The resource gap can be cut by reductions in the costs of drugs
or service delivery.
- To close the gap, highly affected countries and donor nations
alike must strengthen their commitment and improve rates of
disbursement.
- WHO needs US$ 60 million before the end of 2005 to provide the
necessary technical assistance to countries to help them reach
their targets.
What is WHO doing to help reach the "3 by 5" target?
- Developing international policy and vital guidelines for rapid
HIV testing, efficient and simplified HIV diagnostics and AIDS
treatments in order to provide more affordable and equitable
HIV/AIDS services in developing countries.
- Developing training modules and organizing training sessions for
medical and non- medical health workers to deliver HIV/AIDS
services.
- Advising countries on building and managing antiretroviral
procurement and distribution systems, monitoring and evaluation of
scale-up progress, and planning and implementing grant proposals,
- Hiring and training "3 by 5" technical experts and programme
managers to help countries in their efforts to increase access to
treatment.
- Helping to strengthen civil society - particularly people living
with HIV/AIDS (PLWHA) - locally, nationally and globally, through
the 'Preparing for Treatment Programme', which contributes to the
Collaborative Fund for Treatment Preparedness. Treatment literacy
and treatment advocacy are important elements for PLWHA in order to
fully participate in their own healthcare and to advocate for
appropriate interventions for their communities.
Progress in Countries
Botswana: political leadership shows the way
In Botswana, where one in three pregnant women tests HIV positive,
political leadership and public-private partnerships are making a
significant difference.
Faced with the second highest HIV prevalence in the world, the
Government of Botswana has made HIV/AIDS a priority and has adopted
a compelling, long-term vision to have no new HIV infections by
2016, when Botswana will celebrate 50 years of independence.
One of the first steps was creating a public-private partnership,
the African Comprehensive HIV/AIDS Partnerships, with the Bill &
Melinda Gates Foundation, The Merck Company Foundation and the
pharmaceutical company Merck & Co., Inc.
ARV therapy programmes were fi rst implemented in January 2002 with
the Princess Marina Referral Hospital in the capital, Gaborone.
Twelve facilities were offering ARV therapy by 2003 and 23 sites in
2004, covering all but two districts (Fig. 5). The programme is
also being extended from hospitals to clinics.
By March 2004, 2212 health workers had been trained including
physicians, nurses, pharmacists, counsellors and other health
workers. Of these, 536 were recruited specifically to support ARV
therapy and to implement programmes for preventing mother-to-child
transmission of HIV.
The number of adults receiving treatment in Botswana rose gradually
during the first years of the public-private partnership and much
more rapidly in 2004. About one quarter receive treatment through
private facilities. In the public sector (Fig. 6), ARV therapy is
provided free of charge to citizens of Botswana. Adherence in terms
of self-reporting, pill counts and attending scheduled appointments
is good (85%) and is confirmed by complete viral load suppression
every six months.
A social mobilization campaign designed to increase public
awareness of the availability and outcomes of ARV therapy has
helped to reduce stigma and increased the involvement of people
living with HIV/AIDS in promoting a supportive environment. A
comprehensive approach to the entire family of the person initially
diagnosed substantially increases public awareness and support for
the programme. A routine offer of HIV testing was introduced in
hospitals in January 2004.10 Pregnant women are told that HIV tests
are standard and are asked whether they want to opt out an
approach often used for other standard medical tests. During the
first four months, 18 hospitals offered HIV testing to 6384 people,
of whom one in seven opted out.
Cameroon: rolling out testing and counselling
As of 2003, UNAIDS and WHO estimated that 560 000 people in
Cameroon were living with HIV/AIDS, which accounts for about 49 000
annual deaths. Cameroon has set a national target of providing ARV
therapy to 36 000 people living with HIV/AIDS by the end of 2005.
By November 2004, more than 12 000 people were receiving treatment
(Fig. 8). Strong political commitment over the past fi ve years and
a dramatic decrease in cost from US$ 600 to US$ 30 per month of
treatment in four years have been the indispensable prerequisites
for scale-up. Counselling has also become less costly, and more
people are requesting HIV testing. Provincial centres now assess
eligibility for treatment at entry points such as the 14 voluntary
counselling and prevention centres, 160 sites for preventing
mother-to-child HIV transmission, 21 certified treatment centres
and 140 tuberculosis screening centres.
Mozambique: first steps towards an ambitious goal
Ravaged by decades of civil war, a slowly recovering Mozambique is
another example of what can be achieved in extremely difficult
circumstances.
With about 200,000 adults needing ARV therapy, the country's major
challenges include a scarcity of resources, shortages of trained
health care workers and poor coordination among several partners
working in the country. Nevertheless, there is strong political
commitment, and the National Health Sector Strategic Plan to Combat
Sexually Transmitted Infections and HIV/AIDS calls for scaling up
ARV therapy to 132,000 people by the end of 2008.
Mozambique has a specific plan to train 2000 intermediate-level
health care professionals, and a new drug management and logistics
system is being developed in anticipation of a massive increase in
ARV therapy coverage.
Given the scale of the challenges, the increased availability of
ARV therapy during 2004 is encouraging, with the Ministry of Health
reporting almost 6300 people receiving treatment in November 2004
versus 2800 in June 2004. Twenty-three sites offer ARV therapy in
the public sector through collaboration between the government and
nongovernmental organizations such as the Community of Sant'Egidio,
MSF and Health Alliance International (Fig. 9).
Zambia: a rapidly expanding programme
With a national HIV prevalence of 15% and growing numbers of people
with advanced HIV infection, the demand for treatment and care in
Zambia increased rapidly during the 1990s. Until November 2002, a
single drug through the private sector was the only available
treatment. In January 2003, the government decided to purchase
sufficient drugs to treat 10,000 people but within a year its
target increased to 100,000, which is well over 50% of the
estimated number of people needing ARV therapy.
The public sector began providing ARV therapy with two pilot sites
at the University Teaching Hospital Lusaka and at Ndola Central
Hospital. The second phase extended to the remaining seven
provincial hospitals plus Kitwe Central Hospital. The final phase
involved roll-out at the district level. By the end of 2004, ARV
therapy was available at 53 centres (Fig. 11). Twenty-four of 72
districts had at least one site offering ARV therapy and 11
districts had two or more sites. The distribution of sites closely
mirrors Zambia's population distribution, with most sites
concentrated in Lusaka and in the Copperbelt.
By September 2004, more than 11,000 people were receiving ARV
therapy through the public sector versus just over 7000 in July, an
increase of 57% in less than three months. The government decision
to make ARV therapy free of charge is likely to have played a major
role in this rapid increase. An additional 2400 people receive ARV
therapy through the private sector, mainly through the mining
industry. The increase in provision of ARV therapy to children has
been equally rapid, although children on treatment still accounted
for only 2.6% of all those receiving treatment.
Building on experience from TB control: Malawi
In Malawi, an estimated 900,000 people are living with HIV/AIDS,
and 170,000 need ARV therapy. Malawi's plan for expanding ARV
therapy aims to provide ARV therapy free of user charges to 80 000
people by the end of 2005, exceeding their "3 by 5" target of 68
000, despite annual per capita spending on health of only US$ 12
and a huge human resources deficit (Fig. 13).
How will Malawi meet its ambitious target? For many years, the
country has followed the DOTS strategy for effective TB control.
Now, it is applying the lessons learned to accelerate access to ARV
therapy. This means standard definitions of who is eligible, simple
treatment regimens, reliable drug supplies, treatment supporters to
ensure adherence and regular monitoring and evaluation through
standardized recording and quarterly reporting. Thus, Malawi
intends to maximize uptake and adherence to ARV therapy and
minimize drug resistance.
Collaboration between TB clinics and HIV counselling and testing
clinics has led to more than 70% of people being treated for TB
accepting the offer of HIV testing. Lay counsellors relieve nurses
of counselling duties and help to compensate for an acute shortage
of nurses. By January 2005, all 44 hospitals in Malawi's 28
districts will be providing routine HIV counselling and testing for
people being treated for TB. As of December 2004, 23 of 59
earmarked sites in the public sector are providing ARV therapy and
more than 9000 people are receiving ARV therapy. Regional TB
officers have been trained in ARV therapy and are recording,
reporting, monitoring and evaluating for both TB and ARV therapy.
New monitoring and evaluation tools for ARV therapy build on the
cohort analysis approach also used for TB. Central units of the
national TB and HIV/AIDS programmes will work together on analyzing
the data collected by the regional officers.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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