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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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