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Missing the target #4: Time is Running Out to End AIDS – Treatment and Prevention for All!
18 July 2007
International Treatment Preparedness Coalition (ITPC)
The world is still one million people short of the original "3 by 5" goal to put three million people on AIDS treatment by the end of 2005. The slow progress has already cost thousands of lives, and is destined to cost millions more. This is particularly tragic because evidence shows that AIDS treatment delivery is working.
This report demonstrates what a catastrophic mistake and monumental betrayal it will be if the G8 and the governments of countries heavily affected by AIDS renege on their commitment to universal access to treatment, just when it is demonstrating its potential to save millions and to pave the way for broader health systems reform.
This fourth edition of Missing the Target provides original, in-depth assessments of the dynamics of AIDS treatment delivery in six countries -- Cambodia, China, Malawi, Uganda, Zambia, and Zimbabwe. In addition to these new detailed reports, it also includes updates from the six previous report countries -- Dominican Republic, India, Kenya, Nigeria, Russia, and South Africa; and short summaries from five other countries -- Argentina, Belize, Cameroon, Malaysia, and Morocco. Though there are substantial challenges in every country, significant progress in the numbers of people receiving treatment and wider delivery of support services is clearly documented.
All engaged in the global AIDS response must now think and act boldly to re-envision delivery of a range of essential health care services for the poor. The effort to provide universal access to AIDS treatment represents the best hope of establishing the systems, structures, and commitment needed to achieve the 1978 Alma-Ata Declaration goal of “health for all†since that commitment was signed. If we lose this opportunity and the momentum it represents, we will have squandered the energy that is propelling us into a new era of promise for delivering health care in the developing world.
Overall findings
The pace of treatment delivery must continue to accelerate. The current rate of growth -- 700,000 additional people received treatment last year -- means the world will fall short of even the most modest interpretation of the purposefully ambiguous new G8 treatment target -- and a full five million people short of achieving global universal access by 2010.
The world has entered a new phase in scale up. While timely and expanded distribution of ARVs remains the core objective, much greater attention is now needed on emerging challenges such as reaching marginalised groups, children, and people in rural areas, and providing vital support services such as transportation and nutritional assistance.
Supplementary services, in addition to treatment, must be free if poor people are to initiate and sustain care. Our research teams found that what is called "free treatment" is not truly free to the vast majority of people. Transportation costs and charges for diagnostic tests and medical care still put lifesaving treatment out of reach for many.
Integration of prevention and treatment services is fundamental to building healthier communities. Only a comprehensive and coordinated effort will overcome the most difficult challenges in ending the epidemic. False separation of prevention and treatment, divisive either-or debates, and competition over resources must end.
The worsening shortage of doctors, nurses, and community health workers who can provide HIV care and prevention requires increased financial investments, coordinated policy reforms, and removal of fiscal limitations on national health-related expenditures.
Country findings
An in-country civil society team using a globally standardized survey instrument prepared each of the reports in Missing the Target.
In Cambodia treatment access has increased steadily but there remains an acute shortage of health care personnel, inadequate support for treatment adherence, problems with the drug supply system, inattention to needed social supports, fees for diagnostics and other necessary services, and limited access to second-line treatment and TB services.
In China rapid expansion of treatment delivery is still falling behind increasing need. Widespread stigma and extra charges for diagnostic tests impede treatment access. Drugs for TB/HIV co-infection and second-line AIDS therapy are scarce. UN agencies must be more outspoken about barriers to treatment delivery.
Significant progress in Malawi is being hampered by a critical health care worker shortage, particularly in rural areas. Few have access to PMTCT+ or HIV testing, OI treatments are not readily available, TB services are not well integrated in HIV care, and domestic spending is inadequate.
In Uganda a free ARV program has shown impressive results, yet demand for treatment outstrips supply, uptake of PMTCT+ is low, fees for some medical services impede access, second line and OI drugs are often not available, and stock outs, corruption and under-financing plague the response.
In Zambia treatment has markedly reduced mortality rates, but serious inequities in access remain; availability of diagnostic tools, second-line and OI drugs, and paediatric formulations is severely limited, stock outs are frequent, PMTCT+ is largely unavailable in rural areas, and poverty undermines access.
In Zimbabwe treatment access has improved, but political turmoil and a deteriorating economy jeopardize gains; in some areas the health care system is collapsing, hospitals and clinics are threatened with closure, there are long lines for the public ARV program, frequent drug stock outs, and widespread stigma against PLWHA. Greater assistance is needed from multilateral agencies.
Specific challenges in treatment delivery cited by the other eleven countries include:
In the original six report countries...
Dominican Republic -- insufficient access to viral load testing; exclusion of PLWHA and Haitian migrants from new government health insurance program.
India -- National Plan not aggressive enough to provide universal access by 2010; no plans from government on second-line ARVs or to ensure ARV access for marginalized populations.
Kenya -- not enough CD4 testing equipment; poor coverage in rural areas.
Nigeria -- very low proportion of children in need are getting ARVs; not enough viral load monitoring equipment.
Russia -- low uptake of ARVs due to limited awareness of availability and inadequate social support; inadequate targeted programs for marginalized groups, specifically IDUs; drug supply interruptions continue.
South Africa -- new National Strategic Plan process must move quickly to address great gaps between need and access and between policy making and implementation .
In the five new "short summary" countries...
Argentina -- coverage varies greatly by region with rural areas under-served. Because of stigma, many in marginalized groups do not come forward to seek treatment and so are not counted in treatment need numbers.
Belize -- insufficient attention to needs of marginalized and high risk groups; serious shortfall in human resources capacity.
Cameroon -- registration and testing fees as well as transportation costs make access to ARVs effectively impossible for many.
Malaysia -- disparities in treatment access by ethnic group; many hospitals are not meeting their access targets.
Morocco -- limited access to OI drugs; only one viral load testing facility in the country; insufficient access to CD4 equipment.
Global agency and donor findings
Global agencies and donors, partnering with governments, are helping to make the many successes in treatment delivery possible. But donors have failed to establish a formula to secure the predictable and sustainable funding on which universal access depends. Our research also identifies many areas in which global programs must improve their work:
PEPFAR's programs are saving many thousands of lives, but must do better at reaching populations outside of urban centres, integrating treatment services into existing health care structures, building public sector capacity, and increasing support for health care worker education and retention. Community health workers need living wages and other supports through PEPFAR. The program's misguided policies on abstinence-only programming, sex work and harm reduction present considerable, self-imposed obstacles to effectiveness and must end.
Donors must support the Global Fund's plan to triple in size. In many countries, greater transparency is needed in financial and program management of Global Fund grants, and civil society must be more fully included on Country Coordinating Mechanisms (CCMs) so they can lend expertise and serve as watchdogs over program implementation. The Fund -- and its partner organizations -- must be prepared to intervene earlier and more effectively when country implementers encounter challenges or are in danger of losing grants.
UNAIDS and WHO provide important assistance on global treatment scale up through policy development and, in some cases, through efforts that facilitate the inclusion of civil society. But these agencies must be more outspoken when national programs are mismanaged, targets are not met, or vulnerable populations are neglected; it is part of the UN's moral responsibility to speak out when countries fail their people. UNAIDS must move forward swiftly with ambitious resource needs estimates that include a package of health services for PLWHA; need estimates should demand significant increases from both donors and national governments in heavily affected countries.
All global agencies must help governments reach marginalised groups, establish systems that will eliminate drug stock outs, provide CD4 and other needed testing technologies, and integrate TB and other services into treatment.
People who need access to AIDS treatment cannot rely on global institutions alone. Developing country governments must take on greater leadership on HIV/AIDS. PLWHA and civil society must engage with their governments and insist they do more. In advocating for change, PLWHA and civil society members often face serious challenges and risks. But Missing the Target shows that, even in countries like China, advocates can speak up, tell the truth, and urge their governments to act. These courageous voices need to be supported, encouraged, and honoured.
There can be no more excuses for losing this momentum or needlessly letting millions die of AIDS. The last three years have proven that concerted global efforts can save lives and build strong systems of care.
Acknowledgements: ANSA acknowledges www.aidstreatmentaccess.org as the source of this document.
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