On Dec 1, 2003, WHO in partnership with UNAIDS launched Treating 3 million by 2005: making it happen
with the aim of providing life-long antiretroviral therapy to 3 million people with HIV/AIDS in developing countries by the end of 2005. “3 by 5” is widely seen as WHO Director-General Lee Jong-wook's signature strategy
. With only 8 months to go, what progress has been made?
When 3 by 5 was launched, as many as 6 million men, women, and children in developing countries needed antiretroviral therapy, but only 400 000 (8%) actually received treatment. Limiting the 2005 goal to only half of those who need treatment, a modest aim in itself, was described in the launch document as a “necessary, achievable target on the way to the ultimate goal of universal access to antiretrovirals for everyone who requires such therapy”.
6 months after the launch, 440 000 people in developing countries were receiving antiretroviral treatment, an increase of 40 000, but below the published target of 500 000. By December, 2004, the number had risen to an estimated 720 000, which represents 12% of the people who need treatment, and is ahead of the published target of 700 000. In 2 months' time, when the next progress report is due, 1 600 000 is the target.
Although the aim was achieved by the end of 2004, which represents substantial success for the 3 by 5 initiative, closer inspection of the scale-up measures reveals important gaps between the achieved and published targets. The most notable success contributing to reaching the primary outcome measure is the number of outlets providing antiretrovirals, which is three times the target. But the financial resources allocated to 3 by 5 are below what are needed (US$163 million vs 174 million) and the number of WHO staff deployed to the initiative is well below what it should be (112 vs 400). Crucially, the number of countries that have established treatment goals is 30, yet the December target was 50.
Progress has been made. A virtue of 3 by 5 is that by setting a simple target WHO has made what was a concern of non-governmental organisations into a mainstream UN programme. Delivery of effective treatment to save lives is happening and there is now greater focus on HIV prevention than previously. But there are enormous barriers to reaching the 3 million goal within the next 8 months. Three countries in particular—India, South Africa, and Nigeria—need to show their commitment, according to Dr Jim Yong Kim, WHO Director of the Department of HIV/AIDS. Without the political will in these countries, Kim doubts that the goal will be reached.
Overall, it is in Africa that the greatest barriers exist. Of the estimated 4 million in Africa who need antiretrovirals, only 325 000 (8%) were on treatment by December. Despite huge successes in Uganda and Botswana, for example, with both countries already delivering antiretrovirals to half their affected populations, the burden of disease remains great and the distribution of antiretrovirals is poor in South Africa, Nigeria, Zimbabwe, Tanzania, and Ethiopia. If the 3 by 5 programme had the political clout to influence South Africa alone to implement all its recommendations, where the necessary infrastructure largely exists, then the 3 million target would be more likely to be attained. Without South Africa on board, with its 837 000 people affected by HIV/AIDS and its leadership position within Africa, 3 by 5 is but a pipe dream.
For what was a modest target, it is tragic that many of those with HIV/AIDS who desperately need treatment will not receive it by the end of 2005, and will die as a result. Failure to reach the 3 by 5 goal will be even more damaging since the programme has detracted attention from other key projects including the ineffective Roll Back Malaria
partnership. When the 58th World Health Assembly begins on May 16, urgent focus on 3 by 5 is needed. Strategies to put pressure on individual Ministries of Health, particularly in sub-Saharan Africa, must be enacted. Pharmaceutical companies could help with increased antiretroviral donations. Continued leadership from WHO and UNAIDS, together with other partners such as the World Bank and the Global Fund to Fight AIDS, Tuberculosis and Malaria, is essential now, and beyond 2005, but it is individual governments that need to act.