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 fi gure 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.
Crucial to the rapid expansion has been the courageous public commitment by governments in affected countries, making HIV/AIDS interventions a fi scal priority and a consistent theme of public outreach. Led by effective and energetic national AIDS councils, many countries are exceeding their individual targets, showing that the global “3 by 5” target can be attained if countries lead the way, make the most of their own resources and engage partners effectively.
In several countries, dramatic improvements in treatment access have followed an increase in the number of locations for delivering ARV therapy. Generally, the numbers of women on therapy have increased as rapidly as those for men, but treatment for children is still a neglected issue.
Over the past 12 months, a strong international movement has gathered behind the “3 by 5” target. Partnerships, both within countries and globally, are among the main engines of HIV/AIDS treatment scaleup. At the country level, the response has been unprecedented from both the public and the private sectors. Building on ongoing work in many affected 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 all played a critical role in making scale-up possible. Their large new fi nancial commitments have greatly facilitated activities at the country level, augmented responses by other donors and in general boosted advocacy efforts.
The building blocks of ARV therapy scale-up
In many locations, several key building blocks of ARV therapy programmes have been put into place. These include expanding access to HIV testing and counselling; integrating ARV therapy and tuberculosis programmes; improving access and integrating care and support services; preventing mother-to-child HIV transmission; providing drugs and diagnostics; training for professionals, community members and people living with HIV/AIDS; developing systems for tracking and monitoring the people receiving treatment; and institutionalizing operational research to translate hard-won experience into evidence-based programme design adapted to
local conditions. The scaling up of ARV therapy, if managed wisely, can lead to the strengthening of both HIV prevention programmes and the broader health system.
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 diffi cult 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 fi eld 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.
In an effort to keep abreast of rapid changes in the landscape of the HIV pandemic, WHO and UNAIDS report semiannually on progress toward “3 by 5”. The fi rst update was presented at the XV International AIDS Conference in Bangkok, Thailand, in July 2004.
This second report measures progress made by countries and describes how international partners are supporting their efforts. In addition, it summarizes how the building blocks of antiretroviral (ARV) therapy programmes are being put into place and how issues beyond treatment are being addressed.
It provides examples of country progress and a global estimate of the number of people receiving ARV therapy, and it assesses how well the therapy is working. It also identifi es some of the challenges faced in resource-constrained settings and how these are being met by improving health care systems, links between prevention and treatment and providing equal access to quality care.
This report is based on reports and updates provided by dozens of international, national and community organizations involved in scaling up ARV therapy. We thank everyone who has contributed to this progress report. WHO departments at the headquarters, regional and country levels worked with national governments and nongovernmental organizations to gather the latest information on the scaling up of ARV therapy. The UNAIDS Secretariat and the UNAIDS Cosponsors gathered information on how United Nations agencies and international nongovernmental organizations are translating the rapidly expanding commitment to “3 by 5” into action.
Many partners in scaling up ARV therapy have shared their experiences on the ground. WHO, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States President’s Emergency Plan for AIDS Relief and the World Bank participated in special meetings to share data and reports so that this consensus report could present the most accurate estimates.
Reporting the results of the intensive effort to collect information could easily require hundreds of pages. In the context of the semiannual “3 by 5” progress reports, we have chosen to focus on the most common and important themes that emerged from the reports, illustrated by examples provided by countries and partner organizations. The data presented in this report either originated in their entirety with health ministries or, where country documentation did not include all treatment projects, was supplemented by approved figures from externally funded aid programmes.