When Jeanette tested positive for HIV at the Kicukiro Health Centre in Kigali, Rwanda, during a prenatal check-up two years ago, “I didn’t cry or shout,” she told UN Children’s Fund (UNICEF) researcher Alexia Lewnes. “But I was afraid. I thought I was going to die.” Just a few years ago, she would have been right. Only a tiny fraction of the millions of Africans in need of life-saving anti-AIDS drugs could afford them, and an HIV diagnosis was a death sentence for those who could not.
But Jeanette was more fortunate. Under a UNICEF-supported maternal and child treatment programme at the centre, she was able to obtain life-saving anti-retroviral drugs (ARVs) for herself and medication that blocked the transmission of the virus to her baby. Although life remains difficult for Rwandan women a decade after the genocide and Jeanette fears that she will be ostracized if her condition is discovered, she and her children have something she thought she did not have that terrible day at the clinic — a future.
Jeanette and her baby were among the beneficiaries of an emergency drive, known as the “3x5” campaign, to provide ARVs and other medications to 3 million people living with AIDS in developing countries by the end of 2005 (see Africa Renewal, April 2004). Launched in December 2003 by the World Health Organization (WHO), the remarkable effort brought ARVs to almost 1.3 million poor and desperately ill people around the world in just two years — an achievement that many public health officials thought impossible. In 2004, an estimated 6 million people globally were thought to need ARV treatment, which is prescribed only for people with advanced AIDS. Some 40 million people are infected with the virus worldwide, 25 million of them in Africa.
Thanks to the 3x5 campaign, the number of Africans on ARV treatment jumped from 50,000 to an estimated 810,000 as governments, civil society organizations, multilateral agencies and bilateral donors made an unprecedented effort to train staff, build clinics and laboratories and purchase medications and equipment.
Although the number of people receiving treatment fell short of the target, the UN’s special envoy for HIV/AIDS in Africa, Mr. Stephen Lewis, described the campaign as “a breakthrough.”
“The inertia around the pandemic was dreadful, until this inspired and visionary intervention,” he told Africa Renewal. “Now the treatment ethos has taken hold. We have an irreversible momentum in place . . . and we’re going to get there.”
From 3x5 to universal access
The 3x5 effort ended on 31 December 2005. Now WHO and its global partners, including the Joint UN Programme on HIV/AIDS (UNAIDS), the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, are seeking to build on its success. They have kicked off a new global campaign to bring HIV/AIDS prevention, care and treatment to everyone who needs it by 2010. Termed the “universal access” initiative, the campaign was launched in January 2006 and is intended to bring the same sense of urgency and commitment to HIV prevention and care that the 3x5 movement did to treatment — combining the three responses into an expanded and integrated assault on the epidemic.
In contrast to the 3x5 campaign and its global targets, the universal access programme emphasizes country-level efforts. Each country is to develop targets and timelines consistent with national AIDS strategies, with greater involvement of civil society, particularly people living with HIV and AIDS, in planning and implementation. The campaign will be directed by a global steering committee mandated to help governments overcome obstacles in four areas critical to the rapid expansion of HIV/AIDS services:
- Ensuring greater and more reliable financing (including from domestic sources) and better alignment of donor funding with national priorities
- Addressing shortcomings in human resources and health systems
- Making available vital goods, such as affordable drugs and condoms, as well as services for testing, monitoring and care
- Working to achieve gender equity in access to HIV/AIDS services and promoting efforts to end stigma and discrimination against people living with the virus.
The need for a rapid and integrated response is clear. Despite the 3x5 drive, increased funding for global AIDS programmes and encouraging progress in a few countries, the global epidemic continues to worsen. In 2005, there were an estimated 5 million new infections and 3 million deaths — the highest number ever. Africa continues to bear the brunt of the epidemic, accounting for more than 60 per cent of all people with HIV, 60 per cent of all new infections and 70 per cent of deaths last year. Women have been hit hardest, representing 57 per cent of Africans living with HIV and AIDS.
Africa embraces new campaign
Meeting in Brazzaville in early March under the auspices of the African Union, more than 250 representatives from government, civil society and women’s organizations, as well as people living with AIDS and youths from 53 African countries, embraced the initiative. They linked it to the continental New Partnership for Africa’s Development (NEPAD) and pledged to “put people at the centre of the HIV and AIDS response,” particularly women, young people and the soaring number of AIDS orphans. “We are ever mindful of the disproportionate share and severe impact of the HIV and AIDS burden in Africa,” the delegates declared. They noted that the pandemic is driven by “deep and persistent poverty, food insecurity, indebtedness . . . gender inequality and stigma and discrimination.”
The Brazzaville Declaration urged African governments to increase domestic spending on the pandemic, including by devoting at least 15 per cent of national budgets to health services. That is a goal that only three African countries have reached, reports UNAIDS. The declaration also called on donors to support national AIDS programmes with coordinated and reliable funding to avoid duplication, piecemeal support for favoured projects and uneven distribution of resources across geographic and social sectors.
The delegates also called for greater regional cooperation against the disease, including through bulk purchasing of medicines, condoms and other supplies, consolidated training and monitoring programmes and the promotion of local manufacturing of needed goods by the creation of larger, regional markets.
Road map or backlash?
But with time running out for the nearly 5 million people still unable to obtain ARVs and other medicines, some activists are questioning whether the universal access campaign will lose the focus and urgency of its 3x5 predecessor.
Mr. Gregg Gonsalves, director of prevention and treatment advocacy for the Gay Men’s Health Crisis in New York, told Africa Renewal that he is concerned about the lack of numerical targets and timelines in the universal access programme. “There are no targets, no road maps, no accountability mechanisms and no core indicators. The whole global ambition to fight the epidemic has been scaled back.”
Where the 3x5 treatment drive stirred controversy with its ambitious target and its numerical goals and time-frames, Mr. Gonsalves continued, universal access “is entirely too vague.” Leaders of multilateral health institutions and donor governments, he asserted, do not want to take risks. “We’re in a 3x5 backlash.”
But Mr. Michel Sidibe, co-chair of the campaign steering committee, argued that targets and timelines are best set by countries, to account for local conditions and priorities. “The ownership has to be at country level,” he said from his office in Geneva. “They can’t be set outside a country context, because we don’t have one AIDS pandemic in Africa, we have many. Mali has an HIV infection rate of less than 1.5 per cent. You can’t have the same programme for Botswana with a 40 per cent infection rate. Countries are best positioned to allocate resources for the greatest impact.”
Mr. Sidibe, the director of country and regional support for UNAIDS, praised the 3x5 campaign for reaching more than 1 million people globally. “It proves that mobilization works.” But he also noted that this figure was dwarfed by the 5 million people newly infected with HIV in 2005. “We need to come with a holistic approach, emphasizing prevention, care and treatment,” he emphasized. “We have been using a piecemeal approach for 20 years.”
Mr. Sidibe also observed that the universal access campaign has drawn inspiration from NEPAD’s innovative African Peer Review Mechanism, in which member states monitor and evaluate each other’s economic and political policies (see Africa Renewal, February 2003). The campaign will similarly involve African governments in assessing each country’s progress in the battle against the virus. By building bridges among governments, civil society, the private sector and the international community, he concluded, the world can finally turn the corner on HIV and AIDS “and do it in a comprehensive and sustainable manner.”
Speaking to Africa Renewal, Mr. Stephen Lewis, the UN Secretary-General’s special envoy for HIV/AIDS in Africa, dismissed as “balderdash” suggestions that the 16-fold increase in the number of Africans on lifesaving anti-AIDS drugs has come at the expense of essential prevention programmes. He also rejected the notion that compromises have to be made when allocating scarce resources. “There is this constant feeling that you have to be pushed into a corner and pick treatment over prevention or prevention over treatment. People have to absolutely lose that mindset . . . and say, as everybody in the world knows, that both are vitally important. You just keep fighting like hell to get the money you need for everything. You never give up and you don’t accept anything less.”
Before the 3x5 campaign, he recalled, many senior public health and UN officials believed it was impossible to treat people in poor countries. “They said, ‘They’re going to die anyway. Let’s use the money for prevention.’ I used to respond not with an appeal to compassion, but by saying that there is no way you can stop 40 million people who are infected from demanding treatment. So don’t tell me they’re going to die. You’re going to do treatment whether you want to or not. You’re running into the face of history and history will run right over you.”