Americas

H.I.V./AIDS: The Growing Momentum for Universal Access to Treatment

Chinua Akukwe
Worldpress.org contributing editor
March 8, 2006

An AIDS patient collects her antiretroviral medicine at a treatment center in Kisangani, Democratic Republic of the Congo. (Photo: Lionel Healing / AFP-Getty Images)

A quiet but powerful momentum is gaining ground on what had been a cherished and long-term goal of H.I.V./AIDS experts and advocates: universal access to preventive programs, clinical care and support services for individuals and families living with H.I.V./AIDS. The quest for universal access is gathering momentum due to a combination of factors and circumstances. The push for universal access is also forcing a realignment of partnerships and priorities.

The 2005 United Nations General Assembly World Summit adopted a resolution that among other issues committed members to "developing and implementing a package for H.I.V. prevention, treatment and care with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all those who need." Universal access is to be achieved "through increased resources, and working towards the elimination of stigma and discrimination, enhanced access to affordable medicines and the reduction of vulnerability of persons affected by H.I.V./AIDS and other health issues, in particular orphaned and vulnerable children and older persons."

The General Assembly goes further to mandate a worldwide process that will culminate on May 31 and June 1 with "a comprehensive review of the progress achieved in realizing the targets set out in the Declaration of Commitment on H.I.V./AIDS." On June 2, a high-level meeting will be convened "aimed at continuing the engagement of world leaders in a comprehensive global response to H.I.V./AIDS." Under the leadership of Unaids, the U.N. agency coordinating the response to H.I.V./AIDS, and the World Health Organization, a process of "regional consultations" is underway in the following regions and sub-regions: Latin America, Caribbean, Asia and Pacific, CIS Countries, Africa, South-Central Europe and the Middle East. At the end of this process, the U.N. AIDS agency will prepare a document that sets out strategies for achieving universal access on preventive, clinical care and support services.

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The 2005 Group of 8 Summit in Gleneagles, Scotland, resolved to achieve an "AIDS-free generation in Africa" through a coordinated and integrated African, bilateral and multilateral partnership. Group of 8 leaders made a definitive pledge to meet the cost of universal access to treatment. The leaders also pledged $50 billion in additional assistance.

In Africa, continental organizations are focusing attention on H.I.V./AIDS. The African Union is coordinating the preparation of an "African Common Position" for the U.N. General Assembly June 2006 meeting on H.I.V./AIDS. The African Union is also the lead organization in the ongoing regional consultative process for universal access to H.I.V./AIDS treatment. The African Development Bank's new guidelines on communicable diseases identifies H.I.V./AIDS, TB and Malaria as "priority diseases" that require operational attention. The May 2006 African Heads of State Summit (May 2006) in Abuja, Nigeria, will include regional consultation on universal access issues.

France and Britain are examining creative financing mechanisms to meet AIDS and other development remedial efforts. The two countries recently agreed to raise "billions of dollars" for international development through the sale of bonds in global financial markets. This agreement allowed the two countries to back the signature financing-for-development programs championed by each side: Britain's International Finance Facility (I.F.F.) and the France-backed levy on air travel known as the Airline Solidarity Contribution (A.S.C.). The proponents of these financial mechanisms believe that urgently needed finances for AIDS remedial efforts, public health and education could be made available on a more sustainable basis. The Washington-based Global AIDS Alliance estimates that a combined I.F.F. and A.S.C. initiative can provide up to $100 billion additional "up-front money" for international development.

The race is now on to bring Germany and Italy on board for the I.F.F. and A.S.C. The United States remains opposed to I.F.F. In addition, the French government is calling for a comprehensive mechanism for purchasing drugs in bulk and making sure they are available on time and in good quality in developing countries. The proposed drug-purchasing facility will take direct aim at a current anomaly in AIDS remedial efforts: the inability to get readily available antiretroviral drugs to individuals clinically qualified to receive these medicines. If Germany and Italy come on board for these new financial mechanisms, the United States will be hard-pressed to stand alone.

One of the important milestones on universal access is the World Health Organization's recent effort to put 3 million clinically qualified individuals living with H.I.V./AIDS on antiretroviral care by the end of 2005. This initiative known as the "3 by 5" program brought to bear the considerable technical and logistics capabilities of the W.H.O. to jumpstart universal access issues in some of the poorest countries in the world. According to the W.H.O., "Overall, more than 50 countries doubled the number of people receiving treatment between June 2004 and June 2005, and the global total of people receiving treatment increased from 440,000 to about one million in the same period." Although the W.H.O. fell short of its 3 million-on-treatment target, the "3 by 5" program did show that it is logistically feasible to scale up antiretroviral therapy in a relatively short span of time.

Another important milestone regarding the emerging consensus on universal access is the growing role of the Global Fund to fight AIDS, tuberculosis and malaria. The organization is financing promising H.I.V./AIDS treatment programs in developing countries. The latest report from the Global Fund indicates that its financial support over a five-year period will likely provide antiretroviral therapy to 1.8 million individuals. The Global Fund is creating a catalytic situation in countries hard hit by AIDS since governments and other stakeholders now know that promising proposals will receive adequate attention.

The U.S. government's President's Emergency Plan for AIDS Relief is providing significant financial outlays on AIDS remedial efforts in 15 countries and has become a force for expanding access to antiretroviral therapy. According to the Plan's latest report, more than 400,000 individuals living with H.I.V./AIDS are now on antiretroviral therapy in affected countries due to its support.

The role of the humanitarian medical organization, Doctors Without Borders in pioneering antiretroviral therapy in some of the poorest environments in the world deserves mention. As the first nongovernmental organization to focus on H.I.V./AIDS treatment in South Africa, it helped establish a practice model on universal access for resource-challenged environments. One of the beneficial impacts of the program in Khayelitsha, South Africa, is the unprecedented increase in the number of individuals that came forward for testing: from 500 tests for H.I.V. in 2000 to 28,000 in 2005. The governments of South Africa, Botswana and Nigeria are now implementing national H.I.V./AIDS treatment programs that are at early stages and appear promising. However, none of these programs is on such a scale as to make a significant dent on H.I.V./AIDS in their respective countries.

Despite the growing momentum on universal access, there are emerging challenges that could scuttle or scale down the impact of the nascent global initiative. These challenges need to be seriously considered in all ongoing regional consultations and in the deliberations of all stakeholders at all levels.

Emerging Challenges to Universal Access

1. The definition of universal access may become a serious hindrance. There are two major schools of thought. Advocates that focus on unimpeded access to antiretroviral treatment are duly cognizant of the nearly 6 million individuals who need immediate treatment and continue to push for a treatment-oriented initiative. These advocates argue that the lack of comprehensive treatment platforms is a major weakness of current AIDS remedial efforts. The second school of thought focuses on a more expansive definition of universal access, recognizing the intricate linkages between prevention, clinical care and social support. Various U.N. resolutions and the Group of 8's 2005 Gleneagles statement refer to this more expansive and comprehensive definition of universal access. However, the European Union as part of the 2005 World AIDS Day focused on "H.I.V. Prevention for an AIDS Free Generation." To build a truly powerful global momentum of universal access, it would be necessary to clarify the definition of "universal access" and ensure that all stakeholders, especially advocates are on board.

2. Community-based programming is not a major strength of global initiatives. The current momentum on universal access relies heavily on national responses and initiatives. However, to meet the unique preventive, clinical and social support needs of individuals and families at risk of contracting H.I.V. or dying of AIDS, remedial efforts need to include community-based programs that are responsive to the needs of the target population. A community-based programming strategy is critical since the major planks of universal access include: increasing access to programs that can change personal behaviors; ensuring that at risk individuals not only change their behavior but also consistently engage in healthy behaviors; encouraging at-risk populations to go for voluntary counseling and testing; implementing a unique clinical regimen tailored to the needs of each patient; and providing customized social support that responds to the unique needs of the target population.

3. Political support is not guaranteed. The statement of political support and the inevitable political rhetoric on H.I.V./AIDS remains at odds with specific actions on universal access to antiretroviral therapy. Millions of individuals still die of AIDS every year due to lack of access to readily available medicines. The key is to match political rhetoric with specific actions that prevent untimely deaths from AIDS. The growing linkages between remedial efforts and governance issues, in both donor and recipient nations, may further complicate long-term plans for political support. Additionally, the current build up to the June 2006 meeting of the United Nations does not include strong grassroots organizing and representation. Consequently, building a strong political momentum may be lost if grassroots organizations in both donor and recipient nations are not actively engaged in the process.

4. Financial support and deployment may not materialize. I had written earlier on a looming financial crisis in H.I.V./AIDS remedial efforts ("H.I.V./AIDS: Looming Funding Crisis"). This crisis persists. The future financial health of the Global Fund is far from assured. The U.N. AIDS agency estimates now that a "comprehensive response" by 2008 will require at least $22 billion. There is no plan afoot to meet this projected financial outlay. The lag time between announced financial support in donor countries and organizations and disbursement of promised funds for program support in target communities remains a major concern.

5. Technical problems may be formidable. Lack of skilled human resources is a critical challenge in some of the nations hit hardest by AIDS. According to the U.N. AIDS agency, although Sub-Saharan Africa represents 69 percent of AIDS global treatment needs, it has only 1.8 percent of the health workers worldwide. In addition, experts, policymakers and advocates must grapple with finding creative ways to improve the effectiveness of technical programs such as information, education and communication campaigns against H.I.V., clinical care protocols and social support services. Other technical issues include reaching consensus on process and impact indicators for monitoring and evaluating universal access initiatives; designing and implementing safeguards for personal health records; and avoiding ethical compromises in conducting research in resource-challenged environments. In addition, experts must agree on blueprints for assuring confidentiality and the fidelity of informed consent in clinical, policy and program research activities.

6. Logistics support needs will be huge in many areas. Countries emerging from brutal conflicts, such as Liberia, Sierra Leone and southern Sudan, are already showing evidence of rising H.I.V. incidence. Universal access initiatives in these countries, and other nations either emerging or still enmeshed in conflict, will require dedicated logistics support. Significant financial support will be needed to meet these logistical challenges, especially in the areas of infrastructure development and supply chains. Impoverished countries will also require special attention and support. The question is whether political support exists in donor countries for significant logistics support in poor nations battling H.I.V./AIDS.

7. Legal, economic and social issues remain significant barriers. In many nations hard hit by AIDS, significant legal challenges remain. Individuals and families living with H.I.V./AIDS continue to face sustained stigma and discrimination. Legal recourse is minimal in many of these countries, even in the instances of rape and grievous bodily assault. Poverty is a major issue in most countries and continues to have deleterious influence on personal choices and behaviors. Cultural taboos and gender inequities can prevent the full participation of women in universal access programs and services.

Conclusion

The momentum for universal access to H.I.V. prevention strategies, clinical care and social support is gathering speed. The quest for universal access will require creative approaches and the realignment of partnerships. It will also require dealing with major challenges that can imperil the initiative. The Universal Access initiative has the potential to provide sustained assistance to individuals at risk of contracting H.I.V. and relief to individuals and families already battling H.I.V./AIDS.




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