With just a month to go before the deadline for achieving the targets of universal access to HIV prevention, treatment and care expires, it is clear very few countries will reach them.
What is less certain is whether such ambitious goals have positively affected global HIV/AIDS efforts.
The dream of universal access emerged in 2005 when G8 leaders committed to achieving “as close as possible to universal access to treatment for all those who need it by 2010”. At the 2006 UN General Assembly High-Level Meeting on AIDS, world leaders expanded their commitment to include universal access to prevention, care and support and agreed to set national targets by the end of that year.
The targets were adopted just as the UNAIDS/World Health Organization (WHO) “3 by 5” initiative to provide three million people living with HIV/AIDS in low- and middle-income countries with antiretroviral treatment (ART) by the end of 2005 came to an end.
Five years later, sub-Saharan African countries, with the largest share of global HIV infections, have progressed towards universal access (defined as coverage of at least 80 percent of the population in need) with varying degrees of urgency and success.
Galvanizing a response?
Countries concentrated in southern Africa, at the epicentre of the pandemic, have made some of the greatest strides. Botswana, Namibia, South Africa and Swaziland achieved universal access in the provision of prevention of mother-to-child transmission services (PMTCT) by the end of 2009, the most recent year data is available from UNAIDS.
Towards the end of 2009, five countries had also achieved universal access to ART – Swaziland, Zambia, Namibia, Botswana and Rwanda – and several others were not far behind. But the definition of ART needs changed in November 2009, when the WHO raised the recommended threshold for starting treatment from a CD4 count of 200 to one of 350 or less.
The new criteria increased the number of people eligible for ART by about 50 percent. With the goal posts significantly shifted, only Botswana and Rwanda made the grade.
South Africa has by the far the largest ART programme in the world, with nearly one million people on treatment by the end of 2009, but its HIV burden is also the world’s largest and the new WHO guidelines meant that, according to UNAIDS, it has only reached 37 percent of those needing the drugs.
Meanwhile, many sub-Saharan African countries with far fewer HIV-infected citizens have struggled to extend ART and PMTCT to even a fraction of them. Sudan, Somalia and Liberia, where health systems have been weakened by years of conflict and under-funding, are lagging far behind other countries in the region, despite having HIV prevalence rates of less than 2 percent.
Role of targets
Sheila Tlou, new head of UNAIDS in eastern and southern Africa, nevertheless believes that without such ambitious targets many countries would not have made the gains they have.
“People need targets,” she told IRIN/PlusNews. “We always say, ‘Aim for the sky and you’ll reach somewhere’; had countries been given targets that were just mid-way, chances are they would actually by now only have realized half of that.”
However, Alan Whiteside, executive director of the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal, said “unreachable targets” were demoralizing and unfair to the health workers expected to meet them with often inadequate resources.
“They’re rolled out with fancy fan-fairs and then when we miss them again, they’re forgotten and the people who are held responsible for missing them are not the people who rolled them out, they’re the people on the ground,” he told IRIN/PlusNews.
“I agree with deadlines and service delivery agreements at a community level,” he added. “I just think that we never hold the people who set the global targets accountable.”
Even with sufficient funding, many countries in sub-Saharan Africa face overwhelming obstacles to rapidly expanding HIV treatment, prevention and care services. In rural Kenya, condoms – the most basic component of any national prevention strategy – are still not widely available and in Uganda, health facilities are unable to meet the emerging need for third-line ARVs.
The countries that have succeeded despite severe shortages of trained health workers, poor supply chain networks and a lack of equipment and infrastructure have adopted innovative solutions.
Malawi, Mozambique and Zambia have started allocating tasks traditionally performed by doctors and nurses to less qualified staff who are in greater supply. Kenya is using inexpensive cell-phone technology to monitor patients on ARVs and a multi-country campaign in Africa is using cell phones to track and expose drug stock-outs. Other countries are working on better integration of their HIV programmes into other sectors of the health system, such as those that deal with child and maternal health and tuberculosis.
As 2010 draws to an end, attention is turning to the next set of targets. Publicity materials accompanying the release of the latest UNAIDS report on the epidemic on 23 November outlined a new vision: “Zero new infections. Zero discrimination. Zero AIDS-related deaths.”
“It’s a new vision we’re now aiming for,” admitted Tlou, who also highlighted Millennium Development Goal Six, which aims to halt and begin to reverse the spread of HIV/AIDS by 2015.
“I would say we are reaching [that goal] so by 2015, we will be saying, have we reached our vision of zero new HIV infections, zero deaths and zero discrimination? I can see us now taking that vision and saying, let’s see how by 2020, for example, we can reach that particular target.”
Theme(s): (PLUSNEWS) Aid Policy, (PLUSNEWS) Care/Treatment – PlusNews, (PLUSNEWS) HIV/AIDS (PlusNews), (PLUSNEWS) Prevention – PlusNews
|[This report does not necessarily reflect the views of the United Nations]|