EDITORIALS

Changing history — closing the gap in AIDS treatment and prevention

Anthony D. Mbewu

Executive Director Research, Medical Research Council of South Africa PO Box 19070, Tygerberg 7505, South Africa (email: anthony.mbewu@mrc.ac.za)

The global epidemic of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is the greatest threat to human health and development since the bubonic plague and the advent of tobacco consumption. It threatens not only to continue the decimation of millions (over 20 million deaths so far, with 34–46 million people currently living with HIV/AIDS (1)) but also to reverse many of the gains made in developing countries over the past 50 years (2).

Consequently, as The world health report 2004 states, history will judge the current generation by its response to this global threat (2). The ambitious "3 by 5" initiative of WHO and UNAIDS to reach three million people with antiretroviral therapy by the end of 2005 (3) intends to halve the treatment gap, in which only 400 000 of the six million people who need treatment currently receive it. "By tackling [HIV/AIDS] decisively," says LEE Jong-Wook, Director-General of WHO, "we will also be building health systems that can meet the health needs of today and tomorrow, and continue the advance to Health for All" (2).

There is no room for complacency, however, in the false assumptions that we have all the solutions and that we know how to use them. Tuberculosis (TB) and malaria have shown that the availability of effective drugs, control measures and a vaccine do not guarantee success. To await the results of pilot projects of AIDS treatment expansion would be courting disaster, as every day it is estimated that over 6000 people die and 12 000 more are infected with HIV. The motto adopted by 3 by 5 of "learning by doing" ensures that research, monitoring and evaluation are firmly embedded in national antiretroviral treatment expansion programmes — as is the case in the South African plan (4). This voyage of discovery must be a shared one, however, as developing countries share their experiences and participate in the implementation of treatment programmes, with people living with AIDS playing a prominent part.

In the absence of a cure for HIV/AIDS, treatment activities must strengthen prevention programmes — serving as motivating and enabling factors for people to be tested and to modify their sexual behaviour. The five pillars of the 3 by 5 strategy emphasize this integrated approach (3).

Providing access to affordable and effective antiretrovirals alone will not defeat the HIV/AIDS pandemic. Sustainable supplies (and their provision by local manufacture) of the whole panoply of AIDS drugs are vital. Cheaper and more effective diagnostics must be developed and supplied through public/private partnerships such as FIND Diagnostics (5). Food must be provided for those who are hungry, as well as the nutritional supplements that are so effective as additional therapy for AIDS (6). Research must continue into indigenous solutions for AIDS such as traditional and complementary medicines as endorsed by WHO's strategy for traditional medicines 2002–2007 (7). Management of sexually transmitted infections must improve, and TB must be prevented and treated.

Now that antiretroviral drug prices have come tumbling down over the past five years from US$ 10 000 per patient per annum to less than US$ 200, the key constraint to delivery of treatment has shifted to human resources: trained doctors, nurses, pharmacists and community health workers. Solutions include paying health-care workers a reasonable wage, as practised in Haiti (6), in order to mitigate "brain drain" from developing countries.

Developing countries have been hardest hit by the HIV/AIDS epidemic, which takes root in poverty, social dislocation, poor health and education systems and gender disempowerment. An integrated response to this global challenge is therefore needed, including: poverty relief through changes in global trade policies to benefit the marginalized countries of the world; access to global agricultural markets for developing countries; fiscal policy such as debt relief; and regional socioeconomic development programmes, such the New Partnership for Africa's Development (NEPAD). NEPAD's approaches are led by developing countries, but supported by partnerships with developed countries through fiscal and technical provisions (8).

The foundation has been laid by WHO for tackling this devastating epidemic. Success will only come, however, through the unwavering cooperation and support of all nations, constructing the human solidarity required to meet the greatest challenge to health in human history. Under WHO's leadership, partnerships have been established between national governments, international organizations, the private sector, civil society groups and communities. Success will demonstrate that mankind has evolved sufficiently to meet other global challenges, including those outlined in the United Nations Millennium Development Goals such as poverty and hunger, education, geopolitical instability, gender equity, racial disparities, child and maternal mortality, and sustainable development (9). In the words of Dr LEE, "this is an historic opportunity we cannot afford to miss".

References

1. AIDS epidemic update: December 2003. Geneva: Joint United Nations Programme on HIV/AIDS and World Health Organization; 2003. UNAIDS/03.39E.

2. The world health report 2004 — Changing history. Geneva: World Health Organization; 2004.

3. WHO/UNAIDS. Treating 3 million by 2005: making it happen. The WHO strategy. Geneva: World Health Organization; 2003.

4. Operational plan for comprehensive HIV and AIDS care, management and treatment. Pretoria: Department of Health, South Africa; 2003. Available from: www.doh.gov.za

5. Business plan. Geneva: Foundation for Innovative New Diagnostics (FIND). Available from: www.finddiagnostics.org

6. Farmer P, Leandre F, Mukherjee JS, Gupta R, Tarter L, Yong Kim J. Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy). Bulletin of the World Health Organization 2001;79:1145-51.

7. WHO traditional medicines strategy 2002–2007. Geneva: World Health Organization; 2000.

8. The New Partnership for Africa's Development (NEPAD). Available from: www.nepad.org

9. Millennium Development Goals. New York, United Nations, 2000.