PHA-Exchange> THE LANCET: 3 by 5 - but at what cost?

[Claudio]

From: "Beverley Snell" <bev at burnet.edu.au>

> THE LANCET: 3 by 5 - but at what cost?
> --------------------------------------
>
> Lancet, Volume 363, Number 9414
> 27 March 2004
>
> Health and human rights
> 3 by 5, but at what cost?
> By Wendy Holmes
> Centre for International Health, Macfarlane Burnet Institute for
> Medical Research and Public Health, Melbourne 3004, Australia
(mailto:holmes at burnet.edu.au)
>
> The disaster of the HIV epidemic demands an emergency response.
> WHO's recent call to action, the "3 by 5" initiative, builds on
> the work of HIV and human-rights activists who fought for lower
> prices to enable treatment on the basis of need rather than
> wealth or geography. Ironically, the urgency and narrowly de-
> fined objective of 3 by 5 have implications for human rights and
> equity.
>
> It is difficult to question an initiative that seeks to save the
> lives of people with a fatal illness, but it is important to
> consider potential hazards. The DOTS campaign for tuberculosis
> showed how branding a programme could help to disseminate a new
> policy and mobilise resources.[1] 3 by 5 has captured the atten-
> tion of international agencies; their priorities in turn are in-
> fluencing the policy agendas of recipient governments, including
> many in Asia and southeast Asia.
>
> In some countries, targets for treatment far exceed the number
> of people who know they are HIV positive. For example, in Indo-
> nesia the government has pledged to provide treatment for 10,000
> people by the end of 2005, yet fewer than 4,000 have been identi-
> fied with HIV infection. Many Asian countries are still in the
> early stages of establishing voluntary counselling and testing
> services, which can play a vital part in prevention, as well as
> being an entry point to care. However, the pressure to identify
> those eligible for antiretrovirals threatens to skew counselling
> and testing towards screening those with symptoms, and to weaken
> principles of consent and confidentiality. Once these safeguards
> are diluted, vulnerable sections of the community--such as pris-
> oners, injecting drug users, and sex workers--might be coerced
> into testing.
>
> On Feb 10, 2004, Richard Holbrooke suggested in The New York
> Times that testing should be required at marriage, before child-
> birth, and on any visit to a hospital. Stephen Lewis, UN special
> envoy for HIV/AIDS, urged that routine testing be required
> "whenever someone presents at a medical facility, with the op-
> tion of course to opt out". Reports from antenatal clinics show
> that women rarely opt out of HIV testing, but often fail to re-
> turn for results. If testing becomes required, mothers and chil-
> dren may miss out on health care. A study of 764 HIV-positive
> people in India, Indonesia, Philippines, and Thailand [2] noted
> that more than half reported discrimination in the health sec-
> tor. Those who were unprepared for testing or who were coerced
> were more likely to report discrimination. Breaches of confiden-
> tiality were common.
>
> In much of Asia, most of those who test positive will not yet
> need antiretrovirals, but there are often no other supports in
> place. The effects of HIV infection are not confined to early
> death after debilitating illness, but include difficult deci-
> sions about child-bearing, and the loss of livelihood associated
> with discrimination. The least powerful, especially women, are
> most vulnerable to the effects of this stigma. [2]
>
> Experiences in Brazil and Botswana show that people in resource-
> poor settings are able to follow strict treatment regimens. How-
> ever, weaknesses in drug ordering and supply systems in poorer
> Asian countries lead to interruptions in treatment that will
> contribute to resistance and treatment failure. Also, antiretro-
> virals are already for sale in many pharmacies -- planning for 3
> by 5 should not distract health officials from the urgent need
> to strictly regulate distribution. The haste to reach treatment
> targets could compromise the chance of many with HIV infection
> to access effective antiretrovirals in the future.
>
> Freedman and colleagues [3] have suggested that the Millennium De-
> velopment Goal to reduce child mortality could, paradoxically,
> increase inequality, because the goal is easier to achieve by
> improving the health of the relatively better off. Likewise, the
> emphasis on the target-based goal of 3 by 5 could reverse the
> equity lens that should focus strategies prioritising the health
> of the poorest groups in the community. Groups that are diffi-
> cult to reach or treat might be neglected.
>
> The intent of 3 by 5 is to attract additional resources and com-
> mitment for prevention and a continuum of care. Although treat-
> ment does contribute to prevention, it is unlikely that suffi-
> cient new funds will be allocated to avoid resources and atten-
> tion being diverted from other HIV prevention strategies.[4] WHO
> hopes that 3 by 5 will leverage the strengthening of health-care
> systems. But without additional resources and staff, weak sys-
> tems and inequalities between urban and rural areas in many set-
> tings might be worsened. The 3 by 5 initiative must not eclipse
> the WHO 2003 World Health Report, which advocates stronger
> health systems. History shows that when governments are commit-
> ted to public spending, poor countries can have effective
> health-care services, facilitating treatment for all conditions.
> We should not pretend that effective treatment for HIV infection
> can be delivered to large numbers without increasing inadequate
> health sector budgets.
>
> Meanwhile, we should use the energy created by 3 by 5 to estab-
> lish comprehensive care, including antiretroviral treatment, for
> people who know they have HIV infection, and document the les-
> sons learned. Successful treatment will attract others to test-
> ing, without coercion (although treatment should not depend on
> willingness to publicly disclose positive status). We need to
> ensure that other prevention efforts continue, and we must guard
> against coercive testing practices. The 3 by 5 initiative alone
> cannot correct the differential access to HIV treatment between
> rich and poor. Attention to rights and equity is essential to
> maximise the potential of 3 by 5 and to keep harm to a minimum.