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WHO's AIDS strategy misses the big picture

Philip Stevens
February 24, 2005

No one can accuse the World Health Organisation of lacking ambition in its attempts to get to grips with the AIDS crisis that is currently sweeping much of sub Saharan Africa. Its "3 by 5" initiative - a plan to put 3 million people on life-extending antiretroviral treatment by the end of 2005 - is arguably the single biggest push that any multilateral body has yet undertaken to try to tackle the disease. Unfortunately, according to figures recently released by the WHO, the project looks like its going to miss its target spectacularly. Furthermore, in its emphasis on providing ARV treatment, the strategy overlooks the fundamentals that could slow down the progress of the disease: education, prevention and the development of self-sustaining health infrastructure.

According to the WHO, as of January 2005 only 700,000 people are currently receiving antiretrovirals (ARVs). That's well short of the three million figure proposed by the WHO back in 2003, and a drop in the ocean compared to the nine million people in Africa, Asia and Latin America who need them. According to UNAIDS, Sub-Saharan Africa alone witnessed between 2.7 and 3.8 million new infections in 2003.

So even if the WHO were able to give ARV treatment to 3 million people, the absolute number of HIV infections will continue to grow and make a mockery of the program's goals, underscoring the WHO's misguided agenda.

The WHO's "3 by 5" strategy leaves it in much the same position as Sisyphus, who was doomed to spend eternity in Hades pushing a boulder up to the top of a mountain, only to have it roll back to the bottom where he would have to start again.

One way out of this impasse is to put more emphasis onto HIV prevention through education programs. In Uganda, one of the few countries in sub-Saharan Africa where HIV prevalence has fallen in the past decade, education played the key role. The country's ABC programme (Abstain, Be faithful, or use Condoms) emphasised the risks of casual sex and unprotected intercourse, and has had a dramatic effect on patterns of sexual activity, and has reduced HIV prevalence by 80 per cent. Education and other prevention strategies have also reduced HIV infection rates in Uganda, Senegal and other forward thinking countries. But instead of promoting prevention, the WHO continues to promote a wholly unrealistic treatment model.

Of course, even if HIV prevalence is brought under control through education, that still leaves the question of how to best to distribute ARVs to those already infected. A remarkably successful public private partnership in Botswana between the Gates Foundation, several western drugs companies and the government offers some excellent lessons. It involved the construction of clinics from where high-quality ARVs could be distributed, while schools and colleges have undertaken massive public education programmes. Since the programme's inception in 1999, Botswana's HIV rate has levelled off.

Depressingly, the failure of "3 by 5" was entirely predictable from the outset. The majority of people living with HIV/AIDS are in sub-Saharan Africa, where public health systems are fragmented, dilapidated or, more frequently, completely non-existent. Moreover, most countries in the region lack qualified health workers and doctors, many of whom have emigrated to the west or have succumbed to AIDS themselves.

Antiretroviral drugs are complex to administer, requiring specified regimens and oversight by knowledgeable professionals. Most of all, they need health infrastructure (including hospitals, clinics and testing equipment) if they are to be effective.

The challenge here should not be underestimated. It has been calculated that for sub-Saharan African countries to get their healthcare systems resembling that of relatively efficient South Africa would require some $72bn a year. At the moment those health systems receive a mere $8.5bn, including foreign aid. Unless we overcome these basic issues, it will be impossible to get the drugs safely to those who need them.

Seen in this light, the WHO's decision to push "3 by 5" as the key to solving Africa's AIDS crisis was a gross strategic error. But peoples' lives are at stake, as well as the WHO's reputation. In its desperation to increase the number of people on ARVs, the WHO pushed the use of untested triple-drug fixed dose combinations of ARVs. Late last year, the WHO was forced to de-list these drugs, produced mainly by otherwise-reputable Indian drug companies, over concerns about their safety.

This irresponsible strategy also risks spreading drug resistant viral strains across the continent. In the U.S., researchers have noted that unless optimal HIV viral load suppression is achieved, drug resistance is likely to develop. Only about one-third of U.S. patients reach that plateau, with the remaining two-thirds of patients at risk for developing drug resistant HIV. In fact, 48% of those patients will develop resistance to two classes of ARV drugs and 13% to three classes[1]. In Africa, where it is difficult to monitor and enforce ARV doses, the risks of resistant strains of HIV developing are hugely increased. The WHO's '3 by 5' plan simply adds fuel to this fire.

In truth, no donor AIDS program by itself, however well designed or implemented, can address the root causes of Africa's mushrooming health crisis. In the medium to long term, Africa needs self-sustaining, efficient healthcare systems that allow effective distribution of life saving medicines, as well as the propagation of vital health education. These do not come cheap. Australia, for example, spends approximately $2,600 per capita on healthcare. Malawi spends $39.

Africa's poverty, weak health care infrastructure and vulnerability to infectious diseases all stem from decades long corruption and poor governance. Solve one and you solve the other. Ignore the governance issue and Africa's health crisis will continue to fester, as it will not be able to afford for itself the kind of healthcare systems and education necessary to control the AIDS epidemic.

Admittedly, the reform of governance in sovereign states is outside the bounds of WHO policy. But the fact that so many African governments are corrupt and ineffective does not excuse the WHO from promulgating its disastrous "3 by 5" strategy. Indeed, the very fact that health infrastructure is so weak in Africa makes the strategy all the more absurd. By pretending that 3 by 5 is some kind of silver bullet for the African AIDS crisis, the WHO removes pressure from African leaders to reform their governance structures and devote more public funds to healthcare and education.

The WHO should admit its failure and change tack now.


  1. AIDS Drug Developers Struggle To Keep Ahead of Resistant Strains - The Wall Street Journal, 23 February 2005

Philip Stevens is Director of Health Projects at International Policy Network, a London based development charity. A version of this article originally ran in the Johannesburg Business Day.

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