Scaling ‘3 by 5’ to Universal Access requires enhanced prevention

>by Wim Van Damme, Katharina Kober, Guy Kegels, and Marie Laga (Institute of Tropical Medicine, Antwerp, Belgium)

SUMMARY: In countries of high incidence of HIV/AIDS, within 20 years health systems that were mainly set up to deliver maternal and child health services and care for acute episodes of disease will have to cater for large numbers of people living in need of lifelong chronic disease care (1,2). Critical, context-specific thinking on the scale and nature of the challenges ahead for AIDS treatment, and the assistance provided by scaled-up prevention, is essential if universal access is to be achieved. Meanwhile local communities are of necessity developing their own solutions, which deserve scientific study.

WHO and UNAIDS were the initiators of the “3 by 5” campaign to increase access to antiretroviral treatment (ART) for HIV/AIDS, and now the same agencies are taking the lead with its successor “Universal Access to Care and Prevention by 2010”(3). However, for a chronic condition such as AIDS, even 2010 is a relatively short time horizon, and it may be useful to project the challenges over a longer term period, for example to 2025. For this purpose, a simple calculation exercise, with rounded numbers, can illustrate the challenges ahead - both for the scale-up of antiretroviral treatment (ART) and for HIV prevention.

The growing caseload of people on ART

Let us assume that by the end of 2006 there will be three million people on ART in low- and middle-income countries (“3 by 6”); that from 2007, health systems world-wide will continue to expand by putting two million people on ART every year; and that the annual mortality rate of people on ART will be 10%. On these assumptions the health systems of low- and middle-income countries will have to deal with close to nine million patients on ART by 2010, and over 13 million by 2015. In 2025 this would level off, at around 18 million.

In a country with 20% HIV prevalence, unchanged HIV incidence, and an effective ART programme starting in 2005 and putting two-thirds of those in need on ART, then by 2010 over 6% of the adult population could be on ART, a figure that might even increase to almost 12% by 2025. Consequently, adult HIV prevalence would increase to close to 26% in 2010 and even to 32% in 2025 (Figure 1).

If, however, this country managed to reduce HIV incidence by half, its long-term prospects would be quite different. This is illustrated in Figure 2, made with similar assumptions, but supposing that from 2007 on, HIV incidence were halved, and that consequently from 2017 on the number of new people requiring ART would also be halved. This would lead to significantly fewer people on ART from 2017 onward, and a HIV prevalence of 22% in 2010 and 18% by 2025, which is close to half the previous scenario.

Nevertheless, in both scenarios such an expanding supply of long term ART care is likely to be unsustainable for the health system, with the potential crowding out most non-AIDS patients. 

The challenge is unprecedented. Health systems that were mainly set up to deliver maternal and child health services and care for acute episodes of disease suddenly have to cater for large numbers of people living with HIV/AIDS (PLWHAs), in need of lifelong chronic disease care.

The challenges ahead differ between countries, as the data in the Table show. This tabulates for a selection of countries the data published on WHO and UNAIDS websites, on the availability of medical doctors and nurses against the number of PLWHAs in the country, and calculates the number of PLWHAs per medical doctor and per nurse. It is often estimated that some 20% of PLWHAs are presently in need of ART. However, after large-scale introduction of ART these cumulative numbers will grow rapidly, and ultimately all PLWHAs will end up needing ART. It is striking to note that most countries praised for their performance in the ART scale-up are among those with the lowest numbers of PLWHAs per doctor (below the dotted line in the Table). This is most obvious for Brazil, Thailand and Cambodia, which have two, 30 and 75 PLWHAs per doctor respectively. But within sub-Saharan Africa there is also wide variation, as the table shows.

Our contention is that ART delivery models will have to be context-specific. The countries at the top of the table, with over 2 000 PLWHAs per doctor, will have to develop ART delivery models that are quite different from those of Botswana or South Africa, and certainly from Brazil (with only two PLWHAs per doctor).

As RealHealthNews has indicated before (RealHealthNews 3, 2005 pp 26-27) such prospects put into question the adequacy of a ‘medical paradigm’ for ART in high-burden HIV/AIDS countries. Given the human resource constraints, there is a need for innovative, far more de-medicalised delivery models, based primarily on the communities and on the capacity and resourcefulness of PLWHAs, supported by professional back-up when required. This challenge to health systems is unprecedented, but on the ground health services and communities are busy coping with it.

It thus seems likely that creative solutions are being developed, probably not by academics, but by field workers and local communities. These need to be studied, to learn lessons that might be more widely applied. Relatively little is reported about this grassroots reality. This may partly be because practical issues of health services organisation are often considered to be “local” and hence too context-bound to be of “scientific” interest. This bias should be forgotten in the face of the human tragedy that challenges us all. Research should be done to learn useful lessons, as Nduku Kilonzo is doing in Nairobi (RealHealthNews 4, 2006, pp 3-5).

ART scale-up could compromise prevention

The rate at which people get infected still exceeds the speed at which people can be put on treatment. In Malawi, for instance, in 2005 some 30 000 people got access to ART, while an estimated 110 000 new infections occurred in the same year. Unless the rate of new infections can be dramatically reduced in the years to come, sub-Saharan Africa will only move further away from Universal Access.

Success stories in HIV prevention have been documented in sub-Saharan Africa, indicating that reducing HIV incidence is both possible and feasible. However, these efforts were too small in scale to have resulted in a significant decline of the overall HIV incidence. It is shocking to note that more than 20 years after AIDS was first described, less than one person in five of those in need in sub-Saharan Africa have access to essential prevention services. In 2003, 1.5% of adults had received HIV testing and counselling, 5% of pregnant women had access to prevention of mother-to-child transmission programmes, and only 31% of sex workers had access to outreach prevention programmes.

The reasons for this ‘prevention implementation gap’ are multiple, ranging from denial, stigma, lack of financial, human and technical resources, cultural, political or religious barriers, to disagreement among programme managers on efficacy and mix of prevention strategies.

It is important to recognise that the scaling-up of ART could itself further weaken current prevention efforts. The focus, energy and resources, especially the already scarce human resources, could easily be absorbed by the formidable needs posed by the treatment programmes, resulting in an even greater reduction in the scale of prevention activities. As an example, in Africa many grass roots organizations and NGOs for PLWHAs, which were traditionally involved in community mobilisation and prevention, have shifted their focus to treatment support activities.

In conclusion, simple modelling exercises clearly indicate that a significant response to AIDS, which should include both reduction of HIV incidence and of AIDS related mortality, can only be achieved if both prevention and treatment are enhanced simultaneously. In these circumstances, treatment can make prevention more effective, and effective prevention will ultimately make treatment more feasible and affordable. All countries should therefore re-emphasize both emergency and long-term strategies for enhancing HIV prevention, in synergy with their rapidly expanding treatment programmes.

New ART delivery models for coping with the escalating caseloads, as well as enhanced prevention, are the real challenges for ART scale-up in sub-Saharan Africa. Both are compelling reasons why we must look beyond the 2005 time horizon, useful, as it has been for emergency mobilisation. We believe the time has come for policy-makers to take a fresh look at the global need for AIDS control by starting simultaneously to build novel systems to support chronic care for millions and plan for large-scale HIV prevention efforts. This requires a focus on a mid-term horizon such as 2010, or a longer-term horizon up to 2025.

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(1) Van Damme W, Kober K, Laga M. (2006) The real challenges for scaling up ART in sub-Saharan Africa. AIDS 20: 653-656.

(2) Van Damme W, Kegels G. (2006) Health System Strengthening and Scaling Up Antiretroviral Therapy: The Need for Context-Specific Delivery Models. Reproductive Health Matters 14(27): 1–3.

(3) World Health Organization. At: http://www.who.int/hiv/universalaccess2010/en/ Accessed 1 May 2006.

(4) World Health Organization. Global Atlas of the Health Workforce. At: http://www.who.int/globalatlas/default.asp. Accessed 21 February 2006.

(5) UNAIDS. HIV data. At: ttp://www.unaids.org/en/Regions_Countries/default.asp. Accessed 21 February 2006.

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