World overview

An estimated 33.2 million people were living with HIV at the end of 2007¹. Someone who is infected with HIV is likely to become sick with AIDS within a few years, but if treated with antiretroviral (ARV) medication their life can be prolonged, often for a very long time. ARV treatment has already dramatically cut the rate of AIDS diagnoses and deaths in Western countries where it has been provided since the mid 1990s.

As of December 2006, an estimated 7.1 million of the people living with HIV in low- and middle-income countries urgently needed this life-saving ARV medication. Of these only 2.015 million - barely one in four - were accessing the drugs.

Though shockingly small, this figure represents a great advance since 2003, when only 400,000 were receiving treatment. At the UN General Assembly Meeting on HIV/AIDS on September 22nd 2003, WHO, UNAIDS and the Global Fund declared the lack of access to HIV treatment a global health emergency.²

Since that meeting much progress has been made. Many countries have set targets for scaling-up treatment, and global organisations and funding bodies are rolling-out plans to increase ARV coverage.

Never before in the history of the epidemic has so much money been available to finance treatment and care for people with HIV, and never before have life-saving antiretroviral medicines been so cheaply and plentifully available. But still, every day, nearly 6,000 people are dying from a disease which can be treated, but which all too often isn't.

The need for faster progress

The number of people accessing ARV treatment in low- and middle-income countries is constantly growing as more services are set up and more people enrol in existing programmes. During 2006, coverage increased by around 700,000.

Yet although this increase may seem impressive, it is barely an improvement on the growth achieved in 2004. To reach all those in need, the expansion in treatment access must accelerate – from 700,000 per year to one million, then two million and so on. At the current rate of progress, only five million people will be receiving treatment by the end of 2010. Much greater effort will be required to achieve the far higher targets agreed by the world’s leaders.

At the current rate, fewer than 5 million people will be receiving treatment by the end of 2010, instead of the 10 million target.

Treatment targets

Rapid expansion of ARV treatment programmes is unlikely to happen without clear, ambitious goals to pursue. The most important targets of recent years are “3 by 5” and “All by 2010”.

All by 2010

Please use this logo to help raise
awareness and show your support for
the campaign for universal access to
HIV/AIDS treatment by 2010.

“All by 2010” describes the goal of universal access to ARV treatment by the year 2010. Achieving this target means putting many more people on treatment than the 7.1 million currently in need. This is because people who started treatment in previous years must continue to receive medication, and each year many hundreds of thousands of people progress to the stage of disease at which treatment is required.

According to the most common definition, universal access to treatment is achieved when 80% of all people in urgent need of treatment are receiving it. Experience has shown that this level of coverage is seldom exceeded even in rich countries, for a variety of reasons including adverse drug reactions and personal choice. It has been estimated that, under this definition, universal access means at least 10 million people (maybe more than 16 million) must be receiving treatment by the end of 2010. For this reason, some people use the phrase "10 by 10" instead of "All by 2010".

All by 2010: the promises

In July 2005, leaders of the Group of Eight (G8) countries (Canada, France, Germany, Italy, Japan, Russia, the UK and the US) pledged to ensure as near as possible to universal access to ARV treatment worldwide by 2010. Two months later, all United Nations Member States endorsed this goal by committing themselves to:

"Developing and implementing a package for HIV prevention, treatment and care with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all those who need it" - ³

This promise was reaffirmed by the world's leaders at the UN High-level Meeting on AIDS in May-June 2006:

"[We commit] to pursue all necessary efforts to scale up nationally driven, sustainable and comprehensive responses … towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010." - ⁴

African leaders made additional commitments to universal access at a meeting in Abuja, Nigeria in May 2006. According to Nigerian President Olusegun Obasanjo, the leaders agreed to achieve “100 percent access to preventive and treatment services”.⁵

The American PEPFAR initiative and the Global Fund to Fight AIDS, TB and Malaria have also set targets for their own programmes, though these are generally not as ambitious as the All by 2010 goal.

Backtracking by the G8 leaders?

When the G8 leaders met again in June 2007 they had the chance to make additional, more ambitious pledges on access to ARV treatment. Many activists view the declaration produced by the summit as a major disappointment – even a betrayal.

Despite repeating the pledge to work towards “universal access” to treatment, the G8 declaration on Africa also contained the following statement:

"G8 members … over the next few years will aim to employ existing and additional programs to support life-saving anti-retroviral treatment through bilateral and multilateral efforts to approximately five million people." - ⁶

The problem is that providing treatment to 5 million Africans “over the next few years” is not necessarily the same thing as providing universal access by 2010. It is estimated that at least 7 million Africans – and perhaps as many as 11 million – will require treatment for HIV by 2010. The new target appears to limit the contribution that G8 countries will make to meeting this need.

Perhaps even more importantly, the amount of money pledged by the G8 will not be enough to meet the universal access target, according to UNAIDS estimates.

What about interim targets?

At the UN High-level Meeting on AIDS in 2006, the world’s leaders agreed to:

"set in 2006, through inclusive, transparent processes, ambitious national targets, including interim targets for 2008 ... that reflect ... the urgent need to scale up significantly towards the goal of universal access to comprehensive prevention programmes, treatment, care and support by 2010." - ⁷

As of June 2007, some countries have still not set any treatment access goals.

Earlier targets: the 3 by 5 initiative

The 3 by 5 logo

The World Health Organisation created the first global target for ARV treatment access in 2003. The “3 by 5” initiative called for 3 million people in developing countries to have access to treatment by the end of 2005, which meant meeting 50% of estimated need.

Progress towards this goal began well but then failed to accelerate. At the end of 2005 only 1.3 million people in low- and middle-income countries were receiving ARV medication. This was just 40% of the target. In sub-Saharan Africa, 810,000 were on treatment out of an estimated 4.7 million who needed it.

Of the 152 countries targeted by the 3 by 5 initiative, only 18 managed to provide treatment to at least half of their needy people by the end of 2005. The list included Poland, Thailand and thirteen countries from the Americas and the Caribbean. Only three African nations - Botswana, Namibia and Uganda - met their 50% targets.

Yet the WHO has stressed that, even though 3 by 5 didn't succeed within the intended timeframe, this doesn't mean it should be deemed a failure. Much of 3 by 5's work was to set up infrastructure and mobilise resources, laying the foundations for future progress. The number of treatment sites in low- and middle-income countries increased tenfold from around 500 in June 2004 to more than 5,100 by the end of 2005.

"Before 3 by 5, there was not an emphasis on saving lives... Many leaders in the world were saying we just have to forget about this generation of people who are infected, we're really thinking about the next generation... So something has happened that's extraordinary." - Dr Jim Yong Kim, director of the WHO's HIV/AIDS department⁸

"3 by 5 has helped to mobilize political and financial commitment to achieving much broader access to treatment. This fundamental change in expectations is transforming our hopes of tackling not just HIV/AIDS, but other diseases as well." - Dr Lee Jong-wook, WHO Director-General⁹

Progress around the world

The number of people receiving ARV medication increased from 400,000 in December 2003 to 2.015 million in December 2006. However progress has been very uneven around the world. Some countries such as Cuba and Brazil have been providing treatment to most of their needy citizens for some time. Others such as Mozambique, Angola and Russia have yet to reach even 15% coverage.

Crucial to achieving the goal of universal access will be the progress of South Africa, India and Nigeria. At the end of 2006, these three nations between them accounted for around 40% of unmet need. However, there are also many countries that have severe HIV epidemics but whose achievements will have little effect on the global figures. The profiles below present a range of situations from around the world.

Africa

The HIV epidemic has hit Africa much harder than any other region. Large variations exist between individual countries in Africa, but UNAIDS/WHO estimates that 24.7 million people were living with HIV in the sub-Saharan region at the end of 2006, out of a global total of 39.5 million. Across sub-Saharan Africa, UNAIDS/WHO estimate that 1.34 million (28% of those in need) were accessing ARV treatment in December 2006.

Botswana

There were estimated to be 270,000 people living with HIV in Botswana at the end of 2005. This gives Botswana a prevalence rate of 24.1% - the second highest in the world. Of all African countries, Botswana is doing the most to provide its citizens with improved healthcare and prevention and was the first country in sub-Saharan Africa to start to offer ARVs to all who need them through its public health system.

Implementation of the ARV programme started at Princess Marina Hospital in 2001, and has since expanded to at least 32 sites. Alongside this government/private partnership are initiatives set up by employers to provide education and treatment for their employees. About 15% of people receiving treatment do so through private facilities.

At the end of 2006, around 84,000 people were receiving treatment, which was more than 95% of those in need. Botswana exceeded not only its 3 by 5 target of 30,000 by the end of 2005, but also the government's own target of 55,000. Free public sector provision rose gradually from a few hundred people at the start of 2002 to nearly 5,000 in September 2003. It grew much more rapidly during 2004 and 2005.

Find out more about HIV & AIDS in Botswana.

Uganda

At the end of 2005, there were one million people living with HIV in Uganda, according to UNAIDS data. The country's adult HIV prevalence fell from around 15% in the early 1990s to around 6.7% at the end of 2005. Uganda's prevention efforts have been widely praised and are seen by many as providing a model for other nations.

Uganda ran one of the first pilot ARV programmes in Africa. It began in 1998 and aimed to see how an ARV programme could be set up and run in a resource-poor country. The 399 patients involved were responsible for paying for their treatment, and bought their drugs at negotiated reduced prices. At the end of the two-year pilot, patients reported good adherence to treatment and virological and immunological responses to ARVs were similar to those found in Western countries.¹⁰ The Ugandan Ministry of Health has since incorporated the essential elements of the scheme into its National Strategic Framework for HIV/AIDS.

In Uganda, programmes are being designed to bring ARVs to the wider impoverished public sector. There are also some private initiatives starting, spurred on by the reduced costs of drugs and the perceived benefits to employers from having healthy staff. Uganda exceeded a government target of 60,000 on treatment by the end of 2005. The number had risen to 96,000 by the end of 2006, which was around 41% of those in need.

Take a closer look at HIV & AIDS in Uganda.

Malawi

Malawi has an adult HIV prevalence rate of 14.1%, which translates to 940,000 people infected. In 2001, the government came up with an ambitious plan to provide treatment to all 300,000 people who would need it within seven years, and wanted to submit the US$1.62 billion plan to the Global Fund for HIV, TB and Malaria. However, after further consultation the government was forced to scale down its plan to just 25,000 people, costing US$196 million over five years. Antiretroviral therapy began to be provided free of charge in the public sector in 2003. As of June 2004, only 3,760 people were reported to be receiving the drugs.

The government later set a target of 50,000 people on treatment by the end of 2005, which was less than the 3 by 5 goal of 65,000. Having missed both these targets (only reaching 33,000 by the end of 2005) Malawi set another goal of 80,000 by June 2006. In the event it took another six months to reach 81,000 people on treatment, which was 41% of those in need.

The number of public facilities providing ARV therapy grew from three in January 2003 to sixty by the end of 2005, covering all districts in the country.

Find out more about HIV & AIDS in Malawi.

South Africa

Nelson Mandela talks to a child who is receiving treatment in the MSF funded Khayelitsha Clinic in the Cape township of Khayelitsha.

The case for access to ARVs in South Africa has been the most high profile of all African countries. Data from the UNAIDS May 2006 report indicate that 5.5 million people were living with HIV at the end of 2005, which gives an adult prevalence rate of 18.8%. This means that South Africa has more HIV+ people that any other African country.

Yet it was not until November 19th 2003 that the government finally gave approval to a plan to provide free ARVs to all who need them.

The Health Minister Manto Tshabalala-Msimang stated there would be one ARV 'service point' in each of the country's 53 health districts within a year, increasing to one service point in every local municipality within five years. In the same week, it was announced that HIV/AIDS funding was to be increased from R3.3 billion to R12 billion (US$1.8 billion). The executive director of the Medical Research Council Anthony Mbewu said the cost of implementing the plan would be US$45 million for the remainder of 2003/04 rising to US$700 million in 2007/08. It was estimated that 400,000 people will fulfil the criteria for starting treatment.

In December 2004, the WHO estimated that 42,000-67,000 South Africans were receiving treatment. This figure rose to 178,000-235,000 by the end of 2005, representing around 21% of the 983,000 people believed to be in need. This means that, despite being Africa's richest country, South Africa fell a long way short of its 3 by 5 target. At the end of 2006, the number receiving treatment had grown to 325,000, or 33% of those in need, which is slightly above the average for sub-Saharan Africa.

Find out more about HIV & AIDS in South Africa.

Asia

Access to public health provided ARV treatment is still scarce in Asia, though Thailand is leading the way in providing the drugs. Some countries have committed to providing treatment in the near future, with India and China being by far the most significant, due to their massive populations and consequently the potential for many millions to become infected and therefore need treatment.

Thailand

In Thailand, the Ministry of Health began providing ARV monotherapy in 1992 and dual therapy in 1995. In 2000, the Ministry began promoting triple therapy as the norm, using mainly branded drugs. However, since then the use of generic copies has widened. The Government Pharmaceutical Organisation (GPO) produces seven ARV preparations, which are two to twenty-five times cheaper than the cheapest brand equivalents. Before 2000, the cost of a year's treatment of ARVs (2 NRTIs and a Protease Inhibitor) was US$600; by 2002 this had dropped to US$150. When cheap generic versions of ARVs became available in Thailand, the triple combination of d4T/3TC/nevirapine dropped to B1200 (US$18) per month, a price a lot of Thais could afford.

The use of generics allowed the treatment programme to expand more than eight-fold between 2001 and 2003 with only a 40% increase in budget.¹¹ The ARV budget of Baht300 million for 2003 then increased to Baht800 million for 2004.

The Thai Red Cross and the Ministry of Public Health supply all HIV-positive women with AZT and nevirapine during pregnancy, and milk formulas after the birth of their infant. ARVs are available through at least 914 public hospitals in the country, and may require part-payment by the patient.

It is thought that 72,000-91,000 people (60% of those in need) were receiving ARVs at the end of 2005, exceeding the government target of 50,000. By the end of 2006 the number had grown to 112,000, corresponding to 88% coverage.

Find out more about HIV & AIDS in Thailand.

China

After many years of denial, the Chinese government is now publicly addressing the country's epidemic of HIV and AIDS. With a population estimated at over 1.2 billion, China has the potential to become the worst affected country in the world, and UN forecasts state that as many as 10 million could be infected by 2010.

In November 2003, the health minister Ga Qiang promised to expand the policy of 'four frees': free HIV testing, free ARVs, free care for HIV+ mothers and free education for AIDS orphans. Signs are hopeful that the government will indeed take the problem seriously, and on World AIDS Day 2003, the prime minister visited an AIDS care centre and shook a patient's hand, a highly symbolic move in a country still plagued by attitudes of stigma and discrimination.

The government aimed to provide 30,000-50,000 people with treatment by the end of 2005. This target was missed, with only 18,000-20,000 actually getting the drugs. By the end of 2006 coverage had risen to around 31,000, or 27% of those in need, which is slightly below the average for all low- and middle-income countries.

Find out more about HIV & AIDS in China.

India

According to revised estimates published in July 2007, India has between 2 million and 3.1 million people living with HIV - more than any country except South Africa and Nigeria. In November 2003, the government announced a US$43.6 million plan to offer free ARVs through the public health system, beginning April 2004. The drugs would be provided by the three large generic drug manufacturers in India, who were already making cheap ARVs for other developing countries. The government hoped to treat 100,000 people free of charge through the public sector by the end of 2007, beginning with HIV+ pregnant women, all children under 15 and eventually all people with an AIDS defining illness in the six states with the worst rates of infection.

The programme has so far made slow progress. About 36,000-77,000 people were receiving drugs at the end of 2005, of whom only around 24,000 were gaining free access from public sector facilities. By the end of 2006 the total number (including private sector patients) had reached 95,000, but several hundred thousand others were in need of treatment.

At the moment, despite the fact that India is a major producer of cheap generic copies of many HIV/AIDS drugs that are being sold to many countries all over the world, treatment in India reaches only a small minority of needy people.

Find out more about HIV & AIDS in India.

Latin America and the Caribbean

A selection of HIV/AIDS antiretroviral drugs.

Of all developing and transitional regions, Latin America and the Caribbean has by far the most comprehensive ARV treatment coverage, with 72% of those in need receiving drugs. More than half of those being treated live in Brazil, which is a world leader in providing ARVs free to its population, thanks mainly to in-country production of cheap generic ARVs. Progress in other countries varies widely.

Brazil

In 1988, Brazil began to offer drugs to treat opportunistic infections. Then, in 1991, zidovudine (AZT) began to be offered. In November 1996, the government agreed to start providing free ARVs. The government does purchase some drugs from abroad, but the programme is based upon the domestic producers being able to supply cheap generic copies of branded ARVs. The government has said that the logistics of their programme are threatened by the high prices of bought-in ARVs, but they persist in the plan because deaths have been reduced, and quality of life has greatly improved for those living with HIV. It was estimated in 2003 that 660,000 people were living with HIV, 60% of whom were unaware of their infection.¹²

In 1997, an estimated 35,900 people were receiving treatment. This increased to 55,600 in 1998; 105,000 in 2001; 140,000 in June 2004; and 183,000 in December 2005. At the end of 2006, around 180,000 were getting the drugs, out of an estimated 210,000 in need.

Spending on ARVS increased from US$34 million in 1996 to US$232 million in 2001.¹³ Then in January 2004 it was announced that the government had reached a deal with pharmaceutical companies to reduce the price of ARV drugs by around a third. Health Minister Humberto Costa said the deal would save the government about US$100 million during the year. The price cuts brought the total annual cost of Brazil's AIDS treatment programme to its lowest level since 1999 - US$180m - while cutting the average cost per patient to a new low of US$1,200¹⁴. The government proudly stated that they had halved the number of AIDS-related deaths since 1996, when the distribution of free drugs began.

Take a closer look at HIV & AIDS in Brazil.

Cuba

Cuba set up its National Commission on AIDS in 1983, three years before its first case was diagnosed. It has since had a 'strong arm' approach to dealing with HIV, quarantining those diagnosed, employing strict partner tracing programmes, running compulsory eight-week education programmes for those diagnosed, and providing ARVs for all pregnant women (because of which only a handful of children have ever been born with HIV on the island). Cuba consequently has one of the lowest prevalence rates in the world, at 0.1%. At the end of 2003, there were 3,300 people living with HIV.

No ARVs were available in Cuba for many years because of the US trade embargo. But Cuban laboratories began making generic ARVs in 2001 and now Cuba is one of only a few developing countries producing their own supplies of the drugs to all people living with HIV who need treatment.¹⁵ Latest available data indicate 3,000 people receiving ARVs in Cuba, which is more than the number thought by UNAIDS/WHO to be in immediate need. Because of it success in providing ARVs for its own population, Cuba is now looking to export generic drugs to other developing countries.

Haiti

It is estimated that 190,000 people were living with HIV in Haiti at the end of 2005, which gives the country an adult prevalence rate of 3.8%. The yearly total health budget is only around US$15 million, so the government could not have provided ARV treatment unassisted. Treatment began in 1998 in rural Haiti through a US organisation called Partners in Health. The Global Health Fund, USAID and the Bush Presidential Emergency Relief Fund all later pledged money for Haiti.

The Global Fund was the first international donor to provide money for ARV purchasing. In conjunction with the Haitian Ministry of Public Health, money has been used to provide HIV prevention and treatment throughout the country, in Port au Prince at GHESKIO centres and in central Haiti by Partners in Health's HIV Equity Initiative. Providing a comprehensive treatment programme has necessitated revitalising the public health infrastructure, and this has subsequently improved basic healthcare for all.^{16 17 18}

At the end of 2006, an estimated 9,000 people were receiving ARVs, out of 22,000 in need, giving a coverage rate of around 39%.

AVERT.org has more information about HIV & AIDS in Latin America and the Caribbean.

High-income countries

Access to ARVs in high-income countries has been less of an issue than in other parts of the world, as funds have been available to purchase and distribute the drugs. These countries are not included in WHO statistics.

The epidemic has been established in many high-income countries since the 1980s, including the USA and Western Europe. These countries had already established medical and care facilities so that people living with HIV could immediately access care and treatment. Providing ARVs has not been without its problems, though. In particular the drugs can be expensive; at US$20,000 per person per year, the cost of the new fusion inhibitor T20 is by far the highest for any ARV ever produced.

United Kingdom

It is estimated that 63,500 people were living with HIV in the UK at the end of 2005, of whom 32% were undiagnosed. The year 2006 saw the highest ever annual number of diagnoses. The introduction of combination therapy in 1996 led to a big decrease in the number of AIDS-related deaths. It also meant higher costs for treatment and care, as everyone who is HIV+ and legally entitled to reside in the UK is entitled to free healthcare. The combination of more people living longer and needing treatment and increasing numbers of new infections meant that costs were ever increasing to cover the costs of ARVs. In 2000, it was estimated that the average lifetime treatment cost for someone living with HIV would be between £135,000 and £181,000.¹⁹ This figure is for all treatment, including hospital costs, not just the price of the drugs.

According to the National Association of NHS Providers of AIDS Care and Treatment (PACT), the cost of managing a patient with HIV is £15,000 per year. The total cost of treatment and care in 2002-03 was £345 million.²⁰ Around 36,000 people were reported as receiving antiretroviral therapy in the UK in June 2006.

Read more about HIV and AIDS in the UK.

United States of America

Since the mid-1990s, when combination therapy was introduced, US AIDS deaths have dropped by about 70%. At the end of 2005, the estimated number of people living with AIDS in the USA was 437,982, out of an estimated one million living with HIV.

Most people in the US access their care and treatment through privately bought health insurance, as there is no country-wide state provision of healthcare. However, not all people can afford insurance. Instead they use Medicaid or Medicare, programs that pay for medical assistance for certain individuals and families with low incomes and resources. These programs provide medical long-term care assistance to people who meet certain eligibility criteria.

Since 1987, AIDS Drug Assistance Programs (ADAPs), which are federally and state-funded and state-run, have made treatments available primarily to low-income HIV patients who do not qualify for Medicaid. Currently, ADAPs buy around 20 percent of the HIV drugs prescribed in the United States, enough for 92,000 people.²¹ Some states have been forced to close ADAP enrolment for new patients, and others have tightened income-eligibility criteria. In February 2006, 791 people nationwide were waiting to access any kind of treatment through ADAPs.²² There are, even in America, people who die for want of AIDS drugs.²³

AVERT.org has more information on HIV & AIDS in the USA.

Conclusion

AIDS killed an estimated 2.1 million people in 2007. If everyone had access to ARV therapy then the death toll would be much lower.

Treatment for HIV/AIDS has been shown to be effective and feasible in even the poorest parts of the world. Political momentum is building and governments are beginning to show their willingness to help alleviate the suffering. Definite targets have been set which are both ambitious and entirely attainable.

Unfortunately, progress so far has been disappointingly slow, and the current rate of treatment scale-up is not nearly sufficient to achieve the "All by 2010" target. The world's leaders must now demonstrate real commitment if they are to have any chance of keeping their promises. Millions of lives are at stake.

"Along with other partners, the [3 by 5] initiative ... shattered forever the tacit acceptance in industrialised regions that millions in developing nations would die simply because they were poor. For this outcome, the WHO, UNAIDS, and all those who believed in 3 by 5 deserve unstinting praise. But a shift in thinking, however important, will not be enough without the resources and political leadership to back it up." - Dr. Helene Gayle, President of the International AIDS Society -²⁴

Further reading

There are many challenges to be overcome on the road towards universal access, including a shortage of resources, infrastructure and skilled staff, but none of these problems is insolvable. Read more about these challenges and what is being done to overcome them in our treatment issues page.

More information about numbers of people around the world receiving and needing ARV treatment can be found in our treatment access table.

WHERE NEXT ?

AVERT.org has more about:

• HIV treatment and care
• Who is getting drugs now?
• HIV treatment for children
• Worldwide HIV & AIDS statistics