In recent years, considerable energy and money have been spent trying to achieve universal access to treatment for HIV and AIDS. This is part of a wider objective to provide universal access to treatment, care and prevention by 2010.¹ Most countries aspiring to expand treatment access have set themselves a goal of providing antiretroviral treatment to around 80% of those in need.

However, treatment access is low in many developing and transitional countries. In these areas of the world, at the end of 2008, just 43% of people who needed treatment were receiving it, though this is a substantial increase even on the previous year’s 33% coverage.²

Region (lower- and middle-income countries)		Antiretroviral therapy coverage	Estimated number of adults receiving antiretroviral therapy	Estimated number of adults needing antiretroviral therapy
Sub-Saharan Africa		44%	2,700,000	6,100,000
	Eastern and Southern Africa	49%	2,200,000	4,500,000
	Western and Central Africa	32%	500,000	1,600,000
Latin America and the Caribbean		54%	429,000	800,000
	Latin America	54%	393,000	730,000
	The Caribbean	51%	36,000	70,000
East, South and South-East Asia		36%	537,000	1,500,000
Europe and Central Asia		22%	80,000	370,000
North Africa and the Middle East		15%	9,400	62,000
Total		43%	3,755,000	8,800,000

Scaling-up the number of people on treatment involves great challenges including the need for:

• life-long commitment to antiretroviral drugs (ARVs) and supporting patients to adhere to a daily regimen
• adequate health infrastructure including health staff
• supply chains of effective drugs
• widespread awareness of the value of testing and subsequent treatment

All of this requires immense financial resources and political will and it is unlikely that the current rate of investment will be sufficient to achieve the target of universal treatment access by 2010.

Focusing too heavily on treatment can also be problematic if it detracts too much from efforts to prevent new HIV infections, a scenario which would only add to the eventual treatment burden. Furthermore, unless treatment programmes focus on the vital tasks of monitoring and patient retention, many patients will eventually die from treatment failure.

HIV treatment targets

3 by 5

Two ambitious targets regarding global antiretroviral coverage have been set by the international community. The first, ‘3 by 5’, was launched by the World Health Organization (WHO) in 2003 with the goal of achieving 3 million people in lower- and middle-income countries on ARVs by 2005. It was not intended as a final objective, but as a stepping stone to universal access. Though the target was not attained until 2007, it was seen by some as succeeding in a number of ways. Treatment was vastly expanded with coverage tripling from 400,000 people in December 2003 to 1.3 million in December 2005. This included an eight-fold increase in sub-Saharan Africa. Furthermore, treatment infrastructure was expanded with the number of public sector treatment sites increasing from 500 to more than 5,100.³

Another success of ‘3 by 5’ saw countries afford a greater importance to the issue of HIV treatment access.

“Two years ago, political support and resources for the rapid scale-up of HIV treatment were very limited. Today ‘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.” WHO Director-General, Dr Lee Jong-wook, 2006⁴

All by 2010

In 2005, before the ‘3 by 5’ targets had been attained, the group comprising some of the world’s richest industrialised democracies – the G8 – followed by country leaders at the UN World Summit, resolved to work towards achieving universal access to HIV/AIDS prevention, treatment and care by 2010.⁵

However, by the time of the WHO’s 2008 universal access report, the heads of UNAIDS, UNICEF and the WHO conceded that most countries would not meet the 2010 targets.⁶

The ‘All by 2010’ target is also part of Millennium Development Goal 6 which includes the goal of halting and beginning to reverse the spread of HIV/AIDS by 2015.

Practicalities of achieving universal access to HIV treatment

Though massive strides have been made in scaling-up antiretroviral treatment, it is clear that far more progress is needed to achieve anything nearing universal access. There are many constraints on achieving such ambitious targets, with costs and financial resources being at the centre.

Universal access is broadly defined. It does not necessarily mean 100% coverage of all services but can be seen as a desire to move to a high level of access for the most effective interventions that are ‘equitable, accessible, affordable, comprehensive and sustainable over the long-term’. Over 100 countries have set their own 2010 universal access targets with most countries aiming for 80% treatment coverage.⁷

Cost of HIV treatment

It is estimated that to achieve universal treatment targets an investment of $7 billion will be required in 2010 for treatment and care alone. This is of the estimated $25 billion needed to achieve all targets including prevention, care for orphans and vulnerable children, and other programme support costs. Considering less than $14 billion was invested in tackling HIV and AIDS in 2008, a funding shortfall, while not inevitable, is likely unless dramatic increases in financial commitments are made.⁸ The Global Fund expects to be $4 billion short of the amount it requires by 2010,⁹ and PEPFAR spending was not significantly increased in President Obama’s 2010 budget, reflecting concerns that funding would flat-line.¹⁰

In a global economic downturn, the prospect of greater funding for AIDS appears uncertain. In a 2009 World Bank survey of 69 countries, one third expected to see AIDS treatment programmes negatively affected over the year. Treatment programmes in sub-Saharan Africa were predicted to experience the worst of the financial crisis.¹¹ Indirect impacts of the financial crisis on treatment programmes could come in the form of increased poverty levels leading to more risky behaviours such as trading sex for money. Adequate nutrition, which is vital for people on ARVs, could also decline leading to ineffective treatment. In South Africa, some private sector funding, especially from the mining sector, is being cut. Although business has committed funding for treatment programmes, HIV prevention programmes are likely to be affected, inevitably increasing the number of people requiring treatment.¹²

Decades-long commitment to treatment

Another financial barrier to universal treatment access is that once people begin taking ARVs, they must continue taking them for life. This could mean a commitment on the part of governments or international donors to guarantee treatment for many decades, for every person on ARVs.

“AIDS poses a challenge for health systems that is fundamentally different from all of the other health problems ever faced. Transforming a deadly disease into a manageable chronic one turns millions of people into chronic patients, in need of life-long regular follow-up. This implies that present efforts and commitments will have to be continuously increased for many years to come.”Wim Van Damme, Institute of Tropical Medicine, Belgium¹³

Continuing to guarantee treatment for those who need it means treatment numbers will only grow unless people die or stop taking ARVs. Removing the life-line of antiretroviral therapy (ART) from individual patients is unlikely to be an option for governments. Therefore, overall health or HIV/AIDS budgets will have to grow with this expansion of treatment, or the share of these budgets will have to shift in favour of treatment, at the expense of prevention or care services. Alternatively, other public spending would have to be redirected.

When HIV treatment should begin

Another aspect of treatment access to consider is at what point people with HIV become eligible for treatment. In more economically developed countries, the threshold for treatment is a CD4 count (a level of a type of immune cell) that has dropped below 350 cells per cubic millimetre of blood. In less developed countries, treatment does not begin until the CD4 count drops below 200.

The stage of infection at which people are eligible to begin taking ARVs provides some context to the percentage of people regarded as in ‘need’ of treatment. Someone with a CD4 count of 300 in the UK, for example, would be considered in need of treatment, whereas someone with a similarly advanced infection in a less developed country may not be regarded as needing treatment. The levels of investment and resources that are necessary to obtain a certain level of access to treatment are therefore very much linked to a country’s definition of need.

Deferring treatment until infection has progressed may seem a cheaper option for funders of treatment programmes, but some say that initiating treatment earlier may be cost-effective in the long run. They argue the costs of a deferred treatment approach are ‘substantially increased’ by intensive clinical care, having to make more likely switches to expensive second-line treatment, an increased infection rate, and the loss of patients’ economic productivity.¹⁴ Despite the potential cost savings, treating patients earlier would inevitably require greater initial spending on antiretroviral drugs. Therefore it is debatable whether most governments would be prepared to make changes to their guidelines that would appear to boost costs and extend treatment waiting lists.

Establishing guidelines – treatment rationing in practice

Establishing guidelines as to who is entitled to HIV treatment, when, and with which ARVs, is a way of allocating, often scarce, resources. Short of treating everyone who needs treatment, the question remains over how to ration the resources needed for HIV treatment programmes. There are various ways that this can be done.

Firstly, particular demographics can be targeted for treatment. These could include mothers of new infants in order to prevent the child from becoming an AIDS orphan; skilled workers such as teachers, police, judges and civil servants regarded as contributing to economic productivity or social stability; the poorest people least able to fund their own treatment privately; and high-risk populations in order to suppress the level of HIV and consequently reduce onward transmission.¹⁵

For example, in 2005 Ugandan civil servants became eligible for free ARV drugs, with a government minister claiming that such workers’ “expertise is not easily replicated”.¹⁶ A PEPFAR-supported scheme targeted military personnel in Nigeria.¹⁷ In the US, the Ryan White HIV/AIDS Program targets those who do not have health insurance or sufficient financial resources.

Other forms of rationing include targeting people who live in particular areas such as those which perhaps have a high HIV prevalence or are politically important, prioritising treatment to those who can partially fund it, and limiting treatment to those who can demonstrate a degree of commitment to ARV adherence.¹⁸

Rationing can also take place without overt restrictions on access to HIV treatment or programmes directed at particular groups. The time and costs involved in travelling a substantial distance to testing or treatment sites will implicitly favour those who live nearby or have more spare time. Furthermore, any groups who are not targeted for testing, which is necessary before treatment, are indirectly restricted from treatment programmes. Those with power and influence are also likely to be able to take advantage of any rationing system.¹⁹

The potential positive and negative aspects of each system must be weighed against each other when deciding how to allocate antiretroviral treatment.

Patient retention

Establishing when, how and who initiates treatment is one set of issues in getting people with HIV on antiretroviral therapy. However, keeping people on treatment programmes – patient retention – should be considered as important a factor as boosting the numbers of people beginning treatment.

“High rates of attrition from treatment programs thus poses a serious challenge to program implementers and constitute an inefficient use of scarce treatment resources.”Sydney Rosen, Center for International Health and Development, Boston University²⁰

Patients who no longer continue with treatment are often classified as “lost to follow-up”. This could be for a range of possible reasons including simply stopping or interrupting treatment, death, or finding alternative sources of ARVs. The nature of loss to follow-up is that very often a patient’s eventual whereabouts or outcome is unknown, even if efforts are made to trace such patients.

A WHO survey found that more than 20% of all patients were not retained on antiretroviral therapy programmes after 12 months; retention at 48 months was less than three-quarters.²¹

In a review of studies examining patient retention in antiretroviral therapy programmes in Africa, just 60% of patients remained with their programme after two years. The remainder were lost to follow-up or had died.²² Another study examining data on 5,491 patients beginning antiretroviral therapy in 15 treatment programmes in Africa, South America and Asia, found 21% of patients became lost within six months, including 4% who were not seen since receiving their first prescription of ARVs.²³

Some studies suggest that patient retention actually suffers as a result of the drive to boost patient initiation. The research across three continents found the proportion of patients who were lost to follow-up was greater in 2003-2004 than in 2000 or earlier. This, it was suggested, was due to difficulties following-up the growing patient numbers:

“Early patient losses were increasingly common when programmes were scaled up and were associated with a fee for service and advanced immunodeficiency at baseline.”²⁴

Why do people stop treatment?

A variety of factors influence why individuals discontinue their treatment. Cost has a major impact on patient retention and mortality levels.²⁵ Similarly, associated costs such as transportation or “opportunity costs” such as having to forgo a day’s pay are other more structural factors. Adverse side effects of ARVs may cause someone to stop taking them, as could successful therapy if it leads people to become complacent.

Another set of social, cultural and psychological influences should also be considered. Perceptions of disease severity, susceptibility and the benefits or disadvantages of staying on treatment are key in determining clinical attendance. Believing that God or alternative medicine can cure AIDS can also influence treatment patterns. Similarly, misconceptions about ARVs can alter patients’ motivation to stick with them.²⁶

“Those medicines were so confusing. Sometimes you hear that if you use those medicines you will die. So it used to confuse people so much…we used to fear it so much that it means if you take these medicines you may die.”ART patient, Tanzania²⁷

Nutritional support is vital too as a lack of adequate food security could determine whether people remain on treatment. Some medications can only be taken on a full stomach while some ARV side effects are reduced by having adequate nutrition.²⁸

Supporting people to remain on treatment

Sticking to a treatment regimen for life that involves taking daily medication, with potential side effects, presents many challenges that must be overcome if patients are to successfully remain on treatment. If drug resistance occurs through failure to adhere to ARVs, far more expensive second-line therapy, may be necessary.

Having supportive family and community environments, as well as strong networks of people living with HIV are key to promoting adherence to ARV treatment.²⁹ This could come in the form of very practical assistance such as transport to a clinic or help with other activities. Patients may require emotional support to continue their treatment both from their family and HIV-positive peers. The success of other people on ARVs can encourage patients to continue with their therapy.³⁰

“…other patients who used to hide themselves have seen their fellows who come to these services are getting relief so they now turn up too.”ART clinic staff member, Tanzania³¹

Counselling, testing and treatment awareness levels

Before people can be treated they need to know they are infected. This requires not only HIV testing facilities but also widespread knowledge of the importance of testing and where it can be done. People may be more inclined to test if they know of the benefits of antiretroviral therapy and know they could be treated in the event of testing positive. Confronting stigma and denial are absolutely necessary as these are ‘the two factors that often determine whether a person seeks an HIV test or not’, according to the former South African health minister.³²

Trained staff

Many health staff are required at various stages of a treatment programme including for testing and assessment, and ARV prescription. However, countries with higher HIV prevalence tend to have lower health staff-to-patient ratios compared with more developed countries. Malawi, for example, has just one doctor per 50,000 people compared to the United States with one per 390 people. On average, there are 15 times the number of doctors and 8 times the number of nurses in Europe compared to Africa.³³

There are several reasons for this, one of which is AIDS itself. In Botswana, for example, 17% of the health-care workforce died due to AIDS between 1999 and 2005.³⁴

Migration of health staff from poorer to wealthier countries has also damaged the health infrastructure of countries ravaged by AIDS. It has even been suggested that the widespread recruitment of African health workers by more developed countries should be viewed as an ‘international crime’.³⁵

One proposal for tackling HIV with diminished staff capacity is to train or permit lesser-qualified health workers to perform tasks which they were previously unqualified to do. This is known as ‘task-shifting’. Allowing nurses to perform some of the tasks of doctors, and community workers the roles of nurses, for example, could facilitate access to ART and improve adherence and management of therapy. It is argued that quality of care would not be compromised and that it could be more cost-effective than the present division of labour.³⁶ Task-shifting has existed in Zambia, for example, since 2004,³⁷ but has yet to be implemented in South Africa despite the National Strategic Plan (NSP) calling for such measures.

“Nurse-led HIV/AIDS treatment at primary care level is non-negotiable if the NSP goal of providing ART for 80% of people in need is to be met.” Dr Francois Venter, President of the Southern African HIV Clinicians Society³⁸

However, a transfer of tasks must be accompanied by appropriate training. In a survey in Uganda,  64% of people who prescribed antiretroviral therapy were not doctors.  Non-doctors were found to have considerably lower levels of training on treatment initiation and monitoring, and knowledge of antiretroviral therapy.³⁹

Reliable supply chains

Ensuring there are no interruptions in treatment requires a guaranteed supply of antiretroviral drugs from the factories where they are produced to the treatment centres in perhaps remote areas of a country. Laboratory supplies, testing kits and information also needs to pass along the supply chain.

In order to be cost-effective, accurate forecasting of the necessary quantity of drugs is needed. Over-purchasing of ARVs can put strains on money and storage space, and may lead to wasting of drugs with limited shelf-life.⁴⁰ Under-estimating may lead to stockouts and the need to purchase costlier emergency supplies.⁴¹ One report found stockouts were ‘commonplace’ in China, India, Uganda, Russia and Zimbabwe.⁴² It was conservatively estimated that 30 people were dying daily in Free State, South Africa, after ARVs ran out towards the end of the 2009 financial year.⁴³ Such events not only adversely affect those who desperately need to begin treatment but also patients who were on treatment already and who may develop drug resistance.

Quantification and procurement of drugs is trickier for HIV than other areas of public health due to the changing nature of the epidemic, evolving efforts to tackle it, particularly with regards to scaling-up treatment, and changes in the price and quality of drugs.⁴⁴

The transportation phase of the supply chain requires delivery tracking and needs to account for potential customs barriers. Special refrigerated containers may also be needed. In unstable regions theft of the drugs may be a concern and armed escorts and decoy trucks are known to protect expensive deliveries.⁴⁵

Intermediate storage of the medication – such as in large regional warehouses – needs to be safe and secure and be able to efficiently process orders and distribute ARVs to health facilities. Similarly, local facilities should be able to safely and securely store medication often at controlled temperatures.

The massive international logistical exercise involved in creating a reliable supply chain for thousands of vital deliveries has meant the consortium that operates PEPFAR’s supply chain, the Supply Chain Management System, was the organisation that received the most money from the initiative in the 2007 financial year.⁴⁶

Availability of effective drugs and equipment

It goes without saying that HIV treatment programmes need a steady supply of drugs. However, the quality and type of drugs that are available will also have an impact on the effectiveness of the programme. The majority of treatment regimens in most developing countries use a drug called stavudine, or d4T, which has severe side effects that have led to its discontinued use in richer countries. Such side effects may dissuade patients from taking their medication, whereas better quality, though often more expensive, ARVs may encourage people to continue treatment and could require fewer costly treatment switches.⁴⁷

Thankfully, use of d4T has decreased with 56% of patients on first-line therapy in lower- and middle-income countries taking the drug in 2008, compared with 69% in 2006. The most common regimen is d4T + 3TC (lamivudine) + nevirapine, with 45% of patients taking this particular first-line combination.

Other medical supplies besides the antiretroviral drugs are also required. In developed countries, decisions about when to start treatment are based on the results of clinical tests called the CD4 test and the viral load test. Ideally these tests should be used everywhere, but in many parts of the world they are currently unavailable, as they require expensive equipment, electricity and trained technicians. In theory, decisions about when to start treatment may be based on symptoms alone. However, in practice, some treatment programmes provide medication only to people who have had a CD4 count.

The effect on other AIDS activities

Another possible result of the drive to rapidly boost treatment figures is the effect this has on other areas of HIV and AIDS work. Even in 2006, it was believed energy and resources were being redirected towards treatment:

“In Africa many grass roots organizations and NGOs…traditionally involved in community mobilization and prevention, have shifted their focus to treatment support activities” Wim Van Damme, Institute of Tropical Medicine, Belgium⁴⁸

This should raise questions about the very approach of boosting the numbers on treatment and whether the way it is done is good for patient health and cost-effectiveness. For example, is it preferred to put one person on effective treatment with the care and support that could keep them on ARVs for many years to come, or alternatively get three people on treatment for what is likely a shorter period of time? Similarly, is it reasonable to expect higher infection levels in order to treat those with AIDS? Such dilemmas are hard to resolve, yet the present successes or failures of ARV treatment programmes are the consequences of decisions more likely to result in one or another particular set of outcomes.

Achieving universal treatment access

Significant progress has been made in getting millions of people on treatment. Over 3 million life years have been gained since 2002, including 2 million in sub-Saharan Africa thanks to antiretroviral therapy.⁴⁹ Treatment expansion has led to a ten-fold increase in the number of people on treatment in low and middle-income countries by the end of 2008 (around 4 million) compared with 2003 (around 400,000) when the ‘3 by 5’ target was set. Although the ‘3 by 5’ target was not met on time, and the universal access targets are unlikely to be met by the end of 2010, it is likely that they have played a major part in progressing treatment levels far beyond what would have been achieved otherwise.

However, it is clear that in order to realise universal access to treatment, the scale of the task will have to be made easier through effective prevention to drastically reduce new infections.

“The implications of HIV prevention failures are clear: unless we act now, treatment queues will get longer and longer and it will become more and more difficult to get anywhere near universal access to antiretroviral therapy.”former head of UNAIDS, Peter Piot⁵⁰

Treatment will also need to be made more accessible through decentralising entry points to care, task-shifting, and generally having well functioning health systems. Adherence and retention rates will have to be improved both for the health of the patients and so that it is worth the vast and unprecedented financial investment in getting individuals on treatment. All of this will require huge investment and commitment from governments, donors and international organisations. Though it is uncertain whether all of this will be implemented, it is certain that without such factors, universal treatment access will remain elusive.

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