[afro-nets] THE LANCET: 3 by 5 - but at what cost?

[Beverley Snell <bev@burnet.edu.au>]

THE LANCET: 3 by 5 - but at what cost?
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[Copied as fair use. BS]

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@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.

1 Ogden J, Walt G, Lush L. The politics of 'branding' in policy
transfer: the case of DOTS for tuberculosis control. Soc Sci Med
2003; 57: 179-88. [PubMed]

2 Asia Pacific Network of People Living with HIV/AIDS. Documen-
tation of AIDS-related discrimination in Asia: final report, Dec
2003. http://www.gnpplus.net/regions/Human_rights_initiative.doc
(accessed March 18, 2004).

3 Freedman L, Wirth M, Waldman R, et al. Background paper of the
task force on child health and maternal health millennium pro-
ject. http://www.unmillenniumproject.org/documents/tf04apr18.pdf
(accessed March 16, 2004).

4 Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART
in sub-Saharan Africa. Lancet 2002; 359: 1851-55. [Text]

--
Beverley Snell
Centre for International Health
Macfarlane Burnet Institute for Medical Research & Public Health
GPO Box 2284, Melbourne 3001 Australia
Site: Alfred Medical Research & Education Precinct (AMREP),
corner Punt & Commercial Roads, Prahran 3181
Tel: +61-3-9282-2115 / 9282-2275
Fax: +61-3-9282-2144 or 9282-2100
Time zone: 10 hours ahead of GMT
mailto:bev@burnet.edu.au