WHO’s 3 by 5 target:

Three Million people having access to antiretroviral drugs (ARVs) by 2005

Interview with Dr Paulo Teixeira, Director, HIV/AIDS, World Health Organization.

As head of Brazil’s AIDS programme, which received worldwide recognition for getting PLHA (people living with HIV/AIDS) onto ARVs (antiretroviral drugs) what are the key lessons you have learned and would wish to transmit to heads of AIDS programmes in other countries ?

The Brazilian response is based on a concerted early government response, a strong and effective participation of the civil society, a multisectoral mobilization, a balanced approach between prevention and treatment and a systematic advocacy of human rights in all strategies and actions. These principles are an integral part of the Declaration of Commitment on HIV/AIDS adopted in July 2001 at the Special Session on AIDS promoted by the United Nations General Assembly (UNGASS). Another core lesson is that program managers must not wait for the ideal infrastructure to be in place to start rolling out treatment. We must look for new, creative ways to provide the drugs, while realizing that learn-by-doing is key to our success. The founding principles of the Brazilian Program have, therefore, been acknowledged by the international community as basic elements of an effective response to HIV/AIDS. Political commitment and mobilization are key, but in resource-constrained environments there is always the possibility that decision-makers might feel tempted to divert funds to other priorities. In such circumstances, which every single country faces, a vocal and active civil society becomes a fundamental ally of HIV/AIDS program managers because their pressure ensures that the budget allocation process takes AIDS into account.

Do you think the Brazilian model could be used in countries in sub-Saharan Africa, where the situation is clearly different (infections rates are much higher, for example)?*

The Brazilian principle is that access must be integrated. We would like to see this adopted by other countries. And based on our experience, it is difficult. But we have had experience in working in slums, with the homeless, with drug users, and we learned that with the support from the community, from the churches, from the government and from the families we can include these people in treatment that is apparently complex [to administer and monitor]. We learned that this is a long process – it takes a lot of time, energy and money. But the decision to start was vital to achieve what we have now. In countries of sub-Saharan Africa, we are going to do everything that is possible – including treatment – to initiate a process. Maybe we will only start with 500 patients, and in three years, it will be up to 20,000, but we have to stop this discussion about having or not having the infrastructure [to provide treatment]. We have to act. That is the lesson we learned in Brazil.

For lay people, there is a strong feeling that the ethical imperative of getting people onto effective treatments should override considerations of profit for pharmaceutical companies. To what extent might the 3 by 5 serve to raise awareness about the tensions between patent protection and universal access to life saving drugs ?

Although there is no single answer to increase the availability of antiretroviral drugs in developing countries, one thing is certain: drugs and compounds are developed to benefit people. If a new treatment is developed, but only a handful of people can benefit from them, then the international community has the moral imperative to intervene and change this situation. One of the factors that hinder access is obviously price, and the strategies to achieve this goal are multi-fold. Among them are competition, differential pricing, voluntary and compulsory licensing. We need generics; we need brand-name drugs, we need local production; we need research and development. The research-based industry has come a long way in the last years to meeting the low prices – offered by their generic competitors – necessary to make any scale up plan feasible and sustainable. Much more will have to be done in the future to ensure that the drug costs continue to decrease. Special attention will have to be paid to the technology gap that exists, and seems to be widening, between originators and generic manufacturers in order to maintain competition as a viable tool to lower prices. In this regard, India, China, Brazil, South Africa and other developing countries exhibit a huge potential for collaboration and partnership in the technological and manufacturing areas. At the same, the world will need new generations of drugs and treatments, and we are open to exploring all policies that can lead to this objective. This means funding for research and development and clear priority setting on a global level.

One of the comments people make in relation to initiatives to get PLHAs onto ARVs is that they do not even have access to the simplest, cheapest medicines such as antibiotics or even painkillers and in many cases may not even have clean water with which to swallow the pills. How do you respond to those comments?

We acknowledge the many constraints that exist to get three million people on treatment, but we simply can’t wait for the entire infrastructure to be built up and only then offer treatment. If we do that, we will serious endanger the development prospects of billions – not millions – of people. Besides, there is no stronger driving force for continued infrastructure improvement than need itself. If people have already started treatment, if the roll out has begun, the chances that investments will be slowed down or suspended greatly decrease, specially when we take into account the large role international funding plays in financing health interventions in Africa. Also, as I mentioned before, in such situations, we must look for new ways of delivering the same service. If there is no food, then we should look for treatments that require no previous food intake. If there is no electricity, then we should look for treatments that require no refrigeration.

Simply wait is not only ineffective, it is inexcusable.

The commonest criticism of initiatives such as 3 by 5 is that health systems are too weak to support them. Might the 3 by 5 serve the purpose of showing that the number one priority for health in poor countries is to establish - or re-establish - functioning health systems ?

Functioning health systems are fundamental elements to attain the highest standard of health, and they are at the very core of our concerns when developing the “3 by 5” plan. It is true that in most countries of Sub-saharan Africa the health systems are already overstretched or have collapsed. “3 by 5” provides us with a major opportunity to change this situation definitely. This is an area where we have also been working very closely with our partners to ensure that appropriate financial and technical resources are focused at the health systems dimensions of ARV scale up. On the monitoring and evaluation side, there is a “3 by 5” working group looking specifically at this issue, on how to simplify and standardize tools for tracking ARV program performance, including drug resistance surveillance. The international AIDS community has been insisting for a decade now that prevention and care are inseparable. We have all heard that ARVs reduce viral load to almost undetectable levels. In commons sense terms, it is reasonable therefore to suppose that if all HIV positive people were on ARVs, the levels of circulating virus would be much lower. This should, theoretically, lead to lower population transmission rates. We are aware that it is critical to ensure people still practice safer sex including using condoms, but what is the current wisdom on ARVs as a preventive strategy, in the sense just described ? First, I don’t believe that the international AIDS community has been insisting for a decade now that prevention and care are inseparable. Until as recently as two years ago we were still widely criticized in Brazil for adopting a comprehensive response to AIDS that included a treatment component, and we were constantly told that it was not cost-effective, it was too dangerous, it would create resistance. The International AIDS Conference in Barcelona in July 2002 was the first time a true consensus around the inseparability of prevention and treatment seemed to have emerged. However, even now, as of 2003, you see some donor governments pointing out, for instance, that too much resources from the Global Fund are going to procure antiretroviral drugs, when the proportion is actually 15%! Back to your original question, preliminary evidence suggests that antiretroviral treatment plays a role in lowering the transmission rates of HIV. However, we need to marshal efforts to step up the research in this area to fully understand and quantify this impact appropriately. However, the message is clear: antiretrovirals do not diminish the importance of always practising safer sex through condom use. People who receive antiretrovirals have generally developed symptoms of AIDS, and this number is much smaller than the number of people who are actually infected by HIV but are still clinically healthy and do not meet the criteria for ARV uptake. In other words, the majority of people living with HIV do not need to take antiretrovirals and do not benefit, therefore, from the potential impact ARVs have in lowering viral loads. Additionally, we cannot forget the danger of sexually-transmitted infections, which pose a great threat to health and can foster the transmission of ARV. Are you satisfied that the latest WTO negotiations on TRIPS (Trade Related Aspects of Intellectual Property Rights). Will countries be able to make use of the emergency provisions of the TRIPS agreements. While the agreement that was reached on August 30^th was an important step towards clarifying the international legal environment where the pharmaceutical industry operates, we cannot deny that a number of concerns have been voiced about how workable the solution actually is. The solution contains a variety of legal and administrative devices that have to be followed, and the last thing that a producer wants is to pick up a protracted, costly legal battle at the World Trade Organization over such “details”. We hope and urge, therefore, that the solution be implemented in the most flexible manner, reassuring the drug manufacturers, particularly generic producers, that there is no reason to fear a multi-million dollars dispute that might eventually render worthless the investments made in new production lines to meet the needs of “3 by 5”.

We all remember “Health for All by the Year 2000.” Three million people having access to ARVs by 2005 is an ambitious plan. According to current figures there are at least 6 million in need of ARVs. Which countries will be included ? How will people be selected for treatment ? Who will decide ?

In our estimation, the number was based on how many persons we could identify and reach by 2005. We will, of course need to mobilize more resources in highly affected countries but 3 x 5 is for all Member States, of course focusing on developing countries. We are stimulating all countries and this is based on the principle of equity. Of course Bolivia with 300 seropositive persons will need less resources and support than for Botswana who has a much higher rate. We are going to work this way. No lists. As for reaching the 3 million, it will be a natural process. If I have drugs for 3 million people I will not have the 3 million persons immediately. This will take some time and a lot of energy and mobilization to identify people. In our estimate, we can only identify 3 million. Unfortunately, this is the situation. Even mobilizing all the resources, today we cannot reach more than 3 million and we will thus not face the situation of having to choose this person or that person. I hope that maybe in five years it will be different. Unfortunately, the social, economical, political and health structures are so poor that we cannot reach all of them.

* This question taken from Worldlink, the magazine of the World Economic Forum and reproduced with Dr Teixeira’s permission.

Interviewed by Alison Katz and Maria Dweggah.