WHO’s mission impossible

SA HAS been singled out by UK-based medical journal The Lancet as being the key to meeting the World Health Organisation (WHO) target of providing treatment to 3-million HIV-positive people globally by the end of this year (the “3 by 5” initiative).

If SA was that critical to the success of the WHO initiative, one would have expected that there would have been discussions between WHO and government to ensure that the initiative was realistic in its goals. Unfortunately, there was no consultation before the launch of the initiative in 2003. WHO identified 49 low and middle-income countries, including SA, as focuses for this initiative. Targets were set for countries without objectively looking at their capacity to meet them.

Parallel to this process, but unrelated, was the adoption of the comprehensive plan for management, care and treatment of HIV and AIDS by our cabinet in November 2003. The plan had its own targets focused mainly on strengthening the capacity of the health system and expanding the number of service points for AIDS treatment.

According to the comprehensive plan, we had to have at least one service point in every district by March this year and thereafter extend services to all 231 local municipalities. By last month, 143 facilities were providing treatment across SA. This demonstrates we are on track in terms of the implementation of the programme as adopted by the cabinet.

The 3 by 5 initiative, on the other hand, adopted a totally different approach. It estimates the number of people who have progressed to a stage when treatment is needed, and countries are expected to provide antiretroviral therapy to at least 50% of the estimated number needing treatment by the end of this year. According to this initiative, SA has the highest number of people needing treatment, at more that 800000, followed by India at 735000 and Nigeria at 598000 people.

The three countries have to treat half of these people for WHO to meet its targets of 3 by 5. Our experience indicates that the approach of setting targets against the estimated number of people assumed to have progressed to a stage when they develop AIDS-defining conditions is flawed.

Recently, two major South African companies — Anglo American and AngloGold Ashanti— reported that only 25% of target beneficiaries of antiretroviral therapy had enrolled for treatment through their AIDS programmes. This is despite the programmes being marketed in a setting where live-in miners are a captive audience, and using various communication techniques.

We cannot simply question the commitment of the management at Anglo American for the fact that only 2100 people were enrolled in its antiretroviral treatment programme out of its 8500 employees believed to be in need of treatment. We have to look at the factors influencing the reaction of these miners to the programme.

The question that comes up is whether WHO’s HIV and AIDS director, Dr Jim Yong Kim, is justified in blaming the foreseen failure of the 3 by 5 initiative to meet its targets only on the political commitment of India, Nigeria and SA. Second, can SA’s government be held accountable for the targets set at WHO headquarters in Geneva without consultation with the people involved in the day-to-day implementation of health programmes on the southern tip of Africa?

Many people have questioned whether 3 by 5 was a viable project in the first instance. Philip Stevens, of the International Policy Network, in London, raised many issues about this initiative in an article on these pages: “The failure of ‘3 by 5’ highlights the misprioritisation of action by the WHO. Leading public health experts are virtually unanimous in concluding that prevention is of paramount importance in the fight against AIDS …. But instead of promoting prevention, the WHO promoted a wholly unrealistic treatment model. Depressingly, the failure of the initiative was entirely predictable.”

Stevens highlighted genuine challenges facing health systems in Africa, including the recruitment of our health workers by developed countries, as the main barriers to meeting these targets.

He goes on to express concern about desperate measures pursued by WHO to increase the number of people on antiretrovirals, particularly WHO’s decision to lobby for the use of untested triple-drug fixed-dose combinations.

To increase distribution of antiretrovirals, WHO compiled a list of prequalified drugs, mainly cheap generic drugs, and promoted them to relief organisations and governments. Some of these drugs were subsequently withdrawn last year because of safety concerns.

At a meeting I held with him in Geneva in May, WHO director-general Dr Lee Jong-wook indicated that blaming SA’s government for the initiative’s shortfall was not an official view of WHO. I invited WHO to send a delegation to SA to get first-hand information about the implementation of our AIDS programme so that it can at least have an informed view of the pace of implementation.

That invitation still stands because, despite many challenges, we have made significant progress in the implementation of our comprehensive plan.

Dr Tshabalala-Msimang is health minister.