WHO's '2 by 5' not the answer

ACTIVISTS at this week’s world AIDS conference want us to believe that the United Nations’ inefficient and expensive treatment programmes can defeat the AIDS pandemic in Africa. But the single-minded pursuit of these targets has taken the focus away from the only thing which really can defeat it: prevention.

The slogan of the biennial International AIDS Conference in Toronto — Time to Deliver — is somewhat optimistic when one considers the UN’s track record on AIDS. It has no clear idea how many people are infected, and plays down the huge obstacles to delivering treatment to the majority.

In December 2003, the World Health Organisation launched its programme to treat 3-million AIDS patients by 2005. It immediately ran into two problems: the member states had not approved the venture and the member state considered at the epicentre of this disease, SA, had already started its own programme.

The South African method was based on laboratory diagnosis, evaluation of disease progression, the response to therapies and the management of antiretroviral toxicities — the important elements of patient care.

By not following the example of a member state, the WHO signalled that while it had been tardy in leading a global effort for AIDS treatment, it was not going to learn lessons either. Getting the numbers up was more important than dealing with patients responsibly.

To get numbers of victims up quickly, it approved simplified diagnostics so that easy-to-use tests, such as body weight and colour-scale blood tests are used where more complicated and expensive tests are not yet available. The only audited figure is the number under treatment.

Worse, it recommended the use of antiretroviral drugs, though they had not been approved by a stringent regulatory authority.

Subsequently, beginning in May 2004, the WHO had to disqualify 18 of those antiretrovirals but it had no authority to issue mandatory recall orders. It is not known how many AIDS patients were subjected to unregulated antiretrovirals.

SA, on the other hand, does provide basic tests to patients before admitting them into AIDS therapy and it uses drugs approved by its own Medicines Control Council, a stringent regulatory authority. It has also invested heavily in laboratory facilities and in training for medical personnel in AIDS-patient care and management: the trouble with antiretrovirals is they need constant professional evaluation and stringent dosage.

In July last year, the WHO admitted that it would miss its treatment goal but then took the opportunity to hold SA partially responsible.

In March, the WHO released its progress report on “3 by 5”. Instead of 3-million AIDS patients under treatment, there were only 1,3-million. In December 2003, the WHO estimated global costs at $5,2bn. This March, the WHO stated that expenditure for last year had reached $8,3bn, while the International Monetary Fund said 2004 expenditures were $8bn.

For each of the patients treated, then, the cost was $12538 over two years. The WHO states that 250000-350000 deaths were averted (meaning delayed for a few years). At the midpoint of 300000, then, each death delayed costs $54333. The WHO boldly states in its progress report that the “lessons learned” can now serve as the foundation for its new goal: universal treatment by 2010, or 10-million by that date.

The medical and clinical basis for that assertion is not at all evident from the WHO’s report. There is no clinical patient data about: beginning CD4 cell counts; counselling methods; drug therapies used; drug resistance; adherence to therapies; adverse reactions; laboratory results; co-morbidities; causes of death while under treatment; or viral suppression rates after the initiation of treatment. In fact, there is no suggestion there are even medical records for patients.

In its unscientific pursuit of numbers for “3 by 5”, the WHO determined from Geneva what was in the best interests of AIDS sufferers who lived in poor countries.

SA understands only too well what the WHO refuses to recognise: there is no cure, so every AIDS patient accepted into treatment is a responsibility of the state for life. As drug resistance sets in, medical treatment costs increase exponentially. Nowhere in its report does the WHO address this future liability. The WHO insists on being measured by its good intentions rather than by its performance. Member states in the real world have no such luxury.

The Toronto meeting is a chance to highlight the failure of throwing more and more money at treatment without a long-term, practical, connected programme of prevention.

Norris is director, Centre for Science in Public Policy, Hudson Institute, a policy think-tank in Washington.