WHO On Wrong Track With African Aids-Drug Drive

NO ONE can accuse the World Health Organisation (WHO) of lacking ambition in its attempts to get to grips with the AIDS crisis sweeping much of sub-Saharan Africa.

Its "three by five" initiative a plan to put 3-million people on lifeextending antiretroviral treatment by the end of this year is arguably the single biggest push that any multilateral body has yet undertaken to try to tackle the disease.

Unfortunately, according to figures released last week by the WHO, the project looks like its going to miss its target spectacularly.

Only 700000 people are currently receiving antiretroviral drugs. That is well short of the 3-million proposed by the WHO in 2003, and a drop in the ocean compared with the 9-million people in Africa, Asia and Latin America who need them.

However, the failure of "three by five" also highlights the mis-prioritisation 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.

Education and other prevention strategies have reduced HIV infection rates in Uganda, Senegal and other forward-thinking countries. But instead of promoting prevention, the WHO promoted a wholly unrealistic treatment model.

Depressingly, the failure of the initiative was entirely predictable. The majority of people living with HIV/AIDS are in sub-Saharan Africa, where public health systems are fragmented, dilapidated or nonexistent. Most countries in the region lack qualified health workers and doctors, many of whom have emigrated to the west or have succumbed to AIDS themselves.

Antiretroviral drugs are complex to administer, requiring specified regimens and oversight by knowledgeable professionals. Most of all, they need health infrastructure if they are to be effective. It has been estimated that for sub-Saharan African countries to get their healthcare systems resembling that of relatively efficient SA would require about 72bn a year. At the moment those health systems receive a mere 8,5bn, including foreign aid.

Seen in this light, the WHO's decision to push its initiative as the key to solving the AIDS crisis was a gross strategic error.

But people's lives are at stake, as well as the WHO's reputation. In its desperation to increase the number of people on the drugs , the WHO pushed the use of untested tripledrug fixed-dose combinations . It was forced to delist these drugs, produced mainly by otherwise-reputable Indian drug companies, late last year over safety concerns .

According to the United Nations body tasked with dealing with the disease, UNAIDS, sub-Saharan Africa alone witnessed between 2,7million and 3,8-million new infections in 2003. So even if the WHO were able to give treatment to 3-million , the number of people with HIV will continue to grow beyond this.

One way out of this impasse is to put more emphasis onto HIV prevention. Education is central to this. In Uganda, one of the few countries in sub-Saharan Africa where HIV prevalence has fallen in the past decade, education played the key role. The country's ABC programme (Abstain, Be faithful, or use Condoms) emphasised the risks of casual and unprotected sex, and has had a dramatic effect on patterns of sexual activity, and reduced HIV prevalence 80%.

But if HIV prevalence is brought under control, that still leaves the question of how to best to distribute antiretroviral drugs to those infected. A remarkably successful public private partnership in Botswana between the Gates Foundation, several western drug companies and the government offers some lessons.

It involved the construction of clinics from where high-quality antiretrovirals could be distributed, while schools and colleges have undertaken public education programmes. Since the programme's inception in 1999, Botswana's HIV rate has levelled off.

In the medium to long term, Africa needs self-sustaining, efficient health-care systems that allow effective distribution of life saving medicines, as well as the propagation of vital health education.

Africa's poverty and its weak health infrastructure have the same root causes: corruption and poor governance. Solve one and you solve the other. The reform of governance structures must therefore be a priority; that means strengthening property rights, improving legal systems and entrenching the rule of law.

Admittedly, the reform of governance in sovereign states is outside the bounds of WHO policy. But the fact that so many African governments are corrupt and ineffective does not excuse the WHO from promulgating its disastrous strategy.

Indeed, the very fact that health infrastructure is so weak in Africa makes the strategy all the more absurd. The WHO should admit its failure and change tack now.

Mr Stevens is director of health projects at International Policy Network, a London-based development charity.