E-DRUG: Lancet: 3x5 At What Cost?
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[Copied as fair use. BS <bev@burnet.edu.au>]
Lancet, Volume 363, Number 9414
27 March 2004
Health and human rights
3 by 5, but at what cost?
Wendy Holmes
Centre for International Health, Macfarlane Burnet Institute for
Medical Research and Public Health, Melbourne 3004, Australia
(e-mail: 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 defined 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. 13 by 5 has captured the attention of
international agencies; their priorities in turn are influencing 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 Indonesia the
government has pledged to provide treatment for 10 000 people by the
end of 2005, yet fewer than 4000 have been identified 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 prisoners, 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 childbirth, 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 option of course to opt
out". Reports from antenatal clinics show that women rarely opt out
of HIV testing, but often fail to return for results. If testing
becomes required, mothers and children 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 sector. Those who were unprepared for testing or who were
coerced were more likely to report discrimination. Breaches of
confidentiality 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 decisions 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. However,
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, antiretrovirals 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
Development 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 difficult to reach
or treat might be neglected.
The intent of 3 by 5 is to attract additional resources and
commitment for prevention and a continuum of care. Although treatment
does contribute to prevention, it is unlikely that sufficient new
funds will be allocated to avoid resources and attention 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 systems and inequalities between
urban and rural areas in many settings 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 committed 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 establish
comprehensive care, including antiretroviral treatment, for people
who know they have HIV infection, and document the lessons learned.
Successful treatment will attract others to testing, 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. Documentation
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 project.
http://www.unmillennium project.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 ]
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