O blog do GAT

The Economist 30.03.06

The World Health Organisation's attempt to roll out AIDS drugs in poor countries has missed its target. A shame, but not a disaster

AN OPTIMIST, so the old saying has it, sees a glass that is half-full, while a pessimist sees one that is half-empty. And that is probably a good light in which to view the announcement that the “3 by 5” initiative to get 3m HIV-positive people in poor and middle-income countries on to anti-retroviral drugs by the end of 2005 has got rather less than halfway there. According to a report on the initiative, just published by its sponsors, the World Health Organisation (WHO) and UNAIDS, a mere 1.3m of those infected in the target countries are on courses of the drugs.

The “3 by 5” initiative, announced in December 2003, marked the culmination of a change in thinking about how to tackle the global AIDS epidemic that had begun at the international AIDS conference in Durban, in 2000. Until the Durban conference, the general line among experts on the epidemic was that prevention was more important than treatment. That was partly because their focus was on trying to stop the disease spreading, and partly because the drugs required to treat those already infected were too expensive for widespread deployment in poor countries—particularly the very poor ones in Africa where AIDS bites deepest.

The shift in thinking came about because of the protests of those infected—or, rather, of their activist representatives—and also because of a realisation that without the incentive of treatment, those who might or might not be infected had little reason to find out the truth. Such ignorance was undoubtedly helping to spread the virus, whereas if people came forward for testing and treatment, they could, in addition, be encouraged to modify their behaviour to reduce the likelihood that they would transmit the disease.

3 by when?
The disinterested observer's reaction to the report is probably best summed up by the first rule of economic forecasting, “give 'em a number or a date, but not both”. The eponymous goal of the initiative was not quite plucked out of the air, but it was, in retrospect, absurdly optimistic. It was derived from a paper published in Science, in 2001, which attempted to quantify the need for treatment, and the amount of money that could usefully be spent on it. This paper estimated that 6m people were suffering from symptoms so advanced that their lives were in danger, and hazarded that it might be possible to treat half of them with anti-retroviral drugs, and thus save their lives.

Since only 400,000 people were being treated when the initiative began, that number would have to have been multiplied almost eightfold in two years. But even a three-plus-fold multiplication is not a negligible improvement. As Kevin De Cock, the newly appointed head of AIDS at the WHO, points out, this averted about 250,000 premature deaths in 2005.

One of the main problems turned out to be that in most countries the infrastructure to achieve a large-scale roll-out of anti-HIV drugs did not exist. Indeed, it is noticeable that much of the initial benefit has been captured by places that already had good health infrastructures.

In this context, though, the initiative may have been more successful than the headline figure suggests, since part of the money has gone on infrastructure. That means building clinics and testing laboratories, but also training doctors (surprisingly many of whom, more than two decades after AIDS was identified, have still not been taught how to deal with it) and reorganising hospital administrations. This sort of work has spin-offs beyond the treatment of AIDS.

Some of the money to do all this has come from the afflicted countries themselves. Much of the rest has been disbursed through three conduits from the rich to the poor worlds: the Global Fund to Fight AIDS, Tuberculosis and Malaria, based in Geneva; the President's Emergency Plan for AIDS Relief (the president in question being George Bush); and the World Bank. (The WHO and UNAIDS have acted as cheerleaders and advisers, rather than dispensers of largesse.)
The expense of treatment has also been tackled. For the other big change that has come about as a result of the initiative is in the market for AIDS drugs.

Here, a former American president with time on his hands and an urge to do good works has helped things along. The Clinton Foundation HIV/AIDS Initiative has helped to defragment the market for generic anti-retroviral drugs (those no longer in patent) by signing contracts with manufacturers in India and South Africa that guarantee large order-volumes and reliable payment. As a result of this and similar initiatives, the price of a course of these drugs has, in some cases, fallen below $150 per person per year—down from over $1,000 at the turn of the century.

Progress, then, is being made. And perhaps the most telling sign of that is what has not happened. The AIDS-activists' organisations, normally sensitive to the least failure to honour a pledge, have, by and large, kept quiet. Dr De Cock will not be drawn into predictions about what progress to expect over the next few years, but Mr Clinton (admittedly not an epidemiologist) says he will be both disappointed and surprised if the 3m figure is not reached by the end of this year. With an epidemic the size of AIDS, that means a lot of extra deaths. But, realistically, it is not that great an overrun.