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Universal Access Now Campaign

Is Universal Access for HIV a realistic goal?

Von Robin Gorna

The International AIDS Society (IAS) has launched the Universal Access Now campaign to remind the world that universal access is a collective commitment, a shared responsibility, and a realistic, achievable goal. Universal access will not only dramatically reduce the HIV epidemic – it will also provide a strong foundation towards achieving Millennium Development Goals.

Yes. Universal access to HIV prevention, treatment, care and support is not only realistic, it must be achieved.

Yes, we must do it now. The benefits – in lives saved, HIV infections and other illnesses prevented, families and societies supported, children schooled, economies restored, and futures safeguarded – are worth every dollar and every hour of effort invested. And yes, we have a lot of work ahead of us to make universal access to HIV prevention, treatment, care and support a reality for all.

Skeptics say that the world's richest nations, the G8, over-promised when they committed in 2005 to ensure access to HIV services for all who need them by 2010. Or that 189 United Nations member states did not know what they were doing when they agreed in a unanimous vote to join the universal access pledge.

From my perspective, the problem is not over-promising. It's under-achieving. None of us – rich nations, poor nations, policymakers or advocates – have done enough to make universal access a reality. The fact that we will not reach the goal by 2010, however, is no excuse not to act now with more determination than ever to make global access to HIV prevention and treatment a reality as quickly as possible.

Collective Commitment

The International AIDS Society (IAS), our partners, and many other organizations of people living with HIV, funders, policymakers and activists are working through the IAS Universal Access Now campaign to remind the world that universal access is a collective commitment, a shared responsibility, and a realistic, achievable goal. Universal Access Now demands greater action by the G8 and G20 nations, including full funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria, which needs US$20 billion over the next three years to continue and expand its lifesaving work.

With aggressive action, why shouldn't we deliver universal access to HIV prevention, treatment care and support by 2015? Michel Kazatchkine, head of the Global Fund, has stated that "If countries can continue scaling up their efforts at the pace set in recent years, we could come close to, reach or even exceed the health-related Millennium Development Goals. By 2015, millions more HIV infections may be prevented and lives otherwise lost to AIDS saved, and we may virtually eliminate transmission of HIV from mother to child."

Is this massive undertaking worth the expense and the effort? Every public health and development indicator says "yes." Universal access will not only dramatically reduce the HIV epidemic - it will also provide a strong foundation toward achieving Millennium Development Goals (MDGs), including reducing child mortality (MDG 4), improving maternal health (MDG 5), and combating HIV and AIDS, malaria and other diseases (MDG 6).

The number of people receiving HIV antiretroviral therapy (ART) in low- and middle-income countries increased from 400,000 in 2003 to 4 million in 2008. That's good progress, but we're still only reaching about one-third of the people who need HIV therapy today. That number has grown with the introduction of new World Health Organization guidelines, urging earlier treatment for better health outcomes, which include preventing HIV transmission by reducing viral loads in people on therapy, proving once again that treatment and prevention go hand-in-hand.

More action is needed

Globally, coverage of HIV prevention services is improving, but we still have far to go. In 2008, nearly half (45 percent) of pregnant women living with HIV in low- and middle-income countries received ART to prevent vertical transmission and for their own health, up from only 10 percent in 2004. Importantly, an increasing proportion of pregnant women are receiving optimal HAART regimens for their own health, rather than single-dose ARVs designed exclusively to prevent vertical transmission.

Worldwide, more people are getting testing and counseling, too. The percentage of people aged 15-49 living with HIV in low- and middle-income countries, who reported having an HIV test and receiving the results, more than doubled in recent years. Still, studies show that only about 40 percent of people worldwide know their HIV status: a significant barrier to achieving universal access.

More action is also needed to scale up access to highly-effective prevention interventions such as male circumcision and harm reduction for people who use injection drugs, including needle and syringe programs and opioid substitution therapy. Globally, men who have sex with men often have both the highest HIV prevalence and poorest prevention coverage. Sex workers and migrant populations are also overlooked and discriminated against when it comes to access to effective HIV prevention. Measures to reduce this kind of stigma and discrimination, including the reform of laws that criminalize same sex behavior, drug use and sex work must be scaled up urgently.

Improvements across a number of vital health and development indicators

As the universal access target comes due, progress toward the goal is mixed. But, in a world of competing priorities, isn't slow, incremental progress better than nothing? Unfortunately, this epidemic does not work that way. Of course, on an individual level, every person reached with ART or with the tools and information to avoid HIV infection is a victory. Globally, however, the only way to reduce and ultimately end this epidemic is to reach a very high level of people in need. Providing universal access to HIV services would also create dramatic improvements across a number of vital health and development indicators.

Universal access would:

• Significantly reduce the impact of other serious diseases, such as tuberculosis, the world's seventh largest killer. HIV/TB co-infection levels are as high as 80 percent in some sub-Saharan African countries. Multiple studies show that HIV-positive people on therapy contract and transmit TB at much lower rates than those with no access to treatment.

• Strengthen maternal and child health. AIDS is the leading cause of death among women of reproductive age worldwide, and a major contributor to high maternal death rates. Safe breastfeeding, which is made possible by access to ART, reduces diarrheal diseases (the fifth leading cause of death worldwide) and other serious childhood illnesses.

• Strengthen health systems. In many countries, national health policies and programs developed to address HIV are already improving health system capacity to treat and prevent other illnesses. AIDS-related investments in health infrastructure and health-worker employment and training lead to broad health systems' improvements, and decreases in all-cause mortality.

• Foster economic growth and security. The loss of skilled workers to AIDS is a major barrier to development in struggling economies. Access to HIV prevention and treatment keeps women and men productive in their families, communities and national economies, while reducing government health-care costs.

Despite successes to date and overwhelming evidence in support of universal access, there are worrying signs that financial and political support for the goal is weakening just as it should be increasing. The Organization for Economic Cooperation and Development confirms what health and outreach workers are seeing in the field: wealthy nations are falling billions short of their commitments to universal access, and the gap between the resources committed and the resources required is growing. Médecins Sans Frontières (MSF) already reports ART stock-outs in many countries as HIV treatment budgets are cut.

We all have work to do to ensure that world leaders build on the progress to date to keep the universal access promise. IAS's Universal Access Now campaign demands that:

• Donors fully fund the Global Fund, one of the most successful public health funding mechanisms ever developed. US$20 billion is needed to keep the country-level programs the fund supports on an aggressive course to achieve universal access.

• G8 nations, the world's richest and most powerful, increase funding and political support for universal access and national programs such as PEPFAR scale-up to build on successes to date.

• G20 nations increase their commitments to the universal access effort at home and abroad.

• African nations keep the promise of the 2001 Abuja Declaration commitment to dedicate at least 15 percent of their national budgets to health.

• All nations increase national funding and political support for universal access, and support innovative financing mechanisms, such as the proposed Financial Transactions Tax, a tiny surchage on financial transactions that would raise billions for global health, including universal access.

The bailout given to global financial institutions produced more than US$ 1 trillion in a matter of weeks. For a fraction of that, we could end HIV, tuberculosis, malaria and other diseases and create benefits for global well-being that we cannot even imagine.

* Robin Gorna is the executive director of the International AIDS Society (IAS).
This article was published in Global Health magazine


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