Declaring Crisis, Plans a Big Push With AIDS Drugs
Lawrence K. Altman
The New York Times
September 22, 2003
Saying that the failure
to deliver AIDS drugs to impoverished people is so grave that
it has become a global health emergency, the World Health Organization
plans to provide such drugs to three million people, most of them
in sub-Saharan Africa, by the end of 2005.
The number of people
in these countries who would receive drugs under the W.H.O. plan
would be nearly four times the total to be covered by 2005 under
all existing programs. For example, President Bush's initiative
calls for treating two million people in 14 countries by 2008.
W.H.O. plans to adapt
many of the rapid response skills it learned in controlling the
SARS epidemic and in responding to health emergencies in Afghanistan,
Iraq and Liberia, said Dr. Jong Wook Lee, the United Nations health
agency's director general. Dr. Lee is expected to announce the
plan at a United Nations General Assembly meeting on AIDS today
and to ask countries to appeal to his agency for help.
"From a public
health perspective, we need to treat at least three million people
by 2005 to avert an enormous catastrophe," Dr. Jim Kim, who
is overseeing the AIDS treatment program as an adviser to Dr.
Lee, said in an interview. "We cannot wait any longer."
If the 34 countries
with the highest H.I.V. rates "each get 50 percent of those
who require treatment into treatment by the end of 2005, we will
reach 92 percent of our goal," Dr. Kim said.
One AIDS expert said
that AIDS researchers had been discussing such an idea for two
years. The health agency's goal is a good one, the expert said,
but is unlikely to be met because "we lost two years from
inaction." Still, the expert said, "we have to get on
track, and even if we reach one to two million, that would be
a huge success."
W.H.O., with a $1
billion annual budget, plans to add $100 million a year for the
new initiative to the $50 million it already spends on AIDS as
it appeals for more money from governments and other sources.
The plan comes two
months after Dr. Lee became director general of W.H.O., which
was criticized for its slow response to the early years of the
AIDS epidemic. After turmoil within the agency over its commitment
to fighting the disease, the United Nations created an agency,
Unaids, under the direction of Dr. Peter Piot.
Dr. Kim said that
W.H.O. will work with Unaids as well as governments and private
organizations to provide countries with the technical expertise
needed to deliver the drugs.
What is perhaps more
significant than the amount of money being provided is the organization
and the type of experience that W.H.O. has had working with developing
The most optimistic
projections from all existing antiretroviral programs are that
they would reach 800,000 people in the third world by 2005, Dr.
Dr. Lee has given
Dr. Kim's team until Dec. 1, World AIDS Day, to develop standardized
guidelines, including ways to help developing countries get quality
antiretroviral medicines. The guidelines will also deal with simplified
treatment regimens, laboratory testing for complications and rapid
training for the thousands of health workers who will be needed
to deliver the treatment.
W.H.O. has long held
a high reputation for the quality of its scientific expertise
in making recommendations that many countries, particularly those
in the third world, follow closely to control diseases. But it
had seldom been an action agency, like the United States Centers
for Disease Control and Prevention, until W.H.O. coordinated the
response to the SARS epidemic and declared it a global health
That experience taught
W.H.O. the importance of acting quickly and that "we must
change the way we think and change the way we act," Dr. Lee
said. "Business as usual means watching thousands of people
die every single day."
majority of H.I.V. infections are in sub-Saharan Africa, where
women account for 58 percent of cases and the virus is spread
predominantly by heterosexual intercourse. The disease is contributing
to food shortages in that region and threatening progressive economic
Of the 42 million
H.I.V.-infected people in sub-Saharan Africa, five million to
six million urgently need antiretroviral treatment because their
illness has advanced to AIDS, W.H.O. says. But "99 percent
of the H.I.V.-positive people who need H.I.V. treatment today
in sub-Saharan Africa do not have access to it," said Dr.
Piot of Unaids.
After receiving an
appeal for AIDS drug treatment, W.H.O. will dispatch a team to
determine the ability of the government and private organizations
to deliver the drugs.
W.H.O. has not determined
which combination of drugs it will recommend. The agency usually
makes such choices after years of deliberating over findings from
But in recommending
antiretroviral regimens "we are just going to make a decision
because we are working under emergency conditions," Dr. Kim
said. "We have got to start with something and say this is
it" and change later, if necessary.
"We will say,
use this regimen for H.I.V. patients with tuberculosis, that regimen
for H.I.V. patients without TB, and that is it for now,"
Dr. Kim said. Such decisions are important, he said, because generic
drug manufacturers want to know which drugs to produce and how
World opinion has
pressured manufacturers to lower the prices of antiretroviral
drugs for developing countries to the point where the cost is
less than a dollar a day. At the same time, studies in Africa
have provided evidence that patients there are better at following
their pill regimens than Americans, contradicting long-held prejudices.
A senior W.H.O. worker
will lead the teams that go to the countries. Because the agency
does not have enough people in its H.I.V. program, people who
work with other diseases will lead some teams.
W.H.O. will also
develop checklists to determine when a country is ready to start
a treatment program.
"We hope that
through this process with partners we will quickly develop an
information base country to country that currently does not exist,"
in part by using teleconferences and the Internet as it did for
the SARS epidemic, Dr. Kim said.
Because what works
in one country may not work in another, "the antiretroviral
treatment plans could look different in every country and maybe
even in every village and every region," Dr. Kim said.
The agency has consulted
Dr. Donald M. Berwick, president of the Institute for Healthcare
Improvement in Boston, about ways to ensure quality control while
expanding training and field programs.
Dr. Barry R. Bloom,
the dean of the Harvard School of Public Health, said that "anytime
health workers every Friday can analyze what went right and what
went wrong so they can improve performance, it will benefit not
only H.I.V./AIDS but also improve health care for everyone."
H.I.V./AIDS in resource-poor countries will be the defining issue
for W.H.O. and its new leadership," Dr. Bloom said.